MedAware's A.I. analyzes your Rx the way banks detect fraud
5 new health tech gadgets that could move the needle
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/VIRTUAL HOSPITALS /VIRTUAL PHYSICALS /VIRTUAL REALITY /REAL MEDICINE
Why the VA spells opportunity for the next wave of doctorpeneurs
Johns Hopkins hopes new med tech hub will boost local economy
SPRING 2017 ISSUE 8
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WWW.TELEMEDMAG.COM ISSUE 8 / SPRING 2017 Editor's Desk_4 Telehealth Regional News_6 ------telescope
Ophthalmology_9 Pharmacy_12 Prescription Errors_13 ------teletech
Tech Review: Best Health Tech of CES_15 Virtual Reality: VR trends to watch_19 ------television
Loper: Healthcare incentives that actually work_21
pThe Telemedicine Ripple Effect_Page 28 RocketHealth founder and emergency physician Jeremy Corbett wasn't satisfied helping one patient at a time. So he started a software company to aid in diabetes management.
Joshi/Hollander: The virtual physical is better than you think_22 Gordon: Telemedicine's next big tipping point_24 Plaster: Health innovation, the V.A. way_25 Bahagon: Why Israel has become a health tech incubator_26 ------start-ups On the Rise: RocketHealth and the med tech ripple effect_28 Incubators: Johns Hopkins introduces a new med tech hub, and Startup Health announces its 10 "Moonshot" goals_30 ------features
The hospital of the future has arrived_32 Telemedicine's greatest benefits may come through school-based programs_36 Remote care trend watch_38
p The Best of C.E.S._Page 15 Five consumer health gadgets poised to move the needle.
p OurCrowd and MedAware – just two of the Israeli health tech companies pushing the market.
------marketplace_40
---teleport
Rising to the fall challenge_42
13, 26 www.telemedmag.com
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editor’s desk
When the Virtual Becomes Reality
logan plaster
editor-in-chief logan@telemedmag.com
SAVE THE DATE for the Telemedicine Magazine Party Each year at the ATA convention, Telemedicine hosts a party to celebrate the year and connect with new colleagues. Come join us and a few hundred of our closest friends the evening of April 24, at The Tin Roof in Orlando, for music, drinks and a few surprises. RSVP to eliseo@telemedmag.com.
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A
fter only a couple of hours using Google’s new virtual reality program Tilt Brush, Tobias van Schneider felt like a god. "I’m so confident and fluid using these VR tools, they feel almost native," writes the designer in a post on Medium. "I scale my environment up and down, rotate objects and teleport around my own dream world . . . I can do anything I want!” Whether you’re painting with fire or immersing yourself in a fantasy world, advances in virtual reality force us to answer some interesting questions about the nature of reality. After all, writes Rebecca Searles in The Atlantic, “VR’s very purpose is to make it difficult to distinguish simulation from reality.” In this issue of Telemedicine Magazine, we set our focus on expressions of “virtual healthcare” ...Today's market across a range of specialties. But to understand virtual healthcare, we have to start by understand- tells a different story, ing what it isn't. One definition of virtual is “not one where "virtual physically existing as such but made by software healthcare" still to appear to do so.” This idea applies elegantly centers around one to the ethereal environments created by Tobias patient and one van Schneider within the Google Daydream, but provider, connecting feels problematic when used to describe the care a doctor renders to a patient. Is that "virtual" too? over a sacred, albeit After all, what is more physically "real" than life digital, space to share their real lives saving care, however it is delivered? This dichotomy is on display in our profile of for a few intimate Mercy Virtual Hospital on page 32. The state-of- moments. the-art facility is as futuristic as they come, and yet the name is misleading. At Mercy Virtual, the physical has not ceased to exist. The hospital itself, far from being a creation on a screen, is one of the most striking, creative healthcare facilities I've ever seen. The healthcare providers are flesh and blood doctors and nurses, not ones and zeroes. They show up for their shifts day in and day out, like you and me. And their patients? A mess of unique hopes and pain, struggles and passions. In other words, real life – viewed digitally. Brock Webberman, co-founder of Insight Optics, has blended the virtual with the concrete in a way that may also be a bellwether for the industry (read the interview on page 9). His startup took the idea of virtual eye exams and layered on a network of local physicians to gain the best of both worlds – fast, cheap, accessible tests followed by face-to-face followup for improved continuity of care. The realm of virtual reality has created an angst among some physicians about the future of virtual healthcare. What will happen to the doctor's touch in a world of augmented and mixed reality headsets, of bots and algorithms? But today's market tells a different story, one where "virtual healthcare" still centers around one patient and one provider connecting over a sacred – albeit digital – space to share their real lives for a few intimate moments. In the end, virtual healthcare won't make us like gods, or cause us to forget the world, but by increasing access to care, it just might elevate our humanity. As always, if you have a tip for a story that you think should be included in Telemedicine, my line is always open. Together, let's chart healthcare's virtual future.
telemedicine ISSUE 8 – SPRING 2017
EDITOR-IN-CHIEF
What future use for virtual reality most excites you?
Logan Plaster logan@telemedmag.com
Virtual reality memory condition treatment – giving those with conditions like Alzheimer's the ability to revisit their memories in a virtual environment.
EDITORIAL DIRECTOR
Bill Gordon bill@telemedmag.com EXECUTIVE EDITOR
Mark Plaster, MD
CONTRIBUTING EDITORS
Rishi Madhok, MD Aneel Irfan Unity Stoakes
VR will be game changing in medical education, immersive curricula taking simulation training to the next level.
EDITOR AT LARGE
Nicholas Genes, MD, PhD CONTRIBUTORS
Sonya Swink Virtual reality in education will take the museum home. Kids will walk alongside a guide and witness the building of underground railroad or discoveries in space.
Jeremy Lacocque Christy Wyskiel Justin Barad, MD Matthew Loper
Aditi Joshi, MD
VR looks promising for sedation. Early studies suggest patients require less pain medications and lower doses of sedatives when immersed in a VR environment during a painful procedure.
Judd Hollander, MD Scott Jung Chuck Green Brian Robertson
ILLUSTRATION
Leonard Peng (cover)
I am excited for the day when VR becomes standard in education. I'd love to have Professor Elon Musk as my teacher with the Dragon spacecraft as my classroom.
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
ADVERTISING REPRESENTATIVES
Eliseo Rivera eliseo@telemedmag.com Aneel Irfan aneel@telemedmag.com Telemedicine Magazine is published quarterly by M. L. Plaster Publishing Co., LLC. PO Box 121, Galesville, MD, 20765. Printed in the USA. Copyright ©2016. To purchase a subscription, go to www.telemedmag.com/subscribe
The authors, editor and publisher are not responsible for any errors or omissions or for consequences from application of the information in this publication, which remains the professional responsibility of the practitioner. No part of this publication may be reproduced in any format or content without written permission of the publisher. The appearance of advertising in Telemedicine does not constitute on the part of the Publisher a guarantee or endorsement of the quality or value of the advertised products and services or the claims made for them by their advertisers. www.telemedmag.com
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regional news
News from the Consortium of Telehealth Resource Centers
The TRCs have hit the ground running in 2017, with their event schedules about to ramp up, and large projects in several regions under way. There's never been a better time to partner with your local telehealth advocates. edited by aneel irfan
NORTHWEST
SOUTHEAST
SOUTHWEST
GREAT PLAINS
NRTRC's sixth 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. The event will feature national and internationally-renowned speakers on the subject of telehealth and virtual healthcare. Visit nrtrc.org to register today. Education is a primary part of NRTRC’s mission. To fulfill that need, NRTRC offers a number of different educational opportunities, ranging from our annual Regional Telehealth Conference to our monthly webinars (both regional and national) to telehealth toolkits to white papers. We offer educational materials tailored to all levels of telehealth participation, whether it be newly-forming networks or seasoned providers looking for more information on a specific topics
The Florida-mandated statewide telehealth surveys have been completed and final reports delivered for review by the appointed telehealth advisory council. The council will now deliberate monthly, with report of their recommendations due to the Governor, the President of the Senate, and the Speaker of the House of Representatives by October 31, 2017. For more information on the Florida Telehealth Advisory Council, past/future meetings, survey reports and overview of the House Bill 7087 that mandated this effort in Florida visit: www. ahca.myflorida.com/SCHS/ telehealth SETRC is gearing up for their 8th Annual Georgia Telehealth conference hosted by their affiliate organization The Georgia Partnership for Telehealth, March 22-24 at Jekyll Island Club Hotel. Early bird rates are open until February 27th, for more info visit http://www.gatelehealth.org
The 3rd Telemedicine and Telehealth Service Provider Showcase (SPS 2017) will be held October 2-3, 2017, at the Hyatt Regency Phoenix. Visit www.ttspsworld.com for up to date information. We anticipate 500 healthcare leaders and 40 vendors in the expo hall. SPS 2017 “Lightning Rounds” provide exhibitors with a concise, live, high-profile opportunity to describe their services and products to the SPS 2017 attendees. SPS 2017 attendees receive practical advice from nationally recognized telehealth experts on building successful programs; forming effective partnerships and negotiating legal, regulatory and payment hurdles. The SPS 2017 Call for Abstracts for poster presentations will open in mid-February 2017. We will start the second day of SPS 2017 meeting with poster presenters during breakfast in the plenary ballroom. Hope you will join us!
The gpTRAC annual Telehealth conference is the region's only conference focused on telehealth and virtual patient care. At this conference you will hear about creative applications and related services. You will also learn how telehealth can be instrumental in providing services to your patients and community. This year’s conference will be held April 3-4 in Bloomington, MN, with the theme of the summit being, "Telehealth: Bringing Virtual Care to the Consumer.” The meeting will feature nationally and internationally renowned speakers on telehealth and virtual healthcare. To register please visit: http://www.gptrac.org
contact: lloyd sirmons
kerps@telemedicine.arizona.edu
contact: bob wolverton bob@nrtrc.org
lloyd.sirmons@setrc.us
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contact: kristine erps
contact: zoi hills hills069@umm.edu
Share your latest news with Telemedicine Magazine email Aneel@telemedmag.com
TEXLA
NORTHEAST
MID-ATLANTIC
HEARTLAND
The 2017 'Rural Health at the Crossroads' Conference will be June 21– 23, 2017 at the Amarillo Civic Center in Amarillo. This year’s conference will focus on Managing Challenges and Disparities in Rural Health with telehealth as one of the strategies. TexLa TRC is taking Telemedicine 1.0 on the road across the region with one day workshops to provide a roadmap for starting or expanding a telemedicine program. In Louisiana, we will be in Baton Rouge on May 26, 2017; in Texas, El Paso on May 5, Austin on June 14, and Dallas on July 14, 2017. Frontiers in Telemedicine, a one-of-akind training program for clinicians, continues to enroll and has trained more than 150 clinicians. The program focuses on competencybased learning and features a combination of online content and hands-on simulated learning and awards 18 hours of CME or CNE.
Join our third annual Northeast Regional Telehealth Conference on May 23 and 24, 2017, in Amherst, MA. Stakeholders from across the Northeast and beyond will gather to learn about telehealth best practice and innovation, network with colleagues, and identify opportunities to advance their programs. Visit www. netrc.org/conference to learn more and register today! NETRC is working on a variety of projects focused on regional telehealth expansion, including a state-wide assessment of telehealth in MA and a project to expand the reach of autism caregiver training in RI. We are also redesigning our eight-state reimbursement guides. While we continue to see meaningful telehealth policy growth throughout the Northeast, both among private payers and Medicaid programs, stakeholders report that lack of consistent interpretation and implementation of parity laws remains a significant challenge to wide-spread telehealth adoption.
MATRC has begun accepting nominations for 1) the MATRC Telehealth Innovation Award and 2) the MATRC Telehealth Excellence in Service for Rural and/or Medically Underserved Populations Award. The Submission Deadline for both is midnight on Sunday, March 19, 2017. Visit our website beginning February 15 for more information and to submit an entry. www.matrc.org The Annual MATRC Regional Telehealth Summit is coming up April 2 – 4, 2017, at the Lansdowne Resort in Leesburg, VA. Register today. MATRC is also offering three half day Pre-Summit Workshops on Sunday April 2, 2017. These workshops are free of charge, but registration is required. Sessions include: Telehealth in Criminal Justice and Correctional Settings; Telehealth and the Opioid Epidemic: Protecting Safety and Promoting Health; and Telegenetics. Learn more at http://matrcsummit.org.
Missouri’s new governor, Eric Greitens, recently announced deep budget cuts that could negatively impact telemedicine at a state level. The Telehealth ROCKS (Rural Outreach for Children of Kansas) grant, now in its second year, seeks to improve treatment and assessment of children with developmental and behavioral health challenges in rural Southeastern Kansas. In September 2016, the project started accepting referrals. The schools or providers identify parents who are interested in services via telehealth and the parents are connected with the University of Kansas Center for Telehealth and Telemedicine (KUCTT) for assistance with the intake process and then linked with services. Telehealth ROCKS was recently awarded an extension grant for expanding telehealth services to schools. They will continue to expand services over the remaining two years of the grant.
contact: kathy wibberly
jgracy@kumc.edu
contact: andrew solomon
khw2k@hscmail.mcc.virginia.edu
contact: becky jones becky.jones@ttuhsc.edu
contact: janine gracy
asolomon@mcdph.org www.telemedmag.com
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Share your latest news with Telemedicine Magazine email Aneel@telemedmag.com
regional news
SOUTH CENTRAL
CALIFORNIA
PACIFIC BASIN
UPPER MIDWEST
The SCTRC along with the newly-formed Society for Education and the Advancement of Research in Connected Health (SEARCH) is hosting #SEARCH2017, a telehealth research symposium, at the Lansdowne Resort in Leesburg, Virginia, on April 4-5. The research symposium will showcase connected health efforts, strategies and partnerships, specifically those that focus on the research of telemedicine, telehealth, eHealth, mHealth and other healthcare technologies. Ateev Mehrotra, MD, MPH, associate professor of health care policy and medicine at Harvard Medical School and a hospitalist at Beth Israel Deaconess Medical Center, has been announced as a keynote speaker. The one and one-half day research symposium will immediately follow the MATRC2017 Telehealth Summit. To learn more about the research symposium, go to www. LearnTelehealth.org. Space is limited.
