Innovative school-based telehealth programs are breathing new life into struggling communities
telemedicine ISSUE #3 / WINTER 2015
Charting Healthcare’s Digital Future
Hello Holodeck: How virtual reality is changing medical education
The Start-Up Guide featuring What I learned at Health 2.0 On the bus with ‘Rise of the Rest’ Get funded – From pre-seed to series B
Q&A
Qualcomm Life’s Rick Valencia on telemedicine’s next big hurdle
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features 34 The Start-Up Guide: From PreSeed to Series B
p Diamonds in the Rough Steve Case’s ‘Rise of the Rest’ tour is out to prove that great start-ups don’t just grow in Silicon Valley. page 39
43 How School-Based Telemedicine Can Save Rural America 46 Rethinking Telemedicine Business Models: Three Essays
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Telemedicine briefs across the medical universe --------
Practice-changing gadgets and gizmos --------
Industry-shaping ideas and perspectives --------
data security
From Oculus Rift to Microsoft Kinect, the augmented reality platforms that are changing physician education
rick valencia
telepharmacy telegeriatrics drones
steve cashman judd hollander mark plaster bill gordon
contributors 5 | regional news 6 | resource list 52 | teleport 54 www.telemedmag.com
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editor’s desk
Big Problems, Big Solutions
logan plaster
editor-in-chief logan@telemedmag.com
Innovative school-based telehealth programs are breathing new life into struggling communities
telemedicine ISSUE #3 / WINTER 2015
Charting Healthcare’s Digital Future
Hello Holodeck: How virtual reality is changing medical education
The Start-Up Guide featuring
Q&A
Qualcomm Life’s Rick Valencia on telemedicine’s next big hurdle
What I learned at Health 2.0 On the bus with ‘Rise of the Rest’ Get funded – From pre-seed to series B
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Cover Illustration by Nicolet Schenck
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Go big or go home! This has always been one of my least favorite sayings. Part of that is just my nature – I enjoy seeing the seeds of ideas develop over time, like a start-up born at the kitchen table. But more objectively, sometimes it truly is the small things that make the deepest impact. This issue – the third edition of Telemedicine Magazine – we touch on a few of these smallbut-mighty innovations. On page 43, John Tyler Allen writes about how relatively simple school-based telemedicine programs (the technology isn’t anything new) can revitalize underserved communities. By bringing comprehensive healthcare to the child in the school setting, more kids stay in the classroom, which means fewer parents miss work. In some smaller towns – where unemployment is already dangerously high – one missed day of work at a factory or a mine can mean the difference between a paycheck and the unemployment office. These are desperate places in need of real solutions, and even simple applications of telemedicine are beginning to move the needle. And that is just one example. This issue is full of seemingly small steps – from a new Band-Aid-like temperature tracker (page 35) to a better way to organize prescriptions (page 12) – which have the potential to have an outsized impact on healthcare delivery. In this issue, multiple That said, when it comes to turning the corner industry insiders tackle on healthcare’s digital revolution, I might have to rethink my dislike of this axiom. At some point, the question of how we may have to go very big or throw in the towel. much we can really save No one puts their finger on this quite like Rick [through telemedicine], Valencia, head of the decidedly mammoth Qual- and the answers are all comm Life. In his interview on pages 24, Valencia staggering. says that overcoming the many challenges that are inherent in healthcare systems around the world, “requires unprecedented wireless expertise, borderless connections, a global, secure infrastructure, and an open ecosystem approach. Fortunately, making connected health care a reality is a Qualcomm-sized problem.” In today’s local-obsessed society, you rarely hear a business leader who is unabashedly proud of being the big Kahuna. But perhaps some telemedicine problems – like the building of necessary EHR infrastructure – are best tackled by entities that work on a massive, global, interconnected scale. Whether the solution is a tiny postage stamp or a massive global consortium of cloudconnected businesses, one thing is certain – the potential rewards for succeeding in the digital health space are anything but small. In this issue, multiple industry insiders tackle the question of how much we can really save, and the answers are all staggering. Getting patients the right level of care at the right time by using remote care innovations can save the nation billions, probably trillions. Enough to truly move the needle on our out-of-control healthcare costs. And it must be done. So I’m changing my mind on “going big.” It’s not the only way – just ask the hundreds of start-ups carving out a niche at Start-Up Health and HealthBox – but it is a critical piece of the puzzle, and the only way that telemedicine will reach true critical mass. But this is my compromise: Go big and then go home. To your family, for a dose of perspective. Where the little things, like the health of your child and his pregnant mother, are the biggest things in the world.
telemedicine ISSUE 3 – WINTER 2015
This issue we look at how virtual reality has gone from gaming to healthcare platform. What was your favorite video game as a child?
Anything on the Atari 2600 or Tron in the arcade. EDITOR-IN-CHIEF
Logan Plaster logan@telemedmag.com EDITORIAL DIRECTOR
Bill Gordon bill@telemedmag.com
FOUNDER / EXECUTIVE EDITOR
Mark Plaster, MD
I’m the old man in this crowd who really loved PacMan. It was a real step up from Pong. Also, I was 30 when I played it.
EDITORS AT LARGE
Nicholas Genes, MD, PhD Lonnie Stoltzfoos “Mike Tyson’s Punch-Out!!” taught me that I could overcome any challenge, no matter how large, with patience, thumb speed, and a training montage.
CONTRIBUTING EDITOR
I still remember building my own games using LOGO programming language on our Apple 2+. It took awhile, but being a part of the building process ended up being the best part of the “game”.
Rishi Madhok, MD CONTRIBUTORS
Aneel Irfan Unity Stoakes Scott Jung Nathaniel Lacktman
My 1989 consisted mostly of Pepsi, pizza, and Golden Axe
Michael Levin-Epstein Brian Roberts John Tyler Allen Scott Kozicki
EDITORIAL INTERN
Robotron, but any golden age standup (Asteroids, Battlezone, Donkey Kong).
Erika Hunter
ILLUSTRATORS
Nicolet Schenck Grace Helmer INDUSTRY ADVISORS
Ting Shih ClickMedix
Jodi Lyons SeniorSherpa
Dr. Shiv Gaglani Quantified Care
Jon Pearce Zipnosis
Dr. Sylvan Waller Alii Healthcare
Jodi Lyons SeniorSherpa
Haywood Hall, MD PACEMD Dr. Robert Park RelyMD Dr. Judd Hollander Jefferson University
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Diana London diana@telemedmag.com // 929.888.6694
Telemedicine Magazine is published quarterly by M. L. Plaster Publishing Co., LLC. PO Box 121, Galesville, MD, 20765. Editorial offices located at 68 Jay Street, Suite 412, Brooklyn, NY, 11201. Printed in the USA. Copyright ©2015. 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
Regional Updates from the Consortium of Telehealth Resource Centers
Established by a federal grant and propelled by a mission to provide healthcare access to underserved populations, the consortium of telehealth resource centers can be credited with planting some of the vital seeds for telemedicine growth. Geographically oriented and vendor agnostic, these organizations bolster the telemedicine community by providing training materials, bringing together stakeholders and generally building up the community. This is the first Telehealth Resource Center News section, designed to share the latest and greatest updates from a range of disparate organizations. Have a success story – or an upcoming event – to share on these page? Drop us a line. edited by aneel irfan aneel@telemedmag.com
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NORTHWEST
SOUTHEAST
SOUTHWEST
The Northwest Regional Telehealth Resource Center (NRTRC) will hold its annual conference in Seattle, Washington, March 21 – 23, 2016. Keynote Speaker is Jay Sanders, MD, and we have scheduled plenary session and educational track speakers to represent a wide spectrum of telehealth applications and technologies. We also offer an exhibit hall with representatives from manufacturing, service and support companies. For information, visit www.nrtrc. org/annual-conference. NRTRC provides technical assistance, education and support to telehealth networks in Alaska, Washington, Oregon, Idaho, Montana, Wyoming and Utah. We offer direct support, educational webinars, white papers, toolkits and a broad range of expertise in telehealth issues, with a primary objective of providing assistance in expanding care to underserved populations. For more info, visit www. nrtrc.org.
Join us at the 4th annual Alabama Telehealth Summit on Nov. 17 in Montgomery, Alabama, and the 2nd annual Florida Telehealth Summit Dec. 3-4 in Winter Park, Florida! (gatelehealth.org) The Southeastern Telehealth Resource Center (SETRC) provides technical assistance to help health care organizations, networks, and providers implement costeffective telehealth programs serving rural and medically underserved populations in the region with a coverage area of: AL, FL, GA, and SC. SETRC employs an applied approach to technical assistance services and telehealth education to health care providers, facilities, and organizations in order to grow telehealth services and technology in the region. SETRC’s educational arm, the National School of Applied Telehealth, provides online accredited telehealth training for Telemedicine Clinical Presenters, Telehealth Coordinators, and Telehealth Liaisons.
The Southwest Telehealth Resource Center (southwesttrc.org) and Arizona Telemedicine Program (telemedicine.arizona.edu) offer two resources to help decision-makers from rural and urban hospitals and other entities find the clinical telemedicine services they need. The national Telemedicine & Telehealth Service Provider Directory, (telemedicine. arizona.edu/servicedirectory) is a free public service that is searchable and provides detailed company or program information up-front, so users can quickly compare providers to find their perfect telemedicine partners. The directory includes more than 65 clinical specialty services, and it continues to grow. Mark your calendar for the 2nd Telemedicine and Telehealth Service Provider Showcase (SPS), June 2122, 2016, in Phoenix, AZ (ttspsworld.com). It’s a great forum for networking, meeting providers and learning how to create successful telehealth partnerships.
contact: bob wolverton
contact: lloyd sirmons
contact: nancy rowe
bob@nrtrc.org
lloyd.sirmons@setrc.us
nrowe@telemedicine.arizona.edu
TEXLA
NORTHEAST
MID-ATLANTIC
Telehealth continues to advance in Texas and Louisiana and both states are gaining momentum. The TexLa Telehealth Resource Center (TRC) continues to actively support the region and serve as a trusted telehealth advisor. Furthermore, over the last year the TexLa TRC has seen success toward the expansion of telehealth through updated rules from the Texas Medical Board and the Louisiana Board of Medical Examiners. Looking into the fall of 2015, the Frontiers in Telemedicine Certificate Program will open its doors at the Texas Tech University Health Sciences Center and begin to set the standard of telehealth learning. The course will include online modules, simulation center learning, and objective structured clinical examinations (OSCEs) to provide a competency-based model focused on the essentials of telehealth business, presenter protocols, clinical procedures, and technology.
Telehealth activity is booming in the northeast! After wrapping up their Regional Telehealth Conference in Burlington, Vermont, NETRC eagerly awaits many policy transformations, including reimbursement parity laws effective January 1, 2016, in New York and Connecticut, new Medicaid mandates in New Hampshire, great potential for a new parity law in Massachusetts, and many exciting conversations to enhance policy in Maine. To track all of the programs blossoming in this region, NETRC launched the northeast Find Telehealth Providers Tool (originally developed by MATRC). Visit www.netrc.org to explore a map of providers or to add in your telehealth hubs and/ or spokes. While you are online, also check out NETRC’s Resource Library with nearly 1,200 publicly available peerreviewed journal articles and other resources or explore your state’s page with links for policy, regulation, local news, and more!
