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Executive Summary

Five Emory University-affiliated hospitals taking part in a Philips eICU program cut total costs by $4.6m – or $1,468 per average care episode – reduced discharges to nursing homes by 6.9%, and lowered inpatient readmission rates, according to a recent audit by CMS contractors.

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Emory Healthcare reaped $4.6m in savings and reduced 60-day hospital readmission rates for Medicare beneficiaries based on adoption of a Philips Healthcare eICU program that relied on telemedicine supports to monitor patients at night and on weekends.

The results of the 15-month program were highlighted in a CMS-contractor audit conducted late last year by Abt Associates ("Evaluation of Hospital-Setting HCIA [Health Care Information Awards]"). In addition to lowering average costs per each 60-day episode of care by $1,468 (relative to a comparison group), the program increased patient-discharge rates to home health care by 4.9% while reducing the rate of discharges to nursing homes by 6.9%, auditors said. The data was collected from 2014 through 2016, and the program remains ongoing.

The audit sponsored by the US Centers for Medicare and Medicaid Services analyzed financial and clinical outcomes at organizations that received agency innovation grants to tackle health-care challenges with novel solutions. The findings of the Abt audit "verify that our innovative approach to addressing a complex patient population – those in the critical-care unit – improves patient outcomes, allowing them to leave the ICU healthier, thereby reducing the need for patients … to have extended rehab stays or be readmitted," said Timothy Buchman, director, critical care center at Emory Healthcare.

Emory Healthcare's system of hospitals in Georgia – including Emory St. Joseph's, Emory University Hospital, and Emory University of Orthopedics and Spine Hospital and two others – was facing a shortage of critical-care physicians, particularly on nights and weekends, and sought help from Philips' eICU program. The program was set up in the Emory University system to remotely monitor intensive-care unit (ICU) patients in need of immediate attention so qualified staff could intervene more quickly.

The eICU staff at Emory remotely monitored patients in participating intensive-care units by telemetry to look for problematic changes in vital signs.

Manu Varma, business leader of Philips' Wellcentive and hospital-to-home division, noted that as health systems transition to value-based care, population health tools such as the company's eICU program "have the potential to increase hospital ratings and lower the cost of care."

Under the system, eICU staff, including nurse practitioners and physician assistants, were trained to perform common ICU procedures and lead ICU teams to ease the burden on intensivist physicians, particularly at night and on weekends when there were few physicians present in the ICU. The eICU staff remotely monitored patients in participating ICUs via telemetry, and alerted clinicians at the bedside when they noticed potentially problematic changes in patient vital signs that exceeded clinical guidelines.

The Philips' software at the heart of the program, eCareManager, is designed to provide actionable insights and clinical decision support. It also fosters care coordination with the use of advanced clinical algorithms. The technology works by analyzing a patient-specific baseline and underlying conditions, and continuously samples data from patient vital signs, medical lab results and flowsheets. When a significant change occurs, a "smart alert" sends a prompt to the care team.

Benefits And Challenges

The monitoring was credited with numerous patient "saves," when problems that might have gone undetected were brought to the attention of bedside staff. The ICU staff reported that intensivist-directed care at night, rather than having to wait for ICU physicians to return in the morning, was the most important benefit.

But there were also considerable technology challenges, according to the contractor's audit. These included interfacing each hospital's pharmacy, laboratory and electronic medical records (EMR) into the eICU, and an effort to bring smaller, outlying hospitals – which did not have complete IT systems – online. For example, East Georgia Regional Medical Center did not have an EMR center in its ICU.

Another challenge was the need for eICU physicians to manage "lower-acuity issues," the contractor's report stated. eICU doctors found that much of their time at night was spent tending to minor issues that came up at the two community hospitals and could have been handled by a facility provider if one had been available. Also, laboratory and radiology departments were closed at night, so procedures and tests that the eICU physicians ordered could not be performed until the next morning.

While Medicare currently does not reimburse providers for eICU-like consults or technology, bills now under review in Congress would help address that shortfall.

Another problem was the additional costs of hardware and software maintenance and support. Insurers, including Medicare, does not currently reimburse for eICU consults or technology, even though Medicare does benefit in terms of cost savings realized by eICU interventions, the auditors' report stated. At least two bills have been introduced in Congress this year that would provide more Medicare reimbursements to hospital systems using telemonitoring and remote monitoring, including the Chronic Care Act of 2017 (S. 870), and S. 787, recently introduced by Sens. Cory Gardner, R-Colo., and Gary Peters, D-Mich. (Also see "Chronic Care Bill Would Pay Big Dividends In Telehealth Reimbursements" - Medtech Insight, 7 Apr, 2017.)

Auditors also pointed out that the Emory eICU programs "might have had the most impact in ways that are difficult to measure, such as avoiding care delays at night, improving adherence to standardized clinical guidelines, reducing physician burnout and enriching critical-care knowledge of entire care teams." The report added that the improvement may also have contributed to reduced length of stays in the ICU, even if it could not be measured directly using available data.

From the editors of The Gray Sheet

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