2 of 24/7 NP and TelEmergency physician staﬃng partnership was US $53,000 per month per spoke, compared with an estimated US $72,000 per month for a traditional physician staﬃng model [4]. The NP and physician partnership system allowed participating spoke hospitals to provide emergency services equivalent to a physician-only model while realizing signiﬁcant cost savings. In TelEmergency, stroke presentation was a top-ten most common complaint category in the patients over 75 years of age, representing 6% of the diagnoses. Overall patient satisfaction with a TelEmergency program was very high, 94% indicating comfort in the system and practitioner partnership [4]. Other countries, including Australia, England, Scotland, Netherlands, and Canada have adopted midlevel providers in rural and remote regions to address workforce shortage [5]. The midlevel providers have provided safe, high-quality, and cost-eﬀective care. There are many published examples of both NPs and PAs practicing telemedicine [6–9]. In vascular neurology, it is notable that there is a rural metropolitan disparity in acute stroke care with a shortage of vascular neurologists and an aging-aware population. There is more public pressure than ever before. Healthcare organizations are answering by establishing primary stroke centers. However, acquiring the needed work force remains challenging. One solution would be to utilize specialized NPs or PAs. The primary objective of this preliminary study was to establish the feasibility of 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. A secondary objec- tive was to assess agreement between VN-NP and vascular neurologist over the NIHSS score, diagnosis (stroke or nonstroke), head CT interpretation (radiological contraindi- cation to thrombolysis or not), and overall thrombolysis eligibility (yes or no). Thirdly, the encounter time (minutes) intervals of the VN-NP vascular neurologist consultative partnership experience were evaluated. 2. Methods A fully operational single-hub, multirural spoke hospital telestroke network existed in Arizona, United States of Amer- ica. A description of how the early hub and spoke network was established with descriptions of the technological factors, information technology, security, data encryption, the audio visual (AV) camera system, and technique, and prospective reliability have already been published [9–14]. The hub stroke team (on-call 24 hours per day, 7 days per week) was contacted directly by a ring-central operated alphanumeric group pager system or smart phone when a patient with acute stroke symptoms presented at the spoke emergency department. When on-call with the stroke team (1 week per month) the designated hub VN-NP telephoned the applicable spoke emergency department and spoke brieﬂy with the spoke emergency physician in order to determine patient eligibility status for AV consultation. The published STRokE DOC AZ TIME and STARR AV telestroke consultation algorithm was replicated [10, 15]. International Journal of Telemedicine and Applications Eligible consented patients underwent consultation. The hub VN-NP established audio and video contact with the spoke site and immediately acquired a medical history from patients and all the accompanying relatives, supplemented by verbal and written reports from emergency medical systems (EMS), physicians, and nursing staﬀ. Following the history acquisition, the VN-NP, certiﬁed in National Institutes of Health stroke scale (NIHSS) exam- ination, performed the evaluation with the aid of healthcare provider staﬀ at the spoke site. Other relevant elements of the examination were performed by, or reported to, the NP as appropriate. Diagnostic test results were reported to the VN-NP by the spoke emergency physician, either verbally or by electronic-fax (e-fax). The e-fax is a system in which faxed material is received via e-mail. Head computed tomography (CT) images were viewed by the hub VN-NP with digital imaging and communications in medicine (DICOM) viewer. The hub VN-NP completed a prespeciﬁed consultation report form, which included acute time intervals, eligibility criteria checklist for thrombolysis, NIHSS scoring, CT eval- uation checklist, and laboratory ﬁndings. Clinical deﬁcit and functional scale scores (including the NIHSS and prestrike- and poststroke- modiﬁed Rankin scale (mRS) score) were calculated by the VN-NP with the information provided by the bedside emergency physician or other healthcare providers. After a review of the history, the examination ﬁndings, stroke scales, head CT interpretation, laboratory results, and electrocardiogram, the VN-NP communicated with the supervising hub vascular neurology consultant. Communication between the VN-NP and vascular neu- rologist was generally by telephone as they were not in the same location. In every consultation the VN-NP presented a synthesis of the case, the diagnosis, and a recommendation regarding patient eligibility for intravenous thrombolysis to the supervising consultant. The consultant, also certiﬁed in the NIHSS examination, established audio and video contact with the spoke site and was free to repeat, or request a repeated, examination item and could interact with patient, relatives, witnesses, and emergency nurses and review head CT. Within approximately 10 minutes, the consultant notiﬁed the VN-NP of whether or not there was agreement regarding the NIHSS score, CT interpretation, diagnosis, and treatment recommendation. Once consensus was reached (within approximately 5 minutes), the VN-NP presented the recommendation regarding patient diagnosis and eligibility for intravenous thrombolysis to the spoke emergency physician. The VN-NP dictated a consultation summary note, and the consultant added a brief supervisory note. Once transcribed, both were transmitted to spoke emergency department by e-fax. Copies were maintained in the hub and spoke healthcare records. Hub hospital stroke center providers included a Neu- rovascular Education and Training in Stroke Management and Acute Reperfusion Therapy (NET SMART) NP graduate and ﬁve vascular neurologists. Equipment included internet- enabled desktops and laptops with cameras for hub providers and telemedicine platform systems at remote emergency departments [16]. The software enabled site-independent access to two-way audio and high-resolution video, over