Mark Plaster: Why emergency physicians should lead the way
How to architect a profitable telemed program at your facility
Market forecasts by Roy Schoenberg and Jonathan Javitt
Rock Health’s rundown of essential industry legislation
telemedicine “I can’t recall anything in healthcare that moved from just a general notion to the absolute norm in such a short period of time.” roy schoenberg, ceo of american well page 28
CHARTING HEALTHCARE’S DIGITAL FUTURE
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A Med Tech Magazine About People
Our youngest contributor: My 20-monthold son models the Pixie Smart Diaper, which boasts a built-in, no-fuss urinalysis test. Read the full review by Medgadget’s Scott Jung on page 20.
Better, faster, cheaper. That’s the mantra being chanted quietly from the C-Suite and the halls of government in response to today’s healthcare crisis. We want better outcomes, shorter wait times and lower insurance premiums. Healthcare providers in the trenches are caught in the middle, squeezed from all directions. One proposed solution? Become more “meaningful users” of healthcare technology. But for many, this rings hollow. After all, who can worry about hot new apps and gadgets – let alone a cumbersome new EMR – when there’s a line of sick folks weaving out the door? On one hand, they are correct in that the patients will always matter most. No one knows that more than the docs on the ground. On the other hand, any physician who bucks against digital healthcare innovation has missed an important fact: The only way for healthcare to ever become faster and cheaper (occasionally even better) is through remote, digitized patient encounters – i.e. telemedicine. It is into this world – this tension – that we introduce the premier issue of Telemedicine Magazine. Telemedicine will chart healthcare’s digital future in a way that links practicing clinicians – the backbone of our healthcare system – with the tech innovators who are turning that Telemedicine is about system on its head. We’ll publish three issues in a lot more than who 2015; pick yours up at www.telemedmag.com. In his essay on page 32, Editorial Director Bill acquired whom or Gordon describes 2015 as telemedicine’s tipping what new app came point. The technology has arrived, the evidence out of Silicon Valley. base is growing and legislation supporting its Telemedicine is about practice is (slowly) working its way through the the actual delivery pipeline (read Rock Health’s legislative run-down of healthcare, from a on page 47). Not to mention that investors are dropping millions to get a piece of the pie (Scott doctor to a patient. Kozicki covers investment trends on page 43). According to Ron Gutman, the CEO of HealthTap, there’s even been tidal shift in Silicon Valley. Now instead of flocking to gaming and social media, the best tech talent in the industry are turning to medical tech start-ups (read the full interview on page 28). But telemedicine is about a lot more than who acquired whom or what new app came out of The Valley. Telemedicine is about the actual delivery of healthcare, from a doctor to a patient. That’s why, in the end, Telemedicine Magazine is as much about people – innovators and practitioners – as it is about technology and gadgets. It’s about stories of progress, and how we can all play a part. That’s one reason we’ve chosen to publish this magazine in print in an age when so many are flocking to digitally incessant blogs and news feeds. We hope the tactile experience of holding these stories in your hands will help you take the time to slow down and ask big questions. What do you want the future of healthcare delivery to look like? How can the right technology be applied at the right time, in the right way . . . by the right people? Perhaps you’ll find answers to these questions on the pages ahead. Or perhaps the people and ideas you encounter here will spark your own fresh contribution. Either way, I hope to hear from you. If you have comments or queries – or would like to pitch a story – email me at email@example.com.
telemedicine ISSUE 1 – SUMMER 2015
Logan Plaster firstname.lastname@example.org
“What music do you listen to when you need to do your best work?”
Bill Gordon email@example.com
FOUNDER / EXECUTIVE EDITOR
Mark Plaster, MD
Scott Jung, a senior editor at medgadget.com, writes about the new crop of medical wearables. 18
“Jazz (avantgarde/free jazz, not smooth)”
EDITOR AT LARGE
Nicholas Genes, MD, PhD CONTRIBUTING EDITOR
Rishi Madhok, MD CONTRIBUTORS
Sarah Jukes Taja Whitted Dr. Scott Johnson
Jessica Mercado Gourang Patel Dr. Fanie Hattingh
Ting Shih, CEO at ClickMedix, leads off our business guide with three ways to monetize telemedicine. 38
INDUSTRY ADVISORS Ting Shih ClickMedix Dr. Shiv Gaglani Quantified Care Dr. Sylvan Waller Alii Healthcare Dr. Dipak Nandi Go Telecare
Jodi Lyons SeniorSherpa Jon Pearce Zipnosis
Jon Pearce, CEO at Zipnosis, breaks down the regulatory hurdles that stand in the way of telemed adoption. 15
“Techno something with a good beat, few words and a groove”
Jodi Lyons SeniorSherpa Dr. Robert Park RelyMD
Dr. Judd Hollander Thomas Jefferson University ILLUSTRATOR
Kyle Samani, CEO at Prestine, writes about healthcare’s new business models and ‘The Innovator’s Prescription’. 45
Diana London firstname.lastname@example.org 929.888.6694 ----------Telemedicine Magazine is published quarterly by M. L. Plaster Publishing Co., LLC. PO Box 121, Galesville, MD, 20765. Editorial offices located at 68 Jay Street, Suite 412, Brooklyn, NY, 11201. Printed in the USA. Copyright ©2015. To purchase a subscription, go to www.telemedmag.com/subscribe
The authors, editor and publisher are not responsible for any errors or omissions or for consequences from application of the information in this publication, which remains the professional responsibility of the practitioner. No part of this publication may be reproduced in any format or content without written permission of the publisher. The appearance of advertising in Telemedicine does not constitute on the part of the Publisher a guarantee or endorsement of the quality or value of the advertised products and services or the claims made for them by their advertisers. www.telemedmag.com
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telescope Telemedicine briefs across the medical universe
8 wellness 9 psychiatry 10 dermatology 11 patient advocacy 12 geriatrics 14 global health 15 policy
“If you can get a patient with melanoma in [to see a specialist] as quickly as possible, you’re going to see savings over time because you’re going to catch a melanoma at stage one or two, as opposed to stage three or four.” Elizabeth Asai Co-Founder of 3Derm page 10
Rock Health Portfolio Spotlight
LANTERN This San Francisco-based tech start-up offers online and mobile coaching programs to support mental health. Clients complete an online assessment including questions about mood, stress levels and sleeping habits. Users are matched with a “coach” (each a licenced therapist) and take part in an introductory 15 minute conversation over the phone. The coach then assigns a wellness regimen that can include anything from deep breathing exercises to meditation to muscle relaxation. Coaches then check in via email and text to see how each enrollee is getting along. –Jessica Mercado
Lantern is the newest entrant into an active and growing tele-mental health market. Here are a few of the other players to watch.
For founders Alejandro Foung and Nicholas Letourneau, Lantern is personal. They built the platform after experiencing mental health tragedies in their own families.
Positioned as a midway point between self help and expensive psychotherapy, Lantern costs $49/month or $300/year.
a brief history
Lantern was founded in January 2013 and began their Rock Health fellowship in June of that year. Since then, Lantern has been awarded a $4M NIMH grant, won the top health startup award at SXSW, deployed their first product to over 40 colleges and universities, and launched their program to the public in October 2014.
by the numbers
Lantern has published papers to show their programs can reduce symptoms by 50%.
Market Matrix Credentialed
l Breakthrough l eTherapi
Lantern vs. traditional psychotherapy
l Blah Therapy
l Happify l 7 Cups of Tea
l Personal Zen Uncredentialed
traditional psychotherapy 1. Open-ended 2. Aimed at uncovering unconscious motivations cognitive behavioral psychotherapy 1. 10-20 sessions 2. Focused on meeting/ managing specific feelings and behaviors with calming techniques and coping skills.
7 Cups of Tea A mobile app and website, 7 Cups of Tea is known as “an online emotional support service” where a client can talk about practically anything with a ‘trained listener’ – someone who has received a background check and completed an online training session on active listening. Blah Therapy Blah Therapy gives you the option of either talking to a therapist (low-cost) or talking to a stranger (no cost). Their robust network boasts 92,548 members. Breakthrough Breakthrough, which has been featured in Forbes and The New York Times, connects people to mental healthcare providers for online counseling and psychiatric care. You simply go to their website, chose a therapist, book an appointment and begin your video online session. Happify Called “one of the top 10 apps to train your brain” by CNN, Happify provides activities and games that help create habits for a happier life. Customers take an assessment test, then the app provides tracks aimed at improving undesirable emotions and managing stress.
our couch to yours
Improving Your Digital Bedside Manner Therapists and psychologists have learned a few things as pioneers in telemedicine. Here are some key tips from their research to help physicians across the healthcare landscape improve their digital patient encounters. by sarah jukes
As with any innovation, there will always be the early adopters and the laggards. One of the first fields to embrace telemedicine has been behavioral and mental health. Mental health care is particularly well suited to telemedicine because of the cost benefits, its potential to improve access to specialist care and the relative ease of delivering care over a computer. Being an early adopter has allowed telemental health to develop research and evidence-based practices that can be extrapolated to other fields that may be newer to telemedicine. Here are a few of the things they’ve learned over the years.
the art of the video
Providers should be constantly aware of how they present over a video link. The physical separation inherent to telemedicine can be bridged or widened based on the richness of audio and visuals, and on non-verbal cues such as vocal tone, quality, gesture, eye contact and facial expressions. It is therefore important that providers
be as comfortable and confident as possible when providing care via telemedicine technologies. A lack of comfort and confidence on the provider’s part can negatively impact and erode a patient’s trust, satisfaction levels and adherence to treatment recommendations. The literature on the use of telemedicine in psychiatry encourages clinicians to consider increasing their energy levels and expressiveness slightly to help overcome any feelings of distance or remoteness that might result from using videoconferencing. Providers need to recognize that telemedicine is a two-way street, not a forum for the provider to talk while the patient passively listens. Allow time for psychosocial interactions and small talk as a part of the telemedicine encounter, such as allowing them to describe the reasons for the consultation or to express their concerns.
set it up right
Both the patient and provider can make small adjustments to their environment to maximize the chances of a successful telemedicine session. For example, ensure there is adequate and natural lighting where possible, have a neutral and darker background and making sure all of one’s head and upper torso are in full view of the camera. The use of a headset containing a microphone has advantages such as cutting down background noise with an improved ability to hear more clearly. Headsets can minimize echo and can give patients an increased sense of privacy. Consider the location of the video camera. Having it just above the screen of a laptop
or desktop is optimal. Use of ‘picture-inpicture’ display allows the presenter to view how they’re being presented to the patient in real time. A word of warning however – clinicians should not be tempted to watch themselves in the little window while talking. Looking into the camera helps to give patient the impression that the provider is maintaining eye contact during the session.
distance isn’t always bad
The issue of depersonalization is frequently cited as a potential telemedicine drawback. However, the distance created by using telemedicine can be a source of clinical benefit in mental health. Patients can use telemedicine to avoid the potential stigma of having to visit a mental health facility in order to access services. Along similar lines, the distance and remoteness generated by telemedicine can create a sense of safety and depersonalization when discussing sensitive or stigmatized topics. Telemedicine puts control in the patient’s hands, even allowing patients the option of turning off the camera to speak with a degree of privacy. Mental health has been a champion adopter of telemedicine. The available research and everyday experiences of those using telemedicine in delivering mental health care can offer insights and tips for other disciplines that perhaps haven’t fully realized the potential of this technology. Much of the advice is straight forward and easily implemented but it can have a tremendous impact on the telemedicine experience for both the provider and the patient. www.telemedmag.com
3Derm Starts Strong Liz Asai, founder and CEO of 3Derm, is the kind of person who can make anyone feel lazy. In high school while other kids were worrying about homecoming she was researching UV radiation’s effect on cancer. At Yale as a bio med engineering student Asai teamed up with Eliot Swart (another high schooler who spent his summers in a cancer research lab) to put their research into action. As freshmen, not quite knowing where it would lead, they began designing a 3D handheld imaging device. Their work came into focus their sophomore year when Asai and Swart decided to narrow in on dermatology. “We were thinking about places to apply our 3D imaging technologies that we’d been working on for a separate project, and it seemed like a good combination of 3D imaging,” said Asai. They began creating a device that took stereoscopic images of the skin and then sent the images to a cloud server, which could be accessed remotely by a dermatologist. “We realized that the big need in dermatology is that the wait time is so long; that to get a dermatology appointment the average wait is like 40 days in the U.S. And it varies greatly depending on the area,” said Asai. As sophomores, the duo entered their imaging device into the Center for Integration of Medicine and Innovative Technology (CIMIT) student technology contest for primary healthcare. The annual national competition open to undergrad and graduate students provides a way for innovative minds to develop ideas that can potentially change the frontline of medicine. The Yale students’ entry was a finalist, earning them $10,000 to prototype their idea. Using off-the-shelf parts, they went on to win the competition and were granted $100,000 from CIMIT. With the winnings serving as motivation to keep going, the founders had to make a decision: they could either continue going the academic route and get published or become a full-fledged company. They chose the latter and towards the end of their junior year, May 2012, 3Derm was formally incorporated. While many may idolize the idea of working out of a Starbucks café, the 3Derm team knew they had to get serious. Healthbox, an incubator that helps healthcare start-ups get their footing in the field, took them under their wing. Healthbox provided the contest 10
How 3Derm Works The 3Derm device, shaped like a game console joystick, connects to a Microsoft Surface tablet and walks the user through capturing skin lesion images.
