The long reach of a dedicated teleneurology team

Telemedicine, first conceived in the early 2000s, gained significant momentum during the COVID-19 pandemic, revolutionizing access to care for patients who are homebound, disabled or residing far from health care providers. Its potential has since expanded, now transforming the capabilities of rural and community hospitals through innovative partnerships and technology.

Advancing this mission, The Ohio State University College of Medicine’s Department of Neurology has developed partnerships to provide emergency stroke guidance to 31 sites, inpatient neurology support to seven sites and outpatient cognitive evaluation and treatment to one community hospital.

A key architect of this expansion is Alicia Zha, MD, clinical assistant professor of Neurology at the Ohio State College of Medicine. In 2021, Dr. Zha joined The Ohio State University Wexner Medical Center after helping to build and then leading the teleneurology program at the University of Texas at Houston. Her recruitment marked a pivotal step in developing a comprehensive teleneurology program across Ohio.

“Studies support teleneurology programs, demonstrating that they can significantly shorten median length of stay and the time from consult order to consult completion, as well as decrease the number of missed appointments,” Dr. Zha says.

Today, Ohio State neurologists and stroke specialists collaborate closely with community hospital providers, offering essential guidance for patient triage, emergent interventions and inpatient management planning. This partnership reduces unnecessary patient transfers, helps preserve inpatient bed capacity at Ohio State’s University Hospital and ensures that high-quality neurological care is delivered where it’s needed most.

Dedicated stroke specialists provide emergent assessment

The Ohio State Telestroke Network connects 31 community hospitals throughout Ohio to Ohio State neurologists, providing these facilitates with high-level expertise in the diagnosis, triage and treatment of patients presenting to their emergency departments with acute neurological symptoms. When a patient arrives with potential stroke symptoms, a telestroke consult is immediately initiated with a dedicated neurovascular fellowship-trained stroke specialist. Deepak Gulati, MD, clinical associate professor of Neurology, directs the network, which now provides care for more than 6,000 patients annually throughout the state.

“Using the latest software and robotic technology with high-resolution imaging, we can seamlessly communicate with staff in community emergency rooms, review CT scans and provide advice on the administration of clot-busting agents,” Dr. Gulati says. “We also identify patients who may benefit from thrombectomy. For patients with hemorrhagic strokes, we recommend interventions regarding blood pressure-lowering medications, anticoagulation reversal and treatments to reduce brain swelling. Additionally, we can promptly alert our surgical team, ensuring a timely and coordinated response for potential procedures.”

A distinctive aspect of our telestroke program is the presence of a transfer center nurse on every telestroke consultation, offering real-time support.

“I really appreciate this feature, as it translates into better patient care and minimizes unnecessary delays,” Dr. Gulati says. “Transfer center nurses play a key role in expediting patient transfers to Ohio State, alerting our teams, tracking critical imaging results and streamlining communication with our partner hospitals.”

Dr. Gulati highlights that the telestroke program now evaluates patients with symptom onset within a 24-hour window, reflecting advancements in stroke treatment. The treatment window has significantly expanded due to breakthroughs in randomized controlled trials and the evolution of thrombectomy techniques.

“This progress allows us to provide lifesaving interventions to more patients than ever before,” Dr. Gulati says.

The approach enables Ohio State providers to help triage patients on-site, potentially avoiding unnecessary transfer to the medical center for cases that can be successfully managed locally. However, when expertise is lacking in a local ED, transferring the patient to a tertiary referral center like the Ohio State Wexner Medical Center may be the most prudent choice. The role of the telestroke program is to provide the guidance for making these critical decisions.

Local rehabilitation is key

For patients treated at Ohio State, the focus ultimately shifts to reintegration into their community.

“After receiving care here, we aim to send patients back to their neighborhoods – whether it’s to a rehabilitation facility or for follow-up care with a local neurologist,” Dr. Gulati says. Recognizing that most stroke patients will need rehabilitation, Ohio State's social workers are expertly trained to address these needs, ensuring a seamless transition to the next stage of recovery.

Continuity of care through inpatient neurology consults

The Ohio State team extends its expertise beyond stroke care by offering teleneurology services for inpatients with other neurological conditions, such as seizures, encephalopathy, Guillain-Barré syndrome and multiple sclerosis exacerbations. Additionally, the team provides follow-up care for patients whose stroke symptoms resolve after initial treatment at community hospitals, ensuring comprehensive management through the recovery phase.

