Telemedicine Magazine Issue 7

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The bright future of medication delivery

Review: The best of tele-presence robotics

Addicaid app offers new tools for relapse

Connected care in war-torn Afghanistan


Drone On

New FAA regs could usher in a wave of healthcare drone start-ups. PAGE 20

IT'S TIME FOR A BETTER BOT Thanks to machine learning and muchimproved A.I., chat bots are poised to redefine virtual care. PAGE 36

We have your future in telehealth already mapped out. ORGANIZATIONAL STRATEGY





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Hospitals and health systems are thinking about telehealth and planning for it, but there are a number of ways to implement telehealth based on organiztaional needs. Our dedicated provider market team will work with you to create a solution that aligns with strategic goals, so you can execute with confidence. Contact us today and ask about the Telehealth Readiness AssessmentSM, only from Teladoc.

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Teladoc’s telehealth technology platform and licensable software solution has earned the exclusive endorsement of the American Hospital Association. 2

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WWW.TELEMEDMAG.COM ISSUE 7 / WINTER 2016 Editor's Desk_4 Telehealth Regional News_6 ------telescope

Geriatrics_9 Pharmacy_10 Home Monitoring_12 Pediatrics_13 On Demand Health_13 ------teletech

Gear Lab: SmartHeart_15 Tech Review: Tele-presence robots_16 Fashion Tech: Temporary health tattoos_18 Wearables: The next wave of clinical sensors_19 Drones: New FAA regs pave the way_20 ------television

Hubert Zajicek: Texas-style start-ups_23

pAfghanistan's Brighter Tomorrow_Page 40

Ron Gutman: 5 billion questions answered_25

An uptick in telemedicine projects and venture funding might be reason for cautious optimism.

Sam Frons: A new approach to addiction_29 ------start-ups Lessons from 'doctorpreneurs'_32 The Rock Health funding report_34 Post-Mortem: What happened to Happtique?_35 ------features

Let's chat about chat bots_36 Overcoming 'shiny toy syndrome'_38

p Cerora "mindreader" could help physicians analyze head trauma.


p New FAA regulations pave the way for innovative healthcare drones.


p Sam Frons hopes addiction app Addicaid will redefine relapse management.


Lessons in telemedicine accreditation_39 A brighter future for Afghanistan's connected health system_40 ------marketplace_44


Alchemists for the future_50


editor’s desk

Finally, the Age of the Better Bot

logan plaster


Like chat bots, virtual reality has existed for years, but we're finally seeing the level of execution that can truly tranport the user. At our most recent mHealth Toolbox workshop, I got to try out the new Osso VR surgery prep virtual reality module. I nearly forgot where I was as I glimpsed the amazing role VR can play in medical education.


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recently had an email exchange with a colleague in which we decided to have a follow-up conference call. To schedule the meeting, my friend copied her personal assistant and asked that she fix a time for our next chat. The obliging assistant, Amy Ingram, followed up almost instantly and smoothly set up a time that worked. There was a cancellation, a re-scheduling, a flurry of apologies, but we found a time, thanks to Amy’s good-tempered persistence. It wasn’t until we had gone back and forth multiple times that I read Amy’s email signature and realized the significance of “her” initials. It turned out that Amy Ingram (A.I.) was a sophisticated chat bot and that I had been pleasantly corresponding with a robot the entire time. I was floored. The email exchanges had been clear and cordial with nary a hiccup in our conversation. Apparently I wasn’t the first to be fooled. ”She has received flowers, chocolate, and whiskey at the office,” said Amy Ingram’s creator, Dennis Mortensen, in an interview with Business Insider, “and she just might have been flirted with a few times.” The beauty, says Mortensen, is If the intuitiveness that you don’t have to use any special syntax or of my exchange vocabulary to communicate with Amy. She pulls the data she needs from your normal communi- with “Amy Ingram” is a sign of things cation, and she gets the job done. As Rishi Madhok writes on page 36, gone are to come, count the days when a “chat bot” means calling up Mov- me optimistic iefone or using “Clippy” in Microsoft Office. about the future of Even Siri seems gimicky compared to savvy Ms. chat bot-powered Ingram, whose version of automated response is deceptively smart, nearly invisible and miles away personalized medicine. from the uncanny valley. What does this have to do with healthcare? In my interview with Ron Gutman on page 25, the CEO and founder of HealthTap alludes to a new development that will put artificial intelligence front and center. HealthTap will leverage 5 billion healthcare questions answered on the platform to deliver health answers personalized to the patient. As Gutman puts it, it’s all about putting “content in context”. And HealthTap isn't alone. There's the AI-driven health assistant by "Your.MD," Chinese search engine giant Baidu's medical chatbot named Melody, not to mention offerings by Ns1ghter and Babylon Health. If the intuitiveness of my exchange with “Amy Ingram” is a sign of things to come, count me optimistic about the future of chat bot-powered personalized medicine. Imagine an insurance chat bot for when you call to authorize medications, says Telemedicine editor Nicholas Genes. “The bot could automatically collect my patient’s information from the EHR, and would already know my credentials.” But while answers to health questions and medication authorization are great, there’s an even bigger upside on the horizon. Today’s emergency medicine residents spend nearly half of each shift inputting data into a computer. If healthcare chat bots and A.I. can move from being gimmicky and obtrusive to seamless and truly intuitive, they have the ability to pull physicians away from those electronic charts and back to the bedside. Then they can get back to the job that humans do best – like holding the hand of a worried patient, looking them in the eyes and telling them everything’s going to be OK.

telemedicine ISSUE 7 – WINTER 2016


Logan Plaster

Who is your favorite Hollywood robot?

Kitt, my earliest – and by far the coolest – introduction to A.I. in action.



Mark Plaster, MD


Rishi Madhok, MD Aneel Irfan Unity Stoakes

Johnny Five from Short-Circuit – he was built like a tank, was hacked to be used for evil but chose to be good. And had an epic mohawk!

My archetype for robots comes from The Robot on Lost In Space. It was bulky and slow, but smart and strong – and always pointed out danger to Will Robinson.


Nicholas Genes, MD, PhD CONTRIBUTORS

Sonya Swink

Jodi Lyons

David Ho

Jeremy Lacocque

Scott Jung

John Tyler Allen

Vishaal Virani

Michael Levin-Epstein

Mark Shankar

Megan Pfiffner


Baymax from Big Hero 6. Health care assistant by day, superhero by night. And he has the best fist bump ever. Balalalala!

Nicolet Schenck (cover) INDUSTRY ADVISORS

Ting Shih ClickMedix Jodi Lyons SeniorSherpa Dr. Sylvan Waller Alii Healthcare

Dr. Shiv Gaglani Quantified Care Jon Pearce Zipnosis Unity Stoakes Start-Up Health

Haywood Hall, MD PACEMD Dr. Robert Park RelyMD Dr. Judd Hollander Jefferson University


Eliseo Rivera Aneel Irfan 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

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.



regional news

News from the Consortium of Telehealth Resource Centers

As we bring 2016 to a close, the TRCs are in full swing for their 2017 initiatives and it's sure to be a big year for the telehealth industry. Here we highlight upcoming events, legislative movements and milestones. edited by aneel irfan





NRTRC's 6th annual conference will be held in Seattle, WA April 10-12, 2017. This year's conference theme is Next Generation Healthcare: Optimizing Your Telehealth Programs. Our conference kicks off with Telehealth 101 & 102. This four hour program gives those new to the industry a better grasp of what it takes to have a telehealth program. We'll cover technology, operations, and telepresenting. Our 102 session will cover all regulatory and legislative topics both from a national standpoint and also for each of our seven states in the Northwest. To help physicians make the transition to telehealth, technical assistance grants are available through the Wyoming Department of Health Office of Rural Health. When the application is filled out the staff at WIND reaches out to the provider to help identify which other clinics or hospitals they need to be linked to and to help reach out to those other clinics to help with initial setup and training.

SETRC, along with APT, sponsored the 5th Annual Alabama Telehealth Summit on August 7 in Birmingham, Alabama. The summit was our most well attended conference yet with 200 in attendance. On November 17th-18th we had The 3rd Annual Florida Telehealth summit. With Florida’s mandated statewide telehealth surveys now complete and with Florida’s telehealth policies sure to be shaped in the upcoming year, this may become a pivotal event for Florida healthcare providers. SETRC also operates The National School of Applied Telehealth (www.nationalschoolofappliedtelehealth. org) The National School of Applied TeleHealth (NSAT) provides healthcare information and education for providers and consumers through the development of a virtual School for Applied Telehealth. NSAT has now added a certified telepresenter stroke specialty course that is available now.

In ShowLow, Ariz., in August, at a meeting on “Compassionate Care, Close to Home with Telemedicine,” SWTRC staff met with colleagues from the Arizona Telemedicine Program to discuss how health care is changing, and how telemedicine can improve patient care. The day also provided information on the benefits and outcomes of telemedicine across the care continuum from a large health-care system; evolving options for patient care via technology; reimbursement and regulatory hurdles; and resources for implementing telemedicine standards, guidelines and ongoing learning. In August, Kris Erps and Nancy Rowe participated in a webinar hosted by Avizia, which focused on regional telemedicine drivers and trends; innovative telehealth programs and resources; and guidance for telemedicine users. These are the kinds of outreach activities that help us meet our mission goals.

One of the nation’s largest regional health plans in the Midwest has launched a multi-year program to monitor and treat their Medicare populations with heart failure, pulmonary disease (COPD), and diabetes. This program will monitor patients in their own homes to promote patient engagement, improve patient outcomes and prevent costly and burdensome re-admissions. The remote monitoring and management of these patients is provided by AMC Health, a leading provider of virtual care solutions. AMC’s Bluetooth-enabled devices will allow patients to report their daily biometric measurements, such a weight, blood pressure, heart rate, glucose levels, and inhaled medication use. In addition, AMC Health will focus on specific gaps in care to support the health plan’s commitment to clinical quality and STAR ratings.

contact: lloyd sirmons

contact: kristine erps

contact: bob wolverton


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contact: zoi hills

Share your latest news with Telemedicine Magazine email





The TexLa Telehealth Resource Center received notice of continued funding for FY2017. TexLa holds a quarterly Stakeholder Meeting to provide an open forum for anyone who wishes to join. Recent discussions and queries have centered on billing and reimbursement issues. Louisiana has several pieces of telehealth legislation in various stages from proposed to enacted – find the latest on the Frontiers in Telemedicine, a one-of-a-kind training program for clinicians specific to telemedicine, started January 2016 and has enrolled over 130 clinicians. The program focuses on competency-based learning and features a combination of online content and handson simulated learning. Frontiers in Telemedicine provider training is a key feature of a Network Access Improvement Project in conjunction with area health systems and payers.

The NETRC regional telehealth conference will be on May 23-24, 2017 in Amherst, MA, and will be focused on Taking Telehealth Mainstream, and the role of an integrated telehealth strategy in increasing health access and outcomes. Do you receive our monthly newsletter? With a mission to bring you everything telehealth in the Northeast, recent issues have featured: NETRC news (including exciting regional events we’re attending, like the New England Rural Health Conference), NETRC resources (such as a new, comprehensive series of fact sheets developed with the Consortium of Telehealth Resource Centers for NOSORH), regional program updates, recent telehealth job postings from organizations throughout the region, a variety of funding opportunities, and hand-picked telehealth news articles and published literature. Visit to sign up, or send us an email to share an update for our next newsletter

The newly formed Society for Excellence in Academic Research for Connected Health (SEARCH) will hold its first annual meeting in alignment with the MATRC2017 Telehealth Summit. SEARCH invites telemedicine researchers, academicians, innovators, and policymakers to join in structured and open discussions of telemedicine research structure, findings, and priorities. SEARCH seeks to both share findings and foster research partnerships among researchers and organizations that wish to define and develop the field of telemedicine research. This symposium has been added with the purpose of engaging federal policy makers from across agencies in discussion about what type of research and evidence base they most need to make sound policy decisions regarding telehealth. This event will take place April 2 – 4, 2017 in Leesburg, VA.

Last issue we reported Missouri’s expansion of school based telehealth policies. While schools in Missouri were already able to use telehealth, they could not receive reimbursement for the services. Under a new bill, schools will be considered a telehealth origin site by MO HealthNet, Missouri's Medicaid administrator, enablining schools to receive reimbursement for their telehealth services. A recent ATA tele-mental health state policy report showed that the heartland states are leading the way in Tele-mental health. Just eight states received a final composite score of an "A" on the report, two of which were Missouri and Oklahoma. Forty-one states received a "B" grade, including Kansas. Just getting started in telehealth? Heartland’s eSTART Assessment provides a thorough on-site needs assessment, including a technology assessment. This package will provide you with the data you need for a competitive grant application.

contact: becky jones

contact: kathy wibberly

contact: andrew solomon

contact: janine gracy



regional news





SCTRC’s website just added a new free learning module, “Building Your Telehealth Team – An Important Component of Program Development." Building your telehealth team is an important component of program development. It is important to know who will take responsibility for the various pieces required to build a successful program. This free course will help you define each role and corresponding responsibilities for team members at both the originating and distant sites. Roles defined include Medical Director, Outreach Coordinator, Technology Coordinator, Clinical Director, Program Manager, Business Manager and Telemedicine Presenter. Learning to distinguish roles and responsibilities will help your program development process go more smoothly. Also, check out the SCTRC team at The Rural Health Association of Tennessee’s Annual Conference November 16th-18th. For more info visit

California Telehealth Network (CTN), the State’s partnership for telehealth, announced it has received a USDA Rural Development Distance Learning and Telemedicine (DLT) grant award for $405,917. This grant will support the second phase of infrastructure enhancements to the CTN broadband network and videoconferencing service to ensure CTN can continue to provide state of the art service, speed and quality to partner healthcare providers. CTN also announced the selection of TeleConnect Therapies, a tele-mental health partnership serving rural health facilities throughout California, as a “Telemedicine Specialty Care Partner”. CALTRC continue to have award winning telehealth program development resources, visit their site to learn best practices, download their comprehensive program developer guide, browse their frequently updated California telehealth reimbursement guide and schedule an implementation workshop.

