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Dan Gorenstein: A special forces soldier spikes a fever in a remote African village.
Justin: I did an exam on him and started digging through some books. And I realized that this could potentially be dengue.
DG: Justin, the unit’s medic, lacks the expertise and the supplies he needs.
Justin: Oh, shit went through my head immediately. I went to my leadership. I was like, hey, this guy’s got to go.
DG: Rainstorms cut off all evacuation routes.
Over the next 48 hours, the soldier shakes violently with dengue, a disease nicknamed ‘breakbone fever’ for the excruciating pain it causes.
Justin: I got to thinking I’m a little bit of a medical history guy. And I was like, well, can I go down the road of treating the Civil War style and just give him whiskey.
DG: That’s what he does.
But Justin worries the patient – his buddy – could die. The soldier gets lucky…after a few more days, his fever breaks.
And Justin…he finally stops holding his breath.
Justin: I did not have a sense of accomplishment. I think the only thing that happened was like, thank God that that did not get worse.
DG: From New York this Spring…to the Upper Midwest in October, many of the nurses and doctors treating COVID patients have gotten a taste of what Justin faced.
Scared, uncertain, flying by the seat of their pants.
Today, how a small team of military doctors and disaster preparedness experts are taking what they’ve learned at war and bringing it to the frontlines of America’s fight against COVID.
From the Annenberg Studio at the University of Pennsylvania, I’m Dan Gorenstein, and this is Tradeoffs.
DG: On the first weekend of March, Colonel Jeremy Pamplin’s phone rang.
Jeremy Pamplin: General Talley called me that afternoon and said, hey, what can you do for telemedicine that can be used for covid tomorrow, not next week, like tomorrow
DG: General Talley wasn’t asking about the kind of telemedicine that’s become routine these past few months – for earaches, prescription refills, funny looking moles.
The General wanted to know what telemedicine could do for America’s sickest patients, people whose lives were threatened by this mysterious new virus.
News clip: The virus seeming to attack not just the lungs, but the gut, the heart, even the brain
DG: Hospitals in New York, Washington State and Boston were staring down a tsunami.
News clip: That curve is going to turn into a wave and that wave is going to crash on the hospital system
DG: Providers in L.A, Houston and Miami wanted to help…but there wasn’t much they could do. And cases were starting to mount.
News clip: The death toll could soar to 200,000 with millions of Americans infected…if the nation does everything right.
DG: General Talley wanted Jeremy to somehow find a way to help all these overrun nurses and doctors. The General knew who he was calling.
Colonel Jeremy Pamplin, a physician in the Army for almost 20 years, had a reputation.
Montage: pain in the ass / intimidating to some people / uncompromising / too Pamplin / again, a pain in the ass
DG: what some call…persistence. And he had been working on this very puzzle for years.
The story starts…in a place that feels a million miles away from the ICUs of Brooklyn and the Bronx, in sunny Fort Lauderdale.
Ad: Located on the southeast coast of Florida between Miami and Palm Beach…nicknamed the Venice of America…
DG: Jeremy had flown in for a military health conference. It was 2015.
And amid all those Florida waterways, a talk by special forces physician Doug Powell had Jeremy thinking about the jungles of Africa.
Pamplin: Doug happens to be one of my disciples. He was one of my residents. And Doug is just this amazing, really weird dude.
Powell: That’s 100 percent correct. I had a big mid-life crisis and I left Burton Snowboards after 10 years to go to med school at the age of 40 and join the military.
DG: The retired snowboard designer was describing this new problem Special Forces medics were facing. Historically, medics had evacuated soldiers within an hour…known in military medicine as the Golden Hour…but now as units deployed to more remote locations…help could be days away.
Powell: And facing the likelihood that they may have to take care of some of these critically ill or critically injured patients for 24, 30 hours…stabilizing a casualty over hundreds of miles.
DG: Jeremy heard a bunch of stories down in Florida – a lot like that one from Justin who treated a soldier’s dengue fever with whiskey. The idea of medics feeling helpless and scared lit a fire in Jeremy.
Pamplin: These teams that we send to these godforsaken places. They are doing the work that our nation has asked them to go do. And now they’re in trouble, right, and they need help. How do we best help them?