Once the image is captured, 3Derm places the images onto the cloud server so a dermatologist can make a quick triage decision. At first the imaging device was conceived for use by dermatologists themselves, but it quickly became clear that this wouldn’t shorten wait times for patients or lessen the workload for dermatologists. As a result, the device was re-imagined for primary care doctors, allowing them to quickly image a skin problem and send to a specialist.
winners an office in Cambridge and helped them shed their “kids who are engineers” image. They knew this opportunity would give them credibility, but they didn’t expect it would aid in customer intros and help garner big name partnerships. But the next thing they new they were collaborating with Blue Cross Blue Shield who is now one of their lead investors. The 3Derm team has grown to four full-time members in Boston with eight hardware-engineering contractors through Ximedica in Province. In the current healthcare landscape patients concerned about skin abnormalities often skip their primary care doctor and go straight to the dermatologist’s office. According to Asai’s research, this self-diagnosis and self-referral means that as many as 80% of people seeking dermatology consults don’t need to be there. By pushing these patients to their primary care doctor and using the 3Derm device to quickly triage, 60% can be triaged home while 40% go on for a consult. That means dermatologists can focus on the most serious cases. And that means better healthcare as well as cost savings over time. “If you can get a patient with melanoma in as quickly as possible, you’re going to see savings over time because you’re going to catch a melanoma at stage one or two, as opposed to stage three or four,” said Asai. Overall, 3Derm is not just a cool 3-D camera; it is a complete telemedicine care service consisting of hardware, software, licensing and maintenance, which can be compared to radiology’s PACS system. It’s essentially a new workflow system for dermatology. With any start-up there are challenges: figuring out the proper hardware, finding suppliers, footing the bill for engineering. Yet Asai and her team continue to stay motivated. “We’ve created something that actually is going to be the new standard for tele-dermatology and that’s really exciting for us.” –Taja Whitted
Telemedicine Aids in Essential Patient Care Coordination Could telemedicine-backed patient navigators be the cure to an epidemic of non-compliance and needless bouncebacks? by gourang patel, pharmd, msc, bcps
In today’s fast paced health care industry, physicians are overwhelmed with the dual tasks of providing daily inpatient care while keeping a close eye on bouncebacks and readmissions. Given that each year more than 117 million patients are discharged from the emergency department alone, readmissions have created a financial burden that every hospital is keen to bring under control. The federal government estimates the cost of readmissions for Medicare patients at $26 billion annually, and more than $17 billion of it is due to return trips that could have been prevented if patients receive proper care. Medical liability experts say missed appointments and failures to follow up pose some of the greatest legal risks for physi-
cians. A study by The Doctors Company – a physician-owned medical malpractice insurer – reviewed 2,466 claims between 2007 and 2011. The report found that 36% of patient injuries resulted from patient factors such as noncompliance with follow-up calls and not adhering to treatment regimens. Twenty-four percent (of injuries) stemmed from communication breakdowns between patients and health professionals. Communication failures among physicians contributed to 7% of injuries, and failures or delays in obtaining consultations/referrals led to another 7% of injuries. The legal liabilities related to a lack of clear follow-up communication appear to be increasing as team-based models for patient care expand and encompass a wider scope of health professionals. Taking steps to improve follow-up care can prevent lawsuits and save physicians significant time and expense. Even more importantly, coordination of care (i.e. physician appointments, medications, physical therapy, nursing care) can be significantly improved. The only question left, then, is where to begin. According to one report, nearly 20% of patients experience adverse events within three weeks of discharge, nearly three-quarters of which could have been prevented with the implementation of patient advocacy, a cross-disciplinary health communication team, and the use of telemedicine in the coordination and follow-up care during and immediately after hospital discharge. Physicians should start by performing a Risk Mitigation Analysis (RMA). The RMA will allow health care providers to identify gaps in their staff communication systems and ensure that appropriate actions are taken after missed appointments, said Daniel Wright, vice president of patient safety for The Doctors Company. “Just connecting patients to specialty resources doesn’t necessarily promote the continuity of care or health care delivery that we want to see in rural areas,” said Andrew Coburn, the associate director of the Muskie School of Public Service at the University of Southern Maine. To that point, Director Jus-
tin Ward at Patient Advocates and Dr. Siegel from Tufts both point to telemedicine as a part of the solution. Here’s how patient advocates can use telemedicine to bridge the gap and aid in continuity of care. Once a patient is discharged, a patient advocate corresponds with them via Skype in order to discuss the follow-up plan face to face. Appointments are set and questions answered regarding prescription drugs. The patient advocate then reiterates routine discharge instructions to the patient if necessary and demonstrates steps to retrieving their health records using a secure portal. Once in the continual care setting, the patient advocate will educate the patient on the use of their at-home telemonitoring equipment. This equipment – which is improving daily – can monitor a wide range of health issues, can catch early warning signs, such as a sudden rise in blood pressure, and transmit data to the patient’s PCP. But as every provider knows, having the technology isn’t enough; compliance is key. The patient advocate takes on this challenge, working in conjunction with the patient on the implementation of this equipment in order to meet the patient’s ongoing health needs. The Geisinger Health Plan has released results of a study on how telemonitoring can affect patients with heart failure. Researchers studied 541 patients between 2008 and 2012 and found those participating had a 23% lower risk of hospital readmission in any given month than those not using telemonitoring. The 30-day risk of readmission was 44% lower; the 90-day risk of readmission was 38%. With the growth of telemedicine, the role of a patient advocate is becoming clearer and increasingly more essential. They are the guides, the navigators, helping sick or vulnerable populations take advantage of the technology that can save their lives. Telemedicine is changing healthcare, but it may not be enough to simply empower doctors with new tools. The industry may need an army of guides, helping patients to utilize the tools that will keep them healthy and out of the hospital. www.telemedmag.com
Don’t Get Up – We’ll Come to You Telemedicine can help providers move into the patients’ ecosystem, creating more patient-centered care for at-risk geriatric populations. by jodi lyons
Patient-centered care, shared-decisionmaking, and personalized medicine are terms reminding us that people are at the center of our healthcare universe. The Medicare Triple Aim clearly enforces this patient-centered focus as well. Nowhere is the challenge – and importance – of patient-centered care more clear than in geriatrics. Consider a couple I work with, both nearing 100, living in a single family home. They can ambulate within the house with walkers but can’t navigate the stairs to leave. They have 24/7/365 aides after being found in the house dehydrated, with no food, and with no medicine. They have no family. They can use the landline telephone, but that is the extent of their technology. Their home is in a cellphone dead zone unless you stand in the corner of the kitchen or on the front porch. There is no internet access. Creating patient-centered care isn’t an academic exercise. It’s a blending of the art and science of medicine with the realities of billing codes, regulations, technology, time restrictions, and patient perception and satisfaction. Telemedicine is a vital tool in achieving success in this area. Done well, it is the glue that creates and holds together a “patient ecosystem” – a team-based approach to care with the patient at the center. This approach is particularly important in the world of geriatrics. 12
I am part of a patient ecosystem that includes doctors, care managers, home health aides, attorneys, family caregivers, and technologists – bound together by telemedicine. Our patients are geriatric. Their care needs are complex and require us to manage multiple chronic conditions in a variety of settings. The patients can be home, in assisted living, a retirement community, or a nursing home. Most are not particularly mobile. They can’t drive and sometimes require specialized services like wheelchair vans or stretcher transport. Most have some sort of cognitive impairment which reduces the patient’s ability to adhere to medical advice and care plans. In order to treat these patients effectively, we have to meet them where they are – physically, cognitively and geographically. Doctors need to know if the patient can get the medicine they’ve been told to take; if they remember that they have to take their medicine; and if they remember how to take it. We can’t always rely on the spouse to rectify these challenges – often the caregivers of our patients are themselves geriatric. Our care team has different areas of expertise, different geographic locations, and different EMRs that don’t talk to each other. Our approach combines housecalls, telemedicine, and nonmedical support to ensure coordinated care, clear and relevant communication, and a genuinely patient-centered care ecosystem. We can’t move the patients, so we move the
Steps towards building a geriatric patient ecosystem • Allow team members to “talk” to each other, to share data, to save this information, and to move it into the respective EMRs as needed. • Compensate for connectivity and “technical expertise” issues. • Effectively use mHealth screening tools to identify threats to patient adherence, such as cognitive/mood issues, so that the team can mitigate the risks. • Provide a means to screen, monitor, assess, and communicate with the patients. • Support practitioners in the field. • Be simple enough that non-medical, non-technological “eyes and ears on the ground” with the patient can provide necessary information. doctors and the rest of the care team, both physically and virtually. In the geriatric community, there are practical challenges to creating a care team that provides care outside of the traditional medical setting. First, there often are connectivity issues – no reliable internet or mobile phone signal. Second, there often are issues with the environment in which the person lives – many people are shut-ins, many have no photo by Justin Sorensen/Flickr
social support, and a significant percentage, especially those with dementia, are hoarders. Third, many patients aren’t capable of using technology and don’t live with anyone who can – even if it is as “simple” as a smart phone or tablet. Designing an effective telemedicine program that operates within these challenges requires marrying the workflow of the doctors involved, the limitations of who/what is physically with the patients, and the limitations of technology. Sometimes, the telemedicine solution is as simple as a telephone call (maybe even a landline) between patient and doctor. Sometimes the solution is more complex – a camera near the patient being operated by a family member and a doctor on the other end for real-time assessment and treatment. In other situations, the solution becomes even more complex with the patient information uploaded to the telemedicine system and reviewed by doctors at a later time. Some cases involve monitoring devices, but often, neither the patients nor their caregivers can operate these devices. Let’s return to the couple from earlier. How can telemedicine help to reach into their ecosystem? Thankfully for them, their home health aides were armed with smart phones. When there’s a problem, they can use the landline or their phones to call their homecare agency or the doctor’s office. They also can take pictures and stand on the porch to upload them for review by a doctor. Or, they can move the patients to the corner of the kitchen and videoconference. It is basic telemedicine conducted without fancy devices – yet the technology is vital to providing medical care. The doctor only makes a housecall when needed, the rest is done virtually. Without the aides, a nurse, a housecall doctor supported by telemedicine, and the ability to share information among the members of the team, this couple wouldn’t be able to stay at home. Telemedicine is a vital tool in creating an effective patient ecosystem, especially in geriatrics where the technology can compensate for the patients’ lack of physical mobility. As an added bonus: we get to throw out the fax machine!
New Technologies Help Keep the Elderly Safer at Home
Hi-Tech S.O.S. A range of Personal Emergency Response Systems (PERS) help the elderly get the help they need when they are too impaired to pick up a phone. The Mobile Care Monitor The MobileCare Monitor watch contains sensors to detect impacts or falls and provide an alert without the push of a button. It also includes an emergency call button so users can call for help manually if needed. The watch can be personalized to set alerts based on the individual’s baseline and special needs. It also can help identify the person’s location outside. >>more at www.aframedigital.com
Lifeline HomeSafe with Auto Alert The Lifeline with AutoAlert pendant can automatically place a call for help if it detects a fall, even if the wearer is unable to push the button himself. The button sends radio signals to the communicator base which calls the Philips emergency response center. >> more at www.lifelinesys.com
GoSafe The GoSafe system includes: twoway voice communication from the pendant, calling the Philips emergency response center, AutoAlert fall detection that can automatically place a call for help if a fall is detected, and six location technologies to help locate the person indoors and out. >> more at www.lifelinesys.com
A Better ‘Big Brother’ A savvy suite of home monitoring devices learns the life patterns of elderly residents and alerts caregivers when there are deviations from the norm. For many people, the idea of living in a house where they are constantly being monitored is some kind of Orwellian nightmare. But for the elderly, it can mean something quite different: independence. An Israel-based company called Essence is capitalizing on this idea, using smart analytics and the internet of things to enhance the lives of the elderly. Here’s how it works. Once Essence has helped a resident create a wired, smart environment through company’s proprietary hardware, they begin to collect data on the individual’s daily behaviors. How often does he or she use the bathroom, and at what times of day? How often does he or she take headache medication? The Essence system learns these patterns and trends and notifies appropriate health care providers when there appear to be meaningful deviations. For instance, if a resident is sleeping at a time when they would normally be active, they might receive a phone call check in from a caregiver.
low tech, high yield
Logging In For Pandemic Practice African health drill demonstrates the power of low tech telemedicine tools like web cams and basic internet connectivity. by scott johnson, md
& dr. fanie hattingh
On October 20, 2014, as the Ebola outbreak in West Africa was advancing and crossing borders, an international telemedicine field test commenced between South Africa and the United States. The goal of the exercise was to prove the power and potential of robust telecommunication connectivity for telemedicine procedures in screening, treating, and monitoring Ebola patients in remote locations through the virtual collaboration of experts. In one hour of uninterrupted connectivity, the possibilities of driving healthcare into austere locations and orchestrating a global response to an infectious disease outbreak over the information highway were demonstrated. Directing this particular exercise was African health technology entrepreneur Dr. Fanie Hattingh (founder of The Ebola Project) and Prof. Lee Wallis, President of the African Federation for Emergency Medicine (AFEM). With assistance from local Emergency Medical Services, an inflatable “mock” Ebola screening tent was deployed in a field outside Cape Town next to Tygerberg Academic Hospital, simulating a temporary clinic that could be erected anywhere in the world. Gondwana Communications provided a VSAT (Very Small Aperture Terminal) antenna and mobile base station outside the tent, creating satellite-internet connectivity and supplying live video and audio feed for 14
the laptops and web cams positioned inside the tent and mobile command center. Using the low-bandwidth capabilities of the video telemedicine platform VSee, the team in Cape Town initiated a telemedicine call with Johannesburg-based Dr. Brian Levy, a Specialist Anaesthetist and Intensive Care Physician who represented the “Remote African Specialist”. In addition, Scott Johnson, Director of Communications at the Beth Israel Deaconess Medical Center (BIDMC) Fellowship in Disaster Medicine and telemedicine consultant, was video-linked from Ohio as the “Remote US Advisor”. The proof of concept was delivered with basic laptops, projectors, USB webcams and 3G dongles – technology currently available from most computer shops across Africa. The simple web cam placed the eyes of the world on the screening tent, and the personnel inside were guided virtually throughout the assessment of an “acutely ill” patient. With video and audio connectivity, the international team was able to simultaneously coach and advise the healthcare worker, interview the “patient”, connect the “patient” to family located 10,000 km away, and communicate to other healthcare workers. The mixture of relatively inexpensive components allowed for accurate patient assessment, remote documentation of observations, technical advice and guidance to medical personnel, as well as support for healthcare workers in an under-resourced environment. The international team also used the tele-
• Having something (even a web cam) is better than having nothing when lives are on the line • Healthcare challenges in austere areas can be overcome through improvisation and combinations of relatively inexpensive, widely available technology • High tech solutions are the future of disaster and emergency response in remote and low resourced environments; • Collaborators can offer virtual support in any global “hot zone” and instantly guide local health workers without expensive logistical operations and unnecessary personal risk • International collaboration along with access to global health communities and joint-funding, are essential components for effective and timely deployment of these life-saving solutions. medicine interface to observe and instruct the healthcare worker about infection control procedures, such as disrobing and decontamination – a step that is critical in disease control and potentially lifesaving for all workers. The simulation and all procedures were documented on a customized, African-built, electronic medical record platform. This EMR was stored on a secure site for future access and shared confidentially with colleagues globally via the telemedicine platform. Even though digital stethoscopes, otoscopes, and other higher tech telemedicine peripherals were not available at the time of this field test, the exercise nonetheless demonstrated the power of a basic web cam as a cost-effective telemedicine tool when telecommunication networks are intentionally employed. It also proved that with mobile VSAT connectivity, many telemedicine procedures can be employed, data gathered and shared with global collaborators, and experts virtually consulted in a prudent way and with immediate impact and results.
barrier to entry
How to Navigate Telemedicine’s Regulatory Labyrinth Current healthcare regulations are holding back essential telemedicine development. Here are the three biggest hurdles and how to overcome them. by jon pearce
Living in Minnesota, I love it when folks from warmer areas of the country call mid January and lead-in with “How’s the weather”? My unflinching response is “75 and sunny!” The responses are wide-ranging but always entertaining. If you were to ask a similar question on the state of telemedicine regulation, you would find no less amusing and diverse opinions – except that everyone knows that it’s not 75 and sunny. There are many barriers to telemedicine adoption, but few are more monumental than regulatory. I have outlined three changes that are actionable and will reduce complexity, uphold the standard of care and manage risk for healthcare providers as they navigate a massive shift from in-clinic care to virtual care.