The California TRC, in partnership with the California Telehealth Network, presents the 5th Annual Telehealth Summit June 5-7, in Newport Beach, CA. The conference will focus on current telehealth applications, with California-based clinics and hospitals sharing secrets for building successful programs. The agenda will include legislative updates, ROI for telehealth in an accountable care environment, Federal and foundation funding opportunities, and the future of healthcare under the new presidential administration. We will explore innovative telehealth expansion work that’s underway with major Californiabased health plans as well as progress and results from the CPCA’s Alternative Payment pilot program. Over the past several years we have maintained an average of 325 attendees, and anticipate the 2017 event will reach if not exceed this level of participation.
contact: wendy ross
kchorba@caltelehealth.org
On December 15, 2016, the Pacific Basin Telehealth Resource Center (PBTRC) celebrated the opening of the Pohnpei Telemedicine Room in the Pohnpei Hospital. Introduced by Hawaii’s own Senator Brian Schatz (D-HI) as well as Senator Orrin Hatch (R-UT), the Expanding Capacity for Health Outcomes (ECHO) Act was signed into law by President Obama on December 14, 2016. This bipartisan bill aims to increase access to high quality healthcare and health education in rural or underserved areas. The Act requires that the Secretary of Health and Human Services examine whether technology-based projects such as Project ECHO have an impact on workforce development, access to healthcare, and the treatment of specific diseases such as chronic diseases and mental health and addiction issues. The Secretary will also report on any problems faced when adopting technology based learning models. Cost effectiveness will also be included in the report.
In Indiana, four new schoolbased telehealth sites have gone live in the last six months. The UMTRC provides a single point of contact for telehealth resources across Illinois, Indiana, Michigan, and Ohio through educational and outreach presentations, individualized technical assistance, facilitation, connection to local or distant providers, and archived resources via our website and staff. TeleHealth Solutions announced that it has signed a partnership agreement to provide consulting services to customers of the Upper Midwest Telehealth Resource Center (UMTRC). We invite you to join over 250 of your community health center counterparts as they gather for the OACHC Annual Conference. This three-day event will be held at the beautiful Hilton in Polaris, located in northern Columbus, Ohio. The annual conference features two plenary sessions, educational breakout sessions, forums, and valuable networking time.
contact: deborah birkmire-
contact: becky sanders
wross2@uams.edu
contact: kathy chorba
peters
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bsanders@indianarha.org
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opthalmology
telescope Telemedicine briefs across the medical universe --featuring Ophthalmology Pharmacy Medication Adherence
Startup Spotlight
Insight Optics As the number of aging Americans grows, so do the cases of "avoidable blindness." You might not be familiar with that term, but it is one that Insight Optics founder Brock Webberman (pictured) uses often to explain their new teleophthalmology company, which was launched out of the Health Wildcatters incubator in Dallas. We sat down with Webberman to get a better sense of how Insight Optics is tackling mobile eye care. –Logan Plaster
the team
Brock Webberman, CEO of Insight Optics, teamed up with co-founder Aaron Enten during their time attending Johns Hopkins.
the software
Insight Optics created a mobile telemedicine app for primary care providers to record and refer retinal exams to local specialists for review. An iPhone is attached to a handheld ophthalmoscope, allowing the app to record what a physician sees during a retinal exam. The app then presents the user with a list of ophthalmologists or optometrists readily available within a certain geographical area, who review the exam and send back a detailed report with findings.
the mission
"At Insight Optics, we’re in the business of preventing avoidable blindness," says Webberman. These are cases where if caught early enough through detection or screening, blindness can be prevented. Insight Optics found through their research that between 80 and 90 percent of all new blindness cases could be prevented or avoided if caught early enough.
photo by Jonathan Zizzo
the user
"There are 71 million patients with either a history of diabetes, unmanaged high blood pressure, or unmanaged high cholesterol who should be receiving some form of annual retinal eye exam to look out for a number of complications or symptoms that may lead to blindness. Out of those 71 million people, only 50 percent actually follow up and receive that annual retinal exam. We’re trying to capture that 50 percent that may or may not know that they need to get an exam done every year. Maybe they don’t have an optometrist or ophthalmologist readily available in their area to perform the exam or maybe it’s too [costly] both in time or money to go and get an exam done."
the provider network
Rather than stop at app development, Webberman and his team took the next step and built a provider network of primary care doctors who would use the software, and of ophthalmologists and optometrists who would do the readings. “It’s essentially a lead generation tool for [eye care specialists]. Because if they do test a patient with a certain disease, they have the right to then follow up with that patient. Building the telemedicine network is a very stepwise process, almost a Catch 22. www.telemedmag.com
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If you sign up a group of primary care providers and don’t have anybody reading tests, that’s obviously an issue. And then it’s hard to bring on certain ophthalmologists if there aren’t any exams coming in to read. We believe that’s a critical gap.”
the hardware
Insight Optics is only a software company, but it was developed to work with any of the smartphone ophthalmoscopes currently on the market. They have worked with the Welch Allyn PanOptic and their iExaminer adapter, and have considered D-Eye and Volk. "We’ve gone through six or seven hardware devices to make sure that our software works with all of them.”
the future of telemedicine is local
For Webberman, one of Insight 10
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Optics key differentiators is its focus on local providers. “A lot of telemedicine plays that we see even outside of ophthalmology utilize dedicated screening centers; where they’re hiring physicians full-time to essentially sit behind a monitor and read these exams. What we’re trying to do is actively bring on physicians in the area who will not just read the exam but then actually follow up with that patient. We think that’s kind of a gap, at least in ophthalmology. We could easily get somebody to simply read these exams, but if we detect something, that patient is still going to get lost at some point in the process. We’ve found that we can actually increase patient compliance by providing them access to the same ophthalmologist or optometrist that reviewed their case in the first place. That kind of goes
against a lot of things that we think about when we think of telemedicine. So we think that it may actually be the one thing needed to truly get a lot of people’s minds wrapped around the idea."
growth strategy
Because of its founders' roots, Insight Optics is testing its theories in Dallas and Atlanta. And they are taking their time, growing organically. "We’re looking to first bring on one or two key opinion leaders in ophthalmology to be ready to accept exams. Then we actually go out and look for smaller ACOs, bringing on batches of primary care providers at a time; so that we can train them together, monitor them together, bring on their patients together. And we’ve found that that’s been a successful process for us so far.”
80% 71M
approximate percent of new blindness cases that could be prevented if caught early enough
number of patients with a history of diabetes, unmanaged high blood pressure or unmanaged high cholesterol who should be receiving some form of annual retinal eye exam
50% Of the 71 million above who should be receiving regular eye exams, only half are doing so.
tele
business model
Webberman spent three months at Health Wildcatters building a business plan, raising a small seed round and then working with a great group of developers in Austin to build out the app. Exactly how insurance companies will reimburse Insight Optics for its services will vary from patient to patient. "We actually just did a reimbursement test here in Dallas. We took eight diabetic patients with different insurance providers and sent out the codes for each of them. We’re now starting to get results back and so far we’re four for four for getting reimbursements for our exam procedures and getting ready to bring on our first paying customers." Insight Optics charges primary care providers an upfront installation and maintenance fee, which comes with a Welch Allyn PanOptic and an iPhone device. Then there is a monthly subscription fee to be a part of the network. There is no limit to how many exams can be conducted or how much data can be stored. The system is currently free for eye care specialists who receive the tests and offer their services. "We’re still proving out the model of how many we could actually be bringing in terms of lead generation."
starting in dallas
While health tech investment money is concentrated on the coasts, Webberman has found that Texas offers a uniquely advantageous environment for starting a telemedicine company. "I could drive 30 minutes
and go to a city or a town that doesn’t have a dedicated ophthalmologist or optometrist, or only has one of these specialists. Having the ability to go out into more rural areas and find areas where telemedicine does prosper better, where the advantages of telemedicine are much stronger in these smaller communities; I think that has actually been an advantage to us. In New York City you could likely find an optometrist or ophthalmologist every couple blocks. Here we get to work and meet with our physicians and provide them a service that they’ve really been looking for over these past few years.
next steps
"Right now we feel really confident in this unique business model that I don’t think we've seen very much in telemedicine. And I think once we can prove that out, we may be able to expand into building or acquiring our own global ophthalmoscope devices or to go partner with a group that does that. Alternatively, we could expand into ideas outside of ophthalmology and apply our business model to dermatology or ENT. It wouldn’t be difficult for us to transition into those spaces now that agencies and insurance providers and state laws are starting to wrap their heads around the idea of telemedicine. It opens up a world of opportunities for us as we move forward.
ophthalmology
Market Watch Three companies to keep an eye on within the teleophthalmology / tele-optometry space.
–Sonya Swink
D-EYE The D-EYE attachment turns a smartphone into a portable fundus camera. The small device attaches itself to the outward-facing camera and can screen for noticeable eye diseases while capturing information for further medical analysis. It sends pictures to the user and medical providers to determine the need for tests. www.d-eyecare.com
PEEK VISION Peek Vision has a set of apps that can be used to test acuity, contrast, color and visual fields. Their technology requires one person to hold the iPhone at a distance while the other takes a basic eye test. They also have a clip-on retinal scanner to test more thoroughly for specific issues, like color blindness. www.peekvision.org
SMART VISION LABS Smart Vision Labs (pictured) makes getting an eye test as simple as getting a bagel. Just answer a few questions and have a short eye exam done on a Smart Vision device. The small machine utilizes an FDA Registered red wave technology. An ophthalmologist reviews the exam and emails a prescription within 24 hours. www.smartvisionlabs.com
www.telemedmag.com
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Company Spotlight
Market Watch
AdhereTech AdhereTech wants to solve the problem of medication adherence through a connected pill bottle that tracks whether a patient has taken their medications. The pill bottles use cellular technology and sensors to remind patients if they miss a dose through an automated phone call or text message. The bottle can then send real-time data on medication adherence anywhere in the world. We sat down with AdhereTech co-founder Josh Stein to learn more. –Sonya Swink
how it works
"There’s a number of sensors on the bottle, especially the cap. When a patient opens, or does not open, the bottle at the recommended time, the AdhereTech bottle (cap senses and) automatically records that data and sends it to a cell tower. The bottle sends streams of data automatically to our company, the patient and the provider. If a dose is missed, the patient automatically gets an automated phone call or text message, whichever is easiest for them, reminding them to take their medication. The bottle can also light up or chime when a dose is missed. If a pattern becomes an issue, AdhereTech sends an automated question and info message. For example, an immediate real-time phone call will ask the patient to “press one” if they are experiencing ill symptoms from taking the medication, and so on."
ideal use case
AdhereTech is one product in a growing market aimed at improving medication adherence. Here are a few other players to watch.
70 2 20 average age of an adheretech user
number of charges required per year
percent increase in adherence when patients use device
"Our specialty is in making bottles for oncology, Hep C and other more serious illnesses requiring calculated dosage and adherence. The average age of a patient using the bottle is 70."
business model
next steps
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MEDISAFE Medisafe is an app and pill bottle solution for those keeping track of multiple medications. The user can sign up to have reminders, health alerts and a medisafe buddy system where a friend gets reminders of when the user needs medication. www.medisafe.com
MOSIO Mosio has a simple-but-effective product: text message reminders. Healthcare providers use a simple automated “yes or no” text reminder system to ask patients about medication adherence, appointment times and more. www.mosio.com
PROTEUS
"The patient never pays to use the bottle. We partner with over 60 in-hospital and mail-order pharmacies. The pharmacies are our customers, officially. Providers help partner with patients that might benefit from our service." "Our product is analytics based. We aim to improve the hardware of the bottle each year but our data is improving twenty-four seven. We consider ourselves a data and analytics company for patients. One of the biggest problems in healthcare today is how to make tech easy for people. Tech obviously bleeds into people’s lives, so it only makes sense healthcare would too. We have more info now in a smartphone in our pockets than Bill Clinton had when he was president. We really want to connect the patient with seamless tech to improve their care."
---
founders
Josh Stein (pictured giving a Ted Talk) handles the business, side, John Langhauser runs software, data and backend. Mike Morena leads hardware and regulatory elements.
The Proteus smart pill takes adherence to a new level. An ingestible sensor inside the pill is activated upon hitting the stomach and transmits a signal to a patch worn on the patient’s arm. The signal and accompanying information is sent to the patient’s smartphone. Then the healthcare provider can view when the medication was taken, as well as the patient’s activity and resting state. www.proteus.com
tele
pharmacy
Traditional EMRs flag 20-30% of medications with up to 90% false positives, while MedAware only flags about 0.2 to 0.5% with only 35% false negatives.
