Lab Soft News

The Diagnosis and Treatment of Pre-Diseases: A Look at the Future

One of the interesting aspects of the deployment of new wearable medical devices is the use of sensors attached to patients that have the capability of monitoring disease progression in a manner never before possible. This idea was discussed in a recent article (see: IBM Research develops fingerprint sensor to monitor disease progression). Here is a brief excerpt from it:

IBM...announced that it has developed a small sensor that sits on a person’s fingernail to help monitor the effectiveness of drugs used to combat the symptoms of Parkinson’s and other diseases. Together with the custom software that analyzes the data, the sensor measures how the nail warps as the user grips something. Because virtually any activity involves gripping objects, that creates a lot of data for the software to analyze. Another way to get this data would be to attach a sensor to the skin and capture motion, as well as the health of muscles and nerves that way. 

This new article brought to mind my blog note of about ten years ago in which I discussed what I then referred to as the health continuum ranging from predisposition to disease => diagnosed predisease => acute or chronic disease (see: Predisposition to Disease and Pre-Disease on the Health Continuum). Pertaining to the predisposition to disease and diagnosed predisease, I made the following comment at that time:

[O]ne of the most interesting questions associated with the early disease model is whether it is appropriate to treat patients with pre-diseases. If they are deemed treatable and as we come to better understand the nature of pre-disease, a second question is what drugs to treat them with. As soon as we work out this question, we will then be faced with the new question of how and when to treat patients with a predisposition to disease, genetic or otherwise.

A friend has brought to my attention the idea that pharmaceutical industry and its researchers are showing great interest in the genetic predisposition to disease and also asymptomatic diseases in order to expand the size of the market for drugs. In the past, this has been referred to as disease mongering (see: Disease mongering and drug marketing; Disease Mongering (i.e., Medicalization) by Pharmaceutical Companies; Medical Device Mongering, a Variant of Disease Mongering).There is very little information available about treatment of pre-diseases with the notable exception of pre-diabetes (see: Prediabetes: when the pre-disease becomes the focus of treatment) where the treatment can often be behavioral relating to exercise and weight loss and not the use of drugs. At any rate, we can anticipate much more attention to pre-diseases and probably some controversy whether such patients can and should be treated with drugs.

Why "Virtual Assistants" Won't Remove EHR Pain Points Quickly

In a recent note, I commented on the emergence of "virtual scribes" (see: Virtual Scribe Vendors Remotely Generate EHR Notes and Coding). This is hospital service with physicians dictating the details of a patient office encounter. At a later time, a remote transcriptionist employed by a virtual scribe company enters the essential dictated data into the hospital EHR. These remote transcriptionists have access to the hospital EHR for this data entry. This is in contrast with the original and continuing idea of EHR scribes who are physically present in the examining room with the doctor and patient and perform all EHR keyboard entries.

However, It should not some as a surprise that the term "virtual assistant" is now taking on a new meaning and can refer to a software "assistant" rather than to a person. This new definition was explained in a longish recent article on this topic (see: Can Virtual Assistants Eliminate EHR Usability Pain Points?). Here are two quotes from it:

But dictation software is more or less a one-way street. The challenge for AI developers is to create intelligent systems with bi-directional capabilities: [the development of computerized] virtual assistants that can more or less independently perform background information-gathering work and synthesize those results into a meaningful conversation with providers.

[and]

Virtual assistants could be the answer that fed-up providers are looking for. Ideally, these tools will be able to dig through EHR data to present important nuggets of information, place phone calls and prescription orders, take notes, and help users navigate the EHR system itself. Several well-known EHR vendors, including athenahealth, Epic, and eClinicalWorks, are in the process of launching integrated virtual assistants which will be commercially available to providers in the near future. For now, however, virtual assistants are far from commonplace. The tools are predominately being used by small groups of clinicians participating in limited pilot programs as health systems test the opportunities and limitations of the strategy. 

There are plenty of challenges and advantages to virtual assistants, said leaders from Yale New Haven Health, Beth Israel Deaconess Medical Center in Boston, and Vanderbilt University Medical Center in Nashville. All three health systems are exploring whether virtual helpers can improve the provider experience and reduce physicians’ complaints about the drawbacks of EHR use. The need to address the problem of user burnout is more important than ever, leaders from the health systems stressed, but creating a tool accurate and useful enough to convince providers of its promises requires significant investment, creativity, and commitment.

