Page 1

Glass is back. Could augmented reality save the house call?


How to talk so patients will listen

-----Virtual care puts health literacy in the spotlight. Page 10

Simulations explore the threat of hospitals getting hacked.

Three ways virtual care can help fight the opioid epidemic.

A med student reflects on his first experience in the tele-ICU.

FALL 2017 / ISSUE 10

What motivates healthy behavior?

-----Wellth is paying patients to take their pills...and it's working. Page 25

Insights from the TopTelehealth Experts in the Country.

22 1








March27-29, 2018 Washington,DC Co-hosted by URAC and Telemedicine Magazine, this 2-1/2-day gathering brings together the best and brightest minds in healthcare to deliver solid, innovative and valuable information focused on the ROI of telehealth. To view details and register, visit:


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WWW.TELEMEDMAG.COM ISSUE 10 / FALL 2017 Editor's Desk_4 ------telescope

Cardiology_6 Education_7 ICU_8 Neurology_9 Communication_10 ------teletech

Glass EE: Google's augmented reality is back._11 Glass in Action: Loyola and SwyMED have partnered to test drive Glass-enhanced home visits. _12

pGlass is Back!_Page 11 Google's attempt at augmented reality is back for round two, now as Glass Enterprise Edition. We talk to one of the few healthcare companies testing it in the field.

Drones: Three current use cases for drones in healthcare._14 ------television

Corbett: The truth about population health._15 Joshi: How to grade the quality of your program. _18 Watterson: Embrace ubiquitous care or be left in the dust._20 Rizzak: Can telemedicine reduce LWBS in the emergency department?_22 -------

p Matthew Loper Wants to Retrain Your Brain _Page 25

p Is your hospital prepared for a cyber attack? CyberMed Summit plays out scenarios in order to prepare for the worst.

Wellth, Loper's startup, hopes to show that financial incentives – paying people to take their meds – helps improve medication adherence.


Retrain your brain – Do financial incentives improve medication adherence?_25 CyberMed Summit addresses fears of hospitals getting hacked _28 Canadian telemedicine program brings care to the far north _30 Three digital health tools to help fight the opioid epidemic_32

Page 28 www.telemedmag.com


editor’s desk

Less Hype, More Hypotheses

logan plaster

editor-in-chief logan@telemedmag.com

In the Johns Hopkins emergency department, telemedicine is just getting off the ground. If their current screening experiment works – and they have the data to support it – they'll add providers and scale it to other facilities.


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repare Yourselves, Robots Will Soon Replace Doctors in Healthcare." At least that’s what Forbes published in July, 2017. I love dreaming about healthcare’s slick and exciting digital future – whether it’s robots, AI or augmented reality. And walking the floor of any telemedicine conference it’s easy to get caught up in that three ring circus. But walk the halls of a typical hospital and the view is quite different. I recently visited the Johns Hopkins emergency department in Baltimore to check out their new telemedicine set-up. The telemedicine cart looked and operated very similarly to others I’d seen. What stood out to me were the humble surroundings – no futuristic panel of screens, just a cart in a utility room – and the simple objective. According to Junaid Razzak, the emergency physician behind the project, the telemedicine cart was being used primarily to find out if tele-screening in the emergency department could effectively reduce Will robots take the Left Without Being Seen (LWBS) rate (read over the hospital? the interview on page 22). In other words, could a quick video consult with a doctor keep patients Will you receive from leaving the emergency room when there your prescription by happened to be a long wait? Razzak and his team drone? We can take are keeping it simple. Test this hypothesis, track nothing for granted the data, publish the data, and then scale to a few about what form more facilities if it works. telemedicine will Robots replacing doctors? It’s fun to talk about, but at Hopkins, the third best hospital in take going forward. the nation according to U.S. News and World Re- Therefore we must port, telemedicine exists in the petri dish. How it test, fail, test again, performs "in the lab" will inform what happens iterate then try next. It's a slow a steady approach that eschews again. We must glitzy roll-outs. gather data, then we Hopkins isn’t alone. To the north, Mount Sinai in New York City is putting virtual health- must share the data. care strategies to the test. They’ve partnered with a start-up called Wellth, which applies behavioral economics to the problem of medication non-adherence. To put it simply, Wellth will pay you to take your pills, and Mount Sinai is testing to see whether their methods can reduce re-admission rates for a specific set of patients (read the whole report on page 25). A simple, measurable objective that can guide future developments. It should come as no surprise that intelligent folks at major healthcare institutions are playing SMART (Specific, Measurable, Achievable, Realistic, and Timely), yet in a market dominated by the hype of robots, smart watches and virtual reality, it’s good to see an institution tackle problems methodically, with an eye towards evidence-based medicine. Will all home care nurses eventally wear augmented reality glasses? Will you receive your prescription by drone? I don't know. We can take nothing for granted about what form telemedicine will take going forward. Therefore we must test, fail, test again, iterate, then try it all over again. We must gather data, then we must share the data. If that leads to robots replacing doctors, so be it! But I have my doubts.

telemedicine ISSUE 10 – FALL 2017


Logan Plaster logan@telemedmag.com

As we head into another school year we highlight an essay by a med student experiencing telemedicine for the first time (story on page 8).


Mark Plaster, MD

how did you make it through all-nighters in college?


Rishi Madhok, MD Aneel Irfan Unity Stoakes EDITOR AT LARGE

Nicholas Genes, MD, PhD Sour gummy worms - never more than a 7/11 run away


Philip Reynolds Sonya Swink Laura Sansouci

When it's 2 am and the term paper isn't half done, macchiato and chocolate covered espresso beans is the dynamic duo that will keep you typing till morning.

I learned to drink cold black coffee from the big urn in the blood bank where I worked that had been brewing all week. It would give you a real jolt. Two or three cups and you weren't going to sleep if they gave you anesthesia.

Jodi Lyons Jeanine Feirer, RN Scott Jung

Scott Pruden

John Tyler Allen

Greg Barber

Aditi Joshi, MD

David Thompson, MD Jeremy Corbett, MD

For me, there was no greater indulgence before a big exam than sleep itself. More energizing than caffeine or any snack was a few consecutive hours of deep zzzz's.

Jeremy Tucker, MD Dan Watterson

Los Angeles' Koreatown was 5 minutes from campus and open late, so 3 AM Korean food runs became a tradition.


Raman noodles



Eliseo Rivera eliseo@telemedmag.com TELEHEALTH RESOURCE CENTER LIAISON

Aneel Irfan aneel@telemedmag.com

Telemedicine Magazine is published quarterly by M. L. Plaster Publishing Co., LLC. PO Box 121, Galesville, MD, 20765. 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




You scan checks with your phone to deposit them. Why not scan a paper ECG and receive instant analysis driven by artificial intelligence?

telescope Telemedicine briefs across the medical universe

image courtesy of Figure 1

gear lab

Figure 1 Brings Machine Learning to Mobile ECG Interpretation If this experiment is a success, other tests will follow. by philip reynolds


Issue 10


& logan plaster


1 Figure 1, known as the Instagram for Doctors, is currently developing a mobile tool that will scan and interpret ECGs using machine learning and artificial intelligence.

2 The application is only in development, but Figure 1 CEO Josh Landy hints that the tool will be ready to begin field testing before the end of 2017. And when it is fully available, it will be freely available in more than 100 countries.

3 ECGs are only the beginning. According to Landy, anything that’s in graphical format that has a stereotypic pattern is fodder for possible machine interpretation, from pulmonary function tests to urinanalysis.


CMO Spotlight

Josh Landy, MD // Figure 1

education are not in lockstep. Medical education teaches you the background and the basics. But you’re left to do the hardest part, which is to recognize when you’re seeing a patient, which experiences, which knowledge and what vagaries you need to bring to that patient. That’s the moment where medicine happens, where you are connecting the structured pieces of knowledge you have with the experiences you’ve had in the past with what you see happening in this patient."

on how figure 1 spreads the “culture of medicine”

Before Dr. Joshua Landy co-founded Figure 1 – called "The Instagram for Doctors" – he worked at Stanford University as a visiting scholar and studied ways to implement health education through multi-media and online mediums. Now, from his office in Toronto, Landy works on ways to use machine learning and artificial intelligence to enable instant mobile test analysis.

on the heart of figure 1: connecting the theoritical and the practical

“One of the frustrations that I have as an educator in healthcare is that clinical practice and medical

how figure 1 works

Figure 1 is a free app that allows healthcare providers to post de-identified medical images to an account that can be followed by others, similar to Instagram. The app boasts millions of users from more than 190 countries.

"In the same way that people might shoot the breeze about an interesting case they saw and get to know each other and get to learn about each other’s practice patterns, [on Figure 1] you have hundreds of these interactions over the day… these are moments where that practice of medicine spreads from one person to another and the culture of medicine spreads from one person to another."


Market Watch

Telepresence Robots The first notable telepresence robot was developed by iRobot for NASA in the early 90s. This was transformed into the Vita bot which has been used in Midwestern hospitals for decades. Now, a range of companies are entering the space with promises of beaming the doctor to your bedside, no matter where you are.

on achieving respect as an educational tool

“I’m actually perfectly fine with the educational value [of Figure 1] being below the surface. Yet formally and amongst educators, I’d like it to be recognized as a way of presenting unstructured educational content presented in a context of real life, in the vein of problem-based learning as curriculum.”


Joshua Landy, MD Gregory Levey Richard Penners


Total Equity Funding: $23.15 million in 5 Rounds from 11 Investors Most Recent Funding: $10 million Series B on June 13, 2017

business model

In the Spring of 2017, Figure 1 launched a sponsored content revenue channel. Partners – currently blue chip institutions and large biopharmaceutical companies – can target a sponsored post, quiz or grand rounds at their target audience.

Beam Originally designed for large manufacturing spaces, the Beam robot by Suitable Technologies is making waves in healthcare. According to Wirecutter, it is "stable and reliable" and "provides clear sound and video." The newest Beam has two dual-band Wi-Fi radios, up to 8 hours of battery life, faster speed of movement and the best wide-angle display camera on the market. Beam costs about $4,000 plus a $400 annual subscription. continued on page 17

(source: Crunchbase) www.telemedmag.com




digital native

Telemedicine Will Inspire Medical Students—If They’re Exposed to It Reflections on tele-ICU from a fourth-year medical student. by gregory barber The code started one hour into my first shift in the tele-ICU. A patient had stopped breathing in a small community hospital on Maryland’s Eastern Shore. The patient was three-and-a-half hours by car from the spacious room I saw filled with a dozen computer stations that looked like they may have been pulled from the control room of a futuristic space ship. As a fourth year medical student, I haven’t had much time in the ICU, either remotely or in person. So when the code began, I did not quite know what to expect. Surely, I thought, the controlled chaos I am accustomed to when a patient becomes unstable in the hospital would be compounded by the distance between the leader of the code and the nursing staff executing it hundreds of miles away. But the doctor I was shadowing, an intensivist with years of tele-ICU experience, carried the situation as if no space separated the team. I saw the nurse practitioner intubate the patient at the doctor’s command and watched as an8

Issue 10



other nurse began chest compressions with no sign of buffering or lag from the camera that was broadcasting from that understaffed hospital room on the other side of the state. The same cool, dispassionate demeanor of attending physicians that is so reassuring during emergencies in the hospital was on display in that room, no matter the bandwidth of the connection between doctor and patient. As the nurses stabilized the patient, I was aware of a sense of surprise, not that the scene had been chaotic, but rather, that this moment—tense with the stakes of a patient’s life in the team’s hands and commanding one’s full presence—felt so similar to any of the codes I had been a part of in-person. When I bring up telemedicine with other medical students, I am typically met with surprise that such full-fledged programs like the tele-ICU actually exist beyond the proof-of-concept stage. And then, after telling my peers about all the exciting new ways in which telemedicine is deployed at the University of Maryland, I typically hear something like, “But how can you really practice medicine without a physical exam?” In medical school we are fairly indoctrinated with the primacy of the history and physical in our practice, and this skepticism was something I shared as I decided to explore the world of telemedicine more deeply. It wasn’t clear to me that telemedicine could match in-person encounters without the physical touch of the physician, and the intimacy of the patient-physician relationship that such proximity brings. Now that I have spent some time in the world of telemedicine, I see now all the spaces in medicine where telemedicine can fill holes in the giant bucket of the medical system. I see, too, how the classic physical exam paradigm can be updated to accommodate technological advances like telemedicine. Just as tele-intensivists monitor patients for instability in the ICU through telemetry, primary care doctors can track diseases like hypertension and diabetes through remote monitoring of blood pressure and A1C—no physical touch neces-

