There are a number of opportunities to employ health information technology (HIT) in the realm of clinical neurology. Some applications, such as telemedicine, have been well developed and field-tested, whereas others represent areas for future expansion. This article will discuss the use of telemedicine for early diagnosis and treatment of stroke in rural areas, the use of home monitoring of warfarin, and the opportunity to develop custom software to assist in the management of patients with epilepsy.
Diagnosing Stroke at a Distance
Stroke represents a leading cause of morbidity and is the fourth leading cause of mortality in the United States. Some 800,000 strokes occur annually in the U.S.1 Prompt access to a neurologist can impact the care of stroke patients; in many rural areas, a neurologist is not immediately available. By the time a patient can be transported to a stroke center, it may be too late to treat with medications that could potentially change the outcome, such as the thrombolytic agent tissue plasminogen activator (TPA). In order to be effective, TPA should ideally be administered within a 3-hour time interval after onset of stroke symptoms, but in some instances the time window can be extended to 4.5 hours.2,3 Patients must be evaluated by a neurologist to determine whether they are appropriate candidates for TPA administration.2 Telemedicine applications have been proposed as a solution to bring the services of a neurologist to the bedside, regardless of whether the patient is in a rural area or a densely populated urban neighborhood where traffic issues would prohibit timely transportation to a stroke center.
Rural telemedicine and telestroke initiatives have been successful in a number of states. The REACH (Remote Evaluation of Acute Ischemic Stroke) program in Georgia was successful in enhancing stroke care in participating hospitals.4 The program, developed by the Medical College of Georgia, used a 100% web-based two-way audiovisual system that allowed a neurologist to conduct a detailed remote physical examination of the stroke victim, review all laboratory data, including imaging data such as CT scans, and then make a decision about the appropriateness of TPA. With this approach, those stroke victims who are appropriate candidates for TPA can be treated promptly at a community hospital within an optimal window of time and then transported after treatment to the regional stroke center.
The initial experience in Georgia was at seven rural community hospitals in 2003-2004.4 During this time, 75 patients were evaluated by a neurologist via the remote telemedicine link, and 12 patients were treated with TPA. There were no treatment complications, such as intracranial hemorrhage. Consults were generally initiated within 45 minutes after the patient arrived at the emergency room, and when indicated, TPA was administered an average of 2 hours and 15 minutes from stroke onset.
A similar program was initiated in New York State in 2006 under the auspices of the New York State Department of Health and served as a national model for statewide deployment of telemedicine services for stroke care.5,6 In the New York implementation, five trauma centers, considered to be “hub sites,” were initially identified throughout the upstate area (Albany Medical Center, Albany; SUNY Upstate University Hospital, Syracuse; Bassett Hospital, Cooperstown; Strong Memorial Hospital, Rochester; and Millard Fillmore Hospital, Buffalo). Each hub was affiliated with community “spoke” hospitals. Neurologists at the hub sites were on call and available for teleconsultation with patients who presented to the community hospital spoke sites. The involvement of the state health department was critical for developing solutions for licensing and credentialing issues for the consultants. In addition, Medicaid coverage for the service was made available in New York, including enhanced reimbursement for the facility administering TPA and grant money for community hospitals to purchase telemedicine equipment.7,8
In a 2012 survey of 97 stroke programs in the U.S., it was determined that 57 of them had active telemedicine programs for stroke.9 Thirty-eight of these programs in 27 states agreed to participate further in the survey. Ninety-five per cent of all sites used high-quality two-way interactive video conferencing to support the neurologic consultation.9 About half of the sites were able to electronically review the CT scan. Neurologists providing the consults were employed by the hub hospital in 75% of the programs, and in a quarter of the programs, outside contracted specialists were used. In 86% of the sites, consultation was available 24 hours a day, 7 days a week. Third-party reimbursement was problematic in some states; there was no applicable insurance coverage in 43 percent of the programs.9
Telestroke programs represent an important application of HIT in the field of neurology, and with improved third-party reimbursement and standardized policy implementation for licensure and credentialing, these programs are likely to become the standard of care for stroke patients in rural areas.
