Hi, everybody. Thank you for coming. My pleasure to talk to you. If you came here expecting to hear what the standard of care is, you can go ahead and leave because we don't have that information for you at this time. So sorry to disappoint. I am going to talk a little bit about this sort of existential question, I think, of how you identify, determine, and promulgate a standard of care in an area that needs it but isn't mature enough to have it. I don't have anything to disclose. So most of us have just been through a tumultuous period where a lot of things that were considered to be crisis standard of care were done. That was in some ways, I think, a very liberating experience for a lot of people doing what has previously been perceived as cutting edge or scary or whatever. So there's, as you know, a huge explosion in utilization of telemedicine for critical care services in the last three years. In the Joint Commission newsletter, they actually cited some Kaiser Permanente data, and this is even more than I've heard other places, but that some of their clinics went from 80% in person and 20% remote to basically vice versa and having as many as 80% of their clinic visits occur remotely during especially the earliest parts of the COVID-19 pandemic. Regulatory waivers and emergency declarations and sort of special dispensations were offered for many programs that previously had been restricted, and that really opened up a whole new opportunity for programs to grow and spread and provide new services, do things like exploring billing and reimbursement for telemedicine services to avoid some of the potentially problematic parts of HIPAA that can put a real wrench in transfer and sharing of information. So unfortunately, in a couple years, I think we'll have a lot more data from that experience. Things are starting to percolate into the literature. For the most part, these are observational studies, and they're mostly, and I think these are valuable, and this is not to denigrate the work, they're mostly descriptions of what people did and say, hey, we did this, and it worked. I certainly think that there will be some room for showing that there wasn't really a lot of harm, right? We didn't end up with a whole bunch of charlatans masquerading as clinicians. We didn't end up with terrible data breaches. We didn't end up with, the most important thing probably is we didn't end up with patient dissatisfaction. And it seems as though, for the most part, both patients and clinicians found the experience to be kind of liberating. And so I don't think there's any going back. But the real question is, where do we go from here while we're waiting for this literature? I also want to just raise the sort of more fundamental question of what standard of care means and what it means in the context of something like telemedicine. Unfortunately, I have a lot more questions than answers in terms of these topics. But I think still to be explored, still to be studied, and still to be sort of regulated and codified are simple questions like, what can you do virtually or remotely or away from the patient? Can you do exam techniques? Can you really fully examine and interpret a clinical situation? And these are moving targets because, as we know, we have lots of technological solutions that have made things visible that were previously not visible that can potentially have automated a remote control or other means of assessing a patient than the very traditional laying on of hands. The second question is sort of a medical legal one, but also a practical and a standard of care one. What's the difference between calling up your colleague and saying, hey, I got this kind of complicated case I want to run by you, the sort of phone a friend model, which offers potentially, because it's more informal, maybe it's a little safer in terms of how it's currently structured in our medical legal environment, versus medical direction, where you're being directly advised as to what to do, versus direct care and whether how much, again, going back to the first question, how much can I actually manage a patient myself remotely? I remember a few years ago, there was a proof of concept paper done of a remote laryngoscopy of a mannequin driven by a robot, and they did it, but they had to line up the mannequin just so, and they had to do like 80% of the presentation of the laryngoscope before they could drive it the last 20%. So we've got a long way to go, but these are real questions that I think forward thinking folks among us should be really considering now, because there is the potential that many of these technologies can actually do this stuff from far away. And then another important question, is equity of access standard of care, and I think one of the most important things that we've found, or at least that we've been arguing for in recent work on telecritical care, is that it is a way to bring standard care to patients that don't otherwise have access, and places that don't otherwise have access, so things like specialist consultation, or other kinds of multidisciplinary services like palliative care, for example, can you bring that to a patient that wouldn't otherwise have access, and should that be included in our discussions about what is standard of care? We're gonna hear in a few minutes some more detail, so I won't dwell on this, but there's a whole nother standardization question about cybersecurity, privacy, reliability of these technologies, and should that be included in discussions about standard of care beyond just sort of clinical metrics and the traditional