TeleICU Proposal

Team Members

Eric Chavez

Sophia Mantovanelli

Cheryl Schunk

Ashok Tyagi

Telemedicine for the ICU (TeleICU)

• TeleICU is technology that allows critical care specialists to monitor and manage the care of critically ill patients at multiple remote sites from a centralized command center.

• Remote sites are connected to the command center by sophisticated telecommunication systems which provide real-time and continuous audio and video feeds as well as electronic data streams of patient physiological parameters, ventilator settings, and infusion pump settings.

New England Healthcare Institute (2007)

TeleICU Technology• Hardware systems collect, assemble, and transmit remote patient

physiologic data, medical records, and treatment data to the command center.

• Software systems operate the hardware, transmit data, and analyze data for use in decision support with alarms and triggers for actionable situations. Software systems are integrated into the electronic health record, lab, and pharmacy systems.

• Live audio and video streams allow providers at the remote and command sites to communicate with each other and allow providers at the command site to examine the remote patients.

Cummings (2007), Kahn (2014)

TeleICU Program Objectives

• There are currently no intensivists practicing in the ICUs at our satellite hospitals.

• We will develop and deploy a TeleICU system command center staffed with intensivists at our flagship hospital.

• We will extend critical care treatment through intensivist monitoring to the four satellite hospitals.

• This is cutting edge technology and we will save many lives with this state-of-the-art TeleICU.

Measurable outcomes Effective & Efficient24 hour intensivist coverage in an ICU improves patient outcomes as lengths of stay are shortened and mortality is lowered.

As these metrics go down, total cost of care is lowered.

Cost

Mortality

Length of Stay

0 2 4 6 8 10 12 14

5.15

9.4

3.63

6.5

12.9

4.35

Before and after TeleICU4

Before TeleICU After TeleICU(Breslow 2004)

Equitable and patient-centeredMany more patients monitored by a single intensivist team including those in underserved areas.

Safe and timelyFewer patients in satellite hospitals that need a risky transfer in order to receive real-time intensivist care.

Flagship Hospital and

ICU command center

Satellite 1

Satellite 2

Satellite 4

Satellite 3

Measurable Outcomes

Leapfrog Initiatives

“Research has shown that in ICUs where intensivists manage or co-manage all patients versus low intensity there is a 30% reduction in hospital mortality and a 40% reduction in ICU mortality” from the Leapfrog Group’s safety practice, ICU physician staffing web page.

Lives can be saved. The Leapfrog Group estimates 53,000 annually nationwide.

Nationwide Intensivist shortage

• 6000 critical care specialists in the United States – less than one for each ICU

• Experts predict this shortage will continue

• TeleICU is the solution to the intensivist shortage

Young (2000), Pronovost (2001), Rosenfeld (2000), Kelly (2004), Knaus (1985), Knaus (1991)

No. of Intensivists Daytime Nightime0

10

20

30

40

50

60

70

80

90

100

Intensivist Coverage in the Surrounding Area

Our Healthcare System Competitor 1Competitor 2

Inte

nsi

vist

s C

ove

rag

e

Market Assessment

Why do we need TeleICU?

Reduce inter-hospital transfers

Reduce cost per patient episode

Cost Savings

Reduce Intensivist needs

Prevent readmissions

Optimize resources

Projections before and after TeleICU implementation ($/day)

Before After

Average ICU daily cost

1,648 1,411

Average case cost

10,444 7,871

Cases per month

116 124

Contribution margin per month

796,245 1,321,767

Young (2000), Breslow (2004)

MortalityLength of stay

0

2

4

6

8

10

Current flagship vs satellite statis-tics

Flagship Satellites

Financial benefit: $3.14 million over 6 months

Economic Impact

Projected Economic Impact

• Program costs• (hardware and software leasing, technical support, and TeleICU operating

expenses $248,000)

• TeleICU physician staffing $624,000• Total costs over 6 months: $872,000

Young (2000), Pronovost (2001), Breslow (2004), American Journal Medicine Quality 2007

Net Profit: $3.14 million - $0.87 million= $2.27 million over 6 months

6 month cost analysis

Initial cost $30,000 per ICU bed for equipment

10

4

2

ICU Physician Support

Strong Medium Weak

55

22

1

Administration Support

Strong Medium Weak

85

14

1

Strong Medium Weak

Health System Support

• ICU physician champion: Ted Armbruster M.D. who has a strong foundation and interest in TeleICU development

• C-suite strongly in favor• Satellite & Flagship Hospital administrators: Overall strongly in favor of

TeleICU (reduce overall costs & increase revenue)

Self-assessmentProject support

Self-assessment• Project advocates:

• Improved ICU mortality and LOS• Cost savings & sharing, additional

revenue• Competitive edge over other

health systems• Staff support at flagship hospital

readily available• Leapfrog Group initiatives met

with intensivist coverage for all

• Project critics:

• ICU Physicians: More liability and increased workload, same pay

• Learning curve for new ICU software

• Reimbursement for TeleICU is limited

Projected NeedsHuman Resources

Currently available

16 Intensivists

10 Critical care specialty nurses

Projected Total Need

20 intensivists

15 critical care specialty nurses

Necessary to Acquire

4 intensivists

5 critical care specialty nurses

One IT position

• Clinical Workstations• Video Conferencing• Application Software• Real Time Vital Signs Front-End• Hot Phone Risk management• Security• Privacy

• Server Room• Database Server• Alerts Server• Application Server• WAN/LAN Equipment

• Network Backbone• T1 Frame Relay or LAN backbone

Breslow (2004), Philips eICU Program (2014), enVision eICU (2014)

Vendor of Choice: VisiICU

TeleICU Architecture

Established vendor for delivering TeleICU

Billing and Insurance• CPT or HCPCS code for the professional service

• Telehealth modifier GT certifies that the virtual service was reformed.

• CMS has published CPT codes for Telehealth

• Minimal CPT code additions

Legal, ethical, regulatory, credentialing, privacy, and security issues can all be managed by current in-house personnel.

Once TeleICU set up and running well, intensivist command center services can be leased to other hospitals = more return on investment.

Timeline for development and implementation

• Physician Credentialing process for Telemedicine in our state• Approximately 60-120 days

• Equipment ( approximately 4 months) • Order• Install• Testing• Training

• Single ICU focused deployment plan (one at a time)

Negatives Associated with TeleICU

• Telemedicine is an emerging technology and long-range

understanding of its impact has been challenging

• Cost savings is varied based on vendor association and

individual hospital reported expenditures

• Technology implementation highly specialized

• Significant initial out of pocket hospital expense

Kumar (2013)

Positive Reports of TeleICUs

• Baptist Health in South Florida, Fernandez (2013)• 24,656 adult TeleICU patients• 13 % decrease in LOS • 23 % decrease mortality rate• Patient satisfaction reported because they felt “watched

over”

• Berenson (2009)• Increased patient satisfaction as nurses had more time for

families

Summary• TeleICU will support the mission and vision of the medical

center by extending critical care intensivist management to all affiliated hospitals

• TeleICU Programs have been shown to reduce length of stay and reduce mortality rates

• The TeleICU Program will take approximately 4 months to implement

• $3.14M Revenue in 6 months

• $0.87M Cost over 6 months

• $2.27M Net Profit over 6 months

References• Berenson R (2009). Does Telemonitoring Of Patients—The eICU—Improve Intensive

Care?. Health Affairs. 28(5), 937-947.

• Breslow M (2004). Effect of a Multiple-Site Intensive Care Unit Telemedicine Program on Clinical and Economic Outcomes: An Alternative Paradigm for Intensivist Staffing. Critical Care Medicine. 32(1), 31-38.

• Combination ICU Mortality Calculator. (2014, February, 11). retrieved August 16 2014, from ClinCalc.com Web Site: http://clincalc.com/IcuMortality/

• Cummings C (2007). Intensive Care Unit Telemedicine: Review and Consensus Recommendations. American Journal of Medical Quality. 22(4), 239-250.

• enVision eICU. (2014). retrieved August 16 2014, from Inova Web Site: http://www.inova.org/healthcare-services/inova-telemedicine-institute/enVision-eICU

• Fernandez, J (2013, May, 13). eICU: Improving Care and Reassuring Patients. retrieved August 16 2014, from Baptist Health South Florida Web Site: https://baptisthealth.net/baptist-health-news/eicu-improving-care-and-reassuring-patients/

References• Kahn J (2014). Adoption of ICU Telemedicine in the United States. Critical Care

Medicine. 42(2), 362-368.

• Kelly M (2004). The Critical Care Crisis in the United States: A Report from the Profession. Chest. 125(4), 1514-1517.

• Kumar G (2013). The Costs of Critical Care Telemedicine Programs A Systematic Review and Analysis. Chest. 143(1)28(5), 19-29.

• New England Healthcare Institute, (2007). Tele-ICUs: Remote Management in Intensive Care Units. Cambridge, MA: Massachusetts Technology Collaborative and Health Technology Center.

References• Philips eICU Program. (2014). retrieved August 16 2014, from Philips

Web Site: http://www.healthcare.philips.com/main/products/patient_monitoring/products/eicu/Ph]

• Pronovost P (2001). Impact of Critical Care Physician Workforce for Intensive Care Unit Physician Staffing. Current Opinion Critical Care. 7(6),256-459.

• Rosenfeld B (2000). Intensive Care Unit Telemedicine: Alternate Paradigm for Providing Continuous Intensivist Care. Critical Care Medicine. 28(12), 3925-3931.

• Young M (2000). Potential Reduction in Mortality Rates Using an Intensivist Model to Manage Intensive Care Units. Effective Clinical Practice. 3(6)6,284-289.