The mHealth Toolbox: Real physicians review the industry's latest tech
Bathroom sync: Inside the wired water closet
Six ways you might be violating HIPAA
WHEN WEARABLES DISAPPEAR
NODE brings evidence-based reviews to the med tech market 1
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WWW.TELEMEDMAG.COM ISSUE 5 / SUMMER 2016 Editor's Desk_4 Telehealth Regional News_6 ------telescope
Respiratory Care: Cohero puts a wireless spirometer in the palm of your hand. Plus, SpiroCall asks: Why can't any old phone become a spirometer?_9 Optometry: Trouble for Opternative: The Establishment Fights Back_11 Security: Six ways you might be violating HIPAA, plus why "antifragile systems" could be the future of med tech security._12 Mental Health: Telemedicine for the Soul_14 ------teletech
At the mHealth Toolbox, physicians give candid reviews of the latest med tech gadgetry_17 The Smart Bathroom_20 Data Dive: Teladoc's 1 million patient visits_22
pBathroom Sync_Page 20 How a smart bathroom could be the ultimate health tracker.
Hall-Barrow: It all starts with the children_23 Gordon: Process drives your billion dollar valuation_24 Hollander: CONNECT For Health Act – Discussions on the hill_25 Atreja: Evidence-based med tech reviews_27 ------startup
Theranos: Spinning hype into start-up gold_29
p The Gear Lab: Examining the industry's only FDA cleared mobile spirometer
p Seth Sternberg, CEO/Founder of Honor, shares his advice on growing and retaining a great team
p Today’s apps and devices for VR mostly focus on entertainment – but it wasn't always this way.
In the UK, innovation with a doctor's touch_30 Bootstrap it: 3 reasons NOT to raise funding_32 ------features
Finally, a telemedicine bill that has a chance_33 When wearables disappear_36 ---teleport
Virtual reality check_50
Tech From Medicine's Front Lines
In May we gathered in Minneapolis to celebrate another banner year in telemedicine. A big thank you to the hundreds of new friends who were able to make it to our 2nd annual ATA Party. And if you couldn't, here's hoping we see you in Orlando next year.
his past April, I boarded a plane for South Africa and I said an extra prayer that my baggage would arrive safely. Crammed into my suitcase were some of the most interesting new med tech gadgets and wearables on the market, from the Scanadu Scout to the VitalConnect HealthPatch. I was headed to Cape Town for Telemedicine's first mHealth Toolbox, a two-day event that would seek to introduce the building blocks of medical innovation to nearly 100 practicing physicians. The workshop included didactic sessions led by industry leaders from the U.S. and South Africa. But the main event was the gear lab, during which physicians got to play with the aforementioned gadgets – most of which they'd never laid eyes on before. They took each other's vitals using the latest consumer-facing monitoring devices and they experimented with virtual reality headsets. Some devices were hits (like the EMS drone), others were misses, but one recurring comment stuck with me. "This is so cool . . . but it would never never work with my patients." Whenever I heard this, I would To our med tech ask why. industry readers, "It's too hard to open for arthritic hands." don't fly solo. If "It takes too long to boot up." you want to address "It's just too glitchy for the hospital setting." Perhaps counter-intuitively, these responses were real problems with just what I was hoping for. This "I love it, BUT..." practical solutions mentality spoke to the ethos of The mHealth Tool- that will last, get box, and Telemedicine Magazine itself. We weren't docs involved from hosting this workshop to create consumers – there was nary a salesman in site. Our aim was to inspire day one. physicians to see themselves as innovators. At Telemedicine Magazine, we believe that medical innovation needs to begin at the bedside, and in the hands of clinicians who treat real patients. In this issue, we hear from a range of voices who have sought to elevate the practical over the fantastic. In the Scope section, we see how SpiroCall (page 10) took the idea of a mobile spirometer to a radically patient-focused level. By creating a call-in service that can analyze a patient's lung function from just about any phone in the world, SpiroCall opened up mobile respiratory care to low-income countries. In our Vision essays, you'll find an interview with Ashish Atreja, a man on a mission to bring more practical physician accountability to the med tech industry (page 27). Atreja, in an interview with editor Nicholas Genes, explains how his new NODE collective will finally bring evidence-based reviews to bear on the digital health market. We look forward to exciting things from this group in coming years. Finally, in Start-Ups, we meet three UK-based companies founded by physicians (page 30). Part of the "Doctorpreneurs" network, these three teams emphasize the role of on-theground clinicians in medical innovation. "You can’t make a solution to a problem without knowing the problem," says Touch Surgery co-founder Jean Neme. "That’s why I think doctors should be in this space." We couldn't agree more. To our physician readers, I encourage you to grasp the importance of your front line experience to the broader world of medical innovation. To our med tech industry readers: don't fly solo. If you want to address real problems with practical solutions that will last, get docs involved from day one.
telemedicine ISSUE 5 – SUMMER 2016 I set a hard stop and always try to make it home for dinner. That firm end-of-day deadline helps me focus during the afternoon.
Logan Plaster firstname.lastname@example.org
What daily ritual/ habit/practice is key to your productivity?
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FOUNDER / EXECUTIVE EDITOR
Mark Plaster, MD
I have a list of daily goals that I write down and check off that are the result of a brief daily meeting with my staff.
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Streaks is the name of a great app that encourages you to make good habits – whether it's about work, writing, food, exercise, or anything new you're trying to do consistently. When all else fails, I don't want to break a streak!
Dark roast, 30 grams + Kalita wave dripper with a paper filter. Water to violent boil, let stand for 45 seconds. Add 15 grams of water to coffee, wait, then add 45 grams. Drink.
EDITORS AT LARGE
Nicholas Genes, MD, PhD CONTRIBUTORS
Lonnie Stoltzfoos Scott Jung Tim Felz Whatever is most important, do it first. Staying off social media and not opening my inbox first thing in the morning are my two key factors for productivity.
Graham Plaster Dr. Vishaal Virani John Tyler Allen
Mark Lemanski Leonard Peng
Make time for lunch – it helps reinvigorate the mind, and avoids embarrassing stomach rumblings at important meetings!
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
Always remember that helping others transform health care is easier than doing it on your own.
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Telemedicine Magazine is published quarterly by M. L. Plaster Publishing Co., LLC. PO Box 121, Galesville, MD, 20765. Editorial offices located at 68 Jay Street, Suite 412, Brooklyn, NY, 11201. Printed in the USA. Copyright ©2016. To purchase a subscription, go to www.telemedmag.com/subscribe
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Regional Updates from the Consortium of Telehealth Resource Centers intro
In this installment of our regional news, you will see reports on the heavy legislative activity across the country, the few provider requests for telehealth specific surveys and state wide telehealth studies that are kicking off this summer. Also, some brand new service offerings are being introduced by the TRC consortium. And as always, this rundown offers a chance to mark your calendars for upcoming telehealth events in your region. edited by aneel irfan email@example.com
NRTRC's 5th annual conference, held in Seattle in March, was a great success. Speakers like Drs. Jay Sanders and Kristi Henderson captivated attendees. There has been a lot of regulatory movement in this region of which NWTRC has been vital in moving forward. Resolution (SCR 26) was adopted in Alaska to require insurance coverage for mental health benefits provided through telemedicine. Interstate Medical Licensure Compact bills continue movement in Alaska (HB 238) and Colorado (HB 1047). Washington has reintroduced the compact language (SB 6228). Private payer reimbursement bill (HB 1403) was reintroduced in Washington as well. Washington also enacted SB 6519 to add the home as an eligible originating site for private payer plans. A newly adopted rule (effective June 1) allows for school-based health services to be delivered via telemedicine in WA’s Medicaid program.
The Florida Workgroups were successful in helping pass legislation in Florida after five years of failed attempts. HB7087 calls for a council to be formed in efforts to collect and analyze data from providers across the state. The bill also mandates payers to report their reimbursement of telehealth services. The study kicks off in July with the goal to take into account all the data collected with a focus on reimbursement to draft comprehensive legislation in next year’s session. Upcoming events: 5th Annual Alabama Telehealth Summit, August 9th, at the UAB Hill Student Center in Birmingham, AL. 3rd Annual Florida Telehealth Summit, November 16-17, at the Safety Harbor Resort and Spa in Safety Harbor, Florida. In partnership with the FL Partnership for Telehealth, the FL Telehealth Workgroups and Florida State University College of Medicine.
Join the Southwest Telehealth Resource Center at the Telemedicine & Telehealth Service Provider Showcase (SPS), June 21-22, 2016 in Phoenix, AZ. SPS is the only conference focused on building successful telemedicine partnerships. Hear from 29 nationally recognized experts about creating telehealth models and strategies that work; succeeding as a service provider; finding the perfect clinical tele-specialty services provider; negotiating the legal, regulatory, and payment hurdles; and successfully integrating teleproviders into your organization’s work flows. Visit more than 35 exhibitors, including some of the best-known companies in the industry, and see the latest clinical telehealth services and technology. Network with health-care administrators, telehealth service providers, telehealth solutions vendors, and speakers over lunches and coffee. Register now! Go to ttspsworld.com.
contact: bob wolverton
contact: lloyd sirmons
contact: kristine erps firstname.lastname@example.org
The 2016 Rural Health at the Crossroads Conference is coming June 20 – 21, 2016 at the Overton Hotel and Conference Center in Lubbock, Texas. TexLa TRC is collaborating with AHEC, to offer both a telehealth track and community health worker track looking at “Building Bridges to Care.” Telehealth sessions will include school-based telehealth, tele-behavioral health, legislative updates for Texas and Louisiana, and a tour of our new Frontiers in Telemedicine training lab. For more, go to www.texlatrc. org/crossroads_conference. html. Frontiers in Telemedicine, a one-of-a-kind training program for clinicians specific to telemedicine, started training January 2016 and has enrolled 86 clinicians. The program focuses on competency-based learning and features a combination of online content and hands-on simulated learning. Successful completion of the course awards 18 CME or CNE hours.
A new program launched by neurologists at UR Medicine will expand access to care and serve as a national model for the management of Parkinson’s disease and other chronic illnesses. The Parkinson’s Disease Care, New York (PDCNY) program will be a largely virtual network providing free care to as many as 500 underserved patients across the state. Dr. Kenneth McConnochie, University of Rochester Medicine, addressed Capitol Hill to advocate for Medicaid funding for telemedicine. Dr. McConnochie’s white paper presented to the Senate outlines the success of the Health-e-Access Connected Care model, a Rochesterbased telemedicine network allowing children in the city school district to be treated by a physician at their school, daycare or other remote setting. Visit NETRC. org to view a comprehensive collection of publicly available articles and other publications for all aspects of telehealth.
At the 2016 MATRC Telehealth Summit, Dr. Chris Gibbons, Chief Innovation Officer of the FCC’s Connect 4 Health Task force, gave attendees a look into the future of telehealth and the role virtual reality may play. On the legislative front, West Virginia Gov. Earl Ray Tomblin (D) signed into law, on March 24, 2016 House Bill No. 4463, implementing a variety of telemedicine practice standards and remote prescribing rules in the Mountain State. It will be effective June 11, 2016. The new statute may potentially require the Board of Medicine to rewrite some of its current telemedicine rules to the extent the prior rules conflict with the controlling provisions of the statute. West Virginia’s Medical Board previously issued a Telemedicine Position Statement in November, 2014. For more information on the region’s telehealth activity along with speaker presentations from the summit visit MATRC.org.
Montana’s diabetes prevention program has expanded to include 14 telehealth sites. Recent research has demonstrated the telehealth component to be as effective as the in-person class, with similar weight loss outcomes and efficacy, at an average of $90 less than the face-to-face alternative. Montana’s DPP has expanded to 35 sites. The program has assisted over 6,000 high-risk Montanans, and has reduced the annual incidence rate of diabetes in the state by an estimated 19.3 percent. In rural southeastern Kansas, communities are partnering with the University of Kansas Medical Center (KUMC) as part of a 3-year, grant-funded initiative to improve autism and developmental disorder outcomes through the use of TeleECHO clinics. In legislative news, an Oklahoma State Senate bill expanding the definition of optometry to include telehealth was signed into a law by Oklahoma Governor Mary Fallin.
contact: becky jones
contact: andrew solomon
contact: kathy wibberly
contact: janine gracy
The SCTRC is conducting research in Tennessee assessing the current and future state of telehealth in the state. If you are a Telehealth provider in Tennessee and would like to participate, contact Brittany Beasley at email@example.com. The results will be discussed at the South Central Telehealth Forum (#SCTF2016) in Nashville on August 1-2. The South Central Telehealth Forum will be held at The Sheraton Music City Hotel in Nashville, TN. Network with healthcare professionals from 7 states, take part in 8 tracks over two days, including over 40 sessions and state meetings to choose from. Keynotes include Mario Gutierrez, Executive Director of the Center for Connected Health Policy, and Alan Morgan, CEO, National Rural Health Association. You will also be able to attend a highly anticipated special red carpet, cocktails and hors d’oeuvres event for the documentary premiere of UNDERSERVED – Telehealth in America.