Save the date! The 2016 MATRC Telehealth Summit will be held April 10 - 12, 2016, at the Hyatt Regency Chesapeake Bay Golf Resort Spa and Marina in Cambridge, Maryland. Discounted early bird registration and Call for Abstracts for our poster session will open on November 1, 2015. matrc.org/summit. Get ready to join over 400 colleagues as we look at “Improving Lives Through Advances in Technology and Meaningful Data.” Huge funding opportunity: BlueCross BlueShield (CareFirst) plans are to award up to $3 million over the next three years to programs aimed at increasing patients’ access to quality health care services through the use of telemedicine in Maryland, Northern Virginia and Washington, D.C. Proposals must be submitted online at www.carefirstcommitment.com/attachments/ Telemedicine_HowToApply. pdf, and must be completed no later than Nov. 23, 2015.
contact: andrew solomon
contact: kathy wibberly
asolomon@mcdph.org
kathy.wibberly@virginia.edu
contact: carson scott
carson.scott@ttuhsc.edu
Want to be included in Telemedicine’s next TRC News section? contact aneel irfan
aneel@telemedmag.com
www.telemedmag.com
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telescope Telemedicine briefs across the medical universe
“Surprisingly, and perhaps counterintuitively, telepharmacy doesn’t reduce a need for pharmacists, but allows for a reallocation of labor. Rather than spending a shift verifying medication orders or filling prescriptions, the on-site pharmacists are able to be more involved in other clinical activities...” -Brian Roberts CEO, PipelineRx page 12
featuring
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security
Coalfire Systems Reduces Risk Through Independent Assessments
lock down
CuttingEdge Firms Add New Dimensions to Data Security With the health data industry facing increasing cybersecurity threats, data security vendors are adopting new techniques to proactively preempt security breaches while simultaneously ensuring compliance with government and industry mandates. Here are a few recent initiatives by cuttingedge data security firms. by michael levin-epstein
In healthcare, second opinions are standard operating procedure. But that’s not usually the case in health care data security. Coalfire, a global provider of cyber risk management actually advises its health care clients to get second opinions on their data security needs to ensure HIPAA and HITRUST compliance. The 200-employee company, headquartered in Denver, is led by CEO Rick Dakin. Take Note -- In addition to encouraging additional independent assessments, Coalfire Systems emphasizes preemption over prevention. In his March 20, 2015, blog post, Andrew Hicks, director of the firm’s healthcare practice, said that safeguarding data, including tactics like scanning, penetration testing and social engineering, “should be considered mandatory as opposed to best practices.”
----Atlas Health Technologies Takes HIPAA Compliance to Next Level The Nashville-based company, headed by Kris Kelso, uses a cloud-based platform that simplifies HIPAA compliance by automatically encrypting and replicating health care records
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and simultaneously establishing a secure firewall to prevent hackers from logging into the system. In other words, you don’t have to waste time and resources developing a separate system with your vendor to make your system compliant. Take Note -- Atlas is designed from the ground up to comply with healthcare security and data privacy regulations, so upgrades are integrated into the system and application downtime is eliminated. The next version of its system, Health Blocks, will include multiple self-service features, on-demand environment provisioning and scaling, which means you’ll be more in control of your own system and won’t be as hassled with all the back-and-forth that normally goes on with security vendors.
----Proficio Protects against Database Intruders, Ransom Seekers The five-year-old California firm, led by CEO and Cofounder Brian Taylor, is at the forefront in securing patient databases. Here’s how it works. When a hacker attempts to trespass into your database, the company’s data security service immediately determines if the source is from malware and reviews the port used to traverse the firewall. The system then determines if your database was the specific target of mischief. Then the data security system hits the intruder with a power-
ful one-two punch: It collects data on the targeted host – including vital login messages to assess multiple log-in failures – and it provides an automated triggered response, like a firewall block. Take Note -- Proficio specifically targets ransomware – hackers who try to hold your computer hostage. Proficio fights back against ransom seekers by actively looking for vulnerabilities within their system.
----Forty Cloud Allows Healthcare Companies to Make Public Clouds Private If you like working with the big commercial providers of cloud storage, Forty Cloud might be for you. The company — a security-as-a-service provider — lets healthcare organizations benefit from cloud infrastructure services from providers like Amazon or Rackspace by making the cloud-based networks they create private. The startup builds a new virtual private network over any public or hybrid cloud infrastructure deployment, providing a layer of end-to-end security with encryption, firewall, access management and networking. Take Note -- This network can extend to securely connect any remote device, enterprise site or business partner network. In these days of mobile phones, tablets — and affiliate marketing — that could clearly come in handy.
W W W . S A L U S T E L E H E A LT H . C O M
SALUS
Building Healthy Communities Salus Telehealth is leading the nation in designing and implementing PROVEN telemedicine programs that are high quality, efficient, and cost effective. “ The Salus Team truly understands telemedicine. Their proven success and passion to change lives makes them the perfect telemedicine partner�- Jean Sumner, MD
Many facilities are using the Salus TeleHealth platform to transform the delivery of healthcare. GET CONNECTED WITH SALUS Hospitals Urgent Care Centers Long Term Care Facilities Schools Corrections Public Health Stroke Emergency Rooms Ambulances
THE SALUS SERVICES PLATFORM INCLUDES: Needs Assessments Telehealth Consultations Equipment Procurement and Installation Onboarding and Operations Support Program Support Customer Service and 24/7 IT Support Scheduling and Credentialing Training and Education Ongoing Monitoring and Tracking
For more information please contact jeremy.darter@salustelehealth.com
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pharmacy
Rx for change
Next Up for Telepharmacy Telepharmacy is only beginning to scratch the surface of its full potential as a tool for improving patient care and optimizing the pharmacy workforce. by brian roberts
While telepharmacy has a long history – Australia’s Royal Flying Doctor Service used a radio consultation to verify the administration of medications to a remote patient in 1942 – it wasn’t utilized in the United States until the 2000s. In the last fifteen years, healthcare has seen two broad applications of telepharmacy, hospitalbased and community-based, each carrying unique challenges and opportunities. Hospital Telepharmacy Structured from early successful teleradiology models, the hospital application of telepharmacy involves remote verification from a licensed clinical pharmacist for a prescription ordered by a healthcare provider. As automated dispensing cabinets become increasingly common in U.S. hospitals, facilities need this 24/7 verification to ensure nurses are dispensing medications that are safe for the patient, rather than overriding medications at the cabinet and discovering a problem when it’s too late. In rural areas, 12
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recommended 24/7 coverage is often unavailable as trained clinical pharmacists may be attracted to larger urban centers. Telepharmacy allows these hospitals to outsource to a third-party company or “share” a pharmacist between sites, decreasing the cost for the facility and providing tele-monitoring for other facilities. Telepharmacy also enables hospitals to better manage their staffing levels during natural ebbs and flows in pharmacy workflow. For instance, following a morning medication pass, the pharmacy may receive a spike in the number of prescription requests to be filled. Rather than staffing for this level, hospitals are able to maintain a mean-level of pharmacists, filling in when needed with remote services. As electronic health records become mainstream, telepharmacists also have the ability to interface directly into hospital health information systems or patient records, ensuring they have the most accurate information possible before making any medication decision. Telepharmacy enables hospitals of all sizes to better use their on-site pharmacists for patient care activities. The role of the pharmacist continues to evolve to that of a care provider, and the ability to receive reimbursement for direct patient care provided by a hospital pharmacist grows. Whether it be discharge counseling or medication reconciliation, numerous studies show that on-site pharmacists can be better utilized on hospital floors rather than remaining in the pharmacy to verify medication orders. Community Telepharmacy Following the recession of 2007-2008 the number of independent pharmacies in rural areas decreased, leaving patients in rural areas without many services including medication counseling. In conjunction with Medicare reimbursement changes, community pharmacists weren’t able to maintain their practices despite the increasing role for pharmacists as care providers. In 2001, North Dakota became the first continued on page 14
workforce impact
Will the rise in telepharmacy reduce our need for pharmacists?
S
urprisingly, and perhaps counterintuitively, telepharmacy doesn’t reduce a need for pharmacists, but allows for a reallocation of labor. Rather than spending a shift verifying medication orders or filling prescriptions, the on-site pharmacists are able to be more involved in other clinical activities, which will in turn improve patient outcomes, reduce readmissions, and improve hospital clinical activity and profits. The ASHP practice model actually favors bifurcating order entry and verification from clinical services and working with care teams. While there is the potential for rural hospitals to reduce their labor costs by staffing to a mean level, rather than consistently staffing for peak order times, telepharmacy also provides clinical pharmacist coverage to facilities that may have had periods of no coverage before due to cost restraints. Because a telepharmacist can generally cost a hospital less than staffing for a fulltime employee due to the ability to have labor sharing between facilities, it makes 24/7 pharmacist coverage more attainable. This is a very important service for hospitals that have recently implemented CPOE (Computer Physician Order Entry) and need real time verification. By providing this additional coverage, telepharmacy may actually be adding staffing when there was previously no pharmacist covering that shift. Given that 24/7 coverage is a recommendation of the Joint Commission, anything that makes this a more attainable goal for hospital pharmacies is a step in the right direction.
Tomorrow’s Pharmacy Today
KitCheck
Three game-changing pharmacy innovations are reducing error and lowering costs by michael levin-epstein
GoToPills What percentage of medications prescribed in the United States are taken off-label? The answer might shock you. After attorney Tamera Venzke spoke to a client who had suffered serious kidney complications after taking a drug approved only for migraines, she decided to take action. With her physician partner Jim Brantner, she founded GoToPills, which provides a free app for consumers to check drugs they’ve been prescribed for FDA-approved uses. And it offers physicians and pharmacists a comprehensive suite of tools — including off-label alerts, off-label informed consents, and FDA-approved list functions — to make sure they’ve made the right prescribing decision and GotoPillsRx, which tailors medications for each patient. GoToPills is easily integrated into electronic health and e-prescribing systems, according to Venzke. The company was selected by Walgreens to be part of their healthcare app portfolio, she notes, and other affiliations are on the horizon: “GoToPills is in discussion with NASA to be part of the medication program for astronauts and is in discussion with a chain of hospitals for implementation of the prescribing tools,” Venzke tells Telemedicine Magazine. “The health and lawsuit risks associated with off-label drugs are substantial,” Venzke asserts. “Since 2009, more than 14 billion dollars have been paid in off-label drugs settlements and that number is growing.”
ScriptPro Are you ready to have your prescriptions filled by robots? With ScriptPro’s Compact Robotic System (CRS), currently on permanent display in Cleveland, Ohio, at the HIMSS Innovation Center — part of the Global Center for Health Innovation — you can see the robotic future in telepharmacy. The CRS display features a touchscreen kiosk that enables visitors to fill and dispense a sample prescription through the robot. This showcases, according to company officials, the “efficiency, safety, and accuracy” of ScriptPro systems as they are utilized in retail and ambulatory pharmacy operations. Behind the scenes—and less evident to Innovation Center visitors—are ScriptPro’s strategic planning and financial management services designed to help health systems succeed in a dynamic and financially challenging environment. The Global Center for Health Innovation functions as a permanent demonstration and testing site open year round to show how interoperable technologies improve the quality and efficiency of care for patients and communities.
