Building cohesion in distributed telemedicine teams: findings from the Department of Veterans Affairs National Telestroke Program

Telestroke Training: Considerations for Expansion of Vascular Neurology Program Requirements

Telemedicine for stroke (Telestroke) has been a key component to efficient, widespread acute stroke care for many years. The expansion of reimbursement through the Furthering Access to Stroke Telemedicine Act and rapid deployment of telemedicine resources during the COVID-19 public health emergency have further expanded remote care, with practitioners of varying educational backgrounds, and experience providing acute stroke care via telemedicine (Telestroke). Some Telestroke practitioners have not had fellowship-level vascular neurology training and many are without training specific to virtual modalities. While many vascular neurology fellowship programs incorporate Telestroke training into the curriculum, components of this curriculum are not consistent, extent of involvement is variable, and not all fellows receive hands-on training in remote care. Furthermore, the extent of training and evaluation of Telestroke in American Board of Psychiatry and Neurology training requirements and Accreditation Council for Graduate Medical Education assessments for vascular neurology fellowship are not standardized. We suggest that Telestroke be formally incorporated into vascular neurology fellowship curricula and provide considerations for key components of this training and metrics for evaluation.

Telemedicine and Teamwork Among Health Care Professionals: State of the Science

Background: As telemedicine becomes further rooted in standard patient care delivery, it is critical to understand how it may affect teamwork among health care providers. Understanding the state of the science between telemedicine and teamwork is an important first step. Obejctive: The purpose of this state-of-the-science review was to synthesize the published research on teamwork within the context of telemedicine. Methods: Data abstraction and analysis were structured following the Virtual Team Performance and the "Big Five" of Teamwork theoretical frameworks. The concepts within these models were used to organize data extraction. This state of the science used the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Results: A total of 14 studies met the inclusion criteria after final review. The most common variables were communication, tasks, leadership, team orientation, and team cohesion. Despite variable commonalities across the included articles, there was a discrepancy between improved and reduced teamwork outcomes with telemedicine. Conclusions: Multiple teamwork variables are influential across health care teams using telemedicine technologies-those that include communication, task facilitation, leadership, team orientation, and cohesion appear to have the greatest impact. However, it is not an individual teamwork variable, type of technology, or care environment alone that influences positive or negative outcomes among health care teams using telemedicine. Instead, it is a combination of factors and mechanisms that facilitate or hinder teamwork outcomes. A comprehensive model that describes the interaction of these common variables in teamwork among blended virtual and in-person health care teams is needed.

The VA National TeleNeurology Program implementation: a mixed-methods evaluation guided by RE-AIM framework

Introduction

The Veteran Affairs (VA) Office of Rural Health (ORH) funded the Veterans Health Administration (VHA) National TeleNeurology Program (NTNP) as an Enterprise-Wide Initiative (EWI). NTNP is an innovative healthcare delivery model designed to fill the patient access gap for outpatient neurological care especially for Veterans residing in rural communities. The specific aim was to apply the RE-AIM framework in a pragmatic evaluation of NTNP services.

Materials and methods

We conducted a prospective implementation evaluation. Guided by the pragmatic application of the RE-AIM framework, we conceptualized a mixed-methods evaluation for key metrics: (1) reach into the Veteran patient population assessed as total NTNP new patient consult volume and total NTNP clinical encounters (new and return); (2) effectiveness through configurational analysis of conditions leading to high Veteran satisfaction and referring providers perceived effectiveness; (3) adoption and implementation by VA sites through site staff and NTNP interviews; (4) implementation success through perceived management, implementation barriers, facilitators, and adaptations and through rapid qualitative analysis of multiple stakeholders' assessments; and (5) maintenance of NTNP through monitoring quarterly TeleNeurology consultation volume.

Results

NTNP was successfully implemented in 13 VA Medical Centers over 2 years. The total NTNP new patient consult volume in fiscal year 2021 (FY21) was 836 (58% rurally residing); this increased to 1,706 in fiscal year 2022 (FY22) (55% rurally residing). Total (new and follow-up) NTNP clinical encounters were 1,306 in FY21 and 3,730 in FY22. Overall, the sites reported positive experiences with program implementation and perceived that the program was serving Veterans with little access to neurological care. Veterans also reported high satisfaction with the NTNP program. We identified the patient level of perceived excellent teleneurologist-patient communications, reduced need to drive to get care, and that NTNP provided care that the Veteran otherwise could not access as key factors related to high Veteran satisfaction.

Conclusions

The VA NTNP demonstrated substantial reach, adoption, effectiveness, implementation success, and maintenance over the first 2 years of the program. The NTNP was highly acceptable to both the clinical providers making the referrals and the Veterans receiving the referred video care. The pragmatic application of the RE-AIM framework to guide implementation evaluations is appropriate, comprehensive, and recommended for future applications.

Features that hindered the capacity development of a national prostate cancer service

Introduction

In Scotland, prostate cancer services have struggled to meet demand, and urological cancer services have missed Scottish Government waiting time targets to a greater extent than other cancer services. This study provides understanding of the capacity development needs of a national prostate cancer service including why the service had been unable to adapt to meet demand and how capacity could be developed.

Methods

Delphi technique was applied to a purposive sample of prostate cancer clinicians working across Scotland between 2015 and 2017. Interviews were conducted with healthcare professionals involved in delivery of care to people with prostate cancer including General Practitioners, followed by questionnaires which were distributed to Specialist Nurses, Oncologists and Urologists involved in delivering specialist prostate cancer services within NHS Scotland. Findings are reported from interviews analysed using a directed approach to content analysis, followed by three rounds of iterative online questionnaires analysed using descriptive statistics.