The California Telehealth Resource Center is offering four free Telehealth Implementation Work Groups each year on a first-come, first served basis. These four-hour sessions cover five major phases of implementation, from conducting a needs assessment, through launching and sustaining a well-planned program. Hands-on equipment training and operations consulting are also available from the CTRC team, who have provided training to 235 sites within the past 4 years. Visit CTRC at www. caltrc.org. Cyber security and intrusion alert services are available to all California Telehealth Network (CTN) clinics and hospitals as part of their standard CTN participation agreements. Annually, CTN detects and diverts an average of 12 million cyber-attack attempts on participating sites. Find out more: www.caltelehealth. org/cyber-security
The PBTRC serves as a telehealth information resource and a telehealth communitybuilding organization. The PBTRC goal is to assist in the development of existing and new telehealth networks and offer education, training, strategic planning and background information regarding telehealth technology, medical information technology infrastructure, mobile health applications, and telehealth creation, growth and maintenance. On January 7, 2016, the Pacific Basin Telehealth Resource Center co-hosted a Telehealth Policy Workshop with the Honorable Senator Brian Schatz. The workshop, entitled Policy Workshop on Telehealth Opportunities in Hawaii: Planning A Way Forward, brought together key telehealth stakeholders and leaders in the state of Hawaii to discuss and plan tangible next steps to advance telehealth in Hawaii in regards to reimbursement, malpractice coverage, capacity building, health disparities, and others.
contact: kathy chorba firstname.lastname@example.org
contact: erin bush
contact: deborah birkmire-
Want to be included in Telemedicine’s next TRC Regional News? contact aneel irfan
telescope Telemedicine briefs across the medical universe --featuring Respiratory Care Optometry Security Mental Health
3 The system has been shown to improve medication adherence, enhance clinical decision-making and prevent disease complications for patients with respiratory diseases.
5 Cohero Health’s platform pushes medication adherence, spirometry and pulmonary function data directly to an EMR system, smartphone, tablet and physician portal.
4 The proprietary platform allows patients, care givers, and physicians to track medication utilization and measure lung function in real-time.
Cohero Health Puts A Wireless Spirometer in the Palm of Your Hand Gone are the days when testing pulmonary function means using expensive, specialized equipment. Cohero leads a new generation of mobile respiratory products that put lung testing in the palm of your hand, and are as simple as exhaling a puff of air.
1 Industry’s only FDA cleared mobile spirometer
2 Includes wireless medication inhaler sensors and an engaging – gamified – mobile app. www.telemedmag.com
THE BURDEN OF PULMONARY DISEASE By the Numbers
Could Any Old Phone Become a Spirometer? A smartphone that measures lung sounds? Sure. But now, even dumbphones are getting in on the action. by Lonnie Stoltzfoos
Technology that was first rolled out in 2012 as a smartphone app has now been adapted so that virtually any telephone connection—cell phone, landline, or internet call—can be used to analyze a person’s pulmonary function in the clinic. The smartphone app, SpiroSmart, recorded the sound of a person’s exhalations and uploaded the audio file to a central server, which employed multiple regression algorithms to reliably measure lung function by using a physiological model of the vocal tract and by accounting for the sound of reverberation around the user’s head. Most people in lowand middle-income countries do not have access to smartphones, however, so the inventors created SpiroCall, in which a central server analyzes audio data transmitted via cellphone
network (GSM) during an ordinary call. Audio submitted via GSM networks is of lower quality, so the inventors tweaked the algorithms to account for those degradations. The inventors recruited a sample of 50 people to test SpiroCall (age range: 21–67 years; n=30 male; n=20 female). Thirty-two percent of participants reported an existing lung ailment, of whom two-thirds reported asthma. All participants completed spirometry on two FDA-approved clinical spirometers, and on SpiroCall, using a range of telephones devices. Across the four major measurements of lung function (FVC, FEV1, FEV1%, and PEF), the mean error rate of SpiroCall spirometry was 6.2%, below the clinically accepted error range of 7%–10%. SpiroCall performed best at measuring FEV1%, the most common measure used in clinical diagnosis; the error rate for FEV1% was below 6% across all study conditions. One remaining challenge for SpiroCall is that health workers need to show users how to exhale properly for the test, and how to hold the phone. The SpiroSmart smartphone app attempts to train the user to conduct the test independently but, to date, SpiroCall will work best under supervision in the clinic. https://ubicomplab.cs.washington.edu/projects/ SpiroSmart
Chronic obstructive pulmonary disorder (COPD) affects 210 million people
90% of COPD deaths occur in low-income and middle-income countries
COPD is projected to be the fourth leading cause of death by 2030, up from the fifth cause in 2002
235 million people suffer from asthma, a common disease among children
Tobacco smoking is the major risk factor, but the use indoors of solid fuels for cooking and heating also presents major risks Source: World Health Organization
of competing with our solution and that’s the bottom line.” Over 55,000 people have signed up to take Opternative’s test online, however there is no data reported on how many have paid to have an ophthalmologist review their exam findings for a prescription. And while Opternative describes its algorithm as validated and advanced, its published sample size of 30 in their clinical study does not seem to have the numbers to back up their claims. Looking forward one hopes that Opternative uses their large member base to produce more sound scientific validation of their algorithm. This might be their only chance to take some of the heat off from the AOA and FDA.
an eye for controversy
Trouble for Opternative: The Establishment Fights Back The American Optometric Association (AOA) calls Opternative a ‘snake oil salesmen’, but is this just a classic case of turf warfare? by rishi madhok, md
In our last issue, we showcased Opertnative, an innovative Chicago-based start up that was disrupting the process of getting an eyeglass prescription by enabling users to perform an eye exam from home using their smartphone and computer. However, just as they quickly expanded to 33 states – with approval in 45 – they now are facing backlash from optometrists and the American Optometric Association (AOA ). In fact the reaction has been so severe that the optometry lobby (yes, there is one) has managed to get Opternative’s services banned in six states. Laws intended to block Opternative’s service have been passed in Indiana, Oklahoma, Nebraska, Georgia, Michigan and South Carolina. There is pending action in Minnesota. Applauding the cease-and-desist order was AOA president Dr. Stephen Loomis, who feels that Opternative is misleading the public by its online claims. "Online vision tests like Opternative are, at best, estimates of consumers' refractive errors; they are not eye examinations in which a patient can be assured that their prescription has been accurately validated in person, and more importantly, that their eye health has been evaluated by their doc-
tor.” said Dr. Loomis. Opternative’s executives see the problem differently. They described this as an alltoo-common startup dilemma. When you disrupt an out of touch industry with a new technology, the reaction is often fear – fear of losing customers to a cheaper more efficient service. “These are entrenched interests that do not want consumers to have access to convenient, affordable eye care, plain and simple,” Opternative Cofounder Aaron Dallek told BuzzFeed News. “They’re afraid
MARKET WATCH D-EYE: PORTABLE RETINAL IMAGING If you need a permanent visual record of your patients’ eyes, there’s an app for that. D-Eye is a portable ophthalmoscope capable of recording and distributing high-definition images of the posterior of the eye. After attaching
THANKS BUT NO THANKS States currently with laws blocking Opternative's services -1. Georgia 2. Indiana 3. Michigan 4. Nebraska 5. Oklahoma 6. South Carolina
D-Eye to a recent Apple or Samsung smartphone model, the system utilizes the phone’s built-in LED light to capture retinal images up to a 6-degree field of view in undilated eyes, and up to 20 degrees in dilated eyes. Available internationally, $435. -Lonnie Stoltzfoos
6 Ways You Might Be Violating HIPAA Just because you're using HIPAA-compliant telemedicine software doesn't mean that you aren't violating HIPAA. Here are six pitfalls to avoid. by teresa iafolla
One of the most common misconceptions around telehealth and security may be this: using HIPAA-compliant telehealth software will protect you against HIPAA violations. Of course, using telehealth software that follows the clear technical and physical safeguards laid out in HIPAA is a key part of building a HIPAA-compliant telehealth care program. But it’s only one piece of the larger puzzle in maintaining the security of your protected health information (PHI). Navigating the intricacies of HIPAA can be tough, even for top-level healthcare executives trained in health security and compliance. When it comes to telehealth, compliance issues are often more complex because of the introduction of mobile devices, wireless connections, and a long list of technology vendors involved in delivering that telehealth solution. Plus, healthcare staff may not always understand how to apply HIPAA to new technology. Any software tool, no matter how closely it follows the technical and physical safeguards outlined in HIPAA, can be used in an insecure way by medical staff. Beyond knowing the technical requirements of HIPAA and reviewing those with your telehealth vendor, you also need train your staff and put the right clinical workflows in place to create a truly HIPAA12
compliant telehealth program for patients. Here are a few of the most common ways your telehealth program may be breaking HIPAA. 1. PHI is being downloaded or stored on unsecured mobile devices Using a telehealth mobile app can be incredibly convenient. But healthcare providers need to be cautious with any PHI that’s stored on their mobile device. Consider instituting a few extra precautions: • Install remote wipe software on the mobile device to erase PHI if the mobile device is lost or stolen • Password-protecting the device • Requiring a review of data stored on the device before device is thrown away or recycled 2. Logins to your telehealth software are shared around the office “A common HIPAA violation in many offices, is generic, shared passwords,” says Sheryl Cherico, CEO of Healthcare IT company Tier3MD. “Having a unique ID for each user, is required, and will also allow monitoring if necessary.” Beyond having a secure login for any telehealth software that accesses PHI, each user needs to have their own login credentials and should keep those private. 3. You have no systematic HIPAA staff training in place for telehealth One of the core administrative requirements of HIPAA is ongoing training for staff. Adding telehealth services to your practice often creates new workflows and new challenges for maintaining HIPAAcompliance. If you haven’t yet done additional HIPAA training as part of launching your telehealth program, you’re at risk. Staff won’t be able to maintain patient security if they don’t fully understand the new security protocols they should be following.
Is the Secret to Health Tech Security to Build Antifragile Systems? What if we could heal the 'wounds' of a cyber attack in the same way that our body's immune system handles vaccines? by graham plaster
People often assume that the opposite of “fragile” is “robust.” However, according to statistician Nassim Taleb, a robust object merely resists adversity. In fact, says Taleb, what we need are systems which are “antifragile” – systems which thrive and actually improve under adverse conditions. Imagine having a box arrive on your doorstep with the words “Please Shake” stamped on it in red ink. The human body is antifragile. If you are injected with a vaccine, your whole body
learns how to be stronger in case of an encounter with the full-fledged disease. The vaccine stimulates the body's immune system to recognize the threat, destroy it, and record it, to more easily recognize and destroy the same type of micro-organisms in the future. The Internet of Things (IoT) – the network of 25 billion world-wide devices that collect and exchange data – outnumbers humans roughly 3-to-1. By some estimates, the IoT will include nearly 50 billion objects by 2020. The rapid increase in interconnected devices means exciting new opportunities, but it also unprecedented new security vulnerabilities. The rest of the world assumes that medical technology is on the cutting edge of cyber security. But the reality is that when technology is created by idealists (the kind who dream of conquering disease), sometimes aspects of security are ignored or undervalued. The inconvenient truth is that many medical devices are hackable. In August of 2015, the Food and Drug Administration issued a safety notice about an infusion pump used in hospitals all over the country. The pump was determined to be susceptible to receiving information from hackers that could increase or decrease the device’s function, putting patients at obvious risk. According to a study by cloud security broker Bitglass, almost half of all U.S. data breaches in 2014 involved healthcare providers, and the information stolen was up to 50 times more valuable than credit card data. Medical records are much more expensive than credit card records on the dark web, and a hacker can blackmail a user based on health data. Another estimate, by the Ponemon Institute, estimated the total cost of medical identity theft in 2013 to be close to $12 billion. According to the research firm Forrester (report) and Motherboard, ransomware in medical devices is the most significant cyber security threat in 2016. That’s where Taleb and his “antifragile” systems come into play. What if we could
The medical community must take the lead in building antifragile systems for the internet of medical things because medical technology is the true nexus between mankind and machine.
