How a new tele-pain clinic could help fight the opioid epidemic.
WWW.TELEMEDMAG.COM
Doc-in-a-bag opens up treatment options for the disabled.
Vision: "Telemedicine" is on its death bed – and we should rejoice.
Why the *beep* are doctors still using pagers in the hospital?
SUMMER 2017 ISSUE 9
featuring ----
Tricorder XPRIZE Health 2.0 Europe TytoCare Tech Review Doctor on Demand SUPA Powers! The Fall of Scanadu ATA Trend Watch Blockchain Primer
New experiments in telepsychiatry expand access, lower costs – and even help combat the opioid epidemic.
]
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businessdevelopment@urac.org Issue 9 | Telemedicine
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WWW.TELEMEDMAG.COM ISSUE 9 / SUMMER 2017 Editor's Desk_4 Telehealth Regional News_6 ------telescope
Pediatraics_9 Psychiatry_10 Audio_12 Primary Care_13 ------teletech
In-Depth: Meet DxtER, winner of the Tricorder XPRIZE_15 Health 2.0 Europe: Startups to watch _18 ------television
pMeet DxtER, Winner of the Tricorder XPRIZE_Page 15
Tong: Inside Doctor On Demand_19
Dr. Basil Harris, an emergency physician from Pennsylvania, leads the team that recently won the Tricorder XPRIZE. His new tool promises to be even better than sci-fi.
Hollander: Telemedicine is in search of the right research_22 Sabine Seymour: The importance of getting a new generation to track their health_23 Gordon: "Telemedicine" is dying, and we should rejoice_26 ------start-ups Post Mortem: How did Scanadu become #scamadu?_27
p SUPA Sabine_Page 23 SUPA founder Sabine Seymour wants to get millennials hooked on tracking their health data through A.I., jump suits and dance battles.
p Dr. Ian Tong, Chief Medical Officer for Doctor on Demand, talks about DoD's unique value proposition and how they plan to spend $80 million in funding.
Page 19
Case Study: On Long Island, a telehealth suitcase opens up new treatment options for disabled patients_28 Tele-Pain: How a new tele-pain practice could help fight the opioid epidemic _30 ------features
Healthcare: The new kid on the blockchain_32 A rural addiction treatment center turns to telepsych to meet physician shortage_33 Trends and analysis from the ATA floor_35 -----teleport
Why the *beep* are doctors still using pagers?_38
www.telemedmag.com
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editor’s desk
Brace Yourself For The Big Pivot
logan plaster
editor-in-chief logan@telemedmag.com
On the ATA floor, getting a demo from Continuwell, an employee engagement platform. Continuwell was one of many new faces on the floor in 2017 and one of many seeking to nail down a market that can feel like a moving target.
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W
alking the floor at the ATA's annual trade show gives you an interesting bird's eye view of the telemedicine industry. In a year full of growth, consolidation and realignment, the show floor provides an immediate snapshot of who’s in, who’s out and who got a face lift. My first conversation among the exhibits this year was with the folks at Zimmer Biomet. For the unfamiliar, Zimmer Biomet has been a global leader in orthopedic devices like artificial knees and hips for decades. This Fortune 500 company is a mainstay of the device industry, doing $4.6 billion in business in 2013. Yet in 2016 they made a strategic pivot towards telemedicine by acquiring RespondWell, a tele-rehab company. They extended themselves from hardware to software, from the surgical suite to the home. And it made perfect How would a Fortune sense. Better compliance with physical therapy regimens means better long-term outcomes for 50 company like orthopedic surgery. Plus, with such deep penetra- Verizon or Amazon tion into the orthopedic market, Zimmer Biomet leverage its unique was able to scale their tele-rehab solution quickly, resources and giving them an edge in the market. infrastructure to On the opposite side of the floor, I ran into leapfrog into the Trapollo, a remote health monitoring company based in Northern Virginia. In fact, I couldn’t telemedicine space? miss this company – their name was plastered absolutely everywhere. The reason for the big sponsor splash? Probably because they were recently acquired by Cox. That's right, the third-largest U.S. cable TV company, a broadband company serving approximately six million residences and businesses, saw an opportunity and pivoted their way into telemedicine. Now they are poised to use their massive scale and infrastructure to redefine at-home monitoring. In the past, evolution within the telemedicine space was mostly intraspecies, as it were. A national telemedicine provider might acquire a regional provider. A remote monitoring device company might acquire an app developer to help sync up their devices. But now we’re seeing a leap – what you might call evolution between species. What will it look like for global device manufacturer to become a provider of at-home telemedicine services? What efficiencies can be gained from having an internet company run your at-home health monitoring? If Cox wades into the deep waters of telemedicine this year, even bigger fish can't be far behind. How would a Fortune 50 company like Verizon or Amazon leverage its unique resources and infrastructure to leapfrog into the telemedicine space? No doubt, there will be rapid change and consolidation within the telemedicine industry in the coming years. Much of that evolution will come from outside forces seeing opportunity and then acquiring or building their way into the market. These new actors will then use their unique economies of scale in ways we can't even anticipate to push the market in a new directions. The two big questions: Who will pivot next, and who will pivot best. In the meantime, we'll keep watch over the industry and share stories of inspiring, innovative people and companies. We don't care about technology for technology's sake, but rather, what are the ideas and products that will move the needle on healthcare, increasing access while lowering costs. As always, if you have a story tip, my line is always open.
telemedicine ISSUE 9 – SUMMER 2017
EDITOR-IN-CHIEF
Logan Plaster logan@telemedmag.com
Last month Dr. Basil Harris got to channel “Bones” from Star Trek as his team won the coveted Tricorder XPRIZE (story on page 15).
EDITORIAL DIRECTOR
Bill Gordon bill@telemedmag.com
who is your sci-fi hero?
EXECUTIVE EDITOR
Mark Plaster, MD
CONTRIBUTING EDITORS
Rishi Madhok, MD Aneel Irfan Unity Stoakes Mark Shankar
My hero is Yoda. Why? Because he said, "Try? Hmmpf. Do or do not do. There is no try."
MacGyver might not have been sci-fi but he was heavy on the science, and could make something from nothing to solve a problem.
EDITOR AT LARGE
Nicholas Genes, MD, PhD CONTRIBUTORS
Marty McFly from Back to the Future. The guy was just cool –played guitar, rode a skateboard and made life look easy.
Elliot, from E.T., combined 80s hoodies, BMX bikes and a love of Reese's Pieces. We would've been friends.
Alex Fortenko, MD
Heather Zumpano
Sean Bandzar, MD
Judd Hollander, MD
Laura Sansouci
Spock was disciplined, intelligent, cultured and ever curious – the logical choice for a sci-fi hero.
Scott Jung
Scott Pruden
John Tyler Allen
Michael Levin-Epstein
Aditi Joshi, MD
ILLUSTRATORS
Nicolet Schenck (cover) Erin Lux
Marvel's Elektra, because of her complexities and her Sai skills!
ADVERTISING REPRESENTATIVE
Eliseo Rivera eliseo@telemedmag.com TELEHEALTH RESOURCE CENTER LIAISON
Aneel Irfan aneel@telemedmag.com
Telemedicine Magazine is published quarterly by M. L. Plaster Publishing Co., LLC. PO Box 121, Galesville, MD, 20765. Printed in the USA. Copyright ©2016. To purchase a subscription, go to www.telemedmag.com/subscribe
The authors, editor and publisher are not responsible for any errors or omissions or for consequences from application of the information in this publication, which remains the professional responsibility of the practitioner. No part of this publication may be reproduced in any format or content without written permission of the publisher. The appearance of advertising in Telemedicine does not constitute on the part of the Publisher a guarantee or endorsement of the quality or value of the advertised products and services or the claims made for them by their advertisers. www.telemedmag.com
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regional news
News from the Consortium of Telehealth Resource Centers
Whether you're looking to network in telehealth or take the final step in launching a telemedicine practice, there are federally-funded telehealth resource centers ready to help. Here's a rundown of their recent activities. edited by aneel irfan
NORTHWEST
SOUTHEAST
SOUTHWEST
GREAT PLAINS
Education is a primary part of NRTRC’s mission. To fulfill that need, NRTRC offers a number of different educational opportunities, ranging from our annual Regional Telehealth Conference to our monthly webinars (both regional and national) to Telehealth Toolkits to White Papers. We offer educational materials tailored to all levels of Telehealth participation, whether it be newly forming networks or seasoned providers looking for more information on a specific topic. Follow the links at www. nrtrc.org to review our archived resources from each of our educational opportunities. If you have educational needs not addressed on our website, drop us a line and let us know what you’re looking for. contact: bob wolverton bob@nrtrc.org
Make plans to join us for our 6th Annual AL Telehealth Summit on August 17 at the UAB Hill Student Center in Birmingham, Alabama. Conference registration and sponsorship information can be found www.gatelehealth. org/about/conferences/ SETRC Telehealth Workgroups have been formed to (1) provide insight and direction regarding the advancement of telehealth, and (2) encourage collaboration among existing telehealth networks and programs. Follow us on Twitter @SETRCUS.
Hear from frontline experts on making telehealth work at the 3rd Telemedicine & Telehealth Service Provider Showcase (SPS 2017) Oct. 2-3 in Phoenix, AZ. Speakers will provide useful, practical advice on how to get ready for telehealth, how to choose your perfect clinical tele-services partner, how to champion telehealth legislation in your state, how to negotiate win-wins with payers, and how to integrate offsite providers into your organization. You’ll hear directly from researchers on outcomes data, from a Medicare contractor on understanding the fine print, and from technology innovators on what’s next. SPS speakers are confirmed—go to ttspsworld.com for details. SPS 2017 also will feature an expo hall to showcase the latest clinical and technology trends in telehealth. Poster abstract deadline is June 30: Submit your abstract now! ttspsworld.com/callabstracts.
At gpTRAC, we have a fourpart mission: build telehealth awareness, promote education, provide individualized consultation, and provide data specific to telehealth services in our region. We promote healthcare services that take advantage of modern telecommunications technologies such as interactive videoconferencing, secure Internet transactions, and home health monitoring. While we focus on solving healthcare delivery problems for rural providers and their patients, we work with clinics of all sizes and locations to help solve problems of access to and quality of care using telehealth applications. We can also help health organizations navigate other challenging areas in telehealth, including legal concerns, regulatory issues, appropriate technology, the implementation process, and financial issues.
contact: lloyd sirmons lloyd.sirmons@setrc.us
contact: kristine erps kerps@telemedicine.arizona.edu
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contact: zoi hills hills069@umm.edu
Share your latest news with Telemedicine Magazine email Aneel@telemedmag.com
TEXLA
NORTHEAST
MID-ATLANTIC
HEARTLAND
On May 12, 2017, the Texas State Legislature passed SB 1107, a law expanding the use of telemedicine in the Lone Star State. The bill is now on its way to Governor Abbot’s desk where he is expected to sign it into law. SB 1107 allows physicians in Texas to use telemedicine to establish a valid physicianpatient relationship without the need for an in-person exam. The change is the product of months of negotiations between medical boards, regulatory agencies, and industry groups and may finally bring an end to the longtime telemedicine standoff in the Lone Star State. We are hosting telemedicine 1.0 workshops across Texas to provide healthcare admins resources and tools to develop and sustain telemedicine programs. Join us in Austin on June 14th or Dallas July 14th. Our annual Rural Health at The Crossroads conference is slated for June 21st-23rd in Amarillo, TX. texlatrc.org for more details.
Bassett Healthcare Network has acquired a new telehealth platform to connect with 15 school-based health centers (SBHC) to bring telehealth to students in rural New York state. We are thrilled to congratulate this year's NETRC Conference Keynote Speaker, Elizabeth Krupinski, for receiving the ATA President's Award for Individual Leadership! We continue to watch for new funding opportunities that may be of interest to you. The most notable RFA that has been released in the past month may be from the New York State Department of Health to expand Project ECHO. We are also eagerly awaiting the release of the USDA Distant Learning and Telemedicine Grant. Stay tuned for updated reimbursement fact sheets and an announcement about the new Northeast Telehealth Leadership Forum to support collaborative problem solving across the region.
Whether you are just starting out in telehealth or already have experiences and need guidance, stop by one of our open session to get your answers. Open session are on the 2nd and 4th Friday of each month from 12:00 PM 2:00 PM with Jay Ostrowski. As the president of Behavioral Health Innovation (BHI), Jay develops, sells and deploys online mental health applications, and serves as an advisor and telemental health consultant for the Mid Atlantic Telehealth Resource Center. Because rural primary care providers are challenged by little or no access to services that can assist in delivering much needed chronic disease care, East Carolina University (ECU) created TeleTEAM, a telehealth model that connects patients to an off-site diabetes care team during primary care office visits at their local clinics. Visit www.matrc.org/ for additional updates.
