I think it's good to be following that kind of cool and inspiring stuff you just saw about successful programs with some kind of a letdown about some of the barriers that we still face. So it is often said by people who practice telemedicine that technology is not usually the limiting factor. And I think if you look at what Julian just talked about, there's lots of cool stuff we can do, and we can do it pretty quickly. I do think it's worth at least mentioning a few of the potential technical challenges and barriers that still remain, though. And these are just sort of a general nature, but I think we're thinking about the more data streams you get, the more smart alerts you have, the more information that's being fed to you. I think alarm fatigue is a real risk. I think setting and calibrating your notifications is a real challenge, trying to find the balance. And these are things that don't necessarily have technical solutions. They have team-based workflow solutions and can be quite challenging to actually find the right balance. We need to figure out whether our tools are flexible enough to deal with the specific local challenge we're trying to solve, but also keep them usable for all hazards approach. If you build something specifically for COVID, you'd like it to be able to be used in an earthquake or something like that. The devices, as you saw, need maintenance. There's infection control issues. There's all kinds of reliability and technical challenges when you're working with electronics. Network availability is a must, obviously. We're talking about a lot of stuff that depends on bandwidth, that depends on availability, that depends on network communication protocols being secure and reliable. Most of the folks on this panel worked on the National Emergency Telecritical Care Network, and that was a very small pilot program that wasn't heavily advertised, but went live on the internet. And it received numerous malicious threats and attacks. And fortunately, we'd had the foresight to have an IT cybersecurity team helping monitor that stuff. But anything you put up on the web is going to be attacked. So that's a very real risk. And then I put business intelligence there. There's also this sort of challenge of how you're going to deal with different vendors and different health systems and different people who want to own their own information and are sometimes reluctant to share it or to give up devolved secrets or what they might think of as sensitive business information. And then a big challenge that I think we really still have a long way to go on is trying to integrate the EMR so that you can bring in an external system that you can bring in an emergency, but still have it talk back to the system that everybody knows and is commonly using at their home institution. So we've got a long way to go for that to solve some of these challenges. Obviously, people who do telecritical care have been talking about this since it very first started. Some of the very first publications on telecritical care were about the importance of trust and relationship building. And certainly in our experience of rolling out some of these programs, even in an emergency setting where people are very glad to get the help, they still are like, well, we're going to let you guys in. Can we really trust your team? Can we really trust your device? And so what a lot of people fell back to was navigating using their established relationships and basically saying, well, I do have this colleague who went to a different hospital. And I'm going to set up something with his group because I know and trust them. So coming into a scene completely de novo can be challenging. I think managing expectations is a real challenge. There are many things that we can promise and may or may not be able to deliver. And there's often a big gulf between what we know we can realistically do and what the customer side might be expecting or what the patient might be expecting. And then the other really important cultural thing that we haven't really solved, I don't think, is that during COVID, we had a huge outpouring of volunteer effort. So so much of what was successful about the COVID response around the world was that people were willing to pitch in and do things that they wouldn't normally otherwise do or do it without the same kind of compensation. And I haven't seen a lot of reassuring models that show that anybody's really figured out a really good sustainable business model for some of these programs. If you want to bring care to everybody anywhere, it's going to cost money. And we're not exactly sure how we're going to do that yet. And then most pressing or most significant, I think, are some of the policy barriers. So actually, I will confess that I think I made this slide before COVID or in the beginning of COVID. And I went back to Revisa for this talk. And I said, well, I guess I don't really need to because it's still the same. It's still pretty much applicable. So there are a bunch of barriers here, right? So Jasper talked about some of the emergency waivers. But there are some things about the way our system works that are very difficult challenges to solve. And I'm not saying they're necessarily problems with our system. Some of them are things that have value on the other end of the equation. But we have a federal system where we have a bunch of states. And each state makes its own laws and rules about many of these things. And I'll show you a slide in a second that kind of presents this visually. But they have lots of different approaches to these things. And coordinating between different state governments or different municipalities, different health systems is very challenging. There's really very little. The other thing we did in the National Emergency Telecritical Care Network is we consulted with some medical legal experts to try to figure out if we could get any kind of information about what liability, exposure, and protections, and things like that would be for this kind of emergency care. And they basically informed us that there's really not very much, right? You have to develop case law to understand precedents to know what you can expect from the legal system. And it's just not there yet. A lot of the rules, waivers, things that have been put in place don't necessarily explicitly address telemedicine. And then within telemedicine, more to the point, they don't specifically address telecritical care. You cannot bill telecritical care in the same way you can bill critical care. Because one of the key components of critical care billing, for example, is physical presence at the bedside. So a lot of the things that we're able to bill for, some of the E&M you can bill for. You can bill for monitoring. In some places, you can bill facility fees. Some of those things are around the edges. So you can start getting some compensation for your care delivery. But the critical care itself is actually quite different. So if you look, I encourage everybody who's interested in this topic to go to the Center for Connected Health Policy. Not only do they have a very kind of exhaustive amount of information, but they actually also have pretty good data visualization scientists and stuff clearly working for them. So they have a lot of cool stuff. These are interactive maps that change over time that show just as an example of the difference between different states in terms of what's allowed. So every state in the union now has live video reimbursement of some sort. The details do vary. But if you look at whether you can bill for store and forward services, whether there's certain laws that differentiate what private payers do versus what CMS or Medicaid does, whether you can bill for remote patient monitoring, whether there are certain limitations or restrictions on where the site of origin happens, just as an example. In some states, you can bill for these services only if you have an established relationship with a patient. You can't bring a new patient into your system through this method. So just to finish it off with maybe the most sobering thing I would say, it was an example from our own experience during COVID. So we had a working platform that we've called the National Emergency Telecritical Care Network. It had providers ready. It had a system in place that could provide telecritical care anywhere. And we were working with a bunch of agencies. And in particular, in this case, the state of Vermont asked for help from Region 1 of the Regional Disaster Health Response System. Some of the team from the RDHRS Region 1 were aware of the nets and effort. And so they got in touch with us and said, hey, I think this is a great opportunity for you to provide services for us in the state of Vermont. Vermont is obviously a very small state. I think there's only something like 12 significant size hospitals in Vermont. They're all members of the Vermont Hospital Association. The Vermont State Board of Health and the Hospital Association agreed this sounded like a great idea. We had a series of meetings. We decided we would roll out our telecritical care support to their state. So we had, as I said in this slide, a shovel-ready platform, coordinated deployment with buy-in from state and local leadership. Seemed like the perfect situation. And in fact, it did work, but it was painfully slow. Despite all the prep work, everything being in place, the fastest we deployed anywhere in that state was seven days. And the median time from request to active deployment was 27 days. So you probably remember that COVID had these waves. And unfortunately, if it takes you 27 days to get set up, some of the waves had already passed. So the amount of service we ended up providing, and again, what I think was sort of an optimal scenario, was not as much as it could have been. So going back to this slide, in terms of solutions, I think there's still a long way to go. And my request to everybody here is, if you care about this stuff, we really need to resist the urge to return to the status quo. So I think everybody sort of said, whew, that was close. And a lot of bad stuff did happen, but we kind of got through it with our current systems. And so I think there's a strong urge to go back. I'm sure everybody here to advocate for really pushing for extension of emergency compacts, for working on national licensing systems. I think most of us up here believe that the National Disaster Medical System could use a telecritical care response team in addition to their boots on the ground approach. So thank you very much.

telemedicine challenges

cybersecurity threats

legal barriers

sustainable business models

national licensing systems