heal the wounds of a cyber-attack in the same way you would heal a human body, and come out stronger on the other side? The medical community must take the lead in building antifragile systems for the internet of medical things because medical technology is the true nexus between mankind and machine. Wearable tech has the potential to gather extensive data and metrics from human bodies and will increasingly rely on software which imitates human biologic systems to fend off "viruses" of various types. When there is an attack on one of the IoT’s far flung appendiges, the system needs to have the intelligence to create solutions, and then update the network automatically. Addressing the cyber vulnerabilities of medical technology is one of the greatest challenges that the digital health community will face in coming years. Security must be part of the discussion during the early design phases of a product rather than added on as an afterthought. And along the way, we must keep in mind the need to safeguard against manipulation of the whole system. www.telemedmag.com
chicken soup 2.0
Telemedicine for the Soul When we think of telemedicine we often think of speaking with a doctor over a video chat. But Joe Burton, CEO of Whil, has taken these concepts to a new arena: Mindfulness. Whil uses videos and mobile training programs to integrate mindfulness into every aspect of your life so you can pay attention to the present and fully engage in what is happening around you. If that sounds like soft science, you haven’t met Whil’s big data. Joe Burton explains the essence of Whil, and how a new level of data tracking is allowing employers like Google to prove the efficacy of mindfulness training. interview with bill gordon
Telemedicine (TM): Can you tell us about Whil? Joe Burton: Whil is a digital mindfulness training platform. We offer three different programs. One is called Now. It’s 450 mindfulness sessions, really to help relieve stress, anxiety, increase resiliency and increase performance; whatever performance means to the individual. Whether you’re looking to be a better parent or a partner or athlete or executive; we want to help people to be able to focus, relieve stress, anxiety and be able to perform in the moment. We also have 120 sessions of yoga. So, we help people take care of the body as well as the mind; learn to relax the central nervous system. Our second program is called Grow. And it’s 500 sessions of mindfulness training for teenagers. We interviewed over 200 teenagers about the modern teen experience and created a modern, robust training curriculum for them to deal with the stresses of being a modern teen. Our third program is our Search Inside Yourself program. It’s all about leadership and emotional intelligence. This was born at Google. And it’s now been taught at over 200 companies in 20 countries around the world. Our programs are accessible on any computer or mobile device. And we’re really looking for people to sort of use their mobile phones to learn to unplug and take care of themselves because mobile devices are doing so much damage today in terms of people’s stress levels. TM: Can you expand a little bit on the teen program? Is it directed at how to deal with the stresses and pressure of social media, of how connected they are? Burton: That’s included. But we have programs ranging from self-awareness, self-image, emotions, relationships, school, physical performance and sports. We’ve got a wide array of sleep training; so mindfulness meditations for sleep. And really getting to not only sort out the worries, regret, fear, anxiety of teens; but also the amazing
things like unlocking their imagination, their creativity and their focus for performance in different aspects of their life. TM: Can you tell me how you feel Whil fits into the telemedicine-connected health world? Burton: Consumers are taking more control of their own well-being, physical, mental and emotional. Whil is a product that gives people the opportunity to train mindfulness and meditation anywhere, anytime. About 83 percent of our training occurs on a mobile device. People practice during their commute, whether they’re on their train or a bus. They practice taking breaks throughout the day at work. They practice before they go to bed at night to calm the central nervous system so they sleep better. We also have a data enabled program. What we’re really trying to do is learn consumer behaviors and recommend what they should train next based on their interests. If they’re interested in calming anxiety, we may take them to relieving stress. If they’re interested in sleep and if they’re having issues with insomnia, we’re likely to take them through programs that actually help them to calm their nervous system during the course of the day; so that they’re actually better prepared for sleep. And so this kind of data enabled approach and really machine learning around what they’re interested in and what they’re likely to be interested in next; we think is really important to help them accomplish the goals that they have. So for us it’s not just sort of mindfulness for mindfulness sake. It’s really setting goals, having an intention to take better care of their own emotions, mental well-being and physical health. TM: What is Whil’s the cost structure? Burton: So for individuals, they can sign up at $7.99 a month with an annual commitment. But our specialty is in
MINDFULNESS ON THE BOOKS
chronic low back pain In a mindfulness group, 43.6% of adults with chronic low back pain experienced clinically meaningful reductions in pain compared to 26.6% who received usual care (anti-inflammatories, opioids, physical therapy). Cherkin DC et al. JAMA. 2016;315:1240-1249.
s treatment-resistant depression A meta-analysis of 6 trials (n=593) found that patients receiving a mindfulness intervention had a 34% reduction in risk of relapse; patients with ≥3 previous episodes had a 43% relative risk reduction. Piet J et al. Clin Psychol Rev. 2011;(6):1032-40.
s Aging and QOL with HIV Infection Among HIV patients diagnosed prior to 1996, and receiving antiretroviral therapies for ≥5 years, those assigned to mindfulness intervention had a significantly increased CD4 count post-intervention (Cohen’s d = 0.8) compared to controls. Gonzalez-Garcia M. AIDS Behave. 2013; Sep 28.
serving corporations, healthcare systems, universities and that ranges from as low as 40 cents a month per employee up to about three dollars a month per employee for small to mid-size businesses. So, we’re currently working with large corporations like Microsoft, eBay, University of North Carolina. And we have dozens of small to mid-size businesses with employees ranging from five employees up to a thousand. TM: Can you tell me about some of the results you’ve seen or the positive impacts? Burton: We have lots of user testimonials on our site. And we see a tremendous impact on sleep. Our sleep training is based on eye rest. And so we really get focused on one thing as they go to bed; instead of what most of us do, focusing on ten or 15 things that worry us, stress us and keep us awake. We get a lot of feedback on our number two and three training series: calming anxiety and stress relief. So, what we do is take people through a tiered learning system, where they get a better connection to: What are their triggers? What sets them off ? What causes them to worry and be anxious? What causes them to trigger other people, which also creates stress in their lives? And so within four or five sessions of mindfulness training, they get a really good connection on: What is it to calm anxiety? What is it to relieve stress? They take personal ownership of that. So we get a lot of feedback on those. And then what we’re doing in corporations is we use the data so that companies can track how well a community is doing with things like: absenteeism, turnover, evaluations and the cost of healthcare. So, individuals can actually opt-in to share their data. And when they share their data, it’s how much training is occurring in areas of mindfulness, yoga and leadership. So, a corporation could see the aggregate for the community across all the training. And then they can see how much training is occurring for individuals. They never see
for individuals what the individual is training. So, the individual might be training: stress, anxiety, insomnia and also wonderful things like relationships, trust, intimacy and so forth. TM: Tell me what you feel the future of telemedicine or healthcare is from a technology perspective? Burton: I think from a technology perspective, we’re entering into this really amazing time where we’re getting enough data that we can increasingly help people with exactly what they need in the moment. Right? And so an interactive experience where the consumer is saying: Here’s what I need; and putting them on a path that gives them exactly that. In a short enough period of time where they can spend five or ten minutes a day taking better care of their mental health, relaxing their central nervous system and really feeling like not only that they’re in control of what’s going on in their life but seeing the immediate benefits of their own training. I think that kind of data also being connected to wearables, where as wearables get better and better and move away from these things have for a long time just been expensive pedometers. And as they move into tracking things like resting heartrate, diastolic blood pressure and a number of other key indicators that are connected to stress and stress causes most major illnesses and disease; we’re opening up some really important information to put people on increasingly better training paths for their health. So for example in mindfulness, resting heartrate as people practice, they’re able to see if their resting heartrate goes down over the course of time. Meaning that their body and their heart is not having to work so hard just to maintain the system. So, I’m very excited about the data enabled training solutions to help people take better care of their own mental and physical health.
the mhealth toolbox .
An interactive workshop designed for healthcare providers interested in health tech innovation.
attend an upcoming workshop x have your product tested during a hands-on gear lab x learn about sponsorship opportunities
teletech Practice-changing gadgets & gizmos --featuring mHealth Toolbox Smart Bathrooms Data Dive
A participant tests the accuracy of the Scanadu Scout
At The mHealth Toolbox, physicians give candid reviews of the latest med tech gadgetry This past April Telemedicine Magazine teamed up with Weill Cornell and Health Solutions Africa to present a med tech workshop in Cape Town, South Africa. Our goal: Bring together about 100 physicians over two days to learn about healthcare innovation. In addition to lectures and panels, we presented a Gear Lab in which participants had the chance to try out dozens of the most innovative apps, gadgets and wearables on the market. At testing stations, physician participants had the chance to interact with devices and discuss usability with colleagues. After these hands-on sessions, the full group took part in casebased discussions about how these devices would â€“ or wouldn't â€“ be useful in a clinical setting. On the following pages are highlights from that Gear Lab, including insights from an international gathering of practicing physicians. There were no product reps on hand, so reactions were candid.
writer scott jung
the details: A smart pillbox that combats the problem
of medication non-adherence and overdosing by alerting the user (and possibly their caregiver) to take their medication on time. uBox stays securely locked the remainder of the time to ensure that medication is only taken on a pre-programmed schedule. provider feedback:
Attendees liked being able to directly control the uBox with their smartphone and program a dosing schedule. However, they questioned how effective it could be in improving drug compliance as it can’t actually tell if a patient swallowed the medication. Moreover, it doesn’t work well when multiple drugs on different schedules are involved. From a design standpoint, uBox felt a little bulky and might be difficult for patients suffering from arthritis to use.
the details: Scanadu's Scout device has been touted as
the real-life version of the Tricorder from television's Star Trek. It’s packed with sensors designed to read multiple important vital signs with a quick scan of the forehead which are sent wirelessly to your smartphone in a few seconds, any time, anywhere. provider feedback: Physicians were impressed with the Scout's ability to measure your heart rate, blood oxygen saturation, temperature, and blood pressure simultaneously by simply placing the Scout on your forehead. However, many attendees had difficulty getting a scan result if the Scout moved even slightly on their forehead. Our EMT attendees loved the Scout and felt that if the scanning process could be improved and was more reliable, it could be an extremely useful tool for emergency medical personnel.
the details: An ultraportable electrocardiograph that
pairs with your smartphone to record, save, and transmit a single-lead EKG. A recent study showed that Kardia performed just as accurately as Holter monitors and clinical-grade EKGs in sensing heart palpitations, long QT intervals, and potential cardiac arrhythmias. provider feedback: The mHealth Toolbox attendees
were in agreement and found Kardia to be simple and impressive to use. While some attendees felt that it might not yet replace continuously-monitoring Holter devices, others were optimistic that using such a device 18
to manage atrial fibrillation could change how cardiologists determine whether to anti-coagulate, cardiovert, or treat patient’s AF by other means. A few attendees were also hoping that a 3-lead version could be in the works someday.
the details: This all-digital stethoscope – the smallest
on the market – features a highly sensitive electromagnetic diaphragm for picking up a broad spectrum of sounds and the processing power to filter out noise and amplify murmurs and other heart sounds that might be inaudible with traditional acoustic stethoscopes. provider feedback: The One certainly turned some heads because of its unique design. Attendees may have also found it strange that we had it connected to a pair of headphones you’d expect to find on a DJ rather than a doctor, which could inadvertently convey a lack of seriousness and authority. Some attendees had an inclination for the more traditional stethoscope appearance, but liked its ultra-portability. Most did agree that it offered superior sound.
Janacare Aina the details:
The Aina is a point of care device that plugs into smartphones and instantly measures: HbA1c, glucose, Lipid Profile (TC, HDL, LDL, Trig), Cr and Hgb. Data can transmitted to the “HABITS” online platform for consumers, which analyzes the data and provides relevant lifestyle coaching advice. provider feedback: Attendees found Aina to be extremely easy to use and thought it ingenious to use the smartphone’s universal headphone jack to power and communicate with the device. Some of the local South African attendees were unsure if and how the government regulatory bodies, as well as the availability and costs of test strips might create a barrier to entry for
consumers, while some attendees felt Janacare could be better off marketing the Aina solely as a doctor-facing clinical device.
remote area delivery, disaster scene assessment, and communication with disconnected people.
The GearVR headset seamlessly uses the power of your existing Samsung smartphone to provide an immersive VR experience. No wires or other hardware necessary. Imagine VR training modules that allow residents to observe a code, or watch a surgery from the perspective of the lead surgeon. provider feedback: One of the attendees called the GearVR “a foundation for the future”. While health and medical related content is currently limited, attendees were overall wowed by the immersive experience it provided and saw how medical education could benefit from the adoption of virtual reality as a whole. Most realized, however, that their personal smartphones were not compatible and hoped that Samsung could open up the GearVR to a wider variety of smartphones.
