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Hospitals look to the virtual ICU

Doctors say high tech saves lives by reducing the incidence of often-deadly hospital-related infections.

Swedish Medical Center in Seattle, like many health care facilities in the U.S., always considered patient complications an unfortunate but inevitable result of prolonged hospital stays.

Individuals admitted for organ transplants, cancer treatments or emergency care would often end up contracting some altogether different, potentially life-threatening illness, despite the fact that they were under the close supervision of a team of top doctors.

A new intensive care unit technology, however, has worked wonders in one critical corner of the hospital, helping Swedish Medical and others in the often information technology-averse hospital field improve patient safety, reduce complications, and, as a result, shorten patient stays and save money. Many of the more than 100 hospitals around the U.S. that have bolstered their intensive care units with the virtual or eICU facilities designed by venture-backed Visicu say they are confident the technology has saved lives by reducing the incidence of often-deadly hospital-related infections.

Visicu's virtual eICU enables staff doctors to monitor all of the ICU patients from five computer screens in a command center that is sometimes built inside the hospital, or sometimes set up miles away. One U.S. military hospital in Hawaii has even used the technology to oversee ICU operations at an affiliated Navy hospital in Guam.

"The eICU serves as a system of overseeing and helping to make sure that all of these processes are performed every day."
--Curtis Veal, director of critical care services, Swedish Medical

The eICU center collects a battery of subtle and not so subtle vitals--everything from a slight dip in blood oxygenation or hemoglobin levels, to things that can be observed with the naked eye, like dilated pupils or even a patient who is about to fall out of bed. Through a series of cameras, videoconferencing equipment and computer software installed at the patient's bedside and fed to the command center, the on-duty clinician at the eICU can alert doctors and nurses on the ground when intervention is needed.

"The eICU serves as a system of overseeing and helping to make sure that all of these processes are performed every day," explains Curtis Veal, director of critical care services at Swedish Medical. "We now know that when they are done reliably it achieves a beneficial result."

Visicu's technological integration of so much audio, visual and clinical data is a rare feat in the health care industry, where a myriad of disparate applications and systems covering lab tests, pharmacy systems, critical care and nursing management typically need to be purchased from different vendors and are often at odds with one another. "I don't think people realize how complex health care is," says Richard Rogers, vice president and chief information officer of Health First, a health maintenance organization and hospital chain. "There is no single system that meets all the needs of a good-sized health care network. We are forced to work with a number of different vendors. Tying all these systems together becomes very complex."

And costly. "Health care has been in a period of tight financial constraints for years and institutions are often hesitant to make large investments," notes Peter Angood, vice president of the Joint Commission on Accreditation of Healthcare Organizations. "Obviously, technology has been expensive. There needs to be a strong return on investment."

Angood says the eICU seems to fit the bill. While the eICU still needed further study, "preliminary data suggests it is compelling," he says, provided that patients continue to receive the bedside care they need.

Across the country in Norfolk, Va., an early adopter of the eICU quantified the benefits. The journal Critical Care Medicine analyzed the effects of the technology at Sentara Healthcare, a six-hospital chain that incorporated the eICU in 2000. The journal tracked a 27 percent reduction in hospital mortality among patients in the ICU, a 17 percent drop in length of ICU stay, as well as savings of $2,150 per patient, which amounted to savings of $3 million above the cost of the eICU.

The experience of Swedish Medical sheds more light on how a single technology can be so effective. Veal says the hospital managed to cut its incidence of ventilator-associated pneumonia, or VAP, a particular type of the respiratory infection that is linked to hospitals and hospital equipment, by more than 50 percent. Swedish Medical had a rate of 4.8 cases of VAP per 1,000 ventilator days between 2002 and 2004--just below the national average of 4.9 cases per 1,000. Shortly after the eICU was installed, that rate fell to 1.6 cases per 1,000 ventilator days, a compelling statistic since VAP increases the chances of patient death by 50 percent.

And while everything else would seem to pale in comparison to the loss of life, patient mortality was not the only reason the hospital wanted to reduce the occurrence of VAP. Each episode of the condition costs Swedish Medical about $40,000 in extended hospital stays and related care.

Tech laggards
Focusing on a single hospital-related health complication at one midsize hospital in Seattle hardly does justice to the crisis facing the entire U.S. health care system, which is burdened by staff shortages, insufficient budgets, outdated hospital infrastructure, and a stunning lack of procedures and protocol relative to other businesses like the microregulated airline industry. Nonetheless, the results seen at Swedish Medical and Sentara seem to demonstrate a clear return on technology investment.

