The Doctor Is (Plugged) In

How remote patient monitoring lets fewer specialists provide more attentive care
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David L. Bernd hates cold calls from salesmen, same as you do. But in 2000, the CEO of Sentara Healthcare felt he had to listen to a salesman who said he could use the Internet to transform intensive-care units at the nonprofit Norfolk (Va.) health system's seven hospitals. Those ICUs were costing the chain three times as much as its other units, and they were so short-staffed the hospitals routinely had to roust doctors out of bed to race in and handle late-night crises. Worst of all: At one Sentara ICU, 40% of patients who stayed more than a week died. "Mortality is not a vague statistic. It's 'Do you save my life or not?"' says Sentara Executive Vice-President Rodney F. Hochman.

That's how Sentara became the first client for the electronic ICU eICU) -- a technology that combines software, video feeds, and real-time patient information to let intensive-care specialists at Sentara Norfolk General Hospital cover 11 ICUs at six hospitals, spread 60 miles apart, around the clock. Today, the eICU is providing some of the most solid evidence that telemedicine, full of promise for years, is finally becoming real.

The eICU technology, sold by Baltimore's Visicu Inc. (EICU ), lets hospitals leverage the scarce resources of specially trained intensive-care doctors and nur- ses. A single physician and nurse can support bedside caregivers for more than 100 patients at once. "We classify it as transformational because of what it represents," says Gartner Inc. (IT ) analyst Vi Shaffer. "How do you do better with less, and how do you improve care when intensive-care specialists and nurses are scarce?"

The Leapfrog Group, a consortium of big employers, says 54,000 people a year could be saved if every U.S. ICU case were co-managed by a specialist. That's impossible without technology: It would take 25,000 specialists to staff ICUs, and only 6,000 are available. "I've watched eICUs take off just in the past year," says Phillip Dellinger, past president of the Society of Critical Care Medicine. "It inherently makes sense."

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HIGH HURDLES

Still, intensive-care telemedicine is in its infancy. About 100 U.S. hospitals have eICUs, and only 7% of ICU beds are remotely monitored. Why? Most hospitals' gains are less dramatic than Sentara's initial results. Small hospitals struggle to afford an eICU's cost, which has totalled $3.4 million for Sentara to date. And insurance and Medicare don't reimburse for the technology. That's one reason The Johns Hopkins Health System Inc., where Visicu's founders invented the eICU, says it hasn't bought the system. Others are waiting until ICU monitoring can be incorporated into comprehensive medical records software, so hospitals don't need separate systems. "That's why we wouldn't look at it," says Lex Ferrauiola, chief information officer of Hackensack (N.J.) University Medical Center.

But for Sentara, even having a stand-alone eICU system made a huge impact. In two ICUs, deaths fell 27% the first year Sentara had the system up, according to a study in the journal Critical Care Medicine. Based on death rates before and after the technology was rolled out systemwide, Sentara estimates that its eICU has saved 460 patients who would have died in traditional care. And the cost per ICU case also fell, by nearly $3,000, or 25%. Says Bernd: "We realized that ICUs industrywide weren't well managed. It was just a gut feeling that we could improve."

Sentara's Hochman says the system paid for its initial cost ($1.6 million) within six months. Much of the savings came from a dramatic plunge in complications such as hospital-acquired pneumonia and bloodstream infections, which occur more often when patients aren't monitored by experts who understand the meaning of subtle changes in their condition. If not treated immediately, they result in more tests, more treatments, and longer stays in intensive care, which costs about three times as much as the rest of the hospital. The system cut almost a day off the average ICU stay, from 4.4 days to 3.6. And the system generates data Sentara uses to refine doctors' protocols for treating common complications. One example: Sentara reworked the way it monitors glucose levels eight times using Visicu-generated records.

Indeed, the real advantage to the eICU is the change it allows in hospital management. Under Sentara's old system, a patient was admitted to a hospital by a nonspecialist doctor. That doctor made rounds in the morning, then went back to the office. For the rest of the day nurses handled whatever came up, alerting doctors when things got urgent.

The eICU system adds two more layers of patient management. An in-hospital team uses shared data to conduct its own daily case reviews. At Norfolk General, Medical Director for Quality of Critical Care William A. Brock rides a Segway through corridors as he directs a dozen doctors, nurses, pharmacists, and other professionals in reviewing each case in Sentara's cardiac ICU, ordering tests, and offering advice to admitting physicians. And from noon to 7 a.m., the eICU team offers specialized support to bedside nurses, who manage cases while patients' personal doctors do other work.

The new face of telemedicine was on display one day in late May at Sentara Heart Hospital's eight-bed cardiac ICU in Norfolk. Charlotte Pipes, 56, was brought in after suffering a heart attack on May 21 at her home in Elizabeth City, N.C. Overseeing Pipes's care, from the eICU across the Norfolk General campus, was intensivist John T. Bowers III. Bowers works at a stand-up desk, where five screens gave him the basics about 69 patients in Sentara's wired ICUs that day. On one screen, their names appeared on a roster, color-coded by their condition. Newly admitted and gravely ill patients, including Pipes, had red lights next to their names. On other screens, Bowers toggled between video images of patients, test results, and treatment plans from patients' own doctors, and vital signs captured by monitors. He could also use the system's built-in reference database, which has the latest research on how to treat ICU complications.

EARLY WARNINGS

Bowers says the best part of working in the eICU is that he can focus. No beeping pagers interrupt him. On this day, he spent the first hour of a seven-hour shift studying details of red cases and scanning the others. Bowers said data can spot early signs of failure better than he could if he were examining the patient in person -- especially if he were tired, which is an occupational hazard in a 24/7 world such as an ICU. If a patient's heart is racing or blood pressure is rising, Bowers gets an alert that moves the patient to the top of his to-do list. The system also reminds him when a test or treatment is due. "Our goal is that every red patient is looked at by a doctor or nurse at least every hour," he says. "I can be there six times an hour if the alerts put me there."

While the doctor may be miles away, technology is the constant companion of eICU patients. Across from Pipes's bed is a camera with a microphone. A speaker is in the ceiling. On one wall is a big red button that nurses push to turn on the camera if they need help. And the picture is startlingly clear. Tiny numbers on a tube leading to Pipes's nose are plain as day. The sound pickup is sensitive enough that caregivers don't have to shout, cell-phone-style, during emergencies: Mikes can pick up the sound of an off-camera janitor mopping. Harold Pipes, Charlotte's husband, says any intimacy that was lost when Charlotte was treated by an unseen doctor was offset by how closely she's watched. Plus, he can press the button and talk to the eICU if something worries him. "Here it just seems they're more on top of things," he says. "That makes me sleep better."

In fact, that morning Charlotte Pipes's blood pressure sinks rapidly as doctors take a balloon pump out of her aorta. The floor nurse isn't sure the decline is dangerous enough to page her cardiologist. But eICU nurse Jennifer Bartos walks the nurse through the data, prods her to find the doc, and turns the case over to him when he arrives. By that afternoon, Pipes stabilizes; she went home on June 5.

Sentara has seen enough to push forward. Chief Medical Officer Gary R. Yates is planning remote monitoring for medical and surgical units, and obstetrics. Other hospitals may have good reasons for hesitating to follow. Soon, though, they may have to factor in a question posed by Charlotte Pipes's sister-in-law, Janet Eiler: "Patients' families are going to ask: `Why don't you have this?"'

By Timothy J. Mullaney

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