Guardian Drone the details:
Drones are slowly evolving from a hobby to a delivery service. Their speed and maneuverability in and around tight spaces and remote locations make them ideal for transporting emergency supplies and rescue equipment. Created by an industrial designer as part of an engineering Masters project, the “Guardian Drone” is used to swiftly carry and deploy an inflatable rescue tube to someone in need in the ocean. provider feedback: As the attendees were familiar with drones primarily as hobbies or for video production, they were pleased to see a drone being utilized for real life rescue situations. Especially in rural Africa, the attendees felt that drones have amazing potential for
clockwise from left
VitalPatch is a small, adhesive biosensor no bigger than a couple of ECG/EKG electrodes that is worn on the chest area for up to 3 days. Thousands of data points are collected and analyzed every minute, continuously monitoring vital health signs to help predict medical issues before they happen. provider feedback: The potential applications that the attendees came up with during the mHealth Toolbox were endless for the VitalPatch. While discharged elderly patients were an obvious use target, emergency observation and toxicology wards and cardiology offices were also mentioned as possible locations where VitalPatch could be useful. However, as the country is already limited in resources, some of the attendees thought a non-disposable, but more robust version of the patch might be more attractive to the local physicians.
Ting Shih, Founder of ClickMedix; a demo of the Kubi tele-presence robot; the guardian drone opposite
Participants try out the uBox wireless pill dispenser
CellScope Oto the details:
The Oto is a smartphone attachment that utilizes the iPhone’s camera and flash LED to turn it into a powerful otoscope, allowing for the examination and diagnosis of ear as well as skin pathology. Images and videos can be saved, shared, or sent (to a physician consultant for a fee). provider feedback: Attendees thought it brilliant to utilize the smartphone’s built-in camera and were amazed at the quality images that the Oto was able to capture. They felt that the device could be easily modified to image other parts of the body, such as the mouth. They were less thrilled, however, that the Oto was only
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the internet of medical things
The Better Wired Home Starts with Smart Bathrooms In today's healthcare environment, what happens outside the hospital can be as important as what happens within its walls. Thanks to a new generation of wireless monitors, wearables and sensors, health systems are bringing healthcare into the home to track a new level of health data and trends. We call this the Wired Home, and a range of companies are placing bets as to what will be the killer in-home health applications. We begin this series on the Wired Home with a look at the all-important water closet. These new technologies could supercharge your bathroom, giving it the ability to assess health and wellness while you perform your nightly ablutions. by Aneel Irfan
1. Smart Scales Smart scales – currently available from Withings, FitBit, Garmin and Under Armour – can measure weight and even body fat percentage. The scales can distinguish between patients and send data immediately to a user's smartphones or tablet. This data can be served up to a dashboard with trends, benchmarks and milestones. Already commercially available, these devices have been utilized extensively in remote patient monitoring programs. Among other applications, a nutritionist or endocrinologist can make sure patients are keeping track of their diets and care plan with readings from the scale a few times a day. They can also be used as part of a diabetic's take-home care kit.
2. Smart Mirror Many large electronics companies such as Samsung, Panasonic, Braun and even Google have released smart mirror displays. Though many of these have only been applied to retail markets – think smart dressing rooms or customized advertisements – there are developments underway to adapt the technology for personal health monitoring. Researchers are developing the WIZE mirror to deliver a health assessment just by analyzing your facial features. Here's how it would work: The mirror’s cameras document the dayto-day changes in your facial features in order to identify known markers of stress, anxiety and disease. Images from the mirror are used to assess blood oxygenation and heart rate, thanks to minuteto-minute fluctuations in skin color that occur when blood flows. A full 3D facial scanner lets you know if you’ve gained or lost weight. Finally, gas sensors sniff for chemical compounds in your breath to determine how much you drink or smoke and if you’re at risk for disease. After gathering the information, the WIZE mirror displays a score to give you an indication of how healthy you appear.
3. Smart Toothbrush The new Oral-B connected toothbrush may have debuted back in 2014 at the Mobile World Congress, but it's still a trailblazer and a first-in-class for the wired home. The toothbrush connects to your smartphone via Bluetooth, records brushing activity that you can chart on your own or share with dental professionals. You can use the smartphone or connected mirror as a “remote control” to customize the brush to your needs, including settings for your target session length and preferred modes. The brush also tells you if you're brushing too hard, if you've brushed long enough and even if your brushing habits have improved. What's next? How about a toothbrush that tells you how hydrated you are, and gamifies the cleaning process? For that last one, check out the crowdfunding campaing for FlossTime, the smart floss dispenser that turns flossing into a habit-forming game. 20
4. Smart John Because of their regularity of use, the humble toilet offers a nearly unparalleled opportunity for tracking health data. The Japanese company TOTO has led the way by designing a smart toilet called the Intelligence Toliet II which collects weight, monitors sugar levels and other vital signs. These data points are transferred via WiFI to a patient’s computer or tablet. There is a simple “catchILLUSTRATION BY MARK LEMANSKI
er” in the bowl to obtain urine samples. The data can help your physician monitor health and provide early disease detection. Graphs can display fluctuating glucose levels as well as urine temperatures, both of which can help diabetics time insulin shots as well as give insight into hormone levels in women concerned with their menstrual cycles.
INTRO As the oldest and largest of the telehealth platforms, Teladoc has had plenty of opportunity to gather a wealth of data on telemedicine visits. They've completed more than 1 million visits, and are on track to break an unprecedented 2 million by the end of 2016. Here are some of the data points they've collected along the way, which give a peek inside Teladoc's trajectory as a company.
of all Teladoc charts get reviewed for quality
Number of e-visits performed by October 2015. Close to two million expected by end of 2016.
Date of Teladoc IPO
JULY 1, 2015
Visits that required follow appointment when seen via telemedicine, compared with 13% for face-to-face encounters, and 20% for ER visits. (Source: Independent RAND Corporation study examining follow-up visits in a 300,000-member population in California that shared the same diagnosis)
Board-certified physycians and behavioral health providers in the Teladoc network
Teladoc sees a patient every 10 seconds during peak operating periods.
Teladoc patients with at least one co-morbidity
The average Teladoc user is a
Teladoc visits that resulted in a prescription, compared with 82% for office visits, according to the CDC.
The top two alternative places of treatment for Teladoc users are urgent care clinics (45%) and primary care offices (32%). These are followed by the ER (7%), specialists (1%) and "no treatment" (14%). [Source: Member reported prior to consult]
Amount Teladoc estimates they saved their clients in medical costs in 2015.
television Industry-shaping ideas & perspectives --featuring Hall-Barrow Gordon Hollander Atreja
In Dallas, Telemedicine Starts at Children's Children’s Healthcare of Dallas is a leader in the use of mHealth and Telemedicine for pediatric patients in the United States. While at SXSW we caught up with Julie Hall-Barrow, the Vice President of Telemedicine for Children’s, to learn more about their trend-setting program. Interview by William Gordon
Telemedicine Magazine: What is Children’s Healthcare Dallas doing in telemedicine today? Julie Hall-Barrow: It’s exciting; we’re doing lots of interactive things. One of our largest buckets is school-based telemedicine. We are providing acute care services, live, interactive to around 57 schools in the Dallas-Fort Worth area. This really allows us to partner with those schools to take care of low acuity visits and hopefully decrease utilization of urgent care and ER; as well as improve outcomes in learning. We’ll be right at a hundred schools (at the start of the school year) that we’re providing acute care services to throughout the school districts. The next thing is taking all that information and knowledge we have gathered and figuring out how we help other hospitals and health systems do the same in schools. Our program is actually contracting with other health systems to put the infrastructure, training and education into those systems. Their clinical providers will be doing that regionalized care and we hope to expand that by another hundred. So, Children’s Health will actually be expanding telemedicine to over 200 schools in Texas. The other areas of telemedicine and virtual health that we have is hospital-to-hospital traditional telemedicine. Our specialists connect with other specialists at other facilities to help consult on cases. Our biggest and brightest program is our teleNICU program, where our neonatologist connects with another nursery, where maybe a pediatrician or a neonatologist that needs that extra care consults. W e also mimic that same program with the ERs across the State. Usually around 15 minutes, we’re actually on live looking at the patient and talking to the provider that’s requested the consult. Another exciting area is remote patient monitoring. We actually have live audio and video, along with remote patient monitoring. We do that with our transplant program for our liver and kidney program. We’re expanding that to pulmonary as well for our ventilated patients, as well as our asthma children. We’ve just launched it with our
pediatric obesity program, which allows us post-discharge to be able to connect with those patients long-term for up to 90 days and track their weight, as well as all their complications that they may or may not have. We’re also connecting for our children’s health virtual visit. 7,000 employees at Children’s now have access to telemedicine. Why wouldn’t we want to keep our employees well, when our whole job is to keep kids well? TM: Can you tell us about the technology, the tools, the things that you’re using to provide these services? Hall-Barrow: We’re a Cisco infrastructure facility. All of our traditional telemedicine uses Cisco Codec. We use multiple vendors for our peripherals, like digital stethoscopes and otoscopes. For our virtual visit program, we actually are powered through the American Well product. We have an enterprise license that allows us at Children’s to make it our own. We’re powered by their technology, but with our providers. TM: What is your vision of telemedicine in the future? Where do you think it’s going to be three, five or ten years from now? Hall-Barrow: I hope the first thing that we do is to not call it telemedicine. It's really just medicine. But what I think we’re going to see is a lot more of the data and how we use that data to quickly intervene in a clinical situation. We’re doing all these cool things but where’s the data to show what you’re actually doing? I think devices will be the other area. Currently we can see and hear you but from a consumer-driven standpoint, can I look in your ear? I think that’s where technology in healthcare is really going to be at crossroads: to give providers the information that they need to make a good, sound, clinical-quality decision about healthcare.
under the hood
Process Drives Your Billion Dollar Valuation If you want your company to be the next big thing, pay as much attention to how your company operates as you do to the shiny product you provide to the world. by Bill Gordon
In the not-too-distant past I embarked on a series of job interviews for a range of telemedicine and med tech companies. I was in search of the next big career challenge, and the search took me to organizations ranging from 7 employees to over 1000. Through all of these conversations I have come to one cornerstone conclusion. Only those organizations that have mature internal processes will succeed no matter how great their product is. Once, I participated in a round of interviews for a VP-level position with a wellknown telemedicine organization. They had raised a very large amount of venture capital and had a significant number of customers. On the surface they seemed extremely successful, even dominant in the market. However, a series of interviews gradually pulled back the curtain and taught me an important lesson. During my first interview, a senior VP covered the basics about my experience and 24
outlined the rest of the interview process, how it would go and who I would speak to. I noted that he made sure he explained that they had great internal processes. My next interviewer was a gentleman who would be in the direct work path for this role. He spoke of defined processes but also mentioned that there was room for improvement. I began to get curious when he stated that at times upper management had a “just get it done” attitude when it came to implementations or issue resolution. He also stated that while they did have defined code maintenance windows they also deployed code when needed outside those windows. In the fourth interview we got down to the heart of the matter. This interviewer was the last person to perform a function similar to the one I would have assumed. Now I really start to see how things were running. I heard all all about issues and lack of attention to process and a need for someone to come in and uphold standards and define processes. While they had standardized documents they were not always completed accurately or utilized in the same manner. While they had processes they weren’t always followed because not everyone knew them or situations arose where it was more expeditious to “just get it done”. What I learned through the process – and which is a lesson not unique to this company – was that senior management often believes that theirs is a mature, process-driven company, but when everything is laid bare, there’s a starkly different reality. This problem is all too common. I have worked for and with a number of smaller companies in the mHealth and telemedicine world and many of them have this issue. At the root of this problem is that policies and procedures are often created by senior management members themselves when they were still junior members of the staff. Now they have been promoted and they assume that what they left behind is sufficient for their company’s growth and that it is actually being followed. The reality is that these seemingly clear policies can quickly get lost as companies grow. Addressing that gap is of critical importance.
