Redefining Telemedicine in the Age of Resource Limitation

By Matthew Quinn, Science Director, Telemedicine & Advanced Technology Research Center (TATRC)

In March 2020, the world was about to experience an unprecedented surge in the need for critical care.   While COVID-19 strained the healthcare capacity of communities across the nation, it impacted the 55% of US counties that lack an Intensive Care Unit (ICU) especially hard. 

Tele-critical care (TCC) expands both the capability and capacity of nurses and physicians, who lack experience in critical care, to provide this care. As described by Barbash, “Locations without ICU beds do not have clinicians who know how to use ventilators – even if they become available. Necessary is a simple, consistent means to reliably and effectively support people who deliver critical care. As long as network resources are available, Tele-Critical Care is a solution.” 

Formulating the National Emergency Tele-Critical Care Network (NETCCN)

With resources from the CARES Act, the Telemedicine & Advanced Technology Research Center (TATRC), a lab within the US Army Medical Research and Development Command (USAMRDC), established a plan to address this gap in the availability and capacity of critical care expertise and to inform how to deliver “resource-limited” care in future disasters and warfare.

The National Emergency Tele-Critical Care Network (NETCCN – rhymes with “Jetson”) allowed clinicians in need to access an on-demand, interoperable network of clinicians using secure, smartphone-based “anywhere to anywhere” telehealth. NETCCN clinicians would use digital health tools to communicate with and support local clinicians – often people with very limited critical care expertise – in the care of their sickest patients.

Traditional TCC is based on a hub and spoke model working under an established relationship with associated contracts, IT integration and other prior collaborations. During the pandemic – and other disasters – the hub and spoke model for TCC breaks down: If a hub is overwhelmed with a surge, it lacks the capacity to serve its (usual) spoke partners. Further, non-traditional sites of care – like convention centers, field hospitals  – simply could not have been part of TCC networks prior to the pandemic. Thus, the need for NETCCN to establish basic, secure communication means to support frontline clinicians in the delivery of care from where resources are available to wherever they are needed, without hardware beyond a smartphone or tablet and without basic cell connectivity..

NETCCN will become a component of global response as part of our nation’s emergency support functions for public health and medical services.

Launching and Scaling NETCCN

TATRC kicked off NETCCN with an initial cohort of nine clinical-technical teams (i.e., composed of civilian critical care clinicians and a prototype smartphone-based “anywhere to anywhere” telemedicine platform) in June 2022, less than 90 days after the declaration of the pandemic. In early September 2020, NETCCN began support of its first mission: a COVID-19 surge at a civilian hospital in Guam. On its second day of operations, NETCCN assisted a local nurse in diagnosing and treating a tension pneumothorax, which saved the patient’s life.

Through the pandemic and in collaboration with the Department of Health and Human Services (HHS) Administration for Preparedness and Response (ASPR), NETCCN supported over 60 hospitals in 19 states and territories in assisting over 1,000 unique patients. NETCCN assisted as many as 26 hospitals at the same time and enabled the President’s Test to Treat program at community testing centers across Michigan.

NETCCN was the first experience with telehealth for some supported hospitals and a supplement to other telehealth services for others. While NETCCN was available for no cost, the main barriers to deployment were related to licensure, credentialing and conceptualization of an “anywhere to anywhere” TCC service. While there were relaxed licensure restrictions during the pandemic, confusion, uncertainty, and risk aversion slowed the availability of NETCCN on multiple occasions. Similarly, unwillingness to adapt and expedite credentialing using the Federation of State Medical Boards (FSMB) ProviderBridge caused unnecessary delays. 

The Future of NETCCN

The COVID-19 pandemic – and system strains from surges and longstanding disparities – pressed TATRC and those across the healthcare continuum to reconsider traditional models and definitions of TCC.  From disasters like pandemics, hurricanes and floods to modern warfare, we must adapt telehealth and associated care models, policies, workflows and reimbursement to best serve our frontline caregivers and their patients. 

Global Response

The 2023 Omnibus directed ASPR “to continue clinical deployments for… NETCCN, which has helped health systems respond to the COVID-19 public health emergency by accessing skilled telehealth providers, and directs ASPR to make NETCCN partners available to respond to other public health emergencies and disaster response efforts on an as-needed basis.” NETCCN will become a component of global response as part of our nation’s emergency support functions for public health and medical services.

Support for Care in Modern Warfare

Modern warfare against near-peer adversaries – called Multi-Domain Operations (MDO) – will likely be characterized by large numbers of casualties, severe injuries and delayed ability to evacuate injured Soldiers. NETCCN can help address the dual challenges of mass casualties and prolonged care. TATRC is incorporating NETCCN into military exercises and “experimentation” activities to adapt NETCCN from something that made a difference during COVID-19, into something that can also make a difference during MDO.