How telemedicine is revolutionizing end-oflife care in California.
Physician tested: The digital stethoscope buyer’s guide.
ISSUE #4 SPRING 2016
The use of unmanned aircraft in telemedicine is no longer a matter of “if” but “when”.
HERE COME THE
DRONES
Jay Parkinson and Roy Schoenberg face off on telehealth's future.
Could an app-enabled TENS unit disrupt the chronic pain market?
WWW.TELEMEDMAG.COM
Why HealthSpot Failed --Telehealth Regional News --Klara: Telehealth with German Handling
Telehealth Solutions As Unique As Your Patients Our full service, customizable solutions for health systems let you focus on the patient, not the platform. TELADOC is the only telehealth company with a business unit and dedicated platform for health systems. Learn more at Teladoc.com/healthsystems or call 1-844-798-3810 2
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telemedicine
WWW.TELEMEDMAG.COM ISSUE 4 / SPRING 2016
Could a slick, app-enabled TENS unit disrupt the chronic pain market? //42
+
p Diamonds in the Rough Steve Case’s ‘Rise of the Rest’ tour is out to prove that great start-ups don’t just grow in Silicon Valley. page 39
>>Start-Ups: From rising star Opternative to a postmortem on HealthSpot. >>Drones are positioned to be a key part of the future of telemedicine.
telescope_9
teletech_19
television_25
Telemedicine briefs across the medical universe --------
Practice-changing gadgets and gizmos --------
psychiatry
From Littman to Eko,
Industry-shaping ideas and perspectives -------schoenberg/parkinson
ems
The 2016 Digital Stethoscope
gordon
palliative care
Buyer’s Guide
lorenz hollander
contributors 5 | regional news 6 | marketplace 46 | teleport 54 www.telemedmag.com
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editor’s desk
How Shall We Then Innovate?
logan plaster
editor-in-chief logan@telemedmag.com
How telemedicine is revolutionizing end-oflife care in California.
Physician tested: The digital stethoscope buyer’s guide.
Jay Parkinson and Roy Schoenberg go head to head.
Could an app-enabled TENS unit disrupt the chronic pain market?
WWW.TELEMEDMAG.COM
ISSUE #4 SPRING 2016
Why HealthSpot Failed --Telehealth Regional News --Klara: Telehealth with a German Accent
The use of unmanned aircraft in telemedicine is no longer a matter of “if” but “when”.
HERE COME THE
DRONES
Cover Illustration by Nicolet Schenck
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Memento Mori I enjoy taking walks in the winding Green-Wood Cemetery near my home in Brooklyn. Besides the fact that it’s the highest point in the city – offering expansive views of the East River – and it is the final resting place of Boss Tweed, I’m drawn by its emptiness. Here you’ll find nearly 500 acres of silence amid one of the busiest cities in the country. You’ll also find a lot of dead people – more than half a million in all – and a good dose of perspective. Memento mori is a useful Latin phrase which literally means, “remember that you too shall die.” Coined by Plato and popularized in medieval European art, the phrase wasn’t intended to be depressing. Morbid, sure, but in a productive, how-shall-we-then-live kind of way. Like Ebenezer Scrooge and George Bailey, we need to be reminded that our days are finite in order to embrace the moment and reach for things of substance, like love and forgiveness. The adage is indeed true that on his death bed no man ever said he wished he worked one more day at the office. Or, for that matter, got more Series A funding. Speaking of which, memento mori doesn’t just apply to individuals. What does it mean to understand that no start-up, no matter how well funded, will last forever? No shiny wearable or innovative app will end our search for something better, faster, cheaper? ...on his death bed This issue, we look at death straight on, and no man ever said he gain some valuable insights along the way. The first comes from Dr. Michael Fratkin, a palliative care wished he worked doctor in Northern California who has helped lit- one more day at the erally thousands of people walk through the dying office. Or, for that process (see page 14). For Fratkin, remembering matter, got more ones own mortality is the key to being a physician Series A funding. in the digital age. In starting ResolutionCare, Fratkin discovered that telemedicine creates a unique “tunnel” between provider and patient, in which technology “disappears almost instantly. And then it’s just about people.” It has the effect of stripping away the pretense of white coats and framed diplomas. All that is left, says Fratkin, is for the physician to show up with humility – as a fellow mortal – one human being encountering another. Next, Bill Gordon writes in our Vision section about the death – or at least the dwindling – of the digital health tradeshow, and how this downsizing is ultimately a good thing (read more on page 30). As Gordon writes, some companies have died, while others have been assimilated into enterprise products. And while the immediate outcome could appear to be a market slowdown, it’s actually an important sign of maturation. When the digital health exhibit floor returns, says Gordon, it will be “full of products and services not only ready for prime time but with stamina and longevity.” Finally, in our Start-Up section, Rishi Madhok kicks off a new column called Post-mortem, in which we dissect a start-up that has failed (see page 36). We do so not to relish in another’s misfortune, but to acknowledge that failure is a necessary part of innovation, and that as much (if not more) can be learned from the observation of death as from life. In a world of billion dollar IPOs and venture capitalists who beknight the next unicorn, it can be tempting to live for the moment – and the money. But an appreciation of our own mortality – and that of our businesses themselves – will bring us back to the essentials . . . the need to leave not just a product, but a legacy, for our children and the world.
telemedicine ISSUE 4 – SPRING 2016
What is the most under-rated sci-fi movie or TV show of all time?
Flash Gordon. The soundtrack alone made this a classic
EDITOR-IN-CHIEF
Logan Plaster logan@telemedmag.com EDITORIAL DIRECTOR
Bill Gordon bill@telemedmag.com
FOUNDER / EXECUTIVE EDITOR
Mark Plaster, MD
The Adventures of Buckaroo Banzai Across the 8th Dimension. Amazing cast, and it was so far ahead of its time.
CONTRIBUTING EDITORS
Rishi Madhok, MD Aneel Irfan
Brazil. Terry Gilliam’s dystopian sci-fi demonstrated to my impressionable younger self that more technology doesn’t always mean progress
The Thing. Aliens assimilating humans vs. Kurt Russell. Need I say more?
EDITORS AT LARGE
Nicholas Genes, MD, PhD CONTRIBUTORS
Michael Gonzalez, MD
Michael Levin-Epstein
James Langabeer, PhD
Tiffany Champagne, PhD
David Persse, MD Scott Jung Galaxy Quest. It’s a crazy, sci-fi/space opera nerd culture parody film. Never give up, never surrender!
Diaa Alqusairi, PhD
Michael Fratkin, MD John Tyler Allen Jenny Mikhail, MPH
ILLUSTRATORS
Nicolet Schenck Erin Lux
Contact. The Drake Equation for calculating the likely number of communications civilizations in our galaxy profoundly illuminates our cosmic context.
INDUSTRY ADVISORS
Ting Shih ClickMedix Jodi Lyons SeniorSherpa Cocoon. Aliens and elderly having a total blast together. What’s not to love?
Dr. Sylvan Waller Alii Healthcare
Dr. Shiv Gaglani Quantified Care Jon Pearce Zipnosis Unity Stoakes Start-Up Health
Haywood Hall, MD PACEMD Dr. Robert Park RelyMD Dr. Judd Hollander Jefferson University
Get Smart. It foreshadowed everything that is happening today.
DIRECTOR OF ADVERTISING
Diana London diana@telemedmag.com // 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 ©2016. 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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regional news
Regional Updates from the Consortium of Telehealth Resource Centers This year more than ever, with so many states enact telehealth policies, it is essential to work with Telehealth Resource Centers (TRCs) when devising your telehealth programs. Each regional center has its expertise, and there are two national centers which focus on technology assessment and policy. All TRCs participate as a consortium to provide information and assistance to all requests. That means that if your regional TRC can’t answer your question, the national consortium can. The consortium is gearing up for a year full of events and their national educational webinar series conducted monthly. In the second edition of our TRC updates we showcase some of the upcoming events the organizations are hosting across the country along with regional telehealth initiatives that are in the works. edited by aneel irfan aneel@telemedmag.com
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NORTHWEST
SOUTHEAST
SOUTHWEST
The Northwest Regional Telehealth Resource Center (NRTRC) provides technical assistance in developing Telehealth networks and applications to serve rural and underserved communities. We leverage the collective expertise of 41 Telehealth networks in Alaska, Idaho, Montana, Oregon, Utah, Washington, and Wyoming to share information and resources and develop new Telehealth programs. NRTRC offers a range of educational opportunities, from our annual Regional Telehealth Conference to our Monthly webinars to Telehealth Toolkits to White Papers. They offer educational materials tailored to all levels of telehealth participation, whether it be newly-forming networks or seasoned providers looking for more information on a specific topic. Follow the links on their website for their archived resources. NRTRC’s fifth annual conference will be held in Seattle, Washington, March 21 – 23, 2016.
Coming off the successful 2nd annual Florida Telehealth Summit in Winter Park, FL, the Southeastern Telehealth Resource Center (SETRC) is revving up for 2016 with the 7th Annual Georgia Partnership spring conference March 2nd-4th. SETRC now offers online telehealth training through its education arm, the National School of Applied TeleHealth (NSAT). A completion certificate with 0.3 CEU/3 credit hours for this course will be awarded upon completion. Three courses are available on the NSAT website (nationalschoolofappliedtelehealth.com) - Certified Telemedicine Presenter (CTP), Certified Telehealth Coordinator (CTC), and Certified Telehealth Liaison (CTL). Congratulates to longtime SETRC director Rena Brewer on her new role as the CEO of The Global Partnership of Telehealth. Lloyd Sirmons will now officially take over as Director of the SETRC. We wish them both the best of luck!
The Southwest Telehealth Resource Center (SWTRC) draws expertise from the internationally recognized Arizona Telemedicine Program, which has been providing telemedicine services throughout the state of Arizona since 1996. Browse their one of a kind service provider directory, a resource for hospital and healthcare administrators and other decision-makers. The directory lists companies providing medical specialty services (such as radiology, rheumatology, neurology, psychiatry) and ancillary services (such as patient education and language interpretation) through telemedicine to healthcare providers such as hospitals, clinics, nursing homes, private practices and urgent care centers. Their 2016 National Telemedicine & Telehealth service provider showcase is June 21st-22nd in Phoenix. For more information on the showcase & directory please visit www. ttspsworld.com.
contact: bob wolverton
contact: lloyd sirmons
kerps@telemedicine.arizona.edu
bob@nrtrc.org
lloyd.sirmons@setrc.us
contact: kristine erps
TEXLA
NORTHEAST
MID-ATLANTIC
HEARTLAND
The TexLa Telehealth Resource Center is a federally funded program designed to expand telemedicine by providing technical assistance and resources to new and existing telehealth programs throughout Texas and Louisiana, continually evaluates Telehealth programs in these two states for effective delivery of telehealth services, efficiency, sustainability, and patient satisfaction, and providing outreach and education to stakeholders. Frontiers in Telemedicine, an interactive hands-on training center to provide guidance in telehealth planning, implementation, management, and sustainability is now enrolling and has received high praise from the first course participants. The completed course will award 18 hours of CME or CNE. The Tex-La conference, Rural Health at the Crossroads: Building Bridges to Care will be held June 20th-21st in Lubbock, Texas. Please contact Becky Jones for additional information on the event.
There is a real need to develop and leverage more research on telehealth, telemedicine, mHealth, and remote patient monitoring. A recent Agency for Healthcare Research and Quality (AHRQ) draft report on telehealth published in December, 2015 found that although there were “over 200 systematic reviews and hundreds of primary studies published since 2006,” there are still significant gaps that must be filled to advance telehealth. In an effort to compile and share the existing, publicly available, peer-reviewed literature and other resources, NETRC has developed a comprehensive Resource Library. Sort 1,400+ articles and other documents by specialty areas, telehealth topics, and more to create a customized webliography that can be saved, emailed, and shared. Search our Library at: www. netrc.org/resource-library. And as always, don’t hesitate to contact us for free assistance!
The Mid-Atlantic Telehealth Resource Center (MATRC) is seeking nominations that tell a compelling story about an innovative application of telehealth by an individual or organization that has led to improved health outcomes and/or quality of life. Telehealth technologies can include videoconferencing, store-and-forward (data, images or videos), remote patient monitoring, and mHealth applications. The awardee, as selected by a panel of judges, will be awarded a $2,500 cash prize. Awards will be announced and awarded at the 2016 MATRC Telehealth Summit. The MATRC annual summit “Improving lives through advances in Technology & Meaningful Data” is April 10th-12th at The Hyatt Regency Chesapeake Bay Golf Resort & Spa in Cambridge, MA. Registration & sponsorship opportunities for this event are now available.
The Heartland Telehealth Resource Center (HTRC) serves Missouri, Oklahoma and Kansas. Get your Telehealth program started with HTRC’s eStart assessment which is an on-site visit by a project director and systems specialist designed to identify telehealth solutions for your organization. They perform an analysis of your organization and facility’s ability to sustain a telehealth program, whether it be clinical, educational or administrative. Through this process, their experts identify highpotential revenue streams that administrators may not have considered. They want to help your program get off the ground. Telemedicine can help you better serve your patients, but in order to sustain the program, it must be financially feasible. Your facility is valuable to the patients you serve - it’s in everyone’s best interest that telemedicine help improve your bottom line.
contact: kathy wibberly
contact: janine gracy
khw2k@hscmail.mcc.virginia.edu
jgracy@kumc.edu
contact: becky jones
contact: andrew solomon
becky.jones@ttuhsc.edu
asolomon@mcdph.org
www.telemedmag.com
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telehealth
regional news
SOUTH CENTRAL
CALIFORNIA
PACIFIC BASIN
The South Central Telehealth Resource Center (SCTRC) launched five new podcasts in late 2015. The podcast series “Telehealth Talk with Sarah and Delbert” is the first Telehealth podcast available on Soundcloud or iTunes. The monthly broadcast features current telehealth news, program information and personal experiences from hosts Sarah Rhoads and Delbert McCutchen. Additionally, the SCTRC released three new interactive online courses: Arkansas Telemedicine Law, Telehealth and HIPAA, and School-Based Telemedicine. The call for abstracts is now open for our annual South Central Telehealth Forum in Nashville, TN August 1 & 2, 2016. This is a first time partnership between the Upper Midwest and MATRC resource centers to bring AR, MS, TN, KY, IL, IN, and OH together in one regional conference. To learn more about the conference, submit an abstract, take a course, or view other content, go to LearnTelehealth.org.
The California Telehealth Resource Center (CTRC) is housed within the California Telehealth Network, (CTN), the state’s partnership for telehealth. Together, they request your support for pending California state legislation AB 1758 that will not only provide important funding for the CTN, it will also improve rural broadband infrastructure in California. Contact Danielle Smith dsmith@caltelehealth. org for more information on supporting the bill. CTRC offers extensive hands-on experience in telemedicine development. CTRC has worked with hundreds of programs, providers, universities, government agencies, and equipment developers to identify best program practices, newly emerging technologies and trends, and studies that identify the impact of telemedicine services. Visit Caltelehealth.org to learn more about the 2016 telehealth summit being held April 17th-19th at the beautiful Kona Kai Resort & Spa in San Diego, CA.
