title: Reliability of site-independent telemedicine when assessed by telemedicine-naive stroke practitioners.
abstract: BACKGROUND
  Telemedicine is used to assess patients with stroke remotely. The extent of training necessary to use these systems is unknown. A site-independent telemedicine system (used in the STRokE DOC trial) is reliable when used by telemedicine-trained investigators. We report a prospective evaluation of telemedicine's reliability when used by nontelemedicine-trained examiners.
  
  
  METHODS
  In all, 25 patients with stroke were prospectively evaluated. Two team members (one bedside, one remote) simultaneously graded each patient using the National Institutes of Health Stroke Scale (NIHSS), modified NIHSS (mNIHSS), and modified Rankin scale. Patients followed commands of the remote telemedicine neurologist, who was untrained in, and had no experience with, telemedicine.
  
  
  RESULTS
  Remote evaluations by telemedicine-naive examiners were feasible in 25 of 25 (100%) patients. One technical complication, which did not interfere with performing the examination, was noted. Median NIHSS score was 11.5. Average clinical examination took 13.9 minutes (improving from 22 to 8 minutes). Reliability was comparable with published studies, with 10/15 (67%) NIHSS and 9/11 (82%) mNIHSS items showing excellent agreement (Kappa > 0.75). Modified Rankin scale reliability was high (Kappa = 0.90). Spearman correlation (NIHSS and mNIHSS) for bedside examiner was 0.981 and for remote examiner was 0.966.
  
  
  CONCLUSIONS
  It is reliable and valid for telemedicine-naive stroke examiners to assess clinical deficit and functional outcomes using a site-independent telemedicine system. Evaluation time decreased even with minimal telemedicine exposure. Further assessments should determine whether reliability persists with a larger pool of both untrained investigators and patients, and whether reliability improves with a dedicated training program.
authors.affiliation: Department of Neurosciences, University of California, San Diego, School of Medicine, San Diego, California 92103-8466, USA. bcmeyer@ucsd.edu
authors.forename: Brett C
authors.initials: BC
authors.lastname: Meyer
authors.forename: Rema
authors.initials: R
authors.lastname: Raman
authors.forename: Marcus R
authors.initials: MR
authors.lastname: Chacon
authors.forename: Matt
authors.initials: M
authors.lastname: Jensen
authors.forename: Janet D
authors.initials: JD
authors.lastname: Werner
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009460:Neurologic Examination / Q000295:instrumentation / Q000379:methods*; D009462:Neurology / Q000193:education / Q000379:methods; D015588:Observer Variation; D011361:Professional Competence; D011446:Prospective Studies; D015203:Reproducibility of Results; D012720:Severity of Illness Index; D020521:Stroke / Q000175:diagnosis*; D017216:Telemedicine / Q000295:instrumentation