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NEW Stroke Systems of Care
NEW Stroke Systems of Care

4. Virtual Stroke Care

Notes
  • For details in setting up virtual stroke care programs, refer to the CSBPR Virtual Stroke Care Implementation Toolkit.75
  • Please refer to each other CSBPR module for details on specific application of virtual care relevant to that topic area (e.g., acute stroke care, stroke rehabilitation, secondary prevention).5-11, 76
  • Note, provincial virtual care frameworks and implementation processes may vary across jurisdictions.
Recommendations and/or Clinical Considerations
4.0 General Principles of Virtual Stroke Care
  1. Virtual stroke care should be available as an alternative or adjunct to in-person stroke care for individuals with stroke across the continuum of care as appropriate when in-person care is not available [Strong recommendation; Moderate quality of evidence]. Refer to Heart & Stroke virtual care decision framework for additional information.91 
  2. All stroke care providers should consider the use of virtual care technology for assessment and management of individuals with stroke [Strong recommendation; Low quality of evidence].
  3. Virtual care modalities should be integrated into stroke systems of care planning and service delivery across the continuum (i.e., from pre-hospital to acute stroke care, stroke prevention, stroke rehabilitation and self-management, home-based therapy, and ambulatory care) to support optimal recovery of individuals with stroke, provide support for families, and ensure equitable access to care throughout Canada [Strong recommendation; Moderate quality of evidence]. 
  4. Virtual stroke care should be offered to eligible individuals and when an in-person visit is not feasible or not available, and the goals of the visit can be achieved virtually [Strong recommendation; Moderate quality of evidence]. 
  5. Clearly defined criteria, protocols and algorithms should be available to help referring stroke providers determine when and how individuals with stroke may benefit from virtual care, in consideration of individual preferences [Strong recommendation; Low quality of evidence]. Refer to Heart & Stroke virtual care decision framework for additional information.91 
  6. Healthcare providers and individuals with stroke should be aware of available virtual care resources to support competency in operating these resources for clinical care [Strong recommendation; Low quality of evidence].
  7. Individuals with stroke who have functional or sensory limitations such as communication or visual, should not be excluded from consideration for virtual care encounters [Strong recommendation; Low quality of evidence].

Section 4.0 Clinical Considerations

  1. Personal and cultural preferences should be considered when an individual with stroke is eligible for both virtual and in-person stroke care, and the clinician is able to offer either one or a combination of both options.
4.1 Planning Delivery of Virtual Stroke
  1. Preparations for implementing a virtual stroke care program should involve:
    1. A clear identification of program goals [Strong recommendation; Low quality of evidence].
    2. A needs assessment to identify local barriers and enablers to offering virtual stroke care [Strong recommendation; Low quality of evidence].
    3. An implementation plan to address barriers and incorporate enablers [Strong recommendation; Low quality of evidence].
    4. A process for continuous quality improvement [Strong recommendation; Moderate quality of evidence].
4.2 Technology for Virtual Stroke Care
  1. Technologies including internet, hardware (e.g., computers, mobile devices, telephones), video-conferencing platforms, and remote monitoring devices, can be used to enable virtual consultations and/or virtual care delivery and support self-management [Strong recommendation; Low quality of evidence]. 
  2. Asynchronous modalities, such as emails, texts and online learning modules, may be considered where appropriate and permitted for communication, education, scheduling, and planning of care [Strong recommendation; Low quality of evidence].
  3. Documentation and transfer of relevant health information in virtual care should meet the same standards as in-person care [Strong recommendation; Low quality of evidence].
4.3 Consent and Privacy

Note, no evidence-based recommendations available for inclusion in this section.