One evening KitCheck founder Kevin MacDonald was having dinner with a hospital pharmacist who had just spent two days manually checking pharmacy kits for proper medications and expiration dates. With his background in cloud software and RFID, McDonald was confident this mundane task could be automated. What he found out was that not only could automation reduce labor time by about 90%, but it could also eliminate human error. “In just about three years, more than 200 hospitals have adopted KitCheck, which has resulted in an average savings of 71%-96% in labor cost while simultaneously improving kit stocking accuracy by virtually 100%,” says Chief Marketing Officer Bret Kinsella. Kinsella believes that the benefits of KitCheck will make it an industry standard and expects AnesthesiaCheck, the company’s other product, to take off as well for use in the OR. We’re entering a new era of data-driven pharmacy, says Kinsella. “Clinical pharmacy decisions are already being made using data analytics,” Kinsella says. “KitCheck’s solutions are the first to provide medication tracking and operational data, which will enable optimized processes, real-time visibility and better decision making.” Legislators are considering measures to require medication tracking from manufacturers to distributors to the hospital, Kinsella adds. That will be implemented over the next five years to provide a robust view of medication through the hospital supply chain, perhaps similar to the Food Safety Modernization Act now regulates the food chain. “Within a decade, we will know the trail from manufacture to patient use for every medication,” he says, “and companies like KitCheck will provide data to support that visibility and also automate handling processes along the path.” www.telemedmag.com
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TELEPHARMACY continued from page 12
state to allow retail pharmacies to operate without requiring a licensed pharmacist to be physically present. Instead, a pharmacy technician staffs the facility, with a fully licensed pharmacist available remotely to answer any questions and verify medication orders. In this simple way, many retail pharmacies can share the services of one centrally located pharmacist. This system was implemented in the U.S. Navy in 2010 as the largest telepharmacy implementation at that point. A supervising pharmacist offsite can view original prescriptions, offer video consultations, and remotely distribute medications (which are visually verified with another camera on-site) to patients onboard the ships. Future Applications Telepharmacy is growing, but the available technology is still underutilized. While the proof points for patient safety are well developed, the industry is now becoming more nuanced, exploring potential benefits of telepharmacy from an operational standpoint. Recent legislation has been promising, as it redefines the role of the pharmacist as a car provider, particularly in rural areas, allowing these providers to receive Medicare reimbursements for telepharmacy. Telepharmacy is in its infancy, but it’s an idea whose time has come. Whether that means integrating remote pharmacists into patient bedside consultations, or offering home-consults for patients in extremely rural areas, the options are broad, with many more applications yet to be explored.
caveat emptor
Dr. Google and the Dark Side of Telemedicine Telemedicine offers great advances in care delivery, but providers need to be savvy to the pitfalls, such as non evidencebased apps and patients misrepresenting themselves online. A little “buyer beware” will go a long way. by jodi lyons
“All the dollars in healthcare have multiple zeros behind them, that’s just how it works. The average revenue per user in Facebook is $4. For eBay it’s $89 dollars, for Amazon it’s $109 dollars. For Medicare it’s $1,200.” - Abhas Gupta, partner, Mohr Davidow Ventures 14
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As the telemedicine market opens up, patients will be exposed to even more unverified, unhelpful information than they already are. Many of you have had patients show up to your offices with “evidence” printed off of some random website and demanding a particular “medical” treatment. “Dr. Internet” is a popular physician who never went to medical school and doesn’t know the patient, yet dispenses “notquite-but-awfully-close-to-medical” advice. Whether it’s coconut oil for Alzheimer’s Disease or krill oil for cancer, patients are sure to get upset when you tell them that their requested treatment is quackery. Patients therefore are forced into an odd dichotomy – a balance between buyer beware and buyer have faith. “Buyer have faith” – credat emptor – is a term that describes the scenario in which the buyer should ethically be able to trust the advice and expertise of the “seller” – in this case, the person providing medical information
Percentage of employees who used a telemedicine offering this past year as part of employee wellness programs
or care. To quote an old commercial, “an educated consumer is our best customer.” This challenge is only going to get worse as the telemedicine market opens up and web-based applications “replace” humanto-human interaction between medical professionals and patients. The art and science of medicine can be supported by, but not replaced by, an algorithm. It is important to preserve the instinct, training, education, experience, and compassion that medical professionals bring to the table so that the diagnosis and treatment plan don’t take place in a vacuum. The analysis of data is only one part of the equation. Products based on symptom checkers and the like present a particular challenge. Think of how many diseases or adverse reactions to medications manifest themselves in “flu-like symptoms.” Another challenge is mimicking symptoms: is it a GI bleed or a side effect of bismuth sulfide? How are patients to know if they have a serious problem or not? How do they know who or what to trust? Consumer education is vital as is a clear means of differentiating between reliable sources and quacks. Most professionals understand the difference between scientifically validated information with peer review and the information found in a chat room where no one has any medical expertise. Many consumers don’t know the difference. It also is important to differentiate between “real” telemedicine and “there’s an app for that” faux telemedicine. The telemedicine industry needs to thoroughly educate the consumer base so that the distinction between legitimate telemedicine practices and quacks are more easily identifiable. This is vital for patient protection
It is important to differentiate between “real” telemedicine and “there’s an app for that” faux telemedicine. – buyer beware. The second side of the equation is “seller beware.” Medical professionals face a particular challenge if they don’t have a preexisting, face-to-face relationship with the patients before embarking on a telemedicine relationship. That is the “danger” of relying on patient self-reported symptoms and allergies. While similar challenges exist when enrolling a new patient even in a traditional office visit, the online-only world raises the stakes. There is limited data on the patient, and that data often is patient self-reported. How is the practitioner supposed to know if or how much the patient is cognitively impaired? A drug user/abuser? Confused? Misunderstanding the questions or situation? Doctor-shopping? Lonely and just needing someone to talk to? A hypochondriac? It is often easier to “see” these challenges face-to-face. Particularly in the world of geriatrics, it is important in both face to face and telemedicine interactions to perform some sort
Droning On: Improving Access in Rwanda In the landlocked, hilly East African nation of Rwanda, the delivery of necessary medical supplies to remote areas has been a tortuous, if not impossible task. That may all change next year when Rwanda serves as a testing ground for a proposed cargo drone route that
of cognitive and mood screening that identifies executive functioning and decisional capacity, not just a test of short-term memory. This allows the medical professionals a chance to decide whether or not to trust the patient’s self-reporting, to know if the patient truly is able to understand the medical recommendations, to identify whether or not the patient is capable of adhering to the recommendations, and to decide whether or not to treat the patient. There are evidence-based, scientifically validated cognitive assessment and mood screening tools that can be administered in 15 minutes or less in-person, online, or over the phone even over asynchronous care. Using them protects both the patient and the medical professional. Short-term memory retention only tells a small part of the story and tests like the MMSE don’t give enough guidance to the practitioner. Additionally, as the population ages, it becomes even more important to understand the psychosocial and practical implications of the medical interaction. If the medical practitioner calls in a prescription, does s/he know if the patient is able to get the medication and take it properly? Does the practitioner need to know or have they done their job just by calling in the prescription? Is there a need for follow up? Who arranges the follow up? The expanding world of telemedicine and web-based medical advice creates many opportunities to expand access to medical care, especially to those who are not wellserved by “traditional” means. Yet, just as patients need to beware of bad information on the Internet, medical professionals need to beware of bad information from the patients. Buyer and seller, beware!
would deliver medical supplies to hard-toreach villages. The proposal, put forth by the British architecture firm Foster + Partners along with the Swiss Federal Institute of Technology and its Afrotech initiative, calls for unmanned drones with a wingspan of 10 feet to carry deliveries weighing up to 22 lbs. www.telemedmag.com
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KNOW MORE
Introducing GoToPills, the ground breaking health IT that increases patient safety and decreases liability for healthcare providers by delivering offlabel alerts to patients and providers.
www.gotopills.com
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Along with a free consumer app GoToPills will be rolling out a suite of off-label prescribing tools for healthcare providers.
Keep a look out for our forthcoming collaboration with Walgreens.
teletech Practice-changing gadgets and gizmos
After games, we’re going to make Oculus a platform for many other experiences. Imagine enjoying a courtside seat at a game, studying in a classroom of students and teachers all over the world or consulting with a doctor face-to-face — just by putting on goggles in your home.” -Mark Zuckerberg CEO of Facebook, in a statement about Facebook’s purchase of Oculus Rift
featuring
glass ~ pristine ~ insight kinect ~ surgical theater fraunhofer mevis ~ oculus rift www.telemedmag.com
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virtual reality
Holodeck Medicine: How Immersive Technology Is Changing the Doctor’s Point Of View by Scott Jung
One of the hottest trends in the computer industry is augmented and virtual reality, a computing environment which partially or completely skews reality with computergenerated imagery. Somewhat like a primitive version of Star Trek’s “holodeck”, this technology allows a user an escape from real life with immersive sound, lifelike visuals, and interactive, gesture-based interaction. While virtual reality is finding itself increasingly in the next generation of video games, both augmented reality, in which images and information is superimposed over real-world images, and virtual reality, in which one’s entire field of view is completely computer-generated, is also being trialed in the healthcare industry, namely medical education. While an experienced doctor is still absolutely essential, “augmented medicine” and other new technologies are allowing them to extend their talents even further and learn even more about the human body and disease. For patients, this could mean reduced costs and better outcomes for surgical procedures and treatments. Here’s our list of notable technologies that you might someday see in a medical school or doctor’s office near you.
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I L LUS T R AT I O N BY N I C O L E T SCHEN CK
Smartglass Learning Ever since the launch of Google Glass in 2013, the tech industry has eagerly speculated about how each field of medicine would embrace it. In August 2013, a surgeon at the Ohio State University Medical Center wore Google Glass during an ACL repair as medical students watched the livestream on laptops in another area, and since then, a number of doctors have started using Google Glass to stream and record their surgical procedures for educational purposes. Google Glass was officially
discontinued in its app called Telepresence current form in early that can transmit the 2015, but some are smartglass user’s point of still hopeful that view to a remote user’s smartglasses might still tablet. The tablet user be the next revolution can annotate the video or in surgery technology. picture with their finger, Smartglasses by One company, Pristine, and the video feed with inSight Augmented has developed a program annotations, drawings, Medicine called EyeSight to and text is transmitted stream and record live back to the smartglasses video and photos from and seen through its the smartglass user’s point of view. This display. content can be shared with a colleague Both EyeSight and Telepresence were with a simple voice command. developed for multiple smartglass Another company, inSight Augmented platforms, so Google Glass is not Medicine, has developed a similar required. www.telemedmag.com
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Augmented reality can be used to make anatomy education an immersive experience. (Pictured: the Microsoft HoloLens.)
