Chapter 8. Telemedicine

• Creating a centralized ICU care system provides a mechanism for implementing 24-hour 7-day intensivist oversight of critically ill patients throughout a network of hospitals.
• A major goal of centralizing ICU care is to spread intensivist care over larger numbers of patients, thereby extending both the number of patients managed by an intensivist and the hours of intensivist care. Creating a multidisciplinary remote care team in which ICU nurses and ancillary personnel work in support of the remote intensivist is central to maximizing operating efficiency.
• Available data suggest that implementing a remote intensivist management program that supplements on-site physician care can improve clinical outcomes and economic performance. We speculate that dedicated off-site intensivists improve outcomes by closely monitoring patient status when there is no on-site intensivist, thereby ensuring that care plans are adhered to and that new problems are detected and addressed promptly.
• The requisite technology includes 2-way audio and high-resolution video links to each patient room, a robust clinical information system that allows off-site physicians to access patient data, technology tools for performing routine care tasks (e.g., creating notes and orders), and a robust and secure broadband wide area network.
• Clear definition of roles and responsibilities, detailed elucidation of operating procedures, including how the remote program integrates with on-site physician activities, and ensuring compliance with standard inpatient care policies (e.g., licensure, credentialing, quality assurance, and the Health Insurance Portability and Accountability Act) are essential for a smoothly functioning and effective program.
• Centralized ICU care programs as part of a system-wide view of ICU care ensuring consistent 24-hour 7-day intensivist oversight and the use of an information technology backbone, create unique opportunities to standardize care practices, enhance operating effectiveness, and improve outcomes.

There is wide variation in intensive care unit (ICU) care across U.S. hospitals. Despite data showing improved clinical outcomes with dedicated intensivist staffing1 and the institution of a variety of best practices,2 few ICUs are able to implement these care practices broadly and consistently. Fundamental problems in our current health care system make the goal of optimal ICU care nearly unobtainable for most hospitals. Considerable attention has been devoted to the current shortage of intensivists3 and the high cost of 24-hour 7-day staffing models. Similar focus has been devoted to the difficulty of getting physicians to adopt best practices. While there are behavioral and managerial components to this problem, the lack of real-time prompts and data-based feedback represent equally important obstacles. Even where hospital leadership appreciates the clinical and financial impact of improved ICU care, the path is both costly and difficult. This chapter presents an alternate care paradigm—one that addresses many of the most serious barriers to improving ICU care. There are three core concepts central to this new care model. First, ICU care is viewed as a system-wide problem, where care across multiple institutions is addressed comprehensively, resources are shared across a network of facilities, and care practices are systematically standardized. Second, technology tools and alternate staffing patterns are used to allow intensivists to care for greater numbers of patients. Third, computer applications assist physicians in problem detection, guide their decision making, and provide feedback that helps drive quality improvement initiatives. The vision is for ICU care to become an integrated service across a network of hospitals, to be delivered in a consistent manner, and to achieve the highest level of care possible with existing resources.

Telemedicine can be defined broadly as the provision of health care services to patients by care providers that are not in physical proximity to the patient. Telemedicine was initially envisioned as a means of providing geographically isolated patients access to quality health care. Early applications, including military and rural health initiatives, focused on establishing adequate connectivity, developing tools that could be used remotely, and demonstrating clinical feasibility. Costs were high and usage was low—primarily because of low population densities in the target locales—and most projects were abandoned when external funding disappeared. One exception was the use of telemedicine for care of prison inmates. There savings of the high cost of patient transport helped to underwrite infrastructure costs. Over the past decade telecommunication costs have fallen markedly and several new uses of telemedicine have appeared, including teleradiology and telepathology. Both employ store-and-forward technology, in which images from multiple sites are transported to a centralized reading facility. Teleradiology probably represents the leading telemedicine application in use today, almost certainly because work volume is high and these centers can be profitable. This application, although potentially representing a more cost-effective way to deliver a service, does not fundamentally improve the quality of health care. While a variety of new programs are being evaluated, most telemedicine initiatives have failed to deliver on the promise of improved access to health care and better outcomes that spawned the concept 20 years ago.

