In this small, single-centered study we maintained high-quality continuous video transmission along primary ambulance corridors using a low-cost mobile telemedicine platform. The system is designed to be portable and adaptable, with generalizability for rapid assessment of emergency conditions in which direct observational exam may improve prehospital diagnosis and treatment. Thus mobile telestroke assessment is feasible using low-cost components and commercial wireless connectivity. More research is needed to demonstrate clinical reliability and efficacy in a live-patient setting.

Objectives: In this 2-center study, we assessed the technical feasibility and reliability of a low cost, tablet-based mobile telestroke option for ambulance transport and hypothesized that the NIH Stroke Scale (NIHSS) could be performed with similar reliability between remote and bedside examinations.Methods: We piloted our mobile telemedicine system in 2 geographic regions, central Virginia and the San Francisco Bay Area, utilizing commercial cellular networks for videoconferencing transmission. Standardized patients portrayed scripted stroke scenarios during ambulance transport and were evaluated by independent raters comparing bedside to remote mobile telestroke assessments. We used a mixed-effects regression model to determine intraclass correlation of the NIHSS between bedside and remote examinations (95% confidence interval).Results: We conducted 27 ambulance runs at both sites and successfully completed the NIHSS for all prehospital assessments without prohibitive technical interruption. The mean difference between bedside (face-to-face) and remote (video) NIHSS scores was 0.25 (1.00 to 20.50). Overall, correlation of the NIHSS between bedside and mobile telestroke assessments was 0.96 (0.92-0.98). In the mixed-effects regression model, there were no statistically significant differences accounting for method of evaluation or differences between sites.Conclusions: Utilizing a low-cost, tablet-based platform and commercial cellular networks, we can reliably perform prehospital neurologic assessments in both rural and urban settings. Further research is needed to establish the reliability and validity of prehospital mobile telestroke assessment in live patients presenting with acute neurologic symptoms. Neurology ® 2016;87:19-26 GLOSSARY AHA 5 American Heart Association; ASA 5 American Stroke Association; AV 5 audiovisual; BA 5 Bland-Altman; CI 5 confidence interval; EMS 5 emergency medical services; 4G 5 fourth generation; HRSA 5 Health Resources and Services Administration; iTREAT 5 Improving Treatment with Rapid Evaluation of Acute Stroke via Mobile Telemedicine; LTE 5 longterm evolution; NIHSS 5 NIH Stroke Scale; TJEMS 5 Thomas

Quality Improvement Success Stories are published by the American Diabetes Association in collaboration with the American College of Physicians, Inc., and the National Diabetes Education Program. This series is intended to highlight best practices and strategies from programs and clinics that have successfully improved the quality of care for people with diabetes or related conditions. Each article in the series is reviewed and follows a standard format developed by the editors of Clinical Diabetes . The following article describes a resident-led initiative that improved diabetic nephropathy screening in a primary care clinic. It also highlights the challenges of complex metrics, as well as the potential unintended consequences of emphasizing one dimension of a care process over another.

Introduction: In-ambulance use of remote videoconferencing for prehospital stroke assessment (mobile telestroke) is an emerging innovation in acute stroke care. As a new technology, there is a dearth of technical standards to ensure transmission quality and guide deployment in various EMS settings. Hypothesis: Subjective video quality ratings during in-vehicle mobile telestroke assessment correlate to objective video data transmission metrics. Methods: We performed videoconferencing via a low-cost, utilitarian mobile telestroke platform: tablet endpoint, high-speed 4G LTE modem, external antennae, HIPAA-secure videoconferencing application, and portable bracket mounting. We held test calls along typical ambulance routes recording transmission quality by a stationary and a mobile rater. We used a standardized 6-point scale of video quality: rating ≥ 4 deemed acceptable for mobile telestroke assessment. We recorded jitter, the variance in transmission data reception order, as simultaneously reported by the videoconferencing application. Results: We completed five test runs yielding 64 data ratings. Average jitter for ratings 1 through 6 was 434.9ms (SD = 407), 106.1ms (SD = 110), 41.4ms (SD = 29), 35.3ms (SD = 15), 29.5ms (SD = 6), and 29.0ms (SD = 2) respectively. Analyzing the raw data yielded an R2 of 0.41. As seen in Chart 1, video quality decreased as average jitter increased, but jitter values as low as 30ms were still seen across video transmission of all qualities. Conclusion: These preliminary data suggest modest correlation of transmission variance with subjective quality ratings using a low-cost mobile telestroke platform along rural-based ambulance routes. However, average transmission variance correlated highly (R2 = 0.93) suggesting more data ratings may improve the correlation. Testing of our mobile telestroke platform to assess performance and clinical efficacy as well as incorporate live acute stroke encounters is ongoing.