4 Table 3: Consultation time intervals. VN-NP Telemedicine Algorithm (mean Time Interval and standard deviation, minutes) Onset to Door 32.3 ± 20.5 Onset to Call 42.8 ± 21.2 Onset to Lab 110.5 ± 12.0 Onset to Decision 112.6 ± 31.1 Onset to rt-PA 159.0 ± 8.5 Door to Call 19.6 ± 18.7 Door to Consent 39.8 ± 26.0 Door to Lab 75.0 ± 32.4 Door to Neuro Exam 54.2 ± 15.1 Door to CT Reading 78.2 ± 23.4 Door to Decision 69.6 ± 9.6 Call to Consent 21.0 ± 10.8 Call to Neuro Exam 31.5 ± 11.5 Call to Decision 53.2 ± 9.0 Consent to Neuro Exam 9.0 ± 16.8 Consent to Decision 30.7 ± 19.3 Consent to rt-PA 67.0 ± 30.5 Decision to rt-PA 45.5 ± 21.9 Deﬁnitions: Onset:stroke symptom onset time or the time the subject was last known to be at baseline state; Door:emergency department triage time; Lab:time lab results reviewed; Decision:time that thrombolysis eligibility was determined; rt-PA:time of IV rt-PA administration; Consent:time of subject or representative written consent; Neuro Exam:time that the NIHSS evaluation started; CT Reading:time that CT was interpreted. The results from this preliminary study demonstrated the feasibility of establishing a VN-NP and a supervising vascular neurologist partnership to respond, emergently, to telestroke hotline activations in a single hub, multirural spoke hospital telestroke state network compared to those of published traditional vascular neurology consultant telestroke service provision in the same network (STRokE DOC AZ) and a comparable network in a neighboring state (STRokE DOC) [12, 15]. This bodes well in a relatively busy telemedicine net- work hub responding to many, and sometimes, simultaneous stroke alerts. The algorithm proposed is built upon the success of midlevel providers practicing emergency medicine and telemedicine, but there is a fundamental diﬀerence. In our study algorithm, both the VN-NP and the vascular neurology physician specialist were practicing telemedicine remote from the emergency patient. The concept of telestroke is already a decade old but its broad and growing utilization is relatively novel. Elements of this consultative modality remain controversial, debated, researched and pose limita- tions and obstacles to wide-scale adoption. We believe this to be the ﬁrst published description of VN-NPs as telestroke providers. We anticipate the continued, and growing, need for stroke providers and suspect that vascular neurologist numbers, alone, will not suﬃce. Stroke-trained midlevel practitioners, together with telemedicine, may provide a practical and cost-eﬀective solution. International Journal of Telemedicine and Applications In this study, it is important to clarify the scope of practice for NPs and PAs. The healthcare organization, Mayo Clinic, where this study took place, spans three states and employs both NPs and PAs. The policies regulating the scope of practice for NPs and PAs are consistent system wide and are collectively classiﬁed as Advanced Midlevel Practitioners (AMLPs). Many healthcare organizations have policies governing the practice of AMLPs that may diﬀer from the state boards. A study funded by the National Center for Health Workforce Analysis bureau of Health Professions compared changes in the professional practice for NPs, PAs, and certiﬁed nurse midwives from 1992 and 2000 [17]. The PA is a physician extender whose scope of practice is determined by the supervising physician who delegates or assigns duties within their specialty. However state laws and regulations play a signiﬁcant role as well [18] whereas in most states NPs are not dependent on upon physician delegation or supervi- sion with autonomy and have full prescriptive rights [19]. In this study the supervision of the NP by the col- laborating physician is important. Stroke telemedicine is a new frontier. Recently, vascular neurologists were conducting studies to determine if they could accurately and safely make decisions on the use of thrombolysis for acute stroke utilizing audio-video consultation. The research team determined that a partnership of a physician and NP would be a conservative and safe next step for a pilot study. The results could inﬂuence the development of collaborative or solo NP acute stroke telemedicine practices. Many NPs and PAs are becoming more subspecialized in their practice. The NET SMART-APN is the ﬁrst-ever fellow- ship for neurovascular care. It is a federally funded, evidence- based, neurovascular fellowship program supported by the Healthcare Services and Resources Administration. Eighty- one APNs are currently enrolled in the curriculum, and 15 will graduate in 2010. At stroke centers with newly graduated NET SMART APN fellows, the thrombolysis treatment rates have increased substantially [16]. The NET SMART program includes 14 learning modules, with “CT Imaging in Acute Stroke” included as a fundamental topic. The 28-hour module incorporated both online didactic and preceptored training by vascular neurologists and Neuroradiologists with 20 acute stroke cases to be signed oﬀ for accuracy. NET SMART graduates who become proﬁcient with telemedicine techniques have all the requisite skills to serve as providers for rurally located stroke patients in the emergency department, the hospital, and during postdischarge followup clinics. Acute care NPs role in telemedicine practice is expanding. According to the Joint Commission, the medical staﬀ determines which services can be appropriately delivered via telemedicine [20]. All practitioners, including NPs, who diagnose and treat patients using telemedicine technology, are subject to the credentialing and privileging processes of the receiving organization [20]. A receiving organization may elect to use the credentialing information gathered by another JC accredited facility, provided that the receiving organization makes the decisions delineating privileges [20]. The Arizona Board of Nursing does not make reference to NPs and telemedicine. NPs do not require a supervising