The Pacific Basin Telehealth Resource Center (PBTRC) sat down with Dr. David E. Roth, Clinical Director and Derek Vale, Health Systems Management Office Chief, of the Child and Adolescent Mental Health Division (CAMHD) of the State of Hawaii Department of Health (DOH). They talked about how The Child and Adolescent Mental Health Division is Utilizing Telehealth to Improve Behavioral Health Care. The video interview can be found at The Center for Connected Health Policy claims Hawaii’s new law makes their telehealth policies some of the most progressive in the nation. To view the new Act in its entirety, visit: http://www. PDF

Indiana’s first school-based telehealth clinic in Elwood started in September, 2016, under Indiana Rural Health Association (IRHA) and plans to establish clinics in six more school systems throughout the state over the next year. Upper Midwest Telehealth Resource Center (UMTRC) remains an integral partner providing technical assistance to Indiana Rural School Clinic Network (IRSCN). The network plans to expand the school-based telehealth clinic program to southern Indiana. The Southern Indiana Rural Health Clinic will cover Austin, Crothersville and Southwest Jefferson County Schools, beginning in January. UMTRC staff will be participating in the Indiana Rural Health Association’s annual Public Policy Forum in January. For more information regarding registration and agenda for the IRHA Policy Forum go to

contact: wendy ross

contact: kathy chorba


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contact: deborah birkmirepeters


contact: becky sanders


telescope Telemedicine briefs across the medical universe --featuring Geriatrics Pharmacy Home Care Pediatrics


Telemedicine Can Reduce Avoidable Transfers for the Elderly New digital health startups are beginning to reduce costly, unnecessary tranfers for patients at skilled nursing facilities. by jodi lyons

Reducing avoidable hospitalizations is a goal of the Centers for Medicare and Medicaid Services (CMS) and an integral part of improving the quality of care for people residing in long-term care (LTC) facilities. It also dovetails nicely into the Medicare Triple Aim: improving the experience of care, improving the health of populations, and reducing per capita costs of health care. Avoidable inpatient hospitalizations are

expensive, disruptive, and disorienting for many seniors and people with disabilities. According to CMS, LTC facility residents may be particularly vulnerable to the risks that accompany hospital stays and transitions between the two, including medication errors and hospital-acquired infections. Experts know that these transitions also exacerbate cognitive issues. CMS research on Medicare-Medicaid enrollees in LTC facilities found that approximately 45% of hospital admissions among individuals receiving either Medicare skilled nursing facility services or Medicaid nursing facility services could have been avoided, accounting for 314,000 potentially avoidable hospitalizations and $2.6 billion in Medicare expenditures in 2005. Telemedicine is a valuable tool in avoiding unnecessary hospitalizations – particularly in areas where care is geographically difficult to obtain or the patient is difficult to move. Three companies come to mind as thought leaders in addressing this challenge: Call9, Med1 Healthcare Group, and StationMD. See inset for more details on each. 4 Call9, Med1 and StationMD all have the goal of reducing unnecessary hospital admissions, particularly after regular business hours when reaching a doctor may be difficult. They also face similar challenges. First and foremost is the challenge of knowing if they *should* intervene. Knowing the resident/patient’s wishes is the first step. Has the person or his/her family complete a MOLST/POLST/POST form? Otherwise known as Medical Orders for Life Sustaining Treatment, Physician’s Orders for Life Sustaining Treatment, or Physician Orders for Scope of Treatment, these are medical orders that often mirror the end-of-life wishes identified in legal documents such as Advanced Directives, Living Wills, etc. People may choose to prohibit intubation, blood transfusions, transfer to the hospital, etc. The so-called “heroic” measures may not seem all that heroic to emergency room continued on page 10


Market Watch Three companies are leading the pack in reducing avoidable transfers through the use of telemedicine.

-------CALL9 Founded by emergency physician Tim Peck, Call9 is a telemedicine platform that brings top-line emergency care to nursing home patients. In addition to offering telemedicine video consults 24/7, Call9 imbeds a trained employee to assist at the skilled nursing facility, in order to help promote compassionate, value-based care. They also make sure to work within the patient’s wishes – particularly at the end of life.

MED1 HEALTHCARE GROUP Med1 is a telemedicine platform that features an “all-call” model including both emergencies and chronic care management. It has expanded into both LTC and senior living communities, offering services to independent living, assisted living, and Continuing Care Retirement Communities. Their doctors include emergency physicians, PCPs, and Cognition experts.

STATION MD StationMD is comprised of a group of New York City trained emergency physicians. Their secure video-conferencing system is augmented by diagnostic tools including an electronic stethoscope that transmits heart, breath and abdominal sounds to the doctor via the internet.




The PillPack machine creates easy-touse custom packages for medications, making adherence easier for people with complex multi-drug prescriptions.


The Future of Drug Delivery A host of new startups aim to bring medication to patients in smarter, more convenient ways. by nicholas genes, md, phd

Reducing Avoidable Transfers continued from page 9


hat part of telemedicine is often forgotten? The medicine. We’ve come to expect virtual visits with specialists far away, and are nearly living in a world where our apps and wearables aggregate and transmit health data, to inform medical decisions. But when it comes time to obtaining medications? We’re still dependent on a doctor’s prescription, a trip to the pharmacy, and a plain old bottle of pills. If the prescription doesn’t get filled, or the patient can’t follow the regimen, or has issues with the drug, well, hopefully they can have a prompt follow-up visit with the prescriber. A host of new startups aim bringing medication to patients in smarter, more convenient ways. They may be able to improve adherence, and simplify an especially shaky part of healthcare. Along the way, they aim to fulfill the promise of telemedicine. Here are some of the most distinctive companies in this field.

during regular business hours. Consider the following examples:

doctors, so it is vital that they know the patient’s definition before treatment begins. Most staff at LTC facilities are aware, but doctors need to be sure that they know, too. More information about MOLST/POLST/ POST can be found at the National POLST Paradigm: The second step is to fully understand if the “emergency” really is an emergency, an exacerbation of a chronic medical condition, one of the “usual suspects,” or an accident that wouldn’t be considered an emergency 10

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1. Mrs. Smith, who has moderate Alzheimer’s Disease, starts to become combative when the evening aide tries to get her into her pajamas and into bed. She becomes aggressive, shouts, and punches the aide in the face. Staff can’t calm her down. The care notes from the day state that she has been disoriented all day, didn’t eat lunch, and refused her favorite dessert. In short, she’s exhibiting BPSD (Behavioral and Psychological Symptoms of Dementia). There are many ways to approach this, including, as examples: non-pharmacological tools to de-escalate the

Avoidable inpatient hospitalizations are expensive, disruptive, and disorienting for many seniors and people with disabilities.


9 CAPSULE This New York City startup launched earlier this year, coinciding with the state’s e-prescribing mandate taking effect. The idea is simple – replace the corner pharmacy, with its inconsistent stock, inconvenient hours, and a public counter that’s not exactly conducive to private conversations about medications and side effects. With Capsule, doctors don’t have to browse a list of local pharmacies – they simply e-prescribe to Capsule’s massive warehouse, where every med and dosage is likely to be in stock. Capsule’s team fills the prescription and delivers it, for free, wherever a patient specifies – home or office, day or night. Patients can message or call the pharmacist with questions at any time, instead of just at the store. The company can afford free delivery and expanded hours because they’re saving so much on real estate, compared to typical pharmacies. It’s a model that’s attracted a lot of funding in a short time, including from Oscar co-founder Josh Kushner. You might say, in the telepharmacy startup space, Capsule combines the convenient delivery of prescription drugs that ZipDrug introduced last year, with app- or web-based on-demand availability of pharmacists popularized by RobinHealth and TelePharm. 9 PILLPACK Patients on complex, multi-drug regimens still must depend on a confusing array of difficult-to-use pill bottles. While vendors offer devices and apps to organize medications and remind users when to take them, these systems come with their own headaches, and still require a degree of discipline and tech-savviness that many patients lack. The result? Missed doses, switched meds, or accidental overdoses, and all their associated consequences. PillPack pre-sorts medications – including OTC meds – into a roll reminiscent of a tape dispenser. You receive a new roll by mail

problem and determine if there is a behavioral health problem; checking for urinary tract infections, dehydration or medication interactions; administering medication to calm the person down; calling the family members to have them try to calm the person down; or transporting the person to the Emergency Department. Different experts will choose different approaches. Therefore, some telemedicine companies use a network comprised of a variety of experts to get a consensus on treatment options. 2. Mr. Jones falls when he forgot to take his walker and went strolling down the hallway. He doesn’t appear to be injured and doesn’t appear to have hit his head. Is there


every two weeks (PRN meds are delivered in a separate, more traditional-looking bottle). Pull on the tape, peel off a packet labeled with the appropriate date and time, rip it open and take your meds. They also offer on-demand app messaging with a pharmacist; this access, plus frequent medication deliveries, are both free (they can afford these services, they say, because of revenue associated with increased adherence). PillPack has raised close to $100 million in funds, and is now operating in all 50 states. However, Walgreens and CVS have both acquired multi-drug dispensing systems in recent years and may be preparing to launch competing services. 9 SMART PILL BOTTLES AND DISPENSERS It’s certainly a clever idea: combine audio and/or visual reminders for patients to take their meds, with sensors to track adherence, and wireless technology to communicate that adherence to care team. AdhereTech’s approach is to cram all that tech into one cellularenabled device with a long battery, while Round Health distributes some functions to its smartphone companion app. uBox does a bit of both, with device lights that alert you to take a medication, an app for tracking and programming, but also adds a secure dispenser so patients can only take one pill at a time. Tracking medication adherence is a big deal – in high-risk patients across a variety of conditions, there’s probably no better marker of short-term healthcare utilization. These smart pill bottle companies – and others like them – are undoubtedly looking for partnerships with pharmacies, insurers, managed care organizations - or even the drug manufacturers. If they can bring the costs of their smart pill bottles down, or demonstrate to payers that the increased adherence is worth the price, we could see the day where “smart” pill bottles are the new norm, and people will wonder we ever left such a crucial aspect of care to some of the most vulnerable patients.

a need for X-Rays? Does he have to go to the hospital? 3. Mr. Smith falls getting into bed and has a small laceration on her scalp. The nurse isn’t sure if he needs stitches. Finally, the companies and facilities/ communities need to address the reasons for NOT calling 911. Does the facility/ community have a financial incentive to prevent unnecessary hospitalizations? Are the emergency responders getting aggravated by getting “too many” calls from the facility/ community? Do the facilities get deficiencies from their regulators/inspectors if they hospitalize too many people? Do the family members care if the person is hospitalized?

Who exactly defines “unnecessary” anyway? Does that definition change depending on the time of day and staffing? Telemedicine is an important tool, particularly as it relates to the geriatric and cognitively impaired population. Bringing care to the patient instead of bringing the patient to the care is an outstanding way to promote patient-centered care and eliminates many of the physical challenges of obtaining expert care (i.e., geography and mobility). The challenges are ensuring that the care is coordinated, that it reflects the wishes of the patient and his/her family, that it is the right care for the right person at the right time. The opportunities are endless!




[remote monitoring] OXITONE INTRODUCES CONTINUOUS PULSE OX MONITORING . . . MINUS THE FINGER PINCH In 2017 Oxitone will roll out a new tool for tracking and managing chronic conditions. The wrist-worn wearable (pictured) will collect continuous SpO2 and pulse rate readings and store the data in an accompanying app. According to Oxitone, the new wristband solves a problem inherent to today's SpO2 monitors – that cumbersome design means readings are only taken sporadically. The Oxitone 1000 – which can be worn while eating, exercising and sleeping – can track longitudinal SpO2 and pulse data and provide physicians with alerts about important patterns. A continuous, wireless pulse ox would have the added benefit of freeing up nursing time. Oxitone has anticipated this by setting up the video-based Oxitone Home Care Program. Rather than spending time traveling to a patient to check vitals, nurses can log in, view health trends, and spend time talking with the patient. –S.S.

What does Tome do? We’re a software company focusing on workplace wellness. We work closely with furniture companies to help fight the ‘sitting is the new smoking,’ idea by getting people to move at work with timely reminders built right into their computer.

[work well] DETROIT-BASED TOME HAS JOINED THE "WAR AGAINST SITTING" Interview with Massimo Baldini, president and cofounder of Tome by Sonya Swink


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How does it work? A sensor sits atop the user's desk, connected with the computer. It tracks when you're standing, and away from the desk, moving around getting your steps in.

doing that minute. Because Tome is integrated with your computer and your work station, its main focus is your work life, and leaves you alone on your off time. It can sense when you’re typing and only encourages you to move during your pauses in workflow.

How is your concept different than a wearable, like FitBit? We integrate our software into the workday, and that’s where it stays. Wearables like FitBit, are on your body 24/7, go home with you, and tell you to ‘get moving’ regardless of what you’re

What happens with all that data? Users get individual feedback about how often they stand and walk around during the workday, and encourages them to meet goals and stay active. There is also aggregated, anonymous data sent to the

corporate wellness leaders of the company, so they can monitor how employees progress. While there is no intrinsic way to share data directly with people’s primary care physicians, the data is accessible via an online portal, so they could theoretically pull it up in the doctor’s office, or just send the data to them. More important than the data, is the general idea that people are just moving more at work, and therefore fighting off chronic diseases that might arise from a sedentary lifestyle. -Jeremy Lacocque, DO




From blood draws to prescription drugs, new tech companies are pushing the boundaries for on-demand healthcare. by Sonya Swink

POOPMD DOES THE DIRTY WORK IN EARLY DETECTION OF PEDIATRIC LIVER DISEASE PoopMD is more than an app with a giggle-inducing name. Created by Douglas Mogul, MD, MPH, of Johns Hopkins and by HCB Health, PoopMD was developed to help parents understand if their baby’s stool is suggestive of biliary atresia (BA) or liver disease, which accounts for 50% of pediatric liver failure. Here's how it works: Concerned parents simply snap a photo of their child's full diaper and upload the image to the PoopMD app. The app's built-in algorithm analyzes the color of the stool and delivers a preliminary diagnosis to the parent. The parent can then email a pediatrician a copy of the photo and results. Results can be stored in the baby’s record for future reference. Early detection can help decrease the chance that liver disease will lead to a liver transplant. This is particularly valuable for this population, since children with BA look fairly healthy at birth and by the time the disease comes to the attention of a physician, a child’s fragile liver might be irreparable. While PoopMD has the ability to both raise quality care while reducing healthcare spending, usage is still in its early stage. There are currently only 1407 accounts registered with PoopMD, comprised of 1700 babies and a total of 2276 photos. –S.S.