Microsoft Kinect One gadget that could prove beneficial during surgery may already be sitting next to your TV. Microsoft’s Kinect motion-sensing camera has already shown itself to be a useful tool to help surgeons view and manipulate medical images. Within the sterile field, surgeons are usually unable to operate a mouse, keyboard, or even a touch screen with their hands. The Kinect makes viewing and manipulating images and patient data as simple as waving their arms. Moreover, the camera in the Kinect is sensitive enough even to detect subtle changes in a patient’s skin color. An additional Kinect device could theoretically be aimed at the patient being operated on to monitor a user’s heart rate or track radiation exposure from x-rays or CT scans.
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Immersive Surgical Navigation & Planning Brain surgery has always been a risky undertaking. Not only because the brain is the control center for the entire body, but also because it contains a dense network of blood vessels and anatomical features that are unique for every person and extremely delicate to navigate. One company, Surgical Theater, took inspiration from flight simulation technology and developed a platform which integrates CT and MRI scans and traditional x-rays to create a highly detailed three-dimensional model of the part of the brain being operated on. These models can be manipulated and used for planning the best entry/ incision point, the best path around the patient’s vasculature and the minimum amount of skull bone
needed to be removed to facilitate faster healing. Recently, Surgical Theater received approval in the EU to incorporate virtual reality headsets for enhanced navigation and planning. Once the procedure is planned, the details can be imported into another Surgical Theater program which allows the surgeon to see the 3D model and plan in real time from inside the operating room.
-----Tablet-Based Augmented Reality Tablet computers have transformed the computing industry because of their portability and ever-increasing processing power. Fraunhofer MEVIS research center in Germany has harnessed the power of the tablet computer and developed
an augmented reality app to assist with liver cancer surgery. CT scans are used to create a model of the liver and its cancerous site to assist with preoperative planning. However, instead ofbeing sent to a stationary computer monitor, the model is sent to a tablet computer. As a result, a surgeon can superimpose the exact locations of important blood vessels and anatomical features during a procedure when the tablet is held over the patient’s actual liver. The liver can be filmed with the built-in camera, and the tablet can be operated as normal with touch gestures. This technology helps ensure that the surgeon doesn’t make any unnecessary cuts, can make adjustments quickly and flexibly, and completely remove the cancer.
-----Oculus Rift Goes Way Beyond Gaming Like the Kinect, the Oculus Rift is another gaming device that is dabbling in the medical technology industry. The Oculus Rift is a virtual reality headset that displays a fully immersive 3D experience that makes you feel like you are actually in the middle of an environment. Motion sensors detect when you move your head and change your perspective accordingly. Now owned by Facebook, Oculus Rift is still looking for its niche in gaming and consumer media, but it’s already been
used as an immersive medical learning tool. Last July, a surgeon in France wore a GoPro Dual Hero camera system on his head as he performed a total hip replacement surgery. The cameras created a stereoscopic 3D video that could be viewed through the Oculus Rift. Moreover, the sensors in the Oculus Rift allowed the viewer to move his or her head and focus on different aspects of the procedure, such as the surgical site or the assistants. The team behind the surgery hopes that doctors anywhere in the world would someday be able to observe a surgical procedure by simply donning an Oculus Rift. They believe that the headset can be a revolutionary learning tool for both new and experienced surgeons.
Doctors aren’t the only ones that have all the fun when it comes to Oculus Rift, however. They’re also being evaluated in patients as a form of virtual reality therapy (VRT). Dr. Albert “Skip” Rizzo of the University of Southern California’s Institute for Creative Technologies has developed an Oculus Rift version of the Virtual Iraq/Afghanistan PTSD Exposure Therapy System that he created in 2005 to help treat war veterans suffering from PTSD. The system uses virtual reality to recreate combat situations to help alleviate fearful associations linked to traumatic memories and has been shown to significantly reduce PTSD symptoms. According to Rizzo, the lower price point of the Oculus Rift will make it much more affordable for clinics and allow for research to expand to other areas of mental health.
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television Industry-shaping ideas and perspectives
“Overcoming the many challenges that are inherent in healthcare systems around the world requires unprecedented wireless expertise, borderless connections, a global, secure infrastructure, and an open ecosystem approach. Fortunately, making connected health care a reality is a Qualcomm-sized problem.� Rick Valencia Founder, Qualcomm Life page 24
featuring
rick valencia ~ steve cashman judd hollander ~ mark plaster bill gordon www.telemedmag.com
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the internet of medical things
Is Telemed Connectivity “A QualcommSized Problem”? The founder and leader of Qualcomm Life, Qualcomm’s healthcare subsidiary, Rick Valencia directs product, technology and M&A strategy in the wireless health market. With more than 25 years of experience in rapidgrowth, technologyenabled businesses – not to mention his involvement with organizations like the World Economic Forum and Rock Health, Valencia has a voice that is helping shape the telemedicine market. Telemedicine editorial director Bill Gordon caught up with him to find out where he sees the market heading.
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TelemedMag: What is your vision for mHealth/telemedicine in the future?
TelemedMag: Who are the Qualcomm Life partners you are most excited about and why?
rick valencia:
valencia:
Qualcomm Life’s vision has always been a world with access to health care anytime, anywhere, and we have been working to establish and support new care models to make this vision a reality. Health care has historically been very siloed and has revolved around episodic care being delivered in traditional settings – like a hospital or doctor’s office. With the pervasiveness of mobile and connectivity solutions, we see care shifting from episodic to continuous, and being delivered whenever and wherever the patient needs it. Powering this shift is what we call the Internet of Medical Things – a digital ecosystem of medical data, devices and sensors that are all interconnected, and that eventually play an important role in a patient’s care journey. Qualcomm Life’s focus and investment will be a catalyst in the Internet of Medical Things, ultimately enabling intelligent care everywhere.
We have a robust ecosystem of more than 2,000 member companies spanning the health care spectrum, including medical device manufacturers, pharmaceutical organizations, health care providers, application developers and more. Just this week we announced that Qualcomm Life acquired Capsule Technologie, a leading global provider of medical device integration and clinical data management solutions with more than 1,930 hospital clients in 38 countries. By combining Qualcomm Life’s wireless expertise and ecosystem of connected medical devices outside of the hospital with Capsule’s leadership for connecting medical devices, EMR’s and IT systems across the hospital enterprise, we are creating one of the world’s largest open, medical device ecosystems to deliver intelligent care everywhere. Some recent examples of the great work being done within our ecosystem include
our collaboration with Northern Arizona Healthcare, who is leveraging Qualcomm Life’s 2net™ platform as well as HealthyCircles™ to enable an improved remote monitoring solution that expands and enhances the care of cardiac patients, pulmonary patients and those needing postoperative care. This model has been especially effective for remote patients in rural areas of Arizona who have limited access to electricity and running water. Earlier this year, we also announced a collaboration with Walgreens. By powering connectivity for their Balance Rewards mobile application, Qualcomm Life allows members to sync select mHealth devices directly to their Balance Rewards account, earning points, which ultimately turn into cash, to reward and incentivize healthy behaviors. TelemedMag: In your opinion, what is the biggest roadblock to wider spread success and/or adoption in the mHealth/telemedicine world? valencia:
There are two significant roadblocks that continually come up: data security and scalability. Overcoming the many challenges that are inherent in healthcare systems around the world requires unprecedented wireless expertise, borderless connections, a global, secure infrastructure, and an open ecosystem approach. Fortunately, making connected health care a reality is a Qualcomm-sized problem. TelemedMag: What are the future technologies in development that will change the game? valencia:
The Internet of Medical Things is here – and changing people’s lives as we speak. In powering and shaping new digital relationships with traditional and nontraditional partners and patients, we are creating a secure connected fabric that will enable devices and sensors in and around the consumer to connect directly to data and to each other. This data liquidity and accessibility will unlock value by enabling
We are creating a secure connected fabric that will enable devices and sensors in and around the consumer to connect directly to data and to each other. This data liquidity and accessibility will unlock value by enabling systems and companies to securely connect, share, and develop breakthrough intelligence and care efficiencies. systems and companies to securely connect, share, and develop breakthrough intelligence and care efficiencies. This is changing the way consumers receive and act on personal health information, care for themselves, engage providers, and interact with technology. TelemedMag: Any final observations about the telemedicine market? valencia:
With the recent chronic care management (CCM) reimbursement codes and the hospital readmissions penalization, providers are finally being incentivized to keep patients healthier and out of acute care settings. This is a major shift from what has historically been an industry based on a feefor-service model to a fee-for-value or outcomes based reimbursement model. With these changes well underway, telemedicine and mobile health will be critical in keeping at-risk patient populations out of acute care and ambulatory settings through remote monitoring programs.
Qualcomm’s Village Boasting a diverse healthcare ecosystem composed of medical devices, platforms, and applications, you’d be forgiven for asking, “what exactly does Qualcomm Life do?” With an overarching aim as broad as it is ambitious – to make the healthcare system accessible – Qualcomm Life centers heavily around its cloud-based 2net platform. This platform provides digital data acquisition, transmission, and storage of patient records in order to facilitate a seamless mobile connection between physicians, pharmacist, and the patient. Qualcomm Life calls this ‘The Healthy Circle’ and hopes that by connecting the key players in healthcare they can help educate and guide recovery for the patient while keeping providers informed and keeping costs contained. -Taja Whitted
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Why are you succeeding where others may have failed?
hit the spot
HealthSpot Scales Up to Reimagine Retail Clinics Steve Cashman wants to reinvent the retail health clinic – and eventually put one in your living room. His company, Healthspot, is taking strong strides in that direction as it drops turnkey telemedicine pods into major drug store chains across the nation. These “spots” – designed to facilitate, not replace, existing doctor-patient relationships – are constantly evolving, now offering system-onchip blood testing through a collaboration with Samsung. We asked Cashman to share his perspective on the future of pharmacies, chronic care and healthcare’s telemedicine revolution. Interview by Bill Gordon
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steve cashman: I think we’ve developed a unique model that fits the clinical standards that are out there. And with those clinical standards, we’ve been able to garner a business model that’s built around reimbursement and the way healthcare works, versus trying to recreate the whole enchilada and argue about clinical standards. I think uniquely we have done something that is close to what happens in a traditional office or urgent care. We’ve just done it with technology. From a services perspective, tell me why HealthSpot is unique. cashman: What makes us unique is that we’ve really given the doctor a new tool to do his job. We’ve replicated a full exam in an office setting with an existing doctor, with an existing payer relationship. We’ve just done that in a retail pharmacy using telemedicine. And so we’ve really just kind of built the same standards and the same thing they look for into a telemedicine model. That’s given us the ability to really eliminate the overhead from the retail pharmacy that they would have in a traditional convenient care retail clinic. And it’s given the providers reach into a segment of consumerism without them having to get outside of the box in business model and other things. It’s the patient seeing them with the standard billable office rate. They’re examining them. They’re treating them just like they would in their office, but yet they’ve been able to use all this technology. Where do you see the most potential growth for your company? cashman: We’re aimed at reinventing the retail clinic. So the 62,000 U.S. pharmacies is where you’re going to find HealthSpot for the near future. Why that is so significant is because when we look at chronic disease folks, they’re in retail pharmacies 20-plus times a year and they’re in their doctor’s office three times a year. As we try to do
population health management, we need to take the care to where they are and not try to bring them to where we put care. That’s a fundamental shift. The other thing is you saw we had an announcement with Samsung last week, we’re adding other services to the HealthSpot station, such as system-on-chip-blood testing. We’re going to allow the medical community to do more and more remotely by the integrated technology that we have within the footprint there. That neighborhood pharmacy is going to become a fully integrated extension in the local medical community and remain a consumer destination that now has other services in it because of our technology What else do you have on the horizon? Who else have you partnered with? cashman: We’ve done a partnership with Rite-Aid. We opened up stores in Ohio in May and that’s been a big deal to give us a national player that we can grow with. The other partnerships that we are forming range from health systems to payers; but really just building an entire converged network, where the value is built around reinventing this care delivery. Cox is a partner as well through the Vivre Health piece, which is an entity they’ve built around how we move healthcare into the living room. They’re the third-largest cable provider in the country. HealthSpot’s unique in that we’re really a software company. What we do with our software platform in managing doctors, records, claims, remote devices and then obviously all the care delivery video and audio and other things, the support that goes with that; our vision is to make that ubiquitous. As we look down the road, the same way we’ve created a rich telemedicine visit in a pharmacy in a kiosk, ultimately we want to use that technology to build a rich patient experience in the living room of everyone’s home.
