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NA0186

A Telemedicine Opportunity or a Distraction?
Janis L. Gogan, Bentley University
Monica J. Garfield, Bentley University

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hawn Farrell, Executive Director of the Partners TeleStroke program, glanced at his smart phone while striding toward his office at Massachusetts General Hospital (MGH) in Boston; he nearly collided with Lee Schwamm, MD. Knowing that Dr. Schwamm’s overfull schedule as Vice Chairman of Neurology and Director of
Acute Stroke and TeleStroke Services meant he had little time to chat, Farrell used the near-collision as an opportunity to quickly mention a recent conversation with a nurse from Falmouth Hospital on Cape Cod.
An active participant in the TeleStroke service, Falmouth Hospital was regularly honored for its adherence to best practices in stroke care. “Recently some Falmouth nurses asked how we can convince other MGH departments—such as in critical-care pediatrics—to provide similar telemedicine consultation services,” Farrell stated, adding “Their nurse stroke coordinator, Jean Estes, is a huge cheerleader for TeleStroke.”
Dr. Schwamm continued moving toward his office as he replied,

No tC Shawn, don’t we already have too much to do? I need to see patients, complete the analysis for a study I am working on, submit a grant application. Next week I will speak at an international neurology conference. Telemedicine can certainly be invaluable in many clinical domains, but there just are not enough hours in the day for us to get involved beyond stroke care.

Before entering his office and shutting his door, Dr. Schwamm added one last remark: “We can’t do everything, Shawn—but we can do TeleStroke very well.”
Shawn Farrell was not a medical doctor. A graduate of the Boston University
School of Management, he had worked as an operational manager in several Boston area hospitals before joining the TeleStroke team. Farrell was enormously proud of the TeleStroke service, which was helping to save lives and to speed stroke victims’ recovery since its initiation in 2000. As a manager he was also pleased that in 2011
TeleStroke was financially self-sustainable. Now he wondered: How should he respond to the Falmouth nurses’ request?

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Copyright © 2012 by the Case Research Journal and by Janis L. Gogan and Monica J. Garfield. All rights reserved. The authors developed this case for class discussion rather than to illustrate effective or ineffective handling of an administrative situation. An earlier version of this case was presented at the
IT Management Track of the North American Case Research Association (NACRA) annual meeting in
San Antonio, Texas, October 2011. Research funding was provided by Bentley University and the North
American Case Research Association. We thank these two institutions and the anonymous reviewers who made helpful suggestions on earlier versions of this case, and the clinicians and managers who agreed to be interviewed for this case. Some facts and figures have been disguised.

A Telemedicine Opportunity or a Distraction?

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Telemedicine

No tC Physicians used telemedicine systems to provide second opinions or other medical services (such as supervision of surgical or emergency procedures) over distances. Some telemedicine services, such as teleradiology, involved asynchronous exchange of medical images. Others utilized video conferencing technologies, making it possible for clinicians in different locations to confer with one another and/or with patients. According to the American Telemedicine Association (ATA) a “specialist referral service” was a type of telemedicine consultation service that might involve “a specialist assisting a general practitioner in rendering a diagnosis . . . [via] a live, remote consult [with the patient present] or the transmission of diagnostic images and/or video along with patient data to a specialist for viewing later.”1
Farrell made a point of keeping up with telemedicine developments elsewhere. Teleradiology was widely used. The ATA reported that about fifty other medical subspecialties successfully used telemedicine. Dermatology, ophthalmology, mental health, cardiology, and pathology were among the clinical disciplines using telemedicine for specialist referral services. One literature review reported that the field was “maturing,” as evidenced by the broad geographic and disciplinary scope of telemedicine services.2
However, another authoritative paper reported that most telemedicine initiatives had not advanced beyond the pilot-testing stage.3 Few telemedicine consultation services had reached long-term financial viability, and even fewer were directed toward urgent care. One obstacle was reimbursement; most telemedicine services were not yet covered in insurance policies. Another obstacle: the complexity of medical licensure (which in the United States was done on a state-by-state basis) and credentialing (the process by which an individual doctor was authorized to provide care at a particular hospital).
Furthermore, many hospitals—from small community hospitals to large tertiary care centers—had problematic network architectures and extensive interoperability issues that needed to be fixed. Until those hospitals were able to upgrade their IT infrastructures, it would be difficult to implement innovative new services such as telemedicine.
Partners TeleStroke service—a real time consultation service—was one of only a small number of financially viable, ongoing telemedicine offerings supporting urgent care in the U.S.

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The Partners HealthCare TeleStroke Service

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In the United States, most primary care was provided by a family physician or general practitioner, either in private practice or through a health-maintenance organization
(HMO). Secondary care was provided by specialists, usually at community hospitals.
When a patient needed to see a higher-level of specialist for a complicated condition, they were usually referred to a tertiary care hospital, such as MGH. Many of the physicians who worked at tertiary care hospitals had received additional sub-specialty training (such as a pediatrician trained in neonatology or pediatric intensive care, or a neurologist who specialized in acute stroke care).
In 1994 two prominent Harvard-affiliated tertiary care hospitals—MGH and
Brigham & Women’s Hospital (hereafter, the Brigham)—merged, forming Partners
HealthCare. Over the ensuing years, other hospitals joined or developed affiliations with Partners (Exhibit 1).