STUDENTS SHOULD BE INSTRUCTED HOW TO ASK THE RIGHT QUESTIONS ABOUT TELEMEDICINE AND BROADER ISSUES IN HEALTH SYSTEMS, IN THE SAME WAY THAT WE ARE TAUGHT TO TAKE A HISTORY FROM A PATIENT. sary—and supplement office visits with regular video check-ins with patients to help motivate and ensure adherence. I started to imagine the ways a quick teleconference could save a busy parent from having to miss work when their child falls ill or how a psychiatrist could bring mental health services to parts of the country that are in desperate need. Of course, there are a great many benefits to laying hands directly on a patient. But we should not decline to evolve as physicians when doing so would be to forgo the potential benefits of new technologies like telemedicine. Through my experience in the tele-ICU, I began to see telemedicine for what it really is: a technological platform that enables doctors and nurses to attain broader and deeper impact. Indeed, I was instructed by the tele-ICU physicians I worked with to reframe my conception of telemedicine as a medical intervention of its own. Telemedicine is not a medical intervention in the same way that insulin or penicillin are. Rather, it is part of the infrastructure of healthcare, helping to lay the foundation for a broader reach of medical interventions. However, in its own way, telemedicine has the potential to broadly improve healthcare outcomes by offering things like insulin and penicillin to those who would otherwise not have access. Medical students that I have spoken with have expressed


concern that telemedicine could never really be the same as face-to-face interaction with patients. When I brought this up with one of the doctors in the tele-ICU, she responded that the question for telemedicine is not how similar or different it is to the classic way of practicing medicine in doctor’s offices and hospitals. Telemedicine is better thought of as venue for healthcare; it is a space, and really not all that different from a doctor’s office and the four walls of an exam room. Considered this way, and assuming that telemedicine is non-inferior to in-person practice, we can instead focus on telemedicine’s role in helping ease the stress on an overburdened healthcare system. Of course, telemedicine is only as good as a physician’s willingness to use it as a tool in practice. My medical school class had one half-hour long demonstration of telemedicine capabilities during our second year before we were on floor in the hospital and, therefore, before we had much of a sense of the system-wide strains that can be addressed by changing the ways physicians practice. In order for telemedicine to become a tool that is used on a wide scale, medical students should have greater education in all the ways it is and could be applied. And students should be instructed how to ask the right questions about telemedicine and broader issues in health systems, in the same way that we are taught to take a history from a patient. More broadly, medical students need a greater sense for the way healthcare works. We spend a great deal of time studying obscure pathology, but very little learning about the complex healthcare ecosystem that we are expected to enter after graduation and residency. Instead of an ad hoc, piecemeal approach to our health systems education, all students should receive some basic formal training. Once we have achieved these goals, we may one day find it commonplace to be sitting in a quiet room in some far off city, bringing healthcare to all those in need, no matter the distance.

aging in place

New Platform Focuses on Assessing Brain Health BCAT’s new telemedicine program offers dementia patients at-home virtual, personal cognitive assessments by jodi lyons

For aging Americans, getting access to dementia care specialists can be incredibly challenging. Not only are there entire geographic regions where there aren’t any experts, but even when experts are available, there is the logistical challenge of getting elderly, possibly disoriented patients out of their homes and into a doctor’s office. And even if these two hurtles are overcome, there are long wait times to contend with. As with so many emerging medical specialties, it would appear that dementia care – specifically cognitive assessments – is ripe for a telemedicine upgrade. If any patient population could benefit from bringing a specialist into the home virtually, it would be America’s growing elderly population struggling with or concerned about dementia. Into this space stepped the team behind BCAT, the Brief Cognitive Assessment Tool. Founded in Maryland by Dr. William E. Mansbach, PhD, who sits on the Maryland Governor’s Alzheimer’s disease advisory Council, BCAT is known for creating scientifically validated cognition tests in paper form. But Mansbach and company launched a tool in May 2017 called ENRICH (enrichvisits.com) that brings their cognitive testing into the home, including face-to-face video consults.


The ENRICH program is simple, comprised of two basic parts. The first is a cognition calculator. In about one minute anyone with an internet connection can take a survey that gauges their risk for cognitive impairment. How often do you exercise? Do you smoke? What is your BMI? Six simple lifestyle stats result in a score that can clue you in to your mental risk factors and assess how well you’re doing in living a brain healthy lifestyle. It’s free and it’s easy. The ENRICH cognitive risk calculator tees the user up for step 2 – a more in-depth cognitive screening assessment powered by the peer-reviewed tools that BCAT is known for. For $24, users can take a virtual Self Assessment of Cognition (SAC) and get results instantly. But it’s the $89 offering that really makes ENRICH unique. For this fee, a live administrator will walk the patient through a comprehensive 30 minute cognitive assessment and email a written report. Together, these tools offer a powerful way for a patient to gauge whether they need to make lifestyle changes to improve their brain health or need a follow-up with a doctor. And let's face it, with the rising tide of aging Baby Boomers, the number of people concerned about brain health is going to continue to grow in coming years. Cognition tools and games like Lumosity have proliferated, but few offer scientifically validated testing. Cognitive assessments have been available for decades, but BCAT’s ENRICH program represents a new foray into consumer-facing tools and products for patients concerned with, or suffering from, dementia. It is both simple and revolutionary that dementia patients and cognitive screeners no longer need to be in the same room together. It’s virtual, visual, and private. And it’s about time.





Does That Make Sense? In the era of virtual care, a quick assessment of a patient's health literacy is more important than ever. by jeanine feirer, rn

and david thompson, md


urrent data suggests that about a third of all American adults (89 million people) have insufficient health literacy skills to effectively seek and obtain the medical and preventive care they need. Poor health literacy can result in medication errors, decreased compliance with treatment advice, worse clinical outcomes, and increased malpractice risk. And that’s with traditional face-to face medical visits. Virtual healthcare introduces an entirely new set of opportunities for miscommunication and lack of understanding. For this reason, an understanding of health literacy and plain language should be part of your virtual healthcare skill set. Health literacy, according to the Institute of Medicine (2004), is “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.” Those of us who work in health care often think of health literacy as a “patient problem.” However, we contribute to issues with health literacy if we do not communicate clearly with patients. With the increasing prevalence of virtual care and its opportunities for dropped connections and limited point of view, the need for a quick assessment of health literacy has never been greater. It’s an obvious but underappreciated fact that low health literacy can lead to poor health outcomes and even unnecessary patient deaths. Patients with limited health 10

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literacy might take the wrong medicine or the wrong dosage. They might fail to recognize serious complications or symptoms or struggle with managing complex medical problems. Limited health literacy also contributes to poor patient satisfaction and increased health care costs as patients miss appointments, avoid asking important questions, and generally feel frustrated with their physician encounter. In a virtual care visit, assessing health literacy starts with recognizing at-risk groups. Elderly patients and those who have limited income or education can be at risk, as can people who have difficulty speaking English. But there are other, more nuanced factors that can lead to a patient misunderstanding healthcare instructions. These factors include a lack of sleep, fear or anxiety about a new diagnosis, and the presence of separating, complicating medical ailments. One strategy for quickly assessing health literacy at the beginning of a virtual care visit is to use the Universal Health Literacy Precautions. Step one, take time at the beginning of an interaction to develop rapport and trust. Speak in a slow, calm manner in short sentences. Use shorter words when possible. For example, use “get” instead of “obtain,” “help” instead of “facilitate,” and “decrease” instead of “mitigate.” By a similar token, avoid medical jargon by using patient-friendly words. For example, use “heart attack” instead of “myocardial infarction” and “rinse” or “wash” instead of “irrigate.” When in doubt, talk to the patient like you would talk to a family member sitting in your living room. And always verify patient understanding during and at the end of an encounter. Thinking of starting a telemedicine program at your institution? Make sure that health literacy is part of your strategy. This can be accomplished by including health literacy training in your orientation for all new telemedicine providers (doctors, PAs, NPs), your nursing team, and front-end staff. Also, assess health literacy skills (listed above) when reviewing taped calls. You will find certain problem words (medical



onsider this list of common terms and concepts:




Belly, stomach area

Anxiety Bacteria Contraception Feces

Feeling stressed, nervous Germs Birth control Stool, bowel movement, poop


High blood pressure


Trouble or problems with sleeping


Monthly period

Primary care provider

Regular doctor

jargon) that could be replaced with more patient-friendly language. Share these terms with clinicians and other staff. Use this as a learning opportunity for all. Include health literacy topics and exercises in your ongoing staff education. Finally, make sure the materials you send to patients electronically or by mail are patient-friendly and easy to understand. Aim for a 6th grade reading level. Resources can be found at: www.cdc.gov/healthliteracy.


glass enterprise

teletech Practice-changing gadgets & gizmos

glass is back

Welcome to Google Glass Enterprise Edition Google's reboot of its muchhyped augmented reality headset takes the device in an important new direction. Through targeted projects with "Glass Partners," Glass EE is poised to find important applications in healthcare.

by Scott Jung


oogle Glass Explorer was announced to the public with much hype in April 2012 by Google co-founder Sergey Brin. Many speculated that Glass and the new class of devices it would subsequently create would be the next evolution in personal computing. In the original product announcement video, Google presented a vision of the future in which Glass would merge the physical world around you with your smartphone, placing navigation, emails, and social media literally within eyeshot through the use of augmented reality. Google Glass Explorer was initially received with much excitement, however, the device was buggy and with a price tag of $1,500, too expensive for widespread adoption. Price and technology issues aside, Glass also entered a market that was not yet ready for such a novel technology. Privacy and security concerns were foremost, as many were uncomfortable with the notion of Glass recording them without permission. Lawmakers were never able to reach a consensus regarding whether Glass should be considered a recording device that would be banned from certain public establishments or a potentially obstructive monitor that would be prohibited from use while driving. Google officially discontinued Google Glass Explorer in 2015. While Glass’ departure came with a somewhat generic “We’ll be back soon!” statement, it still took many by surprise in July 2017 when Google announced a new version of its wearable known as “Google Glass Enterprise Edition” (Glass EE). So what’s different about Google Glass EE, and has Google learned from the mistakes of

its past? On the technology side of things, Glass EE is still an optical, head-mounted computer with a transparent display that brings information into your line of sight. However, the form factor has been completely redesigned to optimize the way it folds, charges, and even resists sweat. Most notably, Glass EE can be clipped onto a pair of glasses or any type of industry frames, such as safety goggles. Glass EE also incorporates upgraded electronics that make it faster and more reliable, as well as more secure. Moreover, battery life has been increased and the camera has been upgraded. And for those with privacy concerns, Glass EE has a green light that turns on when a video is being recorded. Technology upgrades aside, Google has taken a more restrained marketing approach this time, launching Glass EE in a market that is a little more primed for change: the workplace. At the time of writing, Glass EE is only available through a dozen companies that Google calls “Glass Partners.” Consisting primarily of manufacturing, logistics, and healthcare companies, these Glass Partners have already been using Glass EE for a couple years, all with statistical evidence to support how Glass EE has helped them work faster and more efficiently. And there are no smartphone notifications and no tweeting; Glass EE can only run the single application that its Glass Partner has developed. Only time will tell whether or not Google Glass will find its way back into the consumer space. But until then, enterprise users should be excited that they’ll be at the forefront of technology this time around with a device specifically designed to make their jobs easier. www.telemedmag.com



glass enterprise

the looking glass

SwyMED-Loyola Project Uses Glass EE to Bring Back the House Call The new simulation-based project will train medical students to use augmented reality when visiting patients at home.

by Laura Sansouci


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A community RN enters the home of an elderly patient for a follow up visit, wearing a device that brings the full suite of hospital technology, specialists, and resources with her. The device she uses is small and almost invisible, and it’s compatible with any available source of connectivity from WiFi to cell to satellite, providing real-time telemedicine where the patient needs it. Associated bots test the carpet for dangerous molds, an artificial intelligence identifies which specialists should be consulted, and queues up their attention automatically. Through the eyes and ears of the onsite provider, a pharmacist reviews medications checking for dangerous interactions against the contents of the medicine cabinet, and a dietitian provides recommendations based on the contents of the refrigerator. With the provider's eyes and hands free to examine and talk with the patient, the full picture of the patient's needs is seen, heard, and addressed efficiently, effectively, and with a caring human touch. This vision of the future is closer than one might think. With the recent release of Google Glass Enterprise and integrated swyMed transport protocols and software, providers and students at Loyola University Hospital will soon lay the groundwork for this dramatic change in health care delivery.

