Despite the delays the ongoing COVID-19 pandemic has caused, ICU4Covid has brought telemedical devices – the MONA – to several intensive care units (ICUs) across Europe, with further implementations still to come. As the social science partners in the project, we have closely accompanied this process and want to present a first set of lessons learned in the project co-creation thus far. They together emphasize: Bringing telemedicine to the ICU is as much a social project as it is a technological one – this is a key aspect to consider when wanting to implement telemedicine successfully and sustainably across Europe.

 

#1 Local Specificities Matter and Future Users Need to be Involved From Early On

ICU4Covid brings together a diverse set of hospital partners. Each of these hospitals comes with its specificities. For example, the healthcare systems the hospitals are embedded in are very different and make divergent provisions for how to keep a patient record and how to use telemedicine. Some hospitals have automated patient data management systems in place, while others keep paper files. Some hospitals have already a considerable history of using telemedicine. Others have only recently improvised telemedical solutions to respond to the challenges of the COVID-19 pandemic.                                                        

The technologies that the ICU4Covid project seeks to implement need to be adaptable to such heterogeneous starting points. We draw on a long tradition of social science research that shows that any technological solution incorporates assumptions about how this technology will and should be used in the future. Developers always draw on their experiences, beliefs, and imaginations when making decisions about the design and functionalities of the technologies they develop. Especially the telemedical centerpiece of the project, the MONA, has been developed against the background of the situation in the Aachen region. The experiences from its first implementations in hospitals across Europe show that this may not easily fit the situation in other places. Therefore, the project has to meet the challenge that it cannot roll out the technologies as a one-size-fits-all, out-of-the-box solution. To implement MONA and the other technologies successfully, the future users at the different sites, doctors and nurses, need to be involved as early as possible in the process – often well before the devices arrive in the ICUs and can be integrated into daily practices. Only in this way can the technologies made to respond to the local specificities, needs and desires.

 

#2 Technical Infrastructures Need to be Accompanied by Social Models of Telemedical Care

Responding to the local specificities also means acknowledging that the technologies in the projects are more than just technical devices. To be implemented successfully and sustainably, these technologies need to be taken up and integrated into the clinical routines. In our visits to the hospitals, we have observed how the newly installed technologies changed the ICU as a space. MONA has been added to the existing medical devices at the bedside, and break rooms have been repurposed as the telemedical cockpit. The medical staff sometimes had to develop new routines. Some of the ICUs that use MONA for telemedical consultations have established a second, telemedical ward round to discuss patients with their telemedical counterparts. Telemedical consultations require new ways of documenting and making decisions. Users had to learn new skills for communicating the patient to a remote consultant, compensating for the reduced sensory experience of the patient in the case of being present at the bedside.

These observations show that implementing new technologies within ICU4Covid does more than adding technical equipment to the ICUs. It also changes the social dynamics in the ICU and are meant to create new networks of exchange and support. Therefore, as social scientists in the project, we speak of the “socio-technical implementation” of these technologies: The technical infrastructure needs to come hand in hand with a social model of how the technologies will be used in practice. This starts with developing a vision of using telemedicine together with future users before the installation. Many of the medical staff we spoke to expressed concern that they did not yet know how to integrate MONA into their practice. It continues with a close collaboration between producers and users throughout and after the installation to make telemedicine a routine. Thus far, the focus has been on rolling out the technologies. For the remaining months in the project, the outlines of corresponding social models for each of the hospitals need to be developed.

 

#3 Building the Social Infrastructures for Telemedicine Takes Time

Developing the social infrastructure or models for using telemedicine takes time. During our visits, we encountered skepticism and concerns about the impact of the technologies among staff members to which the project needs to respond. The medical staff needs to adapt workflows and change routines. Conventions for conducting and, later on, documenting telemedical consultations need to be established. Interlocutors need to find a common language. Relations of trust need to be built across the telemedical networks. Hospitals in the Aachen region have maintained telemedical links for about ten years and throughout multiple telemedical projects, using different telemedical devices. Over this time, telemedicine has become ingrained in their daily practice. We have observed that the remote consultations with clinicians at the university hospital in Aachen are a fixture in the daily schedules with other procedures built around it. The doctors have developed an internal classification of particularly “difficult”, “interesting” or “borderline” cases that they want to introduce during the telemedical consultation. The interlocutors on both sides of the screen are already a well-rehearsed team.

​

However, this familiarity is only possible because the social infrastructure for doing telemedicine has grown over several years of (almost) daily telemedical consultations. Other hospital partners in the project have little to no experience with telemedicine yet. However, as ICU4Covid is only a 2-year project, it will be difficult to create social infrastructures similar to those in and around Aachen within the short time remaining in the project. Therefore, it is all the more important that the partners in the project collaborate closely to sow the seeds of viable socio-technical models for each hospital that can grow into a telemedical network connecting ICUs across Europe in the future.