Roger Cooper was sitting in his home office in Sebastopol, CA, when his wife, Kathy O'Connor, came in and asked for help with a computer problem. The retired computer systems expert couldn't understand a word his wife was saying. "I thought it was because I was using the wrong computer terms," recalls O'Connor. "Then I asked if he had something in his mouth because it sounded like there were marbles in it."

Her husband's speech quickly deteriorated into "word salad," she says. Suspecting a stroke, she called 911. As recent transplants from Montana, the couple was unfamiliar with the local hospitals. Ambulance personnel suggested Sutter Santa Rosa Regional Hospital. As luck would have it, Sutter was one of 23 Bay Area hospitals that comprise the California Pacific Medical Center (CPMC) telestroke network—a system of online, telephone, and videoconferencing technologies that connect stroke neurologists at the San Francisco-based CPMC with other hospitals in the Bay Area.

Video Connection

As soon as he arrived at Sutter, Cooper was examined by the emergency department (ED) physician, who sent him for a computed tomography (CT) scan. In the ED, a cart with a video screen linked to a neurologist at CPMC's stroke center was wheeled to the foot of Cooper's bed. "They faced it just right so Roger could see the doctor and the doctor could see him. It was as if the doctor were standing at the foot of the bed," says O'Connor.

Working with the ED physician, the neurologist asked Cooper questions and instructed him to open and close both eyes and grip with his nonaffected hand. The neurologist also reviewed Cooper's CT scans and asked O'Connor to confirm the time the stroke symptoms began. All this helped determine whether to treat Cooper with tissue plasminogen activator (tPA), a fast-acting blood thinner that dissolves blood clots, a common cause of stroke. "The doctor was just as contemplative about treatment as if he were there in person," says O'Connor.

"Once he got the drug, Roger's word salad cleared up, right there in front of us," she says. Thanks to the telestroke network, Cooper could be treated in Santa Rosa, a short distance from his home, rather than traveling more than an hour to CPMC in San Francisco. This is especially important in the case of stroke, where faster treatment is so critical. Studies show that the sooner tPA can be administered, the more likely it is to reverse or minimize stroke symptoms, says Sarah Song, MD, MPH, assistant professor of neurology at Rush University Medical Center in Chicago. The standards set by the American Heart Association/American Stroke Association say tPA should be administered within four and a half hours of a stroke.

Cooper was eventually transferred to CPMC in San Francisco to determine the cause of the stroke—in his case, intermittent cardiac arrhythmia (irregular heartbeat)—and for further care. Three months later, he was planning his next ski trip for the spring. "I have no symptoms, except my handwriting is a bit messy—but then it always was," he says.

Technology Can Save Lives

Cooper is one of many patients benefiting from telemedicine, a combination of real-time audio-video connections, the Internet, computers, and mobile devices that link doctors in one locale to doctors in another and doctors to patients over wide geographic areas. Think videoconferencing programs, such as FaceTime or Skype, plus digital photography platforms such as iPhoto, super-powered to share patient images and support high-resolution video links. With these technologies, patients and doctors can connect and consult even if they are hundreds or thousands of miles apart.

About half of all hospitals in the United States have a telemedicine program, according to the American Telemedicine Association. Neurologists use telemedicine to improve outcomes for acute conditions, such as stroke, and to manage long-term chronic conditions, such as Alzheimer's disease and Parkinson's disease, especially for people who live in rural areas without access to a local neurologist.

"One of the virtues of telemedicine is that you can see the patient and do the same physical exam that you'd do in person. And studies show that an exam via video is perfectly adequate, especially when using the National Institutes of Health Stroke Scale (NIHSS) score [which assesses stroke severity]," says David C. Tong, MD, FAAN, director of CPMC's telestroke program. This approach has been used for a variety of medical conditions for many years, but its use in neurology is more recent, especially with stroke patients, he adds.

The rise of telestroke coincided with the approval of tPA in 1996, says Steven R. Levine, MD, FAAN, FAHA, State University of New York (SUNY) distinguished professor of neurology and emergency medicine and vice-chair of neurology at SUNY Downstate College of Medicine in Brooklyn, NY.