Rx spell check
Israeli Start-Up Introduces Artificial Intelligence To Reduce Prescribing Errors Soon to come to the US, this software can catch deadly mistakes other EMRs would never notice. by jeremy lacocque, do What if your EMR detected medication errors in the same way that your credit card company detected fraud? We spoke with Gidi Stein, MD, PhD, founder of MedAware, an Israel-based company fighting inpatient medication orders and prescription errors in a new way. It all started one day when a nine-year-old boy with asthma fell off of his bike. He ended up dying from an intracranial hemorrhage. Just a week before, his PCP had mistakenly placed him on warfarin, instead of singulair by clicking the wrong entry on a prescription drop-down list. It wasn’t bad judgement on the part of the physician, Dr. Stein argued, but rather a slip-up, a mix-up. “It’s like killing someone with a typo,” he explained. Mistakes like the one potentiating the young boy’s intracranial hemorrhage motivated Dr. Stein to start MedAware, a system adding artificial intelligence to EMRs that goes beyond just the basic interactions between medications and allergies. The software ana-
lyzes the order much like a credit card company would detect fraud. It uses a mathematical model that describes which patients are likely or unlikely to be prescribed for that specific drug at that specific place and time, much like a bank would identify purchases not typical for a certain time, place or person as potential fraud. Put in an order to do a pregnancy test on an 80-yearold man? Give mannitol to a 12-year-old with a URI? If they’re not allergic to it, most EMRs would let the order through. MedAware’s ability to learn a physician's behavior and application of mathematical algorithms takes fact checking a step further, reducing false positives and increasing true positives. According to their research, most EMRs flag 20-30% of prescriptions and have up to 90% false positives for suspected interactions or allergies for medications, leading to “alert
fatigue,” and thus desensitization. It therefore makes sense that 90-95% of these alerts are ignored by physicians, Dr. Stein cited. So, not only are the messages from these rudimentary algorithms contributing to alert fatigue and are they often not helpful, but they don’t catch mistakes like warfarin being prescribed to a nine-year-old with a medical history of only asthma. In contrast, MedAware only flags about 0.2 to 0.5% of all prescriptions, with about 7580% being true positives, and only 35% are false negatives. These deadly medication errors aren’t rare, either. Out of the four billion prescriptions written in the US every year, an estimated eight million contain deadly errors. Most of these errors weren’t typical in the old days, as handwritten prescriptions weren’t as susceptible to “typos,” Dr. Stein remarked. “When I wrote prescriptions, I’d write them on paper and www.telemedmag.com
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physically hand it to the patient. Now, with electronic orders and prescriptions, it’s much easier to click on the wrong patient and give the wrong person the wrong medication.” MedAware is currently live in Israel in their biggest (2,000 bed) hospital, where Dr. Stein practices, and is coming to the US in 2017. “I spend about one week per month in my US office, in Stamford, Connecticut, and the rest at home in Israel, Dr. Stein explained. “We are now planning to enter the U.S. market through strategic partnerships. We just opened the office in the U.S. and are in discussions with leading EMRs for integration and implementation.” There are several other companies out there working on reducing medication errors. What sets MedAware apart, though, is its artificial intelligence, Dr. Stein said. It learns physician behavior, and then identifies the outliers as the potential errors, which seems to be an industry first. The software doesn't tell physicians how to do their job “Even if you’re a great poet and you write the best novels and poetry in the world, sometimes you may have a typo and you use a spellchecker to fix it; and it doesn’t say that your poems are not perfect. It just says you’re human,” Dr. Stein explained. "We don’t tell them what to do. We just say: Hey, did you know that this patient has two 14
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We don't tell them what to do. We don't give advice. We just give the warning: 'Hey, you're an outlier.'
platelets. Maybe you shouldn’t give him the aspirin? Just consider that. I’m not telling you what to do. So, we learn the behavior and then we know how to narrow it. We know how to project it. But we don’t give advice. We just give the warning: Hey, you’re an outlier.” So, what will it cost providers? The cost is commensurate with the practice size, from private practice all the way to the big hospitals. The cost is about 5% of the expected cost reduction, Dr. Stein said. About the industry standard. What advice to do you have for physicians looking to pursue something entrepreneurial like you did? “I think the challenge is really to decide that you stop doing what you did for the last 20 years and do something different, completely different; submerge yourself into the unknown. You know, take your ego and leave it on the beach and start from scratch and to try to make a difference. And it’s a long and tedious road. There’s a ninety percent chance you will fail – again and again and again. But it’s a fascinating ride and you have to enjoy it,
with all the risks involved. I enjoy it. If you don’t enjoy it, you shouldn’t get in there. “I think mainly understanding that you will fail again and again and again and that’s part of life. And it’s much more concentrated when you’re on a start-up roller coaster. But it’s fun. I like it.” So what do other people think of all this? Dr. David Bates, a leading national Patient Safety expert and opinion leader, Professor of Medicine at Harvard Medical School, and a Professor of Health Policy and Management at the Harvard School of Public Health said: “It has been hard to find medication errors which come completely out of the blue – like a medication used only in pregnant women which is ordered for an elderly male – but this approach detects orders which appear to be anomalous in some way, and it represents a very exciting new way to pick these errors up before they get to the patient.” Check out more at MedAware.com and their study in the Journal of the American Medical Informatics Association.
MedAware's Battle Against Alert Fatigue
by the numbers ----
Traditional EMRs flag upwards of 30% of medications --
Clinicians ignore safety notifications between 49 percent and 96 percent of the time. --
MedAware flags between 0.2 to 0.5% of all prescriptions --
When MedAware flags a potential error, 75-80% turn out to be true positives
tech
ces gear preview
teletech Practice-changing gadgets & gizmos
Best of C.E.S.
2017 Gear Preview Every January, thousands of companies, reporters, and tech enthusiasts converge in Las Vegas for the annual Consumer Electronics Show (CES). CES has historically been the place to show off the newest TV’s, smartphones, and computers; however, advances in technology and the rise of social media have also made people more interested in their own health. As a result, there’s been an increasing presence of health, medical, and fitness technology at CES over the past several years as companies seek to create new products to meet consumers’ changing demands. The Neofect Smart Glove can aid in rehab. Review on page 18.
CES 2017 was no exception to this trend, and many notable announcements were made during the week about gadgets that can improve your health. Here are some products that were announced that caught our attention
by Scott Jung
www.telemedmag.com
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ces gear preview
Samsung S-Skin It’s practically an annual tradition to expect announcements about the newest Samsung smartphones, tablets, and Gear smartwatches, but the Korean company’s experimental research arm, C-Lab, used this year’s show to demo some unique concepts that don’t quite fit into Samsung’s mainstream product portfolio.
Omron Project Zero 2.0 Omron, the well-known brand in consumer blood pressure cuffs, showed off the second iteration of their advanced blood pressure monitor called “Project Zero”. What makes Project Zero unique is that it minimizes the ubiquitous inflatable cuff method of blood pressure measurement and shrinks it into a wrist-worn wearable. This makes the device not only more discreet and comfortable to wear, but the wristband form factor allows for all-day and overnight use for near continuous monitoring. As a wearable health device, Project Zero also does step counting, sleep tracking, and syncing to an iOS or Android device to track trends or send data to a physician. 16
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The 2.0 version of Project Zero that was announced this year incorporates a number of new technologies and components that ensures accurate readings. Its appearance has also been redesigned, looking much more like a stylish and contemporary smartwatch. By using a variant of a blood pressure measurement method that’s been around well over 100 years, one might not think Project Zero is a novel, breakthrough device. But this method uses clinically validated and long-accepted technology which lets users be confident that they’ll always be getting accurate readings. The continuous monitoring that comes with a new, wristband form factor only further expands the possibilities of what we can discover about blood pressure’s role in our health.
One such product, S-Skin, is a health device that uses both sensors and therapy to improve your skin. It first analyzes your skin and the surrounding through a combination of cameras, light sensors, and conductivity sensors that measure factors like dryness, melanin, and redness. Using these measurements, the connected S-Skin smartphone app then gives you personalized advice on how to improve your skin’s health. Built-in LED’s on the S-Skin lets you start a light-based skin improvement program right on the spot. But S-Skin takes the skin therapy a step further by incorporating biodegradable, NFC-enabled micro-needle patches that contain ingredients you’d find in over-thecounter skincare products. While it remains to be seen whether S-Skin actually makes your skin firmer and more radiant, it’s a unique concept that incorporates a lot of different technologies both to assess and treat.
PKVitality K'Track Glucose and Athlete PKVitality’s “K’Track Glucose” wristband may have the looks of a common smartwatch, but it is actually a wearable glucose monitor. Underneath the watch face, where you might typically find a heart rate sensor, is a special sensor unit consisting of an array of tiny micro-needles. These micro-needles painlessly penetrate the topmost layer of skin and measure the amount of glucose in the interstitial fluid in just a few seconds. K’Track Glucose wirelessly syncs with an iOS or Android device and can be programmed with alerts, reminders, and trends. It’s also showerproof and tracks your steps, distance, and calories, so there’s little reason to take it off. There’s no limit to the number of readings you can take, but the micro-needle sensor units (known as “K’apsuls”) expire after 30 days, but are user-replaceable. PKVitality also announced a similar fitness-oriented version, called the “K’Track Athlete”. It works similarly to K’Track Glucose, but instead measures lactic acid, a compound that the body produces which is associated with muscle soreness and fatigue during exercise. Unlike K’Track Glucose, K’Track Athlete can continuously monitor lactic acid, and it can also be worn either around the arm or wrist.
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Touch Surgery Augmented Reality Platform London-based Touch Surgery is a company that has developed a tablet and smartphone app with over 200 interactive training programs for surgical procedures. The app is hugely successful and counts institutions like Stanford and Johns Hopkins and companies like Johnson & Johnson and Stryker as their partners. At CES, the company gave a teaser of its latest technology that makes the surgical training experience even more immersive - by incorporating augmented reality (AR). It’s partnered with DAQRI, an enterprise augmented reality company that has developed smart glasses, helmets, and heads-up displays for a variety of industries. Using the DAQRI Smart Glasses in particular, users are able to practice surgical procedures on a virtual patient with the ability to look around by moving their head and interact with their environment with their hands. It’s about as close of an experience as surgeons can get without putting live patients at risk, giving them opportunities to practice their skills and learn new ones. By incorporating surgical education content in augmented reality glasses, Touch Surgery also moves AR one step closer to real operating rooms where they can assist surgeons operating on real patients.
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Neofect RAPAEL Smart Glove For patients recovering from a stroke or neurodegenerative disease, rehabilitation of the extremities is often a long, arduous process. Surprisingly, it’s also a very low-tech approach that usually consists of iterative and repetitive goal-oriented and task-specific motor skills. Moreover, progress measurement can be subjective, making it difficult for therapists to keep patients motivated and challenged. In turn, patients lose motivation and their overall improvement stalls. Korean company Neofect has announced a smart glove they’ve developed called the “RAPAEL” that has been clinically shown to increase the effectiveness of hand movement rehabilitation training. Lightweight and ergonomic, RAPAEL contains a 9-axis movement sensor, bending sensors on each finger, and electronics to detect orientation, position, and movement of the wrist and fingers. Data from the smart glove is wirelessly sent to an app which saves and analyzes the data while tracking the user’s progress. An artificial intelligence based learning algorithm also creates a personalized rehabilitation program that dynamically adjusts the level of difficulty depending on the user’s progress. The program consists of a number of games and virtual ADL (activities of daily living) tasks that make rehabilitation a little more fun. The learning algorithm also helps avoids the decline of user motivation and progress that could occur with traditional rehab exercises.
tech
immersive tech
What You Need to Know About Virtual Reality in Healthcare You've heard of virtual reality, maybe you've even tried Google Cardboard, but the world of augmented and mixed reality is still a mystery, as is its potential impact on healthcare delivery. Justin Barad breaks down what physicians need to know. by justin barad, md
In 2012 a Kickstarter launched for a virtual reality headset called the Oculus Rift. The campaign raised $2.4 million – shooting past its $250,000 goal. What started as a garage-based pet project has turned into a worldwide phenomenon and two new computing platforms: Virtual and augmented reality. The market for virtual reality (VR) and augmented reality (AR) is projected to reach $160 billion by 2020. One of the major useful applications for this technology is in the area of healthcare. In this article, I will try and list a few of the interesting uses of VR and AR in medicine which I have broken down into therapeutics, visualization, surgical navigation, patient education, training, telepresence, telementoring, and workflow/EMR-integration. To begin with I would like to explain the difference between Virtual Reality, Augmented Reality, and the somewhat newer term Mixed Reality. Virtual Reality implies the use of a fully immersive headset display that completely replaces the world around you. Virtual Reality includes 360 video and film, in which you are experiencing real
world camera-captured content, or simulated content, in which everything you look at or interact with is created by a computer. “Mobile” VR is a term used to describe VR content that is experienced by strapping a phone to your face with a compatible headset. Things like Google cardboard, Google daydream, and the Samsung GearVR are examples of Mobile VR. Mobile VR currently lacks positional tracking, so your movement in the virtual world is restricted to the rotation of your head. There is also currently no 1:1 hand-tracking available for mobile VR. On the higher quality end of the VR spectrum is what’s commonly referred to as “Tethered” VR, which would be the Oculus Rift with Touch Controllers, the HTC Vive, and Playstation VR. These devices use tracking systems to allow you to “move around” the virtual world, which tremendously increases the immersion and overall VR experience. Furthermore, your hands are present in the virtual world and you can interact with it in a very natural way that needs to be experienced to be believed. The Vive and Rift require relatively powerful computers and GPUs to support them, however the cost and system requirements are decreasing steadily. Playstation VR runs off of the PS4. Now let’s talk about Augmented Reality, or AR. AR exploded in a big way in 2016 with the release of Pokemon GO, but this also led to a lot of confusion as to what is or isn’t augmented reality. The term augmented reality, meaning a view of the real world “augmented” with computer generated visuals could apply to anything from a phone to a highly sophisticated holographic headset display. For this and other reasons Microsoft started pushing the term “Mixed Reality” to describe its holographic headset display technology, in which holograms and information can be placed into the real world around you in a way that makes it seemingly become a part of the environment. Other holographic display headsets include the Meta 2, the DAQRI, the Vuzix M100/300 and Magic Leap among others.
virtual reality
I think VR and AR will have one of the biggest impacts in the world of medical training.