1. Decouple the Mode of Care from the Standard of Care
In many states, Texas and New Jersey for example, telemedicine is defined as an interaction using a specific mode of care like phone or video. Given the rapid pace of health tech innovation, pegging policies that may be in place for years or decades to a particular mode impedes inevitable innovation. Policymakers should acknowledge
rapid innovation, understand it will not be stopped, and work to draft rules and regulations that exclude specific references to any mode of interaction. Instead, policy should shape the nature of innovation in a way that ensures the standard of care is always upheld. Adopting this “guidepost” philosophy will ensure that medical boards are able to consistently enforce relevant policy without constantly changing the regulatory landscape.
2. Limit Scope of Regulation to the Practice of Medicine
The Supreme Court recently ruled that the North Carolina’s Board of Dentistry (North Carolina State Board of Dental Examiners vs. Federal Trade Commission) violated federal antitrust laws by not having enough independent (non-industry) governance. This ruling opens the door for scrutiny into who and how policy is drafted at the state and national level. One of the criticisms of last year’s Federation of State Medical Board (FSMB) ruling on telemedicine was the paucity of current research used to inform policy and limited industry representation on the advisory group. The Supreme Court’s decision against the North Carolina’s Board of Dentistry may open the door for new legal action against medical boards that continue to dictate the mode of care (read: regulate commerce) without direct data or evidence that it fits under the aegis of medical practice or supports the standard of care.
3. Get out of the 90’s
The early days of the Internet were rife with flashing banner ads and rogue Internet pharmacies. These pharmacy sites were little more than a web form where a person entered a cursory amount of information before getting their drugs. 25 years later some states, like Arkansas, have regulations that explicitly prohibit prescribing based
on an “Internet questionnaire”. While the intent of the regulation is admirable, defining an “Internet questionnaire” these days is problematic. Is Epic’s Mychart, which is often static questionnaires, any different from the forms on www.getyourviagratoday. com? What about the digital asthma monitor platform that asks a patient to enter a few data points online or via a mobile app before a refill is issued? Agree or disagree, the point is that Arkansas and other states that have not revisited prescribing policies for virtual care in the past 5 years need to allocate space on their agenda to review and update accordingly. In a dynamic market like telemedicine, outdated policies can be as harmful as bad policies. For the past 25 years, the Internet was used primarily for passively consuming health information. The next 25 years transition to patients and providers actively engaging with the Internet and devices for diagnosis and treatment outside traditional care settings. By adopting a “guidepost” philosophy when drafting policy, limiting the scope of regulation to the practice of medicine and making time to update stale statutes, policymakers can make it easier for providers to focus on meeting the standard of care regardless of when or where care is provided. www.telemedmag.com
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teletech Practice-changing gadgets and gizmos
20 qardiocore 21 dexcom g4 platinum 21 iphone researchkit 22 a.d.a.m.m. 22 pixie smart diaper 24 healthpatch
BEYOND FITBITS: Meet The New Wave of LifeSaving Wearables by Scott Jung
A 2013 Pew study showed that 1 in 5 people use some form of technology to track their health data. Consider that just 20 years ago, health tracking “technology” was little more than a thermometer under the tongue. Jump ahead to today, and you’ll see that wearable devices are one of the most popular ways of tracking health data and the one of the hottest tech trends on the market. The most popular ones are equal parts fashion and function: stylish to wear and technologically advanced in their sensing capabilities. But the majority of fitness wearables are limited to step counting and are already seen by some as a passing fad that’s already headed the way of the dinosaur. We’re more optimistic about the small, but growing segment of medical wearables - devices that go beyond fitness tracking and monitor important information about your health. Turn the page for our list of innovative wearable medical devices that can help both patient and doctor in the management and treatment of the most pervasive chronic diseases.
QardioCore Prices for EKGs can vary widely. Uninsured patients can expect to pay around $800 (and as much as $2000) for an EKG, according to howmuchisit.org.
Qardio - San Francisco, CA
Electrocardiography is not a new technology, but it requires special knowledge to properly position the various cables and electrodes. Qardio simplifies the process with an upcoming, 3-lead wearable ECG/ EKG device called QardioCore. Looking somewhat like two boomerangs fused together at their elbows, QardioCore measures only 7.3 inches at its longest and is designed to be comfortably worn all day. Its rigid, yet ergonomic design ensures correct electrode placement every time and doesn’t require gels or adhesives. In addition to medical-grade ECG/ EKG sensors to help detect cardiac conditions, QardioCore also includes a host of other health sensors that makes it suitable for patients with a history or predisposition to heart attacks or strokes, high blood pressure, high cholesterol, diabetes, or obesity. A temperature sensor con-
tinuously measures body temperature, and a galvanic skin response sensor helps indicate stress levels. A built-in accelerometers tracks your steps, and a heart rate sensor continuously monitors your beat-bybeat heart rate. On top of all that, it’s waterproof, so you don’t need to worry about wearing in the rain. All of the measured data is transferred via Bluetooth Low Energy to the Qardio app for iOS or Android. From the Qardio app, you can view trends, view data from other Qardio devices, log activities, and set alerts for any abnormal measurements. Data from QardioCore can also be shared automatically with your doctor of those closest to you. COST: $449 AVAILABILITY: Exact date unknown (Spring 2015) WEBSITE: www.getqardio.com
iPhone HealthKit & ResearchKit
Dexcom G4 PLATINUM Continuous Glucose Monitoring System with Share Dexcom - San Diego, CA
Dexcom is a pioneer in continuous glucose monitoring (CGM), which is a method of measuring glucose levels in the body in the interstitial fluid underneath the skin. Up until recently, blood sugar levels had to be measured frequently throughout the day with painful fingersticks. Measurements were limited to a single number. With CGM’s, measurements are taken continuously every five minutes, allowing patterns to be observed and more informed decisions to be made regarding diet and insulin injection. Dexcom’s CGM takes glucose monitoring even further by making the system completely wireless and internetconnected. The system itself consists of four parts: a small, discreet sensor is inserted just underneath the skin to measure glucose levels for up to seven days, a transmitter receives readings from the sensor and sends it wirelessly up to 20 feet, a receiver with a color display, multifunction buttons, Bluetooth Low Energy, and
a speaker displays readings, trends, and alerts, and an iPhone or iPod Touch loaded with Dexcom’s Share 2 app receives and shares the data. Additionally, up to 5 family members, friends, or doctors can download the Follow app on their iPhone or iPod Touch and view the user’s data in real-time. Because glucose takes 5-10 minutes to move from the blood to the interstitial fluid, measurements from CGM’s lag behind what’s actually in your blood and aren’t always accurate. While this means that continuous glucose monitoring can’t yet completely eliminate the need for fingersticks, it allows diabetics to easily monitor trends in their glucose levels and allow their loved ones to be involved in their care. COST: Approximately $1198 (depending on insurance) AVAILABILITY: Available now WEBSITE: www.dexcom.com/ dexcom-g4-platinum-share
Since it was first launched in 2007, the iPhone has grown and evolved from a communication tool to a portable doctor’s office. From visual acuity tests to medical imaging, the iPhone has been utilized in a variety of capacities within the field of medicine. Last year, Apple announced HealthKit, a platform which sought to unify the various streams of health data the iPhone could receive from its apps, built-in sensors, and numerous third-party accessories. For many, it was seen as the first step in validating the iPhone as a legitimate medical device and Apple as a company invested in health care. From the iPhone’s Health app, data is encrypted and can be sent to other health apps for more personalized functionality or shared with health care professionals. The iPhone’s evolution into a comprehensive medical tool continued with a special announcement during Apple’s March 2015 keynote event. Apple announced ResearchKit, an open-source software framework developed specifically for medical research. ResearchKit allows medical researchers to leverage the technological power and popularity of the iPhone to create apps that gather data and help them gain further insight into various diseases. At the time of writing, over 17 medical institutions and foundations have signed on with ResearchKit. It will be interesting to see what medical discoveries and breakthroughs will be made as a result of a communication device we carry every day. www.telemedmag.com
ADAMM (Automated Device for Asthma Monitoring and Management)
Health Care Originals - Rochester, NY
According to the Centers for Disease Control, 25 million Americans suffer from asthma. While most asthmatics can manage their flare-ups through a variety of medications, many patients still end up in emergency departments,
Pixie Scientific Smart Diapers Pixie Scientific - New York, NY
Sometimes, the most straight forward solutions are the most effective. Pixie Scientific’s upcoming smart diapers are a prime example. They turn the simple baby diaper into a mobile pathology lab by using the diaper essentially as a giant urinalysis test strip. Once a urine sample is collected in the diaper (which any parent will agree is simple enough), various compounds in
desperately short of breath. Health Care Originals has developed a wearable device called ADAMM (Automated Device for Asthma Monitoring and Management) that incorporates a number of sensors to help keep asthma under control. Asthma sufferers often have difficulty recognizing symptoms of an imminent flare-up; by the time they experience wheezing and reduced lung function, it means an asthma attack is already happening. ADAMM’s highly sensitive sound and motion sensors coupled with advanced algorithms make it capable of identifying the possibility of an attack in advance. MEMS motion sensors and accelerometers measure respiration, heart rate, and body vibrations caused by wheezing. A microphone counts the number of times a user coughs but can also listen for the subtle changes in breath sounds that accompanies the onset of an attack. ADAMM also has a thermistor that can monitor for exerciseinduced asthma or other respiratory
conditions that cause changes in body temperature. ADAMM wirelessly transmits data directly to the cloud via M2M technology where it can be securely accessed or can alert someone of a possible asthma attack. It can also be paired to a smartphone using Bluetooth Low Energy to remind the user to take their medication, create a digital diary, and change the device’s settings. One critical demographic for ADAMM is children, who account for over 25 percent of asthma sufferers. Children aren’t always able to perceive if their asthma is starting to flare up, and even then, they often lack the discipline to use their inhaler. ADAMM can help ensure that parents can always monitor their kids for asthma flare-ups, which hopefully will lead to less missed days of school, reduced healthcare costs, and a better quality of life.
the urine react with different chemical reagents, causing 12 corresponding squares on the bottom of the diaper to change color. The color of each square determines the concentration of a specific compound in the urine, which aids in the diagnosis of potential urinary tract infections, prolonged dehydration, developing kidney problems, and even type 1 diabetes. There is a high-tech aspect to the smart diapers; in the center of the ring of color squares is a unique QR code. Parents snap a photo of the QR code and colored squares using a smartphone app. The photo is instantly
uploaded and analyzed in the cloud, and detailed report is generated. The results can also be sent to a doctor for further analysis and discussion. Parents will also be pleased to know that the smart diapers are free of irritating chlorine, latex, and fragrances. Pricing is still unknown, but the smart diapers are expected to be sold direct to consumers later this year.
COST: Unknown AVAILABILITY: Unknown WEBSITE: www.healthcareoriginals.com
COST: Unknown AVAILABILITY: Unknown (sometime in 2015) WEBSITE: www.pixiescientific.com
Double duty: Pixie Scientificâ&#x20AC;&#x2122;s upcoming smart diapers turn a simple diaper into a mobile pathology lab.
Vital Connect - Campbell, CA
Some have described it as a “bionic band-aid”, but we like to think of Vital Connect’s HealthPatch MD more akin to Kevlar body armor. That’s because HealthPatch does more than just protect its wearer from injuries that have already occurred, but continuously monitors vital health signs to help predict medical issues before they happen. HealthPatch MD is a small, adhesive biosensor no bigger than a couple of ECG/EKG electrodes that is worn on the chest area for up to 3 days.
It contains ECG/EKG electrodes, 3-axis MEMS accelerometer, and a thermistor and has been approved to measure a single-lead ECG, heart rate, heart rate variability, respiratory rate, skin temperature, body posture, and steps. More than just raw measurements, HealthPath MD also contains algorithms to measure stress, caloric burn, sleep quality, and fall detection. Thousands of data points are collected and analyzed every minute on the HealthPatch MD, which are then encrypted and transmitted wirelessly via Bluetooth Low Energy to a smartphone or other device. From there, it’s accessible in realtime to healthcare professionals via the company’s VitalCloud secure platform or other 3rd-party systems. Given the wide range of possible applications, Vital Connect hopes that its HealthPatch biosensors will someday find themselves everywhere, from the hospitals, assisted living communities, ambulances, and even homes. COST: Unknown AVAILABILITY: Available now WEBSITE: www.vitalconnect.com/ healthpatch-md
Have a medical device or app that we should review in these pages? Email us at email@example.com or reach out on Twitter @telemedmag 24
Unlike some biosensors, HealthPatch MD has been designed to be comfortably worn all day and night... even in the shower.
television Industry-shaping ideas and perspectives
roy shoenberg mark plaster ron gutman bill gordon jonathan javitt judd hollander
In 2014, about 15% of employers were offering telehealth to their employees as part of their medical coverage. That number is projected to move to 80% in less than three years. I canâ&#x20AC;&#x2122;t recall anything in healthcare that moved from just a general notion to the absolute norm in such a short period of time. Roy Schoenberg, MD CEO of American Well page 26
How has the FSMB Policy set the golden standard for telehealth?
Once the West is Won Roy Schoenberg, co-founder and CEO at American Well, introduced the patented service brokerage technology used by his company, which is currently the nation’s largest telehealth network. In 2013, he was appointed to the U.S. Federation of Medical Boards’ task force, where he helped shape guidelines for the “Appropriate use of Telehealth in Medical Practice.” We sat down with Roy to get his thoughts on the current and future state of telehealth, and its role within the healthcare industry.