The use of telemedicine for provision of ICU services dates back to the early 1980s. Grundy and associates established an ICU consultative program, in which intensivists provided advice to clinicians at a remote hospital lacking intensivists.4 While short lived, the clinical teams at both sites subjectively cited value in the program. Almost 15 years later, a team of academic intensivists reported improved outcomes during a 17-week program of continuous intensivist oversight of ICU patients in a 10-bed surgical ICU that did not have dedicated intensivists.5 This program operated 24 hours 7 days a week and the intensivists had real-time access to bedside monitor and laboratory data, as well as two-way audio-video connectivity. The remote intensivists worked in support of the on-site team but were credentialed at the remote hospital and had order-writing privileges. Detailed data were collected on all patients cared for during the pilot program and compared to similar data from patients cared for during two 4-month periods 6 and 12 months prior to the program. The Acute Physiology and Chronic Health Evaluation (APACHE) III methodology was used to adjust for changes in disease severity among the study periods. Actual-to-predicted mortality and length-of-stay (LOS) ratios both decreased by 30% during the intervention period, and the incidence of major complications decreased by 40%. A detailed financial analysis showed decreases in the cost of care that paralleled the shortening of ICU LOS. Although only a pilot project, the results suggested that a 24-hour 7-day remote intensivist care program might provide benefits similar to those reported with dedicated on-site intensivist staffing models.

In 1998, following completion of the continuous ICU telemedicine study described above, two of the investigators (including the author of this chapter) started a company to provide remote intensivist monitoring systems to hospitals. The first ICU telemedicine program using this technology was begun in 2000 in two hospitals at Sentara Healthcare, an integrated delivery network (IDN) in Virginia. A total of 36 ICU beds, representing 3 ICUs, were monitored initially. The remote care center was located in commercial office space 8 to 10 miles from the two hospitals, and staffed around the clock by an intensivist, an ICU nurse, and a clerical assistant. This off-site team worked in support of on-site physicians, actively monitored all patients, ensured that care plans were executed, and assisted with management of new problems. The technology infrastructure was provided and installed by the telemedicine vendor and intensivists from the IDN staffed the remote center. A detailed study of clinical and financial outcomes showed a 27% reduction in hospital mortality and decreases in ICU and hospital LOS of 17% and 13%, respectively.5a Costs of care decreased by 19%, hospital revenue for ICU patients increased by 7.5% as a result of an increase in ICU throughput, and contribution margin rose by $6 million annually. Of note, the decrease in ICU LOS was attributable to a reduction in the number of long-stay patients, an effect that may indicate fewer complications as a result of improved monitoring and earlier intervention.

The Sentara program has expanded over the past 24 months, and currently includes seven ICUs in four hospitals. Similar systems are in place in two large East Coast academic medical centers, a 29-hospital IDN in California, an eight-hospital system in the Midwest, and in several military facilities (including a 4000 mile remote link from Hawaii to Guam).

Over the past 5 to 10 years, multiple studies have documented superior clinical outcomes in hospitals with dedicated intensivist staffing models.1 Mortality rate reductions in these studies average >20%. Many of these reports also describe decreases in ICU LOS and resource utilization. Based on the strength of these data, the Leapfrog Group, an organization formed by Fortune 500 companies to establish health care purchasing standards, has called for all nonrural hospitals to implement dedicated intensivist staffing models within the next 1 to 2 years.6 They project that adoption of this staffing model will result in 50,000 to 170,000 fewer ICU deaths annually in the U.S.7 A number of other health care quality groups have issued similar recommendations for dedicated-intensivist staffing.8,9

Despite compelling evidence that dedicated intensivist staffing models result in better clinical outcomes, fewer than 15% of U.S. hospitals have this staffing in place.3 The two most commonly cited obstacles to implementing this model are cost and the unavailability of intensivists. A common financial analysis places the salary cost of 4 to 5 intensivists (required for 24-hour 7-day staffing for 1 ICU) at >$1,000,000 annually, a number that exceeds projected professional services reimbursement. However, even when hospitals recognize the financial benefits of improved ICU clinical outcomes and management, a severe national shortage of intensivists makes recruitment difficult. A recently completed manpower study estimates that there are approximately 5500 practicing intensivists in the U.S.10 Since the overwhelming majority of these intensivists also participate in other clinical and/or academic activities, the number of full-time equivalents (FTEs) is considerably smaller. When viewed in relation to the 30,000 FTEs required for 24-hour 7-day intensivist staffing in all U.S. ICUs, the shortfall is quite daunting. Moreover, projections based on the current pool of trainees suggest that the problem will worsen for many years.

