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Beyond the Bunker

A Decentralized Model for Tele-Critical Care

For the entire history of critical care telemedicine, the practice of tele-ICU has been primarily associated with central command centers. Central command centers, also referred to as bunkers or hubs, link intensivists and other personnel to multiple hospitals so that a relatively small number of critical care physicians can oversee the care of a large number of ICU patients.

Capital costs of construction, installation, and training for a new command center range from $6 million to $8 million. At a time when healthcare costs must be minimized, reconsidering the value of central command centers is necessary.

In numerous studies, tele-ICU has shown to improve patient outcomes and decrease mortality as well as ICU length of stay. Tele-ICU has clearly shown value in keeping patients closer to home, allowing smaller hospitals to treat high-acuity situations. So the question is, how key is a central command center to an effective tele-ICU program and can a decentralized model be as effective.

A command center is staffed by many nurses who are deeply engaged in data collection for analytics and quality audits. With the advent of AI and machine learning, many of these tasks could be automated and the expertise of these personnel could be devoted elsewhere within the highly constrained healthcare system.

The key resource in the command center is the intensivist. On a basic level, we must consider if there are less expensive models to deliver intensivist services to remote settings. Simply stated, thousands of hospitals cannot afford to subscribe to the bunker-style tele-ICU with its heavy infrastructure. What they are looking for is a cost-effective and efficient means of access to ICU specialists.

With provider burnout at an all-time high and a shortage of intensivists, to not exacerbate the shortage we must also consider what conditions will be attractive to intensivists. Critical care physicians sit in these central command centers for shifts that are typically 12-hours long, scanning dozens of computer screens. This arrangement does not present a very attractive lifestyle option to intensivists, especially when many have additional specialties such as pulmonology that provide the option to work in an outpatient setting. If an intensivist can provide quality care to a remote hospital from the comfort of his or her own home as opposed to sitting in a bunker, he or she will likely see that as more attractive and devote more time to intensive care. Omnicure supports better quality of life.

Omnicure presents an option for critical care that does not require a central command center. With modern wi-fi and the emergence of 5G, internet connection from home is more robust than ever. The expensive infrastructure of central command centers for dedicated internet and T1 lines is a remnant of the past. This infrastructure was necessary when tele-ICU began in the year 2000, but as technology evolves, our delivery of care must also be upgraded and updated in a cost-effective manner.

Tele-ICU Cost Benefit Analysis

The CEO of Omnicure, Sanjay Subramanian, MD, has a great deal of tele-ICU experience. His experience and leadership in critical care medicine have given him insight into cost and revenue centers in tele-ICU. As the prohibitive costs of legacy tele-ICU systems present a significant barrier, a primary motive of Omnicure is to provide a low-cost telemedicine ICU service.

In the 2019 publication, Telemedicine in the ICU [1], Sanjay co-authors a chapter titled “Cost Benefit Analysis of Implementing Telemedicine in the ICU.” Costs of tele-ICU are broken down into the following categories:

Hardware
- Fixed mounted cameras in patient rooms
- Cabling for cameras
- Desktop computers and multiple monitors for remote physician/nursing workstations
- T1 lines to assure connectivity
Software
Staffing costs

The chapter details the maintenance and support costs of hardware, as well as the staffing support of tele-ICU command centers. The hardware and IT costs are quite significant. For example, the hardware for in room audio-video equipment is cited as $7,500 per patient room, with an additional cost for installation.

In centralized models of tele-ICU, a command center is staffed by nurses and support staff in addition to tele-intensivists. While this auxiliary staff is necessary for upkeep of the command centers, in a decentralized model like that of Omnicure, a tele-intensivist works from home. There is no need for additional staffing and upkeep of a command center.

Revenue

Sanjay’s chapter contains extensive discussion of the financial benefits of tele-ICU, under the assumption that there is no insurance reimbursement. It is worth mentioning reimbursement for Telehealth is growing and is an anticipated source of revenue in the coming years.