How does your approach to creating a connected care network differ from other telemedicine companies? cashman: I think the majority of the telemedicine guys that are out there are just doing video. They have no biometric data, they have no way to help impact HEDIS and STAR measures. They have really no way to overall report on people’s total health because they’re just getting a snapshot of a chief complaint that’s episodic. Whereas what we’re doing in the model we’re building out is to really create a platform for population health management, where all the stakeholders: your payer, your doctor, your pharmacy where you get your script are all ultimately integrated and the consumer’s driving that. And so we’re really trying to build converged networks. All the way down to when we do a rollout, we go look at the payer data and say: Okay, where are the people that are disconnected from health care and are going to the ER? Where’s the nearest pharmacy to that ER? Who is the right doctor that we can get them into and really try to converge that? What are the biggest stumbling blocks to making that happen? cashman: I think largely doing this at scale is the only way to try to create that convergence, right? With the amount of work that it takes to converge the data and educate the consumer and achieve the scale
…what we’re doing in the model we’re building out is to really create a platform for population health management, where all the stakeholders – your payer, your doctor, your pharmacy where you get your script –are all ultimately integrated and the consumer’s driving that. necessary such that I can walk into any store and get my doctor – and for that service to be ubiquitous near my work and home – we have to build large networks. It’s no different than what telecom went through when it wanted to launch wireless phones, right? They had to put up a bunch of towers so that you could actually make calls in your car. If it was point-to-point communication, it wouldn’t have worked. So we have to build large networks of providers and large networks of locations and work with the payers to then form large networks of consumers to where this becomes a standard level of care in what they do today. What’s the future of HealthSpot? Give me your prediction for three years, five years down the road. cashman: Five years from now HealthSpot will be in about ten to 15,000 pharmacies across the country. It will be as ubiquitous as getting a DVD from a Redbox, or cash out of an ATM. The things that you will be able to do in those pharmacies will far exceed what most people’s current expectation is, and that’ll largely be around
things like the Samsung device. Things today that are expensive and inconvenient and require multiple days will instantly be turned into consumer satisfaction without the pain and wait, and with a ton of cost savings. What we see is a network across the country that we can wander into, see the medical group that we’re affiliated with and quickly get diagnosis for basic things. As we look towards total population health, we’re going to walk in there and our payer is going to be able to flag: “Hey, we want to grab your blood pressure and your weight and a few other things,” just because we’re trying to keep track of overall health trends. And we’re going to reward you for improvements in these health trends. What is HealthSpot going to look like when it’s fully baked, when it’s a huge company generating hundreds of millions of dollars in revenue? cashman: I think we’re starting to become more like our core, which is a software company. The combination of everybody’s data is going to help us know what care we need today, and where it should be provided. That may be right on your Smartphone. It may be in the living room of your home or it may be coming to a pharmacy to do more advanced diagnostics. Or it may be even going into a medical facility. HealthSpot will be the ubiquitous application that’s helping deliver that; reinventing the patient experience to what is the right care at the right place at the right time, based on what you have going on, what we know about you and what sensors we need to ultimately determine what the root problem is. We will become something that is ubiquitous to the consumer where they work, where they travel, where they live and where they shop. And we’re on our way. In our first 90 days at roughly 25 Rite Aids, we saw nearly 10,000 people. That’s a lot of biometric data; a lot of people and consumers that we now have a relationship with and that’s in a short window of time. www.telemedmag.com
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briefly describe some of our other training programs. After all, our vision is that robust interprofessional training and development opportunities for providers will be a recurrent theme for the continued advancement of our careers.
by the book
Training the Next Generation in Telemedicine New telehealth “boot camps” are ensuring that freshly minted physicians are fluent in a brand new model of care. by Judd E. Hollander, MD & Dimitri Papanagnou, MD, MPH, EdD Candidate
Anyone reading this journal, or more specifically, anyone reading this article, is smart enough to realize that future healthcare delivery models will widely embrace telemedicine to deliver care. The question becomes, “How will providers learn to incorporate this tool into their armamentarium?” A decade or two ago, we did not have tissue adhesives or cardiac troponins. Over 100 million cases later, we know how to use these tests. Telemedicine will follow the same course. Virtually all providers will learn to care for patients where and when patients want care. Like they always have, they will learn to use newer technologies. To facilitate this transition, Thomas Jefferson University has created a robust training program that includes staff, medical students, resident physicians, fellows, and faculty. This article will focus on the goals for the Telehealth Leadership Program. If we don’t train future leaders, we won’t position the field for success. In addition, we
Telehealth Leadership Program (Physician Fellowship) The mission of this year-long program is to train physicians with the knowledge, skills, and attitudes necessary to become independent telehealth researchers and leaders. Utilizing team-based learning, hands-on application of knowledge, and simulation training, the curriculum is informed by the principles of experiential and self-directed learning theories to foster knowledge in four core areas of study (Leadership & Management Skills; Entrepreneurship; Research & Education; and Clinical Skills). These core areas and their associated competencies continuously complement one another and work to build a foundation of telehealth and leadership success. Before taking on new clinical and administrative responsibilities, fellows will complete an intensive “Telehealth Boot Camp,” which will integrate simulation-based instruction, team-based training, and traditional didactic teaching. An essential component of the learning experience and responsibilities of the fellow is the work carried-out in various telehealth use cases. Prospective fellows are required to work on an existing, developing, and new use case with increasing levels of administrative responsibilities. The fellow will be trained in LEAN Thinking, Crucial Conversations, and Emotional Intelligence to provide the tools needed to successfully perform this expectation. To develop global understanding of the complicated nature of telehealth development and application, fellows will have asynchronous, focused immersions into various concentrations of business study, including marketing, finance, legal and health informatics rotations. It is an expectation that fellows con-
hollander
The program was designed for those interested in further developing their careers by acquiring the skills needed to facilitate clinical telehealth encounters at their respective organizations.
tribute in a meaningful way to the current research supporting the evidence base of telehealth. Research training and deliverables are designed to produce independent scientists capable of performing innovative research that is competitive for funding opportunities. To develop the needed research knowledge and skills, fellows will immediately be incorporated into research projects; develop and complete a telehealth research project under the supervision of a team of preceptors throughout the program; and complete a rigorous course of didactics and seminars. The curriculum is tailored to the fellow’s personal interests, allowing for individualized concentrations of research and knowledge application, as well as the option to complete an advanced degree or certificate. To demonstrate their acquisition of knowledge, skills, and attitudes throughout the duration of the program, fellows will be required to complete a capstone use case applying the core competencies of the program. The capstone will complement the entrepreneurial rotations as the fellow builds financial and marketing models alongside developing the legal supporting documentation. Resident Physicians and Medical Student Electives We can’t expect providers of the future www.telemedmag.com
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to be prepared for the medicine of the future if we don’t take advantage of teaching them while they are most primed for learning. We have, therefore, created elective rotations for residents and medical students. These electives are a minimum of 4 weeks in duration. There is a base educational curriculum with an opportunity for learners to further pursue interests appropriate for their degree of training. In addition to basic readings and an interactive curriculum specifically tailored for their level of education, all learners will participate in the conception, development, and implementation of various telehealth use cases throughout the health system, regional ACO’s, and large community groups. To further broaden exposure to telehealth operations, learners will also be given the option to choose an area of concentration (i.e., administrative, clinical, research). Residents and medical students will participate in all major telehealth related work group meetings, including the monthly enterprise-wide leadership committee with representatives from finance, marketing, information technology, legal, and academic departments; weekly team strategy meetings, weekly innovation committee meetings; and biweekly research-in-progress meetings. They will receive formal training in the provision of telehealth services, as well as participate as an instructor in telehealth training sessions. Participants will spend 12-24 hours directly observing and/or providing telehealth care in a variety of use cases (i.e., virtual rounds, on-demand urgent care, and scheduled outpatient appointments) and perform follow-up surveys to evaluate patient and provider satisfaction with telehealth. Telehealth Facilitator Certificate Program Physician support staff is of paramount importance in facilitating seamless patient care. To achieve our vision of providing the option for medical care via telehealth 30
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to all patients, we designed an instructional training program for support staff in healthcare or health-related fields. The program was designed for those interested in further developing their careers by acquiring the skills needed to facilitate clinical telehealth encounters at their respective organizations. Through a series of self-directed, selfstudy, online learning modules, students enrolled in the program learn how to improve patient healthcare access, efficiency, and safety, as well as improve patient outcomes, by acquiring an arsenal of telehealth skills enabling them to successfully facilitate telehealth within their respective healthcare organizations. Students are immersed in modules that promote the skills needed to support clinical telehealth encounters, including, but not limited to, using telehealth in inpatient and outpatient settings, and providing technical assistance when needed. Through a handson practicum module, students have the opportunity to deliberately practice skills covered in previous modules, as well as circumvent common troubleshooting encounters and/or resolve common issues faced during typical telehealth encounters. Paramount to the successful delivery of telehealth is the application of effective interpersonal and communication skills required to assume the role of telehealth facilitator on the interprofessional healthcare team. These concepts are a recurrent theme across all modules. On completion of the program, participants receive a certificate of completion and continuing education credits. Participants also have the option to complete subsequent coursework, which will further build upon the telehealth facilitator skillset. The authors would like to acknowledge the contributions of Alexandra Printz and Shoshana Sicks.