The PBTRC will serve as a Telehealth information resource and a Telehealth community-building organization. The PBTRC goal is to assist in the development of existing and new Telehealth networks and offer education, training, strategic planning and background information regarding Telehealth technology, medical information technology infrastructure, mobile health applications, and Telehealth creation, growth and maintenance. On January 7, 2016, the Pacific Basin Telehealth Resource Center co-hosted a Telehealth Policy Workshop with the Honorable Senator Brian Schatz. The workshop entitled Policy Workshop on Telehealth Opportunities in Hawaii: Planning A Way Forward, brought together key telehealth stakeholders and leaders in the State of Hawaii to discuss and plan tangible next steps to advance telehealth in Hawaii in regards to reimbursement, malpractice coverage, capacity building, health disparities, and others.
contact: kathy chorba
contact: deborah birkmire-
contact: erin bush eebush@uams.edu
kchorba@caltelehealth.org
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peters
| info@pbtrc.org
Want to be included in Telemedicine’s next TRC Regional News? contact aneel irfan
aneel@telemedmag.com
telescope Telemedicine briefs across the medical universe
The patient didn’t have to get dressed. She didn’t have to get into her wheelchair. She didn’t have to get into her car. She didn’t have to drive 25 miles to the clinic. She didn’t have to park and schlep into the office. She didn’t have to deal with the waiting room. She didn’t have to deal with the snotty front desk staff and the damn clipboard with all the redundant information. All she had to do is click on a link. -Michael Fratkin, MD, founder of ResolutionCare, discusses the surprising success of transitioning from a high-touch in-hospital palliative care practice to video-based telemedicine. page 14
featuring
psychiatry emergency medical services palliative care
tele
psychiatry
your couch or mine
Telepsych Solutions Are Critical for the Elderly Anxiety disorders are as common among the old as the young, yet often the elderly go undertreated. Telepsychiatry could offer an elegant solution for older adults – and their caregivers – who have trouble leaving the home. Here are six strategies to consider before getting started. by jodi lyons
Anxiety disorders affect 40 million adults in the United States, and nearly half of those suffering from anxiety also suffer from depression. These statistics have been well publicized in medical journals and consumer publications alike. Less appreciated is the fact that, according to the Anxiety and Depression Association of America, older adults are just as likely to experience depression and anxiety. This is significant because mental health issues often go under recognized in elderly populations. Clinical anxiety is often missed because it gets expressed as another ail10
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ment, like fatigue, headaches, insomnia, irritability, or muscle pain. According to the BCAT Research Center, estimates of anxiety disorders among community-dwelling older adults range from 10%–20%; rates of depression range from 5%–15%; and rates of dementia range from 8%–14%. And what about those who care for the elderly? Today, there are 15.7 million caregivers for the 5.3 million people with Alzheimer’s. Fifty-nine percent of family caregivers who provide care for those with Alzheimer’s or other de-
mentias rate their stress levels as “high” or “very high.” Often, caregivers themselves become housebound in a practical—if not medical—sense, since they can’t leave the person with dementia alone while they go to their own medical appointments. The high prevalence of mental illness in older adults, combined with the propensity for being under-treated in this population, means that they— and their caregivers—represent a significant opportunity for telemedicine, and specifically telepsychiatry. For homebound
older adults, it doesn’t matter whether the setting is rural, suburban or urban, or whether the nearest medical care is five miles away or five hundred miles—getting out of the house is the challenge, and it’s a challenge easily overcome by telemedicine. If your institution is ready to build a tele-psych program to serve older adults and their homebound caregivers, here are some tools and strategies to get you started. 1. Know your patient, and their environment. Best practices still suggest ILLUSTRATION BY ERIN LUX
By the Numbers
46M
Number of adults over 65 years old in the U.S.A. --20%
As many as 1 in 5 adults aged ≥65 years suffer from General Anxiety Disorder (GAD) --As many as
15%
of adults over 65 years old in the U.S.A. suffer from depression. --14%
As many as 14% of adults aged ≥65 years suffer from dementia.
that the initial assessment be conducted in-person. Either the patient goes to the practitioner or vice versa. The patient should be screened for depression, anxiety disorders, and dementia using tools that are sensitive, specific, scientifically validated, and can identify mild cognitive impairment (MCI) in addition to dementia. Since nearly half of people with dementia are incorrectly diagnosed, undiagnosed, or are unaware of their diagnosis, it seems obvious to include this screening along with the depression and anxiety screening. Since MCI is often missed, it is important that the screening be able to identify the disease as early as possible. As part of this assessment, one needs to evaluate the family’s ability to actually implement a telemedicine system on their end. Do they have a phone or computer with video conferencing capability? Do they know how to use it? If not, could a friend, family member, or home care agency help? 2. Make sure that the relationship between practitioner and patient is stable. Practitioners would need to agree to treat via video conferencing for an extended and realistic period of time. Particularly in cases where medication management is necessary, there needs to be a safety net built in to mimic that of traditional treatment sites. This can’t be a few “visits” with no plan for follow-through.
3. Know who you’re talking to. The practitioners need to verify that they are communicating with the actual patient— not with someone pretending to be the patient, speaking for the patient, etc. Fortunately, there are secure video conferencing services allowing for visual communication that email, telephone, and texting don’t. This allows the practitioners to see and analyze visual cues, a vital tool in their diagnosis and treatment plans. Telephones alone aren’t enough. 4. Address privacy concerns. When the originating site is a patient’s home, there will be privacy concerns. Yet, there is a balance between providing the service and ensuring privacy. In homebound patients, there often is no option other than asking the patient if they are comfortable speaking freely. 5. Know what’s happening in the home. The practitioners might be the only professional eyes and ears “in” the home. Look for problems. Has the patient’s appearance or hygiene declined? Be sure to ask questions about eating habits, how the patients get their food/medicine, who prepares the meals, etc. Does the house look dirty or disorganized? Can the patient and caregiver handle the Instrumental Activities of Daily Living (IADLs) or Activities of Daily Living (ADLs)?
6. Develop an exit strategy. Know when the patient isn’t safe at home anymore, or at least when to call in reinforcements. Worsening of symptoms, cognitive decline, and inability to manage IADLs or ADLs should raise safety concerns that need to be addressed. Do you need to call in a care manager, a home care agency or Adult Protective Services? There have been multiple studies showing that telepsychiatry in general offers effective treatment options, particularly in vulnerable populations. When combined with scientifically validated brain rehabilitation, working memory exercises, or meaningful engagement programs, telepsychiatry is a vital tool in maintaining the psychological well-being and brain health of homebound older adults, including those with dementia and their caregivers. 1. https://www.thebcat.com/newsprofessionals#generalized-anxietydisorder-in-late-life-overlooked-andunder-recognized 2. https://www.thebcat.com/newsprofessionals#generalized-anxietydisorder-in-late-life-overlooked-andunder-recognized 3. http://www.alz.org/facts/downloads/facts_figures_2015.pdf 4. Randomized clinical trial of telepsychiatry through videoconference versus face-to-face conventional psychiatric treatment. De Las Cuevas C, Arredondo MT, Cabrera MF, Sulzenbacher H, Meise U. Telemedicine Journal and e-Health; June, 2006
www.telemedmag.com
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ems
frontline telemedicine
In Houston, Telemedicine is Bringing the Doc to the Field A novel telemedicine EMS program has, among other benefits, eliminated thousands of unnecessary ambulance rides. michael gonzalez, md; david persse, md; diaa alqusairi, phd; tiffany
champagne, phd; jenny mikhail, mph; james langabeer, phd
It has been a full year since the Houston Fire Department (HFD) Emergency Medical Services (EMS) launched the ETHAN (Emergency Telehealth and Navigation) initiative. This program is a Mobile Integrated Healthcare initiative, and so far close to 5,400 patients have been a part of the program and that number is steadily 12
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increasing each month. Undertaking a telehealth initiative by one of the largest EMS agencies in the country is quite a project. The logic is straightforward: Many EMS patients with non-emergent conditions just do not need to be transported to busy emergency rooms. Telehealth might provide one solution, although it has not been used historically in pre-hospital care. Every year the Houston 911 system receives approximately 250,000 calls from its covered community of 2+ million people. The result of these calls is more than 300 ambulance transports each day, many of which are determined to be non-urgent, primary care-related events such as reports of headaches, fever, or even needing a prescription refill. The ETHAN program aims to address these non-urgent cases in ways other than using the costly ambulance transport to the emergency department. Both the patient and the community benefit— the patient gets seen by a real physician and navigated to another physician if necessary to follow-up with primary care concerns; the community benefits from lower ED visits and lower city EMS costs. To ensure the
safety and proper care of patients, there are a few factors that will automatically exclude a person from being an ETHAN program participant. These include: complaints of chest pain and/or difficulty breathing; fainting episode within the past 24 hours; pediatric patients if non-accidental trauma is suspected; altered mental status; or inability to walk or stand. All first responders are trained on the ETHAN program goals and guidelines and have the tablet computer with them at all times ready to use if appropriate and have access to a physician consult 24 hours a day. ETHAN’s unique approach of providing face-to-face telehealth physician sessions with patients via Panasonic G1 Toughpads using Cisco Jabber platforms, and then providing personalized navigation based on the diagnosis, is what sets this program apart from others in the country. If an incident is determined to be an ETHAN candidate, the first responder initiates a remote, realtime telemedicine session with a physician at the HFD EMS headquarters. Once the session is completed, the physician will make a recommendation either to go ahead with the ambulance transport to the ED or to schedule an appointment with a partnering clinic in the area for the patient to be seen the same or following day. ETHAN currently collaborates with several safety net clinics who have “reserved” spots for potential ETHAN appointments each day that the referring physician is able to access and schedule. The ETHAN program also engages the patients post clinic or ED visit with a follow-up phone call from a CARE Houston team member. This follow-up call determines the level of satisfaction the patient has with the program, and helps arrange follow-up appointments and issue taxi vouchers if necessary. The ultimate goal is to match the patient to a permanent medical home for all future medical care. Of the 5,400 ETHAN incidents reported so far, it was determined in 18% of cases (978) that it was, in fact, an emergency and the patient was transported to an emer-
cumulative patients in houston fire department telehealth initiative (2015) january february march april may
2362
5345
june july august september october november december
gency department by ambulance. Of the cases that were determined to be non-urgent and resulted in a referral to a clinic, 59% of
patients (3,128) declined the referral and instead took a taxi paid for by the HFD EMS to the ED. The remaining incidents resulted in patients accepting referrals to an ETHAN clinic or to an already established primary care physician using an HFD paid taxi ride if transportation is necessary. Figure 2 summarizes the telehealth participants from December 2014 through December 2015. To ensure the success of the program, ETHAN has made several strategic partnerships in the community. To be successful, ETHAN required more than agreements with safety net clinics and taxi companies. Strategic partnerships and buy-in from the community have been key to ETHAN’s success in Houston. These partnerships include the local safety net community, telecommunications and software firms, the regional health information exchange, the local
health care policy association, and many more. While the goal is to eventually divert more of these non-urgent patient cases to a clinic, the incidents whereby a patient takes a taxi to the ED have already shown cost savings to the department. By employing a taxi at a negotiated rate of $26.50 per ride, this puts the responding ambulance and first responders back in service sooner, decreasing the overall service time per incident. Based on initial assessments of time saved by returning ambulances and personnel back in service faster, this program could increase the department’s unit productivity nearly 2.5 times! While a full comparative effectiveness study of this program is currently underway by the University of Texas Health Science Center, we anticipate telehealth to be an ongoing part of the HFD operations.
CONNECTIVITY IS KING: Telemedicine EMS depends on rugged, always-on connectivity that bridges the ambulance and the hospital. Here are five companies helping make that leap a reality. Cradlepoint COR IBR1100 Series
Sierra Wireless InMotion Solutions
Cradlepoint, a trusted leader in the connectivity and router space, has developed a ruggedized version of their routers for EMS use. Coupled with cloud networking this solution makes vehicle communication and reliability the standard.
InMotion has long been known as a leader in ruggedized solutions space. With the power of Sierra Wireless behind them they bring to market a reliable, welldesigned mounted router solution.
The Details: vehiclemounted router ideal for mass transit, police cars, ambulances, utilities and more. This ruggedized solution features highly available, cloud-managed networking for vehicles.
The Details: The InMotion Solution suite of products include a rugged, mobile communications gateway, a mobile network management system a VPN Server, and applications.
Goodmill Like Cradlepoint and InMotion in the United States, Goodmill has been trusted name in vehicle connectivity in Europe, making it a global offering for in-vehicle services. The vehicle-mounted router creates a reliable and secure connection for emergency vehicles. The Details: Goodmill w24e mobile multichannel routers provide a reliable, fast, and secure broadband connection for improved operations.
Atlas Labs WiFi Hotspot A smaller yet powerful alternative to the traditional router space, the Atlas Labs - WiFi Hotspot provides multiple channels of connection for wireless services in vehicles. The Details: Designed around the needs of public safety, the L-5500 is an industry leader in performance and reliability. The always-on cellular connection ensures hassle free operation as vehicles travel in and out of coverage.
Natick Health A purpose-built tablet, ruggedized for everyday use and abuse, the InTouch Health solution provides users with from and rear facing cameras for remote sharing of video data as well as collaboration via the video service. The Details: Provides a robust and reliable solution for enabling secure, realtime connections to patients anywhere WiFi or cellular broadband is available. The ruggedized form factor is ideal for transport conditions.
www.telemedmag.com
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palliative care
skill. It’s sitting down and talking to people. So any palliative care program is subsidized to at least 50 percent of just the doctor’s salary. I just couldn’t squeeze that out of our organization, no matter what. So I was operating in an environment where most of my day was spent triaging to figure out who was the most miserable person I could take care of. And that was distressing and suffocating over time.
eEmpathy
ResolutionCare Proves that Telemedicine Can Thrive in the Unlikeliest of Places – At the End of Life. Can telemedicine save the soul of palliative care? Dr. Michael Fratkin tells us how virtually delivered palliative care lightens the load of dying patients, increases the effectiveness of pressured providers, and elevates the role of ‘healers’ in the healthcare of the future.
