So, gold star to anyone in the audience that can tell us what this Latin term means. Go for it, shout it out. Optimal care anywhere. How do we use technology to deliver optimal care to where the patient's at, rather than having to do it within the four walls of an intensive care unit or an ER or a hospital at all? Where is that patient at, and how do we make sure that they get the care that they need? See if I can advance, there we go. So, just some quick introductions. Again, this is, you may notice that we've adjusted the sequence of our presentation a little bit. I'll talk about that in a moment, but Dr. Jaspal Singh is a pulmonary critical care physician at Atrium Health in Charlotte, North Carolina, and is involved in their telecritical care and hospital home services. He's also the father of a 14-year-old boy and two girls, age 17 and 20, and he will be talking to us about bringing hospital-like services to patients in their homes. Dr. Julian Goldman, if you could raise your hand, sir, an anesthesiologist at the Massachusetts General Hospital, the medical director of biomedical and engineering at Mass General Brigham, and the director of the medical, assuming the Mass General Hospital Medical Device Interoperability and Cybersecurity Program in the Center for Smart and Autonomous Medical Systems, or SAMS, which he will comment on, and since this is the last session in this room for the day, there will be a follow-on opportunity to talk a little bit more about SAMS. I'll let him do that introduction. He's also the father of two adult girls and his first and only granddaughter, so we congratulate him on that, and he'll be talking to us about the importance of device interoperability and how that can enhance technology use in high-risk care contexts. Dr. Ben Scott, anesthesia critical care physician and associate professor of anesthesia at the Colorado University, and is the immediate past chair of this society's telecritical care committee, now telecritical care section, so shameless plug if you're interested in technology. Please think about, please let him think about, please join the telecritical care section. It will be, it's new, it's just open now. This is the first inaugural class, if you want to call it that. He will be talking to us about some of the commonly perceived and real barriers to delivering technology, delivering care with technology to patients at a distance, and talking about how to overcome some of those. Dr. Kristen Mount is a recently retired army colonel and medical intensivist from Tacoma, Washington. She's fellowship trained in POCUS and an instructor for SCCM's adult ultrasound course. She deployed with the 26th, sorry, the 28th Combat Support Hospital in Iraq and as an intensivist in 2010, and she finished her army career as a consultant to the army, surgeon general for critical care medicine. And perhaps her most important role is she's the mother of three boys, age five, six, and nine. God help her. She will talk to us about some of the real world applications of POCUS in some very austere contexts. And last, but certainly not least, and hopefully the one of the conversations that you will stick around for the entire length of this session for, is Dr. Jerome Lee. He is an emergency medicine critical care trained physician, the vice chief of critical care at Mass General, and an associate professor at Harvard Medical School. He's the co-founder of Health Tech Without Borders, which he will talk to you about today. And he is the father of a nine-year-old boy and one kitten. Dr. Jerome Lee will be talking to us about his experience delivering optimal care to a war zone in Ukraine using telemedicine and other solutions. And finally, I'm Colonel Jeremy Pamplin. I'm the commander of the Telemedicine and Advanced Technologies Research Center, an army research lab, critical care medicine by background. I have a couple boys, 15 and 17, an 11-year-old girl, and I'll be moderating today and trying to keep this show on time. So God help me. In all seriousness, the agenda today is very packed. It's pretty rapid fire. I almost venture to say that it's more of an introduction to a lot of these concepts. So again, we are the last session in this room. So if you want to have a more in-depth conversation, please stick around at the end of the day. And just as a means of orientation, again, we have altered the sequence a little bit. You can see that the desire there is to kind of paint a slightly better picture for you about how we can move from the hospital using technologies, interoperability, overcoming some barriers into some very austere and resource-limited locations. And just so that everyone has an understanding of what those definitions means for the purposes of this talk, an austere, resource-limited environment is a location that has limitations of any or all of the following, the quantity, quality, or availability of equipment, supplies, medications, tests, anything you normally have in your hospital you might not have in some of these environments. It could also be limited by the number or type of caregiver that you have available to deliver patient care. You might be limited by that caregiver's knowledge, skills, or expertise. They may not be ideally trained for the type of care that they're going to be delivering. Ultimately, all of these resource limitations deliver fewer options for the management that you might be thinking about providing for a patient. And under normal conditions, most of the patients in these environments you would consider transferring to alternative locations, but you can't, right, for lots of different reasons. We saw this during COVID. Often we see this in the military. We see this in wilderness medicine, lots of places that you can see this. As an additional context, operational medicine for the purpose of this talk are really those environments where the healthcare team or your equipment is at risk, right? So high-risk situations. This could be from war, conflict, infectious disease, whatever it might be, but that's an operational context that places that provider or provider team health or safety at risk or their equipment potentially. And overall, we're talking today about how technology can improve care in these settings and what are