Queen’s Medical Center in Honolulu is Hawaii’s only comprehensive stroke center. Hawaii is a chain of eight islands spread over 500 miles. On the island of Oahu (home of Honolulu), the drive times to get a patient to the stroke center can take an hour and a half, while inter-island transfers can take four hours.  

The Georgia Health Policy Center recently spoke to Matthew Koenig, M.D., medical director of telehealth at Queen’s Medical Center, about designing a telestroke service during the COVID-19 pandemic.

What has been the biggest accomplishment or an early win in your telehealth program?  

It has been a difficult year to do a project related to emergency medical services (EMS) because we had limited access to EMS during the pandemic. Only recently, did they begin allowing ride-alongs in ambulances again. So, we started on the accessibility testing, the implementation science, and technology selection rather than actual patient-facing implementation. We spent most of the year working with the leadership of EMS to gauge their readiness for telehealth in the ambulance and building partnerships with emergency physicians in Honolulu. 

The meetings allowed us to triangulate between Queen’s Medical Center, the neurologists that will be providing telestroke coverage, EMS leadership at the state and county level, and the two major emergency physician groups in Honolulu. As the project rolls out, I think we will be well situated for the sustainability plan, which is based not just on stroke, but on community paramedicine and the ability of emergency physicians to see patients in the field who are treated and not transported. 

What is an early learning that you would share with an organization launching a similar telehealth program?  

The lesson is to be inclusive. We probably could roll this project out faster, in terms of a ‘technical go-live,’ if we just chose a technology ourselves and then cajoled EMS to put it on the rigs. But I doubt that would be a very effective long-term strategy versus something that they provided feedback on and is baked into their typical workflows and sustainable. 

Part of being inclusive is not just with the EMS leadership but building relationships with the paramedics themselves. One of the ways we are doing that is by working with the community college that does the paramedic training in the state of Hawaii. By including the paramedic students in this process of studying different tools in the ambulance, when they start their job, telehealth will just be a normal part of what they do as a paramedic because it was part of their schooling.  

How do you see participation in the Telehealth Network Grant Program (TNGP) impacting your broader telehealth efforts?  

The great thing about this grant program, and I did not know this going into it, is all the available resources. Historically I have applied to grants to get funding to do a project. TNGP is more than that. The convening role as part of our technical assistance and the administrators of TNGP are as important, if not more important, than the money. I could probably go and find another funding source but getting together organizations and individuals that have done this or are doing this — being able to compare notes with peers and share experiences — is as valuable as the funding itself. 

Some of the organizations that are in our class may be new to this project, but they have experience doing what I want to do, which is prehospital telehealth. The ability to make connections that I can leverage to get advice on things, like what technology works or did not work for you, or how did you get your paramedics to do this, has been so valuable. 

Also, it is because of an early conversation with our technical assistance provider that we are now working on getting covered for the ambulance as an originating site. I had not conceived of the telestroke project that way. I assumed those would be unbilled services, but the services themselves have great value, so the concept of going to the payer and getting data from the payer about how the project would save on a total cost of care on their side, came entirely from our technical assistance.

What will your organization be doing more of or differently to emerge stronger from the pandemic?

For the record, I would rather have slower telehealth adoption than have what we are living through right now; but for adoption of telehealth, the pandemic has been a real catalyst. All the things that we are doing with telestroke we planned before the pandemic. The pandemic has normalized use of telehealth as a standard clinical workflow, and we certainly saw that at Queen’s in terms of the sheer volumes. Prior to the pandemic, we projected to do 2,500 telehealth visits that year, which is a fair amount of telehealth as an organization. We ended up doing 150,000 telehealth visits, so it has been pretty incredible in terms of accelerating the adoption. 

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