Results

Reform is needed to meet demand within prostate cancer services in Scotland. Barriers to capacity development included: lack of shared understanding of quality of care between policy makers and healthcare professionals; lack of leadership of service developments nationally and regionally; and difficulties in drawing on other capacities to support the service. Cohesive working and a need for efficient training for nurse specialists were needed to develop capacity. Consensus was reached for development of national working groups to set standards for quality care (100% agreement) and further development of existing regional working groups (100% agreement) to implement this care (91% agreement), which should include input from primary and community care practitioners (100% agreement) to meet demand.

Discussion

This work provides important understanding of barriers and facilitators to service development across a national service, including highlighting the importance of a shared vision for quality care between policy makers and healthcare professionals. Mechanisms to support service change are identified.

One-Year Costs Associated With the Veterans Affairs National TeleStroke Program

OBJECTIVES

Access to timely care is important for patients with stroke, where rapid diagnosis and treatment affect functional status, disability, and mortality. Telestroke programs connect stroke specialists with emergency department staff at facilities without on-site stroke expertise. The objective of this study was to examine healthcare costs for patients with stroke who sought care before and after implementation of the US Department of Veterans Affairs National TeleStroke Program (NTSP).

METHODS

We identified 471 patients who had a stroke and sought care at a telestroke site and compared them to 529 patients with stroke who received stroke care at the same sites before telestroke implementation. We examined patient costs for 12 months before and after stroke, using a linear model with a patient-level fixed effect.

RESULTS

NTSP was associated with significantly higher rates of patients receiving guideline concordant care. Compared with control patients, those treated by NTSP were 14.3 percentage points more likely to receive tissue plasminogen activator and 4.3 percentage points more likely to receive a thrombectomy (all P < .0001). NTSP was associated with $4821 increased costs for patients with stroke in the first 30 days after the program (2019 dollars). There were no observed savings over 12 months, and the added costs of care were attributable to higher rates of guideline concordant care.

CONCLUSIONS

Telestroke programs are unlikely to yield short-term savings because optimal stroke care is expensive. Healthcare organizations should expect increases in healthcare costs for patients treated for stroke in the first year after implementing a telestroke program.

Considerations for the Implementation of a Telestroke Network: A Systematic Review

The application of telestroke has matured considerably since its inception in 1999. The use of telestroke is now recommended in several published guidelines. Consequently, jurisdictions without a telestroke service are seeking practical information on the best approach to implement telestroke. French et al. (2013) reviewed the challenges of implementing a telestroke network including studies between 2000 and 2010. At the time, telestroke networks were largely limited to the UK, USA, Canada and Europe and only one process evaluation had been conducted. Given the prolific expansion of telestroke services since 2010, we conducted a systematic review to determine factors associated with successful establishment, management, and sustainability of a contemporary telestroke services. A comprehensive search of telestroke studies was conducted in July 2021. Empirical studies published between 2010 and 2021 were included if they contained descriptive, evaluation or operational data on the implementation of a telestroke network. Studies were subsequently evaluated using the Consolidated Framework for Implementation Research (CFIR). The initial literature search revealed a total of 7415 potential studies; 38 of which met the inclusion criteria. The past decade of process evaluation studies has enabled a more nuanced investigations into how to implement and sustain a telestroke network. Pre-implementation planning is crucial to ensure clear telestroke processes, governance structures and stakeholder engagement. Sustainability of networks relies on securing long-term investment, providing adequate resources, and maintaining staff motivation and willingness. Recommendations are provided to overcome commonly identified barriers related to technology, staffing, planning and standardisation of processes, evaluation, and sustainability and scale-up. Further research needs to explore how new advancements in stroke care such as endovascular clot retrieval (EVT) and advanced brain imaging can be considered and planned for during the implementation of a new telestroke service.

"But it's a nice compromise" - Qualitative multi-centre study of barriers and facilitators to acute telestroke cooperation in a regional stroke network

BACKGROUND

Telemedical services can be used to complement on-site services when demand for specialists exceeds supply or when specialists are not evenly distributed across health systems. Using stroke as an example, this study aimed to explore how patients and staff experience telestroke cooperation in a stroke network in Germany.

METHODS

We conducted a qualitative multi-method and multi-centre study combining 32 non-participant observations at one hub and four spoke hospitals with 26 semi-structured interviews with hub and spoke staff as well as stroke patients and relatives. Observation protocols and interview transcripts were analysed to identify barriers and facilitators to telestroke cooperation from the perspectives of staff, patients and relatives.

RESULTS

In terms of barriers to telestroke cooperation, we found technological problems, providing the treatment for one patient from two sites, competing priorities between telestroke and in-house duties in the spoke hospitals, as well as difficulties in participating in the teleneurological examination via a videoconferencing system for older and disabled patients. In terms of facilitators, we found an overall very positive perception of telestroke provision by patients, good professional relationships within the network, and sharing of neurological expertise to be experienced as helpful for telestroke cooperation.

CONCLUSIONS

We recommend better integration of telemedical services into the care pathway, fostering relationships within the network, improved technological support and resources, and more emphasis within networks, in public awareness efforts as well as in academia on the evaluation of telemedical services from the perspectives of patients and relatives, especially older patients and patients with disabilities.