Do any of the readers of this blog think that a practical and appropriate solution to our EHR complexity problem is to develop a software virtual assistant who will understand EHR idiosyncrasies and make them more user friendly? Because our EHRs are intrinsically complicated with difficult UI's, these proposed virtual assistants will also be extremely complicated and will take years to develop. 

Duplicate Patient Records as a Major and Costly EHR and EMPI Problem

I have posted a number of notes about the use of IT to improve efficiency and effectiveness in healthcare. A gnarly but persistent problem has been duplicate patent records and substantial IT resources are required to correct the problem. Below is an excerpt from an article on this topic (see: Artificial Intelligence and ethics will drive a patient matching revolution in 2019):

Existing patient matching technologies are failing, as evidenced by skyrocketing rates of duplicate records in electronic health record (EHR) and enterprise master patient index (EMPI) systems. In fact, duplicate record rates have nearly doubled in the past decade, from an average of 10 percent in 2008 to 18 percent today....These patient matching technologies are failing at the worst possible time—as more and more of a health system’s strategic initiatives fundamentally rely on accurate and complete patient data. The dire consequences of these failures include a third of claims being denied costing $1.5 million annually; massive operational inefficiencies costing $200,000 annually; lowered return on investment (ROI) of EHR deployments; inhibited value-based care initiatives; and drastic consequences to patient safety, care quality, and patient satisfaction....

Yet nowhere can AI have a more immediate and accessible impact than in patient matching. Currently, health systems have teams of data stewards and health information management (HIM) professionals dedicated to finding, reviewing, researching, and resolving records that their EHR or EMPI has flagged as “potential duplicates.” Essentially, these employees are spending hours each day looking at, for example, a record for Jane Jones and another for Jane Smith, trying to decide if both Janes are actually the same person and if her records should be merged. Referential matching technology can automate 50-to-75 percent of this manual effort by being an intelligent and data-driven technology. It can automatically find and resolve duplicate records that EHRs and EMPIs have missed, enabling data stewards and HIM staff to focus on higher-value projects—while simultaneously lowering the operational costs and inefficiencies plaguing health systems by automating manual work.

Here's the way that a company called Verato has tried to solve the patient matching problem (see: Referential Matching: The Silver Bullet for Patient Identity and Patient Matching):

Verato has pioneered a powerful new patient matching technology called “Referential Matching.” Rather than directly comparing the demographic data from two patient records to see if they match, Verato instead matches that demographic data to its comprehensive and continuously-updated reference database of identities. This proprietary database contains over 300 million identities spanning the entire U.S. population, and each identity contains a complete profile of demographic data spanning a 30-year history.

I am sure that there will be many new solutions to this patient matching problem utilizing AI and ever more sophisticated algorithms that do not require a large, remote, proprietary patient database. Nevertheless, attention is now being paid to this major medical record problem that endangers patient lives -- that's the right direction. I will continue to monitor this field to see what other solutions emerge.

Proposed Classification for Health Information Systems: Provider and Individual

Recent events and some of my recent blog notes have caused me to question whether we need a new, high-level classification that encompasses all health information systems. I am going to give this idea a try. The goal of such a large scale systematic plan is to understand the functionality of current and future health information systems. Details are listed below:

1. Provider health systems (PHS's): The common feature of PHS's is that they are designed as tools for use by healthcare providers. The largest and most complex of these systems are EHR's which are deployed in hospitals and health systems. Also included in this category are office health systems (OHS's) designed to support the office functions needed by physicians and other providers like nurse practitioners. PHS's provide all the necessary IT functionality in health systems ranging from hospital inpatient units to the PCP's managing ambulatory patients.

Subcategories of PHS's include departmental systems deployed in hospitals such as LIS's, RIS's, and PAC's. In recent blog notes, I proposed that standalone LIS's, as opposed to LIS's that are part of the software suites of EHR vendors, could perhaps evolve into LIS-A's (see: Predicting the Future Functions of the LIS-Analytic (LIS-A); Continuing Discussion about the LIS of the Future; Analytics as a Key Feature?). Such systems would change from classic, best-of-breed LIS's to systems that support descriptive, predictive, and diagnostic algorithms. By developing such LIS-A's, LIS companies may cede ground to the LIS's provided by large EHR vendors as part of their enterprise-wide offerings. 

