Mission Critical

Season 1: Episode 81
October 29, 2020

Photo by the U.S. Army Telemedicine & Advanced Technology Research Center

With COVID-19 again bearing down on U.S. hospitals, a team of military doctors and disaster preparedness experts are racing to build a system to deploy critical care providers anywhere in an instant. 

Listen to the full episode below, read the transcript or scroll down for more information.

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U.S. Army Disclaimer: The views, opinions and/or findings contained in this podcast presentation are those of the author(s) and do not necessarily reflect the views of the Department of Defense and should not be construed as an official DoD/Army position, policy or decision unless so designated by other documentation.  No official endorsement should be made. Reference herein to any specific commercial products, process, or service by trade name, trademark, manufacturer, or otherwise, does not necessarily constitute or imply its endorsement, recommendation, or favoring by the U.S. Government.

The Basics: Critical Care Capacity in the U.S.

More than half of U.S. counties do not have any intensive care unit (ICU) beds to care for critically ill patients. Among ICUs that do exist, only about one-quarter are fully staffed with doctors trained in critical care, also known as intensivists, despite evidence showing intensivists improve mortality rates for critically ill patients. One reason for this mismatch is that many smaller hospitals do not have enough critically ill patients to warrant hiring specialists, and rely instead on transferring those patients with life-threatening illnesses and injuries to larger hospitals.

While that system has its downsides, such as sending patients farther from home or sucking revenue away from already struggling hospitals, it largely suffices during typical times. But in a disaster or pandemic scenario, where patients need critical care in huge and sudden volumes, this poor geographic distribution of specialized expertise can become acutely problematic. This is true not only of critical care doctors, but also of the thousands of nurses, pharmacists, physician assistants and respiratory therapists also trained in critical care.   

The Problem: Scaling Telecritical Care

For decades, larger health systems have been pioneering the use of telehealth to extend the capacity of their critical care providers to serve surrounding hospitals, especially in rural areas. Evidence shows these so-called telecritical care services can be effective. However, they are also hard to scale, taking months to launch and costing millions of dollars each year to staff and equip with high-tech monitors and sensors. Telecritical care also faces policy barriers, such as properly insuring and licensing providers practicing in multiple states, that make it difficult to scale beyond the local level. 

$ 0 K
per bed per year to provide typical telecritical care¹
0 %
of U.S. ICU beds are covered with telemedicine²

¹The Costs of Critical Care Telemedicine Programs, (Gaurav Kumar, Derik Falk, Robert Bonello, et al; Chest; Jan. 2013) ²Critical Care Telemedicine: Evolution and State of the Art (Craig Lilly, Marc Zubrow, Kenneth Kempner, et al; Critical Care Medicine; Nov. 2014)

Since the Ebola outbreak, and even the attacks of 9/11, some critical care and disaster preparedness experts have wondered whether the U.S. should have a national telecritical care system capable of deploying experts remotely at a moment’s notice to anywhere in the country. With the help of audio and video capabilities, those experts could virtually help providers with less training (or even lay people) administer care to critically ill patients.

The idea has powerful potential, but also poses several daunting policy and technological challenges. How could volunteer providers from all across the country securely triage, treat and monitor thousands of critically ill patients in hundreds of different locations in real time? Due to those challenges and other pressing priorities, the idea struggled for years to gain traction.

A Potential Solution: NETCCN

Jeremy Pamplin and Ben ScottOnce COVID-19 hit, proponents of a national telecritical care network saw their window of opportunity to actually build and test the idea. With support from the Society of Critical Care Medicine, two people in particular took the lead: Col. Jeremy Pamplin, MD, who helped scale the use of telecritical care in the Army, and Ben Scott, MD, a critical care physician and University of Colorado professor. 

Their plan: rapidly deploy a network of remote experts, which they named NETCCN (National Emergency Tele-Critical Care Network), using a simple mobile application that could work on any smartphone. The app would allow experts to perform a variety of tasks — like triaging patients and documenting care — via talk, text or video chat. And, it would operate independent of health care’s existing infrastructure, like electronic health records, which can be expensive and hard to use. The idea represents a sharp pivot away from the traditional, resource-intensive and geographically confined approach to telecritical care.

In April 2020, Col. Pamplin received an $8 million grant from the Department of Defense to run a competition in which teams from the private sector, academia and the military would race to build the best possible version of an app to power NETCCN.

As of October 2020, just four teams remain out of the 79 that originally applied. Two are already deploying their apps to actively support health care workers in COVID-19 hotspots. The competition formally ends in November, but Pamplin says all four teams may continue to serve NETCCN in one way or another, depending on the country’s needs.

On October 22, 2020, the Department of Health and Human Services committed $45 million to scale NETCCN’s capabilities over the next four years. 

