By THIRSTY
In the age of the COVID-19 pandemic, new technologies and techniques to safely leverage trained medical professionals have become urgent. With so many coronavirus patients requiring ICU care, Stay Thirsty Magazine reached out to John McIlwaine, MD, the Medical Director of the Center for Telehealth at Geisinger Health Systems that oversees 3 million patients in 45 counties in Pennsylvania, for his views on the importance and effectiveness of ICU telemedicine.
STAY THIRSTY: What is ICU telemedicine and how is it practiced?
JOHN MCILWAINE: There are a variety of tele-ICU programs in terms of enabling technologies, workforce deployment, monitoring status, to name a few major differentiators. In its simplest form, a critical care nurse or provider can assist in delivery of critical care services from a remote location. Obviously, these services are to assist in the cognitive portion of critical care delivery for one is not able to perform procedures remotely.
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| John McIlwaine, MD |
STAY THIRSTY: How sophisticated is the equipment required both for the telemedicine physician and at the hospital ICU? In an emergency can a hospital use an iPhone and Facetime where the standard equipment is not available?
JOHN MCILWAINE: The equipment can be as simple as point-to-point audio/ video encrypted software system and a remote provider having access to the patient’s EMR [Electronic Medical Records] vs. a dedicated tele-ICU software platform that proactively monitors for signs of physiologic instability then offers data visualization queues to a remote provider that patients are either improving or worsening. The remote provider can then enable encrypted audio/video communication with the ICU room where the patient is located. In this latter scenario, the provider has full prescriptive access to the patients EMR. Regarding your second question, typical iPhone and Facetime capabilities do not meet HIPPA compliant encryption, so no.
STAY THIRSTY: Will the coming 5G high speed broadband produce better and faster diagnoses for ICU patients?
JOHN MCILWAINE: Don’t know. I foresee enhanced prehospital response team protocols.
STAY THIRSTY: What are the personnel requirements to have successful ICU telemedicine involvement both at the telemedicine headquarters and at the hospital using the service?
JOHN MCILWAINE: Tele-ICU systems do not replace beside teams, so this would not change workforce deployment at the hospital using the service. Regarding, tele-ICU hub or support center, we don’t empirically know the answer to this question. The personnel deployed so far are some combination of nurses, advanced practitioners, physicians, pharmacists, and clerical staff to support the program.
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| Telemedicine work station |
STAY THIRSTY: What kind of training is necessary to successfully deliver an ICU telemedicine consultation?
JOHN MCILWAINE: Typically, board eligible or certified physicians and ICU experienced nurses and pharmacists have the cognitive capabilities to successfully provide tele-ICU services; we do need some video conferencing etiquette training, and typically train some unique workflows.
STAY THIRSTY: In normal times, how is ICU telemedicine employed by hospitals? Are more hospitals incorporating ICU telemedicine into their clinical care protocols?
JOHN MCILWAINE: Most tele-ICU programs are deployed at large integrated health care systems or larger academic centers. The business model is hinged upon improved clinical and fiscal outcomes for the hospital in which the services are deployed. There was rapid expansion of tele-ICU beds in the US until about 2010 and a plateauing of bed expansion. As of 2010, about 10% of all ICU beds in the US had tele-ICU deployed.
STAY THIRSTY: How can the use of ICU telemedicine help rural hospitals that are understaffed with budget constraints? Is ICU telemedicine cost effective for small and medium-sized hospitals to use?
JOHN MCILWAINE: They can help those hospitals keep simple, yet sicker patients at their facility by have more critical care support. A tele-ICU can’t help with understaffing but could help improve the revenue stream to allow adequate bedside staffing.
Regarding the cost effectiveness, simple question, complicated answer. It depends upon the financial health of the hospital, meaning one needs to accurately know the contribution margin (CM) per ICU case, averaged over some period, typically a year. If the CM/case is high, then the number needed to breakeven on an investment would be lower than if the CM/case is low. Installing a successful tele-ICU must be viewed as a large capital investment for any hospital, small up to very large (>500 beds). If installing (or outsourcing) a tele-ICU would likely increase case volume, then a breakeven point can be estimated.
STAY THIRSTY: What role do you see ICU telemedicine playing worldwide as the COVID pandemic plays out?
JOHN MCILWAINE: Hard to tell since I am trying to figure out surge staffing and program for my health system. Theoretically, areas that are not overtaxed could help areas beyond capacity of local services. There are numerous regulatory hurdles before this could occur.
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