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Telemedicine in the ICU

clinical outcomes, economic aspects, and trainee education

Becker, Christian D.a,c,e; Fusaro, Mario V.a,c,e; Scurlock, Coreya,b,d

Current Opinion in Anesthesiology: April 2019 - Volume 32 - Issue 2 - p 129–135
doi: 10.1097/ACO.0000000000000704
INTENSIVE CARE AND RESUSCITATION: Edited by Marek Brzezinski
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SDC

Purpose of review The evidence base for telemedicine in the ICU (tele-ICU) is rapidly expanding. The last 2 years have seen important additions to our understanding of when, where, and how telemedicine in the ICU adds value.

Recent findings Recent publications and a recent meta-analysis confirm that tele-ICU improves core clinical outcomes for ICU patients. Recent evidence further demonstrates that comprehensive tele-ICU programs have the potential to quickly recuperate their implementation and operational costs and significantly increase case volumes and direct contribution margins particularly if additional logistics and care standardization functions are embedded to optimize ICU bed utilization and reduce complications. Even though the adoption of tele-ICU is increasing and the vast majority of today's medical graduates will regularly use some form of telemedicine and/or tele-ICU, telemedicine modules have not consistently found their way into educational curricula yet. Tele-ICU can be used very effectively to standardize supervision of medical trainees in bedside procedures or point-of-care ultrasound exams, especially during off-hours. Lastly, tele-ICUs routinely generate rich operational data, as well as risk-adjusted acuity and outcome data across the spectrum of critically ill patients, which can be utilized to support important clinical research and quality improvement projects.

Summary The value of tele-ICU to improve patient outcomes, optimize ICU bed utilization, increase financial performance and enhance educational opportunities for the next generation of providers has become more evident and differentiated in the last 2 years.

aeHealth Center, Westchester Medical Center Health Network, Taylor Pavilion

bDepartment of Anesthesiology

cDepartment of Medicine, Westchester Medical Center

dDepartment of Anesthesiology

eDivision of Pulmonary and Critical Care Medicine, Department of Medicine, New York Medical College, Valhalla, New York, USA

Correspondence to Christian D. Becker, MD, PhD, Division of Pulmonary and Critical Care Medicine, Department of Medicine, New York Medical College, Valhalla, NY 10595, USA. Tel: +1 914 493 1040; fax: +1 914 493 8373; e-mail: christian.becker@wmchealth.org

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INTRODUCTION

A recent provocative read by veteran European intensivists Vincent, Slutsky and Gattinoni speculates what a critical care experience might look like in 2050. The authors envision that remote interactions and videoconferencing with doctors through telemedicine elements will become the new norm [1]. In another recent editorial, Vincent and Creteur [2] summarize in 10 points how hospitals of tomorrow will be different. One of the 10 points is titled ‘Telemedicine will be everywhere.’ Overall, reading through the various prognostications on the future role of telemedicine and actively participating in its expansion in our institution frequently reminds us of the evolution of information technology in the healthcare sector over the last 50–60 years: Following Roger's model of diffusion of innovation, initial niche applications for an exotic, novel, and expensive technology were undertaken only by innovators in the 1950s and 1960s. Later, then cautiously broader acceptance was seen by early adopters in the 1970 s, followed by the adoption by the early and late majorities of providers in the 1980s and 1990s, to the point where in 2018 information technology has permeated almost every aspect of today's healthcare and dominates daily workflows in care delivery. Imagine a similar change with telemedicine as the next logical chapter.

This review will focus on telemedicine interventions in critical care. For a more global discussion on the clinical spectrum of telehealth applications, please see the recent excellent review in NEJM[3▪▪].

Box 1

Box 1

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DRIVERS OF TELE-ICU SOLUTIONS

Telemedicine in the ICU was born out of necessity to bridge a supply and demand gap for critical care providers of all levels. Factors that affect this critical care provider shortage are the ‘perfect storm’ of an aging population with increasing disproportionate ICU use needs, a fixed supply of new critical care providers, increasing exits and/or retirements and a geographical maldistribution of active intensivists [4▪▪,5].