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In 2000, Dr. Schwamm began using telemedicine to help emergency physicians at a Partners-affiliated institution—Martha’s Vineyard Hospital (MVH)—to determine if patients were experiencing an acute ischemic stroke and if so, whether to administer a life-saving drug—tissue plasminogen activator (tPA). Acute ischemic stroke, caused when a clot blocks blood flow to the brain, was a leading cause of death and disability— especially when treatment was delayed. Stroke was the third leading cause of death in the U.S., with about 795,000 cases and 140,000 deaths.4 Worldwide, about 15 million people suffered strokes each year. A stroke could cause devastating disabilities (such as paralysis and speech loss). A patient’s chance of recovery greatly improved if tPA was given within three to four hours of the first onset of symptoms. However, a patient could suffer from another condition which exhibited stroke-like symptoms, but which could not be treated with tPA. In fact, tPA could harm—even kill—a patient who was experiencing internal bleeding or was already taking blood thinners. A neurologist with expertise in acute stroke care was the best judge of whether a patient was a candidate for tPA.
Martha’s Vineyard Hospital could not afford 24/7 stroke neurology coverage, so they agreed to test a telemedicine service. MVH would electronically send a patient’s brain scan images for Dr. Schwamm to review. From his MGH office Schwamm would then participate in a video-conference session to remotely examine the patient. After testing this system with MVH and training the twenty stroke specialists in MGH’s neurology program to use the system, Schwamm’s team started offering this “TeleStroke” service to other Massachusetts hospitals. Data gathered in TeleStroke consultation sessions were analyzed, and Schwamm and his team began to publish scholarly papers on the efficacy of telemedicine for acute stroke consultations.
The TeleStroke initiative gained significant momentum when in 2005 the Massachusetts Department of Public Health issued regulations requiring that ambulance personnel bring a patient who exhibited stroke-like symptoms to a certified “Primary
Stroke Center” to be evaluated as a candidate for tPA (Exhibit 2). One requirement for certification was that a licensed physician with acute stroke expertise must be available on a 24/7 basis. Hospitals that lacked 24/7 neurology coverage could use a service such as TeleStroke to satisfy this rule.
Partners’ Chief Information Officer at the time, John Glaser, provided funds supporting the build-out of the TeleStroke service.5 In offering his support for TeleStroke,
Glaser had told Farrell that he realized that Dr. Schwamm had “gained buy-in” by performing “high-quality studies to gauge the impact of telemedicine on acute stroke care.” Glaser recalled,
Those studies verified that telemedicine consultations are safe and can improve patient outcomes. TeleStroke addresses a real clinical need. I did not require much in the way of a business case; the ‘grant’ we provided was based more on the caliber of the idea.

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A full-time software application specialist was hired to develop browser-based software that (much like an electronic medical record) was used to record data about each consultation (e.g., patient age, time of onset of symptoms, vital signs, lab results, scores on various neurological tests, etc.—100 state-mandated data elements in all). As of
2011 this application and its database were not yet fully integrated with patient medical records at MGH, the Brigham, or participating spoke hospitals. The database did support the TeleStroke program billing requirements and research studies on stroke treatment and outcomes.

A Telemedicine Opportunity or a Distraction?

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As some of the twenty physicians in the MGH neurology program gained experience doing TeleStroke consultations, the value of the service became evident. In 2006 a decision was made to collaborate with the Brigham; their eight stroke neurologists also wanted to offer a TeleStroke service but felt it would be more cost-effective to join forces with MGH rather than develop their own software. As dual “hubs,” MGH and the Brigham provided 24/7 backup care for each other, in case of unexpected demand or network connectivity problems.
TeleStroke was designed to serve hospitals that ordinarily referred patients to MGH or the Brigham; Dr. Schwamm did not plan to extend this service outside Partners’ catchment area.6 By 2011, twenty-seven spoke hospitals in Massachusetts, Maine and
New Hampshire participated in the service (Exhibit 3). One spoke was about three miles away; the furthest was 130 miles away (Falmouth Hospital was seventy-seven miles away).
To establish a pricing structure for TeleStroke consultations, Farrell and Schwamm gathered data about stroke rates in various communities in order to estimate how many patients with symptoms of acute ischemic stroke would likely go to different community hospitals, how many patients might be suitable candidates for a TeleStroke consultation, and how many would qualify for tPA. They learned, for example, that
Cape Cod Hospital in Hyannis (a sister hospital to Falmouth) was especially busy during the summer tourist months (with about 27,500 emergency department (ED) visits in June, July and August, accounting for about thirty-one percent of ED visits in 2009), and that Cape Cod’s permanent population included a large number of elderly retired people and hence had a higher rate of stroke than younger communities.
Also, some hospitals needed 24/7 stroke neurology coverage, while other hospitals only needed weekend or late night coverage.
Having analyzed the varied needs of spoke hospitals and the populations they served, a price of $10,000 was set for a “book” of ten pre-paid TeleStroke consultations, with an option to purchase additional consultations. In the first few years that the service was offered, no spoke hospital used all ten TeleStroke consults before the end of a contract year. However, over time participating hospitals improved their workflows, enabling them to process incoming patients more efficiently (mindful of the 3–4 hour tPA “window”). This increased the numbers of tPA-eligible patients, which in turn increased TeleStroke usage. As of 2011, each participating spoke hospital pre-paid their primary hub (MGH or the Brigham) for ten TeleStroke consultations and some purchased additional blocks of five pre-paid consultations, with a rollover provision
(similar to unused cell phone minutes). Some hospitals paid Partners additional fees for technology support and onsite training.
Over time the TeleStroke software was enhanced to include decision support, clinical reporting, and other functions. In 2011 two full-time technical employees supported the system. Other members of the team included Shawn Farrell and two other full-time employees: one handled coordination and credentialing (all Partners stroke neurologists were credentialed at all twenty-seven spoke hospitals) and another employee was in charge of video/imaging, IT, and information security engineering. Half of Dr. Schwamm’s time was devoted to the TeleStroke program, and half of another Partners employee’s time was devoted to marketing and network development.

