Remote Neurology Coverage for New England Hospitals

Remote Neurology Coverage for New England Hospitals

Since 2000, Mass General TeleNeurology has been expanding from a small pilot on Martha’s Vineyard to one of the largest academic TeleNeurology networks in the nation. 6.5 million New Englanders have access to a neurologist through the 35 programs at 23 Mass General TeleNeurology hospitals in their counties. Additionally, Mass General Neurology patients can often conduct their follow up appointments from their homes or workplaces.

• Mass General TeleStroke has increased use of thrombolytics to 9x+ the national average while avoiding unnecessary and costly inter-hospital transfers in 70%+ of consults.
• This suggests more than $6 million in potential reimbursements for community centers.
• More recently, Non-acute TeleNeurology, which is growing at a rapid rate, has allowed 95%+ inpatient retention, again avoiding high cost transfers and keeping care local.

Our remote TeleNeurology clinical services are classified in two groups: those covering the hospital setting and those covering the outpatient setting, such as a primary care practice. Hospital services require dedicated telemedicine endpoints as well as a radiology image transfer technology, and can be Emergent, like TeleStroke, or non Emergent, like inpatient TeleNeurology.

On the other hand, our General and Subspecialty Outpatient TeleNeurology service provides access to primary care practices affiliated with our community hospital members. This service does not require dedicated telemedicine endpoints or radiology transfer connections. It relies on mostly scheduled virtual clinics that minimize the disruption on local primary care provider workflows. 

Hospital TeleNeurology

Emergency TeleNeurology: 24/7 access, within 5 minutes to an emergency neurologist. Typical conditions includes stroke, hemorrhage, status epilecticus, comas, chord compressions, Guillain-Barre, acute non-traumatic weakness.

TeleStroke: 24/7 access, within 5 minutes to a stroke specialist.

Routine Hospital Consultation: Business hour access, within the same business day to a general neurologist. Typical conditions include headache, sub-acute stroke, encephalopathy, vertigo, weakness, cognitive changes, seizure, etc.

TeleEEG: Access to remote interpretation of inpatient and outpatient EEG studies during business hours. 

Outpatient/Multi-subspecialty

Outpatient TeleNeurology: Business hour access, within the same business day to a general or subspecialty neurologist. We work with you to adapt our resources to your primary care practice’s processes through mutually convenient virtual clinic sessions that minimize the time demand for the local physician, and to enable continuity of care for common chronic diseases, like movement or memory disorders. Typical conditions include headache, sub-acute stroke, encephalopathy, vertigo, weakness, cognitive changes, seizure, etc.

Emergency TeleNeurology

24/7 access, within 5 minutes to an emergency neurologist. Typical conditions includes stroke, hemorrhage, status epilecticus, comas, chord compressions, Guillain-Barre, acute non-traumatic weakness.

TeleStroke

24/7 access, within 5 minutes to a stroke specialist.

How does Emergency TeleNeurology or TeleStroke work?

Consult Request
When a patient with stroke/neurology symptoms is in need of emergent care, your team pushes the patient’s imaging studies and pages the on-call TeleNeurology specialist for a consultation.

1. Case Review
   The TeleNeurology specialist immediately begins the assessment of the images and returns the page by phone to review the case; the consult may transition to a videoconference call, if appropriate. Using the video connection, the specialist will review the patient’s presentation with your emergency department physician and, aided by your local staff, will perform a neurological assessment.
2. Online Assessment
   The TeleNeurology specialist documents the information within the TeleNeurology Web Portal. You can access the portal to retrieve your local EMR or have it sent via fax.
3. Collaborative Decision Making
   Upon completion of the examination, the findings will be discussed with your team. Together you will decide on a plan of care.

Routine Hospital TeleNeurology

Business hour access, within the same business day to a general neurologist. Typical conditions include headache, sub-acute stroke, encephalopathy, vertigo, weakness, cognitive changes, seizure, etc.

TeleEEG

Business Hour Remote Interpretation of Inpatient and Outpatient EEG Studies

How does TeleEEG work?