Why? Because to survive and thrive, your organization needs to have the capability to handle both simple and complex projects and issues with dexterity and ease. What happens when you sign that marquee partnership that puts your organization on the map and in the news and you fail to execute the implementation properly? What happens when you have code management issues that cost time and money for both you and your customer? It could cause irreparable harm and that billion dollar valuation is out the window. Instead of going IPO you are acquired down the line because the damage was too great to overcome. Having worked in a mature Fortune 50 organization that was constantly looking for ways to improve processes and procedures I can tell you that the basics – the foundation of any organization – are the things that smaller companies tend to overlook. I have worked for a start-up that saw the value in 100% compliance with process and procedure, almost to a fault. They actually fired employees for failing to follow the proper process or procedure. Why go that far? Because in the healthcare world you cannot afford to make a mistake with someone’s PHI or risk failing quality or HIPAA audits. It can be the difference between survival and the death of your organization. If you don’t believe me look at Theranos. In our regulatory environment the least of your worries is making a customer mad because of a code implementation mistake. You could wind up in jail or have your company shut down if you fail basic process and procedure adherence. If you want to be the next billion dollar telemedicine darling – or just take your organization to the next level – you should start working on your process and procedures now. As you grow and add staff and experience turnover you have the opportunity to implement and ingrain these very important characteristics as a seed with your team. Use your next round of funding to hire the right resources to make the engine run smoothly. Your investors, customers and your valuation will appreciate it.
"how do you grow and retain a great team?" Rock Health recently brought over 140 CEOs together for off-the-record discussions on building a healthcare technology company. Here are a few tips on employee recruitment and retention that are applicable no matter where you find yourself in the market.
Seth Sternberg ceo / founder Honor “You have to pitch your employees just like you pitch investors. They’re getting options and investing their time and sweat—which is arguably a lot harder as it’s probably their sole investment.”
Caitlin Collins vp of operations
Mango Health “Creating a goal-setting process often involves growing pains. Part of that may be due to the pressure employees feel to score perfectly on defined goals. Mango has found success in a more holistic approach to setting goals with its employees. We focus on the ultimate end goal of growing as individuals and as a company: it’s more about valuing the process itself over the score.”
On the Hill
CONNECT for Health Act: Discussions on the Hill While it may be imperfect, the CONNECT for Health is a critical step in telemedicine adoption. On a recently trip to DC I got to discuss the bill with key legislators, and a few critical issues rose to the surface. by Judd Hollander, MD The CONNECT for Health Act is major step toward allowing people to receive the care they need and deserve in a more efficient patient-centered manner. The Act would create a bridge program to help eliminate or reduce some of the restrictions Medicare now applies to telehealth, especially with alternative payment models (APM) and metric based incentive payment systems (MIPS); promote the use of remote patient monitoring for certain chronic conditions, expand allowing originating sites to include telestroke evaluation and management sites, and dialysis facilities; and further permit telehealth in community health and rural health clinics. The proposed Act is not perfect; but it is an important step forward. My colleague, Roger Band, and I thought members of Congress and federal agencies might like to hear from providers who utilize video visits to care for patients. We met with 8 members of the House and Senate
or their legislative aides. These included bill sponsors Senator Roger Wicker [R-MS], Senator Brian Schatz [D-HI], and Diane Black [R-TN]; PA Senators Bob Casey [D] and Pat Toomey [R]; and PA Congressmen Robert Brady [D], Pat Meehan [R] and Charlie Dent [R]). Additionally, we spent time with representatives from the Food and Drug Administration Center for Devices and Radiological Health (Digital Health Division); White House Office of Science and Technology Policy (OSTP); Office of the Assistant Secretary for Planning and Evaluation (ASPE) in Health of Human Services; Veterans Administration (VA), and the Office of the National Coordinator (ONC). Rather than go to Congress asking for money, we chose to discuss broader issues of the Act. We chose not to discuss reimbursement. We emphasized that access is more important than geography. Timely and appropriate medical care can be very difficult in rural environments; however, rurality is not the only item that impacts access. Greater numbers of people in urban communities might have access difficulties than much larger areas of rural counties. Although most medical expenses occur in people with chronic diseases, hospitalizations, which are the main drivers of expenses, occur in people with acute exacerbations of chronic diseases. It is imperative to be able to utilize telemedicine to treat acute exacerbations of chronic conditions. The requirement in the Act that people have two or more chronic conditions and be hospitalized or seen in the emergency room twice in the past year is not practical for the average provider to know. It may result in the unintended consequence of having providers send more people to the emergency room just so they meet criteria to be better managed at home with telemedicine. This could drive up expenses. We are deeply concerned about the way care coordination gets emphasized by many people. Restricting telemedicine use to an “established relationship” or “primary care provider” may not help achieve the goal of www.telemedmag.com
care coordination. In the ideal world, a patient would speak with their provider who can access their medical record. In reality, the “on call” physician is usually someone they don’t know who does not have access to their medical record, yet that provider is considered to have an established relationship. We would proffer that the ability to perform care coordination is more important than whether or not the provider meets the definition of an established relationship. For example, an emergency physician, with access to the medical record, can better coordinate care with the primary physician than their partner who is in a restaurant when fielding the call. Additionally, let’s not limit telemedicine use to primary care providers such as family or internal medicine. If a woman with breast cancer has her medical oncologist effectively delivering all her care, her telehealth option should not be limited to care provided by her family physician.
We should not limit provider-to-provider critical care consultations to stroke. Stroke has served as a model for these types of consultations, but we would recommend using the infrastructure that exists to treat other life threatening conditions. After our day in Washington DC, there is clarity about how we can get over the Hill. It is a four-letter word – DATA. Although everyone supported telemedicine conceptually, everyone expressed concern about the paucity of data. The government will not support higher expenses in the absence of higher value care. Does telemedicine reduce expensive care or result in more visits without improved outcomes? Which subsets of patients benefit? Does it reduce caregiver time commitment for visits? Does it improve or worsen antibiotic resistance. The telehealth industry can help by reducing barriers to research. Large telemedicine providers need to partner with researchers who can analyze and publish their data. In-
dustry should not keep their data private. Health systems must make sure they do not sign vendor contracts that enable information blocking (creating hurdles regarding sharing of data). Researchers must begin to address these questions. Academic Medical Centers (AMCs) need to brainstorm about how they can work together. A meeting of AMCs this June 21 and 22 will address the ways they can form clinical and educational partnerships, as well as develop the research infrastructure required to facilitate creation of the evidence base that can be used to inform policy makers. Already 70 representatives from AMCs, Congress, government agencies, and the FDA are attending (contact email@example.com for further information) Finally, want to make a difference? Speak with your federal representatives and ask them to support the Act. It is not perfect, but it is one step we must take to get telemedicine over the Hill.
Text-first virtual care is transforming health care with 10x higher utilization • Patients text local physicians for direct asynchronous communication without waiting in a queue, easily switching to video if the need arises. • Doctors can manage multiple patients at a time, creating scalability while maintaining response times under 1 minute. • CirrusMD fully integrates with your EMRs and patient portals so doctors have instant access to patient history and data easily flows back to the patient’s PCP.
NODE members represent a diverse group of academic innovation centers, industry, investors, and entrepreneurs. To share evidence news with the NODE team, use #digmedevidence on twitter, or follow them @digmedevidence
At Last: EvidenceBased Med Tech Reviews NODE health is the Network for Digital Evidence – a group of clinicians, researchers and developers who set themselves the task of evaluating digital health. Brought together by Dr. Ashish Atreja, NODE holds that digital health devices and platforms are lacking the studies and evidence that we associate with other healthcare interventions. It’s the goal of NODE to generate and apply this evidence. NODE members represent a diverse group of academic innovation centers, industry, investors, and entrepreneurs. Telemedicine editor Nicholas Genes sat down with Ashish to talk about his work – where NODE came from, and where he thinks it’s going.
Telemedicine Magazine: Why have so many well-meaning clinicians and developers released apps without good evidence? We’d never do that for a drug, after all. And why have prior approaches at evaluating health apps failed?
quences. Bates just published a great paper in JAMA on this topic, how digital health must strike a balance between innovative problem-solving and patient safety. Of course, there are apps that will require FDA approval – but we need a system to evaluate the quality, usability and value of the other 99% of apps that will not go through the FDA process. But NODE Health is about more than evaluating apps – it's about creating an ecosystem for partnerships, to develop a science for mHealth and digital medicine. We're seeing too much fragmentation – 165,000 apps out there in the Apple and Google stores, and too many health innovation centers that aren't sharing what they're doing. There’s too much needless duplication. We wouldn't be good doctors if we didn't go to conferences and learn from each other – but that's not happening enough in mHealth. Instead when we do have conferences they are vendor-based, and it’s not always clear what to trust. So as NODE network we're making a platform, a system, to develop trustworthy processes so that folks can find high-quality apps and feel safe using them. NODE Health will be a crowdsourced community. It will include payers, doctors, and patients as well. Accelerators, VCs can contribute. No one will be excluded – but it will be transparent and unbiased.
Ashish Atreja: There’s a general perception that an app can’t hurt you. But think of Google Maps, which can steer users into a ditch. Any app can carry unintended conse-
TM: You’ve won grants to build mHealth apps, to engage with patients over the web and through apps. Why did you start down this path?
Interview by Nicholas Genes, MD, PhD
Atreja: Really the first thing that got me into mHealth was UpToDate, from my first day on the job at the Cleveland Clinic. My first patient in clinic was a lung transplant patient, and I had never seen a lung transplant patient before. It was 2000 and the world wide web was just getting underway. My senior resident told me to check out UpToDate – it was fast, and there was pertinent information for this specific case, stuff that wasn't in Harrison's – even a video. It was a new way to see the evidence, it was curated, and there was obviously a sophisticated back end. In short, technology was making a difference in healthcare. That got me interested in how I can leverage technology in healthcare further. I don't consider myself a geek – I’m not a coder or engineer – but I am a believer in the potential for technology. TM: Where is the need for app evaluation greatest? Is it the apps for providers, or the patient-focused health and therapy apps? Will NODE evaluate both kinds of apps? Atreja: NODE will help both patients and providers navigate and choose high-quality apps. Right now we’re more focused on patient-centered apps but there’s also resources for telemedicine, and provider-focused tools. We will end up with working groups to evaluate tools for population health, messaging between doctors and patients, and more. The current health and wellness continued on page
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start - ups post - mortem
theranos: spinning hype into start-up gold As recently as last September, Theranos still seemed like an amazing Cinderella story. Nineteen-year-old Stanford dropout disrupts the laboratory testing industry and becomes America's youngest female billionaire. But as a lack of transparency gave way to unsettling reports about test accuracy, this Silicon Valley unicorn began to fall apart before our eyes. Before October 2015, Theranos seemed to be a beautifully written Cinderella story. A 19-year-old drops out from Stanford while majoring in chemical engineering to start Theranos, a company to disrupt the stale and inefficient laboratory industry. At the core of Theranos was Edison, the device that could run nearly 100 tests with a few drops of blood instead of vials. Within 7 years of being founded the company had a $1 billion valuation. The company formed partnerships with Walgreens, Safeway, the Cleveland Clinic, and entered into discussions with the US military to use the Edison device and expand their Theranos wellness centers. Elizabeth Holmes, the CEO and founder (pictured), was an icon as America's youngest female billionaire. However, the scientific community raised an eyebrow at Theranos’s claims. JAMA, in February 2015, published an editorial noting that Edison had been the subject of much mainstream media and press, yet had not been reviewed in any peer-reviewed biomedical literature. In fact, Theranos kept the process of their blood test extraor-
THE SAVVY START-UP Don't Bypass the Physician While mystery behind their lab practices occupies most Theranos headlines now, there was a “second hit” that scuttled the would-beunicorn: they bypassed the physician. Theranos’s blood tests offered more information than the average consumer product could provide. Such tests that influence the health of the patient face the harshest scrutiny by the FDA, even with a physician. Remove that doctor and you’ve painted a bullseye on your back.