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“Time Is Brain”

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No tC Clinicians understood that “time is brain;” every minute counted since a stroke patient needed to receive tPA no later than 3–4 hours since last seen well. Ambulance personnel (Emergency Medical Specialist, or EMS) were expected to phone a spoke hospital’s emergency department to say that a possible stroke victim was en route. An attempt would be made to determine when the patient’s stroke symptoms began (for example, a family member or co-worker might be able to say that they saw the patient in normal condition and then “he suddenly couldn’t move his arm”). The EMS checked vital signs and conducted a simple stroke screening test in the ambulance.
Once alerted, a nurse in the spoke hospital readied a room for the patient and grabbed a stroke care packet containing a patient consent form, Emergency Department Stroke Algorithm, National Institute of Health (NIH) Stroke Scale, a sheet reminding the team of time targets (such as “Time from order of CT scan or MRI scan to performance: Within 25 minutes of order being written”), and other forms. The
Stroke Algorithm document (Exhibit 4) described the clinical workflow (for example, step 1c stated that Radiology should be notified to place this patient next in the queue for a CT scan).
A patient was brought to a treatment room that was equipped for video conferencing (with either a mobile video cart or a permanently-installed unit). A nurse undressed the patient and attached a mobile monitor so that vital signs could be observed and recorded. An emergency physician (EP) examined the patient and reviewed his or her medical history to identify anything that would disallow tPA (such as recent surgery or being on blood thinner). If s/he was a good candidate for tPA (inclusion criteria satisfied, no exclusion criteria identified), the EP sent the patient to the CT scan lab and requested a TeleStroke consultation.7
Before the patient returned from the CT scan, a nurse or other stroke team member would ensure that the video conferencing equipment was connected to the network.
For best viewing by the hub neurologist, the camera was placed at a 45 degree angle to the patient’s bed. A “super user” might assist the attending nurse. “Super users” were nurses or assistants who had received extra training so that they could do some technical trouble-shooting. Super users were also expected to promote appropriate use of the
TeleStroke system (when to use it and when not to use it—such as in cases when the patient or his/her family could not identify when stroke symptoms started).
The neurologist in Boston needed to quickly receive and review the CT scan (target for time from completion of scan to interpretation by consultant: twenty minutes) at a TeleStroke station on the hub neurology unit. If the scan revealed that the patient should not receive tPA (a frequent occurrence) the neurologist phoned the spoke team to let them know (in which case, a TeleStroke consultation would not take place and the spoke hospital would not be charged for the phone call). About one in five phone calls actually led to a video consultation.
If the scan did support a diagnosis of acute ischemic stroke without exclusionary complications, the neurologist would get ready for a TeleStroke consultation (Exhibit
5). During the initial call and subsequent video consultation, the hub neurologist entered the patient’s lab results, Time Last Seen Well, Time Presented in the ED, and

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other data on the browser-based TeleStroke software. Similar to drug-drug interaction software, the application was rule-based and had error-checking capabilities to ensure that the data captured was of high quality and that the physician did not make errors that could lead to a poor decision (e.g., if more than 3 hours had passed, the system alerted the doctor that tPA might not be a viable option). If the patient had not been ruled out as a tPA candidate, the NIH Stroke Scale appeared on the neurologist’s screen to support input of the results of this test into the record.
The Boston neurologist used the video system to collaborate with a spoke nurse putting the patient through the NIH (National Institute of Health) Stroke Scale tasks
(stick out your tongue, raise your right hand and hold it there for five seconds, etc. see www.nihstrokescale.com ). The neurologist remotely controlled the spoke camera, zooming in or panning out as needed. Once the Stroke Scale test was completed the neurologist would confer with the attending emergency physician, who was legally responsible for the patient’s care. If the neurologist decided that tPA administration was a viable option, then together the two physicians would discuss benefits and risk factors of tPA with the patient and family members. At some point they would usually pause the video connection and step away to give the patient and/or family a moment alone to make a decision. If the decision was “Yes” a consent form was filled out, tPA administered, and the patient was immediately transferred to MGH or the Brigham for close monitoring (this “drip and ship” requirement was specified in the TeleStroke contract).
Alternatively, the neurologist might conclude that this patient should not receive tPA. In that case, the neurologist might recommend other treatment options, such as a type of catheterization that used a suctioning device to pull clots out of blood vessels, or another type that used a tiny cork-screw shaped device to wrap around a clot and pull it out. Or, the physicians might judge the patient’s condition to be too unstable for such treatments at that time, and they might recommend ways to stabilize the patient or just to keep him or her comfortable.
The data recorded by the hub neurologist was the official TeleStroke consultation record. Authorized personnel could print this off or cut-and-paste the record into their hospital’s electronic medical record (after verifying the data against their own patient charts).

