Avel eCARE, a telehealth network and virtual hospital, helped develop the federally funded initiative known as the National Emergency Tele-Critical Care Network and is now expanding its work with the Department of Health and Human Services and the Department of Defense to provide critical-care expertise to hospitals and municipalities struggling with COVID-19 surges in the South.

Over the past few months, the organizations have deployed telemedicine services to support care in at least a half-dozen states, including Texas, Florida, Georgia, Alabama and Louisiana.

For example, in Florida, Avel eCARE partnered with EMS workers to help get Regeneron delivered to homebound patients. EMS workers administered the treatment, then Avel eCARE clinicians provided remote monitoring to ensure the patients received 60 minutes of observation, enabling EMS workers to respond to others in need and distribute care faster on the ground.

As part of the government-funded program, Avel eCARE also provided critical-care consulting to a small community hospital that was inundated with COVID-19 patients. They weren't staffed to treat patients who were so sick and didn't have experience with ventilators.

This hospital already had called 150 places to try and find a tertiary care center to transfer folks to, but to no avail. Avel eCARE was able to provide remote support to help staff by providing critical-care consulting to clinicians on-site.

Healthcare IT News sat down with Lisa Lindgren, vice president of clinical operations at Avel eCARE, to learn more about the National Emergency Tele-Critical Care Network (NETCCN) and telemedicine in the age of COVID-19.

Q. What was the problem before the National Emergency Tele-Critical Care Network?

A. Avel eCARE, based in Sioux Falls, South Dakota, is a leader in delivering telemedicine care impacting millions of patients and clinicians around the country. Since 1993, Avel has developed innovative service lines, ranging from emergency and pharmacy to ICU and school health, to ensure everyone has access to care when and where they need it.

In June 2020, Avel and ViTel Net, a telehealth technology company, were awarded funds as a team to compete in the NETCCN project, provided by the U.S. Army Medical Research and Development Command's Telemedicine and Advanced Technology Research Center.

NETCCN is a virtual health project designed to address the shortage of critical-care-trained clinicians. It was developed in direct response to the pandemic, and its purpose was to support the rapid development, deployment and testing of a mobile solution for tele-critical-care services to respond to emergencies, such as the COVID-19 pandemic, medical trauma, natural disasters – or disaster events, including war.

In the case of the pandemic, the surge of those experiencing severe symptoms created a shortage of ICU beds in hospitals throughout the country. Where there are no ICU beds, there are no critical-care-trained clinicians. And even where there are ICUs, especially during surge situations, there are not enough of the right kinds of trained clinicians. For example, during the coronavirus crisis, hospitals without ICUs were provided ventilators, but the staff didn't know how to use them in many cases.

NETCCN is now an evolving network of clinical care teams that provide expert medical advice, particularly related to managing critical illness from severe COVID-19 infection to any individual who needs it using mobile device applications. The simple act of supporting local clinicians and care teams without critical-care knowledge, skills or abilities – with expertise from remote tele-critical-care specialists enables these caregivers to provide more support to patients than would otherwise be possible.

Q. How would NETCCN resolve these problems?

A. To achieve this solution in a rapid, agile fashion, the United States Army Medical Research and Development Command Telemedicine and Advanced Technology Research Center (USA MRDC TATRC) leveraged an Other Transaction Authority (OTA) contracting mechanism and structured a contract with several industries and academic expert teams in a competitive, down-selection process to ensure that working solutions would be available in the shortest period with the most robust features and options for the communities in need.

The overall effort commenced with nine specific teams being awarded a contract for a two-week sprint to develop a minimal viable product (MVP) that the government systematically assessed. The second phase of the effort advanced six teams to expand their basic mobile phone-based solution to a more robust set of functions, which were then assessed from a simulation and human-factors perspective and a cybersecurity perspective.

As a result, four teams reached the final phase of the down selection and supported needed locations across the nation. The Avel and ViTel Net team was among them.

To help develop a collaborative solution, Avel eCARE drew on its 28 years of experience supporting patients and clinicians with a team of medical experts through robust communication and video infrastructure.

Avel conducts specialty consults out of its Sioux Falls hub, primarily servicing rural healthcare facilities. In 2004, Avel evolved to begin providing 24/7 on-demand services. While this service initially began with intensive care unit services, they were one of the earliest adopters of telemedicine to support rural clinicians.

Since then, Avel eCARE has evolved to provide telemedicine care to rural emergency rooms, behavioral health clinics, critical-access hospitals, senior care facilities and many others. Today, Avel offers one of the largest and most comprehensive virtual health networks in the world – serving more than 450 healthcare systems and facilities across the country. Avel's services span the entire inpatient and outpatient continuum, including tele-critical-care coverage of 300 ICU beds and virtual support of 190 emergency rooms in their critical-care delivery.

As part of the NETCCN project, Avel eCARE worked collaboratively to develop a cloud-based, low-resource, stand-alone health information management system to create and coordinate flexible and extendable "virtual critical-care wards."

These high-acuity, virtual wards bring high-quality critical-care capability to nearly every bedside, healthcare facility, field hospital or other location that lacks the expertise and resources necessary to care for severe COVID-19 illnesses.