Section 4.3 Clinical Considerations 

  1. Clinicians should follow discipline-specific and organizational virtual healthcare guidelines, policies and other mandates, as well as those established by their professional regulatory organizations, when providing virtual stroke care. 
    1. This includes requirements related to consent and privacy when delivering virtual stroke care within clinicians’ jurisdictions and the jurisdiction where the individual with stroke is receiving virtual healthcare.
  2. For individuals with stroke who do not have access to the technology required for virtual care, or did not consent to virtual care, organizations should have alternate processes available to ensure access to care.
  3. Established privacy procedures should be followed when providing virtual stroke care, such as confirming the person’s identity at the beginning of the virtual encounter and ensuring that all participants are in an appropriate setting, where privacy can be optimized.
  4. Process in place to deal with emergencies or safety issues that may occur during virtual visits.
4.4 Training and Competency
  1. Interdisciplinary team members should maintain the necessary competencies to provide safe and appropriate virtual stroke care using designated virtual healthcare platforms [Strong recommendation; Low quality of evidence]. 
  2. Referring and consulting service providers should be trained in using virtual stroke care systems and understand their roles and responsibilities for technical and clinical aspects of a virtual stroke care consultation [Strong recommendation; Low quality of evidence].

Section 4.4 Clinical Considerations

  1. Individuals with stroke and their families and caregivers should receive advanced education about optimizing participation in virtual care sessions. Areas to address may include:
    1. Access and use of digital technology and web platforms.
    2. Health literacy.
    3. Language and communication limitations.
    4. Preparation for virtual stroke care sessions, including appropriate clothing, lighting, and equipment that are needed to facilitate the encounter. 
    5. Alternate means of contact should the system be interrupted, or a safety issue occur.
Rationale +-

Virtual care offers a flexible and accessible approach to managing stroke across the continuum of care, from acute treatment to rehabilitation and long-term follow-up. It enables timely access to specialists, particularly in underserved or remote areas, supporting rapid assessment and triage in the hyperacute phase (e.g., telestroke for thrombolysis decisions). During rehabilitation, virtual platforms can facilitate interdisciplinary therapy, promote continuity of care, and enhance patient engagement through home-based monitoring and exercise programs. In the long term, virtual care supports ongoing management of risk factors, medication adherence, and patient education, contributing to secondary prevention and reducing the likelihood of recurrent stroke. By bridging geographical and logistical barriers, virtual care strengthens the coordination and quality of stroke care across all stages.

Individuals with stroke value the flexibility and accessibility that virtual stroke care can support, including more equitable access to care and resources, especially when access to in-person services may not be available or feasible. They recognize that there may also be benefit to combining virtual and in-person visits to help meet differing needs of the individual with stroke, at different points of their recovery. For example, they reflect on the benefit that in-person visits provided, particularly at the beginning of recovery, to provide reassurance and motivation. They stress the importance of collaborative decision making when determining when to utilize virtual stroke care and that use may depend on the type of therapy being provided, comfort level of the individual receiving care with virtual modalities, familiarity and skill level of the healthcare provider with virtual modalities, and safety cautions that need to be considered. Equitable access to necessary infrastructure, such as internet connections and technology is also a factor. The potential challenges for those engaging in virtual stroke care have been identified as discomfort with use of technology and low digital literacy, being unfamiliar with what virtual care is and how it can be used, as well as cognitive and/or visual changes that may increase difficulty of participating in virtual rehabilitation.

Individuals with stroke stress that virtual modalities should not replace all in-person visits and emphasize that different individuals will prefer a different style of visit, pending on the goal of the encounter. They also encourage options, where appropriate, for individuals to participate virtually in groups, so that they can build connections with other individuals also recovering from stroke. By integrating virtual stroke care that is tailored to the unique needs and preferences of each individual, while ensuring a balanced approach that maximizes the benefits of both virtual and in-person interactions throughout the recovery journey, the stroke care system can support diverse individual needs.

System Implications +-

To ensure that as many of these virtual stroke care recommendations as possible are implemented across Canada, health system leaders, funders, and administrators at all levels of government and in all regions need to be actively engaged in and committed to building sustainable models for virtual stroke care. Many of the enablers listed below are beyond the scope of direct clinical care providers and many health professional groups.  

Health system leaders, funders and administrators should ensure that all healthcare providers have the necessary tools, resources, and processes to provide high-quality, evidence-based stroke care across the full continuum of care.   