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Technical and Process Issues

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Several constraints affected the TeleStroke system architecture, especially MGH’s complex and aging IT infrastructure and the heterogeneity of spoke hospitals’ clinical databases and applications. Incompatibility among spoke clinical systems and incomplete internal integration at MGH necessitated re-keying of some patient data (such as a patient’s medication history and blood type) that were already maintained in other databases.
Under Dr. Schwamm as medical director and Farrell as executive director, MGH developed an implementation methodology and standards for preparing spoke hospitals to participate in TeleStroke. Spoke institutions needed to purchase video conferencing equipment. Although a few hospitals installed fixed equipment in an ED treatment room, most bought a mobile video conferencing console (at a cost less than
$10,000) and stored it in a closet (with an electric outlet; its battery was charged while stored). When needed, the cart was brought into a designated treatment room wired for both Internet and ISDN (ISDN was being phased out, and a few spokes were also

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experimenting with wireless connections). Partners specified off-the-shelf equipment that was easy to deploy and use and that supported remote camera control from the hub (which gave the consultant the ability to focus closely on the patient’s face), and multi-user support (so both a consultant and a colleague could attend a consultation via separate devices). Multiple ports were required, since one port was dedicated to a digital video recorder for archiving.
Each hospital’s stroke team included emergency physicians and nurses. Team members received training about using tPA to treat acute ischemic strokes. Dr. Schwamm often used the term “brain attack” instead of “stroke,” in the hope that clinicians (as well as patients and family members) would think of it as a condition requiring an immediate response, like a heart attack. Some clinicians had only recently learned about the tPA three-hour window. A nurse explained:
I, like many other nurses, thought that stroke was my most stable patient, because they didn’t look like they needed me . . . Somebody had chest pain next door; I needed to treat that because that could be a heart attack . . . My whole perception of stroke was: This is a process that is going on and there is nothing much I can do about it . . .
Some stroke patients can’t speak; they are sitting very quietly having their stroke and meanwhile you’re taking care of somebody else who is louder . . . When these mandates came out, I realized . . . There are interventions that we can provide for this patient.
Everybody has to work a little bit faster.

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No tC Partners provided advice regarding network connections, appropriate lighting, video cart placement, and so on. Stroke teams were taught how to hook up and use the video conferencing equipment, and each team analyzed their hospital’s patient intake and evaluation procedures to find ways to reduce delays at each step and to ensure the shortest time from a patient’s first stroke symptoms to tPA administration.
For example, at one hospital where treatment rooms were quite small, nurses learned to place the video cart in a corner, use a short cord so no one tripped on it, and to turn the patient’s bed around. This required a little practice.
Video consultations also gave rise to an adjustment in the order of steps on the
NIH Stroke Scale. With the traditional scale a patient was asked to alternately use their face, upper body, and legs. In a video consultation, the hub clinician had to zoom in and out on the patient multiple times. Since every second counts, a peer-reviewed study was conducted to verify that the altered scale was clinically valid. The new NIHapproved scale was incorporated into Partners’ software.
When the TeleStroke service started, most radiology departments were already transmitting CT scans to external partners using the DICOM (Digital Imaging and
Communications in Medicine) standard. At first, hub neurologists complained that they waited too long to receive the CT scan data at their workstations. Investigation revealed that the brain scans were first being sent to the MGH main server and then copied to the TeleStroke server. To reduce delays, the system was redesigned: CT scans were first sent to the TeleStroke server, then to the MGH main image server for archiving. With that change, a technical manager stated, “Our physician opens up the one image viewer . . . and boom! The scans are right there.”
Each spoke institution was asked to conduct a once-weekly test of the radiology image transfer system (by sending a sample CT scan to the hub’s data repository for radiology images), and the videoconferencing system (by connecting to a device that streamed both video and audio).

A Telemedicine Opportunity or a Distraction?

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Soon, other tertiary-care institutions began to ask Partners for guidance on how to set up similar acute stroke care tele-consultation services. This led the TeleStroke team to establish a new consulting service, “TeleStroke Network Partner Program,” whose mission was to help other institutions set up their own telemedicine networks
(Exhibit 6).

Telemedicine for Critical-Care Pediatrics: Opportunity or
Distraction?

Reaching his own office, Shawn Farrell sat at his desk, where his thoughts returned to the Falmouth nurses’ request for more telemedicine services, such as in pediatrics.
Mass General Hospital for Children (MGHfC, a Partners hospital that was affiliated with MGH) had used telemedicine with a few other hospitals (see Exhibit 7), so Farrell phoned Dr. Natan Noviski, the MGHfC Chief of Pediatric Critical Care Medicine
(Pediatric critical or intensive care, a relatively new sub-specialty in pediatrics, arose as a result of research that demonstrated that critically ill or injured children experienced different symptoms and required different care than adults. MGHfC offered one of the premier training programs and a fourteen-bed pediatric intensive care unit, or PICU.)
Dr. Noviski first experimented with telemedicine in the late nineties, in collaboration with North Shore Hospital in Salem, 16 miles from Boston. (North Shore subsequently joined the Partners organization.) Noviski explained that emergency physicians sometimes needed assistance in stabilizing a critically-ill child before transferring the patient to the PICU for specialized care:

No tC Around 1997 the idea arose from the need to stabilize kids and take care of them before they are transferred to our hospital. We used to do this by phone, and it was frustrating for me and for the doctor on the other side. Rather than taking care of the patient he needs to sit on the phone and ask for my advice. I was frustrated because I could not see the patient. Telemedicine was advancing at that time, but no one was using it to take care of acute care patients. So, we decided to try it out.

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The emergency room pediatrician at North Shore would call when they needed to transfer a sick kid over here, and we’d see the patient through telemedicine. We remotely controlled three cameras that they had over there. We could see all the monitoring equipment; see the patient; see the x-rays, the EKG’s, and all the other stuff. Today, our situation with North Shore is a little different, because now they are not just a referral hospital; they are part of Mass General Hospital for Children and our physicians rotate between the two locations. We still offer critical-care consultations but now we also schedule daily video conferences to discuss complex cases.

