Thank you for the opportunity to present. Again, I have nothing disclosed, but just like Ben, there's a lot of opinions in this, and they're all mine. There isn't a lot of literature written on this, so I'm going to wax poetic for the next 15 minutes. So some questions that were posed were the minimum standards to mitigate potential harm to patient, who's responsible, and then is there a need to standardize or accredit? So there are many national guidelines when it comes to telecritical care that are set up by multiple different agencies, academic associations, and government-funded resource centers, when it comes to cybersecurity, bandwidth, encryption data, credentialing, licensure, documentation, et cetera. But there's very few standards of what we should do when the system fails and what should our fallback procedures be. So when I was thinking about this, it came up to me that really what it comes down to is do you have a plan and do you have time? Can you imagine the failure that's going to come and therefore have the time and have the ability to make a plan of what you're going to do when that happens? And then do you have lead-in time? Do you know when it's going to come? And can you have that time then to implement your plan? So I'm going to use some real-world scenarios that we've experienced to kind of demonstrate these. So I think the one that's most basic to everyone is weather. Everyone has an inclement weather plan in usually their continuum of operations. We're based in the upper Midwest, so we handle our cold a little bit differently than most folks. But even with that, there's times where even the National Weather Service says that the weather can be life-threatening. And then the other problems with these is that it can fail into other problems, power outages, et cetera. So fortunately, meteorologists are pretty good to give you a couple of days' lead-in times. This last blizzard that we had, we brought in extra food and water for our staff so if they would have to stay over, if we had trouble getting people into the core, they were able to stay over. And that gives you the opportunity for both time and plan. One of the things that we all have dealt with is computer issues, server issues, network issues, et cetera. Again, you should be able to imagine that these problems are going to happen, have a plan in place. The problem is, when does it happen? One of the things that we're frequently having to deal with is IT always thinks the best time for an upgrade is 2 AM on a Saturday morning because that's when the fewest people are around. That's the exact problem, though, for us. If it doesn't go perfectly, doesn't come back up online, they're the fewest people around. So how do you get back online when you're scrambling to call IT and biomed techs at home to say, hey, we can't get back up online. The upgrade didn't go as smooth as you promised us. And that's part of the unpredicted nature. And of course, other failures always happen in inopportune times. So then there's the things that you can't anticipate and you couldn't predict. So being based out of Minneapolis, we experienced the George Floyd protests. The initial couple days of it were pretty, I'd say, mundane when it comes to clinical operations. We just had to have our cards. And when we were going out past curfew, the sheriffs would check your cards and they'd let you on your way. Then the picture on the right there is from when the police at the third precinct decided to evacuate. And they decided to relocate in a park and ride parking lot, which was immediately adjacent to our parking lot. So our hospital administration was kind of concerned that the protests would kind of follow the third precinct down where they were restaging and decided that, hey, we should close you up because we're in this off building and move you up to the main hospital. And we're like, okay, great. Tomorrow morning, like, no, no, like four hours, we'd like you out of here. So fortunately, because it was COVID, there were some empty office space. They said, you're gonna move up into this part of the hospital, great. Then we realized we needed to get our computers up there. So we took half of our staff, they stayed live clinical. The rest of the staff, the administrative staff, we started packing up computers with our biomed folks, loading them into trucks, driving them up to the hospital, plugging them in. Our biomed techs worked like crazy to get the ACLs all pointed in the right direction. And amazingly, within four hours, we were able to get up and get running. So that just shows that sometimes you just have to go with the flow and you're gonna have to make it up as you come along. Then sometimes things fail despite your best plans to mitigate the problems. So we have like a lot of programs, two ISP providers that run into our building, told you're never gonna have two ISP providers fail at the exact same time. They'll always have connectivity. Well, apparently about a mile away from our building, there's a point where the two ISP lines basically are within five feet of each other and a city worker took a backhoe and took out both ISP lines. So we thought we were being smart and being planned. We didn't. Another example was we had generators. We have our monthly generator power checks. Everything was going fine. Power's being run by the generator, full of fuel, we're good to go. We actually had a power failure and then realized the way they hooked up the electrical panel, it wasn't then supplying electricity to the rest of the building. So when they would check it, the power was getting to the panel, it just wasn't getting out of the panel. So again, scrambling, that's pretty much the definition of this talk is scramble and try to figure it out on the fly a lot, but sometimes even your mitigation