By Deborah Borfitz
August 4, 2020 | The Medical University of South Carolina (MUSC) is trying to quickly stand up a telemedicine system to increase ICU surge capacity across the state during the ongoing COVID-19 outbreak. Up until two weeks ago, it was among the final nine (of an initial 78) organizations competing for financial support from the U.S. Army’s Telemedicine and Advanced Technology Research Center to build out a prototype on a nationwide scale. A team of biomedical informatics, telehealth, and critical care experts at MUSC nonetheless continues working at a feverish pitch to turn its envisioned Portable Remote Operational Wireless Enabled Surge Specialist ICU (Prowess-ICU) into a reality in pandemic-weary South Carolina.
So says the team’s co-leader Dee Ford, M.D., director of the MUSC Telehealth Center of Excellence and professor in the division of pulmonary and critical care. The ultimate goal of the competition was to create and coordinate a "virtual ward" that would offer technology-based and patient-centered care solutions. MUSC’s unique proposal was a model for COVID-19 care that is tightly integrated within existing regional healthcare networks to expand the usefulness of field hospitals and allow data-sharing about treated patients back to local providers.
For the first leg of the national competition, before MUSC was eliminated, the team spent 15 days and a $540,000 award to adopt an existing home care system to meet the Army’s specifications, says team co-lead Leslie Lenert, M.D., MUSC assistant provost for data science and informatics and chief research information officer. That resulted in a lengthy report detailing how Prowess-ICU could be used to care for patients at home with COVID-19.
The larger vision, Lenert says, is “to allow people to integrate data from eight to 10 sites via the cloud and feed that into a mothership institution to support both home care and long-term facilities, and surge ICUs associated with rural hospitals. We’re trying to build a solution for a surge capacity that will not go unutilized but actually graft into existing healthcare systems.”
The multi-tiered system is to include “austere” as well as advanced surge ICUs for sicker patients, all integrated together under a mothership facility caring for the sickest of the sick and using a single EHR, says Lenert. The austere, or makeshift, ICUs are intended to be deployed rapidly in response to a surge and, if needed, eventually be replaced by more robust and better-equipped advanced ICUs.
The modular structure of Prowess-ICU, which Lenert likens to an “ICU on a pallet,” will ensure ICU care gets done well and quickly almost anywhere with just the right amount of software, equipment and staff support needed at a particular time in a specific community. “The whole system scales,” he says.
“Even in the farthest reaches of South Carolina, clinicians in rural healthcare facilities can collaborate with thought leaders remotely to be able to deliver excellent care… and [later] move them to the mothership facility for needed long-term care,” says Lenert. MUSC, a regional critical care and telehealth leader, will serve as this mothership.
The Prowess-ICU concept also involves the development of smartphone apps that could read data from remote sensors and help people struggling with COVID-19 on a daily basis at home, Lenert says. Devices and apps would connect to the MUSC’s Epic EHR so high-quality critical care could happen almost anywhere.
Most immediately, MUSC will identify four to eight partners to help it deploy the system in rural areas of South Carolina. It is already in deliberation with the National Guard about this and plans to bring the state health department into the discussion, says Lenert.
Some of the simulation exercises foreseen under the original plan for Prowess-ICU will likely happen, adds Ford. Medtronic, a MUSC corporate partner, has already installed its remote surveillance system for monitoring the respiratory status of patients at some locations and they’re to be field-tested to ensure they work properly in a clinical workflow context. “In South Carolina… we have a pretty compelling need to be able to deploy some technology-enabled solutions for rural hospitals,” she says. “It’s getting pretty bad down here.”
Breadth and Depth
MUSC is hardly a telemedicine newcomer. Even pre-pandemic, it had a track record in telehealth going back 15 years that included a tele-ICU and strong regional partnerships, says Ford. Last year, it provided 117 unique telehealth services ranging from medical specialty consultations in acute care hospitals (e.g., strokes and infectious diseases) to home-based remote monitoring for the management of chronic diseases (e.g., diabetes) at almost 350 different locations, including rural and acute care hospitals, numerous schools, and rural primary care clinics. The overall volume of telehealth interactions was nearly 400,000 in 2019 and is already above 500,000 for 2020.