Therapeutics is an exciting area that is laser focused in the VR arena at the moment because it gives you the power to really take control of a patient’s brain in order to ease their pain, anxiety and many other conditions. One of the more exciting companies in the space is Applied VR, which has been conducting some interesting clinical research in partnership with Dr. Brennan Spiegel at Cedars Sinai. Applied VR is creating a validated VR "pharmacy" to treat patients in and out of the hospital. Some of their early results have to be seen to be believed, and the testimonials and videos they have are truly moving. Early results show that VR can decrease the use of deadly and addicting narcotic medications. VR is also being used to treat some psychological conditions such as PTSD and various phobias. Vivid Vision is another interesting company in the therapeutics space. They are using VR to treat various ophthalmologic conditions such as strabismus, amblyopia, and convergence disorders. In terms of therapeutic AR, an exciting company called Brainpower is using this technology to help patients with autism. I had the opportunity to see psychiatrist Dr. Arshya Vahbzadeh, Brainpower’s CMO, and discuss a demo of the technology in www.telemedmag.com
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The OssoVR surgery module in action which Brainpower enables a young child to make eye contact with his mother and to recognize her emotions. The mother is brought to tears as she exclaims that he has never before made eye contact in this way with her. VR and AR companies are taking on medical image visualization in a big way. Seeing a 3D reconstructed MRI or CT in VR and AR can give you insight into anatomy, approaches and pathology that you sometimes could not have seen otherwise. It is also tremendously cool. Companies in this space that are approaching VR visualization include Echopixel, Surgical Theater, and Bioflight VR. In the AR space NYUbased MediVis is bringing 3D imaging to the hololens. Surgical navigation may see a major utility shift with the use of AR technology. Currently when using navigation systems a surgeon must look up or to the side at a screen which is ergonomically suboptimal and also requires a lot of different “views” to figure out where s/he really is in physical and virtual space. Integrating a holographic headset will allow surgeons to “see through” the patient in a natural stereoscopic way that should streamline and hopefully improve the utility of navigation technologies. Startups like Augmedics are using this approach for spine surgery, and Phillips just recently announced an interesting augmented application for their navigated Hybrid OR. Patient education will likely be an early area of VR and AR innovation. It is often hard for patients to understand the complex nature of their disease states, treatment options, and also for them to have a spatial sense of the 3D aspects of their anatomy. Applications like The Body VR allow patients to get a better understanding of these challenging concepts with creative techniques like allowing them to "walk-through" their own anatomy. Another example comes from Lighthaus, which produced an interactive simulation for pediatric cardiac surgery for Lucile Packard Children’s Hospital. I think VR and AR will have one of the 20
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biggest impacts in the world of medical training. The apprenticeship model has been used for physician training for over a century, yet it is starting to show its age. My personal experience in VR comes from the work I've done at Osso VR, where we are providing a way for physicians to practice critical procedures wherever and whenever they want. This will provide a way to standardize physician training and ensure that there are no "training gaps." VR will also allow more established surgeons to transition to newer and more effective technology, as often the lack of time or ability to travel to expensive training courses limits the adoption of new devices and techniques. Telepresence is something that has existed in hospitals for some time both for patients and physicians, however VR is going to increase its effectiveness in a major way. Dr. Spiegel from Cedars-Sinai showed a demonstration at CES’s Digital Health Summit in which a patient who had been in the hospital for months was “transported” home via a live-streaming 360 camera and a mobile VR headset. The reaction was incredibly moving. This demonstration is only scratching the surface of what this technology is capable of. Telementoring is an interesting area that is useful for procedures and surgeries. The concept is that if the performing physician is new or has any questions they can reach out to an expert who can see what’s happen-
ing, assess, and provide advice in addition to showing the provider what to do. An early example of this technology was VIPAAR, which used Google Glass and an iPad to accomplish telementoring. It is likely that this technology will start to become more mainstream with some of the newer holographic headsets coming down the pipeline to help democratize access to more advanced surgical treatments. EMRs have been making the lives of physicians and healthcare providers quite difficult over the past few years. AR technology may be a way to ease that burden. Companies like Augmedix use AR technology like Google Glass to provide “virtual scribes” that can document and code a patient visit without requiring a physical scribe to be present. Furthermore, they can fetch data from compatible EMR systems to be displayed on your headset to allow providers to focus more on patients and less on their computers. Honestly these are only a few of the applications of VR and AR we’re going to be seeing in the next few years. As physicians, it will be up to us to be open-minded about these new applications, provide resources and validation to test their effectiveness, and provide insight into where the true needs are and what innovators should be focusing on. I have no doubt that VR and AR are going improve outcomes and decrease costs for patients in addition to improving the quality of life for providers.
vision
television Industry-shaping ideas & perspectives
incentives that work
Smarter Devices Don’t Create Smarter Behaviors New tech companies are going beyond the gadgetry to learn how to change population behavior through simple incentives. by Matthew Loper CEO of Wellth
R
emote Monitoring is a popular idea that has spread amongst healthcare innovation circles over recent years. This idea states that if we give patients a bunch of “smart devices” that can gather data on their health and behaviors while they are outside of care settings, we can better allocate resources and intervene before something bad happens. As a result, there
has been a proliferation of smart devices. We have created smart glucometers, smart blood pressure cuffs, and even pills with tiny embedded chips that can be ingested and report back as to whether Hypertensive Joe took his medication today or not. But there is one key issue with all of these smarter devices. The problems that plague our healthcare system, the billions of dollars wasted on preventable hospitalizations, readmissions, and complications, are not the product of “dumb” devices. We do not suffer from technology problems, we suffer from behavior problems. The true essence of our healthcare problem has begun to be borne out by a number of thought-leading researchers. Kevin Volpp and his group at the Center for Health Incentives and Behavioral Economics (CHIBE) at UPenn performed a study in 2014 where they gave away connected glucometers, blood pressure cuffs, and scales to Diabetic patients and told them that their three biometrics would be monitored everyday by physicians. By the third month, less than half the patients were still using the devices daily. By the sixth month, only 27% of patients still used the devices. So, the vast majority of these smart devices had become expensive paperweights, sitting in patients’ homes and collecting dust. But since Dr. Volpp is an expert in Behavioral Economics, he understands how to use the right incentive structures to change patient behaviors. In another group of Diabetics, he gave away the same devices and instructions but this time offered just $1.40 a day for three months to patients who used all three connected devices. The results were astonishing. At month three when the incentive period ended, 75% of patients were still using all three of the remote monitoring devices every day. At month six, even after three months of no incentives, 62% of patients were still adherent to their daily biometric check-ins. So, by offering only about $130 of incentives to patients, the CHIBE team was able to double the effectiveness of remote monitoring. Devices, no matter how smart they may be, are useless if patients don’t use them.
loper
There are a number of companies that have begun to take the proven concepts from Behavioral Economics research and apply them to real world healthcare problems. Last year, CVS Caremark instituted a new smoking cessation program in their own employees that leveraged loss aversion by allowing employees to deposit their own money in a pledge to quit smoking. Coincidentally, this program resulted after another study by CHIBE that showed the ability to triple six month smoking cessation in CVS Caremark employees. DietBet is a company that applies a similar concept to weight loss by allowing participants to bet their own money against their weight loss goals. The participants who fail to hit their goal lose their money to those who succeed. According to DietBet’s website, the company has helped over 470,000 participants lose an aggregate 6.3 million pounds. At Wellth, we allow payers and risk-bearing providers to offer incentives to chronic condition patients in order to produce more adherence to medications and disease appropriate remote monitoring. In a pilot with a large national insurer, we were able to demonstrate the ability to increase both medication adherence and glucometer check-ins by more than 45%. We are currently studying our ability to increase adherence and decrease readmissions in the 90 days after heart attack and congestive heart failure hospitalizations at UPenn and Princeton Healthcare System, respectively. There is a common dream shared by every doctor, health system, payer, and venture capitalist. A dream where new technologies scale broadly and produce massive improvements to population health and healthcare efficiency. A dream where patients receive the exact right care at the exact right time. A dream where we are able to save millions of lives and billions of dollars. This dream will never become a reality by simply creating new apps, devices, and widgets that measure, monitor, and annoy patients. In order to achieve this dream we have to focus on effectively changing patient behaviors.
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+ hollander majority of an examination is possible through video with a little creative thinking; and because the alternative to examination via video is often no visit or simply a telephone conversation. The question should not be about whether or not the physical examination is as complete as an in-person visit but whether or not enough of a physical examination can be done to lead to an appropriately actionable decision. Let’s examine both in turn.
Reliability
let's get physical
Why the Telemedicine Physical is Better Than You Think Physicians who are new to telemedicine often fret about the appropriateness – and the limits – of a remote physical. Here are a few lessons we've learned at JeffConnect. by Aditi Joshi MD, MSc, Medical Director of JeffConnect On Demand & Judd E. Hollander, MD, Associate Dean for Strategic Health Initiatives, Sidney Kimmel Medical College 22
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L
ike all new beginnings, telemedicine is greeted with both excitement and caution. It’s exciting that we have yet another avenue of seeing our patients. Yet, we’re cautious in rethinking our own ways of doing histories and examinations as it’s unlike our training and what we assumed to be possible. A common concern regards our physical examination. How can one perform an examination that is appropriate for patient care? If we can't, how can telemedicine be a part of our medical practice? It’s a legitimate question and we get it. We have also seen a lot of patients and can say it’s not nearly as different as you’d first imagine. In no way is this an argument against physical exams. We all know they are more cost effective, give information that cannot be gleaned from invasive testing and are a check on our increasingly low threshold to order a battery of tests. What we do argue against is saying that the lack of ability to perform a “complete” physical examination is a reason to invalidate telemedicine. It’s simply not true for three main reasons: (1) because physical examination is not always reliable; (2) because the great
First, the assumption that our physical exams are reliable. The implicit assumption regarding the physical examination is that there is a gold standard correct answer. We all know that this is not the case. We can all think of times when we disagreed with a resident or student finding on examination, or times when a specialist or consultant had a different input entirely. Was there one correct answer? No, of course not. In order to be the true “gold standard,” the exam must be both reliable and valid. Let’s take the most basic clinical features used to diagnose a life threatening condition – acute myocardial infarction. Features classically used to evaluate the possibility of AMI, such as pleuritic, positional and sharp chest pain have poor to fair inter-physician reliability (kappa values of 0.27 to 0.44). Think of the last time you heard an S3 or maybe even an S4 – was it obvious to everyone who listened? What about wheezing or rales? Have you ever heard it transiently in a patient? Are you certain about what each and every murmur you think you hear means, if in fact you do hear the same one your colleague said they heard? The physical exam can, of course, be valuable, but even Osler said 95% of the diagnosis is in the history. He was right. We should listen to our patients. He might have loved telemedicine, where we listen to and observe our patients.
Value of Video PE
Also, we are doing physical examinations. We always do one via video. We simply use our power of observation better. There is a lot of information to illustration by Leonard Peng
TELEMEDICINE PHYSICAL EXAM PEARLS --Common complaints and how to examine them remotely
1. CONJUNCTIVITIS
2. PHARYNGITIS
3. ANKLE PAIN
Can easily see an eye on video to assess for injection, icterus and symmetry
Finagle the camera to evaluate the tonsils for redness, exudates and swelling
Use the Ottawa Ankle rules
Visual acuity with help of eye chart applications which can be downloaded while on the phone
Ask the patient to evaluate if they have tenderness over their lymph nodes
Instruct patients to move eyes to evaluate extra ocular movements Have the patient use a flashlight to evaluate for reactivity
be gained looking through the camera at someone (and for our purposes we consider only video visits in this scenario). We can assess skin tone, rate of breathing, gait, clarity of speech. Are they sitting up or lying in bed? Are they pale? Does their breathing look rapid and are they unable to complete full sentences? Or are they walking around in no distress while listing their symptoms. Much of the information from this initial 10 seconds we do as second nature and counts as part of the physical examination. Patients can also follow our instructions to aid in their own examination – we can have them move their joints, assess if they have pain in specific areas, move the camera to see their eyes, throat, skin rashes, etc. They can take their own pulse while we time them and use their own thermometers to assess for fever. Family members can also be recruited: we’ve used them to examine an abdomen and assess for tenderness under our instructions. We have diagnosed biliary colic and appendicitis in this manner. Not only does this add valuable information to the physical examination, it aids the patient in being an active part of their healthcare. In the above example, having the patient understand where the right lower quadrant is and why it is important to know whether
Observe if they cough, or have a runny nose, and observe them take their temperature These are the same criteria used in an urgent care to screen for strep throat versus a viral sore throat
Ask whether they were bearing weight at time of injury Have patient the family or patient palpate over the specific areas of bony tenderness included in the rule Evaluate whether they can bear weight If it is all negative, you can save most patients a visit to the urgent care or emergency department for an X-ray.
the pain localizes in that region helps them also realize when and why they might need further evaluation. Yes, without the addition of a device to listen to heart and lungs attached to the patient’s phone, we are unable to perform this examination. How often and how well does the average practitioner hear murmurs, gallops and PMI? As we noted above, our inter-rater reliability is low. Is it really necessary to listen to a patient’s lungs if they have two days of rhinorrhea and a cough, but no fever, shortness of breath or sputum production? We would not treat them with antibiotics for their viral illness. I bet you commonly treat family members over the phone without seeing them. Video visits allow you to see much more - a more comprehensive exam than for your loved ones. For the bulk of the common telemedicine complaints, our management wouldn’t change. Also, our close, uninterrupted online counseling allows the patient to know when it’s appropriate for a higher level of care and what that level is, i.e. urgent care versus the ED. We get the added bonus of seeing the patient in their home environment and understanding what that looks like. You never see that in an office visit.