Kansas is one of only seven states where physicians can now apply for expedited licensure to practice telehealth across state lines. This opportunity, courtesy of the Interstate Medical Licensure Compact, is currently limited to the other member states. Although 18 states have joined the compact, according to mHealth Intelligence, 11 states have encountered implementation delays because of an issue with criminal background checks accessed through the FBI. To qualify, a physician must meet one of the following requirements in the member state: -Be a resident of the state. -Have at least one-quarter practice in that state. -Be employed at a health care system in the state. For more information, please contact HTRC at 877-643HTRC.
contact: andrew solomon
khw2k@hscmail.mcc.virginia.edu
contact: becky jones
asolomon@mcdph.org
contact: janine gracy jgracy@kumc.edu
contact: kathy wibberly
becky.jones@ttuhsc.edu
www.telemedmag.com
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telehealth
Share your latest news with Telemedicine Magazine email Aneel@telemedmag.com
regional news
SOUTH CENTRAL
CALIFORNIA
PACIFIC BASIN
UPPER MIDWEST
Tina Benton, BSN, RN, and Sarah Rhoads, PhD, DNP, APRN, were recently honored by the Great 100 Nurses Foundation at an event held at the Embassy Suites. Benton is the Program Director of Antenatal & Neonatal Guidelines, Education and Learning System (ANGELS) in the Department of Obstetrics and Gynecology at the University of Arkansas for Medical Sciences (UAMS). She is also Clinical Division Director and Operations Manager of the Center for Distance Health. Rhoads is the Program Director for the South Central Telehealth Resource Center, Education Director for the Center for Distance Health and Associate Professor at UAMS. SCTRC serves Arkansas, Mississippi and Tennessee. The resource center website, www.LearnTelehealth. org, targets health care and health education groups that have an interest in using telehealth. The SCTRC focuses on telehealth media and education. Hands-on training in the Adam Rule Training Center or at your site are available.
The California Telehealth Network (CTN), a leading nonprofit provider of telecommunications infrastructure and telehealth services in California, recently joined forces with OCHIN, a leading national nonprofit health IT, research, and innovation organization. Join us for the 5th annual statewide Telehealth Summit in Newport Beach June 5-7. The conference will focus on current telehealth applications, with California-based clinics and hospitals sharing secrets for building successful programs using live video, store and forward, and eConsult applications. The agenda will also include California and nationwide legislative updates, key elements for successful program development, change management techniques, and the convergence of telehealth and the electronic health record. The conference will be attended by telehealth clinician champions, coordinators, C-suite leadership, and IT professionals. Register today at www.caltelehealth.org/2017telehealth-summit.
The Pacific Basin is a region with unique characteristics and challenges, including a vast geographic area with diverse cultures, limited resources, varying levels of infrastructure, and differing needs. There is a common thread, however, connecting the US affiliated Pacific Islands to Hawaii. There is a long history of collaboration between the entities treating each other as “Ohana” or family. Our vision is to provide cost effective access to connected, high quality, health care services for all people. We are committed to expanding the availability of healthcare to undeserved populations via telehealth. 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. Visit www.pbtrc.org/ to learn more.
UMTRC provides technical assistance to Health Resources and Services Administration (HRSA) grantees interested in establishing or expanding a telehealth program including, but not limited to, Office of Advancement for Telehealth (OAT) Telehealth Network, Community Health Centers and the Federal Office of Rural Health Policy grantees. Two tiers of assistance are available: Tier 1: Call or email us any time to learn more about our program and discuss the telehealth landscape. Tier 2: We provide each client up to 10 hours of free technical assistance per year. Requests for assistance can be submitted using our Contact Form, calling 855-283-3734, ext 232, or emailing us. For additional assistance, a client may wish to inquire about engaging the UMTRC for consultative services.
contact: wendy ross
contact: kathy chorba
contact: deborah birkmire-
wross2@uams.edu
kchorba@caltelehealth.org
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peters
| info@pbtrc.org
contact: becky sanders bsanders@indianarha.org
tele
2 Tool includes a high resolution digital camera, otoscope, stethoscope, and tongue depressor.
telescope Telemedicine briefs across the medical universe
gear lab
TytoCare Gives the Tele-Physical a Hardware Upgrade This Israeli start-up is attempting to bring comprehensive telemedicine into the home – specifically into the hands of parents. With a sleek form factor that rivals an Apple product, TytoCare has created a handheld, multi-purpose diagnostic tool they hope moms will actually enjoy using when their children are sick. Tyto is also branching into professional solutions through TytoPro and TytoClinic.
pediatrics
1 Received FDA Clearance in November 2016 and is now rolling out a remote examination and telehealth platform.
3 TytoHome's selfguidance technology assists users as they conduct and record medical exams of the heart, lungs, ears, throat, skin and temperature.
Unlike many mobile diagnostic tools, TytoCare claims to be able to detect stomach and bowel sounds to help diagnose G.I. issues.
4 Enables patients to send their exam data to their physician for review, or conduct a live telehealth exam. 5 Works on an open API for integration with EHR systems and 3rd party telehealth tools.
www.telemedmag.com
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psych
48% of psychiatrists are currently over the age of 60, which means the current psychiatrist shortage is only going to get worse.
perfect storm
The Massive Benefits of Tele-Psych Have Yet To Be Realized With a decline in providers and an increase in demand, the need for supplementary psychiatric services has never been clearer. Now, healthcare companies are scrambling to set up tele-psych networks, some opting for acquisition while others build from within. by Mark Shankar, MD Alex Fortenko, MD MPH Sean Bandzar, MD
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T
he steady hum of voices and buzzers in the emergency department slowly escalates as staff gear up for a busy Friday night. The summer months bring with them a restless crowd of acutely ill patients. Dr. Schneider scans the board for his next patient. Jack, 32, has been off his psychiatric medications since moving, four months ago. He is here this evening because his thoughts of suicide have become both more frequent and more forceful, and he is afraid he will hurt himself. There is no doubt that Jack must see a psychiatrist emergently. The only problem is that the nearest one is 80 miles away. Despite the distance, getting immediate psychiatric evaluation is a non-issue for Jack. A tech wheels over a remote-control operated robotic iPad stand and within three minutes, Jack is face-to-screen with a telepsychiatry consult physician. After a thorough evaluation, it is clear that an admission is warranted and arrangements are made to transport Jack to the nearest standalone psychiatric facility. An hour later, Jack is en route to the inpatient facility. Our telepsychiatrist moves on to his next patient - in an ER over 100 miles away.
This scenario occurs hundreds of times per day all over the Unites States. While telepsychiatry has existed for over two decades, recent advances in mobile technology and payment reform have made it a viable and common-sense solution for the access gap in mental health. According to Merritt Hawkins, a physician recruiting firm, forty eight percent of psychiatrists are over the age of sixty, a looming statistic indicating that psychiatry may actually see an imminent decline in the number of providers. This growing shortage means that patients already struggling to find psychiatric services will have increasingly sparse access. Patients with untreated mental illness suffer from higher rates of medication noncompliance, emergency room visits, and inpatient admissions, resulting in preventable cost to the healthcare system. Samir Malik, co-founder and CEO of 1DocWay, which was purchased by Genoa, a QoL Healthcare Company and rebranded as Genoa Telepsychiatry, cites high-quality psychiatric care as a major factor in decreasing the cost of overall medical care for the most vulnerable patients. The ability for telepsychiatry to help mental Illustration by Nicolet Schenck
health patients in geographically underserved areas has been greatly augmented by recent legislation making telemedicine an economically viable model for providers. As of 2011, Medicare defines telemedicine services reimbursable by Medicare as those that include “interactions between a healthcare professional and a patient via real-time audio-video technology.” While Medicare mandates that patients be in what is considered a defined “rural” region, private insurers and Medicaid plans in 24 states and the District of Columbia reimburse providers for care delivered to patients in any geographic setting. Changes to Medicare guidelines in 2015 have made some allotments to telepsychiatry from home, making the mandate of “clinicbased” telepsychiatry to guarantee reimbursement more flexible. The impact of telepsychiatry is already unmistakable but is especially apparent in rural populations. A recent study in Health Affairs shows a 45.1% increase in telehealth visits among rural patients with mental illness between 2004-2014. In Iowa and South Dakota, ten out of every hundred beneficiaries with any psychiatric illness used telehealth services. According to Dr. Matt Stanley, a psychiatrist at Avera Health in Sioux Falls, the economic benefit of such widespread telepsychiatry use among rural patients is expected to be experienced as cost savings on prevented inpatient admissions. When asked about any policy changes that can boost the impact of telepsychiatry, Dr. Stanley and his colleagues agree that reimbursement for provider services rendered through Direct to Consumer (DTC) apps is a necessary next step. The importance of fast access to a provider in high-quality psychiatric care makes DTC products especially valuable as patients can use apps such as TalkSpace to get on demand counseling. TalkSpace has several tiered services, the first of which gives you access to a dedicated licensed personal therapist over text message for $32 per week. For $59 per week, couples can get virtual relationship therapy and for $99
per week, consumers have access to talk therapy over the phone. Consistent and trusting patient-provider relationships are essential for the treatment of mental illness, making on demand DTC services like TalkSpace especially impactful as telepsychiatry evolves. While DTC services still rely on consumers willing to pay out of pocket, enterprise solutions are being heavily sought out by health systems looking to expand access to psychiatric services. Companies like Genoa Telepsychiatry offer telepsychiatry services to emergency departments, community mental health centers, correctional facilities, primary care practices, and federally qualified health centers. The Genoa platform allows patient scheduling, ePrescribing, video conferencing, note taking and billing services to ensure providers are getting reimbursed. Most companies offer integration into an already-existing health system electronic health record. The reliable reimbursements from telepsychiatry platforms have drawn investors and merger and acquisition activity to the space. In addition to Genoa acquiring 1DocWay in 2015, Pharos Capital, a private equity firm, acquired FasPsych, LLC in 2016. TalkSpace has raised a total of $28 million, most recently $15 million in a Series B led by Norwest Venture Partners. WeCounsel, focused on provider and enterprise solutions, has raised $4.1 million, including a $3.5 million Series A in May 2016. Canyon Healthcare Partners, a private equity firm invested $2 million in InnovaTel Telepsychiatry, an Erie, PA based telepsychiatry company that caters primarily to rural populations. Investment in this space is already driving rapid technology and platform development. As mental illness, drug addiction, and suicide rates are brought to the forefront of the healthcare conversation and new legislation recognizes the importance of access to psychiatric care, we are at the cusp of a behavioral health revolution in which telepsychiatry services will play a central role in bringing care to typically underserved populations.
Market Watch Five companies to keep an eye on within the tele-psych space.
INSIGHT TELEPSYCHIATRY Founded in 1999, InSight has grown into one of the nation's largest telepsychiatry companies. In 2016, they conducted more than 200,000 remote psych encounters. www.insighttelepsychiatry.com
IRIS TELEHEALTH Founded in Virginia and now operating in 15 states, Iris Telehealth's team of 60 providers works with everyone from ERs to outpatient clinics. www.iristelehealth.com
JSA HEALTH This rapidly expanding group boasts a phone response time of less than one minute and high patient satisfaction score. Plans are in the works to expand services to China. www.jsahealthmd.com
BRIGHTER DAY HEALTH Brighter Day is an industry leader in providing mental health services to rural nursing homes delivered via telemedicine. www.brighterdayhealth.com
WE COUNSEL This group focuses on behavioral health private practices. Their tools include videoconferencing, instant chat, secure messaging, scheduling, document storage, and billing. www.wecounsel.com www.telemedmag.com
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audio
more signal, less noise
Why High Quality Audio Matters in Telemedicine Award-winning audio engineers from the music industry are making the case for higher fidelity audio in telemedicine. Here's why. by laura sansouci Imagine settling into a luxurious reclining theater seat to view a widescreen HD premier movie while listening to the audio through your laptop speakers. The picture unfolds in detail so fine the star's nose hairs can be counted, but the tension-building ominous music can barely be heard. That's telemedicine without diagnostic quality audio. The human ear is tuned to the high frequencies of the human voice by nature, however most of the thoracic and intestinal sounds essential to auscultatory diagnosis are low frequency and up to eight times more difficult to hear. Heart, lungs, or intestines may be playing that ominous soundtrack of disease outside the range of your hearing. Using high quality headphones and straining your auditory cortex until your head aches is only a partial solution. Dynamic range control (which balances the volume of high and low frequencies) is the solution for making movies and music sound great, but those systems were not tuned for medical use. While they boost the volume of the low end, they may also create distortions, effectively making the audio unsuitable for telemedicine as well as teaching or lecture scenarios. Recent advances in audio processing have addressed these issues. A prime example (and the only FDA listed post-processing 12
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algorithm) is Bongiovi's MDPS™ system. The MDPS™ software interprets the sound just as your auditory cortex does, raising the low frequency sounds for consistent volume without unnatural artifacts, bringing the audio sharpness in line with the quality of the video on your existing equipment. Included profiles are tailored to types of input including speech intelligibility and heart/ lung sounds. Several other post processing advances ensure that the resulting audio is accurate and free of distortion. This clarity is essential to “seeing” the whole picture. Here's what you might be missing: 1. Accurate representation of tone and demeanor. Weakness, slurring, nasal obstruction, mental status, and indicators of substance abuse are subtle and go beyond understanding the words the patient uses. Low quality audio may miss the influence put on a word or phrase that is key to accurate diagnosis and treatment. Advanced audio processing will equalize the volume without distortion. 2. Clear communication. A low quality audio recording can increase the likelihood of both obvious and insidious communication errors. If information is obviously inaudible, the process stops while the correct information is obtained, a frustrating experience and a waste of valuable time in critical situations. More insidious is the mind's tendency to jump to dangerous conclusions when mishearing a garbled recording. 15mg can become 50mg—with huge impacts to patient health as well as serious
legal consequences. 3. Clarity in challenging environments. Background noises from office or medical equipment in the recording or listening environment are difficult to control, and a patient with a quiet voice or unusual accent may increase the difficulty of interpreting the audio. The MDPS™ system is proven in standardized tests to improve speech intelligibility in the presence of background noise. 4. Increased productivity. Asking patients to repeat themselves, or to repeat a procedure because the results are unclear costs time, money, and frustration that would have been avoided by using advanced audio processing on the original session or recording. An investment in true diagnostic quality audio has the potential to increase productivity and quality of care immediately. 5. Improved auscultation. The low frequency sounds of heart murmurs, pleurisy, wheezing, stridor, and digestive symptoms may be outside the range of human hearing, even in a high quality recording. The MDPS™ audio algorithm brings these key factors into the volume range easily processed by the human ear and auditory cortex. **** The sounds of sickness are like the low frequency theme from Jaws, pounding in the background and warning of the next attack. If you aren't hearing it clearly, you may be missing crucial clues of what is happening in the depths. It might be time for a bigger boat.
