Newsletter #2
December 2022
We are excited to share with you the second newsletter of the ICU4Covid project. It presents the inputs and outputs of the project as well as where the project vision is headed.
The impact of ICU4Covid: Challenges and future insights
Prof. Ricardo Jardim-Gonçalves
UNINOVA
ICU4Covid delivers intensive care medicine fit for the fight against COVID-19 to the EU citizen and the health workforce rapidly and at scale, by clinically validating and deploying the Cyber-Physical-system for Tele- and Intensive Care Medicine (CPS4TIC).
ICU4Covid is a Cyber-Physical System for Telemedicine and Intensive Care (CPS4TIC), a medical solution for well respond to COVID-19 further outbreaks or similar infectious diseases. The CPS4TIC consists of a telemedicine cockpit, a connector platform, and smart hubs. The hub continuous real-time tele-monitoring and smart care environment. The CPS4TIC is shaped for delivery of the level of treatment that is needed for the individual patient in an effective, economic, and efficient manner. By integrated use of telemedicine, the time gain for diagnosis and treatment are significant. Thus, resources can be used more efficiently, and staff exposure will be further diminished.
With CPS4TIC, the doctors in a center core hospital can see and hear both the colleagues and patients in other areas of the same hospital or in connected hospitals, e.g., peripheral hospital or health center. Moreover, beside seeing the patient, a connector platform allows the connection to the patient data management system in the hub network connected hospitals. This enables the health workers to overview all relevant data, such as vital data, lab data, microbiology, radiology, and data from the electronic health record (EHR).
ICU4Covid deploys and test the CPS4TIC at large-scale in 10 ICU Hubs in Europe. Each ICU hub operates telemedicine, continuous real-time tele-monitoring and a bedside smart care environment. The bedside smart care environment reduces the risk of infection for the health workforce significantly both for the central and peripheral hospitals.
ICU4Covid enables access to the recommended coverage of intensive care, real-time tele-monitoring and bedside smart care environment. It delivers a Personal health solution, throughout a personalized diagnostics and clinical management of COVID-19 patients that are clinically entering a critical stage for a high number of cases. Hence, a SAFE health setting is implemented, protecting from further spreading of the disease among the healthcare workforce and the patients.
ICU4Covid is Inclusive, reducing the distance as a barrier between patients and physicians. With CPS4TIC the transport of patients can be minimized, while patient real-time monitoring is assured. It takes the Societal dimension as the basis to respond to the Citizens needs through a Social Sciences and Humanities Framework for ICU Hubs. To assure sustainability and long-term success of the implemented Cyber-Physical System for Telemedicine and Intensive Care (CPS4TIC), ICU4Covid put in place co-creation environments in each ICU Hub, engaging the stakeholders affected by the implementation to assure that solutions are attuned to the different expectations, knowledges and needs.
Furthermore the results of ICU4Covid project were presented at the Digital Transformation Summit (https://summit.digit-madeira.pt) meeting that took place in Madeira, 25-27, October, 2022 and with the support of the Madeira government. The Summit involved many participants from various fields in industry, government, and academia as well as from the European Commission. This was a wonderful and important opportunity to share the success of the ICU4Covid project and create significant impact.
ICU4Covid grants excellence in medical treatment to Everyone, Everywhere, Any time.
The widespread of Telehealth within ICU4Covid
Univ.Prof. Dr. med. Gernot Marx*, PD Dr. med. Lukas Martin**
(Janine Meyer-Christodoulou, Anna Christina Boersma)
*Uniklinik Aachen, **Clinomic
The project ICU4Covid came to life as a rapid response to the Covid-19 pandemic. Amongst others its goal was to establish a telemedical network across Europe with a two fold use:
On the one hand was the creation of regional ICU-Hubs, aiming to support smaller and peripheral hospitals that often face shortage of medical staff. In order to do so a central hospital, usually a university hospital or specialized clinic, with great medical coverage, is connected to multiple peripheral hospitals and performs regular telemedical rounds. Providing medical expertise remotely to the doctors on site of the peripheral hospitals offers the opportunity to make use of the bed capacity, which is of utmost importance especially in situations like the Covid-19 pandemic.