Phlebotomy 30-40 percent of all scheduled blood draws will never take place, according to Dr. Shaiv Kapadia, the CMO and co-founder of Iggbo. With this app, a patient picks out a convenient appointment date, then a phlebotomist comes to their door to perform the blood draw and process the test. So far it's working – the app has a compliance rate of 98%. Iggbo contracts with 8,000 specimen collectors nationwide and 56 specialty labs.

Pharmacy Almost 20% of new prescriptions are never filled. Zipdrug allows a HIPAA-trained, background-checked and licensed messenger to bring a needed medication to the front door of any patient who orders on the app. The only thing more convenient than this might be Cleveland Clinic’s new "Bedside Pharmacy" program which brings the pharmacy right to the patient's bed. Cleveland Clinic now has a 100% prescription fulfillment rate.

House Calls Launched originally in New York City, Pager brings doctors to your door within two hours using a sleek on-demand smartphone app. Heal uses a similar on-demand house call model, but has focused on the West Coast. While some question the efficiency of having busy physicians travel around to individual homes, both Pager and Heal have growing user bases and funding from investors that are looking toward an app-guided health system.

[concussion care] CERORA "MINDREADER" COULD HELP PHYSICIANS ANALYZE HEAD TRAUMA The Center for Disease Control and Prevention (CDC) estimates that concussions, or mild traumatic brain injuries (mTBI), comprise about 90% of the 1.7 to 3.8 million traumatic brain injuries occurring each year in the United States. Cerora – based at Ben Franklin TechVentures – is on a mission to become the standard in brain health measurement. The Cerora Borealis headset biosensor and accompanying app work in unison to

analyze cognitive brain function. The data helps clinicians make informed decisions about concussion care. The product will launch in early 2017.




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teletech Practice-changing gadgets & gizmos


1 The only FDA-cleared consumer device that replicates a hospitalgrade 12 lead ECG 2 Connects with your smartphone or tablet through the Smartheart app 3 Test takes about 30 seconds

gear lab

Smartheart Smartheart, the latest product developed by SHL Telemedicine, is the "world's first mobile 12-lead ECG for personal use." Its slim, intuitive design means that smartheart could be deployed within any population where there is concern of repeated heart attack. At its core, Smartheart is trying to shorten the time between the onset of a heart attack and life-saving medical treatment. If a patient is at home and thinks they are experiencing heart attack symptoms, they can strap on the device and start the ECG. But perhaps the most important element of the smartheart comes next, with its propietary feedback service. Transmit your ECG from device to smartphone to your doctor or to smartheart's ECG service and get recommended guidance in seconds.

4 The smartheart feedback service gives you an action recommendation based on a four part scale. 5 ECGs can be securely accessed for review by a local emergency medical team and follow you to the hospital. 6 Electrodes get placed in your armpits and in your waistband, halfway between your belly button and your hip bone.

Photo by Colin Strohm




The Best in Tele-Presence Robotics


Of all the futuristic innovations that science fiction has brought us, none has had a more significant impact on our society than robots. Whether it’s a killing machine in the likeness of California’s 38th governor, or a white, inflatable “healthcare companion”, we are fascinated with robots’ potential for transforming society. Perhaps its no coincidence, then, that of all the technologies depicted in science fiction, robotics might be considered the least fantastical. Robots have made their way into practically every area of society. From the floors of expansive automobile factories to the reaches of outer space, they tirelessly help their human creators with tasks that are too dirty, dull, or dangerous. Naturally, robotics have found a perfect fit in healthcare. Though the ethical issues are still being debated, advancements in artificial intelligence are allowing robots to assist physicians in making better, more informed decisions without cognitive biases that could affect a diagnosis. Less controversial are robots that replace the surgeon’s hands and translate his movements in delicate procedures. Surgical robots such as Intuitive Surgical’s Da Vinci system can perform many difficult and complicated procedures that require extremely precise skill on the surgeon’s part. Unlike the surgeon, however, robots aren’t affected by factors like too little sleep or too much caffeine that can lead to shaky hands. Another kind of robot one might find assisting clinicians is a tele-presence robot. Fundamentally a mobile videoconferencing system, these robots allow doctors to work remotely with patients, allowing them to extend their range of care to a greater number of people. In turn, patients also benefit from lower costs and a greater quality of care. One study forecasts that the tele-presence robot market will grow from $825 million in 2015 to $7 billion as technology continues to advance and the number of applications both within and outside of healthcare increases. Here’s a look at some of the telemedicine robots you may already find roaming the halls of hospitals or even going home with patients. by scott jung


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By relying on live video feeds, these robots avoid the uncanny valley

Kubi We first met Kubi when it joined us in South Africa for our inaugural mHealth Toolbox. While not as sophisticated as other telemedicine robots, it's portable and easy to operate. Kubi, which is Japanese for “neck”, is essentially a motorized tablet mount. Its electronics allow it to pan horizontally up to 300 degrees and tilt vertically up to 90 degrees, and it can be placed on a table or screwed into a standard camera tripod, making it useful for both remote exams and consultation.


Simplicity and versatility is what we thought makes Kubi most useful for provider-patient interaction; not only can Kubi be placed virtually anywhere, but users can use their own tablet computer and interact with someone using just about any computer. Kubi integrates with multiple video conferencing apps, including HIPAAcompliant Zoom and Vidyo, and can also be used in a company’s own platform with Kubi’s API (application programing interface).

3 2 Double Double is a telepresence robot that seems to like attention. It has an eye-turning design, which some describe as an “iPad-on-a-stickon-a-Segway”. It’s caught the attention of the media as well, having made cameos on “The Colbert Report”, “NCIS”, and “The Good Wife”.

Vita InTouch Health is one of the pioneers of telehealth, and in many ways, it is still one of the most advanced. Its robot, Vita, was developed in partnership with iRobot, the company most well-known among consumers for its Roomba line of vacuum robots. Vita is based on iRobot’s “Ava” robot, runs on InTouch’s telemedicine platform, and aims to be as close to a real doctor as possible. Enhanced mobility and navigation features allow doctors to remotely move Vita anywhere; with just a single click, they can command Vita to autonomously travel to a target destination. Vita is even able to detect and avoid obstacles like IV lines and glass doors while moving toward its destination. While autonomous navigation is already impressive for a telemedicine robot, Vita takes its medical assistant role even further with the ability to integrate itself into a hospital’s EMR platform to display and modify live patient data. It is also equipped with the ability to connect with diagnostic devices such as otoscopes and ultrasounds, and comes with a built-in electronic stethoscope. While it still is not nearly the same as having a doctor available in person, Vita can be beneficial in critical situations where a timesensitive diagnosis must be made.

But more than just looks and fame, Double is a powerful and versatile robot for use in business and education environments. The Segway-like design allows for superior shock absorption, making video smooth and stable even if it encounters cords, bumps, and other floor obstacles one might find in a clinic. The optional camera kit provides a 150 degree field of view as well as a persistent view of the floor so you don't accidentally crash Double into something. And of course, it uses an iPad and can be controlled anywhere in the world through a web app. At the meeting of the American College of Emergency Physicians in October, we had an opportunity to try out Double. It was quick to set up and was an easy crowd favorite. conclusion

While politics and ethics might prevent us from seeing an R2-D2 in every home in the near future, healthcare robots are already helping doctors have a presence in every home. Patients are able to maintain their independence, but still have immediate access to a medical professional, no matter how far away. Medical schools can "bring in" the best teachers from all over world and allow them to literally look over students' shoulders as they do their rounds. And robots will only help doctors provide more excellent care to the patients who need them.




nice tat

Fashion Meets Health in New Data Tracking Tattoos A new breed of temporary tattoos offer wearable health tracking like we've never seen it before. They also have the ability to make a fashion statement and bring health tracking out of the shadows. by megan pfiffner

Did you ever think that gold feather temporary tattoo your daughter insisted on wearing to her first day back at school could somehow be more than an adolescent fashion statement? The latest craze in festival accessories could actually make its way into healthcare, thanks to a few new companies capitalizing on the trend. Hi-tech flash and peel-and-stick tattoos now offer a way to gather data from patients in a non invasive way, while allowing patients to express themselves through fashion. Temporary tattoos are in direct contact with your skin, so the data they track and collect has the potential to be more accurate than what you would get with a traditional wrist-worn wearable like a Fitbit. They can track basic health and body data or work in tandem with an ingestible health tracker. Companies like Chaotic Moon have developed tattoos that allow you to “send, receive, collect and store data” meaning they can upload everything they collect via bluetooth and send it directly to the patient’s doctor. DuoSkin tattoos, which were created in the MIT Media Lab in collaboration with Microsoft Research, have output display 18

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capabilities causing the tattoo to change color, alerting you to changes in temperature or emotion. Researchers at the University of California, San Diego, have tested tattoos that can gauge glucose levels in patients so they don’t have to use a finger prick test. Other health tracking tattoos can track heart rate, stress levels, hydration levels and even location. While the technology is in its infancy, the possibilities are easy to imagine. Health tracking temporary tattoos could allow a doctor to track when and where a patient was feeling stressed, having an allergy attack or a spike in heart rate based on solid data. The data would be collected over time for seemless trend tracking, transmitted via bluetooth to the patient's phone, where it would be available for sharing with healthcare providers. Time to get tatted up (in the name of science).


1. "Selfies and electronic tattoos the future of biometric data collection and authentication"

2. "Peel, Stick, Check: GlucoseSensing 'Tattoo' Could One Day Replace Finger-Prick Testing"

3. "This temporary tattoo can control your smartphone"

4. "Microsoft Research's metallic smart tattoo works as an NFC tag"

5. "Tech Tats: Tattoos that can track your health data"


beyond fitbits

The Next Generation Of Clinical-Grade Wearables Is Quietly Ushering In A Healthcare Revolution One in five Americans now owns an activity tracker such as a FitBit, AppleWatch or Nike Fuel Band, and the market is only expected to grow significantly. Yet few realize that the stunning success of these consumer devices is merely the first chapter in the wearable sensor story. by unity stoakes

The next generation of devices is going above and beyond today’s activity trackers. In addition to helping us meet our fitness goals, the next wave of sensor technology will help us tackle some of our most complex medical problems. As devices become smaller, more intelligent and precise, wearable sensors are poised to revolutionize health inside-out. In fact, this revolution is already taking place. Over the past 18 months we’ve witnessed an historic tipping point in the shift from consumer to medical-grade technology. Today’s wearable sensors are more accurate, more flexible and more reliable than ever before. They are so important to the future of health that the United States Food and Drug Administration, which regulates

medical devices, has signaled its desire to bring more of these devices to the market. Sensors that were once marketed exclusively as consumer fitness products are now finding a home in a wide variety of healthcare settings, from elderly care and at-home monitoring, to sensitive biometric analysis that will help bring new drugs to the market. Granted, we are still in an early-adopter phase of wearable sensors in healthcare, and many of these devices are still proving their worthiness in large, scientific studies. But the future is bright. Sensors are now ubiquitous in mobile phones, woven into clothing, and integrated into everyday appliances. Collectively, these devices are providing a trove of valuable data that are starting to empower patients to make better decisions and enabling care providers to offer more customized care. There are several practical benefits of next-generation sensing technology. First, remote monitoring is liberating healthy patients from the burden of unnecessary check ups or routine tests. Blood pressure, pulse, sleep patterns, smoking habits, and a wide range of biometric data can be measured and with the sensors packed into clothing and at-home applications. Companies like Babyscripts are using these tools to better monitor high-risk pregnancies virtually for example. We are already seeing, as devices gather more data, powerful software is helping to make predictions, providing patients and caregivers with alerts that could save patients from hospitalization or worse. Babyscripts’ early warning system has already helped doctors save at least two babies lives with early detection of larger issues. Second, wearables can help sick patients stay healthy. Today, a patient with a heart problem might undergo surgery and then be sent on his way. But with the ubiquity of wearable devices, he could also be given a sleek echocardiogram that monitors his heart activity for a continuous and accurate picture of his heart health. That data can


"...this revolution is already taking place. Over the past 18 months we’ve witnessed an historic tipping point in the shift from consumer to medical-grade technology."

help his cardiologist prescribe new therapies that will keep him healthier longer. Third, remote sensors are helping healthcare companies create a future where personalized medicine is possible. Patients participating in clinical trials can wear sensors that collect precise measurements on their well-being. This data can help drug companies decipher why some patients do better than others, an insight that can later help create a personalized treatment plan. Wearable sensors are not the latest fitness fad - they are here to stay. The business models in healthcare are changing, as patients and care providers are incentivised to consume less rather than spend more. Sensors will provide an opportunity for patients to be happier and healthier, all while spending less money and time on healthcare services. The wearables landscape is rapidly evolving from first gen FitBits to a new era of powerful smart sensors that will revolutionize health and wellness in the years ahead.




drone on

New FAA Regs Signal that Healthcare Drones Are On Their Way

Current FAA regs state that drones can't be operated outside of the operator's line of sight. But even that rule may be about to change.

The regulatory sea change could bring about a wave of innovative new uses for UAVs in the healthcare space. by michael levin-epstein Telehealth use of drones, already steadily on the rise, is expected to expand dramatically under new rules promulgated by the Federal Aviation Authority (FAA) in late August. The FAA’s regulations —the agency’s first comprehensive set of rules governing the commercial use of unmanned aircraft— is explained in a 500+ page guidance document that details specific requirements for drone airspace use, pilot training, and operator requirements. The new rules represent a sea of changes in the way non-hobbyist drones are regulated in the United States. Prior to these rules, commercial businesses that wanted to use drones to deliver consumer goods, survey constructions sites, repair utility lines —or transport life-saving drugs —had to apply

it's 5am in rural rwanda and a woman just went into labor...