Anticoagulant Management
Anticoagulation services for patients with atrial fibrillation are another area where HIT in conjunction with point-of-care analytics can have a major impact. In the classic analysis of risk factors for stroke from the Framingham Study, atrial fibrillation was found to be an independent risk factor associated with a five-fold increase in the risk of stroke.10 Maintaining therapeutic levels of the anticoagulants used to treat atrial fibrillation, as measured by the prothrombin time and international normalized ratio (PT-INR), is a critical component of the care of such patients to prevent stroke, and also to prevent hemorrhage caused by excessive anticoagulation.
Home devices now exist for rapid determination of the PT-INR. Studies show that the majority of patients can successfully be trained to use these devices with minimal coaching, thereby providing valuable preventive care opportunities.11 Other studies suggest that patient self-testing of the PT-INR can improve the quality of anticoagulation and reduce complications such as hemorrhage and thromboembolic events, thereby maintaining the patient in a state of well-being with consistent values within the normal range.12,13 Patients using home PT-INR devices can transmit their readings directly to their clinician team over the Internet using software that will interface with the clinician’s electronic health record (EHR), thereby keeping the healthcare team up-to-date with the patient’s progress. Medicare now provides coverage for home PT-INR monitoring for a number of indications, including atrial fibrillation.
Potential for Managing Epilepsy
The management of patients with epilepsy has become increasingly complex with the introduction of many new agents. This can be particularly problematic for the family physician or internist who might be seeing a patient who has epilepsy along with other co-morbid medical conditions. Thus, the management of epilepsy reprepresents an opportunity for HIT innovation.
The first-generation antiepileptic drugs, such as carbamazepine, phenytoin, phenobarbitol, and primidone, have a high risk of drug interactions.14 These drugs can induce many CYP450 and glucuronyl transferase enzymes and can reduce the serum levels of other agents that are substrates of these enzymes. Examples of potentially interacting drugs include cyclosporine A, oral anticoagulants, and a variety of cardiovascular, antineoplastic, and psychotropic drugs.14 Valproic acid can interact with phenobarbital and lamotrigine by inhibiting their metabolism.14
During the period from 1989 to 2009, there were 14 new antiepileptic drugs (classified as second- or third-generation drugs) introduced into the marketplace. The second-generation antiepileptic drugs are felbamate, gabapentin, lamotrigine, levetiracetam, oxcarbazepine, pregabalin, rufinamide, stiripentol, tiagabine, to-piramate, vigabatrin, and zonisamide.15 The third-generation drugs are eslicarbazepine acetate and lacosamide.15 Several hundred pharmacokinetic interactions have been described for antiepileptic agents; there are fewer pharmacodynamic interactions. Overall, the second-and third-generation antiepileptic drugs are less interacting than the first-generation drugs.15
Because patients with epilepsy are often treated with more than one antiepileptic agent, it is important for clinicians to be aware of interactions between agents. Comprehensive analyses and tables of the clinically relevant interactions have been published.15-17 There are 139 known pharmacokinetic interactions between concurrent antiepileptic drugs.16 In addition, among the new agents, a total of 68 pharmacokinetic interactions with other drugs have been described. The most interacting of the newer drugs are lamotrigine (n = 22), topiramate (n = 18) and oxcarbazepine (n = 7).17 There is a great need for comprehensive neurologic software in an EHR that can map out a patient’s epileptic treatment history, along with other agents, and provide a custom report of potential clinically relevant interactions. Current electronic prescribing packages have general algorithms that can alert the clinician to potential interactions, but there is not currently a custom software package that is specifically designed for neurologically active agents.
Conclusion
In summary, there have been major advances in stroke management with telemedicine applications, and this technology is rapidly becoming the standard of care in rural areas where a neurologist is not otherwise available. The management of patients with atrial fibrillation to lower the risk of stroke has been enhanced by point-of-care technology coupled with software that can automatically report the results of home monitoring of the PT-INR to the clinical care team. In the care of patients with epilepsy, there are hundreds of potentially relevant drug interactions, complicated by the introduction of many new agents in the past few years. There is a great need for customized neurologic EHR software that can be employed by clinicians to help manage the complex needs of patients with epilepsy.