By permitting a single intensivist-led team to provide care to patients in multiple sites simultaneously, telemedicine offers a potential means of leveraging the current pool of intensivists over larger numbers of patients. Central to this model is the creation of a network of ICUs and other high-acuity beds (e.g., stepdown, ED holding, and postanesthetic care unit) and the use of a dedicated team of intensivists and other care providers to supplement on-site care and thereby achieve 24-hour 7-day intensivist care. Viewing the delivery of critical care services from a system-based perspective, rather than the traditional model in which each individual ICU functions autonomously, represents a major shift in how we conceptualize the care of critically ill patients. This change in perspective (and execution) allows resources to be allocated more efficiently, ensures a more uniform level of service across facilities, and it also creates a platform for practice standardization. The use of a centralized intensivist team for the provision of physician services traditionally provided by on-site physicians creates a mechanism for increasing operating efficiency. By using physician extenders and technology tools to increase operating efficiency, this physical redeployment can enable intensivists to care for considerably larger numbers of patients than with traditional on-site physician staffing. Both staffing models and technology tools are covered later in this chapter.

When evaluating the potential for remote ICU care to permit more efficient provision of intensivist services, several important questions arise. Some of these are technology-related—connectivity, reliability, data access, and security—and are addressed in the next section. Others are more operational in nature. How does remote care integrate with on-site activities and how is continuity of care ensured across multiple care providers? This question is not unique to remote care, but one that assumes greater importance given that 24-hour 7-day intensivist care becomes feasible with this model. These operational issues require new processes and operating procedures. Several solutions developed by early adopters of this new technology are described in a later section of this chapter. The most important questions, however, concern the extent to which intensivist activities can be provided effectively by off-site intensivists. The improvement in clinical and economic outcomes reported with remote care trials suggest a level of efficacy comparable to that reported in studies examining the impact of implementing a dedicated daytime intensivist care model. However, understanding the strengths and weaknesses of this alternate care paradigm will be essential to defining the optimal balance between on-site and remote activities, and optimizing ICU care models moving forward.

At this time there are insufficient data to answer these important questions. However, considering the likely reasons for superior clinical outcomes with dedicated intensivist staffing may provide some useful insights and identify areas for future study. First, intensivists, as a result of their training and clinical activities, have greater familiarity and expertise in managing critically ill patients. This expertise presumably leads to more accurate and timely problem recognition and better management decisions, regardless of whether these activities are provided on-site or remotely. Second, dedicated ICU physicians coordinate the diverse tasks of the care team (consultants, nursing, pharmacy, respiratory, nutrition, etc.), establish priorities, and create a comprehensive care plan. This important activity, setting the care plan, usually occurs at the beginning of each day. Because it is time consuming and entails integrating large amounts of data (including physical exam findings) and communicating with multiple care providers and the patient's family, one might hypothesize that this activity is better performed by on-site physicians. Third, dedicated intensivists monitor each patient's progress throughout the day (altering therapies as needed to ensure that care objectives are met), and detect and respond to new problems promptly. This constant adjustment of care can only occur when intensivists monitor patients continuously, analyze new data as they become available, and respond immediately when changes in therapy become necessary. It is this continuous monitoring of patient status that is at the heart of the dedicated intensivist model. Because of their inherent physiologic instability, ICU patients sustain adverse events and develop complications at rates far exceeding those of other patients. Only through continuous monitoring by highly trained physicians can we ensure that patients progress according to plan and receive appropriate and timely treatment of all problems. We hypothesize that this continuous care function, which requires 24-hour 7-day physician vigilance, can be performed effectively by intensivists regardless of their location, and represents the optimal use of this new technology.

Effective telemedicine applications must provide off-site care providers with access to the key data required for monitoring clinical status, reliable mechanisms for communicating with on-site personnel, and tools to perform routine tasks such as generating notes and orders. Many of the tools used to enable off-site care will also be deployed in the ICU in order to facilitate integration of remote and on-site activities.