Timothy Buchman, the Editor-in-Chief of Critical Care Medicine recently published an article, which summarizes these factors and then goes on to describe the Emory University approach to bridging the provider gap through the use of innovative solutions. In addition to employing telemedicine solutions, his institution is at the forefront of training and deploying acute care nurse practitioners. This care delivery model is associated with similar outcomes compared with resident-driven care [6]. Additionally, their approach provides supervision through tele-ICU intensivist providers, creating a synergistic combination of solutions. Their most recent solution attempts to ameliorate the negative effects of nighttime intensivist work (which both bedside and electronic ICU providers are equally at risk for) by taking advantage of differences in global times zones. Using the simple fact that it is daytime on the other side of the globe when it is nighttime in the United States, Emory has devised a system to provide US nighttime tele-ICU monitoring and intensivist coverage through a daytime center in Sydney, Australia (Turning Night into Day Program) using Emory intensivists [4▪▪]. Other areas in Medicine like Radiology (tele-Radiology) as well as other tele-ICU operations have for some time been taking advantage of this ‘time-zone’ solution.

Tele-ICU may have been born out of necessity to simply bridge the provider gap, but in ‘growing up’ it ‘discovered’ other valuable abilities in the process. With the move to value-based care and ever decreasing hospital-operating margins, the pressure to define the value of telemedicine in the ICU is increasing as well. Value is defined as Quality divided by Cost or ‘Outcome Achieved per Dollar Spent’ [7]. ‘Quality’ strives for positives like clinical outcomes, patient/provider satisfaction, and enhanced postgraduate medical education. ‘Cost’ summarizes complex metrics that address resource utilization of ICU beds, providers, hospital throughput/capacity management and reduction of complications through standardization of care. The value equation ‘Value = Quality/Cost’ illustrates the overlap between clinical outcomes and economic metrics, which are both addressed successively below.

The evidence base for tele-ICU has rapidly expanded becoming more differentiated in the last decade. In particular, the last 2 years have seen interesting added evidence on clinical outcomes and economic benefits. Overall, we have evolved from the question as to whether telemedicine in the ICU adds value to the more differentiated view on when, where and how, that is, through which aspects of the multifactorial intervention and through which driving mechanisms value is added.

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CLINICAL OUTCOMES OF TELE-ICU

Three systematic reviews and meta-analyses have been published assessing the effect of tele-ICU implementation on the core clinical outcomes of ICU and hospital mortality and length of stay (LOS). The most recent systematic review and meta-analysis was published just last year. It showed reduction of ICU and hospital mortality and ICU LOS, but not hospital LOS [8▪▪].

We discussed the two previously published meta-analyses [9,10] in an editorial in 2016 [5].

Table 1 summarizes the findings of all three meta-analyses on the main outcome measures and details the number of studies shared between the three meta-analyses, which helps to explain the differences in their findings (see the Venn diagram in the right column of Table 1). The constellation of more consistently confirmed ICU mortality and LOS reduction and less consistently confirmed effects on hospital mortality and LOS through tele-ICU implementation seems intuitive to us and mirrors our own experience (in preparation for publication), as a multitude of nontele-ICU-related additional factors are involved in determining hospital-based outcomes.

Table 1

Table 1

Kahn et al.[11▪] in 2016 used a different combined data set of Medicare claims data linked to a national survey identifying hospitals adopting ICU telemedicine to confirm a positive effect of tele-ICU adoption on ICU mortality.

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HOW DOES TELE-ICU ADD VALUE?

Subgroup analyses through meta-analyses as well as independent studies have contributed additional understanding to the question of how tele-ICUs convey their value.

The degree of integration of clinical information and monitoring as well as the clinical care teams clearly matters. Continuous monitoring with active alarms and alerts is more beneficial than episodic consultations only without continuous data feeds or alerting mechanisms [12].

Similarly, tele-ICU setups fostering integration and close collaboration with the bedside teams and giving the tele-ICU team authority to intervene and actively participate in patient care strengthens the outcomes improvement seen with tele-ICU implementation [9,12].

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DOES THE CLINICAL VALUE OF TELE-ICU ALSO CARRY OVER INTO NON-ICU SETTINGS?

A recent publication found telemedicine interventions in the progressive care unit setting (TPCU) to be associated with similar mortality and LOS improvements to tele-ICU interventions [13].

Telemedicine may also add value when taking the ICU beyond its borders for the evaluation and management of decompensating general ward patients [rapid response teams (RRT)] [14].

