It's my distinct honor to stand before you today on behalf of the really hundreds of of individuals who represented the both the creation of the National Emergency Telecritical Care Network and then ultimately deliver of services to some of our most vulnerable hospitals and communities across the nation during during our pandemic through the through the Netson and certainly to be joined by the two individuals at my left here, Dr. Lilly and Dr. Scott. I think it's especially meaningful to me because Dr. Lilly was instrumental in my early career in telecritical care, and I think had he not been there for me at that time, then I probably wouldn't be here today. So thank you, sir, for for your guidance and your wisdom overall. Thank you. Appreciate that. Overall, we hope that today's discussion will really provide what we what we hope to be a nice bookend to what's been a years long endeavor that is known as a national telecritical care, emergency telecritical care network project that surprisingly began as a strategic proposal to the Society of Critical Care Medicine in 2019. That was that was between Dr. Scott and Matt Getty that's in the audience and myself and a few others that were on the telecritical care committee at that time, now the telecritical care section for the society and was picked up and approved as a white paper back in 2020 and then not very long after that, the same obviously spring, it got launched very rapidly into a national response system. So again, a long journey to get to where we are today. Really it's my purpose today to kind of provide a little bit of a background then to hand it over to Dr. Scott and Dr. Lilly to provide their thoughts and insights for the project, how it was successful and maybe some of the lessons learned and how we can move forward with a project like this as a nation. So these are our overall disclosures. I think for the sake of time, we decided to put them all in one location. There's no specific disclosures that we have related to this project or this presentation. We have obviously all received grants almost entirely from the federal government or from the military and those both have helped this project and are instrumental in the rest of the work that we do. That's the overall overview of what we'll be doing and then for some background. So I don't think I need to spend a lot of time with this audience going over the problems with our healthcare system and how so many of them were really unmasked by the pandemic. But it is certainly worth highlighting some of the drivers that inspired the vision of the National Emergency Telecritical Care Network or NETCEN. First of all, large-scale disasters, whether they are man-made or natural and certainly mass casualty events that unfortunately all too many of us are familiar with these days, stress our healthcare system. Most of our hospitals truly operate at or very near capacity on a routine basis and this is because that's the most cost-efficient model, but it really leaves little room for resilience within our system. Furthermore, our healthcare system is for many reasons not distributed equally across the nation. Where there is a lack of infrastructure for subspecialty or specialty support, that lack of infrastructure usually also leads to a lack of expertise in those specialties and it's clear that a lack of critical care beds leads to a lack of critical care expertise in a community and therefore the primary response to obtain that resource or that expertise is to transfer either resources to that location or to transfer that patient to those resources. And these challenges that our healthcare system faces were really profoundly apparent during the pandemic, especially one that caused acute respiratory failure for so many. So it was with the intent to really address the scarcity of critical care expertise during high volume surges in either critical illness or injured individuals, so trauma care was also the initial perspective behind this, but transitioned to the pandemic illness as the pandemic kicked off. We envisioned that really telecritical care could be a means to rapidly expand the capability and capacity of a hospital by delivering expertise to the point of need without having to move physical resources of either humans, experts, or patients to those experts. And it was in this kind of context that we imagined the same expertise that we, many of you understand, delivering as part of a tiered staffing model in which critical care experts, whether they're physicians, nurses, respiratory therapists, or pharmacists, guide a team of non-critical care trained clinicians to deliver services, the right care at the right time to a larger number of patients. We imagined that we could do this without a physical person on premises and we could do that virtually wherever that support might be needed. Ultimately that vision turned into what became a funding opportunity through both the military and what was then the Assistant Secretary for Preparedness and Response, it's a slightly older slide now. Now obviously that's the Administration for Strategic Preparedness and Response. And this was to rapidly form these clinical technical teams that you see before you to deliver the capability that was NETS. One question that people might have is why was the military interested in this? For the sake of time today, we're not going to get into a lot of that. That could potentially be a question at the end of the day. But there are certainly overlaps between large pandemic patient volumes and large scale combat operations and large scale numbers of patients or casualties. I think it's also worthwhile just to describe some of the differences between what is NETSEN and what is maybe considered more traditional or common telecritical care. Certainly one of the most important ones is that NETSEN was always imagined to be a temporary solution, right? It was designed to go in to a hospital, stand up rapidly, be