These are only some examples. As with any consult, advising each patient on what is considered an emergent or worrisome progression of symptoms is important. Not everything is appropriate for telemedicine. If you cannot exam something you need to exam, you need to have them be evaluated elsewhere.
Conclusion
All of these exam components can be done over video with patient cooperation and provider explanation. While we accept video evaluation has limits, it is not something that should stem the tide of innovation and expanding our interactions with patients. The alternative for many of these patients is either a phone call with a provider or not having any visit. In both these cases, they get no examination. We have to make sure we have the required information for an appropriate evaluation to help treat the patient’s symptoms.. If not, we need and would ask for more help, similar to an office or ED visit. Scrutinizing our basic assumptions and releasing our preconceived blocks about what constitutes care for a patient can aid even more of our population.
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gordon
market maturation
Telemedicine's Next Big Tipping Point As large health plans begin to fold in telemedicine services, we will see the overall market reach a new level of maturity and acceptance. The next tipping point will be the flourishing of remote patient monitoring and diabetes management solutions. by William Gordon
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n a previous issue I wrote about the telemedicine tipping point, a point in time that would occur with the end result being the mainstream adoption of telemedicine. We have reached that point, and it is now time to look at what’s next. Let me explain. Quite a number of my friends know that I do some work in the area of telemedicine and write for this magazine, so they feel compelled to send me text messages letting me know that they can now do a virtual doctor visit or a telemedicine visit via their insurance plan. In fact, many have stated that their plan actually encourages it for certain ailments over an urgent care visit. My wife, who recently took a new job, brought home her benefits information and sure enough, in the package of information, there was a two-page section on telemedicine services and how they should be utilized. I have seen big players named in these plans, everyone from MDLive to Teledoc, American Well and Welldoc. These are 24
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some of the known names in telemedicine, the ones who have raised copious amounts of venture capital and have survived the early lean years. They are finally getting their due and it only took about five to seven years to get to this point. Adoption and acceptance rates will only go up from here as these service providers get more deeply embedded into numerous employee health plans.
What is next?
Now, the next layer of telemedicine or mHealth providers will get their seat at the table. I believe that you will see two specific categories of providers and solutions. They are remote patient monitoring devices/applications and diabetes management solutions. These two areas can provide significant results such as dollar savings on overall patient costs to service and measurably better outcomes. There have been numerous providers in this space who have come and gone, unable to weather the storm, exhausting their capital only to fall short for no other reason then the market matured at a much slower pace than expected. That is the name of the game, right? The VC’s knew that some of their investments would generate zero return but they had to take a shot in order to find the next Fitbit.
Who is the next Fitbit?
Diabetes management solution providers are ready to take center stage. They will be the next to be added to the covered services by the big (and little) payers. The providers will jump on board because they will have a mechanism for getting paid. Some will get paid more for better results so they will embrace this “new” technology. I placed new in quotes because it isn’t new at all; in fact many of the solutions available now have been available for many years. But now they'll get their time in the spotlight. Now is their time to shine. Personally, I worked for a diabetes management solution company and it was way ahead of its time. Years, in fact. We were talking about converged health management platforms and aggregation of data
across multiple end points and unified data presentment long before the solutions gaining market traction today. Unfortunately, the company did not weather the storm and was acquired for a very small fraction of its original venture capital raise. My point is that we are seeing the natural progression of market solution adoption at work. Good solutions die horrible unnecessary deaths, others who may not have the same robustness will live to close another round, and this is health solution Darwinism at its best. Those who have weathered the storm are poised to succeed where others have failed. They have pretty solid solutions and have been able to stretch that VC money out longer than others. They are survivors and will now be rewarded. They have learned the lessons taught by their fallen brothers and sisters; they have perfected their crafts and they will now take pages out of the telemedicine providers playbooks and achieve the mass adoption they have longed for. Finally, I believe that remote patient monitoring solutions, those that utilize multiple diagnostic tools such as BP cuffs, weight scales and pulse oximeters, will see a renewed level of success. This will be a much harder sell to the payers due to the overall cost of the equipment and the user error factor involved in their operation. For patients with CHF and COPD, these solutions can absolutely provide a higher level of care with better outcomes and reduced expense to treat and manage, but that will be in specific situations and optimal conditions. It is important to note that the VA has just awarded $1 billion in contracts for this very type of solution. It was spread amongst four different service providers equally. That is $250 million each. The payers will be keeping a close eye on the results of this initiative (as they have with the previous VA awards in the area of remote patient monitoring) and as soon as it can be justified via results, we will have the next telemedicine domino fall.
vision
the V.A. way
Small and Large Telemedicine Companies See Opportunity with the VA Goliath companies are still formidable opponents. But at least David is now in the fight. by Mark Plaster, MD
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he VA is trying to reinvent itself from being the poster child of inefficiency to the model of the next generation. The vehicle for that change is “T4 NG”, Transformation Twenty-One Total Technology Next Generation (a typical government acronym). It will award up to $12 billion in what are called IDIQ (indefinite delivery, indefinite quantity) contracts, half of which will be awarded to small businesses, so called SDVOSBs (service disabled veteran owned small businesses). One of the first contracts to be awarded was recently announced, a $258 million maximum contract spread among four potential vendors to provide telehealth services to veterans. Each potential contractor is offered the opportunity to develop a platform of telehealth services and technologies from which VA health providers, doctors, care coordinators, and others can choose to enroll patients for telemonitoring, such as diabetes care, COPD management, or mental health coordination. The contractor that builds the “better mousetrap” could win
big. While many of the these contracts will ultimately be awarded to giant corporations that have extensive histories with government contracts, some will present opportunities for new ideas and new companies to break out with their first big contract. An example of this David and Goliath contest is the competition between two identified vendors for their portion of the $258 million. Golliath is the medical device giant Medtronics and David is 1Vision, LLC. Medtronic, a global company that moved its headquarters from Minnesota to Ireland to save hundreds of millions in taxes boasts a workforce of over 85,000 employees. When I called 1Vision, located in West Virginia, I got Jeremy Fort, the General Operations Manager on the phone directly. He was quick to point out that 1Vision was a merger of an IT and cybersecurity companies with government contract experience and their on-the-ground experience. But yes, they were still a small business. But he was quick to point out their advantages. “We might be the only contractor that has visited every VA facility in the nation,” he said. Mr Fort further noted that they have a connection to emergency medicine in that they were the ones who brought EZ IO, the intraosseous infusion device, to the attention of the military, securing a huge contract for that start up. “We have experience contracting with the government,” he said. But making it to the final list of four vendors has no guarantee of success. In fact, it is a huge gamble for this small company. Many of the small companies who make it this far only go on to bankruptcy. In order to make a single dime of profit they need to develop a host of software and management applications to offer to patient care coordinators at the various VA sites around the country. Although Fort declined to say how much they had to invest to get their product in front of the potential users, it was no doubt significant, but he assured me that they had the financial backing to see it through to completion. It goes without saying that if they succeed, they will catch the eyes of larger investors who would likely of-
plaster
RESEARCH THE COMPANIES THAT ARE PITCHING TO THE GOVERNMENT FOR THE OPPORTUNITY TO REVOLUTIONIZE THE VA. THEY'LL HAVE A LOT OF MONEY TO SPEND OVER THE NEXT FEW YEARS.
fer to buy the company. They have six months to develop their product line of services. Then it’s up to them to offer it to the hundreds, if not thousands of end users, in the VA system. And that’s where having a good, if not best product, is just the first step in the competition. Medtronic is the “incumbent” contractor for the past five years. They are already in the VA system. So it will be up to 1Vision and the other three competitors to prove that they have a better line of products and services. And that might prove easy or difficult, depending on what inroads Medtronic has already made in the system. The challenge in many cases is tailoring the product to operate within the VA’s cybersecurity framework. So if you have a good telemedicine idea or a product that is fully developed, and you’d like to present it to the VA, this might be your opportunity. Research the small and large companies that are pitching to the government for the opportunity to revolutionize the VA. They'll have a lot of money to spend over the next few years. As they say in the military, it’s a target rich environment.
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bahagon
startup nation
Why Israel Has Become the Perfect Health Tech Incubator Dr. Yossi Bahagon, a family physician and Managing Partner at Israel’s first digital health VC fund, talks about patientcentered healthcare, new companies to watch, and why Israel is a unique place to start a med tech company. interview by Logan Plaster
Telemedicine: I’m interested in hearing from you about a couple of companies or technologies coming out of Israel that you are particularly excited about or inspired by. YOSSI BAHAGON: There has been a lot of hype around digital health and telemedicine in the last five years. In reality, the adoption of digital health technologies is not standing up to the hype. Some of this is because it’s an emerging field and buy-in by physicians is very early. So in spite of the hype, I believe we are still in the early days of this revolution. Talking about patientcentered platforms, talking about the integration of genomics into our day-to-day health, talking about utilizing artificial intelligence in our day-to-day healthcare and so on; this is still very, very early. TM: What are the specific trends you’re seeing out of Israel? BAHAGON: First is patient-centricity. Many organizations talk about patientcentricity but it’s by far not a reality. The 26
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usual model today even with regards to digital health is B to B to C. So, you have to go through the healthcare organization, whether it’s a provider or payer, and offer the value proposition through them. And then maybe they will take it to the end consumer. Imagine a world where 30 percent of the transactions and interactions will be at the level of the end consumer. This issue hasn’t been cracked yet. More than 90 percent of digital health companies do it B to B to C, while the whole idea was to move the power into the hands of the consumer. When you say E-Health, many people think the E stands for the technology. I think that the E stands for the empowered patient, the educated patient, the enabled patient, the expert patient. So for me, the E stands for me being at the center of the system. This can be translated to reality in many ways. It can mean connected devices that truly monitor me in a convenient way and transfer only clinically significant data to my provider. This can be a system that learns my habits and provides me with true insight and actionable recommendations that can affect my
daily living. Today, our clinical data is being utilized by our payers and by our providers who sell them to pharmaceutical companies, to medical device companies in anonymous ways. But since it’s my data, why am I not getting anything out of it? I’m talking here about the market of billions of dollars a year. The patient is not in the center. TM: Are there specific companies that you see taking strides in the area of patient centrality? BAHAGON: Let’s start with personalized disease management. A company named Dario developed a connected glucometer which connects to your Smartphone and provides insights both on the patient level and on the medical team level. There are many connected devices and there are several connected glucometers. What makes Dario different is not their solution – though you can argue they have a brilliant solution – but the fact that they are succeeding in selling this comprehensive diabetes management solution direct to consumers. Tens of thousands of people from
all over the world pay out of pocket money because this solution brings them value that they don’t get from the traditional solutions that their payer and provider gives them. Another example is a company named Sweetch, which translates your data from your smartphone into actionable recommendations in order to promote your physical activity and weight reduction. This platform learns your habits end-to-end without asking you any questions: Where you live, work, go to lunch, how your calendar looks. Based on that, it provides you “just in time, just in place” baby steps recommendations in order to increase your physical activity. Let’s say you have a 40 minute gap in your calendar. It might tell you to walk seven minutes to the nearest Starbucks, buy yourself a coffee and you’ll come much more alert to your next appointment. It takes the general notion of “you need to walk 30 minutes a day” and turns it into dynamic recommendations. Another example is a company named TytoCare, which bridges the gap of enabling the physical examination of the patient when he’s remote. For the first time in the history of medicine, you can really check the patient from a distance. And all these pictures and sounds are recorded. And it’s the patient who owns them. And based upon these recordings, you can offer the next generation of Tyto, which is by analyzing these sounds and images. In several years, the patient will be able to put the Tyto on his chest and the device will hear his lung sounds and say: There is an 80 percent chance that you have pneumonia. The platform won’t replace the physician, but will serve as a clinical decision support, both for the physician and the patient. TM: What makes Israel such a unique environment for health tech innovation? BAHAGON: Israel is really a unique place with regards to the ability to develop disruptive healthcare solutions. Why? Because the Israeli healthcare system is 100 percent digital and has been for ten years. Health
ISRAEL IS REALLY A UNIQUE PLACE WITH REGARDS TO THE ABILITY TO DEVELOP DISRUPTIVE HEALTHCARE SOLUTIONS. WHY? BECAUSE THE ISRAELI HEALTHCARE SYSTEM IS 100 PERCENT DIGITAL AND HAS BEEN FOR TEN YEARS.
