Managing A CRISIS, Targeting Better Healthcare

The COVID-19 pandemic has exposed some of the fragilities of the U.S. healthcare system. The U.S. Army Medical Research and Development Command’s (USAMRDC) Telemedicine and Advanced Technology Research Center (TATRC), is working to rapidly expand care capacity for acute and critically ill patients, even when those patients are care providers themselves.

By COL Jeremy C. Pamplin, Director, TATRC

From Combat & Casualty Care, Summer 2020

The mission of the U.S. Telemedicine and Advanced Technology Research Center, or TATRC, is to “forge the future by fusing data, humans, and machines into solutions that optimize Warfighter performance and casualty care.” We organize our team into four core research areas, including artificial intelligence and machine learning; robotics and autonomous systems; digital health; and medical modeling, simulation, and information sciences. These research areas are managed by corresponding innovation centers which include: the Biotechnology High Performance Computing Software Applications Institute (BHSAI), the Digital Health Innovation Center (DHIC), the Medical Modeling, Simulation and Information Visualization Innovation Center (MMSIV), and the Medical Robotics and Autonomous Systems Innovation Center (MedRAS). These teams work closely together to create medical intelligent systems to optimize Warfighter health – a key component of Warfighter performance – and deliver increased medical capability and capacity at the point-of-need; both of which are necessary to optimize outcomes.

TATRC also manages the Advanced Medical Technologies Initiative (AMTI) program for the Army Office of the Surgeon General and the Defense Health Agency (DHA). This program supports small scale, innovative projects and technology demonstrations in various clinical contexts across the Military Health System (MHS) in order to identify solutions to pressing clinical needs. Projects in this portfolio are championed by MHS clinicians and are often adopted by the enterprise because they enhance quality and safety, reduce costs, improve access to care, and promote force health readiness. With an extensive network of partners, TATRC expertise is focused on the entire research spectrum, from early stage innovative research to studying how technology impacts casualty care on the battlefield and in the hospital. TATRC is engaged in essential medical research focused on advanced medical technologies and is dedicated to bringing innovative telehealth solutions to the Warfighter and the MHS.

Telemedicine is evolving rapidly into more complex digital health systems that support health and healthcare across a broad range of contexts from home to space, and from maintaining wellness to optimizing surgical outcomes. Much of this pace is due to the advances in communication technologies, telecommunications infrastructure, broad mobile device adoption, elastic cloud computing, the internet of things, big data and artificial intelligence. These technology advancements are paralleled by changes in society’s perspectives on technology’s place in everyday life and its impact on personal freedom and privacy. In particular, people are often choosing – sometime unwittingly – to exchange privacy for personal convenience. Nonetheless, technology acceptance and use of telemedicine is expanding across all medical specialties in the United States. This expansion offers opportunities not previously available in healthcare including unprecedented access to medical specialties and improved healthcare from rural or historically under-served areas. The COVID-19 crisis has further accelerated telemedicine adoption by reducing legal and policy barriers related to billing for telemedicine and cross state licensure. These opportunities are further encouraged by the 21st Century Cures act (which was signed into law in 2016), and in particular, its Final Rule published on 9 March 2020. This rule encourages unprecedented medical data and device reform toward standardization, accessibility, sharing, and interoperability.

Addressing a Health Crisis

The personal health risk for healthcare providers delivering physical care to patients, and the risk of system failure if key healthcare persons – like intensive care unit clinicians – become sick or die, are critical aspects of healthcare. Both USAMRDC and TATRC are working with the U.S. Department of Health and Human Services (HHS), the Federal Emergency Management Agency (FEMA), and the Society of Critical Care Medicine (SCCM) to develop a telemedicine solution that allows resource-rich or unaffected regions to provide critical care support using mobile technologies in the midst of a regional or national disaster. The National Emergency Telecritical Care Network (NETCCN) addresses the immediate shortage of critical care trained medical professionals resulting from the COVID-19 pandemic.

The NETCCN project intends to create a national telemedicine system using secure, cloud-based platforms that leverage the current cellular-enabled mobile device infrastructure. The project also focuses on developing models of care/staffing models that are the most efficient and safe to use during a disaster. Furthermore, a governance structure for the system must be rapidly assembled during emergencies to coordinate disparate resources into a uniform virtual critical care relief system. Ultimately, the NETCCN may evolve into a national emergency telehealth network and must be incorporated into the next generation National Disaster Medical System – an effort being led by the Office of the Assistant Secretary for Preparedness and Response (ASPR).

Telemedical Health Monitoring

Telemedicine, a healthcare delivery model that has struggled to take hold in the U.S., has taken a central role for healthcare with regards to COVID-19. Although reports vary, only about ten percent of U.S. healthcare was conducted with telemedicine before COVID-19; this number has skyrocketed to 70-100 percent of care in many circumstances since the beginning of the outbreak. Telemedicine, as opposed to care in person, is now the norm. At this time, it is unclear what percentage of care each of these two models will account for in the future, but it is clear that that U.S. healthcare delivery will never return to what it was prior to the pandemic. We are likely to see telemedicine as more of a norm, especially for routine visits and follow up care, going forward.

What remains less clear is the role of telemedicine in austere care contexts – like rural America or military operational medicine – contexts were the technology infrastructure is less mature, telecommunications and network resources are less robust, and in-person capability or capacity may not be available. These care contexts are not new to the military and have been the focus of TATRC research and development for years. Necessary for success in this context are care models that anticipate network interruption, take advantage of clinical decision support and autonomous medical device technologies as well as new training models for caregivers that emphasize the necessary skills to find answers to unexpected challenges encountered in resource limited contexts.
Other important issues related to technological enhancements and integration into the continuous monitoring of the health status of a population – in particular the military population – are related to privacy, operational security, and data quality.

ADVANCING WITH LESSONS LEARNED

In general, key areas of development for telemedicine and medical technology that will be affected by the crisis are in telehealth policy and data/device interoperability. From a policy standpoint, the nation must accept care delivered using telehealth as healthcare. They are the same. Therefore, the billing rules that have made telehealth encounters equivalent to in-person encounters must remain in affect long term. Furthermore, cross state licensure and credentialing barriers must be reduced or eliminated. While care during a disaster requires physical tasks, many of these tasks can be performed by less trained or even untrained persons under the supervision of a remote expert. Incorporating telemedicine and telemedicine clinicians into the future National Disaster Management System (NDMS) should be considered so that fewer clinicians must be physically mobilized to provide response to physical disaster location.

A national emergency telehealth network and data-structure – one that multiple technology platforms can connect-to and read-from – would facilitate real-time situational awareness of the population’s health, medical assets, and resource priorities. A plug-and-play network of devices and data sources (e.g. medical records), especially if built upon a backbone of mobile health, would be valuable and save lives during disasters. This type of system supports the goals and adheres to the requirements of the 21st Century Cures Act Final Rule; this type of system, built for a disaster, could have broad ranging impacts on the overall healthcare economy moving forward.

TATRC has a rich history of fueling telemedicine adoption across the U.S., the U.S. military, and indeed across the globe. We are encouraged by the growth across U.S. healthcare and the continued potential for telemedicine, telehealth, and digital health to shape U.S. healthcare in the future. While we don’t know what the future will look like post COVID-19, it is clear that telehealth and other advanced medical technology that has been implemented during this time will secure their places in the future continuum of healthcare. Medical technology will continue to evolve and we will adopt it as permanent parts of our lives; bringing our “doctors” back into our homes – just as in the days of house calls – will forever change how the healthcare system helps people live happy, healthy lives.