The Tradeoffs

Trust

Pamplin and Scott intentionally chose to build NETCCN outside of existing health care infrastructure, giving it more flexibility and simplicity. But that decision also introduces unique challenges. Pre-COVID studies show that expecting health care workers to learn a new technology and trust the advice of an unknown expert is very hard, and only becomes harder during crises. It is too soon to know what the adoption rate will be for the NETCCN app, but it is a key determinant of the network’s potential for impact. 

Scale

One of the difficult decisions NETCCN’s founders faced is deciding how robust the underlying technology should be. Some argue that the primary value of telemedicine is in connecting humans and that adding other features to the tool only dilutes that connection and decreases the likelihood of adoption. Others believe additional capabilities, such as using AI to help triage patients or integrating data from other medical devices, are critical to helping NETCCN reach its full potential as a national disaster response tool.

Complexity

By taking a national approach, rather than a local or regional one, NETCCN gains the benefit of having as much capacity and flexibility as possible in terms of how it deploys available critical care experts. However, many health workforce regulations revolve around local and state lines, posing extra policy challenges for NETCCN. Some states have reduced those barriers during COVID by enacting emergency exemptions, such as those allowing providers to practice across state lines, but those exemptions may not exist during the future disasters that NETCCN is also being built for.

About the Competition

The Final Four Teams

Avera Health with VitelNet and DocBox

Deloitte with AWS GovCloud, Decisio Health, Elsevier, Qventus, T6 Health System, Verizon and Zyter

Mercy Virtual with Expression Networks, Active Innovations and SDSE Networks

Madigan Army Medical Center with the Geneva Foundation, Omnicure, Society of Critical Care Medicine, DocBox and MD PnP

Listen to the Madigan team’s app demo:

Early NETCCN concept diagram:

NETCCN diagram
(Benjamin Scott, Geoffrey Miller, Stephanie Fonda, et al; Telemedicine and e-Health; Oct. 2020)

This episode was produced as part of a series on health workforce issues funded by the California Health Care Foundation.

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Episode Resources

Select Reporting and Critical Care and Telecritical Care:

Full hospitals, talk of rationing care: New wave of coronavirus cases strains resources (Hannah Knowles and Jacqueline Dupree; Washington Post; 10/25/2020)

Telecritical Care Clinical and Operational Strategies in Response to COVID-19 (Jaspal Singh, Michael Green, Scott Lindblom, et al; Telemedicine and e-Health; 8/17/2020)

Tele-Critical Care: An Update From the Society of Critical Care Medicine Tele-ICU Committee (Sanjay Subramanian, Jeremy Pamplin, Marilyn Hravnak, et al; Critical Care Medicine; 4/2020)

Millions Of Older Americans Live In Counties With No ICU Beds As Pandemic Intensifies (Fred Schulte, Elizabeth Lucas, Jordan Rau, Liz Szabo and Jay Hancock; Kaiser Health News; 3/20/2020)

Military Telehealth: A Model For Delivering Expertise To The Point Of Need In Austere And Operational Environments (Jeremy Pamplin, Konrad Davis, Jennifer Mbuthia, et al; Health Affairs; 8/5/2019)

ICU telemedicine and critical care mortality: a national effectiveness study (Jeremy Kahn, Tri Le, Amber Barnato, et al; Medical Care; 3/2016)

Adoption of ICU telemedicine in the United States (Jeremy Kahn, Brandon Cicero, David Wallace, Theodore Iwashyna; Critical Care Medicine; 2/2014)

The effect of telemedicine in critically ill patients: systematic review and meta-analysis (M Elizabeth Wilcox and Neill Adhikari, Critical Care, 7/18/2012)

Episode Credits

Guests:

Col. Jeremy Pamplin, MD, Director, U.S. Army Telemedicine & Advanced Technology Research Center

Ben Scott, MD, Associate Professor of Anesthesiology, University of Colorado

Doug Powell, MD, Assistant Professor of Critical Care Medicine, West Virginia University; and consultant to the Office of the U.S. Army Special Operations Command Surgeon

Lt. Col. Chris Colombo, MD, Director of Virtual Health and Telecritical Care, Madigan Army Medical Center

Jeremy Kahn, MD, Professor of Critical Care Medicine, University of Pittsburgh

Kristina Ieronimakis, RN, ICU Nurse, Madigan Army Medical Center

Lisa Lindgren, Vice President of Clinical Operations, Avera

The Tradeoffs theme song was composed by Ty Citerman, with additional music this episode from Martin Cee, Tanya Tucker, Parallel Park, Lawrence English, Alan Piljak, Moby and Blue Dot Sessions.

Additional thanks to:

Lew Kaplan, Donna Lee Armaignac, Lori DeBernardis, Jeanette Little, Donna Lightner, Andrew Hersh, Ian Barbash, Sean Keenan, Teresa Rincon, Ellen Conti, Shaun Rangappa, Srini Attili, Jessica Gaikowski, the Tradeoffs Advisory Board…

…and our stellar staff!