06:00 The laboring mother starts severely hemorrhaging and is in urgent need of blood.

by David Oh


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for an exemption under Section 333 of the aviation statutes. These Section 333 exemptions were difficult to comply with and some types of operations were functionally almost legally impossible. Since September 2014, the FAA has granted thousands of exemptions for drones involved in certain industries — especially agriculture and entertainment — as well as telehealth. But the process was extremely cumbersome and time-consuming. Now, drone operators need to only complete a relatively simple application, and operate under less cumbersome restrictions than the Section 333 exemptions. Numerous industries, such as mining, surveying, insurance, real estate, law enforcement, security, and, especially consumer companies, from Amazon to Pizza Hut, are expected to take full advantage of the new opportunities. Indeed, the FAA already has approved

06:03 A nurse sends a text to Zipline, specifying the type of blood needed, and where it should be dropped.

06:10 The Zipline drone takes off from HQ using a slingshot-like launching device.

thousands of Part 107 remote pilot certificate applications in just two months. Telehealth use is expected to be a prime beneficiary for the new process, as hospitals, health care systems, and telehealth companies continue find both practical and creative ways to use drones for both emergency and more routine situations. “The creation of Part 107 lowers many barriers to entry for the health care industry to use drones for emergencies and everyday use,” asserts Jonathan Rupprecht, an aviation attorney and commercial pilot focusing on drone law. "Healthcare will not be any different than other industries being transformed by UAV technology. Solutions for search and rescue are obvious but other uses will develop that will help the elderly do tasks and maintain independence longer,” says Jeremy Tucker, DO, emergency physician, publisher of

Zipline can send blood up to 50 miles away at a speed of 60 miles/ hour and can carry 1.5 kg of blood.

Drones in Healthcare blog, and vice president of US Acute Care Solutions. In addition, Tucker tells Telemedicine Magazine, combining telemedicine with UAV technology will bring better healthcare to more people around the globe. “Even simple solutions like delivering a smart phone with a telehealth app and some monitoring sensors will be industrychanging," he explains. It is important to point out, however, that under the new rules, there are still plenty of important restrictions. For example, drone operators must keep their drones within their line of sight, and the drones cannot be flown over people, at night, or higher than 400 feet above the ground, unless they obtain waivers from the regulatory prohibitions on these types of operations. However, FAA Administrator Michael Huerta, a keynote speaker at the InterDrone conference in Las Vegas, told attendees just one week after the announcement of the August regulations that the agency already was working on rules that could permit drone flights beyond line of sight, which could possibly be out by the end of this year, and that it was also considering new regulations on drone flights over people. In addition, under the regulations that went into effect on August 29, drone operators are allowed to deploy an external load if it is securely attached and does not adversely affect the flight characteristics or controllability of the aircraft. And, in general, drone operators can also transport property for compensation or hire within

According to WHO, 330,000 women around the world die from preventable causes related to pregnancy and childbirth.

state boundaries provided the drone – including its attached systems, payload and cargo – weighs less than 55 pounds. Not surprising, the drone industry as an emerging new business, has skyrocketed in the last several months, as banking institutions and angel investors have been inundated by business plans and funding requests from start-ups firms. Those new organizations see multiple opportunities for drone expansion — ranging from security alarms to amphibious landings to reconstructing lethal automobile crashes. As far as telehealth is concerned, here are some recent uses of drones in the United States and abroad, where commercial drone use is often not as restrictive. Drones as Ambulances In the Netherlands, an engineering student at TU Felft designed a drone capable of flying at speeds up to 60 mph to assist patients suffering cardiac arrest. The drone’s payload includes an on-board camera and interactive voice capabilities enabling a remote health care specialist to communicate with people near the suspected cardiac arrest and to provide emergency instructions that could save the patient’s life. Drones Carrying Medical Kits Guided by GPS, the drone drops a modular medical kit that contains diagnostic and treatment equipment for the patient’s situation, such as dangerous fever. The FDA already has approved an ECG recording device that attaches to a smart phone, which has a built-in thermal camera that can take a patient’s temperature.

Drones for Remote Areas Working with drone manufacturer Vayu and supported by the Madagascar’s government and the U.S. Agency for International Development (USAID), the New York State University at Stony Brook’s Global Health Institute completed the first-ever long-rang, fully autonomous drone flights, in which stool and blood samples were collected in rural village in the African country and flown back to the university for testing. It could be extremely helpful if were able to send packages of medicine and vaccines over long distances, says Stan Brock, founder and president of Remote Area Medical (RAM), a nonprofit relief organization based in Tennessee that provides medical care to remote areas, has said. Matternet, a drone company based in Silicon Valley, is working with UNICEF have tested out a similar project in Malawi. Drones during Disasters Drone manufacturer Flirty completed the first ship-to-shore drone delivery in the country following a staged disaster in New Jersey. Flirty, working with the Johns Hopkins University’s School of Medicine and the nonprofit Field innovation Team, transported medical supplies and water to a mock relief camp at Cape May and at a test facility off the New Jersey coast. Clearly, using drones to conduct search and rescue operations will be part of the expanding use of drones in telehealth. And, of course, while drones are deployed routinely now as part of military operations, they could also be used to deliver needed medical supplies in war zones.

07:00 The drone drops off the blood by parachute within six feet of its destination and returns to Zipline Headquarters.

07:05 One hour after the emergency ensued, life-saving blood is available in the labor room.




Drones Delivering Vaccines The UPS Foundation, Zipline, and Gavi, the Vaccine Alliance, has begun transporting vaccines to rural areas in Rwanda to protect children from preventable diseases. The project is expected to last 18 months. The drones have the capability to complete about 150 deliveries a day. The cost today of airlifting a patient by helicopter to the nearest hospital in Rwanda: $10,000. Zipline recently announced it will start similar missions in the United States, which will also involve delivering blood supplies. Using unmanned vehicles to deliver vaccines in the developing world could make a dramatic impact on the spread of deadly disease, according to a recent study by the Johns Hopkins Bloomberg School of Public Health and the Pittsburgh Supercomputing center. “Many low- and middle-income countries are struggling to get lifesaving vaccines to people to keep them from getting sick or dying from preventable diseases,” says senior author Bruce Y. Lee, MD, MBA, an associate professor at the Bloomberg School and director of operations research at its International Vaccine Access Center. “You make all these vaccines but they’re of no value if we don’t get them to the people who need them. So there is an urgent need to find new, cost-effective ways to do this.” The research was supported by the Bill and Melinda Gates Foundation the agency for Healthcare Research and Quality, and the Eunice Kennedy Shriver National Institute of Child Health and Human Development. Looking to the Future *Suppose a patient in a remote area of the world has an undiagnosed cough. What if a drone could be deployed to secure a sputum sample that could be tested for tuberculosis and, if positive, then flown back to the site the next day with medication the patient needs. That’s the vision of Peter Small, the Founding Director of the Stony Brook Global Health Institute. About a bil22

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What if defibrillators could be accessed quickly through drone transport? RAM is working on just such a possibility in Greece.

lion people in the world live in very remote areas and could benefit from these drone capabilities, according to Small. *Defibrillators now are found at almost every airport in the world. But what if defibrillators could be accessed quickly through drone transport. RAM is working on just such a possibility in Greece. If you can get a drone with a person having a heart attack to a person having a heart attack, it doesn’t matter how you use if you get it to the patient quickly enough because it’s the time after event that’s really critical, according to cardiologists. “With cardiac arrest, access to early defibrillation is paramount. If you are outdoors, AED's may not readily be available. This AED drone solves that issue and will save lives," notes Tucker. *What about drone delivery within a hospital? Can we bypass pneumatic tubes and foot travel between health system facilities? Experts, like Will Stavanja founding of the North Carolina-based consulting firm Wilstair, thinks it’s a distinct possibility. “Small sized drones can be pre-programmed to travel via a dedicated safe space indoors, and enable them to travel between previously programmed position nodes in space, he told Telemedicine Magazine. “For hospitals considering to expand their infrastructure, the addition of pneumatic tubes

can be an expensive endeavor. Drones are a great substitute solution to mobilize small payloads across hallways, floors, and external buildings, “he added.” *Finally, what if drones could somehow help out our aging baby boomers? At the University of Illinois researchers are working on project involving small drones with arm manipulators that will be used to bring them medication and water or pick up something they dropped. The bottom line: “With the regulatory barriers to entry greatly reduced and the cost of technology steadily dropping, the only barrier to drones operating on a large scale is finding the right advisors to put all the technical and legal pieces of the puzzle together to have a working operation,” says drone attorney Rupprecht. “Drones are here to save time, money, and hopefully many lives.” Drones and telemedicine. Likely to be inextricably intertwined for years to come. "Drones paired telemedicine will create a powerful tool that can extend beyond our current boundaries of care. Reaching people where they are will improve our ability to deliver healthcare to more people," concludes Tucker.


television Industry-shaping ideas & perspectives

Tell us a bit about what Health Wildcatters is working on at the moment. What are you excited about right now? Hubert Zajicek: So, big picture, we’ve got with this class that’s going to graduate soon. We have 42 portfolio companies that have gone through the program. Obviously this class hasn’t raised any funding yet. The previous 32 companies have raised above $20 million now; so that’s been in less than three years. And they all started very early, as you can imagine.

Tell us about the start-ups within Health Wildcatters. lone star startups

Health Wildcatters Gives Health Tech Startups the Texas Treatment Health Wildcatters is a mentor-driven health tech incubator located in Dallas, Texas. Wildcatters takes on about 10 early stage companies each year, culminating each December in a pitch day before an audience of potential investors and collaborators. We recently caught up with Health Wildcatters founder Hubert Zajicek to learn about the incubator's current class, and why Dallas is a great place to launch a health tech company. Interview by Logan Plaster

Zajicek: We have companies in I think close to 20 states now and in two countries that have joined among those 42. So, this is not just a DFW or a North Texas group. The highest grouping is still healthcare IT or digital health. And the second largest group is medical devices. We have a couple that are more in the invasive side but the majority are noninvasive medical devices. And then we have an unclassified group that covers anything from tech-enabled services to healthcare consumer goods, even a pharma company.

Who is in your most recent class of startups? Zajicek: First there’s Oqulus, a company that combines retinal scans and a propietary algorithm to instantly identify a wide range of cardiovascular and cerebrovascular biomarkers associated with diabetes, hypertension, muscular dystrophy and stroke risk. The gentleman that runs Oqulus is the ex-director of research for Alcon and is a serial entrepreneur. He’s got partnerships with a variety of large entities that want to dig into their databases. Optologix is a research tool that could be sold to bench researchers that work in molecular biology. MediBrookr is like PriceLine for imaging centers. If you want to get an MRI


done, you just plug what you need into the app or website and they’ll get you pricing. With high deductible plans, people want to shop around, not just pay whatever comes in the mail. KnKt’d is a behavioral health platform. It enables a social worker or someone who manages many behavioral health patients to have a dashboard of today’s health. Basically it works with an app that the patients interact with and that helps you deduce how well they’re doing. It’s very important for that workforce, since they are overworked and need a way to triage patients. HealthNextGen is a software that would help you optimize treatment and predict outcomes of certain lesser-known diseases and how to manage them, especially when there isn’t a big patient base to predict. This is built on machine learning. HealPal is like a peer-to-peer cancer platform to match you with someone that has a similar cancer. Just because you have brain cancer doesn’t mean that it’s comparable to somebody else with “brain” cancer. There’s dozens of different kinds. So, it matters greatly who you get matched with and for them to be somewhat similar to you, so that our information matters to you. Friendly is like an asynchronous telemedicine platform that helps compress the doctors visit, gathering data before the physician encounter. The physician can view that data then decide whether he or she wants to go ahead and act on that information or wants to go live. Endogenesis is basically an optical system that can detect cancer in the gut while you’re doing a colonoscopy, without a biopsy. This technology also involves machine learning. Clinical Solutions is a marketplace for clinical trials. Let’s say you have some sort of obscure disease or a cancer. If you’re trying to get matched with a trial, it’s extremely difficult and opaque. Even if you go to the government website that lists everything, it’s very, very difficult to maneuver. Clinical Solutions allows these patients to input some information and





Hubert Zajicek speaks at a recent Health Wildcatters Pitch Day

then be matched with some clinical trials. Finally, Amity Cloud is an application that helps train healthcare professionals in home healthcare settings. Let’s say you run a home health agency. You have huge a turnover issue to deal with, and you need to verify that care is being delivered at the right time. Very basic things, like: Was my son fed today? If that person is a nonverbal person, you might not know. This gives them the tools, and the evidence to show that services were rendered.

How many applicants apply to Health Wildcatters each year? Zajicek: Typically about 15 to 20 to get to a single applicant. Generally about a five percent or so acceptance rate. We have gotten to the point where we qualify the applicants a little bit, in the sense that we discourage some that are too early. We have a health innovation hub here and we have some office space now, so we can give assistance and help to people who are thinking 24

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about a startup but where it wouldn’t be appropriate to join the incubator yet.

Taking a bird’s eye view of the more than 150 companies applying for the program, what are some of the trends you’re spotting? Zajicek: Last year we had half medical devices. This year we’re back stronger on the health IT side. Two of the big trends out there have to do with the high deductible plans and the ACOs driving patients and behavior by the hospitals into two different directions. When you look at MediBookr, which would be like PriceLine for imaging centers, that would be something that appeals to people with high deductible health plans. The other trend is that ACOs and the various attached entities are pushing entities like Friendly, which is the asynchronous telemedicine platform. Because of their inherent constraints, ACOs are inclined to abbreviate the patient visit

when it’s something that doesn’t need to be a live visit. That trend is supported by people’s lifestyle choices – that people don’t want to wait in waiting rooms or be on the phone. Oqulus fits squarely into the ACO and population health play. Oqulus is the one where they can take your retinal scans and run them through their software and tell you that you missed 20 people who have signs of diabetic retinopathy. Since an ACO owns your vertically integrated life and healthcare cost, they know that if you become blind, you’re going to be much more expensive. And of course your quality of life goes down. They’re incentivized to catch you earlier, which is where Oqulus comes in.

Given the amount of investment capital in Silicon Valley and New York City, Dallas is a somewhat atypical place for a health tech

incubator. What makes the city and region suited to the task? Zajicek: It’s an interesting geography. There are over seven million people in the metro area, and it’s rapidly growing. We’ve got over seven hospital groups that are competing here. And unlike other cities, they are not compartmentalized. They are encroaching on each other’s territory everywhere. Many residents can literally choose within a five mile radius between a top notch hospital or one of their secondary hospitals, depending on what they prefer. So these groups are all competing and growing, which means they have more resources available. Overall, Texas is fairly entrepreneurial. The laws in healthcare allow physician co-ownership of various entities. We have tort reform here and the economy is doing fairly well. Plus, I think the most independent set of physicians are here in Texas, and that drives quite a bit of ingenuity.

