Telemedicine and COVID-19

​​Episode 1: In this episode, Dr Rizzo interviews Michael Ries, MD, MBA, about telemedicine in the electronic intensive care unit (eICU), including tracking data, its evolution, and lessons learned during the COVID-19 pandemic.

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​​​​​​​​​​​​​​Michael Ries, MD, MBA, is the medical director of System Critical Care, Tele-Critical Care, TeleSepsis/ Deterioration, and the Patient Command Center for Advocate Aurora Health in Greater Chicago, Illinois.

Albert A. Rizzo, MD, is the chief medical officer of the American Lung Association and a member of ChristianaCare Pulmonary Associates in Newark, Delaware.

TRANSCRIPTION:

Host: Hello, and welcome to Critical Observations in Pulmonary Medicine led by chief medical officer of the American Lung Association, Dr. Albert Rizzo, the views of the speakers are their own and do not reflect the views of their respective institutions.

Albert Rizzo, MD: Hello, I'm Dr. Albert Rizzo and welcome to Critical Observations in Pulmonary Medicine. Today's guest is Dr. Michael Riese and our topic is telemedicine, particularly tele-ICU medicine and how it has evolved during this pandemic. Dr. Reese received his MD degree at Chicago Medical School, and he completed his MBA at the Kellogg School of Management of Northwestern University. As medical director for adult critical care and the Tele-Critical care program for Advocate Aurora Health system, he oversees clinical and financial outcomes, integration and process improvement initiatives for Advocate Aurora's 34 ICUs located at 26 hospitals and the Advocate Aurora Tele-Critical care program.

The 768 bed tele-ICU program he oversees represents one of the largest programs in the country. Dr. Riese has authored numerous articles and book chapters on Tele-Critical care and its impact on the quality and cost of healthcare delivery. And has lectured extensively on the topic, including at national conferences. Let's start out, Dr. Reese, with you telling us really about how you ended up where you are with the interest in telemedicine and pretty much the current focus of your career is overseeing this large network of ICU beds on a telemedicine platform. How did that all start?

Michael Ries, MD, MBA: It actually started about 20 years ago, I had just completed my MBA at Kellogg and I was sitting at my desk saying, "What am I going to do with my extra time?" And I just happened to get a fax across the desk saying that Advocate Healthcare is looking for a director of EICU, at that time was called EICU. Had no idea what EICU was. So what do you do? You pick up the phone. I called there was one pilot program in Sentara in West Virginia. I called the CMO of the company that provided the software and I called the medical director at Sentara. And when I heard about what the technology, how they used it, I just sat back and I said, "This is the future of medicine." Obviously it took a lot of time for people to adapt to that. There were a lot of naysayers. Remember giving a grand rounds at a university system about a year later after I'd started and I got laughed out of the room saying, "You can never do this. You can't take care of patients in the ICU critically and telemedically."

And about two years ago, they actually called me to consult because they were starting their own program. So, it usually takes physicians about 17 years to change their ways. But I think over time I initially got interested because when I learned a little bit more about the technology and we never knew how to use it, there was a way to reduce length of stay, reduce morbidity and mortality and also identify ways to reduce cost. And over the years, I think the use evolved. Being one of the original people, we were just given some camera views, some audio, and then we realized we could provide evidence based practices across all critical care patients. What I call population management of critical care patients.

We could reduce the burnout some of the older physicians and nurses, as you know, that critical care is a very physically trying profession. And as people started to get out of critical care at the age of 55 to 60, they still had significant experience and significant brain power. And you could put those people in the tele-ICU and use their expertise. And the other thing is really, we could have a way of centralizing data collection. We're a very data driven organization and without data, you don't know how to make improvements. And so the tele-ICU provides a way of getting data from all the patients, risk adjusting it to look at ways to further improve the care of the patients.

Albert Rizzo: Great. Let me go back to the physicians you mentioned, the manpower issue. The boots on the ground in many of your ICUs come from varying backgrounds and different training levels. And they also have different levels of support. Your EICU physicians as I understand, that also come from various disciplines, critical care surgeons, critical care medical docs, anesthesiologists. How do you address maintaining some of the standards of care guidelines when you have such a diverse group of physicians, both in your EICU home base, as well as those various ones out in the different ICUs that you're covering across states at this point?