tele
primary care
Survey Says
Industry Survey Notes Improved Consumer Attitudes Towards Telemedicine in a Variety of Circumstances Doctors take note: Your patients are becoming more and more interested in the option of a telemedicine visit and are more willing to switch doctors to find a practice that offers them. That’s according to a new survey by telemedicine provider American Well and Harris Poll. The Survey outlines just how much patient perspectives on telehealth are changing. by Scott Pruden Patients are Delaying the Care They Need
Consumers Recognize the Potential for Telehealth
The survey found 67 percent of consumers have delayed care because of excessive cost (23 percent), difficulty in scheduling a visit with a doctor or nurse (23 percent), hope that the problem will resolve itself (36 percent), or they’re just too busy (13 percent). These delays not only result in insufficient or non-existent care for health issues when they occur, but also potentially exacerbate minor problems down the road because the consumer misses reminders about vaccinations, preventative exams or flu shots.
When it comes to a variety of diagnostic, health management and follow up visits, consumers show that they’re increasingly willing to conduct those visits via video, according to the survey. Of those with chronic conditions such as diabetes or heart disease, 60 percent responded in favor of using telemedicine for regular doctor check-ins. Customers also expressed enthusiasm for the option of video visits for post-surgical or hospital stay follow-ups, middle-of-the-night care, elderly care, prescription and birth control pill refills. In all of these cases, convenience and time savings are maximized for the consumer, and in the case of off-hours care and elderly visits, there are significant cost and safety benefits, the survey notes. The survey concludes that for primary care providers, health systems, employers and insurers, there are growing benefits to offering telehealth visits as an option. Those include lower costs, greater patient convenience, improved patient outcomes and increased customer satisfaction.
“Delaying care for serious health concerns can have costly ramifications for the patient and the healthcare provider – with fewer, often far more expensive treatment choices available when diagnosis is delayed,” the survey states. Video Visits Are a Viable Option Two-thirds of consumers are willing to see a doctor via video if the service is available, the survey found. Factors driving this trend may include the time it takes to get an in-office appointment with a healthcare provider, which The Washington Post reports can average more than 18 days from the time an appointment is made. According to a Harvard University report, the average time for an in-office visit is two hours, including travel and wait time, with only 20 minutes of that time spent seeing the doctor. When offered the option of a video visit, the majority of adults surveyed (69 percent) said they would prefer that option. In addition, results from surveys of American Well’s telehealth service showed that of those patients who used a telemedicine doctor’s visit, they felt their healthcare needs were met 85 percent of the time, compared to 64 percent for those who visited doctors in person.
50 million
Number of U.S. adults willing to switch their primary care provider for video visits
79 %
52
Consumers interested in using video visits for post-surgical or hospital follow-up
Consumers with ill or aging relatives that find video visits helpful in coordinating care
78 % Those willing to have a video visit with a doctor or primary care provider to have prescriptions refilled
60 % Consumers who would use video for chronic care management
50 % Women interested in telehealth visits to renew birth control prescriptions.
Source: Telehealth Index: 2017 Consumer Survey, American Well
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ISSUE 6
8/22/16 3:51 PM
tech
tricorder xprize
teletech Practice-changing gadgets & gizmos
the future is now
Physician-Led Team Wins Tricorder XPRIZE with DxtER It’s a laid back Friday evening in San Jose, but judging by his huge grin and enthusiastic handshakes, Dr. Basil Harris is as excited as can be. Harris has just arrived from the Qualcomm Tricorder XPRIZE awards ceremony in Los Angeles, where he and his team were announced as winners of the grueling five year competition. In what could be considered a victory tour of sorts, Basil and his brother and co-inventor George made a stop in the Bay Area to show off their winning device before heading home to Philadelphia.
by Scott Jung
Dr. Harris shows off the orb-shaped digital stethoscope, one of four components of DxtER.
The event wasn’t a medical conference or technology symposium, however. Rather, it was a media welcome reception for the annual Silicon Valley Comic Con. Alongside Star Trek celebrities like William Shatner and Nichelle Nichols, Harris was invited as a guest to spend a few hours demonstrating his own contribution to Star Trek. From Harris’ big smile, you could tell that he was proud of his team’s accomplishment and enjoyed sharing it with the press. But the big highlight for Harris was when the show’s owner, Apple co-founder and tech legend Steve Wozniak, arrived to meet the guests. Excited, nervous, and a little starstruck, Harris gave a quick demo of DxtER to “the Woz”, even jokingly blaming his increasing heart rate readings on “the Woz’s” presence.
Dr. Harris demonstrates DxtER for Apple cofounder Steve Wozniak.
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tricorder xprize
The multi-year Qualcomm Tricorder XPRIZE competition kicked off in 2013 and sought a solution that would integrate the latest in wireless sensors, medical imaging, microfluidics, and cloud computing into a device that could allow a user to self-diagnose health conditions anywhere, thus lowering the constantly-increasing time and costs of healthcare. The competition started with a field of 34 teams of clinicians, engineers, and health experts from all over the world. That number eventually narrowed down to the second-place winner, team Dynamic Biomarkers Group out of Taiwan, who won $1 million for their “DeepQ Kit” device, and Harris’ team, who took home $2.5 million for DxtER. To Boldly Go A Star Trek-themed competition was a natural fit for Harris and his team, who were already science fiction and Star Trek fans. “Being fans played a big part in getting interested in this project. It is just so cool to play even a little role in bringing the medical Tricorder from Star Trek to life,” Harris says. His team was appropriately named Final Frontier Medical Devices, a reference to the description of space used in Star Trek’s opening narration. Aside from being a Trekkie, Harris is a practicing emergency physician at Lankenau Medical Center, just outside of Philadelphia, and much of the approach to DxtER’s design and functionality he credits to his experiences in the ER. “We first recreated the diagnostic process as performed by physicians 16
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in an actual medical encounter,” says Harris. “Only after we had that built and validated with real medical data did we start building hardware.” He believes it was this approach, which also spurred development of DxtER’s artificial intelligence engine, that set the device apart from the competition. Harris believes strongly that medical technology design as a whole should start with input from doctors. “Practicing clinicians and those active in all areas of clinical care who work on the front line of patient testing and clinical care are critical players in advancing new technologies,” says Harris. They are uniquely positioned to fully understand the challenges posed by providing realtime quality results in the face of diminishing resources and pressure on turn around times.” The Best Crew in the Fleet For Harris, success also hinged on forming a unified team with a common vision of his team. Many people in the DxtER team are family members who bring diverse skills to the table. Co-inventor and brother George is a network engineer, another brother, Constantine “Gus” is a practicing urologist and electrical engineer, and sister, Julia is an expert in health policy. “If you have a truly symbiotic team, you can build a group with an incredible amount of trust,” Harris explains. “Our people were all sergeants, not privates or generals. Everyone respected and held onto the understanding that, when a task was assigned to someone, that person could solve and complete
DxtER can diagnose and interpret a defined set of 13 health conditions, while continuously monitoring five vital health metrics. "It's more advanced than the tricorder from Start Trek," Harris says.
that task and any related issues that would crop up.” Better Than Sci-Fi DxtER consists of a system of non-invasive sensors: an orb-shaped digital stethoscope, an array of ECG sensors that sticks to your chest, a spirometer to measure lung function, and a finger probe that noninvasively measures glucose and can perform other blood tests. All the sensors pair with an app that guides
the user through using each sensor and can diagnose and interpret a defined set of 13 health conditions while continuously monitoring five vital health metrics. “DxtER is more advanced than the Tricorder from the Star Trek series,” Harris says. “In the TV series, the Tricorder was used by the ship’s doctor, Leonard “Bones” McCoy, to obtain vital signs and other information. He would then interpret that information to come up with a diagnosis. In the Qualcomm Tricorder XPRIZE contest, we had to do the same thing, plus include the doctor into the device!” To accomplish this, DxtER’s AI-based engine would learn to diagnose medical conditions by integrating knowledge from clinical emergency medicine with data analysis from actual patients. Upcoming Missions While the competition portion of the Qualcomm Tricorder XPRIZE may be over and the $2.5 million prize awarded, work on DxtER is far from complete. The device will continue to undergo development with support from the FDA and other regulatory bodies. “We put the best stuff we could into the prototype demo kits for the Qualcomm Tricorder XPRIZE, but our next generation sensors are already in testing,” Harris says. Harris hopes that the first production-grade components will be approved and available for sale in about two to three years. In addition to commercialization, DxtER will also be used as part of a public health collaboration with a hospital in Mozambique, Africa and other
developing countries. Harris has also brought DxtER back to Lankenau Medical Center, where his own patients can test the device and offer their input. Tricorders for Everyone Fifty years ago, Star Trek aired on television and gave viewers a glimpse of what the future might look like. Few probably could have imagined that 2017 would be the year where the idea of the Tricorder would start to move from the realm of science fiction to science fact. At the speed that technology is advancing, the next fifty years of medicine might look even more similar, or perhaps vastly different, than the future that Star Trek predicted. “Tricorders of all types for everyone!”, Harris predicts when asked about what the next fifty years might bring. “Personal in-home Tricorders, public kiosk Tricorders, emergency Tricorders, rugged wilderness Tricorders.” But Harris stresses that the Tricorders’ utility will largely depend on input from health professionals. “This technology is going to happen whether the clinicians are involved or remain on the sidelines. But we need clinicians to guide the development and direct the conversation. The clinicians understand the importance of obtaining real and reliable data. We need to demand that devices coming to market deliver worthy medically significant data. The more robust the technology is, the more likely it will be adopted into practice. We'd love to have more people in this space, innovating, and thinking about how to make these products better.” www.telemedmag.com
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health
2.0 europe
Beyond Silicon Valley
tech sans frontiers
The Best Tech of Health 2.0 Europe The world is small, and technology has shown us how easily our data crosses borders. In that tradition, I headed over to Health 2.0 Europe to learn a very small amount about the digital health landscape across the Atlantic. Here are some of the highlights. by aditi joshi, md
Trend #1: Symptom Trackers At this year's Health 2.0 Europe, more than a few companies presented their ‘symptoms checker’ apps geared toward either physicians or patients. One in particular, Mediktor, hosted a presentation on their clinical trial results, noted to be the first for this type of app. They enrolled 1015 patients (622 included) triaged at levels 3-5 in a large tertiary ED and used their app to determine possible diagnoses. Data collected by an independent researcher compared the ED physician’s diagnosis versus the Mediktor’s pre-diagnosis. The results showed an accuracy of 91.3% for the diagnosis being in the top ten results and 75.4% were in the top 3. While a list of ten seems long, it can aid in considering less likely diagnoses that may be missed. Mediktor partner Josep Carbó acknowledged that his app was not a replacement for physicians but a “tool for professionals.” He also noted that the way forward for the entire field will be more research and quality measures and is looking to further partner with other academic centers interested in working on it. Our Two Cents: As Jefferson is also involved in telehealth research, we acknowledge this part of the tech revolution might not be as ‘fun’ but will be a necessary step in our evolution and adoption.
Trend #2: New Applications for Artificial Intelligence Artificial Intelligence solutions had a predictably large presence at Health 2.0 Europe. Aidence, a radiology service based in the Netherlands, pitched their app which helps radiologists diagnose pulmonary nodules on CT scans of the chest. COO Jeroen van Duffeln stated that the statistics show that radiologists can miss approximately 35% of nodules. The AI, on the other hand, missed between 4-20%. The company hopes that earlier diagnosis can decrease deaths from lung cancer. It can also be used to monitor lesions already being treated or monitored for comparison. Our Two Cents: While the use of AI to find pulmonary nodules is here, the reality is that most pulmonary nodules are not cancerous. What will an increased finding of nodules do to the burden of testing and screening? What will be the number needed to save a life? Sometimes more data becomes unwieldy rather than helpful and having a frank discussion with providers can help bridge this gap. Wish I could have gotten to everyone – thanks for being a gracious host, Barcelona!