DG: Jeremy knew U.S. hospitals had figured out one solution to this type of problem. Some doctors called it telecritical care…
Ad: All the bedside nurse or physician has to do is press his e-alert button…
DG: A way to virtually connect providers in remote areas to experts often in big cities. There was a huge gap for it to fill: just 25% of America’s ICUs have the critical care specialists they need to treat life-threatening traumas, infections and organ failures.
Jeremy and Doug wondered how to make that work worlds away from the country’s fanciest hospitals…where Special Forces medics had little time, spotty service and almost no supplies.
Pamplin: It’s not about perfect. It’s about good enough.
DG: Talking it over, the two hit on an idea: a phone line…that special forces medics could call anytime, from anywhere…about anything from gunshots to gangrene.
They’d staff it themselves with help from a few other critical care friends.
Pamplin: It went to my cell phone. It went to some expert in the field. And that’s not normal in medicine, normally you try to protect yourself from these types of phone calls. And we weren’t into protecting ourselves from the phone calls. We were like, “Hey, just call us any time, day, night, doesn’t matter, we’ll wake up,” because that’s what these guys wanted and that’s what these guys needed.
DG: Just two months later, the pair flipped the switch. The new phone line was modest and simple…Jeremy and Doug were basically taking the Ferrari of telemedicine, stripping it down to its most essential parts, duct taping them together and testing how well it could run.
Pamplin: Telecritical care at that point in time…is a high definition camera sitting up on a wall with a screen under, the ability to see vital signs from a distance and the ability to see an electronic medical record and to do all that with a team of remote experts. And each room costs somewhere between $30-50,000 dollars to start to turn on. And we’re now delivering critical care expertise with this.
DG: Say what this is, because it’s radio
Pamplin: A, a phone, or whatever the heck it is that that guy or gal on the other end of the line has available to them.
DG: Turned out that Frankensteined Ferrari…it could run a pretty damn good race.
Eventually the DoD formalized the line, added surgeons, toxicologists, burn experts and other specialists, and opened it up to anyone on the battlefield.
To date, the line, now named ADVISOR, has handled more than 200 calls from the field and the DoD estimates it’s saved more than $1 million in averted evacuations.
Even with the success of the line, Jeremy wanted to avoid the cardinal sin of military strategy: preparing to fight the last war instead of the next one.
So around 2018 he began to wonder how the hotline could work on a much larger scale…if the US ever went to war with a global power.
Pamplin: I mean, war is horrible. People die. And when you’re talking about the scale that we saw in World War Two
News clip: This is Charles Collingwood on the beach today, on D-Day…
Pamplin: Tens of thousands of people dying a day.
News clip: This place even smells like an invasion, which we all associate with modern war.
Pamplin: And if we ever went to war with Russia or China or any other peer competitor right now, that’s the kind of that’s the kind of scale we’re talking about.
DG: But the Can-do Colonel realized his idea, making the military hotline work even when several battalions need it at the same time, would require a big budget and a lot of logistics.
Pamplin: How do we study that? I mean, how can we actually develop systems that allow you to manage ten thousand casualties at a time? There’s no model for that.
DG: At least not in the military…so Jeremy turned to work being done in the civilian world, where critical care colleagues had been doing their share of doomsday planning.
And that took him to San Antonio for the 2018 annual conference of the Society of Critical Care Medicine, where Jeremy met Ben Scott.
Ben Scott: Associate professor of anesthesiology at the University of Colorado
DG: The two got to exchanging what passes for small talk in a room full of critical care providers.
Scott: mass casualties…natural disasters…poisonings, burns, explosions…fire, flood, famine, war.
DG: Another conference, another kindred spirit. In between boxed lunches and breakout sessions, the two hammered out how to take an idea kicking around in military and disaster preparedness circles for a few years…and actually bring it to life.
Basically spiff up the original Special Forces hotline, stick it in a mobile app that any of the country’s more than 200,000 critical care providers could use anytime, anywhere, and suddenly you could deploy experts in an instant…in a hurricane, a mass shooting or a battlefield.
Jeremy and Ben agreed they’d need to take a sharp left turn away from the expensive and siloed systems set up inside hospitals and clinics across America.
Scott: We share the idea that actually to do it the best way is to basically make something that’s new, that’s independent, that’s free-standing, that’s very light…that anybody can download on their on their personal device…something that is truly kind of revolutionary.