Key ICU telemedicine components include:

• Two-way audio-video: Audio-video equipment is used for visual monitoring of patient status and communicating with on-site personnel. Individual connections to each patient room are preferred, although portable devices may be useful in some low-use settings. Desired functionality includes full-motion video (>25 frames per second), remote camera control, automatic aperture control, zoom capability, and synchronization of audio and video switching.
• Real-time viewing of bedside monitor waveforms and digital readouts: Vital signs and other physiologic data provide essential information used for monitoring patient status. In addition to digital readouts of heart rate, vascular pressures, and other data, waveform displays are necessary for evaluation of rhythm disturbances and other cardiac anomalies.
• Radiography and other image viewing: Although on-site staff will read most radiographic studies, emergency viewing capability is important. High-resolution medical grade scanners can be used for this purpose in hospitals that have not changed over to digitized radiographs.
• Access to detailed clinical data: A wide variety of clinical data must be available to the care team, including laboratory, culture, and other test results; medications; vital signs; and other physiologic data (e.g., invasive hemodynamics and input and output, among others). Aggregating these diverse data can be a formidable undertaking, as can organizing and displaying them in user-friendly formats. Successful applications provide considerable value to on-site caregivers and can serve as a platform for knowledge-based applications, such as those described below.
• Physician notes and orders: Off-site care providers must be able to both generate notes and orders (the products of their work), and view physician documents created on-site. While many hospitals are evaluating the feasibility of system-wide computerized physician order entry systems, few have these in place. Some system for creating orders and printing them in the ICU is required, preferably one that captures key medication information and provides screening for allergies and drug interactions. Similar tools must be available for creating and viewing physician notes, as these contain key patient data not available elsewhere. The use of computer-based note writing tools is highly recommended, since traditional handwritten notes are very inefficient for information transfer (due to wide variations in content/organization, poor legibility, and lack of portability).
• Communication tools: The primary rationale for introducing a centralized care team is to expand intensivist coverage to both greater numbers of patients and more hours of the day (24 hours 7 days a week is optimal). Because of both geographic separation and expanded hours of physician coverage, specific tools to ensure rapid and effective communication between care teams is essential. Dedicated phone lines ensure that on-site personnel can access the remote team rapidly during emergencies, while the audio-video system allows effective in-room communication. Efficient and effective physician-to-physician communication is equally important. Although traditional verbal sign-out rounds can be used to outline treatment goals, delineate key tasks, and communicate ideas and clinical information not appropriate for inclusion in traditional physician notes, they are time-consuming and difficult to coordinate. The use of computer-based applications for transmission of these data offers clear advantages.
• A wide area network: A wide area network that connects each ICU (or other high-acuity site) to the centralized monitoring center is necessary to support all the above applications. This network must be reliable (redundancy is desirable), secure, and have sufficient bandwidth to support full-motion video.

Commercial systems in use today also include computer-based decision-support tools and an alerting system that evaluates new clinical data (e.g., labs, physiologic data, and medications) and flags potential problems. These tools facilitate problem recognition and assist both remote and on-site physicians with decision making. Figure 8-1 shows a schematic representation of a remote care system.

Establishing the technology platform to support a centralized ICU care center is a complex undertaking. While some required functionality may be available in existing ICU or hospital applications, the entire system must function as an integrated whole. The diverse components must be simple to use and support routine ICU care processes. A dysfunctional technology infrastructure will limit the number of patients the remote care team can manage, thus undermining one of the key reasons for centralizing this function. On the other hand, installing a comprehensive patient care system that supports physician workflow, facilitates problem detection, standardizes practice patterns, and improves decision making can provide real benefits. Such systems can also bring value to on-site intensivists and help improve the safety and efficiency of their activities.

Establishing a remote ICU management program changes the care paradigm at several different levels. First, a host of new procedures must be introduced to support off-site care. Areas that must be addressed include credentialing, clinical processes, communication, documentation, training, and quality review. However, implementing a remote ICU program entails fundamental changes in ICU management—adopting a system-wide approach to ICU care, moving to 24-hour 7-day intensivist oversight, and standardizing care processes. Migrating to this alternate care paradigm provides substantial benefits, but requires strong institutional leadership and experience in implementing new clinical programs. Establishing clear goals, identifying champions and local leaders, creating appropriate incentives, and aggressively managing the change process are essential to achieving high levels of success.

Although centralized ICU care programs are still relatively new, the accumulated experience of the sites in current operation have generated considerable useful information. A brief summary of their experience in several key areas follows.