The second idea of the project is that the network will enable cross border exchange and thus facilitate knowledge transfer and best practices amongst the different countries and partners.
Now the project runtime of two years has almost passed it is time to investigate the results - those are quite remarkable: Telemedicine is running across Europe and the network is growing.
The hospitals have found further helpful ways in the use of telemedicine. Aside from the suggested use cases - a local network and cross-border collaboration – the hospitals are also using telemedicine internally for either training purposes of residents or nursing staff or for facilitated consultations across different specialties within the hospitals’ units.
One specific success story that is worth highlighting is the creation of the Romanian network within an exceptionally short timeframe of less than one year. Not only did the central hospital acquire additional peripheral hospitals for the network, but they quickly learned about the recommended standards and workflows of telemedicine with the help of an experienced cross-border project partner. Currently they are in the phase of transferring the gained knowledge into their network of 5 hospitals and establishing a telemedical routine within the Romanian network, while the rounding with the German partner continues.
Additionally, there is a strong hub-structure in place in Germany with one central hospital and 5 spokes hospitals. These hospitals usually perform the rounds on a daily basis. Furthermore, the German central hospital is also connected to most of the other European clinical partners. Aside from the above-mentioned Romanian partners they perform regular rounds with two Greek hospitals, a Latvian partner and are in preparation to start the rounding with Austrian hospitals as well.
Looking at these outstanding results, that were achieved facing multiple Covid-19 waves and a relatively short timeline to implement the technology and new workflows in a complex system such as an ICU, one can only imagine what the next years of further collaboration and expansion of the network will bring.
Accounting for the Heterogeneity of Hospitals: The Co-Creation of Models of Using CPS4TIC beyond the Tele-medical Ward Round Model
Prof. Dr. Ulrike Felt
(Timo Bühler, Carsten Horn, Michaela Scheriau, Neringa Simkute)
University of Vienna
Any technology comes with a vision of how it will be used. Developers envision future users, their skills, needs and the circumstances under which the technology will be used. They also anticipate the role of this technology in the place it is used. Often, innovators draw on their own experiences or at least experiences from their immediate environments when they imagine the future use of the technology they design. This technology, hence, often fits best with the circumstances developers experienced but may not be as easily transferable to other places as envisioned. In the ICU4Covid project, UNIVIE encountered similar transfer challenges. CPS4TIC or, more precisely, the tele-medical system MONA that is at its core responds best to the experiences and challenges from previous tele-medical projects in the region around Aachen in which the co-founders of the developing company have been involved. However, the hospitals in the ICU4Covid consortium are very heterogeneous. The varying starting points and health care systems hospitals are part of entail different needs, expectations, and concerns.
One example for this has been the models for doing telemedicine with CPS4TIC. Initially, and following the way telemedicine has been done in the Aachen region, the project had aimed for a “hub model” in which a central hospital is connected to one or several smaller hospitals as the telemedicine receivers. The consortium quickly had to realize that this was not applicable to all sites and that hospitals wanted and needed to develop site-specific models of using these tele-medical possibilities.
The co-creation approach that ICU4Covid has adopted seeks to explore and document the differences between the hospitals and facilitate conversations between developers and future users to collaboratively develop models of using CPS4TIC and corresponding user roles in ways that respond to these local needs and possibilities. Indeed, when engaging with the different hospital partners and during site visits, we encountered a considerable diversity of “socio-technical use models” across the hospitals in the consortium. In the following, we briefly describe each of these models that are either in practice or have been discussed as future scenarios for the use of CPS4TIC.
While it might seem as a “deviation” from the initial model proposed by the project, the opposite is true: Committing to co-creation means that there is space for acknowledging the heterogeneities of needs of future users and for adapting solutions accordingly.