DG: What they were proposing was in some ways a total repudiation of the U.S. health care system, a system infamous for spending billions on software, sensors, policies, and protocols. Predictably, Jeremy met tons of skeptics.
Pamplin: They literally just said what you’re asking for can’t be done. And the ask is take the health care system out of the solution. I mean, so many of our health care systems are designed around the health care system and not around the patient or the care delivery. And a lot of people had a hard time making that break
DG: But the pair tuned the naysayers out. Ben in particular thought if technology could mobilize volunteer experts effectively…the results could be remarkable. He had caught a glimpse of that potential nearly two decades earlier.
News clip: In this plaza once a crossroads of the world…
Scott: I was a medical student in New York for 9/11
News clip: Hundreds of firemen, doctors, paramedics pulled at the mountain of debris…
Scott: And our class got involved with some of the relief efforts.
News clip: …iron workers, carpenters, nurses, all volunteers
Scott: There wasn’t a lot of medical care that needed to be provided, but the one outlet we had at the time was that we were processing human remains, samples that were at the at the site.
News clip: We were very concerned that most of the victims were going to be unidentifiable but we chipped away at it
Scott: And I got introduced to some people from something called the DMORT, which is the Disaster Mortuary Operations Response Team, and that is a branch of the National Disaster Medical System. That’s mostly coroners and funeral home directors, morticians who basically take on this role of responding to disasters…I then went on to..
DG: Sorry, I got to interrupt you. You’re telling me there’s some like Navy SEALs of morticians?
Scott: I think they would probably say that’s maybe over glamorous, but there is a standing group of coroners and morticians who, you know, basically volunteer themselves to serve as a disaster response teams to go in and deal with human remains when there are mass casualties
DG: Ben spent nights side by side with fellow students and the DMORTs.
Scott: And other nights I was working up in a lab where we would process very small samples of what might be tissue or other clothing or something that might have DNA on it, but it was obviously a very powerful experience.
DG: During those dark nights, Ben came to appreciate just how many different kinds of first responders are needed in a disaster. And how the worst disasters could bring out people’s best.
Scott: This was people who were from the south and the West and the Midwest to put down everything to come help. And so that was very, you know, ironically, I guess, life affirming to them to see that effort.
DG: The spirit of camaraderie inspired Ben and gave him an idea for how to design a national network of critical care providers – like the DMORTS – but virtual, so they could help a lot more people in a lot more places at once.
With telemedicine, one critical care doc in St. Louis could manage dozens of patients in Sioux City, Cheyenne and Superior all at the same time.
DG: By early 2020, two years after Ben and Jeremy first met in Texas, they had made progress…by academic standards.
Two society task forces, one white paper, and a few possible grants. And Jeremy had gotten a promotion, now leading the Army’s Telemedicine and Advanced Technology Research Center. The two planned to meet up at the Society’s annual meeting in February to discuss next steps.
Weeks later, those next steps would turn into the sprint of their lives.
DG: By March, the coronavirus was posing a real and present danger on American soil.
Colonel Jeremy Pamplin and Dr. Ben Scott were pretty sure telemedicine could help, but had no way to test their idea until Jeremy had gotten that call from General Talley, his commanding officer.
Pamplin: What can you do for telemedicine that can be used for COVID tomorrow? Not next week, like tomorrow.
DG: Jeremy immediately dusted-off the idea he and Ben had laid out and gave it an acronym only the military could love – NETCCN – or the National Emergency Tele Critical Care Network.
Pamplin: And I pulled mostly an all nighter to put all this stuff down on paper, on paper about what the hell it looks like. Honestly, it was a brain dump from what we had been talking about for years.
DG: He rushed the plan back to his higher-ups…optimistic they would consider this a chance to save American lives and an opportunity to test a tool fit for the future of warfare. Then…reality hit.
Pamplin: This was out of left field. No one thought this was something that was valuable, investing in it, and how could you do it fast? Right. There’s no way you can do this fast…and who uses tele critical care in disaster.
DG: To the top brass he was pitching, military officers and federal health officials, talk of telecritical care immediately conjured gleaming white hospital rooms with special cameras installed in every corner.
Pamplin: That’s like that thing that’s up on the wall. Then you have to spend fifty thousand dollars to to install it in the room. Right. We can’t do that for a pandemic…there was a lot of inertia against doing this at all.
DG: But Jeremy kept being Jeremy.