Q. How did the vendors and NETCCN meet the challenge of COVID-19 and other critical-care needs?

A. Avel helped NETCCN design a solution for resource-limited, rural and underserved settings. It is intended to be rapidly deployed, easy to use, and help with tiered staffing models where local, non-critical-care-trained clinicians can have critical-care-trained experts in the palms of their hands. The solution requires only smartphones and 4G to operate and features nearly instant setup with no additional hardware.

Basic capabilities include:

• Secure, mobile communications capabilities, including synchronous audio/video and asynchronous messaging.
• Capability for basic documentation in real time as well as data collection and reporting.
• A patient registration and cohorting system.
• A team organization and management tool, including handoff features for change of shifts and transfers of care.
• Cloud-based information storage, including the ability for later offloading to EHRs, HIEs and other systems.
• HIPAA compliance.
• Survey and consent tools.
• A well-described clinical and staffing model that incorporates the technology in a simple, reliable manner for scaling during a disaster.

Here are some examples of how NETCCN can help hospitals and local care teams:

• Relief. Local experts – nurses, doctors, RTs – may be called upon to be continuously available to "supervise" their local team members who are not familiar with critical-care tasks like managing continuous sedation, troubleshooting a ventilator or addressing multiple organ failure. NETCCN can help by providing any amount of coverage for local teams – a night, a day, a weekend. Whatever is needed to allow local critical-care experts to recharge and resume their important duties.
• Relieving anxiety. There is a high level of anxiety when caregivers, inexperienced or forced by necessity, manage patients outside or at the limits of their scope of practice. Small, rural hospitals amid a surge – or even tertiary care medical centers that are overrun by patients as was the case in New York City – must often manage critically ill patients for longer than usual because referral hospitals are full. When patients meet the local care standard for transferring a patient to the next level of care but cannot do so, Avel's remote experts are there to help via NETCCN. They can guide the local care teams to manage patients best while awaiting transfer using available resources. In some cases, this type of support can relieve the transfer burden on the referral hospital by giving local care teams the confidence needed to continue managing a patient without transfer.
• A second set of "brains." Local care teams can be overwhelmed during a disaster and may not be available at all times. When a care team is managing one emergency, another emergency may occur at a different location. While waiting for the local experts to become available, remote experts can help local caregivers make diagnostic decisions by ordering appropriate tests so that necessary information is made available for the local experts to act upon as soon as possible. In some life-threatening situations when local expertise is not available, remote experts can even coach local caregivers through advanced procedures like needle or tube thoracostomy to relieve tension pneumothorax.
• Remote patient monitoring and hospital-at-home services. Monitoring patients at home, whether before they present to a hospital for services or after discharge, can help improve hospital capacity by admitting only patients who need hospital services and keeping others at home. While monitoring patients at home, Avel has helped identify those who would benefit from oxygen and has sent it to the patient's home – without a hospital visit. Similarly, patients recovering from severe illness may be able to go home earlier with appropriate oxygen support and routine telemedicine monitoring using a NETCCN application. Overall, home monitoring and home-based "hospital-like" care support optimizes hospital resources and maximizes hospital bed capacity. The local EMS or other home medical service providers can help provide additional resources like IV placement or wound care in some situations. Home monitoring also helps relieve patient anxiety by reassuring them that trained experts are monitoring their symptoms and can be available on-demand if needed.

Q. What have been some hard results you have achieved?

A. Telehealth has proven to be a vital resource to clinical-care teams during disaster scenarios, including the COVID-19 pandemic. Through their work on the NETCCN project, the Avel team has collaborated with government and private facilities to rapidly implement a NETCCN solution to support lightly resourced care teams in the current pandemic.

Over the past few months, they have deployed telemedicine services to provide relief in stressed communities, alleviate burnout for vulnerable clinical workforces and support care in more than half-a-dozen states.

In one example, one of the Avel partner sites used the NETCCN application internally to assist with remote patient monitoring and interaction to reduce PPE use. This site capitalized on the two-way camera system integrated with the NETCCN solution to check in on patients virtually from their central nursing station.

This option gave the staff a quick way to talk to a patient or check vitals remotely, allowing patients to rest uninterrupted and helping the facility preserve their limited PPE supply.

Partner sites turned to Avel to assist with patient care management due to local surges causing staffing shortages, critical-care needs for patients who are typically transferred to a tertiary center for a higher level of care, additional clinical training above what was available locally, and assistance managing their limited PPE supply during the pandemic.

The approach will serve as a model for delivering crisis telehealth in future pandemics and natural disasters.

Q. What advice would you offer healthcare provider organizations needing help from something such as NETCCN?

A. To best prepare for the next disaster where telehealth can be used to support local teams, facilities should prepare now. Utilization of programs like NETCCN and partnership with other federal organizations for disaster planning will ensure staff have the training and awareness needed to leverage telehealth in a time of need.

These systems work best when used regularly, and the local team has confidence in the program and the guidance of the remote experts. Planning and preparation ahead of a disaster will ensure a seamless launch in a time of need.

Twitter: @SiwickiHealthIT
Email the writer: bsiwicki@himss.org
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