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11/30/2000

Telemedicine Company Brings ICU Patients to the Physician

Tzipora R. Lieder
George P. Provost Editorial Intern

The full-time presence of an intensivist—a physician trained in critical care medicine—in the intensive care unit (ICU) has been shown to improve patient outcomes, said physician Michael J. Breslow, but "there are not enough intensivists to bring into every ICU" in the country. Breslow's solution? "Bring the patient to the intensivist."

With a vision of melding technology and clinical expertise to achieve this goal, Breslow and fellow intensivist Brian Rosenfeld left their positions at Johns Hopkins Hospital's ICU in 1998 to found IC-USA, now known as VISICU. The telemedicine company launched its operations this past June, after contracting with Sentara Norfolk and Sentara Hampton general hospitals in Virginia.

"I think the ICU represents the last frontier of poorly managed care," Breslow said during an October company presentation at ASHP headquarters in Bethesda, Maryland. Each of the subspecialists called in to consult on a critically ill patient focuses exclusively on one organ system, said Breslow, and the physicians "are often working at cross-purposes." Even worse for quality of care, he said, is the fact that these physicians visit the ICU for only a few minutes each morning; the nurses who monitor the patients throughout the day must decide which physician to contact when a potential problem arises.

Intensivists who supervise ICU patients for the entire day can take a more integrated approach, Breslow said, coordinating patients' conflicting needs and monitoring closely to forestall complications. VISICU attempts to achieve this model of care by placing patients under the continuous surveillance of an intensivist and a critical care nurse. But the novelty of the company's method lies in the location of this team-not the ICU, but an "eICU," a remote site electronically linked to the physical ICU.

Contracting hospitals can decide whether to use VISICU's services 24 hours a day seven days a week or for some portion of that time. At Sentara Norfolk, onsite intensivists are available to consult about patients between 7:00 a.m. and noon, said Neil A. Davis, a critical care pharmacist at the hospital, during a telephone interview. Then, the VISICU eICU kicks in to monitor patients until the intensivists return to the hospital the next morning.

The eICU is staffed primarily by local intensivists, who alternate working at Sentara Norfolk during the morning hours and the eICU at other times. VISICU hires full-time intensivists to serve as local medical directors at each site, said Erkan Hassan, director of pharmacotherapy services at VISICU, while the local intensivists receive an hourly fee. The local intensivists are licensed and credentialed and have privileges at both of VISICU's hospitals. As VISICU expands, the intensivists will have to meet the standards at the newly added hospitals. About 18 intensivists and 20 nurses staff the various clinical shifts at VISICU, said Hassan; while they currently monitor 36 beds in three ICUs, the company projects that one physician–nurse team can monitor up to 50 beds at one time.

Watching from a distance. The eICU personnel have access to all the information they need to monitor patients from afar. Each eICU workstation, which is manned by a single physician or nurse, features three computer screens. One is linked to the patients' bedside monitors, another displays the output of wall-mounted cameras in patients' rooms, and the third provides access to VISICU's software, including electronic patient records and a clinical decision-support tool. The cameras can be manipulated from the eICU, allowing the team there to zoom in on patients and their equipment. Microphones and speakers in patient rooms and nursing stations allow for oral communication with patients, family members, and caregivers.

With this wealth of patient information at their fingertips, eICU intensivists can spot potential problems early on and take the necessary actions to avert trouble. Depending on what the admitting physician requests, the eICU intensivists "can either be just the eyes and ears or the effector arm as well," explained Breslow. Physicians can select the level of interventions the eICU team may make; these can range from simply notifying the admitting physician to actually writing medication orders or taking other concrete actions.

The accessibility of intensivists in the eICU, said Deno Sebastian, pharmacy manager at Sentara Norfolk, during a telephone interview, is a major advantage of VISICU's services. "Rather than paging [the physicians] and waiting for 10 minutes for them to call [back]," Sebastian said, pharmacists and nurses with questions can "just pick up the phone" and reach the intensivists immediately. The speed of contact can sometimes "stop an accident from happening," he said. So can the fact that eICU intensivists are alert, unlike groggy physicians being awakened at home to answer an emergency question. Another benefit of the eICU, said Sebastian, is the ability of one physician and one nurse to monitor patients in "three different physical areas of the hospital and of the community." From one minute to the next, the eICU team can take care of patients at hospitals 20 miles apart without ever having to move.

Simplifying data collection. But the system is more than a sophisticated babysitting service. VISICU's computer software helps the intensivists make decisions. In the intensive care setting, Breslow said, "there's a huge amount of clinical information that needs to be processed." But in most ICUs, he said, this information is too difficult to marshal, because "it's on 10 different pieces of paper." VISICU's software centralizes this information in an electronic patient record so that it can be used to track progress and make clinical decisions.

Since physicians create patient notes mostly by making selections from pull-down menus, the information can be displayed "in a different context where it has more value," Breslow said. For example, when a physician documents the insertion of an intravenous catheter, a short version of the note consistently appears on the left side of the patient profile screen, with details available on the "Line Log" screen.