records have been digital for the last 15 years. For the last seven years, every citizen in Israel has been able to access his electronical health records or personal health records from his Smartphone whether it’s his lab results or his last discharge from hospital. I can log in and order my chronic prescription with a few clicks. And this is at the nation level. So things are a reality here that I would say will take the U.S. about five years to achieve. That makes Israel a living lab. It will take Europe about seven to ten years to come to this place. So things that we already are doing and the mistakes that we’ve already done and the successes that we already achieved are a great learning park for all the other countries that are going through this path. In one of my previous roles, I was the founder and the manager of Digital Health Division the largest HMO in Israel. It’s an HMO that has 4.4 million members, 14 hospitals; 1,300 ambulatory clinics. It’s only second to Kaiser in the States. We built a system with a very patient-centric approach that is currently being used by over two million different patients each month, for over four million interactions each month. And the amount of knowledge and experience that you get regarding what works, what doesn’t work, was enormous. I had a
group of people whose entire job was to go out into the clinics and hear the physicians: Where were the pain points? What do they think about the system that we developed? Are they afraid of this system? Are they empowered by this system? All this experience and knowledge is out there to be replicated by other countries. The other aspect of Israel is that it simply has an innovation atmosphere. It has been called the “start-up nation” but that’s not just a slogan. Really, there is innovation in the air here. And you can find the roots for that in the fact that Israel is continually in survival mode. We live a good life, but it’s not like living in a place where everything is in place and nobody threatens you. Israel lives under a lot of threats and these threats create an environment where you need to innovate to survive. The third component is the support of the government. There is an Innovation Authority in Israel that gives non-diluting funding for selected start-ups. Every industry needs someone that will believe in the young entrepreneur and give them the runway that they need in order to build a company when the risk is very high. And the Innovation Authority in Israel gives this runway for selected companies. They have a due diligence process in place. And selected companies get millions and sometimes tens of millions of dollars in non-diluting equity to realize their dream. And it is done not from the return on investment perspective. It’s done as a strategic move to leverage and to create this innovation and ignite this innovation environment. TM: What can the American health tech community learn from Israel’s start-up mentality? How can we cultivate more of an “start-up nation”? BAHAGON: It’s not that you can copypaste what happened here in Israel. It’s never the same. The population is not the same. The culture is not the same. The payment methods are not the same. Everything is different. But the most important thing www.telemedmag.com
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compared to 2007 or 1997. There’s never been a time where technology allows us to do so many incredible things with so few individual people. If you can leverage technology appropriately and still have that really important people element, you can help countless people that just ten years ago would have been left completely on their own. Branching into the business world
the med tech ripple effect In his second year of an emergency medicine residency, Jeremy Corbett began to question the impact of his care. Not satisfied with helping just one patient at a time, he began to imagine a software platform that could be leveraged to assist whole communities. Soon after residency, Corbett founded RocketHealth, a company that provides a real-time dashboard of health metrics to diabetes patients and the coaches who manage their care. as told to logan plaster
The entrepreneurial 'Aha' moment The "aha" moment honestly was sitting down with a colleague who asked, “What would be required to keep potentially preventable emergency department visits from occurring?” My response then was the same as it is today. If I can get real time data in the hands of clinicians or behavior change scientists or somebody who could intervene at the time of need, I could change 28
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the number of people that come into the emergency department every day to see me for something that could be cared for at a less acute level of care. Two years later after I answered that question, RocketHealth was launched. The patient who sparked it all There was a gentleman who said he had noticed that he was sluggish, tired, and not thinking clearly. He had a good primary care doc and claimed he had been mentioning this over and over again and nothing really came of it until he told his doc he was just drinking nonstop. I was probably the fourth or fifth clinical patient encounter for this one poor guy and told him he had diabetes. He says, “Well, you haven’t run any tests.” I told him this is just a storyline that only ends with one diagnosis, and sure enough his sugar was out of control. So I thought, “Man, how many folks are running around like this with all of the right boxes checked?” They’ve got an employer. They’ve got coverage. They’ve got insurance. They’ve got a primary care doc. But yet they don’t have an answer, somebody to walk down this journey with them. What if we created a system, a platform, a program, a product that actually cares for people with a chronic condition in a way that they can’t by themselves; in a way in which their doctor has no capacity to? And that’s why I get excited about 2017
I was intrigued by starting a company, and I wanted to test the theories I had around population health. I also wanted to leverage my skills as a doctor for a larger group of people. The answer for me was a business – a startup. RocketHealth: The Basics RocketHealth is on a mission to transform the way insurers, clinicians, doctors and individuals manage chronic disease. We feel like we’ve been thinking about telemedicine wrong for quite some time and we [healthcare] should be much further along in leveraging data for better medicine and we’re not because it’s too complicated and we’re a little too isolated. We have the premise that if we put real time data, real time biometrics in the hands of people who can enact change – whether that’s a provider, a coach, a certified diabetic educator, a nurse, a case manager; that not only can we predict the future but we really do believe we can change the future of that individual with an X,Y or Z chronic condition, whether that’s diabetes, hypertension, congestive heart failure or in the not too distant future, some kind of cancer diagnosis or sickle-cell disease. So the idea is to find that person who’s three, four, eight, 12 months away from having their heart event, get that person engaged, and keep that event from taking place. Making the leap from emergency medicine to business Docs are pretty risk averse. We test a great deal—not just because of liability but
by the numbers
19
Every 19 seconds, someone is diagnosed with diabetes. 29 million Americans have diabetes and 86 million are at risk.
2x 3.5k
The cost of diabetes is expected to double in the next decade
Number of cell-enabled glucose meters currently deployed by RocketHealth
400k i6% h28% Number of individual glucose readings RocketHealth has captured since program launch
The average drop in glucose across the entire population using RocketHealth On.Demand
The average increase in testing compliance across the entire population using RocketHealth On.Demand
because we don’t like being wrong. We just spent all this time, all this money to get a degree, to get specialized training to become board certified. And then we’re going to leave that to go start a company? It’s just too risky for most people. I just determined that at 28, I would rather have a swing and a miss than to look back in 15 to 20 years and have regret about not taking a swing. I researched every single person, every single company, every single idea that was even close to this population health idea I had. I wanted to see who’s doing what and if the question’s being asked, who is articulating an answer? That took a month of just day-do-day, and it was the most fun I’ve ever had because it was pseudo-clinical. The secret power of the doctorpreneur What I found is that an "MD" opens up crazy doors. I used it to my advantage to get conversations going with people that I had otherwise no connectivity to. Flattery always helps, as long as it’s appropriate and truthful. And so it went from initial individual research I was doing to create a list of names of people that I should connect with to then literally connecting with those folks. And that part comes pretty easily for most docs. Most docs are relational and have good bedside manners and encounter abilities, otherwise they wouldn’t be in medicine. I got in touch with 30 or 40 of them pretty quickly and had really for me foundational, really pivotal conversations that further bolstered my confidence in my idea and the realization that nobody else was doing it. Finding the right business partners Take the science and the tech side of it. Find a partner that makes up for your shortcomings or covers your gaps, first and foremost. It doesn’t matter if you’re starting a school, a church or a tech company; you have to have great leadership, domain expertise and you’ve got to be well-capitalized. People who don’t know how to code but have a really great idea for an app ask me all
time, “Should I go hire a coder as a partner?” I say, “It depends. If the only thing you’re missing is coding ability, then absolutely. But I would look at what you need from a relationship standpoint and from a business standpoint first and then dive into what you might need.” On the larger trends within telemedicine for chronic diseases We’re seeing a lot of mid-level providers provide what was traditionally provided by the physician. So nurse practitioners and PAs are changing the landscape and I think in a very positive way. We’ve got to be able to leverage the less costly alternative, as more and more people get put into a pool that isn’t growing in terms of the finances applied to it. We’ve got to be able to do more with less. Every 19 seconds a new diabetic is diagnosed. We found that the best way to manage a person with diabetes may not be getting that person in the primary care office 37 times this year. That’s going to back up the office; the doctor only has so much time available to that member. What if we could leverage a less costly provider? And in this analogy, it’s a coach. And we like the term coach because it’s exactly what it is. So somebody has diabetes and absolutely we’re not trying to take away the care provided by a provider; we’re trying to augment and relieve some of the pressure that that doctor feels for managing the diabetic. We believe the best quality care will ultimately be the most cost-effective care. I’m proud that some of our staunchest advocates are the doctors or the members in the program. On defining success People ask all the time, “What was it that made this successful?” I always say, “In my mind, it won’t be really successful until we’ve really changed the way diabetes is cared for.” But we’ve certainly had great success measures. Our engagement rates are up. Our enrollment’s up and we’ve decreased the average glucose score by six percent.
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start - ups incubators
johns hopkins hopes a new med tech hub can help revitalize baltimore The new FastForward project combines co-working with stateof-the-art lab facilities. By Christy Wyskiel Johns Hopkins Tech Ventures
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nnovation is embedded into Johns Hopkins’ DNA. Since 1876, the institution has used discovery to benefit countless lives, most notably by pioneering breakthroughs that prevent, detect and treat disease. We take immense pride in what our researchers and clinicians have accomplished, but Baltimore has not fully felt the economic benefits of this innovation. Since 2012, startups based on Johns Hopkins technologies have raised more than $1.1 billion in follow-on funding, but 85 percent of that has left Maryland. In 2013, Johns Hopkins Technology Ventures set out to rewrite this story through, among other efforts, the platform of FastForward. This program encourages early-stage ventures to start and stay in Baltimore by providing affordable space, services and funding opportunities. For the past three years, FastForward has seen strong early returns from its efforts. The doors to our first innovation hub, FastForward Homewood, opened in 2013 near the Johns Hopkins University campus and has operated at capacity ever since. The FastForward East innovation hub opened on the Johns Hopkins medical campus in 2015 and has served as the headquarters for 30
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a number of successful startups. Due to the success of and demand for these two spaces, we opened our third innovation hub, FastForward 1812, this year. This 23,000-square-foot space, also on the Johns Hopkins medical campus, more than doubles our footprint in the city. Its hub space features private offices, coworking desks, state-of-the-art conferencing and meeting spaces, and access to legal, accounting and fundraising experts. It also offers a BSL2 lab space – from benches in a large shared lab to small, medium and large private labs, along with cell culture, microscopy and cold storage rooms, and an assortment of other shared scientific instruments and equipment. “FastForward allowed us to get up and running quickly,” says Brian Halak, President and CEO of WindMIL, a FastForward 1812 startup developing cell therapies for oncology indications. “It has the infrastructure that allows a brand new company like ours to work on the things that will generate value without worrying about vital, but less directly value-generating activities like finding office space, ordering lab equipment and the like.” From finding affordable space and equipment to navigating unfamiliar legal and accounting procedures to securing funding, entrepreneurship presents challenges
that derail startups based on even the most promising technologies. Sebastian Seiguer, CEO of emocha, a mobile health platform headquartered at FastForward 1812, says FastForward’s space, resources and connections have kept the startup competitive. Less than three years after its inception, emocha has customers from Baltimore to Australia. “The Tech Ventures team offers tremendous support, while giving us the space to grow at our own pace,” Seiguer says. “We have what we need to succeed and to ramp up our business with the FastForward community as our base. This has included great introductions to our seed investors on the West Coast, New York and Boston.” The support that FastForward provides high-potential startups like WindMIL and emocha not only accelerates the commercialization of life-changing technologies; it helps startups establish roots and grow in Baltimore. This, in turn, creates jobs and revenue for Baltimore. Additionally, as more and more companies start and stay in Baltimore, investors will take notice of the city’s burgeoning innovation ecosystem, creating a virtuous cycle of startup support leading to the commercialization of innovative technologies and the emergence of Baltimore as a leading hub for biohealth innovation.
startup health stakes its future on the 'moonshot mentality' At the recent Startup Health Festival (pictured) the health tech hub unveiled 10 healthcare "moonshots" as well as the audacious goal of seeing 100 years of progress in 25 years. We asked Startup Health co-founder Unity Stoakes to describe the moonshot mentality, and explain why it is so critical. as told to Logan Plaster photos by Monica Semergiu
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e are living in a moment when anything is possible. It's not a time for innovators, entrepreneurs or doctors to be thinking incrementally, because all of these amazing conditions are aligned for extraordinary progress in healthcare. The moonshot mentality is about thinking boldly, doing the impossible and pushing boundaries. Combine that mentality with an army of entrepreneurs – who we call health transformers – and we believe we can make 100 years of progress in 25 years. To do this, we have to rethink everything. A practical example is the idea of a siloed approach to healthcare innovation within institutions. There is currently very little sharing of knowledge or data between facilities. There's been a hoarding mentality. So the first thing that needs to be done is collaboration – break down these silos. Healthcare needs to embrace the open source mentality of the tech industry so that other people can build on your progress.
We also need to completely rethink old business models. Why would we focus on solving cancer in markets where they can't afford the drugs? Or why would we focus on mental health issues in India if there are fewer than 2,000 psychiatrists for 1 billion people. Everyone assumes that we have to focus on markets with the best bottom line. We have to rethink these business models from the ground up. Why is the moonshot mentality important? Because there are billions of people dying of health issues that can be resolved using the tools and technologies that have already been invented. They are on a shelf or in a lab somewhere. They just haven't been unleashed on the world yet. One practical first step is that we need to inspire our most talented doctors to think about innovation in a new way. And that starts at medical school. We're just starting to see early signs of this, which is a good sign for things to come.