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North Shore was the only location outside Boston that actively participated in the
MGHfC telemedicine consultation service (other hospitals used it for routine consultations and other forms of video conferencing, but not for critical care consultations). Noviski’s short-term priority was to use telemedicine more extensively within
MGHfC. For the past year, six intensivists had participated in a pilot test of a telemedicine application using “PICU-Bot.” Each on-call intensivist had a workstation at home. On the floor of the PICU, a telemedicine unit (a “bot”) could be placed next to any PICU bed when an attending physician requested advice from the intensivist.
“The results so far are very encouraging,” Noviski stated.
Farrell asked: “Would it be a good idea to expand your telemedicine offerings to other spoke hospitals?” Noviski replied, “I’m not sure.”

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Many hospitals get maybe only six pediatric critical-care cases within a year when they could use our help; I don’t know whether they are willing to pay a reasonable price for us to offer this service. One of the few hospitals that signed on to our initial telemedicine service did not keep their equipment up to date and no longer initiates telemedicine consultations; they say they can’t afford to upgrade their equipment.

After he hung up, Farrell thought for a moment about what Dr. Noviski said.
Pediatric critical-care incidents were far less common than stroke. While children with concussions, broken bones, rashes and other conditions were often treated in EDs, critically-ill or critically injured children were rarely seen). So, the pricing model that worked for TeleStroke might not be ideal for critical care pediatrics. Although Falmouth nurses were clamoring for more telemedicine services, Farrell did not know whether Falmouth administrators would be willing to pay for them.
Telemedicine consultation services were not centrally managed at Partners; each medical department (such as neurology or critical-care pediatrics) made its own decisions about services to offer. One organizational unit—Partners Center for Connected
Health (CCH, Exhibit 8)—was testing various “tele-health” services (using internetconnected devices to monitor patients’ blood pressure or blood sugar levels, to connect patients with Partners physicians for second opinions, and other services). CCH had helped Dr. Noviski’s group with the PICU-Bot pilot test. However, CCH did not have a mandate to oversee all telemedicine services.
Later that day, Farrell chatted with another pediatric intensivist, Dr. Ricardo, who described a memorable telemedicine episode:

No tC One North Shore case stands out very easily: a child who came in with seizures. The child was not breathing effectively and needed a breathing tube. Using telemedicine,
I’m watching the patient, and I notice that when the anesthesiologist is about to insert the breathing tube, the abdomen begins to contract. I said, ‘I think the patient is going to vomit, you need to turn him.’ No one responds, so I’m yelling, ‘The patient’s gonna vomit; turn him, turn him, turn him!’ Finally they turn him, the child vomits, they suction, and they eventually get the tube in and transport the patient to us. That evening, the dad walks in to our ICU. I introduced myself. He goes, ‘You! I saw you on the screen! You were telling them to turn him and they weren’t listening to you.’

That was a few years ago. It is getting more and more cost effective and it works better now. There used to be a delay in the feed—sort of like in the old movies. You’d hear the sound and then all of a sudden the patient’s mouth moves. The images are much less choppy now. Mobile applications are starting to take off, which is exciting. However, they are still working on designing a firewall or encryption for wireless applications that will protect patient privacy yet not cause a choppy video image.
We did at one time consider extending this service to other hospitals, such as Martha’s
Vineyard and Nantucket. It’s burdensome to put a child on a ferry for a few hours in order to see a sub-specialist on the mainland. We can provide that specialty care via telemedicine. However, I have not actually used telemedicine in about two years.

Do

Farrell stated, “TeleStroke serves twenty-seven hospitals right now.”
With twenty stroke neurologists at MGH and eight at the Brigham, we could comfortably provide TeleSroke consultations to twice as many hospitals. Your unit has seven pediatric intensive care specialists, but I don’t know anything about their work load.
How many hospitals could your group support via telemedicine?

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“I don’t know,” replied Dr. Ricardo. “I do know this: When we provide help using telemedicine, it often means that the patient can stay right there at the community hospital.” Dr. Ricardo focused on treating those patients who could benefit from her specialized skills. If a patient could receive appropriate care at a community hospital, she wanted the patient to stay there. Similarly, most TeleStroke consultations resulted in the patient not being treated with tPA and not leaving the spoke hospital. The TeleStroke
“drip and ship” stipulation did bring some patients to MGH or the Brigham, but these were the patients who most needed to be cared for by the highly trained neurologists in their residency and post-residency fellowship programs.
Shawn Farrell described his recent conversation with the Falmouth nurse. “Oh, yes,” replied Dr. Ricardo. “We have had conversations with Falmouth and six or seven other hospitals.”
And, I think Dr. Noviski did talk with Dr. Schwamm about adding a pediatric consultation layer to the service you provide—something like a package of three or four consultations per year. However, it was unclear how we would compensate your TeleStroke program for the investment you already made in technical infrastructure and operations.
I hope we can reach an agreement on a reasonable fee to pay your group and a fee to charge hospitals to participate in a critical-care tele-pediatrics service.

Do

No tC Returning to his office, Farrell felt a little uneasy. It was only natural that Falmouth and other hospitals would want to take fuller advantage of the video conferencing equipment in their emergency departments, since the TeleStroke service was working well and saving lives. On the face of it, the addition of a pediatric tele-consultation service seemed like a great idea. However, Farrell worried that using the TeleStroke platform for other purposes could be problematic. Most spoke EDs had only one telemedicine cart. Farrell wondered: if a critically-ill child and an elderly stroke patient were to arrive at an ED at the same time, wouldn’t clinicians have to choose between using the telemedicine equipment for the child versus for the elderly patient? That scenario was fairly unlikely, since Doctor Noviski had stated that complex criticalcare pediatric episodes occurred very infrequently. Also, critical-care pediatrics encompassed a wide range of conditions (from a child dying of cancer to the victim of an automobile accident or poisoning). “The telemedicine cart is multi-purpose,” Farrell mused, “but our processes, which are optimized for acute stroke care, may not be ideally designed for a different clinical domain.”
Although he wanted to be helpful, Farrell needed to think through the financial and workflow implications and other aspects before proceeding further. Still, he did feel obliged to respond to the nurses at Falmouth Hospital.

