The Avera Health system is composed of 235 facilities in 87 communities in a rural, five-state region with a geographically dispersed population of about 1 million people over 71,550 square miles. Avera implemented the nations first rural, multistate, remote critical-care telemedicine program in September 2004. The goal was to leverage critical-care specialists, based in the tertiary hospital, across the health system to create a regionalized critical-care delivery model that improved quality and safety and reduced costs.
No. 2: Avera Health
Through the wire: Telemedicine program helps improve critical care in rural region
Rural areas represent close to 25% of this countrys population, but have only 10% of the physicians. This health information technology implementation improves the delivery of critical-care services to underserved areas without regard to time of day, travel time and expense, or the absence of local intensivists (critical-care specialists who have been shown to reduce mortality and costs of care). The nationwide scarcity of intensivists and the projected worsening of this shortfall over the next 30 years are well-documented.
Averas program consists of 72 networked beds spread over a tertiary-care hospital, three Avera regional centers and 14 rural and critical-access hospitals, some outside of the Avera system. The remote-care center is staffed 24/7 with a critical-care nurse and clerical support.
A critical-care physician is present 20 hours daily to provide consultative care, including performing virtual patient rounds; evaluating proprietary alerts for vital signs, checking for laboratory abnormalities and gaps in best practices (decision support at the point of care); and responding to requests from the local bedside nurses and physicians.
Highlights of the Avera model include:
- Local hospitals that provide care to intensive-care-unit patients by attending internists, surgeons and family-practice physicians supplemented by few or no subspecialists. Startup costsremote facility build-out, hardware/ equipment and softwarefor the program were $2.8 million. Operating costs averaged $2.2 million per year in the first three years.
- Evidence of how the health IT system is being used to improve patient care or patient-care delivery. Avera evaluated the impact on clinical outcomes and cost savings by examining mortality rates, changes in length of stay (the primary determinant of ICU cost), the number of transfers from smaller hospitals and staff satisfaction.
Improvements in patient-care delivery include:
- Care protocols that were standardized across the system, improving glycemic management and ventilator-bundle compliance.
- Mortality rates at Avera are as much as 81% better than Apache III- and Apache IV-predicted for the ICU population. As of March 31, 352 individuals not predicted to survive, left the hospital alive because of this care.
- ICU length of stay at Avera is as much as 37% better than predicted for severity-adjusted length of stay for the ICU population.
- Surveyed physicians and staff rate the technology easy to work with and report better triage decisions, improved patient safety and enhanced staff comfort.
Using conservative savings estimates, the Avera remote critical-care program has generated real cost savings.
The calculated savings attributed to reduced ICU days was $8 million to the system by the middle of the third year of implementation.
Length-of-stay reductions also can eliminate the need for capital spending for additional ICU beds. The financial benefits attributable to length-of-stay reduction are supplemented by cost savings from fewer transfers from small to tertiary hospitals. In a system-led study, these latter savings were estimated at nearly
$1.25 million by the middle of the third year.
Ten sites and beds scheduled to go live during the coming year are already grant-funded. An additional 29 beds at two other sites may benefit from funding by the American Recovery and Reinvestment Act of 2009. This remote critical-care program meets the criteria for meaningful use and health information technology advancement:
- It has proven quality improvement data. In fact, the program demonstrates the ability of IT to reform healthcare. Averas remote critical-care program demonstrates reduced actual to predicted ICU mortality, reduced actual to predicted ICU length of stay and reduced actual to predicted hospital mortality.
- It is a cost-effective and visionary model for replication in rural settings. There is little organization of critical-care services in the U.S. and more than 1,300 critical-access hospitals serve millions of patients who have no access to critical-care physicians.
Some experts have called for regionalization through a model patterned after regional trauma and burn centers, where high-acuity patients transfer to tertiary centers for care. While such a model matches patient acuity and resources, it is costly, imposes travel burdens and can overload tertiary-care resources. The Avera model augments the capabilities of smaller, more remote facilities, reducing the need for patient transfers.
It is a staffing effectiveness and employment model. Critical-care practice has historically been an all or nothing profession with a high burnout rate. Shift work in remote-care programs provides new opportunities for critical-care doctors, is a cost-effective staffing model and addresses the shortage of critical-care physicians.
Senior vice president and chief information officer
Sioux Falls, S.D.
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