Barriers, Legal Issues, Limitations and Ongoing Questions in Telemedicine Applied to Stroke

Bustos, Elisabeth Medeiros de; Moulin, Thierry; Audebert, Heinrich J.

doi:10.1159/000213057

Cited by 47 publications

(12 citation statements)

References 25 publications

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“…On the spoke level, Rogove et al [ 30 ] found that lack of leadership support was a major barrier to telestroke, thus emphasizing the enabling role of “managerial telestroke championship.” O'Toole Jr. et al [ 29 ] identified the lack of “local neurological expertise” in rural areas as a major barrier to telestroke adoption and implementation. Other studies have pointed to the need for “continuous telestroke process improvement.” For example, Medeiros de Bustos et al [ 51 ] identified the lack of predefined procedures and uneven standards of evaluating stroke care quality as major challenges to telestroke utilization, and Gogan and Garfield [ 50 ] identified the need to create appropriate checklists and protocols for stroke care and to engage users in developing repeatable processes. Interestingly, although many studies point to the general need for internal and external coordination for stroke care [ 29 , 52 ], few studies have examined the role of a stroke committee of key stakeholders in directing such efforts or of a dedicated telestroke coordinator in facilitating day-to-day stroke delivery.…”

Section: Discussionmentioning

confidence: 99%

Assimilation of Web-Based Urgent Stroke Evaluation: A Qualitative Study of Two Networks

Singh¹,

Mathiassen²,

Switzer³

et al. 2014

JMIR Med Inform

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BackgroundStroke is a leading cause of death and serious, long-term disability across the world. Urgent stroke care treatment is time-sensitive and requires a stroke-trained neurologist for clinical diagnosis. Rural areas, where neurologists and stroke specialists are lacking, have a high incidence of stroke-related death and disability. By virtually connecting emergency department physicians in rural hospitals to regional medical centers for consultations, specialized Web-based stroke evaluation systems (telestroke) have helped address the challenge of urgent stroke care in underserved communities. However, many rural hospitals that have deployed telestroke have not fully assimilated this technology.ObjectiveThe objective of this study was to explore potential sources of variations in the utilization of a Web-based telestroke system for urgent stroke evaluation and propose a telestroke assimilation model to improve stroke care performance.MethodsAn exploratory, qualitative case study of two telestroke networks, each comprising an academic stroke center (hub) and connected rural hospitals (spokes), was conducted. Data were collected from 50 semistructured interviews with 40 stakeholders, telestroke usage logs from 32 spokes, site visits, published papers, and reports.ResultsThe two networks used identical technology (called Remote Evaluation of Acute isCHemic stroke, REACH) and were of similar size and complexity, but showed large variations in telestroke assimilation across spokes. Several observed hub- and spoke-related characteristics can explain these variations. The hub-related characteristics included telestroke institutionalization into stroke care, resources for the telestroke program, ongoing support for stroke readiness of spokes, telestroke performance monitoring, and continuous telestroke process improvement. The spoke-related characteristics included managerial telestroke championship, stroke center certification, dedicated telestroke coordinator, stroke committee of key stakeholders, local neurological expertise, and continuous telestroke process improvement.ConclusionsRural hospitals can improve their stroke readiness with use of telestroke systems. However, they need to integrate the technology into their stroke delivery processes. A telestroke assimilation model may improve stroke care performance.

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Section: Discussionmentioning

confidence: 99%

Assimilation of Web-Based Urgent Stroke Evaluation: A Qualitative Study of Two Networks

Singh¹,

Mathiassen²,

Switzer³

et al. 2014

JMIR Med Inform

View full text Add to dashboard Cite

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“…To allow breakthrough results, several issues still need to be tackled, including data security, privacy, medical device regulations, liability on product failure and reimbursement [44,73]. …”