Roy Schoenberg: Before the Federation of State Medical Board (FSMB), there was no real consensus in the market as to whether telehealth was safe or not. FSMB came in and legitimized the practice of telehealth, while also setting guidelines (see Model Telehealth Policy ratified April 2014). One of these guidelines is that the doctor-patient visit can happen only when there is a visual, synchronous interaction—essentially an audio/video functionality. The FSMB guidelines also required that patients have a choice of physician, as well as specified how documentation should take place. Overall, they stipulated over a dozen operating principles for telehealth, and in one clean swoop moved telehealth from the “wild, wild west” to a valid, standardized channel of delivery.
In the commercial population, most people get their health insurance through their employer. In 2014, just about 15% of employers were offering telehealth to their employees as part of their medical coverage. That number is projected to move from 15% to 80% in less than three years. The expectation is that this is going to become the norm. I can’t recall anything in healthcare that moved from just a general notion, to the absolute norm in such a short period of time.
The telehealth market has come a long way since American Well was founded in 2006. How has the market migrated from being a “system” to an “ecosystem?” RS: It started off with the singular notion that if you were able to get a patient in front of a physician, good things would happen. Then, we developed a better understanding of the technology behind telehealth, along with all the rest of the ingredients that make it clinically sound, safe, and valuable to both patients and physicians. This includes understanding payments (otherwise it’s cost-prohibitive) or understanding the importance of patient history, and then integrating with other systems that may have relevant information for the physician. Downstream care is also an important component. Then there’s the fact that it’s not just urgent care, but other types of healthcare that benefit from telehealth; chronic patient management, behavioral health and
disease management are just a few of these. Telehealth has evolved from the simple understanding that technology can help get a patient in front of a healthcare professional, to the understanding that this is a dimension of medicine.
How are telehealth product offerings going to evolve in 2015 and beyond? RS: Part of the evolution will result from physicians better understanding the role telehealth can play in how they interact with patients, while at the same time being financially incentivized. We will also see a big change in the way these services are being paid for. Health insurance com-
panies—who just a year ago were thinking about telehealth strictly academically—are now making telehealth part of the benefit structure. The regulators and the authorities that govern the practice of medicine are also taking two very significant steps toward telehealth. One is the Licensure Pact, which is going to allow physicians to treat patients of telehealth across state lines. The second is the coverage of telehealth under Medicare. We believe both will take place in 2015.
What new projects is American Well working on to enable innovation within the telehealth industry? RS: We have opened up the opportunity for physicians to see patients remotely, which in itself opens up a whole world of opportunities. Apple’s decision to connect the iPhone to home medical devices means that American Well physicians seeing patients through the phone can be significantly more helpful. Because telehealth is becoming an ecosystem, there are so many more innovations that are possible, making it even more effective, accessible, and affordable.
What telehealth forecast do you find particularly interesting? RS: In the commercial population, most people get their health insurance through their employer. In 2014, just about 15% of employers were offering telehealth to their employees as part of their medical coverage. That number is projected to move from 15% to 80% in less than three years. The expectation is that this is going to become the norm. I can’t recall anything in healthcare that moved from just a general notion, to the absolute norm in such a short period of time. This is going to dramatically change how the market operates, and how people view telehealth and its importance in healthcare delivery.
Who Will Be the Next Bruce Janiak? by Mark Plaster, MD
Bruce Janiak has always been my hero. Just two short years after the founding of the fledgling American College of Emergency Physicians by a handful of dreamers, Bruce responded to Dr. Herbert Flessa’s call for residents to train for a new specialty, emergency medicine. That was 1970. Talk about an early adopter. I’m sure Bruce could give you a zillion reasons for his interest in emergency medicine. It was where the excitement was. The sickest patients came in all hours of the day and night. There was also a social egalitarian aspect to emergency care. People were receiving care in the ER who were being turned away from private offices. There was a lot of potential to a career in emergency medicine in 1970, and Bruce could see it. Fast forward to 2015. Emergency medicine is an established specialty. We’re the undisputed experts at seeing the sickest of the sick. It is federal law that everyone must be seen in the ED without consideration of their ability to pay. The new challenge is cost. Healthcare has alway been expensive – after all it takes years of study and research to diagnose and treat diseases – but in the past the best care was reserved for the wealthy. Now we’re opening wide the gates for healthcare access – declaring it even a human right – and the result is a newfound strain on the collective wallet. There are two ways to approach the problem – provide less care or provide more efficient care. In the end we need to do both. But efficient care is where emergency physicians lead the pack. It takes two weeks for a family doctor to get done what I can accomplish in a few hours in the ED. And now that payment models are beginning to seriously shift around to capitated care or
simply incentives for efficient care, we are all going to be looking for efficiencies in the provision of care. Enter telemedicine – the new emergency medicine. Just like EM, telemedicine is not so much about a field of study as it is about a new model for the delivery of care. Just like people began flooding the ERs in the 60s and 70s, patients are rapidly turning to the internet today to find more efficient healthcare options. This is where emergency physicians should be leading the way. Who were the first physicians to do remote monitoring, besides NASA? Emergency physicians. Who were the first physicians to truly embrace and empower care extenders besides the military? Emergency physicians. Emergency physicians want to work hard in the ED, but also get real time off. Can you imagine a day when your ED shift is all admissions and your next shift is spent sitting in a beautiful home office? You sit, manning a big screen as you receive histories and observe the exams of multiple extenders as they go to patients homes or go to retail clinics. The really sick patients will still go to the ED, where they belong, but now they’ll get the attention they deserve, rather than being lost among the worried well. Patients who didn’t need the bricks and mortar of a hospital, or even office visit, will pay less for telemedicine and get more. EPs will do what they do best, communicate and use their intelligence instead of racing through a shift sorting mild complaints. The technology has arrived and the laws are catching up. Are you ready to embrace the future of healthcare? We just need to find a few Bruce Janiaks who can see the future. www.telemedmag.com
On the shifting trends in Sillicon Valley
Could a Physician Social Network from Silicon Valley Redefine Telemedicine? When Ron Gutman started HealthTap, it was to create a physician network where patients could pose questions to doctors and have those answers ranked and stored for later. While that databank has grown, so have HealthTap’s ambitions. This past year they launched a nationwide telemedicine service that could change the entire landscape. We caught up with Ron Gutman to hear his thoughts on where HealthTap is heading.
It’s my 12th year in healthcare and I’ve never seen anything like the current times. There’s a wind in the sails now, particularly here in the heart of Silicon Valley; to see not only the level of investment that is going into this space but even more importantly the kind of talent that is now knocking on our doors. Some of the brightest people in Silicon Valley that in the past used to do gaming and social media. Some of these amazing talented people from engineering, product data design are now moving to healthcare. We are getting a ratio of about 630 applicants for every hire. And it’s really unbelievable how the quality curve became in the past several months. And I think that’s what makes the big difference. The other thing that I see that has changed dramatically is the attitude of the industry. We are a consumer company that has served more than 2.6 billion doctor answers to date. Healthcare institutions that traditionally have been extremely conservative are now much more open to innovation and to implementing, particularly telemedicine. HealthTap is the first business I’ve ever built where we have more inbound than we can handle; in terms of how much the industry is asking us to come and implement virtual care solutions. And it’s not just providers or the HMOs. They’re across the board. You see entities that you’ve never even imagined that would want to have virtual care coming up with use cases to provide care virtually.
Is Healthtap moving towards a focus on enterprise solutions?
We didn’t plan on this initially. We are a consumer company, so our main focus is to serve patients all over the world and help them manage their health and well-being. To do that we have an information module and a communication module. Differently from other players in telemedicine, we don’t just focus on the telemedicine side. That’s just one module, the health com-
munication module. But our information side is very deep. Doctors are answering questions. They’re curating news. They’re reviewing apps. We also have an engagement module that’s been launched a few months ago that is based on a set of checklists that a doctor can prescribe alongside medications of treatment. And we help patients adhere to whatever treatments or whatever they should do or shouldn’t do because adherence is a big problem. But in terms of moving to enterprise solutions, the thing that got a lot of institutions excited is this whole notion of end-to-end provision of virtual care. I think that a lot of people have this, “Let’s set up Skype and we’ll have telemedicine” mentality. But we think about these things more from a holistic perspective; designing experiences in care that start from the moment that people discover that something is wrong or they have a concern. It’s either an emotional or a physical pain or a combination of the two, but try to be there for the patient all the way through the process. And what is really appealing to some of these institutions is that we have a platform that takes care of the patient end-to-end when they are not in the doctor’s office. So we started getting a tremendous amount of inbound interest from a lot of reputable institutions around the country. And we just didn’t have the infrastructure, to be honest with you, because we are serving patients and the DNA of the company is consumer DNA. So what we did recently was hire a Senior Vice President of Enterprise Business Development and Sales. I always like saying that I hired Gary Robinson as our first sales guy mostly because he’s not a sales guy. Gary has two engineering degrees from Stamford and he went to the business school. But most importantly, recently he actually took a company from less than $2 million in revenue to more than 125 million and took them public. And he was selling exactly into these kinds of organizations that are reaching out to us regularly. He is the guy that is starting to manage these things inter-
nally. And that means that we are going to do more work with these institutions. We will basically provide institutions the infrastructure to provide virtual care to their own patients when the patient is not in the doctor’s office. And that’s exciting.
Why should providers consider using Healthtap concierge? The physician is at the core of what we’re doing. We spend a tremendous amount of time building software for physicians and interacting with them. We are the only virtual care provider in healthcare today that actually has apps for both doctors and patients on all platforms. So a doctor can provide virtual care services to his or her patients from his iPhone or from his Android phone or from even wearable devices right now. So first, we’re really integrated with any and all major platforms. And we are the only ones. Other platforms don’t have the capability to have doctors literally have a virtual consult from their Android phone from the beach in Hawaii on a 3G network and prescribe medications that will wait for the patient in New York in Duane Reade down the street. We spent a tremendous amount of time building the capability to make the platform available through native apps, not just through browsers, on a variety of devices. Concierge is an innovative platform that we introduced. Our philosophy in working with doctors on the virtual care platform is that different doctors have different needs. Some of them just want to work with us and not do anything in offices. These docs work on Prime, which is the premium service that we provide directly to consumers or now as part of the enterprise model. So they work with us and we employ them with one of our professional corporations. We have physician groups basically that employ them. And then we work with them directly to provide care to patients who come to HealthTap.
But a lot of doctors came to us who already have their own patients. They like what we’re doing; they feel like it’s the future. But they have a practice that is going well. They do want to provide some care virtually, but they want to do it themselves. So we said why not take our platform and package it as in a Software as a Service (SAAS) model. Add a scheduling component to it. Add a payment component to it. And just create a license and provide it to doctors to provide virtual care to their own patients. I think doctors love the fact that they have the independence to provide virtual care from any mobile device or with connection and do it with their own patients on their terms at their own time. They can basically establish virtual office hours. We give them free virtual practices. They don’t need to have a website. We can give them a page in our app or one of our websites. They can just send their patients there, have them click a button and schedule an appointment in less than 12 seconds. We’re doing this in all specialties right now.
HealthTap has traditionally benefited from physicians providing free advice. Do you foresee a shift to providers insisting that they get compensated for their expertise? There are like 26 different value positions that we are offering doctors on our free app. And that free model continues. Since we started with the more consultative module, the paid versions, the free part has actually taken off dramatically. It’s actually doing better now because a lot of doctors wanted to establish a reputation on HealthTap. In the past they joined for other reasons. Now as they bubble up on the searches, people can connect with them and they can actually monetize. So they actually have a monetary incentive to build their reputation by just engaging on the free stuff as well. They
come. They build their reputation. And then they can translate it to whatever they wish to translate it to, including money. In the past the free service appealed to more altruistic doctors or those wanting to find new patients. But now that we’ve added the payment component, doctors can translate it into virtual consult that you can monetize immediately. The free side of HealthTap creates for them a way to shine on merit. It creates a transparent meritocracy where the best doctors just bubble up to the top because they provide a lot of value. And now they can get paid really well for having that reputation.
How much can docs get paid working on the Healthtap platform? Let’s say you practice telemedicine with HealthTap for two hours a day with their own patients. You take all your simple cases in your practice and move them virtually. You say to your patients, “It’s going to cost you a little bit more than a copay but you get to do it from the convenience of your home. You don’t need to waste time or money traveling. You don’t need to catch another germ in the waiting room. But you pay me directly and that will cost you $44 per consultation; whether you do it on video or you do it by text.” And if you do that for two hours a day and get a full flow of patients for these two hours you can add up to $100,000 net to your bottom line before the end of the year. It’s very significant. Doctors obviously capture most of the value. We just take a little bit for facilitating it and for the license for the platform. I think that the primary care physician in this country makes an average of $175,000. So another $100,000 is obviously a pretty big deal.
What is the HealthTap lisencing fee? Actually we don’t charge a licensing fee for now. We decided initially for the beta not www.telemedmag.com
to charge any licensing fee to the doctors because we’re in the process of just introducing it to the market. If you’re a large practice, we do charge fees. But I mean, if you are small or medium-size practice, you can come to us and at least in this stage we just charge nothing.
How does HealthTap envision the future of telemedicine? I’m a big believer that by 2020 every physician around the world will have a virtual practice alongside their real practice. And they will take all the simple cases and move them to virtual care. Once you start doing it, you’re like, “Oh my God, for simple things I would never do anything else.” We want to build the foundation. We want to build the infrastructure for that and either provide it as a service to doctors or actually help them do it. If they want to do it through us, that’s fine. And we have very big global aspirations as well. With Concierge, we’re not just confined to the United States. We can easily take the service globally.
Speaking of expansion, how does HealthTap deal with legislation regarding providing care across state lines?
We don’t do it. One of HealthTap’s first non-engineer hires was Michael Nichols who is our general counsel. One of the reason I brought Michael onboard is that he has a deep background in healthcare regulations. We didn’t launch our virtual care platform until we had doctors in all states. We have doctors in 4,000 cities and towns across the country, in 137 specialties. And we waited until we had a critical mass so that we could actually provide virtual care within state lines. The beautiful thing about Concierge is that it’s providing care to your own patients. And that’s fantastic because it’s not just local, it’s hyper-local. So we’re definitely playing within the rules of the game.