1. Local Testing
   The EEG is ordered by the patient’s local provider and performed by technologists onsite.
2. Professional Interpretation
   The interpreting provider at the Massachusetts General Hospital Division of Clinical Neurophysiology is notified upon completion of the exam.  A preliminary report is typically completed on the same day or day after the study by a Mass General Clinical Neurophysiology fellow.  A final report by a faculty level physician is made available shortly after.
3. In Case of Emergency
   The requesting hospital works with TeleNeurology to establish pathways for STAT and urgent tests.

Outpatient/Multi-subspecialty

Outpatient TeleNeurology: business hour access, within the same business day to a general or subspecialty neurologist. We work with you to adapt our resources to your primary care practice’s processes through mutually convenient virtual clinic sessions that minimize the time demand for the local physician, and to enable continuity of care for common chronic diseases, like movement or memory disorders. Typical conditions include headache, sub-acute stroke, encephalopathy, vertigo, weakness, cognitive changes, seizure, etc.

How does it work?

 

Hospital Teleneurology Implementation Process

Emergency TeleNeurology

Our implementation process is streamlined to ensure you have the appropriate technology and training to effectively serve your patients. Our program will guide you through every step of the process and will ensure you have the clarity and information you need to move forward swiftly. Once your local medical and technical champions have been identified, and deployed and tested your technologies, we conduct three carefully designed training sessions to ensure the comfort of your staff. With our clinical and technical support processes, your staff will have the confidence to accurately and safely treat your patients. During our last training session, we will simulate a real video consult from request to patient examination. After go-live our teams continue to work together to carefully screen and identify areas for continuous improvement.

The implementation of Emergency TeleNeurology takes an estimated two to three months.

Credential Partners Physicians at the member hospital	Setup and test videoconferencing equipment	Ensure comfort with technology protocols for your staff, through three comprehensive training sessions.	Continuous technical and clinical support and improvement
Identify Clinical and technical champions	Establish Radiology Tunnel to send images to Partners' Neurologists	Leveraging a train the trainer model, our program will empower your local champions to serve as experts in program, and adapt it to your local processes and needs.
Deploy Technology Order Equipment: -Option to purchase equipment on your own, or let us facilitate the lease of equipment -Determine radiology and video conferencing requirements	Set up MGH TeleHealth Consult Portal access for your staff

 

Comprehensive Hospital TeleNeurology (Emergencies and Non-Emergencies)

Comprehensive TeleNeurology implementations may require additional time to ensure you are well prepared to utilize both emergency and non-emergency processes. Our comprehensive offering also usually involves distinct clinical champions for each care setting (ED, ICU, and Ward) and a higher number of credentialed Mass General TeleNeurologists.

The implementation of comprehensive Hospital TeleNeurology takes an estimated two to four months.

General and Subspecialty (Outpatient Teleneurology)

Setting up a facility for General and Subspecialty Outpatient TeleNeurology services is simpler in terms of technology deployment, as most consults are performed on office computers, laptops or tablets. Thorough testing is conducting with the primary care practice to ensure the reliability of wireless signals for the mobile devices. Radiology image transfers can occur through the associated hospital’s radiology department (as for hospital TeleNeurology) or directly from the practice through radiology CDs. The clinical and administrative staff is then trained on the use of the systems- the video system, the Mass General TeleHealth portal as well as in the Mass General Outpatient TeleNeurology processes. Our final phase of training includes a mock drill with the providers and a stand in patient, conducting a consult from start to finish.

The implementation timeline for Outpatient TeleNeurology services takes an estimated one to two months.

 

The TeleNeurology Program provides our partners with quarterly check-ins, including a yearly site visit.  During these check-ins, we jointly and collaboratively review:

• Utilization of the program: the types and number of consults requested, tPA treatment rates and review opportunities to increase the rate of patient retention, if that’s among the goals of the local team.
• Updates to the program.
• Technical checks and reviews.
• Gather feedback from the site and develop plans for continued success. 
• During the site visit we tour the hospital and meet established and new staff, increase awareness and answer questions about the program.