outcomes that we pay attention to in medicine? Similarly, how do we regulate the people who are providing this care? How do we know, a big fear that we definitely encountered when we were expanding our practices during COVID was, just sort of a generalized, but very nonspecific fear that you might get people who aren't qualified who show up over the computer to take care of your patients. And then the last thing is, how are we gonna figure out what is best practice, and I mean this in the more traditional sense, like how are we gonna study these things, what kind of outcomes are we gonna pay attention to, and how are we gonna organize ourselves as we try to answer this question? So I sort of said this already, but the other argument I would make is that there's a question about what should be standard in telecritical care, and then there's a question of how can telecritical care relate to the overall standard of care? So we all know this, I'm probably preaching to the choir for the most part, but telecritical care can provide access to any patient, anywhere, theoretically. It can increase clinical bandwidth. We all know that we're all dealing with staffing shortages, I suspect a lot of people might be here if they weren't having been sort of called to action in their own hospitals and clinics. But telecritical care can be a force multiplier, it has the opportunity to expand the provider base to counter burnout, to give people rest. Obviously it has a potential role as a standardizing tool, and it's been used this way to try to improve bundle compliance, to try to get rid of unnecessary care variation. It can support the infrastructure needed to do quality and effectiveness work, to help build large research networks, to help build large data sets. And then in some of the work that I've been doing over the last couple of years, to build emergency networks and to be able to provide care where it's not otherwise there. So there's again, just to summarize, two questions, right? What is standard practice for telecritical care, and then how does telecritical care help us improve standard care for every patient? There's a lot of things to be worked out. So in terms of some of the obvious risks and barriers, there are really not very strongly developed medical legal frameworks to address questions of cross-jurisdictional care, to address things like medical command and medical direction. I've spent a lot of time, my wife's an emergency medicine doc, and I've spent a lot of time talking to her about the questions of how do you do that medical direction when somebody just calls you and says, I got this patient, I think they need to be transported, what should I do? And it turns out, I've tried to do a little work on this, the literature, the legal frameworks for those questions are not very well developed, and they're even less so for providing remote critical care support. Our licensing and credentialing system is obviously very inefficient. We're going to present some data soon about our efforts to roll out some of the national emergency telecritical care network programs. And even when we had everybody say yes, the state, the hospital, everybody on all sides said yes, it still took us sometimes as many as two or three weeks to get into a place to provide care when we had the technical capability to do it in an hour and a half. So stay tuned for more on that, but these things, this sort of concept of licensing and credentialing is still very locally administered and is a huge hurdle. Well, again, I'll go back to the integrity of our networks and our systems and cybersecurity is of paramount importance. In the short time that Netzen has been up and running, it's had already, you know, quite a few attacks and attempts to break the network, which is probably true of all systems, anything you put online or on the internet. Reimbursement obviously remains a challenge. I think that the biggest question is how to handle reimbursement, and it's quite complicated. I think the future is probably that because this work is being done, somebody's going to have to figure it out, but we're still in a very early stage of being able to sort of classify how the work should be done and how it should be compensated. And then, you know, the research agenda is, I think, also relatively underdeveloped, although there's a lot of people working hard on demonstrating success in their programs, most of the literature we have currently at our disposal still tends toward retrospective single center analyses. So where do we go from here, right? So it's been about 25 years, depending on who you talk to, 25 years, three decades of work in this area since the first tele-ICU programs rolled out, and the telecritical care committee at SCCM has been in existence for a good portion of that time. But I think the question is how do we build some structures to try to move beyond where we are now and to harness some of this energy. So the first thing most of you are probably aware of, most of what I do next is going to be marketing and trying to get you to join up. So the telecritical care CAG, which is the knowledge education group, was started in 2020. Majdi Hammarshi and some of the other committee members were active in getting this going. There's currently 127 members. And the idea behind the CAG is to provide a forum for regular dissemination of information for people who are interested or practicing telecritical care, or in particular to provide support for people who may be starting or expanding programs and want to talk about that. So that is live and active. Please