Why is it so important to be hyper local? A lot of telemedicine players, especially the new ones, are doing what I call one-anddone care. And I think in medicine this is problematic. If you talk with any physician that has been in practice for a while they’ll tell you that there’s something very important about the continuity of care and having patient data. People are not use cases. In HealthTap, we’re not allowing you to just see a physician, any physician, go away and disappear. If you want to use our premium services, you either use Prime, which means it’s access to primary care physicians and the data is kept in the system itself and it’s available to the other doctors. So there is continuity of care there because HealthTap knows you really well. Or you use Concierge and then you can either find a new doctor or invite your own doctor and start establishing a relationship with them. We’re not allowing you to connect with them until there is a relationship. Why? Because we believe that relationships in healthcare matter.
Talk a bit more about HealthTap’s use of big data If you ask me what’s my number one mantra and why HealthTAP is different than anybody else in the industry it’s all about the data. We have a tremendous amount of data and we serve hundreds of millions of people and tens of thousands of doctors and we’re actually connected to hundreds of thousands of doctors. Because of that data, we can serve the right care at the right time at the right place at the right cost. And if it means sending someone to a repository of doctor answers that were given before, that’s fine. And if it means allowing them to have a quick text conversation with a doctor, that’s fine. And if we need an HD video consultation, that’s fine. There are almost 19,000 people who have sent us notes thanking us for saving their life; not just treating cold and stomach flus. You know, we are dealing with people that are taking
care of their pregnancy, that are taking care of cancer, that are taking care of diabetes. And the reason is because we understand people well. And we build relationships. And we have a tremendous amount of data. We don’t push anyone towards a particular care solution. We will try to show you the way but always give you the option. You are not funneled necessarily to a certain experience. For example, if you asked a question, we’re going to show you answers that were given to people like you in the past. But if you don’t like it, you can jump directly into a video consultation if you want. And that’s fine. If you feel that you want to jump into the emergency room immediately, that’s absolutely fine. If you want a video consultation immediately or a text message immediately, that’s fine too.
What are the industry’s greatest challenges?
If we want to make this industry successful and an important part of the texture of care we need to be honest and to be consumercentric and keeping asking: What is the right level of care that we need to provide to the person. If it’s a text message, great. If it’s an answer that was given by a doctor and kept in a repository, great. And if now is the time to send someone to the emergency room, it’s our responsibility as well. So I think the key component to that is data, smart systems and machine learning. But how do we take all this huge amount of data and leverage it in order to give people access to the right level of care at the right time at the right cost? We need to optimize between quality and cost and data can help us do that. The more people use these kinds of systems, the more they carve the pathways; the more our machine learning algorithms and engineers here can predict what’s the right level of care for each patient.
Under Armour Sets the Stage for Broader Telehealth Integration In a world of rocky telemedicine regulations, it takes bold steps by innovative companies to shift the tide. by William Gordon In my opinion February 2015 will be known as the tipping point for Telemedicine and mHealth. Why? That is when Under Armour announced that it had acquired MyFitnessPal for $475 million. It also announced that it would acquire a European based fitness app provider called Endomando that along with MapMyFitness brings its total digital health user base to over 120 million people. This is significant in that an internationally recognized brand has seen the value in these applications and built a platform for success via acquisition. This is the moment we have all been waiting for. How long will it be before their apparel directly connects with these apps and that data is collected and linked via API to EMR providers? Epic integration here we come. But don’t pop the champagne cork just yet; the industry is still significantly challenged. Payers are stifling SIE’s (Self-insured Employers) and their ability to deploy meaningful mHealth and telemedicine solutions to their employee bases. I have seen 32
it first hand – an SIE says that they want to deploy a solution, they bring their payer to the table who has their own care management/disease management group and set of programs and the next thing you know, there is no support for this new program. Either that or you will get support but there will be no resources to manage the solution. The ability to earn more via their own solutions becomes more important then actually providing quality programs. And then there is the ever-present interoperability issue. If you aren’t designing an open system that will allow your data to easily flow to any number of systems then you are missing the boat on the biggest challenge in the industry. Organizations have literally spent hundreds of millions of dollars on their EMR deployments; they aren’t going to change their system for your solution. It’s a fact, yet so many in the industry refuse to accept it. Every new solution should be designed with the understanding that integration with the top EMRs (and EHRs) should be a given before launch. Lastly, CMS has yet to fully embrace telemedicine and mHealth. Even with the recent announcement that telemedicine will be included in their next generation ACO model, ACOs will still need to apply to be included in the program and then offer telemedince solutions. While this is a significant step in the right direction, it is only the beginning of the changes needed in order for telemedicine to be fully embraced. The ability to receive compensation for telemedicine and mHealth services and solutions or lack thereof, is still a gating factor in overall industry success. The old saying still holds true: “If CMS is reimbursing for it, then everyone else will.” What is interesting is that the VA has been utilizing telemedicine and mHealth for years yet others from a governmental perspective have yet to follow suit. If they would only talk to each other, share lessons learned and help each other understand what works and what doesn’t; we could see another tipping point.
“Wait until an Under Armour sleep shirt with sensors hits the market and they have the ability to detect sleep apnea and help people maximize their sleep patterns. You will see prescriptions for these shirts, which will cost thousands less then sleep center based studies.”
There is no denying that we stand on a precipice. All over the country telemedicine programs are publishing positive quantified results. Yet many are caught between whitepapers pontificating on glorious results and the inability to scale due to regulations. Something’s gotta give – someone has to make the first move – pushing the system one direction or the other. Which brings us back to Under Armour. Their acquisition of applications that give them access to over 120 million user lives is a significant win for telemedicine and mHealth. It legitimizes to the public and other Fortune 500 organizations the concept and viability of these types of solutions. There are leaders and there are followers, in this case an innovative leader has made a bold move into the market, others are sure to follow which will open the door to endless possibilities. Wait until an Under Armour sleep shirt with sensors hits the market and they have the ability to detect sleep apnea and help people maximize their sleep patterns. You will see prescriptions for these shirts, which will cost thousands less then sleep center based studies. Payers will have to take notice; they need to cut costs and improve outcomes.
the long view
Looking Beyond Today’s EMRs to a Future of Direct-to-Patient Connectivity Former White House healthcare adviser and TelCare founder Jonathan Javitt (left) casts a vision for telemedicine’s future, and explains why connected devices are just the beginning. interview by Mark Plaster, MD
Tell us a bit about the health IT work you did for the Bush administration. jonathan javitt: First of all, I didn’t join the Bush Administration in order to computerize medical records. I joined the Bush Administration because I was so shocked and outraged on 9/11 2001 that I felt like it was time to join the fight. And I actually spent the first 18-24 months of my time in the Administration in the National Security Health Policy Center, working on stuff that had nothing to do with Health IT but was all about preventing the next bioterrorism attack. At the end of that stint, the President’s chief domestic policy advisor came to me and said: We’d really like you to consider doing something in the civilian health care sector. And we talked about a number of different opportunities. I said: Well, you know, the thing I’ve always wanted to do is get the paper out of the health care system and move the United States in the 21st century when it comes to medical records and Health IT. And they said: Well, that’s not on our agenda. Why are you talking about that? I said: Well, here’s the problem. We’re going to spend $2 trillion on health care next year. And right now the only options on the plate are either deny care to patients or pay less money to doctors
in the hospitals. Or both. If you deny care to patients, you run the risk of killing people. And if you reduce payments to doctors in hospitals, we’re at the point where they just go out of business. So the only third alternative is to make health care more effective and more affordable. And the only way I know to do that is with Health IT. Even before we’d done anything, [Bush] put a line in the State of the Union saying: Electronic medical records save lives and save money. And people were scratching their heads and saying: Where did that come from? So we convened a task force. The President appointed me as the Chair of the Health Committee of the President’s Information Technology Advisory Committee. And we started listening. We started doing town halls all over the country. I went to HIMSS and did a couple of town halls and talked to people in industry and really started listening and understanding: Well, what can electronic medical records do and how do you deploy them? And over and over again we started hearing: Well, until you really connect the patient to the electronic medical record, at best you’ve taken something that could be done on paper and put it into a computer. But the minute you connect the patient, now you can create magic. So that was the surprising outcome of the process in which we engaged. And it’s really what led directly to TelCare.
How do you feel about the current state of Health IT? jj: I’m not satisfied with the direction and pace of electronic health records. Then again, I’ll spend my life being dissatisfied. It’s never fast enough for me. It’s never comprehensive enough for me. That’s why I’m always pushing.
Why did you launch TelCare? jj: So our focus is on using connected medical devices to join doctors and patients around improving care for chronic illness. www.telemedmag.com
And right now our first product is a connected blood glucose meter. Every time you test your blood sugar, the data goes up to the cloud. You get immediate feedback. And we’ve got a published study showing that that seemingly simple innovations – we didn’t invent the blood glucose meter; we didn’t invent the cell phone. All we really did was take a couple of chips out of the cell phone and put them inside the blood glucose meter. That little intervention seems to double or triple adherence to blood sugar testing. And at least from one study it’s reduced the cost of care by 50 percent. The real reduction is you’re spotting the people who are running sugars of three, four, 500 on a daily basis before they wind up in the hospital. These are people who wind up in the hospital in hyperosmotic coma. These are people who stroke. They wind up with gangrenous toes. All of that’s avoidable. The product is commercial. It’s been FDA cleared for more than two years now. We’ve put out 50,000 units in people’s hands.
Where do you see the greatest opportunities for remote monitoring?
jj: I think the low-hanging fruit for avoidable hospital admission is people with diabetes. It’s people with pulmonary disease. Cardiology is a little tougher. Cardiac event monitoring is technically more difficult. And building the device that lets you really spot the events is more difficult. Although I’ve seen one interesting technology for people who have sort of chronic unstable chest pain and getting cardiac enzymes drawn on a regular basis; I’ve seen a pretty nifty electronic device that’s almost as good as enzymes. But if you just attacked diabetes and pulmonary disease, that’s a lot. You don’t have to go the whole enchilada to make a huge difference. You could start out by putting the history gathering and review of systems gathering tool in the front room of the ER.
“Until you really connect the patient to the electronic medical record, at best you’ve taken something that could be done on paper and put it into a computer. But the minute you connect the patient, now you can create magic.”
How has your recent move to Israel impacted your med tech ventures? jj: For me Israel is just the world’s greatest medical start-up environment. Part of what makes it so exciting is if you show up with $100,000, the Chief Scientist for the State of Israel will match it with $500,000. That’s why Israel is ten percent of the NASDAQ. That’s amazing. As I drive from my house to the university where my wife teaches, I pass Qualcomm and Google and Yahoo and Microsoft and Intel. Pretty amazing start-up environment. Oh, and GE and Phillips. I’m part of a venture fund over there as well. We just did an IPO. I’m passionate about what TelCare is doing, but I’m passionate about the whole field. So, for instance, in the last three months we’ve had two IPOs out of Israel. One’s a company called ReWalk. It’s an exoskeleton that lets people with quadriplegia walk for the first time since their injury. The second one’s a company called Check-Cap. It’s a capsule you swallow with a camera in it and it’ll show you the small bowel. The problem is once it gets down towards the cecum, it can’t see through the fecal stream. So that’s the end of its usefulness. So Check-Cap has a capsule with a very small X-ray emitter in it. It’s doing the same kind of reflectance
X-ray as the body scanners in the airports and images the entire large bowel for you. It passes through and you poop it out. It’s a prep-less colonoscopy.
What are telemedicine’s greatest hurdles moving forward? jj: I don’t think the hurdles are political. First of all, the payers are terrified of opening one more spigot for reimbursement. That to their way of thinking is always going to be additive to everything else. A big hurdle is that, until recently, the technology wasn’t there. I mean, if you walked around the ATA ten years ago, you would have seen pretty clunky old modems; I mean, real Rube Goldberg stuff. You know, TelCare is the first product where somebody ever took a state-of-theart cellphone chip and put it inside a medical device and said: This is seamless. All you got to do is stick your finger, put a drop of blood on the strip, pull the strip back and it transmits. Nobody ever saw that before. Even now most scales, you know, you got to pair it with an iPhone. Well, that’s a frustrating process. It stays paired until your phone pairs to your car. And then all of a sudden it knocks off the Fitbit. The whole Bluetooth thing to is very unstable. I think you’re going to see cloud-connected devices.
What about the challenge of health data security? jj: Some patients will say: Well, is this HIPAA compliant? Or is this secure? And you’ll say: Well, here’s the data that says it is. And that’s the end of the conversation. People are worrying more about their bank accounts being hacked than their health records being hacked. I’ve known a number of people who were killed or injured because their health information was not available to somebody when it needed to be. I’ve never met anybody who was killed, injured or even inconvenienced because their health information was improperly
made available to somebody it shouldn’t have been. HIPAA is a great law. Being able to put somebody in jail for invading somebody else’s private information is a really good thing. So, I’m not suggesting for a minute that that’s not a good legal remedy. But normal levels of encryption are more than adequate to deter all but a committed thief. And if you’re going to be a committed thief, you’re better off spending your time invading somebody’s bank account.
How do you see payment reform and capitated care driving med tech? jj: Once you’re doing capitated care, then the government policymakers say: It’s not our problem anymore because we pushed the risk down to the care system. If med starts capitated and they can do half as many visits, they will. I just spent time with a young man today who’s built a little company around normal low risk OB. And they put a box together that costs a couple hundred dollars with a scale and a blood pressure cup and some nifty apps. And they’ve got OB groups who are taking a $3,000 global fee for labor and delivery. And they’re saying: Gee, by deploying this and we’ve got a daily weight and a daily blood pressure we can cut our number of prenatal visits in half. So the Med Star OB Group is paying a couple hundred dollars per woman for this product and service because they’re saving $800 per woman. So capitation does drive the stuff in the right direction. Now the problem you run into of course is some bright guy will say: Well, why don’t we do a study because maybe we’re seeing people twice as often as we need to? So rather than paying this nice little start-up company a couple hundred dollars for their box, let’s just cut the number of prenatal visits in half and see if anybody suffers. That’s what’s going to happen.
