1. Mannion, Annemarie


Expensive, in vogue, but is there evidence to support it?


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Telemedicine, one of the buzz words of modern health care, is an electronic system designed to allow intensive care medicine specialists (intensivists) and ICU nurses to manage ICU patients from afar. The majority of telemedicine systems are under the trademark eICU, and that name is commonly used to describe all such systems; eICU has a growing presence on ICUs and is used in as many as 10% of all U.S. hospital networks.


Implementing an eICU system is enormously expensive, and third-party payers almost never cover the costs of care provided by workers at a remote site. The primary argument for its use is that it allows more constant monitoring of critically ill patients, especially in hospitals that don't have enough intensivists or ICU nurses, and even when units have critical care experts on hand, proponents say, the inherent redundancy is both welcome and reduces morbidity and mortality. A new analysis calls the latter assertion into question, however, suggesting that there is a paucity of hard data demonstrating the effectiveness and efficiency of this approach to recommend its use.


The interview-style study explores why some hospitals have adopted telemedicine in their ICUs and others have not. It notes that 24-hour-a-day, intensivist-managed care (which was championed by the Leapfrog Group in the early part of this century) was prompted by a study that indicated that the approach could save more than 50,000 lives a year. Doubt was cast upon that figure, though, by a recent study (in the June 3, 2008, issue of the Annals of Internal Medicine) of 100 hospitals that showed that the odds of dying in the hospital were higher in patients whose care was managed by intensivists than in those whose care was not.


The eICU model involves "intensivist physicians and nurses, located in a central monitoring station, [using] a combination of visual and electronic monitoring and software tools to track care for patients across multiple ICUs in many hospitals. The eICU staff can use remote-control communication devices to see and hear ICU activities and orally communicate with the ICU."


The authors found widespread belief among hospitals that have adopted ICU telemedicine that it has improved quality and safety, even though the facility representatives interviewed could provide no data to support the notion. The authors conclude that these processes warrant as much study as drugs or devices and call for a comprehensive, nationwide evaluation, possibly in clinical trials.


Disputing the results of the analysis, however, is Robin Simmons, "eCare" ICU director at Via Christi Regional Medical Center in Wichita, Kansas. Since telemedicine in the ICU was adopted by Via Christi in 2007, 40,000 patients have been seen by a critical care intensivist, says Simmons. She says the hospital has accumulated data showing that mortality rates have decreased between 15% and 36% in the ICUs across the system.


Simmons says she would support studies of the effectiveness of telemedicine. She says that her nurses, particularly less experienced ones, benefit from the extra set of eyes provided by telemedicine and that care of patients has improved.


"The [telemonitoring] nurse is able to mentor the nurses at the bedside," Simmons says, "especially at night, when it tends to be new graduates who are on duty."


Annemarie Mannion


Berenson RA, et al. Health Aff (Millwood) 2009;28(5):w937-w947.