High in a Manhattan skyscraper near Grand Central Terminal on a recent Tuesday, 80 critically ill patients in intensive care units scattered from Georgia to New Jersey were being monitored, remotely, by a doctor scanning a dozen computer screens.
Nicole Bengiveno/The New York Times
Dr. Mary Jo Gorman of Advanced ICU Care in a tele-ICU command center in Manhattan with Dr. Corey Scurlock, right.
On one monitor, she scrolled to a report of new symptoms in a 77-year-old patient in High Point, N.C. On another, she summoned a graph of blood pressure readings from a woman struggling with chronic pulmonary disease. Finally the doctor — who is an "intensivist," or critical care specialist — clicked to a live image of an unconscious 60-year-old man in septic shock in Warner Robins, Ga., and zoomed close enough to check the dial on his ventilator. The setting was correct, she said, reflecting an algorithm designed to improve survival rates and shorten ICU stays.
More than a decade ago, this kind of tele-ICU command center was trumpeted by its creators as the new standard in critical care, a way to save lives and money by stretching the skills of an inadequate pool of intensivists to help oversee more of the country's sickest patients. Today, with the growth of such systems stalled at about 10 percent of ICU patients nationwide, and wildly contradictory studies about the results, no one can say with authority if, or under what circumstances, tele-ICUs deliver on their promises.
Like many expensive innovations in medicine, from robotic surgery and designer drugs to electronic medical records, tele-ICUs have shown their most stellar results in studies linked to the companies that sell the systems; some hospitals in these studies cite as much as a 40 percent decline in mortality and a tenfold return on investment. In contrast, some independent studies published in the last five years have found no significant effect on survival rate, complications or length of stay, and have found that tele-ICUs brought new budgetary burdens, not payoffs.
In New York, in a sense, this is a second act for the tele-ICU. It was developed in 1998 by intensivists at Johns Hopkins, who later sold their company to Philips Electronics of the Netherlands, which now licenses the software as eICU. NewYork-Presbyterian Hospital adopted the technology with great fanfare in 2003, but only two years later, deactivated it. At Kaleida Health, a large Buffalo-based hospital system, the tele-ICU lasted no longer. At least three other hospital systems, in Michigan, Texas and Kentucky, have also unplugged command centers installed in 2004 and 2005.
"The eICU was a marketing success, but there's still legitimate concern about whether there's any improvement as far as patient care," said Michael P. Hughes, a spokesman for Kaleida. "We studied it, and there was no statistically significant improvement in the mortality rate and complication rate over a 12-month period. We discontinued it, and moved that personnel back to the bedside."
Proponents of tele-ICUs suggest that poor implementation, and the reluctance of physicians to cede authority to remote intensivists, explains the disappointing results in some places and some studies.
"It's not as simple as hanging a camera and a microphone in the room and calling it an eICU," said Dr. Robert Groves, who led the installation at Banner, one of the largest of more than 40 hospital systems that use such tele-ICU command centers. Banner monitors 423 ICU patients in 18 of its 23 hospitals from remote locations in Mesa, Ariz., Denver, Los Angeles and Tel Aviv. Dr. Groves credits that with keeping ICU deaths at half the number that would have been expected, judging by patient scores on a nationally accepted illness severity index.
But Dr. Matthew Fink, a neuro-intensivist who heads neurology at NewYork-Presbyterian, remains skeptical of such metrics. "This is more focused on trying to save the hospitals money," he said. "The companies that produce this technology want to sell it, so they are going to push it very hard."
"Nurses are the key to success in a good ICU," he added.
If or when tele-ICUs pay off financially is also disputed. Medicare and many insurers typically pay hospitals a bundled rate for a particular diagnosis, whether the patient spends two days or 12 in the ICU, where as much as 40 percent of hospital spending takes place. By intervening before a patient crashes, or reducing complications like ventilator-induced pneumonia, watchful intensivists significantly improve the hospital's bottom line by helping patients improve and leave the ICU faster, proponents say.
Round-the-clock access to intensivists also allows smaller hospitals to safely keep sicker, more lucrative patients rather than sending them to distant medical centers, said Dr. Mary Jo Gorman, founder and president of Advanced ICU Care, a St. Louis-based company with a branch in Chennai, India, and since 2011, the office near Grand Central.
The company licenses the software from Philips and provides services to 26 individual hospitals typically without the deep pockets to spend $6 million to $8 million to establish their own command centers. Dr. Gorman estimates that hospitals reap an extra $2,000 to $3,000 per patient after paying annual fees ranging from $750,000 to $2 million.
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