Do you compete with Silicon Valley for the best startups? If so, how do you make Dallas attractive? Zajicek: Most of the money is on the East or West Coast, obviously. Dallas can’t compete with that. But specifically in healthcare IT, we’ve got large corporations here. We’ve got quite a bit of activity, albeit it more the B2B healthcare IT end of things. We’re not so much about the glitzy consumer app in healthcare, but rather the doing end of things: dealing with large corporations, large populations, big data sets. A lot of stuff here has to be proven the hard way. The entrepreneur will be told: Okay, show me how it works for real, not just in theory. These startups have to pass a pretty high hurdle. Most of our investors are going to come from the region at first and only the next step, an A round or B round would they be able to attract resources from the big strategic VC firms.

Telemedicine: Ron, the last we spoke was when I interviewed you for our launch issue. How is HealthTap doing?

billion with a "B"

Next Up for HealthTap? Content in Context HealthTap chief Ron Gutman looks back over 5 billion medical answers served, and looks forward to a next gen digital health service that can finally put our queries in their proper context. interview by Logan Plaster

RON GUTMAN: We’re doing great, man. We’re growing. We’re expanding globally. We are landing some very big partnerships. It’s been a blast.

I understand that HealthTap has hit a huge benchmark in terms of patients served on the platform. GUTMAN: I still remember when we started putting the network together, we gave ourselves a target of 5,000 answeres served. That was our huge, pie-in-the-sky target. We said: Wow, if you can get doctors to answer 5,000 questions, we can have a meaningful library that will be attractive to people. And it’s kind of funny looking back because the benchmark we recently passed was literally million times bigger than what we aimed to do back then. And that was only five and a half years ago.

So HealthTap hit 5 billion answers provided by your physician network. What are some of the things that you’ve learned poring over that mountain of data? What are some of the big themes? GUTMAN: It’s fascinating. We recently built a large data science team here at HealthTap that’s doing a lot of data and analytics on our repository of doctor knowledge. First of all, we are learning what the most common things are that drive patients to a virtual care platform. We’re seeing clustering around the usual suspects – the complaints that people are slightly concerned about but which don’t justify the need to go to a doctor visit. Common cold, rashes, eye problems. And on the other hand, you have another




huge cluster that was more of a surprise – patients in search of personalized information. Let’s say you have a question about the potential implications of being diabetic and pregnant. You’re going to have a hard time if you just browse the internet. This concept of healthcare personalization has become very important to us. We went and started building algorithms that actually take into account things in the personal health record that influence the answers that you’re getting from us. If you ask what are the potential implications of diabetes and we know that you’re pregnant, we’re not going to show you answers that were given to a person who is 78-years-old with four co-morbidities and a male. That was a huge aha moment for us. The word that we are using internally is context. There is always context to a person’s complaint. So, how do you take content, which is onedimensional, and put it in context? We did a lot of research on doctor-patient interactions. We put in a lot of time with doctors themselves, sitting in the clinic and listening to the interaction. We try to simulate that using technology.

Are chat bots playing a strong role in this virtual care scenario? GUTMAN: It’s more than the Chat Bot. I think that the Chat Bot is kind of like a simple way of looking at these things. I think that you will find something really exciting coming from us very soon. I can’t talk about it yet but it will take this thing to the next level. Chat Bots are exemplifying an initial opportunity to take this technology and create an interface that simulates the doctor-patient interaction. But we think that there’s actually interfaces that are even better than that. In one second you need to figure out: What are the things that can be solved by technology alone? What are the things that can be solved by a combination of technology and machines? And how do we make our machines smarter all the time to be able to tackle the mundane simple things that 26

Issue 7



doctors do not want to tackle day in and day out; so they can concentrate on more interesting cases or they can concentrate on the places where humans have an advantage over the machine and leave the machine to do the things that there are just repetitive, mundane and simple.

Let’s return for a moment to the five billion visits. What other aha moments have you had while observing the data.

GUTMAN: The other thing that they gave us a lot of data is this whole notion of peer review. The concept is borrowed from academia, and we just thought it’d be a good idea to bring it to consumer health. We invented this idea of basically every answer on HealthTap, every tip, every piece of content basically is peer reviewed by other doctors that have the same expertise. First we discovered that doctors love doing it. It’s the most popular feature on the library. Second, it’s really enabled us to see where doctors gravitate on certain issues that don’t yet have very clear scientific evidence. A lot of things are opinions and starting to look at where doctors gravitate as a community is really interesting. The most famous example is the debate about vaccination and autism. On HealthTap, you will see a clear gravitation towards saying that there isn’t a correlation between the two. But there’s always one physician or two that say: Oh, we think there is. And then the beautiful thing about peer review is that the doctors will call each other out: Just show evidence. Share with me the peer review articles that support what you’re saying. From the peer review we created in the library itself the notion of RateRX. Doctors actually rate medications for efficacy in a structured way. For example, there is a lot of clustering around people asking questions about medications, particularly efficacy. It’s very hard for people to know how one drug stacks against the other when it comes to efficacy. The interesting thing is that when the


FDA does clinical trials, it’s always in the context of a drug versus a placebo. They never do comparative research. So people are saying: Okay, all of these drugs are approved but which one is the best for me? And there’s no reference materials for that. So we went and said: Wow, there’s a lot of energy around medications and efficacy. Why don’t we start structuring it? So we basically opened up an opportunity for doctors to rate drugs on a one to five star basis and add comments and peer review each other. And we opened up the results.

Talk to me about the side of HealthTap that allows physicians to provide telemedicine services directly. GUTMAN: This side of HealthTap is obviously cloud-based, connecting any mobile device and any web connection. At least until about six, seven months ago HealthTap was the only player in the market that actually had native apps for both doctors and patients. So we have a native app for telemedicine on Android, on Android tablet, on iPhone, on iPad, on the web. So a doctor can provide telemedicine consultation via video in a 3G connection on an Android phone from anywhere in the world, right. So that’s a unique capability for us. Remember, we’re a technology company and not a services company, right. So, we really perfected the ability to deliver and access care from any mobile device or web connection. The modality is very, very flexible; meaning that you can actually even within a particular communication, you can actually text chat or video chat. You can turn on and off text. You can turn on and off video. You can do voice. We do multiparticipant chats. So, you can actually have a translator calling in. We launched a translation service; so you can actually ask for a translator to join the call. You can invite a specialist. We have a cool feature that you can actually call even from a landline into a video call.

What does your fee structure

look like on the telemedicine side of the business? GUTMAN: Well, it depends. Some is paid by the user, by the consumers who have HealthTap Prime. Then we have HealthTap Compass, which is our enterprise product that we’re selling to large self-insured employers and Fortune 500 companies and insurance companies. We have HealthTap Concierge, which is a platform on the service that we are selling all the way from individual practitioners to clinics to big healthcare systems. And we have customers all the way from individual practitioners to actually a Health Board in New Zealand that is paid by the government. So, the entire gamut from an individual to a corporation manager that manages more than a million people.

A year and a half ago you were just launching this paid telemedicine service on HealthTap. How has usage been since the launch?

GUTMAN: It’s amazing. We have multimillion dollar businesses in each and every one of these verticals. We have thriving businesses right now on both the consumer side, the enterprise side and the clinical side. Prime, Concierge and Compass are all multimillion dollar businesses.

The telemedicine provider space is getting crowded. How do you distinguish yourselves?

more than just telemedicine.

You’re a big picture thinker. Unshackled from the details of where you are right this moment, what do you think that digital health will look like five years from now? GUTMAN: I think that the mission should be digitizing healthcare. So in the best of all worlds, people manage their health and well-being from their mobile device, from their computer, from their wearable. So, the other thing that I’m very keen on and you’ll see a lot coming out from us next on this thing is this whole notion of moving from reactive medicine to proactive medicine. My vision is that we are able to use our data in order to make medicine more proactive. There will be doctors standing by who start getting signals from you on an ongoing basis. They will be able to tell you if it’s time for you to come and talk with them because you are on a risk trajectory. I think that this is the Holy Grail, right? When people manage the entire continuum of health from a digital channel and they collect all the data from all these places in one place, we’re able to move from a reactive to a proactive mentality. So I think that this is where medicine is going too. And this is what we are pushing towards. And I’m super excited about it.

GUTMAN: We are not a telemedicine provider per se. Telemedicine is just one part of what we’re doing: We provide endto-end virtual care. Nobody else has the library. Nobody has the engagement tools that we have. Nobody has the health operating system, the analytics player, the personal health record. These are things that took like good six years to build. So, the value proposition that we’re providing to hospital systems, to insurance companies now, large self-insured employers is a lot


"...when you learn the skills that you need to get better in in-patient treatment, so many times it doesn’t last because there’s no continuum of care." Sam Frons, Founder of Addicaid


Issue 7




real apps for relapse

It all began when I built this meeting finder, just for AA meetings in New York City. And then that ballooned up to include alternatives to 12 Step meetings, like moderation management or smart recovery and harm reduction. That made it more than just a meeting finder into a full-fledged product and companion. And then the past few months we’ve been working on the provider-side and figuring out ways that we can help patient management. And so it’s not just for the client but for businesses as well, so we can scale the solution.

Kicking the Habit

How did your professional background prepare you to launch Addicaid?

Addicaid founder Sam Frons relied on personal experience with addiction to launch an award-winning app for addiction management.

FRONS: I was at IBM Watson just before Addicaid. Before that, I worked at McKinsey and did consulting for Bloomberg, Chipotle, and T-Mobile, among others. I was all about user-centric design. I was thinking, “How can I leverage all of the beautiful opportunities that mobile technology provides us, combined with the frictionless design that makes something engaging, enjoyable and rewarding?”

interview by Logan Plaster

TELEMEDICINE: While telemedicine is experiencing a boom in activity, there haven’t been many strides made in tele-addiction therapy. How did the idea for Addicaid come about? FRONS: I’ve experienced the problem of addiction on so many sides, as a child of someone in recovery and then struggling to come to terms with it myself—that I had a problem and then going into in-patient treatment, trying 12 Steps and going through different therapeutic approaches. And what I realized was that when you learn the skills that you need to get better in in-patient treatment, so many times it doesn’t last because there’s no continuum of care. The only thing they really told me to do initially was: Go to 12 Step meetings. And even that in itself was difficult.

How have people responded to the app? FRONS: In one of my favorite reviews on the App Store, someone said that Addicaid helps them make better decisions in a new and creative way and makes recovery engaging and—believe it or not—rewarding. And I thought to myself: “That is really what our mission is.” It made me so happy.

You stress the idea of “creative” recovery tools. What do you mean?

FRONS: We supply individuals with these different prompts and goals, inspired by different elements of cognitive behavioral therapy. People can write or audio-record their response to them. And Addicaid is also community driven. So rather than having this more structured personal recovery


journal, the treatment experience is crowdsourced, in a way. You can see the successes and struggles of other people in this great community of people in recovery; not just from drugs and alcohol but from process disorders as well, like watching porn or gambling. I want to validate a thesis I have that treatment will become more effective over time when we stop boxing people into these different categories of alcohol, opioids, porn, gambling.

It sounds like there’s a unique treatment philosophy at the heart of Addicaid. FRONS: The underlying philosophy is that we’re not treating people as having a flawed core belief system and focusing on the way that they cope with their urges and impulses. If we could take some lessons from Schema Therapy and figure out what this underlying issue is for these individuals and treat that accordingly, that’s much more effective. Because what happens so often with addiction is you just bounce from disorder to disorder. I’ve done drugs and alcohol, had issues with different process disorders, hoarding, overeating—all of these things. They go in succession, and that happens for so many people because there’s this complex network of co-occurring issues that they have. Cognitive behavioral therapy is the foundation of our approach. And then we mix and match elements of dialectical or motivational interviewing, community reinforcement, based on what clinicians have studied and validated. Specifically, it’s called Dual Focus Schema Therapy, which is using Schema Therapy to treat addiction disorders. But just like there’s been this huge burst of digital CBT, there hasn’t been digital DFST. I think that’s what we’re going to be moving toward: This paradigm where CBT is the bedrock of what digital therapeutics are. And then the therapy branches off into different elements for different individuals that addresses their exact needs rather than being these static programs.




That seems to be central to the unique approach Addicaid has. FRONS: Having a model that incorporates the latest findings but does it in an accessible, smart way—that collects a lot of valuable data and gives action-oriented insights—is something that’s really missing in this space. But we augment it by making it more intelligent for different disorder profiles. And it’s not just this funnel that is this two-way relationship between patient and provider. It’s extending the community, so you can have all of these resources and communication because that’s a big part of it: the network effect. And it needs to be promoted. For the next few months, we’re working on restructuring and advancing the structure of the way the program works. So every day you have this multiple choice assessment questionnaire that then gives you a generated prompt or goal that you follow along with a group of six or seven other individuals. That way you have the accountability and more personalized process on a daily basis. So while you have the community, it’s still tailored to your responses.

And who is that community? Who are those six people?

FRONS: Ultimately, what we will be doing is matching them up based on an assessment on what their coping mechanisms are and what their maladaptive schemas are. Are they dealing with subjugation or codependency issues or overcompensating or social anxiety? What are the issues behind the behavior? We address the curriculum more in that fashion. So people are tied together not by their vices or their method of acting out but the reasoning behind those behaviors. And that’s something very difficult to do, obviously. But we want to take a stab at it.

So you’re aiming to alter the way that addictions get 30

Issue 7



managed? FRONS: Exactly. And another element that I think is very important—that is overlooked a lot of times—is the family members. For a pilot we’re working on with Elements Behavioral Health, which has treatment centers all over the country, we’ll be introducing a family circle; you’ll have a way to share more than just simply a binary status, as in “Am I engaging in my recovery or not today?” You can share different posts or goals with friends or family members if you want. There is a level of autonomy in your recovery, but you can still share. For example, I entered recovery when I was 19 or 20, and having my mother ask me every day how therapy was, or if I drank today, was very daunting. To have some separation is really helpful. Our goal is to also educate friends and family members about the complications of being with somebody who has an addiction disorder. Over half of our member base of individuals struggling with addiction has an immediate family member who also struggles with addiction. There’s a lot of complications that come from having someone within your familial or friends circle who also has those disorders. And so understanding how to treat it and not just controlling your own impulses with substances but how to helpfully separate yourself is important, but is not getting as much attention as it deserves. Because one in four individuals has a family member who struggles with an addiction disorder. That’s 25 percent of our country.