For virtual stroke care, the following actions, structures, resources, and processes need to be considered: 

  1. The need for appropriate technology and access to stable internet and phone services to support virtual stroke care for healthcare providers and individuals with stroke. 
  2. The need to train and support healthcare providers and individuals with stroke on how to use virtual stroke care technologies.
  3. Virtual stroke care should be integrated and seen as part of larger regional or provincial stroke delivery plans that decentralize expertise to support clinical care in less well-resourced areas. Inherent in such a system are clear criteria, protocols, algorithms, and service agreements for the transfer and repatriation of individuals with stroke when clinically indicated. 
  4. A governance structure with a clear framework of accountabilities for virtual stroke care services is required. This includes facility, regional and/or provincial levels of governance. 
  5. The considerable human resource implications include establishing the appropriate number of healthcare providers to participate in virtual encounters, and right-sizing the work force to take into account the time taken away from the in-person clinical duties of consulting clinicians at their places of work.
  6. Clear guidelines and processes for healthcare provider reimbursement need to be established as part of the development of a virtual stroke care program. 
  7. The need for service agreements that address the availability of maintenance and technical support to ensure the clinical requirements of virtual care are met.
  8. The need for all users of a virtual stroke care system to be aware of their roles and responsibilities and know how to use the technology. This includes regular updates to maintain competence.  
  9. The need for agreements and protocols for interprovincial and territorial consultations where appropriate and time efficient, and where service gaps exist. 
  10. Processes need to be established to monitor and evaluate virtual stroke care services, including the use of validated data collection mechanisms and the establishment of standardized key quality indicators. 
  11. Provincial healthcare administrators need to work together to build sustainable models for cross-border care delivery. Licensing requirements for virtual healthcare vary among provinces and territories. Healthcare professionals may have to be licensed in multiple jurisdictions, possibly both in their location and in the location of the individual with stroke receiving care. In addition, special requirements and/or conditions on the provision of services may be required in some jurisdictions. Privacy legislation should also be followed in each applicable jurisdiction. 
  12. Virtual stroke care may present challenges with consent. In addition to obtaining informed consent for the proposed treatment, healthcare professionals may want to ask individuals with stroke to read and accept standard terms and conditions for virtual stroke care and services and document the consent and any discussion. 
Performance Measures +-

Refer to other CSBPR modules for additional virtual stroke care performance measures relevant to those specific topic areas (e.g., acute stroke care, stroke rehabilitation, secondary prevention).

System indicators

  1. Cost effectiveness of virtual stroke care compared to in-person stroke care, within each setting where virtual care is provided.
  2. Proportion of individuals with stroke who have access to virtual care modalities regardless of geography, income, age, or disability (e.g., internet, devices, digital literacy).
  3. Proportion of individuals with stroke with access to appropriate technology (internet, device).
  4. Proportion of individuals with stroke in underserved populations accessing virtual care (e.g., rural, Indigenous).
  5. Proportion of stroke care providers using evidence-based virtual care guidelines and protocols with appropriate documentation of each visit.

Process indicators

  1. Median wait times from referral to first appointment for a scheduled virtual stroke care encounter.
  2. Proportion of individuals with stroke who receive stroke assessment and/or management through virtual healthcare modalities. 
  3. Proportion of individuals with stroke who underwent a virtual care session indicated by the presence of the virtual care consultant’s note in the person’s health record.
  4. Median duration of scheduled virtual stroke care encounters, with values reported separately for each service (e.g., physician, nursing, allied health).
  5. Proportion of virtual stroke care encounters requiring urgent transfer of individuals with stroke to an in-person healthcare visit.
  6. Proportion of virtual stroke care encounters disrupted by technical difficulties faced by the healthcare provider.
  7. Proportion of virtual stroke care appointments provided using synchronous two-way video conferencing compared to by telephone only. 
  8. Proportion of virtual stroke care visits with documentation in the individual’s health record.