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CONTEXTUAL WORKLOAD

Unlike many other areas in medicine with fairly steady workloads, critical care environments inherently are very susceptible to large contextual workload fluctuations, and therefore varying stress levels. Using tele-ICU services specifically to alleviate contextual workload increases and surges in intensivist cognitive demand, in particular is a very attractive concept for added value. A recent study found benefit in a tele-ICU service to alleviate postoperative Post Anesthesia Care Unit (PACU) surges in a large volume PACU-Surgical Intensive Care Unit (SICU) environment [15].

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HANDOFFS

Another area of special interest to anesthesiologists is the operating room to ICU handoff. A recent study has shown potential to use videoconferencing participation and oversight as a standardization and quality improvement tool [16].

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WHERE IS THE EVIDENCE FOR TELE-ICU VALUE ORIGINATING FROM?

The majority of evidence-based literature on telemedicine in the ICU originated in the United States. Use of tele-ICU is expanding from the USA to other parts of the world including London, UK and Tokyo, Japan as well as to Australia, where geographical variations in access to critical care expertise and distances for interfacility transports to centers of excellence constitute accentuated challenges when compared with the United States. A recent publication from Australia provides a first assessment of the magnitude of benefit of tele-ICU approaches in this very large and inhomogeneously populated country [17].

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ADULT VERSUS PEDIATRIC CRITICAL CARE

The scope of adoption and expansion of tele-ICU has been much larger in adult mixed and subspecialty ICU settings compared with pediatric and neonatal ICU settings. The driving forces for innovative solutions to staffing shortages are similar between adult and pediatric critical care. Expansion of telemedicine solutions in pediatrics is, therefore, to be expected to accelerate in the future. Nadar et al. [18] summarize the existing evidence base in pediatric acute care telemedicine, which overall lags behind but mirrors the evidence in the adult literature. Adult and pediatric/neonatal critical care providers train through different pathways, which makes cross-coverage of tele-ICU services across the age spectrum of critical care impossible unless the patient volume warrants deployment of both adult and pediatric critical care providers simultaneously. From the technical standpoint, differences in physiologic parameters like vital signs and laboratory values result in different acuity-scoring models and different alarm and alert parameters. As a result of these differences, adult and pediatric tele-ICU applications are, therefore, destined to coevolve.

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ECONOMIC ASPECTS

Tele-ICU implementation is associated with significant upfront investments as well as ongoing operational costs. Economic value is added when the cost savings or revenue increases realized through tele-ICU outweigh combined investment and operational costs over time. The core equation ‘Value = Quality/Cost’ can be expanded by adding the element of ‘Access to Care,’ thereby creating a Quality–Cost–Access triangle, with the three sides of the triangle being Quality–Cost, Access–Cost and Quality–Access [19].

Cost savings of tele-ICU are realized directly through LOS reduction, which can lead to reductions in ICU variable costs, such as manpower and pharmaceutical expenses. Also, given that tele-ICUs can increase best practice adherence, like venous thromboembolism (VTE) prophylaxis, complications can be reduced and better pay-for-performance metrics achieved. Tele-ICUs can also lead to increases in revenue and increased case volume by allowing greater capacity without having to build more ICU beds.

Revenue increases are realized through improved acuity distribution, optimized throughput/bed utilization and capacity management, particularly in larger healthcare systems dependent on optimizing access across a spectrum of care from outpatient to community hospital to tertiary and quaternary care centers.

A recently published simulation analysis determined that tele-ICU implementation based on severity of illness likely improves tele-ICU cost effectiveness [20]. In the accompanying editorial, Ries [21] raises the importance of activity-based cost accounting to determine the return on investment for tele-ICUs.

