We Have the Technology... (Part II)

September 13, 2010
Steven Zuckerman, MD

The why and how of implementing a telemedicine system in a neurology practice.

Since the last post, the results of a telestroke survey by the Regional Telestroke Initiative in the Northwestern United States has been released. To save you some time, the bottom line of the polling was “Clearly, telestroke is emerging as a standard of care in the treatment of stroke related illness.”

The majority of Telestroke programs use a “hub and spoke” configuration. This means that the remote hospitals (mostly rural and without a neurologist available) contact the “hub” facility. This is usually an academic center with specialized stroke neurologists who evaluate the patient via a video conferencing system with the capability of both seeing the patient and the CT scan in order to decide whether the patient should receive tPA or requires transfer to a more specialized care setting. Many of these programs are supported by outside funding—whether in the form of grants or other governmental money.

However, I think that a better system would involve non-academic clinicians managing these patients in their own geographic vicinity. If this system could be established, then usual referral patterns could be supported. This would be a more “natural” referral and the potential for education of the referring facility is thus enhanced.

What business model could support such a system? In the above-mentioned survey, 36% of the neurologists taking stroke call were not being reimbursed for their availability. This is clearly not a sustainable model. The neurologists supporting the telestroke program would need to be paid a reasonable amount for providing coverage to the referring facility. The remote hospital should not expect the neurologist to simply accept a fee for service from insurance companies. The referring hospitals would benefit both by improving the quality of services they offer their local community, as well as financially by retaining patients they otherwise would have to transfer.

The above is made possible by applying inexpensive technology for video conferencing. There are several companies that offer high-end systems (for example, Polycom), but those systems cost around $25,000. More reasonable solutions require a good-quality video camera (webcam) and an Internet connection. For example, the Logitech HD Pro Webcam C910 enables High Definition picture transmission at 1080p. This should provide a very clear image using standard bandwidths. The camera is currently available through Amazon for $79.99. There is likely a HIPPA requirement that the information be transmitted in an encrypted format so the images may not be viewed by weirdo hackers. The majority of free video conferencing software does not provide this encryption and so should not be used. However, Skype reports that they use 256 bit AES encryption, which is more than sufficient to satisfy any HIPPA security requirements. Therefore, with a free Skype account, a laptop computer, high-speed Internet connection, and a relatively inexpensive webcam, you can perform an excellent neurology exam and provide much-needed neurological services. In order to examine the patient, training of the personnel at the remote facility is necessary to facilitate a detailed neurology exam. In addition, the transmitting hospital must have in place a PACS system so you can view the CT images at your receiving computer.

Another method to transmit the images of the patient involves some means of viewing what is displayed on the monitor of the remote computer. Thus, the webcam is attached to a computer at the distant site, and the consulting facility takes control of that computer by means of third-party software. One such program is called LogMeIn. It is possible to set up a free account to view and control remote computers. Again, the data is encrypted, so this is HIPPA compliant. There is even an app for that. LogMeIn is available as an iPad program; you could be available to evaluate patients wherever you and your trusty iPad get 3G coverage.

Has anyone been considering offering Telemedicine/Telestroke services? Let us know what you are doing, and please contact me if I can be of any assistance.