location, location
The Trillion Dollar Question As an emergency physician, I know that getting low-acuity patients out of the ED and into cheaper settings isn’t simple. But the rewards are game changing, and new technology is making it more possible daily. by Mark Plaster, MD Can direct-to-patient telemedicine save money over the current model of bricks and mortar medicine? Absolutely! But how much? The answer starts in billions per year. But how can we do that safely? Let me show you. It’s popular these days to do studies that show the high percentage of ER patients who don’t actually need to be seen in the emergency department and could have been treated safely in a cheaper setting. This, it is argued in the press, is unnecessary care. But emergency physicians rightfully complain that calling care unnecessary in a retrospective study is the ultimate in Monday morning quarterbacking. Of course, anybody could see (from the sky cam) that the pass would be intercepted. But see what happens when the camera tries to get down and look over the quarterback’s shoulder, showing what he sees of the evolving play. It isn’t so obvious. So when studies come out like the one reported in Becker’s Reviews by Truven Health Analytics showing that 71% of 6.5 million ED visits studied were unnecessary and/or avoidable, emergency physi-
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cians howled in protest. It turns out they are both right. And both are missing the other part of the play. Noting that the average ED visit in 2010 cost over $1,316 while the average primary care visit cost $145, the authors were right to point out that there was a lot of potential savings for the system. And yes, it was true that the visits in question were unnecessary in retrospect. Unfortunately, however, the retrospective methodology of the study provided no clue as to how to address the issue. Some emergency departments have tried to address this problem of unnecessary visits by putting higher and higher skilled providers – even to the point of putting experienced emergency physicians – in triage. Other EDs expedite low acuity care by syphoning it off to lower intensity, lower cost, settings, such as ‘Fast Track’. But the problem they all seem to encounter is that unavoidable fact that careful triage requires a lot of information being processed by an intelligent, experienced provider to determine that the patient does not, in fact, require true emergency services. The classic example is the patient with “indigestion-like pain.” Is it a stomachache (non-emergency) or a heart attack (life-threatening emergency)? You can move the triage to the parking lot or to the street, being performed by EMS in contact with providers by radio, but it still requires that tedious teasing of information from the patient before a knowledgable and safe disposition of the patient can be undertaken. So time is somewhat of a constant in this process. Somewhat, I say, but I’ll return to that in a moment. What is clearly not constant is the overhead requirement. The basic problem is that emergency departments are equipped to take care of virtually anything that comes through the doors. That means standby surgeons for trauma, ready access to CT and other sophisticated radiographic capabilities to see into the body cavities, and quick turn around lab. Each bed has full cardiac, vital signs and respiratory monitoring. Every case clearly does not need all of this capability. But if you are lying in the bed, prevent-
Last year American EDs saw 136.3 million patients. If even 10% of these visits could be accurately triaged to a low cost, low-acuity setting, the savings could be in the tens of trillions. ing another patient from using it, you are occupying that equipment. The same can be said for the facility itself. The wide hallways to accommodate a gurney racing to the OR with people around it. Bright, expensive surgical lights and staff, lots of staff, available 24 hours a day, seven days a week, 365 days a year. So that’s where a lot of that ‘unnecessary’ cost occurs. See the same patient in a small plain office, staffed by a nurse or two and a doctor and the overhead cost goes way down. But see the wrong patient in that setting and you are asking for a catastrophe. So how do we see the right patient in the right setting to reduce the unnecessary overhead costs? You must look at how and where you gather the information that determines the care setting. Match the right patient to the right setting and costs go way down. How far down? Well, if we look back at the Truven study and presume we can match the right patient to the right setting, the cost reduction is significant. Last year EDs in America saw 136.3 million patients. If we could save $1,171 per patient that would be $159.6 trillion per year nationally. Of course, not every emergency patient would be triaged away from the ED. I only submit that total number to say that there is a lot of money to be saved just by safely matching the right patient to the right setting. But that takes the right information in the hands of the right provider. And that’s where the second part of the equation starts
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to kick in. What is the most efficient way to collect the correct information from a patient that will provide the clinician with the information needed to match the right patient to the right setting? Just ask them, right? Not so fast. While running a high volume ED I had the opportunity to attend law school. And I found that I had a knack for interrogating a witness because I’d been doing it for 20 years. “This is the worst pain of your life?” I ask the patient who’s calmly texting a friend. “You only had two beers?” I ask the guy who is dead drunk. I know that both answers are wrong. But the intern, nurse, or computer algorithm all report out the patients’ answers unquestioned. So is the only way to take a good history the old fashioned way, one experienced doctor asking a hundred questions? Not exactly. With today’s technology and advanced A.I. we are fast approaching the day when the initial digital interaction with a patient will be extensive, providing the triaging clinician with all the information he or she would ever need, even some information that they might not take the time to probe into. The diagnosis is in the quality of the history. And that is soon to be the real strength of digital medicine. Questions that are repeated or slightly changed could weed out prevaricators. Facial recognition software can learn to question patients’ answers on issues such as pain scales. The future of digital history taking will lead to efficiencies currently only imagined, allowing the human interaction to hone in on only those areas that are questionable. Like the digital technologies that assist pilots in the increasing complexity of modern aircraft, digital health has the potential to collect and collate more information than a human would ever be able to do, thus increasing the margin of safety. In the end, this is a plane that will always and forever require an experienced pilot to fly. But the efficiency and cost savings of utilizing the emerging technologies in this critical, time-intensive first phase of care will be enormous.
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numbers game
Why the 80/20 Rule Will Kill Your Business Want to prove your telehealth concept in the marketplace? Target the 80% of the population spending 20% of healthcare dollars. by Bill Gordon Everyone’s heard of the 80/20 rule. In healthcare it goes like this: 80% of the money is spent on 20% of the patients. This means that the sickest of the sick, the folks who have significant health issues, are accountable for 80% of the dollars spent. A quick Google search will tell you that the amount spent on healthcare in the United States in 2014 was between $3.5 and $3.8 trillion dollars. For the purposes of this article we will use the $3.5 trillion figure, quoted by numerous sources. So, 80% of $3.5 trillion is $2.8 trillion. That’s the amount of money spent on 20% of all patients treated in 2014. That is an astonishing – and tantalizing – number. But chasing that number could kill your business. Here’s why. The 80% sector may only be responsible for 20% of health spending, but here’s the catch – that’s about $700 billion, and this sector of the population is more likely to spend their own money for products and services. These folks are more apt to be the early adopters, which means these are the people telemedicine companies should be targeting with their marketing programs. The high-spending 20% might look tan32
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talizing, but anyone who overlooks this $700 billion sector is focused on the wrong things. One percent of that market is $70 million. I know a few CEOs who would love to have that on their P&L. Many start-ups have been operating under the premise that the 20% high spenders are their target market because that is where the outcomes of their services will show the greatest impact. They are trying to prove that their solutions will cost payers less in payouts, show better care results and ultimately be better for the consumer by making them healthier and creating higher satisfaction levels. Sound familiar? It’s a page ripped right out Meaningful Use legislation and all the financial analyst briefings on healthcare that have been published for the last decade. The problem is that it requires that a company prove their solution by targeting one of – if not the hardest – market to succeed in. Why not target the 80%, the much larger portion of the population, where consumers/patients have shown that they will spend their own money on healthcare innovations? All you have to do is look at any of the players in the connected Diabetes market. There has been over $100 million of venture capital invested in this market and not one of those players have made a significant splash. Not one has gone public and not one has reported statistically significant revenue to date. Not Telcare, not Livongo, not Glooko, not Entra. Why? They are going after the 20%. Until recently payers have resisted largescale mHealth or telemedicine deployments. They hadn’t been proven and no one was really sure that they actually worked. Fast forward just a couple of months and we now see the momentum shift we have all been waiting for. United Healthcare announced that they would offer telemedicine visits to everyone in their payer network via three service providers. This is ground breaking. Why would United offer this service system wide? Because the 80% want it, will use it and it will ultimately lower United’s operational costs. Want more proof ? Fitbit clearly targeted the 80%, they went after the healthy and
People no longer want to have to go and find things; they want them served up where they want it, when they want it. those who want to be healthier. These are people who spent their own money (for the most part) on a product that they believed would help them improve in some way, shape or form. I believe that this same populace would also buy BP Monitors, Blood Glucose Meters, connected weight scales as well as other connected healthcare related devices. Why? For the simple fact that people want to be in charge of and have command over their information. Plenty of weekend warriors, bike riders, half marathon runners and triathletes have medical issues like diabetes, high blood pressure or just want to optimize their performance. Marketed properly, mHealth tools like connected peripherals will enhance their experience and provide better results. Why does that bike rider buy new pedals? They want a better experience or an advantage. Why does the runner buy new shoes? They want faster times or a better fit. It’s all about perspective. We live in a “take the services to the people” society. People no longer want to have to go and find things; they want them served up where they want it, when they want it. It would be easier to list the things you can’t do utilizing apps rather than listing the things you can. With this kind of mindset prevelant among the 80%, telemedicine and mHealth service providers should be racing to capture this market sector. They have money to spend, have shown that they will keep spending it as long as they are receiving a quality product and experience. Finally, remember that todays 80% will eventually be tomorrow’s 20%. Want to create loyal telemedicine customers? Get them while they’re young.
Telepsychiatry for Hospitals Crisis Telepsychiatry
On-Demand Access to Psychiatry InSight is the leading national telepsychiatry service provider company with a mission to increase access to behavioral health care. InSight specializes in crisis telepsychiatry and can provide on-demand psychiatric evaluations and care within an hour of a request on average.
Impacts of Telepsychiatry
- Lower Inappropriate Admissions - Reduce Length of Stays - Decrease 1:1 Evaluations - Reduce Risks and Liability - Increase Regulatory Compliance - Improve Employee Retention - Improved ED Throughput - Improve Consumer Satisfaction InSight providers collaborate with onsite resources to augment and enhance the existing system of care, finding the most appropriate and least restrictive level of care for each consumer who receives a psychiatric evaluation.
InSight’s crisis telepsychiatry services providers are available to evaluate consumers within one hour of a request on average. After preforming a psychiatric exam, the provider collaborates with onsite resources to jointly determine appropriate disposition. Documentation is promptly returned to the hospital via secure electronic transmission immediately following each encounter. InSight crisis providers can serve as a consultant or prescribe medication directly.
Inpatient Telepsychiatry
InSight’s telepsychiatry services can be used to support an inpatient medical setting for weekend rounding, crisis response or afterhours admission services. An InSight telepsychiatrist integrates into the onsite system of care to expand the facility’s psychiatric capacity.
Urgent Telepsychiatry
InSight can serve medical or surgical floors as a consultation services to hospitalists or other physicians to provide expertise on the behavioral health concerns of medical patients throughout the hospital. Telepsychiatrists are also available to directly interview and assess consumers via video.
Phone Consults, Questions and Orders
InSight’s telepsychiatrists are available 24/7 for phone consultations with physicians, nurses, social workers and case managers for encounters that don’t require the initation of a video session.
ED Rounding for Follow-Up Care
Supplement a facility’s behavioral health capacity by providing follow-up psychiatric consultations to consumers who have already been seen via videoconferencing but who are still awaiting placement. These services can be provided during designated time periods each day or can be requested as needed with a 4-hour response time on average. “In the emergency department, the availability of specialty services is always difficult. We were finding that the availability of psychiatrists was increasingly more difficult, because of their professional load in their offices. The immediacy that we needed just wasn’t there. Our hospital turned to InSight for their telepsychiatry services which have been very successful. We’re not waiting for a psychiatrist to come in when his office hours are over. The physicians are very skilled, and the patients like that it’s private. You almost forget in today’s world that you’re talking on videoconference. ” -- Betty Brennan, Director of Emergency Services Chester County Hospital
www.InSightTelepsychiatry.com
www.telemedmag.com 33 856.797.4772
start - up guide
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he 9th Annual Health 2.0 Conference convened this October in Santa Clara, California. With more than 1,000 attendees and keynotes ranging from Chelsea Clinton to Dr. Vivek H. Murthy, the Surgeon General of the United States, and a swarm of innovative startups, it was a dynamic year that signaled some important trends. Here are a few takeaways spotted by the StartUp Health team: It feels like the ‘End of the Beginning’ In years past, the stage and exhibition floor were filled with point solutions and feature sets. This year, discussion was elevated from feature sets to more comprehensive solutions and established industry partnerships signaling the next wave of progress and maturation of the market. Many new entrants to healthcare New players and talent were circling the conference this year, from electrical engineers and software developers to nuclear submarine mechanics and political figures, all with solutions to problems in the healthcare system. Big name consumer players like Under Armour were also present.
