STAT WEBSITE University of Virginia Health System

University of Virginia Health System
Department of Neurology
Stroke Telemedicine And Tele-education Program
STROKE - HOME PAGE
For many years stroke was rated the third leading cause of death in the United States and the
leading cause of adult disability. It touched as many as 795,000 in a single year with either a
new or recurrent stroke. Interestingly enough, this number excludes the countless persons
who are now faced with the challenge of providing specific and constant care—and, without
warning.
Because of premier advances in technology and identification of time-­‐critical diagnoses, it has
recently dropped to fourth place. Although great strides have been made to reduce mortality
and morbidity of stroke, a significant amount of work and effort is still needed to reduce
unnecessary transfers and improve in the quality of care offered.
Fortunately, therapies and devices exist to dissolve clots or provide for removal if the stroke is
ischemic. An ischemic stroke is the blockage of a vessel in the brain causing death to the
healthy tissue. Since time equals brain, we must rapidly diagnose and treat (or provide
appropriate therapies) as quickly as possible. Therapies are time-­‐sensitive—meaning, we have
a short three-­‐hour window to provide thrombolytics for ischemic strokes. If we have a succinct
and direct system in place, we can save precious moments resulting in better outcomes.
The University of Virginia (UVA) has taken the lead in providing our community and many other
underserved and/or rural areas in the effort to reduce stroke disability rates. Through reliable
technology and physician expertise, we have been able to overcome many geographic and
transportation barriers while delivering cost-­‐effective and quality care to many individuals
across the Commonwealth. Through our Stroke Telemedicine And Tele-­‐Education (STAT)
Program, we provide cutting-­‐edge, stroke care as well as unique comprehensive stroke services
including both neurointerventional and neurosurgical procedures through our total system of
care. To find more resources about stroke systems of care, please refer to the Virginia Stroke
Systems Task Force [www.virginiastrokesystems.org]
TELESTROKE
UVA is a Level 1, Comprehensive Stroke Center, in addition to being a Joint Commission
Accredited Primary Stroke Center. And, our medical center and team of stroke neurologists are
ready to provide telestroke consultative services for the care of patients by providing around-­‐
the-­‐clock telestroke coverage, uncomplicated ED acute stroke consultations, structure and
ongoing process improvements, technical support and educational services through our Stroke
Telemedicine And Tele-­‐education Program (STAT).
With our telemedicine program in place physicians at remote hospitals can link to our
institution for real-­‐time guidance in emergency situations to facilitate needed treatment. We
provide the tools, methods and specialty neurologists to streamline the delivery of quality care

in a moment’s notice. These services and improvements can improve the average door-­‐to-­‐
needle time for thrombolytic treatment, average length of hospital stay, long-­‐term disability
and overall cost per case. Our mission is to share the responsibility with regional hospitals for
building quality acute stroke programs in the Commonwealth.
We believe in: 1). Using technology to deliver quality stroke treatments in the closest location
to the patient, 2). Spreading knowledge and first-­‐hand experience to accelerate door-­‐to
treatment time, and 3). Help more patients; strive to provide services and support at the
lowest possible cost.
“Strokes don’t ask questions or make exceptions for anyone. Being prepared for
the worst has prepared us for being the best when it comes to striking back at
stroke. By working together and using a stroke delivery system, we exhibit a
STROKE OF GENIUS.”
Andrea C. Lomboy
STAT Program Coordinator
STROKE TELE-MEDICINE AND TELE-EDUCATION (STAT)
The mission of the Stroke Telemedicine And Tele-­‐education (STAT) Program is to provide
advanced specialty care resulting in the best and timely treatment for acute stroke patients
received by our skilled team of stroke neurologists from referring hospitals. By collaborating
with regional hospitals, we can build quality stroke systems of care, reducing the burden of
stroke in the Commonwealth of Virginia. Our goal is to use every resource available to enhance
the quality of life pre and post stroke with comprehensive and compassionate care. In addition,
we provide support to local medical professionals through our telestroke and educational
services.
“The STAT Program allows 24-­‐hour acute stroke expertise-­‐on-­‐demand, as well as
the added expertise of our entire team of stroke care specialists, from emergency
department staff to the neurocritical nurses.” “We offer a 100% acceptance policy
for all acute stroke transfers – maximizing the patient recovery by delivering a
timely assessment, diagnosis and determination of eligibility for short-­‐term
therapy and treatment. “
Nina Solenski, M.D.
Director, STAT Program
University of Virginia
The UVA Health System is able to break through many of the barriers that hinder access to
specialty care and key medications for timely treatment. This system provides for constant (24
hours a day, 7 days a week), yet flexible way to provide quality care that is monitored and
improved through both the hub and spoke hospitals.
2

