Newsletter # 1
We are excited to share with you the first newsletter of the ICU4Covid project. It presents the vision, the challenges, and the activities during the first year of the project.
ICU4Covid - vision, challenges, and current status
Prof. Ricardo Jardim-Gonçalves
The European health services have well responded to the Covid-19 emerging crisis, especially if and where the intensive care unit (ICU) capacities were sufficient, were prepared and collectively cooperating, sharing knowledge and were able to protect from further spreading of the disease among the healthcare workforce and the patients. Today, only 47% of hospitals have the recommended coverage of intensive care specialists and they are unevenly distributed between centres and periphery. The ICU4Covid’s Cyber-Physical System for Telemedicine and Intensive Care (CPS4TIC) enables existing or new ICU structures to transform and operate as one ICU Hub with one central ICU and connected ICUs in peripheral hospitals, to ensure efficient and effective diagnosis and treatment of Covid-19 patients, while reducing the risk of infection drastically.
Hence the European health services have well responded to the Covid-19 emerging crisis, especially if and where the intensive care unit (ICU) capacities were sufficient, were prepared and collectively cooperating, sharing knowledge and were able to protect from further spreading of the disease among the healthcare workforce and the patients. ICU4Covid challenges to deliver the capacity of ICU that EU citizens deserve and reduce the risk of infection of the medical workforce involved. It creates a powerful infrastructure to diagnose and treat patients of COVID-19 outbreaks best, especially at times, when vaccination and pharmaceutical products are under development and the pandemic with induced political measures have deep impact on the society and economy.
Large scale pilots and deployment is performed in real ICU settings (ICU4Covid Hubs) located in 9 different European Regions (Austria, Germany, Greece, Portugal, Madeira Islands, Azores Islands, Latvia, Romania, Italy) involving more than 30 000 patients/year at large university hospitals as well as connected peripheral hospitals with a coverage range of approximately 85 Million citizens. Today, the installation of the ICU4Covid Hubs is ongoing with installation in verification in the ICUs of the hospitals at Germany and Madeira Islands. The installation of all other Hubs are progressing until the end of 2022.
Telemedicine in ICU
Univ.Prof. Dr. med. Gernot Marx*, PD Dr. med. Lukas Martin*
(Janine Meyer-Christodoulou, Anna Christina Boersma)
*Uniklinik Aachen, **Clinomic
Intensive Care Units (ICUs) are facing the challenge of an aging society on the one hand and a shortage of specialized staff on the other hand.
In order to meet this challenge, while maintaining high-quality intensive care close to home, innovative structures come in handy.
One considerable innovation is the use of telemedicine in the ICUs. Telemedicine, as a broad term, can be used to describe overcoming spatial and temporal distances with the help of technologies. Its field of application reaches from consultation hours between doctors and patients to professional consultations amongst physicians only. The latter is applicable in the context of telemedicine in ICUs. This offers the opportunity to digitally connect peripheral hospitals, that might not have all necessary medical expertise in-house, to an expert center in a more central location, assuring 24/7 availability of medical expertise.
Two major scenarios in using telemedicine on ICUs exist: periodic rounding and ad-hoc / emergency consultations. During the digital rounds, patients are presented to the remote physicians and further treatment is discussed on a regular basis, in critical situations the remote experts can offer guidance to the staff on site. Patients benefit in staying close to home while receiving high quality medical care and a reduction in complications. Potential abnormalities can be detected early on and treated accordingly. For medical staff, the second opinion by a remote colleague means stress reduction and quick access to an additional “security layer” if there is no knowledgeable colleague available. In crisis situations, like the COVID-19 pandemic, the knowledge transfer via telemedicine offers efficient use of resources as it increases the bed-capacities.
With ICU4Covid, we are building up a pan-european tele-intensive care network, helping to face today's challenges in the medical field, and ensuring high quality intensive care medicine.
ICU4Covid in the Second Year: Lessons Learned from a Social Science Perspective
Prof. Dr. Ulrike Felt
(Timo Bühler, Carsten Horn, Michaela Scheriau, Neringa Simkute)
University of Vienna
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.
