ICU Telemedicine: From Theory to Practice* J e re m y M . K a h n , M D , M S
CRISMA Center Department of Critical Care Medicine University of Pittsburgh School of Medicine; and Department of Health Policy and Management University of Pittsburgh Graduate School of Public Health Pittsburgh, PA CU telemedicine is the remote provision of critical care facilitated by audiovisual conferencing technology. Encouraged by a perceived shortage of trained intensivist physicians and known quality gaps even in well-staffed ICUs, the use of ICU telemedicine has rapidly increased over the last decade (1). At last, estimate over 10% of ICU beds in the United States were covered by ICU telemedicine in the form of continuous remote monitoring (2), with many more using some other form of remote care (3). The pervasiveness of ICU telemedicine in the United States is remarkable for several reasons. First, telemedicine is expensive, with technology and staffing costs often exceeding $3 million per hospital per year (4). Second, there are enduring concerns about the effectiveness of the intervention itself. The existing literature is extremely limited, with a preponderance of beforeafter studies that are confounded by temporal trends (5). Sys tematic reviews demonstrate a small mortality benefit, but this benefit is largely driven by a few studies with an extremely large effect, counterbalanced by many studies showing no effect (6). Concerns about effectiveness were highlighted in a 2009 study of hospital administrators and key clinical leaders published in Health Affairs, which concluded that stakeholders “have little objective information on which to judge the worthiness of this innovation” (7). The tensions surrounding effectiveness are further high lighted in a comprehensive narrative review published in this issue of Critical Care Medicine (8). In this review, the members of the Society of Critical Care Medicine Tele-ICU Commit tee outline the history of telemedicine, discuss the strengths and limitations of the existing outcomes data, and highlight some of the legal, regulatory, and financial issues relevant to telemedicine in the ICU. Perhaps the most salient conclusion
I
*See also p. 2429. Key Words: intensive care units; quality improvement; telemedicine Dr. Kahn consulted for the U.S. Department of Veterans Affairs (consulting on the topic of ICU telemedicine). His institution received grant support from the National Institutes of Health (grants on the topic of ICU tele medicine), U.S. Health Resources and Services Administration (grant on the topic of emergency telemedicine), and the Gordon and Betty Moore Foundation (grant on the topic of ICU organization and management). His institution received support from the Cerner Corporation (in-kind research support in the form of data). Copyright © 2014 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins DOI: 10.1097/CCM.0000000000000596
Critical Care Medicine
of the review is the notion that programs vary widely in their effectiveness. Many programs appear to dramatically save lives and reduce costs, whereas others demonstrate no impact at all. Yet the factors distinguishing effective programs from ineffec tive programs are poorly understood, with little research into the organizational and clinical determinants of effectiveness. As a result, health systems wishing to implement ICU telemed icine are “flying blind,” lacking the tools necessary to ensure that telemedicine achieves its goal of expanding access to highquality critical care. Some of the potential factors that may influence the suc cess of program effectiveness are shown in Figure 1. This conceptual model, developed in part during a federally funded consensus conference on the issue (9), posits that the effectiveness of an ICU telemedicine program will be influ enced by the characteristics of the target hospital, the target ICU, and the telemedicine unit itself. When optimized, these characteristics facilitate increases in timely treatment and guideline adherence, leading to improved quality. When suboptimal, telemedicine fails to change practice patterns, and thus fails to improve quality. The problem with this conceptual model is that it lacks details. We do not know what specific characteristics of the target hospital, the target ICU, and the telemedicine unit are important. As mentioned in the Society of Critical Care Medi cine’s narrative review (8), some investigators have tried to study this issue, determining that factors such as the frequency of remote-intensivist case review and more rapid responses to alarms may be associated with increased effectiveness (10). However, these findings are just the tip of the iceberg. In reality, effectiveness is likely determined by complex organizational relationships between the target ICUs and the telemedicine unit, the make-up of the interprofessional ICU care team in both units, and the degree to which the telemedicine clinicians are proactively engaged in quality improvement rather than simply reactively responding to alarms. Defining these characteristics would not be easy. It will require a diverse program of effectiveness research using a vari ety of research methods, not only traditional clinical epidemi ology but also qualitative approaches derived from the social sciences. Yet this research is essential for ICU telemedicine to fulfill its promise. ICU telemedicine, like other enabling tech nologies in healthcare, does not automatically translate into higher quality (11). Telemedicine is simply a tool, and, like any tool, the benefit is derived not from whether it is used but how it is used and where it is used. We need to move past the ques tion “does telemedicine work?” and instead take up the ques tion “how and where does telemedicine work best?” By shifting the evaluation paradigm away from effectiveness and toward the clinical and organizational determinants of effectiveness, the next generation of research must provide clinicians, health care administrators, and policy makers with actionable data to guide truly effective implementation. w w w .c c m jo u r n a l.o r g
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Editorials
REFERENCES 1. Kahn JM, Cicero BD, Wallace DJ, et al: Adoption of ICU telemedicine in the United States. Crit Care Med 2014; 42:362-368 2. Fifer S, Everett W, Adams M, et al: Critical Care, Critical Choices, the Case for Tele-ICUs in Intensive Care. Cambridge, New England Health Care Institute and Massachusetts Technology Collaborative, 2010 3. Vespa PM, Miller C, Hu X, et al: Intensive care unit robotic tele presence facilitates rapid phy sician response to unstable patients and decreased cost in neurointensive care. Surg Neurol 2007; 67:331-337 4. Kumar G, Falk DM, Bonello RS, et al: The costs of critical care telemedicine programs: A systematic review and analysis. Chest 2013; 143:19-29
Figure 1. Conceptual model for ICU telemedicine effectiveness. Under this model, the effectiveness of ICU telemedicine is determined by identifiable characteristics of the target hospital, the target ICU, and the tele medicine unit. Ql = quality improvement.
Luckily, there is increasing enthusiasm for this line of work. Healthcare dollars are scarce, and healthcare payers know that we cannot afford to broadly implement expensive technology without a solid understanding of how to make it work (11). At the same time, efforts to expand intensivist physician staff ing have been ineffective, with fewer than one quarter of U.S. hospitals meeting suggested staffing requirements (12). We need innovative solutions like ICU telemedicine. We just need them to be implemented effectively, with the right goals in mind, in the hospitals most likely to benefit. And we need this effort to be guided by high-quality research, not just single center before-after studies but comprehensive evaluations of the circumstances in which ICU telemedicine truly saves lives and reduces costs.
2458
w w w .c c m jo u rn a l.o rg
5. Kahn JM: The use and misuse of ICU telemedicine. JAMA 2011; 305:2227-2228 6. Wilcox ME, Adhikari NK: The effect of telemedicine in criti cally ill patients: Systematic review and meta-analysis. Crit Care 2012; 16:R127
7. Berenson RA, Grossman JM, November EA: Does telemonitoring of patients-the elCU-improve intensive care? Health Aff (Millwood) 2009; 28:w937-w947 8. Lilly CM, Zubrow MT, Kempner KM, et al; for the Society of Critical Care Medicine Tele-ICU Committee: Critical Care Telemedicine: Evolution and State of the Art. Crit Care Med 2014; 42:2429-2436 9. Kahn JM, Hill NS, Lilly CM, et al: The research agenda in ICU tele medicine: A statement from the Critical Care Societies Collaborative. Chest 2011; 140:230-238 10. Lilly CM, Fisher KA, Ries M, et al: A national ICU telemedicine survey: Validation and results. Chest 2012; 142:40-47 11. Kellermann AL, Jones SS: What it will take to achieve the as-yetunfulfilled promises of health information technology. Health Aff (Millwood) 2013; 32:63-68 12. Moran J, Scanlon D: Slow progress on meeting hospital safety standards: Learning from the Leapfrog Group's efforts. Health Aff (Millwood) 2013; 32:27-35
November 2014* Volume 42 • Number 11
Copyright of Critical Care Medicine is the property of Lippincott Williams & Wilkins and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