Patient Oriented Outcomes and Experience Indicators

  1. Clinical outcomes for virtual vs. in-person care (e.g., BP control, stroke risk factors). 
  2. An individual with stroke’s reported experience with virtual stroke care related to attributes such as feasibility, satisfaction, quality, sound, visual clarity, reliability of technology, and ease of use. 
  3. Proportion of virtual stroke care encounters disrupted by technical difficulties faced by healthcare provider or individual with stroke. 
  4. Median time from referral for virtual stroke care to first virtual stroke encounter. 
  5. Proportion of individuals with stroke who report they were able to communicate effectively with provider.
  6. Proportion of individuals with stroke who report feeling involved in decision-making during virtual visit.
  7. Patient-reported experience of their safety during virtual stroke care encounters, including prevention of risks. 
  8. Proportion of virtual stroke care encounters that included family members and/or caregivers who were in a different location from the individual with stroke.
Implementation Resources and Knowledge Transfer Tools +-

Resources and tools listed below that are external to Heart & Stroke and the Canadian Stroke Best Practice Recommendations may be useful resources for stroke care. However, their inclusion is not an actual or implied endorsement by the Canadian Stroke Best Practices or Heart & Stroke. The reader is encouraged to review these resources and tools critically and implement them into practice at their discretion.

Healthcare Provider Information

Resources for Individuals with Stroke, Families and Caregivers

Summary of the Evidence +-

Evidence Table and Reference List 4

Telestroke, or virtual interventions, care can be used to enhance stroke care delivery across the entire continuum—from acute diagnosis and triage to rehabilitation and secondary prevention. 

Virtual Care for Acute Ischemic Stroke

Acute virtual stroke care – or Telestroke - can be used to increase access to thrombolytic treatment at facilities that lack 24 hour, 7 days a week onsite stroke expertise, using 2-way audiovisual equipment to carry out a detailed stroke examination, combined with a system to reliably transmit CT scan results. The safety, feasibility and efficacy of the “hub & spoke” model, which connects a tertiary stroke center to one or more distant primary care centers, has been established in many studies conducted in Europe and North America. In some of these studies, although minor technical difficulties were reported, the number of patients treated with intravenous thrombolysis increased at the spoke sites where telestroke systems were implemented and the symptom onset-to-treatment time decreased. The outcomes of 153,272 patients treated at hospitals with and without telestroke capacity following admission for acute ischemic stroke in the United States, were compared. 92 The frequency of reperfusion therapies received was significantly higher at telestroke hospitals (6.8% vs 6.0%; difference, 0.78 percentage points; 95% CI 0.54-1.03, p < .001). The likelihood of receiving thrombolysis and thrombectomy, were both significantly higher at telestroke enabled hospitals (RR=1.12, 95% CI 1.08 to 1.17 and RR=1.42, 95% CI 1.25 to 1.62, respectively). Both 7 and 30-day mortality was significantly lower in the telestroke hospitals (7-day: 6.03% vs. 6.33%; RR=0.95, 95% CI 0.92 to 0.99, 30-day:13.1% vs 13.6%; RR=0.96, 95% CI 0.94 to 0.99). 

In a systematic review, Mohamed et al. 93 compared the outcomes of patients who received thrombolysis with alteplase via telemedicine consultation to those who were treated through conventional, in-person care. The results of 33 studies (2 RCTs) and 12,540 patients were included, of whom 7,936 (63.9%) were thrombolyzed. Mean times from symptom onset to thrombolysis administration and door-to-needles times were similar between the groups. The odds of a good clinical outcome were not significantly higher in patients treated conventionally. The odds of 90-day mortality were not increased significantly in patients treated with telemedicine, nor were the odds of symptomatic intracerebral hemorrhage significantly higher in the telemedicine group. In Ontario, Porter et al. 94 conducted an audit to determine whether the safety outcomes of 214 patients treated using the Ontario Telestroke Program with intravenous thrombolysis over a two-year period were comparable with those of 1,885 patients treated at regional stroke centres, district stroke centres and non-designated centres. The administration of alteplase using telestroke was not associated with an increased risk of death within 7 or 90 days (adjusted hazard ratio [HR] =1.29, 95% 0.68- 2.44 and adjusted HR=1.01, 95% CI 0.67-1.50, respectively), nor was its use associated with an increased risk symptomatic intracerebral hemorrhage (ICH) or poor outcome (adjusted HR= 0.71,95% 0.29-1.71 and adjusted HR=0.75, 95% CI 0.46-1.23, respectively). Also using data from Ontario, Ho & Fawcett 95 compared the outcomes of patients who were treated with either intravenous thrombolysis with alteplase or endovascular thrombectomy (EVT) who were assessed after a telemedicine or an in-person assessment. There were no significant differences between the groups in median door-to-needle times for alteplase administration, door-to-puncture time for EVT, or in the percentage of patients with early symptomatic intracranial hemorrhage, or 3-month mortality.