some of the technologies using it. So without further ado, I'm gonna turn it over to Dr. Singh. All right, thanks. Thanks, Jeremy, for that awesome putting this together, for me being part of it, and I'm delighted to be here. And thanks, everybody, for joining us in an afternoon session in a dimly lit room where it's easy to fall asleep after lunch. All right, so let's get going. I have a disclosure. I do consult for Intuitive Surgical. So let's talk about the critical care journey. I think what Jeremy painted was a very nice picture of where optimal care everywhere, what does that look like? Well, we all know that critical care, the journey is not just beginning in the ICU. The ICU is a bed, right? So we have all these things that happened before in the pre-hospital setting, to the post-hospital setting, to the home setting. So I'm gonna give a little bit of a snapshot. So I'm a tele-intensivist. I love a lot of the work that we do in the telecritical care unit. It's central. We take care of patients who are in rural areas. We put the right patient in the right ICU bed. We take care of patients with general ICU needs, specialty ICU needs, and I work in the major, the quaternary center, and we take care of very complex things, triage them accordingly. That's cool. For that, we'd be successful, right? But we're not satisfied with that, and we'll talk about that a little bit later. I'm gonna focus today, not so much in the pre-hospital, that's a different sort of discussion, but the tail end of this, the focus of the hospital at home, what the post-ICU journey potentially might look like now and hopefully in the future. So the hospital at home, creating capacities, what we call this slide. So we have our hospital at home program. How many of you in here have hospital at home programs? How many are involved with them? So a couple of hands. Good, that's fantastic. So this started in March, 2020. For those who've done it, you kind of know what we're talking about, and we'll talk a little bit about it. But it had to do with, we had not enough ICU bed capacity, simply out of the recovery phase. Patient had too much oxygen, respiratory failure that was just not amenable to just sending them home. And so they would sort of clog the system, right? They would sort of, you couldn't create ICU capacity because on the tail end, you didn't have enough capacity. And so this is a very common theme, whether it be pandemic, whether it be other sort of chronic critical illnesses, that happens a lot. And so in March, 2020, in response to the pandemic, we created this sort of, this idea that a technically licensed inpatient bed could be done at the home, that same level of care could be done at the home with some bare bones technology and support services. So we started this within 10 days of the initial sort of concept. And then we basically, the concept's been around for some time. It's been published here and there. Some institutions have done this. And so we sort of created this actually in our institution and leveraged internal resources and expertise with around 10 surrounding counties within the area, the greater Charlotte, North Carolina area where I practice. And then the team delivered services from March, 2020 to 2021 without issuing a single claim. This was free care, essentially, until CMS implemented the acute care at home waiver in March, 2021. And then it'd be provided full inpatient payment DRGs. So some of you remember that legislation that kind of went through during the flurry of legislation in the pandemic. This kind of, this changed our ability to do some of this just out of the financials of it. But basically we're gonna compare it to what we're gonna call brick and mortar hospitalizations. And so why do we have the hospital at home thing? Well, basically driving forces were initially patient preference. If they're gonna be sitting on opti, they're gonna be sitting on three liters of nasal cannula, five liters of nasal cannula in a hospital setting for days on end, they'd rather be at home. How many of you would rather be at home? We'd all rather be at home, right? The aging polychronic population, they have other comorbidities. They have other things that they need attended to. It's easier to do at home. Capacity challenges. We were challenged with capacity. All of you were probably challenged with capacity. Around the globe, we were challenged with capacity during a pandemic. And that's not gonna change where we are in any time in the near future, regardless. It's going, it's being challenged right now, right? For many of us. The risk of hospitalization. So hospitalizations, as we all know, through our safety and quality work, being hospitalized is itself a danger, right? Errors happen, problems happen, and you're away from family and loved ones. And so a lot of the safety mechanisms that we take for granted are not there. So the risk of hospitalization is also a driving force. Healthcare inequities, I'll leave it at that. But the idea that basically those who have access to a hospital, sometimes the best hospitals are not where our patients are at. The costs of care. We're gonna come back to that a little bit. But the goal is to avoid brick and mortar hospitalizations and admissions, and we're gonna talk about that a little bit. We also found that our Hospital at Home program had fewer falls, our patients had fewer falls, hospital-required infections, and delirium. It also expanded our support. It provided broad and durable health outcome impact and a lower cost for clinicians, payers, and patients. So that's a good overview. Let's talk about a little more specifics. What's it involve? If a patient's in the Hospital at Home program, they get remote patient monitoring, two-way audio-video connectivity, with a 24-7 virtual RN assessment and monitoring. Right now it's continuous monitoring. We're actually deciding as to which patients can be intermittent monitoring right now. So we're still in the phase of that right now. And it's twice daily at-home community paramedic or RN visit, basically. So twice a day they would get someone to come into their house, basically do bedside vitals, essentially, and report back. A daily virtual visit with the clinician, that's usually a hospitalist physician, with