join it if you haven't. We're hoping that the more people that join, the more productive that dialogue will get. But I think a lot of us have also felt that we probably need to consider trying to go further than that. And so there's been a lot of discussion on the telecritical care committee, and we just had an information session about this, about whether it's time to try to form a telecritical care section. Sections were, committees, sorry, were originally designed at SCCM by the council as a way to provide sort of subspecialty or specialist expertise to the council to help them with decision making. But the way the committees are structured, the participation is supposed to cycle, and I think that's good for having turnover, but you're allowed to be on a committee officially for about three years, and there's some ways you can extend that time period a little bit. But many people, and I know from talking to many of my colleagues at this meeting, every year there's quite a few people who would like to stay involved but aren't really sure how to because they're not technically allowed to be on the committee. So we've discussed this idea of basically trying to improve our strategic vision and long-range planning for telecritical care by becoming a section. And I think the point here is not to discuss whether or not it's the right idea, but my vision has always been that the process of trying to become a section could be an in and of itself in the sense that to become a section you need to have a specialized body of knowledge, and I think that we are working on that. There's a research subcommittee of the Telecritical Care Committee, which is, I just gave one example of a product that's in process right now, which is an assessment of the sort of training practices and requirements of different programs that Andre Holder is running. We are developing modules for FCCS. We've been working on developing a pre- and post-telecritical care course for SCCM. We have upcoming sessions proposed for the next Congress and there will probably be more. We need evidence of interest that the members of the society care about this, and so the very first step, and it's just a preliminary step, is that we need 200 signatures. So I attached the link floating around here. We have some copies of a QR code that you can scan. Going beyond that, I mean, I think the other thing that a lot of us have been interested in is trying to expand the footprint even beyond SCCM, and so in 2020 and 2021 we had two strategic proposals accepted for what we've called the Telecritical Care Collaborative Network. The purpose of the network is sort of modeled after the CCSC, is to have a multi-organizational, multidisciplinary body that can provide meaningful statements about critical care and can basically serve as both a forum for national stakeholders and leaders in telecritical care and also to provide some meaningful guidance to experts and decision makers. And so that project has started with our first product, which we are hoping to have published in the next few months, which is a modified Delphi method. Given that there is a lack of data, we are in a perfect sort of environment for a Delphi panel. So we've convened two panels. We have an oversight editorial panel that's made up of members of the Telecritical Care Collaborative Network, and then we have a voting panel of about 40 recognized experts in telecritical care from around the country, and we've managed to, I think, recruit a lot of impressive people to weigh in on this project. We've just finished three rounds of voting. We have about 70 statements, best practice recommended statements, that achieved over 85 percent agreement among our experts. The domains there are on the side. I won't read them for you, but the idea there is that we'll be able to say at least something about each of these different core domains of telecritical care. So stay tuned. We hope that'll be available soon. And then the last thing I think that we're heading toward and that I would advocate for is that what we then really need is some mechanism to try to develop standards and accreditation process, both for programs and for clinicians. And I think this is obviously a longer-term goal, but I think to get to a standard of care, you have to have some institutions that can both define and then measure performance against a standard. So I think, you know, whatever, as I said, a five- to ten-year goal is the creation of some kind of nationally recognized accreditation process. There are existing programs that will come and certify your telecritical care operation, but in my experience with a few of them, their standards are pretty vague. It's a little bit opaque and unclear how they determine whether you meet standard or not, and they're very expensive. And I think having one that works a little more as a public service and has a more transparent process would be very helpful. I just want to give a quick acknowledgment to everybody who's worked on this. We have at least, you know, over 250 members of the Telecritical Care Committee over its history who we want to thank. The Collaborative Network, I won't read everybody, but there's been a core group of people that have showed up every other week for the last year and a half to do this. I want to thank Christina Kordick, who does mostly everything for our administration of this group. And then Jose Luis Diaz-Gomez has been very helpful and supportive of our committee. Thank you.

telecritical care

establishing standard of care

remote patient care

telemedicine regulation

equity of access