CHAPTER 10: Telemedicine and Regionalization

KEY POINTS

• Intensive care unit practitioners increasingly will be required to develop, manage, and participate in regional systems of critical care.

• Regionalization and telemedicine are two strategies by which critical care can be coordinated across a region.

• Regionalization entails the systematic triage and transfer of high-risk critically ill patients to designated regional referral centers. Regionalization might improve outcomes by concentrating patients at high-quality centers of excellence and by increasing the efficiency of care.

• Important barriers to regionalization include the need for a strong central authority to regulate and manage the system and potential capacity strain at large-volume hospitals.

• Telemedicine entails the use of audio, visual, and electronic links to provide critical care across a distance. Telemedicine might improve outcomes by leveraging intensivist expertise across greater numbers of patients and facilitating local quality improvement, thereby improving access to high-quality critical care.

• Important barriers to telemedicine include the high cost of the infrastructure and operation, local resistance to organizational changes, and pragmatic barriers related to interoperability with existing clinical information systems.

• Both regionalization and telemedicine will play an important role in future critical care delivery. Critical care clinicians should be prepared to help shape these complementary approaches, as well as work to maintain patient centeredness in the face of a rapidly evolving critical care system.

INTRODUCTION

For most of its history, critical care medicine has existed as a local pursuit. Nurses and physicians provided high-intensity care to seriously ill patients within a hospital, but rarely thought beyond the hospital walls. More recently, however, the practice of critical care has evolved into a regional endeavor, one in which intensivists across multiple hospitals must provide for the critical care needs of an entire populace within a region. Regional referral centers now routinely provide specialty critical care services to the highest-risk patients,¹ interhospital transfers of critically ill patients are increasingly common,² and the threats of pandemics and natural disasters are forcing hospitals within regions to coordinate their critical care services.³ Governmental agencies will soon require that regional critical care services not only be coordinated but also be accountable—that is, hospitals and regions will have to show that they are capable of effectively providing high-quality critical care to all patients in need.⁴

Several factors explain this paradigm shift in critical care. First, the expansion of information technology allows hospitals to share clinical information rapidly and securely.⁵ Second, advances in the quality of interfacility transport allow the safe transfer of extremely sick patients across large distances.⁶ Third, a shortage of trained intensivist physicians has made it difficult to match intensivist supply with the increasing demand for critical care under the current system.⁷ Finally, and perhaps most importantly, health care stakeholders increasingly recognize that hospitals vary widely in their capabilities and overall quality of critical care.⁸ Not all hospitals are capable of providing 24-hour trauma care, stroke diagnosis and treatment, emergent ...