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TeleMedMag: You transitioned from a traditional hospital-based palliative care model to crowdfunding ResolutionCare, an innovative telemedicine approach to palliative care. What was your impetus to leave the traditional structure? MICHAEL FRATKIN: The backdrop was eight or nine years of doing palliative care in an under-resourced department where there was always ridiculous demand for the capacity that I had. There were always three, four, or five requests for consultation for every one that I could do, and no responsiveness from inside the institution, which was bound to a productivity and revenue generative model of providing resources and support. If you’ve got a fee-forservice structure and doctors are the engine of economic energy, a palliative care doctor doesn’t fit well into that structure. The palliative care visit is about two or three times as long as the fee schedule supports. In palliative care, time is our gift to patients. It’s not a spectacular amount of technical support or technical information or procedural
As 2014 emerged, I knew that I had to make a change. I was backing into this reluctant idea of working for a bigger organization, one that was better resourced, but a kind of corporate or industrial delivery model. Ultimately, I didn’t want to do that, and I didn’t want to leave the area. I’ve been here in Humboldt county for 18 years now, and I’ve probably taken care of 1,500 people who’ve died. And that’s soul. I run into the friends and family of my patients in the produce section, in the park, and at the farmer’s market. I love walking through a town being a symbol for caring. That gives me a sense of place. So there I was. I had this dilemma. There’s only one game in town, institutionally— one hospital system, and they weren’t going to pony up. TelemedMag: So plenty of doctors see the problem. What caused you to actually go outside of the system to create a solution? FRATKIN: Two things emerged in early 2014. One was the short-lived project by Google, called Google Helpout. It was an online collaboration platform that they played around with which allowed users to share their expertise through live video. A friend who works for Google suggested that I do one for palliative care. So I made a web page. I offered it for free. I put it out there a little bit in social media and I engaged with four or five people, making it clear I wasn’t doing medicine but offering some counseling regarding issues of serious illness.
I used the platform with a few of the patients that I was already caring for. After five or ten encounters, Google cancelled the project, but I had discovered that the relationship space that emerges over a reasonably good quality video conferencing platform is powerful, and it just plain works. I was like, Wow, telemedicine. And then in June 2014 I read about Sanjeev Arora and the University of New Mexico’s “Project ECHO” in The New York Times. It inspired me with this idea that if you have a reasonably seamless platform, you can use video conferencing technology to share scarce expertise and force multiply your impact. And that just matches the palliative care problem enormously. We have huge workforce shortages and exploding demand for services, and a difficulty in terms of a revenue model. Then I was introduced to the Zoom Platform, which is cloud-based video conferencing, HIPAA compliant, and incredibly intuitive and better than anything I’ve ever used. Zoom is so easy that little old ladies can be coached in ten minutes to engage with ease. At the same time, the consumer technology was maturing. Devices are everywhere. Broadband internet connectivity is everywhere. Finally, these moves aligned with a larger trend in the industry of sitting people in their homes rather than inside a clinical environment. The trend is now shifting toward community-based care, engagement with the medical home. TeleMedMag: So the stars aligned for you to leave the hospital setting and build something new in ResolutionCare. Why did you decide begin with crowdfunding? FRATKIN: The crowdfunding piece has just been kind of percolating in the background. I’ve supported a number of people in their efforts and have been kind of interested in how that worked. But by the time I encountered video conferencing for
the practice of medicine, Project ECHO, the Zoom Platform, and all of the energy around it, I realized that I needed to go out and find some startup money. Crowdfunding just dropped into my consciousness. I found a consultant and pulled the trigger actually almost exactly a year ago. TeleMedMag: Logistically, telemedicine is great. You can be in more places at once. You can see more people. But palliative care is so personal. Can a video visit really replace the house call? How much of a degradation in quality is there? FRATKIN: That’s kind of how I thought about it at first. I thought that I’d be giving something up but that maybe I’d be getting enough in return to make it valuable. But that’s actually not what has happened. As it turns out, the telemedicine platform and the capacity to connect and engage is entirely superior in certain elements to a face-to-face. TeleMedMag: Superior to faceto-face? FRATKIN: Just imagine that you’re a little old lady with metastatic breast cancer. You’ve had 150 visits in the last year of your life for lab work, infusions, doctors’ appointments, X-rays, episodic care in the emergency department, maybe a hospitalization or two for a complication, maybe radiation therapy. Literally 150 visits to some site of care. And then I add myself to that mix, and I symbolize death and dying. To tell that same person: “Listen, we’ll come to you, either in person or virtually. You don’t have to go anywhere. And we think we can help you with your symptoms.” So that little old lady doesn’t have to spend two, three hours getting ready in the morning (because she has this culturally normative behavior to dress up for the doctor). She doesn’t have to get out of her fuzzy slippers. All she has to do is click on a link
in an email with a device that either she has or her granddaughter sets up, or we send a community health worker to set up, and click through to the doctor. The patient didn’t have to get dressed. She didn’t have to get into her wheelchair. She didn’t have to get into her car or get her family member to take her. She didn’t have to drive the average of 25 miles around here to get to the clinic. She didn’t have to park and get schlepped into the office. She didn’t have to deal with the waiting room. She didn’t have to deal with the snotty front desk staff and the damn clipboard with all the redundant information. All she had to do is click on a link. So there’s one major advantage; by the time we see each other all of that stuff isn’t in this space. And then I can create the illusion, which is generally not an illusion. I mean, I presence myself before I click on my link; I just drop in and there I am magically in this communicational space, this relational space. It’s like a tunnel that connects me to this person. TelemedMag: How has your workflow changed since moving to virtual visits? FRATKIN: I didn’t really understand this at first, but I’m starting to see that there’s a magical efficiency that’s built into a virtual visit. I used to give two hours for an introductory meeting with a new client. With the video visits, I allotted the same two hours, but all of a sudden an hour has gone by and we’re done. When you’re holding a person’s attention inside this kind of magical tunnel, it’s just you and them (plus whoever else might be around), and that quality of attention is an advantage. TeleMedMag: What are the downsides to virtual palliative care visits? FRATKIN: What you give up are hugs. You give up eating their cookies on their couch. You give up really strolling around their house freely, looking in their refrigerawww.telemedmag.com
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Whether it’s in-person, on the telephone, or over video, check your own shit at the door and show up for these people. I want to be able to inspire people to love their work and to understand its real value to people. But I can’t give them the recipe for being a human being. But it’s being a human being that answers the profound unmet need of other human beings.
tor, seeing how they store their medicines. But actually, depending on the person and who’s there, we can still accomplish some of this. I ask them to give me a little tour around. I also give up having their dog hump my leg and bark at me. Dogs are a lot happier to look at me on the screen than in the house. TeleMedMag: How do you extend yourself physically into the community. At-home aides? Nurses? FRATKIN: Palliative care is by definition an interdisciplinary team. A palliative care specialty trained provider is a part of the team that includes a palliative care nurse, a palliative care social worker, and a palliative care chaplain. In our practice there is a really exciting opportunity for development which we’re calling a “community health worker.” That person is sort of boots-onthe-ground, base-of-the-pyramid, and will rarely use the video conferencing technology. They are the ones most often out and about in the field, answering questions, identifying problems, looking in the cabinets, and all the rest. And they’re coming from a world of the most talented and able caregivers: private hire caregivers who just have a certain special talent for this work. Our community health worker, Kat, is really in some ways the most profound leader on the team, because she spent ten years working in hospice giving bed baths to people who were dying. You could send her 16
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to school and they’d give her letters to put after her name, but that kind of almost tactile understanding of what’s needed is leading the team to respond in creative ways to meet the needs of these people. TeleMedMag: And that frees you up to do the work you need to do behind the screen, knowing that she’s out there. FRATKIN: Absolutely. I could send a nurse out there to say: Can you find out how she’s taking her medicine? Can you inventory what’s in the home? And can you do some teaching about the fundamentals of patient-empowered use of medication? The doctors in offices have this sort of magical thinking that they write a prescription and that’s how it’s magically taken. And then they adjust the medication instructions from the list, and we know how terrible people are at taking their medicines. For control of symptoms, it’s not rocket science. We just have to find out how they’re taking it and train them to take them in a sensible way. TeleMedMag: Everyone is trying to reach the consumer with these different digital health devices and apps and wearables. Beyond the video interface, is ResolutionCare starting to incorporate other digital health devices and wearables so that you can gather
more health data? FRATKIN: We have a relationship with a really great little company called TapCloud, which is an mHealth application that we’re going to be loading onto a set of tablets that we provide to our clients. It gives them an opportunity to communicate with us, and it’s a creative, interesting way to track how they’re feeling. It gives them notifications and prompts: Have you had a bowel movement today? Have you done [this or that]? Those data get uploaded to a dashboard, then we play around with what we discern are potential high quality applications that will give us that kind of information. More importantly, it will hopefully engage the patients in an interesting way that fits into their life. Rather than use a linear pain score, TapCloud has this unique kind of intelligent swarm of words that gives people a chance to identify things of importance. For example, if yesterday they said that their pain was getting worse, today pain will be in a larger font. And when they tap it, it’ll ask them a question that will relate to yesterday: better, worse, or the same? If they’re having trouble with their caregivers, or are about to run out of a medication, or their advance directive hasn’t been formed, that’ll populate as a larger font and a prompt. So this cloud that they tap on each day to give information kind of learns their communication style and tracks certain things in a seamless and organic way.
The more important point is that what we’re doing has almost nothing to do with technology. What we’re doing is humancentered care of human beings, in their homes, with whatever tool is available, just like it’s been for all of human history. People approaching the end of their life are not having a medical experience. They’re having a human experience. And what matters is being heard, being in control, and understanding what tools there are in the environment so that they can make choices about it. The best part about our technology is that it tends to disappear almost instantly. And then it’s just about people. TeleMedMag: Often physicians fear that telemedicine will kill the personal nature of the doctor-patient relationship. Some of them might already have difficulty relating to people, and video will just add another layer of distance. How do you retrain these physicians to use this technology effectively? FRATKIN: I think that we’re doing in palliative care is responding directly to that. What we want to work with are people who already have a certain sensibility about the primary care role—about the importance of trust and relationship. We want to provide them with a handful of skills. Again, palliative care is not rocket science, as much as the academics might want to distinguish themselves as huge experts. It’s just human beings looking at each other like human beings. And from my point of view, that is exactly right. If we can inspire people to settle down and drop their role, drop their identification, their strict and concrete identification as a doctor who’s driving medical science down the throat of a human being who’s having a human experience, then we can give them a handful of skills. More importantly, we can infuse a certain mindset that our patients are begging for: they are begging to be seen
Dr. Fratkin estimates that moving his practice to virtual care has saved him 15,000 miles of driving so far. That’s more than two trips around the moon.
as people. So the pain points for all the stakeholders are technical and evidence based, and even academic, and also economic. But the experience of being a sick person in our absurdly complex system responds most importantly to just being connected. They want to know that you give a shit. And if you give a shit, then that’ll come through. And we want to teach doctors that it’s safe to care, and that their relationship is not fraught with fundamental antagonism. One of my catch phrases is, “What we’re doing is restoring the traditions of trusting alliances for healing by using the technology that happens to be available in 2015.” Next year we may find something better, or we may get rid of TapCloud and put some kinds of constipation monitoring devices on our patients. I don’t know. If it helps to improve their quality of life and their satisfaction with their experience, as well as reduce costs, that’s the holy grail, the triple aim, right? TeleMedMag: What’s one piece of advice that you would give to a doctor who’s hesitant to use telemedicine because of this fear of a loss of human interaction? FRATKIN: The technology disappears. And the only way to really discover that, since people are so filled with their assurance that their biases are correct, is to try it. Try it. Think about how doctors must have
felt about doing telephone work. And think of all the meaningful work and engagement that doctors do with the telephone to forward the well-being of people. Add a whole order of magnitude of greater impact and engagement by visually connecting in real time with people. TeleMedMag: What if the clinician is truly not good at relating to people and the telemedicine platform is going to really create a barrier? How do you teach a young physician to make a more human connection? FRATKIN: That’s a good question. It really has to do with just simply showing up as a person. I mean, whether it’s in-person, on the telephone, or over video, check your own shit at the door and show up for these people. I want to be able to inspire people to love their work and to understand its real value to people. But I can’t give them the recipe for being a human being. But it’s being a human being that answers the profound unmet need of other human beings. TeleMedMag: There are some people who really struggle with empathy out there. FRATKIN: Yeah, well, they might have gotten into widget making or something else. Not everybody is a healer. For the last 70 years, we actually have not been selecting our physicians and providers as healers. It’s a selection problem. I’m willing to work with anybody to inspire them toward this end, because I know that they’re actually humans. They may not know how to just relax and be that way. But that’s what our future is calling for. Not just in healthcare but in political discourse, in communication, and content creation. Can we actually get real and authentic in the personhood that we assume in life and in society? TeleMedMag: One of the undercurrents I hear from you is the www.telemedmag.com
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importance of humility, of having doctors let go of their identity and drop their merit badges a little. FRATKIN: That’s right. And I think that over the next 20 and 30 years we’ll see that those folks are selected against. I think that the answers to the future character of our healthcare delivery system and well-being systems as a society will not be determined by how bright and clever guys like me and policymakers and payers and stakeholders are—the future of our healthcare system will be determined by empowered people with illness. People and populations are getting involved in moving these recalcitrant institutions from the status quo to something that actually serves their needs and at lightning speed. I’m just a part of that wave, not as a doctor but as an entrepreneur— somebody who’s just looking at the problems and following the currents of change.
We’re going to have artificial intelligence that’s way smarter than even the geekiest nephrologist and it won’t be long before the technology does all of that intelligence-based heavy lifting. And what will be left for doctors is to be a guide and to be wise, just the way it always has been, long before medicine was medicine.
TeleMedMag: So what’s next? FRATKIN: I think we are going to welcome back into the training process in medicine people that have a much deeper connection to what it actually means to step into somebody else’s life and offer service. Whether that’s with cardiac surgery, brain surgery, radiology or whatever; my hope is that the society will change the selection criteria and that we realize that medicine is not fundamentally technical. It’s fundamentally human. We’re going to have artificial intelligence that’s way smarter than even the geekiest nephrologist and it won’t be long before the technology does all of that intelligencebased heavy lifting. And what will be left for doctors is to be a guide and to be wise, just the way it always has been, long before medicine was medicine. TeleMedMag: Now that you’ve been running ResolutionCare for a year, what are the technological pain points that you have 18
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running the business? Is there a program, an app, a device that you wish that you had now, that you hope gets developed? FRATKIN: It has to do with the economics. Value-based payment is the key. If those that pay for healthcare agree that palliative care is an extra layer of support to the care that people are receiving in other practice settings, whether it’s cancer care or cardiology care or chronic disease management; if they say that it’s worth it to have palliative care, then it will be paid for in a way that’s not based on fee-for-service. All those trends are emergent. We’re involved in a pilot program that pays us a set amount per month to deliver on the outcomes that we agree on. And so they don’t care if we see a patient by telemedicine, carrier pigeon or smoke
signals. They don’t care if we see them three times a day or once a month. They don’t care if it’s a social worker or a chaplain. They just pay us per member per month to deliver on quality as defined by the patient: quality of life; satisfaction as defined by the patent; and to deliver on a reasonable return of investment. That economic revolution changes everything in healthcare and palliative care is perfectly positioned to take best advantage of that. Because we deliver on patient-centered goals, as the air that we breathe. But in terms of the technology, the electronic medical record is the world’s greatest technological albatross for every practice setting that there is. The medical record must be transformed, from my point of view, into an information sphere with the patient inside and inviting all of the other participants to share information. It doesn’t become a documentation and coding structure. And so my only hope going forward is that somehow the electronic medical record can transform and get out of the way and become actually seamless and invisible, like the video conferencing technology. My only hope for that is the iconic provocateur Jonathan Bush from Athenahealth. He’s the only one who’s in the business who’s willing to make his platform open for APIs. And he is the only one willing to say that electronic medical records suck entirely and their impact on healthcare delivery and the fulfillment and satisfaction and experience of people providing healthcare, it’s driving people to suicide, drug addiction, burnout and all the rest of it. My hope is that the economics that come along with value-based payment and outcomes-driven payment models transform the electronic medical record.
teletech Practice-changing gadgets and gizmos
That it will ever come into general use, notwithstanding its value, I am extremely doubtful; because its beneficial application requires much time, and gives a good deal of trouble both to the patient and the practitioner . . . It must be confessed that there is something even ludicrous in the picture of a grave physician formally listening through a long tube applied to the patient’s thorax, as if the disease within were a living being that could communicate its condition to the sense without.” -John Forbes, MD, the secretary of the Royal Geological Society of Cornwall, writing in 1821 on the dubious prospects for a new invention called the stethoscope.
featuring
the 2016 digital stethoscope buyer’s guide www.telemedmag.com
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Written by Scott Jung Physician Tester: Nick Genes, MD, PhD
The 2016 Digital Stethoscope Buyer’s Guide The stethoscope is one the oldest medical tools still used daily by doctors worldwide. Invented 200 years ago by French physician RenÊ Laennec, the first stethoscope consisted of a simple wooden tube that allowed him to hear heart sounds without having to immodestly place his ear on a woman’s chest. Surprisingly, the stethoscope and the practice of auscultation has evolved little with the advancement of technology in the field of medicine. A few companies, however, have managed to bring the humble stethoscope into the 21st century, amplifying and digitizing the internal reverberations of the human body to help physicians to pick up subtle, nearly inaudible sounds. These electronic stethoscopes can also easily record sounds for remote diagnosis and teaching. Read on for our look at some of the most popular electronic stethoscopes on the market.