How My Mother Would Practice Telemedicine With any innovation there is risk, but let’s use common sense and never forget to render care that we would deem appropriate for our own family. These should be guiding principles as we move forward in a regulatory vacuum. by Judd Hollander, MD
Did you see the 2015 Super Bowl? It was a great game between the Seattle Seahawks and the New England Patriots. Both teams showed up with all their supporting cast, including the team physicians. As one would expect, when a player was hurt, the physicians and trainers ran on to the field, obtained the history and physical and rendered the requisite medical care. What interested me more, however, was what went undone. During all of the on-field medical care that was provided, not a single commentator asked whether these physicians were licensed in the state of Arizona. Check the replays. Didn’t happen. Now consider this: If these physicians had been rendering the same care via telemedicine they would have been held to a higher, more onerous, licensing standard. The fact is that as medicine takes bold steps towards new, innovative care delivery models, outmoded licensing structures create needless roadblocks. Reimbursement
models are changing – from fee for service to more value-based care – and physician groups are figuring out more efficient ways to care for patients. But we do so in a veritable legal vacuum, lacking a full legal precedent to support what we’re doing. I understand that healthcare institutions are by nature conservative. There are a plethora of regulations that they should and must follow. As physician innovators, we must lead this process and create the regulations that will allow the best care to be delivered in the best way at the best time. So how do we proceed? I would advocate two simple guiding principles as we navigate these deep waters. We must use common sense, and we must always keep the patient central. Put another way, how would you care for your own mother? The following five areas are sorely in need of these two litmus tests if we’re to move telemedicine forward in a productive way. What’s good enough for phone is good enough for phone + video. Can we agree on a very simple concept – adding video to a telephone call so that it now includes both audio and video assessments of a patient is at least as good as, if not better than, audio only? Why then have practitioners always received telephone calls from patients, helped them address their medical needs and never before been required to determine what state the patient was calling from? Does anyone know a physician who routinely asked their patients what state they were calling from? Do you ever recall a patient volunteering that information? I would proffer that having a more stringent requirement for communication with a patient by video and audio, than by audio alone, does not meet the common sense threshold. Does this rule protect the patient? If a patient travels to a pre-eminent institution, say the Cleveland Clinic or Mayo Clinic, to see a specialist for a rare condition and then returns home to another state, is it logical that the specialist who provided their care can no longer provide medical coverage www.telemedmag.com
for that patient? Could you imagine if you needed a driver’s license to drive in the state adjacent to yours? Common sense should prevail here. In fact I could argue that not caring for the patient would be abandonment – if not legally, perhaps ethically. Pre-existing relationship. Some states require that practitioners using telemedicine have a pre-existing relationship with the patient. That’s odd; as an ED doc I don’t have a pre-existing relationship with many of my patients. When my family members call our own providers, we most often get the “covering physician” whom we have never met. They are home, without access to my medical records. Should they be considered to have a pre-existing relationship with me just because I met their business partner? The covering physician knows less about me than the emergency physician. Of course, most patients are not sick enough to need the emergency physician, so why would we want to encourage them to go to the ED, when they can talk with or video chat with another provider? Do you want your mother to have to go to the ED every time she has a question or concern, or shall she wait until Monday to call her primary provider and then several more days for an appointment? Does the need for a preexisting relationship protect the patient? Does it make medical care more patient centered? Privacy Laws. Some of the privacy discussions around telehealth have been fascinating. I have heard people concerned that someone might listen in (or watch) the discussion between the patient and provider. This might be a concern, and all physicians should pay attention to it. Patients who value privacy should also pay attention to it. On the other hand, we stand in the emergency department hallways and speak with patients all day and night. On the hospital wards, we round in shared rooms and hallways and we sit at the nursing stations speaking with consultants, as patients and families walk by. We should do better in all situations, but telemedicine does not pose special challenges. Let’s be careful, but let’s 36
“As physician innovators, we must lead this [regulatory] process and create the regulations that will allow the best care to be delivered in the best way at the best time.”
also let patients control their own access. Back to the Super Bowl story. We watched the physician evaluate the patient on television. I did not see the player-patient pause to sign a HIPAA waiver. If patients want to make the telemedicine call from the mall, it is up to them. Physicians need to assume patients always want privacy, but let’s not demand more of them over live-video than we demand in the hospital or emergency department. Simple common sense. Patient identification. I have heard conversations regarding whether or not providers should require patient identification before treatment. I did not turn away the homeless gentleman I saw in the ED when it was 8 degrees outside. He did not have identification or a medical emergency, but a turkey sandwich and a bit of rest didn’t seem contraindicated due to the lack of identification. Should telemedicine physicians turn away patients who request help but cannot prove who they are? What if someone lost their wallet? Are we in medicine for the patient? Did the Hippocratic oath say we would only treat patients with a driver’s license? What about insured people who don’t drive? Do not confuse the issue of identification before treatment with identification for billing purposes. Do use common sense. Patient consent. Perhaps the strangest concern I have heard raised about telemedi-
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The Business of Telemedicine
For many physicians, telemedicine offers the tantalyzing dream of making more money while working fewer – or at least less onerous – hours. But telemedicine is a business, and there are a few building blocks you’ll need to understand before you can swap your scrubs for an iPhone.
In 4 parts
Getting Started: Three Ways to Get Paid for Telemedicine Services by Ting Shih, CEO of ClickMedix
Before we can begin to talk about getting paid for telemedicine services we need to agree on our terms. Telemedicine is the practice of providing remote consultation – to patients directly or to another healthcare provider. There are two main categories that telemedicine typically falls into: Live-video and store-and-forward. live-video
is just as you’d expect – interactive consultations using a video conferencing system. The experience is similar to Facetime or Skype, however in clinical settings it typically involves going to a designated room with video cameras and special software. With the advancements in mobile technologies, live-video now can take place through smartphones and tablets provided that they’re HIPAAcompliant. pros: More widely reimbursable cons: Requires some setup time for each conference on both ends (doctor-side and patient-side); requires scheduling between both parties and it’s not necessarily shorter than an in-person consult. store-and-forward
telemedicine involves asynchronous consultations using software tools. For the provider the experience is similar to going through your email and responding to each request in turn. pros: Easy to setup and saves time for physicians and patients. There are no timeconstraint and scheduling issues, no special room/environment needed (consult any 38
time and get paid) cons: Some states do not reimburse for store-and-forward consultations Of course, a third method – which existed long before video and store-and-forward is simple telephone telemedicine. This is still a cost effective option, and as mobile phones become more sophisticated, the opportunities only increase. Another step you need to take before providing telemedicine services – and trying to get paid for it – is to mitigate risk. Start by asking if your current malpractice insurance covers telemedicine. If it doesn’t, add it. Second, verify state rules for providing telemedicine. Some states only permit telemedicine for follow-up care, or only through video for patients in rural-designated areas. Finally, to get paid for telemedicine, there are three primary options. First, you can join an existing telemedicine service provider, such as MDLive or American Well as a part of their workforce. This can be attractive because these companies provide telemedicine malpractice insurance, they handle marketing and they compensate providers directly. This option also removes a lot of the administrative hassles associated with running your own practice. On the flip side, this option requires that you abide by the corporations rules and contracts and you’ll get paid a fraction of the price charged to end users. Plus, working for a large telemedicine provider will mean promoting their brand over your own – patients know the service, not you as the great physician in most cases. The second way to get paid is to use an off-the-shelf telemedicine system and establish your own branded telemedicine service. Depending on which state you reside in, you may be able to collect both reimbursement payment as well as private pay via online credit card payments. This option appeals to physicians who want to brand a product as their own. In addition, this option allows providers to take home more revenue and determine their own pricing (on average it’s $49 for video consultations and between $65 and $99+ for store-andforward specialist). This method also allows doctors to set their own
PICTURES BY FARIS HABAYEB
schedules and service quality as well as consider scaling the business. Of course, this autonomy and increased revenue comes at a cost. Going this route means taking on significant administrative tasks, from insurance to technology selection to marketing. If you decide to go the off-the-shelf route, start by determining what’s reimbursable in your state (e.g. live-video or store-andforward). Second, determine the consultation services you’ll offer. Will you simply offer your own services or contract with additional physicians or specialists? Third, select the right tools for the job. There are new companies being born every day who provide video and store-and-forward solutions. Finally, determine your business model – what unique value proposition will you bring to your specific market? The third way to get paid for telemedicine is to use these tools to increase your patient satisfaction and referrals. From telemedicine referrals you gain patients who otherwise would not have access to your services online or in-person. In states where telemedicine is not reimbursable, the cost of setting up your telemedicine consultation service is akin to costs to marketing your service, but enables further customer engagement. For example, tools like ZocDoc have increased the number of patients for physician practices. Telemedicine tools can also provide increased online visibility to end-consumers adding to in-clinic visits if remote visit cannot be provided. This strategy can create additional revenue as it generates more in-clinic visits for when patients cannot be served remotely. It requires no additional setup if you’re using your telemedicine tool for follow-up care for existing patients or for new patients to learn about your clinical services. Finally, it can increase patient satisfaction by providing more access to your patients without consuming your time. On the flipside, as with any marketing efforts, the increase in revenues may not be immediate as it takes time to let consumers know about your remote care services. Revenues may not be as much as collecting reimbursements or private-pay for consultations initially, but would be more cost-effective than traditional marketing efforts
Go Big: You’ve Invested in the Hardware, Now Scale It Up. by Paul Murphy
You are the administrative or clinical champion for your hospital’s telemedicine program. Your program has been functional for just over 24 months and continues to expand. In fact, your hospital has been recognized for being innovative with how it is using telemedicine technology for three service lines. Your market share for the service lines that are using telemedicine has increased. Your community awareness programs that include telemedicine demonstrations are consistently well attended. How was this accomplished? By looking beyond a single telemedicine application and planning to scale intelligently. The telemedicine market is growing at a rapid pace. This includes increasing market competition and advances in technology options such as robotics, carts, tablets, and smartphones. Technology vendors and healthcare administrators recognize that a successful telemedicine program can influence a variety of a hospital’s (or healthcare system’s) business, including patient referral patterns, revenue, and patient satisfaction. If your organization is considering a telemedicine program or has already invested in telemedicine technology, there are a few items that need to be addressed early in the process so that the program and technology can be scaled for maximum impact. An important first step when developing www.telemedmag.com
the business of telemedicine
In 4 Parts
a telemedicine program with the intent of scaling is to first determine what the program is going to be used for. This is critical as it determines the first telemedicine application (e.g. stroke, respiratory, psychiatry) and will also influence how the technology or device is actually going to be used. This is also important as your team’s efforts should be focused on the successful launch of the first service line and not distracted by potential future service lines. A successful initial telemedicine program launch is important. It not only supports buy-in from internal and external stakeholders, it also demonstrates that your team is capable of providing telemedicine services, thereby succeeding with the “proof of concept”. Going live also supports the use of the technology by both the hub and spoke locations. Exposure to and using the technology promotes familiarity and increased comfort levels for the staff. Activities such as these also help to set the stage for scaling and potentially avoiding the situation where the telemedicine equipment is “sitting around for days” waiting for the next consult. When preparing to scale the telemedicine program and technology it is important to clearly determine the focus of the second service line. If the initial service line was clinical in nature, a logical step is to add a second clinical application. The traditional hub and spoke telemedicine model offers an ideal environment for this. Consider the hub-spoke model in which the hub provides telestroke services to the spoke site. During the scaling planning sessions staff from the hub and spoke facilities meet to explore options. It is determined that the second clinical application will be cardiology. The spoke will continue with telestroke in their emergency department and cardiology will be phased-in over time. The hub and spoke facilities then use the resources (e.g. planning documents) from the telestroke program and modify them for telecardiology. Soon telestroke and telecardiology service lines are operational with positive patient outcomes being reported. 40
When scaling up, don’t limit yourself to clinical applications. Consider “social” applications such as education and marketing. A potentially easyto-implement opportunity is educational support between hub and spoke facilities. This can range from conducting “mock codes” to patient care reviews and team huddles.
The scaling of telemedicine technology or the expansion of a telemedicine program does not need to be limited to clinical applications. Consider “social” applications such as education and marketing. A potentially easy-to-implement opportunity is educational support between hub and spoke facilities. In this model the hub and spoke facilities schedule educational in-services that can be also be delivered or supported by telemedicine devices. This can range from conducting “mock codes” to patient care reviews and even team huddles. Using the technology socially can also help to build rapport between the staff at the hub and spoke facilities. Hospitals and healthcare systems have successfully included telemedicine technology in their marketing efforts, such as at local community events,
fundraising events, and public speaking events. Depending on the technology that is being used in the telemedicine program, a “wow” factor can be leveraged to heighten the awareness surrounding the technology that is available in the local healthcare system. There may also be opportunities for the technology to be scaled and utilized in your backyard, or “systemically”. If your institution/system has multiple facilities, explore how the technology can be used in the other locations. For example, some hospitals have clinics located in different geographic areas, such as throughout a city. Telemedicine services can be provided to those outlying clinics, essentially as spoke sites. Examples of applications include supporting mid-level providers when they perform school physicals, remote patient follow-ups as an alternative to having the patient travel miles to the primary facility, and specialty clinics. Telemedicine technology can also reduce or eliminate the need for a provider to leave their primary location (e.g. private practice or office) when providing consultations to other offices “on campus” or other remote providers. When implementing and scaling a telemedicine program, consider tracking any lessons-learned with each service line. This can be invaluable with future implementations. The lessons-learned may reduce future implementation timelines, may assist in avoiding mistakes that were made in the past, and may ultimately promote successful implementations. This not only creates a cumulative win-win situation for all stakeholders, it also demonstrates your commitment to achieving a quality telemedicine program that is scalable. You have the technology. You have a vision. You have identified at least one telemedicine service line. By scaling the technology you may become a “healthcare market disruptor”. As technology and innovation continue to expand, only a lack of imagination will limit what may be possible with the scaling of telemedicine technology.
