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Providing virtual care from the other side of the globe

Time zones can work wonders for productivity.

Dr. Milad Sharifpour knows firsthand: For several months, he lived in Perth, Australia, but worked in intensive-care units at four Emory Project Japan hospitals and one non-Emory hospital, guiding care for patients during his daytime and Emory's nighttime. He was one of the first providers Emory sent to a time zone 12 hours ahead to provide virtual nighttime coverage back in the U.S.

The aim is to improve the quality of nocturnal ICU care by addressing both a supply and skills shortage. “In the daytime, there are lots of experienced people at a hospital,” said Dr. Timothy Buchman, founding director of the critical-care center at Emory, the largest health system in Georgia, with six hospitals and 16,000 employees. “At night, it doesn't look that way.” That's because the more experienced providers with seniority choose to work during the day.

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“Our goal is to take the experienced intensivists and nurses and provide their support via telepresence to folks at the bedside where and when needed,” Buchman said.

The program also addresses one of the most concerning issues regarding burnout by allowing physicians to work without disrupting their circadian rhythms.

So Sharifpour moved to Perth. He began his days at 7 a.m. in Australia to sync with 7 p.m. in the U.S. Those who volunteer for the duty spend eight to 16 weeks at Royal Perth Hospital in Australia, which Emory chose because of the 12-hour time difference. “It's much easier to work during the daytime,” Sharifpour said. “I'm much less fatigued,” he said. “And it's a great surprise for the patients when you camera into their room, and they see daytime.”

Each ICU room at Emory that's linked to Perth has a camera, screen, speaker and microphone enabling bidirectional communication. A digital platform, built by Philips, beams data feeds from the bedside monitor 
and electronic health record to providers in Perth, who also get 
algorithmically derived patient-monitoring alerts.

Work on the eICU program began after the CMS gave Emory a $10.7 million Health Care Innovation Award in 2012 to explore how virtual critical care could increase access and lower costs.

That has also helped cover the cost of the technology. Additionally, Emory pays for housing. Physicians stay in $5,000-per-month units in an executive apartment complex.

The results of the eICU were almost instant after Emory launched the program in three larger hospitals in 2014 and then in two smaller, rural hospitals. At one hospital, in Statesboro, Ga., the ICU mortality rate dropped 56% in six months, and the length of stay went down by 30%. And during the 15-month CMS evaluation period, Emory cut Medicare spending per patient stay by $1,486 for total savings of $4.6 million.

The program has also been good for providers. “The message we're getting, at a time when burnout is rampant, is that this is meaningful for our staff and for their quality of life and job satisfaction,” Buchman said.

The program also allows providers with physical limitations to continue caring for patients.

But while sandy beaches help attract clinicians, it's not all fun in the sun. Sharifpour spent his working hours in Perth in a physically isolated room with one ICU nurse. That's not stopping Sharifpour from returning, which he'll do in 2019. “This program gives you a chance to go explore that side of the world,” he said.

Though Emory has seen marked cost savings and quality improvements from its eICU programs, questions about cost and value persist. “There's no question that telecritical care is costly,” Buchman said. “But any time you look at the cost of a tele-
critical care implementation, you have to look at the cost of the alternatives,” he said. “It really becomes a question not of, 'Do I have to make the investment?' but, 'How does the investment translate into a benefit for a hospital and for society at large?' ”

Indeed, it's a mistake to focus on cost savings alone, said John Gardner, a partner at NGP Capital. “There's a lot more that's being fundamentally demonstrated with this type of a service,” he said. “It's not about replacing people in the hospital—it's about the ability to expand their capabilities and leverage their time in more efficient ways that makes their daily workflows more productive.”

Another benefit is patient retention. Emory's Statesboro hospital, for instance, can now can keep most of its ICU beds filled rather than having to send patients to far-away facilities because of staffing issues.

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