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Tech Dx The Good News Trusted name Familiar form factor On-board recording The Bad News Not compatible with mobile devices Can’t auscultate at all without power Recordings are saved in a proprietary file format The Prognosis
3M Littmann Electronic Stethoscope 3200 $549 (MSRP), APP. $400
Littmann has a time-honored name in auscultation. Their electronic stethoscope combines the superior quality of Littmann with the power of amplification and recording. However, as long as it lacks mobile device compatibility, Littmann will be following, rather than leading, this wave of next gen telemedicine devices.
Littmann stethoscopes have been found around the necks of nurses and physicians for many years, so it was expected that they would modernize their flagship device for a new generation. The 3200 model is the more expensive of their two electronic stethoscopes, with the less expensive 3100 model lacking Bluetooth connectivity or recording capability. The Littmann stethoscope, while a little heavy, is comfortable to handle, making it pleasant to use. The electronic aspect is straightforward and unobtrusive; sound quality is excellent, and the controls are fairly easy to use with limited learning. The stethoscope is powered by a single AA battery, which means you’ll need to have extra batteries available, but won’t have to worry about recharging it. Importantly, you won’t be able to hear anything – the “not smart” part of the stethoscope can’t work without battery power. The optional StethAssist software enhances the stethoscope’s electronic capabilities by connecting via Bluetooth to transmit recordings and even perform live, remote auscultation via the internet. However, the StethAssist software is limited to a PC or Mac, and Littmann has no plans currently to make the stethoscope compatible with smartphones. This seems like a relatively glaring flaw given how mobile healthcare is becoming.
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Tech Dx The Good News Inexpensive Simple one-button operation Can be attached to any single-tube acoustic stethoscope Stethoscope still usable if charge runs out
Eko Core
Fully-featured mobile app with web-based dashboard and EHR support The Bad News
$299 (EKO CORE WITH ANALOG STETHOSCOPE) $199 (EKO CORE ATTACHMENT ONLY)
Attachment is heavy and somewhat bulky
Launched in 2015 by three UC Berkeley grads, Eko Core is the newest player in the electronic stethoscope arena. The founders strived to create a product that would enhance the clinician’s experience and skills without the learning curve that technology often creates. The result is that Eko Core itself is an attachment that is compatible with practically any stethoscope and consists of only a micro-USB charging port and two controls: An on/off switch and volume up/down buttons. It can be used on its own as a sound-amplifying stethoscope, but as Eko was started by three digital natives, the HIPAA-compliant Eko mobile app adds a great deal of functionality and is a highly important part of the system.
No selectable audio filters
After installation of the app, signup through Eko’s service, and pairing of the Eko Core via Bluetooth Low Energy, the user can listen to a patient’s heart sounds through the device while recording and visualizing the sounds through the mobile app. The sounds can be played back through the smartphone’s speakers, or back through Eko Core itself (meaning you can use the stethoscope’s ear buds for smartphone playback). The recordings can be annotated, uploaded and shared with other clinicians, or even attached to a patient’s EHR (only Drchrono is currently supported, but more platforms are coming soon). A word on the sound quality: Eko processes heart sounds and digitally removes ambient noise, to a remarkable degree. The result is a crisper, clearer auscultation than anything we’ve heard before. So if you’re looking to be a more high-tech clinician, but still enjoy the feeling of rubber tubing from a traditional stethoscope, Eko Core might be the stethoscope for you.
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The Prognosis The Eko Core combines the familiarity of a traditional acoustic stethoscope with advanced mobile technology and powerful audio processing. The powerful app allows you to listen live while recording and play back through your device or the stethoscope itself. EHR support, while currently somewhat limited, allows for integration into a more universal record.
Thinklabs One $499 From a distance, Thinklabs One looks like the amputated distal piece of a traditional stethoscope. But contained within this compact stethoscope head is a highly sensitive electromagnetic diaphragm for picking up a broad spectrum of sounds and the processing power to filter out noise and amplify murmurs and other heart sounds that might be inaudible with traditional acoustic stethoscopes. While the Thinklabs One is extremely powerful, the experience might have somewhat of a learning curve. Aside from its unique form factor that replaces acoustic earpieces with electronic ear-buds, the alldigital audio might take a little getting used to. You’ll also have to learn how each of the four buttons on the Thinklabs One controls its numerous features. On the telemedicine side, the Thinklabs One itself inherently lacks recording features or wireless capability. Output is limited to the 3.5 mm headphone jack on the side of the device that is used to listen through earbuds or headphones. While some may see this as a weakness, founder Clive Smith sees this as an advantage, as the sound isn’t dependent on any kind of proprietary app or system. High-end speaker systems, digital voice recorders, and smartphones are all compatible if they have this universal 3.5 mm jack, making the actual telemedicine possibilities endless. However, Thinklabs has developed a complementary iOS app for capturing sound from the stethoscope and also includes the cables to connect it to your iPhone. I found the app to be limited in functionality and difficult to use. For superior audio fidelity, Thinklabs One is the hands-down winner of our set. While its controls are not as intuitive, and recording the sounds may require a few extra steps, it’s the only stethoscope on the market that’s completely compatible with Beats by Dre.
Tech Dx The Good News Lightweight and portable Uses standard earbuds or headphones Multiple audio filtering options The Bad News Easy to lose (a stethoscope too small for one’s neck seems prone to getting lost) No built-in wireless compatibility All-digital audio signal takes a little getting used to iOS-only app has limited functionality Controls are not as intuitive The Prognosis Don’t let the Thinklabs One unusual appearance dissuade you. It’s acoustically the most advanced of the bunch as its electromagnetic diaphragm is highly sensitive and its powerful sound processor helps you hear only what is beneficial. Output is limited to a basic 3.5 mm headphone-style plug, but this also means that this stethoscope doesn’t have to be tethered to proprietary software.
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Tech Dx The Good News Integrated 3-lead ECG Compatible with any singletube acoustic stethoscope Fully featured mobile app provides analysis based on ECG and heart sound data The Bad News Attachment is heavy
Rijuven i2Dtx CardioSleeve $449
By no means lean, the computer mouse sized attachment feels functional and capable in your palm. The two lone status lights on the front provide information about battery and power levels and Bluetooth status. They also act as buttons to power on the device and start a recording. Invest a little time up front with the manual, learning each button’s function. Once you’ve quickly mastered that, it’s fairly simple to use. Once the CardioSleeve is attached to a stethoscope, you’ll need to pair with the Rijuven i2Dtx app (iOS only, Android version coming soon). From there, you have an extensive list of exam options that involve basic vitals, glucose levels, and lung function in addition to cardiacrelated exams. All patient measurements are stored on the cloud and can also be accessed through a web-based patient management portal. At the time of writing, I found the app to be a little buggy, but we’re told that a more polished version is around the corner.
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Limited utility if not used in conjunction with the app The Prognosis
The Rijuven i2Dtx CardioSleeve is the only one on our list that takes the stethoscope beyond auscultation by incorporating a 3-lead ECG to allow clinicians to view heart sounds and the electrical signals that create them at the same time. As a stethoscope accessory, the CardioSleeve is compatible with almost any standard acoustic stethoscope. You’ll want to commit yourself to actually utilizing it, however, as you’ll no longer be able to even go acoustic-only once the CardioSleeve is attached.
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With an integrated 3-lead ECG that allows you to hear and see heart sounds, but also see the heart’s electrical activity, We consider the CardioSleeve to be the most technologically advanced device we reviewed. However this marks a departure from auscultation as an aide to physical exam, and enters the realm of procedures. That’s OK for research and teaching but its clinical utility is still unclear. Still, aside from an app that needs a little more work and a device design that could be streamlined, there’s a lot of potential for this device.
television Industry-shaping ideas and perspectives
“In Germany we are very detailed and quality driven. We think that design is very, very important. We believe that the use of our software or our solution should be an experience, and an enjoyable one. Because of this focus on design and usability, we might move a little slower because we want to understand the details.� Simon Lorenz, MD Founder, Klara page 31
featuring
roy schoenberg ~ jay parkinson simon lorenz ~ judd hollander bill gordon www.telemedmag.com
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about half of the health insurance plans around the country. We have 30 or so of the largest health systems in the world. Plaster: Is that perspective unique in the telemedicine market?
in conversation
Scale or Niche, Video or Text: When Distinct Visions for Telemedicine Converge Roy Schoenberg, CEO of American Well [L] and Jay Parkinson, founder of Sherpaa, have a lot in common: They both want to revolutionize healthcare delivery. But is that going to mean synchronous or asynchronous care? And how will we succeed in increasing user adoption of telemedicine? To dig into the specifics, we invited both men to debate the next steps for the industry. interview by Logan Plaster
Roy Schoenberg: Jay and I are remnants of the early days of the Health 2.0 conferences, and boy has the world changed. Jay Parkinson: There have been a lot of success stories, but also a lot of casualties in the market. Logan Plaster: Roy, what makes American Well unique in the market? Schoenberg: We’ve been in the business of telehealth for almost 10 years now. We’ve 26
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always believed that telehealth should be blended into the traditional practice of medicine with the understanding that it really is a communication infrastructure that brings physicians and patients closer together. What you see in the media is that telehealth is a kind of quick fix, a way for anyone to get in front of a physician in two minutes or less. We have a slightly different view. We believe that we are a clinical communication infrastructure between patients and physicians fostering deeper and more intimate relationships. Today we serve
Schoenberg: If you look at the people we serve, and you look at how our systems are designed, we operate very, very differently than the other guys out there. While we do fill an urgent care role similar to the Teladocs of the world, the vast majority of our business is spending time with the physicians and the health systems, doing all of the things that are less popular and less public, things like EMR integration, dealing with insurance and eligibility, dealing with physician workflow. If you think about infrastructure projects, that’s the investment in the highways and gas pipes. That has always been our approach. We’ve always believed that telehealth should become an infrastructure for care delivery rather than a quick fix solution on the side. Plaster: Jay, tell us what makes Sherpaa unique in the telehealth marketplace? Parkinson: We see ourselves as a health service that is powered by a new genre of healthcare. You’ve seen how asynchronous messaging has really taken over the world from the synchronous phone call. That’s had a profound effect on how we communicate as a culture, and we’re bringing that to healthcare to solve the doctor-patient relationship. I think it’s a little bit absurd that in traditional health care our health stories have to be told within the confines of 10 minute office visits. That’s not really how health stories work. Things evolve and it is important to let people communicate those evolutions over time, around a core case. Our main difference in the healthcare space is this: We hire our doctors – more as a healthcare service than a platform – and then we carefully target companies that would understand and appreciate the kind of relationship that their employees could have with doctors. We’re working to match early adopter doctors with early adopter
patients so that we can create what the future of healthcare delivery will look like. That is, once we get out of the confines of the transactions that power healthcare payments today. Plaster: Jay, you’ve gone on the record many times eschewing video telemedicine in favor of asynchronous text. Could you explain why? Parkinson: The reason we do that is that we don’t really want to change people’s behaviors too much. Apple has gone on the record saying that they serve about 40 billion iMessages a day, and only about 15-20 million FaceTime chats. In our three and a half years, we’ve never really had anyone ask for a video chat. Ninety-eight percent of our cases are taken care of over asynchronous text on our secure platform. Only about 2% of the time do we jump on the phone. Twenty-five percent of texted cases have photos attached. I think that photos combined with asynchronous messaging with the occasional use of phone is sort of the ideal means of communication for a few reasons. One, it doesn’t force people to think on their feet, on both ends. As doctors, if we get a case that we’re not particularly familiar with, we can go read up on it and then get back to the patient once we’ve brushed up on it. For the patient, talking with a doctor is stressful. If you can eliminate the concept of time and let them think about their responses and respond on their own terms, I think it’s just an ideal means of communication. Schoenberg: I whole-heartedly agree that if you want to relieve some of the pain of healthcare delivery, you have to speak the patient’s language. However I also don’t want to be unrealistic and think that we can pass in one clean swoop into the patient domain. If you want an example of how radically problematic that could be, ten years ago there were all of those internet pharmacies. They were the most convenient way to get medications because you bypassed the physician. Admittedly from a patient standpoint, when you are educated
We consider American Well more as the switchboard. We are the AT&T. We connect supply and demand . . . Frankly, we could work with [Sherpaa] tomorrow to expose them to the population that we serve today. -Roy Schoenberg, American Well
and you know what you need, that would be by far the easiest thing to do. But very quickly everyone realized that that is not a good way of doing medicine. There are a lot of different components to the interaction between the doctor and the patient that need to be upheld in order to do good medicine. While giving patients the kind of care or the convenience of care that they are looking for is a valid goal, we have to balance it with the notion of patient safety. If you are a physician and you are treating your patients, you know who your patients are. You met a couple of times and you have a good understanding of what their reality is. Are they frail? Do they have multiple conditions? At that point, the means of communication that you need could be very asynchronous. Text messaging might be fine. When it comes down to patients that you don’t know, clearly you need more indications as to what is the state of that patient in order to do your job responsibly. Jay is right that there is no right modality, and the ability of the patient to get in front of the physician is very important, however I wouldn’t go as far as to say that we should just eliminate all of the important communication modalities between the physician and the patient for the purpose of conve-
nience because I think many physicians would appropriately say you are making it very hard for us to truly keep up to the professional standard that we signed our name to. Plaster: How many cases are able to be handled in-house and what percentage gets handled with a referral? Parkinson: We solve about 70 percent of our cases that come at us. About 30 percent of cases are actually referred to be in person. That statistic has held true for the last 3-1/2 years. Schoenberg: On our direct-to-consumer side, anywhere between 75 and 85 percent of patients state that their issue has been effectively resolved and that they did not need to do any kind of follow up. But to be very, very clear, the reason why that is the case is because physicians are instructed to immediately – within the first minute of the transaction – instruct patients who present with issues that they consider to be inappropriate to be handled through telehealth to seek care in more appropriate venue. When this happens, the transaction is nullified. So even though they give them guidance, they’re not assuming that the transaction is going to resolve the issue. And that is, by the way, a commitment that we’ve made to medical boards around the country; again very unlike most of the other people that offer telehealth that are in really deep trouble with medical boards, sometimes in court. Parkinson: We hear those numbers from your direct to consumer line and it just confirms to us that so much of this stuff can be handled with good communication, no matter what that communication is. Plaster: What are some of the ways you’ve seen the market shift since you first joined a decade ago? Schoenberg: Really over the last year or year-and-a-half the world has completely done a 180. It is unbelievable. Standing in www.telemedmag.com
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“Ninety-eight percent of our cases are taken care of over asynchronous text on our secure platform. Only about 2% of the time do we jump on the phone. Twenty-five percent of
let’s talk about text
“I wouldn’t go as far as to say that we should eliminate all of the important communication modalities between the physician and the patient for the purpose of convenience. Many
texted cases have photos attached. I think
physicians would appropriately say you are
that photos combined with asynchronous
making it very hard for us to truly keep up to
messaging with the occasional use of phone is
the professional standard that we signed our
sort of the ideal means of communication” -Jay Parkinson
front of medical boards even five years ago was like a crucifixion. And today they’re inviting us to come in and help them, literally help them write their new regulations to embrace safe telehealth. Towers Watson – probably the largest benefits broker in the U.S. – just came our with their analysis. They said that between 2015 and 2017, we’re going to go from 20 percent of employers requiring telehealth services for their employees to 80 percent. So within the next two years, telehealth is going to become the required norm of essentially your health insurance. If that number actually pans out, this will become the fastest adopted healthcare benefit in American history. Parkinson: My problem is this: If 80 percent of people are offering these services but only two to three percent of people are using them because maybe they’re uncomfortable using them, the modality doesn’t resonate with how they want to communicate; how do we sort of get from two to three percent usage to something like our usage, which is 85 percent of our companies employees sign up and 60 percent of their employees be28
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name to.” -Roy Schoenberg
come users of the service more than once a year. Schoenberg: I’ll be the first one to say that what you guys are doing is at the highest level of personalization – you feel warm and fuzzy when you work with your providers because that’s how you build the brand and the product. It is realistically also more expensive to do. And down the stream are very, very high end concierge services and so on. I think we need to realize that the more you’re providing those kind of services to the masses, which is really where Teladoc is and where we are, you inevitably are not going to be able to tie an individual physician face to the service. It’s going to be very, very difficult to say to people in 48 states: This is the doctor or two doctors that you’re going to end up talking to. Our networks really have thousands of physicians who are serving all of these states 24/7. I would also say that it really depends how you market it. And Jay, you do an amazing job in communicating kind of the warm embrace of your services. I think a lot of companies have done not such a good job
in doing that. When we work with a large manufacturer, somewhere in the northern United States that has blue collar employees, many of them don’t even have email. So you’re going to get to that three, four, five percent level of use. Oracle is a client of ours. And when they deployed telehealth in collaboration with us utilization rates were 25 percent. So that’s five-fold or six-fold difference. The reality is that that is also changing very, very fast. People are very comfortable with using mobile devices. Facebook is introducing video chat. Skype has become something that people actually know about. The financial incentives are there. The adoption is there. The clinical validation, the clinical support, the physician support for that kind of medicine is there. Regulation is changing in this direction. I think we’re playing with numbers that realistically within two or three years are not going to matter. Telehealth is going to become one of the ways you interact with your physicians. Plaster: Jay, would you say that Sherpaa’s higher end model of care would be difficult to scale up in a massive way?
