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Zen and the Art of Telestroke Quality

Disclosure: Dr. Scott has nothing to disclose.
Pub Date: Thursday, Nov. 3, 2016
Authors: Phillip A. Scott, MD, MBA, FAHA, FAAEM
Affiliation: University of Michigan


Wechsler LR, Demaerschalk BM, Schwamm LH, Adeoye OM, Audebert HJ, Fanale CV, Hess DC, Majersik JJ, Nystrom KV, Reeves MJ, Rosamond WD, Switzer JA; on behalf of the American Heart Association Stroke Council; Council on Epidemiology and Prevention; and Council on Quality of Care and Outcomes Research. Telemedicine quality and outcomes in stroke: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association [published online ahead of print November 3, 2016]. Stroke. doi: 10.1161/STR.0000000000000114

Article Text

A frequently quoted health-system aphorism for acute care (whether stroke, cardiac or trauma) is to get “the right patient, to the right hospital, at the right time.” In the US in 2011, there were over 136 million emergency department visits and 35 million hospital admissions. Adult visits for strokes or TIA represent 26 ED visits per 10,000 population.1 On the inpatient side, care of patients with in-hospital stroke has been identified as having longer times from symptom recognition to neuroimaging and lower rates of use of thrombolysis, with only a minority of these patients being cared for by neurologists.2 The aging population of baby boomers portends a growing need to enhance acute and ongoing care in both settings.

Potentially answering these needs, telemedicine adds a new dimension - to deliver “the right specialist, to the right patient, at the right time”.

Physical barriers of distance, as well as hospital-resource barriers, are being electronically dissolved by the emergence of telehealth networks, allowing care by stroke specialists in remote locations. The market (healthcare system, payer, provider and patient), national demographics, governmental forces (Affordable Care Act), and shifting patient attitudes are all key drivers in this expansion.

Miniaturization of technology, improved internet-connectivity and the prevalence of smartphones and remote monitoring have enabled this advancement. Many new computer peripherals, real-time audio and video technology allowing "face-to-face" interaction between physicians and patients, and devices that can transmit data directly to a physician's electronic medical record are all on-line or will be added soon.

Simultaneously, efforts to contain healthcare costs are frequently focusing on enhancing healthcare provider efficiency and maximizing utilization, particularly for those providing specialized human resources. The vertical integration of large health delivery systems, ironically, may have the effect of limiting the availability of office-based neurologists able to respond to an emergent case in hospitals sourced only by local physicians, further stressing a stroke care delivery system and its providers if provision is not made for alternative methods of care.

The ASA’s new Scientific Statement regarding Telemedicine Quality and Outcomes in Stroke3 could not come at a more propitious moment given 1) the convergence of patient, clinician and hospital need; 2) the growth in specialists providing stroke care; 3) a shift toward population-based care (Accountable Care Organizations); 4) rising telemedicine reimbursement and insurance coverage – with 29 states now having laws ensuring some level of commercial insurance coverage for telemedicine, and 5) changing technology allowing affordable, easy-to-use communication.

This convergence is expected to generate explosive growth in the near term. In 2015, the global telemedicine market had an estimated value of $23,224 million (US) and is forecast to reach $66,606 million by 2021.4 Given telemedicine/telestroke’s rapid expansion and increasing influence on patient care, well-considered guidelines are needed to monitor telestroke systems in order to ensure optimum patient care.

This scientific statement provides a strong foundation upon which telehealth systems may evaluate their stroke performance. The document reviews the history and current models of telemedicine care delivery and their role in stroke systems of care and provides clear recommendations on monitoring telestroke process measures (time to treatment and transfer tracking) as well as outcome measures (including patient outcomes, diagnostic accuracy, thrombolytic use and safety). Importantly, the document includes assessments of both patient and provider satisfaction that will be important in enhancing acceptance of telemedicine by both groups.

Important cautions on telemedicine implementation are provided that will be of particular interest to health care systems new to this field. The statement provides detailed information on the technological needs of a telemedicine system and provides guidance on monitoring its quality. Finally, it covers the administrative side of telehealth, including recommendations on monitoring the process of quality reporting, licensing/credentialing/training requirements and necessary documentation. This has been done with a thoughtful and spare approach to limit unnecessary burdens on telestroke providers and networks.

In his 1974 book, Zen, and the Art of Motorcycle Maintenance, Robert Pirsig explores the meaning of “quality”, a term he considers undefinable as it exists as a perceptual experience before it is ever analyzed.5 That is, you know “quality” when you see it. Throughout the novel, he uses the performance of an old motorcycle as a quality metaphor, sometime its running rough and other times not at all. We’ve all been there at some point.

Hopefully, however, those delivering stroke care can recall instances where the system worked with ballet-like smoothness and precision – “quality”. You know the feeling as it happens – advance notification of stroke, rapid ED evaluation and imaging, smooth intravenous line placement and rapid lab results, stroke specialist at bedside, an efficient discussion on treatment risks and benefits, delivery of thrombolytics and/or a rapid trip to the neurointerventional suite, the subsequent NIHSS score of zero, and admission to the stroke unit. A win.

Telemedicine and telestroke systems represent a significant change in the stroke care delivery. They can provide patient access to specialists who were previously unavailable, thereby lowering the impact of stroke on both an individual and societal basis and offer the possibility of true population-based care and research. While “quality” itself may not definable under Pirsig’s Metaphysics of Quality theory, its static components - everything which can be defined - can be measured and used to build a knowledge base. This may, in turn, be used to create more that is good or “quality”.

With the dynamic changes occurring in healthcare delivery that knowledge base for telestroke is needed now. It suggested beginnings are found in this scientific statement – and the reader is encouraged to utilize them to smooth the ride for both ourselves and our patients.


  1. National Hospital Ambulatory Medical Care Survey: 2011 Emergency Department Summary Tables
  2.  Saltman AP, Silver FL, Fang J, Stamplecoski M, Kapral MK. Care and Outcomes of Patients With In-Hospital Stroke. JAMA Neurol. 2015;72(7):749-755.
  3.  Wechsler LR, Demaerschalk BM, Schwamm LH, Adeoye OM, Audebert HJ, Fanale CV, Hess DC, Majersik JJ, Nystrom KV, Reeves MJ, Rosamond WD, Switzer JA. Telemedicine quality and outcomes in stroke. Stroke. 2016;47:XXX–XXX. doi: 10.1161/STR.0000000000000114
  4. Modor Intelligence Aug 2016 Global Telemedicine Market – Growth, Trends and Forecasts (2016-2021)
  5. Pirsig RM. Zen and the Art of Motorcycle Maintenance. 1974 William Morrow & Company. ISBN 0-688-00230-7

-- The opinions expressed in this commentary are not necessarily those of the editors or of the American Heart Association --