Michael Ries:  The first way I look at that is about 90% of critical care is the same. Whether you're in a medical ICU, med-surge ICU, a neuro ICU, surgery ICU. We're lucky because we're large enough during the day and at night, especially we have five different intensivists working in the tele-ICU hub. And amongst those, we have surgical critical care physicians, anesthesia, and medical. And so you've got a team sometimes, we help each other out. We look at different CTs of the abdomen. There may a surgical intensivist, but also using that expertise. Some of the sites we cover, because we cover 42 ICUs, they may not even have an intensivist on staff. In which case there's the expertise from different angles of care. So I think just partially because of the volume that we have, the number of different clinicians, we have that expertise.

And then you can always call one of your bedside colleagues, a neurosurgeon for a specific question. We have a technology called Perfect Circle. We can catch them whether they're in the, or at home, et cetera, for those few cases where we really need a subspecialization. And the same thing with our nurses, we have 14 nurses working every shift and they come from different avenues, different critical care. And they all have to have at least five years experience before they can work in the tele-ICU hub. So I think that's way we maintain the clinical quality.

And then we track our interventions in terms of how do we do peer review. We track our interventions and we categorize them three different levels. Depending on the intensity of the intervention, we expect a certain amount of interventions per shift. We also will look, because the data shows that the initial view of a patient when they are admitted to the ICU will reduce their... The shorter the time from initial onset of critical care physician viewing the patient, looking at the patient, decreases mortality and length of stay. We can actually, we do track how quickly our intensives see the patient on admission. And we actually have a rule that the patient needs to be viewed by a nurse within the first 15, 20 minutes and by a critical care physician within the first hour of admission.

Albert Rizzo: How many of your clinicians in the EICU continue to also do bedside critical care?

Michael Ries: The majority of them do. We have a few that full time that as they got older, they didn't want to do cardiac surgery anymore. Couple have medical issues that they can't be at the bedside and still are extraordinary clinicians, but the majority, probably 90% work both sides of the camera.

Albert Rizzo: Getting back to the comment you made about all the data that has accumulated. I know looking at some of the things you've published in the past and working with you when you covered our ICUs, things like ventilator bundles and weaning seem to be a way to facilitate that by using these critical care physicians around the clock, collecting data and going through checklists in many ways. Can you comment on that?

Michael Ries: Yeah, I think one of the important things we learned is that you can't just practice telemedicine and apply it and get the benefits. It's a collaborative effort on both sides of the camera. So I think not only, and it's not just the technology, it's not the technology, it's how you use the technology you have, but also tele-ICU is a facilitator of changed management. For every successful program, what we've done is we've looked at the bedside workflow of how they manage a patient. Whether it's a ventilator patient, and sedation withdrawal, and the spontaneous breathing trials, or DVT prophylaxis, whatever it may be. We look at the workflow and we integrate the telemedicine to tele-ICU into their workflow. But for every project we've had, we've realized there are opportunities in the bedside workflows, certain omissions, certain delays that by going through the workflow, we improve that workflow also.

So it's really a facilitator of change with what the bedside does. And so I think working together and then seeing the data, you entertain a project, you put it in place, you accumulate data, you look at the data and then you go month to month and see has it improved and where there are some other opportunities. And the benefit of a large system is sometimes within projects at certain sites that are so successful, we take those to the other 33 ICUs in the system. Now every ICU is a little bit different. So there's a little bit of personalization of the technology where a neurosurgery ICU may have a few different workflows, a few different changes in their workflow that a medical ICU may not have, but you adapt to that. And for every ICU we put in a workflow, we meet with that team beforehand several times. And after we put it in place, we do the typical PDSA. We try to see where the opportunities are to avoid issues that we didn't foresee or make improvements.

Albert Rizzo: You mentioned the importance of the collaboration between your EICU clinicians as well as those at the bedside. And you mentioned earlier on that 20 years ago, when you got into this, you certainly were in that early adopter phase of [inaudible] a device in medicine. And I think, and again, what I've experienced and heard from over the years is that sometimes that interaction between the bedside nurses, the EICU clinicians, is not always as collaborative as we would like from the beginning. And that sometimes is a struggle for bedside nurses and physician to deal with in overseeing EICU physician. Can you tell us how that's worked out over the years? And I know you've been able to manage some of those hurdles pretty well.

Michael Ries: We wore them out. No, I think in the beginning, I think one of the key things that you have to look for when you start a program is look for a champion physician and a champion nurse on the other side of the camera. And they have to be respected by their peers and let them lead the charge. Nevertheless, they're going to be clinicians who this is a new way of practicing. They're set in their ways. Same thing with nurses and nurses are just as resistant as physicians. But I think the way we've learned to adapt to them is we don't come in and take over. We collaborate with what they do. We make their life easier. We take stresses off of their work. We make their work more efficient so they can do what they need to do, which is spend time with the patient.