The most comprehensive and robust experiential financial outcomes study to date was published last year (2017) by the University of Massachusetts/Worchester tele-ICU operation (2 campuses, 834 bed academic medical center), which has been operating since 2006 [22▪▪]. Lilly et al. used activity-based accounting methodology for this single center three phase before–after study. The primary outcome measure was change in annual direct contribution margin (aggregated net case revenue minus direct costs). The pretele-ICU intervention phase contained baseline preintervention outcomes and financial performance data on 14 257 patients from 2004 to 2006. The second phase contained data after tele-ICU implementation on 14 552 patients from 2006 to 2010. The final third phase added Logistics Center Functions to the tele-ICU intervention for 22 394 patients from 2010 to 2013. The Logistics Center functions were targeted at increasing access to critical care and optimizing capacity/throughput as well as providing support for 51 care standardization projects. Tele-ICU support increased the direct ICU contribution margin by 376% from $7.9 to $37.6 million/year, decreased hospital LOS by 6.7% and increased case volume by 20.7%. Added Logistics Center functions increased the contribution margin to $60.5 million/year, reduced hospital LOS by 15.4% and increased case volume by 38.5% compared with baseline. Per case costs initially increased because of tele-ICU implementation costs, but were recouped within 3 months because of increased operational efficiency. The significant increase in case volume was attributable to reduced ICU and hospital LOS, improved ICU bed utilization and throughput via tele-ICU-directed removal of impediments to timely ICU admission and discharge, thus accelerating transfers and increasing bed sharing across most ICU beds.

Care standardization efforts through a newly formed care standardization committee implemented a total of 51 separate projects ranging from patient experience to patient safety to care pathway modifications and overall were estimated to have reduced direct costs/case by 4.2%.

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INTERHOSPITAL TRANSFERS

There is conflicting data as to whether tele-ICU implementation increases interhospital transfers [23,24] or decreases them [25]. A multitude of factors specific to the hub and spoke hospital settings and the healthcare systems in question likely determine the effect of Tele-ICU on this metric.

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META-FACTORS AFFECTING SUCCESS

There are a multitude of factors that in aggregate shape the response of any given healthcare institution to tele-ICU implementation. They all address the ‘How?’ domain. Like any other intervention in medicine, tele-ICU implementation can either be supported and shaped to succeed or destined to fail depending on how these surrounding meta-factors are handled. A recent comprehensive ethnographic study by Khan et al.[26▪▪] confirmed our beliefs that domains surrounding leadership, perceived value of tele-ICU, change management strategies and organizational structure are most closely associated with success of tele-ICU implementation.

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TRAINEE EDUCATION

A prior review in this journal on the future of anesthesiology raised the question as to whether we can utilize new technologies to provide supervision and oversight in the critical care setting [27]. Most healthcare providers graduating today irrespective of specialty are estimated to routinely use some form of telemedicine in their future clinical practice, yet systematic training in telemedicine for the next generation of physicians, nurses and allied health professionals on a global and national scale is only in its earliest stages. Few institutions have established structured telemedicine curricula, clerkships and clinical rotations for medical students, residents and fellows. As of November 2018, there are currently only four telehealth training programs accredited by the American Telemedicine Association (https://www.americantelemed.org/main/ata-accreditation/training-programs).

The Anesthesiology Residency Review Committee of the Accreditation Council for Graduate Medical Education and the American Board of Anesthesiology do not list any specific requirements for tele-ICU training in Anesthesiology or Anesthesia Critical Care. The AMA only offers an online course in the ‘Practice Transformation Series’ on ‘Adopting Telemedicine in Practice.’

At our institution we have successfully developed a tele-ICU curriculum, 1-day clerkships for medical students, as well as 1-week and 1-month long clinical tele-ICU rotations for residents and fellows to enable our trainees to have structured exposure to this specific clinical care environment.

Apart from teaching the next generation the nuts and bolts of executing telemedicine, tele-ICU can also be used as a centralized education and clinical supervision tool for trainees, particularly after hours, when direct supervision by critical care attending is often limited. We have found our tele-ICU to be extremely useful in the direct supervision of nighttime ventilator management, bedside procedures and bedside point-of-care ultrasound (POCUS) examinations. Nighttime POCUS exams are often conducted by medical trainees with basic training but little experience, but frequently have huge treatment implications for patients. We have successfully used tele-POCUS supervision by the tele-ICU attending to standardize POCUS image acquisition and interpretation [28,29]. Others have shown that tele-ICU-directed ultrasound can even function with unskilled bedside operators guided by tele-intensivists who supervise image acquisition and handle image interpretation of focused critical care ultrasound [30].

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RESEARCH POTENTIAL

Finally, the rich and granular data generated by most tele-ICU operations on a routine basis often includes risk predictive outcomes scores like Acute Physiology, Age and Chronic Health Evaluation (APACHE) and/or acuity of illness scoring like Sequential Organ Failure assessment (SOFA), which can readily be harnessed to support medical trainee-driven research projects. On a national level, this has led to the formation and growth of a uniquely powerful clinical database for clinical research [31▪].

