HIMSS News

Telemedicine: Bringing Capability to the Point of Need

Approximately 10% of ICU beds in the United States are currently monitored by teleICU services1.  TeleICU services improve patient outcomes, reduce ICU and hospital length of stay, reduce errors, and are cost effective1-5.  It is expected that these services will continue to expand as the demand for critical care services outpaces the training of the critical care workforce6-8.

Access to critical care providers is not, however, the only mechanism by which teleICU services improve patient outcomes; indeed, many of the benefits of teleICU have been witnessed in academic medical systems where there is abundant access to critical care resources2,3.  TeleICU, its technology and its workflow, offer advantages over traditional models of critical care delivery related to automation, decision support, and performance review2,9,10.

Another aspect of teleICU, however, should also be highlighted: teleICU (telemedicine in this context) offers the opportunity to rapidly promote clinicians from “novice” to “expert” 11Consultation, an act clinicians perform regularly to resolve uncertainty about clinical problems that surpass one’s knowledge, skills, or confidence, is common and expected.  Consider the following scenario:

A house explosion severely burns a family of five. They are taken to rural community hospital emergency department.  Over the next eight hours, they are transported to regional burn centers, one-at-a-time, using two helicopters and an ambulance.

While consultation for this event occurs intermittently over a phone, little information is actually transferred between the referring physician and the burn center.  Furthermore, the the only consultation occurs between physicians – the nurses, paramedics, and others have no access to expertise beyond the referring physician – who is also busy caring for other patients.

A better care care paradigm would be real time physiologic monitoring from the expert facility and two-way video-audio communication between the two care teams – services provided by most teleICU providers.  This type of support would ease the anxiety of inexperienced providers, improve clinical decision making, and optimize patient outcomes.

This scenario challenges our traditional, healthcare centric paradigm which focuses on moving patients to necessary capabilities.  This paradigm makes sense when there are ample resources a short distance away.  When available resources are limited, further away, or transfer is delayed, moving a capability to the patient makes more sense (see figure 2).

Facilitating expertise at the point of care is technically possible in most situations13,14.  Consider this: A remote military outpost is attacked by militants.  A soldier is shot through his thigh.  Evacuation resources are not immediately available.  An on-site surgeon performs damage control surgery, however, he has never performed an external fixation of a femur fracture.  The team utilizes a commercial, mobile video-teleconferencing application to engage a remotely located orthopeadic surgeon to successfully “walk through” the procedure.

This technology is available. Establishing a distributed network of virtually connected providers – “specialists on demand” – who respond to individual requests, or, potentially, to a mass casualty event (using mobile, satellite connected kiosks), is a challenging, but not impossible, problem.

The world is becoming more connected.  As it does, the healthcare system is more accessible through applications that connect the right people together: clinicians to patients or clinicians to clinicians.  We can monitor patient physiology, their habits, and their environments.  These same technologies may be leveraged to provide the necessary medical support anywhere and at any time, regardless of the bedside clinician’s experience or skills, if or if they even exist at all.

References:

  1. Lilly CM, Fisher KA, Ries M, et al. A National ICU Telemedicine Survey. 2012;142(1):40-47. doi:10.1378/chest.12-0310.
  2. Lilly CM, McLaughlin JM, Zhao H, et al. A Multicenter Study of ICU Telemedicine Reengineering of Adult Critical Care. Chest. 2014;145(3):500-507. doi:10.1378/chest.13-1973.
  3. Lilly CM, Cody S, Zhao H, et al. Hospital mortality, length of stay, and preventable complications among critically ill patients before and after tele-ICU reengineering of critical care processes. JAMA. 2011;305(21):2175-2183. doi:10.1001/jama.2011.697.
  4. Yoo B-K, Kim M, Sasaki T, Melnikow J, Marcin JP. Economic Evaluation of Telemedicine for Patients in ICUs*. Crit Care Med. 2016;44(2):265-274. doi:10.1097/CCM.0000000000001426.
  5. Franzini L, Sail KR, Thomas EJ, Wueste L. Costs and cost-effectiveness of a telemedicine intensive care unit program in 6 intensive care units in a large health care system. Journal of Critical Care. 2011;26(3):329.e1-.e6. doi:10.1016/j.jcrc.2010.12.004.
  6. Angus DC, Kelley MA, Schmitz RJ, White A, Popovich J, Committee on Manpower for Pulmonary and Critical Care Societies (COMPACCS). Caring for the critically ill patient. Current and projected workforce requirements for care of the critically ill and patients with pulmonary disease: can we meet the requirements of an aging population? JAMA. 2000;284(21):2762-2770. doi:10.1001/jama.284.21.2762.
  7. Afessa B. Tele-intensive care unit: the horse out of the barn. Crit Care Med. 2010;38(1):292-293. doi:10.1097/CCM.0b013e3181b9d4dc.
  8. Bauman KA, Bauman KA, Hyzy RC, Hyzy RC. ICU 2020 Five Interventions to Revolutionize Quality of Care in the ICU. Journal of Intensive Care Medicine. 2014;29(1):13-21. doi:10.1177/0885066611434399.
  9. Khunlertkit A, Carayon P. Contributions of tele-intensive care unit (Tele-ICU) technology to quality of care and patient safety. Journal of Critical Care. 2013;28(3):315.e1-.e12. doi:10.1016/j.jcrc.2012.10.005.
  10. Goran SF. A Second Set of Eyes: An Introduction to Tele-ICU. Critical Care Nurse. 2010;30(4):46-55. doi:10.4037/ccn2010283.
  11. Hwang JS, Lappan CM, Sperling LC, Meyerle JH. Utilization of telemedicine in the U.S. military in a deployed setting. Military Medicine. 2014;179(11):1347-1353. doi:10.7205/MILMED-D-14-00115.
  12. West AF, West RR. Clinical decision-making: coping with uncertainty. Postgraduate Medical Journal. 2002;78(920):319-321. doi:10.1136/pmj.78.920.319.
  13. Luxton DD, Mishkind MC, Crumpton RM, Ayers TD, Mysliwiec V. Usability and feasibility of smartphone video capabilities for telehealth care in the U.S. military. Telemed J E Health. 2012;18(6):409-412. doi:10.1089/tmj.2011.0219.
  14. Kirkpatrick AW, LaPorta A, Brien S, et al. Technical innovations that may facilitate real-time telementoring of damage control surgery in austere environments: a proof of concept comparative evaluation of the importance of surgical experience, telepresence, gravity and mentoring in the conduct of damage control laparotomies. Can J Surg. 2015;58(3 Suppl 3):S88-S90. doi:10.1503/cjs.014214.

 

About the Contributor

LTC Jeremy Pamplin, MD, FCCM, FACP is currently the Medical Director for the U.S. Army Burn ICU, Chief of Clinical Trials for the U.S. Army Institute of Surgical Research, and Associate Professor of Medicine for the Uniformed Services University.  Dr. Pamplin graduated with honors from the United States Military Academy, West Point, where he earned a B.S. in chemistry and life sciences.  He subsequently attended the Uniformed Services University of the Health Sciences in Bethesda, MD where he earned his M.D. in 2001. Following medical school, Dr. Pamplin completed an internal medicine internship and residency at Eisenhower Army Medical Center, Ft. Gordon, GA, and then a critical care medicine fellowship at Walter Reed Army Medical Center, Washington, D.C.  Dr. Pamplin has deployed twice in support of Operation Iraqi Freedom and Operation Enduring Freedom.  His research interest include developing clinical decision support technologies, salient information displays, and automated systems that support critical care and combat casualty care clinicians as well as using simulation and telemedicine to improve clinical decision making.