The situation of a telemedical consultation
How Mona was installed in the ICU
Responsible Innovation in Health: Bridging the Gaps - Connecting Technological, Medical, and Social Language
Dr. Tal Soffer
(Anat Soroka Zuta, Idan Edut)
Tel Aviv University
The Covid-19 pandemic has led to the accelerated entry of technologies into everyday life. The social isolation imposed on citizens alongside the need to provide an immediate medical response to masses of citizens has led to the need of using innovative technologies in the field of health and especially in intensive care units. As such, the implementation and use of new technologies provide many opportunities and benefits, which are reflected in improving the quality of health services, providing effective, faster, and customized medical care, disease prevention and more. Alongside these benefits exist inherent challenges in issues related to values, privacy and ethics, equality, social inclusion and more. Many of these challenges are related to the differences in perspectives and motivation of different stakeholders (e.g., the general public, experts, policy makers), which stem from gaps in knowledge and common language in the same field. For that end, the ICU4Covid project has adopted the approach of Responsible Innovation in Health (RIH), which is based on the Responsible Research and Innovation (RRI) approach. The concept of RRI describes the relationship between science and society, stating "science with and for society".
#1 The challenges
According to the definition, “Responsible Research and Innovation” is a transparent, interactive process by which societal actors and innovators become mutually responsive to each other with a view to the (ethical) acceptability, sustainability and societal desirability of the innovation process and its marketable products.” (Schomberg, 2013).
Further elaboration of these ideas by the appointed European Commission (EC) expert group described six major dimensions of RRI that signify the importance of keeping to the norms of responsible research and innovation that considers different societal needs. Among them are public engagement, gender equality, science education, open access, ethics, governance. Two additional dimensions, sustainability and social justice, overlap with the previously named ones (European Commission 2015). All these dimensions require the involvement of SSH experts in the process of ICT development. The EC endorsed the SSH-RRI approach, which is defined as a continuous engagement of societal actors during the entire research and innovation process to better align both the research process and the results with the values, needs, and expectations of the “European Society” (Soffer et al, 2019).
As health has unique challenges to mitigate conflicts in clinical and policy issues, RRI implementation in health (RIH) has some unique characteristics. Among them are the tension between the need to save life and the patient's freedom of choice to get treatment, as well as the question concerning priorities, like avoiding diseases rather than treating them. As the use of technologies increases, so does the discourse on these issues among the public and decision-makers. In light of these challenges, it is essential to consider the equity and sustainability of health systems around the world, applied to the framework for RIH, to better align health and innovation policies and connect between different stakeholders in that field.
#2 Increasing engagement and mutual communication - Bridging the knowledge gap
Implementing the core ideas of RRI, the RIH offers a process that requires/demands all actors included in or affected by research and innovation activities to anticipate, monitor, and assess the social, economic, and environmental impact, taking into consideration purposes, motivations, assumptions, values, beliefs, uncertainties, risks, and dilemmas (Pacifico Silva et al., 2018). When discussing RIH, there is a need to consider the scope and specificity of addressing the challenges and needs of the healthcare systems in a sustainable manner. This require mutual collaborative of stakeholders who are committed to meet the ethical, economic, social, and environmental principles as well as values and specifically, it becomes even more essential when they design, fund, manufacture, distribute, use, and deploy socio-technical solutions.
ICU4Covid project adopts the RIH approach by making public involvement, ethics and governance an integral part of its activities. The public engagement is one of the methods to cover all the challenges and needs of users and end users. Moreover, research and innovation process in the medical field and specifically in ICU, may raise more challenges related to privacy and ethics (Timmers et al., 2019), mostly due to the patients’ condition which in most cases makes it impossible to ask them for informed consent prior to their hospitalisation.