2. Individual (or personal) health systems (IHS's): These are systems designed primarily for consumers. I blogged recently about the Rally system of UnitedHealth Group that initially provided coaching and other health services (see: UnitedHealth Group to Launch Its Own Variant of an EHR in 2019). It's similar to Apple Health which is an app that runs on iPhones and the Apple Watch. Analytics will be a major thrust in the consumer healthcare market and delivered via IHS's (see: The Future of the LIS: Reflections about Consumers Ordering Their Own Lab Tests) particularly when PHS/EHR clinical data can be downloaded by consumers from their EHR accounts. Apple is already providing such a feature for iPhones in collaboration with selected health systems (see: Apple Has Plans to Copy EHR Records to iPhones and Apple Watches).

3. Hybrid health systems (HHS's): These would be systems such as the one being developed by UnitedHealth Group mentioned above that span physican office health systems (OHS's) and individual health systems. The advantage of such systems is that they fulfill the desire of patients to share health measurements obtained in their homes such as EKG tracings recorded by their smart watches or home lab testing performed by devices that plug into their iPhones. 

As to the future of health information systems, most of the development (and consumer market) is going to be related to IHS's and perhaps relatively simple hybrid systems. This is where consumers will be operating as well as health wearables and home testing devices. EHR's are expensive and accessed only via complex user interfaces. Hospitals will continue to use them because they have no substitute products. Consumers will never use them directly because of their complexity and because of the security concerns of the health systems that own and operate them.

UnitedHealth Group to Launch Its Own Variant of an EHR in 2019

I have commented in previous notes about the increasing role of health insurance companies like UnitedHealth Group as healthcare providers (see, for example: Major Trends for the Year: Payers Use IT to Provide Total Care Management; OptumHealth, a Division of UnitedHealth, to Offer Virtual Patient Visits Nationwide). This trend, along with the growth of walk-in clinics in "big box" stores, will provide competition for health systems in the area of primary care. Now comes news that the UnitedHealth Group is launching its own e-health record in 2019 (see: UnitedHealth Group to Launch Electronic Health Records Platform in 2019). Below are the details:

Before the end of 2019, UnitedHealth Group plans to introduce an electronic health records (EHR) system that it developed internally....UnitedHealth Group...CEO David Wichmann announced plans to roll out a “fully individualized, fully portable” EHR platform in 2019 by leveraging Rally, their existing mobile wellness platform....With 20 million registered [health insurance]  users already using Rally, this could encourage adoption and use of the new EHR among UnitedHealth Group’s 50 million fully benefited members....Exact details of the platform’s capabilities are still unclear. However, additional information...indicates that the new platform might function more like Apple’s approach to personal health records (PHRs) and less like a traditional EHR....

Coverage from Forbes [see: UnitedHealth Group: 50M To Access New Personal Health Record In 2019] indicates the UnitedHealth IHR will be available to both patients and healthcare providers, with UnitedHealth Group predicting usage by one million medical care providers by the end of 2019. “A traditional electronic medical record focuses largely on streamlining internal business processes for facilities and medical groups,” Steve Nelson, CEO of UnitedHealthcare (UHC),.... “But the IHR [individual health record] connects numerous EMRs, creating a unified and secure source of truth for both consumers and care providers, and unlocking the value of data that is currently trapped in today’s fragmented healthcare system....This would allow UnitedHealth to utilize the strong points of Optum—a UnitedHealth Group venture focused on providing health services and innovations—to leverage analytics capabilities aimed at both encouraging patients to take an active role in managing their health and finding the best providers in their area.

First of all, its important to understand that OptumHealth, a division of the UnitedHealth Group, is one of the largest employer of physicians in the country (see: OptumHealth, One of the Largest Employer of MDs, Pursues Telemedicine). As such, the company perhaps should develop an office EHR for the use of its MD employees rather than depending on a commercial product. UnitedHealth thus seems to be in the process of deploying an upgraded version of Rally for use in physician offices and simultaneously offering it to its insurance clients where it would function as an IHR (individual or personal health record). This is a strategy similar to that being pursued by Apple for its iPhone Health app absent the office EHR component (see: Apple Has Plans to Copy EHR Records to iPhones and Apple Watches). 

Rally has previously served as an IHR-like product for UnitedHealth insurance clients. One of the previous goals for Rally was to provide wellness coaching. By moving to a more robust platform including heath data, the Rally successor could then provide a higher level of surveillance of health risks. For example, if the consumer has a history of congestive heart failure, the IHR could be designed to accept data from a smart watch monitoring heart function or a home blood pressure device. Using algorithms from Optum, the IHR could also function proactively in terms of its recommendations to healthcare consumers. This may be one of the goals of the new Rally release: to provide an IHR that contains health data and also utilizes algorithms provided by Optum to make recommendations as part of its health coaching feature. 

