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Obstacles and solutions in the implementation of telestroke: billing, licensing, and legislation.

The American Heart Association in its 2013 Stroke Statistics Update1 reports the annual direct and indirect costs of stroke in the United States to be $62.7 billion, with 15% to 30% of stroke survivors being permanently disabled and 20% requiring institutional care at 3 months after stroke. Rapid recognition and accurate diagnosis are critical to optimize outcomes in patients with acute stroke. Patients treated within 90 minutes of stroke onset with the thrombolytic tissue-type plasminogen activator (tPA) have increased odds of improvement at 24 hours and favorable 3-month outcomes compared with patients treated later than 90 minutes.2,3 Timely thrombolytic treatment also substantially lowered the long-term costs of stroke.4

In the United States, there are ≈4 neurologists per 100 000 people, caring for >700 000 acute strokes per year,5 although many parts of the United States lack access to acute stroke services entirely.6 Telemedicine provides a means to increase access to limited specialty expertise and facilitate timely remote neurological assessment, neuroimaging evaluation, and therapeutic decision making for patients with acute stroke.

In its 2009 Scientific Statement, which reviewed evidence for the use of telemedicine within Stroke Systems of Care, the American Heart Association/American Stroke Association “recommended that a stroke specialist using high-quality videoconferencing provide a medical opinion in favor of or against the use of tPA in patients with suspected acute ischemic stroke when on-site stroke expertise is not immediately available.”7

In making this class 1 recommendation, the American Heart Association/American Stroke Association cited studies that showed increased rate of tPA treatment and good functional outcomes at telestroke network hospitals. The TEMPiS project established high-quality videoconferencing services to a network of 12 regional hospitals in Bavaria serviced by 2 stroke centers.8 It reported a 10-fold relative increase in tPA treatments at telestroke …