Furthermore, the co-creation approach is one of the foundations of the project, reflecting the importance of the local context in which health technologies should be applied. Therefore, the involvement of the various stakeholders (hospitals, medical staff, decision makers) from the very beginning of the project is vital to address the project's objectives. Hence, a variety of activities have been adopted to boost communication and engagement between the various stakeholders:
(a) Increasing engagement –continuous meetings, interviews and dialogues, conducted by the project team with the medical staff at the hospitals, in order to explore the work environments of each hospital with an emphasis on ICU, the infrastructure, the arrangements of health services and the resources available to implement the CPS4TIC system. In addition, there’s a need to identify the challenges and barriers in the process of implementing the system in hospitals, all while maintaining the principles of privacy and ethics as required by the GDPR.
(b) Mutual communication – our ability to communicate and deliver our message with consistency, while still having the ability to speak with different target groups, is another aspect of public engagement and policy. To that end, dedicated workshops have been conducted, to create uniform and clear communication between all stakeholders. The main goal is to bring together medical professionals and technologists, to bridge the knowledge gaps in technology to medical staff on one hand and present the user experience and medical needs to R&D staff on the other one. The workshop’s participants expressed very high satisfaction. In addition, to reach diverse audiences, we produced special documents and videos that were distributed through the media channels and the website to spread the project's activities and create mutual communication.
(c) Joint cooperation - another good example of our collaborative effort is our installation teams that work together: once in two weeks there is a joint meeting, aiming to share the latest updates. In addition, all parties work with one cloud system, so everyone can deliver their needs and outputs. In this way we ensure the i nvolvement of as many partners as possible in the implementation processes and that everyone works with the most relevant and up-to-date information.
#3 Bridging "language" gaps - Connecting different professional communities
As ICU4COVID aims to be a bridge through which technological, medical, and social language connect, it all has a great influence on each other and the ability to successfully weave them together depends on patience, understanding, and willingness to learn, and to know more about what connects us than about what separates us.
Professionals from various fields perceive the meaning of terms and ideas in the context in which the discourse takes place - they all know the linguistic shortcuts and the special codes used in every language. Therefore, when people from the same field use the same language, either verbally or in writing, the margin of error in understanding is smaller. However, discourses that combine different areas of practice, can lead to problems of inaccuracy, ambiguity, and confusion, which can be very problematic when trying to save lives.
One of the most significant lessons we have learned in this project is how to succeed in bridging the gaps in language - between the technological, medical, and social language. The difference between them is not only in their character, but also in the way they explain reality.
The technological language - is designed to enable us to operate technological systems. It is a sharp and unambiguous language that requires a great deal of knowledge and that most people are unfamiliar with. It has clear and precise lines and connections that even those who know how to operate technology at the basic level may not understand.
The medical language is also a very professional one. It allows quick access to complex information and connects many important factors together. This is a language that only professionals are proficient in, and misunderstandings can be costly.
The social language is a very flexible one, it varies easily from place to place, full of metaphors and influences from different cultures. It includes verbal gestures as opposed to physical and non-verbal ones. It is more emotional and loaded with a lot of political weight - things that are acceptable and unacceptable to say.
As part of the project, one of our solutions for bridging language gaps was a development of a joint communication strategy framework that set up the main project's outputs in terms of technological and clinical dimensions in addition to timing and budget aspects. Specifically, it clarifies how the overall system would work at the hospitals and highlights its added value to the stakeholders (the hospitals). A short illustration video, helped to bridge perception gaps. It presents the project in various events and appears on the project website. This process, of creating joint language, required us first to look at the similarities that bind all together. One of the most interesting things to discover is that they all rely on traditions, norms, beliefs, and values that make them what they are.
Being able to operate and move forward safely in a project that connects these three aspects requires great care and emphasis on explanations and collaborations. We have learned that sometimes we need "translators", professionals who know how to speak the three different languages. For example, social sciences researchers who have an affinity for medical technology. We know today that mutual understanding is the key. We are constantly thinking of new connections and new ways of listening to nuances that can allow us to better understand each other. We are constantly looking for our linguistic blind spots and seeking solutions to problems that may arise in the communication that takes place between us