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The Telehospitalist


 

The patient was in the ICU at Saint Clare’s Hospital in Wausau, Wis. An intensivist from St. Louis who had been caring for her remotely through telemedicine technology was helping clinicians manage the end-of-life issue for her and her family.

Subjects like this can be difficult for hospitalists, who may not have as much experience with the protocols involved in end-of-life care. But at Saint Clare’s, which offers remote care and monitoring by intensivists and critical-care nurses through an eICU program, critical-care specialists are there to provide continuous care to the hospital’s sickest patients, as well as support for the onsite clinicians in any number of situations involving ICU patient care.

Dellice Dickhaus, MD, medical director for Advanced ICU Care and a practicing intensivist, helps provide remote care around the clock for patients in Saint Clare’s ICU. Advanced ICU Care’s board-certified intensivists and critical-care nurses remotely care for and monitor patients in multiple sites from their operations center, more than 400 miles away in St. Louis. They use telemedicine technology developed by Baltimore, Md., firm VISICU that combines clinical management software with real-time video feeds and patient data, such as labs, vital signs and medications.

In the case of the critically ill patient, while the hospitalist was driving the patient’s care program and taking care of many of the daily issues, Dr. Dickhaus helped manage the end-of-life issue. She was available at the push of a button to talk with relatives and provide information they needed to make decisions about their family member’s care. She discussed the patient’s prognosis and options with the family, and kept the hospitalist on staff apprised of the conversations.

Because Dr. Dickhaus and other clinicians at Advanced ICU Care had been helping manage the patient’s care in the ICU, the patient’s family gained confidence in the remote intensivists, says Dr. Dickhaus.

Advances in telemedicine technology have come a long way. Take remote robotic systems, which allow physicians to consult with patients, family members, and on-site caregivers while seated in their office, in another wing of the hospital, or even at home.

Demands of an Aging Population

The aging of America will have a tremendous effect on healthcare, particularly regarding care of the critically ill and in managing such areas as pulmonary disease. Consider that more than half of all ICU stays are incurred by patients older than 65. Further, patients older than 65 account for more than two-thirds of all inpatient pulmonary days.

What does this mean for hospitalists? For one, the aging population will create a demand for care that is projected to outpace the supply of intensivists and pulmonologists.1 With fewer of these specialists, hospitalists may be compelled to take on more responsibilities with critically ill patients, leaving less time for other patients. The expectation of healthcare services provided will likely change, possibly growing in scope and complexity. The time it will take to deliver care is also expected to rise. All these are reasons for the growth in telemedicine technologies, with many designed to improve patient care by delivering limited resources where they are needed most.

Continuity of Care

Richard Bailey, MD, medical director of Inpatient Care and Hospitalist Services at Saint Clare’s, says having remote intensivists lets his staff focus on hospital patients outside the ICU.

“One critical patient can tie you up for hours,” Dr. Bailey says. “Advanced ICU Care’s intensivists are hands-on physicians, helping us round on ICU patients, take patient notes, and handle first-line phone calls.”

There is no difference, he says, between having intensivists in St. Louis, for example, versus on-site. “They are more than a microphone and a camera in the ceiling; they are members of our staff,” he says. “We trust them to take care of our patients.”

He explains that remote intensivists are often good at being the “bug in the ear” for hospitalists, helping with treatment recommendations and asking, “Did you remember to … ?” While stabilizing a just-transferred ICU patient in a near-code situation, Dr. Bailey needed immediate access to the patient’s labs. An intensivist in St. Louis was able to look at the labs and recommend treatment.

Preliminary numbers at Saint Clare’s hint at a reduction of one day in ICU length of stay and two days for total hospitalization, notes Dr. Bailey. Figures like these can mean real savings in hospital costs.

Working together, hospitalists and remote intensivists can provide continuity of care as the patient is admitted through the emergency department and brought into the ICU, explains Dr. Bailey.

William D. Atchley Jr., MD, medical director for the Division of Hospital Medicine for Sentara Medical Group in Norfolk, Va., agrees with Dr. Bailey’s view. Dr. Atchley’s group also uses telemedicine technology for the remote care and monitoring of ICU patients. He is also a member of SHM’s Board of Directors.

“This is a true team effort, creating a seamless continuity from the emergency department to the ICU,” says Dr. Atchley. He cites septic shock patients as an example. He is able to start the septic shock protocols with the patient in the ED, and the intensivist will carry the protocols forward with the patient in the ICU. By morning, Dr. Atchley says he knows the patient has received the care needed, which frees him to care for other patients.

Sentara Healthcare, based in Norfolk, Va., was the first hospital system in the nation to implement VISICU’s technology, which allows hospitals to create a systemwide critical-care program. Using the VISICU eICU, the hospital or healthcare system provides the intensivists to staff the program, helping to leverage scarce clinical resources among the system’s ICUs.

Studies have shown that care by intensivists via telemedicine technology improves patient care and safety in the ICU. In a 2004 study, Sentara documented a 27% decrease in overall ICU and hospital mortality.2

Mobile Telemedicine

Advances in telemedicine technology have come a long way. Take remote robotic systems, for instance, which allow physicians to consult with patients, family members, and on-site caregivers while seated in their office, in another wing of the hospital, or at home.

InTouch Health, a Santa Barbara, Calif., company, uses about 100 robotic systems. While seated at a control station, equipped with video capabilities, a microphone, and a joystick, the physician can “drive” the robot into a patient’s room for consultation. The patient can see the doctor’s face on the monitor and—on the other end—the physician has access to patient data and can see the patient through a live video image.