Virtual urgent care visits with MUSC providers have traditionally happened using a variety of telehealth platforms, such as Zipnosis and Doxy.me, Ford says. For Prowess-ICU, such platforms will be used to determine whether a patient needs COVID-19 testing.
In addition, MUSC is part of a longstanding tele-ICU program offered by Advanced ICU Care, an acute care telemedicine provider that has been remotely providing surge ICU support to hospitals around the country. For the Prowess-ICU project, Advanced ICU Care will be helping MUSC think through the remote provider workflows and communication standards needed between the mothership and off-site providers, says Ford.
When the pandemic hit, MUSC swiftly deployed several major telehealth programs specific to COVID-19, continues Ford. It reengineered a virtual urgent care tool being used for minor ailments like sinusitis and heartburn to be a no-cost COVID-19 symptom screener. The data feeds into Epic, allowing the creation of a COVID-19 patient dashboard. Its virtual urgent care program, meanwhile, became the pathway for referral to diagnostic testing.
“The idea was to keep patients out of emergency rooms and clinics where they would expose others,” says Ford. The initiative required onboarding and training an additional 100 advanced practice providers to support the existing pool of virtual urgent care providers. From a technology standpoint, it was also a “pretty big deal” that MUSC was able to create a pathway for information patients enter into the virtual urgent care platform and have it flow into Epic and then migrate into the dedicated dashboard.
At the same time, MUSC established a program for remote patient monitoring of patients diagnosed with COVID-19 and under home quarantine, Ford adds. Patients self-complete a questionnaire about their symptoms, which get monitored by a dedicated team of nurses who can check in on them as needed. Close to 600 COVID-19 patients have been so monitored.
The plan now is to add in an option for continuous or intermittent pulse oximetry monitoring so, if patients’ condition worsens, they’d be equipped with connected devices measuring their oxygen saturation level, continues Ford. The data would flow to the cloud and into the COVID dashboard.
Additionally, MUSC has used some of its telehealth video conferencing systems for communication between COVID-19 patients in isolation rooms at the hospital and their healthcare team, says Ford. This minimizes the need for healthcare workers to make unnecessary trips directly into patient rooms, thereby reducing their exposure to the virus and conserving the supply of personal protective equipment.
It takes a village to build a surge ICU system of this magnitude. Other partners in the effort include the South Carolina Clinical & Translational Research Institute, funded by the National Institutes of Health, which is providing substantial logistical and organizational support, Ford says.
MUSC’s Biomedical Informatics Center will also help create the digital infrastructure for the project and customize off-the-shelf sensors to collect COVID-19-relevant data, adds Lenert. Partners on the sensors include Masimo as well as Medtronic.
The analytics team at MUSC also plays a vital role in the project, Lenert says, as it is their job to channel data from existing and planned IT systems to Microsoft Azure's cloud computing platform. The telehealth group is also vital, of course, since they’re the ones pushing the Prowess-ICU vision forward.
Numerous provider organizations are also serving as partners. Massachusetts General Hospital is working with MUSC on standards so ICU equipment will talk to each other regardless of manufacturer, says Lenert, as well as the development of simulators for critical events. The University of California, San Diego is helping to set up high-performance “batch calls” that would distribute connections—e.g., internet, satellite, ethernet and cable—across telecommunication companies like Verizon, Sprint, AT&T and T-Mobile, to ensure Prowess-ICU always has the best possible bandwidth.
University hospitals affiliated with Case Western Reserve University will be collaborating with MUSC on safety issues and ensuring the system is “a good place to care for people from a whole system’s perspective,” Lenert continues. Dartmouth University has been tapped to help with artificial intelligence (AI) work and predictive analytics, although this is contingent on the availability of funding.
The intention is to build AI algorithms that will analyze the data for indications of patient improvement or decline, says Ford, citing a parallel example with MUSC’s virtual urgent care program. AI and natural language processing have been used to stratify patients into a high-, medium- or low-risk group based on their likelihood of having a COVID-19 diagnosis, which helps with rationing PCR tests when the supply is low.
For Prowess-ICU, the AI algorithm could similarly be used to assess which COVID patients are staying stable and to predict respiratory failure and when patients on mechanical ventilators are ready to be extubated, she says.
Another academic partner stands at the ready to take on development of a “robotic respiratory therapy,” Lenert adds, but that is more a future direction.