Geisinger Health has two comprehensive stroke centers, a primary stroke center, and six satellite hospitals that are acute stroke ready and can give thrombolytic therapy. However, they can’t keep patients there who have thrombus. For this grant, Geisinger targeted three of the most rural satellite hospitals, with the longest transport times to one of their comprehensive centers, to pilot telestroke services in ambulances. 

The Georgia Health Policy Center recently spoke to Anthony Noto, M.D., the vice chair of acute care neurology for Geisinger Medical Center, about the center’s participation in the Telehealth Network Grant Program. 

What has been an early win in your telehealth program?   

When I first got to Geisinger, we were doing just the bare minimum as far as acute stroke telemedicine for some of the smaller emergency departments within our system. What we realized was that we were transferring a whole lot of patients who otherwise could have stayed at these great facilities with better ratios of nursing care and care managers and could be closer to their families. They did not need to be transferred to the larger centers. So, we worked with a new telemedicine vendor who was able to put more carts in some of our smaller hospitals, which allowed us to extend our reach as a neurology program and to keep appropriate patients at those locations. This really cut down on the number of transfers and increased patient satisfaction, both because they were closer to home and because the care they received was more personalized. 

What is a tip or early learning that you would share with a health system launching a telestroke program?  

I think everybody is very concerned about how telehealth will be perceived by the physicians or the staff at these locations. When getting started, we found that the worst thing you can do is buy equipment, put it in those sites, and not use it. The best thing to do is to really try to talk with your boots on the ground at those locations. I think you will find that they are very supportive of everything — from moving the cameras into the rooms to staying in the rooms to help facilitate the exams. It also really helps to have a telehealth champion — someone who is really engaged and energetic about it. 

How do you see participation in the Telehealth Network Grant Program impacting your broader telehealth and health improvement efforts?  

Across the nation, the recommended times for giving thrombolytic therapy are becoming tighter and tighter. The fact is that we need to get people in and out of some of these smaller hospitals into our major centers when they have severe strokes or problems with blockages of major blood vessels that could require surgery. This is a main focus. We are hoping to use this grant to move the needle on that by bringing the televideo encounter into the field. We have a lot of rural centers that have long drive times where patients are in the ambulance for extended periods of time. If we can use that time as an opportunity to see those patients before they reach their smaller hospital destination, we can potentially impact the door-in-door-out time and how quickly they can receive thrombolytic therapy, as appropriate. 

At least one other health system has tried this and had some decent results. For this project, we chose to pilot some of our most distant centers — where drive times can take an hour and 45 minutes — where time really matters. The earlier we can launch our critical care transport teams to get these patients, the earlier we know if they are having a stroke, how severe it is, and if they need to be transferred. Using cell signal devices and even satellite devices, in some cases, we can see into the ambulances and see patients en route. 

I am a vascular neurologist, so I specialize in stroke. Yes, of course, we have neurologists scattered throughout the system, but we may only have vascular neurologists in one area, while other areas are underserved. Through using telemedicine, we can pair devices in our clinic with vascular neurologists wherever they happen to be. That really has allowed us to expand our patients’ access to subspecialty care. The patient can go to their local neurology clinic, and a nurse will room them and take their vitals. The vascular neurologist, who may be somewhere completely different within the system, will be able to log in and see them. From 8 to 9 a.m., I may see someone in the northeast far reaches of our territory, and then from 9 to 10 a.m., see someone in the southern region without ever moving my location. Launching outreach clinics are great, but it takes up a lot of time to drive to those sites, hoping that the patients can come to those sites during those very specific times. 

How has COVID-19 impacted your plans?  

The pandemic had a significant impact on our telehealth program. We had a fairly robust telehealth program prior to the pandemic, but this accelerated it significantly. The pandemic afforded us the opportunity to get closer to patients — to get these cameras, cell phones, and the webcams they have at home — so that we could see them. We also expanded into the prison population because it was difficult to transport those patients to clinics, and the same thing with nursing homes. The pandemic really allowed us to explore what worked and what did not to really hone the patient population that would benefit the most from telemedicine and expand on that. 

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