And then you find one successful program and you show the benefits to everybody in your meetings with your ICU community. And when they see what you've accomplished at one site, you can take that to other sites and they'll buy in. And I think once you help them, it's really beneficial. So I'll give you a great example. One of our 34 ICUs has always been the most resistant. After 17 years, they didn't want us in their ICU. They felt that they could do their work much better without us. So COVID came and they were extremely hard hit. They were overworked, stressed, they were fatigued. They were beginning to burn out. So what we did was we took mobile carts and we were the clinicians who responded to rapid responses on the floor. That had originally been the intensivist job to go to RRTs, to take care of the patient.

We now brought a mobile cart in, the tele-ICU physician took over the role of the physician during the RRTs. And after about 500 RRTs without a serious safety event, they realized the benefit. Now we've got multiple other projects going forward in that ICU. And the nurses are now and the physicians are calling us to help out with, "I just put a line in, I got to go down to the ER, can you follow up on the x-ray?" Things like that. So I think you have to prove your value, go in little steps. It's the Ruth Bader Ginsburg approach. She worked for women's rights, but she didn't take one huge case to get to her goal. She took small cases, small steps to get there. Pacing, because you can't just come in and win someone over with one fell swoop.

Albert Rizzo: Can you go back to, you mentioned the RRTs and for our listeners. Can you tell us about the RRTs stand for, and also give us some examples of what you were talking about?

Michael Ries: Yeah, RRTs are what we call rapid response teams and they've been successful over the years in most hospitals. It's whereby any clinician, physician, family member at the bedside or nurse can call for a rapid response team for an unusually rapid heart rate, increasing shortness of breath, a drop in oxygen, all signs of maybe something is developing and to have clinicians, nurses, and physicians go to that patient's room, do a differential and make sure nothing significant is going on. And if something is significant, you actually intervene earlier and prevent their further deterioration. And may perhaps further need to go to a step down unit or to the intensive care unit. And it's shown to reduce mortality and transfers to the ICU.

Albert Rizzo: Would you say this is also helpful sometimes in cardio pulmonary resuscitation efforts that occur outside the ICU, being able to have this remote telemedicine capability?

Michael Ries: Definitely. What we'll do is we'll always camera in, we may be the first physician in the room and will be the team leader of the cardio pulmonary resuscitation. If a bedside physician comes into the room, if they feel comfortable running it, we'll stay in for a while to see if they need any information. So as they're running the code and busy with ordering different medications and different interventions, we may tell them the last potassium was such and such. This is the patient's history, to be reading out of the charts. So they don't have to go back and forth. And then if it's physicians in training, house staff will actually stay in the room the entire time to make sure that cardio pulmonary resuscitation is handled in the proper ACLS method.

Albert Rizzo: I think you mentioned already some of the evolution in the technology that's taken place in tele-ICU. I know initially there were hardwired closed circuit television screens in each ICU bed, and now we refer to mobile carts and robots. Can you give us a little more information on how you utilize those different capabilities across your 40 plus ICUs?

Michael Ries: Yeah. So, it's what I call centralized versus non-centralized. In centralized tele-ICU, every room in the ICU has a camera. In decentralized, you have several mobile carts, either in an ICU or elsewhere in the hospital that actually requires someone to move the cart into that room. And again, as I say over and over again, it's not the technology. It's how you use the technology you have. So, especially during COVID, we found a lot of utility in the mobile carts. We were able to help hospitals manage the hypoxemic patients who ordinarily would be in the ICU, but there was no capacity. So we served as a tele consultation. We weren't in there all the time monitoring or going in every hour to make sure the patient's okay, unless that patient had a cart wheeled into the room. We tracked something called the ROX Index, which is oxygenation that we track for COVID patients on supplemental oxygen.

And when that deteriorated, it's a sign that they probably need to be transferred for possible intubation and placed on a ventilator. We actually started using the mobile carts many years ago when we had a serious safety event in one of our emergency departments where a patient was admitted. But that hospital had sometimes as many as eight or 10 boarders in the emergency room for ICU admission. They had a patient who was down there for 16 hours and just gradually deteriorated, ended up having a bad outcome. So one of the opportunities we found after doing a root cause analysis was they didn't have an intensivist, even though the intensivist came down periodically from the ICU, she had a significant number of sick patients in the ICU. She had to spend most of their time up there. So we actually brought mobile carts down to the emergency department and started monitoring those patients.