Parkinson: I would agree with that. I think Roy and I are doing something markedly different in terms of strategy. In terms of our mission, it’s very much aligned. But strategy-wise, my concern right now is really targeting those forward thinking companies. We’re not going after these production facilities in Iowa that have no email addresses. We’re going after the forward thinking companies that have a collection of employees that just immediately get this. And by doing that, it’s a much smaller growth, smaller company. But it gives us an opportunity to sort of iterate quickly and treat our patients as partners in our process. That’s what I’d be happy doing for the rest of my life, always being at that cutting edge of what the future of healthcare should look like.
Plaster: To downshift and get a bit more personal, what was your a-ha moment for knowing that you wanted to move away from practicing medicine into business, business development and healthcare technology.
Schoenberg: The truth is that our models are actually complementary, right? When people walk into an urgent care center they can expect a certain level of care and a certain level of sophistication. They also know that if they walk into the Cleveland Clinic, it’s going to cost more. It’s going to be very, very serious, very highly educated and capable and experienced physicians. Telehealth is no longer monolithic. There are different services available on the same telehealth system. Some of them are high end and some of them are low end. Historically, telehealth was all about primary care. Now we have specialties. We consider American Well more as the switchboard. We are the AT&T. We connect supply and demand. That does not mean that the supply is monolithic or that the demand is monolithic. There are different services and they all need to be connected through technology. And frankly, we could work with Jay tomorrow to expose Jay to that population that we serve today. And some people will kind of dive in and say: Yeah, that’s the kind of service I’m looking for. That’s the kind of interaction I’m looking for.
Plaster: What would be a concrete first step for someone who has those inclinations and that curiosity?
Parkinson: When I graduated from Hopkins residency I became a practicing physician, and then I really stumbled into the business side of things. It’s not something I had on my radar at all, besides being a small business owner. But I think the most important quality that I have is curiosity. If I see something that I’m unfamiliar with but looks extremely intriguing, I’ll dive right in. And I think that’s probably the characteristic we need in physicians who want to become business people.
Parkinson: That’s a good question. I have my master’s in public health. If I’d go back and do everything over, I’d probably have gotten my MBA with a healthcare perspective. But you live and you learn. But in reality, it’s really about jumping in and doing something. Because like everything, you go to school for something. Whenever you get out of school, you’re doing something very different than what you studied. So to me, having the opportunity for a young physician or an older physician who wants to get into this world, jump right in and start working with companies that are already doing this and getting some experience and then see if it’s in your wheelhouse to strike out on your own. I think Roy and I have both seen a lot of ideas and a lot of executionary [failures] in our years of witnessing this sort of Health 2.0 space. So, curiosity isn’t the only characteristic. It’s really a good idea; understanding the sort of healthcare economic landscape and executing well. And I think Roy and I have both agreed that executing well is the hardest thing to do.
Plaster: Roy, what was you’re a-ha moment for transitioning from medical practice into business? Schoenberg: Well, so my reality was at the moment I finished my medical training, I actually became a military physician and was running the hills, trying to charge my lift-up from military generators. I really want to thank Jay for coming up with the most important word here: Curiosity. You want to do things differently. Curiosity is probably the most important ingredient or foundation for you to move into that domain. The one thing, however, that I think is very, very important: Too many people say that they want to go into a start up. They want to start a company. And that scares me. Because I think historically people started the company when they wanted to do something. They had an idea. They saw an opportunity to do something more efficiently, in a way that delivered value. And today a lot of people are saying: I just don’t like the way my life looks, so I’m going to start a company. Jay mentioned the fact that you are specifically in healthcare dealing with a lot of different people, where the safe choice is to not make any changes. Introducing change in healthcare is tougher for some good reasons. So the only two cents that I would say is that: Curiosity is the key secret ingredient in moving into this world. You have to have it in your blood. But if you’re going to move from clinical practice into telemedicine or healthcare innovation or something like that, you really have to have a passion about an idea; not a passion about changing your lifestyle. And I think that’s an important thing and it’s not easy. If you end up running a healthcare company or a healthcare technology company, if you think that that means you’re going to sleep more and that you’re not going to be busy on weekends, you better think again. That’s not the case.
www.telemedmag.com
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vision
gordon
the shake-up
The Exhibitor Floor Is Dying [And That’s A Good Thing] The consolidation of the telemedicine market might feel like a slowdown, but it portends a brighter future. by Bill Gordon
In November of 2010 I attended my first mHealth Summit, it was in the lobby of the Ronald Reagan Convention Center in Washington DC. Exhibitors were mostly in development and utilizing tabletop displays with handmade prototypes of their products. We were packed into the lobby with the ballroom space saved for keynote speakers and educational tracks. There were 150 or so real exhibitors there. Over the next couple of years the location would change and the number of exhibitors would increase by multiples. The show grew to multiple ballrooms at the Gaylord National Harbor and it was a bona fide event. ATA and HIMSS evolved to marathon show floors as well with it taking a couple of days to see everything and everyone in attendance. At my first ATA one of the show floor booths was actually a working pub that opened at 4:30 PM for beer service. They even had Spring and Fall events because they could. Fast-forward to 2015/2016 and the show floors are a shell of what they once 30
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were. Sure, there are still new companies with new products on display and some of the big players are still participating but the heyday has past. Before you get too concerned, here is why that might be a good thing: Because it signifies the mainstream acceptance of mobile healthcare and telemedicine solutions and the natural evolution of elimination and contraction. Today many of the companies that took part in the mHealth product boom of the last decade no longer exist, memorialized by a LinkedIn photo or an abandoned Twitter account. Some were acquired and folded into a broader product offering. Others were assimilated into a strikingly similar product suite to their own. Others couldn’t survive because they were ahead of their time. They didn’t have the stamina – or the bank account balance – to last. Some simply couldn’t survive the survival of the fittest in a crowded market. There have been numerous diabetes management solutions, Bluetooth peripherals and gamification tools in the market, for instance, and it was only natural that some would disappear and give rise to those who will last. Companies like MDLIVE, Teledoc, Welldoc and American Well are gaining more momentum every day, which is great for all the other players in the market but not great for the trade show organizers. The more mainstream they become, the more widely accepted their solutions are, the less likely they are to need that exhibit floor. CMS just announced that telemedicine visits are acceptable for face-to-face visits prior to home health services for Medicaid patients. As the adage goes “If CMS says it’s OK then everyone else will follow suit”. This is a huge endorsement for telemedicine providers and their services. It is only a matter of time before every payer has a telemedicine service offering that is as commonplace as therapy benefits. The next step in the evolution is significant contraction. As the industry leaders grow their businesses they will start to realize that they are missing key components required to meet all of their customers needs. Rather than building it on their own
When will an unexpected player like Nike or Under Armour jump into the telemedicine fray even further by acquiring their way into a business line?
they will have the financial power to acquire and fold in what they need – and to do it quickly. This will empty the show floors even further. How long will it be before one of the major telemedicine providers acquires a diabetes management company and can now provide their own device and the service delivery platform to go with it? When will an unexpected player like Nike or Under Armour jump into the telemedicine fray even further by acquiring their way into a business line? In my estimation, you can count it in months, not years. Again, more show floor contraction. Telemedicine and mHealth conferences are headed for a period of flux, where their sizes will decrease and attendance will plateau if not decrease. But not to worry, this will all change once telemedicine and mHealth service providers are truly offering mainstream services and benefits via their contracted customers. Then you will see the re-emergence of the telemedicine/mHealth conference and their return to glory. This time around they will be bigger and better, think CES (well maybe not that big) but a show floor full of products and services not only ready for prime time but with stamina and longevity. It will be a show of champions; a show of new kids on the block and a show supported by the billions of dollars we only dreamed about back in 2010.
vision
patients and their staffs, but they’ll be able to collaborate with other doctors. We want to become the central communications system in the healthcare market; like the central nervous system for communication in healthcare. I know that’s a bold statement.
build it beautiful
One Chat Tool to Connect Them All Simon Lorenz, founder and managing director of Klara, wants to change the way doctors communicate. Originally a telemedicine company focused on dermatology, this Germanborn company has morphed into a communication hub that Lorenz hopes will become the central nervous system of the healthcare system. How? Introduce a little sleek German engineering to the American telemedicine market.
TeleMedMag: Tell us a bit about Klara. Simon Lorenz: Basically it’s an intelligent system that doctors can use to communicate securely. For any kind of chat. They can also send payment requests and charge the patients very simply by just hitting one button. It’s also a portal that connects the entire team. We don’t see the doctor as the sole user of the system. You have to integrate the nurses and the PAs because they handle so much of the patient communications. Klara facilitates that kind of collaboration. Eventually, doctors on the system will not only be able to talk to
TeleMedMag: Who are Klara’s primary users? Lorenz: Our target audience are mostly single and joint practices. However, we are planning on having three pilot hospitals that are going to work with us. TeleMedMag: Klara is open to any specialty? Lorenz: Yes. We want to see communications as open as possible; so doctors can use our system to just generally communicate or support staff can use our system to generally communicate with patients in a very easy way. If the patient or the doctor sees that an online visit makes sense, then they can actually do an online visit with our system as well. That part is simple – It’s asking a certain number of questions and sending in pictures or having a video call, right? TeleMedMag: You first launched Klara in Germany. What was the impetus for making the jump to New York? Lorenz: We realized that the U.S. market is a very good fit, as the U.S. healthcare system has already implemented newer technologies I would say in comparison to other countries. You have EMR companies, HIPAA compliance regulations and the necessary infrastructure. TeleMedMag: How has your European perspective influenced Klara’s development? Lorenz: In Germany we are very detailed and quality driven. I think German engineering has always been a sign for quality and detail and design especially. And I
lorenz
would really say that these are the things that make us stick out as well. Because we think that design is very, very important. We believe that the use of our software or our solution should be an experience, and an enjoyable one. It has to be nice and easy. Because of this focus on design and usability, we might move a little slower because we want to understand the details. For instance, when we started the company, we focused on a low number of users in order to understand how we can actually do this. For over two years we analyzed the technology behind of B2C teledermatology, then B2B teledermatology. Then we went and opened up our system for general communication. TeleMedMag: So you transitioned from a more traditional telemedicine company (focusing on telederm) to your current form as a broad healthcare communication platform. Why did you make that transition? Lorenz: In 2014, we were looking purely at telemedicine. And then by the end of that year, we looked at it and we saw that telemedicine as a standalone platform, based on our experience, was not going to be the most successful. We realized at the end of 2014 that our product needed to be a complementary thing, something that comes alongside the communication that’s already happening with the [doctor] communication. Everybody speaks about telemedicine, but I don’t think the sweet spot has been found yet. If you think about it, doctors have been practicing telemedicine ever since phones existed. Now that communication is generally moving to messaging, it is clear that there is a need for a secure messaging platform that is designed for the medical environment. Teladoc may have gone public but I know they have difficulties in building up their B2C model. We saw these challenges, and then noticed that our doctors were using our telemedicine system in a very different way than expected. We saw that they were using it for general communication, to funwww.telemedmag.com
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nel the patient in and build a relationship with them and then get them into their practice. They were also using the system for online follow up visits and for general questions from the patient. We found that every doctor, and every practice, was different in how they used the system. Doctors want to have a system that gives them all the possibilities for communicating with their patients in an easy way. TeleMedMag: How big is the Klara team?