We also conduct detailed stroke operations “Gap analyses” for new partners, to identify opportunities to strengthen the local stroke operation.  Additionally, Mass General TeleNeurology openly shares clinical guidelines, screening tools and a wealth of top quality clinical information. 

Through these efforts, our program has also been instrumental in supporting our network community hospitals in attaining local, state or national recognition for their achievements in stroke care.  100% of our Massachusetts sites are DPH certified stroke centers and 50% of all of our partners have obtained Silver, Silver Plus, Gold or Gold Plus certifications with the American Heart Association/American Stroke Association, Get With The Guidelines program.  Many of the remaining hospitals in our network are certified as advanced primary stroke centers by Det Norske Verita (DNV). Along these lines, we promote efforts to improve quality, for example by working to decrease door to needle times network-wide, by analyzing data for our partners and sharing individualized, actionable recommendations.  Other quality initiatives we have implemented include 90 day follow up modified Rankin Scales on patients who receive IV tPA and remain at their community hospital, as well as monitoring our own TeleNeurology report completion times to ensure vital information such as treatment recommendations, sub-acute care and secondary prevention measures are available in a timely manner.

Our team members are personally available to our partner teams to answer questions, provide follow up and review cases on an ad hoc basis. It’s our commitment to support our partners’ efforts to continuously improve their performance.  Close, mutually respectful and sustainable relationships lay at the very core of what makes us successful.

Mass General TeleNeurology is focused on enhancing the educational opportunities available to our partners, thereby increasing and supporting the improved identification and care of stroke and general neurology patients. To this end, we offer a web based educational program, hosted by Partners HealthCare Continuing Professional Development.  Our series of cerebrovascular lectures are CME and CEU eligible, and can be accessed from a computer or mobile device anytime, anywhere.  Our speakers are world renowned Mass General physicians and nurses and many are Harvard Medical School faculty members. In parallel, we also offer ad-hoc onsite CME lectures from these same faculty members, with topics ranging from the signs and symptoms of an acute ischemic stroke to cutting edge endovascular therapies.

“May 31, 2008.

I remember it all. 

I am awakened by the slap of my right hand striking my right cheek. I cannot control or feel the action. The entire right side of my body is weak and numb. My head aches acutely and there is severe pain in my right eye. My vision is blurred. My low lip feels (and is) swollen on the right. I attempt to stand and am immediately dizzy and uncoordinated. I alert my partner and realize it is difficult to speak. I slur out my issues and call 9- 1-1 for help.

I am ambulance-driven to York Hospital quickly, where I am evaluated and stabilized thoroughly by the Emergency Room Team. I am told that the hospital has communicated my details via its TeleNeurology Network with MGH and recommends that for further treatment I be transferred there (I accept and arrive at MGH within 2.5 hours of the onset of stroke symptoms). Four intensive treatment inpatient days, then transfer to the Spaulding Rehabilitation Hospital-the MGH adjunct facility- for 3.5 weeks and outpatient therapy results in complete recovery: an amazing and gratifying result. I “do gym” frequently and volunteer my time both at York Hospital and an elder service agency in Maine. None of such activities, or my recovery would have been possible without the TeleNeurology initiative.”

Alan C. Nichols (Stroke Survivor)

“Our hospital's

TeleNeurology Program

began in 2007.

As a small community hospital, our relationship with the Mass General TeleNeurology Program has been invaluable to providing our community with world-class neurology care. We strive to provide our patients with exceptional quality care delivered with compassion and kindness. The knowledge and reliability of the Mass General TeleNeurology initiative fits right in with our mission – compassionate, high quality medical care experiences.

Not only has TeleNeurology been able to provide us with the capability to handle acute stroke cases, they have also offered us important guidance in helping us to achieve our goal of Gold Status as part of the Get With The Guidelines through the American Stroke Association®. By achieving this status we are now aligned with the latest scientific guidance and have seen measurable results in patient outcomes and family satisfaction. The immediate around the clock access to the TeleNeurology team ensures that we can diagnose and treat our patients with a high level of clinical expertise.”

John Alexander, MD
Former Emergency Room Leader, Integrated Medicine, York Hospital