A pilot program beginning late this summer will use simulations to develop best practices and procedures for using the Glass Enterprise technology and swyMed software by bringing back the home visit with a high-tech twist. “This program is really about connecting with our patients in ways greater than what we are doing now, exploring those new ways, leveraging the technology to do so,” explains Capers Harper, Manager of the Virtual Medicine Program at Loyola University. “We are studying combining the clinical communication technology of swyMed with the hardware of the Enterprise Edition Glass technology and how that works in our focus of providing the human touch to our patients.” Invisible Technology Launched in 2012, Google Glass Explorer featured line-of-sight app access and video streaming, but was not well received by the public. Not only was the consumer product buggy and awkward to wear, the technology was perceived as invasive and was even banned in some places due to privacy concerns. These problems led to Google stepping back from the product in 2015 with their website stating, “Thanks for exploring with us.”

<< Dr. Aaron Michelfelder, chair of Family Medicine at Loyola University Medical Center (L) and Capers Harper III, use Glass EE to transmit a patient encounter during a recent demo.

In the background, however, industries were finding that with custom software applications, the early edition of Glass was generating astounding results. Google quietly shifted focus into working with these partners to develop both new hardware and purpose-driven application software to better meet the needs of companies like GE, Boeing, and DHL, turning the technology from a high-tech toy into its naturally developing niche as a valuable tool of industry. Improvements to the Enterprise Edition hardware include better connectivity, longer battery life, faster processing, an upgraded camera, lighter weight, less heat generation, and the ability to use the device on a variety of frames including safety glasses and prescription eyeglasses. The Enterprise Edition is only available through the Glass Partners program, which includes companies such as swyMed, Ubimax, Upskill, Aira, and Augmedix who are producing integrated software for a variety of industrial, medical, and assistive applications. Evie Jennes, CCO of swyMed states, “The reason that Google wanted us to become part of the program is because our software works on low bandwidth. We are bringing more reliability in these particular use cases that Glass will actually be able to stream. We were attracted to it because we knew we wanted to focus on the mobile side (of telemedicine), and this would add a big advantage to our providers on the patient side.” These advances were crucial to the upcoming pilot program as noted by Marcus Shipley, CIO of Trinity Health. “By nature of being an enterprise solution, that's what you will see that you didn't see in the consumer world. They are putting optimization software into the platform that is purpose built for our situation.” Astounding Connectivity SwyMed's patented transport protocols

provide real-time audio and video, integrating with the Google Glass hardware to increase speed and reliability in mobile applications. To support that connectivity, swyMed has developed the DOT backpack, which serves to utilize any available WiFi or cell signal, allowing Glass to function in almost any environment. A remote satellite beacon is in development that will provide the necessary signal even if cell towers are not in range or are overloaded, a known issue during rescue or disaster scenarios. As Jennes describes it, “We basically break up the data in such tiny little pieces that we can push it through a very small pipe, and then we organize it on the other side very quickly. That’s where our focus is. We built this backpack strictly as an enabler of the software... The backpack is brought in if there’s a connectivity issue—so in disaster response, community paramedicine, mobile tele-stroke, or remote triage.” With this innovative solution, bandwidth, cell signal, and wifi connections are no longer limiting factors for the Glass technology. Innovative Onsite Care “Getting that connection between patient and provider on a routine, regular, and consistent basis—that is the best way we can impact the health of our patient,” says Capers Harper. As part of Trinity Health's Innovation Program, Loyola University Hospital will be piloting the technology in simulations of home visits to train secondary providers and medical students on this “high tech/high touch” technology, allowing “a hands-on approach to their next generation of patient, next generation of clinical technologies, and the next level of patient care.” When the process and results have been well established in simulation, the technology will move into practice. “We believe the technology is ready now,” says Harper. “This simulation will test that.” As technology is being adopted in health care at a rapid rate, it can sometimes be seen or felt as invasive to the patient/provider experience. Holding a camera, wearing a microphone, entering notes into a device are all activities that prevent direct eye contact and the full engagement of the provider with the patient. Harper explains, “What

we are looking to show through this simulation is that by having a wearable eyes and ears approach to this, it frees up the hands of the secondary provider. They are not holding a piece of technology. It is not getting in the way...We are just having a regular interaction with that patient.” As Shipley elaborates, “It gives these physicians literally eyes and ears into the patient's lives and homes. It gives us a way to look deeper into their unique experiences, to really meet them where they are and tailor our experiences accordingly. Our elderly and community benefit population of the poor and under-served is front and center to our mission. It will allow us to more seamlessly bring in the entire care team that supports that person at home, and this is all going to happen with no intrusion of the technology into the process. Can you imagine how much more awareness we will have of the real need of the patient when we are in their home?” Given the projected shortage of primary care physicians, enabling a multi-disciplinary team to be virtually present in the home of the patient will increase efficiency while raising the quality of care: a truly innovative win-win. “We hope that a positive outcome from the project will lead us to use this and leverage this wherever the patient may be—to serve their need wherever they are,” said Harper. Through the program, Loyola's secondary providers will bring a network of services to the patient in a single visit, eliminating no-shows and streamlining the path to successful treatment, as well as allowing primary care providers to see more patients in a more impactful way. Through this Looking (and Listening) Glass, these next-generation care providers may truly reverse the impacts of isolation and provide patients with access to a dream team of experts without leaving home. Any needed specialist may be instantly onsite no matter how remote the location and never again be limited by bandwidth or signal in providing life-saving care and guidance. Now we can see through a Glass, clearly, a future where telemedicine is so advanced, it's invisible. www.telemedmag.com




Zipline's fixed wing drones got their start dropping blood products in Rwanda, but they're coming to the USA soon.

three if by air

Healthcare Drone Use Cases Take Off In a few short years, the use of drones in healthcare has gone from a speculative side show to a firm reality. Since drone technology is available to the masses and the FAA instituted drone regulations in 2016, it’s now simply a matter of inventing new use cases and applying these tools to deliver time critical and life-saving resources. by jeremy tucker, do While there are a myriad of uses for drones in rescue scenarios (think drones dropping life preservers to drowning surfers), their applications in actual healthcare delivery have so far been more limited. Some of the limitations have been due to the technology. Although improvements continue to be made, payload and battery life remain limiting factors to many situations. While FAA regulations have been established, they are fairly restrictive and most—if not all—applications would require a waiver of one or more of these restrictions such as the ability to fly beyond the line of sight, fly over people, or fly at night. Here are three current use cases that have been developed for drones in healthcare.


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1. The Telemedicine Pack

2. Rapid AED Deployment

3. Medical Supply Delivery

Dr. Italo Subbarao and Dr. Guy Paul Cooper from Carey University Medical School have developed a telemedicine pack that can be delivered by drone to provide medical services to remote populations. This drone is an octo-copter and can carry about 20 lbs and fly up to 40 mph. It would be summoned to fly to a GPS point near the victim. It can carry a medical “suitcase” that has variable equipment depending on need, such as medical supplies for trauma including inflatable splints, dressings, clotting sponges, tourniquets, etc. The pack contains a video connection to a medical provider who can direct the bystander to render first aid to the victim. Before actual clinical use can occur, a number of FAA regulations will need to be waived or modified when it becomes clear that drones can safely share airspace even in our busiest cities.

Defibrillators are in malls, airports, and wherever large crowds of people gather. But what about more remote locations such as golf courses, parks, and rural America? AED delivery to a victim of cardiac arrest is possible with an AED drone developed at Delft University of Technology in the Netherlands in 2014. With the touch of an app or a text, an AED could be summoned and on the scene very quickly. They claim that they can reach a victim within 7.4 square miles within 1 minute. A research letter published in the Journal of the American Medical Association in June, demonstrated a median response time reduction of 16 minutes over standard EMS response times in simulated cardiac arrest around Stockholm, Sweden. While this has been developed, it’s practical use will also require FAA waivers in the United States.

Delivery of medical supplies, including vaccines, medications, and blood products, are another compelling drone use case. Zipline currently delivers blood products and medical supplies in Rwanda. Initiated by a SMS text and using a fixed wing drone, their delivery network allows them to rapidly deliver supplies to hard-to-reach areas. Their drone allows delivery up to 75 km away and in most weather conditions, including high winds and rain. Their drones are limited to 1.5 kg of payload, but their network has an average fulfillment time of 30 minutes and the capacity to do 500 deliveries daily, according to their website. Zipline is also trialing delivery in the US to remote island populations in Washington State and the Chesapeake Bay.


television Industry-shaping ideas & perspectives

the greater good

The Fallacy and Opportunity of Population Health Population health presents a seismic opportunity for the telehealth industry if we can all agree on a few things. By Jeremy J. Corbett, MD Chief Health Officer, Envolve PeopleCare


uzzwords are overrated. Most executives cringe at pitches promising “disruptive” or “interoperable” healthcare solutions. They don’t want to hear how a web app “harnesses big data” or “reduces health disparities.” Just tell them what it does, and prove that it works. Consequently, the term “population health” has garnered a bad rap. While it’s the industry’s buzzword du jour, it’s misleading at best, an outright lie at worst.

The vast majority of programs marketed as population health actually deliver subpopulation health. Population health ought to refer to approaches that improve health outcomes for entire groups of people. But it doesn’t. At least not yet. Rough estimates indicate program penetration rates of less than 10 percent in any given population. While this may appease the C-suite and shareholders, it won’t address the ever-increasing burden of chronic disease on the healthcare system. As diagnoses of diabetes and other diseases like hypertension and cancer multiply, employers, private insurers, and government-sponsored health programs are scrambling to care for their sickest, costliest members. “Shifting age and social demographics are transforming the labor force,” says John Bigalke, CEO of Second Half Healthcare Advisors and former National Industry Leader of Life Sciences and Health Care for Deloitte. “This, combined with the increasing demand, will make the current delivery system inadequate.” Chronic Disease Will Sink Health Systems More than half of all Americans manage one or more chronic conditions. Naturally, older Americans have even higher prevalence rates; nearly 9 in 10 adults 65 and older manage one or more chronic disease. As Boomers age and life expectancy grows, so too will both the costs to treat these populations and the demand for technologyenabled solutions. Already, a staggering 86 percent of the nearly $3 trillion we spend annually on health care in the U.S. is spent treating people with chronic and mental health conditions. Individuals with chronic conditions are much more likely to be hospitalized and incur far more costly in-patient stays. They also spend more on prescription medicine. They see doctors and specialist more often, and require more home health visits. This dramatic increase in health care services results in costs 2.5 times higher for individuals with one chronic condition and 6 times higher for those with three chronic


conditions. The 9 percent of Americans managing five or more chronic conditions drive a staggering 35 percent of all health care spending, up from 22 percent in 2006. Chronic diagnoses can’t be undone, but there is a bright and achievable silver lining: With aggressive preventive care, proactive engagement, and the full application of lifestyle and behavior change science, chronic diagnoses will no longer be equated with chronic financial loss. Only then will the industry realize the full promise of population health. “This increasing pressure on healthcare systems will require novel and flexible models of care, as stakeholders across the system look to create efficiency and better outcomes,” says Anna Grant, Vice President of Clinical Operations for HMC HealthWorks, a health management company based in Florida. Telemedicine Places True, Total Population Health Within Reach Valued at $20 billion in 2015 according to Grand View Research, the population health management market will swell to nearly $90 billion by 2025. This growth will be fueled in large part by a dramatic uptick in the use of remote patient monitoring (rPM) devices. In its annual mHealth report, Berg Insight pegs the current number of remotely monitored patients at 7.1 million, a figure that’s expected to reach 50 million within five years. Telemedicine strategies including storeand-forward, real-time video, and rPM will revolutionize population health in five key ways.


Telemedicine will upend traditional identification and stratification models. Identification and stratification have always been—and remain—core tenets of disease management programming. Payers weigh a variety of factors when enrolling members in these programs, but even the most advanced predictive modeling programs rely on reports of adverse health events and expenditures that took place months ago. As a result, only a fraction of a given popwww.telemedmag.com




ulation receives tangible support in managing their condition. This approach naturally zeroes in on the highest-risk, highest-cost members. Programs launch with little more than the hope—and often the promise from vendors—of dramatic cost savings. Although risk and cost are great indicators of where problems have been, they are woefully insufficient in predicting where the problems will be. Up-to-the-minute biometric data from rPM devices, wired, routed, and reported to insurers will help identify a new pool of members for program enrollment before they experience a costly medical emergency.