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Notes

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No tC 1. www.americantelemed.org
2. Demiris G., Tao D. An analysis of the specialized literature in the field of telemedicine. Journal of Telemedicine and Telecare 11(6): 316–319, 2005.
3. Grigsby B., Brega A. G., Bennett R. E., Devore P. A., Paulich M. J., Talkington
S. G., Floersch N. R., Barton P. L., Neal S., Araya T. M., Loker J. L., Krohn N.,
Grigsby J. The slow pace of interactive video telemedicine adoption: The perspective of telemedicine program administrators on physician participation. Telemedicine Journal and e-Health 13(6): 645–656, Dec 2007.
4. www.stroke.org
5. Subsequently Glaser left Partners to become CEO of the Health Services Business of Siemens Healthcare.
6. A catchment area is the geographic area served by a particular institution.
7. Some spoke hospitals did sometimes have neurologists on site or on call. At those hospitals, a nurse or clerk had to determine if the on-call neurologist could reach the emergency department within 15 minutes. If not, a phone call was made to request a TeleStroke consultation.

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Exhibit 1: Partners HealthCare Members and Affiliations

Partners HealthCare, founded in 1994 by Brigham and Women’s Hospital and Massachusetts General
Hospital, is an integrated health care system that offers patients a continuum of coordinated highquality care. The system includes primary care and specialty physicians, community hospitals, the two founding academic medical centers, specialty facilities, community health centers, and other healthrelated entities. Partners HealthCare is a non-profit organization.
Major Teaching Affiliate of

• Harvard Medical School

Founding Members

• Brigham and Women's Hospital

• Massachusetts General Hospital

Members

• Faulkner Hospital

• Martha's Vineyard Hospital
• McLean Hospital

• MGH Institute of Health Professions
• Nantucket Cottage Hospital
• Newton-Wellesley Hospital

• North Shore Medical Center

• Partners Community Healthcare, Inc.
• Partners HealthCare at Home

• Spaulding Rehabilitation Network

Partners HealthCare Programs
• Asthma Center

• Center for Connected Health

• Center for Personalized Genetic Medicine
• Online Specialty Consultations

• Research Ventures and Licensing

No tC • Mongan Institute for Health Policy
• Telestroke Center

International Programs

• Partners Harvard Medical International

• Partners International Medical Services

Community Health Centers

• BWH Brookside Community Health Center

• BWH Southern Jamaica Plain Health Center
• MGH Charlestown HealthCare Center
• MGH Chelsea HealthCare Center
• MGH Revere HealthCare Center

• Boston Healthcare for the Homeless
• Codman Square Health Center

• Dorchester House Multi-Service Center

• East Boston Neighborhood Health Center
• Geiger-Gibson Community Health Center

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• Lynn Community Health Center

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• Martha Eliot Health Center (Jamaica Plain)
• Mattapan Community Health Center

• Neponset Health Center (Dorchester)
• North End Community Health Center
• Salem Family Health Center

• Peabody Family Health Center

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• South Boston Community Health Center
• South End Community Health Center
• Upham’s Corner Health Center
• Whittier Street Health Center

Collaborations

• Center for Integration of Medicine and Innovative Technology
• Dana-Farber/Partners CancerCare

• Harvard Clinical Research Institute

• Ragon Institute of MGH, MIT and Harvard

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No tC Source: www.partnershealthcare.com.

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Exhibit 2: Massachusetts Department of Public Health Primary Stroke Center
Regulations (DPH 105 CMR 130.1400 through 105 CMR 130.1413)

To be certified as a Primary Stroke Center under the above regulations, a hospital is assessed on the following capabilities, which must be available 24 hours a day, seven days a week:
1. A licensed physician with acute stroke expertise serves as Stroke Service Director or Consultant.

2. Written care protocols “including both the emergency and post-admission care of acute stroke patients by a multidisciplinary team” are available in the Emergency Department and include time targets that help ensure that eligible patients will receive tPA within the three-hour window.

3. Hospital and Emergency Medical Service (EMS) personnel coordinate effectively so that the patient with acute stroke symptoms is efficiently admitted, tested, diagnosed and treated.
4. Hospital can quickly perform and interpret brain computed tomography (CT) or magnetic resonance imaging (MRI) scans.

5. Hospital can quickly perform and evaluate chest x-rays and electrocardiograms and various laboratory services.
6. Neurosurgical evaluations and/or interventions are performed within acceptable time targets.
7. If patients need to be transferred to another hospital, there is a transfer agreement in place.

8. Hospital collects and analyzes process and outcomes data and submits required data to the
Department of Public Health.
9. Physicians, nurses, allied health professionals and EMS personnel receive appropriate training on a continual basis.

10. Hospital offers community education regarding stroke.

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No tC Source: http://www.mass.gov/eohhs/docs/dph/regs/105cmr103–140-amend.pdf.

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Exhibit 3: Partners TeleStroke Network

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Source: Presentation developed and delivered by Lee H. Schwamm, MD using Google Maps.

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1

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Exhibit 4: Falmouth Hospital Emergency Department Stroke Algorithm
Entry into system via ED. START STROKE PACKET.