Cost of Hospital Care in Michigan; Numbers Not Necessary Relevant for Consumers

Hospitals are now being required to reveal their master price lists but these data may not be of much help to consumers (see: Hospitals must post prices online, but they may be more confusing than helpful). That's because the price lists displayed recently on the basis of a federal requirement, called chargemasters, are massive compendiums of the prices set by each hospital for every service or drug that a patient might encounter. However, I did find some of the prices published for a set of hospitals in Michigan by diagnosis were interesting in a general way to assess the cost of healthcare (see: Hospital price lists revealed: The cost of care at 9 Michigan medical centers). Below is an excerpt from this latter article:

....[W]hile a new federal mandate that took effect Jan. 1 requires hospitals to reveal their once-secret master price lists of every service or procedure they provide,...[but an expert of the topic] warned that patients should view the prices only as "context-setting" starting points. "The hospital's charges are not very relevant to the patient, because the patient bill can be significantly discounted, either by the health plan, which is what health plans have been doing for 50 years, or even in some situations where patients have to self-pay, they can negotiate by themselves"....Below, you'll find...[examples] of base and average prices for common hospital procedures provided by hospitals all over Michigan....:

Normal newborn birth:

• Metro Health, Grand Rapids: $1,835
• McLaren Bay Region, Bay City: $2,849
• Mercy Health Saint Mary's, Grand Rapids: $3,339
• Spectrum Health Butterworth, Grand Rapids: $4,088....

Concussions:

• McLaren Bay Region, Bay City: $10,646
• Covenant HealthCare, Saginaw: $13,473
• McLaren Flint: $15,840
• Spectrum Health Butterworth, Grand Rapids: $19,923....

Pneumonia:

• Spectrum Health Butterworth, Grand Rapids: $10,299
• Metro Health, Grand Rapids: $10,411
• Mercy Health Saint Mary's, Grand Rapids: $11,780
• Michigan Medicine, Ann Arbor: $12,796....

Femur fracture:

• McLaren Bay Region, Bay City: $14,206
• Spectrum Health Butterworth, Grand Rapids: $15,545
• Metro Health, Grand Rapids: $15,737
• Bronson Methodist Hospital, Kalamazoo: $16,539....

Just a reminder here for the uninsured. Many hospitals like the University of Michigan (Michigan Medicine) have financial assistance programs. Here's a quote from this institution about their program (see: Financial Assistance): A patient may receive 100% of their services free if their income is below 2½ times the Federal Poverty Guidelines and meets other financial criteria.

23andMe Adds Weight Loss Coaching to Its DNA Testing Service

I have generally been supportive of 23andMe but their latest "wellness" oriented initiative has me wondering. Here's a report about it (see: 23andMe Will Add Weight-Loss Advice to Its DNA-Testing Services) and below is an excerpt from the article:

Consumer DNA-testing giant 23andMe...plans to add new wellness offerings it hopes will help its customers shed a few pounds, but some genetics experts say the jury is still out on the science behind the products....[The company] announced a partnership with Lark Health, an artificial-intelligence coaching service that delivers personalized advice for weight loss and diabetes prevention via an app. Lark will allow customers to incorporate weight-related genetic data from 23andMe into its service....The move will put 23andMe in a crowded -- and oft-criticized -- marketplace of companies that use DNA analysis to give personalized advice on wellness or family history....In Lark’s wellness and diabetes-prevention programs, AI coaches help people track things like meals, exercise and sleep and serve up advice to help meet health goals. Users can message their AI coach to help them decide whether a burger was a good choice for dinner....If their 23andMe genetic weight report suggested limiting red meat, the coach might recommend laying off the burgers....[Lark's] diabetes-prevention program is recognized by the Centers for Disease Control and peer-reviewed research has suggested the AI coach is at least as effective as a human one.....For those that opt-in to sharing their genetic data, Lark’s apps will incorporate data from eight different 23andMe reports, including a weight profile of people with similar genetics, whether they have a heightened sense for bitter-tasting foods, or an associated tendency to sleep deeply.