there for a period of time and then leave. It was never intended to be an enduring capability. And in that context, that presents certain constraints to the way that you would deploy a system, but also to certain expectations that you might have from both the service provider and also the customer that's receiving that service. An example of which might be integration into the electronic medical record. Even though every hospital might have an Epic or a Cerner deployment of an EMR, those EMRs and their back end are not all identical, right? And there requires integration with the third party system to work with those electronic medical records on premises. And there's no possible way to do that in a speed of relevance during a pandemic or any other type of disaster. So there's things that you can do and there's things you probably can't do on an ad hoc basis. Some of the other really kind of important things I think that are differentiating between NETS and kind of normal telecritical care is there's no negotiation about what services you're going to get. We came with a plate of services and this is what you get. If you don't want more, we're not going to be able to provide a tool that we do not otherwise have. And that became some negotiating challenges with some of our deployments. The other thing surprisingly, as you might imagine, that no cost for services you'd think would be great. There are a variety of folks that are out there, especially CEOs in some of these hospitals that see free as being concerning. Maybe free wasn't well designed or maybe free wasn't validated or a lot of other issues that are associated with free and we had to get over some of those concerns. I'll just highlight the software solutions for these two systems are not terribly different. They all have the right cybersecurity, HIPAA compliance, et cetera. I would say that most traditional telecritical care software solutions are a little, have a few more bells and whistles to them. Hardware, however, was significantly different. Our primary hardware solution was a mobile device, right? No deployed hardware associated with NetSend. We weren't putting cameras in people's rooms or microphones, just mobile devices. And then the way that we manage data was significantly different. So all those clinical technical teams that you saw before had a standardized interoperable data standard across the vendors and most of the telecritical care platforms in normal use had proprietary data structures. And then the model of telecritical care delivery is not dissimilar to what most people would understand or see or recognize as telecritical care in the community today. In the end, most of what we were doing was reactive model of telecritical care for a variety of reasons. These were the core functions of the NetSend applications. I'll only touch on a couple of them. Again, it was mobile device centric. It could be Apple iOS or Android iOS. We didn't have others in the pandemic. Team collaboration was key. Communication was key through both asynchronous methods as well as voice and video. There were elements of care management, keeping patients coordinated wherever they may be. So if you were in a gym or a hotel, these platforms could deploy and keep track of where the patients were in those types of environments. We had push survey data capture. So if you had questions about what was going on at the edge, we could ask some of those questions. And then what we called documentation was really what you might call light documentation. It wasn't all of the documentation for billing purposes that what you might have in our normal electronic medical records. These were really communication tools for documentation, what do you need to know when you need to know it. And then finally, I just want to kind of go over our general timeline for how the portfolio played out. You can see the first six months of work from the time the emergency declaration was kind of made for the nation, obtaining funding, doing contract, et cetera, was at light speed for the government. So within six months, we were actually to start to deliver services on a relatively small basis. But our initial pilots were within six months of the initial kind of concept ideation here. We did eight requests and seven live sites in the first several months of deployment. This was under military funding, and then during the alpha kind of wave is when we transitioned over to ASPR funding, and that was kind of a contracting phase, and we provided almost no services. That picked up again, obviously, during Delta and Omicron, and you can see the kind of numbers here. Overall, we have received 131 requests from a variety of states. Ben will show some of that data. We're doing live in a little under half of them with a large percentage of being in some of our most at-risk communities, 35 critical access hospitals, one EMS system, and one clinic. And then just because this slide is here right now, and I think it just picks this challenge very graphically and it's easy to see, you know, request doesn't mean start service on day one, and you can see for both Omicron and Delta, you know, the request volume went up right as the waves were starting to peak, right? People were going into the waves, and people recognized there was going to be problems. But the going live, the red lines here, so black line peak here, red line below, was the going live dates, and they were always delayed from the request, right? And in fact, the last go live request, go live for the Delta wave was really after the Delta wave was over, right? And we got a little bit better at doing that. Ben will show some of the data for the go lives during Omicron, but, you know, this is just, it shows, speaks to some of the complexities and the challenges of actually doing this, and I think this was just a good graphic for people to be aware of.

NETCEN

telecritical care

COVID-19

remote expertise

healthcare integration