The benefits include providing or improving access to care in neurologically underserved areas,
and reducing medical costs (e.g., travel to UVA, equipment). The results can drastically reduce
stroke mortality and disability while improving quality of life for survivors and their families.
When our STAT system is activated, everyone – from our page operators and radiology staff, to
our highly trained nursing and medical staff – are sequentially alerted and begin emergent
preparations to treat our patients with the highest level of care available. Quality is our
primary goal. To achieve this we provide on-­‐site partnership training, and offer online training,
to assist in the development of community healthcare events. We are committed to constant
improvement, and we conduct 24-­‐hour feedback and quarterly feedback for quality initiatives.
We also meet quarterly with the local Emergency Department and staff to provide a six-­‐month
review of all of the presenting cases to close the loop on each patient.
The following graphic is a snapshot of our system-­‐to-­‐system overview representing a hub (UVA
HS) and spoke (initiating or referring hospital) configuration.
THE SYSTEM
The goal of this flexible STAT program is to provide an efficient and methodical approach for
quickly recognizing an acute ischemic stroke and treating it as quickly as possible with the most
appropriate treatment available in your institution and in ours. Our system includes the
following conduits that lead to a successful program:
• Physician to Physician (Consultation)
• PACs (Radiology & Image Transfers)
• EMS (Patient Transfer)
• Telemedicine (Policy, Procedures, Manuals, How To’s, Training, Video Conferencing)
3

Each component can be customized for maximum performance thereby improving overall
quality of life outcomes. Every element of the system is necessary to make the process
seamless increasing survival and minimizing disability.
Evaluation and Treatment in 60 Minutes or Less:
• Door to MD ≤ 10 minutes: Patient complaint, vital signs, ECG
• ED Physician ≤ 15 minutes: Focused history and physical exam, laboratories, stroke team
activation, transport for CT Scan (stroke protocol) vital sign monitoring, neurologic
checks, seizure and aspiration precautions
• CT Scan and Stroke Neurology Consult ≤ 20 minutes: Review history, physical exam, CT
Scan interpretation
• Treatment Decision and Initiate IV rt-­‐PA infusion ≤15 minutes: per guideline based
protocol
Naturally, the first component of our system is a complimentary, customizable and quick
quality improvement program that is simple to implement. Upon implementation of the STAT
PAC Program, you will be given a supply of STAT PAC materials that are “ready to go.” The
contents of the packet will assist your team through the process systematically and the
documentation will lend itself to quality improvement—measuring areas of effectiveness and
efficiency—leading to even more successful outcomes! This packet will be opened for every
acute stroke and direct precise documentation of every key step in the appropriate care and
treatment. This is the initiation of the first conduit (Physician to Physician). The ED Physician
“the personal provider contact” at the hub hospital will open the packet, begin treatment and
initiate contact with the Acute Stroke Team Leader at the UVA Health System.
Critical tests are then obtained and discussed in consultation (via video teleconferencing or
telephone (PACs -­‐ Radiology & Image Transfers). Once contact has been established,
consultation will begin as images are exchanged and treatment ensues (Telemedicine -­‐ Policy,
Procedures, Manuals, How To’s, Training, Video Conferencing). Once a plan of care has been
determined, the patient either remains at the referring hospital for extended care, or
transferred to the UVA Health System for supplemental care (EMS – Patient Transfer).
However, the system doesn’t stop there. The documentation that was filled out at the referring
hospital is sent with the patient to the receiving hospital. The case is reviewed and key data is
extracted and presented for quality improvement (Case Specific Feedback – and overall process
review) with our Acute Stroke Quality Improvement Team.
If the patient somehow falls outside of the window of opportunity for thrombolytic treatment,
there are other options, including interventional radiology (mechanical clot retrieval devices
and others) or neurosurgical procedures that can be offered at our comprehensive stroke
center. With your partnership, we are able to use combined best practices, therefore, raising
the level of acute stroke care and treatment all across Virginia.
"We offer a 100% acceptance policy for all acute stroke transfers – maximizing the
patient recovery by delivering a timely assessment, diagnosis and determination
4