Dr. Levine—who, along with his colleague Mark Gorman, MD, is considered one of the fathers of telestroke—came up with the idea to combine tPA delivery with telecommunications technology when rushing to the ED while on call late one night in Detroit. At the time, he was working on one of the definitive clinical trials of intravenous tPA (the National Institute of Neurological Disorders and Stroke rt-PA Stroke Trial), and as he passed a billboard advertising news anchor Ted Koppel and ABC's Nightline, he had a brainstorm. "I suddenly thought, 'Why don't we do what Ted Koppel does when he interviews people located in other states or countries and use a video monitor to talk to another doctor about acute stroke treatment?'"

In 1999, Dr. Levine and Dr. Gorman described the concept in a paper published in Stroke. They explained how it could help hospitals and health systems speed up stroke care to support use of tPA. "Telemedicine for stroke—'telestroke'—holds promise as a technology-intensive, rather than manpower-intensive, method of providing rapid acute stroke expertise to local hospitals," they wrote.

Expansion Plans

The use of tPA alone is enough to increase positive outcomes threefold, but only 3 to 6 percent of patients receive it, according to the American Stroke Association. Increasing access to tPA is one of the key goals of telestroke.

"In my opinion, right now, telemedicine is the single most effective way to extend the use of tPA to more patients," says James C. Grotta, MD, FAAN, a vascular neurologist and director of stroke research at Memorial Hermann Hospital in Houston, TX. "There's no question that telemedicine can provide the expertise needed to turn a regular hospital into a primary stroke center."

With an aging population and a shortage of stroke neurologists, becoming part of a telestroke network is the best way to provide quality patient care, says Tzu-Ching Wu, MD, assistant professor of neurology and director of the University of Texas Health Science Center (UTHealth) at Houston's telemedicine program. "Telestroke closes the gap in access to neurologists," he says.

Hospitals that operate outside a telestroke network rely on phone calls with stroke neurologists, a practice akin to "flying in the dark," says Andrew D. Barreto, MD, associate professor of neurology at UTHealth in Houston. "The most important thing is being able to look at the CT scan and the patient yourself. If you can't see the patient or the scan, you can end up using tPA to treat something that looks like a stroke, such as a very small hemorrhage or a stroke caused by bleeding in the brain, which is contraindicated for tPA. When you have to make decisions based only on a phone call, you're putting your patients at risk," he says.

Going Mobile

Many hospitals with telestroke programs are adding mobile units. UTHealth, for example, has a telestroke program that serves 17 hospitals within a 200-mile radius of Houston. In February 2014, in partnership with Memorial Hermann-Texas Medical Center, UTHealth packaged its stroke care expertise into a mobile stroke unit, which includes an ambulance with a CT scanner and telestroke connections staffed by medical care providers who can administer tPA.

Joseph Carrabba was one of the patients who benefited from UTHealth's mobile unit. On June 23, 2015, the 59-year-old Houston resident was getting ready for work just like any other weekday morning. But when he walked down the stairs to head out, he noticed that his left leg wasn't hitting the steps quite right.

"I went into the kitchen, and my hand started hitting the table uncontrollably. When my wife walked in, I was slumped over and weak on my left side," he recalls. His wife recognized the symptoms of a stroke and immediately called 911.

UTHealth's mobile stroke unit intercepted the call and instructed ambulance personnel to deliver Carrabba to the specialized unit at the closest location, which happened to be a gas station. Once inside, Carrabba had a CT scan, which was sent to a telestroke specialist at UTHealth, who paged Dr. Barreto about an incoming patient. With access to Carrabba's scan, Dr. Barreto was able to diagnose, direct ambulance personnel to administer tPA, and prep neurosurgeons for endovascular treatment, a procedure that removes blood clots using a thin catheter and a retrievable stent, thus restoring blood flow to the brain. A 2015 Canadian study in The New England Journal of Medicine reported that endovascular treatment decreased overall mortality rates by 50 percent.

"First responders see a lot of stroke victims, and they said I was pretty bad," says Carrabba. "Getting the tPA in the ambulance saved my life. When I got to the hospital they already had a plan for me, and a few hours later I was in my room recovering."

Carrabba spent just two days in the intensive care unit before going home. "I tell you I had no symptoms at all. I didn't need any speech or physical therapy," he recalls. Carrabba's clot, which was 24 on the NIHSS (the scale runs from 0 to 42, with 0 being the lowest score, and any score higher than 20 considered severe), was indeed a killer, but just a year after his stroke he's back at work. He's also running, eating right, and enjoying life.