Tele-medical Ward Round Model
This model is the initial vision of the project and follows the way telemedicine has been practiced in the Aachen region for more than ten years. In this case, the telemedicine unit at the University Clinic of Aachen conducts daily tele-medical ward rounds with other hospitals in the region. More recently, hospitals in Romania and in Greece have also taken up this offer and started presenting patients during regular rounds. As not all patients can be presented during the tele-medical online ward round, hospitals using this tele-medical model developed often tacit classification of patients in the ICU as “interesting”, “borderline cases” or “on the verge of deterioration” which needed external expertise. It would be interesting in the long run to reflect this classification in order to understand where telemedicine is seen as the most rewarding and necessary add on to classical care practices.
Emergency Model
In Madeira and, to a lesser extent, in Germany, CPS4TIC has also been used to initiate telemedical consultations in case of emergencies. On Porto Santo, a smaller island in the archipelago of Madeira where care is provided by a small Regional Health Center, physicians can use the system to stabilize patients with the help of the remote consultants and prepared them for the airlift to Funchal hospital. The use of CPS4TIC in emergency cases requires a 24/7 availability of the telemedicine donors that not all hospitals may be able to provide, however, which also points to some limitations.
In-house Consultations or Remote Monitoring
Some hospitals, e.g. in Vienna, are built as a campus, sometimes entailing longer walking distances across campus between the wards of different specialties. In these cases, CPS4TIC will be used to connect different buildings on the same campus to speed up the flow of information and reduce the need for physically traversing the campus, especially in the case of emergencies. In one Viennese hospital, the emergency room will be equipped with a MONA device to make special expertise from other wards in the hospital quickly available. Similarly, in one hospital the healthcare professionals have used CPS4TIC for monitoring patients in the isolation ward for COVID-19 patients and for communicating with nursing staff within the ward. This has allowed them to reduce the time necessary for (time consuming) changing into the protective gear and the unnecessary exposure to infectious patients, making their work easier and safer.
Home Shift
In some hospitals, night and weekend shifts are staffed by resident doctors and non-intensivists with trained intensivists with more experiences on-duty at home. During interviews and conversations, CPS4TIC came up as one way to improve this situation: The on-duty intensivist could get a better image of the patient (especially if the data-solution the MONA system is capable of is activated) and give advice or participate in making clinical decisions. Yet, in some hospitals this model would entail fundamental changes of existing shift rhythms and of the culture of doing intensive care that can vary among different countries quite substantially. Thus, the home shift has been controversially discussed, also due to different legal frameworks.
Tele-Education
Especially due to the pandemic, access to ICUs has been limited drastically. This has also meant that medical students could not enter the ICU as part of their training as usual. In the university hospitals participating in the project, physicians have thus discussed using CPS4TIC for a kind of tele-education: Using the technology, live images from patients could be transmitted to the lecture halls of the medical universities given patients’ consent. As an added value, this would also train doctors-in-training in the use of telemedicine as a routine component of their everyday work – a field that is currently still missing in most curricula.
Tele-Nursing
CPS4TIC has mainly been developed to facilitate communication between physicians. But could it also be used to establish connections among nursing staff in different hospitals? Given the on-going scientification and specialization of nursing, the nurses we spoke to agreed that this could be a possibility, for instance, to exchange expertise about wound treatment. However, as nurses already saw themselves as under heavy time pressure due to understaffing, they expressed concerns that using more technology-mediated interaction with patients could compromise the patient-centric and physical proximity-based approach they feel is necessary when providing care for critically ill patients.
European Telehealth Network for Acute Care
ICU4Covid has a commitment to be sustainable beyond the duration of the two-year project. The vision for the time after is that of a European Telehealth Network for Acute Care. Using CPS4TIC as an infrastructure, hospitals with different core areas are envisaged to be connected to facilitate the exchange of clinical expertise across Europe. This is seen as essential to develop common standards of tele-medical consultation and documentation to further improve care.