Although this is the first time I have encountered the phrase AI health coaching, the idea does hold some interest for me. For a start, I believe that there is an important connection between behavioral/lifestyle issues and many chronic diseases including obesity, diabetes, and perhaps even hypertension. I have blogged extensively about the relationship between lifestyle issues and chronic diseases (see, for example: Seeking Solutions to the Chronic Disease Epidemic; Treatment of Patients with Chronic Diseases: Important for the Future of Telemedicine; Relevance of Lifestyle Analytics for Healthcare Organizations). I believe that one of the key ways to ameliorate some chronic diseases like obesity and diabetes is behavioral support via telemedicine. Programs like Lark Health are also promising.

I also think that the proposed connection between the 23andMe DNA analysis and the Lark Health wellness programs like weight reduction is bit of a stretch. Here's the sentence from the article that caught me attention: For those that opt-in to sharing their genetic data, Lark’s apps will incorporate data from eight different 23andMe reports, including a weight profile of people with similar genetics. In time, there may definitely be a link between obesity and one's DNA analysis but I don't think that we are at that point yet.

Free Genomic Testing Offered by Nebula Genomics but for a "Price"

Given the popularity of genomic testing among healthcare consumers, it's not surprising that such programs are proliferating. Keep in mind, however, that the test results of such consumer DNA testing can be of great value to pharmaceutical companies because they can contribute to drug research. More than two years ago I reported that Strata Oncology was performing free DNA and RNA sequencing for cancer patients in order to identifying those with certain gene mutations. Patients were then referred to pharmaceutical companies where drug therapy may have been recommended or, possibly, patients were enrolled in clinical trials (see: Strata Oncology Offers Free Cancer Genomic Testing to Some Patients). 

Another lab company has come up with a variation on this same theme, performing complex genomic analysis for free but with the a priori requirement that the patients' test results will be of interest to the researchers of a drug company (see: Nebula Genomics Offers FREE Whole Genome Sequencing to Customers Willing to Allow Their Data Be Used by Researchers for Drug Development). Below is a an excerpt from the article:

Clinical laboratory leaders and anatomic pathologists will agree that offering whole genome sequencing to customers for FREE is unique in the direct-to-consumer (DTC) genetics market. Nevertheless, Nebula Genomics (Nebula), a start-up genetics company in Massachusetts, has announced exactly that....Nebula aims to connect customers with scientists to advance biomedical research....Interested customers answer questions about their health history, physical activities, medications, and more. The information helps them earn Nebula credits toward free genetic information. Researchers then can review this biographic information and elect to subsidize the cost of sequencing specific customers in exchange for access to the resulting genomic data, which they use to develop pharmaceutical drugs and treatments. Customers wishing to avoid answering questions can pay Nebula $99 for a personal genome sequencing, which delivers a basic analysis of their ancestry and inherited traits....According to NPR, the process may begin with a researcher or pharmaceutical firm contacting Nebula expressing interest in studying a group of patients with a specific disease—such as diabetes—adding that Nebula follows up the request with an encrypted search of participants.

My own bias in this case would be to opt for the consumer genomic testing offered by companies like 23andMe or Ancestry DNA for a modest price. Keep in mind, however, that the two consumer testing companies mentioned above may share anonymized data with pharmaceutical companies. That's a key part of their business models. 

Can the Number of Unnecessary Knee Replacements Be Reduced?

An article that I came across recently suggested that up to one-third of patients undergoing knee replacement continue to experience pain post-operatively and one in five of them regret having had the procedure. The conclusion is that this procedure is perhaps being performed too frequently (see: Up To A Third Of Knee Replacements Pack Pain And Regret). Below is an excerpt from the article:

Most knee replacements are considered successful, and the procedure is known for being safe and cost-effective. Rates of the surgery doubled from 1999 to 2008, with 3.5 million procedures a year expected by 2030....Doctors are increasingly concerned that the procedure is overused and that its benefits have been oversold.....Research suggests that up to one-third of those who have knees replaced continue to experience chronic pain, while 1 in 5 are dissatisfied with the results. A study published last year in the BMJ found that knee replacement had “minimal effects on quality of life,” especially for patients with less severe arthritis. One-third of patients who undergo knee replacement may not even be appropriate candidates for the procedure, because their arthritis symptoms aren’t severe enough to merit aggressive intervention, according to a 2014 study in Arthritis & Rheumatology. “We do too many knee replacements,” said Dr. James Rickert, president of the Society for Patient Centered Orthopedics, which advocates for affordable health care, in an interview....Although Americans are aging and getting heavier, those factors alone don’t explain the explosive growth in knee replacement.

