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CHAPTER 10: Telemedicine and Regionalization 67

Telemedicine has also the potential to substantially decrease costs in Additional insight was provided by a more recent study showing
critical care, although the theoretical rationale behind cost reduction 60% reduction in the adjusted odds of death in seven ICUs under the
is less clear than outcome improvements. By preventing ICU-acquired telemedicine model. What differentiated this study from others is that
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infections, triaging ICU patients, and reducing ICU length of stay, tele- there were extensive efforts to couple telemedicine with specific qual-
medicine could reduce overall expenditures in critical care. However, ity improvement initiatives such as daily screening for best-practice
costs of ICU telemedicine are extensive and include not only infrastruc- implementation. Patients in the telemedicine were more likely to receive
ture and staffing costs but also the costs of ongoing system maintenance. practices such as deep-vein thrombosis prophylaxis and stress-ulcer pro-
Future savings are not assured and may not offset these costs. phylaxis. However, it is not clear why these practices and others could
■ UNINTENDED CONSEQUENCES not also be effectively provided by intensivists at the bedside, calling
into question whether the benefits of telemedicine in this model could
Implementation of an ICU telemedicine program carries the potential not be obtained through easier means. Nonetheless, this study provides
for several unintended adverse consequences. The most obvious risk is important conceptual evidence that telemedicine can be used to improve
that any quality gained by the introduction of ICU telemedicine will not critical care delivery and increase survival.
justify the costs. Telemedicine is not a therapy itself, but a tool through
which therapies can be administered—its impact depends not only upon ■ BARRIERS
its existence but on how it is used. Like the pulmonary artery catheter, The primary barrier to further adoption of telemedicine is cost, which
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another once-widely used tool in critical care, use of telemedicine may includes initial capital investment in the technology and ongoing operat-
facilitate small changes in minute-to-minute patient management but ing costs. This barrier may become less of an issue in the future as the
not impact overall outcome. 47 costs of the technology decline. Yet even systems that are technologically
Another risk of telemedicine is that it might paradoxically lead to
decreased vigilance and increased errors through a sociospychological inexpensive still carry the costs of the workforce to staff the telemedicine
unit. Depending on whether telemedicine is used continuously or as
phenomenon known as diffusion of responsibility. Shared patient over- needed, these costs may be extensive. Additionally, there are important
sight necessarily means that oversight is not explicitly assigned to a opportunity costs associated with telemedicine. Trained intensivist
single provider, and the knowledge that another clinician is watching physicians and nurses are in short supply, and clinicians that work in
may lead bedside clinicians to pay less attention to critically ill patients. a telemedicine unit cannot work in an actual unit at the same time. In
Providers may overlook or ignore important problems if they feel that theory, telemedicine could help ease the workforce crisis by increasing
someone else is taking care of such issues. Redundancy in oversight has efficiency, but these efficiency gains are not yet proven.
improved safety in other industries such as aviation and manufactur- Other important barriers to ICU telemedicine are the pragmatic
ing, but it may not translate to critical care, which is more expectedly aspects related to interoperability, billing and reimbursement, licens-
dynamic and unpredictable than those fields. ing and credentialing. Interoperability with existing electronic health
A final risk is the risk of technological failure and down time. As we records is a major concern as hospitals frequently have made substantial
become more dependent on technology in medicine, we put ourselves at investments in these systems and do not want to purchase additional
greater risk if that technology fails. No amount of fail safes can prevent systems that cannot work with the existing ones. In health systems with
the occasional systems outage. Such outages may have minimal impact fee-for-service physician payment, there is not yet consistent reimburse-
when telemedicine is purely used for redundant care, but they can be ment for critical care services provided via telemedicine. In the United
disastrous in cases where telemedicine represents the only immediate States, most health care purchasers will only pay for critical care that is
access to a trained intensivist. provided at the bedside. Although this policy acknowledges the critical
■ EVIDENCE importance of physical assessment in the practice of critical care, it fails

Systematically evaluating the telemedicine programs is inherently dif- to recognize the growing intellectual expertise inherent in critical care,
expertise that may be effectively provided from a remote location.
ficult. ICUs are complex, and the clinical impacts of organizational Regarding licensing and credentialing, several major issues must be
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changes can be hard to detect. Telemedicine programs themselves are addressed prior to widespread adoption of ICU telemedicine. Under a
equally complex, frequently involving a number of simultaneous orga- telemedicine model there are no geographic or political boundaries that
nizational changes. Determining which part of the intervention led to could limit access to care. Strategies to credential physicians to provide
the observed changes in outcome can be difficult if not impossible. care across hospitals, states, provinces, and even countries are necessary.
Also, since ICU organization is frequently changing in other ways, any These issues are by no means insurmountable—similar medicolegal
changes in outcomes are not necessarily attributable to the telemedicine issues exist in all telemedical fields, and they did not prove a barrier for
intervention under study. the widespread adoption of teleradiology, in which health care is often
Nonetheless a growing body of literature has sought to determine provided across hemispheres.
the relationship between ICU telemedicine and patient outcomes. The A final barrier is that of provider acceptance. Telemedicine can be
vast majority of evaluations are before-after studies in a single center, transformative in the ICU, but that transformation can be both posi-
and few systematically address differences in case mix or coincident tive and negative. Whenever care processes are fundamentally changed,
interventions that might confound the results. A 2011 report compre- providers and patients may react negatively. In the ICU, communication
hensively reviewed these studies and performed a meta-analysis of their between care providers and interpersonal trust is critical. The degree to
findings. The meta-analysis showed that, on average, introduction which these issues are affected by telemedicine, in which clinical rela-
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of a telemedicine program did not reduce either in-hospital mortality tionships occur between people who are not only in different physical
(odds ratio for in-hospital death: 0.82, 95% confidence intervals 0.65 to locations, but also may not ever have met, is unknown. In fact, lack of
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1.03) or ICU length of stay (adjusted difference: −0.64 days, 95% con- provider acceptance is often the primary reason cited to explain inci-
fidence interval −1.52 to 0.25). However, there was wide heterogeneity dences when telemedicine failed to improve outcomes. 43
between studies, with some studies showing a substantial benefit and
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the potential mechanism of the effect, nor did they specifically examine ■ IMPLEMENTATION STRATEGIES
others showing no benefit at all. Additionally, few studies addressed
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telemedicine in the extremely small, resource-poor hospitals where it Effective implementation of ICU telemedicine is similar to the imple-
may be most beneficial. These data demonstrate that more evidence mentation of any broad quality improvement measure, but similarly
about the mechanism and impact of telemedicine is necessary before challenging. The first step is to perform a comprehensive needs assess-
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widespread adoption is possible. ment and environmental scan. What quality deficits currently exist in

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