Numerous publications to date have already successfully used this dataset [32].

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CONCLUSION

Evidence is expanding on the value of tele-ICU to improve meaningful clinical outcomes, financial performance metrics like case volume and direct contribution margin through optimized ICU bed utilization and capacity management. As with any other complex intervention, numerous meta-factors related to administrative buy-in and leadership, change management techniques and organizational structure surround tele-ICU implementation and operation and in aggregate crucially shape its ultimate success. Integration of tele-ICU into the educational curriculum for the next generation of medical providers is lagging behind the pace of expansion of its clinical role in healthcare.

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Acknowledgements

We would like to thank Dr Michael Ries for inspiring discussions on tele-ICU economic issues.

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Financial support and sponsorship

This work was supported by the Westchester Medical Center Health Network's eHealth Center.

Funding: Internal.

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Conflicts of interest

There are no conflicts of interest.

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REFERENCES AND RECOMMENDED READING

Papers of particular interest, published within the annual period of review, have been highlighted as:

  • ▪ of special interest
  • ▪▪ of outstanding interest
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REFERENCES

1. Vincent JL, Slutsky AS, Gattinoni L. Intensive care medicine in 2050: the future of ICU treatments. Intensive Care Med 2016; 43:1401–1402.
2. Vincent JL, Creteur J. The hospital of tomorrow in 10 points. Crit Care 2017; 21:93.
3▪▪. Dorsey ER, Topol EJ. State of telehealth. N Engl J Med 2016; 375:154–161.

This recent review article summarizes overarching issues in Telehealth in general, including current development trends, reimbursement issues, regulatory hurdles and prospects for future adoption.

4▪▪. Buchman TG, Coopersmith CM, Meissen HW, et al. Innovative interdisciplinary strategies to address the intensivist shortage. Crit Care Med 2017; 45:298–304.

This article very nicely chronicles the journey of Emory University and its Critical Care Center under Dr Timothy Buchman's leadership and with a collaborative team to bridge the intensivist gap, reduce burn-out and increase access to critical care experts through innovative and unconventional solutions.

5. Becker C, Frishman WH, Scurlock C. Telemedicine and Tele-ICU: the evolution and differentiation of a new medical field. Am J Med 2016; 129:e333–e334.
6. Landsperger JS, Semler MW, Wang L, et al. Outcomes of nurse practitioner-delivered critical care: a prospective cohort study. Chest 2016; 149:1146–1154.
7. Porter ME. What is value in healthcare? N Engl J Med 2010; 363:2477–2481.
8▪▪. Chen J, Sun D, Yang W, et al. Clinical and economic outcomes of telemedicine programs in the intensive care unit: a systematic review and meta-analysis. J Intensive Care Med 2018; 33:383–393.

This most recent meta-analysis on the clinical and economic outcomes of telemedicine in the ICU includes a total of 19 studies and has added 6 studies not contained in any of the other recent meta-analyses. It, therefore, includes the broadest number of patients to date to conclude that tele-ICU reduces ICU and hospital mortality as well as ICU length of stay, but not hospital length of stay.

9. Wilcox ME, Adhikari NK. The effect of telemedicine in critically ill patients: systematic review and meta-analysis. Crit Care 2012; 16:R127.
10. Young LB, Chan PS, Lu X, et al. Impact of telemedicine intensive care unit coverage on patient outcomes: a systematic review and meta-analysis. Arch Intern Med 2011; 171:498–506.
11▪. Kahn JM, Le TQ, Barnato AE, et al. ICU telemedicine and critical care mortality: a national effectiveness study. Medical care 2016; 54:319–325.

This National Effectiveness Study adds important evidence on the association of tele-ICU interventions with clinical outcomes that are drawn from an innovative combined data source of Medicare claims data linked to a national survey of US hospitals adopting telemedicine.

