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The eICU: Beyond the Hype
About the Author
Michael Koppenheffer, M.B.A.
koppenhm@advisory.com
202-266-5484
Michael Koppenheffer is Managing Director of the Innovations Center. An expert on the adoption and impact of medical technologies, Mr. Koppenheffer has more than a decade of experience advising the hospital, pharmaceutical, and medical device industries. Prior to joining the Advisory Board Company, Mr. Koppenheffer worked with a leading pharmaceutical company developing consumer marketing strategies for a new prescription drug product. He also worked as a journalist covering health care and health policy, notably serving as Congressional correspondent for policy newsletter Health News Daily and European editor for drug industry weekly The Pink Sheet. Mr. Koppenheffer received a M.B.A. from the Fuqua School of Business at Duke University, where he was named a Fuqua Scholar. He received his undergraduate degree in English and Russian magna cum laude from Williams College.
Executive Summary
The remote-monitored intensive care unit, often called an "eICU," is emerging as a potential solution to cost and quality issues in critical care medicine. The eICU is an application of remote telemedicine technology in which several intensivists and nurses monitor multiple ICUs from an off-site command center. Early studies suggest cost and outcomes advantages for the eICU, but the financial return to date has been indirect at best: an eICU center is a multi-million dollar investment, and except in very limited circumstances, reimbursement is currently unavailable. That said, "soft" returns in terms of physician, nurse, and patient satisfaction, not to mention improved clinical quality, have been substantial. Today, eICU monitoring does not yet constitute a minimum standard of care, but it represents an innovative and effective tool to improving ICU care and alleviating the intensivist shortage.
The Problem at Hand - ICU Quality, Costs Under Scrutiny
Over the past several years, spurred by industry reports and pressure from advocacy groups, quality shortfalls and exorbitant costs in the nation's intensive care units have come under public scrutiny. Over four million patients nationwide are admitted to the ICU each year, and of those, approximately 50,000 die preventable deaths. Hospitals and health systems also spend a staggering sum to care for ICU patients -- over $67 billion annually, at last tally.
Ongoing Concerns in the ICU
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Source: "ICU Factsheet," The Leapfrog Grou, www.leapfroggroup.org, (April 7, 2004); Clinical Advisory Board; "Intensivist Best Practice Implementation Kit," The Advisory Board Company, Washington, DC (2001); "Celi, L., et al., "The eICU; It's not Just Telemedicine," Critical Care Medicine, 29(8): N183 (2001).
Intensivists an Effective but Scarce Solution
Staffing the ICU with full-time physicians who specialize in critical care medicine, called intensivists, has been shown to improve the efficiency and effectiveness of ICU care. Accordingly, the Leapfrog Group employer coalition has called for intensivist monitoring at each bed as a central quality improvement initiative. The unfortunate reality is that there are far too few qualified intensivists to go around, limiting how far even the best-intentioned hospitals can pursue this avenue of performance improvement.
Telemedicine to the Rescue?
Remote Monitoring Presents a Potential Solution
Innovations in ICU telemedicine may alleviate, if not eliminate, the intensivist shortage. Remote ICUs—also known as electronic or eICUs—network monitoring equipment, video, PACS, and medical records between hospital-based ICUs and a remote “command center” located off-site. The remote ICU enables physicians to monitor up to 150 patients and nurses up to 40 patients across multiple hospitals. The first company to market the eICU, VISICU, is the only commercial provider in this area today, although other health care informatics companies have been investigating the field.
VISICU System the Pioneer, Market Leader
The vast majority of eICU installations today are based on the VISICU system, which was developed by two Johns Hopkins intensivists. The VISICU system comprises a software platform integrating health records, patient vitals, audiovisual feeds, image acquisition software, and decision support tools, networked across multiple hospitals. eICU staff can monitor patients' vital signs, assess condition, be alerted when a patient's condition worsens, and likewise, alert nurses on the floor when they observe signs of an emergency.