CRISMA Center Department of Critical Care Medicine University of Pittsburgh School of Medicine; and Department of Health Policy and Management University of Pittsburgh Graduate School of Public Health Pittsburgh, PA CU telemedicine is the remote provision of critical care facilitated by audiovisual conferencing technology. Encouraged by a perceived shortage of trained intensivist physicians and known quality gaps even in well-staffed ICUs, the use of ICU telemedicine has rapidly increased over the last decade (1). At last, estimate over 10% of ICU beds in the United States were covered by ICU telemedicine in the form of continuous remote monitoring (2), with many more using some other form of remote care (3). The pervasiveness of ICU telemedicine in the United States is remarkable for several reasons. First, telemedicine is expensive, with technology and staffing costs often exceeding $3 million per hospital per year (4). Second, there are enduring concerns about the effectiveness of the intervention itself. The existing literature is extremely limited, with a preponderance of beforeafter studies that are confounded by temporal trends (5). Sys tematic reviews demonstrate a small mortality benefit, but this benefit is largely driven by a few studies with an extremely large effect, counterbalanced by many studies showing no effect (6). Concerns about effectiveness were highlighted in a 2009 study of hospital administrators and key clinical leaders published in Health Affairs, which concluded that stakeholders “have little objective information on which to judge the worthiness of this innovation” (7). The tensions surrounding effectiveness are further high lighted in a comprehensive narrative review published in this issue of Critical Care Medicine (8). In this review, the members of the Society of Critical Care Medicine Tele-ICU Commit tee outline the history of telemedicine, discuss the strengths and limitations of the existing outcomes data, and highlight some of the legal, regulatory, and financial issues relevant to telemedicine in the ICU. Perhaps the most salient conclusion
I
*See also p. 2429. Key Words: intensive care units; quality improvement; telemedicine Dr. Kahn consulted for the U.S. Department of Veterans Affairs (consulting on the topic of ICU telemedicine). His institution received grant support from the National Institutes of Health (grants on the topic of ICU tele medicine), U.S. Health Resources and Services Administration (grant on the topic of emergency telemedicine), and the Gordon and Betty Moore Foundation (grant on the topic of ICU organization and management). His institution received support from the Cerner Corporation (in-kind research support in the form of data). Copyright © 2014 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins DOI: 10.1097/CCM.0000000000000596
Critical Care Medicine
of the review is the notion that programs vary widely in their effectiveness. Many programs appear to dramatically save lives and reduce costs, whereas others demonstrate no impact at all. Yet the factors distinguishing effective programs from ineffec tive programs are poorly understood, with little research into the organizational and clinical determinants of effectiveness. As a result, health systems wishing to implement ICU telemed icine are “flying blind,” lacking the tools necessary to ensure that telemedicine achieves its goal of expanding access to highquality critical care. Some of the potential factors that may influence the suc cess of program effectiveness are shown in Figure 1. This conceptual model, developed in part during a federally funded consensus conference on the issue (9), posits that the effectiveness of an ICU telemedicine program will be influ enced by the characteristics of the target hospital, the target ICU, and the telemedicine unit itself. When optimized, these characteristics facilitate increases in timely treatment and guideline adherence, leading to improved quality. When suboptimal, telemedicine fails to change practice patterns, and thus fails to improve quality. The problem with this conceptual model is that it lacks details. We do not know what specific characteristics of the target hospital, the target ICU, and the telemedicine unit are important. As mentioned in the Society of Critical Care Medi cine’s narrative review (8), some investigators have tried to study this issue, determining that factors such as the frequency of remote-intensivist case review and more rapid responses to alarms may be associated with increased effectiveness (10). However, these