Eight European Health Tech Startups to Watch ARTHRO THERAPEUTICS With a mission of helping people deal with – or avoid – arthritis, Arthro is in the early stages of using A.I. to formulate exercise regimes. BRAINCONTROL This Italian company uses brain waves to allow its users to control a computer; can be used by patients with ALS or diseases that cause ‘locked-in’ syndrome for communication. NEUROELECTRICS Wireless EEG and brain stimulation device to monitor brain health with use cases to treat neuropathic pain, epilepsy, depression. SXT This UK-based app allows patients to find the right sexual health clinic or service nearby – from testing, to contraception to sexual assault support service. B-WOM This women's health app tracks habits, sleep, diet, sex, and gives tips and exercises to help combat pelvic floor weakness as well as other complaints. Watch for great things from CEO Helena Torras. HELPAROUND Network of patients with diabetes and caregivers for questions, support and help with management. WELLMO Helps insurance companies find the digital and mobile health technologies best for their users. S-THERE Sensor placed into the toilet to measure urine parameters to assess hydration status. -Aditi Joshi, MD
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vision
television Industry-shaping ideas & perspectives
The DTC Play
Doctor on Demand Got the Funding. Now What? Dr. Ian Tong cringes when his company, Doctor on Demand, is compared with other telemedicine providers. Whether that is because of DoD's consumer focus or their video-only strategy, one thing is certain. With nearly $100 million in funding, this telemedicine provider has pockets deep enough to distinguish themselves in the market. Telemedicine spoke with Tong, who has been DoD’s chief medical officer for four years, to talk about his path to telemedicine and why the future is all about synchronous video consults. Interview by Logan Plaster
TelemedMag: Tell us a bit about how you got into telemedicine generally, and Doctor on Demand specifically? Dr. Ian Tong: I wasn’t brand new to telemedicine. I had been exposed to telemedicine at the Palo Alto VA. That’s where I was doing most of my clinical work. I had launched an outreach program there that targeted homeless veterans. We did really well. We won a national award from the Secretary of the VA. That led me to find that there were other veteran populations who were eligible for VA services but couldn’t take advantage of them for a variety of reasons. And so about 10 years ago the VA set up a telehealth program. I got my introduction there. Then the first iPhone came out that year, and I kind of knew someday these things would come together. Fast forward to four years ago, when someone came to me and told me that Doctor on Demand was going to do the things that we only talked about in the VA, and on a mobile device. TelemedMag: So one of the things that’s unique about DoD is that it’s co-founded by Dr. Phil and his son, Jay Mcgraw. What was it like launching the platform on daytime television? Dr. Tong: We were busy getting the practice together and then about a week before launch on Dr. Phil’s Show, I found out that I was actually going to have to see a patient, on television. It was really cool to be on a nationwide television, but it was also very nerve-wracking. You don’t really practice medicine in front of an audience. But I believed that we could do a lot of good, and what better way to deliver the message to so many people that we’ve created a great service than to do it with a big megaphone. TelemedMag: I read that you’ve had about a million people download the app. What are your usage rates like compared to those download numbers?
tong
Dr. Tong: We’re seeing record numbers of calls right now. We have seen a doubling of the size of our practice, if you just want to count that in terms of visit volume or patient encounters. We don’t usually quote out the exact number. I think we’re close to 35 million lives that have access to Doctor On Demand, but they probably don’t all know it yet. They may have it through their health plan or through their employer, who hasn’t done much communication. And I think that’s kind of an industry-wide challenge. When people have it and use it, they love it. But if they haven’t used it, there are still a lot of questions, like “Can my problem be resolved there?” TelemedMag: Who is using the platform? What are your demographics? Dr. Tong: The core group is from 30 to 60 years of age; we see double digit percentage use there. And then it starts to tail off a little bit as you get above 60. TelemedMag: Which is great to get things rolling, but in terms of actually tackling some of healthcare’s stickier problems, correct me if I’m wrong, but you don’t really move the needle if you’re only treating young people. Dr. Tong: That’s right. By my background, you know that I didn’t focus on the easiest patient population to try to impact. I get satisfaction from targeting tougher problems and patients who really get the most benefit out of the services. The impact and benefit of telemedicine isn’t just about being a cool gadget that millennials find easy to use and that becomes some sort of social sharing application. It’s actually real healthcare. Telemedicine will eventually move from the younger population that is mostly healthy but understands technology to start to prove itself to be able to address more chronic conditions.
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tong
TelemedMag: How are you expanding your services? Dr. Tong: We added mental health and behavioral health over the last two years, all doctoral level therapists. And then we added on psychiatry last year. TelemedMag: I’ve seen in press releases that DoD has raised over $80 million in funding. That’s sort of a wild amount of money, even in this industry. How are you using that money to improve telemedicine? Dr. Tong: The first thing is to continue to develop the video platform. The other big element is that we invest in employing our doctors, rather staffing our service with independent contractors who are moonlighting. TelemedMag: Why invest so heavily in employing your physician workforce? Dr. Tong: We are actually trying to create a career ladder for our doctors. When you do that, you can engage your doctors. You can implement a training program. For example, we have an antibiotics stewardship program that really trains our doctors to know when to prescribe and when not to prescribe. And when they don’t prescribe, to really know how to talk and to educate the patient. Having an employed workforce allowed us to implement that kind of program and have the longitudinal buy-in that you need from your physician workforce to continue to iterate and improve on that program. Because our providers are employed, we can put in the financial investment of time and resources to build out an integrated medical practice. So we can start to address chronic conditions and behavioral health. Over time we know that patients are going to need more and want more and expect more from telemedicine. And at some point one-off doctors, and doctors who are just moonlighting can’t provide you the continuity you need and the relationship 20
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is not going to be as rewarding. And we see that in our reviews. Patients talk about the doctor specifically. I didn’t know that the patient would respond to the doctor that way and that over a screen, they would feel like they made that connection, but that’s definitely happening. TelemedMag: Let’s say a patient calls up and gets one physician but that physician wants to hand them off to another specialist and maintain continuity. How does DoD set that up on your end, since these doctors are all over the country? Dr. Tong: Yeah, so our doctors are all over the country, but they have licensure and are assigned to regions of the country. And so you’re going to see the same doctor is available depending on where you are. If you’re a patient and move across the country, that’s a little bit different. When you go through our app, you can select a doctor as your favorite or in your favorites. And so you can actually go back to that doctor. You can see their availability. And you can schedule an appointment with them for the future if you want. You can always come in through the on demand side. But you can actually go and schedule directly with them and get a follow up. And all the mental health practice is by appointment. Those are all longitudinal relationships. TelemedMag: What about on the physician side? If you see a patient that you think needs follow up care, can the doctor seeing them over a video visit for the first time connect them to another doctor, and then follow that conversation longitudinally? Dr. Tong: You’re kind of predicting a little bit of the future. We can do that now. We can connect you, but we’re going to be making that even easier. I can’t tell you too much about it yet, but it will allow us to leverage the expertise that we have across the entire practice for each individual patient, regardless of where they are.
[TELEMEDICINE] COMPANIES WHO DON’T LEAD WITH VIDEO, WHO AREN’T COMMITTED TO IT, ARE COMPROMISING.
TelemedMag: I saw that you have 1,400 credentialed physicians. How actively are you recruiting? Dr. Tong: We actually are recruiting right now. It feels like that’s kind of become a never-ending part of the business. In terms of the number of clinicians on staff, that’s part of our secret sauce. When I look at other things that are in the press about the size of telemedicine practice, I think there’s so many different ways that our competitors could choose to report on that number. Rather than fixating on the size of our practice, we try to commit ourselves to the service levels themselves. So you know that you’re going to have about a five-minute or less wait time to see a board certified physician. We ‘right-size’ our practice to be able to deliver that service level across the country, 24/7. I don’t necessarily want to broadcast to my competitors how we do it or what size because I don’t think they know exactly what the number should be. TelemedMag: Why should your typical ER doc consider working for Doctor on Demand? Give us the recruitment pitch. Dr. Tong: First of all, that’s a tough career, right? Their careers can be shorter than a typical primary care doctor. What I find is that we are able to extend the emergency physician’s career a bit. And then
they’re also really interested in lifelong learning. Often they do not see what happens to their patients when they triage or dispo them. With DoD they get to see the whole spectrum. I’ll tell one story. One of our lead physicians is an ER doctor who was feeling a bit burned out in need of a change. One of the things that we trained our providers in was how to screen for and diagnose mental health conditions, and then provide psychopharmacology. This doctor became one of the leads of that program even though he’d had very little exposure to that as an ER doc. So I think there’s great potential for those doctors to be able to join our practice and thrive in new ways. TelemedMag: What is the compensation like for these physicians on your team? Dr. Tong: They will probably get paid more if they’re in a high volume emergency room in a rural area. But they could do very well here and extend the length of their career. In some regions, like San Francisco or in New York City, doctors can make above market working with Doctor On Demand. It’s very comparable what physicians will make in primary care fields. And sometimes it’s more. TelemedMag: Let’s talk about the RAND study that came out recently, which talked about how some of our thoughts about telemedicine lowering the costs of healthcare might not be true. The study stated that only 12 percent of patients are using telehealth to replace a provider visit and the other 88 percent are tacking it on a new service. What are your thoughts about Doctor On Demand moving the needle on actual healthcare costs? Dr. Tong: I know the author of that study, and I have high respect for them. But I do think you have to look closer. The study is really focused on telephone visits. Plus, the study pulled data from 2011. Telemedicine was in a very different
place then from where it is now. I mean, DoD didn’t exist then and neither did the current ability to provide a video visit with a physical examination, the way we do. That’s a whole different ballgame. What we’ve found is that about 50 percent of our patients would have gone to an emergency room or urgent care. And we know the prices there. You’re talking about 4X, 5X sort of costs to the patient or to the payer or employer. Using our service, we know that it’s going to save money. We don’t have a formal study of it. But I’d really like to see one that looks at a video visit practice because I’m pretty sure it’ll contradict this RAND study. TelemedMag: There’s been a lot of talk about large telemedicine providers having great services but not being profitable. Is Doctor on Demand profitable, and if not, what does the path towards profitability look like? Dr. Tong: Again, that’s part of the secret sauce. Because we right-size the practice, I think we are able to control the cost. The revenue side is definitely something that you can tweak. You can increase the price or find the right price. So we came out with a lower price. We’ve raised our price already to adjust for that. And I knew coming in that the service was being offered for really cheap. But in Silicon Valley, it’s very common for a tech company to do that so they can acquire users and learn very quickly. I feel very confident that we have learned some things that no one else has learned yet. TelemedMag: So the cost per visit is underpriced. Are there plans to raise those prices? Dr. Tong: I don’t think I want to comment just yet on if we will elevate the price. We may have to. If we continue to see more complex cases and can continue to deliver solutions for things like depression and diabetes, that justifies a different price than
what we currently offer. One thing I did learn at the VA is that giving away free care could undermine the doctor-patient relationship. And so I think it does have to be the right price. It has to be valued by the doctor and the patient. TelemedMag: The last thing I want to hit on are the key differentiators between DoD and the other big players in this space. You’ve mentioned that you employ your physicians. What are the other big differentiators? Dr. Tong: The direct-to-patient facing nature and DNA of our company is unique. We were built to be direct-topatient in the beginning, and that matters. We also were built on a more recent technology platform. So that makes for a better video physical exam. Finally, there is the fact that we’re video only. It baffles my mind that people think video and phone consults are equal. If you’re committed to video because of the quality reasons, I mean, you can save lives by seeing a patient. So I think that’s huge. TelemedMag: But the big telemedicine providers, they all have video visits. Dr. Tong: They like to show that they do. But you should look at the data. How many people actually use video on their platform? If you have good video that works, then you can get a higher quality medical visit. I think you can look at the patient reviews and there’s evidence there that tells the story. Companies who don’t lead with video, who aren’t committed to it, are compromising. Compromising might be okay if you’re talking about getting a different VCR or your cable service, but not in healthcare. I hope that that is obvious to the readership. And I hope it becomes obvious eventually to the rest of the country who want to get healthcare this way that there is a difference between video and phone telemedicine. It’s not the same. www.telemedmag.com
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hollander
show me the data
Bring On the Telemedicine Researchers Telemedicine's success going forward is going to hinge not on new devices, but on whether we embrace academic telemedicine. We need to do the foundational research to find out exactly what works and what doesn't. by Judd Hollander, MD
P
atients desire care when and where they want. They prioritize cost and convenience over reputation, quality and service. Medical centers have learned that despite projections about the robust growth of telemedicine, adoption rates are slower than they hoped. Studies assessing patient satisfaction have generally been favorable, but studies that evaluate access to care, cost, cost effectiveness, quality of care and provider experience are sorely needed. The academic community must give patients the evidence based care that they want without wasting their time or money. We have an obligation to determine what options may improve medical outcomes, and we must offer patients valid options to improve their health. We cannot just embrace the coolest new toy. We must begin by asking, “What problem do I need to solve?” rather than “How or who can I use this device for?” A year ago, Jefferson hosted the first National Academic Telehealth Consortium. CEOs and Deans from academic medical centers (AMC) were invited. Sixty-two 22
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people attended this two-day workshop. There was uniform agreement that AMCs needed to work together and answer questions about what type of interventions improve clinical outcomes, how we train providers in telemedicine and how we measure, assess and reward quality. Quality is being addressed by National Quality Forum (NQF). By the end of the summer, NQF will release a report with recommendations on how to create a measure framework for telemedicine. This framework will likely inform future pay for performance measures, and provide guidance for MIPS and MACRA. But we need to have research on how we can hit our quality metrics. Virtually all new areas of research begin similarly. There are simple descriptive studies reporting observations without a comparison. The data from these studies generate hypotheses that can be testing in comparative effectiveness trials. We must design these trials correctly. Telemedicine is not a stand-alone intervention. We won’t treat heart failure patients with telemedicine. We will leverage telemedicine to enhance heart failure treatment programs. We should not be randomizing patients to telemedicine versus an in-person visit. We should compare usual (or standard) care to telemedicine enhanced care (with patients also still getting the things they normally get). In some of your institutions, 30 percent of appointments may be cancelled. Can telemedicine decrease this? Can it get people more care? Can it improve outcomes over usual care? Does it cost more or less? What is the value of asynchronous care vs. synchronous care? Provider to provider consultation? Patient to provider? Urgent care? eICU? Store and forward for dermatology? Radiology? Ortho? There are more questions that one can imagine, but they are not all about telemedicine. They are about providing care to patients, some of whom may utilize some type of telemedicine some of the time. They are about the strategy, not the device. If we really want to begin to answer the
questions relevant to our patients, we need to begin to do some of the things that researchers typically do. We need to develop a framework to combine data. This begins with a common data structure. Many areas in medicine have standardized reporting criteria. When writing a cardiac marker paper, one describes patient demographics, test characteristics and clearly defined outcomes. We need to develop reporting criteria for studies that utilize telemedicine. We need to make sure the products we use allow us to capture that data. When we use telemedicine tools for clinical research, we need to have the same contractual rights as we have in research agreements. I do not know any AMC that will sign a research agreement unless the investigator has the rights to publish the findings without influence of the sponsor. We can never ever sign a vendor agreement with a telemedicine company that prevents us from publishing and reporting how the product works. We cannot describe access to care, cost effectiveness or patient or provider satisfaction without being able to report operational effectiveness of the platform. Imagine if we were able to develop a data repository of all of the data from all of our telemedicine efforts, and it was collected with a standardized format so we could combine it and do large scale analytics. We could answer all the important questions in short order. Can we get there? We are trying. The Society for Education and the Advancement of Research in Connected Health (SEARCH) is just getting started. SEARCH aims to create educational programs, establish forums for research and dissemination of knowledge and help those who want to develop careers in the academic side of connected health. If you are interested in learning more, reach out to Wendy Ross from the South Central Telehealth Resource Center at researchconnectedhealth@gmail.com. Or join us at our next meeting in Philadelphia in October.