And not only have we not had a serious a safety event now in five years, but we saved the system a significant amount of money, just because 20% of the patients by that earlier critical care involvement no longer needed to be admitted to the ICU, that they could be admitted to a lower acuity bed. So during COVID because of the capacity issues, we now have rolled that emergency department boarder program out to 17 of our emergency rooms. For two reasons, A, patient safety, but also to alleviate some of the stress on our caregivers, the physicians and nurses who are just getting bombarded with patients.

Albert Rizzo: We touched on one of my comments that I was going to make, as we've heard repeatedly that the COVID pandemic jump started the field of telemedicine. And certainly what you're describing is it's really jump started tele-ICU as well. And do you see how things will continue in this manner going forward? Do you think hospitals and intensive care units will be more willing to seek remote tele-ICU monitoring going forward?

Michael Ries: Yeah, I think it has made a believer of a lot of people just out of necessity that telemedicine works. So I think more and more people are understanding its benefit. My concern is as COVID comes under control, will people continue to use it the same way they do now, the same intensity? I think what COVID also taught us is that when you start a tele-ICU program, it is key that you have certain goals in mind. And one of the goals, especially during COVID was how do you offload the work of the bedside clinicians who are just undergoing more stress, more burnout, more physical fatigue? So during COVID last year, we identified for instance, 26 different ways that we could use the technology to offload some of the work. Some of it was as simple as taking the technology out of the tele-ICU and also putting it into the individual ICUs that their nurses stationed the monitors. So the physicians and nurses could watch their patients and talk to their patients without putting on and taking off their PPE, which is time-consuming.

And the other issue in 2019 was the scarcity of PPEs. We're all worried about running out. So it was a way to decrease the amount of PPEs used, plus allow the clinicians to take care of the patients with less exposure. And it goes back even to Ebola, which is a much more contagious disease. We instituted that during the Ebola crisis, about six years ago, now. Other ways we cover more of the hospitalists, we bring our expertise to the hospitalists, to the COVID patients on the floor who ordinarily would be in the ICU or are pretty critically ill and just multiple different ways of using it.

Albert Rizzo: I want to get back to the data collection that you talked about, and certainly you're doing a lot of real time overseeing and monitoring the of patients. But I believe you've also used some of this technology to identify early warning trends and ways of intervening before an RRT is necessary or looking at the development of sepsis. Can you comment on your experience in those early warning areas?

Michael Ries: Sort of a project of mine that I've had at heart for about five years now. And so there are multiple early warning systems out there. We have some in the tele-ICU we use, but an early warning system usually is too sensitive and usually not very specific. And I've found over the years that an early warning system is only as good as putting a clinician at the end of that alert. And so about five years ago, we entertained a project. Sepsis is our number one in-hospital killer disease that kills patients and it is a significant problem. And if you develop sepsis in the hospital, mortality is about 40% nationally. Some sites less, and some more. So what we did is we took that early warning system, an alert that we created for sepsis, and we took it out of the chart.

It used to go to the chart and the nurse or the physician would see that alert only when they entered the chart. So we did a pilot where we took that alert and brought it to the tele-ICU and the tele-ICU physician would determine A, sepsis and then call the bedside to initiate therapy. B, not sepsis and reset the alert for another eight hours. Or C, not sepsis and something else is going on. So as I said, we took our worst performing site and within about an eight week period, we saw fewer patients progress from sepsis to septic shock. Fewer patients were transferred to the ICU. Fewer patients had RRTs called. More patient's mortality was less. More people on discharge from the hospital, went home and not to nursing homes and skilled nursing facilities. And to make our administration happy, it saved a thousand dollars per patient with sepsis.

So that was so successful that we've now taken the alert and the EMR and the electronic medical record and changed it to a certain degree. And we now have a tele-sepsis hub, and we're rolling that out across all 25 hospitals on the med-surge floors. And the other thing was, CMS has a compliance data collection where they track hospitals, how well you comply with the therapy of sepsis and that hospital where we did the pilot, their compliance was 30%. The worst in our system at the time went up to 60%. Hundred percent improvement within eight or nine weeks. So that's another way of using it.

Albert Rizzo: You've alluded a couple times during this discussion about the improvement of care that tele-ICU can offer, and therefore it's some cost savings as well as improving outcomes. What I often hear, at least in the past, was that one of the big hurdles to implementation of tele-ICU is a fairly big economic upfront cost of some of the technology and how it affects manpower and intensivists. And can you kind of talk about that a little bit? I know you have an MBA background and have looked at the economics of this from a couple angles over the years. And I think people thinking about EICU need to hear some of the positives about how this could be offset.

