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Critical Care Network

December 1, 2009
by Kate Huvane Gamble
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ICU telemedicine can help ease the burden of caring for critically ill patients - provided all the right pieces are in place.

Joy grossman

Joy Grossman

ICU telemedicine is quickly gaining traction. With the number of intensivists declining, cutting-edge hospitals are leveraging round-the-clock ICU technology to improve the delivery of critical care services in underserved areas. Electronic ICU - or eICU systems, as they are commonly called - combine telemedicine with software applications to monitor patients at satellite locations from a central site staffed with intensivists and critical care nurses.

Frequently used in rural areas as a way to cut down on costly and time-consuming transfers, the technology has the potential to improve factors like mortality and length of stay, according to a study by the Washington-based Center for Studying Health System Change (HSC), which estimates that only 10 percent of all hospital ICUs use advanced monitoring. And with grant money becoming available from federal agencies like the Department of Agriculture, more hospitals could turn to ICU telemedicine to improve the treatment of critical care patients, according to Joy Grossman, Ph.D., senior researcher at HSC.

“It's enabled us to redefine processes and procedures, as well as react to problems when they happen, instead of on a delay.”

“The primary goal is to improve clinical quality and patient safety,” she says. “We're seeing examples of hospitals using the technology to leverage intensivist staffing and enhance the coverage they provide.”

“We incorporate very little faxing or scanning of paper. We've connected our EMR system into the ICU and made it as integrated … as possible.”

However, while there is a great deal of interest surrounding eICUs, HSC says there is little objective data to support their benefits. As a result, organizations like Avera Health, a five-hospital system based in Sioux Falls, S.D., are conducting studies to document their success.

For Avera, the findings were positive. Since going live with the eICU in 2004, the organization has seen a decrease in the average length of stay in both the ICU (by one day) and the hospital (by two days), according to Pat Herr, director of the eICU. What's more, the organization has avoided more than $1.2 million in transfer fees, she says. Currently, 18 hospitals in Avera's system are live with the eICU, with plans in place for implementations at several other facilities.

“It started off small and has continued to grow since I've been here,” says Senior Vice President and CIO Jim Veline, who began his term about a year after the program was deployed.

The eICU, Herr says, is constantly staffed, enabling physicians at the “hub” - located at the McKennan Hospital and University Health Center campus - to keep a close eye on patients at Avera's hospitals and facilities, some of which are hours away from a critical care specialist. “It has allowed us to do real-time interventions. If an abnormal lab comes back at 5 a.m., we see it right away,” Herr says. “It's enabled us to redefine processes and procedures, as well as react to problems when they happen, instead of on a delay.”

In order to facilitate this type of workflow, Avera had to make sure the systems could speak to each other. According to Herr, the software in the eICU, which is from Baltimore-based Visicu (acquired by Netherlands-based Philips in 2008), interfaces with cardiac monitors and other systems, including admissions, registration and lab, to analyze patient data and trigger alerts for physicians.

Ken lawonn

Ken Lawonn

Once Avera was able to move past the initial challenges of implementing the technology, the early eICU adopter was able to start reaping the benefits. “This model has been so successful,” says Herr, adding that there are plans to leverage the infrastructure that is now in place to launch several more programs, including e-pharmacy, e-emergency and e-stroke. “It's a way to sustain the type of care that we feel patients deserve.”

Taking it to the next level

Alegent Health may not have been one of the first organizations to implement ICU telemedicine, but the Omaha, Neb.-based system is raising the bar by maximizing the functionality of its eICU. According to Senior Vice President and CIO Ken Lawonn, the technology, which was first implemented in 2007, is now live at six of Alegent's nine hospitals and will expand to more facilities. “It's a question of getting the right equipment and infrastructure in place,” he says, particularly in the rural hospitals. And once that happens, “We want to make sure it's fully functional.”

That, says Lawonn, requires a strong focus on automation and interoperability. “We incorporate very little faxing or scanning of paper. We've connected our EMR system into the eICU and made it as integrated and electronic a solution as possible.”

Connecting the dots, however, can be tricky. Alegent, which uses Malvern, Pa.-based Siemens' Soarian as its nursing documentation system, had to build an interface into the eICU system to enable the data that is charted in the critical care area to flow into the alert system.

But for some of Alegent's facilities that don't have a hospital EMR, critical care software needed to be tied into Visicu's eCare Manager, which was in the central eICU. “It took some time to work through all the little nuances,” Lawonn says. “You need to understand what those connection points are, what your capabilities are for capturing information in the critical care units, and how you're going to interface that into the eICU function and software. I think CIOs need to really be cautious of an implementation where you use the eICU software in the critical care department, because then you have to sort through the interoperability issues. We really pushed to get our basic EMR component in critical care and then interfaced with the eICU.”

In doing this, Alegent cleared a major hurdle, as interoperability is one of the biggest barriers to successfully implementing an advanced ICU system, according to Grossman. “When there is poor interoperability between the eICU software and the hospital's other IT systems, it really limits your ability to use all of the advanced monitoring and outcomes analysis features.” It is crucial, she says, that bedside monitors, ICU equipment and hospital IT systems speak to each other, and that core data such as vital signs can be easily viewed and accessed by staff at the central and satellite ICUs.

For Alegent, fully leveraging the technology's capabilities meant installing a two-way video connection allowing patients and staff at the satellite critical care unit to speak with and view the staff at the central monitoring site, and vice versa. “We felt that this way, we would get a better reception or acceptance of the program,” says Lawonn. “We insisted that we have that kind of capability, which actually requires a little higher speed connection.”

However, although that wasn't a problem for Alegent's Omaha-based facilities, which already had a reliable high-speed connection, Lawonn says the rural communities did require an upgrade. “In order to run two-way, full-strength video between two sites, you need to have a certain level of connection. Because we already ran central applications that served all of our campuses, we had that in place. But you need to make sure that's there.”

According to Lawonn, Alegent runs a full gigabit connection to ensure redundancy in the connections between each of its sites and the main data center, as well as to the rural hospitals. Being able to properly support the eICU has meant increasing the number of T1 connections, he says.

With a strong network in place, Alegent has positioned itself to leverage ICU telemedicine - not just for advanced monitoring capabilities, but also outcomes analysis, a tool that Grossman says can push an eICU program to the next level. “The really cutting edge organizations are using the full functionality to produce reports and more sophisticated analysis,” she says. And those could come in the form of real-time reports advising staff on how to treat a patient, or long-term analysis focusing on meeting certain quality metrics. “That's one of the key benefits of this tool - the ability to analyze data and give the staff additional information that they might not have with a regular IT system.”

Lawonn says Alegent has already begun the early stages of tracking data and utilizing it to measure outcomes. So far, the results have been positive, he says. “Once we had the integration and the interoperability figured out, it's been fairly seamless. The biggest thing has been leveraging the eICU and having everyone understand what it can and can't do. But we've been very happy, and we'd do it again.”

Healthcare Informatics 2009 December;26(12):26-30

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