Health 2.0 Marks the ‘End of the Beginning’ Data obsessed, multidisciplinary, global, trend sensitive, a tad chaotic, and brilliantly viable—this conference is beating on the doors of established medicine.
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An international delegation Many international delegates (especially Nordic and Japanese innovators) are hoping to break into the U.S. market for capital and customers. There were nearly 30 startups from Finland alone in attendance with a diversity of solutions.
Unity Stoakes Cofounder, Start-Up Health
Sensors sensors everywhere So many more sensor types—ranging from rings, to beds and pillows, to shirts and hats tracking blood pressure, sleep, EEG, ECG, and heart rate and activity. The wearable, “nearable,” and embeddable market was a huge theme this year. A cluttered but wide-open market There are a lot of players trying to crack the code on patient engagement with clever solutions to connect, funnel, reward, entrench, socialize, and gameify their way to the top. Patient engagement remains one of the most popular areas of focus, and one that hasn’t found a clear winner yet but with lots of good contenders.
PRE SEED Start-Up Spotlight
STEMP
Pre-seed funding is the first stage of funding a new venture. Pre-seed capital is usually less than $500K and is used to build a team and an initial prototype. Pre-seed capital may come from the founder’s personal assets and family members or friends.
What is the difference between pre-seed funding and angel investing?
2014 Pre-Seed Funding USD $328,500 Average amount of pre-seed funding deal 73,400 Entrepreneurial ventures that received pre-seed funding USD $24.1 billion Total of pre-seed investments 16% Proportion of total pre-seed funding awarded to healthcare services/devices enterprises, second only to software, at 27%
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hink of it as the thermometer meets the band-aid. STEMP’s first personal health monitoring product combines the STEMP sensor, medical-grade adhesives, and smartphone apps to provide immediate, accurate, continuous body temperature measurement. With the app and a battery that lasts 30 days you can identify trends in temperature over hours, days, even weeks. Founded in 2013, STEMP recently completed a crowdfunding campaign that raised $34,260, 15% over their goal. Led by their three cofounders Zsolt Krajcsik, Barnabas Gero, and David Whelan, STEMP is looking to bring “situational wearables” to the public. The STEMP temperature sensor is marketed most clearly for pediatrics but its founders are looking into other applications, like chronic disease and fertility tracking. STEMP has even been in talks with USAID about using the temperature sensor in Ebola-like quarantine situations.
Source: Jeffrey Sohl, “The Angel Investor Market in 2014: A Market Correction in Deal Size,” Center for Venture Research, May 14, 2015.
“Pre-seed” funding is generally synonymous with “angel investing.” Both terms, along with “seed funding,” refer to either the amount of capital raised, or the developmental stage of the concept, or both. Pre-seed, however, is increasingly used to refer to funding “an idea,” and, of course, the people with the idea who are working in their spare time to bring their ideas to fruition. Pre-seed funding can occur before proof of concept, or before the actual startup stage. Some start-up ideas simply don’t require more money—generally <$500K at this stage—to get the ball rolling, and its founders may also want to avoid the pressure and attention that can come with raising more capital than they may actually need to scale appropriately.
How Three Digital Health Companies Fared Using Crowdfunding for Their Pre-Seed Raise Tympani Infra-red tympanic thermometer that connects to smartphones via headphone jack. Company Caring Things Crowdfunding Raise $18,244 (goal $10,000); raised by 354 people in 1 month Site indiegogo
Kinsa
STEMP
Smartphone-enabled thermometer that can aggregate local illness symptoms to show “Health Weather.”
A “patch” that is applied to the body to provide continuous temperature monitoring via smartphone.
Company Kinsa Health
Company STEMP
Crowdfunding Raise $134,908 (goal $50,000); Original campaign was 266% funded on October 1, 2015
Crowdfunding Raise $34,260 (goal $30,000) Original campaign was 115% funded on April 15, 2015
Site indiegogo
Site indiegogo
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SEED ROUND Start-Up Spotlight
EMBRACE FAMILY
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aunched in 2013, this San Francisco-based start-up connects mothers and families to a digital network of obstetricians, pediatricians, geneticists and lactation consultants. “Healthy families start with healthy mothers and babies,” says CEO and cofounder Denise Terry, a serial tech entrepreneur and mother of twins. Terry teamed up with Dr. Jan Rydfors, a world-renowned educator in obstetrics, to launch their service, which has, to date, raised $400,000 in funding. Terry says EmbraceFamily has plans to raise another seed round of $1 million. EmbraceFamily’s current offerings include the Pregnancy Companion MD app, a so-called “digital obstetrician” for expectant mothers that has more than 500K registered users. They also refer their users to the First Opinion app, their partnering startup, which members can use to text a physician for free. Membership is also free, but à la carte fees do apply for specialty consults, such as texting a photo to the corresponding physician using the First Opinion app; that function requires a $9/month subscription. –Erika Hunter 36
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The initial capital used to start a business. As in the “pre-seed” stage, seed capital may come from company founders’ personal assets or personal network but also from “angel investors,” who typically receive equity in the company.
5 questions with EmbraceFamily CEO Denise Terry What problem are you addressing? As providers, we realized how our patients lacked one source of credible, mobile medical and health information to help them self-manage their own care. We understand patient challenges yet have little time during office visits to address all of our patients’ questions and concerns. When it came to finding the right telemedicine partner, what made you decide to utilize offshore physicians? There are two sides of that. One is the business side – what is most cost effective – and the other is the question of the user experience. We are very consumer focused, so the answer for me is whatever is in the best interest of the consumer. Where can the
consumer get the most cost effective, responsive, 24/7 positive patient experience from trusted providers who are certified doctors. I won’t comment on if off-shoring is better . . . it’s definitely cheaper. As a consumer, would I rather pay $9 a month or $99 a month? I’d rather pay $9. What are your company’s biggest challenges? Keeping pregnant women engaged after the birth is challenging because new moms focus most of their time, effort and attention on their baby. We are extending our solution to include postpartum, lactation and
Market Watch Rock Health’s 2015 midyear report found that most of the action in health tech investing has centered around early stage Seed and Series A funding deals. Stride Health – a San Francisco-based start-up that uses advanced algorithms to match users to appropriate health insurance plans – was particularly noteworthy for having progressed from Seed to Series A in under 12 months, the report said. According to Start-Up Health’s 2015 Q3 report, this year saw a marked uptick in the value of seed deals in the health tech sector. The percentage growth in seed deals increased faster than that of Series A deals. 4
...patients lacked one source of credible, mobile medical and health information to help them self-manage their own care
pediatrics to extend the relationship with our users beyond the pregnancy. One of our biggest challenges is also recruiting trusted providers to provide services through our platform. Lastly, hiring the right people who fit with our company’s values and mission can be a challenge, especially as we are looking for providers who are technology-savvy as well as technology people with a passion for healthcare.
Digital Health Seed Funding by Year (Start-Up Health) 2010 $1.0 M 2011 $0.8 M 2012 $0.6 M 2013 $0.8 M 2014 $1.3 M 2015 (YTD) $1.7 M
SERIES A
Series A funding usually refers to a company’s first significant round of venture capital financing. This level of funding typically ranges from $2M–$10M, which is used for building product and establishing product-market fit.
what they expect from investing: significant returns within a 5-10 year period on a business that can scale quickly.
Start-Up Spotlight
SHERPAA
WAY OVER ABYSS
The Valley of Death 90 percent of new start-ups will never bridge the gap from their seed funding to a Series A. Here are a few reasons why
by Rishi Madhok, MD
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his Brooklyn-born start-up positions itself as a companion service for members already insured with traditional health plans. Sherpaa coordinates and streamlines access to health care for its members, who sign up through their participating employer. Sherpaa members may consult a physician via web or app, and Sherpaa physicians resolve about half of all cases remotely. All doctor-patient communications are documented, free of the time constraints of an office visit, and physicians are able to search the literature as needed, resulting in a malpractice rate one-third of that of a traditional office-based physician. Because Sherpaa provides easy access to physicians, its members can use the company’s physicians to receive diagnosis and treatment for common complaints and ailments. Consultations with Sherpaa physicians are not billed to patients’ traditional insurance plans, ultimately resulting in very low (≤2%) premium increases for clients.
different strokes Seed investors can be from friends and family or regional or state grants. Those initial investors often care more about the person behind the concept – or the potential for job creation – than they do the actual business value. A VC on the other hand is very clear in
people risk VCs invest in both a business and the people behind it. Small start-ups do not have the ability to compensate for bad hires or poor management dynamics. As a result, some of those intense, driven personalities drawn to start-up culture can drive away talent and eventually investors as well. One toxic partner or bad seed money can be fatal to getting VC funding and closing your Series A. fail fast, fail cheap The old mindset of getting a product 95% “right” before taking it to market is gone. This style of development leads to a product that is outdated before it even reaches its users; making changes expensive or impossible. Don’t underestimate the power of getting the idea 50% right and improving on the 50% wrong. Get users, learn from mistakes while its easier to change, show growth, and bridge the valley of death.
Deal Activity by Stage Seed u and Series A u made up 64% of funding activity in 2015 YTD. An increase in Series B and C deals demonstrates the maturity of the market. Source: Start-Up Health 2010 2011 2012 2013 2014 2015 YTD
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SERIES B Start-Up Spotlight
POKITDOK
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okitDok is a cloud-based application program interface (API) platform that powers healthcare interoperability. Third-party developers such as payers, health systems, and digital health companies who license the PokitDok platform can easily create new apps to streamline healthcare transactions, with the intention of creating better experiences and bending the cost curve down. PokitDok CEO, Lisa Maki, says that there are over 2,400 applications on their platform today. “That’s what excites me,” says Maki, “people pulling these services together in ways that we can’t even imagine.” Financial transparency and savings are a significant aspect of the PokitDok mission. Maki recently announced that all clearinghouse transactions on PokitDok’s X12-compliant API, such as preauthorizations and submitting or checking claims, would be completely free of charge, effective immediately. With modern technology and cloud services, the cost of moving data from point A to point B is now “close to zero,” she said. “So we want to start passing that savings back to all of you.” 38
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Series B funding typically ranges from $6M–$15M. Raised from venture capital markets or private equity investors, this round of funding occurs after a company has encountered and successfully surmounted several challenges in developing its business.