Virtual Stroke Rehabilitation

The results from a rapidly expanding volume of literature suggests that virtual stroke rehabilitation can be both feasible and effective compared with in-person encounters. The authors of recently published systematic reviews examining remotely delivered therapy reported that measures of balance, upper and lower extremity motor function, mobility, and performance of activities of daily living, were not significantly different compared to those of persons receiving conventional rehabilitation, and in some cases, were superior.96-101 In the Cochrane review authored by Laver et al., 97 virtual care was also used successfully to treat persons with speech and language impairments and low mood post stroke. Knepley et al. 102 reported that functional outcomes among those that received virtual stroke rehabilitation were equivalent or better compared with those that received in-person therapy, as was patient satisfaction. Additionally, some virtually provided therapies were less costly than in-person therapy.  

Several recent RCTs have examined virtual therapies for both upper and lower-limb rehabilitation. Late-Life Function and Disability Instrument scores were improved in both the virtual care group and the usual care group that received standard rehabilitation therapies, following hospital discharge in the Singapore Tele-technology Aided Rehabilitation in Stroke (STARS) trial in which 124 patients were randomized to receive 3 months of physiotherapy (PT) and occupational therapy (OT) via a tele-rehabilitation system using an iPad based system to provide exercises 5 days a week. 103 In the Augmented Community Telerehabilitation Intervention (ACTIV) trial, 104  a structured 6-month program using face-to-face sessions, telephone contact, and text messages to augment stroke rehabilitation was compared with usual care. The ACTIV focused on two functional categories: “staying upright” and “using your arm” and was provided to patients with a stroke occurring an average of 6 months previously, by physical therapists. There were improvements in both groups in the physical subcomponent of the Stroke Impact Scale (SIS 3.0), the primary outcome at 6 months, and the SIS subcomponents, with no significant differences between groups. The outcomes of patients who received virtual rehabilitation services have also been shown to be better than those who received conventional outpatient therapy. The Fugl-Meyer Assessment scores of patients who received a 12-week telerehabilitation program were significantly higher compared to those who received the same duration of outpatient therapy. 105 In the same study, telerehabilitation was found to be non-inferior for the modified Barthel index.

Adaptation of existing rehabilitation programs may offer alternative solutions to in-person therapy. Yang et al. 106 provided a virtual version of the Graded Repetitive Arm Supplementary Program (GRASP) over 10 weeks, to 9 persons with residual difficulty using their affected upper extremity following remote stroke. There were significant improvements over time for all outcome measures, which included the Arm Capacity and Movement test (ArmCAM), a new assessment tool developed for online use.

Assessment of performance-based measures in a virtual setting has not been well studied and poses challenges. Some previously validated outcome measures may not be appropriate, feasible or valid for virtual use. It remains to be determined whether new assessment tools will need to be developed and validated for virtual use. In some cases, adaptation of an existing measure may be sufficient. For example, Peters et al. 107 developed a version of the Fugl-Meyer (FM) assessment, suitable for virtual care use (FM-tele) and demonstrated its feasibility. In addition, although the sample size was small (n=5), the proportional agreement between the FM-tele conducted in person and conducted remotely by the same assessor, one week apart, was good. Both patients and assessors reported some issues with technical difficulties, a common complaint when using virtual platforms.  Inter-rater reliability of the Balance Scale, Fugl-Meyer Assessment and the Action Research Arm Test has been shown to be good to excellent when comparing in-person assessments with those conducted virtually through videoconference.108, 109

Stroke Prevention

There are several ways in which virtual care can be used to facilitate secondary prevention interventions. Telehealth consultations with physicians, including neurologists or primary care providers, enable timely medication management, risk factor control (e.g., hypertension, diabetes, atrial fibrillation), and individualized patient counseling without requiring in-person visits. Remote monitoring technologies can track blood pressure, glucose levels, and heart rhythms (e.g., for atrial fibrillation detection), allowing for prompt response to abnormal readings. Virtual self-management programs and mobile health apps can also provide reminders for medication adherence, lifestyle modification tools (e.g., smoking cessation, diet, physical activity), and stroke warning sign recognition.