Telemedicine will enable 100 percent reach. Technology is finally democratizing remote care management. Driven by thought leadership from organizations like the American Telemedicine Association, massive venture capital investment and frenzied mergers and acquisitions, wearables and other home health care devices are more accessible and affordable than ever. At the same time, hardware like eDevice’s technology agnostic, cellular HealthGO and Cellgo hubs, and YOFiMeter’s blood glucose meter-hub combo are taking home health monitoring to the next level, enabling comorbid condition management at an individual and population level. Hardware like these allow members or their insurers to implement a suite of connected devices and transmit biometric data from disparate sources to the cloud at a fraction of the cost of previous solutions. Emerging technologies like these expand the reach of population health programs, most notably to underserved populations in rural areas, which account for 20 percent of the U.S. population. Perpetuated by the inability to find and afford quality health care, rural populations face disproportionate incidences of chronic disease, according to the National Institutes of Health. While rural and socio-economically disadvantaged populations’ access to care is limited, audio and video telecommunica16

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tions abound, says Bigalke, making it one of the most viable means of connecting with them. These populations have the most to gain as telemedicine expands the reach of population health programs and delivers quality healthcare across the care spectrum. “Hot spotting can be used to target these populations for education, and telehealth tools can enable a wide range of care from prenatal to chronic care management,” he says.


Telemedicine will solve the perennial challenge of care coordination. While traditional, human-directed disease management programs yield a significant return on investment, logic demands we do more… better and faster than we’ve done it before, with an emphasis on coordinating care across providers and settings. People don’t scale; Technology does. Physicians are unprepared and illequipped to manage the complex suite of health and life services their chronic patients require. While they know poor care coordination produces negative health outcomes, they feel powerless to intervene, according to a joint study by Johns Hopkins University and the Robert Wood Johnson Foundation. To help connect the dots, most large insurers field a team of case managers who help members navigate the system while attempting to stay connected to the providers tasked with managing the same members’ diseases. Case managers often have little more to go on than members’ self-reported case histories, forcing decisions absent concrete information. Disease managers and health coaches remain an essential part of the care continuum, but they are all too often reaching out to members who already exert a disproportionate strain on the system, utilizing telephonic communication at predetermined intervals rather than at the point of need. Patients often go weeks or months between clinical appointments. “Having access to real-time biometric data enables meaningful connections between appoint-

AS IMPORTANT AS RATINGS ARE, THEY ONLY TELL HALF THE STORY. UTILIZATION PATTERNS AND THE ELIMINATION OF FRAUD AND ABUSE MATTER AS WELL. SO TOO DO PATIENT ENGAGEMENT RATES... ments if negative trends emerge,” says Grant. Telemedicine can’t be simply a means to an end. It must nimbly bridge two people to each other, one with a real-time need and one with answers, on a journey towards health. It must break down silos and consistently route individuals toward the lowestcost, most effective care in real-time, then capture and share relevant data across the care team. “This will enable the system to optimize quality, efficiency, patient satisfaction, and financial performance under value based care,” says Bigalke.


Telemedicine will improve quality. The annual growth rate of digital healthcare data is 48 percent. If that trend holds, the volume of healthcare data will reach 2 trillion gigabytes by 2020, according to a recent IDC report. But more data is only beneficial if it is effectively harnessed and meaningfully applied. Telemedicine increasingly puts data in the hands of the individuals tasked, paid, and challenged to improve quality scores, including the historically difficult to penetrate provider network. Actionable data makes everyone’s job easier, enriches quality initiatives, and enables health plans to engage the right members at the right time based on today’s needs.

Market Watch With the shift toward value-based reimbursement models, payment is increasingly tied to health outcomes rather than services provided. Savvy shoppers demand quality, too. More than ever before, they’re considering a health insurance plan’s STAR or HEDIS rating in addition to cost and the accessibility of providers as they peruse the insurance marketplace. As important as ratings are, they only tell half the story. Utilization patterns and the elimination of fraud and abuse matter as well. So too do patient engagement rates and member satisfaction with the programs plans offer. In the same way a handwritten note will always mean more than a mass email, the personalized intervention telemedicine enables will be better received by patients. With biometric data on each person and interventions tailored to each individual’s communication preferences, it will enable what amounts to custom healthcare. Custom and quality always go handin-hand.


Telemedicine will make the healthcare system more nimble. Agile and responsive have never been used to describe the healthcare system in our country. It’s arcane. It’s rigid. It’s resistant to change. It will be forced to adapt, however, and telemedicine is poised to accelerate the pace of change. Patients’ demand for telemedicine is at an all-time high, with 65 percent of healthcare consumers expressing interest in seeing their primary caregiver via video, according to a 2017 consumer survey by American Well. Startups in particular play an increasingly important role in dragging Luddite systems into the 21st Century. The big players in the space recognize this, which is why more than 40 health systems have started their own venture funds, including Kaiser Permanente and Mayo Clinic. “Entrepreneurs are empowered to innovate and adjust to shifting winds,” says Chris Knotts, CEO at SimpleVisit, a platform-agnostic video conferencing service for telemedicine. “This changes the ecosys-

tem in the health tech industry. Organizations with established research engines and market share gain a competitive advantage in collaborating with startups. Big health systems and large insurance companies are essentially outsourcing R&D to inspired teams developing innovative solutions.” Progress is slow, but there are promising signs of adoption. Pennsylvania-based Geisinger Health System was an early adopter of telemedicine and has led the way with its collaborative teleICU approach. Avera Health has reached more than 1 million patients with its expansive telemedicine initiative called eCare. The program, which reaches eight Midwestern states and many with large rural populations, offers emergency and pharmacy telehealth services, among others. Looking toward 2018, population health will continue to headline both agendas at healthcare conferences and in-depth stories in national and trade publications. It will drive new market movement and dictate C-suite conversations. Meanwhile, chronic disease will continue to overwhelm the healthcare system until we can figure out how to develop and deploy technology-enabled programs across entire populations, not just the lucky few. “We have to all be on the same page with the same goal in mind,” says Grant. “To utilize technology to connect patients with caring professionals who are driven to improve outcomes.” Bigalke agrees, and notes that telehealth companies ought to focus on the value proposition. “Their goal is not solely to avoid admissions but to find the right point of care,” he says. “They must make the case that their solution not only increases consumer satisfaction but also defines a business case for improving the economics for all parties involved.” We owe it to the people we employ, insure, and treat to deliver solutions that provide help to individuals in need at precisely the right time, technologies that scale to meet increasing demand, and most importantly, programs that work.

Telepresence Robots continued from page 11

iRobot The most recognizable robot in the market, the RP-Vita, comes with an automated navigation function that allows the device to autonomously navigate the hallways of the hospital. However, with a pricetag of $80,000, the list of facilities that can afford the RP-Vita is relatively short. VGo Based in Cambridge, MA, VGo bills its robot as an ambidextrous device suitable to a range of environments. It is lightweight, has a long-lasting battery (the VGo website boasts 12+ hours) and is far cheaper than a RP-Vita. VGo is a division within Vecna Technologies, a Cambridge based company started by a consortium of MIT engineers. Double Robotics The Double is the simplest of the bunch. It's comprised of a tall self-balancing unit that houses an iPad supplied by the user. The barebones design, simple set-up and $3000 price tag make it an easy first step for small offices or rural hospitals to try out telepresence for the first time. www.telemedmag.com




report card

How Would Your Telemedicine Program Score? As the medical director for JeffConnect, Jefferson University Hospital’s telemedicine service, I often get asked questions about quality. Namely, how do we assess and evaluate telemedicine as a practice and ensure that quality is as high as it needs to be? It’s a great and complicated question. Outside of operations, I tend to divide a telemedicine quality assessment into four broad categories: Patient care, consumer utility, costs and access, and technology. We’ll take each in turn. by Aditi Joshi, MD, MSc Medical Director, JeffConnect at Jefferson University


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Patient Care When it comes to patient care over virtual platforms, we’re not re-inventing anything. Our job is to make sure that the quality standards we uphold in our respective specialties carry through to the Telemedicine encounter. Clinical guidelines exist within every medical specialty to uphold the standard of care and are constantly being updated when new research, medications, or processes are discovered. Because providers may be coming from different training backgrounds, having set guidelines, quality measures, and expectations are especially important to keep clinical standards high. Also, it might sound obvious, but all video visits should be staffed appropriately, e.g. an internal medicine provider should not be caring for pediatric patients. Physicians need to stay credentialed within their specialties and hold active licenses for states they practice in. Currently, the American Telemedicine Association has a set of guidelines specifically for telemedicine. Some direct-to-consumer (DTC) companies and academic institutions (including Jefferson) have created their own. The main thing to remember about these guidelines is that they are existing guidelines tailored to a telemedicine medium. For example, the existing clinical guidelines for treatment of sinusitis have been tailored to a telemedicine visit, not the other way around. Other quality improvement programs that exist are taken from current medical performance improvement programs and include peer review (colleagues rate each other’s charts for appropriate history taking, physical exam and management), antibiotic stewardship (tracking antibiotic prescriptions to see whether they are being prescribed appropriately), tracking of appropriate referrals, time to see provider. This data can help record stats and work to improve within the system. In essence, all of the above is reiterating the simple fact that telemedicine should be held to the same standards as clinical medicine. It shouldn’t be lower, and it shouldn’t be held higher simply because it uses tech-

nology in a novel way. I’m often asked if patient feedback should be part of a quality assessment. In today’s culture of Amazon reviews and Yelp ratings, it would seem natural to tack patient reviews onto the end of a virtual care visit. These types of healthcare reviews are imperfect due to instances where quality care and patient desires are in disconnect, yet they aren’t always wrong. I suggest they be utilized as a tool to improve quality, but taken with a grain of salt. Patient Care Assessment Questions: 1. Is your Telemedicine program meeting the same rigorous guidelines as the individual specialties involved? Has the standard of care been lowered in any way? 2. Are appropriate providers being used to see patients virtually? 3. What quality improvement programs are you running? 4. Is your program accredited and your physicians credentialed? ------Consumer Utility Patient care focuses heavily on how providers use telehealth; the other side is how patients use the service safely and effectively. Aside from security of data, providers have to ensure the encounter is confidential. Safety also means understanding how and when one can use telemedicine, its availability, and ease of use. In general, telemedicine is not well understood by patients. Does the website offer the correct information about what services are offered and its limits? Does the app offer a clear user experience? If the service is offered by an insurance company or an employer, is it clear to their users that it’s available to them? If covered, it should also be affordable, i.e., having similar copays for similar services. It should also have a mechanism to get patient feedback about tech failures, flow, and practice issues to both improve quality and patient safety. Ideally, services should be available 24/7/365, offer multiparty availability in

case family wants to join, and lead to increased communication between patient and providers because that improves the quality of care. Understanding the patient’s local environment and being connected to their health system to refer to specialists and schedule for other appointments is always ideal. For best utility, care coordination is necessary to ensure a patient’s care is seamless rather than staccato. Consumer Utility Assessment Questions: 1. How do you ensure patients understand your services? 2. How easy is the app or website to start a telemedicine visit? How often is it available? 3. What policies are in place to improve care coordination for your patients? Are you in their local area or understand it enough to offer quality care planning? ------- Costs and Access Cost savings has long been seen as a reason to switch to video over in-person urgent care or ED visits. However, it’s unclear how. Contradictory studies have ‘proven’ that telemedicine does and does not save costs. Currently, implementing a telemedicine program at your hospital is an expensive endeavor and won’t lead to any cost savings in the short run. It can, however, decrease costs of transportation, time and productivity lost to travel, and missed days of work leading to societal benefits. However, proof of this is also nascent. Wanting to implement telemedicine merely as a way to save money is short sighted, and it is not a great way to judge its current effectiveness. Telemedicine hits its stride when we talk about increasing access. Whether it’s to a remote reservation, the beside of a dying cancer patient, or an underserved urban area, virtual care brings doctors to places they couldn’t go before, providing quality care to patients who may not be able to access it. When telemedicine is working and access is expanding, healthcare usage increases. This is not necessarily bad if the issue is due to

lack of access to healthcare. While traditionally lack of access has been attributed to rural areas, the reality is that even in urban areas there are large number of patients who don’t have access to healthcare for a variety of reasons. Reimbursement of more of these urban patients under Medicaid and Medicare will help (and there’s every reason to be optimistic about this). Thinking of telemedicine as a means of increasing access may be exactly how we help modernize medicine by making sure we don’t leave a larger section of the population behind. Improving access and the quality of care for those who have the hardest time finding it is a necessary cornerstone of a telemedicine outreach and program goal. Cost/Access Assessment Questions: 1. If your program was designed to save money, are you financial goals realistic? Are there processes in place if the shortterm goals don’t lead to cost savings? 2. Are your patients able to get high quality care at a reasonable rate for them? 3. How many patients have access to highquality care thanks to your telemedicine program? 4. How do you ensure your program reaches still underserved populations? ------Technology Setting up a telemedicine service either means buying and tailoring an existing platform or creating your own. Both are time and resource heavy propositions and require research and manpower. It requires making sure the user experience is easy for both provider and physician, has adequate security for patient data, and can be implemented within the existing infrastructure and organization. Of course, there will always be issues implementing new services, as patient and provider comfort levels with technology vary. Much of this can be alleviated with a strong support staff able to effectively train and troubleshoot when patients and providers have issues with their systems. Rely-

ing on providers will create burdens that will allow things to fall through the cracks and is not a viable long term solution. As important as choosing a telemedicine platform provider can be, there’s a more basic piece of technology that needs to be in place for your program to succeed. Your virtual care platform is only as good as the Internet access available to your underserved populations. If they don’t have good WiFi, they can’t use your service. The FCC is proposing subsidized WiFi for certain areas, which would help. Also, having access points in care centers (urgent cares, clinics, pharmacies) can give video visit access to more patients. Technology Assessment Questions: 1. What is the quality of your platform and ease of use for providers and patients? 2. How strong/effective is your tech support team? Where does it need to grow or improve? 3. Does your patient population have adequate Internet access to reach your services? If not, what can you do to advocate for those patients? Thinking of telemedicine by these generic measures helps us figure out what is actually useful, but it is hardly comprehensive. The good news is that the National Quality Forum’s support measures for Telehealth is committing itself to outlining measurements we can all work toward. Much of our problem with quality questions is the lack of enough data on patient care, not sharing available data, the small patient pool that have access or have used telemedicine, fighting on changing laws to get reimbursement to support future goals, and knowledge of the right quality measures once we have more of this data. Luckily, many different people, institutions, and researchers are committed to improving these measures, and I look forward to this article being out of date sooner than later.