A key issue regarding knee replacements is what can be done about over-utilization of this type of surgery while at the same time avoiding the stigma of too much intervention and limited freedom of choice for patients. A recent article discussed this issue (see: Reducing unnecessary hip and knee replacements could save billions a year) and below is an excerpt from it:

“With the U.S. currently spending nearly 18% of its gross domestic product on medical care, almost twice as much as other high-income countries, we need to look at every opportunity to reduce costs from services that may be overutilized. Elective joint replacements could represent an area for significant savings,” co-author Jonathan Fielding, M.D., founder and co-director of the Center for Health Advancement, said in a statement. In addition to capping payments, Fielding and his colleagues recommend creating decisions aids to inform patients about alternatives and risks to help them avoid unnecessary hip and knee procedures.

The use of "decision aids" to help inform patients who are contemplating major surgery has been recommended. Here's an example of such a tool for knee replacement developed by HealthWise: Arthritis: Should I Have Knee Replacement Surgery. I navigated through this decision tool and thought that it was informative and clear. Take a good look at it and make up your own mind. However, a patient with severe knee pain may be willing to try almost anything for relief. I will concede that it's hard to advise patients about a choice of surgery compared to, say, physical rehabilitation, because the orientation of some patients may be to fix the problem once and for all" without a deep understanding of the risks of surgery and of a possible suboptimal outcome from it.

Reducing the Cost of Care; Provide Home Care for Sicker Patients with Remote Monitoring

Although changes often come slowly in healthcare, we are now in the midst of the following three major changes in the field: (1) reduction in inpatient admissions that is driving the growth of bedless or mini-hospitals; (2) provision of first-tier outpatient care in walk-in clinics such as CVS/MinuteClinics; (3) the transfer of some inpatient care to patients' homes, partly as a cost-reduction strategy. This latter topic was previously covered in one of my blog notes (see: Some Details about Hospital-at-Home (HaH) Services for Selected ER Patients) and also in a recent article (see: Commentary: Reducing the cost of acute care by going home). Below is a quote from the latter:

An ideal way to...[reduce healthcare costs while increasing quality] is to keep patients out of the hospital whenever possible through proactive, preventive care. Yet even when this fails and patients do need acute care, we can successfully treat many of them outside the hospital. Hospital at Home is an innovative program that provides hospital-level service in the patient's own home, at a fraction of the cost of hospitalization. Health systems across the country are prepared to launch such programs, which would save Medicare hundreds of millions of dollars, once an appropriate payment model is in place. Elderly patients with illnesses such as pneumonia, asthma and urinary tract infections, can be treated at home where they face less risk of falling, sleep better, receive better nutrition, and are far less exposed to drug-resistant bacteria, all of which contribute to better outcomes and greater patient satisfaction....

The acute-care team includes doctors and nurse practitioners who provide a daily visit and are on call 24/7. Nurses visit twice a day. Social workers, physical therapists and other providers are available as needed. The program brings portable medical equipment to the home, including X-ray machines, electrocardiograms, infusion pumps, and ultrasound machines, while state-of-the art communications technology can supplement in-person visits to ensure the patient is well-monitored. If clinical concerns develop, the patient is quickly brought to the hospital. Following the acute-care episode, a 30-day period of transition services provides a smooth discharge and appropriate support. 

One of the reasons that home care as a substitute for some inpatient care makes so much sense, in addition to being less expensive, is that modern telecommunications technology can provide physiologic monitoring of the home-based patient. All of this reminds me of tele-ICU which is defined in the following way (see: Tele-ICU: Efficacy and Cost-Effectiveness Approach of Remotely Managing the Critical Care): Tele-ICU...[is based on the idea of] an off-site command center in which a critical care team (intensivists and critical care nurses) is connected with patients in distant intensive care units (ICUs) through a real-time audio, visual and electronic means and health information is exchanged.

This concept of tele-ICUs has been in vogue for a number of years for health systems with smaller hospitals and a small number of intensive care beds. These critical-care patients were monitored by intensivists located at command centers in one of the larger hospitals in the same system. I first blogged about this concept eight years ago (see: Telemedicine Transforms Intensive Care Units in Smaller Hospitals with Remote Monitoring). Another reason why the Hospital at Home concept is so appealing is that CMS will now reimburse for remote patient monitoring (see: New CMS Reimbursement Guidelines: Support for Provider-to-Provider Consults.