The general diagnostic and treatments steps, within each health care setting, are presented in a simplified workflow shown in Figure 2.

The three algorithms work as a handy framework for the most critical steps in the care of patients with ischemic or hemorrhagic stroke. These algorithms were based on decision trees that represent the clinical requirements and specifications of the system and consist of checklists and questionnaires [27] evaluating common physiological variables, the patient’s clinical background, different predictors and scales, and specific laboratory tests according to each algorithm stage. The responses to these questionnaires determine the next step to be performed.

The predictors, scales, and scores implemented in this system allow the assessment of the vascular insult severity and neurological status of the patient. Other factors that determine patient management, either in situ or in a distant health care setting, are shown in Table 1. The clinical background, physical exam, stroke severity, and radiological findings were stored in basic modules within the clinical algorithms. These modules, as implemented in our telestroke system, are shown in Table 3. The software outputs corresponding to specific diagnoses, clinical scenarios, and transfer decisions are shown in Table 4. The checklists for risk assessment before the administration of reperfusion therapies [24] are detailed in Table 2.

The algorithms included in the three health care settings were incorporated into web-based software. Individual user profiles were created for the administrative staff and health care providers, who were assigned specific privileges.

A user-friendly interface reduces human error and assures the completeness and integrity of the information. The questionnaires implemented were straightforward and only required single-click selections instead of free-text typing for easy and rapid data input. The software was developed using the Hypertext Preprocessor and JavaScript languages and could be executed in any web browser on a laptop, tablet, or smartphone.

For data storage, a MySQL 5.1.40 database (Oracle Corporation, Redwood City, CA) was used, wherein sensitive data were encrypted (ie, patient identification). Data were stored in a structured relational database, allowing future evaluation of the system performance as well as a strong foundation for public health policies. The database included the administrative information of each facility in the telestroke network and the possible referral facilities (ie, those that have a given facility that was contracted to receive patients when a transfer is required). This information allowed the rapid selection of the most suitable stroke center according to the patient’s needs after a judicious assessment of the clinical requirements and transfer times. Given that “time is brain,” potential administrative pitfalls between primary health care settings and advanced health care settings also had to be considered for a quick and effective transfer. In our country, patients may be transported to various emergency departments until they are accepted in one of them, producing a critical delay in the required care known as “the death ride.”

Since a patient can arrive at any given hospital and may be transferred across several health care settings without receiving adequate stroke care, a “case” starting point was defined as the time when the first medical contact was documented in the last visited hospital until the final patient outcome was reported before the patient’s discharge. Therefore, when a patient is transferred to a second health care setting, all the information for the case is available in the receiving facility given that all data are stored in a server database and shared with all the facilities. This design decision allows common access to the patient’s health condition at any moment from any health care setting while also avoiding the entry of redundant information. Hence, past medical history, current clinical condition, blood test results, imaging evaluations, and procedures are available in real-time for all health care facilities across the whole spectrum of stroke patient care. In addition, this allows transfer reporting to the referral facilities ahead of the patient’s arrival, avoiding prolonged waiting times at emergency departments.

Software validation was performed in different phases. The first phase consisted of a simulation of the test scripts on all possible workflow pathways for each of the health care settings, which was performed to validate adequate software representation of each the algorithms. To validate the software implementation, more than 1211 test scripts were performed covering all possible pathways in each of the predefined health care settings. The second phase consisted of a retrospective registry of cases from our stroke database (nearly 600 patients in the last 5 years). The third phase was the validation of the software by neurology residents, who utilized the software while also performing a usual clinical assessment with printed forms. The final phase is to be performed between different health care facilities to test the performance of our telestroke network with real-life cases and transfers based on the information broadcast. The total number of possible pathways documented after this initial experience was as follows: 10 in the primary health care setting, 39 in the intermediate health care setting, and 1162 in the advanced health care setting.

The final system was named Telestroke-RU (copyright 13-70-240, 03/12/2018 from the National Copyright Office, Colombia) and is available for authorized users [28]. This system is not a product intended for commercial or profit uses and may be used for educational purposes.

The comprehensive telestroke platform developed in this work is the first stage to optimizing health care delivery for patients with stroke symptoms regardless of the entry point into our local emergency network in both urban and rural regions.

This system supports health care personnel by providing adequate stroke care and facilitating the prompt transfer of patients to a more appropriate health care setting according to the specific cerebrovascular disease at presentation. This system facilitates stroke care delivery for patients with acute ischemic stroke within the therapeutic window who are candidates for reperfusion therapies. Therefore, the system will contribute to mitigating the well-known mortality and morbidity associated with stroke.

Further evaluations will be performed to assess the true impact of this tool in terms of reductions in critical time windows, such as the time between symptom onset and reperfusion, door to needle time, primary health care setting to advanced health care setting transfer times, discharge clinical outcomes, accuracy of the final diagnosis, and the clinical outcomes of patients at 30 and 90 days using the modified Rankin scale [29].

To the best of our knowledge, in our country, there are no software tools for the assessment and management of patients with stroke symptoms. Worldwide, smartphone apps and web-based tools are available [30-34]. These solutions were designed for acute ischemic stroke care, for triage protocols, and as an aid for transfers when reperfusion therapies are needed (eg, Field Assessment Stroke Triage for Emergency Destination score) [30] as well as the delivery of efficient inpatient or ambulatory stroke care [32,34]. Other tools have been developed with the purpose of the evaluation of specific clinical scales or radiological scores [33]; these tools use the same algorithm independent of the level of resources available at the entry point to the health care system. In contrast, our system integrates 12 clinical and radiological scales, scores, and predictors according to the specific health care setting or the referral facility to provide a specific diagnosis (hemorrhagic stroke; acute, subacute, or chronic ischemic stroke; TIA; stroke mimic). Our system allows either immediate treatment or further transfer to the appropriate health care setting. Since our solution is not integrated with the hospital electronic health record (EHR) system, it can be used in all health care services, independent of the EHR system used at each facility. It is worth mentioning that, in our country, EHR systems are not available at several rural primary health care settings.

The continuous improvement of evidence-based stroke care guidelines motivates the continuous review of health care setting algorithms and, therefore, software updates. Further work includes the use of GPS and traffic applications to calculate the actual duration of real-time patient transfers and adequate selection of the referral facility with the shorter transfer time. In the short-term, this system will be migrated to a smartphone app to allow for a greater number of system users in a friendlier interface.

The implementation of this system in a telestroke network contributes to the fulfillment of and adherence to recently published stroke care guidelines, providing evidence-based practice, improving patient outcomes, and supporting the achievement of several requirements to achieve and maintain primary stroke center certification.

This telestroke system allows the assessment of different therapeutic alternatives according to the specific patient’s clinical condition, thus improving efficiency and providing high-quality delivery of care. Finally, the epidemiological information stored in the database will inform public health care policies to design and implement better national policies for remote regions with significant underreporting of acute cerebrovascular diseases.