Supporting Medical Staff and Patients in a New Era,The Physician Executive Journal

By Mary Jo Gorman, MD, MBA, CEO of Advanced ICU Care

The Physician Executive Journal
September/October 2011

In this article...
As physician shortages increase and patient care grows ever more complex, many health care organizations are turning to telemedicine to fill the gaps.

A 62-year-old patient was admitted to a community hospital with an aspirin overdose, complicated by severe metabolic acidosis, acute chronic renal failure and respiratory failure. He was intubated and underwent dialysis.

Using telemedicine technology, intensivists more than 800 miles away supported the onsite staff in instituting accepted best practices for ventilator patients and other evidence-based interventions for reducing complications of mechanical ventilation.

The tele-intensivists provided daily ventilator rounds with the hospital respiratory therapist and managed the patient in conjunction with the local pulmonologist. Through continuous monitoring of patient data, supervision of spontaneous breathing trials and sedation interruption, the off-site intensivists facilitated extubation -- reducing the number of ventilator days, ICU length of stay, complications and health care costs.

As broad physician shortages become more acute, physician leaders will need to recognize telemedicine's capabilities to solve their local needs. The AAMC Center for Workforce Studies estimates that the shortage in the U.S. could be as high as 159,000 by 2025.

According to the Society of Critical Care Medicine, the shortage of full-time physicians will approach nearly 125,000 by 2025. It is estimated that we will need 1.7 new physicians to replace each one of our retiring physicians due to the work/life balance expectations of many new physicians

Telemedicine, whether it's used in primary care or a specialty service, can help close this gap and advance the opportunities for physicians to be in contact with patients.

More and more hospitals and medical groups are looking to telemedicine programs -- across many specialties -- to deliver access to specialized care and technology that their patients otherwise would not receive. Demographics will drive the need, with the aging of America bringing older, sicker patients.

In addition, many physicians are looking for better work-life balance at the end and the beginning of their careers, and telemedicine can help support medical staff.

Current trends

There are compelling reasons for medical groups and hospitals to pursue a telemedicine strategy to ensure that staff will be available to serve their community.

For instance, simply stepping up physician recruitment efforts will not work. As it is, physicians have a wide variety of opportunities available to them, and even those just halfway through their training are receiving offers. The supply and demand characteristics of the physician labor force suggest that even intense, consistent recruitment will not be a long-term solution.

Initial solutions using telemedicine came from radiology firms that were trying to support a better lifestyle for radiologists. The availability of the digitally transmitted image accelerated the adoption of this transformative service. Now, radiology continues to be one of the largest specialty users of telemedicine.

Beyond radiology, telemedicine has evolved to meet needs for other specialty services as well; in all, almost 50 specialties are successfully using telemedicine.

Telemedicine technologies are being used to address the shortage in primary care physicians, with outpatient monitoring of patients with congestive heart failure, diabetes, high blood pressure and other chronic conditions.

Numerous medical devices enable the transmission of patient physiological data from at-home monitoring tools to hospitals or other disease management centers. Changes in a patient's condition are recognized immediately -- often by nurse practitioners and nurses, making better use of physician time -- and appropriate treatments can be made.

Outpatient specialties

Outpatient specialties like psychiatry have been using telemedicine technology to reach patient populations most in need of services. Telemedicine-enabled psychiatry visits and treatments are used in rural areas, prison populations, with the homebound and elderly, and with others who do not have access to actual face-to-face interactions.

Children and adolescents who require psychiatric evaluation and treatment are particularly vulnerable, especially those in underserved areas. There is a severe shortage of these specialists; for instance, in Alabama, only 12 counties have one or more practicing child or adolescent psychiatrists.

Cardiology is another specialty that is successfully using telemedicine technology. The need for cardiology expertise continues to burgeon in the face of spreading obesity and diabetes mellitus. The ability to assess patients and make dispositions from the emergency department or telemetry floor is an especially good use of telemedicine.

In neurology, there is an increasing need for rapid response for critical clinical situations. The prevalence of stroke centers across the country is increasing with the marketing message "time is brain."

Every minute counts when a stroke occurs, and immediate evaluation for administration of thrombolytic therapy, the use of drugs that dissolve blood clots, is essential. Through stroke networks, this is enabled by mobile connectivity between the physician and the patient, usually in the emergency department of a participating hospital.

The Michigan Stroke Network is an example that has proven extremely effective in treating stroke patients. The use of telemedicine-enabled stroke centers means patients can be seen 24/7 by specialists who can make treatment decisions quickly -- often meaning the difference between life and death. Additionally the telemedicine-enabled network means patients are often able to stay in their local hospitals.