A Command Center for ICU Care
The heart of the eICU monitoring system is the off-site command center. These workstations, with their multiple displays, headphones and microphone, enable nurses or intensivists to monitor many patients at once. Typically, remote practitioners conduct virtual rounds on patients at the beginning of their shifts, then look in on patients as prompted by automated alerts and acuity segmentation.
Early Evidence Suggests eICU Improves Quality, Costs
Initial studies of eICU systems suggests that the remote monitoring technology can have measurable benefits on health outcomes and resource utilization. The best-documented eICU study to date was performed at Sentara Health System, where mortality, ICU stay, and average case cost all declined significantly followed eICU implementation.
Clinical Outcomes, Not Financial Return, Main eICU Driver
The direct financial case for eICU remains limited. Setting up an eICU facility is a multimillion dollar investment, and intensivist and nurse salaries can be an ongoing burden. At the same time, facility and professional reimbursement is virtually nonexistant, although work is ongoing to establish appropriate tracking codes and (eventually) payments.
"Soft" eICU Benefits Offer Additional Justification
Quality improvements the eICU affords are augmented by softer benefits. Since the eICU monitoring equipment tracks and trends patient data and outcomes, the data can be retrieved and used for educational purposes, helping to disseminate best practices. Additionally, eICU staff can pull these outcomes from patient charts and compile them into a format that can be presented to JCAHO or CMS for quality reports. Administrators have also reported improved nurse satisfaction after implementation jitters subside.
New Business Models
Multi-Hospital Collaborations Defraying the Expense
Despite the high cost of purchasing and maintaining an eICU, small hospitals and health systems can realize its benefits through collaboration. The more common emerging model is one in which a large health system with an eICU monitors smaller hospital for a perbed monitoring fee. In a second model, pioneered in Wisconsin by Critical Care Solutions, LLC, multiple smaller hospitals and health systems collaborate to create an eICU as a joint venture, spreading costs and benefits across unaffiliated hospitals.
"Homegrown" Models an Intriguing Alternative
A few institutions have effectively created their own remote ICU monitoring systems on their own. Lehigh Valley Health System created its own remote ICU- called the "aICU"- based on an electronic patient record (EMR) system custom-designed by iMDSoft. The EMRs are shared between the aICU and two of the three Lehigh Valley hospitals. The system is structured similarly to VISICU's eICU, with monitors, networked vital signs, and audio/video monitors.
Future of the eICU
Expanding ICU Monitoring Capabilities Beyond the ICU
Although the ICU offers the greatest immediate return for remote monitoring, some early adopters have been investigating other settings where the eICU concept could contribute to quality of care improvements. Post-anesthesia care and the emergency department are two potential areas for expansion. Another approach is to use mobile monitoring units to provide virtual intensivist
consultations outside the ICU, either through a computer-based cart or a self-propelled robot.
Program Guidance
Integration Into Bedside Care Processes a Key Issue
Anecdotally, the most success has been observed in ICU units where the eICU physicians are given the greatest latitude in treating patients, but entrenched care processes and physician "turf" concerns can make implementing a high-involvement eICU protocol an insurmountable challenge, at least at first. Presenting attending physicians with data demonstrating quality improvement associated with eICU interventions has helped some administrators overcome physician pushback, while painstaking efforts to collaborate with doctors has been the key to others' success. A strong physician leader to enforce eICU guidelines is also helpful in rallying physician cooperation.
