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Telemedicine Success Requires an Alignment of Incentives (and Attitudes)

A telemedicine expert says eICU programs are beginning to succeed because doctors and administrators on both ends of the platform are collaborating.

- The physician at the head of a recent study on eICU benefits says the biggest challenge facing healthcare providers adopting telemedicine these days isn’t the technology. It’s the attitude.

“If you apply the technology the way it was designed (to be applied), it can make a difference,” says Craig M. Lilly, MD, director of the eICU program at UMass Memorial Medical Center. “But if you don’t have collaboration, it’s not going to work. Then you have … relative antagonism.”

Lilly, one of the acknowledged experts in the advancement of telemedicine services in critical care environments, recently concluded his fourth analysis of the eICU or tele-ICU model of care. His study, focusing on Philips telemedicine technology, found that a tele-ICU or eICU program with centralized bed management control can increase case volume by as much as 44 percent and improve contribution margins by almost $53 million.

Lilly and Brian Rosenfeld, vice president and chief medical officer of Philips Hospital to Home and a former Johns Hopkins clinician who participated in some early studies on the eICU concept, say past attempts to create a telemedicine platform in the ICU failed because they put clinicians in the smaller, more rural “spoke” hospital at odds with those in the larger hospital charged with overseeing them via the telemedicine platform.

Some of those programs were “spectacular examples” of how not to coordinate a telemedicine platform, Lilly says. Those overseeing the ICU from a distance weren’t communicating with those at the site, while doctors and nurses at the bedside felt they were ignored or devalued and, in some cases, simply turned off the equipment so they could treat their patients without what they saw as an intrusive ‘big brother’ looking over their shoulder.

Lilly’s telemedicine studies, conducted over a span of several years, found that too many clinicians and supervisors were looking at the platform as “just a bunch of cameras and microphones,” and weren’t seeing the platform’s effect on ICU workloads and patient outcomes.

“The ICU used to be referred to as the command center” of the hospital, Rosenfeld, who launched the eICU company Visicu before it was acquired by Philips in 2007, pointed out. “It should be looked at as a service center, though. You’re getting a service, not a command.”

“It’s an evolutionary process,” adds Lilly, whose studies have shown that a coordinated telemedicine platform in the ICU can improve workloads at both ends of the platform, reduce patient length of-stay and eventually help a hospital run an ICU in the black. “We’re not quite there yet on a standard of care, but we’re moving in that direction.”

Lilly says more and more smaller and regional hospitals are looking at telemedicine as a means to treat more of their patients in-house, rather than transporting them to larger hospitals. That improves the hospital’s business plan, keeps patients closer to their homes and makes the payers happy. The larger hospitals, he says, see the platform as both an extra business line and a means of reducing overcrowding and unnecessary patients in their ICUs and ER departments.

“When we’re overwhelmed, we want to be able to take care of the patients we have to take care of,” he points out.

“It’s a move toward population health” that some smaller hospitals might be slow to understand, Lilly says. “Clinicians sometimes don’t see the benefits of population-based care because they’re so focused on the individual patient.”

In his latest study, Lilly, a professor of medicine, anesthesiology and surgery at the University of Massachusetts Medical School, led a project that analyzed more than 51,000 patients across seven adult ICUs on two campuses of an 834-bed academic medical center in Massachusetts. It compared a traditional ICU with UMass Memorial’s Philips eICU program, as well as a tele-ICU program with a logistical center to improve bed use and standardize care.

The study, while will appear in the February 2017 issue of CHEST, compared case volume and contribution margins, which are derived from total revenue minus direct costs.

According to the study, the UMass Memorial Medical center’s tele-ICU program

  • improved case volume by 21 percent over traditional models; and
  • improved contribution margins by 376 percent ($37.7 million compared to $7.9 million) due to increased case volume, shorter lengths of stay and higher case revenue relative to direct costs.

When combined with a logistical center, the study found that a tele-ICU program

  • improved case volume 38 percent over traditional models; and
  • improved contribution margins by 665 percent ($60.6 million compared to $7.9 million).

"An ICU bed costs approximately $2 million to build, and this study demonstrates a significant increase in case volume by better utilizing existing resources," Tom Zajac, Philips’ chief executive officer and business leader for population health management, said in the press release. "This shift enables care for expanding populations without having to build and staff additional ICU beds, thus helping hospitals thrive in a value-based care environment."

“This is really the only cost-effective way to do population management for really large demographics,” adds Rosenfeld.

This study comes at just the right time, Lilly says. Many small or community hospitals have little money to spend on capital investments and are operating with legacy IT platforms that are difficult to upgrade. To convince them to adopt a new technology platform, one needs to show them that’s it’s more efficient, and that they’ll waste more time, money and effort staying with an old idea than in moving to a new one.

Most importantly, Lilly and Rosenfeld say, clinicians at both end of the telemedicine link are realizing they have to work together, as part of one care team.

“They’re starting to see how the incentives can be aligned,” says Lilly, who estimates it takes a good four to five years for an eICU program to take hold. “We’re getting to a point where doctors no longer feel the need to push a button and shut things down. These programs are no longer failing.”

Maybe they’re finally adopting the right attitude.

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