SUPA innovations include sensors in undergarments and personalized modules that allow users to pick what they'd like to achieve.
the kids are online
Telehealth Gets a SUPA Power Boost This Spring, SUPA rolls out a limited line of fashion-forward, health tracking sports bra. But the garments themselves are merely window dressing for the main event – biometric sensors that send data to the SUPA app on your smartphone or Apple Watch. We caught up with SUPA founder Sabine Seymour during crunch time to talk about health sensors, dance party marketing and why SUPA is like a Japanese zipper maker. Interview by Logan Plaster
photo © Anna Rose for She’s Mercedes
TelemedMag: You're in go mode for your Spring roll-out. How’s it going? Sabine Seymour: Pretty good. Crunching, crunching, making sure that the launch works and then raising [funds] and being a little crazy. TelemedMag: How would you describe SUPA? You market SUPA as “biometrics + sports + fashion + artificial intelligence in a onesie at a dance party.” Are you selling software or actual health-tracking sensors? Seymour: It’s a combination. Our product is 80 percent A.I./software/algorithm and 20 percent textile-based sensors. The sensors that we develop with our partners and sell as “trims” to integrate into their apparel. A fashion brand or sports brand doesn’t have to do anything but just integrate it. And the consumer uses the SUPA app for any apparel or any SUPA-approved device where you will see the “SUPA S.” It’s like anything that has an Intel inside – we’re SUPA Powered.
TelemedMag: What kind of data are you going to get from the sports bra that launches this season that you might not be able to get with a typical wearable? Seymour: For starters, we have the ability to gather more data because it’s so easy. You wear a bra. You don’t have to wear a bracelet or any other gadget. Another advantage with SUPA is the accuracy and the ability to attach additional sensors over time. And then the third aspect of it is that the app itself not only integrates the biometrics but it creates a personalized module for you. Let’s say you’re a runner, plus you’re a female, plus you train 24/7 for your marathon, and on top of it you have asthma. We basically create a module for you that allows you to pick what you’d like to achieve. TelemedMag: What exactly is launching and when? Seymour: We are launching in the app store for IOS and for the Apple Watch soon. We also have SUPA-powered apparel www.telemedmag.com
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online for sale. We are not a fashion brand per se, but we collaborated with a fashion design company to bring our health-tracking sports bra to the market. At the same time we are internally working with B2B customers to disseminate SUPA. TelemedMag: Can a patient dial up their health data that you’ve tracked and share it with a physician? Seymour: That is the idea, that that data will be available to healthcare professionals, but that is the next phase. The first phase right now is to focus on the consumer. TelemedMag: You make a point when you get interviewed about talking about how SUPA is fashion agnostic and it can be incorporated into any apparel. Do you have any fear that by coming out with a sports bra and jump suit you’ll get confused as a company that’s producing a specific type of apparel? Seymour: Honestly, I would have never come out with our own product but investors liked the idea, and consumers really liked the designs. So we decided we could showcase what we can do with a limited edition run of the SUPA-powered sports bra. The app will launch in tandem with the apparel, so that consumers can actually get the two together if they want. The Apple Watch app is a great way for us to showcase that we are agnostic, that you can use SUPA without apparel, with just a watch. That we can integrate other devices and also other datasets that you get through your phone, whether that is the weather or pollution levels and pretty much anything that influences your body. TelemedMag: What are some challenges of working within the fashion industry? Seymour: Fashion collaborations always take much longer than you expect. I’ve been in this game for a long time, so I know 18 months is short for a life cycle production of a garment, in particular for 24
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IT’S NOT NECESSARILY ABOUT TRACKING HEALTH DATA THAT IS NEEDED RIGHT NOW... WE AT SUPA FOCUS ON THAT GENERATION THAT WILL BECOME OLD AND WILL BE USED TO DIGITAL DATA AND WILL WANT TO ACTUALLY USE DIGITAL HEALTH IN THE FUTURE.
digital health data from a generation that is currently not necessarily sick or considered sick. A lot of health companies and a lot of people are focusing on the aging population. That’s fantastic but that is not what I’m focusing on. What we at SUPA focus on is that generation that will become old and will be used to digital data and will want to actually use digital health in the future. If we don’t have the data, we can’t fix you. So we need to actually create a system to engage young people. And that demographic is engaged through dance battles and parties and extreme sports. So that’s how you get people involved in that space.
sports garments.
TelemedMag: How do you succeed with this younger demographic? What’s the strategy?
TelemedMag: You can tell immediately from your marketing that you’re trying to give health sensors a more youthful face. You’re trying to make them hip. So talk to me about the ethos behind trying to get younger people interested in health tracking. Seymour: It’s because we need to create large sample sizes. Now you’re 16 but then suddenly there’s something going on with you when you’re 25, or 55, or 65. We do not have any data that we can use to look at you individually, where you have been. We need to know about your environmental health factors, how much you move, what you’ve eaten, how much you’ve been sitting in front of a screen. We cannot right now get all this data from somebody who is 65, 70 or 80 years old because we just don’t have enough datasets. But now a generation is starting to use biosensors who will need that data 20 years from now when they need a bionic leg. It’s this sentiment that I want to put forth. It’s not necessarily about tracking health data that is needed right now. But if we get people in that age group to actually start using these types of devices, it will benefit us down the road. For me it’s much more interesting to actually get this larger sampling size of
Seymour: The plan right now is to work strategically with brands to create experiences for young people to engage with health data. We bring in gamification, which helps build a posse or tribe around the idea. We are working with the brands that are already doing this successfully. TelemedMag: It sounds like you’re trying to sell young people something that they don’t need right now but will be good for them later. Is that an uphill battle? Seymour: That’s not our message to the consumer. I don’t tell the 16-year-old that they need to use SUPA because they’re going to get sick in 30 years. I sell them on the fact that they want to win that dance battle or have a million followers on Instagram showing the SUPA move in that crazy cool outfit that actually shows some type of visual interface. It’s a different way of thinking about health data. TelemedMag: Was reaching out to this younger demographic a natural fit for you? Is that a world that you’re already comfortable in? Seymour: This all comes from personal
move more. How do you get a young person to move? Well, get them to a party. TelemedMag: Compared with many companies, you’re taking an extremely long view of digital health. Given the pace of market changes, does that put you at risk? What are the odds that the data that you’re gathering is going to still be around and useful 40 years from now? Seymour: Oh, it’s raw data. It’s the grain, not the actual plant itself. TelemedMag: And will the consumer own that data if they want to move it elsewhere and continue to have longitudinal data?
experience for me, from knowing that you need a lot of data in order to support your health. I come from extreme sports. I’ve been doing sports my entire life. I surf. I’ve been snowboarding and skiing forever. I’ve been a long boarder, a skateboarder, and I got my set of injuries. And even right now I’m getting a knee MRI done, and they can’t figure out what’s wrong with me. But after skiing powder for four days, my knee is as big as a balloon. And I’m doing all the rehab and everything. But you know what I mean? It’s an injury I endured when I was 16 years old. And then I’m starting to move differently because the knee is hurting me, and I have a back thing going on. I also come from the digital media experience space. I’ve been doing multi-media installations and party dancing, all of that, so to me understanding that space is extremely important. A lot of times we can do prevention in a fun way. We just need to get people to photo © Anna Rose for She’s Mercedes
Seymour: We will have the raw data in our SUPA Cloud. Because what we need are a lot of datasets to be able to correlate and to create a Smart A.I. Right now an A.I. is dumb. They’re in the infant stages, and we want to get it up at least to a teenage phase. So that’s why we need to have data across the spectrum. That data, however, is not only owned by the actual consumer but it is also residing completely anonymized as a dataset, because that’s basically what we are interested in. However, I’m not interested in you as an individual consumer. That is yours. That’s why we are also offering users the option of carrying their data forward to somebody else in order to receive care. TelemedMag: How did you get into health tracking sensors and A.I.? Seymour: I started my first company in 1998. That’s when I was focusing only on mobile and wearables. My first game controller was a helmet in ’96. I’ve been doing what people call wearables since the mid 90s. I wrote a few books on the topic, have been consulting with the likes of North Face and Intel. I’ve been doing this for 20-odd years. TelemedMag: After decades in gaming
and sports, why branch into health tech now? Seymour: This is just perfect timing. A.I. is finally coming around. I’ve talked about the body as a node in a network system for the last decade. Plus, recent advances in sensor technologies are incredible. You now have fabrics that we can pick up and make into intelligent systems. Not to mention advances in social media and data distribution in general. Everything is aligned right now. I just want to make sure that this space actually grows and doesn’t go through the same problems that wearables went through a few years back. TelemedMag: You’re starting with a sports bra. What do you feel is the optimal garment for health tracking? Seymour: The ideal scenario is that whatever data you need to get from the skin you get through base layers like underwear, socks and undershirts. If you need to have it on your actual body, it’s a clip on or it’s maybe a small little button. It has all to do with the antenna technologies. So if we can start getting away from Blue Tooth and find a smaller antenna that we can just print on: boom, here we go. What you do is you basically create a mesh network. And then you use the data from your car, from your house, your Nest, your external environmental. That’s basically what we’ve built. That’s what SUPA does. TelemedMag: Do you envision the SUPA sensors moving beyond garments to the general internet of things? Seymour: It’s already happening. We are curating the right sensors. We don’t build all of them ourselves. Think about how a car is built. The body and the design and some of the interior and some of the features are designed by the automobile company. But everything else is coming from OEM.