Six Critical Success Factors from Early Adopters
Success Factor #1 Open Communication Channels To ensure that physicians and nurses on the floor will implement eICU technologies, administrators and doctors must be open to discussing concerns or problems. Additionally, clear guidelines about which situations eICU intensivists may intervene in are key to avoiding turf battles and confusion. | Success Factor #2 Collaboration Between eICU, Bedside Uncooperative physicians and nurses on the floor may actually lower thequality of ICU care, and eICU intensivists who intervene without an physician permission can interfere with floor staff's work. All parties must work together when setting up and implementing the eICU to reach a consensus about the level of care the eICU team will provide. | Success Factor #3 Physician and Nurse Advocates Physicians and nurses will never universally accept the eICU. However, on units where a strong physician or nurse leader enforces theeICUrules, cooperation between eICU |
Success Factor #4 Financial Security Hospitals with eICUs must finance them without any support from insurers of additional charges to patients. Consequently, the hospital or health system with significant funds that can be allocated to new technology is more likely to maintain a successful eICU. | Success Factor #5 Clear Division of Tasks Avoiding confusion between the eICU and the floor is critical to a functional eICU and clearly delineating when and in what situations the eICU physician will take over for the attending physician or nurse. Clarity is key to maintaining strong communication and collaboration between the eICU and the physicians. | Success Factor #6 Patience Many early adopters have found identifying significant improvements in quality is difficult to measure when the eICU has been up and running for less than two years. Additionally, physicians and nurses may require a significant amount of time to “win over.” |
Opportunities and Challenges
Opportunity #1 Improved Quality of Care Administrators reported that despite the fact that they lack data showing significant improvement in outcomes and quality metrics, they have observed a trend toward better quality in the ICU. Additionally, with an eICU, a hospital can fulfill the Leapfrog intensivist staffing standards and show a commitment to improving the standard of care. | Opportunity #2 Fewer Intensivists Needed By taking advantage of intensivists' knowledge and applying the principle of economies of scale, a few intensivists and critical care nurses off-site can monitor eICU beds at multiple hospitals. The negative effects of a shortage of intensivists nationwide can be largely mitigated for those hospitals implementing an eICU. | Opportunity #3 Decreased ICU LOS, Increased Throughput The eICU can help to decrease ICU length of stay because intensivists and critical care nurses are able to prevent serious complications before they occur by monitoring patients while the attending or nurse is not available. Patient care is expedited, medical errors are reduced, and patients can be moved out of the ICU more quickly, according to clinical studies. |
Opportunity #4 Increased Nurse Satisfaction Despite initial concerns about “Big Brother” oversight, most nurses have reported overall improvements in job satisfaction, because they can be certain another set of eyes is monitoring their patients. Younger nurses in particular appreciate the eICU because they can rely on the team’s expertise in situations where they are uncertain of what to do. | Opportunity #5 Physician Resistance Physicians tend to be more resistant to eICU intervention than nurses, because there are prevailing concerns about their expertise being questioned, turf conflicts, and a dislike of other physicians caring for their patients. eICU administrators consider this to be an unavoidable challenge that all hospitals must confront. | Opportunity #6 Slow to Show Significant Improvement Creating metrics for quality improvement is difficult and many uncontrollable factors influence patient mix and acuity. Consequently, measurable improvements in the quality of ICU care will not be immediately apparent. Administrators can expect to rely on trends toward lower LOS and improved outcomes for several years before determining whether the eICU has significantly improved patient care. |
Opportunity #7 High Financial Outlay The eICU– whether purchased from VISICU or built independently– requires hospitals have millions of dollars available to purchase equipment, and software, as well as to fund physician and nurse salaries. Gaining a full return on investment is highly unlikely, so the eICU will become a cost sink. For smaller community hospitals or health systems the expense can prove to be a hurdle difficult to surmount. | Opportunity #8 Lack of Reimbursement Compounding the financial hurdle is a current lack of reimbursement for eICU services. Hospitals must pay for all eICU operations out of their operating budgets without expecting financial returns from payers. Administrators anticipate that reimbursement is in the pipeline, and the Society for Critical Care Medicine is currently requesting a CPT code dedicated to eICU services, but it is unclear when reimbursement will be determined. |
Health Care Advisory Board
Innovations Center Staff
Managing Director
Michael Koppenheffer
Project Author
Erika Kottenmeier
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Note on Data Use
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