• Staffing: All programs to date have targeted reaching 35 to 50 networked beds within a short time frame. This represents a comfortable number of monitored patients for a physician/nurse team, and it also is of sufficient scale to justify the operating expenses of the remote center. As additional beds are added, more staff are required. Although experience is limited, it appears that a second physician will be needed when the number of networked beds approaches 100. Nonintensivists may be able to function as the second physician since they will be working in tandem with the intensivist. ICU fellows and acute care nurse practitioners may prove to be valuable additions to the care team. Because the remote care program supplements, rather than replaces, on-site clinical activities, the program will require the addition of new physicians and nurses. Although some individuals may prefer to work in the remote center exclusively (or may need to because of disabilities, such as latex allergy), most physicians and nurses prefer to divide their time between on-site and remote care. Many hospital systems have multiple groups of intensivists, sometimes representing different private practice teams, and other times representing different medical specialties (e.g., medical intensive care unit, surgical intensive care unit, or neurologic intensive care unit). Creating a structure in which all groups are able to participate in the remote care program simplifies staffing of the remote center and helps to build support for the project. It also increases the breadth of experience, fosters collaboration, and helps with standardizing practice patterns. Where ICU care is highly specialized, open discussion of care practices for different populations and formal back-up procedures for complex specialty cases are important.
• Financial structure: Third party reimbursement for telemedicine professional services is very limited at this time. As a result, all current ICU telemedicine programs are funded by the participating hospitals. Hospitals recognize cost savings from reduced ICU and hospital LOS and lower daily ancillary cost expenditures, and they also are able to create additional ICU capacity as a result of the decrease in ICU LOS. Initial data suggest that these financial benefits exceed the implementation and operating costs of the program, including the salary costs of the intensivists and other care team members. Salary levels must be appropriate for the market and sufficient to entice physicians to work nights and weekends.
• Remote center operations: The remote team consists of physicians, nurses, and clerical personnel, as well as dedicated administrators. It is important to clearly define the roles and responsibilities of each member of the team. This requires developing procedures for how all key tasks are to be performed (e.g., rounding, data gathering, and communications). Assembling a multidisciplinary team consisting of hospital administrators, program administrators, ICU team members (physicians and nurses), and stakeholders from other areas that interface with the ICU (e.g., pharmacy and ED) ensures broad representation and is recommended. Once remote care processes have been defined, they need to be documented and understood by all. Formal training programs must be developed so that each participant is familiar with the technology and the clinical procedures. Back-up plans must be developed in the event of technical problems (e.g., network failure) and to deal with common problems. The more effective the planning process, the smoother the operation will be.
• Integration with on-site activities: The remote care team functions in support of the on-site physicians. In most ICUs the attending of record (or on-site intensivist) will review all data at least once a day, coordinate communication with all members of the team (nurses, consultants, respiratory therapy, etc), and establish the care plan. When that individual leaves the ICU (the time of day will vary depending on the staffing model), the remote team assumes responsibility for executing the care plan, making adjustments to ensure that goals are met, monitoring patients for new problems, and intervening where needed. The smooth transfer of responsibility embodied in this model requires effective communication between the on-site and remote teams. The computer-based applications required for off-site care, if deployed in the ICU, can provide a convenient forum for this information transfer. In this way the thoughts and plans of the attending of record are available to the remote intensivist, and the assessments and interventions of the off-site intensivist are immediately apparent to the on-site physicians when they return to the ICU. However, in order to get the requisite buy-in from busy ICU clinicians, effort must be devoted to ensuring that the on-site care team understands both the value provided by the remote team and the importance of effective communication. It is similarly important that the remote intensivist notify the attending of record when important decisions arise during off hours.
• Oversight: As should be evident from the above discussion, implementing a system-wide remote ICU care program is a major undertaking. A new operating center must be established, staff must be hired/recruited and trained, and a complex set of operating procedures need to be developed. ICU staff will need to be trained and physicians that admit to the ICU will require education as well. Assembling an experienced leadership team is essential to the success of the program. Senior hospital executives must clearly enunciate the rationale and vision of the program. Dedicated project leaders must be appointed, usually an intensivist physician and a remote center manager. These individuals should have the requisite skills for the job and have protected time to devote to the project. In addition, a broad-based program oversight committee should meet regularly to review problems, modify operating procedures, and track program progress. This committee, in conjunction with senior hospital leadership, should establish yearly goals for the program and track progress against these.