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new norms
The Happy Death of Telemedicine Telemedicine is dying a rapid death. It will become a thing of the past in the next two to three years after a decade plus struggle for relevancy, a fight to gain respect, and a push towards significant adoption rates. What's more, this is the best thing that could have happened to telemedicine. Let me explain. by Bill Gordon
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ast issue I spoke about how many people I know who have corporate healthcare have a telemedicine component listed in their benefits in many cases as a preferred service. The cost is now somewhere between a Primary Care and Urgent Care visit. It is quickly gaining momentum as the preferred non-traditional PCP visit option. This is what we have all been waiting for. In some rural hospitals an ER Psychiatric visit is virtual 100% of the time. There is no late night, on-call or staff mental health professional. The ER is tapped into a “big city” hospital or telepsychiatry service that provides the service and fills the need. As these services become more and more prevalent and integrated into regular operational flows the line between telemedicine and just plain old medicine will blur to the point that there will be no distinction between the two. In the next two to three years we will be calling all new healthcarerelated technology and services just that, 26
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healthcare technology and services. We won’t be calling American Well or Teladoc, or Livongo “Telehealth” providers. They will simply be healthcare Tech companies. This is the best thing that could happen to telemedicine. It will prove what many of us have been saying for the last decade plus, "Telemedicine is the future of medicine. It will shape the way we treat patients, handle data and improve outcomes." Venture Capital companies have been wagering against this bet to the tune of billions of dollars, and they are about to cash in. As I have stated before, for every 10, 15, maybe even 20 dead start-ups that have blown through all their funding there is a Fitbit that is worth billions. More and more states are adopting telemedicine resolutions. As expected, the states are targeting the very costly Medicaid population. More and more Medicaid patients are being given access to telemedicine services to help reduce the overall cost of services as well as the influx of patients at brick-and-mortar locations. The federal government has included telemedicine in numerous pieces of proposed and passed legislation. Telemedicine is taking its place as the value-add and soon to be crucial service it has been stated to be. Just Google "Telemedicine Healthcare Plans" and you will find a wide variety of solutions. For example, eHealthInsurance.com offers a telemedicine plan for $24.95 per month for an entire family. You have access to doctors, online tools, information etc… This packaging that resembles a traditional health insurance plan is becoming the new norm. I want to close with the two following graphics. The first is from 2014 and shows that when surveyed, only 33% of practitioners provided or participated in telemedicine services. The second from 2017 shows that almost 75% have virtual care initiatives and services in place. That is 100% growth in less than 36 months. Telemedicine is a rocket moving at blazing speeds – so fast in fact that it will cease to exist as we know it today and will become part of the new norm in healthcare by the end of 2020.
2014 US Healthcare Practitioners Who Currently Provide or Plan to Provide Telemedicine Services* % of respondents
29% No, but planning to in the next few years
38% No Immediate Plans
33% Yes
Note: n=759, *healthcare services via telephone, video or webcam visits Source: Academy of Integrative Health & Medicine (AIHM) survey as cited in press release, Nov 11, 2014
2017 How Would You Classify the Maturity of Your Virtual Care Initiatives?
5% 18% 22% 45% 29%
Advanced virtual care program Sustainable virtual care program Sustainable, decentralized virtual care program Just beginning with one or two pilot projects Early program investments
Source: KPMG Digital Health Pulse 2017/HIMSS Analytics
start - ups post mortem
how did scanadu become #scamadu? In a couple short years, Scanadu went from crowdfunding success and XPRIZE darling to managing mass consumer outrage. Here are a few lessons to be gleaned from their struggles. By Rishi Madhok, MD
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n 2013, Scanadu broke the crowdfunding record for Indiegogo by raising $1.6 million from 8,500 backers in less than a month. They raised another $17 million from traditional venture capitalists. Despite some early delays, the product began to ship in 2015. The Scanadu Scout promised to deliver readings for heart rate, body temperature, blood oxygen saturation, and blood pressure. The device had two sensors. Holding one on your forehead and the other with the left index finger, a circuit with your heart is created. The device reads the data, which takes less than a minute to collect, and sends it to your smartphone via bluetooth signal, where you can track trends in your data. Early adopters loved their devices. The product iterated over the first two years and kept improving on both its form factor and data readings. However, there was one issue continually looming for the Scanadu Scout: When would this device receive its FDA approval?
Wait a minute. How did Scanadu raise millions of dollars in funding and acquire 8,500 paying customers for a medical device that hadn’t received FDA approval? Here's how. The Scanadu Scout was an investigational device. By supporting the initial crowdfunding campaign, users were opting into a large two-year study that would allow Scanadu to collect data from the Scout and prepare its application to the FDA, as well as further the development of its other products. How much data could such a “study” generate? With 8,500 users, the company had access to over 5.6 billion data points. To be fair, Scanadu clearly and repeatedly stated the fact that the Scout was an investigational device and was being used for data collection for a study. However, much of that message was lost in the media hype around the Scanadu Scout. Furthermore, lay consumers of the device are unlikely to understand the risk of purchasing an investigational device and the risk behind both its readings and the likelyhood of it being decommissioned. In November of 2016, the Scanadu Scout study had reached its endpoint. For reasons unknown, the company did not receive FDA approval for the Scanadu Scout. The FDA regulations require all investigational devices be deactivated once the study is complete. At this point, the company's misalignment in expectations between its customers and the brand was
realized. Customers of the Scanadu Scout were both shocked and outraged when the company issued a statement that the Scout would be deactivated by May 15th, 2017. Scanadu did not offer any compensation or voucher for future discount on products. They didn't even apologize for bricking a two-year-old device. With little recourse, customers turned to social media with their frustrations and the hashtag #Scamadu Scout was born. Scanadu lives on. In fact, it's doing reasonably well. Having raised more funds from investors they are promising new products on the horizon. The company brilliantly managed to run a profitable(!) study, collect large amounts of data, show that their product had a market, and gain the trust of investors. Unfortunately, they’ve lost the trust of their customers, which is a heavy price to pay. The lesson here is simple and obvious once you’ve engaged with enough startups or early technologies: Buyer beware. Timelines for delivery will always be delayed, the product will almost never function as you expect at first. Change (both positive and negative) comes quickly, and often with little notice. What can you do? Embrace the risk or wait to adopt; but if you take the plunge, don’t count on anything until you have it in your hands.
A woman tests the Scout at the mHealth Toolbox workshop in South Africa. Scanadu shut down support for its Scout device per FDA regulation on May 15.
www.telemedmag.com
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start - ups case study
ON LONG ISLAND, TELEHEALTH SUITCASE OPENS UP NEW TREATMENT OPTIONS FOR DISABLED PATIENTS A developmentally disabled teenager arrives in the emergency department with a temperature of 105 degrees. You mobilize the staff, diagnose and treat the patient, and send them home. The patient will be fine, but it's a timeconsuming, resource intensive, and extremely expensive visit. Not to mention the stress on the child. This is the kind of challenging situation that caused James Powell, an internist in Long Island, to seek a telemedicine solution. Powell, who is the Chief Medical Officer at Long Island Select Healthcare in Suffolk County, New York, used a grant, and new MobileDoc technology from MedPod, to launch a program that enables him to improve care, extend his reach, and lower costs. Here's Dr. Powell's story. As told to Logan Plaster
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Passion Play I was practicing internal medicine about 15 years ago when I had an “aha” moment. A 22-year-old man came into my office. He was nonverbal, unable to communicate, and the staff was convinced he had ear pain. So I took my otoscope and started to put it into his ear. He turned around, hit me, and almost knocked me down. And I thought, I have a guy who has ear pain, who can’t communicate with me, and can’t tell me what’s going on. And I’m trying to shove a metal object toward his ear. He's doing the right thing. At that moment when I realized that I had to revisit the way I look at this population, the way I look at myself, and the way I look at the examination techniques I utilize. For example, how can I manipulate my examination tools and stethoscopes and examine people when they don’t want to be touched? And how do I examine someone when they’re standing instead of lying down? Now I’m medical director for several agencies which deal with people with disabilities — DDI and United Cerebral Palsy of Suffolk County. I’m also a former board member of the American Academy of Developmental Medicine and Dentistry (AADMD), which helps provide resources for providers that treat patients with developmental disabilities. Helping these patients has been my passion for the last 15 years, and for me, it’s been rewarding because it involves pediatrics and geriatrics,
with a dose of Sherlock Holmes thrown in. Most importantly, it’s helping those who may need a little extra help to feel better — people who are wheelchair bound or who have autism, Down Syndrome, or cerebral palsy — with complicated and challenging issues. A Tech-Enabled Solution Enabled by a grant through the New York State Department of Health, we had the opportunity to use new technology to help my patients. We partnered with a health care technology company called MedPod to deploy their new MobileDoc, which is essentially a roller suitcase containing a range of medical diagnostic tools geared towards a remote patient encounter. The suite of devices in the suitcase can remotely treat over 70 conditions using an integrated vital signs monitor, stethoscope, dermascope, otoscope, ECG spirometry and other devices. At 30 pounds, this mobile doctors office can be wheeled into a patient’s home in minutes. By conducting a pilot test, we’ve learned about the technology and how it can be effectively used by non-physicians, such as nurses familiar with this patient population. Before we rolled out the MobileDoc, we had patient volunteers, who came into our offices to be examined by nurses using MedPod technology. And I would listen to them from my office with the digital stethoscope. The quality of the data from the re-
[L] A nurse uses the MobileDoc to examine a disabled patient, connecting directly to Dr. James Powell in his office [R].
mote stethoscope was better than what I use in my office. For example, I can hear abnormal findings easier than I could before. We would then look at their throats and ears and take pictures to show the patient what we saw. And then the nursing staff would do the same thing; so I could determine later how effective the equipment and the examination were. In the end, we weren’t picking a particular product for telehealth use; we were choosing a company to partner with to improve the lives of patients. That said, that actual devices included in the suitcase proved a huge success. We could use the Horus digital scope system including the otoscope to look in a patient's ears and the general exam camera to look in his throat, and at his eyes. The multiscope has interchangeable attachments that allows us to look at a patient’s ears, throat and skin with a quick change of the lens. The technology also allows us to save pictures to refer back to for comparison. Building the Necessary Infrastucture Of course, there’s infrastructure necessary for this kind of operation. We have more than 2,000 people enrolled in our grant program. The program created a call center, which is serviced in part by a triage team that can dispatch a nurse to the
patient’s house. The nurse will text me that he or she will be at the house at a certain time. I log into my E-Clinical Works system on my tablet, and I’ll prescribe directly to the pharmacy. For documentation, I’ll fax a note to the house about what took place, what we saw, what we did, and what we prescribed. And I’ll give instructions on what to do. If they are current patients, I can set up an appointment for them that night for follow up. We have three providers in our group, who comprise two different teams. One is a Suffolk and Nassau county team and one is the New York city team, with two providers on call at all times. The largest number of patients I’ve had in one night was seven. Our hours are 6:00 P.M. to 10:00 at night. Sometimes I don’t get a call. But we usually handle a few calls a night. Unexpected Benefits of the Video Examination The main camera is directed at the patients face during the visit, but I can also have the nurses use the general exam camera so I can watch where they are pushing on the abdomen. The bottom line is that I feel like I’m doing my own exam! When I’m examining someone in my office, I’m looking at their face as I palpate their abdomen, looking for wincing, grimacing, signs of discomfort. So, in the telemedicine setting, I can guide them with my voice to tell them where to push. At the same time, on the same screen, I’m looking at their facial expressions. And, in this population, that’s extremely important. The patients are engaged with the screen, so there’s constant interaction. I haven’t changed what I would normally do during an exam. But I’ve noticed myself focused on certain parts of the exam, maybe an inquisitive look, a laugh, or a smile. And I’ve seen myself engaged in a way you might not in an office setting. The patients love it. The staff love it. I see staff sneaking a look to just to see who’s on the other line. In my office, I start my exam with a handshake. I end it with a handshake. And, in this telehealth scenario, I start with a “hi” and it ends with a “goodbye” and a wave.