Montage: pain in the ass / intimidating to some people / uncompromising / too Pamplin / and again I have to say pain in the ass
DG: He pointed to the unfolding horror in New York City….
News clips: The city’s death toll has soared past 10,000. The mayor says the city may have to temporarily bury bodies on public land if they run out of morgue space
DG: …pressing his case for funding.
Pamplin: One of the hardest things for me to do is to watch New York happen and to be able to do nothing about it…nurses crying, doctors crying, I mean, people being just overwhelmed by not knowing what to do and not having bandwidth and not being able to take care of patients. I’m like, guys, this is taking forever.
DG: What felt like an eternity to Jeremy was actually just a few weeks. In early April, DoD awarded the NETCCN project $8M in seed funding…less than what Jeremy wanted…but enough.
Pamplin: So in the grand scheme of you know, a three trillion dollar investment package from the federal government, that’s dust. That’s a speck on the floor. Right. It’s like not even that little thing is what really allows us to gain momentum. And, you know, the big mo, right? Momentum is everything.
DG: Jeremy and Ben decided the fastest way to get NETCCN off the ground was to do something that flies in the face of traditional grants and government bureaucracy.
Launch a competition.
Think of it like some mash-up of the BBC TV show Top Gear, where car technology is pushed to the edge…and the reality-hit Survivor…with teams cut after each round…but with real-world stakes.
NETCCN was open to all comers — academia, industry, the military — anyone with a bright idea on how to bring this virtual network to life, and fast.
Pamplin: Our timeline was a two week sprint, followed by a four week sprint, followed by a 45 day sprint. I mean, that’s like, deliver now.
DG: Each ‘sprint’ represented a new phase of the competition. Jeremy calls them ‘tasks.’ And by the end of the three tasks, he hoped to have a working app that could remotely triage and treat thousands of patients in COVID hotspots or any other disaster site. 79 teams submitted proposals in April. By May, 9 teams had been chosen to compete. Among them, some industry heavyweights, Deloitte, Philips, and some leading academic medical centers.
There was even a military team led by a former med student of Jeremy’s, Lieutenant Colonel Chris Colombo. And he was stoked.
Chris Colombo: It was like the scene from from Apollo 13, where they just say, make this fit into this, using only this. I’m a full go.
DG: By June 15, the teams were off and running. The first task: prove their app could securely connect one local patient and provider to one remote critical care expert by phone, video and text. It all struck Chris as pretty straightforward.
Colombo: For goodness sake, if my kid can FaceTime his grandmother…my 77 year old mother, my 14 year old son, can figure it out across the country, there’s no way we shouldn’t be using this for leveraging our COVID response and saving lives.
DG: And his team breezed through early tests of their tech, like this simulated call.
[FaceTime call ring]
PFC: Hello, hello?
CC: Hey this is Dr. with the care service…who’s this?
PFC: This is PFC McCanless
CC: I got a patient added and a consult requested. What’s happening?
PFC: He came in today with chest pains in his upper right hand side…and after he was given medications, he’s a bit unconscious.
CC: So are you evaccing him or sheltering?
PFC: Yes, the evacuation is delayed twenty four hours.
CC: OK so ever taken care of a ventilated patient before?
PFC: No, no, sir.
DG: While many of us communicate like this everyday, the teams needed to build systems that were intuitive, immune to hackers, power outages and human error.
It’s one thing when Face-Time cuts out on a call with Grandma but it’s another when you’ve got a doc offering life-saving guidance.
Over those first few weeks, one constant, says Jeremy… teams suffering from a kind of Stockholm Syndrome…unable to think outside of health care’s big, bloated box.
Like when he asked teams to come up with fast and easy ways to document the care provided.
Pamplin: And I’m clicking you know five thousand little things in order to… document what’s going on. And and they’re like, we have to do that in order for you to get data out of the backend of it. I’m like, oh, okay, well be more creative. We need a new system because that system doesn’t frickin work.
DG: While Jeremy channeled his inner drill sergeant, Ben was drumming up volunteers from the Society of Critical Care Medicine……providers….and policy experts to navigate the mess of the laws that dictate who can practice where.
Scott: The technology in some ways is the easy part. But the regulatory change, the policy, the legal barriers are very real and are going to be quite challenging to overcome.
