When patients arrive at UPMC Passavant for treatment of acute stroke, the hospital's emergency physicians no longer pick up the telephone to seek input from stroke experts.

V.W.H. Campbell, Post-Gazette Demonstrating the videoconferencing technology that expands access to stroke experts, Dr. William Kristan, chairman of the Department of Emergency Medicine at UPMC Passavant, sits in the emergency room and speaks with Patrick McCarthy, director of the Healthy Lifestyle Center, who is in the intensive care unit two floors above the emergency room. Click photo for larger image.

Videoconferencing technology allows a neurologist from the UPMC Stroke Institute to appear on a computer screen and actively participate in cases 24 hours a day, seven days a week.

From their headquarters at UPMC Presbyterian, or even from their homes, stroke specialists can converse with emergency physicians, patients or their family members. They also can view CT scans and determine if patients need treatment with a clot-busting drug, known as tPA, that may reverse disabilities caused by a stroke.

"It's almost like being in the same room," said Dr. Lawrence Wechsler, the institute's director, noting the technology also has been installed at UPMC Braddock. UPMC also is seeking to use it to link its stroke specialists with other area hospitals.

In the Pittsburgh area and elsewhere, videoconferencing techniques are offering promise for expanding access to stroke experts and improving acute stroke care.

Results from early studies are favorable, though numerous issues regarding payment, appropriate security protocols, physician licensing and other matters remain to be addressed, said Dr. Larry Goldstein, director of the center for cerebrovascular disease at the Duke University Medical Center.

While Stroke Institute specialists typically aren't paid by insurers for providing the consultation, Dr. Wechsler said UPMC is implementing the technology to improve care at its hospitals.

Since the technology was installed in March, six stroke patients at UPMC Passavant have been treated with tPA, up from five in the previous three years, said Lori Massaro, a Stroke Institute nurse practitioner.

Tissue plasminogen activator, or tPA, has been available for more than a decade, but only a small fraction of the nation's stroke patients receive the drug. A survey of area hospitals conducted jointly last year by the Pittsburgh Post-Gazette and the Hospital Council of Western Pennsylvania found that tPA was given to about 3.8 percent of patients in the region whose strokes were caused by clots.

Experts note that many people ignore stroke symptoms early on and arrive at the hospital too late to qualify for tPA, which generally must be given intravenously within three hours of the onset of stroke symptoms.

Patients whose strokes are caused by hemorrhages, or who have uncontrolled hypertension or other conditions, also would not qualify.

But even if patients are eligible to receive tPA and arrive in time, some emergency physicians are reluctant to administer the drug.

TPA treatment carries a 1 in 15 risk of bleeding, which can be severe. Results of a national survey of emergency physicians released last year found that 40 percent were unlikely to use tPA even under ideal conditions.

Stroke experts could step in to help, but they may be unavailable, particularly in suburban or rural hospitals. Patients could be sent to larger medical centers with more expertise, but that, too, takes time.

Some emergency physicians just aren't convinced that the scientific case has been made for administering tPA to stroke patients, said Dr. Jonathan Edlow, vice chairman of emergency medicine at Beth Israel Deaconess Medical Center and a proponent of using the drug.

Their minds probably won't be changed by making stroke experts available through the latest technology, but the approach could make many other emergency physicians feel more comfortable about using tPA, said Dr. Edlow, who is also an associate professor at the Harvard Medical School.

Dr. William Kristan, chairman of emergency medicine at UPMC Passavant, expressed strong support for the concept. Having the ability to immediately consult with stroke experts can give emergency physicians "more confidence in using the drug," he said.

Hospitals in Massachusetts, Georgia, southern California and Utah are using the technology to treat acute stroke patients, and officials in other states have expressed interest, said Dr. Lee Schwamm, director of TeleStroke and acute stroke services at Massachusetts General Hospital and a Harvard Medical School associate professor.

In Massachusetts, the TeleStroke program provides stroke experts to 14 hospitals, he said.

Dr. Wechsler said UPMC is exploring the possibility of creating a similar network.

UPMC plans to install the technology at UPMC McKeesport, Ms. Massaro said, and has applied for a state grant to also make it available at UPMC Horizon, UPMC Bedford and UPMC Northwest. Some Western Pennsylvania hospitals not affiliated with UPMC also are interested, she said.

In Massachusetts, the technology helps some hospitals meet state standards for providing stroke care, Dr. Schwamm said.

Pennsylvania does not have a state certification for acute stroke programs, though some hospitals, including UPMC Presbyterian and Allegheny General Hospital, are certified by the Joint Commission on Accreditation of Healthcare Organizations as primary stroke centers, the only national certification available.

M.J. Hampel, senior associate director for the Joint Commission, said the technology could be used to help hospitals meet some of the center's requirements for stroke center certification.