Get Your Program Into Gear So you have been put in charge of developing your healthcare organization’s telemedicine program. Here are some tips on getting started. by Aneel Irfan, CEO of IMST Innovations
Telemedicine is an ever-changing landscape in America. Regulatory changes are happening swiftly and when your organization is looking for telemedicine solutions, being up to date on these issues is key. Here are a few places to begin. Know Your State If you’ve been put in charge of launching a telemedicine program at your hospital, the first thing you need to know is your primary operating state. There are many states that have adopted telemedicine laws with full parity on reimbursement from medicare and private payors, but others are still behind the pack. Some even have barriers that limit the use of these technologies to “rural” areas. Some states present issues with providing and prescribing via telephone, crossstate licenses and a lot of these laws seem to change from one state to the next. Even though it is expected at some time in the near future that all states will put some sort of telemedicine regulation into law, until then it is very important to stay in touch with these movements. A great way to do so is to connect with your local telehealth resource centers. These are at many times government-funded organizations spread out around the country. They are a wealth of information and their sole purpose is to advance the adoption of telehealth. Get to know them, attend their conferences and be a fixture in their discussions. They will be a vital part of your region’s tele-
health growth. Also, always keep an eye on updates from the American Telemedicine Association. They are the authority when it comes to telmedicine in our country. They often publish great articles on regulation and use of telehealth for specific specialties. Which leads me to my next point. Know Telemedicine Isn’t One Size Fits All Telemedicine can help all types of providers and specialties but the type of rollout needed is often very different. For a simple example take an independent mental health counselor, who may just need a HIPAAcompliant video conference platform to extend the reach of their care. A telehealth platform for mental health is pretty simple with no need for much more – just please don’t use Skype or Facetime. Now take a dermatologist with several locations. A provider like this may require a more extensive rollout with integrated “connected” medical devices and patient sites across several clinics. This involves more equipment and training. Understand that organizations have different goals and initiatives. Know your vision of how the telemed program should operate. Ask yourself what the goals are for the program. What patients will be enrolled into the program, how you will use it and your future plans for scaling. Keep in mind that the outcomes of these programs differ from organization to organization. A sole practitioner may use telehealth to grow their practice and offer an alternative for follow ups. A hospital will use their program to bring down readmission or cut down mortality rates in their ICUs. A group of physicians might want to use telemedicine to collaborate on cases and cut down on travel costs from clinic to clinic etc... Telemedicine programs come in many shapes and sizes. They include not only video conferencing but remote patient monitoring, software, hardware and the list goes on. No matter the situation, large or small, it is important to diagnose your needs first and understand telemedicine isn’t a cookie cutter solution. www.telemedmag.com
the business of telemedicine
In 4 Parts
Program Design First, Technology Second There are many technologies on the market, some better than others. But in the end, as long as they are compliant and certified, they all basically do the same things. That is why it is so remarkable that so many people overlook the critical step of program design! Just as you wouldn’t build a house without a blueprint, the same goes with a successful, built-to-last telemedicine program. Now, as I said before, organizations vary and so do the intricacies of their program design, but some basic principles always apply. Such as having a complete collaboration between stakeholders. From vendors to IT, admin to users and patients. Yes, patients! At times they are left out of the discussion when they will probably interact with your telemedicine system the most. Make sure they are kept in mind during the design process and technology selections. Workflows need to be documented, easy to learn and thorough. Think about patient enrollment, malpractice coverage, state guidelines, best practices and elements that will scale the program for the future. With these components in place, implementation with a testing phase is next and then a go-live rollout. This is when all the time taken in developing the program is executed. Program design and development isn’t the sexiest thing about telemedicine, but it is extremely important. Technology Should Facilitate, Not Complicate The use of technology and some sort of software system is now a reality for all healthcare providers. There are times when introducing new systems into your organization can be met with some resistance. Do yourself a favor and try your best to introduce telehealth technologies that streamline – not complicate – your workflows. No matter if it is an EMR, EHR, LIS or whatever other acronym for a system you can come up with, to me one rule applies: It needs to be user and integration friendly! Offer up a solution that integrates easily with your existing EMR while not hindering access to it. It’s very im42
Step 1: Get Connected Telehealth Regional Resource Centers TexLA
TX + LA
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portant to have the ability to look into patient records during these remote consults. Make telemedicine simple to deploy for your organization. A good software solution should be one that anybody, not just an expert, can log into without much training and be able to figure out. Hardware, on the other hand, can be tricky, especially if the software platform is built to only integrate devices from that specific vendor. Use these integrationaverse vendors at your own risk. Depending on the size of the program being deployed, hardware should be chosen on projected frequency of use and, of course, specialty. Here are a few questions to have answered: Are you looking for more of a stationary site or mobile solution? For example, a clinical access station is ideal for a stationary remote patient site but a mobile transportable exam station option may be perfect for telemed consults on the go. What types of “connected” devices do you wish to introduce? Connected exam cameras, stethoscopes, EKGs
and others are all options available but make sure they can be integrated into the chosen software platform. Build to Scale Once your telemed program is initiated, there need to be measures in place to grow the program into other service lines. For example, your initial program may just cover stroke or behavioral health but simply adding peripherals can expand into other modalities. Introducing a 12 lead EKG can be your base for a tele-cardiology program. When designing your program, make sure there are plans for expanding into all the service lines your organization offers. Take into account what additional costs that may accrue with any expansion of the program and keep these funds available in your overall budgets. A successful telemed program for any organization takes careful planning, collaboration and execution. Use these steps in getting your program into gear and on the path to ROI.
Investing in the ‘Quantified Self’ While many consumers see wearables as a way to simply track their steps, investors see a bigger picture – a world where consumer data is constantly building an evidence base for better, cheaper healthcare interventions. by Scott Kozicki
Unless you’ve been living under a rock lately, by now you’ve heard of a new category of consumer electronics called ‘wearables’. These are things like the Fitbit or the Jawbone Up. If you wander into a Best Buy or electronics store near you, you’ll notice an entire section of these devices from lots of manufacturers. They do things like track how many steps you’ve taken in a day, or what your heart rate is when you’re doing that mad dash to pick the kids up from school. There’s the obligatory weight scale. And even some really interesting devices that help people with asthma track air quality based upon where they are. Some smart phones like the Samsung Galaxy S5 or Apple iPhone 6 even track some of this information while they’re sitting in your pocket. All of these devices and a slew of smart
phone apps fall into the Quantified Self movement. Quantified Self is a very 1960’s science fiction sounding term that operates on the axiom that you cannot manage what you do not measure. In the health care industry, we refer to it as mobile health or mhealth or digital health. The idea being that you already carry devices with you which do everything from help your dating life to managing your finances, so why not use them to help you lose 10 pounds or train for that 5k or remind you to take your medication? After all, you’re already staring at that screen most of the day. Sounds like a great idea, right? The obviousness of how useful this can be isn’t lost on investors or entrepreneurs or big companies either. In 2014, startups in this space raised over $5B, which was nearly www.telemedmag.com
the business of telemedicine
In 4 Parts
double the 2013 total of $2.8B and a cumulative $13B(!) since 2010. New brands like Misfit Labs and MyFitnessPal are starting to take the stage alongside recognized brands like Nike, Google, and Apple. But why so much money into something that seems at best a novelty and at worst the 21st century version of the Tamagotchi for the cross fit crowd? First, it goes back to the Quantifed Self axiom. Without truly knowing what your body is doing, there’s no way to really improve or optimize your activity. Most of us would say that we’re pretty healthy. Maybe we need to lose a few pounds or get off the couch a bit more, but other than that, we’re okay. The Center For Disease Control however, paints a very grim picture of American’s health habits. About half of adults already suffer from at least one chronic disease, and one in four have two or more. That means that the other half are at very high risk for developing one, as 47% of Americans have at least two risk factors already. The CDC also reports that about half of all adults don’t meet the requirements for aerobic exercise activity and nearly two-thirds don’t meet the requirements for strength training activity. Sadly, the numbers are even worse for children. The number one killer of American’s isn’t Ebola or terrorists or guns. It’s heart disease. And it will kill 2200 people today. So much for self assessment, huh? Without tracking what we are actually doing, there’s no way for us to find ways to improve in meaningful areas. There’s no way to see how much improvement we’ve actually made when we do decide to quit smoking, eat healthier, and get more exercise. Things we all know we need to be doing, yet those tend to become just vague concepts without some tracking. There’s no way for our doctors and the health care delivery system to figure out who needs the most help right now, without some way of tracking who is at the most risk. We already know that what we’re doing isn’t working out so well, so the only way to improve is to measure, try something else, and measure 44
again. So that’s great. But why all the money being spent in an effort to help us use our smart phones to notice that we took the stairs up to the office after lunch instead of the elevator? Can’t my belt be the indicator that this is working? The problem with the CDC’s numbers aren’t just the staggering death toll. Although that should be enough. It’s the cost associated with these bad habits. American’s spend $3T (yes, trillion) on health care EVERY YEAR. That’s one fifth of the entire economy! And those are direct costs. It says nothing about the day you had to take off of work because you had to take dad to the doctor because he was having chest pains again. With three trillion dollars on the line, it’s easy to see that there’s huge money to be made in helping to reduce some of those costs or merely replacing them with tools that yield more value for the dollar spent. Not only will we save lives but we’ll
There’s no way for our doctors and the health care delivery system to figure out who needs the most help right now, without some way of tracking who is at the most risk. We already know that what we’re doing isn’t working out so well, so the only way to improve is to measure, try something else, and measure again.
get very valuable data on what works and what doesn’t. Something that the existing health care system has a very hard time producing. There’s one more thing that is pushing this new frontier and it’s perhaps the most important one of them all. The rise of the consumer. Today, you can barely function without your smart phone and connectivity to the web. It permeates our entire lives. From finding a store to booking travel to checking our account balance, everything is done on those small screens we carry around with us. Except our health. Very few of us, albeit a growing number, use some mobile app or gizmo to help us with our health. Like it or not, the Accountable Care Act (or Obamacare) started getting us to think about how our own hard earned dollars are spent on the health care services we consume. That is now starting to get people thinking about why they can book a flight on any number of apps on their phone but it’s very hard to book a doctor’s appointment. This is changing rapidly. And it may be the single biggest factor in ushering in a wave of innovation and disruption of how we select, pay for, and engage with health care services. The goal being that this is easy and provides good value for the dollar spent. Here’s another way to look at it: if I told you that I could save even one of those 2200 heart disease deaths today by using a mobile app, would it sound so crazy? If I asked you to spend $11B over five years in order to try and reduce the number of children who will develop type 2 diabetes over the next 20 years, wouldn’t that sound like a great deal? Probably. And here’s the most exciting part: we are just getting started. It took about 5 years from the introduction of the Apple iPhone in 2007 for mobile apps to be so ubiquitous in our culture to the point where your mom probably knows what Instagram is. What if in 2020 everyone knows what their LDL and BMI are and how much they’ve dropped since New Years? That’s where we’re headed and it’s going to be an exciting ride.
The Innovator’s Prescription
Telemedicine Must Address Tomorrow’s Business Models Incentives are re-aligning and business models are changing. Here’s how telemedicine meets healthcare’s next challenge. by Kyle Samani According to Clayton Christensen, one of the core problems in healthcare delivery is a mix of intertwined business models that create massive operational overhead and inefficiency. In his book The Innovator’s Prescription, Christensen lays out the problem – with a focus on understanding unique healthcare business models – and offers his prescriptions for improvement. In the end, though he rarely calls it by name, the chief enabling technology for all of Christensen’s solutions is the same: telemedicine. Christensen lays the groundwork by describing the three distinct business models that exist in hospitals. We’ll outline each here, along with the new reimbursement to support the care delivery models, and how telemedicine enables each model. Business Model #1: Diagnostics and non-linear treatments The process of diagnosing and treating many complex patients is a non-linear process. There are often many unknowns that cannot be predicted or understood without sophisticated testing and experimentation. With enough time, money, and energy, physicians can usually diagnose and treat the problem. The diagnostic and treatment business, according to Christensen, is akin to the strat-
egy consulting business. Strategy consultants are rarely paid based on outcome, but rather based on the time and energy they put into solving the problem at hand. Consultants can’t guarantee an outcome on a pre-determined schedule because they simply can’t understand the depth of the problem prior to committing to solving it. They rely on specialized training to determine the root cause of problems and devise elegant solutions that balance the needs of all stakeholders.
ment – and can guarantee results with precision.
Business Model #3: Wellness and chronic disease management Most of the attention and innovation happening in healthcare today revolves around wellness and chronic disease management. The premise of this business model is predicated on tracking and understanding one’s health on an ongoing basis to make better lifestyle decisions to avoid interacting with business models #1 and #2 deBusiness Model #2: Repeatable, known scribed above. procedures The fundamental problem Unlike the diagnostics dewith chronic condition manscribed above, there is a masagement is assuring adherence For Christensen, sive sector of medicine that is to the prescribed therapies. the key to highly knowable and repeatMost patients unfortunately reducing costs able. Physicians can guarantee don’t adhere to the prescribed and creating a outcomes for many procepolicies that are intended to – more affordable dures because the diagnostics and are generally effective at healthcare and treatments are extremely – preventing costly hospitalsystem? well understood and formuizations. Thus, the challenge Embrace more laic. Providers can diagnose of chronic condition managedisruptive quickly against explicit, easbusiness models. ment is really one of behavior ily measurable criteria. With modification and change. The a well understood diagnosis in most effective therapies for behand, providers can prescribe havior change have been social a treatment plan, and patients in nature. Patient networks verify everything independently online; pasuch as PatientsLikeMe, Alcoholics Anonytients don’t need to rely on their physicians mous, and others have proven extremely sucprescription, although many do. This is parcessful in changing behaviors at scale. ticularly common in surgery, as well as many Unfortunately, healthcare insurers today office-based procedures and cosmetics. Usdon’t financially support and providers rarely ing Dr. Google, patients already do this toprescribe these programs. Thus patients who day en masse. Dr. Google helps patients keep need a chronic disease management system providers in check. are forced to interact with a system that’s deChristensen compares the procedural signed to treat acute conditions. medicine business to the manufacturing Christensen compares the chronic manbusiness. Factories guarantee 99.X% of the agement business to other online-enabled widgets they produce will come out to spec. networks such as eBay. The goal of the marThey even typically warrant that the widget ketplace provider is to ensure rich, dynamic, will work for at least Y days, and offer reand meaningful interaction between the funds in the case of failure. Manufacturing market participants to maximize mutual businesses take a set of inputs and guarantee value for both sides of the marketplace. If the a set of outputs at a known cost. Similarly, marketplace provider fails to facilitate intermany treatments have knowable inputs – the action, the market fails. patient, diagnosis, and tools for the treatwww.telemedmag.com
The Innovator’s Prescription
Do changing reimbursement models align with the underlying business models? Providers are increasingly assuming risk for patient outcomes. There are a number of reimbursement models that allow providers to assume risk – capitation, bundled payments, shared savings, and more. Do these reimbursement align with the underlying business operations? Remarkably, the answer is “yes.” Below I’ll provide a broad description of the reimbursement models that the Center for Medicare and Medicaid Services (CMS) has authorized, and how each of those models works with the operational business models outlined above. Shared saving models are reimbursement models in which providers bill in a traditional fee-for-service model. However, at the end of a given time period, typically three months, providers compare their billings with a predetermined benchmark given the risk-pool and size of the population they’ve been treating. If the provider bills less than the benchmark, the provider shares in some percentage of the savings (the insurance carrier – in many cases Medicare or Medicaid – shares the remainder). Bundled payments is a model in which providers received a fixed payment for all care associated with a given episode of care. If the patient has complications or requires extra care as a result of the procedure, the provider must incur all of the costs associated with that care without additional reimbursement. Capitation models are models in which providers receive a fixed amount of capital per patient per month that providers must care for. The rate is adjusted to accommodate for the risk associated with the patient population and regional differences in costs. Integrated delivery networks (IDNs) such as Kaiser Permanente and Geisinger are among the few delivery models that have achieved global – or in other words, 100% – capitation because they are both insurers and providers.