Not convinced? This isn’t the first Silicon Valley rocket to get knocked out of the sky by the FDA – just ask 23andMe. 23andMe attempted to provide genetic information, specifically health risks, to its consumers without coordinating with a provider. They were ordered to stop in 2013 by the FDA and were required to validate their testing methods. It took two years for the company to resume with FDA approval. They returned with a new test that reported significantly less information. In fact, 23andMe can only report carrier status and does not have approval to report on actual health risks.
dinarily secretive. That secrecy broke in October 2015 when the Wall Street Journal quoted many unnamed current and former employees of Theranos who cited that Edison may provide inaccurate results. At the time the New York State Department forwarded a formal complaint to CMS and others When the Wall Street Journal published their pivotal report on Theranos in October 2015 they not only quoted concerns
While Theranos finds itself in a similar fight, 23andMe chose to cooperate, pivot, and work within the system to bring an approved product to market. If Theranos’s statements are any indication, they seem more inclined to go down with the ship. Theranos’s story highlights a major difference in innovation in healthcare versus other industries. In health tech, openness and collaboration are a must. Best said by a cofounder of 23andMe to Tech insider, "You have to be willing to show what you're doing," said Linda Avey. "The proof is in the data."
by former employees about Edison's testing accuracy but also described the “other” testing methods Theranos was using to keep up with demand. Reportedly the bulk of blood tests being performed by the company was actually being done on traditional machines of competitors, such as Siemens, rather than Theranos’s Edison Machine. Edison was again called into question when Theranos was exploring a partnercontinued on page
start - ups trending up
in the uk, innovation with a doctor's touch by Dr. Vishaal Virani
Fast Company, the Financial Times and The Economist have all reported in recent months on the growing trend of doctors getting involved with healthcare startups. In the UK this has been an inexorable and exciting trend that is undeniably changing healthcare dynamics. One of the benefits of physician-founded startups is that they have a unique ability to address pain points that hitherto fellow physicians and patients have found to be intractable. The irony is that these pain points cannot typically be solved by conventional clinical treatments that doctors are trained to master, but instead require doctors to lay down the text books and think creatively. To exemplify this trend and and creative thinking we have profiled three physician-founded startups in the UK that we are excited about. All of these startups disrupt traditional doctor-patient interactions.
Patients Know Best (PKB) Founded in 2008 by NHS physician, programmer and patient with a rare genetic disease Mohammad Al-Ubaydli (pictured), Patients Know Best is the world’s first fully patient-controlled online medical records system. It is designed to empower patients to manage their care, whilst enabling clinicians to share information and engage with patients in new and powerful ways. As one patient puts it “With Patients Know Best, it’s very reassuring that I can reach my entire medical team [and medical history] anywhere in the world – this makes me feel far more independent.” In the early years Patients Know Best had difficulties getting healthcare purchasers in the UK to believe in the product. Indeed, breaking into the NHS is an insurmountable challenge for many UK-based startups. However, Patients Know Best has now signed up over 60 institutions in the UK and 6 other countries (including NHS hospitals and pharmaceutical companies). With a recently raised $5.1m round of funding, led by Balderton Capital, Patients Know Best is headed in the right direction with contracts in place for millions of patients. When asked if doctors should consider the entrepreneurial life founder Mohammad emphatically stated “Yes. Too few pursue it. You have the opportunity to make an impact more quickly and you get to do extraordinarily interesting things."
Doctorpreneaurs, Unite! Doctorpreneurs is a global community for medical entrepreneurs based in the UK. Find interviews of doctors-turned-entrepreneurs, jobs in startups for doctors and medical students, as well as a regular podcast. www.doctorpreneurs.com 30
Outcomes Based Healthcare (OBH)
Founded in 2013 by an NHS physician Rupert Dunbar-Rees (left) Founded in 2012 by NHS surgeons Jean Nehme and Andre Chow along with co-founders Nasrin Hafezparast (also an NHS physi(pictured), Touch Surgery allows trainees to practice surgical procecian), and a third non-medical co-founder Juliana Bersani. Outdures using a mobile surgical simulator application. The team have comes Based Healthcare (OBH) offer tools and technology to help designed Touch Surgery with the physician in mind from the early healthcare purchasers and providers make a reality of outcomesdays – “we released a minimally viable product [in January 2013] based contracts. Rupert started OBH, as whilst he was a GP he was that we subsequently redesigned based on our user feedback and “frustrated that we were terrible at understanding whether we are metrics,” says co-founder Jean Nehme. The rather noble aspiration making a difference to people’s lives in a systematic way”. Patients is to “make Touch Surgery accessible to the world so we can make know which treatment outcomes matter to the world a better place.” It certainly has made them, and OBH’s cloud based product propracticing surgery eminently accessible, with vides an easy, fast and accurate way to use users taking to Twitter to report having pracPhysician-founded data to measure those outcomes. ticed virtual heart surgery on the bus journey The majority of OBH’s customers are into work. Touch surgery is completely free startups have a NHS Clinical Commissioning Groups and for users, which has helped drive a global user unique ability to adhospitals. Future plans involve commercialisbase of over one million to date. Interestingdress pain points that ing current research projects, such as a $1.5m ly, patients have also been benefitting from project part-funded by Innovate UK, to use Touch Surgery, with one surgeon using it to fellow physicians and machine learning techniques to predict if help a child visualise an upcoming appendecpatients have found and when diabetics will suffer major complitomy. cations. A second part-funded $150k project The Touch Surgery journey began in 2013 to be intractable. is focused on the development of a smartwhen the two co-founders joined the Bluephone app that can predict patient reported print Health accelerator in New York. Touch outcomes amongst diabetics, through data Surgery now has partnerships with residency collected passively from in-built smartphone programs at Harvard, NYU and Johns Hopsensors. “We know that people use their phones differently when kins, plus significant venture capital funding. The team is currently they are sick or unhappy, so this kind of data can be collected confocused on building functionality for more surgical procedures, and tinuously and passively to measure patient-reported outcomes” says developing partnerships with more residency programs. Nasrin at OBH. On the case for doctors founding startups co-founder Jean says Rupert’s advice for doctors considering startups as a career path “You can’t make a solution to a problem without knowing the probis that “if you are having these [entrepreneurial] feelings early, listen lem…that’s why I think doctors should be in this space.” to them. There are lots of people who are very unhappy in medicine, and even though they are doing wonderful jobs, their skills could be very well be deployed elsewhere.” www.telemedmag.com
start - ups funding
bootstrap it: 3 reasons not to raise funding by Tim Felz
Browse the homepage of any tech reporting website and you will learn that private tech companies are headline junkies. This should be no surprise given the sky high valuations of 2015, record-high seed funding, and Series A/B/C rounds mimicking IPO cash injections. All of the hype around who’s funded whom seems as if we’re now focusing on the ability to raise money rather than the ability to earn it. Where will that leave us in 10 years? Here we explore three reasons why your start-up should consider shunning venture capital in favor of the getting money the old fashioned way: earning it from clients. Do a google search with keywords “raises funding” or better yet, put a specific amount in there, say $50 million. Fivestars, Handy, FreedomPop, Gusto, and a few other companies, eerily reminiscent of boyband names, pop up. All of these companies have one thing in common: they believe that debt in the form of venture capital is the best way for them to win. And let me be clear: venture capital IS debt. If you don’t think so, try not paying it back. Here’s a simple explanation of how it works: you agree on certain terms, and assuming you make money, your investors will get their capital back, plus, a nice 32
return. Due to the inherent risk of business, your investor will get a negotiable amount of ownership in your business. If you achieve the magical moment known as a liquidity event, you will pay your investor a sum according to his or her ownership. The alternative option is to grow a business without outside financing. You accomplish this by selling your product to customers for more than it costs you to deliver it, resulting in a profit. Take these profits, pour them into delighting customers and acquiring new ones, and you’ll grow. This is called bootstrapping, and these days, other than an occasional Medium post, you rarely if ever read about it. I suppose growing year over year to a multimillion dollar company is not as newsworthy as raising millions in one round? When you choose to make your money versus raise your money, you do three things:
1) You determine your identity
When you don’t take money, no one tells you what to do. YOU choose what product ships and when, the suppliers and vendors you deal with, and the people you hire. The result is that the company you build is based on internal values you define.
2) You minimize waste
When the only money you have is the money you have earned, you hate to waste it. You streamline your business around what matters most, constantly determining what is working and what is not as a means of survival. You learn to compete in ways that require a fraction of the customer acquisition cost of your competitors. You hire excellent people because you cannot afford lazy ones, and you treat them well because you don’t want them to leave because you know it’s worth investing time in people versus starting over. Startups use buzzwords like lean, agile, or hustle to describe this mentality. Bootstrapped companies like ourselves call this normal—this is how we’ve always paid the bills.
3) You maximize customer value.
When your customer is the sole source of finance, you listen to them when they speak.
You give them respect. You do your best to delight them. Your customers are the reason you are in business. They keep your lights on and allow you to reward employees for their hard work. Oddly enough, it all comes full circle: happy employees equal happy customers, which equals organic company growth. After all, your customers are the reason you exist, not the last round of financing you raised. Bottom line: the problem is not raising money. The problem comes when your company identity and core values are no longer in your control. THE SAVVY START-UP Five Companies That Bootstrapped Their Funding j Basecamp. Formerly 37Signals, Basecamp started in 1999 as a web design firm and developed a product to help them manage their long term projects. That product helped them get organized, and millions of users later, Basecamp is helping tons of businesses stay organized. k GoPro. Now publicly traded, GoPro began because Nick Woodman wanted to capture better images of surfing. He raised some of his initial working capital by selling bead and shell belts out of his VW van. l TechCrunch. Started as Michael Arrington's personal blog in 2005, where he'd post multiple times a day about what's happening in the world of tech. AOL acquired TechCrunch in 2010. m Patagonia. Founder Yvon Chouinard began making the most durable pitons for climbers in the US. One winter, he purchased a rugby shirt to use climbing and his friends responded so well to it, he decided to start selling clothing to climbers. n Burt's Bees. Started as a simple candle business in the 80s, Burt's Bees founder Roxanne Quimby would use Burt Shavitz's extra beeswax to make candles, selling them at state fairs. Business grew steadily and she kept introducing products, eventually launching their now-famous lip balm.
finally, a telemedicine bill that has a chance The proposed CONNECT For Health Act may finally be hitting telemedicine’s legislative sweet spot. by Aneel Irfan
or years legislators have been trying to pass comprehensive telehealth policies with little success. But a new proposal on the table may be telehealth’s best chance to date to finally bring together policymakers and CMS in support of telehealth’s expansion. While many previous attempts at telehealth legislation were slowed down by geographic issues – the complexity of crossstate service offerings – the real problem was that nearly all of them were predicated on a dying model – fee for service. Sure, many state programs have enacted fee-forservice reimbursement regulations that require insurance parity for consults. And CMS itself will even reimburse for virtual visits on the per-visit premise, specifically in behavorial health. But the truth is that this type of reimbursement model is no longer Medicare’s mantra. It is now all about Value-Based Care payment models. CMS is dedicated to creating reimbursement tracks that enforce providers to show and measure markers in the triple aim of healthcare. They want to see providers create positive outcomes in their patient’s conditions, cut costs in delivery of the care to them with measureable and documented success over time. They have vowed to tie provider’s bottom lines to it. This success will primarily be achieved by leveraging telemedicine and telehealth tools but legislators have not yet presented policies for widespread approval to mirror CMS’s payment reform vision.
Which brings us back to The Creating Opportunities Now for Necessary and Effective Care Technologies (CONNECT) for Health Act, a bipartisan bill introduced by Senator Brian Schatz (D-Hawaii) along with six other senators from across the country. CONNECT would expand telehealth services through Medicare, ostensibly improving care outcomes, facilitating patients’ ability to connect with their doctors, and implementing cost-effective remote care solutions for patients and providers. U.S. Representatives Diane Black (R-Tenn.) and Peter Welch (D-Vt.) introduced companion legislation in the House of Representatives. Why is CONNECT different from previous attempts at telemedicine legislation? Because for the first time, a bill uses language that ties telehealth application and usage to value-based care models, which is, as mentioned earlier, the model CMS is wanting to introduce. This bill uses phrases referencing the emphasis on cost containment, with the goals of CMS alternative payments models clearly stated in the bill with regards to value, resource utilization and clinical practice improvements in care coordination along with patient engagement. This value-based language appeases CMS leaders and policymakers who before may have opposed telehealth expansion due to its previous fee-for-service nature. The proposed bill creates a bridge program to help providers transition to the goals of the Medicare Access and CHIP Reauthorization Act (MACRA) and the Merit-based Incentive Payment System (MIPS) through using telehealth and Remote Patient Monitoring. Looking at previously released programs such as CMS’s Chronic Care Management (CCM) or CPT 99490 released at the beginning of last year, phrases like “non-phase to phase electronic communication” or “24 access to a patient’s care plans” are all in telehealth/ telemedicine technology’s wheelhouse. Even the recent release of CMS’s Comprehensive Primary Care Plus (CPC+), the deputy commissioner of CMS, Dr. Patrick Conway, has been quoted saying “The CPC+ initiative is to support primary care doctors and other clinicians to spend time
the word on the hill senator brian shatz, hawaii
This CONNECT 4 HEALTH Act is critical because it hits the sweet spot. Usually you have to make a trade off in cost and care, especially when allocating dollars. Here we have an agreement, left, right and center, that telehealth will save money and improve outcomes. Even though we are in a good spot, it’s important to note, we are far from enactment. What this bill is attempting is going to be very hard with no clear timeline in an election year, we require sustained and even escalated bipartisan support. We are now just on first base, which is a good start, because if can’t make it to first base, you can’t score.”
