Remote Patient Monitoring Telemedicine: The VISICU system allows critical-care specialists to work at a distant site to supplement coverage in an ICU July 22nd, 2002 By M. William Salganik Two years ago, IC-USA, a startup launched by two Johns Hopkins doctors, had an intriguing idea - using telemedicine to oversee intensive-care patients - and was bringing its first customer on line. Results were dramatic: lower mortality, shorter hospital stays and cost savings for the hospital. But no other customers signed up. Now, the company has a new name, VISICU, a new chief executive and a new business model. And the customers are coming. In recent weeks, VISICU has announced deals with two high-profile clients. New York-Presbyterian Healthcare System, affiliated with the Columbia and Cornell medical schools, will be using VISICU's system to help monitor 100 critical-care beds. Tripler Army Medical Center in Hawaii will be using the technology to manage an intensive care unit (ICU) at Guam Naval Hospital, 4,000 miles away. Frank T. Sample, who became president, chief executive and board chairman in October, said VISICU also has a deal with "another major health system on the West Coast" which will be announced within a few weeks. The Canton company has about 50 employees. Privately held, it does not disclose revenue or its bottom line. Sample said the company should be profitable by next year. Sample, who had worked previously at several health-information companies, said that when he arrived, "I immediately identified that the business model had to change." Under the old model, the company built a monitoring center, provided some of the intensive care doctors and all of the other staff to operate it, and managed the operation, charging the hospital a per-bed, per-month fee. Hospitals were reluctant to sign on for a system managed by VISICU, Sample said, because intensive care units are so important to hospitals. ICUs account for about 10 percent of hospital beds, he said, but 25 percent to 30 percent of hospital costs. And efficiency in stabilizing patients in ICUs can allow hospitals to handle more patients in their emergency departments and operating rooms. "If I consider it a strategic asset, why would I farm it out?" Sample said. Under its new business model, VISICU sells hospitals licenses for its proprietary software, the computer hardware and training. The hospitals staff and run the units. The company began in 1998. Michael J. Breslow and Brian Rosenfeld, intensive-care doctors at Hopkins, saw technology - monitors, cameras and computers - as a way of stretching a scarce resource: themselves. Eventually, they left to work at the company full time; both are executive vice presidents. Research showed that mortality rates were lower in ICUs run by a doctor with specialized critical-care training, called an "intensivist," but there aren't enough intensivists. About 20 percent of the ICUs in the country have intensivists on staff, according to the Society of Critical Care Medicine, and those ICUs don't necessarily have them around the clock. The VISICU system isn't designed to replace intensivists, but to allow them to work - at a distance - to supplement coverage. Doctors from a remote site can look at patients and check their vital signs; one intensivist can keep an eye on 50 or more patients - more than could be managed in person. Dr. Michael A. Berman, executive vice president and hospital director at New York-Presbyterian, said his hospitals have round-the-clock intensivists, but see the VISICU system's value as "another set of eyes to assist the person at the bedside." The system might allow his intensivists to work fewer night shifts, he said, and would provide support for critical care nurses, who face more demands. "You don't lose effectiveness by being at a distance," Breslow said. "Most of what I did as an on-site intensivist was cognitive." The system can help the cognitive part of the work, Breslow said, with "smart alerts," giving early warning of trends that could indicate trouble. "We're not diagnosing rare diseases in the middle of the night," said Dr. Steven Fuhrman, who runs the first VISICU electronic control center, called an eICU®. "We're taking care of bread-and-butter things, but we're doing it earlier." He is director of the eICU® for Sentara Healthcare, a six-hospital system based in Norfolk, Va., and VISICU's first customer. From an office park, Sentara's eICU® monitors 50 beds in five ICUs at three hospitals. Initially, Fuhrman said, many doctors admitting patients to Sentara hospitals had reservations about remote monitoring. About 70 percent chose to have the eICU® doctor authorized to make only emergency decisions without consulting the admitting doctor. Now, Fuhrman said, that's down to 11 percent. Nationally, intensive-care specialists viewed the VISICU experiment with "a mixture of skepticism and excitement," said Dr. Jay Cowan, director of critical care at Northwest Community Hospital near Chicago. "Critical care is a difficult business under the best of circumstances," he said. "It can be hard to diagnose a complex patient when you can touch them." However, Cowan said, when it comes to results, "the data are extremely compelling." In a study commissioned by VISICU, consultant Cap Gemini Ernst & Young compared the first six months of last year at Sentara with the previous 12 months. It found a 25 percent drop in mortality rate, a 17 percent drop in how long the patients stayed in the hospital, and a $3 million annual benefit to the hospital's bottom line. Dr. Thomas Rainey, director of critical care at Suburban Hospital in Bethesda, said, "It has proven itself more capable than we ever thought without human eyes and hands." Rainey also is a consultant to Leapfrog Group, a Washington organization started by large employers to look for ways of improving care. He went to Norfolk to see the VISICU system. He said he saw an eICU® doctor and the family of a patient have a delicate discussion, over closed-circuit television, of withdrawal of life support. "It isn't as big-brothery as you'd expect," he said. "It's a warmer medium than we thought." With the new business model requiring a hefty upfront investment, VISICU seems most likely to be adopted by large hospitals. Sample declined to discuss pricing in detail but said, "Nobody does too much with us for under $2 million." However, those large hospitals might use it to reach out to smaller ones. Fuhrman said Sentara is considering using its system to offer service to rural hospitals that don't have intensivists. Berman said New York-Presbyterian might eventually use the system to connect to 30 hospitals with which it is affiliated, and which have varying levels of intensivist coverage. VISICU believes its system can be extended to medical settings other than ICUs, but, in the short run, Sample said, "it's important to keep focused."