Section: New Developments and Future Conceptsmentioning

confidence: 99%

Prehospital Stroke Care: Limitations of Current Interventions and Focus on New Developments

et al. 2014

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Background: The global burden of stroke is immense, both in medical and economic terms. With the aging population and the ongoing industrialization of the third world, stroke prevalence is expected to increase and will have a major effect on national health expenditures. Currently, the medical treatment for acute ischemic stroke is limited to intravenous recombinant tissue plasminogen activator (IV r-tPA), but its time dependency leads to low utilization rates in routine clinical practice. Prehospital delay contributes significantly to delayed or missed treatment opportunities in acute stroke. State-of-the-art acute stroke care, starting in the prehospital phase, could thereby reduce the disease burden and its enormous financial costs. Summary: The first part of this review focuses on current education measures for the general public, the emergency medical services (EMS) dispatchers and paramedics. Although much has been expected of these measures to improve stroke care, no major effects on prehospital delay or missed treatment opportunities have been demonstrated over the years. Most interventional studies showed little or no effect on the onset-to-door time, IV r-tPA utilization rates or outcome, except for prenotification of the receiving hospital by the EMS. No data are currently available on the cost-effectiveness of these commonly used measures. In the second part, we discuss new developments for the improvement of prehospital stroke diagnosis and treatment which could open new perspectives in the nearby future. These include the implementation of prehospital telestroke and the deployment of mobile stroke units. These approaches may improve patient care and could serve as a platform for prehospital clinical trials. Other opportunities include the implementation of noninvasive diagnostics (like transcranial ultrasound and blood-borne biomarkers) and the reevaluation of neuroprotective strategies in the prehospital phase. Key Messages: Timely initiation of treatment can effectively reduce the medical and economic burden of stroke and should begin with optimal prehospital stroke care. For this, prehospital telemedicine is a particularly attractive approach because it is a scalable solution that has the potential to rapidly optimize acute stroke care at limited cost.

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“…However, the system generates immediate costs which have been poorly assessed to date. Moreover, as these charges are mainly attributed to the spokes, many hospitals are reluctant to become “rt-PA capable” centers representing a hurdle to the implementation of telestroke ( 6 , 7 ). The answer to this dilemma could be the application of an economic model regulating the financial flow between a hub and its spokes but this has never been reported before.…”

Section: Introductionmentioning

confidence: 99%

Implementation and Evaluation of an Economic Model for Telestroke: Experience from Virtuall, France

et al. 2017

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BackgroundTelestroke is recognized as a safe and time-efficient way of treating stroke patients. However, admission centers (spokes) are subject to financial charges which can make them reluctant to join the system. We implemented and assessed an economic model supporting our telestroke system, Virtuall, France, which includes one expert center (hub) and six spokes.MethodsThe model is based on payment for the expertise provided by the hub, distribution of charges related to telemedicine according to the fees perceived by the spokes, and transfer of patients between the spokes and the hub. We performed a cost–benefit analysis for all patients included in Virtuall from January 2014 to December 2015 to assess the economic balance in each center.Results321 patients were prospectively included in the study. Application of the economic model resulted in overall financial balance with funding of a dedicated medical service in the hub, and reduced costs directly related to telestroke by an average of 10% in the spokes. The conditions generating the highest costs for the spokes were: a patient returning from the hub for re-hospitalization (mean cost of $1,995/patient); management of patients treated by intravenous thrombolysis without transfer to the hub (mean cost of $2,075/patient). The most favorable financial condition for the spokes remained simple transfer of patients to the hub and no return (mean cost of $329/patient).ConclusionWe describe an economic model which can be applied to any telestroke system to ensure the optimal balance between hub and spoke centers.

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Barriers, Legal Issues, Limitations and Ongoing Questions in Telemedicine Applied to Stroke

Cited by 47 publications

References 25 publications

Assimilation of Web-Based Urgent Stroke Evaluation: A Qualitative Study of Two Networks

Assimilation of Web-Based Urgent Stroke Evaluation: A Qualitative Study of Two Networks

Prehospital Stroke Care: Limitations of Current Interventions and Focus on New Developments

Implementation and Evaluation of an Economic Model for Telestroke: Experience from Virtuall, France

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