• July 2008 FEATURE ARTICLES •
Telemedicine/Telehealth: Case History
Robotic Assistance Remedy
The Michigan Stroke Network utilizes remote presence robots to bring needed specialists to stroke patients at remote hospitals.
By E. Victor Brown, Senior Editor
One promise of telemedicine/telehealth
technology is greater access to healthcare professionals,
regardless of the remoteness of patient location. Although the
physical presence of physicians at the bedside cannot and should
not be supplanted, an aging population, rise in chronic illness
and the need for the limited number of specialists to be
everywhere at once are key drivers in the development of one
form of telemedicine/telehealth — robotic assistance. Solutions
and cooperative efforts that serve the best interests of
patients are being explored and vetted around the nation and the
world. One such success story regarding the use of robots began
10 years ago in Pontiac, Mich.-based St. Joseph Mercy Oakland
hospital (SJMO).
SJMO is a 443-bed comprehensive community
hospital and is a member of Novi, Mich.-based Trinity Health —
the 4th largest Catholic healthcare system in the United States.
Ranked in the top 5 percent of hospitals throughout the nation
for clinical excellence, and among the top 100 cardiovascular
programs in the U.S., SJMO was Michigan’s first certified
primary stroke center and is, today, one of 21 in the state with
this designation.
By 1997, SJMO was treating a large number of
stroke patients. Major advancements in stroke care began to
improve patient outcomes, with clot-busting agents becoming part
of stroke therapy. However, time to intervention still ruled
patient outcomes.
The hospital leadership had concerns, not
only about those patients with significant distance from the
hospital working against them, but also the fact that many of
the other hospitals in the state could not afford or attract the
specialists who could perform any of the specialized
interventions. "If you are trying to get patients to this
technology within a very short time frame, it requires some
different kind of program deployment than what we had in any
other system or procedure at the time," says SJMO CEO Jack
Weiner.
Robot Discovery
Over the next several years, SJMO began
looking at technological advancements in the intensive care unit
(ICU) when leadership came across a story of a Los Angeles
hospital that was using a very basic robotic technology to make
rounds in its ICU. In 2006, this led SJMO to contact the
California-based InTouch Technologies Inc., which engaged
hospital leaders in a demonstration of the vendor’s latest
remote presence robot, known as the RP-7, at a clinical systems
meeting.
The RP-7 is a wireless, mobile, remote
presence robot that can be placed under the direct control of a
remote physician seated at the vendor’s proprietary
ControlStation, or software-equipped laptop, for those
physicians who are not in a fixed remote location.
The ControlStation or laptop allows the
remote physician to control the RP-7, which can move untethered,
allowing the physician to freely interact with patients, family
members and hospital staff from anywhere, anytime. The laptop is
outfitted with an EV-DO wireless card, enabled by 3G wireless
technologies from Calif.-based Qualcomm Inc. When necessary,
physicians may use the card to gain connectivity virtually
anywhere, through the region’s broadband networks. Ultimately,
the solution bolsters patient care by allowing doctors to
interface with nurses and patients when sick or traveling.
The ControlStation and RP-7 robot are linked
via a secure combination of broadband, Internet and wireless
technologies. Together with the software and the vendor’s RP
Connectivity Service, the user has a unified system that doesn’t
require the involvement of IT personnel on either end.
Michigan Stroke Network
Although intrigued by the technology, SJMO
leadership voiced numerous concerns about deployment, acceptance
and a unified strategy for stroke care. As leadership began
brainstorming on different program approaches, they also looked
at the broader challenge of stroke intervention across the
state. "Many of these smaller hospitals had some very
significant shortcomings in their ability to provide stroke
therapy," says Weiner. "Lack of an onsite specialist to make
treatment decisions meant that transport by air ambulance would
come well outside the optimum treatment window, making for a
very expensive patient."
SJMO felt that robotic technology provided a
basis for a physician on one end of an Internet connection to
evaluate a patient and also communicate effectively with
somebody on the other end of that communication. The Michigan
Stroke Network (MSN) concept emerged from this line of thought.
The hospital had now identified a technology and devised a
program that would take its stroke expertise into rural
hospitals by leveraging the newfound technology.
The emerging concept rested on deployment of
robots into smaller hospitals — or essentially any hospital that
lacked an onsite specialist in stroke therapy. The first human
link in the concept revolved around an on-call team at SJMO that
would provide almost instantaneous access to a stroke
specialist.
Robot Vetting
Assessing the technology’s visual/audible
acuity to ensure that the appropriate information could be
conveyed was the first order of business. "Portability and
mobility were paramount in order to facilitate a relationship
with the patient and family that wasn’t scary or overwhelming,"
says Weiner.
With effective two-way communication, time of
deployment became the next question. "We couldn’t have a
technology that required a technician’s intervention or took 30
to 45 minutes to activate," says Weiner. "With the RP-7, a
physician with a laptop, software and an access code can start
the unit and control it remotely."
After preliminary testing in the ICU, clinics
and ED, a multidisciplinary team of endovascular surgeons,
neurologists and interventional cardiologists; intensivists,
clinical nurse specialists and nurse educators; as well as,
administrators and finance personnel from SJMO developed the
program concept and rollout plan.
A central tenet of MSN is that there would be
no cost to participating hospitals in the network, as the
technology is provided as part of SJMO’s community benefit
ministry program. "We ask all participating hospitals to do two
things," says Weiner. "Agree to become a Joint
Commission-certified stroke center, and make an investment in
enhancing the awareness of stroke symptom identification so
community members can do a better job of getting to a hospital
early."
