Wednesday, August 12, 2009

Group Backs Telemedicine for Stroke Care


This is a guest post by Ethan Segal, MD. If you're interested in submitting a guest post, please contact me.

An article “Groups Back Telemedicine for Stroke Care” appearing in the July 1, 2009 issue of JAMA reports how the American Heart Association and the American Stroke Association in early May 2009 released a statement which demands that all facilities which lack an onsite stroke neurologist should have teleconferencing systems in place to consult expert stroke neurologists at another facility. These neurologists could then remotely evaluate an acute stroke patient possibility needing tPA treatment. The group defines teleconferencing as “the use of dedicated, high quality, interactive, bidirectional audiovisual systems coupled with teleradiology for remote review of brain images.”

The main author of the statement by the AHA is Lee H. Schwamm, MD, a pre-eminent stroke neurologist at Massachusetts General Hospital. Dr. Schwamm cites preliminary work published in Neurology, which supports the notion that using telemedicine with remote neurology consultation dramatically improves acute stroke outcomes. Dr. Schwamm also raises the issue of a scarcity of stroke neurologists available in the US to see acute stroke patients (Currently, there are only four neurologists per 100,000 people in the US and many are not experts in stroke. Compare that with 700,000 acute strokes occurring annually in the US causing 163,000 deaths).

Highly critical of the statement is Dr. Robert Solomon, MD, an ER physician, and board member on the ACEP. “The committee noted a lack of comparative assessment of telemedicine to alternatives that could also improve stroke care…” notes Dr. Solomon on the supporting studies cited by Dr. Schwamm. He continues, “There seems to be an inherent assumption that if the hospital does not have a neurologist available to come to the emergency department to see the patient at the time of initial presentation, that that situation fits the definition of ‘these people don’t know what they’re doing’ and clearly they must have telemedicine with a neurologist. That’s not the reality; there are lots of hospitals where patients are getting excellent care where the neurologist is nonexistent or cannot see the patient at the time of presentation.”

Regardless, there are many obstacles to providing telemedicine at the bedside. There remain strict guidelines by Medicare on reimbursement for telemedicine consultation, only in specifically designated rural areas. Many insurers are extremely reluctant to pay for such consultation. Furthermore, there remain problems of licensing by state medical boards that restricts the out-of-state use of the technology, and liability concerns. On April 23, a bill was introduced in the House called the Medicare Telehealth Enhancement Act, which would provide $30 million to help health facilities pay for telemedicine equipment and expand Medicare reimbursement to urban and suburban areas (HR 2068 [http://thomas.loc.gov]).

Personally, I feel there would be a more direct way to deal with the shortage of stroke specialistsincrease the number of training programs. I am currently applying to neurology residency positions in the match and it seems like the average neurology class has maybe three positions. Some have one position for the entire class. Compare that with typical residency class sizes of other advanced specialties, like anesthesiology, having two or three times as many spots. 30 million dollars a year could provide a lot of neurology residency spots and stroke fellowships. Being a current applicant, maybe this is just my bias, but it seems neurology has to do more to expand training programs in the US, especially considering the rapidly aging population. The current scarcity of neurologists could very well be due to the highly inaccurate view of neurologists as “medical nihilists,” therefore useless to the medical community. Im glad that the AHA and ASA realize the urgent need in this country for neurologists and their expertise.

Telemedicine could do wonders outside the US, in desperate areas of Africa and Asia. I was lectured, by a nephrologist, on how he used teleconferencing to teach doctors at the bedside in Africa. I regularly attended grand rounds in neurology at my own medical school, which is conducted through teleconferencing between all three Boston area hospitals that make up the program. Clearly, there are educational applications for this technology. As the population continues to age and the physician shortage becomes more apparent, telemedicine and its clinical applications in the US will no doubt continue to be a hotly debated topic.

This guest post was written by Ethan Segal, MD. Ethan Segal earned a BA from Amherst College and a MD from Tufts University School of Medicine. He is currently working freelance as a medical writer and applying to residency programs for July 2010. He can be reached at Ethan.Segal(at)mac.com

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