with patients outside of office visits, better coordinate with specialists which will result in healthier people and smarter spending of our healthcare dollars” The CONNECT for health act also allows telehealth and RPM to be not only used for qualifying participants in alternative payment models, but permits the use of remote patient monitoring for certain patients with chronic conditions. For example, Medicare beneficiaries with two or more chronic conditions and two or more recent hospital admissions would qualify the providers for reimbursement for placing them on a remote patient monitoring program. It also expands current classification limitations of originating sites, telestroke evaluation or management sites; Native American health service facilities; and dialysis facilities for home dialysis patients in certain cases, will now have the enhanced ability to qualify for telehealth reimbursement via CMS, with the CONNECT for Health Act. It also permits further telehealth and RPM in community health centers and rural health clinics and allows telehealth and RPM to be basic benefits in Medicare Advantage plans. www.telemedmag.com
As a direct reflection of the requirements in the bill regarding cost containment, quality measures, and data collection. The bill’s Avalere analysis of two of three of the major provisions showed $1.8 billion in savings over 10 years. The CONNECT for Health Act is supported by more than 50 organizations such as AARP and The American Telemedicine Association. Current CMS reimbursement for telehealth services have been relatively restricted with the only steady growth or expansions seen in the state managed programs such as Medicaid. Where the national legislation has failed is restricting originating sites, geographic designation to only rural areas & the amount of covered medical specialties. Aligning Telemedicine’s proposed legislation to Value Based Care Models many organizations are already starting to attest to, is the rightful track telemedicine regulatory expansion must take. If telemedicine wants to become a healthcare delivery CMS or any payer will compensate providers for utilizing, its foundational policies need to meet these payer’s value-based principles. An underlining notion of the possibility of the over utilization or even abuse of telemedicine tools in a fee-for-service based environment, even though they probably won’t admit it, is a Pandora’s box, in my opinion CMS doesn’t
Next Steps– Seven critical elements to getting CONNECT For Health passed into law. 01 Most bills take six months to a year to pass 02 S.2484 is now in the Senate Finance Committee 03 April 1 – June 30: 2016 CMS Physician Quality Reporting System &
want opened, the telehealth policies tied to their alternative payment models proposed in the CONNECT for Health Act affords them some more control. Telemedicine and telehealth technologies are just tools. These tools are not only becoming viable but essential cogs in the reform of our broken healthcare system. In the future, as the value based care models mature, telehealth will be a common avenue to deliver access to providers in the continuum of care. This is where our healthcare reform is poised to go, awarding incentives to the best providers who provide the best care and can show it definitively. Telehealth policy will continue to follow healthcare reform’s lead to achieve widespread adoption along with optimizing its revenue potential. The passing of the bill isn’t imminent as it was introduced in February and now has been referred to the senate finance committee who will set a future hearing. In an election year things can change but at this time The CONNECT for Health has a lot of momentum. Obtaining collective bipartisan support spanning across many legislative agendas and an enormous amount contributing telehealth workgroup usage data research from leading active telehealth programs around the country such as Mississippi (which we feature in issue 2) bring-
Eligible Group Reporting Option Registration Open – Step1 04 In March 2016, the Administration estimated that its goal was to tie 30 percent of Medicare payments to quality and value through alternative payment models by 2016. 05 The administration’s next goal is tying 50 percent of Medicare payments to alternative payment models by 2018
06 (CPC+) model, will be implemented in up to 20 regions and can accommodate up to 5,000 practices, which would encompass more than 20,000 doctors and clinicians and the 25 million people they serve 07 CMS will accept practice applications for CPC+ in the determined regions from July 15 through September 1, 2016.
SUPPORTING CAST This bi-partisan team has thrown their weight behind CONNECT For Health. If your congressman isn't in support of the Act, you might consider asking why. ---Sen. Roger F. Wicker R-Mississippi Sen. Thad Cochran R-Mississippi Sen. Ben Cardin D-Maryland Sen. John Thune R-South Dakota Sen. Mark Warner D-Virginia Sen. Christopher Coons D-Delware Rep. Gregg Harper R-Mississippi
ing context to the proposed bill, it may be built to notch a national telemedicine policy win for us stakeholders. The drumroll that is telemedicine has been beating louder & louder. This group of policy makers may have begun to orchestrate the correct chord for telemedicine’s beat to become the bassline in the new song healthcare is now singing.
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WHEN WEARABLES DISAPPEAR
Will the eventual subsuming of wearables into our being rescue us from our present numbed existence or finally snuff out those qualities that make us most human?
john tyler allen
The human brain – critical, linguistic, selfaware – is the matryoshka doll of miracles, nested within the larger miracle of life. We’re surrounded by a symphony of stimuli we can not only perceive, but filter, process, and use to build meaning. Out of this meaning comes the unique way in which we understand our place in and engage with the world around us. We can appreciate. We can discern. We can think in systems, intuit outcomes, and envision the future. And we can conceive of and implement the complex tools necessary to build that future. These attributes don’t make us human, but they do imbue us with humanity.
This is why Nicholas Carr, in his book The Shallows, cautions against shortsighted misuse of these tools. “An honest appraisal of any new technology, or of progress in general, requires a sensitivity to what’s lost as well as what’s gained,” he says. Socrates told the father of letters that his invention would cost us our memory. When we reconceived time as a series of numbers on a mechanical clock we fell out of rhythm with the sun. In The Shallows, Carr unpacks the neurological cause and effect enabling the Internet and technology to rewire our brains in a way that now, only a few years after first booting up the World Wide Web, we’re beginning to lose ourselves. David Rose is trying to prevent that from happening. He’s a lecturer and researcher at MIT Media Lab and the CEO of Ditto Labs, where he’s trained a system recognize ten thousand objects and five hundred scenes in photos. He is our Nikola Tesla. Which is to say, Rose didn’t invent the computer or the microprocessor, or the Internet, but he has a prescient understanding of the way to make these things useful in a way that will fundamentally alter our relationship with technology and the world. Also like Tesla, Rose seems a bit mad. Not in his behavior – he’s actually quite calm and contemplative – but in the way he seems to disregard impossibility to create objects that are equal parts obvious and fantastical: an umbrella that glows blue when rain is forecast, requesting you to take it with you as you walk out the door, a wallet that is increasingly difficult to pry open as your spending nears the limits of your budget. “The most humanistic approach to computing… is not about fanciful, ephemeral wishes,” he writes in his book Enchanted Objects, “but rather persistent, essential human ones.” Those persistent and essential human wishes, she says, can be broken down into six human drives. We want to know and understand, to maintain connections, to be secure, to be healthy, to express ourselves, and to be transported wherever it is we want to be. Internet-connected devices have become the tools we most often use to engage with and shape the world around us, and pursue these www.telemedmag.com
when wearables disappear
drives – the way we exercise our humanity. But today’s gadgets, he says, are the antithesis of the tools we’ve used in the past to accomplish these things. “The smartphone is a confusing and featurecrammed techno-version of the Swiss Army knife, impressive only because it is so compact,” he writes. “It is awkward to use, impolite, interruptive, and doesn’t offer a good interface for much of anything. The smartphone is a jealous companion, turning us into blue-faced zombies, as we incessantly stare into its screen every waking minute of the day.” He concludes: “It has little respect for humanity.” Like the smartphone, the majority of our digital technology takes little advantage of our miraculous brains and disregards those things about us that make us most human. But things are slowly changing. After transitioning them onto our bodies, we seem to be searching for less stilted interactions with our digital tools (Rose would attribute it to our six human drives), a more human experience. As we imagine and invent, reimagine and reinvent, our wearables are being miniaturized and refashioned, integrated into our existing aesthetic. They’re becoming seamless, enchanted, intuitive, and as they do, they’re beginning to disappear. In February, market research firm Gartner forecasted two hundred and seventy four million wearables will be sold in 2016, an eighteen percent year-over-year increase. Smartwatches are expected to contribute most significantly: sixty-six percent growth to sales of fifty million units. The numbers can be justified on paper; Fitbit’s sales seem exponential lately and Silicon Valley’s determination to wrap our wrists with increasingly feature-rich activity trackers and smartwatches has become something of an arms race. Curiously, the zeitgeist doesn’t agree. The market feels stagnant. Our wearables just haven’t clicked. Even the earliest adopters seem to be waiting for the innovation or the feature or the design that will see them finally mesh with us. “That’s one of the reasons they’re being abandoned,” Steve Brown, formerly Intel’s chief evangelist and futurist, said. “It can’t be a force fit – they have to naturally fit with the existing ecosystem, the way people live their lives.” In 2014, technology and strategy consulting firm Endeavor Partners released a report that said a third of activity tracker owners abandon their device within six months. 38
Smartwatches are equally uncompelling. “In their introduction, the Apple Watch didn’t provide much more utility above and beyond the smartphone,” he said. “Any time you have a tethered device you have a failed situation.” He’s certain these devices won’t last, that wearables will be uncoupled from serverlike reliance to connect directly to the Internet, and the features crammed into smartphones and smartwatches will dissolve into the world around us. This is the point, he said, when we’ll finally see an interesting interplay.
ut wearables have an even greater shortcoming, a problem of significance, of fundamental importance: they’re ugly. The leading smartwatches are bulky, angular, attention-grabbing devices that look alien on our wrists. In an attempt to remedy this, the recent round of innovation introduced a circular watch face that was no less bulky and just as alien. As a result, the only real market traction they’ve gained is among tech enthusiasts. Dr. Paul Marsden, a psychologist at the London College of Fashion, studies the various facets of consumers’ relationship with wearables. One such study is currently a pilot examining what it is about wearable technology that turns off many consumers. “The whole techy association is a big block,” he said. “The main reason…is the association with technology and performance, rather than lifestyle. One of the primary functions of fashion is to communicate who we are and what we stand for to others. It’s kind of difficult to do that with a one-size-fits-all activity band and a one-size-fits-all iPhone.” He later added, “The research that I’ve been doing is relatively clear. What people want is good design and an effortless experience.” Wearables companies are showing signs they’ve realized this. Nearly every one of them has paired with a fashion designer to slap a coat of paint on activity trackers offering the same handful of features tethered to a smartphone. But two years into these efforts, wearables still feel like someone else’s tech. Per Moore’s law – that the required footprint of a processor will be halved every two years – computer technology will likely be its own savior. Intel’s Edison Chip is a twenty-two-nanometer single-board computer that functions as a development system
people want... an effortless experience. -Dr. Paul Marsden for wearable devices. Using the Edison Chip, Intel debuted the Mimo smart baby monitor in 2014, which is sewn into a onesie and, at the CES demo, transmitted vitals not only to a smartphone, but to an intuitive display on a coffee mug. Under Armour, the polymorph of the fashion world, could just as easily be called a wearable tech company. Google has patented contact lenses with a microchip the size of a piece of glitter that can monitor and transmit the glucose level in the wearer’s tears. Google’s partner Novartis also announced they would soon trial an autofocus lens to treat farsightedness. And then there’s Samsung’s patent for a contact lens with a display system that works by projecting an image into the eye. David Rose wonders if it won’t be long before cameras are incorporated into shirt buttons, ushering in an era of life-logging that will see deeply meaningful insights pulled from photographs of our environment. Google’s Project Jacquard, the recent innovation that’s most widely applicable and illustrative of just
continued from page
currently compatible with a few iPhone models, which are far less common in South Africa than Android smartphones.
