Telestroke: variations in intravenous thrombolysis by spoke hospitals.

BACKGROUND: Telestroke extends stroke expertise to underserved hospitals and facilitates treatment with tissue plasminogen activator (tPA). We investigated the variability in tPA treatment rates across 2 large telestroke networks-consisting of hubs at Georgia Regents Medical Center (GRMC) and Medical University of South Carolina (MUSC) and their affiliated spoke hospitals-to identify spoke-related factors predictive of greater tPA use. METHODS: Observational study of tPA treatment rate at 32 spoke hospitals within the GRMC and MUSC telestroke networks. Spokes were characterized by primary stroke center status, local stroke nurse coordinator, local neurology support, hospital size, post-tPA management strategy, whether the spoke hospitals paid to participate in the network, and whether the hub or the spoke hospital initially proposed the telemedicine linkage for consultations with a remote stroke specialist. Primary outcome was tPA treatment rate adjusted for emergency department (ED) volume. RESULTS: There was substantial variation in the adjusted tPA rate across spokes (range, .85-8.74 administrations/10(4) ED visits/year). Only spokes with a stroke nurse coordinator (4.75/10(4) ED visits/year versus 2.84/10(4) ED visits/year, P = .03) were associated with higher tPA use. CONCLUSIONS: The application of telestroke has variable results on tPA delivery in spoke hospitals. However, the presence of a stroke nurse coordinator at the spoke facilitated treatment of ischemic stroke cases with tPA.

Assimilation of web-based urgent stroke evaluation: a qualitative study of two networks.

BACKGROUND: Stroke is a leading cause of death and serious, long-term disability across the world. Urgent stroke care treatment is time-sensitive and requires a stroke-trained neurologist for clinical diagnosis. Rural areas, where neurologists and stroke specialists are lacking, have a high incidence of stroke-related death and disability. By virtually connecting emergency department physicians in rural hospitals to regional medical centers for consultations, specialized Web-based stroke evaluation systems (telestroke) have helped address the challenge of urgent stroke care in underserved communities. However, many rural hospitals that have deployed telestroke have not fully assimilated this technology. OBJECTIVE: The objective of this study was to explore potential sources of variations in the utilization of a Web-based telestroke system for urgent stroke evaluation and propose a telestroke assimilation model to improve stroke care performance. METHODS: An exploratory, qualitative case study of two telestroke networks, each comprising an academic stroke center (hub) and connected rural hospitals (spokes), was conducted. Data were collected from 50 semistructured interviews with 40 stakeholders, telestroke usage logs from 32 spokes, site visits, published papers, and reports. RESULTS: The two networks used identical technology (called Remote Evaluation of Acute isCHemic stroke, REACH) and were of similar size and complexity, but showed large variations in telestroke assimilation across spokes. Several observed hub- and spoke-related characteristics can explain these variations. The hub-related characteristics included telestroke institutionalization into stroke care, resources for the telestroke program, ongoing support for stroke readiness of spokes, telestroke performance monitoring, and continuous telestroke process improvement. The spoke-related characteristics included managerial telestroke championship, stroke center certification, dedicated telestroke coordinator, stroke committee of key stakeholders, local neurological expertise, and continuous telestroke process improvement. CONCLUSIONS: Rural hospitals can improve their stroke readiness with use of telestroke systems. However, they need to integrate the technology into their stroke delivery processes. A telestroke assimilation model may improve stroke care performance.

Interpretive flexibility in mobile health: lessons from a government-sponsored home care program.

BACKGROUND: Mobile technologies have emerged as important tools that health care personnel can use to gain easy access to client data anywhere. This is particularly useful for nurses and care workers in home health care as they provide services to clients in many different settings. Although a growing body of evidence supports the use of mobile technologies, the diverse implications of mobile health have yet to be fully documented. OBJECTIVE: Our objective was to examine a large-scale government-sponsored mobile health implementation program in the Danish home care sector and to understand how the technology was used differently across home care agencies. METHODS: We chose to perform a longitudinal case study with embedded units of analysis. We included multiple data sources, such as written materials, a survey to managers across all 98 Danish municipalities, and semistructured interviews with managers, care workers, and nurses in three selected home care agencies. We used process models of change to help analyze the overall implementation process from a longitudinal perspective and to identify antecedent conditions, key events, and practical outcomes. RESULTS: Strong collaboration between major stakeholders in the Danish home care sector (government bodies, vendors, consultants, interest organizations, and managers) helped initiate and energize the change process, and government funding supported quick and widespread technology adoption. However, although supported by the same government-sponsored program, mobile technology proved to have considerable interpretive flexibility with variation in perceived nature of technology, technology strategy, and technology use between agencies. What was first seen as a very promising innovation across the Danish home care sector subsequently became the topic of debate as technology use arrangements ran counter to existing norms and values in individual agencies. CONCLUSIONS: Government-sponsored programs can have both positive and negative results, and managers need to be aware of this and the interpretive flexibility of mobile technology. Mobile technology implementation is a complex process that is best studied by combining organization-level analysis with features of the wider sociopolitical and interorganizational environment.

Sustainable rural telehealth innovation: a public health case study.

OBJECTIVE: To examine adoption of telehealth in a rural public health district and to explain how the innovation became sustainable. STUDY SETTING: Longitudinal, qualitative study (1988-2008) of the largest public health district in Georgia. STUDY DESIGN: Case study design provided deep insights into the innovation's social dynamics. Punctuated equilibrium theory helped present and make sense of the process. We identified antecedent conditions and outcomes, and we distinguished between episodes and encounters based on the disruptive effects of events. DATA COLLECTION: Twenty-five semistructured interviews with 19 decision makers and professionals, direct observations, published papers, grant proposals, technical specifications, and other written materials. PRINCIPAL FINDINGS: Strong collaboration within the district, with local community, and with external partners energized the process. Well-functioning outreach clinics made telehealth desirable. Local champions cultivated participation and generative capability, and overcame barriers through opportunistic exploitation of technological and financial options. Telehealth usage fluctuated between medical and administrative operations in response to internal needs and contextual dynamics. External agencies provided initial funding and supported later expansion. CONCLUSIONS: Extensive internal and external collaboration, and a combination of technology push and opportunistic exploitation, can enable sustainable rural telehealth innovation.

An analysis of business issues in a telestroke project.

A telehealth network based at the Medical College of Georgia was established in 2003 to treat stroke patients in remote hospitals. In the first three years, more than 400 patients were evaluated at nine rural hospitals. A total of 65 patients (16%) were treated with tissue plasminogen activator (approximately half of them in less than 2 h). Although clinically successful, the system reached the point at which it would either further diffuse or die out. We examined the roles played by internal and external factors in the development of the system. We interviewed 25 individuals in five hospitals (the hub hospital and four rural hospitals). Important business issues were identified that would need to be addressed in order to expand the project and make it self-sustaining. The external factors were economic, legal and market issues. The internal factors were organizational, technical and educational issues. Early identification and negotiation of business issues related to project implementation are likely to be important in diffusion and sustainability.