Trans-border ICU

Physicians and nurses in a Delaware command center will monitor intensive care unit (ICU) patients in six Maryland hospitals as part of the Maryland eCare initiative. From the Washington Post:

The program, funded with a $3 million grant, “allows us to provide the same high level of care at 2 in the morning as we provide at 2 in the afternoon,” said Maryland eCare Director Marc T. Zubrow, director of critical care medicine at Wilmington’s Christiana Care Health System, where the critical care doctors will be based. “It’s about crisis prevention rather than crisis response.”

A video camera and computer terminal positioned in a patient’s room will send vital signs, test results and information about patient responsiveness to Wilmington, where a doctor and several nurses will view the data and photographs on high-resolution computer monitors.

If command center staff members see the patient’s health deteriorating, they can communicate with nurses to provide medicine or additional tests…

The technology, known as eICU, was developed by Baltimore-based Visicu, a medical technology company, and is used in about 200 hospitals throughout the country.

This initiative is interesting in its own right, because it’s extending the telemedicine concept beyond its typical bounds. However, the implications are potentially quite profound:

  • If people are comfortable with the idea of monitoring ICU patients from 50 or 100 miles away, they should be equally comfortable with a distance of 5000 or 10,000 miles. The communications links are just as good to Asia as they are to Delaware, so why not have doctors and nurses there monitoring the ICU? Actually, it could be better. When it’s 2 am in Maryland (and Delaware) it’s 2 pm in Singapore and Manila, when people are wide awake. What’s more, labor costs are a lot lower. At this point the barriers are more regulatory in nature than anything else.
  • The concept could and should be extended to the emergency department as well. We increasingly hear that specialists, such as neurologists, are refusing to take call in emergency departments. With modern communications technology much of what a neurologist does could be done remotely. At a minimum it could cut down on the number of in-person staff needed.
  • Younger physicians are increasingly seeking to limit their total number of hours at work. (The Wall Street Journal wrote about it today.) That’s a change from the medicine-is-everything attitude of earlier generations and it’s exacerbating the shortage of staff. On average, female physicians want to work fewer hours than men, especially those that want to have kids. Perhaps there’s an opportunity to tap into some underutilized resources by providing telemedicine work for stay-at-home moms and dads.

Radiology has paved the way with the “nighthawk” concept, and while there are definite advantages to in-person care, more specialties than one might initially expect can conduct at least some of their patient care activities remotely.

April 29, 2008

5 thoughts on “Trans-border ICU”

  1. I feel it important to point out that critical care is more amenable to this type of technology for a number of points. First, patients are often already attached to all necessary monitors and have multiple points of access (through IVs, central and arterial lines, etc.). Second, the physical exam in critical care is less important than the data we collect from these monitors. Likewise, many of the interventions delivered in the ICU are through changes in medication or support delivery (like changing a ventilator setting) which an intensivist can outsource to another trained professional.

    Other points of care, such as the emergency room, may be less receptive to technologies that come with the price of losing physical interaction and intervention.

  2. Interesting post – I had missed the original article. However, having drafted an extensive report about this technology (see http://www.healthpolcom.com/Documents-Publications.htm) I want to point out that one of the key things that make eICU systems effective in improving care is how well they foster effective teams among the clinicians at the bedside and within the tele-command center. Creating effective teamwork among those people in different geographic locations is often requires face-to-face interactions as well as virtual meetings. Users of these systems have described the value of driving several hours to have such face-to-face meetings with the bedside clinicians they are working with. Another way to look at this, is that the bedside clinicians are often reluctant to take directives and advice from some distant disembodied consultant. However, sitting down and discussing care protocols, actual clinical care problems, etc. in the real ICU makes the two groups together much more effectively.

    The importance and value of this teamwork and relationship building is often not recognized by those promoting the value of these systems. The time and costs to foster these relationships is vital to having them improve clinical outcomes – and possibly reduce costs. In addition, these relationships have long-term value since teams that work effectively together, make it much easier to implement and update agreed upon care protocols, such as for the use of insulin, ventilator management, infection avoidance protocols, etc.

    OK – I’ll stop now….

  3. Dr. Miller,

    Thanks for your comment and for pointing us to your excellent paper on the topic.

    I agree that effective teamwork is key to making coordination work and would advocate investing the time and effort to have teams meet face-to-face even if that means traveling across 12 time zones to do so. Although it increases expenses, it’s likely to be a solid investment. Once a team has met face to face it becomes easier to sustain and build the relationships through electronic means.

    Similar observations apply outside of health care. For example, a colleague of mine who founded a software company in the US outsourced development to India. He brought the Indian team over to the US for two weeks to develop relationships with the US-based staff. It was the right thing to do from a number of angles, and he also believes it paid off financially through a shorter development timeframe and a better product.

    David

  4. Michael, you’re point regarding teamwork cannot be stressed enough. Even years after implementing Peter Pronovost’s catheter-related blood stream infection (CRBSI) protocol across all of the ICUs at Hopkins, we’ve noticed that lapses in teamwork and the safety culture lead to increasing BSI rates. Teamwork and communication are by far the cardinal components of a safe (and efficient) healthcare system.

    Likewise, one should certainly worry that health systems that blindly implement eICU-type systems without addressing the need for a cohesive culture of safety and teamwork may only exaccerbate current safety risks as well as introducing a whole host of new opportunities for error.

  5. I have been a practicing Intensivist for over 24 years and have had the experience of Telemedicine. I remember that the most important advice that my Professors have told me about practicing intensive care is that one needs to be caring intensely and that no better tests or therapy is more importatnt than having a nurse and physician at the bedside in person to evaluate the patient. There can and should not be any better outcome than having the ability to touch and listen and palpate and fully examine a crtically ill patient, nor any greater humane and compassionate care than having a Physician and Nurse addressing the issues of a sick patient together. I would gather it would be favorable from a patients viewpoint that seeing a Physician and Nurse is far better than seeing a video camera or a distant voice from a speaker above, or by a healthcare worker who may have only seen the patient for their 8-12 hour shift and have no contact further with the patient care again and no continuity of care. Telemedicine will continue to seel itself and the data will be biased in its analysis, to favor its true outcome and that is to obtain its profits.

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