Applying the Model: Diagnostics and non-linear treatments It’s always been difficult to account for risk in consulting businesses. After all, the premise of consulting is to solve a challenging, not-yet-fully understood problem. Shared savings models are aligned with the consulting model. Shared savings models* accommodate the intrinsic risk associated with consultancy by not forcing providers to take on risk they can’t control for, but at the same time create upside opportunity for innovative providers who excel in diagnostics and complex treatments. How does telemedicine play into complex diagnostics? By connecting patients to the specialists they need more quickly. Companies such as Grand Rounds enable second opinions to happen at scale. Although this isn’t thought of as a huge market, it’s rather large: Grand Rounds has raised more than $50M and is growing rapidly. Applying the Model: Repeatable, known procedures Bundled payments also align incentives for knowable episodes of care. Bundled payments are analogous to warranties that come with widgets that factories produce. If the widget is bad for some reason, the manufacturer warrants that they’ll provide a new widget at no cost to the consumer. Similarly, bundled payments create incentives for providers to find ways to lower costs, improve efficiencies, and ensure repeatable, scalable quality. This model encourages quality and scale, enabling profitable privatization without fear of rationing and unethical, short term profitability-centric thinking. If there are complications, the provider must address the complications without any additional reimbursement. This model incentivizes providers to deliver high quality results every time. Patients win in a big way in this model. How does telemedicine play into knowable, repeatable treatments? Telemedicine is already taking off in this space. Companies such as American Well and MD Live and Doctor on Demand are expediting the process for diagnostics and basic treatments by improving access to care at a lower cost.
These virtual doctor visits are performed with significantly lower overhead, and enable physicians to move between patient exams much more efficiently. Telemedicine in these environments leads to significant cost savings while improving the patient experience. Applying the Model: Wellness and chronic disease management Capitation aligns with this model reasonably well, although capitation is plagued with a number of intrinsic incentive problems. Capitation models create incentives for providers to fight with one another over the distribution of payments; capitation models also create incentives to ration care to achieve desired financial return. On the other hand capitation models create incentives for providers to pro-actively monitor and care for patients to help patients lead healthier lives and use fewer healthcare resources. If providers can work with patients change behavior to adhere to clinical prescriptions, hospitalizations can be avoided. In turn, providers, as the patients’ guide through the support groups and functions, can reap material financial reward. How does telemedicine play into these chronic disease management? The opportunity here is absolutely massive. Patients with chronic diseases are increasingly measuring their key health indicators. Combined with Apple’s HealthKit and technology by startups such as PatientIO, care teams can monitor patients’ compliance at scale and watch for outliers. When patients fail to adhere to their prescriptions, families and care teams can engage the patient using telemedicine. This new model for the future is all about “flipping the clinic” to reduce costs and deliver a better patient experience. Telemedicine clearly aligns with the healthcare delivery and reimbursement models of the future. CMS is increasingly acknowledging this, but has yet to come out and state in clear terms how telemedicine can and should be incorporated into each of the business models above.
rock health round-up
Telemedicine Regulations: Past, Present and Future Forecast
Medicare coverage remains restrictive, as of September 2014, 47 states do offer some level of Medicaid telehealth reimbursement and 21 states require private insurers to also reimburse telehealth services. States can limit coverage based on a number of criteria including provider type, patient type, technology format, location, and type of service; however, unlike Medicare, Medicaid laws in 23 states and D.C. have expanded the scope of telemedicine by not specifying a patient setting or patient location as a Telemedicine is taking condition for payment. healthcare by storm, but Policymakers have historically been slow progress will be slow until to embrace telemedicine, but there is cerlegislators address a few key tainly reason to be hopeful. A number of bills in the pipeline could fuel massive adopregulatory gaps. tion by payers, patients, and providers. But by Sarah Jacobson let’s start by taking a look back at the key & Teresa Wang legislation that has shaped telemedicine to date. After all, the idea of having e-consults between physicians, virtual doctor visits, store-and-forward, This article One analyst estimates that the and remote patient monitoring was originally global telemedicine market has been around for years. published on will reach $36.3B by 2020. rockhealth.com In 2014 alone telemedicine BBA in February funding reached a whopping The Balanced Budget Act 2015. $289M. Providors are getting (BBA) of 1997 authorized partial more comfortable with the technolMedicare reimbursement for teleogy and investors are getting more excited health services in rural areas with healthabout economic opportunities. care professional shortages. However, strict But these are only two of the pieces of restrictions provided reimbursement for the telemedicine puzzle. Telemedicine’s “live” services where Medicare practitioners future progress also depends heavily on reare required to be present with patients, imbursement and regulatory policies both which only account for 10% of telehealth at the federal and state level. And that’s a services. steep road. According to a survey of healthcare executives, 41% of respondents do not BIPA receive reimbursement at all for telemediThe Benefits Improvement and Proteccine services. Medicare will only reimburse tion Act (BIPA) of 2000 expanded payface-to-face video interactions that mimic ment for telehealth services. It removed the in-person physician visits, and the patient need for a telepresenter to accompany the must call in from a medical facility and patient and expanded eligible geographic reside in a designated Health Professional areas from rural health professional shortShortage Area (HPSA). age areas to include counties not in a metAs of 2015, CMS expanded the list of ropolitan statistical area. covered services to include annual wellness visits and psychotherapy but expects HITECH overall Medicare payments for telehealth The HITECH Act – best known for to increase only 0.8% this year. Although promoting meaningful use of EMRs – pro-
Digital Health Market Report by Rock Health • In 2014, 258 digital health companies each raised more than $2 million • Venture funding of digital health companies surpassed $4 billion in 2014, nearly equal to the prior three years combined. • Three sectors experienced breakout growth in investment in 2014: telemedicine, payer administration, and digital therapies. • San Francisco Bay Area-based companies accounted for 25% of all 2014 digital health funding.
moted adoption of health IT infrastructure and enhanced privacy and security requirements. This helped lay down the foundation for telemedicine adoption. For instance, communities can receive awards to install and set up telemedicine services through the Beacon Community Cooperative Agreement Program. Investors have good reasons to be excited with a number of bills in Congress that could open the floodgates for telemedicine reimbursement and adoption. In the 113th Congress alone, 57 bills were introduced to change current policies. Here are a few upcoming bills to keep an eye out for: Medicare Telehealth Parity Act: Phase 1 works to expand coverage for real-time and store-and-forward services. Phase 2 extends telehealth access to metrowww.telemedmag.com
rock health round-up
politan areas and coverage of home health services.
doctor of choice, regardless of geographic location.
Telehealth Enhancement Act of 2014 The act aims to greatly expand Medicaid coverage by removing geographic eligibility for critical access and sole-community hospitals. It may also include coverage for home-based video care services at hospices, home dialysis patients and homebound seniors, and telehealth services for women with high-risk pregnancies.
21st Century Cure Act The act would require telemedicine services to prove cost neutrality, if not savings, in order to seek reimbursement from CMS. With this additional time-consuming hurdle, this could greatly deter and slow the expansion of telemedicine.
TELE-MED Act This Act allows Medicare providers to treat patients across state lines without needing to obtain multiple state medical licenses. Patients would have access to their
State Progress We expect to see heightened activity on the state level. New York recently passed the landmark Telehealth Reimbursement Bill requiring that Medicaid deductibles, coinsurance, and other coverage conditions for virtual visits match in-person service coverage. Similarly, Tennessee passed tele-
Telemedicine Business Models Examples of the varying telemedicine services on offer
medicine parity legislation that goes into effect in this year and focuses on expanding Medicaid coverage, including managed care and state employee plans. Arizona is also a longstanding telemedicine leader and currently covers the most extensive list of storeand-forward services including dermatology, ophthalmology, and surgery follow-ups. Of the 25 states that have developed State Health Innovation Plans with federal government support, 19 of them want to use a portion of resources to focus expanding telehealth services. However, not all states believe telemedicine delivers equivalency. In January, the Texas Medical Board implemented a new rule that requires physicians in Texas to have met with patients in-person prior to treating via telemedicine. (The rule does not apply to mental health services.)
Despite progress being made in various states, there are a few glaring holes to tend to. Specifically, before telemedicine becomes a widespread treatment option, policy makers will need to address the following areas of concern State licensing According to an update from Federation of State Medical Boards (FSMB) in January 2015, 47 state boards require physicians to be licensed in the state where the patient is located, and only 13 state boards issue a special purpose telemedicine license for telemedicine practice across state borders. Many states make exceptions for physicianto-physician consultations if the referring doctor is licensed, but licensure requirements that limit physicians to see patients in the same state need to extend across state borders in order for telemedicine to scale and remain cost effective, especially in rural states that have a shortage of physicians. Additionally, another challenge is that telemedicine crosses all medical professions and each profession has different licensures. Reimbursement coverage Coverage policies are not yet defined for telemedicine. Definitional clarity is needed on the types of services covered and their reimbursement rates compared to in-person services. The Telehealth Parity Act aims to clarify this discrepancy, but each state will need to set its reimbursement rates as well. The same FSMB report cited that only 19 states require both private insurance companies and Medicaid to cover telemedicine services to the same extent as face-to-face consultations. Quality/Scope There is no consensus on the type of medical services that can, and should, be offered using telemedicine. For example, the recent Google Helpouts failure illustrates how not setting clear parameters on the scope of care hinders health professionals’ ability to deliver quality care and sets unrealistic patient expectations. There needs to be a standard of care for telemedicine that clearly determines the services that can
be virtually delivered, both effectively and safely, and the services that will still require a physical visit. In April 2014, the FSMB adopted a model telemedicine policy, which 10 states have adopted. However, no states have implemented a formal telehealth law, so more work is required on defining the standard of care. HIPAA Compliance Patient privacy remains a primary concern for telemedicine. Before patients virtually connect with their doctor, telehealth providers must guarantee the same level of privacy assumed in a physical doctor office. HIPAA encrypted systems do exist, but CMS has not officially regulated the use of telemedicine communication platforms. Fraud and abuse Under the Anti-Kickback Statute, it is illegal to knowingly pay, offer, or solicit referrals or services reimbursed by CMS. Given that telemedicine historically involves sharing equipment or products across unrelated health entities, providers must be careful not to misalign incentives. Telemedicine may be exempt under certain safe harbor laws, but until the laws are made clearer, providers must tread carefully. It’s hard to deny that telemedicine is a game changer in healthcare. It was the fastest growing category in digital health in 2014 at 315% year-over-year growth. Studies have shown care delivered via telemedicine can be as effective as in-person visits and reduce costs. While the cost savings magnitude is not yet conclusive, a study by Towers Watson claims that U.S. companies could save $6B on healthcare spending per year. The promise of telemedicine yielding improved care and cost savings is still attractive to more than just Medicaid, and a number of private insurers and self-insured employers are jumping on board as well. The same Towers Watson study reported that 20% of employers surveyed currently offer telemedicine consultations to their employees as an alternative to ER or physician visits for non-emergency health issues,
and 34% are considering offering telemedicine to their employees in 2016 or 2017. And then there’s the fact that patients like it. The VA has seen a 94% satisfaction rate for clinical video telehealth. Ross Friedberg, General Counsel and Chief Privacy Officer at Doctor on Demand, believes patients will be a key driving force in telemedicine adoption. “After years of slow progress, telehealth is beginning to show great potential. While the landscape for telehealth remains challenging due to complex and outdated laws and the fact that telehealth is still new and unfamiliar to many people, these obstacles are being outweighed by the demands of a public that is increasingly fed up with status-quo healthcare and technology that makes telehealth easily accessible to nearly everyone that owns a smartphone, tablet or computer.” Despite the reimbursement limitations and policy concerns, we are excited about telemedicine. The thought of having access to a medical professional whenever and wherever you are is no small feat. With the influx of funding to telemedicine companies, we expect the list of services offered virtually to expand and a better alignment of healthcare professional supply and demand. For example, 1DocWay offers a platform that helps patients in rural America access telepsychiatry services. Coupled with the wave of new at-home diagnostic hardware accessories, like CellScope, CliniCloud, and Cue, the scope of care that can be delivered over telemedicine will expand. It’s also worth noting the opportunity for telemedicine extends beyond the traditional physician-patient relationship. For example, telepharmacy companies like TelePharm are leveraging video conferencing technology to extend access to rural pharmacies and help lower the overall cost of pharmacy services. Despite these innovations, the overall question remains whether the federal and state governments will be able to create laws and reimbursement policies to sustain telemedicine business models and incentivize user adoption. www.telemedmag.com
In the September, 1925 issue of Science and Invention, Inventor and publisher Hugo Gernsback imagines what telemedicine will look like in 1975.
What will telemedicine look like 50 years from now? Send your predictions to logan @telemedmag.com
“The Teledactyl (Tele, far; Dactyl, finger — from the Greek) is a future instrument by which it will be possible for us to “feel at a distance.” This idea is not at all impossible, for the instrument can be built today with means available right now. It is simply the well known telautograph, translated into radio terms, with additional refinements. The doctor of the future, by means of this instrument, will be able to feel his patient, as it were, at a distance....The doctor manipulates his controls, which are then manipulated at the patient’s room in exactly the same manner. The doctor sees what is going on in the patient’s room by means of a television screen.” –Hugo Gernsback, 1925
JeffConnect is putting health .in the palm of your hand. V
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Jefferson is bringing doctors and patients together.
Whenever and wherever. Through JeffConnect TM, our comprehensive telemedicine initiative, Jefferson is creating new ways to improve the health of our community. Whether it’s attending a doctor visit on your smartphone, connecting a son in San Francisco to his mother’s bedside in Philadelphia, or by creating one of the largest telemedicine networks in the world, we’re using technology to bring the expertise of Jefferson health care to you. As JeffConnect continues to expand, we are hiring a range of positions – from ED physicians to telehealth assistants. If you are interested in the innovative world of telehealth, we would like to connect with you. Contact Judd Hollander or Kate Fuller at the email addresses below. JeffConnect. Helping to reimagine the future of health care. Kate Fuller
Judd E. Hollander, MD
Telehealth Program Manager | Jefferson University Hospitals
Associate Dean for Strategic Health Initiatives | Sidney Kimmel Medical College Vice Chair for Finance and Healthcare Enterprises | Department of Emergency Medicine | Thomas Jefferson University