Patient arrives in ED as a walk-in with symptoms of stroke: Patient is triaged by a registered nurse. If symptoms began within 3 hours (document time of onset and how the time is known), patient is at least an ESI 2 Triage Level.
Patient arrives by EMS: Stroke Screening Tool will be completed prior to arrival and ED notified that a possible stroke is coming in. Patient will be triaged upon arrival.
CT is alerted to hold the next bed.

2
*3

Patient is taken to appropriate room (a monitored bed with a scale). EP is notified immediately and assesses patient.
Patient goes to CT within 20 minutes of arrival. CT is read within 45 minutes of arrival.

4

If patient DOES NOT meet criteria for thrombolysis . . . patient continues on appropriate pathway for treatment.

5

If CT is consistent with a hemorrhage, prepare for transfer, as recommended by physician.
Call MedFlight or ground transport; follow transfer protocol. Do not delay transfer of patient secondary to awaiting Neurologist. Neurosurgical intervention may need to be implemented.

*6

If patient DOES meet criteria for thrombolysis . . . alert the following:
Go to Teleneurology* algorithm.

If teleneurology consultation is to take place, use green Teleneurology packet (located with teleneurology cart)
Stroke Team: Call the group pager: “84” and extension number.
Laboratory

Neurologist on call, if available.
Pharmacy
7

Lab work is drawn and sent ASAP in red Translogic container.
Stroke Panel (CBC, BMP, PT/PTT/INR, blood bank hold).

Tubes are sent in the red Translogic container to alert the Lab that it is a high priority.
Stroke Orders/Packet will be instituted.

9

If tPA is ordered, it is mixed by Pharmacy if they are in house (0700–2200).

No tC 8

When Pharmacy is not in-house, RN mixes the drug following directions in packet, and administers dose, checking with another clinician before administering the dose. Document double signatures on dosage sheet.

10

Call Lab to complete type and screen. Alert Lab that tPA has been given.

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Patient is transferred (to the Brigham or MGH) after utilizing Teleneurology Service or per
Neurologist order.
Follow transfer protocol.

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Stroke packet is to be used for all stroke patients.

*Simultaneous actions need to occur in the interest of the critical timing criteria for stroke victims. Source: Falmouth Hospital

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*Note: Falmouth Hospital refers to the TeleStroke service as the “Teleneurology” service.

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Presentation by Jean Estes, Falmouth Hospital’s Nurse Stroke Coordinator: http://wn.com/The_Use_ of_TPA_in_strokes_Jean_Estes_ Case Research Journal • Volume 32 • Issue 2 • Spring 2012

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Exhibit 5: Partners TeleStroke Consultation Overview

Key

CT:
Computed Tomography (see CT-Scan)

DICOM:
Digital Imaging and Communications in Medicine standard, used for distributing and viewing medical images
CT-Scan:
Computed Tomography scan, a medical imaging method

TCP-IP:
Transmission Control Protocol (TCP) and Internet Protocol (IP), a set of computer network protocols ISDN:
Integrated Services Digital Network, a set of tele-communications standards
VC:
Video Conferencing unit

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Source: presentation developed and delivered by Lee H. Schwamm, MD

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Exhibit 6: Telestroke Network Partners Program: Web Page Description

Network Partners Overview

If your hospital already employs a team of skilled stroke neurology physicians, and you are planning for or are already designated as a comprehensive stroke center, you may have already begun exploring what it takes to implement a telestroke program. Forging ahead independently can be very costly, technically challenging, and prone to errors.
The “TeleStroke Network Partner” Program offers a proven service delivery model that will flatten out your learning curve, get a successful “hub and spoke” telestroke network up and running quickly and cost-effectively, and allow your institution or hospital network to continue focusing its scarce resources on improving patient care and achieving better patient outcomes.
Implementation

Implementing the “TeleStroke Network Partner” Program in your hospital will enable you to provide
24/7/365 clinical expertise to any surrounding hospital that joins your local telestroke network, regardless of whether they are part of your integrated hospital network, part of another hospital network, or independent. Many of our own telestroke-networked “spoke” hospitals have used this arrangement to successfully secure designation as “Primary Stroke Centers” in the Massachusetts state-based stroke designation system. A successful telestroke program can represent a possible new revenue stream for your own institution; enhance network cohesion within your own integrated hospital system; and generate good will and positive publicity throughout the state and surrounding communities.
As part of the “TeleStroke Network Partner” Program implementation, your hospital will receive all the necessary materials, software tools, training, and implementation support to develop your own branded telestroke “hub and spoke” network, including:
• Marketing Materials

• Contracting Materials

• Credentialing Materials

• Video/Radiology Network Layout Guidelines
• Software Admin Tools

• TeleStroke Consult Software Use
• Clinical Protocols

• Remote Unit Technology/Installation Guidelines

No tC • TeleCME Guidelines

In addition, the Telestroke Network Partner “hub” hospitals interact with each other in a collaborative fashion to share best practices and drive innovation.

Please contact us at (617) 724-3999 or telestroke@partners.org for more information and to discuss the benefits of the “TeleStroke Network Partner” Program.