DG: …like this one in the Lone Star state…
Scott: Physicians have to take a test about law and medicine in the state of Texas. And to get a license you have to take that and if you just magnify that times 50 states, the number of sort of idiosyncrasies and slight differences can be kind of overwhelming.
DG: By the time Task 2 was under way, six teams remained. Jeremy was excited to see the progress, but he’d been forced into some hard choices.
Some of the lessons Jeremy had learned from the early special forces line…keep it simple, reliable and valuable…were at odds with the pressure he was now feeling to do more, go bigger and go faster.
Should the app be for providers…or patients too? Jeremy said yes to both.
What else should the app do besides connect person A to person B? Jeremy’s list was long…documentation, data collection, medical device integration.
Pamplin: One of my greatest fears in all of this is that. It’s too me. Right, it’s too Pamplin, it’s got too much of my ideas and my concept in it, and I’m wrong.
DG: Others in the competition worried, too.
Jeremy Kahn: I was immediately afraid that we would overemphasize the technological component.
DG: Dr. Jeremy Kahn led the team from the University of Pittsburgh Medical Center.
Kahn: We see this in health care and in the ICU in particular, because it’s so technology heavy, right? There’s so many bells and whistles and monitors and machines. We put inherent value on this technology at the expense of the human side, because that’s what the real power of telemedicine brings. That’s the power of telemedicine: connecting humans.
DG: As the Colonel was weighing what NETCCN could do against what it should do, an unexpected opportunity presented itself.
News clip: A flare up of cases Guam let its guard down…
News clip: Bringing the total count to 820 cases of coronavirus. Guam remains with a maximum restriction lockdown in effect.
DG: In late August, Jeremy got a call asking for NETCCN’s help in Guam, where a local hospital’s ICU beds were being overrun.
It was well ahead of when he’d planned to deploy this tech in a real crisis. On the one hand, it seemed like a great chance to help real people and prove the project’s worth in real time.
Pamplin: The reason we’re doing this is that we can provide help to people who need help, right, and if that’s the fundamental need, we should do that as soon as we possibly can.
DG: On the other, he worried about rushing a half baked cake out of the oven. It wasn’t likely to hurt anyone since the hospitals had other ways of getting help, but like anything in beta, rollouts can be clunky, filled with bugs. And the threat of unveiling something unreliable really concerned the other Jeremy from the Pittsburgh team.
Kahn: One thing we’ve learned in telemedicine is that you have one chance to do it right before you turn people off. And if you turn people off, they will not use the system. When people call for help and they don’t get what they need, they will simply not do it again.
Pamplin: Jeremy really thought it was a bad idea to go live. He had a lot of concerns and they kept me up at night many times trying to figure out whether it was the right thing to tell the teams to go live
DG: Ultimately, the opportunity to test the technology and help people won out.
In the middle of September, Gabriella, an Army nurse stationed at Guam Memorial Hospital opened the Deloitte team’s NETCCN app to call stateside.
Telecritical care nurse Kristina Ieronimakis at Madigan Army Medical Center in Washington state picked up the call.
Ieronimakis: All of a sudden I get a “bing!” right at shift change and I’m doing a narcotic count with the oncoming charge nurse. And I go, “We need to finish up! One of our nurses in Guam needs me!” and I kid you not, I went running from one side of the unit to the other. And my face was all excited. I go, “Gabriella needs us, Gabriella needs us!”
DG: Gabriella wanted to know how to safely use a medication that was new to her while other staff were tied up.
Ieronimakis: I very quickly logged into the Lexicom app on our our computer desktop and looked it all up. I took multiple pictures and I didn’t want to pester her, but I was just so excited. “Gabriella, did you get it, Gabriella? Do you need anything else?”
DG: Gabriella was all good, but Kristina was pretty sure she had made a small difference.
Ieronimakis: I was presenting Gabriela the information and she had the opportunity to to make a clinical decision in the best interest of her patient. So that is that was just so exciting for me. And everyone on the unit thought I was bonkers for this. But I think at one point both my feet were off the ground as I was running from one unit to the other.
DG: Stories like Kristina’s encouraged Jeremy, but he had some doubts in the back of his mind.
Pamplin: There’s a lot of positive feedback about how it’s working, but it’s certainly not being used to its maximum potential.