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virtual hospitals
The Hospital of the Future Has Arrived Last year Mercy Virtual Care opened a first-of-its-kind facility that could redefine remote patient care. by chuck green
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ooking like it could have been designed by Frank Lloyd Wright, the four story, 125,000 square foot Mercy Virtual Care Center screams modern even before you enter it. A reflecting pool leads from the exterior façade into the spacious lobby. Accents of color compliment elegant white, wooden, and stone surfaces welcoming visitors, while prominent digital LED displays showcase cross-fading historical photos. But it’s the second floor of the Center that most evokes the future of medicine. It’s like you’ve stepped into a massive, perpetually buzzing, super secret society, liberally dotted with seemingly futuristic technology and a knot of specially trained staff, diligently going about its business in tightly choreographed coordination. Providing care to patients both nearby and far—but none in the $54 million firstof-its-kind facility itself—330 specialized medical professionals monitor 2,431 patient beds, of which 458 are occupied by the critically ill. Physicians are seated at a console with six computer monitors filled with a wealth of data to enable them to better assist bedside providers, according to Ashok Palagiri, MD, an intensivist and medical director of TeleICU services at Mercy Virtual, located in St.Louis. Secure web cameras allow them not only to see what’s going on, but also be seen by those on the other side, whether in one of Mercy’s traditional hospitals, a phy32
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sician’s office, or in some cases, the patient’s home. “We have the medical team here, but with technology like highly-sensitive cameras and real-time vital signs, our providers can ‘see’ patients where they are,” explained Palagiri. With its single hub electronic intensive care unit, doctors and nurses monitor patients' vital signs and provide a second set of eyes to bedside caregivers in 30 ICUs across five states, while offering 24/7/365 operations. The facility's also designed to be a workspace for innovations in patient care and product testing. With meeting spaces that boast multiple floor-to-ceiling whiteboards on tracks and giant computer monitors, the building, which opened in October 2015, invites collaboration and new ideas for getting care to patients when and where they need it with less expense.
A Brave New World
According to Deloitte’s 2016 Survey of US Consumers, patients of all demographics, including seniors, as well as caregiversare warming to technology-enabled care. In fact, 48% percent of consumers surveyed were very or somewhat interested in consulting with a doc or other provider using a video connection. Engaged consumers along with value-based care payment models, an aging population that prefers to age in place and an increasing prevalence of chronic disease, are largely driving growth
in new technology development, reported Deloitte. Along those lines, many providers are experimenting with delivering care outside the traditional setting, recognizing the potential efficiency and cost savings of keeping patients out of the hospital, lowering readmission rates, and promoting adherence to care plans. These technologies, often based on Internet of Things applications, will likely begin to transform how health care is delivered and alter hospital, health system, nursing home, and medical device company operating models. The survey found patients are most inter-
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Mercy’s Virtual Care Center is a work space designed to spark collaboration and innovation.
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Dr. Matthew Boland oversees patients in ICUs across the country through Mercy SafeWatch TeleICU.
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ested in using technology for post-surgical care and chronic disease monitoring. Subgroups especially keen on these technologies include those with chronic diseases, millennials for telemedicine, and seniors for remote monitoring. Meantime, an IBM white paper stated that more efficient, digital hospitals are emerging as critical hubs in these integrated healthcare networks, holding the potential to drive greater efficiency, improve quality of care, and provide access for more people than ever. Whether by newly built or retrofitted existing buildings, digital hospitals promise to boost efficiency and quality through better integration with all sources of care and enable deployment of eHealth systems to provide online information, disease management, remote monitoring, and telemedicine services that can extend the reach of scarce medical resources and expertise. Digital hospitals provide faster and safer throughput of patients, creating more capacity through process efficiencies, while containing costs, the paper continued.
The Human Factor
Of course, there are differences between practicing as an E-physician, as doctors do at a place like Mercy Virtual, and practicing at a typical facility. For example, E-physicians aren't physically in a unit, alongside bedside nurses, patients and their families, said Palagiri. However, E- physicians can communicate with them on two-way videos. "It allows us to be visible and part of the team, " he said. “When you're a beside physician and receive a call about a patient, often, the patient's information isn't at your fingertips. Conversely, a virtual clinician can immediately pull up the patient's data, which can be vast, while on the phone with a bedside provider, and make better informed decisions about patient care,” added Palagiri. Nevertheless, he acknowledged it takes E-physicians a while to acclimate themselves with the virtual world and not see patients face to face. “We're trained as physicians in the faceto-face arena with an emphasis on, for ex34
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ample, physical exams, conversations, and time spent with families and patients, said Palagiri. “In the virtual world, our job is to provide an extension of the bedside providers—not a replacement." The physical disconnect between an Ephysician and a patient and his or her family also can be overcome—or at least minimized—with tools like Facebook, Twitter and Skype. "So speaking to a physician over a camera is no longer novel," noted Palagiri. But can that form of communication be slightly more daunting for relatively older physicians, who might not be as accustomed to applications like Facebook? First, the daily routine of an E-hospital physician at Mercy tends to break down into years of experience, said Palagiri. "Newly graduated physicians from a critical care training program are usually just picking up a few shifts a month and spending the majority of their time at the bedside, as they need more experience and time at the bedside to improve their knowledge and skill base." Meanwhile, older physicians who have spent 20 or 30 years or more at the bedside are often looking to move into a virtual position to bridge over to retirement and often work full time in the virtual arena. The intermediate range physicians work anywhere from 25-50% in the virtual arena, and the rest at the bedside. "We encourage the younger physicians to spend as much time at the bedside as possible," Palagiri said. Palarigi believes that for any physician entering a virtual position, the best way to abet their adjustment is to work more shifts
03
Mercy Virtual Care Center is a first-in-class facility for monitoring patients outside its walls 24/7/365.
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Mercy Virtual's first floor lobby
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Balconies and terraces provide Mercy Virtual co-workers with places to rest.
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Mercy SafeWatch, the largest single hub electronic ICU in the nation, provides 24-hour observation of critically ill patients.
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Dr. Ashok Palagiri, an intensivist and medical director of TeleICU services at Mercy Virtual (left), assists bedside medical teams virtually.
in the virtual arena, and feel at ease with the technology. "The older physicians that apply for virtual positions are usually more adept at using newer technology," Palagiri pointed out. "What an older physician may lack in technological prowess, they make up for with a greater comfort level in treating sicker patients and a multitude of presentations, all from having greater experience, than a newer physician that is familiar with newer technology.”
Filling the Void
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Accordfing to Palagiri, E-physicians often fill a void, such as lack of night time physicians or intensivists. "They're actually bridging and improving the connectivity that the bedside physician and family currently have," he said. In fact, Mercy staff members often hear that the families and patients feel "an added layer of comfort knowing a virtual team is available to assist the bedside staff during periods when they may be otherwise occupied and when bedside physicians aren't available." During the virtual day shifts, the hospital focuses on providing consultation type notes for facilities that don't include intensivists on staff, he explained. "These consultations assist the medical staff with patient care and also determining if patients can remain at their facility, or need to transfer to higher levels of care."
Additionally, during night shifts, the facility assumes the role of the bedside intensivist (without procedures), Palagiri explained. "The E-physician not only takes calls from the bedside nurses and physicians, but also reviews data and alerts that many times can identify deteriorating patients sooner rather than later." "A large part of our clinical work is done at night, to allow the bedside physicians rest, and provide coverage that otherwise wouldn't exist, creating a gap in communication outside of the handoffs between shifts," he said. Still, at least in some ways, practicing as an E-hospital physician can spark a different dynamic with colleagues, Palagiri said. "It takes a longer time for bedside colleagues to become comfortable with their virtual partners—more so than if a new bedside partner was hired." However, this
process is eased when you sit with your colleagues at meetings, and walk by them in the halls of the hospital. “You become comfortable with them and are able to have spur of the moment conversations, which builds relationships," he said. Palagiri believes it's only a matter of time before E-hospital physicians become a greater part of healthcare. "I believe this isn't a question of 'What if ?' but when. As the virtual concept continues to grow and institutions become more comfortable with it, I think patient care will improve and we'll finally overcome the day/night and weekday/weekend dichotomy that's existed in medicine for years… Bedside physicians will accept their virtual counterparts as true medical partners and patients will receive true 24 hours a day, seven days a week, 365 days a year care." www.telemedmag.com
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school - based telehealth
Telemedicine's Greatest Benefits May Come Through School-Based Programs School-based telehealth programs keep parents at work and kids in the classroom, a win-win for families and the community. Brian Robertson, PhD Michiko Clutter, PhD & Julie Hall-Barrow, EdD by
I
magine waking up in the middle of the night. Your child is sick, and you are afraid for their well-being. An emergency room is not available, and there are no paramedics around. You need medical advice and your child needs attention, so you call your child’s pediatrician. They listen to your child breathe and cough over the phone, quickly diagnosing your child based on what they can hear. They then reassure you that the problem is of little concern, that everyone can go back to sleep, and that the physician will see you in the morning. Your fears and concerns are relieved, and it was all due to technology. This may sound like a familiar situation in how we leverage technology to quickly meet our medical needs with minimal disruption to our lives. Telemedicine has the ability for rapid assessment, treatment, and referral all at the patient’s convenience. But the scenario above is likely the first documented use of telemedicine where a physician was able to allay a parent’s fear that their child did not have the croup. The year was 1879; thee years after Alexander Graham Bell transmitted his famous words to his assistant, ushering in the telephone era. While technology has drastically improved over the next near century and a half, the key tenets of why people use telehealth have not: speed, efficacy, and convenience. While that first instance of telehealth was limited to auditory assessments, 36
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today’s technology includes audio, video, and peripherals capable of transmitting blood pressure, temperature, heart rate, and blood oxygen to a distant physician capable of writing and delivering a prescription in a matter of minutes. Technological advances have allowed telehealth to move from triage to treatment, and with that advance came rapid deployment across a number of environments, including schools. One of the most significant benefits to telehealth programs is the ability to provide care for non-emergent medical issues with minimal inconvenience to the patient. That increased convenience may be through a kiosk down the road, one in the child’s school, or even an application on a mobile device. Regardless of how people virtually connect to a physician, they are connecting for the single purpose of receiving near-immediate care with minimal disruption to their personal life. While virtual physicians have limitations to a physical physician (such as equipment, visuals, and connectivity), the speed and convenience of care remains a primary advantage of virtual health over inperson physicians. “I was scrambling to find someone to pick up my daughter and take her to the doctor until I remembered we had signed up for this [program]. My daughter missed a minimal amount of class and I was able to pick up meds on my lunch break and bring them to her.”
This comment came from a parent of a student who utilized the Children’s Health System of Texas’ (CHST) school-based telehealth program. Similar to that first use case in 1879, it illustrates the ideal scenario for school-based telehealth: A working caregiver with an inflexible schedule, a child with a medical need, an effective medical solution, and a child who is able to be treated in school and returned to class. Beyond the reason for using telehealth lies the outcome of the interaction. Did the patient get their medical needs met? Was their care accurate or did they need additional care from their primary physician? Where else would they have gone without it? Did we save them money? What was the total benefit of the service? These questions are key components to the effectiveness of telehealth: accurate diagnoses and comparable treatment to standard medical practice. These are simple questions; however, several challenges exist prohibiting the direct assessment of these questions. Many telemedicine services aren’t structured for direct follow-up, and some services are contracted to a different party so that outcomes cannot be objectively captured. These elements make the direct assessment of virtual health outcomes very difficult. In the case of the school telehealth program at Children’s Health System of Texas, surveys were deployed to both school nurses and caregivers to assess multiple perspectives on both outcomes and satisfaction. These topics covered the areas of needing additional care, preventing absenteeism, and averting emergency and urgent care centers in addition to overall satisfaction and willingness to recommend telemedicine services to others. Along with telehealth’s convenience is the ability to be seen by a physician without having to leave work. In the case of school telehealth, it saves a parent or caregiver the need to leave work, pick up the child, and take them to see a physician. In cases of hourly workers who have no paid time off benefits, this can result in significant income losses. Further, in cases where the child could have returned to school, these situa-
Telemedicine in Schools
by the numbers ---Would YOU have missed work if your child had not received school telehealth services? No 26%
Yes 74%
Would the CHILD have missed school without the school-based telehealth program? (As reported by school nurses.) No 31%
Yes 69%
According to caregivers, 51% of children would have missed up to a full day of school without the telehealth program Yes 51% No 49%
tions result in unnecessary losses in income. All caregivers were asked if they would have missed work without the school-based telehealth program, and 74% of respondents reported that they would have had to miss work. In addition, over 70% of the caregivers report saving up to four hours with the
school telehealth program, and 67% report that it saved up 25 miles of travel, resulting in additional $13.75 directly back in the caregiver’s pocket when factoring in a rate of $0.55 per mile for travel costs. In conjunction with keeping caregivers at work is the ability to also keep children in school for minor medical problems. When asked if the student would have missed school without the school telehealth program, 69% of nurses responded that the child would have left school. Further, 51% of caregivers report that their child would have missed up to a full day of school. At a projected reimbursement rate of $53 per day over a 180-day school year, our programs may have saved over $350,000 to schools on reduced absenteeism alone since the program’s inception. Another benefit of telemedicine programs is the ability to provide care for low-acuity visits. In many cases, time, as opposed to either insurance status or the presence of a primary care physician, is a more significant indicator of where care will be received. A patient may have primary care, but when that fact is coupled either with potential loss of income or extended wait times for the next available physician appointment, places such as emergency rooms and urgent care centers become viable options not for emergency care, but for immediate care. One challenge with this approach is that low-acuity visits in the emergency room not only take up valuable resources for emergency needs, but may also lack the interventions required to generate income. Further, the cost burden to the patient and the insurer is significant when comparing costs of care. When asked if patients would have gone to emergency or urgent care centers, more than two-thirds of the school nurses agreed that the child would have gone to one of these two centers. Almost one-quarter of caregivers provided the same response. Given the cost differences between urgent care, emergency care, and school-based telehealth, we estimate that nearly $1 million has been saved to payors in cost avoidance since the program’s inception. A critical component of any effective ser-
vice is user satisfaction. Previous conversations with patients on primary care physicians have found that patients will stay with a provider they like despite some inconveniences (such as long wait times or limited availability). At the same time, a highly effective program will see limited use if the customers are not satisfied with the service. To that end, the school telehealth program has three different customers: the parent, the child, and the school nurse. Based on survey responses, 91% of the caregivers report positive satisfaction levels with the program, including 85% who are “very satisfied,” and 6% who are “somewhat satisfied.” In fact, only 5% of the respondents were dissatisfied with the service. Where parents have an array of responses to satisfaction levels, nurse satisfaction is more heavily-weighted toward positive satisfaction. In our findings, 95% of the nurses report positive satisfaction (74% were very satisfied) and there were no dissatisfied responses. The remaining 5% in the sample reported neither positive nor negative satisfaction. Another key indicator of a program’s ability to provide quality services is to examine the willingness to recommend services. On a scale of 0-10 with 10 being “highly likely to recommend services,” the average rating for caregivers was 7.69 out of 10. This is somewhat misleading in that 78% reported being “very willing to recommend” school telehealth, and only 4% responded that were not likely to recommend services. Nurses report more favorable responses with an average score of 9.39 out of 10, and only 3% not likely to recommend services. At the heart of the school-based telehealth program is effectively treating the child’s medical needs. The impact of this program, however, reaches far beyond the delivery of clinical care. It is a convenient, patient-centered solution that impacts the child, the nurse, the school, and the caregiver. The ability to provide effective care in a convenient location, at a convenient time, while saving the caregiver time (and a little money), is a welcomed service in a time where most budgets are being tightened. www.telemedmag.com
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trend analysis
Virtual Care Trend Watch Market trends (and a few bold predictions) in the evolution of the telehealth and telemedicine landscape by aneel irfan
I
n this series we will examine the current state of virtual healthcare and plot a few important trends to watch.
