Georgia Regents Medical Center is located in Augusta, Ga., a city of fewer than 200,000 citizens situated right on the Georgia and South Carolina border. Though there are a handful of other hospitals in the Augusta area, GRMC is the only academic medical center, and many patients in the surrounding area seek care at local hospitals between 25 and 100 miles away, oftentimes transported to GRMC.
But in time-sensitive situations when each passing minute can affect the clinical outcomes, a long transfer is less than ideal, which is why in the early 2000s, a group of physicians at Georgia Regents began implementing a telestroke program.
Before, when a patient was admitted to a local hospital for stroke, the specialists often called Georgia Regents for clinical decision support, says Jeffrey Switzer, DO, director of telestroke and teleneurology at Georgia Regents Medical Center: "We were often called by these hospitals concerned they had a patient with acute stroke and needed to know what to do. It was very hard to make decisions remotely on how to advise them, so patients had to be transferred in."
The key issue was the waning time window in which physicians can intravenously administer tPA — tissue plasminogen activator — for Ischemic stroke patients, a drug that helps dissolve blood clots. tPA is only approved for administration within three hours of the onset of stroke symptoms, a window of time which Dr. Switzer says was sometimes impossible to achieve due to the distance between hospitals and the time it took to transfer patients.
In some cases, Dr. Switzer says a stroke specialist at Georgia Regents would be contacted by a physician at one of the rural hospitals for advice on a stroke patient. The stroke specialist would have to advise the rural clinician without seeing the patient, a practice the clinicians referred to as "tPA by Russian Roulette."
The physicians discussed the feasibility of a program where stroke patients could be visually evaluated locally to reduce the need for hospital transfers.
"The impetus was to develop a system where in real-time we could evaluate these patients at their local facility and then make decisions there on what needs to be done and whether or not they would benefit from tPA treatment," Dr. Switzer says. "Secondary to that, if they needed to be transferred, we could transfer them."
In 2003, the physicians started using makeshift self-assembled telehealth carts, consisting of an IV pole with a computer and camera. The initial technology was a one-way video connection and a phone plugged in at the bedside. Given the early adoption of rudimentary technology, Dr. Switzer says they experienced a number of technical issues and failed connections during those first consults.
Now, the hospital has updated, state-of-the-art technology, developed and supported by REACH Health, on which they run their telehealth program, also called REACH. However, the level of technology isn't the only indicator of whether or not a telehealth program will succeed.
"Nothing kills a telemedicine network quicker than when the consultant doesn't answer his page and return a call," Dr. Switzer says. "The technology has to work and be reliable, but for a network to succeed or not succeed is on the back of the physician taking the call. If the physician is reliable and takes the calls promptly and has relatively good social skills, then the system will be used."
In a state like Georgia where most counties have their own community or critical access hospitals, telehealth programs close a healthcare accessibility and clinical quality gap.
"Without [our telemedicine connection], the patients just won't get the care," Dr. Switzer says. "Before we were in there, before we did telemedicine, not a single patient [at the remote hospitals] had ever received an IV tPA because [the clinicians] simply didn't have the expertise that was necessary for making those acute stroke decisions."
Moving forward, Dr. Switzer says states and payers have a key role to play in ensuring telehealth is an option for rural hospitals, largely because these hospitals, the ones that could benefit most from telehealth programs, don't have the resources, financial and otherwise, to do so.
"Some of these small hospitals are struggling so bad that they don't have the financial resources to do this," Dr. Switzer says. "This is a place where the state or the insurers really have to come in and make this happen because the hospitals themselves are simply too small and too financially strapped to make this happen."
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