In a rural hospital in the Arizona desert, a 5-foot robot leaves an elevator, navigates down the hall around personnel and equipment, enters a patient's room, and comes to a stop at the bedside. Two hundred miles away, Bart M. Demaerschalk, M.D., a neurologist at Mayo Clinic in Phoenix, drives the robot. It is Dr. Demaerschalk's face on the screen and his voice that greets the patient.
With the aid of the on-site robot, Dr. Demaerschalk begins his neurologic examination. Separated geographically, the robot and the Mayo telestroke team act in real time, and together they are taking telemedicine to the next level.
About 40% of the US population lives in counties without a hospital actively engaged in acute stroke care. A gap exists between the number of certified stroke centers and stroke specialists and the need for stroke expertise in both urban and rural settings. Internationally, most strokes occur in underdeveloped or developing nations where specialized stroke care is often not available.
Rapid evaluation and intervention in acute stroke are critical. The administration of tissue plasminogen activator (TPA) in the first 4 1/2 hours, for example, can limit the amount of brain injury in ischemic stroke. Yet TPA is underutilized by hospitals that lack stroke expertise. The American Stroke Association estimates that only 5% to 10% of eligible patients in the United States receive TPA. Other immediate decisions include whether the patient needs to be transferred to a primary stroke center for further intervention, such as the evacuation of a brain hemorrhage or surgical management of a brain aneurysm.
In 2007, Mayo Clinic neurologists addressed this gap in Arizona by providing stroke telemedicine to the rural communities of Yuma and Kingman. In a hub-and-spoke model, Mayo neurologists at the hub in Phoenix use a two-way audio-video platform and a remotely controlled camera to conduct patient examinations and consultations with emergency department physicians at the affiliate hospital. Neuroradiographic images, laboratory reports, electrocardiograms, and vital signs can be reviewed by the stroke specialist via the Internet, and triage decisions can be made.
Since the telestroke program's inception, Mayo Clinic in Arizona has added the robot and the telestroke team has conducted more than 400 telestroke examinations. Before the telestroke program, virtually all rural stroke patients were transferred to a primary or comprehensive stroke center. But now, with telestroke consultation, only 30% of patients examined by Mayo telestroke physicians are transferred. The remaining 70% have been able to stay in their communities with the support of their family, local physicians, and care providers. That 70% represents a commensurate savings in the human and economic cost of unnecessary ground or air ambulance transport.
On-site training by Mayo physicians and administrative personnel includes training nurses in the affiliate hospital to provide some physical support to the robot. They are trained to conduct the examination sensory functions and reflexes and to help position robotic extensions, such as an ophthalmoscope, otoscope, and stethoscope, for the neurologist at the hub site to conduct the physical examination.
In addition to gathering information through patient interaction, the stroke specialist can test speech, language, and other cognitive functions by projecting diagrams, words, and sentences onto the robot's screen. Through this interaction at the bedside, the Mayo physician can assess the cognitive and behavioral status.
Dr. Demaerschalk says that although initially surprised, patients and families adapt within about five minutes to this form of health care delivery. The robot, informally known as Bart2-D2, begins to assume human qualities, and people respond as if the physician was in the room.
The Mayo Clinic telestroke network has grown to include 7 affiliate hospitals in Arizona, including 1 in Phoenix. Seven more hospitals will be added in the next 12 months.
The program has also expanded from a regional to a national service. Dr. Demaerschalk and his team worked with their clinical and administrative counterparts in the Department of Neurology at Mayo Clinic in Jacksonville to bring telestroke to Florida. Since its inception in May 2010, the Mayo Clinic program in Florida has already provided 60 telestroke consults to an affiliate hospital in Titusville.
Plans are under way at Mayo Clinic in Minnesota to provide telestroke services to affiliate hospitals in the Mayo Health System, which reaches communities in Minnesota, Wisconsin, and Iowa.
Initially, telestroke service was delivered to and from large, stationary workstations. Now, the telestroke robot can access any area in the affiliate hospital and can be activated from a laptop computer at the hub hospital, or even from the physician's home, with the same level of privacy and security as in the hospital. The robot can go on rounds and conduct follow-up visits as needed.
The next step under investigation by Dr. Demaerschalk and colleagues is the use of smart phone technology. With a smart phone application, the robot could be activated even more easily from anywhere in the world, eliminating the need to access a computer and a wireless setup.
In January 2010, Dr. Demaerschalk and the Mayo Clinic stroke telemedicine team were awarded the first Mayo Clinic Connect, Design, and Enable (CoDE) Innovation Award. The goal of the award is to facilitate innovation, collaboration, and transformation of the way health care is experienced and delivered.
Dr. Demaerschalk points out that neurology is particularly well suited to telemedicine because "so much of what we do is listening and observing; interacting with patients; testing consciousness, cognitive skills, language, vision, motor and sensory function, movement, coordination, balance, and gait; and evaluating diagnostic data, such as neuroimaging studies and electrophysiologic reports (eg, EEG), all of which can be done from a distance. By synthesizing that information, we can come up with a diagnosis and a management plan, one that in many cases can be implemented in the local community."
Not surprisingly, the telestroke teams have been asked by affiliate hospitals to extend their telemedicine services beyond stroke to other neurologic disorders. By providing specialized care to distant communities, the telestroke teams are helping Mayo Clinic meet one of its key goals for the 21st century—that of providing medical expertise here, there, and everywhere there is a need.