Tele-ICU comes of age

ATA session examines the benefits of telemedicine in intensive care
By Mike Miliard
03:13 PM

After 25 years, virtual critical care is getting a closer look.

The time is right for tele-ICU. The need for more intensive-care beds is acute. The cost of caring for critically ill patients has never been higher. Intensivists are in short supply, and only getting scarcer as the population gets older.

That was the case made in a Tuesday afternoon session at the American Telemedicine Association's 18th Annual International Meeting & Trade Show titled "The Tele-ICU: How to Communicate, Compare and Evaluate Models of Care, Technology and Value?"

Herb Rogove, DO, chief executive officer of Ojai, Calif.-based C3O Telemedicine, laid out the numbers: There are 5,800 acute care hospitals in the this country of 312 million people, with some 67,000 ICU beds. More than 55,000 ICU patients are treated each day, he pointed out.

And even though there are more than 40 million people aged 65 and older in this country, there are fewer and fewer physicians who can care for them as they age.

"By the year 2020, we'll be 22 percent shy in number of intensive care physicians needed," said Rogove.

Enter the tele-ICU, a concept that's been around for a quarter-century but has only recently started to get the attention it deserves.

There's more than one way to approach a tele-ICU initiative, said Rogove.

There's the centralized model, in which "you a have a facility – a bunker – in which you have nurses, a doctor and administrative support that goes out to your spoke hospitals and provides that level of care," he said.

Then there's the decentralized approach, which allows physicians to "be anywhere," said Rogove. "Intensivists can be in their office, they can be in their car, they can be at home, using various modes of technology to communicate directly with that hospital."

There are seemingly obvious benefits to implementing one version or the other, he said, such as a reduction in mortality rates and hospital lengths of stay and a positive return on investment. But it's true, too, that there are skeptics who want to see hard evidence. Does mortality really go down? Reduced length of stay? "Prove it."

It's sometimes "difficult to assess financials," he said, and for some facilities the "long-term economic benefit is not clear."

Those barriers so common to other types of telemedicine initiatives can be a huge headache, too, said Rogove. Licensure is "absolutely the most agonizing, ridiculous, costly process you can ever go through," he said. He recalled that one such process took 14 months. Reimbursement is often problematic, of course. And credentialing can be "another costly three-month process."

Even still, it's usually worth it in the end, Rogove argued – as long as an organization is clear about which path to take, and ensuring it's the right one. It's important to ask tough questions, he said, and lay out a clear roadmap about how – and how far – to deploy the IT.

"It's disruptive technology, of course, but we don't want to disrupt the process and flow of patient care; we don't want to add more," he said. "A good tele-ICU program provides satisfaction because we've made it easier for the people that are on the front lines, getting the support from the ICU to make it a fully-integrated system that works seamlessly."

These are essential things to ponder, said Rogove: "Do you want a model that's continuously monitoring the patient and intervening? Or do you want an as-needed, coverage at night? Do you want to untether your doctors from their computers and just use smartphones and tablets?"

A centralized tele-ICU works best with larger populations and with more sophisticated IT networks. It means that "a tremendous amount of data is collected" and is well suited for vertical growth.

The decentralized model is cheaper – there's less cost for real estate because "people are on the go." It might be a good fit for smaller organizations – one or two rural hospitals, say. Its open architecture means it's relatively easy to add other specialties, and it's a good candidate for vertical growth.

In the closed model, "physicians are taking care of patients in their own hospital, and specialists – from the neurologist all the way down to the neurosurgeon – have to call down to the center to find out what's going on," said Rogove. "They can't take a look at the ventilator waveforms or the EKG monitor: they're really dependent on the physicians and nurses to give them information."

In the open approach, "you have an ICU doc that can beam in," he said. "You have specialists that could be anywhere remotely – in a car, even. We've done consultations at rest stops in Texas, off the 405 freeway in Los Angeles, at LAX. Thanks to broadband, we're able to give tPA or take care of a critical patient."

"Your tele-ICU can be whatever you want it to be," said Rogove. "It's up to you, because it's your tele-ICU."

Theresa Davis, RN, clinical operations director for the enVision eICU at Inova Health in Falls Church, Va., said her organization drew up its own specific definition of its own tele-ICU: "A network of visual communication and computer systems which provide the foundation for a collaborative inter-professional care model focusing on critically ill patients."

But it's about so much more than mere technology, she said.

Conceiving and building a tele-ICU "is the most major relationship-building experience of your life," she said. "When you come into it, you're thinking about the technology, but the technology is a just communication tool. The relationships last a lifetime. The way you build trust to be able to work from a remote site is key to building those relationships."

Yes, the return can be hard to gauge, sometimes.

"ROI is the most challenging piece of all of this, because it's hard to prove where those benefits occurred. Was it the tele-ICU? Or the ICU? Or was it what the tele-ICU and the ICU did together?" said Davis.

"But I'm here to tell you, it's the last one," she said. "If you build those relationships and you integrate those teams and you use the technology, you will see improved outcomes."