The robotic system provides added ability for intensivists and other specialists to do another evening round on their patients, explains Tim Wright, vice president of strategic marketing for InTouch. A recent study shows that when physicians use robotic telepresence to make rounds in the ICU in response to nursing pages, physician response is significantly faster. Additionally, the study found a reduced length of stay, particularly for patients with subarachnoid hemorrhage and brain trauma, as well as an ICU cost savings of $1.1 million.3

The idea of robotic telepresence is similar to the telemedicine model of care being used in the ICU. Through the robotic system, an intensivist can log in and perform an evening round, updating hospitalists on new patients and issues that may have arisen.

“The beauty is that the intensivist and the hospitalist can be looking at everything together,” Wright says. “The intensivist can provide the specialist knowledge and training, while the hospitalist provides the ongoing care.”

Not Just the ICU

Of course, telemedicine is not limited to the ICU. It is being used for virtually every medical specialty to help provide greater access to care.

Take the University of Texas Medical Branch at Galveston (UTMB), which has used telemedicine technologies since 1994. Its Electronic Health Network (EHN) utilizes telemedicine to help care for the state’s indigent and rural populations, as well as other groups, such as the elderly, prisoners, and even researchers in Antarctica.

One of the fastest-growing services UTMB operates is the telemedicine-based corporate healthcare programs, allowing employees to “see” a primary care physician without leaving work. Companies see this as a way to help control healthcare costs and make preventive care more accessible, notes Glenn Hammack, OD, assistant vice president and executive director of the UTMB Electronic Health Network. He also pegs the application of telemedicine to psychiatry as another growing service and one that illustrates how the technology is being used to help address a shortage of providers, especially in rural and underserved parts of Texas. Like the eICU programs designed to bring scarce intensivist care to ICU patients, UTMB’s services help distribute rare resources, such as child and adolescent psychiatrists who speak Spanish, to patients.

The telemedicine program at UMTB began in 1994 as a way to help provide cost-effective healthcare for inmates in the Texas prison system. Today, the Correctional Managed Care (CMC) department has telemedicine stations in 120 correctional units throughout Texas and accounts for about half of UTMB’s telemedicine program.

The 11 telemedicine studios at UTMB used for patients across the EHN are equipped with live interactive video links that allow the telemedicine physician to see and hear the patient, located at the remote station with a registered health professional on-site. Digital stethoscopes, hand-held cameras, and other electronic medical devices help the physician treat patients. The telemedicine program also utilizes shared electronic medical records, which are critical to its success, says Dr. Hammack.

Telemedicine can also be used between departments within the hospital. Dr. Hammack notes that hospitals have become large and complicated; the journey from one end to another for a test or procedure can be difficult on patients. “Telemedicine offers the ability for face-to-face interaction, and when used within hospital departments, it can bring some humanity of scale back to the increasingly complicated hospital environment,” he says.

Another Vision

Troy Sybert, MD, medical director for CMC Hospital Medicine and a practicing hospitalist at Texas Department of Criminal Justice (TDCJ) Hospital in Galveston, Texas, was hired a year ago to help create a hospitalist program within the prison system. His is the only health facility dedicated to prisoners and located on a medical school campus.

While his six-member team is not engaged in telemedicine, he sees a number of possibilities for CMC hospitalists to utilize telemedicine technology. For one, hospitalists could use their expertise in admissions to help triage patients via telemedicine. The CMC recently created a network of regional hubs similar to ED observation centers but without a 24/7 physician presence. Telemedicine triage could help the system offload the decision to admit and would likely reduce the number of hospital admissions, says Dr. Sybert.

Telemedicine technology could also provide other possibilities in perioperative care for surgery patients at TDCJ Hospital. In partnership with the surgery and anesthesia departments, pre- and post-operative work up and care could be done remotely with the patient back in the unit, promoting shorter lengths of stay and reducing transportation needs. The hospitalists, trained in correctional care, would provide support and coordinate with surgery—especially on the patient’s transition to and from the prison facility.

“The whole concept of telemedicine is to utilize experience from a centralized location,” says Dr. Sybert. “We have a vision for where we might like to go with telemedicine, bringing our hospitalist group’s experience with managed correctional care to prison units throughout the state.”

Whether it is bringing intensivist care to a critically ill patient, providing therapy sessions to patients in rural areas, or delivering the expertise of hospitalists, telemedicine technology is likely to play an ever-increasing role in healthcare. Dr. Hammack believes telemedicine will be used more and more as care providers and administrators find the right balance between technology and touch.

“It can be difficult to figure out how telemedicine can fit into the way hospitals do things. But it can fit in and does so very well. Technologies like these have the promise to provide support and result in better quality of care for patients,” he says.

Donya Hengehold is freelance medical journalist.

References

  1. Angus DC, Kelley MA, Schmitz RJ, et al. Current and projected workforce requirements for care of the critically ill and patients with pulmonary disease. JAMA. 2000 Dec 6;284(21):2762-2770. Comment in JAMA. 2001 Feb 28;285(8):1016-1017; author reply 1018. JAMA. 2001 Feb 28;285(8):1017-1018.
  2. Breslow MJ, Rosenfeld BA, Doerfler M, et al. Effect of a multiple-site intensive care unit telemedicine program on clinical and economic outcomes: an alternative paradigm for intensivist staffing. Crit Care Med. 2004 Jan;32(1):31-38. Erratum in: Crit Care Med. 2004 Jul;32(7):1632.Comment in: Crit Care Med. 2004 Jan;32(1):287-288. Crit Care Med. 2004 Jan;32(1):288-290.
  3. Vespa PM, Miller C, Hu X, et al. Intensive care unit robotic telepresence facilitates rapid physician response to unstable patients and decreased cost in neurointensive care. Surg Neurol. 2007 April;67(4):331-337.

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