of eligibility for short term therapy and treatment. This system works for any
location because it is complimentary, completely customizable and critical for
achieving comprehensive care and quality outcomes.”
David Burt, M.D.
STAT Emergency Medicine & Systems Consultant and
Assistant Professor, Emergency Medicine
University of Virginia
We invite you to learn more about telestroke. We are not only interested in helping your
organization, but advancing the overall system of care across Virginia (and beyond state lines).
We have provided a Frequently Asked Questions (FAQs) to summarize key points that may be
of interest to you. We look forward to hearing from your organization.
IMPLEMENTATION
Our program can easily be implemented with our Office of Telemedicine. The timeline for
implementation depends on whether the site has existing equipment experience and sufficient
connectivity. The technology cost (equipment) can range from a modest $10k -­‐ $18k depending
on the sophistication and specifications of the system.
Cost savings are accumulated when considering the
possibility of decreasing unnecessary patient
transfers and/or retaining patients at the local
hospital for care (or returned to local
rehabilitation). Once a system has been set into
place, it is very easy to extend our services to
include remote inpatient stroke consultations.
"With good planning and vision, our
telestroke program can be operational
quickly and in an affordable manner-­‐
increasing the capability of the local hospital
with teleconsultation.”
David Cattell-­‐Gordon
Director, Office of Telemedicine
University of Virginia
OUR TEAM
INITIAL TECHNICAL CONSIDERATIONS
Site Requirements
• Dedicated Emergency Room with a
landline telephone connection and
internet access
• 24-­‐hour laboratory testing
• Pharmacy access for TPA
Equipment & Technology
• Video Conferencing equipment, H323
Compatibility
• 24 hour CT scanner
• T1 connection with a minimum
available bandwidth of 900 Kbps
• PC with internet
• Teleradiology capability (PACs)
Our team of double-­‐boarded stroke neurologists is dedicated to providing specialty telestroke
consultative services for acute stroke care. Our overall goal is to increase quality of life pre-­‐ and
post-­‐stroke. We provide 24/7 telestroke consultative services for those who are connected to
our system.
5

Our supporting team provides advanced capabilities at our comprehensive Stroke Center and
includes:
• Dr. Nina Solenski, Associate Professor of Neurology—the Director of the STAT Program,
Board-­‐certified Vascular Neurology, General Neurology
• Andrea Lomboy, STAT Program Coordinator
• Amy Halpin, STAT Data Analyst
• Dr. David Burt, Associate Professor, Emergency Department
• Dr. Lee Jensen, Director of Interventional Radiology/Professor of Radiology and
Neurosurgery
• David Cattell-­‐Gordon, Director of the Office of Telemedicine
When our STAT system is activated, everyone – from our page operators and radiology staff, to
our highly trained nursing and medical staff – are sequentially alerted and begin emergent
preparations to treat our patients with the highest level of care available. To complement our
medical staff, we employ three additional interventional neuroradiologists along with two
neurovascular surgeons (on cases requiring endovascular treatment, or emergency
neurosurgical care). We are devoted to enhancing the quality and duration of life for all who
have been faced with the devastating effects of stroke. Even if we miss the narrow three hour
window of opportunity to treat an acute ischemic stroke with tPA, our team expands the
possibilities of additional life saving and enabling treatment.
We strongly believe in sharing the burden of responsibility for stroke. We have participated in
raising the bar across the Commonwealth as participants in the Virginia Acute Stroke Telehealth
Network (VAST). Our contributions in the initial design, development, testing and evaluation of
a model stroke network has set the stage for small rural hospitals—lending stroke expertise in
regions of Virginia that might have not otherwise received such specialty care.
OUR FACILITY
The UVA Health System is a tertiary care institution with 13 dedicated stroke beds and 16
dedicated neurosciences ICU beds. And, is ever growing to meet the needs of our community
throughout the state. It is ranked among the nation’s top 20 centers by U.S. News & World
Report in research and treatment for disorders affecting the nervous system. As a Level 1
Comprehensive Stroke Center, we are nationally certified by the Joint Commission [link to
http://www.jointcommission.org] as a Primary Stroke Center and are recognized for the
exceptional quality of services we offer to achieve better outcomes and long-­‐term success rates
for our stroke patients.
Stroke patients transferred or admitted to the UVA Health System will be cared for in the
Nerancy Neuro Intensive Care Unit (NNICU) to receive state-­‐of-­‐the-­‐art care. The NNICU
provides skilled intense observation and monitoring of patients following a stroke, through
compassionate and highly skilled neuro-­‐trained nursing care staff.
Post-­‐stroke, patients may be seen in one of our two clinics: UVA Comprehensive Stroke Clinic
or the Neurovascular-­‐Neurosurgery Clinic. Patients are frequently evaluated by a team of
physicians, a stroke neurologist, vascular neurosurgeon, and neuroradiologists. For patients
6

