After joining other rural hospitals in a statewide telemedicine initiative, Atlantic General Hospital and Health System has curbed complications in its ICU and implemented around-the-clock intensivist coverage at one-third of the cost.


Atlantic General PhotoAtlantic General Hospital and Health System, Berlin, Md., and five other rural hospitals have developed a collaborative model for delivering intensive care unit (ICU) services using telemedicine technology. Called Maryland eCare, the model has helped Atlantic General reduce costs by $300,000 each year from shorter ICU length of stay (LOS) rates alone. More importantly, patients are 26 percent more likely to survive their stay in the hospital’s ICU.

Creating the Infrastructure

In 2006, Atlantic General was struggling to maintain appropriate physician coverage in its ICU in the evenings and on weekends. That spurred the hospital to join Maryland eCare, a group of independent hospitals united by the same drive to improve quality and achieve cost savings in their ICUs. The project was funded by a $3 million grant from CareFirst Blue Cross Blue Shield of Maryland.

To roll out the collaborative model, the participating hospitals followed a series of steps.

Establish the legal structure. The six rural hospitals formed eCare as a limited liability company (LLC) so they could participate in joint contracting with the hospital operating the main telemedicine hub. Currently, the University of Maryland Medical System (UMMS), Baltimore, manages the hub and provides remote monitoring of ICU patients in the eCare hospitals.

Create an operational agreement. “The operating agreement sets the ground rules for the hospitals in the LLC,” says Michael Franklin, FACHE, president and CEO, Atlantic General. Specifically, this document spells out the leadership structure for the collaborative. Each member hospital has a seat on eCare’s board of directors and has voting rights that reflect the hospital’s number of monitored ICU beds, which range from four to 24.

The number of monitored beds also dictates how much each hospital contributes to the LLC for operating capital. Capitalization and operational costs not covered by the grant are the responsibility of each member hospital.

Additionally, the operating agreement creates the group purchasing model that allows member hospitals to receive a discount per monitored bed.

Develop a service agreement. The service agreement details the roles and responsibilities of UMMS as the hub operator and the six eCare hospitals as members. It also includes expectations for the vendor providing the telemedicine technology.

Franklin says the service agreement binds the member hospitals to create an environment that fosters collaboration and continuity through eCare. “Together, the eCare hospitals must maintain a minimum of 72 monitored beds to support University of Maryland’s capital costs so the service does not become a cost drag for that organization,” he says. “If a member pulls out of the LLC and we drop below 72 monitored beds, the beds we lose need to be covered by the other members. So it creates the incentive to keep us all working together and create a program that meets everyone’s needs.”

The service agreement also spells out the technical requirements that member hospitals must meet to ensure that the telemedicine monitoring equipment functions properly. The agreement also states that UMMS physicians working at the hub must be credentialed at each of the remote hospitals because they are prescribing patient care.

Educate staff, patients, and families. One of the early challenges that Atlantic General faced was allaying fears among the medical and nursing staffs that telemedicine would lead to reduced staffing and compromise patient care in the ICU.

“Fear is what prevents many people from using innovative technologies, but we believed that if staff could overcome their fears, they would see that this was the right thing to do for the patients,” says Colleen Wareing, MS, BSN, RN, NEA-BC, FACHE, vice president of patient care and CNO at Atlantic General. Early on, hospital leaders sought buy-in for telemedicine from the board of trustees and medical staff leadership, which helped ease some staff concerns. They also gave physicians the choice to opt their ICU patients out of remote monitoring early on.

Eventually, the fear lessened. “Staff members needed time to learn for themselves that telemedicine was truly an adjunct to the care they provided,” Wareing says. “We let them know that our objective was not to catch someone doing something wrong, but to add another layer of patient safety.”

Patients and families also needed reassurance and education, so the eCare hospitals created an educational brochure describing how ICU telemedicine can improve patient outcomes and reduce LOS. As more families experienced telemedicine, its acceptance grew throughout the community, Wareing says.

Analyze data and identify areas for performance improvement. As a member of the LLC, Atlantic General receives a quarterly report of its ICU quality indicators. Early data revealed that the hospital had an opportunity to reduce actual versus predicted deaths from sepsis. Predicted deaths are based on patients’ Acute Physiology and Chronic Health Evaluation II (APACHE) scores, which drive patient acuity measures.

To improve sepsis outcomes, Atlantic General adopted a sepsis management protocol from UMMS and rolled it out to its own medical staff. In just one quarter, the number of sepsis deaths dropped to less than predicted while the number of sepsis patients remained steady. The hospital also reduced the LOS for sepsis patients in the ICU.

Exhibit 1 Atlantic General Feature

In another data-driven performance improvement initiative, Atlantic General implemented a weaning protocol for patients on ventilators to reduce ICU ventilator days, another key quality metric. In just one quarter, they cut “vent days” from 35 percent greater than predicted to nearly the expected number.

Exhibit 2 Atlantic General Feature

Delivering Real Results

Since joining the LLC, staff members at Atlantic General have improved their adherence to ICU best practices. As a result, the hospital has seen a significant reduction in complications and improved ICU outcomes.

Today, ICU patients are 26 percent more likely to survive the ICU. They also get discharged from the ICU 20 percent more quickly. Other outcomes include:

  • No ventilator-acquired pneumonia cases since 2008, resulting in an estimated cost savings of $40,000 per prevented case
  • Reduced medication costs for ventilator patients (estimated at $150,000 annually for four ICU beds)
  • No central line-associated blood stream infections (CLABSI) for more than a year, resulting in an estimated cost savings of $45,800 per prevented infection
  • Sixteen percent reduction in ICU LOS, which equates to 403 days (the cost of an ICU day at Atlantic General is approximately $955)

This reduction in ICU LOS translates to more than $350,000 in annual savings for the hospital, which is paid a fixed amount per admission according to Maryland’s all-payer rate setting system.

Atlantic General also has avoided an estimated $700,000 yearly cost to hire two additional intensivists to cover the ICU around the clock. Currently, the total cost of staffing 2.0 FTEs to cover the day shift seven days per week is $700,000, while telemedicine coverage on nights and weekends costs $228,000 annually. That translates to nearly $500,000 in savings each year.

“We’re basically getting full intensivist coverage at one-third of the cost,” Franklin says.

In the near future, Atlantic General and other eCare hospitals may use the existing telemedicine platform to treat stroke patients in their emergency departments, pending the finalization of state regulations.

Giving Credit to the Collaboration

With years of experience using telemedicine, leaders at Atlantic General believe their organization has learned how to gain the most from this type of collaboration. In particular, Franklin and Wareing credit eCare for providing a forum where they can share best practices that improve outcomes and reduce costs.

“Collaborating with other hospitals speeds up the learning time in our own location because we have more eyes on the same process or problem,” Franklin says. “This accelerates the performance improvement process, particularly our efforts focused on improving patient care.”


Laura Ramos Hegwer is a freelance writer and editor based in Lake Bluff, Ill.

Interviewed for this article: Michael Franklin, FACHE, president and CEO, Atlantic General Hospital and Health System, Berlin, Md.

Colleen Wareing, MS, BSN, RN, NEA-BC, FACHE, vice president of patient care and CNO, Atlantic General Hospital and Health System, Berlin, Md.

This article is based in part on a presentation at the Congress of the American College of Healthcare Executives in Chicago in March 2014.

Publication Date: Wednesday, July 30, 2014