Diabetic Nephropathy Screening in a Residency Clinic: Improvements Also Reveal Limits of Healthcare Effectiveness Data and Information Set (HEDIS) Metric.

Quality Improvement Success Stories are published by the American Diabetes Association in collaboration with the American College of Physicians, Inc., and the National Diabetes Education Program. This series is intended to highlight best practices and strategies from programs and clinics that have successfully improved the quality of care for people with diabetes or related conditions. Each article in the series is reviewed and follows a standard format developed by the editors of Clinical Diabetes. The following article describes a resident-led initiative that improved diabetic nephropathy screening in a primary care clinic. It also highlights the challenges of complex metrics, as well as the potential unintended consequences of emphasizing one dimension of a care process over another.

A low-cost, tablet-based option for prehospital neurologic assessment: The iTREAT Study.

OBJECTIVES: In this 2-center study, we assessed the technical feasibility and reliability of a low cost, tablet-based mobile telestroke option for ambulance transport and hypothesized that the NIH Stroke Scale (NIHSS) could be performed with similar reliability between remote and bedside examinations. METHODS: We piloted our mobile telemedicine system in 2 geographic regions, central Virginia and the San Francisco Bay Area, utilizing commercial cellular networks for videoconferencing transmission. Standardized patients portrayed scripted stroke scenarios during ambulance transport and were evaluated by independent raters comparing bedside to remote mobile telestroke assessments. We used a mixed-effects regression model to determine intraclass correlation of the NIHSS between bedside and remote examinations (95% confidence interval). RESULTS: We conducted 27 ambulance runs at both sites and successfully completed the NIHSS for all prehospital assessments without prohibitive technical interruption. The mean difference between bedside (face-to-face) and remote (video) NIHSS scores was 0.25 (1.00 to -0.50). Overall, correlation of the NIHSS between bedside and mobile telestroke assessments was 0.96 (0.92-0.98). In the mixed-effects regression model, there were no statistically significant differences accounting for method of evaluation or differences between sites. CONCLUSIONS: Utilizing a low-cost, tablet-based platform and commercial cellular networks, we can reliably perform prehospital neurologic assessments in both rural and urban settings. Further research is needed to establish the reliability and validity of prehospital mobile telestroke assessment in live patients presenting with acute neurologic symptoms.

Mobile Telestroke During Ambulance Transport Is Feasible in a Rural EMS Setting: The iTREAT Study.

BACKGROUND: The use of telemedicine in the diagnosis and treatment of acute stroke, or telestroke, is a well-accepted method of practice improving geographic disparities in timely access to neurological expertise. We propose that mobile telestroke assessment during ambulance transport is feasible using low-cost, widely available technology. MATERIALS AND METHODS: We designed a platform including a tablet-based end point, high-speed modem with commercial wireless access, external antennae, and portable mounting apparatus. Mobile connectivity testing was performed along six primary ambulance routes in a rural network. Audiovisual (AV) quality was assessed simultaneously by both an in-vehicle and an in-hospital rater using a standardized 6-point rating scale (≥4 indicating feasibility). We sought to achieve 9 min of continuous AV connectivity presumed sufficient to perform mobile telestroke assessments. RESULTS: Thirty test runs were completed: 93% achieved a minimum of 9 min of continuous video transmission with a mean mobile connectivity time of 18 min. Mean video and audio quality ratings were 4.51 (4.54 vehicle; 4.48 hospital) and 5.00 (5.13 in-vehicle; 4.87 hospital), respectively. Total initial cost of the system was $1,650 per ambulance. CONCLUSIONS: In this small, single-centered study we maintained high-quality continuous video transmission along primary ambulance corridors using a low-cost mobile telemedicine platform. The system is designed to be portable and adaptable, with generalizability for rapid assessment of emergency conditions in which direct observational exam may improve prehospital diagnosis and treatment. Thus mobile telestroke assessment is feasible using low-cost components and commercial wireless connectivity. More research is needed to demonstrate clinical reliability and efficacy in a live-patient setting.