Long Island Case Study Just the Tip of the Iceburg The potential of this new technology for telehealth is virtually limitless. There’s no population with whom this technology couldn’t be rolled out. I could see it in being used in hotels, cruise ship, prisons. I could see it at the Special Olympics or in a large corporation. If an employee is not feeling well, he or she could go up to fifth floor and get checked out for a sick visit or a routine visit for renewal of their blood pressure meds and they go right back to work. Count on Cost Savings The reason we’re so bullish on this telehealth deployment is the cost savings, especially among those with developmental disabilities, since they’re over lab-tested and over radiographed. They get more CAT scans to the heads than they need. We had a patient who had fallen in the shower; didn’t lose consciousness, but had a slight hit to their head. We went to evaluate him. We did a full exam on him with the MedPod MobileDoc and just told him to take Tylenol. I could almost guarantee that patient would have had a CAT scan of his head if he went to the ER and that would have been a thousand dollar ED visit. So the cost of Tylenol, plus the cost of a physician visit based on insurance is a dramatic savings. But, of course, in the end, it’s all about sustainability. How are we going to make this into an ongoing, viable program? Right now, a grant pays the bills but ultimately, it will be our responsibility. So how do we look on our return on investment with the provider time, MobileDoc, call volume, and community engagement? We’re collecting data to try to develop a long-term business model for ourselves and others. And we’re trying to take advantage of our FQHC at Long Island Select Healthcare. After the grant, can we continue the project through our organization? I think that if you want to use the equipment through MedPod, it could be done through primary care providers or a network of providers. It doesn’t have to be done through urgent care facilities, hospitals, or health care systems. I think the goal would be to have more outpatients. Let’s try to keep patients out of hospitals. www.telemedmag.com
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start - ups tele - pain
Great Scott! One anesthesiologist thinks it's high time hospitals use telemedicine to adopt opioid-asa-last-resort pain management protocols. This Fall he's going to help them do it. by john tyler allen
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r. Thomas Scott was still in medical school when one of his classmates came into the emergency room one night DOA. An opioid overdose. On another night, during Scott’s residency, a friend and fellow resident never showed up to work. Another overdose. In total, the pills have already buried four of his friends. Scott, an anesthesiologist at George Washington Hospital in Washington, D.C., speaks passionately about pain management, and his intensity ramps up when he calls out current pain protocols and their perverse reliance on opioids. “The opioid epidemic is killing one American every 16 minutes,” he said. He’s particularly affected by a recent study by researchers at the University of Michigan that found that, among both major and minor surgical patients, six percent of first-time opioid users went on to show new persistent opioid abuse. With approximately 50 million ambulatory surgical procedures performed in the United States in 2010, the authors’ findings suggest that more than two million individuals may transition to persistent opioid use following elective, ambulatory surgery each year. Scott doesn’t have grand visions of ending the epidemic, but he wonders: “What
if we can reduce that [six percent] by half ?” he said. “Reduce it by a third? How many families can we spare that pain?” That’s why he’s quitting his job. He intends to find a better way, and maybe he already has. This fall, Scott will launch Nopium, his pain management practice and telemedical service that will first help hospitals develop and implement modern, evidence-based pain protocols, and then provide ongoing physician support and patient consultation via remote, HIPAA-compliant connection. Scott, who is 40, has spent his career developing pain management systems that leverage multiple treatment modalities to achieve the greatest level of pain relief with the fewest adverse effects. In other words, effective pain management where opioids are not a first-line, but a last-line therapy. “Telemedicine is really going to be the key to making evidence-based, non-opioid pain therapy available to the masses,” he said. Nopium’s protocols would see hospitals tweaking the pain management algorithm to prefer generic remedies like acetaminophen, ibuprofen, regional nerve blocks, intravenous lidocaine, and low-dose ketamine. Scott is still designing the training
program, but he expects it will begin with a round of phone consultations that will allow him to understand a facility’s needs and begin prepping the physicians, pharmacists, and nurses for hands-on learning. On-site training will likely last a week, longer if necessary. Physicians in the ER and the operating room can be trained in ultrasoundguided regional anesthesia. Nurses and pharmacists will learn to safely mix, dispense, administer, dispose of, and account for treatments like intravenous lidocaine and low-dose ketamine. Once the protocols have been tailored and the staff has demonstrated that they can safely and effectively administer the appropriate treatments, Scott will return to his Philadelphia practice and begin providing doctor-to-doctor telemedical support to continue training and coaching, and, when appropriate, consult with and manage patients. “Above all else,” he said, “we have to be available.” Say a patient with a hip fracture comes into the hospital at two in the morning. A nerve block is needed. If a physician Scott has trained in ultrasound-guided regional anesthesia isn’t yet comfortable placing a block, a headset with a front-facing camera, an earpiece, and a microphone—think Google Glass—will essentially put Scott in the room to coach the physician through the procedure (He is currently talking with various telemedical hardware manufacturers.). If a team isn’t quite comfortable managing catheter infusions, Scott can consult for these as well. “These techniques are not known by a lot of ER docs, surgeons, and hospitalists,” he said. “But they are known by anesthesiologists and pain specialists. The problem is, we're not out there. Right now, about 80 percent of acute care in this country is rendered in hospitals that are less than 250 beds.” Small hospitals often can’t afford to staff a full-time acute pain specialist. Through Nopium, Scott said, hospitals could effectively employ the equivalent of .05 full-time acute pain specialists. Apart from the maintenance of relatively inexpensive telemedi-
"RIGHT NOW, ABOUT 80 PERCENT OF ACUTE CARE IN THIS COUNTRY IS RENDERED IN HOSPITALS THAT ARE LESS THAN 250 BEDS. SMALL HOSPITALS OFTEN CAN’T AFFORD TO STAFF A FULL-TIME ACUTE PAIN SPECIALIST. ...IT'S NOT JUST SUFFICIENT TO SAY, GIVE IV LIDOCAINE AND WALK AWAY. THE TREATMENT AND SUPPORT PATHWAYS NEED TO BE IN PLACE SO THAT PATIENT SAFETY, ABOVE ALL ELSE, IS THE HIGHEST PRIORITY.”
cal hardware and software, overhead fees would nearly disappear. Contracts will be flexible. Scott currently sees two possible business models. One sees the hospital granting Nopium telemedical privileges, and then Nopium bills for consults directly. Another sees the hospital billing for the consult and then paying Nopium an a la carte fee. Or the model may include a retainer for a specific number of consults. “There are a lot of ways to solve this contracting problem,” Scott said. “I just need a hospital that’s interested in solving it.” Questions about educational standards
will likely surround Scott’s early efforts. The Nopium model has positive aspects, said Dr. Daniel Carr, Professor of Public Health and Community Medicine at Tufts University School of Medicine and former president of the American Academy of Pain Medicine. But, he noted, subspecialty training is rigorous and exacting. Graduate medical education standards have been carefully crafted. For instance, the application proposing the standards for the Accreditation Council for Graduate Medical Education’s (ACGME) new regional anesthesiology and acute pain medicine subspecialty ran over a hundred pages. “The current approach to training is not a haphazard or poorly thought out thing,” he said. Scott holds Nopium to the same expectations. While Nopium’s training model and standards are still being developed, he said, the requirements set by the ACGME will serve as scaffolding. The training model that allows practicing surgeons to learn and become credentialed in a new surgical technique will also likely inform the process, as will state regulatory considerations and individual hospital credentialing requirements. “It's not just sufficient to say, give IV lidocaine and walk away,” he said. “Intravenous lidocaine is a treatment that can result in seizures. If a dose error is made or if a seizure occurs, the cause of that seizure needs to be elucidated quickly. The treatment and support pathways need to be in place so that patient safety, above all else, is the highest priority.” Scott is eager to prove his concept. He talks of changing the culture within acute pain management. “Pain is not an opioid deficiency in your bloodstream,” he said. He’s not against opioids—he still prescribes them when necessary—but he speaks of the opioid epidemic as if it were a personal affront. He knows that Nopium won’t end the epidemic and neither will telemedicine. But together they might chip away at that six percent of newly dependent opioid users.
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----Blockchain is already coming to healthcare. Here's a sampling: Gem Health: Started in April of 2016, Gem Health is working with Phillips as its first partner to promote collaboration in the healthcare space using blockchain.
New Kids On The Blockchain There's a good chance you haven't given any thought to blockchain, yet this digital transaction system made famous by Bitcoin has the ability to revolution healthcare from the inside out. Here's your water cooler primer. by rishi madhok,
MD
W
hat is blockchain? It's become a buzzword within health tech and telemedicine, yet 99% of people still have no idea what it is. Many physicians and hospital admins see blockchain as a panacea for healthcare’s information woes, yet their eyes glaze over halfway through its explanation. Let's get something straight out of the gate. You don't need to know about blockchain. Yet. Experts agree that it isn't going to change the way healthcare is practiced any time soon. But for the future oriented, this technology can offer an important glimpse into where telemedicine is heading.
Blockchain 101
Originally devised as the undergirding
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of Bitcoin, the digital currency, blockchain is a digital ledger that records transactions. Think of it as an open database of information where each party on a blockchain has access to the entire database and its complete history – not unlike the way we interact with a Google Doc. No single party controls the data or the information. Every party can verify the records of its transaction partners directly. What makes this revolutionary is that by its structure it eliminates the need for third party verification, such as one might require from a bank or insurance company. "Above anything else," writes the author Ian Khan, "the most critical area where Blockchain helps is to guarantee the validity of a transaction by recording it not only on a main register but a connected distributed system of registers, all of which are connected through a secure validation mechanism.” Once an event is recorded into the database and the accounts are updated, the records cannot be changed or deleted. Events, recorded as “blocks,” are linked to the events that directly proceeded them and linked together (hence the term “chain”). A lot of complex algorithms, math, and technological wizardry are used to verify chronicity, permanence, and appropriate access to others on the network.
Healthcare Applications
Imagine that Hospital A wants to add an admission note as an event to the Patient Record B. This event is broadcasted to the network of other members holding a copy of the blockchain for validation that this
MedRec: Utilizing the Ethereum blockchain, MedRec manages medical records and gives user access to census level data for both research and clinical purposes. PokitDok: Launched DokChain, a blockchain platform to better augment its existing services, including checking patient insurance eligibility and incorporating bitcoin payments with insurance providers.
event is real and accurate. The network verifies that this event is valid and accurate (using that tech and math wizardry we spoke about). The event is added to the blockchain permanently. The database is automatically updated for all members of the network now ready to accept the next transaction or addition to the blockchain. Why is this important? We now have created a highly secure dataset that is not bound to an intermediary and is still openly accessible to parties who have the correct permissions. Blockchain’s greatest potential is to standardize secure data exchange, deemphasizing the healthcare system as the keeper of data and placing the patient at the center. There you have it. The oversimplified, health-oriented explanation of blockchain. Still a little lost? Don’t worry, blockchain needs a more time before its ready for primetime, and healthcare applications need even longer. Illustration by Erin Lux
GET THE TRAINING
M
Tele-Psych Fills a Void in Opioid Addiction Treatment In rural Maryland, a telemedicine experiment solves pressing physician shortage in addiction treatment centers. by
Michael Levin-Epstein
S
ince its founding more than four decades ago, Wells House has served the needs of addicted individuals in rural Hagerstown, Maryland. Operating at first as a halfway house for homeless alcoholic men, Wells House eventually provided more comprehensive behavioral health treatment, including counseling and rehab services for men and women addicted to drugs and alcohol. However, the Wells House bench was shallow, and when one local physician, Martin Gallagher, MD, announced his retirement, the future seemed uncertain. Gallagher was invaluable to Wells House residents because he was specially wavered to prescribe buprenorphine, which suppresses withdrawal symptoms, relieves cravings and helps patients control behaviors that may prompt them to use opioids. When he announced he was going to retire, the Wells House was forced to scramble to meet the medical and psychological needs
of their residents, many of whom were attempting to manage withdrawal symptoms and/or prevent relapse. Without a trained clinician to prescribe and manage the essential medication component of treatment, the Wells House program was in a precarious position. At first, Charlie Mooneyhan, the director of Wells House, hoped to have a physician from the University of Maryland Department of Psychiatry travel to Hagerstown and replace Gallagher. But Hagerstown is nearly two hours away of Baltimore, so this wasn’t a practical solution. Fortunately, Mooneyhan was able to link up with two physicians in Maryland’s Department of Psychiatry, and they began thinking outside the box. Eric Weintraub, MD, and Christopher Welsh, MD, both associate professors of psychiatry at the UM School of Medicine, thought that telemedicine might just be the solution that Wells
edication-assisted addiction treatment may be the only solid path to recovery for many opioid abusers, according to addiction experts. And telemedicine may prove to be a boon to the delivery of that vital piece of the puzzle. Training to qualify for the waiver to prescribe buprenorphine requires an eight-hour commitment for physicians. In a recently enacted law, nurse practitioners and physician assistants now also can be trained and receive the waiver after completing 24 hours of training. That should help to ease some of the shortage of prescribers, which, though felt more keenly in rural areas, can also be a problem in major cities. “Opiate patients won’t stay in treatment if they are not on medication because they experience withdrawal symptoms and cravings,” Welsh explains. “Telemedicine allows them to stay in treatment and do the counseling piece and get further into recovery.”
House was looking for. “We had been talking with the director about doing telemedicine with substance abuse and saw this as an opportunity to expand what we are doing,” says Welsh, who is medical director of the Substance Abuse Consultation Service. Prescription opioid use is disproportionately impacting rural areas, according to Weintraub, also the School of Medicine’s Alcohol and Drug Abuse division head. “There is a huge increase in overdose deaths,” he notes. “There is a lack of access to medication-assisted treatment, very few methadone programs, and very few waivered buprenorphine physicians in rural areas,” Weintraub adds. www.telemedmag.com
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Planning the Program
Planning for the Wells House telemedicine program began in Spring 2015, but the first patient wasn’t seen until the end of August. Telehealth programs don’t happen overnight, note Welsh and Weintraub. “We had to appoint a coordinator in the Department of Psychiatry to work with a coordinator at Wells House. Wells House patients work with counselors and other staff there, while we provide the medication management component of their treatment,” explain Welsh and Weintraub. The physicians set up two, two-hour blocks of time every week to see Wells House patients (via teleconferencing). Wells House provides the doctors with a list of patients they will be seeing ahead of time, and the coordinator brings each patient into a secure area there, one at a time. “Before we see the patient, the Wells House coordinator sends us clinical information and urine toxicology screens,” Weintraub explains. “Then Chris and I put together progress notes and evaluation forms, consistent with what we do with our nontelemedicine patients. We maintain charts on both ends.”
Interoperable Records Prove Challenging
One aspect of the telemedicine approach that Welsh and Weintraub hope to improve upon is the record keeping. Currently, Wells House has an electronic medical record (EMR) system that is different from what the UM School of Medicine uses, and that’s an issue, says Welsh.
Figure 1: Preliminary Results from University of Maryland/Wells House Telepsych Program
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“We made attempts to create a template that would let us be able to log in to their EMR, but that didn’t go well,” says Welsh. “Now it’s a little primitive, but we actually write paper notes and fax them to Wells House. We are hoping that with future places we work with, we can streamline that a bit.”