There are a number of regulatory issues that must be considered when implementing a remote ICU care program. First, off-site intensivists are providing patient care. Although most remote care programs cover a limited geographic region, some may cross state lines, and physicians in the remote center must be licensed to practice medicine in each state that has hospitals within the network. Physicians also will need to be credentialed at each participating hospital. A few hospitals have developed special credentials for this purpose. The second important area concerns ensuring patient confidentiality. The recently issued federal security guidelines (part of the Health Insurance Portability and Accountability Act; HIPAA) outline general principles for protecting patient data and confidentiality. These have clear implications for remote ICU care, including keeping transmitted data secure, and instituting appropriate security policies at the remote site. Most hospitals include consent for remote care as part of their hospital admission consent process.

The Leapfrog Group has indicated that hospitals may use remote intensivist monitoring in order to meet their intensivist standard. They suggest that this may increase the feasibility of implementing dedicated intensivist coverage. They have defined several key features for a remote management program,11,12 including:

• An on-site intensivist must review patient data and set the daily care plan.
• The tele-intensivist must provide care during all hours that there is not an intensivist on-site. He or she must be physically at the remote care site and have no concurrent responsibilities.
• Clinical data must be available to the remote intensivist, including laboratory results, medications, and notes, among others.
• The remote care system must be robust (>98% uptime) and secure (HIPAA compliant).
• The remote intensivist must be able to visualize the patient and communicate with on-site personnel, so camera resolution and bandwidth must be sufficient to assess breathing.
• The program must adhere to written standards, including at a minimum: (1) critical care certification, (2) state medical licensure, (3) hospital credentialing, (4) quality review of the program, (5) explicit policies defining roles and responsibilities, and (6) a program to educate staff about the program.
• Remote intensivist care must be proactive and include routine review of all patients.
• The workload of the tele-intensivist should not be excessive; he or she should be available within 5 minutes of a request from ICU personnel.
• There should be written procedures to ensure effective communication between the tele-intensivist and the on-site personnel.
• Actions performed by the remote intensivist should be documented and included in the medical record.

Implementing a remote care program represents a major change in the patient care paradigm. The rationale for this change, as discussed above, is to improve clinical outcomes in our most vulnerable patients. However, there are several intriguing consequences of this new model. First, critical care is viewed as a system-wide priority and intensivists are viewed as the key resource. By elevating both the prominence of critical care and the importance of intensivists, centralized care programs should have a beneficial impact on the specialty. Second, conceptualizing critical care at the system level should facilitate practice standardization, which will further improve clinical outcomes. Third, the program aspires to continuous intensivist oversight, regardless of time of day. This care model accepts the need for 24-hour 7-day dedicated physician care, and as a result, requires a move to fixed shifts of clinical responsibility. While this change in staffing requires increased focus on processes to ensure continuity of care, it should improve quality of life for intensivists and address a major factor contributing to early burnout and choosing alternate career options. Fourth, remote care depends on the introduction of technology systems that are actually used to care for patients. This technology infrastructure creates opportunities to use information systems to improve the care process. Automated alerts can reduce errors, detailed information on practice patterns can be used to drive performance improvement initiatives, computerized decision support tools can ensure ready access to current knowledge, and time-saving computer applications can improve physician efficiency and effectiveness. It is worth noting that the promise of these smart systems can be realized because there is a physician monitoring all critically ill patients at all times, in contrast to other monitoring paradigms, because the physician doing the monitoring has the clinical skills to analyze the incoming alerts, and he or she is empowered to initiate a response. Finally, because the program views critical care as a system-wide service, operating efficiency can be optimized and resources can be used more effectively. As a result, this re-engineering of ICU patient care can both save lives and have major financial benefits for the hospital.

Centralized ICU care is still in its infancy. As experience increases we can look forward to an improved understanding of which elements of the program have the greatest effect on outcomes, and which functions are best performed by on-site physicians. Efficacy needs to be confirmed in different environments (academic, community, and rural) and with different on-site staffing models. Considerable uncertainty exists regarding preferred off-site staffing models, particularly as the size of the ICU network increases. Operating procedures need to be refined and new systems developed for training both on-site personnel and the remote team. Almost certainly the technology infrastructure will evolve, and this should both simplify establishing a remote program and increase operating efficiency. Like many new technologies, increased experience will enhance efficacy and expose weaknesses. It is important to recognize that the supporting technology enables new systems of care. As such, the success in different sites will depend on the diligence of the clinicians responsible for providing patient care. The potential looks promising and it should be exciting to follow the evolution of this care model moving forward.