Google Cardboard the details:
At about $15, Cardboard is the ultra-affordable virtual reality headset that allows for easier entry into the VR landscape for both consumers and developers. Though it’s quite literally made of cardboard, the viewer is compatible with just about any iPhone or Android smartphone and can play a wide variety of content, from YouTube videos to Google Street View to 360° surgical procedures. provider feedback: Despite the low
how invisible wearables will be, is a platform featuring a conductive thread around which anything from denim and wool to polyester and silk can be woven to create yarns compatible with the looms and machinery already being used by the textiles industry. The yarns can be combined with tiny electronics to allow any cloth surface to, in effect, function like a touchscreen or control a paired device. It’s wearable technology literally woven into our fabric. Nicholas Carr hints at the dangers of progress when he implores we appraise what’s lost and what’s gained as our technology evolves. “An honest appraisal of any new technology, or of progress in general, requires a sensitivity to what’s lost as well as what’s gained,” he says. “We shouldn’t allow the glories of technology to blind our inner watchdog to the possibility that we’ve numbed an essential part of ourselves.” Will the eventual subsuming of wearables into our being rescue us from our present numbed existence or finally snuff out those qualities that make us most human? What’s left of us once we’ve delegated the functions of our brain and become robots responding to the commands of the enchanted objects surrounding us? Who’s more human, HAL 9000 or Dave?
price and cheap materials, the attendees were impressed by the quality of the VR experience, making Cardboard in many ways superior even to VR products from Oculus and HTC. As the low-cost device is somewhat of a one-size-fits-all gadget, some sort of eyepiece adjustment would have allowed some of the attendees with differing vision to see the content more clearly. conclusion
Health is and always has been a global issue. Advancements in telemedicine and mobile health technology will only increase our awareness of healthcare problems and allow greater access to their
solutions worldwide. Despite the fact that resources available to clinicians may vary from country to country, the mHealth Toolbox was a reminder of the value of collaboration. We were surprised to learn how some of the gadgets were beneficial, while others were less useful or difficult to use. We were impressed with some of the ways the attendees thought to use the gadgets they evaluated at the workshop and how they could be improved. And we were excited for them to leave with ideas on how to encourage the adoption of technology in their clinics. Companies would do well to think globally when it comes to developing solutions to our greatest health problems. www.telemedmag.com
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The companies and brands mentioned in this issue.
CellScope Oto www.cellscope.com Page 19
Cohero Health www.coherohealth.com Page 9
Withings www.withings.com Page 20
Start-Ups ----Patients Know Best www.patientsknowbest.com Page 30 Doctorpreneaurs www.doctorpreneurs.com Page 30
Real Time Clinic www.realtimeclinic.com Page 41 IMST Telehealth Resources www.imsttelehealth.com Page 44
SpiroSmart ubicomplab.cs.washington. edu/projects Page 10
FitBit www.fitbit.com Page 20
Opternative www.opternative.com Page 11
Garmin www.garmin.com Page 20
Outcomes Based Healthcare www.outcomesbased healthcare.com Page 31
D-EYE www.d-eyecare.com Page 11
Under Armour www.underarmour.com Page 20
Touch Surgery www.touchsurgery.com Page 31
Iggbo www.goiggbo.com Page 45
Whil www.whil.com Page 14
Oral-B www.oralb.com Page 20
MyOnCallDoc www.myoncalldoc.com Page 51
Panasonic www.shop.panasonic.com Page 20
uBox www.my-ubox.com Page 18
TOTO www.totousa.com Page 21
Scanadu Scout www.scanadu.com Page 18
AliveCor Kardia www.alivecor.com Page 18
Rock Health www.rockhealth.com Page 25
Thinklabs One www.thinklabs.com Page 18
Honor www.joinhonor.com Page 25
Janacare Aina www.janacare.com Page 18
Mango Health www.mangohealth.com Page 25
Samsung GearVR www.samsung.com Page 19
NODE health www.nodehealth.org Page 27
VitalPatch www.vitalconnect.com Page 19 46
Teladoc www.teladoc.com Page 2 Zipnosis www.zipnosis.com Cirrus MD www.cirrusmd.com Page 26 Sentrian www.sentrian.com Page 28 Salus Telehealth www.salustelehealth.com Page 35 Premium Telehealth Domains www.premiumtelehealth domains.com Page 40 National Fingerprint Inc. nationalfingerprinting.com Page 40
SnapMD www.snapmd.com Page 44 Specialists On Call www.specialistsoncall.com Page 45
JeffConnect www.hospitals.jefferson.edu Page 52 Conferences ----Telemedicine Telehealth Service Provider Showcase www.ttspsworld.com Page 41 mHealth + Telehealth World www.worldcongress.com Page 42 South Central Telehealth Forum www.learntelehealth.org Page 42 ATA Fall Forum www.americantelemed.org Page 47
learn more at www.telemedmag.com
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vision : atreja continued from page
post mortem : theranos
apps and devices from Apple and Android are really just business-to-consumer. The only comments we see are from end-users. But that has to change. We need trusted intermediaries to evaluate before we can prescribe or recommend these apps to patients. TM: NODE seems unapologetically academic, so can it scale? How can it keep up, in a world where apps are constantly introducing new features, new versions? Atreja: NODE can keep up, because of crowdsourcing. Every app, every company, will have a profile page. The profile has got to be maintained, and the vendors themselves will want to issue updates. But they may want to put spin on their content – so we need someone unbiased to review their claims and approve it before it’s visible to the community. We have to leverage the power of the community. NODE Health has three guiding principles. First: sharing data about ongoing pilots. Second, standardization – for regulatory policies and governance. Third, multi-site pilots – taking away the biases that come from research done at a single site. This is necessary, as right now a lot of places are evaluating the same app, the same device, in a silo – we need to share data and reduce the number of duplicated pilot projects. TM: So industry will be involved, but unbiased reviewers from the community will have the final say. What about the government? US regulatory agencies have done a good job protecting consumers from untested drugs. But these same agencies haven't tried to regulate EHR. Is NODE a necessary role that the government is neglecting? Atreja: We’re not aiming to have a regulatory effect or try to police the field. And we’ve certainly spoken to regulators and government officials. We're focused on knowledge and data sharing. We can help doctors and patients adopt digital medicine tools. We’ll providing checklists and a pathway that startups will want to follow, to increase their apps’ adoption and get the ser-
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Right now it takes nine months to onboard a technology at a hospital. If a new startup wants to follow Node precepts, I hope we can say: they'll launch faster. We’ll be encouraging adoption of standards, and when an app or company has shortcomings, we’ll be clear about it, but really we’re offering a carrot; NODE is not a stick.
vices underway at more institutions. Right now it takes nine months to onboard a technology at a hospital. If a new startup wants to follow Node precepts, I hope we can say: they'll launch faster. We’ll be encouraging adoption of standards, and when an app or company has shortcomings, we’ll be clear about it, but really we’re offering a carrot; NODE is not a stick. Regarding industry, there’s some news to share. HIMSS/PCHA (the Personal Connected Health Alliance) is going to be a co-founding partner for NODE Health. NODE Health remains independent, but HIMSS liked the approach and they wanted to have a neutral, unbiased voice. HIMSS will have a seat on the NODE Health steering committee. But at its heart, individuals will still be the most important aspect of the community. And individuals can serve as nodes, themselves – to distribute apps, reviews or insights to, say, the telemedicine community or the emergency medicine community. ACC (American College of Cardiology) is coming onboard, the GI society is on board. Many specialties will be represented, and each issue of the newsletter will highlight different specialties, the different parts of the ecosystem.
ship with the US military. “Issues” were found with the device and a request was made to the FDA to investigate. This request was denied by the U.S. Marine Corps Gen. James Mattis. Not long after, Mattis joined the Theranos board of directors. In late October of 2015, the FDA required Theranos to stop running all but one of their 200 offered tests on the Edison machine. They cited that they had not tested the accuracy nor approved the other tests Theranos was performing at that time. After the FDA citing and the Wall street Journal’s report, Theranos promised to publish validated data in a peer-reviewed journal. However, the planned validation study with the Cleveland Clinic has not commenced and no statement has been issued as to when it will. In Janurary of 2016, CMS threatened to pull the certification of Theranos’s Newark, California lab. The “immediate jeopardy” was centered around the company’s test for coagulation. Theranos proposed changes to remedy the situation but CMS felt that the company’s response did “not constitute a credible allegation of compliance and acceptable evidence of correction for the deficiencies cited." Inability to fix this issue would result in severe sanctions including inability to accept Medicare payments and loss of certification of its main facility. The final decision is still pending, however the threatened sanctions (some of the most severe the CMS has ever handed out) include revoking the California lab's CLIA license after 60 days, barring the lab from participating in the Medicare program and possibly fining the lab $10,000 per day for each day it isn't compliant with CMS. Most publicized was a recommendation to bar Holmes from owing or operating any lab for two years.
Virtual Reality Check In the century before Oculus Rift there were dozens of visually-immersive products, several of which focused on clinical applications. What can the history of VR teach us about the technology's future? by Nicholas Genes, MD, PhD
irtual reality is experiencing a resurgence in interest, including renewed attention toward medical applications. New VR research shows promise for applications like physical therapy, pain control and distraction, cognitive-behavioral therapy for phobias and PTSD, and new frontiers in medical training. While VR technology is already in use for laparoscopic surgery and colonoscopy training, enthusiasts hope VR will eventually help students and residents manage resuscitations, and improve skills in performing invasive procedures. Today’s apps and devices for VR mostly focus on entertainment – but it wasn't always this way. An early underpinning of VR, the stereoscope, was developed for research purposes by Charles Wheatstone to aid his depth perception research. By holding two slightly different images, aligned sideby-side, stereoscopes let viewers feel an immediacy and stronger sense of depth than traditional photographs (see illustration). This proved immensely popular through the 1800s – more than half of photos taken during the Civil War, for instance, were stereoscopic. Even as photography (and later, film and television) displaced stereoscopic imagery in popularity, interest in VR-like technology persisted. Morgan Heilig unveiled Sensorama in the mid-1950s, where a customer would stick his or her head into a special box and experience changing perspectives, as well as stereo sound, blowing winds and specific aromas triggered by events in the film – even a vibrating chair. Heilig later invented the first head-mounted display, called Telesphere, to watch stereoscopic films. None of these stereoscopic or shifting-perspective viewing devices were interactive at this point; computer technology just wasn't developed enough. But the idea of simulators had already taken hold, without computers or screens. The Link Trainer, for instance, was a flight simulator of the 1930s whose motors could simulate pitch and roll, as pilots controlled a rudder in a mockup fuselage. VR, as we recognize it, wasn’t demonstrated until 1968, when Ivan Sutherland introduced the "Sword of Damocles." This computer-powered headset earned its nickname because of the wires, piped from the ceiling to the head-mounted display, which hung over the user and followed him or her around the room. While the computer powering the headset was huge and the stereoscopic images it produced were primitive, today's gaze-tracking interactive VR goggles are direct descendants of this technology. 50
The term "virtual reality" wasn't coined until the 1980s. Jaron Lanier popularized it, though he was referring to his tactile gloves and not the increasingly sophisticated headsets. His company, VPL, made virtual surgery an early priority. By the 1990s, companies like Virtuality were making stereoscopic VR arcade games, and movies like "Lawnmower Man" were advancing the concept of people gaining new abilities, or seeking escape, through the technology. But even with more powerful gear, the public failed to adopt VR in large numbers. Nintendo's Virtual Boy was a commercial flop, and Sega’s VR console never made it to market. With the rise of the web, then mobile phones and smartphones, VR development took a backseat. Oculus Rift’s successful crowdfunding campaign rekindled interest in VR, in 2012 – and the company was snatched up by Facebook two years later for $2 billion. But nothing has done more to introduce people to the potential of VR than Google’s cheap and kitschy Cardboard headset. Cardboard simply cradles a modern smartphone over one’s eyes, and app makers have rushed to design smartphone apps that respond to head movements and use the screen as a stereoscope. As simple as it is, Cardboard creates an immersive environment and should be lauded for making the ubiquitous smartphone seem magical again. In recent years, hundreds of trials of VR have been published in the clinical domain – for medical training, rehabilitation medicine and psychiatry to name three. A few medical schools have made high-profile changes to anatomy curricula, incorporating VR glasses and displays from zSpace to allow lifelike rotation and manipulation of anatomic models. Studies often show benefit to learners – or patients – whether it’s planning complex surgeries with VR, or using the technology to practice resuscitation and managing trauma teams. But the studies are small and the technology is still maturing – and still expensive. It’s certainly possible that VR – whether through Oculus, Cardboard or other up-and-coming headsets – never becomes more than a niche entertainment device. In a world where Google Glass was polarizing, VR headsets remain socially isolating. But with VR, seeing makes believers: folks who’ve tried the early apps for education and simulating procedures tend to evangelize the experience. The way I see it, there’s likely a bright future ahead for VR in medicine.
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Whenever and wherever. Through JeffConnect TM, our comprehensive telemedicine initiative, Jefferson is creating new ways to improve the health of our community. Whether it’s attending a doctor visit on a smartphone, drawing on expertise across the country for a valued second opinion, or by creating one of the largest telemedicine networks in the world, we’re using technology to bring the expertise of Jefferson health care to you. JeffConnect. Helping to reimagine the future of health care. Kate Fuller
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Associate Dean for Strategic Health Initiatives | Sidney Kimmel Medical College Vice Chair for Finance and Healthcare Enterprises | Department of Emergency Medicine | Thomas Jefferson University
Issue 5 | Telemedicine HO M E O F S IDN E Y KI M M E L M E D I C A L C OL L E G E