This is part of IEEE Spectrum's special report: Critical Challenges 2002: Technology Takes On
The well-being of tomorrow's patients demands changes in the healthcare structure of today. So says a committee of experts from the U.S. Institute of Medicine (IOM), Washington, D.C., in an analysis of the state of U.S. healthcare in 2001. If even now the system cannot consistently get the right care to the right patients, "we may conclude that it is even less prepared to respond to the extraordinary scientific advances that will surely emerge during the first half of the 21st century," the IOM study warns.
Besides the failure to disseminate medical knowledge fast enough or to use it in a methodical manner, there is another shortfall: medical practitioners with scarce, specialized knowledge cannot bring it to bear beyond their geographical confines.
But technological solutions, telemedicine in particular, are being implemented right now that can spread critical medical expertise across a region and around the globe. For example, a U.S. company believes that the shortage of physicians specializing in intensive care can be mitigated by its telemedicine system. In September 2001 the performance of transatlantic surgery by remote control proved that, with the right equipment, surgeons can perform and teach advanced procedures from thousands of kilometers away. Finally, in the nations and territories of the Pacific Rim, healthcare information networks are granting the region's widely scattered citizens new access to medical expertise.
Air traffic control for intensive care
In the course of over 15 years of practice in intensive care units (ICUs), Drs. Brian Rosenfeld and Michael Breslow slowly realized they didn't have to be there. They were certainly needed--the effectiveness of the ICU specialist, known in the field as an intensivist, is well documented, yet only a third or so of the patients in U.S. ICUs ever get to see one.
As Rosenfeld pointed out, the bulk of the intensivist's job is analyzing physiological data, like electrocardiograms and blood pressure readings, and coordinating care with the surgeons, primary care physicians, respiratory therapists, and others involved in a patient's treatment. That data is available electronically, and the coordination of care can be done remotely with telecommunications.
In a trial at a hospital (one of many) lacking around-the-clock intensivist supervision, the two specialists and their collaborators set out to prove their point. They fed audio, video, and physiological data, as well as treatment records from the hospital's ICU, to a remote site. There, intensivists monitored patients' vital signs and coordinated their care, periodically making virtual rounds by video at any time of the day or night. The hospital's usual ICU staff delivered the hands-on care in the 10-bed facility. Thanks to the round-the-clock expert supervision, the results were dramatic: mortality just about halved, a typical stay in the unit was cut by 28 percent, and the incidence of complications fell by 40 percent. (All the comparisons were adjusted for the severity of the patients' conditions for a proper analysis.) Thanks to the shorter stays and fewer complications, the cost of running the unit fell by one-third. In the four months that the trial ran, "we never set foot in the place," said Rosenfeld.
Armed with these statistics and some venture capital, the two doctors set up Visicu of Baltimore, Md., which proposes to run multiple remote ICUs from a single control center, 24 hours a day, seven days a week. Already it is running an all-electronic ICU (eICU) in Norfolk, Va., a remote site serving units in five hospitals in the region [see figure]. "To a certain extent [this] is air traffic control for patient care," said Rosenfeld. With one physician managing up to 25 patients at one time, the hope is that the company can better distribute the talents of the few intensivists there are. "The reality is that to cover the ICU patients in this country24 hours a day, seven days a week, would take 35 000 intensivists, and we only have about 5500 in active practice now," said Rosenfeld. "And that 35 000 is assuming you could get that many to work nights and weekends."
Although it is only one of several solutions to the shortage, such telemedicine has merit, according to Dr. Ann E. Thompson, president of the Society of Critical Care Medicine, Des Plaines, Ill. "It has a long way to go to demonstrate exactly what its potential is, but it may be a way of spreading a thin resource over a much larger population," she said.
The technique also has some limits. "We don't know yet how widely applicable the approach can be, nor do we know how many centers or patients an intensivist can observe at one time using telemedicine," she noted. "Another limit is that you must have people present in the ICU who have the technical capabilities to effect the specialist's recommendations. Interestingly, it is easier to find someone technically competent than someone who can recognize that the patient is developing a difficulty and who knows the right moment to intervene. But you need both."