DG: The reality is for every Kristina and Gabriella, there were plenty of others in Guam who were making do by “phoning a friend” or using other tech they already know, like WhatsApp. And that had both Jeremys worried.
Kahn: You know, Pamplin is right to be concerned about this
DG: As much as docs and nurses love to hate an electronic medical record or even a fax machine, in a crisis…when given the choice, says Jeremy Kahn, you pick what you know over what’s new.
Kahn: So put yourself in the position of the overwhelmed nurse at a small community hospital who needs help. So they’re going to use this app to get advice from an “expert.” But they have never met this expert before. They have no idea what this person looks like. They don’t know what their credentials are. How do you very, very quickly and rapidly create trust? And that is a really challenging thing to create.
DG: But as a third COVID wave began to surge earlier this month, Colonel Jeremy Pamplin suspected that providers might not have the luxury to go with what they know.
Those friends to phone, those well-worn workarounds…might be overwhelmed and unavailable…and that would be NETCCN’s moment to shine.
Three weeks into October, South Dakota and Minnesota may be proving him right.
Lisa Lindgren: Every hospital in a 10 state area right now is maxed out with patients.
DG: Lisa Lindgren leads the NETCCN team for Avera, a telehealth provider headquartered in Sioux Falls, South Dakota.
Her team flipped the switch in early October, making their app available to a couple COVID hotspots, including a tiny hospital two hours outside Minneapolis.
Lindgren: They normally have a little, gosh, I think three bed ICU that they use. But now you’ve added 10 COVID patients that are critically ill into that mix and it’s a whole different animal.
DG: Lisa wondered if they’d be too overwhelmed to even ask for help.
Lindgren: They called within seconds of the system being live.
DG: And the calls have kept coming. Avera’s NETCCN app has been used to help 90 patients in just three weeks. And Lisa gets why. She’s worked in rural hospitals like these.
Lindgren: They just don’t normally take care of ventilated patients. And COVID is so strange. It doesn’t follow the normal playbook. And so it really needs those experts that have been dealing with this day in and day out.
DG: And that, says Lisa, is exactly what NETCCN’s delivered.
Lindgren: It’s without a doubt saving lives in those communities by the partnerships we have between the boots on the ground and the system. And it’s been one of the probably most rewarding times of my entire nursing career.
DG: The New York Times reports COVID is now killing close to 800 people every day…a nearly 15% jump since earlier this month.
In the next two weeks, teams led by Lt. Colonel Chris Colombo and St. Louis-based Mercy Hospital, will join Avera and Deloitte in the field.
Jeremy worries about what this winter holds. He’s thinking of exhausted doctors in Des Moines, overwhelmed nurses in El Paso and struggling home health aides in Milwaukee.
Pamplin: These teams that we send to these godforsaken places…
News clip: At this facility outside Columbus, Ohio the employees have even volunteered to lock themselves in with the residents
Pamplin: These, you know, I mean, these places that are in the middle of nowhere with very limited support.
News clip: Nurse: We’re rationing masks, protective gear. / News clip: My patient took the last ventilator available in the hospital
Pamplin: They are they are doing the work that our nation has asked them to go do.
News clip: In a wartime scenario situation such as this, it’s a calling. I have to go in. / News clip: That’s what we do. That’s what nursing is.
Pamplin: And and now they’re in trouble, right, and they need help.
News clip:I sort of feel like being a solider on the frontline of a war and the opposite army is charging at us and we don’t know when they’re gonna hit.
Pamplin: How do we best help them?
DG: Jeremy knows the answer may come from outside this NETCCN competition.
But thanks to COVID, military and health care leaders now believe the nation needs some kind of national network that gets critical care docs and nurses to wherever they’re needed in an instant.
Pamplin: I wish I could say, “Oh, yeah, it’s all done,” but I know that the conversation has changed, right? The DoD is having the conversation. National societies are having the conversation about how telemedicine should be used to help people deliver the best health care we possibly can in the worst situations.
DG: When the competition ends next month, a few teams might win, each contributing some piece of their tech to this national network. With COVID continuing to surge, it’s possible all four will be asked to deploy again.
Just last week, the U.S. Department Health and Human Services committed $45 million to scale NETCCN over the next four years.
As one top HHS official said, “If we get this right, if we nail it, we have an opportunity to change the way that medicine will be practiced around the world.”
I’m Dan Gorenstein and this is Tradeoffs.