Telemedicine in intensive care

Worldwide, there is a need for novel strategies to alleviate the lack of specialized medical care, including critical care medicine. Societal changes in demographics, epidemiology, and culture, in addition to significant technologic advances, have positioned telemedicine as a useful tool to narrow the gap between available and needed medical care. Thus far, it has proved to be a disruptive technology, potentially altering traditional paradigms in the critical care environment, particularly in medical education, team organization, medical licensing, quality improvement, disaster response, and research. A recent report estimated that 13% of non–federal-funded hospital adult intensive care unit (ICU) beds were supported by some form of ICU telemedicine program. Despite its relative novelty and rapidly changing technology and legislation, additional information has accumulated in the last few years suggesting potential features that can be leveraged to achieve an ideal model of tele-ICU care. Here we present our perspective for the current state-of-the-art and practical considerations on these matters ( Fig. 169.1 ).

Definition

Telemedicine can be described as the use of electronic information and telecommunications technologies to support and promote long-distance clinical health care, patient and professional health-related education, public health, and health administration. Technologies include videoconferencing, the Internet, store-and-forward imaging, streaming media, and terrestrial and wireless communications.

Potentially related benefits may include improved access and enhanced efficacy, quality, and efficiency in the delivery of healthcare services, in addition to equality in distributing scarce resources and the reduction of costs.

Although we can track the use of telecommunications with this purpose to the first half of the 20th century in Australia and decades later with the National Aeronautics and Space Administration (NASA) and the space race, it was not until the past 2 decades when critical technologic developments allowed for an explosive increase in its use as an alternative for overcrowded traditional models of care.

Traditionally, telemedicine modalities can be classified into store-and-forward, real-time, or remote monitoring. In store-and-forward, medical information is sent electronically to a remote physician for assessment offline, without direct simultaneous interaction between a remote medical team and a telemedicine physician. In the real-time mode, a direct video interaction exists between a telemedicine physician (or a physician extender) and a remote patient, physician, or medical team. Finally, remote monitoring implies the monitoring of a patient from a distance using different technologies depending on the physiologic system to be followed.

Telemedicine in intensive care

The implementation of a new tele-ICU program should focus on each one of the following aspects:

1.
Telemedicine-related laws and regulations at state and national levels
2.
Technologic platform
3.
Staffing
4.
Model of care

Telemedicine-related laws and regulations

There are basic elements that any telemedicine program should consider to comply with national and state laws, in addition to technical regulations pertaining to the particularities of the telemedicine interaction ( Box 169.1 ). The American Telemedicine Association has published core guidelines for baseline technical requirements and telemedicine operations and guidelines for tele-ICU operations in particular. Policies that foster telemedicine use are being promoted in most states (state parity laws) and should be consulted to adjust the tele-ICU program model accordingly, given that they will affect reimbursement and credentialing. In broad terms, signed patient consent must be obtained and patient confidentiality should be preserved at all times regardless of the model of care used in any tele-ICU program. A practitioner licensed in the state where the medical care is being delivered is mandatory during the teleconsultation, and by-proxy credentialing issues should be addressed between connecting hospitals. The Interstate Medical Licensure Compact is an agreement between 29 states, the District of Columbia, and the territory of Guam, offering an expedited way for licensure in those states participating in the compact. Moreover, documentation of the telemedicine consult should be in the patient’s medical record.

BOX 169.1

Telemedicine-Related Laws and Regulations

National telemedicine laws
State parity laws US
Patient confidentiality/consent (Health Insurance Portability and Accountability Act)
By-proxy credentialing

Finally, the unique setting of virtual telepresence results in distinct communication needs that are different from the regular onsite, traditional team interactions and “telemedicine etiquette” ( Box 169.2 ). They should be kept in mind during telemedicine consultations to be efficient in the art of “the systematic finding and delivery of bad news to the remote team.”

BOX 169.2

Telemedicine Etiquette

Identify yourself and the remote team
Ensure patient confidentiality
Respect the remote team’s work
- Listen to the remote team first
- Connect in time
- Keep teleconsultations as brief as possible
Comply with telemedicine laws and regulations
Objectively evaluate the patient
Provide advice based on the best available evidence

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