Led by Dr. Zha, this relatively recent initiative offers 24/7 neurology coverage for non-stroke neurological emergencies, maintaining high-quality care around the clock. For hospitals with in-house neurologists, the program provides supplemental support during vacations, conferences, weekends and holidays, effectively addressing critical gaps and enhancing care continuity.

According to Dr. Zha, confusion and delirium are the second most common reasons for teleneurology consultations after stroke.

“Many of our partner physicians want to exercise caution and ensure they’re not overlooking a stroke, seizure or another atypical condition,” she says, highlighting the program’s role in providing clarity and confidence in complex cases.

A Teladoc robot, mounted on a mobile cart, can be deployed throughout the community hospital, allowing consulting neurologists to replicate many of the protocols used at Ohio State, while integrating notes into the local hospital’s electronic medical record system. On-site, a nurse or nurse practitioner facilitates the consultation, serving as a vital link between the neurologist, patient and family.

“Given the limitations of Teladoc, the on-site facilitator is crucial,” Dr. Zha says. “They assist with the neurological exam and provide contextual details, such as whether a family member has just entered the room. They are our eyes and ears on the ground, ensuring a comprehensive and empathetic approach to care. At the same time, we offer them training opportunities to deepen their knowledge of neurology.”

The teleneurology program has experienced remarkable growth in a short time, expanding from approximately 100 consults in its inaugural year of 2022 to nearly 1,500 in 2023. This meteoric rise highlights the program’s significant impact and the increasing demand for its services.

“The feedback from our partner hospitals has been overwhelmingly positive,” Dr. Zha says. “Patients and their families are not bothered by the fact that the neurologist is consulting via camera. On the contrary, they appreciate being able to receive expert care while staying at their home hospital, in their own community.”

Telecognitive consults focus on the gray areas

For the growing number of people experiencing symptoms of cognitive decline, a telecognitive consult with a neurologist specializing in dementia and other cognitive disorders offers a vital resource. This service is particularly helpful for patients and providers in rural health settings, where access to specialized care may be limited.

Arun Ramamurthy, MD, a clinical assistant professor of Neurology, focuses on patients whose symptoms fall into a diagnostic gray area. These symptoms may sometimes be consistent with normal aging but are often indicative of early-stage conditions such as Parkinson’s disease or Alzheimer’s disease.

Ohio State currently maintains a telecognitive care partnership with Madison Hospital, located in London, about an hour’s drive from Columbus. Through a webcam-based telehealth program, Dr. Ramamurthy evaluates patients – typically referred by their primary care physician – providing specialized cognitive assessments and care remotely.

“Someone may have a known cognitive disorder or suspect they have one, and this can be challenging to assess,” Dr. Ramamurthy says. “Patients and their families are seeking clarity. Our goal is to determine whether the condition is one that will progressively worsen, evolving into full-blown dementia, or if it reflects normal aging or an underlying comorbidity, where we might not expect rapid progression and, in some cases, may even see improvement."

The focus of this telecognitive care program is on milder cases – patients who experience some memory issues but remain independent and generally functional. Dr. Ramamurthy notes that traditionally these patients often receive little support or information, despite the potential to address early signs of cognitive decline and provide guidance for patients and their families.

“They may be told, ‘We think it’s fine,’ or ‘Try this medication,’ or perhaps, ‘I’m not sure, but we’ll check again in six months,’” Dr. Ramamurthy says. “Our approach is different – we engage these patients by asking, ‘What can we do for you? How can we help? How can we track your progress? How can we ensure all your questions are answered?’ Providing a clear diagnosis and prognosis not only can offer reassurance but also empowers patients and caregivers to take proactive steps.

“For this population, maintaining an ongoing relationship is crucial,” he says. “Nearly everything we do needs to be monitored and measured over time to ensure we’re providing the best possible care.”

Education woven into every relationship

Education is a cornerstone of all Ohio State’s teleneurology programs, with a strong emphasis on training the neurology and emergency department teams at partner hospitals. Each Teladoc consultation not only serves the immediate medical needs of the patient, but also acts as a valuable opportunity to educate local staff. In addition to this hands-on training, Ohio State provides neurology lectures to local communities at partner sites, fostering a broader understanding of neurological care.

“We aim to be integrated into each community we serve, because they rely on us heavily,” Dr. Zha says. “One of my favorite comments from our providers is that they truly appreciate how we work hard to educate patients about their conditions and the care they’re receiving in the hospital.”