Revenue is generated through increased volume, retaining more patients who may otherwise be transferred to outside facilities. Sanjay writes, “The added ICU occupancy can elevate the case mix index for the hospital which in turn has a positive effect on reimbursement.” The chapter also discusses cost avoidance subsequent to tele-ICU implementation, acknowledging that the literature has reported a variance in the extent. Cost avoidance is a result of fewer ICU complications, appropriate bed utilization, and reduced length of stay.

Sanjay analyzes tele-ICU literature on cost-effectiveness, finding a range of statistics. In one 2017 study by Lilly et al. [2], “The capital costs of implementing a tele-ICU program (~$7 million)* were recuperated in roughly 3 months based on the improved net contribution margin of $30 million seen with the tele-ICU program. In addition to improved clinical outcomes, this study showed improved financial outcomes with an ICU telemedicine program.”

*This figure includes set-up of a centralized command center and hardware in every patient room

The high cost can impede the adoption of tele-ICU. Omnicure aims to provide comprehensive tele-ICU services without capital costs that are deterrent.

Receiving hospitals report improved patient outcomes. These hospitals are able to generate revenue from a tele-ICU program through increased volume, retaining more patients who may otherwise be transferred to outside facilities. Sanjay writes, “The added ICU occupancy can elevate the case mix index for the hospital which in turn has a positive effect on reimbursement.” The chapter also discussed cost avoidance subsequent to tele-ICU implementation, acknowledging that the literature has reported a variance in the extent of cost reduction.

Across the board, studies have shown that tele-ICU programs result in improved patient outcomes, and decreased length of stay and ICU mortality. It is important to consider the cost and revenue centers, and develop a program that will minimize implementation costs while delivering a service that still results in improved patient care.

“The impact of an ICU telemedicine program has the potential to be far reaching, both clinically and financially... The up-front capital investment in a tele-ICU program may be substantial, but through cost-effective care, the return on investment can be significant and realized quickly.”
Sanjay Subramanian, MD

Koenig, Matthew. Telemedicine in the ICU. Springer, 2019.
Lilly CM, et al. ICU telemedicine program financial outcomes. Chest. 2017;151(2):286–97.

Innovating Critical Care

Omnicure was founded to innovate the delivery of critical care. Almost 3 years ago our team banded together to create an intuitive, simple, and mobile-friendly solution to provide tele-critical care with no hardware costs for the hospital.

Our primary motives?

The belief that healthcare as a whole can be improved through efficient allocation of physician resources.
The commitment to provide critical care expertise to settings without intensivists. Whether that is a Critical Access Hospital with a small ICU, or an ED where high-acuity patients wait to be transferred to a hospital bed, we set out to create a model that enabled bedside providers to easily connect with intensivists.

Sanjay Subramanian, a critical care physician in St. Louis, experienced the inefficiencies of legacy tele-ICU systems and considered the limitations. He saw an opportunity to make a positive change. Having previously practiced in Seattle, Sanjay reconnected with old friends and colleagues including Paramesh Vaidyanathan. Paramesh would go on to lead software development and become Omnicure’s CTO, with unique access to the tech talent of Seattle. Sanjay and fellow critical care colleagues helped guide product development, methodically designing workflows that would be natural and intuitive to providers.

Omnicure is an emerging force in tele-ICU, and more broadly provider-to-provider telemedicine. Our platform is nimble yet comprehensive. We knew the platform alone could help health systems better utilize intensivists to optimize their coverage. The next step was building a team of intensivists to provide coverage and consults to hospitals and systems that did not have critical care physicians in-house 24/7.

Intensivists loved the idea of providing remote coverage from home as opposed to the traditional centralized bunker locations associated with tele-ICU. We are still adding intensivists to prepare for additional coverage as we scale. If you are an intensivist reading this and want to learn more, don’t hesitate to contact us.

We are excited to have our new website up and running, and look forward to using this blog as a medium to discuss critical care, telemedicine, and all things healthcare.

Stay tuned as we work to bring critical care to new locations and strive to make a positive impact in healthcare through the use of our unique technology.