the clock is ticking

Providers: Embrace Virtual, Ubiquitous Healthcare or Risk Extinction In large part, state and federal regulators are rolling out the red carpet for telemedicine. Are you ready? Here are ten crucial steps to take in your virtual care transformation. by Dan Watterson Principal, North Highland


here is little debate that virtual health is the future of healthcare. In fact, as has been written in this publication, the terms “virtual health, telehealth, and telemedicine” will be obsolete in the near future. Virtual health will be ubiquitous, a routine element of everyday healthcare. Health care systems and clinicians must embrace this shift in care delivery or risk being left behind. Inconsistent and fragmented reimbursement and regulations have generated robust debate regarding the timing of when healthcare will make the ultimate virtual shift. However, healthcare providers must devote resources today to begin the foundational implementations of virtual health in 20

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order to keep pace with consumer demand and competition. A “wait and see attitude” could be catastrophic in today’s rapidly changing healthcare landscape. Online physician visits are happening more and more frequently and investment in the telemedicine market is expected to grow to $13 billion in 2020. According to a recent survey, between 53 and 67 percent of adults are willing to use video to manage chronic conditions and as of 2015, there were 100,000 mobile healthcare applications. According to an estimate, more than seven million patients worldwide utilize remote monitoring and connected medical devices. State government policy changes that make it easier for providers to offer and for patients to access telemedicine and virtual health care are gaining steam. There are several recent trends that show coverage expansion and standard-enhancing care delivery are on the rise: 1. Parity legislation requiring equal reimbursement for telehealth is becoming the norm 2. Almost half of states have signed onto the Interstate Medical Licensure Compact and in July 2017, North Carolina became the 26th state to join the enhanced Nurse Licensure Compact 3. Rules for a patient's location (the "originating site") during telehealth encounters are softening 4. New telehealth modalities beyond live video are being added 5. States are expanding the types of providers that can practice and be reimbursed for telehealth services This is just the beginning. In the next decade, we expect to see the expansion of remote monitoring through wearables and implantable tech, plus an even more powerful smartphone experience. Phones and wearable technology will contain built-in sensors to act as glucose meters, stethoscopes, pulse oximeters, transdermal blood chemistry monitors, and other biometric monitors. Flash forward to a day when patients receive a message on a smartwatch or smartphone that alerts them to contact

a clinician because of high blood pressure, irregular heart rhythm or abnormal blood chemistry/cell count. These virtual health trends fuel the fire for providers to forge ahead, though do so carefully and methodically. Dr. Randy Moore, President of Mercy Virtual, summed it up succinctly when he said this regarding the transition. “You have to figure out how to go from here to there without imploding or going bankrupt in between.” Providers must assess, strategize and implement with forethought. Pushing forward too fast or in the wrong direction could be as detrimental as doing nothing at all. No one can predict the future, and questions abound. What are the next steps toward realizing a future with ubiquitous healthcare? What are the patient needs to consider? Are patients ready to manage their own wellness? What can healthcare businesses do to be ready for this evolution?

10 crucial steps for providers to begin the virtual health transformation:


Remember the patients. Healthcare delivery today is physician-centric in design and, to no surprise, many virtual health programs are geared in the same fashion. While virtual health leaders continue to include the physician’s perspective in their efforts, they cannot ignore the patient’s point of view. It seems like a simple concept, but often no one asks the patient (or family) what would benefit them most. With increased competition from “payers as providers,”, internet-based telemedicine service companies, and the ever-present provider across town, understanding the patient’s “wants” is critical to success.


Don’t leave it all up to the techies. Integrate ubiquitous health strategically from a clinical standpoint, with IT as support, not vice versa. Virtual health is a fundamental change to how care is delivered, and how patient-to-clinician and/or clinician-to-clinician communication takes place. It requires detail, insight, oversight, and coordination from experienced clini-

cians. From the get go, clinicians must have input into the technology requirements to effectively deliver care. Streamlined methods that allow clinicians to provide timely suggestions and feedback must also be implemented.


Understand today before moving on to tomorrow. Most providers use virtual health in some capacity, but it is siloed. A full assessment and review of current capabilities, to include pros and cons of such, should be completed before planning for the future. In many cases, existing EMR’s and technology can be leveraged for future expansion. Also, in larger providers, it is not uncommon for there to be multiple duplicative technologies serving the same purpose. Cost savings can be achieved by consolidation and renegotiation with vendors.


Macro before micro regarding technology. Multispecialty providers should evaluate potential technology partners across all specialties initially. Virtual health vendors are becoming more sophisticated and offer solutions that can cover the enterprise. If a system initially focuses solely on a single service line they may pick a vendor that does not meet other service lines. There is always a place for best in breed to meet an individual service line’s needs, but these should only be selected after an enterprise-wide scan is completed.


Understand the regulatory and reimbursement trends, challenges and opportunities, driving change toward achieving ubiquitous healthcare. Evolving national, state and local health regulations and laws, and clinician licensure, are challenges that must be meticulously planned and managed. New or proposed reimbursement models must be evaluated for the role of virtual health.


Examine target patient population changes. More than 20 percent of the U.S. population will be over 65 by 2040, 44 percent have functional limita-

tions, 60 percent manage two or more diseases. Alzheimer’s affects more than 5.4 million seniors, so technology that provides automatic reminders or instant care will become more important. Socioeconomic status and cultural components, including populations who speak English as a second language, are also key components to weigh.


Collect and analyze data. Fast expanding capabilities to access, integrate, and analyze traditional and non-traditional data will improve evidenced-based clinical practice and self-care, enhance customer insights, and improve collaboration and communication. With this advancement, there must be a collaboration between clinicians and the data analysts to understand what really matters and to filter out data “noise.” Providers should also closely evaluate what data is requested from patients. Asking the same questions repeatedly or taking a shotgun approach to gathering patient data is a dissatisfier. Clinical relevance and value should be the driving principal regarding data collection and analytics.


Influence mindsets regarding virtual health. A shift is happening from viewing individuals simply as patients to empowering consumers who utilize selfcare approaches and value-based shopping while comparing healthcare options. A well-planned marketing and communication plan must be part of any virtual health implementation. And, providers must not forget to market internally. Many a virtual health programs fail due to lack of clinician buy-in. A well-respected clinical champion should be assigned to represent the overall and service-specific virtual health programs. This champion must possess impeccable communication skills and be highly regarded by the medical staff.

care occurs at home via remote monitoring and digital interaction. As care is pushed further toward the patient’s home, the need for the traditional inpatient hospital room and medical office building will shrink. Satellite virtual brick and mortar clinics staffed by lower cost clinicians and supported by virtual specialists will be the norm. As post-acute treatment is moved to the home, distribution centers for efficient delivery and tracking of medical equipment will be needed.


Dream for the future. What’s beyond 10 years? Already there is talk of drone drug and supply delivery, autonomous vehicles equipped with imaging equipment, home kits for common lab tests, robot caregivers, nanobots that scan inside the body for disease or break up clots, and human organs grown in labs. These possibilities may or may not come true based on what people desire, what they can manage, and their tolerance for nonpersonal interaction. Futures studies can create strategic foresight to help with the exploration of possible futures and their implications. This helps identify unique insights that enable organizations to become more resilient, anticipate change, and make better strategic decisions. Plan for ubiquitous health today by choosing the right leadership and stakeholders, understanding the current state, all with a lens looking toward the future. Adequate preparation will lead to a place where consumers will enjoy the highest convenience, the lowest cost, and the best outcome, and organizations will benefit from improved productivity, lower costs, and increased employee retention. Ideally, once virtual health is ubiquitous, the world will be a healthier place to live.


Plan for a change in facilities. Telehealth’s effects on post-acute and chronic care (e.g., the number of open hospital beds, the number of hospitals, and clinics needed, etc.) will change as more www.telemedmag.com




the trial balloon

Johns Hopkins Emergency Medicine Tests New TeleScreening Program This limited-run pilot has shown early success and Hopkins hopes that the final stats will warrant broad expansion. We caught up with Dr. Junaid Razzak, the architect of the program, to learn more about the effort, and where he sees telemedicine heading globally. Interview by Logan Plaster


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Telemedicine: Can you give us a little bit of background on the telemedicine work you’re currently doing in at Johns Hopkins?

process. We started doing that between 1:00 A.M. and 3:00 A.M., then we increased it to early morning hours and weekends.

Dr. Junaid Razzak: Johns Hopkins has established an Office of Telemedicine and we have an ophthalmology faculty who’s heading that. What we [in emergency medicine] are working on is to see if we could use telemedicine to reduce the “left without being seen” rate. We have these patients who would come in to the ED, especially at odd hours, later at night and in the early morning. They would get triaged and if they were not considered critically ill but sick enough to be seen, they would have to wait. And many of them would leave if the ED was busy. They didn’t know how long the wait would be and they felt like they were not getting the care they needed. To address this issue, the department started what we call "the screening process." After the nurse triages you, you are seen by a provider – a physician or a PA – who starts the treatment and some investigations, as well as give pain and fever medicine. That way, once you’re actually seen by a person who can make a decision and physically discharge you, they have all the information. Because while you are waiting, we are processing you. We were doing that screening process during the daytime, most of the time. But we had periods of time during the night where there was a need but it was intermittent. There were a couple of hours that we needed some help and it didn’t make financial or logistical sense to bring somebody in. Around this same time we were also feeling a shortage of physicians. We thought: What would be an out-of-box solution? And one of the things that came out was tele-screening, using telemedicine at the front door of the emergency department. Telemedicine: Where did this fall in your workflow? Dr. Razzak: After triage and before the patient is traditionally seen by a physician, we have this telemedicine-based screening