plans need backup plans. So are there minimal standards? So when you look around, most of the standards refer back to this standard from 2014 from the ATA, American Telemedicine Association. And it's about a 20 page document out of which two pages are regarding technical. And the kind of standards are pretty basic. Basically, you should be able to test from a distance. You should have a testing plan. You should have appropriate downtime procedures to ensure continuity of services and built in redundancy, et cetera. And you should kind of proactively address ongoing equipment issues and update your continuing operation plans in a proactive manner. So are there any U.S. government standards? And the short answer is really no. When it comes to some clinical support software or medical devices, the FDA does have some references or input when it comes to the failure rates and stuff like that. But their kind of general guidance is probably the best way of putting it. And not really system-based, but like individual software or equipment-based. And then Ben already kind of talked about are there agencies interested in accrediting us? Well, yeah, there's always gonna be someone that kind of wants to be involved with you. So currently, the Joint Commission does outpatient or ambulatory and behavioral health, telehealth accreditations. But it's probably not a large jump to see that the umbrella of telehealth accreditation might expand. So how do you plan for failures and try to mitigate harm? This is one of the tools. It's a failure mode and effects analysis. It's kind of fun. You sit around a table and you sit down and you try to dream up every single possible way your system can fail. And then you assign it a score by how severe the failure's gonna be, how likely it is to happen, and how easy it would be to detect the failure when it happens. And then you kind of rate that and then you kind of build your mitigation and continuity of operations plans off of that. We've done this and revised it a couple of times. And at the end, you get a little slap happy and everyone wants to do, okay, what happens if aliens invade? But it's kind of fun after sitting around for a whole day. All right. One of the things that we have the advantage of is we're a nationwide system. So we have the ability to kind of relocate our care or where our care is provided out of. So if there is like a blizzard in the Midwest, we just kind of relocate to our hubs in Las Vegas and Los Angeles. So the, if you're a smaller or, there's programs that have international locations, which clearly removes you from any kind of regional issues. This will be my plug for Netson being that if you're a smaller regional program that doesn't have kind of a grasp, if a regional disaster will take out all of your locations and you don't have a place to fill over, that something along the lines of a Netson would be a good advantage to kind of be that service to fail over to provide ongoing care, even if your local infrastructure is taken out. So in the past, the fallback has always been, well, we'll just go back to the bedside. We'll go back to how it always was. There's nurses and physicians and respiratory therapists and pharmacists at the bedside. We just fail over and they go back to how they've always done it. But the question is, is as the telecritical care programs get more integrated with the bedside, does that really provide a functional mode to return to? And I started correlating this in my head to when your EHR fails. So our last failure at the university with the EHR, everyone's like, okay, EHR is down. Let's pull out paper. Let's start writing admission orders. And I literally had to teach all the trainees and some of the more junior staff, like ADC, Vandemo. People don't know how to write paper orders anymore. So the concept of, well, we'll just fail over to the bedside might not always be applicable. And initially you think about those small places that only have hospitalists or APPs or need that additional support because there's one intensivist and they're doing 24-7 coverage and you're really backing them up. But even at the largest centers, you see that it does start putting a strain on the system when you're not there at a moment's notice. So maybe just saying, we'll just fall back to the bedside is not always the best idea. So kind of like before, this is gonna be my call for more research and best practices. There's been an outgoing request for telecritical care studies. Even the Joint Commission's journal now is asking for quality and safety papers in telehealth. So it is getting noticed by a lot of different sources. And I think publishing some of these safety plans and stuff like that may be a benefit going forward. So to kind of wrap things up, is there a need to standardize and in my mind that is, well, what is the criticality of telecritical care? Is it a vital part of the healthcare system? Is it just as necessary as bedside monitors or the EHR or something like that? And I think that if we've risen to that point and I would argue that we are, I think some standardization of what the plan is when the system doesn't work is probably important. Then the question on should we accredit programs to ensure that they're complying with the standardization falls back to is telecritical care a unique entity or is it really just part of the larger healthcare enterprise? Is it just another section of that hospital that's being accredited? So is it like the OR, is it like the ER? Should it just be part of the system? And I think hopefully that's where telecritical care is moving, that we're just another mode of where care is provided and we're just part of the larger hospital system. Thank you.

telecritical care

plans and standards

fallback procedures

system failures

patient safety