IV infusion and meds can be given, oxygen can be given, up to a certain amount. EKGs were available on-site, as well as labs can be drawn on-site as well. We weren't able to get radiographs yet. We're still working on that part, but that's also gonna be part of the future program. And I guess they don't just get that. They also get pharmacy services. So pharmacists can be called and get rapid assessment. They get order verification, dispensing, figure out which meds can be delivered to the home, for example. Medication consultation, including reconciliations, can be done at home. Care management. These patients all get access to social work, social care case managers. They also get respiratory therapy assessments, nutrition assessments, PTOT speech can be accessed somewhat virtually as well. We're still working to the exact parts of that as well. And then also diabetes education. In fact, education for a lot of things, including smoking cessation or other sort of at-risk efforts. And then patient support. They also can access to palliative care, behavioral health, and pastoral care services through the virtual platform. Remember, this is during the pandemic, so a lot of our specialty services were already giving care virtually. This was just another way to enhance that care, but now doing it through the home. Specialty consultations, cardiology, pulmonology, and even surgery. Obviously, we're still in the learning process when we first started this, but this was the goal of how we developed this program. And we started with the pandemic aspect, the patient population with respiratory failure, but we sort of learned that basically there are certain things that lend themselves quite well to a virtual hospital at home. Congestive heart failure, for example, exacerbations, COPD or asthma, diabetes, hypertensive emergencies, hypertensive urgency, sorry, and then acute episodic conditions that are fairly clean, like a cellulitis, a pylo, or a DVT. For example, things that are sort of algorithmic, you might say, might lend themselves to this type of admission. And so this is sort of where, instead of being in the hospital, you can just be discharged from the ED or somewhere to the home under this care program. And it's considered still an inpatient hospitalization. Clinical factors, obviously there's some paradigms, some lanes to swim in. For example, not too much oxygen, for example, vital signs are relatively manageable, and not regular vital signs needed as frequently as you might in the ICU, for example. I know this is an ICU audience, but you start thinking about capacity building and how do you create that ICU capacity? Well, downstream, you gotta clear it. Patient factors, the patients have to want it. They have to be able to comply, they have to be adherent to the therapies that are prescribed. And the social factors, they have to have a working phone, you gotta be able to track them down easily. Easier said than done in many of our patients, as we all know. Emergency contacts and a safe, stable living condition. But who's not eligible? Sort of like those types of the opposite. The patients who need continuous IV infusion, for example, even IV insulin continuously, we didn't feel comfortable giving that through in this program, or TPN. Patients who are hospice, or SNF, or LTCH, we just didn't have the resources to do all that. And then patient factors. Patients not wanting to have this care. We only did an adult program, we did not do pediatrics. And again, the social drivers of health we can kind of talk about, but they have to have a working phone and a safe situation. So how do we do? This is all great in theory. What's interesting, actually, labor costs. We start dialing down labor costs. Hospital at home costs $247 a day in that model when we studied it. For a nurse and a clinical paramedicine person. Brick and mortar, over $500 a day. We know it's more than that now, right? With our costs been going up. Operations, we basically took care of about 8,000 patients early on, and avoided, as of a few months ago, about 30,000 brick and mortar admissions through this program. Three and a half day average length of stay. And the quality, the readmissions were lower than we expected. Mortality was less than 1% in this program. And the return to admission was less than 4%, which is important. Very few patients went back, actually. Very few died in this process. So the safety was great. And the patient experience, for those who care about patient experience scores, it actually far exceeded the scores of the brick and mortar admissions. Everybody liked it, right? As a working son of parents that were sick, for example, I'd rather have my family at home, right? You start thinking about the personal aspects of what this means. Now, you're gonna hear later about licensure, accreditation, compliance. I'm not gonna bore you with all that. There's still, a lot of this still is in flux with licensure, accreditation, and what the requirements are. But I hope that you all pay attention because this clearly affects our ICU community. This is fundamentally changing what Jeremy was getting at earlier. How we deliver critical care is gonna be extremely dependent on the capacity that we built. And this is an important part of capacity building. Now, the military's done some of this work, but I'm gonna potentially, for time reasons, skip some of this stuff. But we can talk more on the questions and answers about how we talk about how we communicate, all the operations and logistics of how we do some of the communication tools. There's actually a communications thing that we recorded through Ben's, on one of the, what's it called? On-demand course? Yeah. We recorded some talk about communicating in the ICU about some of this aspect. But essentially, the idea is that basically, what we're trying to develop is a means to take care of, deliver care anywhere under any circumstances. And I just love this quote. And the bottom, in the end, if we get it right, if we nail it, we will change the way medicine is practiced around the world, and everyone will benefit. Thank you so much. I'm Jaspal Singh, and we'll have our next speaker.

Hospital at Home

remote monitoring

patient care

technology in healthcare

Atrium Health