Michael Ries: Yeah. I think one of the biggest hurdles as you said, was the financial of cost. And we talked about a centralized model versus decentralized. Centralized is a camera in every room, decentralized you use fewer mobile carts. So one of the ways to reduce your costs, even though it's not as good, you go to mobile carts. Because you save on $7,000 per camera, per room. You don't save on nursing hours or physician hours, but where you do the cost savings is by working hand in hand with the bedside. You reduce length of stay and you reduce the cost of the additional stays. You also reduce ventilator days. Being on a ventilator is more costly than being on a ventilator. And those are the main ways to reduce your costs. Other ways to reduce your costs is again, it's the technology that you have and not rather than how you use the technology.

So you look at your resources. If you have a centralized model, you've got to have similar vital sign tracking equipment. And if you have different products like Phillips or GE, you got to consolidate that. And that'll uniformly put in uniform vital sign monitoring in the ICUs, which is an additional cost. If you don't want to do that, you just use a mobile cart and the vital signs you have. So I think it's, do you have clinicians at the other end? Do you have an EMR at the other end? You don't have to add a lot of cost, but you take what you have and put in place a program that if you're better tomorrow than you are today, then you've used telemedicine efficiently and cost efficiently. And I think you have to continually improve.

Albert Rizzo: In your system, I think you covered several states, maybe over 400 beds. Can you give a sense as to what the penetration of telemedicine tele-EICU is across the country right now? Do you have a sense as to [crosstalk].

Michael Ries: I think it's obviously more. Obviously you raise the issue of financial cost. So several of the small hospitals, especially the rural hospitals, don't have the resources to spend money on that. So I think in those situations, you have to create a more consultative type model where you put a mobile cart in their ICU and they may have to move it around, but you provide critical care expertise that they may not have at their rural sites. I know there's a national program now called NETCCN we're involved with that is run by the Department of Defense. It's called National Emergency Tele-Critical Care Network. So that for the next disaster, how do you take the resources nationwide, the clinicians and the technology and deliver the care that they need in the rural areas and the areas of the country that don't have as many hospitals or resources?

Albert Rizzo: Well, that feeds right into one of my closing questions was what do you see on the horizon with regard to how tele-ICU is going to evolve from here?

Michael Ries: I think the opportunities are unlimited. I think I mentioned when I first started, I walked in the tele-ICU the first day we went live and I go, "Now, what do I do?" And so you learn over time for opportunities. I think you have to decide how do you take the workload off the bedside? You've got six customers, seven customers, the patient is always the customer. How do you deliver better care? The physician, how do you offload some of the work of the physicians or provide care to the bedside where they may not have the physician expertise? The nurses, the respiratory therapists, how do you offload the work for those other service lines? You've got the CEO, the COO that you've got to deliver better outcomes clinically, and hopefully financially, because they're the ones who pay for it.

You've got the regulatory because likely sepsis, you got to provide data and show benefit with what you're doing. And you've got the payers and the insurance companies to show them that you're working in as cost effective manner as possible. So you got to identify your customers, you got to identify your goals. And I think one of the key areas in the future is how to integrate AI. AI is not where it's at yet, but in the future, we'll be able to expand what we consider average or reality today and use AI to focus on providing solutions to the bedside faster and more efficiently and clinically make improvements for patient care.

So those are the main ways. The Metaverse is out there. It's the future. So how do you use the Metaverse? I've already gone to my IT people with a Microsoft HoloLens and said, "I want to be there in three years." And they told me it was too or early and told me to come back in a couple years. So, but the Metaverse. The AI, that's the future of the technology and how you can apply the technology to the bedside care.

Albert Rizzo: Well, we may have to come back in a few years and have this discussion again. I think, first of all, I mean, your experience and your perspective on this is more than many people could have given us today. And I really appreciate the time that you shared with us and your insights. Any last comments? I mean, I think you covered a lot.

Michael Ries: No, I think still for those naysayers is just try using it to your benefit. Identify what you need and see if the technology can even help you a little bit. Because the practice of medicine is way more complicated today than it's ever been. And it's going to get more complicated with subspecialization and more technology and more medications to use.

Albert Rizzo: Thank you.

Michael Ries: Thank you.

Host: For more pulmonary and critical care content, visit our website consultant360.com.​​​​​​​