Visicu, which currently holds a patent on its eICU technology, was founded in 1998 by two former intensivist physicians at Johns Hopkins University Medical Center who, after spending years working in the ICU, concluded that a system of continuous and pro-active management of patients could improve patient outcomes and that such a system of close 24/7 oversight could be just as feasible from a remote location. Their vision offered a futuristic view of medicine that is rarely seen in the conservative health care industry.

Health care is the only major industry that still relies on handwritten notes--often sloppily written ones--to convey life-or-death instructions. Most hospitals continue to struggle over how to deploy a system of bar-coding on patient prescriptions, even though that same technology was broadly adopted by the retail grocery sector well over two decades ago.

In 1999, a report from the Institute of Medicine found that between 44,000 and 98,000 hospitalized Americans die each year as a result of medical mistakes--everything from the wrong medication being administered to the wrong patient having a limb removed. As that study indicated, VAP is by no means the worst thing that can go wrong: Technically VAP does not even count as a medical mistake since it so routinely strikes individuals with prolonged stays in intensive care.

"It's like air traffic control in the intensive care unit."
-- Dr. Lynn Simon, vice president of medical affairs, Jewish Hospital

But major errors often grow out of unintentional oversights, and that is where eICU pays off, says Dr. Lynn Simon, vice president of medical affairs at Jewish Hospital in Louisville, Ky. She notes that even in the best-staffed intensive care units where one nurse is assigned to just one or two patients, there are so many vital signs to monitor, medicines to administer and subtle things that may start to go wrong before they are easily detected that it is virtually impossible for clinicians to stay on top of every existing and potential problem.

Visicu executives declined to discuss their technology, but Ralph Sabin, managing director of Pacific Venture Group, which invested $4 million in Visicu in 1999, says he backed the start-up because "it looked like a strong clinical solution that could help hospitals avoid medical errors, coupled with a strong financial component." At the time, he recalls, "there was a growing recognition that unnecessary medical errors were occurring, and they were costly. We felt that Visicu makes physicians' jobs a lot easier and allows them to reach a greater number of patients."

Visicu's customers agree. "It's like air traffic control in the intensive care unit," Simon says of eICU. Jewish Hospital installed the system in late summer 2005 and in the first month and a half had already traced a reduction in mortality and length of stay at its ICU.

"It enables you to intervene and prevent small issues from turning into big issues," explains Simon.

While hospitals have for years been toying with some sort of teleconferencing, Visicu's eICU was one of the first technologies that clearly demonstrated the benefits of connecting bedside clinicians with specialists in a command center, says Jewish Hospital CIO David Pecoraro. Equally important, while some health care technologies merely add a layer of complexity into a system already bogged down with multiple, often incompatible applications, the eICU serves to combine disparate pieces of important data into a single package that makes it easier to analyze and respond to, he says.

Tough to install
Pecoraro says that "one high-tech problem that is somewhat unique to the health care industry is that there is not a single IT application that solves problems." Pecoraro, who shepherded the eICU equipment installation and central command center setup at Jewish Hospital, notes that "in retail, or finance, you tend to have one or two major applications that drive the business, then you look at health care and we have upward of 50 different clinical applications, from lab systems and pharmacy systems to critical care and nursing management systems, all of which are part of a bigger enterprise and each of which has to be 'interfaced and integrated' as they say, so it looks seamless to the caregivers."

Nancy Foster, vice president in charge of patient safety policy for the American Hospital Association, adds that new technology can also backfire. So-called computerized physician order entry, or CPOE, for example, is designed to eliminate the common problem of administering the wrong medication by replacing handwritten prescriptions with an electronic system of ordering drugs.

"Normally, the physician would check this, but if they believe the software is checking for them, they have created a gap where a new error could occur," says Foster. For this system to work effectively, it must connect to another system that will check for potentially dangerous drug interactions.

The positive track record of eICU so far seems almost to be fostering a new outlook toward technology among hospital IT managers. Despite a long installation time and steep up-front costs, Health First has found clear signs of a return on investment. CIO Rogers estimates it took about six months and $3 million to install the eICU at its three hospitals, plus another $1 million a year in operational expenses, a considerable investment considering that these costs cannot be passed on to patient bills.

Moreover, Rogers is beginning to gather data on the eICU that should please the hospital's safety officials as well as its bean counters. Mortality risk and length of patient stays have both declined since the eICU was installed in June of 2004.

"It lets us monitor a lot of minute changes in patients' conditions much more closely than we can do at the bedside," he says. "It's the difference between crisis intervention and crisis prevention."

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