Editorial Comment— Telemedicine: The Solution to Provide Rural Stroke Coverage and the Answer to the Shortage of Stroke Neurologists and Radiologists
While the world seems to get “online” at an unbelievable speed, telemedicine is slow to follow. Other than teleradiology, which has been widely accepted in practice for several years, it is puzzling that the use of 2-dimensional live images on a computer or television screen is still being studied. While direct visualization or so-called seeing is believing is in the process of getting the statistic power to prove its worthiness, the world is faced with the increased demand and task to improve stroke care. The TESS project has hopefully provided the last bits of needed information to prove to the world that telemedicine for stroke care works. As Wiborg et al report, telemedicine is easy to set up (“online” within 10 minutes) and operate. It requires a low level of training and is interactive with accurate diagnoses. Furthermore, it assists in making a diagnosis other than stroke (26% in TESS). Despite in TESS the use of telemedicine was only once per consultation, it is certainly conceivable that the system can be used more frequently or as needed. The cost of $8000 for a stroke network center and $500 for each network site is very affordable.
As the TESS project reported, telemedicine offers reliable stroke coverage to rural areas. According to the Hospital Statistics 2002, of 4856 US hospitals reported,1 >50% of hospitals (<100 bed size) were located in rural areas. These institutions may have been able to provide image studies, but often there was no neurology or radiology coverage. Therefore, establishing a telemedicine link would provide immediate access to neurological expertise.
In addition to lack of stroke care coverage in rural areas, there is currently a shortage of neurologists and radiologists to care for approximately 700 000 new stroke and nearly 1 million new TIA patients every year in the United States alone.2 These 2 specialties are needed for stroke care because, unlike the diagnosis and management of myocardial infarction, stroke care is much more complicated and there is no biological marker for stroke. Thus, making a timely accurate diagnosis of stroke relies on a detailed history and neurological examination and imaging studies (CT, MRI) with interpretation in a defined time. It therefore demands the availability of a neurologist, radiologist, and imaging study technicians 24 hours a day, 7 days a week. Many healthcare institutions, particularly hospitals located in rural areas, are unlikely to have adequate coverage.
According to the Neurologists 2000 (survey by the American Academy of Neurology), there were 10 038 US neurologists registered, with 83.7% being adult neurologists. Only 42.3% had stroke as their practice focus, and only 47% strongly agreed and felt comfortable about giving intravenous tPA.3 In addition, according to the 2000 AAN survey, the distribution of the Neurologists indicates that 20% of the US population is without any neurological services. There is also a shortage of radiologists. There are about 25 600 post-training diagnostic radiologists in the United States (survey by the American College of Radiology) and about 73% of these radiologists work full time.4 More than half of the radiologists indicated that they were overworked. It is unrealistic to speculate that there will be enough trained neurologists and radiologists in the near future to provide adequate care to stroke patients. Establishing telemedicine would in part resolve the “man power” shortage problem.
Telemedicine also fits well within the concept of establishing primary and comprehensive stroke centers. These designated centers will likely receive federal and state financial support. Telemedicine may become an essential part of these centers by providing coverage to their designated network sites.
Lastly, telemedicine may be able to allow other sites within a network to participate in clinical trials. From consenting to follow-ups, all components needed to conduct a quality stroke trial can potentially be achieved by telemedicine. With increased difficulties in enrolling patients in acute stroke trials, telemedicine may be the solution to facilitate more sites to participate in clinical trials.
Despite the benefit demonstrated by telemedicine, several key issues may need to be addressed before its full implementation. These issues include reimbursement for usage, liability coverage, cross-states physician licensing, equipment upgrade, and quality assurances. With the continued shortage of both neurologists and radiologists needed for stroke care, telemedicine offers an affordable, reliable, and timely solution.
Facilities and Services in the U.S. Census Divisions and States. Hospital Statistics. Chicago, Ill: Health Forum LLC, an affiliate of the American Hospital Association; 2002.
American Heart Association. 2002 Heart and Stroke Statistical Update. Dallas, Texas: American Heart Association; 2002.
Swarztrauber K, Lawyer BL, and Members of the AAN Practice Characteristics Subcommittee. Neurologists 2000. AAN Member Demographic and Practice Characteristics. St. Paul, Minn: American Academy of Neurology; 2001.