Rollout
Rob Fisher, associate VP, Rural Network
Development at SJMO, and Connie F. Parliament, RN, clinical
director, Neuroscience Services at SJMO, conduct the initial
outreach to area hospitals. According to Parliament, she and
Fisher first present the technology to the remote hospital’s
administration with Parliament conveying the clinical side while
Fisher handles the business aspects. If all are in agreement,
SJMO offers a contract for inclusion in MSN.
Once signed, Parliament conducts onsite
clinical education for the medical and nursing staff. After
conducting a clinical tutorial in the ED on whether patients are
appropriate for inclusion in MSN, Parliament takes the robot to
the ICU and repeats the process. "I have the robot with me and
the laptop set up on a cart, which allows me to demonstrate the
laptop control and the robot," says Parliament. "At that point,
I encourage staff to drive the robot around the unit and work
with both sides of the system, so they can see how the two-way
communication occurs."
The SJMO campus was already equipped with an
802.11g wireless network, so the first order of business was
making sure that the remote hospitals in the network had a
compatible and robust wireless infrastructure and Internet
capabilities. According to SJMO IS Director Robert Jones, each
robot must be provided with an IP address to allow them to
connect via the Internet to SJMO. In order to pass through the
firewall at SJMO, certain ports must be opened to allow
connectivity to other sites.
Wireless access points and the mix of
wireless devices also are significant considerations. "You may
encounter some bandwidth limitations if you’re simultaneously
running wireless devices utilizing 802.11g while others utilize
802.11b, but that is true of any wireless devices that you may
put on the network," says Jones.
Joseph Bander, M.D., director of adult
critical care for SJMO, had worked with earlier versions of the
RP-7 in addition to other robotic technology. According to
Bander, earlier versions of the robot were more difficult to
steer and visualization was not quite as sharp. Today’s RP-7 has
a different lens that provides a broader view for easier
maneuvering. With simple and fluid operation, high visual acuity
and a number of potential accessories available — such as use of
a stethoscope via the robot — Bander pointed out one use beyond
stroke care. "I have assisted in cardiac arrest and
resuscitative efforts in the middle of the night, which is
superior to assistance by telephone," says Bander.
Results
With more than 34 robots in the field around
the state, but with only a single year of the robots in use,
there has not been sufficient time to conduct longitudinal
studies that accurately reflect less morbidity or mortality.
However, the network has a plethora of anecdotal data of
patients who come in, get identified, transferred and treated
and then walk home instead of being wheeled home.
Early data presented by MSN to the 2008
International Stroke Conference shows that 16 of 23 eligible
patients (70 percent) received the intravenous clot-busting drug
rt-PA; 36 percent of consults resulted in transfer; and, a total
of 190 robot hours were logged for training, education and
consultation.
MSN developed an extensive support system for
patients and families who are thrust into unfamiliar settings
after transport to SJMO. The support includes special packages
for stroke transfer patients, which are placed in the EDs of
participating hospitals. Each package contains an ID badge,
directions, parking and other info for the patient and the
family. Additionally, the program so impressed one SJMO donor,
he arranged for hotel services for families of stroke victims.
"We tried to make the total experience a supportive one and as
anxiety-free as possible," says Weiner.
Keeping control of patient care with the
primary physicians was an initial concern of hospital staff
throughout the network. MSN assured them that primary physicians
and hospitals would still be in charge to ensure that patients,
once stabilized, go back to their local hospitals for follow-up
treatment. With the success of MSN, discussions regarding
deployment to Trinity Health institutions in other states have
begun.
Although the robots have been highly
effective, MSN cautions against implementing technology for
technology’s sake. "This technology provides significant
opportunities for major advancements in access to healthcare for
rural, underserved and international communities where needs
outpace distribution," says Weiner. "If you can generate even
base incomes to support deployment and share resources, it opens
some very interesting possibilities."
The MSN Process
Upon arrival by ambulance at the network
hospital, clinical staff performs a CT scan of the stroke
patient’s brain to facilitate assessment. If the patient is
within the eight-hour window, the local hospital ED staff
calls MSN. The MSN specialist — whether at the stroke center
or some other location removed from the network hospital —
connects and appears on the robot within eight minutes of
receiving the page. That page includes the hospital name,
onset time of symptoms and the name of the ED physician
making the call. Within moments, the specialist "arrives" in
the hospital ED via the robot.
After introductions, the robot gets
escorted to the patient where the MSN specialist conducts an
assessment, reviews lab reports with the ED nurse or the
physician, and obtains a medical history from the patient
and the family as to the time the symptoms appeared and what
was observed. The MSN specialist uses the remote software to
drive the robot over to the computer to personally study the
CT scan or hard copies, and then inform the patient and
family of his diagnosis and discuss treatment options with
the ED physician.
If the patient is within the three-hour
window, the MSN specialist may recommend giving the patient
the IV rt-PA (Activase) — a clot-buster drug. The onsite ED
staff administers the drug, sometimes with the help of the
MSN specialist (who is operating the robot remotely) to
manage blood pressure. The ED staff may also recommend drugs
that should be given at that time. The MSN specialist can
view the cardiac monitor as if he was standing at the
bedside assisting the ED staff managing the patient’s care.
If the network hospital has an ICU, the patient may stay if
the IV treatment alone results in improvement. If there is no
improvement with the drug, the patient is still within the
extended eight-hour treatment window for possible adjunct
therapies and critical care management. In this scenario, the
MSN specialist contacts the case manager in the participating
hospital to authorize transport of the patient to SJMO. The case
manager then informs Medflight of a patient ready for transport.
Upon arrival at SJMO, the patient receives a CT scan and then
goes to the catheterization lab for a procedure or admittance to
the ICU.