and chronic care of all neurological
patients. Interestingly, fewer than
half of the inpatients we serve have
acute stroke. The majority are patients
experiencing a myriad of neurological
disease processes — seizures,
altered mental status, dementia, and
neuromuscular conditions, to name a
few.
TELEMEDICINE BENEFITS HOSPITALS,
PHYSICIANS, PATIENTS
The need for general neurology
inpatient coverage continues to surge.
Many rural hospitals have no staff
neurologist, and many urban hospitals
do not have enough neurologists
to provide 24/7/365 coverage.
Telemedicine offers solutions for
the spectrum of coverage gaps. It
allows small, rural facilities to achieve
Primary Stroke Center certification
with 24/7 neurology availability, and
in metropolitan centers, teleneurology
supplements coverage to local
neurologists. Burnout is common
for a single neurohospitalist or a
small group of neurohospitalists who
must provide continuous coverage.
Telemedicine provides respite for them
on nights, weekends and vacations.
The economy of scale inherent to
telemedicine allows fractionalization
of specialty physician capacity across
many centers. This supports the
financial and clinical sustainability of
a program, without sacrificing patient
care. In fact, quality of care often is
enhanced due to the specialization of
telemedicine physicians.
The rural/urban disparity in stroke
care has been well-documented. Causes
for this difference include vascular
neurology shortage, geographic
barriers and limited resources. This
regional discrepancy leads to reduced
tPA treatment rates among eligible
patients in rural areas (52.2%)
compared to those in urban areas
(82.7%). The factors associated with
significant increase in tPA utilization
include hospital certification and access
to neurology. Telemedicine has been
shown to achieve tPA rates of 25% of
ischemic stroke patients — that is five
times higher than the national average
(5%). Not only does telemedicine
increase thrombolytic usage, it reduces
door-to-needle time and enhances
identification of candidates for
neurointervention, as exemplified by
the following case.
On Valentine’s Day, a 73-year-old
woman presented to a rural Texas
facility that was not stroke certified.
She presented with dysarthria, hemineglect,
14 Dallas Medical Journal November 2018
gaze deviation, homonymous
hemianopsia, and left hemiparesis
(NIHSS 16). Within minutes of
her arrival, she was evaluated by
teleneurology. Intravenous tPA
was administered 38 minutes
after arrival. She was transferred
to a comprehensive stroke center
because of large vessel occlusion and
underwent successful stent retrieval of
the clot. She was discharged home four
days later with a complete resolution
of symptoms (NIHSS 0).
This time to treat and outcome
would be considered remarkable if the
patient initially had presented to an
urban stroke center, but this occurred
in a rural, noncertified center due to
the availability of telemedicine! This
case is not an exception, but rather
demonstrates the rule in teleneurology.
Telemedicine truly brings state-of-theart,
expert care to patients in the most
remote settings.
TELEMEDICINE PROS AND CONS
From the clinical care perspective, the
scale weighing the pros and cons of
telemedicine not only has tipped, but
has plummeted, to the side favoring
pros. Telemedicine allows rapid
access to highly specialized care in
all settings. It allows the majority of
patients to be treated in their own
communities, staying close to their
families and minimizing transport
expenses. It triages those who
require tertiary level care, such as
neurointervention, to the appropriate
center. This ensures that appropriate
patients are transferred without
overloading comprehensive facilities
with patients who rightfully could
have remained in their community. It
reduces expenses for facilities that may
not have to cover the cost of employing
multiple on-site specialists. It allows
for the achievement of Primary
Stroke Center certification, which,
based on Texas law, allows increased
EMS traffic. Telemedicine provides
rapid bedside neurology evaluation,
allowing hospitals to meet the evershrinking
door-to-needle goal, now
set at 45 minutes. The majority of
cons remain on the administrative
side and include reimbursement,
licensing, credentialing, and liability.
Although parity laws are addressing
these, physician reimbursement
predominantly is derived from
hospital-paid subsidies. The cost of
infrastructure and subsidy may not be
feasible for the smallest, most remote
hospitals with the greatest need. As
payors assume the responsibility
for physician reimbursement, the
financial burden limiting universal
implementation will be minimized.
In teleneurology, many lessons have
been learned, and many challenges
overcome. I look forward to the day
when the administrative obstacles
have been resolved as successfully as
have the clinical challenges, and the
remaining gaps in clinical care are
bridged. Telemedicine is transforming
the delivery of medical care throughout
the world, bringing specialty care to
patients and regions who previously
had only dreamed of such access.
DMJ
Lise A. Labiche, MD,
is a board-certified
vascular neurologist
in Dallas. Before
joining Questcare
Telehealth, she
practiced hospitalbased
stroke
neurology at two
major hospital systems.
Dr. Labiche received her medical
degree from Louisiana State University
Medical School and completed a
neurology residency at UT-Houston.
She completed her fellowship in
vascular neurology and received a
master’s degree of science in healthcare
management from the UT-Dallas. Her
passion for expanding the delivery
of pre-eminent neurological care to
all patients fuels her commitment to
comprehensive teleneurology system
development, through strategic
integration of EMS and stroke centers
into a coordinated system of care.
lise.labiche@questcare.com