Telemedicine: How well is it working? Dr. Razzak: We're assessing the quality of the program by asking four questions. Number one, how good is the quality compared to in-person screening? Then, what is the level of efficiency? Third, how are patients feeling about it? Finally, how are the providers feeling about it? We looked at quality of care in terms of the care being provided for pain patients as a surrogate marker for care overall. We wanted to collect the numbers. We wanted to make sure that we actually do prove that it works or doesn't work in a scientific way. We wanted to know the limitations. We have screened over 4,000 patients and that data is being written up right. Telemedicine: What have you discovered so far? Dr. Razzak: We looked at the use of payment and we found that there is no difference between telemedicine screening versus in-person screening. Secondly, we were looking at the efficiency piece. We were questioning how the efficiency of telemedicine compares to a person who is there in person. What we found is that it's all about comfort level. We saw a learning curve. That learning curve showed us that after about six months, the person on tele-screening is just as efficient as an in-person physician. We've also done some basic data collection on patient satisfaction and the results are very encouraging. Telemedicine: Is the six month lag in efficiency simply a matter of getting used to a new technology platform? Dr. Razzak: Yes. Primarily it’s getting used to looking at the screen on one side and EPIC on the other screen, all while engaging the patient. The patient’s comfort level is on a curve as well. They are trying

to get used to a physician talking to them. In terms of efficiency, we also had to get consent from the patient, so you’re talking to them a little longer. They would ask questions about the system. It was surprising to me that the efficiency difference when we started was not that great, and it gradually went away completely. That's when started wondering if this remote physician could actually provide care that was both at the same quality and efficiency as in-hospital care. Telemedicine: Perhaps someone in Australia, helping out during your night shift. Dr. Razzak: Exactly. So that opens up so many opportunities to provide care. It’s just changed the paradigm completely. It also made us ask: Can we do this in multiple hospitals with one provider? Hopkins has several hospitals across the state. Can we do it in a couple of hospitals at the same time, with this one provider? That's what we are learning now. It made a human resource sense because we already had a shortage of people, especially at odd hours. We have learned that it is as good in terms of quality. Patient satisfaction-wise it is as good. Provider satisfaction is pretty good because they’re working from home. They don’t have to drive an hour and go back; so you save all that time. This can make financial sense if you can prove the quality of care is good and the patients are satisfied and they feel that there is a value in this whole process. That is something we’re still working on and hopefully we’ll come to that. Telemedicine: How well to doctors adapt to the technology? Dr. Razzak: There can always be minor issues. But I think the technology is so good and the internet is so great because everything else in the hospital is based on that infrastructure. We have a whole system working on it. We use peripherals, like a stethoscope and an otoscope, and once in


a while you get into issues with those. But generally speaking, they’re quite reliable. Telemedicine: Has anything surprised you about the program so far? Dr. Razzak: What was surprising to me was that it worked out so well! When you work with technology you always feel like something is going to go wrong. And things always go wrong when you try to do something. Telemedicine: Tell me more about the tech that you chose. Dr. Razzak: We bought [a telemedicine cart] off the shelf from Global Med, and then our IT person went to spend a week at their headquarters working with them to customize it for our needs. Telemedicine: What's coming next for this project? Dr. Razzak: What we really want to do is figure out how to integrate telemedicine into the working of emergency departments. We have a toe in the water right now. I don’t think telemedicine is ready for replacement of people in the emergency department. I think there are areas where it could augment the care process, like with patients who are waiting to be discharged

from the observation unit. They have already been seen. Telemedicine: Almost like a health navigator guiding you towards your next point of care. Dr. Razzak: Exactly. So lots of those kinds of options, which would allow our providers to focus on the sickest patients who need them most. And we'd use telemedicine to take some of the peripheral work out and put it somewhere else. That’s where I’m thinking about. The other thing that we see developing is complex decision-making support – ITbased guidance to augment and support physician decisions. We see patients with multiple disease properties going on at the same time. And we are trying to make complex decisions based on multiple pieces of information. The human brain has limitations of how many variables can it consider at the same time. But machines do not. This is low hanging fruit. First line providers are actually at the one point in time maybe caring for 20 patients. Each patient is very complex and then you multiply by 20, you need some help and that’s where the error happens. And technology can help there. I think there is a big hope for that. Another hope of telemedicine is that sometimes when you’re outside the unstable environment of the ED you can make better decisions. Say I am seeing a patient from my office, in a quiet room. Compare that to seeing the same patient in the middle of a chaotic emergency department. I’m getting all these signals from the environment and my ability to focus and make correct decisions is limited. So can we take some of those environmental factors and position the decision maker away from that noise level. When a surgeon goes to the operating room, you don’t have a lot of input coming in. It’s a very controlled environment. But the emergency department is not. Can we use technology to bring the provider and their mindset to a geographical space where the decision making can be more accurate? www.telemedmag.com




Telemedicine: You do these telemedicine screenings all of the time. How have you felt about the quality of the interactions that you've had? Dr. Razzak: There are many patients where I feel very comfortable. For example, you have a patient who comes in with ankle pain. And you can focus on their ankle and you can make them walk. You can actually tell the patient: Where is it hurting you? And it gives a lot of information and whether to get an X-ray. There are some patients where I feel that telemedicine has a limitation. A patient comes in with abdominal pain; that becomes more complex. I need a little more information than what my telemedicine system can give me. Chest pain? I think I’m okay with telemedicine. Telemedicine: What will be the life cycle of this particular Hopkins telemedicine experiment last? Dr. Razzak: We’re going to add other hospitals. We’re going to continue to learn how we can improve it. We started with four providers. It’s a smaller group who was committed. We expanded to other providers. We feel like we need to go out and see how we can make it sustainable. That telescreening right now is not billable. What can we do to make it sustainable in terms of service? There is a lot of scope for us to learn. What we also wanted to do was to make us as emergency physicians and as a department feel comfortable with the technology. We're moving away from a very traditional way of patient care, the doctor-patient relationship. We wanted do so in a way that shows success, learn from our mistakes and then expand it to other areas. We have achieved some of those goals. But new technology is coming all the time. . Telemedicine: As things move forward do you see in the near future improving certain aspects of the technology that you’re using? Dr. Razzak: We will probably use EPIC 24

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I SEE A MUCH BIGGER ROLE FOR TELEMEDICINE OUTSIDE THE U.S. FOR EXAMPLE, IN KARACHI, THERE’S 23 MILLION PEOPLE. IF YOU GO TO SEE A SPECIALIST THERE, YOU’RE PAYING $20, $30, $40. BUT THE VOLUME IS VERY LARGE. AND THAT’S TRUE NOW FOR MOST OF AFRICA, ASIA, INDIA AND CHINA. to its fullest. Right now it is not integrated into EPIC. We would like to have integration, although right now it’s not making that big of a difference. We run two systems and they work fine. But if it was one system, it would be better. I don’t know how that will eventually look like but that will be something we’ll be doing. Telemedicine: The trend we're seeing is that it’s not about the technology. It’s about implementation. Does that ring true? That basically the technology exists to do this. The challenges are in how to do it and get paid for it. Dr. Razzak: I'd agree with that completely. The tele part of telemedicine has been there for a while. However, on the technology side, I think the ability to feel is where there's room to grow. We can hear. We can see. We can’t feel with telemedicine. So abdominal exams are not possible. And a lot of what we do, even though we use a lot of technology and tests, still is based on our touch for the patient and patient’s different body organs.

Telemedicine: Can a physician extender be your hands? Dr. Razzak: That’s what you’re doing right now. But that sometimes is a skill that requires a lot of time. We use our nursing assistants when we do tele-screening. And we train them on what parts of chest do you want to hear for heart sounds vs. breath sounds. Where do you put your stethoscope? How do you use the camera? How do you look inside the ear? But abdominal exams are a little bit more interesting because, you know, sometimes you distract patients. It’s a whole technique because it’s so subjective sometimes. I would be very excited with a technology, sort of a glove or something that if I put my hand in it I can feel the patient’s abdomen. Telemedicine: Given your work internationally, how do you see telemedicine playing out around the globe? Dr. Razzak: I see a much bigger role for telemedicine outside the U.S. Internationally, the demand for services is so high. There is a very large middle class in many parts of the world who are willing to pay for healthcare but they do not have expertise. So I feel that if we can find a McDonald’s or Coca-Cola solution that can be exported at a reasonable price point for cash, I think it’ll be a huge success. For example, in Karachi, there’s 23 million people. You know, if you go to see a specialist there, you’re not paying hundreds of dollars as we charge here; but $20, $30, $40. But the volume is very large. And that’s true for now most of Africa, where there’s a pretty big middle class, and Asia, India and China. I think a lot of companies are focused too much on the American market.

Retrain the Brain A multitude of challenges in healthcare can be traced back to poor medication adherence. Patients fail to fill prescriptions, fail to take their medications, and fail to get refills. Along comes Wellth, a health tech company that is betting that medication adherence starts with rewiring our brains using smart incentive programs. In other words, they'll pay you to take your pills. by john tyler allen

$ Matthew Loper scooted to the edge of the couch where he sat flipping through medical research studies on his laptop and talking fast, his words jumbling together and spilling out as he tried to keep pace with his own narrative. “This one is actually fascinating,” he said, stopping at a 2010 study. “For every 100 prescriptions written, only 50 to 70 even get picked up at the pharmacy. Only 25 to 30 percent are actually taken. Only 15 to 20 percent are refilled.” He paused for effect. “This is insane to me,” he said. Loper, who is thirty, is tall and thin with messy brown hair that seems wholly unconsidered, as if his mind has been preoccupied with something much more important. He is the co-founder and CEO of Wellth, a startup aiming to increase adherence and decrease hospital readmissions using a simple app with a reward system. It targets our inherent need for immediate gratification (a neurological predilection that usually works against us) to create and reinforce medication-craving habits. Or, more simply: he’ll pay you to take those pills. Wellth works like this: Patients are enrolled via their care provider and credited $150 on their Wellth app. Daily prompts cue patients to submit a photograph of their medication before they take it. This is called a “check-in.” When patients fail to check-in for the day, they lose two dollars from their credit. At the end of 90 days, the patient is awarded the remaining balance on a gift card. “The largest driver of patient readmissions is that patients just don't do what they're supposed to when they leave,” he said. Take heart attack patients. He referred to another study. “By month three, less than half of those patients are still taking the medications they were prescribed at the time of discharge,” he said. Also by month three, 34 percent of them will be readmitted to the hospital. www.telemedmag.com


medication adherence retrain the brain

Treatment for chronic diseases make up as much as 86% of U.S. health care expenditures. But only 50 percent of patients suffering from a chronic illness will ever complete their therapy. Nonadherence alone costs us more than $100 billion annually. And, since the 2012 launch of the Affordable Care Act’s Hospital Readmission and Reductions Program (HRRP), excessive readmissions of certain patients have resulted in many hospitals paying steep financial penalties. Mount Sinai Hospital in New York, for example, with whom Wellth will soon launch their second pilot study, is facing more than $1 million in penalties for fiscal year 2017. Of the chronic diseases Wellth is currently targeting – heart failure, heart attack, chronic obstructive pulmonary disease, and type 2 diabetes – readmissions are penalized in all but diabetes. Loper walked me through research revealing why. These chronic diseases demanded the most healthcare dollars; medication adherence has been proven problematic in each; and if adherence were improved and readmissions reduced, these diseases would most quickly impact a hospital’s bottom line. And, perhaps most importantly, these diseases all had actionable behaviors that could be verified, and thus incentivized, using a smartphone. But Wellth isn’t a med-tech company, or even a tech company, Loper said. He was adamant: Wellth is a behavioral economics company. Technology alone won’t solve our medication adherence problem — many have already tried that route: lights on pill boxes, microchips on the bottles, chips in the pills. We’ve also tried patient education, pamphlets in hospitals, pamphlets mailed directly to the home, text message alerts, call center follow-ups, counseling and coaching sessions with physicians and pharmacists, and home visits from patient educators and care managers. Just to name a few. Research has shown us that humans are irrational, Loper said, but we’re irrational in predictable ways. “That's the whole imbalance we're trying to overcome in human psychology,” he said. Paying people to take their medications is, at a high level, a simple concept. But there’s also a nuance to it if you want to inspire longterm behavior change. “To actually get habit formation, you have to get so much right,” he said. “If you don't have the right incentive structure, if you don't have the right dollar amount, if you don't have the right interface, if it's tedious or frustrating or doesn't work well, people will just stop using it.” Wellth’s structure leverages the idea of “loss aversion,” a concept formed by Daniel Kahneman and Amos Tversky, psychologists whose attempts to understand the way we make decisions, take risks, and interpret probabilities gave us our modern understanding of behavioral economics. Their theories were first published in a defining paper, “Prospect Theory: An Analysis of Decision Under Risk,” in 1979. Tversky died in 1996 and, in 2002, Kahneman was awarded a Nobel Prize in economic science for the work. In his more recent book, Thinking Fast and Slow (a much more accessible explanation of Prospect Theory), Kahneman unpacks loss aversion and demonstrates the psychological weight of loss by inviting the 26