Physicians in the eICU key in their medication orders, which are then printed at the ICU nursing stations. Although pharmacy staff must still enter the medication order information into the pharmacy's computer system, the legibility of the typed orders is an advantage, said pharmacy manager Sebastian. The date and time on the printed order helps provide a sense of the urgency of the order, he added, as well as "a better chronological view of what has transpired."

Since most of the onsite intensivists also work for VISICU, they use the electronic record and order-entry system located at the ICU nursing stations as a matter of course, reported Davis, the critical care pharmacist. Although the other physicians have the option of using the system as well, few choose to do so. In cases where the physicians do not use VISICU's system, Hassan said, eICU staff members enter the information into the database.

Streamlining decision-making. The other part of VISICU's software solution tackles a situation that Breslow considers a major impediment to medical progress: the way physicians make decisions. "Most doctors, myself included, do things 90% the way they were taught during residency and 10% as they've learned along the way," he said. "The reality is that the knowledge explosion is much faster than that, and we're finding all sorts of rationalizations for why we haven't progressed as fast as technology."

At a community hospital such as Sentara Norfolk, Davis said, "there are variations in care that occur when you have...multiple numbers of physicians caring for the patients." For example, he said, physicians differ in their approaches to weaning patients from mechanical ventilators.

To create the algorithms for its decision-support system, VISICU compiled professional society guidelines, evidence-based literature, and expert opinions on the management of 150 commonly encountered ICU complications, according to the company's Web site. The result: a tool that walks clinicians through a series of questions and then presents a summary of patient characteristics and recommendations on what actions to take. The computer then requests feedback from the physicians on what was done and why.

These algorithms, however, are not one-size-fits-all. For example, Sebastian said, to have value, a pneumonia treatment protocol must recommend antimicrobials that conform to a particular ICU's antibiogram. Tailoring such algorithms to his facility, he said, is a "collaborative effort" between Sentara's physicians and pharmacists and VISICU's staff, including Breslow and Hassan. These collaborative efforts extend to the development of new protocols as well, said Sebastian, as the two groups try to find ways to "improve the prescribing habits" of ICU physicians. And of course, VISICU's system must be consistent with the programs already in place at Sentara, including the pharmacy's methods for adjusting dosage on the basis of patient renal function. After the monthly pharmacy and therapeutics committee meeting, Sebastian explained, "we send a copy of the minutes to them [VISICU] so they can ensure that their computer systems are in compliance with the formulary."

In addition to the patient care advantages of VISICU's computer technology, Breslow sees more far-reaching implications. "By capturing this information and drawing it into a relational database, we can go back and look at these patients in the future," he said. The possible applications for research are extensive, he said, and can help add concrete information on treatments and outcomes to the scientific literature.

Hassan agreed. When he wanted a list of the drugs most commonly used in the ICUs served by VISICU, Hassan obtained it from the database within minutes. The last published information on the top ICU drugs dates back to 1991. With the use of this technology, Hassan told ASHP staff members, "the ability to pick through the information we need is going to be that vastly different."

The critical role of pharmacy. There is a "disproportionate amount of drug use" in ICU patients, said Hassan, and management of "drugs with narrow therapeutic indices in patients with rapidly changing states of physiology" is a delicate balance. Hassan draws upon his years of experience as a critical care pharmacist to deal with drug-related issues in all of VISICU's operations. He gives advice on how to improve the electronic patient record, customize the order-entry system to individual hospitals as VISICU expands, keep algorithms up-to-date, and more. "The biggest thing that changes with all these algorithms and treatment guidelines is the drugs," he said, so pharmacist participation is crucial.

To date, Sentara Norfolk has not compared pharmacist interventions before and after VISICU implementation, said Sebastian. But as the kinks in the system are ironed out, Davis predicted, the number of interventions will decrease. By being involved in setting up protocols for use at the time of prescribing, he said, pharmacists can "drive appropriate therapy from the beginning" so that fewer interventions must be made retrospectively. After all, Davis said, setting up a protocol can affect hundreds of patients, achieving the same results as hundreds of individual interventions.

How Well Does the System Work? 

It's too soon to have any data on the Sentara hospitals' eICU experience, but results of an alpha test Breslow and Rosenfeld conducted at a Baltimore ICU for four months in 1997 provide some impressive figures. While the technology was cruder than the current model, the four intensivists who ran the ICU from a remote site had the ability to see patients, monitor their vital signs and laboratory data, and have videoconferences with nurses. 

When the charts of all patients admitted to the ICU during the four-month period in 1996 and 1997 were tracked and compared, the results, Breslow said, were "out of proportion to what we expected." The risk-adjusted mortality went down by 60%, the frequency of seven major complications fell by 40%, and the lengths of stay and percentages of patients with extended lengths of stay decreased significantly. ICU costs per case fell by 28%. The yearly savings for a 12-bed ICU were estimated at $1.45 million. 

According to VISICU's Web site, current fees for the company's services range from $60,000 to $80,000 per ICU bed per year.