We want to become the central communications system in the healthcare market; like the central nervous system for communication in healthcare. I know that’s a bold statement.
Lorenz: We are in total about 30 people and we are growing. TeleMedMag: What kind of trajectory do you think you’re on? Lorenz: In terms of our staff, it’s not so much about the quantity of people as the experience and the quality of the people we are gathering. In terms of customers, we want to have millions of users that are using Klara. TeleMedMag: There’s a wide range of options for revenue models for companies like yours. What’s your model? Lorenz: Our model is that you can have Klara for free. Our aim is to build the biggest medical communication network. We want to monetize when the provider makes more money via the use of Klara. So one revenue stream is that doctors can collect balances (copays, downpayments, cosmetic holds, tele-health visits etc.). When they do that we take a transaction fee similar to what credit card companies charge. There will be more and more premium features like that that enable doctors to make more money via Klara. If you want to have customized integrations and features then you will be able to get Klara “Premium”.
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flight of fancy
Should Healthcare Follow the Lead of the Airline Industry?
So you can have the basic concept for free. Why do we offer it for free? Because if you enable doctor-to-doctor communication, when a doctor invites a different doctor to use the system, you have to be for free that this person can actually use your system in order to communicate back. We also want people to experience at first how easy it is.
A recent long-haul flight to Asia provided me with a useful comparison and lens through which to see the future of healthcare delivery.
TeleMedMag: What is Klara’s price tag?
Recently I was fortunate enough to be invited to give a plenary session at the Asian Conference of Emergency Medicine in Taiwan. I was supposed to predict the future of medicine in the year 2050. Among other things, 35 years from now I think medicine will be more customer focused, safer and higher quality. But as I boarded a plane in Philadelphia, another line of thought came to mind. I have often heard people say that healthcare should operate more like the airline industry. Is that where we are heading? Can a trip through the airport serve as a foreshadowing – both good and bad – of things to come in my hospital? While I don’t feel that the airline industry should be healthcare’s model or goal, the comparison offers a useful lens and measuring stick. Here’s how I see these two industries stacking up.
Lorenz: Klara “Basic” is free and can be used with an unlimited number of patients and colleagues. If you want to collect money via Klara then you pay a small transaction fee. In the future we will have more revenue related premium features. Klara “Premium” is $99 per month per doctor. So if you have a multi-specialty group, we don’t bill for the nurses or the PAs or the patients or anyone; we just bill for the doctor accounts.
by Judd Hollander, MD
vision
Making the reservation Although both can be tedious, the airlines are more likely to accept online booking. Medicine, on the other hand, does not charge extra when you call and speak with a live person to make your appointment. Neither typically gives you an appointment soon. The airlines will, however, make it available for an absurd price. Then again, they actually tell you the overall price, which is a positive. Physicians will rarely make reservations available for the same or next day, but at least they don’t charge extra when you get one. Verdict: Pretty even. With Telemedicine, healthcare can move more towards online booking. Arrival Parking at a health system can rival parking at an airport. At the airport you have to pay for parking, but they often tell you how many spots are available on each level, so you don’t need to drive through every inch of the parking lot. Verdict: Health systems could learn from airlines how to better streamline the arrival process. Finding the right location Hospitals generally have volunteers who will help you wander around the buildings and halls a little less aimlessly than you might have done on your own. They are pleasant and most seem to genuinely care about you. You also don’t get searched before you get to your destination. Airports have different terminals and they don’t tell you which gate you need to be at very far in advance. Verdict: As confusing as hospitals can be, this is one area where we do not want to follow the airline industry’s lead. Welcome reception Sign in on a piece of paper and go sit in the corner and wait to be called. It doesn’t sound great, but it sure beats get undressed, unpacking your computer, taking
off your shoes and belt and going through a metal detector. Verdict: We’ll take a cranky triage nurse over the airline security line any day. Waiting room If you love to watch people, both are great. The airport is crowded, does not have enough seats (or enough electrical outlets), but usually Starbucks is nearby. You have some idea how long you will need to wait because flight times are posted. You don’t know if the people around you are carrying a contagious disease. In the medical office, you have a pretty good idea many of the people are sick and have no idea how long you will wait. Usually there is not a Starbucks within walking distance, but you can usually get a seat and it is usually clean. Verdict: This one is even, but healthcare could take a few pointers on giving people an estimated wait time. The event Although it may not be fun to get undressed and wear a cheap gown with an opening in the back, at least you have your own room and ample leg room. Unless you are in the emergency department, your office visit takes less time than almost any flight. The emergency department might be an exception to this rule. Verdict: With the recent race to the bottom in the airline industry, the flight experience is no longer something that the healthcare industry can look up to. Extras Airlines have pretty much eliminated the extras but you can buy food or drink on most flights. They tell you how much it costs before taking your money. In a physician’s office, if you need or want something extra, they may literally take your blood without telling you the price. Worse yet, they may send you somewhere else and make you wait again. Verdict: Healthcare can learn a thing or two about price transparency.
hollander
Discharge On my most recent flight, I made the mistake of checking luggage. Arriving in Asia and speaking to 2500 people the next day without my luggage arriving made it extra special. By comparison, I can usually remember where I parked at the doctor’s office. Verdict: While discharge instructions can be confusing, at least I can remember where I parked at the doctor’s office. Checklists The airlines have them. Most doctors don’t. More people die each year from medical errors than on flights. Verdict: This is the big one. While this isn’t the only measure of quality, it’s one that healthcare needs to address in the next 35 years. A comparison between medicine and the airlines is pretty much a neck-in-neck race toward mediocrity. What does this have to do with telemedicine? Everything. Telemedicine solves most of these problems. Telemedicine systems allow you to either schedule an appointment with your own provider or see an emergency physician whenever you want without driving downtown, paying for parking, or waiting next to someone unknowingly trying to infect you. You know what you pay. You get treated by a boarded certified physician, and your records are sent to your primary provider. The physician might even use checklists and templates. Bottom line: Until the major carriers can beam you up, up and away from home, telemedicine has the ability to best the airline industry at its own game in the next 35 years.
www.telemedmag.com
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W W W . S A L U S T E L E H E A LT H . C O M
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For more information please contact jeremy.darter@salustelehealth.com 34
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start - ups
The A-List
rising star: opternative by Rishi Madhok, MD
Company: Opternative Founded: 2013 Founders: Aaron Dallek & Steven Lee www.opternative.com Employees: 11-50 Funding: $1 million Seed in two rounds, 12 investors; $2 million in Debt Financing ------Would I Use It? Yes. I fit their narrow patient profile and prefer to interact with technology to an optometrist. Would I Invest? Not just yet. While they are making it “easier” for some to have an up-to-date refractory eye exam and prescription, they have replaced the barrier of seeing a doctor with a high technology and literacy requirement and as a result have also narrowed their clients to a specific socioeconomic class. Opternative’s exam has not been validated in a large multicenter study. Outside the US, refractory exams are readily available at eyewear stores and kiosks. In developing countries where such store fronts don’t exist, the technological infrastructure (internet access and hardware requirements) also doesn’t exist to make Opternative a viable option. For these reasons, I fail to see its ability to scale.
I
see patients online. I buy groceries online. I leased my car online. I buy my glasses online. Unfortunately, I use a prescription from 2013 for my glasses. Why? Going in for an eye exam isn’t how I want to spend my afternoon. This is where Opternative steps in. Active in 33 states, Opertnative replaces the giant multi-lens system of your optometrist with your phone and a computer. In under 30 minutes, you are taken through a familiar yet innovative process. You follow written and dictated instructions from your computer: 3 lines vs 4? X vs O. However, the way Opternative involves your phone as a remote – and will even use your shoe size to determine how many heel-to-toe steps you need to take away from your computer before answering – is what makes it stand out. Going through the exam, you feel as though you are a part of a techieMacGuiver experience, bringing together what you have in hand to accomplish what you should not. This is Opternative’s market discriminator; other startups are using VR headsets and other gadgets to bring the eye exam to the home, but this still requires new, “special” equipment. Opternative utilizes what most of us have readily available on our desk and in our pockets. How Good Is It? Dr. Steven Lee, Opternative’s founder, says their clinical trials were a “wild success.” The Opternative eye exam was as accurate as a traditional refractive exam performed by an optometrist or ophthalmologist using a phoropter. A closer look at Opternative’s clinical study on their site shows a single center enrollment of 30 patients (60 eyes). Their data lines up with their claims, an accurate exam that also yields high patient confidence and satisfaction. However, I’d
The Opternative instruction video seeks to make at-home eye exams a simple – dare we say enjoyable – experience.
like to see this replicated in other centers with different populations of patients before I am a believer. Opternative is approved in 45 states and they have made their service available in 33 to start. Eventually, Opternative wants to make eye exams cheap and readily accessible for the developing world. They are currently working on an in-store kiosk as well to place into eyewear stores. It is important to note that Opternative only offers a refractive eye exam and cannot comment on any other eye health. Also, a close look at their recommendations suggest patients age 18-40, who are in good health, use Opternative. Healthy, technology-enabled patients, age 18-40, with a high degree of both traditional and computer literacy represents a significant barrier to access and narrows Opternative’s market and ability to have meaningful impact.
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start - ups
Why some start-ups fail
postmortem: healthspot by Rishi Madhok, MD
Company: HealthSpot Founded: 2010 Founder: Steve Cashman, Kevin Banion Employees: 101-250 www.healthspot.net Location: Dublin, OH Total Equity Funding: 23.11 M in 4 Rounds Most recently financed 11.56 M in Debt Financing ------Company Description: “Our mission is to increase access to high quality, convenient and affordable healthcare services. We do this with the innovative application of technology to healthcare. Our telemedicine Care4 Station is the ultimate access point to better healthcare, using our powerful custom software platform to bring together patients and providers in convenient neighborhood locations. We have the tools to empower healthcare professionals, making healthcare smarter, simpler and more accessible for everyone.”
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n Dec. 28, 2015, HealthSpot, which offers telemedicine kiosks and service, notified its partners, including RiteAid, the Cleveland Clinic and University Hospitals that it would cease operations in three days. The abrupt and unexplained shutdown left many shocked and confused, and without official word from the company, we along with other telemedicine leaders are left to speculate. HealthSpot had built a telehealth platform centered around kiosks to establish face-to-face consults, create a treatment plan with follow up, maintain a readilyavailable medical record, and provide electronic prescription information as part of the patient medical record. In 2013, in an email blast to attendees of the International Consumer Electronics show, HealthSpot CEO and Founder Steve Cashman claimed “We are making it possible to seamlessly deliver advanced healthcare through modern technology… We are not just hardware; we are not just software; we are a complete integrated network of traditional doctor care and cuttingedge telemedicine. We are healthcare reinvented.” In four years, Healthspot had its technology platform, its retail partners, and 43.8 million in funding. So why did it fail? Many tech start-ups are “pre-revenue.” This means they don’t make any money – instead they are focused on creating, testing, and validating their technology platform. Simultaneously, they are working on establishing partnerships, early clients and bookings, and continually fundraising, because without money, these companies wind up in the boneyard very quickly. HealthSpot had worked with Kaiser, Cleveland Clinic, and the Mayo Clinic to test its kiosks and platform for 18 months. They then moved into pharmacies, an-
nouncing a partnership with RiteAid, and opened 25 kiosks in Northeast Ohio by July, 2015. Patient calls seemed to be coming in regularly and Cashman stated that HealthSpot had done nearly 5,000 consultations by May, 2015. But was it enough? While these numbers are impressive, what does it really mean and how does it compare to the costs and overhead of setting up and running these telehealth kiosks? In an article for Medcity News, Jason Gorevic, CEO of Teladoc, pointed out that, “Consumer engagement is hard to do...this is where HealthSpot may have fallen down.” Kiosks suggest health care on demand, however HealthSpot required pre-arranged appointments and perhaps this contradiction in workflow was one of many comorbidities for HealthSpot. Despite the funding, platform, and healthcare partnerships, perhaps HealthSpot failed to drive enough patients to its service to make the venture viable. In three years the company reported 1.1 million in revenue, $500,000 in 2015. Others have noted that HealthSpot, in its final months, had been experimenting with different business models, again pointing to signs that the company could not make the numbers work. But where was the money going? Companies like American Well have pointed out that their kiosks are one of the fastest growing part of their business. This notion discredits theory that high overheads of setting up telehealth kiosks are an Achilles heel to companies such as Healthspot. However, Healthspot had nearly $3.5 million in inventory, which included 137 kiosks in storage, when they stopped services. Those 137 kiosks represent investment without growth. When you are trying to stay alive, in the ICU and as a start-up, you want to account for your I’s (input) and O’s (output). An-
Failures, repeated failures, are finger posts on the road to achievement. One fails forward toward success. -C.S. Lewis
Best in Class
other questionable loss to the company was the $1.46 million paid out to 7 senior officers of Healthspot as wages in 2015. $500,000 of revenue in and $1,460,0000 out to just the executive team – Healthspot was bleeding out. Some might be quick to counter, if you want to create a world-class product, you need to recruit and retain top talent with the appropriate incentives. However, Healthspot’s leadership lacked any significant experience in telemedicine. At best their COO, Bruce Roberts, had a strong background in applying technology to delivery of care. Investing in talent is critically important, but for founders and senior executives of a start-up, the pay off in compensation comes as equity, and the long-term realization of its value, not as cash. That $1.46 million should have been allocated toward business development and securing a more immediate revenue stream. And finally, there are questions for their investors. Investors are a source of guidance and control for start-ups. Money helps, but often more important are the introductions that come with it, from investors to partnerships. With money also comes strings, board seats, and the ability for investors to point start-ups in the direction they deem appropriate. Too much time was spent on anticipating the long term instead of focusing on immediate growth and revenue (again look to their large inventory of kiosks in storage). Start small, prove your technology platform (which they did with academic partners) and your business model, then expand. In the end, HealthSpot succeeded in demonstrating the relevance of telemedicine and the technology, but ultimately failed to realize its short-term needs and risks, misallocated its resources, and thus the company fell before reaching its longterm vision.
Fastest Rising Start Up: Slack Slack, a real-time team communication and collaboration tool, has essentially changed the way we work. Well, except for healthcare. Slack allows users to collaborate, share files easily, and create groups by topic. Everything shared is searchable to team members, making information available when it is needed. Runner up: Postmates
the 9th annual crunchies awards Ever wonder what the Oscars would look like for the tech industry? On February 8th, Silicon valley dusted off its tux and honored startups, CEOs and, VCs, and thought leaders at the Annual Crunchies Awards. Healthcare: take note on what innovation looks like from the best in class of tech. We have profiled a few stand-outs.