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reader to consider a series of propositions. For example: You are offered a gamble on the toss of a coin. If the coin shows tails, you lose $100. If the coin shows heads, you win $150. Is this gamble attractive? Would you accept it? “Although the expected value of the gamble is obviously positive... you probably dislike it — most people do,” Kahneman writes. But if the amount you stood to gain were to increase, your good opinion of the gamble would increase with it. On average, our “loss aversion ratio” ranges between 1.5 and 2.5, which means potential loss has twice the weight of potential gain. Dr. Kevin Volpp, a professor at the Perelman School of Medicine and the Wharton School at the University of Pennsylvania, and director of Penn’s Center for Health Incentives and Behavioral Economics (CHIBE), is leading the adoption of strategies and concepts from behavioral economics into health care and health policy. In 2008, CHIBE published their first study testing the potential for a lottery system to incentivize medication adherence. Every day that patients took their pills (Warfarin in this case), they were entered into a lottery with a 10 to 20 percent chance of winning ten dollars and a one percent chance of winning one hundred dollars. Between two pilot groups, incorrect Warfarin doses dropped from 22 percent to 2.3 percent and 1.6 percent. CHIBE has also studied the prodding potential of other structures in various applications. Reminder devices like specialty pill boxes didn’t work. Straightforward financial rewards had little success in encouraging weight loss and helping participants to quit smoking. Lotteries were productive in both motivating weight loss (50 percent of patients lost 16 pounds in 16 weeks) and adherence to home health monitoring devices (71 percent). Loss aversion, in which the participants wagered their own money, proved successful in two weight loss studies (47.1 percent and 41.2 percent success rates). In another CHIBE study Loper referenced showed a greater impact from loss aversion than from financial incentives. Participants were asked to walk 7,000 steps per day. The traditional financial incentive and lottery incentive groups barely outperformed the group that saw no incentives, while the group walking every day to avoid losing $1.40 from an initial credit proved nearly 30 percent more adherent. Loper spent Wellth’s first years researching behavioral economics, patient motivations, and various incentive structures with Mike Fuccillo, Wellth’s chief scientific officer. Once the research proved solid, Alec Zopf, Wellth’s co-founder and chief technology officer, and Mark Loper, who is head of design, began building the technology platform to support and leverage the concepts. “You have to do things in a very measured and rational way,” he said. “You can’t just move fast and break things. The stakes are very high in healthcare.” It was on the strength of this early research, in 2014 and 2015, that

Wellth secured their first outside investments and family – sometimes need a nudge from an extrinsic launched their first pilot study with a large national motivator – I want $150. Layering these motivators health insurer (marketing restrictions bar them is essential for long-term habit formation, Loper from releasing the name). In May, they closed a $2 said. The third version of the Wellth app, which is million round of seed funding, which is helping expected to launch later this year, integrates video to fund two more randomized controlled trials clips of encouragement messaged from family at two prominent academic medical centers, and and friends that can be unlocked after a successful in June, Wellth and Mount Sinai Hospital were series of check-ins. jointly awarded a $24,500 grant from the New “I'm hopeful that the psychological tools are “To actually get habit York City Economic Development Corporation catching up with the technological tools and the formation, you have to fund their pilot study. combination is going to succeed where education to get so much right,” and well wishes have failed,” Genes said. However, When Loper, Zopf, and Fuccillo presented to Mount Sinai earlier this year, their pitch deck said wellth ceo matthew he said, Wellth, nor any other technology, will highlighted the hospital’s 25% readmission rate singlehandedly resolve our issues with adherence loper. “If you don't for heart failure patients. They projected the and the resulting readmissions. “I love technology,” have the right incentive he said. “But it’s not a silver bullet.” Care team readmissions onto an entire year, tracking the rate along the same curve as the national average. structure, if you don't interventions might not always have access to After 90 days, the data showed, Mount Sinai could a patient and, yes, they might be expensive, but have the right dollar be looking at 40% readmissions for this patient they’ll continue to have a valuable role to play. amount, if you don't population. After 365 days, readmissions could “Does the Wellth intervention, on top of all the reach 65%. The next slide showed Mount Sinai’s have the right interface, other stuff, actually improve adherence?” he said. projected return on investment using Wellth and That’s what they would study at Mount Sinai. if it's tedious or estimated an annual savings of more than $1.3 “These are still patients that are going to have frustrating or doesn't million in heart failure patients alone. The patient trouble filling their scripts, they're going to have population that will see the intervention is still work well, people will trouble getting transportation to an appointment, being decided. they're going to have trouble paying their bills.” just stop using it.” “I see the revisits, I see the problem firsthand Mount Sinai is still implementing best practices, -Matthew Loper and it is frustrating,” said Dr. Nicholas Genes, still actively looking for solutions, Genes said. an emergency physician at Mount Sinai who is And the problem, really, is that we’re complicated Wellth Co-Founder also board certified in clinical informatics and beings. “You really have to take into account the is involved in a hospital initiative to use patient human factors,” Genes said. “It’s an art.” generated health data to improve outcomes and adherence. Patients One of the defining aspects of human nature is our irrationality, will leave the hospital after being stabilized and seeing their health our inherent bias for whatever is right here and right now, the restored, and then physicians will see them in the emergency room potentially self-sabotaging pursuit of immediate gratification. But again one week later. In some patients, he said, it’s clear that there are if we can find patterns in this behavior, predictability within the dietary indiscretions and lack of adherence. It’s a complex problem irrationality, maybe we can create solutions that begin to “move the for a large hospital system like Mount Sinai (which has six emergency needle,” as Loper said. In April, he wrote a vision-casting email to departments all facing the same issues), and it’s a complex problem his team. What if they were able to increase efficiency by just a few for patients, who, he said, are clearly just as frustrated when they find percentage points? He linked to a study from a Harvard economist: themselves in the emergency department. “A firm that was able to reduce the overuse of care by even a quarter “You know, we're all human. You can totally understand it when would save the health system $330 billion annually,” he quoted. For you're sitting in the hospital,” said Dr. Genes. “'I’m not going to take now, though, he sees Wellth’s impact on a more human scale. “We another drink. I'm not going to take another smoke. I'm going to wake up every day and we see the majority of our patients taking take all my pills.' Anything to get out of here and not come back. their pills and we know, without us, half of them wouldn't,” he said. But then you start taking these pills and they don't make you feel “That's literally dozens of lives we'll save this year.” By the end of any different. They're not tasty. You don't see the effect day after day. next year, maybe they’ll be saving thousands or tens of thousands of You're investing in an abstract future. That's why I think Wellth has people's lives. “I truly believe we have the best approach to solving a great strategy, because they’re rewarding explicitly what you might this problem,” he said. “There are literally millions of patients out not feel implicitly.” there who would benefit from it. My goal is to help as many of those Intrinsic motivators – I want to be healthy because I love my patients as possible.” www.telemedmag.com


cyber security

CyberMed Summit Addresses Fears of Hospitals Getting Hacked Three physicians participate in first-of-its-kind simulation. by kevin j. kohler


ou’re working your usual shift in the ED when you are called upon to take care of a patient with atrial fibrillation and a rapid ventricular rate at 190 bpm. Her blood pressure is a little soft, but she does not require cardioversion yet. As your nurse starts to mix and hang the diltiazem you ordered, you begin your point-of-care ultrasound of the patient’s heart. Suddenly, you notice that the bag of diltiazem has been bolused in its entirety into the patient’s vein over the course of a mere 10 minutes. Your nurse looks at you with shock and horror. “I didn’t do that doc!” she screams as the patient’s blood pressure and heart rate drop to fatal numbers. Just as you begin giving medications in an attempt to reverse the effects of the calcium-channel blocker overdose, your jaw drops. You see several other medication pumps in adjacent resuscitation bays start doling out entire bags of medications as well! This may sound like a sci-fi thriller, but security researchers have shown that pacemakers, insulin pumps, and other medical delivery systems are vulnerable to cyber attack. To play out these nightmare scenarios and learn from them, the University of Arizona hosted the first ever CyberMed event in Phoenix last June. The two-day event brought together 155 clinicians, policy-makers, security researchers, and industry insiders to watch dramatic simulations and discuss the grave threat that hacking poses to today’s healthcare delivery. 28

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Laerdal SimMan 3G used during the simulated CyberAttack could blink, sweat, and cry.


Dr. Wu directs the simulation scenario behind the one-way mirror while being filmed by ABCWorld News with Dan Harris.

Just weeks after the summit, new ransomeware known by some as “Petya” quickly spread to countries around the world, including the United States, with hackers holding computers hostage for payouts. Last January, Hollywood Presbyterian Hospital in Los Angeles paid out $17,000 after hackers took control of its computers. “We went from being prone and prey with no predators to now a little blood in the water,” cybersecurity expert Josh Corman told ABCNews. “Hospitals and health care went to the No. 1 targeted industry last year, in less than one year—so our relative obscurity is over.” Not scared yet? Last month, a worldwide cyberattack by a ransomware called WannaCry not only hit computers but also storage refrigerators and MRI machines, shutting down 65 hospitals in the United Kingdom. The FDA has been urging manufacturers to update their products’ security measures since at least 2013. However, agency guidelines issued last year are not binding, and the FDA does not review the vast majority of cyber security updates made to devices under its own rules, which are intended to streamline medical device upgrades. In a collaborative effort to increase awareness of such cybersecurity threats in healthcare, doctors Teresa Wu, Jeff Tully, and Christian Dameff worked to create a simulation-based conference focused on creating awareness of the issue and finding solutions. Josh Corman, Director of the Cyber Statecraft Initiative at the Atlantic Council’s Brent Scowcroft Center, and Beau Woods, founder of the grassroots computer security organization “I am the Cavalry” and Deputy Director of the Cyber Statecraft Initiative, further aided the team. “Simulation is an incredibly powerful learning modality, particularly for the rare or novel situation requiring specialized responses,” says Dameff. “It also allows the translation of theoretical or conceptual problems to ‘real’ patient physiology and care. Designing and

executing the first ever simulations of patients affected by compromised medical devices allowed us to take the work performed by security researchers in the laboratory and demonstrate what that may look like to the ER doc and team who will have to care for the patient who rolls in with a hacked AICD or insulin pump.” Three physicians with no foreknowledge of the simulation were selected by Dameff and the team to act as “unwitting physicians,”— one for each scenario. Each physician was called to do damage control post-cyber attack, assessing and caring for critically ill patients targeted by hackers across the globe. Actors portrayed patients and real paramedics served as support staff, responding to the attending doctor’s directions. Each scenario involved a compromised device based on research: a medication infusion pump dosing the full quantity in minutes, a wearable insulin pump causing the wearer to go into a coma and crash a car, an a hacked pacemaker eventually causing cardiac arrest. Thirty-five attendees viewed the simulation from behind one-way glass; the rest viewed a live stream from down the hall. As Dameff explained, in each scenario when something grave happened, the lights would be turned off, freezing the simulation, as the human patient would be replaced by a high fidelity simulation mannequin that could blink, sweat, and cry. Outside the room, Dr. Wu was the wizard behind the curtain, using a computer to control the mannequin based on what the physician did, increasing heart rate, stopping breathing, etc. None of the physicians realized that the equipment was hacked, but all of the patients ultimately survived. Doctor Anne-Michelle Ruha’s patient was in a rapid atrial fibrillation. “When his heart rate and blood pressure began to drop, I assumed it was related to his primary condition, until I discovered an entire bag of diltiazem had infused in minutes. Despite knowing the theme of the conference, it did not occur to me that hacking of the infusion pump had occurred--I assumed human error,” she said. Of course, her focus was then on treating the calcium channel blocker toxicity. Once her patient was stabilized, she learned about the hacking. “I think in a real-life situation the physician deals with the ‘What went wrong?’ question after the patient is stabilized, and I don't


Directions were provided to actors by Dr. Wu via hidden two-way headsets.