eceiving rehabilitation, UVA is affiliated with the accredited UVA-­‐HealthSouth Rehabilitation
Hospital.
TELE-EDUCATION
Education is key to understanding and ascribing to good health and reasonable health practices.
With the availability of distributed mobile distance learning, the opportunities to teach about
stroke and the co-­‐morbidities of stroke are at our fingertips are plentiful throughout the state
[link to: http://www.healthsystem.virginia.edu/pub/office-­‐of-­‐telemedicine/map-­‐of-­‐facilities].
We have expanded our Stroke Telemedicine And Tele-­‐Education (STAT) Program to provide
professional stroke education vignettes and lectures that are housed online.
We are currently collaborating with HEALTHeCongregations ® to educate communities of
faith about stroke. We hope to empower the local congregations (7,000+ in Virginia) through
mobile distance learning prevention and awareness educational programs for both leaders and
members. Our goal is to leverage the power of technology while uniting faith-­‐based principles
with health best practices to promote prevention to build healthier communities.
“We must align the best practices of the health and faith communities, as they are
intricately linked. Through synergistic programs, we can capture the interest of our
communities and teach good health from the cradle to the grave—and, when health
fails, be strengthened ultimately by faith. This collaborative approach is sorely needed,
as stroke does not discriminate. Everyone can be at risk. “
CONTACT US
Rev. Andrea C. Lomboy
Chair, Community Education Committee
Member, Virginia Stroke Systems Task Force
Stroke Telemedicine And Tele-­‐Education Program Coordinator
University of Virginia
For more information about the Stroke Telemedicine And Tele-­‐Education Program, feel free to
contact the following:
• Nina Solenski, MD, STAT Program Director & Associate Professor of Neurology
UVA Primary Stroke Center
Box 800394, Hospital Drive
Charlottesville, VA 22908
Office: 434-­‐924-­‐2783
Fax: (434)982-­‐1726
Email: njs2j@virginia.edu
7

FAQs
• Andrea Lomboy, STAT Program Coordinator & HEALTHeCongregations ® Program Manager
University of Virginia, Primary Stroke Center, Department of Neurology
Mail Box 800394, McKim Hall, Office 1057 Cobb Hall
Hospital Drive, Charlottesville, VA 22908-­‐0394
Cell: 703/581-­‐4323
Fax: 888-­‐221-­‐1649
Email: alomboy@virginia.edu
• David R. Burt, STAT Emergency Medicine & Systems Consultant and Assistant Professor,
Emergency Medicine
University of Virginia
Department of Emergency Medicine
PO Box 800699
Charlottesville, VA 22908-­‐0699
Cell: 434-­‐924-­‐2428
Email: drb5p@virginia.edu
What is telemedicine and how does it relate to telestroke?
Telemedicine is the use of electronic communication and information technologies to provide
or support clinical care at a distance. Telestroke is further defined through the use of
telemedicine services with a specialty in acute stroke care and rehabilitation.
What are the bottom line benefits from telestroke services?
Thousands of patients in underserved areas may receive services that they may not have
otherwise received without traveling great distances or overcoming personal or transportation
barriers. We offer our telestroke services at the lowest cost possible, with the highest quality
of care available today. The cost savings are across the board—patient, spoke hospital and the
hub hospital.
Through telemedicine we are able to help you keep nearly 70% of all consults at your institution
increasing spoke hospital revenues. Even if the patient is transferred, they typically return to
the community for local rehabilitation.
How much will a telestroke program cost?
The costs for the implementation of a telestroke program varies with each spoke hospital.
Costs include:
o Equipment
o Network/Connectivity (adequate bandwidth is necessary for quality operation)
8