12. Hawkins HA, Lilly CM, Kaster DA, et al. ICU telemedicine co-management methods and length of stay. Chest 2016; 150:314–319.
13. Armaignac DL, Saxena A, Rubens M, et al. Impact of telemedicine on mortality, length of stay, and cost among patients in progressive care units: experience from a large healthcare system. Crit Care Med 2018; 46:728–735.
14. Pappas PA, Tirelli L, Shaffer J, Gettings S. Projecting critical care beyond the ICU: an analysis of tele-ICU support for rapid response teams. Telemed J E Health 2016; 22:529–533.
15. Collins TA, Robertson MP, Sicoutris CP, et al. Telemedicine coverage for postoperative ICU patients. J Telemed Telecare 2016; 23:360–364.
16. Barry ME, Hochman BR, Lane-Fall MB, et al. Leveraging telemedicine infrastructure to monitor quality of operating room to intensive care unit handoffs. Acad Med 2017; 92:1035–1042.
17. Panlaqui OM, Broadfield E, Champion R, et al. Outcomes of telemedicine intervention in a regional intensive care unit: a before and after study. Anaesth Intensive Care 2017; 45:605–610.
18. Nadar M, Jouvet P, Tucci M, et al. Impact of synchronous telemedicine models on clinical outcomes in pediatric acute care settings: a systematic review. Pediatr Crit Care Med 2018; 19:e662–e671.
19. Lilly CM, Motzkus CA. ICU telemedicine: financial analyses of a complex intervention. Crit Care Med 2017; 45:1558–1561.
20. Yoo BK, Kim M, Sasaki T, et al. Selected use of telemedicine in intensive care units based on severity of illness improves cost-effectiveness. Telemed J E Health 2018; 24:21–36.
21. Ries M. Evaluating tele-ICU cost–an imperfect science. Crit Care Med 2016; 44:441–442.
22▪▪. Lilly CM, Motzkus C, Rincon T, et al. UMass Memorial Critical Care Operations Group. ICU telemedicine program financial outcomes. Chest 2017; 151:286–297.

This study is of outstanding interest as it describes the financial outcomes of tele-ICU intervention in a large integrated healthcare network in three phases and over a total period of 9 years. The preimplementation phase was followed by tele-ICU implementation. The third phase consists of tele-ICU along with added functions directed at care standardization, ICU bed utilization and access to critical care. It may serve as a model for other healthcare organizations challenged with similar capacity and access to care issues.

23. Tyler PD, Celi LA. Tele-ICU increases interhospital transfers: does big brother know better? Crit Care Med 2017; 45:1417–1419.
24. Pannu J, Sanghavi D, Sheley T, et al. Impact of telemedicine monitoring of community ICUs on interhospital transfers. Crit Care Med 2017; 45:1344–1351.
25. Fortis S, Sarrazin MV, Beck BF, et al. ICU telemedicine reduces interhospital ICU transfers in the veterans health administration. Chest 2018; 154:69–76.
26▪▪. Kahn JM, Rak KJ, Kuza CC, et al. Determinants of intensive care unit telemedicine effectiveness: an ethnographic study. Am J Respir Crit Care Med 2018; [Epub ahead of print].

This comprehensive ethnographic study found very important meta factors associated with tele-ICU success that relate to domains of leadership, perceived value of tele-ICU and organizational characteristics of the telemedicine program.

27. Prielipp RC, Cohen NH. The future of anesthesiology: implications of the changing healthcare environment. Curr Opin Anaesthesiol 2016; 29:198–205.
28. Becker C, Fusaro M, Patel D, et al. Tele-ultrasound to guide management of a patient with circulatory shock. Am J Med 2017; 130:e205–e206.
29. Becker C, Fusaro M, Patel D, et al. The utility of teleultrasound to guide acute patient management. Cardiol Rev 2017; 25:97–101.
30. Olivieri PP, Verceles AC, Hurley JM, et al. A pilot study of ultrasonography-naive operators’ ability to use tele-ultrasonography to assess the heart and lung. J Intensive Care Med 2018; 885066618777187. doi: 10.1177/0885066618777187. [Epub ahead of print].
31▪. Pollard TJ, Johnson AEW, Raffa JD, et al. The eICU Collaborative Research Database, a freely available multicenter database for critical care research. Sci Data 2018; 5:180178.

This recent pulication in Nature Scientific Data describes the history and development of the eICU Collaborative Research Database, which contains high granularity data for over 200 000 ICU patient stays and is a rich freely available resource for critical care researchers.

32. Badawi O, Liu X, Hassan E, et al. Evaluation of ICU risk models adapted for use as continuous markers of severity of illness throughout the ICU stay. Crit Care Med 2018; 46:361–367.
Keywords:

electronic ICU; tele-ICU; telemedicine

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