Founder of the Year: Stewart Butterfield, Co-Founder Slack Stewart Butterfield co-founded Slack in 2013. His communication tool has drawn interest from investors including Accel, Andreessen Horowitz, Index Ventures and Social Capital, and raised $340 million. Previously Stewart founded the photo sharing site Flickr, which sold to Yahoo for nearly 30 million less than a year after it was founded. Runner Up: Tristan Walker Diversity Award: Kimberly Bryant, Black Girls Code In its third year, Black Girls Code has reached 3,000 girls through hackathons, workshops, and summer camps. Black Girls Code’s mission is to teach 1 million girls across the world to code by 2040. http://www.blackgirlscode.com Runner Up: Laura Weidman Powers, Code2040
Hardware of the Year: Samsung VR Sleek, appealing, refined, and yet usable and intuitive (again, healthcare take note). Samsung launched the second generation of the Gear VR virtual reality headset in November. Retailing for just $99 and compatible with the wide array of Samsung’s current and previous line-up of smartphonesand tablets, Samsung made VR relevant by bringing it within the average consumer’s reach. Runner Up: Sphero BB-8 Best New Start Up: Honor Providing on-demand caregivers, Honor represents a solution Silicon Valley created to help the aging population. Its service will provide a caregiver who can help with medication administration, buy groceries, make meals, give companionship – all within two hours of notice. Runner Up: Robinhood Biggest Social Impact: Code.org Runner Up: Freada Kapor Klein and Mitch Kapor, Kapor Center Reading through this list, we hope you find inspiration and draw examples of ways to solve problems in healthcare – a sector still badly in need of innovative thinking. www.telemedmag.com
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next gen ems
HERE COME THE DRONES You receive a notification from a first responder who has just found out about a serious rock slide in the treacherous mountains about 35 miles from your hospital. The roads are blocked, and there seems to be no way to quickly reach the injured. And that’s not the worst of it. It’s unclear how many are injured, what their needs are, and ground vehicles cannot reach the site until the debris is cleared. Who you gonna call? How about your friendly neighborhood drone operator? It’s no longer a matter of “if” drones will play a significant role in telemedicine going forward, but a question of “when.” Already, drones have been used in the aftermath of the earthquake in Haiti in 2015. And as we reported in this magazine (Issue #3), drones are expected to
words Michael Levin-Epstein illustration Nicolet Schenck
be deployed this year in the landlocked, hilly East African nation of Rwanda—a country lacking a sophisticated transportation structure—where the delivery of necessary medical supplies to remote areas has been a tortuous, if not impossible task. And in September, the first FAA approved drone delivery of medical supplies in the United States occurred in rural Virginia. Unmanned aerial vehicles (or drones as they’re commonly called) are expected to proliferate significantly in the next few years, experts predict. Drones will be deployed as “ambulances” to deliver invaluable medical equipment, such as automated external defibrillators, that could potentially save those injured in a rock slide, for example. The logistics are straightforward: Using drones can decrease response time and increase survival rates. Drones have the ability to deliver supplies from landing bases, which can be deployed almost anywhere. And, as far as returning to home base is concerned, no sweat. The drone’s flight path can be preset to make a drop off and return back home on its own. www.telemedmag.com
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next gen ems
Three Stages of Drone Use
this is a kitty hawk moment
There also will be a live video feed connecting the patient with a health care professionals who can guide them on how to use the medical kit. (The live video feed is encrypted to ensure patient information remains secure.) “We think this has great relevance for disaster response and wilderness medicine, but it could also be used in the event of a terrorist event or a hazmat spill—the drone’s sensor could relay information about whether the area is contaminated,” explains Subbarao.
There are three stages in the progression of drone use for telehealth purposes, says Rishi Madhok, an emergency physician at the University of California at San Francisco hospital, who has been following telehealth drone development closely for the last several years. The first stage is “reconnaissance,” says Madhok, where drones provide aerial -Virginia Gov. Terry photography and a video feed of the McAuliffe scene of an accident or natural disaster to give emergency responders a better idea of the situation on the ground. The second stage is “delivery,” where Matternet: Attempting to Master the Matter drones literally serve as the vehicle to transport needed medical Subbaro’s project is clearly worth monitoring. But a small Silicon equipment and drugs to administer to the injured at the scene, as Valley startup called Matternet has gotten a head start on drone use happened in Haiti. The Mayo Clinic has suggested that blood prodfor telehealth. Matternet has been developing drone delivery techucts and antivenom for snake bites could be excellent candidates for nology for several years, and the company’s co-founder and CEO, drone delivery in the next several years. Andreas Raptopoulos, recently gave a TED talk about drones that The final stage, says Madhok, is “medical command,” where generated more than 200,000 views. Under Raptoulous’s leadership, drones, through their video sensors, provide high fidelity data and Matternet designed a system of autonomous flying vehicles, pre-destwo-way communication between providers and responders — or ignated landing stations, and software that is able to cost-effectively even lay people — on the scene. transport packages, such as medical supplies. Matternet implementDelta in Mississippi: A Potential Force? ed pilot programs (including in Haiti and the Dominican RepubDoes all this sound like science fiction? It’s not. If you live in Mislic) to test the transportation of medical diagnostic samples from sissippi, for example, a telemedicine drone soon may be arriving at remote clinics to central hospitals where treatment can be more easa town near you. At least that’s the aim of a physician named Italo ily assessed. Subbarao. Matternet was also recently invited to Bhutan, under the auspices Subbarao, an associate dean at the William Carey University of the World Health Organization, to help implement Prime MinCollege of Osteopathic Medicine in Hattiesburg is developing a ister Tshering Tobgay’s dream of creating an advanced telemedicine full-service medical drone with telemedicine capabilities. His mosystem in his country. The dream is based on necessity: Bhutan has tivation: To be able to deal better with the after-effects of natural only 0.3 physicians per 1,000 people, according to World Bank data. disasters, such as the EF4-level tornado that levelled Hattiesburg And with only 31 hospitals, 178 basic health unit clinics and 654 three years ago. The damage in the surrounding area was so extensive outreach clinics serving a population of more than 700,000, access that local ambulances had trouble reaching all the homes that had to quality health care is clearly an issue in the country. For the pilot been affected. So Subbarao decided to move forward manufacturing project, Matternet used autonomous flying robots to connect the a drone that could serve as an ambulance for emergency response or Jigme Dorji Wangchuck National Referral Hospital in Thimphu, wilderness medicine. Bhutan’s capital, with three small rural healthcare units. That drone is still in the testing phase, but ultimately, it will be To date, Matternet has flown over 100 missions, in five coundesigned to incorporate integrated healthcare recovery capabilitries, at altitudes ranging from one to 3300 meters, in high winds ties, according to Subbarao. Here’s how it works: Guided by GPS, and rain (often cited as a problem with drones), transporting goods the drone drops a modular medical kit that contains diagnostic from local hospitals to remote clinics. “From everything we’ve learnt and treatment equipment for the patient’s situation, such as heart through planning and implementing these pilot programs it’s clear attack, trauma, or dangerous fever. Subbarao notes that the FDA to us that the vehicles that gain the greatest trust within a commualready has approved an ECG recording device that attaches to a nity are those that the community has greatest access to and control smart phone, which has a built-in thermal camera. “If we can send in over. Our product has been designed ground-up to be owned and that kit,” he explains, “we can take the patient’s temperature without run by the communities it serves, and to be navigated by people who having to do anything extra.” have little experience in piloting aerial vehicles,” Raptopoulos said 40
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the three stages of drone use -Rishi Madhok, MDin his TED talk. By establishing routes between clinics and local hospitals (the hub and spoke), he explained, Matternet is able to envision a cost-effective solution for transportation between communities (spoke to spoke), which, would fuel local trade. The bottom line, according to Raptopoulos: “We believe that the business of building flying robots is at an inflection point. We believe it’s moving beyond the domain of the military, the hobbyist or enthusiasts to becoming a viable solution to the extreme needs of transportation, creating a new paradigm.” The reason that many telemedicine experts and entrepreneurs are so bullish on unmanned aerial vehicles is that commercial drone use is expanding exponentially, led by Amazon Prime Air’s game plan for package delivery. But while you or your neighbor can pick up a drone at your local Radio Shack for under $100, drones used to deliver medical supplies — and receive Federal Aviation Authority (FAA) approval — will be far more costly. Indeed, the wild card in the future of telemedicine drone use may just be the FAA—the federal agency with jurisdiction over nonmilitary unmanned aerial vehicles.
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These operators can apply for an exemption, and that’s what health care organizations are now trying to do, and are expected to do even more going forward. RECONNAISSANCE In September, the FAA gave a WashDrones provide aerial photogington D.C.-based startup called Measure raphy and video feed of the scene permission to fly 324 drones. But Measure at an accident or natural disaster to give emergency responders a won’t be using its drones to deliver medical better idea of the situation on the supplies; it will be using its UAVs to collect ground. data, which is a priority for the federal government. Measure is a drone consultancy and service business that focuses on the agriculture, oil and gas, insurance, and other industries in which aerial photography and other data is a valuable commodity. DELIVERY Drones literally serve as the veWhile it’s unclear what the Measure aphicle to transport needed medical proval will mean for telemedicine, there equipment and drugs to adminiswas concrete movement in this area last ter to the injured at the scene, as year when, in July, the agency approved happened in Haiti. The Mayo Clinic drone delivery of medical supplies, includhas suggested that blood products ing asthma, high blood pressure, and diaand antivenin for snake bites could betes medications, to ill patients at a large, be excellent candidates for drone rural health clinic in Virginia. delivery in the next several years. Virginia Gov. Terry McAuliffe (D) was euphoric, to put it mildly: “It’s going to revolutionize the way we deliver health care. This is a Kitty Hawk moment.” MEDICAL COMMAND As Chris Hall, chief operating officer Drones, through their video senof Remote Area Medical, which put on the sors, provide high fidelity data and free clinic, noted at the time, in places like two-way communication between rural Virginia, it can take an hour for health providers and responders — or FAA Proceeds at Own Pace in care workers to get medicine and supplies even lay people — on the scene. Approving Medical Drones to residents, but drones can fly them over In terms of regulatory oversight, drones in five minutes. “The future of this delivery are no different than 757s. Both are under technology could be tremendous, not only the jurisdiction of the Federal Aviation Adfor Remote Area Medical (RAM) but for relief ministration (FAA). organizations worldwide,” said RAM founder Stan Brock. The VirBut despite a mandate from Congress to integrate UAVs into ginia drone deliver was organized by Flirtey, a drone delivery comFAA’s overall monitoring and regulation of U.S. national space, the pany founded in Australia. agency is proceeding with all deliberate speed. To be fair, experts Throw into the mix the fact that Congress is expected to put insay, it’s not easy to establish ground rules for drones, noting the near creasing pressure on the FAA to promulgate regulations. Sen. Ron misses and actual accidents that have occurred with drones not just Wyden (D-Ore) is honchoing a bipartisan effort to get the agency in the United States but globally. to take quicker action on drone regulation for commercial use. In Whether for medical purposes or not, the FAA has established a a letter to the FAA, Wyden, joined by Sens. Jeff Merkley (D-Ore), complicated, bureaucratic system that all drone operators and busiHeidi Heitkemp (D-N.D.), John Hoeven (R-N.D), and Corey ness utilizing drones — from big-time players like Amazon to the Booker (D-N.J), stated: “These (regulatory) delays force manuremotest urgent care facility — must follow in order to garner FAA’s facturers and operators who play by the rules to sit on the sidelines approval to fly. Those rules include flying no higher than 400 feet while they wait for approval, while others chance fines and operate above the ground, and always within the line of sight of human opwithout any certification from the FAA, which raises serious conerators. cerns about public safety.”
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PAIN: COULD THERE BE AN APP FOR THAT? This start-up hopes their efforts to take TENS units from a bulky, complicated, marginally effective technology to a slick, app-enabled wearable will change the way we treat chronic pain. by John Tyler Allen
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I
t was still early one fall evening in 2011 when Shaun Rahimi lay alone in his dorm room, afraid to move for fear he’d stoke the neuropathic flame that burned from his neck to his feet. At thirteen he had developed Scheuermann’s disease, a skeletal disorder that caused several of his thoracic vertebrae to form into a wedge shape and force his spine into an unnatural forward curve. Because sudden movements meant worsening his already unbearable pain, he would often resign himself to immobility, a tacit acceptance that he was a prisoner of his own nervous system.