REFERENCES
1. Roger VL, Go AS, Lloyd-Jones DM, et
al. Heart disease and stroke statistics–2012 update: a report from the
American Heart Association. Circulation. 2012;125:e2-e220.
2. Adams HP Jr, Brott TG, Furlan AJ, et
al. Guidelines for thrombolytic therapy for acute stroke: a supplement
to the guidelines for the management of patients with acute ischemic
stroke. A statement for healthcare professionals from a Special Writing
Group of the Stroke Council, American Heart Association. Circulation. 1996;94:1167-1174.
3. Del Zoppo GJ, Saver JL, Jauch EC,
Adams HP Jr. Expansion of the time window for treatment of acute
ischemic stroke with intravenous tissue plasminogen activator: a science
advisory from the American Heart Association/American Stroke
Association. Stroke. 2009;40:2945-2948.
4. Wang S, Gross H, Lee SB, et al. Remote evaluation of acute ischemic stroke in rural community hospitals in Georgia. Stroke. 2004;35:1763-1768.
5. NYS Department of Health. Telemedicine
initiative using REACH (Remote Evaluation of Acute Ischemic Stroke)
System.
www.health.ny.gov/professionals/hospital_administrator/telestroke/reach.htm.
Accessed November 24, 2013.
6. NYS Department of Health. Rural
hospital telemedicine/telestroke initiative.
www.health.ny.gov/professionals/hospital_administrator/telestroke/.
Accessed November 24, 2013.
7. NYS Department of Health. Medicaid
update. Coverage of specialist consultations via telemedicine. September
2006.
www.health.ny.gov/health_care/medicaid/program/update/2006/sep2006.htm#tele.
Accessed November 24, 2013.
8.
NYS Department
of Health. Medicaid update. Expanded coverage of telemedicine
specialist consultations. July, 2010.
www.health.ny.gov/health_care/medicaid/program/update/2010/2010-07.htm#exp.
Accessed November 24, 2013.
9. Silva GS, Farrell S, Shandra E, et al.
The status of telestroke in the United States: a survey of currently
active stroke telemedicine programs. Stroke. 2012;43:2078-2085.
10. Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. Stroke. 1991;22:983-988.
11. Dolor RJ, Ruybalid RL, Uyeda L, et
al; THINRS Site Investigators. An evaluation of patient self-testing
competency of prothrombin time for managing anticoagulation:
pre-randomization results of VA Cooperative Study #481—The Home INR
Study (THINRS). J Thromb Thrombolysis. 2010;30:263-275.
12. Gadisseur AP, Breukink-Engbers WG,
van der Meer FJ, et al. Comparison of the quality of oral anticoagulant
therapy through patient self-management and management by specialized
anticoagulation clinics in the Netherlands: a randomized clinical trial.
Arch Intern Med. 2003;163(21):2639-2646.
13. Heneghan C, Alonso-Coello P,
Garcia-Alamino JM, et al. Self-monitoring of oral anticoagulation: a
systematic review and meta-analysis. Lancet. 2006;367:404-411.
14. Perucca E. Clinically relevant drug interactions with antiepileptic drugs. Br J Clin Pharmacol. 2005;61:246-255.
15. Landmark CJ, Patsalos PN. Drug interactions involving the new second- and third-generation antiepileptic drugs. Expert Rev Neurother.
2010;10:119-140.
16. Patsalos PN. Drug interactions with
the newer antiepileptic drugs (AEDs)-Part 1: pharmacokinetic and
pharmacodynamic interactions between AEDs. Clin Pharmacokinet. 2013;52:927-966.
17. Patsalos PN. Drug interactions with
the newer antiepileptic drugs (AEDs)-Part 2: pharmacokinetic and
pharmacodynamic interactions between AEDs and drugs used to treat
non-epilepsy disorders. Clin Pharmacokinet. 2013;52:1045-1061.
To comment on this article, contact rdavidson@uspharmacist.com