That’s an enormous group. What has kept something like this from already having been created?

FRONS: With technology in general, implementing things in a way that is frictionless and easy to use is very difficult. Design, usability and standards have been changing. And medicine is so complicated and multifaceted that it’s hard to make a really usable, seamless app for delivering digital thera-

peutics versus one that allows you to order a car. It’s a very different product. Also, the community of people who value and care about these treatment methods hasn’t been sprouted enough from the design and technology realm. There’s more people now who are working from that space and that angle, rather than coming from the clinical side. And then there’s this continual question that hasn’t been answered: What is most effective for different types of people? It’s been very hard to personalize this kind of medicine.

How do you see your treatment approach juxtaposing with the 12 Step Program?

FRONS: It’s crazy to think that the 12 Step model has been around since about 1934. And not much has changed since with it. When you realize, “I have an addiction issue,” you’re going to go to a 12 Step meeting. That’s what people think of. In drug courts, they say: Go to meetings. And that’s another outlet we see for adoption: Helping case managers work with their clients, so they can be more accountable. The problem is that the 12 Step model hasn’t embraced innovation and change. They’re very traditional, and they go by this book of what they’ve said has worked. And I don’t like to discredit the 12 Step model; it works—but just for a very small amount of people, like between .5 and 5 percent. One gripe that I have with them, for example, is they say that medications shouldn’t be used to treat substance disorders. But nowadays with pharmacological treatment being so promising and so many people having addiction issues because they’re selfmedicating for an underlying mental health disorder, that needs to be revised based on the latest findings. And they’re hesitant to do that. They’re so tethered to certain belief systems that it becomes restrictive.

Companies in this telemedicine space are going to rush after where the pot of gold is. Yet


you’ve created a tool based on a true need that you saw and felt personally. FRONS: Exactly. And the pot of gold at the end sort of emerged in the past few years. When I started the company, everyone asked me: “Why aren’t you a nonprofit?” And I said: “Because nonprofits don’t scale very well, and it’s also a huge market.” I just wasn’t sure where the market was, and we’re a few years ahead of time.

What is the business model?

FRONS: It involves providers and payers. The way it would work is insurance companies would pay per member per month. And we’re thinking of down the line a shared savings model might be a very cool hybrid structure to introduce. And for treatment centers, it’s either a licensing or a [per receipt?] prescription model for their clinicians. The way that we envision it working—and we’re still refining it and doing customer immersions—is having them charge a flat fee of, say, $100 for each patient. So the treatment center would up their fees by $100, and their patient has ongoing access to this aftercare alumni relations platform. And then that way they cover their costs; it doesn’t cost the treatment centers anything over time. For the insurance companies who cover the treatment for a certain facility, then the

facility would be reimbursed for that. And the reason why insurance companies would want to cover it is because it reduces their exorbitant costs of treatment over time. They now have this system where people go into in-patient treatment multiple times. But by having a system that ensures that people reinforce the skills they learn inpatient and that strengthens this outpatient and aftercare system, they’ll reduce relapses and also costs associated with, for example, hepatitis treatment. That costs $70,000 each time. It works fine. But the problem is that there’s such high relapse rates among IV drug users.

Do you currently have any insurers onboard?

FRONS: We’ve had some talks with very large insurance companies. And so we know that these huge insurers are interested in our platform. Right now, they’re hard to sell to, and treatment centers are easier. Yet you only need one insurer. And by working with that company, first as a case study as a way to warm up to it, will be a huge milestone for us. Going to the provider first, then to the payer is a more accessible model, from our experience and seeing other companies in it.

So Addicaid doesn’t replace the meeting. I’m thinking

of the potential pushback if someone says: “No, addiction management can’t be handled over a phone. You need personto-person interaction.” FRONS: It facilitates that. If you want attending meetings to be a part of your treatment, we make it very easy.

How do you encourage positive behavior through the app? FRONS: We emphasize relapse management a lot and view successes not just in terms of your day count but how conscious you are of the consequences: your urges to use and your success handling that; your engagement with the community and with completing your goals, the content that you create through the app—not just how many days you’ve been sober. That’s one metric to measure your success in recovery. It’s not the only one. And by showing people that once you relapse, that doesn’t mean that you’re starting your recovery over. A relapse is a way to learn and understand: “Okay, how do I do better? How do I avoid this in the future?” A lot of people become discouraged because the 12 Step model is so black-and-white with it. We have a whole different set of values of what addiction recovery should be based on and the way it should be managed and handled.

On the clinician side, what does Addicaid offer?

FRONS: We have this system where you’re able to follow-up with patients—who we call “alumni”—and see: “Okay, here’s 20 clients of ours who have relapsed the past month and here’s another 50 that have been doing very well. How can we connect them better? Who should we follow-up with?” It’s an automated system, so the alumni outreach coordinators have a partial autopilot setting, and that way they can connect with the patients who need the most and also imcontinued on page 43


start - ups doctorpreneurs

‘Equity is gold dust,’ says Dr. Stephanie Eltz, co-founder of Doctify. q

embracing failure in medical entrepreneurship Entrepreneurial doctors in the United Kingdom met in November for the inaugural Doctorpreneurs Startup School. Here are a few key takeways from the event including tips on funding, building a great team and learning from failure. by Dr. Catherine Schuster Bruce & Dr. Vishaal Virani


raditionally the UK has lagged behind the United States in terms of digital disruption and startup innovations, partly due to the historically more risk averse British temperament. However, on a backdrop of global political uncertainty, under high ceilings and tall wooden beams, the inaugural Doctorpreneurs Startup School at St Thomas’ Hospital in London sought to redress the balance. It brought together entrepreneurial doctors and medical students in the UK seeking to disrupt the status quo, and set a more ambitious direction for the future of UK healthcare innovation. One suggestion as to why UK entrepreneurs have been relatively less successful in the startup scene is that we are less ambitious than our US counterparts, because we worry more about failing. Successful doctors-turned-entrepreneurs at the Doctorpreneurs event did indeed talk openly about failing. Though perhaps more importantly, they addressed the fear of failing. That intangible feeling that can constrain us, especially those who have limited experience of actual failure, and stop us in our tracks. Coupled with this internal fear is


Issue 7



the unwelcome external reality of funding difficulties in the UK, compared to the US, that perpetuates a culture of startup failure. Hussein Kanji, co-founder of Hoxton Ventures, in a recent BBC report stated that ‘It would still be hard for something like an Uber to be born out of the UK because I don’t think there’s a financing community that would give Uber the billions of dollars that it has consumed to get to the global stage’. BBC commented that the funding for startups in the UK is ‘appallingly bad’, hindering their expansion into global markets. Hard, but not impossible. To be sufficiently ambitious to create a so-called unicorn in the UK these fears of failure and funding difficulties need to be overcome, and the Doctorpreneurs event served to do just that. ‘Pivot is another word for failure’ joked Ragen Nagar, founder of MedicaliQ, ‘don’t be afraid of failure’. It seems the ability to conquer the fear of failing lies in a form of ‘cognitive reframing’, a psychological technique that enables a supposedly unfavourable situation to be viewed from a new perspective. It was noticeable how the speakers, when divulging the highs and lows of their entrepreneurial journey, did not ever ‘fail’. Instead, they ‘pivoted’; they changed direction and tried something new or slightly different. Success followed. Dr. Felix Jackson of medDigital ‘pivoted’ four times before his UK company started growing exponentially. ‘Pivot early or re-articulate’ advised Dr. Guy Gross during an afternoon workshop. At this event, failure was reframed to be positive, to be embraced, and integral to the overall entrepreneurial journey. Quite frankly, it was hard to ignore the infectious go-for-it attitude of the doctors-turned-entrepreneurs: ‘Live a full life and do the best you can. Let's do that and not worry about failure’ encouraged Dr. Owain Rhys Hughes, founder of UK integrated healthcare platform Cinapsis.

A few keys to success that emerged during the Doctorpreneurs Startup School held in London in November Don't Undervalue Passion Each doctorpreneur told of a unique experience but passion was the common thread that weaved together the success stories. The message was simple. Choose something you are passionate about, because it will be this passion that will fuel the fire when embers are burning low and you are about to pack it in. The same passion will ignite confidence from within to stand up for an idea in front of investors. Most crucially, passion cannot be replicated by anyone else, even if they have a similar idea. It is an inherent USP. ‘This [passion] is something you will need bucket loads of ’ proclaimed Na’eem Ahmed, Founder of Selfless. Passion does come with a price though, and you should not let investors undervalue this. ‘Believe in yourself and don’t give out freely what you are going to be working very hard at for the next five years […] equity is gold dust’, cautioned Dr Stephanie Eltz, cofounder of Doctify, a leading UK appointment-booking platform.

Recruit a Talented Team ‘Hiring the best people is like saying ‘do a good job’’ teased Julian Hamann, co-founder of Cupris. He has a point. Patronising as it may sound, the importance of a good team cannot be underestimated. ‘With a good team, you can adapt the idea to be successful’, highlighted Rajen Nagar, founder of DentaliQ. Recommendations on how to find your dream team included networking at events such as this Startup School, mining LinkedIn, and using Escape the City, the UK’s go-to website for those transitioning from a corporate to start-up career. ‘'Your network will be your biggest asset. Keep in touch. You don't know where in journey they may help you’ emphasised Dr Kartik Modha, founder of myHealthSpecialist.

Get Good at Story Telling ‘At any level, you are more likely to win funding if you can tell a story.’ This was a lesson taught by physician, physiologist and serial technology entrepreneur, Dr Jack Kriendler, and exemplified during the lunchtime pitching competition, won by Suvera duo Ivan Beckley and Will Gao. Go back to basics and tell a story, like you are sitting around a campfire. Everyone loves a good story. If you are relatable, engaging, can hold an audience, perhaps even make them laugh or even ‘add a bit of drama’, you will be hard to resist.

"Go back to basics and tell a story, like you are sitting around a campfire. Everyone loves a good story."

Medical training in the UK is increasingly supporting innovation and entrepreneurship, exemplified by the NHS Innovation Accelerator that started up in 2015 and the introduction of a flagship Future Medicine course led by renowned surgeon Shafi Ahmed at a London medical school next year. Alongside these formal programmes, the Doctorpreneurs community through this Startup School is inspiring UK doctors and medical students to embrace failure and ambitiously scale their healthcare start-ups. The status quo has been disrupted, and Silicon Valley had better watch out, there may be some UK healthcare unicorns on the horizon.

Doctorpreneurs, Unite! Doctorpreneurs is a global community for medical entrepreneurs based in the UK. Find interviews of doctorsturned-entrepreneurs, jobs in startups for doctors and medical students, as well as a regular podcast.


In Partnership With

start - ups funding report

the 2016 Q3 digital health funding report 2016 is shaping up to be yet another banner year for digital health funding. Here's our industry report, created in partnership with Rock Health. by mark shankar, md


his year is on pace to have nearly as robust a funding landscape as the prior two years, with close to $3.3 billion total venture funding already invested by Q3. This is in comparison to $4.3 billion and $4.5 billion in all four quarters of 2014 and 2015, respectively. One hundred seventy-six unique companies have closed 233 rounds of funding, an increase from the 219 rounds closed by Q3 2015. While the digital health financing space was anticipated to see a decline this year, it is now expected to closely match funding levels seen in previous years. Digital health funding in the first half of 2016 represented 8% of the total venture funding, a sign of healthy investor ecosystem. According to Rock Health’s 2016 yearto-date funding report, six categories of technologies represented 44% of all venture funding in the digital health space in the first three quarters of 2016: analytics/ big data ($309M), genomics and sequencing ($274M), wearables and biosensing ($263M), telemedicine ($231M), digital medical devices ($202M), and population health management ($190M). Of these dominant areas of investment, only two ranked on the top charts in 2015: wearables/biosensing and telemedicine. This represents a shift in funding from services such as payer administration and care coordination, with an increased focus on consumer-facing technologies. Additionally, 34

Issue 7



2016’s largest funding category, analytics/ big data, showcases industry excitement over the growing impact of data science and anticipated monetization of large-scale data sets. Thus far, the companies raising the largest rounds of venture funding are Human Longevity ($220M), Flatiron Health ($175M), Jawbone ($165M) and Healthline ($95M). While these companies have raised Series B, C, E, and growth rounds, Seed and Series A financing still account for nearly 60% of 2016 deal volume. 2016 has seen an influx of new investors in digital health, with almost 40% of the 248 distinct investors making their first and only investment in the space since 2011. Both venture funds and corporate funds have led the charge—these venture leaders include Khosla Ventures, Jump Capital, Norwest Venture Partners, Pritzker Group, Safeguard Scientifics, and Tribeca Venture Partners. Corporate funds prominent so far in 2016 are UPMC, Heritage Group, BlueCross BlueShield Venture Partners, Merck, and Sandbox Industries. While there has been an active push to fund digital health companies, a question commonly asked by investors and companies is - what about the exits? According to Rock Health’s 2016 Funding Midyear Review, 87 mergers and acquisitions occurred in the digital health space, accounting for $10.4 billion. This is less M&A activity than seen in 2014 and 2015, which saw 92 and 96 deals by the midyear mark, respectively. While slightly below activity levels for the last 2 years, there have been several large acquisitions this year including, Change Healthcare’s acquisition by McKesson for $3 billion, Truven Analytics’s acquisition by IBM for $2.8 billion, and eResearch Technology’s acquisition by Nordic Capital for $1.8 billion. Though M&A deals have been active, the market for digital health IPOs has been less robust, with only NantHealth issuing a public offering. This is in comparison to 2014 and 2015, which saw ten IPOs from

All Other Venture Funding

Digital health funding represented 8% of the total venture funding in the first half of 2016, a sign of a healthy investor ecosystem. --

Big Checks Who Raised the Most So Far? Human Longevity ($220M) Flatiron Health ($175M) Jawbone ($165M) --

Seed +A Seed Still Solid Seed and Series A financing account for nearly 60% of 2016 deal volume.

venture backed companies in the space. Publicly traded health tech stocks have performed below the S&P 500, with Bessemer Venture Partners’ Healthcare Index (an index of 33 publicly traded healthcare companies) down 17.2% since the start of 2016, compared to positive gains of 6.8% for the S&P 500. As 2016 draws to a close, investors have already begun to anticipate public offerings in 2017, with 23andMe, Health Catalyst, and Flatiron Health among some of the most heavily speculated to issue an IPO in the coming year. Data from Rock Health's Digital Health Funding Midyear Review, 2016 YTD Digital Health Funding 10 Things You Should Know, and Digital Health Funding 2015 Year in Review" by Ashlee Adams, Mitchell Mom, Mollie McDowell, Teresa Wang, Halle Tecco, Emily King, and Mara Perman.

start - ups post - mortem

whatever happened to happtique? With solid financial backing, Happtique stepped into the market to vet unregulated mHealth apps and sell that data to healthcare systems. What could go wrong? by rishi madhok, md


n 2010 the mHealth app market was growing at a fast and unchecked pace. As apps with bold medical claims began to flood app stores, there was an outcry for regulation and quality control. While many looked to the FDA for a solution, the slow moving bureaucratic giant would not be able to issue guidance until 2013. As often happens, the establishment’s inability to quickly adapt created a space for innovation. In the absence of the FDA’s guidance, the founders of Happtique seized a potential opportunity. Happtique launched as a spin-off from the Greater New York Hospital Association, and had financial backing from GNYHA Ventures. Happtique’s model was to create a rigorous certification program for mHealth apps that would represent a seal of quality and security to potential users. The company’s business model involved building a library of clinically-vetted apps, and then charge health systems for access so that providers could “prescribe” mHealth apps. Timing Happtique’s launch was well timed, however their certification process was not ready. And unfortunately, it would take three years to validate a certification process. So while the company was initially

covered with much fervor by health media outlets, much of the steam that could have propelled the company forward was lost due to their sluggish go-to-market process. When Happtique was ready to start certifying developers in 2013, their initial inertia was all but lost.