As Rahimi lay in his bed that night, the open window next to him let in the music and the noise from a fraternity party down the street. It occurred to him that this was his life and his youth; this was the closest he would come to the college experience. Bitterness followed. The partygoers’ voices were alive with a happiness he would never know, and he resented them for it. He shifted in his bed and another jolt of pain lit up his spine. This is when his thoughts began to border on delusion, he said. He began to mash at one of his wrists, desperate to turn off his pain. He could almost see a button there, and if he only pressed it, he could calm the fire in his neck and back. And what if the debilitating carpal tunnel in his arms suddenly vanished? What if he regained his hands? It was absurd, he knew, but the thought wouldn’t leave him. What if something as simple as a button, right here on his wrist, could stop all of this? Now, four years later, Rahimi, a twenty-six-yearold biomedical engineer and entrepreneur from San Francisco, is hoping to soon bring to market a wearable device engineered to do just that. The unit administers transcutaneous electric nerve stimulation (TENS), a low-grade electrical current that can be manipulated to inhibit the brain’s ability to perceive pain signals from virtually any point on the body. Professional units are roughly the size of a thick hardcover book and allow a physician to fine-tune the pulse rate, pulse width, and amplitude of a current until it achieves a strong but comfortable level
the chronic pain crisis
of motor nerve stimulation. Rahimi’s device is the size of a wristwatch and not only provides “the same features and benefits” as the most powerful professional units on the market, he said, but it does so by self-calibrating at the touch of a single button. Electrotherapy dates to ancient Rome and the first modern, wearable TENS unit was patented in 1974. Since then, and despite the therapy’s longevity, poorly designed studies (patient non-compliance, lack of placebo, inadequate sample sizes, the misunderstanding of dosage requirements) have reinforced a perception of TENS as a therapy defined by inconclusiveness. A recent Cochrane review of TENS studies evaluated nineteen randomized controlled trials and found only six studies that could contribute meaningful data. The best the authors could muster: “We concluded that TENS may reduce the intensity of acute pain in some patients but the quality of evidence was weak.” Rahimi’s belief in the therapy’s potential remains unfettered. “I understand that perspective because it’s a common one, especially when considering the need for evidence-based medicine,” he was quick to point out. “But I think it’s misleading.” Small sample sizes and underpowered devices don’t negate the fact that the majority of TENS studies are positive, he said. More formative, though, was that time when Rahimi lived with mind-altering pain and, after a year and a half of trial and error with eight different prescription pain killers – “I don’t remember my third year of college,” he said – a physician attached a TENS unit to his neck and his pain disappeared. Perhaps this makes it less surprising that Rahimi has given his device the rather high-achieving moniker, CŪR. Rahimi, who is the CEO of CŪR, Inc., developed the first prototype with Kevin McCullough, cofounder and chief technical officer, and Earl Vickers, a digital signal processing engineer. The main innovation lies within a basic closed feedback loop. As CŪR self-modulates its current, an accelerometer and bioimpedance sensor detect both the unit’s place on the body and specific movements within the muscle that indicate motor nerve stimulation. www.telemedmag.com
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the chronic pain crisis
Within a few seconds, the device can calibrate itself to the optimal strong but comfortable level. And if the wearer wants more control, the settings can be further customized via a smartphone app that pairs with and controls the unit. CŪR has also been fitted with an advanced waveform generator – a particular point of pride for both Rahimi and McCullough – which enables it to produce a “new type” of waveform that will “affect the nerve in a more compelling way,” Rahimi said. He declined to elaborate. The simplicity of the design, the “form factor,” as Rahimi and McCullough kept calling it, was approached with as much purpose as the technology it holds, and it stands alone as its own feat. CŪR’s electronics are housed in a sleek plastic square the size of a watch face, which magnetically attaches to the electrodes in a two-inch-by-five-inch reusable gel patch. In past interviews and in online start-up forums, Rahimi introduced CŪR as “a Band-Aid for pain;” the influence on the design and the ethos are obvious. “You can put it on, go to the bathroom, hang out with your friends, go to a concert, whatever you have to do, and not think about it,” Rahimi said. “The form factor is a big part of it. That’s what drives adherence to TENS treatments.” “There are small TENS units you can put in your pocket or clip on your belt,” Dr. Joanna Katzman,
THE SCIENCE OF TENS
by Rishi Madhok, MD TENS’s scientific foundation is still in its infancy. Most recently there have been two systematic reviews, one meta-analysis and one Cochrane Review. These examined experimental pain models, chronic musculoskeletal pain and chronic low back pain. Khadilkar et al were only able to include two randomized controlled trials of TENS for low back pain in their Cochrane Review2. Heterogeneity among the
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study populations prevented the authors from pooling data. This resulted in inconclusive evidence for the application of TENS in lower back pain. Thirty-two studies of TENS and six on percutaneous electrical nerve stimulation were pooled by Johnson and Martinson to evaluation electrical nerve stimulation for chronic musculoskeletal pain3. Conditions for the 1227 patients evaluated ranged from rheumatoid arthritis, lower back pain, osteoarthritis, ankylosis get spondylitis, and myofacial pain. Results demonstrated a significant decrease in pain with
director of the University of New Mexico Pain Center and president of the American Academy of Pain Management, said. “But you can’t go to a gym class so easily, or run three miles.” CŪR’s design and function could inspire greater compliance in patients prescribed TENS to treat arthritis, musculoskeletal pain, neuropathic, and acute post-operative pain. However, she added, “patients with moderate pain probably aren’t doing that high, high level of activity.” Katzman also stressed the complexities of pain, saying any implications that pain management can be reduced to a single device are unrealistic. “Most patients who have chronic, non-cancer pain usually need a multi-modal approach,” she said. “It’s rarely just one pill, just one device like a TENS unit, just one thing that is the answer.” She was optimistic about the potential for CŪR’s size and portability to reduce reliance on medications: “We’re always looking for integrative approaches to pain management that don’t include pharmacotherapy…(especially) in this era of opioid overdose and risk of opioid dependence and addiction.” Dr. John Garzione, a physical therapist and electrotherapy expert currently studying the effects various treatments have on the nervous system, says, “Some people respond better to one type of
electrical nerve stimulation when compared with placebo. A review of 13 studies by Chen et al4 sought to establish the hypoalgesic effect on pulse frequency for experimental pain. Three of the 13 studies reported a significant difference for pulse frequency. When pulse intensity was standardized at a strong yet tolerable level close to the pain site, pulse frequency did not show to be a key determinant of positive outcomes. 1. Deyo RA, Walsh NE, Martin DC, et al. A controlled trial of transcutaneous electrical stimulation (TENS) and exercise for chronic low back pain.
N Engl J Med. 1990;322:1627–1634. [PubMed] 2. Khadilkar A, Milne S, Brosseau L, et al. Transcutaneous electrical nerve stimulation (TENS) for chronic low-back pain. Cochrane Database System Rev. 2005;(3) 3. Johnson M, Martinson M. Efficacy of electrical nerve stimulation for chronic musculoskeletal pain: a meta-analysis of randomized controlled trials. Pain. 2007;130:157– 165. [PubMed] 4. Chen C, Tabasam G, Johnson MI. Does the pulse frequency of transcutaneous electrical nerve stimulation (TENS) influence hypoalgesia? A systematic review of studies using experimental pain and healthy human participants. Physiotherapy. 2008;94:11–20.
stimulation than another.” And some can’t tolerate a TENS current strong enough to incite the motor nerve or the resulting muscle contraction. To this end, CŪR’s ability to self-modulate to a strong but tolerable level could demonstrate value, he said. But he cautioned against lapsing into unsubstantiated hype. For instance, claims of superior waveforms were popular thirty years ago, soon after the arrival of wearable TENS units. “The research has not, at this point, said that one waveform is superior to another,” he said, alluding to a 2007 study by the Pain Research Program at the University of Iowa that found “differences in waveform characteristics do not affect the anti-hyperalgesia produced by TENS.” “(Research) is all we can really go on as professionals,” Garzione said. “What does the research show us?” Both Garzione and Katzman reiterated this warning. The device has yet to be cleared by the FDA (Rahimi’s “the same features and benefits” comment is the most concrete claim the FDA will allow him to make) or endure a single clinical trial. Rahimi welcomes the burden of proving CŪR’s effectiveness. “We want to build a brand and a company that has a strong scientific basis,” he said. “Not only so consumers, but especially physicians, can appreciate the data we have.” To this end, the founders are currently designing studies in coordination with two well-known medical centers – one in the San Francisco area and one in the Midwest – to be launched in the next year. In the past year, CŪR’s founders have been criticized for using a crowdfunding campaign to market and take orders on a device that lacks FDA approval. In a statement addressing the allegations, Rahimi countered that the fundraising was “designed to support the continuing development operations,” and that the product would only ship after FDA approval. McCullough added that, before the campaign, the CŪR founders submitted their verbiage for rigorous legal vetting by FDA regulatory experts and, to date, CŪR’s messaging has been sufficiently compliant. Still, the website for Thimble Bioelectronics – from which CŪR, Inc was born – currently advertises for a wearable device that will “heal back pain as quickly and easily as healing a cut.” And the CŪR website features what amounts to a two-minute
testimonial advertisement in which a TENS unit is attached to chronic pain sufferers who, as soon as the machine is turned on, sigh in relief and revelation. An emotional piano soundtrack swells in the background and, through a series of cross cuts, we’re implicitly told CŪR will see chronic pain “vanish,” leading to “a life without pain.” The video’s implications are “very bold claims,” one pain management physician said (she asked that her name not be given). “Patients come to us and they want to (their pain intensity) go from an eight over ten to a zero over ten. If we can lower the pain by fifty percent, that’s considered extremely good. But sometimes getting to zero, once the patient has gone down the road of chronic pain, might be unrealistic…They’re very confident that this device will help people completely.” Dr. Garzione also voiced frustration with the claims in CŪR’s promotional material. “As professionals,” he said. “We really have to protect people from (unsubstantiated claims).” “There’s a lot of science in the past twenty years that’s been developed around TENS and which settings are more effective for a given user,” Rahimi said. “But the technology has not caught up to that science at all.” McCullough elaborated: “We can make miniaturized electronics, we have better sensing technology – we can really make some very smart devices. But when it comes to treating pain, there haven’t been significant companies to step forward and make those innovations.” Garzione admitted that this was one aspect of CŪR that was especially intriguing. “We have seen innovation in electro-medicine go, basically, down the tubes,” he said. And later he added, “I’m excited about any innovation…If this really is truly effective, I’m excited about it…I really hope it does what they say.” For Rahimi, the TENS perception, the technology, the friction of introducing a new product into a noisy market, are all secondary to the pain. “As long as the technology (is) somewhat feasible from the start,” he said. “You (can) build things people don’t expect to be possible. Questioning what’s possible or not doesn’t really make as much sense as asking, How important is the problem?”
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WHERE INSPIRATION AND DISCOVERY HAPPEN “SXSW is a giant, three-week technology, film and music festival, but it is South By’s first week, SXSW Interactive, with which technology and start-ups are obsessed.” –Financial Times
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the list
teleSCOPE ----Cradlepoint www.cradlepoint.com 855.813.3385 Page 13 Sierrawireless www.sierrawireless.com 760.444.5650 Page 13 Goodmill www.goodmillsystems.com + 358 40 734 0462 Page 13 Natick Health Page 13 ResolutionCare www.resolutioncare.com 707.442.5683 Page 14 ProjectECHO www.echo.unm.edu 505.750.3246 Page 15 Zoom www.zoom.us 888.799.9666 Page 15 Tapcloud www.tapcloud.com 847.239.7224 Page 16 teleTECH ----Littman www.littmann.com 800.228.3957 Page 21 Eko Core www.ekodevices.com 844.356.3384 Page 22
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The companies and brands mentioned in this issue.
Thinklabs www.thinklabs.com 800.918.1088 Page 23 Rijuven www.rijuven.com 412.404.6292 Page 24 teleVISION ----American Well www.americanwell.com 617.204.3500 Page 26
Robinhood www.robinhood.com Page 37 Blackgirlscode www.blackgirlscode.com 510.398.0880 Page 37 Laura Weidman Powers www.code2040.com Page 37 Code.org www.code.org Page 37
Sherpaa www.sherpaa.com 844.283.3979 Page 26
Kapor center www.kaporcenter.org 510.488.6600 Page 37
Klara www.klara.com Page 31
Thimble www.thimblebioe.com Page 45
Start-Up Guide ----Opternative www.opternative.com Page 35
Features ----CUR www.cur.me Page 43
Health Spot www.healthspot.net 855.585.7768
TENS www.tensunits.com Page 43
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Slack www.slack.com Page 37 Postmates www.postmates.com Page 37 Samsung VR www.Samsung.com Page 37 Honor www.joinhonor.com 415.549.0685 Page 37
Sponsors ----TelaDoc www.teladoc.com 888.835.2362 Page 2 Salus Telehealth www.Salustelehealth.com 866.892.9493 Page 34 National Fingerprint www.natinalfingerprint.com 888.823.7873 Page 46
RealTime Clinic www.realtimeclinic.com 469.801.9334 Page 48 SnapMD www.snap.md 310.953.4800 469.801.9334 Page 51 MyOnCallDoc 855.362.3278 Page 55 JeffConnect www.hospitals.jefferson.edu 215.955.6840 Page 56 Conferences ----Telehealth Summit www.caltelehealth.org mHealth Toolbox www.mhealthtoolbox.com Telemed/Health Service Provider Showcase www.ttspsworld.com SXSW Health & MedTech Expo www.sxsw.com/HMT Health Experience Refactored www.hxrefactored.com American Telemedicine Conference www.gotoATA2016.com Telemedicine Programs & Services www.acius.net
learn more at www.telemedmag.com
Make 2016 Your Brand’s Best Year
From expanded circulation to an online buyers guide, Telemedicine Magazine offers a range of new ways to build your brand in 2016. SXSW March 12-13 Austin, TX
1) bonus distribution In 2016, in addition to its circulation of 30,000, Telemedicine will be distributed at major conferences around the world, and through multiple telehealth resource centers. Here is our current list of meetings. Contact us to arrange custom distribution at your event or place of business.
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South Central Telehealth Summit August 1-2 Nashville, TN
ACEP S.A October 15-18 Las Vegas, NV
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Telehealth Summit April 17-19 San Diego, CA
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contact Diana London: Diana@telemedmag.com www.telemedmag.com
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The Once and Future Oracle An old approach to artificial intelligence never really left us, and may rise again by Nicholas Genes, MD, PhD
B
efore smartphones and apps, before the World Wide Web or graphic user interfaces, scientists and engineers tried to build computers that could out-diagnose doctors. These “Expert Systems” were an early approach to artificial intelligence, and their successes and failures have particular relevance today. For MYCIN, the premise was simple: teach a machine the necessary “rules” about infectious disease so that, if a user answered enough questions about a sick patient, the machine would ultimately arrive at the correct diagnosis and recommend appropriate antibiotics. MYCIN was developed in the 1970s by one of the founders of clinical informatics, Ted Shortliffe, while he was a computer science student at Stanford. Its predictions for likely causes of bacteremia and meningitis were based on history, exam and lab findings, and incorporated unknowns and degrees of certainty, well before cultures were resulted. And MYCIN worked better than doctors – blinded ID faculty evaluators rated MYCIN’s choices for antibiotics as correct 65% of the time, beating the human specialists ratings of 42.5–62.5%. MYCIN’s edge was its memory and its methodical nature – it never forgot a detail or overlooked a disease, and it never jumped to conclusions before systematically evaluating all the facts. But these advantages were also shortcomings. The knowledge base and hundreds of rules took a long time to develop, were hard to maintain, and each diagnosis required many dozens of questions to be asked of the user. Other systems, like INTERNIST-I (modeled after Dr. Jack Myers’ ranking algorithms for generating differential diagnoses in internal medicine), tried to expand the scope of what expert systems could approach, with mixed results. These were time-consuming solutions that didn’t scale well. Expert systems remain useful for constrained domains like EKG interpretation, but weren’t practical for routine 54
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diagnosis. Critics lamented the “Greek oracle” proclamations of these systems, which relegated the physician to the role of passive data entry clerk instead of leveraging their knowledge and judgment. Looking back, the name “Expert System” expresses a naive confidence in the power of computers, and an appeal to authority, that seems dated. Today’s Clinical Decision Support, baked into our electronic health records, sound meek and apologetic by comparison. But these CDS tools are based on similar rules engines as the Expert Systems, and even though popups about core measures or irrelevant drug interactions can be annoying, it’s still progress. The system is integrated into workflows and monitors physician activities in realtime, trying to steer us in a direction that seems adherent to guidelines and best practices. With the arrival of “big data” and personalized medicine, it’s likely CDS algorithms will get more sophisticated, with tailored recommendations based on a patient’s demographic, historical and genetic information. IBM has touted Watson’s ability to absorb rules from the medical literature, as well as a hospital network’s own logs of data and outcomes, to guide physician decision-making. Ubiquitous advertising for Watson is raising public expectations of what physicians and their tools can accomplish. It’s not clear that Watson, or other insights gleaned from big data, will ever live up to expectations. But prominent institutions are already investing in systems to synthesize health data and guide physician behavior. The role of clinical decision support tools will only continue to expand to more aspects of care. Ultimately we may end up with CDS algorithms so complex, physicians won’t be able to piece together the specific reasons why a recommendation was made. If that day comes, it would represent the unexpected triumph of the expert systems of old – we’ll have our “Greek oracle” issuing pronouncements, after all.
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JeffConnect is putting health .in the palm of your hand. UA RT I 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 a smartphone, drawing on expertise across the country for a valued second opinion, 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. JeffConnect. Helping to reimagine the future of health care. Kate Fuller
Judd E. Hollander, MD
Telehealth Program Manager
Associate Dean for Strategic Health Initiatives | Sidney Kimmel Medical College Vice Chair for Finance and Healthcare Enterprises | Department of Emergency Medicine | Thomas Jefferson University
kate.fuller@jefferson.edu
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