Critical care

Physicians with busy hospital practices -- such as pulmonologists, cardiologists, surgeons and hospitalists -- often find the ICU a poorly paying, stressful environment. In order to optimize their practices' financial performance, intensivist support for their patients in the ICU is needed.

This support allows physicians to continue their other practice activities with less interruptions and better productivity. Many hospitals have made commitments to aroundthe- clock hospitalist programs that also serve the ICU. Having intensivists supporting the hospitalists, and working in collaboration with all ICU support staff, can mean measurable improvements in hospitalist staffing needs and outcomes.

Unfortunately, there is a shortage of intensivists. Pulmonologists, who tend to be older than the intensivists in the field and more likely to retire earlier, are also in short supply. According to the 2000 study by the Committee for Manpower for Pulmonary and Critical Care Services, we can expect a shortage of 10,000 intensivists by 2030. Given that fewer than 1,000 graduates are produced each year, this is a formidable challenge.

Tele-ICU programs can help fill the intensivist gap. Hospitals are using these programs to help stretch scarce resources, reduce time demands on medical and nursing staff, and reduce costs and improve patient care in the ICU. Numerous independent studies show the improved patient outcomes that result from tele-ICU programs.

A study recently released by the New England Healthcare Institute (NEHI) and the Massachusetts Technology Collaborative found that patient mortality decreases significantly -- as much as 36 percent -- when hospitals adopt tele-ICU technology.

Also, patients' length of stay in the ICU decreases by almost two days -- or 30 percent. There is a meaningful impact on costs as well. The NEHI study showed that average costs per case decreased by approximately 20 percent, largely due to the decrease in length of stay.

Additionally, the study showed the average cost per ICU case for payers could be reduced by about $2,600 for patients treated in academic medical center ICUs. For the two community hospitals in the study, retaining patients who were previously transferred to teaching hospitals saves payers approximately $10,000 per case, according to the study.

Proactive staffing strategies

The shortages in primary care and specialist physicians will continue to worsen. Physician leaders need to have proactive and creative staffing strategies for long-term solutions, and properly identifying the needs and goals of the program will lead to greater success. Some factors to consider include:

• What program will have the greatest multi-disciplinary/multispecialty impact? Is there a challenge in emergency department throughput? Can we enhance response time?
• Is there a medical risk area that we can address with better access to specialty services?
• Do we have a challenge with patient retention due to lack of specialty care? Could we see a positive financial impact for patient retention?
• Do we have cost control issues due to delay in treatment?
• Are our quality results where our board and community would like them to be?
• Would our employed physicians (family medicine, cardiology) be more productive if different, more readily available support were available?
• Is there an opportunity to position us for future demands of health care reform, such as accountable care organizations?
  

Telemedicine is not a quick solution but a strategic one that requires examination and commitment. Initial hardware costs can be significant. Analysis of the options should include cost, the need for wireless or wired service, cable or Internet delivery, and mobile or fixed installation.

Consider if the device must transmit parts of the physical exam and identify a device that meets this need. At a more basic level, broadband access may be an issue for some rural areas. However, the boost in broadband investment by the FCC will pave the way for telemedicine to extend the reach of physicians to very small communities.

Providers will need to obtain state licensure prior to evaluating and treating patients. Recent rulings have required a medical license to prescribe medications across state lines.

For physicians who interact with hospitalized patients, hospital credentialing and privileging for telemedicine physician providers is necessary. Currently, each physician is required to be on staff at both the originating and the distant hospital.

The Joint Commission allows the originating site to use the credentialing and privileging information from the distant site if some basic requirements are met.

This summer, the Centers for Medicare and Medicaid Services (CMS), which had precluded this process, took a huge step in support of telemedicine, allowing hospitals to rely on the credentialing and privileging decisions of the distant site. This reduces the regulatory burden on hospitals, while greatly improving patient access to expertise and technology.

In order for this new rule to reach its greatest potential, however, hospitals need to recognize the streamlined process and accept the privileging decisions of the clinician's home hospital or facility.

Additionally, reimbursement for some services provided through telemedicine has been approved by CMS. Hospitals need to determine if this professional fee billing is a meaningful offset to the cost of the program and if it is necessary for program success.

Despite some of these challenges, telemedicine is a viable option to address the looming physician shortage. Hospital leaders need to think ahead -- the horizon is nearer than one might think. Now is the time to move forward with planning for and implementing solutions to solve local staffing needs.

There will be limits, of course, and advanced technology projects will take lead time. However, creative thinking with proper planning creates telemedicine solutions that better serve the community, its patients and the staff caring for them.

Mary Jo Gorman,MD, MBA, MHM, is chief executive officer and co-founder of Advanced ICU Care. mjgorman@icumedicine.com