TELEMEDICINE TAKEAWAYS
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hree tips for implementing a similar opioid addiction telemedicine program:
Keeping It Simple
From a technology standpoint, the telemedicine connection between Wells House and UM School of Medicine is fairly simple. “I’d highlight that anyone can do it,” says Weintraub. “We are not the most tech savvy of our colleagues.” We use straightforward software, called Acano and we rely on our IT guy, Dave Flax, when needed.” In the end, it’s simple – a little cumbersome in the charting – but highly effective. “We can do whatever we need to do to manage medication and facilitate professional treatment. We focus on a visual assessment, as opposed to anything that requires us to lay hands on the patient,” says Weintraub. “When you are dealing with opioid addiction, you mostly want to see if somebody might be intoxicated or in withdrawal, so the cameras are sufficient for that,” he says. “We look at their pupils, see if they are sweaty, that kind of thing.” Overall, Welsh and Weintraub say the program is successful. A chart review they conducted after one year showed that, by the primary outcome measures of treatment retention and opioid use, their success rate is equal to what they would see with in-person treatment (see Figure 1).
The following data were pulled from the first 150 patients seen via the telemedicine program. The three-month retention is lower than it should be because patients leave Wells House for a variety of reasons, according to Welsh and Weintraub.
Make sure you’re meeting an urgent and rising need for medication management and consultation
•
Understand that, if done correctly, telemedicine consultations yield the same outcomes as inperson consultations and that care should not be compromised
•
Keep the technology simple and have IT backup
Indeed, the program proved so fruitful that at the end of last year, Welsh and Weintraub began to work with the Garrett County (MD) Health Department to provide the same service in a new county. Garrett County is even more rural than Washington County. Unlike Wells House, where many patients are residential, the Garrett County patients are all outpatient.
Positive for Opiates in Tox Screen: 1 week: 12% Yes 1 month: 11% Yes 2 months: 11% Yes 3 months: 6% Yes >3 months: 12% Yes
•
Engagement in Care after Initial Telepsych Evaluation: 1 week: 98% still in care 1 month: 91% still in care 2 months: 76% still in care 3 months: 59% still in care
analysis
Emerging Trends from the ATA Annual Conference Three notable trends offer a glimpse into where the telemedicine market is heading.
Telemedicine is having a significant impact on healthcare and the economy, with growth projected to be 1319%. The market optimism was palpable in Orlando.
by heather zumpano
D
uring the latter half of 2016, key industry reports published by the likes of Kaiser Permanente Medical Group (KPMG), American Telemedicine Association (ATA), American Well and Zeigler showed telemedicine making a significant positive impact on healthcare and the economy. Depending on the report you read, projected growth ranges between 13% and 19% per year over the next five years. At the ATA Conference in Orlando this April, that market optimism was palpable, and was demonstrated in three key trends: Increased patient demand for telemedicine visits, increased telemedicine investment by health organizations, and transition from fee-for-service to value-based healthcare payment models. A large percentage of the consumer market is aware of telehealth. Again, depending on which report you refer to, 68%-75% of those polled said they would prefer a telehealth visit over an in-person visit. This is huge! Virtual visits
are no longer an option of last resort. Many survey participants cited convenience as the number one factor that makes telemedicine attractive.
Key Drivers
As the costs for infrastructure decrease, expansion of wireless and internet communications into rural communities increased. According to the 2010 U.S. Census, 46.2 million people occupy rural areas, and 72% of the land is rural. Across the country, many rural hospitals are closing because they’re unable to attract the specialists and advanced care technologies of urban medical centers. This is making access to health services even more strained for people. Health organizations want to adopt telehealth to meet consumer demand, and there are investment dollars available to help them. For instance, if you visit the Rural Health Information Hub website, ruralhealthinfo.org and search for “telehealth grants,” you’ll find funding opportunities
from various government agencies, such as the U.S. Department of Health and Human Services’ Health Resources and Services Administration (HRSA), for Federally Qualified Health Centers, (FQHCs), critical access hospitals, rural hospitals, schools, and senior care organizations. Last September, the C. L. Brumback Primary Care Clinics, FQHC in Palm Beach County, Florida were awarded $93,476 to help pay for a wireless network and telemedicine services by HRSA. Across the board, payers and regulatory agencies are constantly pressuring health care systems and providers to improve quality and lower costs. Health care administrators and physicians have been looking for a solution to this problem for a long time. As more accountable care and meritbased incentives are introduced for Medicare recipients, we can expect telehealth to be more widely utilized to conduct routine follow-ups, specialty consults, pawww.telemedmag.com
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analysis
tient education, and remote monitoring. Value-based healthcare payment models (VBCs) support and reward the optimal use of Health IT through up-front bundled payments for patients in specific diagnosisrelated groups (DRGs). Merit-based incentive payments are another option for reporting core measures that demonstrate positive health outcomes. Since the elderly and chronically ill use a large amount of the health care resources, the Centers for Medicare and Medicaid Services (CMS) developed the Chronic Care Management Program and together with the American Medical Association adopted CPT codes 99487, 99489, and 99490 to indicate 20 minutes of monthly non-faceto-face follow-up consultations with their Medicaid or Medicare patients who have two or more chronic diseases. CMS offers to pay one member of a patient’s health care team an incentive bonus per ranging from about $35-$45 a visit, per patient per month for these monthly communications in order to reduce hospitalizations and improve population health. Non-face-to-face visits can be conducted via telephone or live video conference. CCM can add up to significant new revenue upwards of $200,000 for a private practice. To learn more, visit www.cms.gov and search in the Medicare Learning Network for “chronic care management.” With increased use, chronic disease management is expected to generate revenues for doctors and better health for patients, and less spending for health care payers.
“Convenience, high quality experiences, and improved health outcomes continue to propel telehealth technologies into the future...Presenting patients with turnkey solutions that require little more than wearing a sensor and having the device turned on and wirelessly connected will become commonplace.”
Industry Supports the Trends
Convenience, high quality experiences, and improved health outcomes continue to propel telehealth technologies into the future. Companies such as Care Sync and Smart Link are helping doctors track their time and ensure they can be reimbursed for CCM efforts as they strive to keep patients healthy at home. Commercial insurance payers like Aetna, Cigna, Anthem have developed provider networks designed to deliver telemedicine as a benefit to their members. 36
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Private businesses are also offering provider networks who exclusively practice telemedicine to help hospitals, nursing homes, and rural hospitals improve access to care. These provider networks can be multi-discipline practices, or all from one specialty. For example, Iris Telehealth supports the increased demand for mental health services by providing locum tenens and supplemental telepsychiatry professionals. CEP America provides a range of health care specialists who work together to
care for patients with acute medical conditions through post-acute care, to include: emergency, hospital, urgent care, anesthesia, and post-acute care physicians who work together as a patient-entered health care team. Many virtual services have been developed to cater to the specific needs of their populations. At the conference, I saw Laurence Girard of Fruit Street demonstrate their interactive diabetes education and self-management software solution, designed to meet Center for Disease Control guidelines. eCare21 is a mobile health application that features patient-centered monitoring, lifestyle tracking, and communication designed for seniors. Honeywell remote sensing technologies can detect falls, abnormal daily living patterns, or important vital sign changes.
What’s Next?
The telehealth industry is changing to improve care by addressing real problems and providing real business and technology solutions. As the novelty fades, and these tools are used on a normal basis, health organizations will realize higher revenues. This is because each role will be redefined and normalized to incorporate digital health operations in to the continuum. Presenting patients with turnkey solutions that require little more than wearing a sensor and having the device turned on and wirelessly connected will become commonplace. Health care spending will be normalized and more predictable, improved communication of health information will advance the practice of medicine and push towards personalized medicine. The next logical trend that will become prevalent is big data analytics. Integration of telehealth and EMR data to gain a better understanding of cause and effect for patients will better inform clinical decision making, because health care teams will be able to see the cause and effect relationships more readily, and learn the whole story of what happened to the patient.
“Telemedicine Magazine has come at the right time. The field is taking off with unprecedented investment . . . the promise of improved access and quality of care with lower costs for this field can add more value to healthcare than any other trend or technology. This [magazine] meets a very strong demand from virtual care companies, providers, payers and other stakeholders in this critically important field.” -Jay Wohlgemuth, MD SVP & Chief Healthcare Officer HealthTap
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Connected health starts in the kitchen
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/VIRTUAL HOSPITALS /VIRTUAL PHYSICALS /VIRTUAL REALITY /REAL MEDICINE
THE BEST NEW TECH FOR EYE HEALTH PAGE 16
Hub & Spoke Avera builds the ultimate telemedicine hub in South Dakota PAGE 36
Drone On
New FAA regs could usher in a wave of healthcare drone start-ups. PAGE 20
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IT'S TIME FOR A BETTER BOT Thanks to machine learning and muchimproved A.I., chat bots are poised to redefine virtual care. PAGE 36
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HOW ONE DATADRIVEN OLYMPIAN IS USHERING IN THE 'QUANTIFIED LIFE' A CONVERSATION WITH SKY CHRISTOPHERSON PAGE 40
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Why the *Beep* Do Doctors Still Use Pagers? The anachronistic pager still lives on in healthcare. Here's why, and what it will take to leave them behind. by Nicholas Genes, MD, PhD
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patient has taken a turn for the worse, and the doctor needs to be notified. What to do? For decades, the way we reach out to doctors has remained the same: paging them. Even through the rise of the internet, the smartphone revolution, and the mass adoption of electronic health records, the pager has endured.
One of the pioneers of paging systems, Sherman Amsden, began researching pagers because he was dissatisfied with the frequency that doctors checked in on his popular call forwarding service. His Doctor’s Telephone Service, later called Telanswerphone, was a big hit when it was introduced in New York in 1924. Calls to a doctor’s office after hours would be forwarded to an operator, who would transcribe and sit on the messages until a doctor called later to retrieve them. But what if some clinical news couldn’t wait? Amsden dreamed of a radio system, broadcasting only to doctors with dedicated receivers. He finally realized his dream in 1950, when his New York City broadcasting antenna reached a doctor golfing 25 miles away. But the service was expensive, and every doctor received every signal – they’d have to wait and listen for 38
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their own unique code to learn if they had, in fact, been paged. The service didn’t take off. Instead, in another part of New York, Al Gross was developing a paging system of his own, for Brooklyn’s Jewish Hospital. Gross had already developed walkie-talkie technology in World War II, and in 1949 he adapted this two-way radio technology for one-way telephonic signaling. His patent actually predates Amsden’s technology, but the FCC didn’t approve his telephone transceivers until 1958. It was Motorola that coined the term “pager” and introduced the Pageboy in 1964. This first commercially successful pager had a rechargeable battery but no screen, and no ability to store messages. The only notification that a message had been sent was a single tone, hence their eventual
moniker: the beeper. Doctors who heard the beep would call a pre-arranged number, usually the hospital operator, to hear the message. Voice pagers proliferated in the 1970s. After the tone, a recorded snippet would play, instructing the doctor on where to go or whom to call. This was considered progress. LCD screen technology didn’t come along until the 1980s to help restore quiet after the beep. The number of pagers in the US crept past 3 million in the early 80s, and exploded to 22 million by 1990 as widearea paging technology was adopted, and people began using pagers outside of work. The 90s also saw the rise of 2-way pagers with QWERTY keyboards, from Motorola and a company called RIM that would rename itself Blackberry. American pager penetration peaked at over 60 million in the 90s, but began to decline as mobile phone technology became smaller and more affordable. Still, pagers have persisted in their original home – the medical field. Paging networks have more broadcast power than cell networks (so they can reach those basement
call rooms where the radiologist is lurking). These networks are also more reliable than cell or wifi networks that can easily become overloaded, or inoperable, during an emergency. Another 90s development – HIPAA – meant that text messages with patient information could lead to liability. Paging for a voice conversation was viewed as more secure, even if less efficient. Pagers are also cheaper than cell phones. And so, even though US pager usage is down more than 90% since its heyday 20 years ago, the medical field keeps beeping. Finally, pagers are facing the technology that could ultimately make them obsolete, even in healthcare: • Secure texting apps like TigerText and Cureatr leverage the power of the ubiquitous smartphone, or PC on the web, to engage in text (and media)-based conversations. Texts are less disruptive than pages to voice calls, and providers can review past
•
•
correspondence or carry on simultaneous conversations about multiple patients with multiple parties. EHR-based “ticklers” – Providers ordering a blood test or radiology scan can flag it, so when a result is available, their phone (or smart watch) gets a notification. One such system, EurekAlert, was recently shown to improve ED disposition time. Health Information Exchanges offer Clinical Event Notifications (CENs) to subscribers, Health Homes and managed care services. When a high-risk patient shows up at an affiliated clinic or ED across town, a CEN is sent to a care manager, nurse or physician’s email inbox (or, you guessed it, a smartphone app). From there, the care team can reach out to those caring for the patient, to arrange prompt follow-up or reduce redundant testing. Evi-
dence suggests CENs can reduce utilization and costs of care. Medicine’s adoption of pagers in the mid-20th century demonstrated ours was a field on the cutting edge. But in 2017, consumer technology has long since surpassed these devices. Continued reliance on pagers is emblematic of broader problems in US healthcare – bureaucratically inflexible adherence to dated practices, with dissatisfied stakeholders nonetheless unable to agree on a way forward. Perhaps mounting evidence of security, efficiency and savings with new smartphone-based messaging can achieve what the embarrassment of anachronism has not and consign pagers to the past. Nicholas Genes, MD, PhD is an emergency physician and clinical informaticist at Mount Sinai Health System in New York.
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