Facing the future: European Telehealth Network (ETN) in acute care
Dr. Tal Soffer
(Anat Soroka Zuta, Sky Sofer)
Tel Aviv University
The ICU4COVID project began as a response to the COVID 19 pandemic. The aim of the project was to deliver intensive medicinal treatment fit to fight against COVID-19 and provide European citizens with rapid care along with providing safety for the health workforce, by delivering that care through the Cyber-physical- system for tele and intensive care medicine.
One of the main challenges in the implementation of innovative technologies in organizations in general and in health organizations, is the synergy between technology and society. The ability to remove the barriers and encourage the advantages and benefits. One of the ways for successful implementation is through co-creation process, which advocates the cooperation of all stakeholders from the very beginning. This approach was widely adopted during the project by identifying the relevant stakeholders and making them an integral part of the implementation process of the CPS4TIC system. Through various activities such as: ongoing meetings, interviews, and workshops we shared ideas, collected information and insights that significantly contributed to the project’s activities.
In the final stage, as the project is set to end after a two-year span, we are looking towards to establish a European Telehealth Network (ETN), based on the insights and outputs of the ICU4COVID project. Consequently, in our final meeting which took place during the Madeira Digital Transformation Summit with all partners we conducted a workshop, based on a world café methodology to discuss the initiation of European Telehealth Network in acute care. To explore the challenges and obstacles, the threats and risks, incentives, and future needs. The participants were worked in groups, each group had a moderator and rapporteur (figure 1). During the discussion the participants used stickers and notes to write their ideas and create their “story” for future ETN. The discussions were very lively, and the participants contributed from their rich experience in the various fields (medical, technological, social).
Figure 1: World café methodology – The European Telehealth Network in acute care
The results of the discussion yielded interesting and important ideas that could assist in the initiation of the future ETN, based on the projects’ results. The following are highlights from the insights which raised during the discussion:
Challenges and obstacles: The challenges as well as the obstacles raised by the participants were mainly focusing on technological issues such as: low stability of the infrastructure at the hospital; low Internet connection and luck of interoperability connections between the different systems within the hospitals and between other hospitals. Other challenges referred to societal aspects which emphasize the knowledge gap in digital skills to medical professionals; the resistance to use technology by the healthcare team due to the fear of dependency, preserving the interpersonal connections with patients – empathy. Finally financial aspects were also raised to establish such network.
The main risks and threats that were discussed were also refer to the technology domain, specifically the safety and vulnerability of the technological systems, and the ability to penetrate the hospital's databases and disrupt and even paralysis the daily activities that may cause damages and injury to human life. The privacy issue also discussed – how to balance between the use of technologies and privacy. In the social aspects - physician skepticism regarding the digitization of health care can pose a serious threat to a new ETN. Other concerns raised when collecting the data were lack of in person care because of the telemedical services.
Therefore, to promote the implementation of ETN we discussed the future needs and incentives. Undoubtedly, one of the biggest incentives in initiating ETN is the ability to provide better medical treatment, personalized, and flexible - anywhere, at any time, and to anyone. It enables the medical teams to save time spent on administrative activities for the benefit of patient care. It will also create more efficient hospital communications. Thus, to successfully initiate ETN we need to address all the above, understand the future needs and provide solutions. Hence, the participants sketched number of future needs and solutions to support the establishment of ETN. From the technological point of view, it is necessary to adapt the technological infrastructures to the needs of the systems, to ensure the interoperability with the hospitals’ systems, as well as the stability of the infrastructural (e.g. the internet). In addition, to establish cybersecurity system to protect the data base at the hospital and in the network and to create data standardization. In the social aspect, it is necessary to develop suitable educational curriculum to provide the young generation the acquired knowledge and practices to use digital technologies in health. Provide dedicated training to medical teams relating to digital health and telemedicine. Develop and establish organizational policies and procedures for the implementation and use of telemedicine as well as enforce the privacy and data protection laws. And finally, to foster engagement, transparency, and cooperation with all relevant stakeholders, with a special emphasis on the patient at the center.