Who will succeed at mHealth app curation in Happtique's absence?

Pricing and Value First to market generally sets a precedent to pricing. App stores up until this point had minimal to no pricing barrier to entry. Happtique’s three-year lag to deliver on a product left them with no momentum and now an established, low barrier to entry, unregulated app marketplace had thrived in their absence. As a result, Happtique’s $3,000 certification for mHealth apps represented an obstacle to adoption and no long an opportunity for innovation. Normally, to justify such a high price point, companies can offer premium services that set them apart from the other “freemium” options. Happtique’s exclusive market place failed to deliver on such a premium experience. They didn’t attract any well-known apps or developers. Instead the marketplace offerings were sparse and lacked clinical relevance. Those that did pony up the $3K and passed certification were hacked and user information exposed. These successful attacks on Happtique’s certified apps rendered their certification process valueless and crippled the company’s revenue stream. In just two weeks after launching their long awaited app library, Happtique shut it down due to the attacks and embarrassing news.

1. The Hacking Medicine Institute

Silver Lining Perhaps the only silver lining to Happtique’s story is their acquisition by SocialWellth in December of 2014. Happtique’s story is a lesson in moving your product to market quickly. Announce your intentions too soon without a product and you will lose that initial inertia (this is why you hear of companies in “stealth”). If you keep your users waiting, they will be less

The Contenders

A non-profit created in a collaboration between MIT and Harvard that evaluates apps based more on consumer behavior than physician usage. 2. SocialWellth + HITLAB SocialWellth, which acquired Happtique in 2014, teamed up with Columbia University's HITLAB to put medical apps through "a set of science-based, industry-developed and reviewed criteria." 3. NODE Health Created out of the Sinai AppLab at Mount Sinai Hospital, NY, NODE purports to be an academic home for evidence in digital medicine.

forgiving of those early deployment mistakes and expect a more polished solution. Finally, pricing a product needs careful consideration as you develop it. Price too low and you will find yourself fighting an uphill battle to justify price increases later. Price it too high and risk lower traction. Either way, be wary of the existing markets that your product will be compared to. There is definitely a place for validated mHealth apps, yet the secret sauce is yet to be discovered to achieve the right mix of value, pricing, and adoption.


chat bots

Let's Chat about Chat Bots Thanks to machine learning and much-improved A.I., chat bots are poised to redefine virtual care. And it won't look like anything you've seen before. by rishi madhok, md illustration by nicolet schenck


et’s start with the basics. What is a chat bot? A chat bot is a service, powered by rules and sometimes artificial intelligence (AI), that you interact with via a chat interface (email, Facebook messenger, WhatsApp). Why is there so much interest in this 36

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space? 90% of our time on mobile devices is spent using email or messaging services. Companies like to build stuff for places where users spend their time. But how does it work? The concept of chat bots in not new. There are examples of using if-then statements in MS-DOS to facilitate process way back in the “early days.” If you don’t know what MS-DOS is the relevance of devices such as the Commodore 64 or phrases such as “you’ve got mail” or perhaps mentioning the Sony Walkman might be lost on you. Please take a minute to look those up, not for the sake of this article, but just for your own understanding. Back to chat bots. What is new about chat bots is the technology that helps run them. Hard rules were previously coded into bots or programs that need to be satisfied. Think about MovieFone in the 90s (again look it up if you are scratching your head). I would like to watch a movie today, but I need to find out times. I dial (800) 777FILM, and reach movie phone. “Press 1 for movies today, Press 2 for

movie times for tomorrow," the automated MovieFone tells me. I press number 1. "Movies for today: Press 1 for Top Gun showing times, Press 2 for Star Wars showing times, Press 3 for The Thing showing times.” I press number three, because obviously I'm seeing The Thing. Movie Phone: “The Thing is showing at 12PM, 2PM, 4PM, 6PM, 9PM, and 11:30PM. Thank you for calling MovieFhone. Press 1 to start over. I hang up, stoked for an 11:30 showing of my favorite film. The intent of the user (me) is to find out a movie time. The service of the “bot” is to provide me with movies, locations, and times to drive users to go see such movies. By choosing from the options listed by the movie phone bot, I am satisfying pre-programed rules. Jumping forward to today's chat bots, the theory is still the same. Chat bots are “agents” or services. They look to determine user “intents” or actions through messag-

ing. In order to provide users with specific information, the conversation has certain contextual requirements. In the example of movies, it still needs to know date, movie, time, and location. Here is how the Movie Phone example would work with a modern chat bot. I start in a Facebook message, selecting a MovieChatBot. "Hi, how can I help you?" says the bot. "I’d like to watch Top Gun this evening," I reply. "Where would you like to watch the movie?" says bot. "Within 5 miles of 94110" I reply. "Top Gun is showing at the Alamo Draft house at 5:30, AMC Van Ness 14 at 7:30PM or 9:30PM. Would you like me to book this for you?" "I’ll watch the 9:30 showing," I type, then return to aimlessly scrolling my Facebook feed. Here is what the chat bot sees, and why it was successful in guiding me towards my goal: Action: watch Object: movie Date: today Type: Top Gun Time: 9:30PM Location: AMC Van Ness 14 What’s happening here and in most chat bots is the concept of Natural Language Understanding (NLU) and Natural Language Processing (NLP). These technological developments allow users to type casually to a bot and the bot is able to identify and transform the text into actionable data. In order to do this, the developer needs to set the same basic rules they would have in the 90s (the above action, object, date, type, time, and location), but then sets other ways that the same data may be said or texted by the user. The chat bot looks to satisfy these rules and extract data off of what it is trained to see (passive learning) and eventually starts to learn all the ways we may ask for movie times on its own (active learning). This passive and active learning by the bot or machine is aptly named machine learning. As a fail safe, the developer may put a catch all clause for the bot to say

“I’m sorry I didn’t understand that” for those times our language doesn’t fit any of the chat bots known options. In those cases we have to try again. This is clearly an oversimplified explanation, but essentially this is how your chat bot thinks. NLP, NLU, and machine learning has allowed technology to move away from the rigid physics approach to computer science of if-then statements and towards a more organic process of evolving in sophistication through user interaction. The more people who interact with the bot, the more expansive and refined its vocabulary will become. How does this apply to healthcare? Lets take the mnemonic OPQRST used when taking a patient’s HPI. We as providers normally ask in some way or another the following about a patient’s chief complaint: O: Onset of event P: Provocation or palliation Q: Quality R: Region or location S: Severity T: Time Each of these components of the HPI can be programed into a chat bot to be extracted for a history. So when our patient messages: “I’ve had a headache for 3 days.” The bot will know the location and time. If so programed, it will inquire about the rest before moving on. Chat bots have a long way to go. Ordering a pizza or getting movie times is much easier and less risky than clinical interactions. But that doesn't mean there isn't great potential. Like a July intern, we are still trying to grow the young bot’s fund of knowledge. Furthermore we have yet to answer questions about accountability of bots and what limits should be placed on them. Will they be life long interns or eventually move toward unsupervised treatment recommendations and prescription? Maybe. Meanwhile, hopefully engineers and medical providers will participate in the responsible co-development of such technologies moving forward."

Top Bots A few companies are racing to define the health chat bot sector 1. Your.MD Your.MD is a London-based company that provides medical guidance through artificial intelligence. Their bot works on multiple platforms such as Skype, Facebook Messenger, KiK, Slack, and Telegram. You can check your symptoms, ask for information, or find help through their specialist services. 2. HealthJoy Founded in 2014, HealthJoy’s platform called “Joy” uses a virtual assistant to help users cut costs and navigate their insurance plans. Accessible through their app or website, Joy can assist in picking the most cost effective prescription or even negotiate medical bills. If you would like to connect to a physician, the human-powered concierge takes over to help. 3. Baidu China’s biggest search engine, Baidu, announced their bot named Melody to help ameliorate the heavy demands on the Chinese health system. A 1,000-person team came together to develop the AI which uses advanced deep learning and natural language process to interact with users. A person feeling sick can message the bot and through a series of questions the bot will suggest a diagnosis and a doctor with whom they can follow up.


launch plan

'Shiny Toy Syndrome'– Invest in Knowledge Before Technology We all know the gadgets and gizmos are cool. But if your institution is seriously considering a foray into telemedicine, take a step back, assess your needs and make a plan before investing in technology. by aneel irfan and heather zumpano


n a year of record amounts of monies granted for expansion of telemedicine programs across the country for distance education, rural areas and even to fight the opioid epidemic, what is being uncovered is the lack of not only knowledge about telemedicine in general but more importantly the basic principles of telemedicine program development. The truth is, there is a direct relationship between obtaining this knowledge and taking a planned approach to program development, and long-term success of a program. 38

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Many organizations begin their programs with investigating technology options. In many cases, decisionmakers contact a technology vendor and get what I call “shiny new toy” syndrome. They are fascinated by the capabilities of the digital scopes, cameras and robots, so they buy the tech before a plan for how the tools can maximize their operations and increase access to care is established. I can’t blame any one group for this. We all agree these emerging digital health apps, platforms, and peripherals with their mind-

blowing capabilities and the possibilities that come with them are truly amazing! However, this is a clear case of putting the cart before the horse and the leading reason why many telehealth programs are unsustainable. Unfortunately, by beginning with technology first, many organizations purchase equipment that’s more than what they need, or too intimidating for end users to want to learn. As a result, the expensive fancy equipment ends up sitting in a closet, collecting dust. No business case is developed, staff is unfamiliar with telehealth best practices, they don’t learn how the legislative/reimbursement landscape could affect their program, the community is not engaged, a clear model for the program is not defined and the readiness of the organization is not assessed. What’s the difference between dusty computers and a successful telehealth program? First, there is no substitute for adequate program planning. Healthcare leaders should conduct a thorough needs assessment and market analysis to develop a telemedicine business plan. Most programs start with a need, telemedicine is a gap filler.

Set SMART Goals for your telemedicine program ---Specific Measurable Achievable Relevant Time bound

Dive into your referral patterns and find the gaps that exist in clinical care. Those gaps become starting points for your program. Dig into your data. High mortality rates or staffing issues may be the beginning of an eICU program. A need for neurological expertise to administer tPA could suggest the need for a tele-stroke program. And most hospitals today wouldn't have to look too far into their psych boarding data to see a use for a tele-mental health program. A business plan and cost-benefit analysis are great ways to gain knowledge about how a telemedicine program will impact your organization, and the bottom line. Until you take the time to conduct a detailed analysis of the community, talk to physicians, and identify champions for the program, you can’t assume there is a genuine market demand for the service in any modality of medicine. Many organizations have learned the hard way, by building their program based on assumptions rather than facts. I’m sure you can guess, their endeavors became a big waste of money, time, and energy. It’s best practice to define SMART goals that align with your organization’s objectives. As an example, if your hospital

is getting a lot of financial penalties from Medicare for heart failure patient readmissions, then a great SMART goal may be to reduce heart failure readmission rates by 30% in one year with remote patient monitoring to follow-up with the patient post discharge.

Lessons in Telemedicine Accreditation

Start With a Pilot Program

You'd be forgiven for describing today's healthcare landscape as the Wild West of digital health. URAC entered that fray in order to provide independent telehealth accreditation and objective recognition of telemedicine quality. Here are a few lessons they learned about the marketplace along the way.