Dr. Jesse Shriki (left), Dr. Teresa Wu and Dr. Tarann Henderson.

think knowing what happened would have affected my treatment,” said Ruha. “However, I do think it is important to be aware of the possibility because if I had seriously suspected hacking, I would have instructed the nurses to set the infusion pump aside and not use it for anything.” Ruha added hacking really never crossed her mind in the past, and she’s glad to now be aware of the potential problem. “I still don't think I would be likely to consider it if something like this occurred with a single patient, but if several pumps 'malfunctioned' simultaneously, hacking would now be the first thing I would think of,” she said. “We had to design and create a clinical environment and patient scenarios that enabled our physicians and audience members to suspend disbelief,” said Wu, who is the Simulation Director at the University of Arizona, College of Medicine-Phoenix and also for the national American College of Emergency Physicians. “Our scenarios were so realistic and engaging that audience members almost jumped right out of their seats to help the physician and team members caring for the affected patients,” she said. “Part of the problem is, as physicians, we are trained to rely on a vast array of technologies to assist us in the care of our patients,” said Tully. “From decision support tools to actual implantable medical devices, we have an implicit trust in such technologies that they will do what they are intended to do without need for additional scrutiny or oversight. We are now entering a world where such trust without vigilance and verification may become negligent. We need to prepare for such a practice environment.” The summit was the first ever simulation of cyberattack in medicine, and attendee feedback was 90% “extremely satisfied” and 10% “satisfied.” The team hopes to expand the conference nationally and even internationally. Wu, who has been creating, designing, and running medical and surgical situations for more than a decade, hopes people will start to understand just how dangerous and unpredictable these types of cyberattacks can be. “We wanted folks to walk out of the sessions amped up and ready to make a difference. I think we achieved our goals and so much more with our CyberMed Summit,” she said. For more information about cyberattacks in medicine and patient care, follow these doctors on Twitter: @TeresaWuMD, @CDameffMD, and @Jeff TullyMD.



global perspectives

Canadian Telemedicine Program Brings Care To the North Canada is a unique launchpad for virtual healthcare as it combines a modern, nationalized health system with incredibly remote towns and villages. One program in Ontario has had significant success and may serve as a model for other provinces. by scott pruden


he baby was coming – but much earlier than expected. Karina Beavis was 30-weeks pregnant and in early labor when she rushed to the emergency room at rural Espanola Regional Hospital and Health Centre in Espanola, Ontario. The problem? Espanola had no OB-GYN on staff, and the transfer hospital was an hour away in Sudbury. 30

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Dr. Sean Mahoney, the famCaroline Chum, a Moose ily physician on staff at EspaFactory local with Type 2 nola, had no obstetric expertise diabetes, looks out from her and was desperate to have the home at the Elder’s lodge, a laboring woman transported live-in retirement home. to Health Sciences North, the photo by Christopher Manson large regional hospital in Sudbury. “[Mahoney] called the obstetrician on the phone. He said there’s no way the mother’s going to get here on time,” says Dr. Derek Manchuk, Medical Director of the Virtual Critical Care (VCC) Unit at Health Sciences North (HSN), the regional hospital in Sudbury. “They’re going to deliver in the ambulance, so it’s better to keep them in the hospital emergency room.” Mahoney then asked if he could have the obstetrician help him via telemedicine using VCC. A nurse set up the connection, and by consulting directly with specialists in Sudbury via the dedicated video conferencing system, Mahoney successfully delivered Beavis’ daughter, Leah, who weighed in at four pounds. “We were able to involve the VCC nurse, the obstetrician and the pediatrician, who helped deliver and resuscitate the baby, who was then transferred to HSN and did very well,” Manchuk says. “The mother was very happy with what had happened and the care that she could receive.” Happy, but pleasantly surprised, she said after Leah’s delivery. “It was a little weird having people in another hospital watch me

Health Sciences North in Sudbury, Ontario, serves a number of remote communities throughout Northeastern Ontario via its Virtual Critical Care Unit.

give birth,” Beavis told the local newspaper. “But it made a huge difference for the delivery. We feel very blessed that everything came together and that Virtual Critical Care unit was available.” According to Manchuk, without VCC, Leah’s birth likely would have gone much differently. “One of two things would have happened. They would have tried to muddle through on the phone giving advice without seeing what was going on, or they would have just said, ‘Best of luck to you, get them here when they’re stable,’ and hung up the phone,” he says. “I think it’s a quantum leap in terms of the care that can be provided.” Putting Practitioners and Patients Together Leah’s birth, which took place in September of 2016, is just one dramatic example of how the province is leveraging the power of telemedicine to provide first-class care to patients at remote hospitals throughout northeastern Ontario. The system, launched in 2014, is the first of its kind in Canada. Through the program, HSN maintains a group of doctors, nurses and specialists on call to respond to emergency and critical care situations at remote hospitals throughout the Canadian province. For Americans, it’s sometimes hard to grasp the geographical challenges facing patients in farther-flung areas of Canada who need help beyond what their local doctors can provide. Within northeastern Ontario, for instance, many communities maintain hospitals like Espanola’s, with a staff of primarily nurses and family physicians. Others are even smaller and more distant,

and their lack of healthcare providers is compounded by their geographic inaccessibility. It’s in these circumstances that VCC is invaluable, Manchuk says. Recently, VCC was used to assist a patient in the town of Hearst, which has a population of 5,000 and is an eight-hour drive away from Sudbury and two hours away from its next closest community. “We had a patient that was in their emergency room for well over a day because the air ambulance couldn’t get there because of weather,” Manchuk says. “[Using VCC] we could maintain that patient in Hearst for almost two days, a critically ill patient on life support with the family physician there and a nurse – and they have very little experience in terms of managing critically ill patients. They see maybe a handful a year at most.” And then there are spots such as the remote town of Moose Factory, a native community of 1,700 on the Moose River near the southern tip of James Bay. Moose Factory is more than 300 miles away from Sudbury and completely inaccessible by car during spring, summer and fall because it depends on ice roads for surface travel. Bridging Geography, Saving Money The foundation of the Canadian health system, known there as Medicare, is ensuring that every Canadian citizen will receive health care, regardless of their ability to pay. What results is a system that would, to Americans, be somewhat familiar in the way services are provided, but is entirely different when it comes to payment. For standard procedures, doctors bill each provincial health care system directly and are compensated accordingly using funds collected through taxation. There are no insurance company middle men, a limited amount of red tape, and zero costs – such as deductibles or copayments – passed along to the patient. However, costs associated with pharmaceuticals, dental and vision are not covered through the national health plan. Canadians pay those out-of-pocket or have them covered through private insurance companies. On the upside, because there are no costs to the patient, there are fewer roadblocks to preventative treatment and early detection, which results in lower per capita spending on health care by Canadian residents. In 2015, the per capita rate of health care spending for a U.S. resident was $9,451 (U.S.), compared to $4,608 (U.S.) for a Canadian. On the downside, Canadian healthcare maintains a documented reputation for long delays – some up to 10 months or a year – in scheduling elective or non-emergency surgeries and procedures compared to those for providers in the U.S. Because of the limitations to healthcare access in areas like northcontinued on page 33 www.telemedmag.com


addiction recovery

Three Digital Health Tools for the Opioid Epidemic The greatest health crisis of our generation is going to require that we use every innovative tool in our arsenal. by aneel irfan


ack in 2011, South Florida was the epicenter of a prescription drug epidemic. There were pain clinics on every corner, one stop shops for on-demand pills of poison. Being a South Floridian, I witnessed this first hand. Ever heard of the Oxy Express? This was the nickname of the stretch of I-75 that during this time was frequented by out-of-state addicts and drug traffickers making their way down to South Florida for their prescription drug supply. Many never made the trip home. From 2012 to 2013, after a Florida crackdown to shut down these pill mills, those addicted to the shrinking supply of prescription painkillers searched for alternatives. Since then, the use of heroin, fentanyl and deadlier synthetic offshoots has exploded in South Florida, and the ripple effects are now being felt across the county. Drug overdose deaths in 2016 exceeded 59,000, the largest annual jump ever recorded in the United States, according to preliminary data compiled by The New York Times. More Americans died of drug overdoses in 2016 than died in the entirety of the Vietnam War. The question that I ask myself as I watch yet another dubious recovery center crop up in a nearby strip mall: "How can we leverage digital health tools to counteract the rising need for addiction treatment? Here are three specific ways, though its only the tip of the iceberg.

Increase Telemedicine Use for MedicationAssisted Treatment Programs

Treating opioid addiction via MAT is probably the most prevalent and impactful way to break down these chemical dependencies. Medication-assisted treatment (MAT), including opioid treatment programs (OTPs), combine behavioral therapy and medications to treat substance use disorders. The problem is, especially in rural areas, the demand for this type of treatment far exceeds provider capacity. For people with Opioid Use Disorder who are receiving medication treatment with buprenorphine, a telepsychiatry approach—using video conferencing as an alternative to in-person group sessions—provides similar clinical outcomes, reports a study in the Journal of Addiction Medicine. A key aspect of the opioid epidemic is the lack of these types 32

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of treatment options for millions of Americans living in these rural communities where opioid addiction has been most prevalent. Current thinking is that there needs to be a mechanism in place to expand access to these services via primary care practices—the places where most rural Americans receive care. Last year The Agency for Healthcare Research and Quality released a series of grants that awarded $12 million in funding over the next three years. The initiative brings together innovative teams of state health departments, academic health centers, researchers, local community organizations, physicians, nurses, and patients. Together they're charged with delivering MAT to hundreds of rural practices in places such as Muskogee County, Oklahoma, where there were more than 10 opioid-related deaths per 100,000 people per year over the past few years, where over 1300 people are thought to be in need of treatment for opioid addiction, and there are currently no primary care physicians providing MAT. And Bent, Colorado, where the overdose death rate has increased from fewer than 10 to over 20 per 100,000 since 2002. The practices involved in the initiative are working towards providing access to MAT to over 20,000 individuals struggling with opioid addiction using innovative technology, including patient-controlled smart phone apps, and remote training with expert consultation using Project ECHO. Project ECHO is a telehealth program started with AHRQ support that links specialists at an academic hub to primary care providers working on the front lines in rural communities. Together with their grantees, AHRQ will build a blueprint for how other communities and primary care teams can overcome the barriers of providing MAT, and ensure access to care across America’s rural communities. Telemedicine will continue to emerge as an essential avenue for administering these critical MAT services to patients.

Alumni Programs via mHealth

One of the biggest issues in treatment today is the lack of, or limited ability for centers to provide follow-up care after a resident completes their program. This is an important factor in reducing the depressing statistic that 60 percent of people who go to drug or alcohol rehab relapse after one year and another 80 percent will go to another facility. Much of this can be credited to the lack of follow


on a monthly basis for the app service. A consistent digital touch and following of these patients after they leave is what will be needed to make sure they don’t bounce back.

Substance Abuse Treatment Via Virtual Reality

care from these facilities and now app-based after care solutions are being developed to address this gap in treatment. The idea is that by maintaining a connection with residents utilizing digital platforms when their programs end, treatment providers can now know how their patient populations are faring in the world. One such app is Sparkite, which a patient downloads at the time they leave a rehab program and receive weekly quality of life surveys to fill out. From a business point of view, treatment providers can influence the likelihood that if the patient does relapse, they’ll return to the their facility rather than going to a new one. The treatment centers get billed

canadian telemedicine


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To help people overcome drug addiction, many research studies are turning to virtual reality. They are building hyper-realistic virtual worlds to recreate situations that trigger cravings for nicotine, alcohol, weed, and now, hard drugs like heroin. Traditional relapse therapy usually involves role playing: Therapists often pretend to be a friend or some other familiar person and offer the patient their drug of choice in order to teach them avoidance strategies. By strapping patients into a virtual reality headset and running them through a familiar scenario where they commonly use the drug, such as at a party, the role playing can be much more realistic and effective. The trick is to make addicts crave virtual drugs. And then choose not to use. The opioid epidemic may be the most critical medical outbreak of our generation. Now more than ever, there needs to be a deep understanding from providers that this epidemic cannot be cured without incorporating innovative technologies. Solutions like the ones outlined above are pushing the limits and creatively attacking a problem now effecting millions. The need for treatment, education and access will drive the market for these technologies. Whether they can truly make a dent in the rise of the abuse of these substances still remains to be seen.


eastern Ontario, many patients wouldn’t have the opportunity to see specialists or receive advanced care at all were it not for telemedicine allowing doctors to provide care from a distance with the least amount of technical interference, Manchuk says. “The whole benefit of the video conference is not the technology. The technology should be easy to use and almost transparent in terms of its presence,” he says. “It’s about the discussion of the patient and involving the team members on each end of the connection.” That’s not to say, however, that the system doesn’t also save Canadian healthcare money. Manchuk notes that because of the differences in their system and that of the United States, it’s difficult for Canada to track costs and savings per procedure the way we do here. However, just in the realm of transportation, he estimates

that Ontario saves up to $16,000 (Canadian) per round trip with each air ambulance it doesn’t have to dispatch to transport a patient. That adds up to $1.4 million (Canadian) in just transportation savings since VCC was launched in 2014. But cost savings aren’t foremost among VCC’s goals, he notes, and should the U.S. expand its use of telemedicine in emergency and critical care situations, he says it shouldn’t be here, either, whether it’s used for something as major as assisting a remote hospital with advanced procedures or as ordinary as helping someone decide if a cut needs stitches. “At the end of the day the goal should always be to improve patient care, because if we do that we’ll save money,” he says.



“It was fun to be at something so energizing, looking at new models of care.” ™

“The information shared was some of the best I’ve ever encountered.” “This was a great conference. It was very, very informative and allowed for easy networking. Bravo! Thank you!” SM

“[The Lightning Rounds] stimulated thinking and prompted me to reach out to providers I had not approached prior.”

Join us for SPS Oct. 2-3, 2017 Hyatt Regency Downtown Phoenix, Arizona | ttspsworld.com

health literacy


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Your Achievement of the URAC Telehealth Accreditation Proves It. Download Disrupting Healthcare: Risks and Rewards of Telehealth at info.urac.org/telehealth-report businessdevelopment@urac.org


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Profile for Telemedicine Magazine

Telemedicine Magazine Issue 10  

Telemedicine Magazine covers the telemedicine, digital health and virtual care markets. The print publication is distributed quarterly to an...

Telemedicine Magazine Issue 10  

Telemedicine Magazine covers the telemedicine, digital health and virtual care markets. The print publication is distributed quarterly to an...