Virtual care interventions (remote monitoring and telephone-based counselling or support, or web-based interventions), were associated with significant reductions in both systolic and diastolic blood pressure (MD= -4.37 mm Hg, 95% CI -5.50 to -3.24 and MD= -1.72 mm Hg, 95% CI -2.45 to -0.98, respectively) in a systematic review of 13 RCTs including 3,803 participants with a history of stroke or TIA +/- hypertension.110 Telehealth interventions were also associated with better medication adherence (SMD=0.52, 95% CI 0.03 to 1.00). In the SPRINT INDIA trial, 4,298 patients, recruited from 31 centres, following a first stroke were randomized between 2 days and 3 months after symptom onset to an intervention group that received 68 regular short SMS messages and 6 short videos that promoted risk factor control and medication adherence, or to a usual care group. At one year, there was no significant difference between groups in the primary outcome (a composite of recurrent stroke, high-risk TIA, acute coronary syndrome, or death) or any of its components; however, patients in the intervention group were more likely to reduce or quit drinking alcohol, reduce smoking and be more compliant with medications. 111 In a systematic review by Deng et al. 112 that included 32 randomized controlled trials of patients with established arteriosclerotic cardiovascular disease, outcomes were compared between those randomized to a telemedicine-based secondary prevention (TOSP) group and those receiving usual care. Participants in the TOSP group received remote interventions delivered through telemedicine modalities such as phone calls, text messages, mobile apps, emails, and remote monitoring. Phone-based telemedicine interventions significantly improved body mass index, blood pressure, and enhanced exercise capacity. The effects on medication adherence, diet, knowledge, self-efficacy, depression, anxiety, and safety were inconsistent across studies. Combined remote monitoring and consultation was associated with a significant reduction in the risk of cardiovascular mortality and a reduction in the risk of cardiovascular hospitalisation, in patients with heart failure who received telehealth interventions. 

Virtual interventions can also be used in primary prevention to improve cardiovascular risk factors. Jaén-Extremera et al. 113 included 28 studies including 5,460 persons from the general public with one or more of the following conditions or habits: diabetes, hypertension, obesity, hypercholesterolemia, sedentary lifestyle and smoking. Telemedicine and e-health interventions were targeted at ≥1 of the 6 conditions. E-health interventions were associated with a significant decrease in hemoglobin A1c in persons with diabetes, a significant decrease in systolic and diastolic blood pressure in persons with hypertension, and a significant decrease in weight in those who were overweight. Salisbury et al. reported that monthly phone calls with a health advisor resulted in significantly lower systolic and diastolic blood pressures in participants with a 10-year cardiovascular disease risk of 20% or more, no previous cardiovascular event, at least one modifiable risk factor, and was also associated with significant improvements in diet, physical activity, drug adherence, and satisfaction with access to care, compared with usual care. 114 Digital health interventions including telemedicine, web-based strategies, email, mobile applications, text messaging, and monitoring sensors significantly reduced the risk of cardiovascular events including myocardial infarction, stroke, or revascularization, hospitalizations, and all-cause mortality (RR=0.61, 95% CI, 0.46–0.80, p<0.001) in a systematic review of 51 studies (n=23,962 participants).115

Sex & Gender Considerations

Research in this area is limited. Pérez-Sánchez et al. 116 compared the outcomes of 3,009 men (57.3%) and women (42.7%) with suspected stroke, attended to in a telestroke network over two years. There were no significant differences in the proportions of men vs. women who received treatment with thrombolytics, thrombectomy, or both interventions, nor were there differences in process times between the groups (time from symptom onset to Emergency Department arrival, door-to-needle time, or door origin-to-arterial puncture time). There were no significant differences between groups in 90-day or 3-month mortality, or good function (modified Rankin Scale ≤2) outcome at 3 months. Women may be less likely to consent to receiving thrombolytics. 117

Stroke Resources
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