Beyond Stroke

As a tool for bridging time and distance, telemedicine allows neurologists to treat more patients and gives more patients access to neurologists, particularly in rural areas. Mountain towns with ski resorts, for example, typically do not have a brain injury specialist on call, even though 20 percent of skiing and snowboarding injuries involve head trauma, according to the American Association of Neurological Surgeons.

In Colorado, Centura Health is addressing this shortfall with a teleconcussion service that connects its urban hospitals to smaller community hospitals. For example, St. Anthony Summit Medical Center in Frisco, CO, which is located between three major ski areas, can link head injury patients to a brain injury specialist located about 120 miles away for assessment via video conference. This connection supports faster access to specialist care for early diagnosis, which is key to recovery, as well as to preventing secondary concussions.

For almost 10 years, E. Ray Dorsey, MD, MBA, professor of neurology and director of the Center for Human Experimental Therapeutics at the University of Rochester Medical Center in New York, has treated people with Parkinson's disease using telemedicine. He also has conducted extensive research on how access to neurologists improves care for people with the disease.

A study published in Neurology in 2011 showed that people with Parkinson's disease who saw a neurologist had a 14 percent reduced risk of hip fractures and a 22 percent reduced risk of death, in part because neurologists tend to treat Parkinson's disease more aggressively than a primary care physician. The critical issue for most people with Parkinson's disease is getting access to this better care.

"I do my patient work using telemedicine and the occasional house call," says Dr. Dorsey. "By taking advantage of technology, we can deliver virtual house calls."

For these virtual calls, patients need a computer monitor with a camera and a high-speed Internet connection. During the session, Dr. Dorsey has patients walk for him and perform finger taps or other movements in front of the monitor to assess symptoms.

"Dr. Dorsey noticed things in our video session that my general neurologist hadn't seen," says Steven DeMello, who is participating in a telemedicine and Parkinson's disease trial with Dr. Dorsey. "Dr. Dorsey changed my treatment, accelerating it considerably."

DeMello, who is a retired health technology researcher and a visiting scholar at the University of California's Center for Information Technology Research in the Interest of Society, also notes that being a patient using telemedicine technology is far more powerful than he ever anticipated as a researcher. "It feels very personal, even more so than an office visit, because you have the doctor's undivided attention via the video monitor," says DeMello.

Telemedicine becomes even more beneficial as conditions progress and people find it harder to drive to appointments, a situation that may lead to its expansion, Dr. Dorsey says.

Telehealth for You

To find out if telemedicine services are in your community, contact your local hospital. If you have a chronic condition such as Parkinson's disease, ask your specialist about it. Currently, there are no registries of telemedicine services, according to the American Telemedicine Association. People in rural areas in particular should know whether they have access to telestroke facilities or other telemedicine emergency support.

A registry of telestroke networks is a much-needed resource, says Christy Ankrom, program manager for UTHealth's Lone Star Stroke Research Consortium. If legislation to expand telestroke (the FAST Act) passes, Ankrom predicts demand will lead to the development of a registry.

A Hospital Without Beds

A health care facility in Missouri provides patient care entirely through telemedicine.

In October 2015, the Mercy health system opened the first bedless hospital. Called the Mercy Virtual Care Center, this new institution uses telemedicine and virtual communications technology to deliver care to 60,000 emergency department and critical care patients a year located in the 33 other facilities that comprise the Mercy nonprofit health system.

At Mercy Virtual, 330 employees provide telemedicine services, including telestroke, online nurse consultations, remote monitoring of patients in the intensive care unit (ICU), and remote care for patients in their homes. The building is furnished with desks and cubicles holding multiple monitors, where nurses observe the monitors of remotely located ICU patients, for example, and alert local doctors when their attention is needed.

The facility just confirmed partnerships with two outside health care systems—Penn State Milton S. Hershey Medical Center and University of North Carolina Health Care—to provide their virtual ICU patient monitoring services.

In addition to providing support for hospital ICUs as well as telestroke services, Mercy Virtual allows patients to be in touch with providers from their homes. Called remote patient monitoring (RPM), this type of telemedicine allows people with chronic conditions to stay home and check in three times a week with care providers via a video connection on a tablet computer. Today, 80 individuals are enrolled in this program.

Participant numbers double in size every couple of months, says J. Gavin Helton, MD, who heads up Mercy Virtual's RPM program. "The future is here," he says.