o Program Support Fee (contracted well in advance of implementation)
In our experience, many hospitals already have some or most of the essentials in place
already—it’s just a matter of us helping you fill in any missing pieces or gaps to make the
system complete.
For more information, please contact the Office of Telemedicine Director or the STAT Program
Coordinator at the University of Virginia Health System. We can arrange a site visit for you and
your staff.
Are there any additional consultation costs that we should expect?
No. Our program fees covers all on-­‐call and consultation services. We make it simple and easy.
How does telestroke billing work and what are the federal mandates associated with it?
Clinical services provided through telehealth is reimbursable by Medicare and most third-­‐party
payers. Medicaid reimbursement policies vary by state. In Virginia, reimbursement for
telehealth services is determined on a case-­‐by-­‐case basis. Technical fees to cover the network
expenses are not included in the reimbursement structure.
The University of Virginia Health System (UVA HS) will bill the patient or the patient’s insurance
for the consultation fee only. The site hospital will bill for the interpretation of the CT. UVA HS
will not bill for the CT interpretation or ‘over-­‐read.’ In the event the patient is referred or
admitted to for services other than those specified in our agreement, UVA HS will bill the
patient, or the patient’s insurance carrier for only those services in accordance with its normal
conduct of business. Our guidelines are based on the federal mandates that can be found
published in the Federal Register / Vol. 76, No. 87 / Thursday, May 5, 2011 / Rules and
Regulations, pages 25551 and following.
Can you help us throughout the implementation process to become part of your successful
and sustainable telestroke network?
Absolutely! Within the past 17 years we have had the privilege to perform nearly 24,000
consultations in over 30 specialties along side telestroke. We have a system in place that
ensures success with the cooperation and coordination of your facility—at your pace, and at
your request.
Does telemedicine and the teleconsultation provide for adequate patient privacy and
confidentiality?
Yes. A telestroke consultation is HIPAA-­‐compliant, and the spoke site personnel are responsible
for obtaining a signed telemedicine consent and HIPAA policy from each patient. Our site
utilizes a HIPAA-­‐secure virtual private network to ensure secure transmission of all electronic
patient health information.
Are there liabilities associated with telestroke consultation?
9

The liabilities are virtually the same as if the consultation were performed in person. There are
no hidden or extra liabilities by using telemedicine or telestroke consultations.
How can I be certain that the physicians at the hub hospital are qualified to perform
telestroke services?
Our STAT Program has been built from the ground up with the most experienced acute stroke
neurological attendings employed by the UVA HS. Each have been adequately trained and
experienced in every aspect of our system. We train not only our physicians, but also every
individual from our page operators to our neurosurgeons about their role to contribute to the
best possible outcome possible.
How do you handle physician credentialing issues?
The CMS and Joint Commission agree that physicians can only engage in telemedicine in states
where they hold a professional license. Secondly, for purposes of telemedicine between
facilities UVA complies with all CMS rules regarding credentialing and privileging. Effective July
2, 2011, the final rule revised sections of the CoP for hospitals and CAHs allow the governing
body (or responsible individual for CAHs) to accept the “credentialing and privileging decisions
made by the distant-­‐site telemedicine entity” for individual physicians or non-­‐physician
practitioners asked to provide telemedicine services. In addition, the governing body must
obtain a written agreement specifying the distant-­‐site entity as a “contractor of services” and
stating the distant-­‐site entity ensures all furnished services will comply with applicable CoP
criteria for hospitals or CAHs.
What if the spoke ED physician does not agree with the telestroke consultant?
The final decisions are always made by the bedside physician treating the patient. We
understand your role and relationship with those who you serve in your community. We trust
that you know what’s best for your patient. You are under no obligation to follow our
recommendations as consulting physicians.
Am I obligated to send all referrals to the UVA HS if they provide the initial telestroke
consultation?
No. Your decision to make a transfer or referral is solely your choice. We are happy to
participate in the process. After all, our goal is to improve acute stroke across the
Commonwealth—not just where we can have a profound effect on mortality and morbidity.
What if I no longer desire to use the STAT Program or make referrals to UVA HS?
We hope that our 24/7 acute stroke care services and consultations will assist you in every way
possible. You are under no obligation if you choose not to use our services. However, we are
always available any time you need us—with a 100% bed acceptance guarantee every time.
10

We are new to this telestroke concept. Will you “take” our stroke patients away from our
facility and our community?
No. Our mission statement says it best, “We hope to empower the local community hospital so
that they can provide specialty treatment to patients so that they can remain in the community
in which they reside.” Our goal is to confer with the local physicians by providing the best
teleconsultations we can. Together we can improve health outcomes, especially those in
regard to acute stroke.
What will happen in follow up with patients transferred from the spoke to the hub hospital?
We realize that the UVA HS is a large organization, but our focus is upon each and every patient
that comes here. We provide follow up online with access to the referring physician. In
addition, we contact each referring physician with either a phone call or written follow up.
What if the patient is not a resident of Virginia?
Patients with out-­‐of-­‐state Medicaid can still be seen through telemedicine, however it is
recommended that the individual contact their insurance provider prior to consultation. This is
typical for the stroke survivor in regard to rehabilitation services.
How do I know what happens to the patient once they leave my facility?
The STAT Program has a built in mechanism whereby you receive immediate feedback letter
about your patient within 24 hours within patient arrival. You will also have immediate access
to the patient reports via a secure web portal that is only accessible to approved designees.
Additionally, we internally monitor every case and provide quality improvement data to the
local ED physician and staff every six months.
11