Value-based payment
The arrival of value-based payment is no longer something of the future. 2017 will finally bring on the true age of innovative payment models and performance-based payment adjustments/incentives. These changes will not only effect physicians accepting and billing medicare but also commercial payors. These payors have already started to initiate programs modeled after CMS’s MACRA. As I have written many times, telehealth tools will be critical in achieving these performance-based incentives by cutting costs for virtual visits while increasing patient engagement and access, which are pillars of value-based care. Many that will begin down the road of value-based payment will quickly learn that deploying a telehealth program will not only make reporting, measuring and attaining incentives in these alternative payment models easier, 38
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but a necessity to compete in the healthcare marketplace. Also, pending legislation such as the Connect 4 Health ACT (which we covered in issue #6) will provide reimbursement regulations and make it attractive for entities to utilize telehealth. Though a ton is up in the air in regards to an impending ACA repeal with our new administration, legal experts I've talked to in D.C. say that you can count on these value-based payment reforms to stay intact. A lot of the telehealth bills like the Connect 4 Health Act that still have strong bi-partisan support are likely to be reintroduced.
Demand for interoperability will create even more strategic partnerships.
The days of telemedicine solutions existing alongside a health system or provider’s EMR – rather than being fully integrated – are coming to an end. Previously, a lot of telemedicine solutions separated the EMR to avoid the time and cost associated with having a true (HL7) interface completed,
which is the type of file format necessary for clinical software programs to exchange health data securely. All certified EMRs have to be HL7 compliant to achieve Meaningful Use incentives and have the ability to support these interfaces. They all can be interfaced, but the cost of integration is still enormous, especially for large health systems that have already dished out millions for EMR implementations. The hospital is then asked to spend money on another interface for their telemedicine solution, which is projected to have low utilization early on. Not surprisingly, may hospital systems saw these additional integrations not as “must haves” but as features that they could grow into. That thought has changed. With more and more providers/healthcare systems now tied to the hip with their EMRs for Meaningful Use attestation, having integration with their telemedicine platform is going to become a requirement for many, and an industry standard. The EMR market in which EPIC and CERNER have now become the top dogs, is full of partnerships with leading telemedicine companies. I believe this will dictate the winners of the telemedicine market share race. Partnerships like Vidyo + EPIC and CERNER + American Well are very influential. To clarify, these are strategic partnerships that are basically agreements that have allowed the companies to begin the process of opening up the capabilities of seamless integrations between the platforms. This could become a huge competitive advantage for these telemedicine companies, having already drawn out technical pathways for integrations with the biggest players in the EMR market and easy access to those established customer bases should allow them to capture an unprecedented market share in the upcoming years. Expect many other telemedicine companies to follow suit. Healthcare providers are inundated with their electronic medical record systems; asking them to work outside these systems just won’t cut it. The bi-products of these integrations should be improved workflows, increased adoption and better
continuity of care.
Virtual visits alone won’t be enough.
The remote patient monitoring market saw a big jump in the last year. In 2016, 7.1 million patients enrolled in some form of digital health program featuring connected medical devices as a core part of their care plan. Swedish market research firm Berg Insight, which specializes in internet-ofthings (IoT) verticals, tracked a 44 percent jump in remotely-monitored patients last year. While that’s not counting the various connected devices used for personal health tracking, the researchers predict that will begin to play a larger role in healthcare. They estimate that the number of remotely monitored patients will reach 50.2 million in the next four years, with 25.2 million comprised of those with connected home medical monitoring devices and the rest coming from personal devices. For providers, this means becoming savvy with their
yossi bahagon
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care plans to balance in-person encounters with virtual visits and remote monitoring. For example, healthcare providers will need to focus on patient selection in order to identify the patient profiles best fit for a monitoring program. It is not feasible to monitor each and every patient. A remote patient monitoring program has associated fixed costs. Identifying your high risk patient populations, specifically ones with chronic disease that are most likely to be readmitted, will be vital. Care teams capturing consistent data from patients, proactively catching downward trends in their conditions and swiftly intervening with virtual visits from case managers are all strategies that not only cut costs but have been proven to improve outcomes long term in patients. Which takes us right back to the impending value-based payments mentioned earlier, which at their core are about slashing costs and reporting quality healthcare
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I would say is to learn to listen. Both sides – not just them listen to me but also me listening very, very carefully to what they say. And if you are not in a true listening mode, bi-directional, it will fail for sure. TM: What has been your experience in terms of entering the U.S. healthcare market? BAHAGON: The U.S. is a really great place for digital health because the system is becoming more and more digital. They have the budgets in place. Everybody understands the value proposition. On the challenging side, there is a lot of noise in the U.S. Meaning, even if you come with a great team and with a great solution, you will find 20 more companies claiming that they do the same thing that you do, whether they do it or not. At the end, I believe the leaders will show themselves and stand out in the crowd. That’s the reason why companies, in order to stand out,
outcomes. Having the tremendous capabilities of collecting vast amounts of clinical data on large patient populations should make remote patient monitoring an essential practice at the epicenter of the healthcare ecosystem in years to come.
What's in a name?
Digital health, telehealth, virtual health or whatever buzzword you wish to use, my position is that eventually this will all just be plain old healthcare. It will just be clinicians providing care while comprehensively leveraging technology to do so. If you haven’t planned for this or put a strategy into motion, you may already be behind the curve. Though there will be many future changes in the market, the foundational principles of these practices have been laid. The good news is that it’s just the second quarter, and there's time to get off the sidelines and into the virtual healthcare game.
27
need to raise tens of millions of dollars. And when you raise these amounts of money, it becomes a chicken and egg problem. Now you have to sell your product at a very high price in order to bring the money back to your investors and to survive. TM: Is there a way around that vicious cycle? BAHAGON: What I recommend – and this is not trivial – is that start-ups try and go global as fast as they can. Sometimes they say, “Listen, I don’t have enough money to go global. It will defocus my efforts.” And I’m not saying it’s easy to go global. But if you want to go only to the U.S. market, take into account that you will need $30 million to start with. If you think globally, maybe you can create your initial penetration in easier, cheaper countries and then penetrate the U.S.
TM: What’s a practical way to collaborate internaionally? BAHAGON: One of the ways is definitely OurCrowd. OurCrowd is currently the most active VC in Israel, by far. Allen Kamer – a successful digital health entrepreneur himself who sold his last health analytics company to United Healthcare – and I established this digital health fund a month ago. We keep a database of all the digital health companies in Israel. The second resource that I would recommend is an organization named Start-Up Nation Central, which is a not-forprofit organization that gives a bridge to outside investors, organizations, in healthcare and beyond. The third way is through the Authority of Innovation in Israel. It’s a small community. So, we all know each other. We brainstorm from time to time on how to raise and grow this industry in Israel. www.telemedmag.com
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the
marketplace
ENGAGE! 2017 Spring Telehealth Conference Schedule Region
Conference
Mid-Atlantic
Great Plains
Dates
Location
For More Information
MATRC 2017 Telehealth April 2-4 Summit: Quality and Innovation in Health Care
Leesburg, VA
MATRCsummit.org
Telehealth – Bringing Virtual Care to the Consumer
Minneapolis, MN
gpTRAC.org
Leesburg, VA
LearnTelehealth.org/searchsymposium-2017
April 3-4
South Central/ SEARCH2017 – Telehealth April 4-5 Mid-Atlantic Research Symposium Northwest
Next Generation April 10-12 Seattle, WA Healthcare: Optimizing Your Telehealth Programs
NRTRC.org/annual-conference
Northeast
Taking Telehealth Mainstream
May 23-24
Amherst, MA
NETRC.org/conference
California
California Telehealth Summit
June 5-7
Newport Beach, CA CALTRC.org/telehealth-summit
Telehealth Resource Centers are federally funded by the Office for the Advancement of Telehealth (DHHS/HRSA). Learn more at: TelehealthResourceCenters.org
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tele
port
Rising to the Fall Challenge Personal Emergency Response Systems give way to fall detection, risk stratification and fall prediction by Nicholas Genes, MD, PhD
I
t's generally agreed that reducing hospitalizations and minimizing hospital length of stay is in the best interest of elderly patients, as it prevents infections, deconditioning, and episodes of delirium.
On the other hand, less time in the hospital means the elderly patient is no longer under the health system's watchful eye. This problem can be partially solved by empowering patients to collect their own vital signs and other biometric data. But what if the flow of data stops? Is it a temporary disruption, or an actual emergency? How can a patient who falls, or is otherwise incapacitated, reach out for help? As the population ages, and as pressure mounts to keep patients out of the hospital, these questions grow in urgency. Falls have been called "the great plague of the modern era," already affecting one in four elderly U.S. patients each year, leading to millions of ED visits and almost a million hospitalizations. Falls have become the leading cause of accidental death among the elderly, with the CDC reporting an increasing death rate over the past decade. Survivors are often left with debilitating injuries, including fractures and concussions. Remote monitoring of falls and other emergencies dates back to the 1970s, when gerontologist Dr. Andrew Dibner and his sociologist wife, Dr. Susan Dibner, patented a wireless alarm system that could be activated by a portable push button. Their first personal emergency response system (PERS) was a simple auto-dialer that sent a pre-recorded message to the service in the event of a button press, or if too much time elapsed without routine telephone usage. After promising early controlled trials showed cost savings and reduced time spent in nursing homes, the company, Lifeline Systems, Inc., expanded operations and developed a central call center. By 1983 Lifeline had over 20,000 subscribers wearing an emergency pushbutton neck pendant or wristband. An industry sprang up, with companies like LifeCall running a campy, dramatized commercial beginning in the late 1980s featuring an elderly woman who exclaimed, “I’ve fallen, and I can’t get up!” The service could also be set to notify primary care doctors or desig42
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nated family members. Even as the popularity of PERS exploded, new methods of fall detection emerged, such as wearable accelerometers and impact detectors, specialized motion detectors, cameras and microphone setups, and floor pressure sensors. Few peer-reviewed studies exist comparing the real-world effectiveness of various systems, but there’s definitely a trade-off: a passive monitoring system that can automatically activate emergency response, even if the patient is unconscious, can certainly catch more events than a user-activated system, but is also prone to more false alarms. And patients tend to view automated monitors with suspicion and distrust. As passive monitoring technology is refined, however, its appeal should grow – at least among insurers and managed care organizations. A major benefit to the systems consisting of cameras, microphones and distributed sensors is the abundance of collected data. Properly analyzed, this data can aid efforts at risk stratification and ultimately, fall prediction. For example, the use of GE QuietCare’s passive monitoring system at an assisted living facility was able to give health professionals insight into patient’s sleep behavior, and performance of activities of daily living. This permitted the administration to make more informed selections of supervision and care level. A peer-reviewed study of QuietCare showed the system’s insights into appropriate placement led to patients experiencing fewer falls, fewer hospitalizations, and fewer transfers to nursing homes. We might expect some peace of mind after equipping our elderly parents’ homes to detect emergencies. But that could quickly turn to a sense of betrayal if the network of sensors and cameras analyzes their gait and sleep, only to conclude they’re better off living in another setting. To me, it seems that these systems can improve patient outcomes, but we might not accept the recommendations if they tell us something we don’t want to hear. The button-activated speakerphone system from decades ago is outdated technology, but at least it was entirely under the control of the patients. We may look back on personal emergency response systems as a state we’ve fallen from…and can’t get back up to.
]
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