The American Telemedicine Association recommends after conducting the analyses, deciding on one modality of medicine and one site, to set up a pilot program before branching out to the entire health system. This is so you can make your mistakes and perfect the workflows in a small sector of your organization and then repeat a successful model throughout your organization. Last but not least, a supportive management team is critically important to the success of your telemedicine program. If the Administration and/or the Medical Board have program champions then they will establish a vision that is accompanied by resources dedicated to conducting thorough assessments and plans. If organizational leaders see the value of bringing telemedicine services to a community and influence widespread buy-in, then the chances for success in your program increase exponentially. Offer telehealth educational resources to your staff, bring a team together, break through tendencies of fragmentation – the trend of healthcare organizations working in silos. Bring together all your clinical, administrative and IT teams to work together. Developing a successful telemedicine program has to be a collaborative effort. Once these initial planning activities are completed, you'll have a clear understanding of needs and you'll be able to define a program model and have an understanding of the available financial, human IT resources. This knowledge should then spark the technology selection process. Taking these steps can avoid many future pitfalls and builds a foundation for your program’s success.

by deborah smith, mn, rn-bc


ealth systems, telehealth enterprises, and academic medical centers, are rapidly creating and deploying telehealth services, creating unique opportunities and challenges. Consistency of services, provider credentialing, HIPAA compliance, state-bystate regulatory compliance, and patient protection are just some of the issues being addressed by industry groups. In response to industry requests, URAC – under the guidance of a national stakeholder expert panel – created a first-of-its-kind independent telehealth accreditation program. The market-based desire for accreditation standards is reflected in the demand by providers for an objective recognition of the highest standards of telehealth performance, quality, and patient protection. Some are driven by competition in the market. All want to offer the best quality of care possible. In our work with industry stakeholders and early adopters of telehealth accredicontinued on page 43


in afghanistan, cautious optimism for a future of connected care by john tyler allen The war-torn nation is hardly out of the woods, but recent telehealth collaborations and an uptick in venture funding for digital health enterprises may suggest a brighter future.


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In 2009, Roshan – Afghanistan’s largest telecommunications provider – partnered with Cisco, the Afghan government, The Aga Khan University Hospital and the French Medical Institute for Children to create a telemedicine network that could bring remote specialty care to thousands of Afghan citizens. The program, the first of its kind, has so far added connections to hospitals in Faizabad province, Kandahar, Tajikistan, and Paris. A French Medical Institute for Children report said more than 19,000 had been performed and 25,000 people have been reached. While the technology for telemedicine has existed for decades, its recent progress in the war-torn Afghanistan is worth celebrating, and may suggest a brighter future for the troubled region. In 2002, Afghanistan’s Ministry of Communication and Information Technology found itself facing a level of decimation rivaled only by the rest of the country’s crumbling infrastructure. Telephone penetration, for example, had been reduced to .05% of the country found one study that paired the health needs of healthcare organizations in Kabul and Bamyan with each city’s readiness for a telemedical solution. Internet access had been banned entirely.



Most reports from aid organizations on Afghanistan’s healthcare, by necessity, and with a sorrow usually accompanying the news, point to the same dark period in the country’s past. In 1996, nearly twenty years into the war in Afghanistan, the Taliban took control of Kabul, the Afghan capital, and enforced their own repressive interpretation of Islamic law, beginning a six-year span of aggressive stagnation that ravaged the nation’s infrastructure. American-led forces arrived in 2002 and the Taliban melted into the White Mountains, but the country’s infrastructure had already been gutted. “Afghanistan's Ministry of Public Health inherited a devastated health system and some of the worst health statistics in the world,” said a 2014 report published in Global Public Health tracking the ministry’s efforts to rebuild. Three data points glared. “The maternal mortality ratio, estimated at 1600 per 100,000 live births, was the highest ever recorded,” the report said. “The infant and child mortality rates, 165 and 257 per 1000 live births, respectively, both ranked as the fourth highest in the world in 2002. And access to health services, defined as living within one hour walking of a health facility…was limited to less than 10% of the population.” Fourteen years later, Afghanistan remains among the least developed countries in the world. The World Health Organization and the Human Development Index rank the nation 171st out of 188 countries. For every 10,000 people in Afghanistan, there are only two physicians and five hospital beds. Compounding the issue, corruption, funding, and regional insecurity are preventing the Afghan Ministry of Public Works from maintaining road infrastructure, said a recent New York Times article. And a 2016 report from the Special Inspector General for Afghanistan Reconstruction said the country continues to be among the least electrified in the world. A 2015 study in International Health featuring a collection of statements from patients about their attempts to access healthcare reads like a vestige of those dark days. “The fighting doesn't stop when there are injured people,” said the 25-year-old male from Baghlan province in Afghanistan. “So we wait, and then they die… Even if you are able to move with your wounded you still have to get through roadblocks, checkpoints, questioning and harassment before you can reach the hospital.” The “National Optical Fiber Backbone,” a planned $64.5 million, 3,000-foot fiber optic cable that would trace a ring from Kabul to Kandahar to Heart to Mazar and back to Kabul, most of the country’s interior, began in 2006 and was expected to be completed in five years. In 2011, citing significant delays for the project, World Bank, the international financial giant aimed at ending global poverty, pledged $50 million to accelerate and expand the project. As of January 2016, 560 kilometers of cable have been installed, the average retail price of Internet has fallen from $450 in 2011 to $37, the number of users has grown to 3.5 million, and Internet access is now available to seven million. The success of Afghanistan’s recent technological developments seems to be inspiring something approaching optimism. A 2013 42

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Startup culture and entrepreneurship is also on the rise. “In recent years, the number of entrepreneurship support entities (venture capital funds, accelerators, and events) in [the Middle East and North Africa region] has increased nearly three-fold— from 183 in 2010 to 463 in 2015.” -Stanford Social Innovation Review report.

USAID report estimated that the communication and technology industry had seen investments from private companies north of $1.5 billion and had generated nearly $2 billion in revenue. Startup culture and entrepreneurship is also on the rise. “In recent years, the number of entrepreneurship support entities (venture capital funds, accelerators, and events) in [the Middle East and North Africa region] has increased nearly three-fold—from 183 in 2010 to 463 in 2015,” said a recent Stanford Social Innovation Review report. “And within this movement is MENA’s first generation of health entrepreneurs.” Openness to digital solutions is growing with the market, and startups are capitalizing on the movement to address the many shortcomings in the region’s health systems. Afghanistan is close behind. Taking the cue, the Ministry of Communication, in collaboration with World Bank, launched Ibtikaar, Afghanistan’s first startup incubator, in 2014. By May of 2016, Ibtikaar had graduated twenty-three startups from two classes. It’s no surprise that nineteen of them were providing information technology services – each, presumably, recognizing an increasingly interconnected communication market and a country with nothing but progress ahead.

lessons in accreditation


continued from page

tation, several themes arose related to common challenges seen in the marketplace. Here’s a brief snapshot of what URAC clients are seeing as they pursue accreditation.

Regulatory Variability

One of the biggest challenges faced by telehealth and telemedicine providers is the variability in state requirements. Some laws and regulations enable, and others prohibit, access to patient evaluation and treatment in a technology enabled environment. And the landscape keeps evolving, so balancing how and what you try to deliver to the populations you want to serve is a time consuming challenge. Inconsistency in state laws and regulations dampens access by those who need and want it. Regulators want to know if you’re improving access and convenience for consumers, in addition to protecting their safety. We’ve seen that third-party validation offers telehealth organizations a framework in which to continue innovating while meeting standards of accountability.

Prescribing Safety Concerns

Given concerns about patient safety, telehealth and telemedicine practitioners are sometimes criticized for some prescribing practices. Regulators worry about such things as consumer safety, potential harm from over-prescribing of antibiotics, and costs associated with inefficient or ineffective prescribing that results in duplicative care. Some states, such as Texas, require

sam frons on addicaid



a face-to-face pre-established providerpatient relationship as a condition of prescribing, setting up a barrier for direct to consumer practice models. Many who practice in a technology-enabled environment self-regulate and choose not to prescribe controlled substances as a matter of policy. Gathering sufficient patient information to support the desired standard of care and promoting coordination of care with primary care providers may be an answer to defining what a successful telehealth patient-provider relationship looks like. If you want to avoid surprises and unexpected turns during a patient’s course of therapy, focus on creating a solid clinical foundation for diagnosis and treatment.

Standard of Care

A principal value of telehealth and telemedicine practice is the access to care that the use of technology at a distance enables. Patients in rural America and underserved urban areas can be availed of quality health care services otherwise not open to them or located at a distance. Enhanced access includes the valuable involvement of specialists such as psychiatrists and other behavioral health practitioners in areas where such expertise is rare or nonexistent. Patients who are evaluated and receive treatment from a telehealth or telemedicine practitioner should expect the same standard of care as an in-person, face-to-face encounter. Sufficient history and clinical data are the foundation of high quality care. It’s

continued from page

critical that patients treated in an encounter mediated by technology receive the same education and information as communicated by top tier practitioners during in-person interactions. In addition to promoting and fostering coordination of care, top performing telehealth providers evaluate the quality of care they provide, and the patient’s experience. Patient satisfaction and the measurement of effectiveness will be key drivers of success as systems move forward.


Telehealth providers continue to bring new tools and devices to market that disrupt the traditional visit-based health care system while, at the same time, increasing timely access to needed services. Employers and payers – both commercial and government – are promoting the trend by gradually expanding coverage of telehealth services. Telehealth will continue to grow rapidly, and it may innovate in unexpected ways. We believe telehealth accreditation, conducted by independent, third parties, offers an important framework for differentiating the top tier organizations, even as the industry continues to progress. By focusing on effective business, legal and regulatory practices, as well as consumer protections, empowerment, and data measurement, independent accreditation will help diverse stakeholders identify high-performing telehealth providers who believe in and practice health care excellence.


prove outcomes over time.

What do you feel like right now is the killer app within the app? What’s the functionality that you’re most excited about?

that give you your daily prompt or suggestion, combined with the accountability of the peer group. I think it’s a way that hasn’t been explored before with digital CBT. And I’m really excited to see how it does in our first clinical pilot.

FRONS: Right now I’m really excited about the daily multiple choice assessments

How are you funding efforts faring?

FRONS: We are in the middle of raising a seed round. We have been self-funded and have grants of about $70,000 so far but are looking for a small seed round of $1.5 million.




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the list

The companies and brands mentioned in this issue.

teleSCOPE -----

PoopMD Page 13

Call9 Page 9

Zipdrug Page 13 AdhereTech Page 11

Med1 Healthcare Group Page 9 StationMD Page 9 Round Health Page 11 uBox Page 11 Tome Page 12 Cleveland Clinic Page 13 Cerora Page 13 Heal Page 13 Iggbo Page 13 Pager Page 13


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Capsule Page 11 PillPack Page 11 teleTECH ----SmartHeart

Remote Area Medical Page 21 Zipline Page 22

teleVISION ----Health Wildcatters Page 23 Addicaid Page 25 HealthTap Page 28

Page 15

Kubi Page 16 Double Page 17 InTouch Health Page 17 Chaotic Moon Page 18 DuoSkin Page 18 Babyscripts Page 19

Features ----Doctorpreneurs Page 32 Rock Health Page 34 The Hacking Medicine Institute Page 35 SocialWellth + HITLAB Page 35 NODE Health Page 35

Sponsors ----Teladoc Page 2 Zipnosis Page 14 National Fingerprint Inc. Page 44 NuPhysicia Page 44 Avera Health Page 45 JSA Healthcare Page 45 World Congress Page 46 SXSW Conference & Festivals Page 46 IMST Telehealth Resources Page 47 CirrusMD Page 47 URAC Page 52

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Alchemists for the New World Pharmacists once had a key role in healthcare – and they might again. by Nicholas Genes, MD, PhD


harmacists – known in various times and places as druggists, chemists, or apothecaries – used to have a closer relationship with patients. Throughout the 19th and early 20th century, pharmacists in the US and elsewhere not only synthesized medication, but diagnosed conditions and dispensed meds.

Their stores stocked a variety of goods and were frequented for many common needs. Thus, pharmacists often served as the first entry point into the healthcare system, for patients. As industrial manufacturing of pharmaceuticals brought down costs and improved quality and uniformity, the role of pharmacists changed. Instead of using a mortar and pestle to crush and grind medications, pharmacists increasingly focused on safely dispensing drugs. This process was hastened by an amendment to the FDA act in 1951, written by Durham and Humphrey (two trained pharmacists serving in the House and Senate, respectively). Before their amendment, pharmacists could dispense almost any medication, save for narcotics. Afterward, most drugs would require a doctor’s prescription – and the modern conventions of over-the-counter medications, or having a doctor phone in prescriptions and refills, was established. In the 21st century, the role of pharmacists has been expanding – in hospitals, in drugstores, and yes, even virtually – driven by a growing emphasis on safety, and concerns about medication reactions in an aging population with complicated regimens. Tele-pharmacy got its start in the US in 2001 in North Dakota, and now the rural areas in many states, as well as branches of the military, can rely on remote pharmacist consultation, as well as remote dispensing of medications. Studies say it’s safe and effective, and is getting a new generation of patients comfortable with what can literally be described as tele-medicine. Startups and innovative health systems are increasingly turning to pharmacists for solutions. And why not? They’re ideally positioned to explain the importance of each drug, to highlight alternatives, 50

Issue 7



and identify patients at risk. With new incentives for managing chronic disease, and keeping patients out of the hospital, measuring medication adherence has become a major focus. Novel business models that include free drug delivery, on-demand remote consultations, and adherence tracking are improving patient access to drugs while keeping costs down and ensuring the regimen is being followed. Clinical pharmacists working under special settings can make dosing adjustments in response to changing patient conditions or test results. Through e-prescribing, prescription drug monitoring databases, and the expanding capabilities of the Surescripts network, pharmacists are gaining the ability to create a digital snapshot of each patient – checking for errors, redundancies and risk. In short, pharmacists can coordinate care, make adjustments to care plans, and perhaps restore their position as the interface between the community and the healthcare system. That’s today’s cutting edge. Down the road, “precision medicine” is expected to play an increasing role in managing disease, with medications and doses tailored to each patient’s particular genotype. Pharmacists trained in the new methods of pharmacogenomics will be able to cut down on medication ineffectiveness and protracted periods of risky trial-and-error. The view of the primary care doctor as gatekeeper to medicine, so central to the model of US healthcare since the 1950s, may end up appearing as a historical aberration. Aided by on-demand virtual consultations, and a steady stream of data from EHRs, mHealth apps and wearables, genetic information, and medication adherence data, pharmacists could have much of the data and authorization they need to steer patients to better, safer outcomes, or direct them to the appropriate care. It’s easy to imagine a future where pharmacists again assume their position as a primary point of contact with patients. Nicholas Genes, MD, PhD is an emergency physician and clinical informaticist at Mount Sinai Health System in New York.


CareKit's first apps are out. Now what?

Smith Island: A study in rural connectivity

Unity Stoakes: The leapfrog effect

Connected health starts in the kitchen



Hub & Spoke Avera builds the ultimate telemedicine hub in South Dakota PAGE 36



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