findings are just the tip of the iceberg. In reality, effectiveness is likely determined by complex organizational relationships between the target ICUs and the telemedicine unit, the make-up of the interprofessional ICU care team in both units, and the degree to which the telemedicine clinicians are proactively engaged in quality improvement rather than simply reactively responding to alarms. Defining these characteristics would not be easy. It will require a diverse program of effectiveness research using a vari ety of research methods, not only traditional clinical epidemi ology but also qualitative approaches derived from the social sciences. Yet this research is essential for ICU telemedicine to fulfill its promise. ICU telemedicine, like other enabling tech nologies in healthcare, does not automatically translate into higher quality (11). Telemedicine is simply a tool, and, like any tool, the benefit is derived not from whether it is used but how it is used and where it is used. We need to move past the ques tion “does telemedicine work?” and instead take up the ques tion “how and where does telemedicine work best?” By shifting the evaluation paradigm away from effectiveness and toward the clinical and organizational determinants of effectiveness, the next generation of research must provide clinicians, health care administrators, and policy makers with actionable data to guide truly effective implementation. w w w .c c m jo u r n a l.o r g
2457
Editorials
REFERENCES 1. Kahn JM, Cicero BD, Wallace DJ, et al: Adoption of ICU telemedicine in the United States. Crit Care Med 2014; 42:362-368 2. Fifer S, Everett W, Adams M, et al: Critical Care, Critical Choices, the Case for Tele-ICUs in Intensive Care. Cambridge, New England Health Care Institute and Massachusetts Technology Collaborative, 2010 3. Vespa PM, Miller C, Hu X, et al: Intensive care unit robotic tele presence facilitates rapid phy sician response to unstable patients and decreased cost in neurointensive care. Surg Neurol 2007; 67:331-337 4. Kumar G, Falk DM, Bonello RS, et al: The costs of critical care telemedicine programs: A systematic review and analysis. Chest 2013; 143:19-29
Figure 1. Conceptual model for ICU telemedicine effectiveness. Under this model, the effectiveness of ICU telemedicine is determined by identifiable characteristics of the target hospital, the target ICU, and the tele medicine unit. Ql = quality improvement.
Luckily, there is increasing enthusiasm for this line of work. Healthcare dollars are scarce, and healthcare payers know that we cannot afford to broadly implement expensive technology without a solid understanding of how to make it work (11). At the same time, efforts to expand intensivist physician staff ing have been ineffective, with fewer than one quarter of U.S. hospitals meeting suggested staffing requirements (12). We need innovative solutions like ICU telemedicine. We just need them to be implemented effectively, with the right goals in mind, in the hospitals most likely to benefit. And we need this effort to be guided by high-quality research, not just single center before-after studies but comprehensive evaluations of the circumstances in which ICU telemedicine truly saves lives and reduces costs.
2458
w w w .c c m jo u rn a l.o rg
5. Kahn JM: The use and misuse of ICU telemedicine. JAMA 2011; 305:2227-2228 6. Wilcox ME, Adhikari NK: The effect of telemedicine in criti cally ill patients: Systematic review and meta-analysis. Crit Care 2012; 16:R127
7. Berenson RA, Grossman JM, November EA: Does telemonitoring of patients-the elCU-improve intensive care? Health Aff (Millwood) 2009; 28:w937-w947 8. Lilly CM, Zubrow MT, Kempner KM, et al; for the Society of Critical Care Medicine Tele-ICU Committee: Critical Care Telemedicine: Evolution and State of the Art. Crit Care Med 2014; 42:2429-2436 9. Kahn JM, Hill NS, Lilly CM, et al: The research agenda in ICU tele medicine: A statement from the Critical Care Societies Collaborative. Chest 2011; 140:230-238 10. Lilly CM, Fisher KA, Ries M, et al: A national ICU telemedicine survey: Validation and results. Chest 2012; 142:40-47 11. Kellermann AL, Jones SS: What it will take to achieve the as-yetunfulfilled promises of health information technology. Health Aff (Millwood) 2013; 32:63-68 12. Moran J, Scanlon D: Slow progress on meeting hospital safety standards: Learning from the Leapfrog Group's efforts. Health Aff (Millwood) 2013; 32:27-35
November 2014* Volume 42 • Number 11
Copyright of Critical Care Medicine is the property of Lippincott Williams & Wilkins and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
