US Pharm. 2014;39(1):HS18-HS20.
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
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
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
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
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
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.
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