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Source: http://telestroke.massgeneral.org/servicesNetwork.aspx

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Exhibit 7: Mass General Hospital for Children: Pediatric Critical Care

Critical Care at a World-Renowned Academic Medical Center: The Mass General Hospital for
Children Pediatric Intensive Care Unit (PICU) is a fourteen-bed, multidisciplinary unit, which has distinguished itself by providing high quality care for critically ill infants, children, and adolescents. Our patients present with a wide variety of life-threatening issues, such as severe infections, respiratory diseases, trauma, and post-operative care of various complex surgeries.
Our Mission: Our mission is to provide state-of-the-art critical care medicine by bringing together the most sophisticated technology and scientific advancement in an environment sensitive to the multicultural patients and families we serve. Excellent communication with the family and primary care pediatrician is seen as a critical success factor in optimizing outcomes. We have a complete range of pediatric consultant services, including:
• Pulmonology

• Endocrinology

• Cardiology and cardiac surgery
• Gastroenterology

• Hematology/Oncology
• Infectious diseases
• Neurology

• Nephrology

• Trauma surgery

• General surgery

• Orthopaedic surgery
• Neurosurgery

• Transplant surgery

The telemedicine program provides live video conferencing between the PICU and select patient rooms in emergency departments at outlying community hospitals, including North Shore Medical
Center and Newton Wellesley Hospital. Via this link, the PICU staff may provide on-demand medical advice and guidance to help assess, and if needed, stabilize critically ill infants and children and prepare them for transport to the PICU. This telemedicine technology also supports an international link between the Buen Samaritanu Hospital in Aguadilla, Puerto Rico and the PICU.
There are three components to the telemedicine service provided through the MGH PICU.

No tC First, through our state-of-the art telemedicine link, we provide live video conferencing between the
PICU and select patient rooms in emergency departments at outlying community hospitals. Via this link, fellows provide on-demand medical advice and guidance to help assess, and if needed, stabilize critically ill infants and children and prepare them for transport to the PICU.
Secondly, our telemedicine technology currently supports an international link between the Buen Samaritanu Hospital in Aguadilla, Puerto Rico and our PICU. Under the supervision of the on-service attending, the fellow provides teaching and consultation on challenging pediatric cases presented by faculty in Puerto Rico.

Finally, this innovative technology is designed to support live video conferencing between the PICU team in-house overnight and the on-service attending, at home. Any member of the team may request a teleconference with the attending for the purpose of virtual bedside evaluation of a new patient, reassessment of a patient whose condition may be deteriorating, or a team meeting with other subspecialty consultants and family members at the bedside. One of the many advantages of this technology is that it allows the on-call fellow the opportunity to be on the frontline, independently leading the unit overnight while still having access to appropriate faculty supervision. All faculty live in close proximity to the hospital and can return to the hospital within minutes to provide direct supervision of the fellow when needed.

Both the inpatient unit and pediatric emergency department at Mass General for Children at North
Shore Medical Center are staffed by jointly appointed NSMC and MGHfC staff. Daily teleconferences are held between the two facilities to review complex cases with key specialists.

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Through this powerful collaboration we are able to offer common standards and protocols, as well as a network of subspecialists on staff at MGHfC.
Source: http://www.massgeneral.org/children/specialtiesandservices/critical_care_medicine_picu/ default.aspx A Telemedicine Opportunity or a Distraction?

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Exhibit 8: About Partners Health Care Center for Connected Health (CCH)

The term “connected health” reflects the range of opportunities for technology-enabled care programs and the potential for new strategies in healthcare delivery.
Founded in 1995 by Harvard Medical School teaching hospitals, the Center for Connected Health develops new strategies to move health care from the hospital and doctor's office into the day-to-day lives of patients. Leveraging information technology—cell phones, computers, networked devices and simple remote monitoring tools—the Center helps providers and patients manage chronic conditions, maintain health and wellness, and improve adherence, engagement and clinical outcomes.
Actively involved in sponsored research, the Center evaluates new technologies and programs and develops and executes feasibility studies and randomized controlled clinical trials. It has generated over 100 scholarly publications and helped over
30,000 patients. What unites these efforts is an emphasis on practical innovations that make a difference in peoples’ lives.
Guided by a relentless focus on what works and what doesn’t, the Center aims to change the way doctors and nurses deliver services even as it expands the ability of patients to manage their own health. Its staff serve on government advisory committees and corporate boards and are active speakers.

No tC Annually, the Center convenes a Symposium attracting over
1,100 thinkers, innovators and funders from all over the world. The meeting has become the preeminent global conference of ideas about healthcare, technology and policy.

Research and evaluation is a critical component of connected health innovation and adoption. Our focus is on nurturing and evaluation new ideas, products and delivery models by rigorously testing them via feasibility pilots as well as randomized controlled trials. Our goal is to understand how people interact with technology, and how we can change behaviors to achieve better clinical outcomes. Learn more. Our programs in heart failure, hypertension, diabetes, and other chronic conditions, as well as online second opinions and enhanced medical education and training, are being successfully integrated across the Partners HealthCare network and implemented by major employers.

• Diabetes Connect and Blood Pressure Connect—These programs offer patients and their care providers a way to keep track of their blood sugar or blood pressure readings, and to collaborate on a care plan between office visits.
• Connected Cardiac Care—A home telemonitoring and education program for patients with Heart
Failure who are at risk for hospitalization.

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• Partners Online Specialty Consultations (POSC)—This program offers patients and their treating physicians from around the world online access to thousands of leading specialists at Massachusetts General Hospital, Brigham and Women’s Hospital and Dana-Farber/Partners Cancer
Care. POSC has helped more than 10,000 patients with a life-threatening or unusual diagnosis to better understand their options, find answers or, simply, have peace of mind that their treatment plan is right for their situation. Visit econsults.partners.org for more information.

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• Collaborative Media Services—Provides video-conferencing and streaming media services that facilitate teaching and learning for clinicians and patients worldwide. Our expertise includes podcasting and web conferencing, streaming media hosting and cross-platform video on demand.
Visit collaborative-media.partners.org for more information.
Source: adapted from http://www.connected-health.org/about-us/about-us.aspx

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