How I raised $1.3M in seed funding in 8 months as a woman in Silicon Valley STOP WORRYING about appearing as an outsider in your field and focus on your strengths (most Silicon Valley seed-stage startups are filled with young men in their twenties). Focus on what you can affect—your idea, pitch, team, tech, and timing. You’ll make a difference by executing and succeeding. If you are a woman and your target audience is too, use that to your advantage. No one knows your audience better than you do. PREPARE by educating yourself on incorporation, funding,
that of others (don’t chase an outcome you can’t realistically achieve). Focus on investors who will evaluate you and your business outside of the flash funding lens and on the merits of your team, tech, and timing. Lisa Maki PokitDok CEO
operations, and everything else about your company. You will need to be able to answer questions about your company in any period of time and in any order, so do yourself a favor and learn it in your bones. Or, as my sensei sometimes required when we practiced sparring, pitch blindfolded. DON’T FOLLOW the herd and don’t worry if your “raise” doesn’t look as large or come as quickly as
LEARN TO JUDGE people quickly and well. I have amazing women on my team who move mountains every day to build our company. Three of our advisors are women who dominate their field. However, the only people who have invested their money in our company, and in me, are men. Men are not our enemy, they are our allies. Find the good ones, male or female, and discard the rest. And never waste time on anyone who wastes your time.
How Much Is an API Worth? The API model, which enables greater interoperability, could eliminate billions of dollars annually by reducing unnecessary services, administrative costs, inefficient care, price inflation, fraud, and lack of preventive care.
eligibility verification
$5B saved annually
claims processing
$17B saved annually
total projected saviings
$320B saved annually
Source: “The Future of Healthcare: The $320 Billion Cost Impact of an API Model”
How the Rest Was Won Steve Case is on a mission. The cofounder of AOL wants to find a diamond in the rough – a start-up worth funding that hails from an unlikely location – i.e. anywhere outside of New York, California and Massachusetts. by Jeremy Lehrer
Steve Case (top center) takes the stage during the Rise of the Rest tour, taking questions from local entrepreneurs (L).
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f American farming replicated the pattern of venture capital investment, there would be three fertile states in the country—New York, California, and Massachusetts—with little else in between. The three areas garner a whopping 75% of VC funds in the U.S., though entrepreneurs in other locations have projects ripe for funding. That’s why AOL cofounder Steve Case started Rise of the Rest, a multicity innovation catalyst that supports big ideas from startups in nontraditional locales. Now in its fourth edition, the tour travels by bus to several cities—this season’s stops included Baltimore; Philadelphia; Buffalo, New York; Manchester, New Hampshire; and Portland, Maine—where Case along with local officials and colleagues from his investment firm Revolution visit area businesses and then corral everyone together for an evening pitch competition. In this town hall Shark Tank, entrepreneurs have three minutes to pitch their idea to Case and a panel of judges (among them politicians, investors, and celebs), followed by four minutes of questions. After the pitches, the judges confer, and at the end of the event, Case presents the winner with a check for $100,000. Healthcare entrepreneurs made a strong showing in the current roadshow: www.telemedmag.com
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Of the 39 ideas that were presented during the tour, 10 were health-related. And these companies sparked interest from venture capital investment, with health tech companies garnering a $100K payout in three of ROTR’s five stops. The Baltimore competition champ, Sisu Global Health, is producing a low-tech device for emerging markets that would allow medical personnel to autotranfuse a patient’s blood when donor supplies aren’t available. FreshAir Sensor, the Manchester prizewinner, is debuting an app-connected device—wearable and plugin versions are in the works—that detects nicotine and marijuana smoke. Buffalo winner Pop Biotechnologies is preparing for clinical trials of a cancer-targeting nanotechnology (there were two winners in the city, thanks to local investors who matched Case’s funds with an additional $100,000). Mark Plaster, MD, attended the Baltimore session and saw enormous potential
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in a software that would identify cancer cells in the effort to eliminate interoperator variability between pathologists. “The computer would learn what the pathologist was looking for,” says Plaster. “That would save the medical system billions of dollars and an enormous amount of time.” Other standout tech-in-development included Sonavex’s system for monitoring vascular blood flow after anastomosis, using an implant and software to reveal potential blood clots. The trend toward health care apps was also in evidence, as with Calibrater Health, a patient care CRM, and Life.io, a health management tool. Baltimore’s pitches leaned the most heavily toward medicine; five of the eight companies pitching healthcare technology took root at FastForward, a business accelerator at John Hopkins University.
Health tech entrepreneurs made a strong showing on the five-city roadshow, during which they had three minutes to pitch ideas to Steve Case and a panel of judges. The winner’s takeaway? A check for $100,000.
Pitch Perfect
ROTR Pitch Competition Finalists
Baltimore
Philadelphia
Buffalo
Manchester
Portland
ShapeU, LLC – Datadriven solution to group personal training
SmartPlate – A plate that instantly analyzes everything you eat
4 Sisu Global Health – A medical device company for emerging markets
4 Scholly – An easy way to find scholarships
KeepUp – A productivity app that lets you take back your life from social media
Adored Inc. – A loyalty experience platform that is strengthening the relationships users have with the businesses they visit and brands they love
Likeable Local – Social automation software for small businesses to monetize their social media presence
Edessa – A scalable automated hand washing system that standardizes the hand washing process Sonavex, Inc. – A platform that detects blood clots prior to morbid surgical failures Gift Card Giving – A platform that allows nonprofit organizations to accept and turn unused gift cards into cash Proscia – Implants image analysis and big data within digital pathology Javazen – Compound analysis to develop a healthier and natural coffee PapGene – Early ovarian cancer detection system
4 = winners
I’m Sorry to Hear – Funeral planning online made easy Byndr – Mobile learning management system for emerging markets WhoseYourLandlord – Platform to review a landlord and find your home Wash Cycle Laundry – Sustainable commercial laundry service Life.io – Solution that motivates and rewards users for tracking and improving health FOCUS Foods Inc. – Urban, aquaponics farming on rooftops and in old warehouses
triMirror – 3D virtual fitting room with realtime clothing simulation Cartefi – A network for entities to post, find and share new opportunities 4 POP Biotechnologies – Nanomedical cancer drug delivery solution interactiveX – Helps professors collaborate in the development of interactive e-books 4 Energy Intelligence, Inc. – A road-mounted energy harvesting system Heads Up Display Inc. – Wearable technology company helps users make data-driven decisions in real time Smart Walls – Deployable, precast concrete walls used to protect buildings or neighborhoods from flooding
VidFall – Social shopping platform, where brands leverage video to inspire purchasing 4 FreshAir Sensor – Novel sensor technology that detects smoking AlignRevenue – A collaborative virtual meeting and sales analytics platform that makes remote sales meetings interactive
Dream Local Digital – Digital marketing agency for small businesses 4 Rapport – Sustainability software for small and midsize businesses CourseStorm – Online registration for programs offering local classes Spring Point Solutions – Software development catered to the electric motor/pump sales industry
HappsNow – Brings every social opportunity on and around college campuses to life
iKNO Intranet – A corporate intranet system to allow for more company and customer engagement
Calibrater Health – Improving patient care through real-time feedback
Introspective Systems – Developing introspective software
Fliq – Seamless, scanbased social media platform to connect across platforms and networks
Lobster Unlimited – Building products from the waste products of lobster fisheries
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school telemedicine
T Wired Schools Offer Health Care for the Underserved In rural counties where healthcare access is sparse, simply taking care of a child with a cold can have far-reaching implications for parents. Innovative school-based telemedicine programs are beginning to meet that need, reducing absenteeism while creating a much-needed node for care in low-resource communities. by John Tyler Allen
ILLU STRATI ONS BY GRACE H E LME R
here’s an understanding in Mitchell County, North Carolina: if you miss your shift at the factory for any reason, don’t bother showing up tomorrow. “You don’t get to miss work and still have a job,” one Mitchell County resident told me. “You can’t leave and go to a doctor’s appointment. You can’t call in sick. It’s harsh.” The zero tolerance policies common to the factories are made possible by what feels like compounding misfortune. Deep down, Mitchell County is an Appalachian mining community where the ground produces quartz and feldspar in unusual abundance and purity. The small mines that used to dot the mountainside were owned and worked by locals. Now, the conglomerate Unimin is the largest mining operation and thirdgeneration miners hope for work. For a working parent, An assortment of manufacturing something as common plants, the area’s second-largest inas a first-grader’s dustry, was, until recently, a buoy for the local economy. But in a re- sore throat and the cent six-year period, one town of resulting call from the two thousand lost a total of two school nurse can mean thousand jobs when their work was choosing between a outsourced to cheap labor. With paycheck and medical unemployment still surging to fifcare for a sick child. teen percent, the community has yet to recover. The offence feels more personal, though. For a working parent, something as common as a first-grader’s sore throat and the resulting call from the school nurse can mean choosing between a paycheck and medical care for a sick child. “You have to weigh that carefully,” Amanda Martin said. “Can I leave to go get my kid? You put your job at risk every time you do that.” Martin is the executive director of the Center for Rural Health Innovation in Mitchell County. The center, a nonprofit with a mission to “apply innovative technologies to improve access to healthcare in rural communities” came out of Dr. Steve North’s work providing care in a school-based health center at the north end of Mitchell County. In addition to the isola-
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school telemedicine
tion and the poverty, the shrinking job market and the stifling work schedules, North noticed that parents weren’t able to get their kids in to see primary care physicians. The schools, North said, were looking at unusually high absentee rates due to health problems that, otherwise, wouldn’t warrant missed class time. The connection, he said, was obvious, and he soon began assessing other health data in the area. In a state where eight in ten counties are rural, Mitchell ranked 89th out of 100 in clinical care access. With only 15.6 physicians per 10,000 residents, it had been designated a Health Provider Shortage Area by the Health Resources and Services Administration. School officials said sixtyfive percent of students utilized the free and reduced lunch program, which meant it was likely as many families depended on Medicaid. Finally, what was perhaps most telling, North said: in the previous year, seventyfive percent of daytime emergency department visits for children ages five to eighteen had been for non-emergent issues. This was a community that had been subjected to the failings of a porous, incomplete healthcare system. North was determined to find an answer. A year later, he founded the Center for Rural Health Innovation and launched the Health-e-Schools program, which equipped three schools with a crude telemedical cart – general exam camera, digital stethoscope and otoscope, and a highdefinition camera for imaging bruises, rashes, and the like – taught existing school nurses to operate the equipment, and gave them remote access to a physician and on-call nurse practitioner. Five years later, Health-e-Schools carts now feature fully integrated state-of-the-art diagnostic 44
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“That kid got care they were not going to get. And it may mean that parent keeps their job. That’s a game changer for that family.”
equipment and access to a cloud-based server that allows parents with access to a camera – a smartphone, perhaps – to conference in to their child’s visit. For many families in the area, the Health-eSchools program was the first regular access their children would have to a healthcare provider, and their only opportunity to escape a cycle of healthcare avoidance and preventable emergency room visits. “We’re able to evaluate and treat their child, send them home with follow-up instructions, and a prescription has been called in to a pharmacy that is open late,” Martin said. “That means that kid got care they were not going to get. And it may mean that parent keeps their job. That’s a game changer for that family.” “Sick kids are the number one reason parents in America miss work,” North added. Last year, the Health-e-Schools program expanded to the neighboring McDowell County. Of the first one hundred visits they conducted at McDowell schools, only four students had to be sent home. “Previously, at least half of those kids, their parents would have needed to come pick them up and take them to the doctor,” North said.
L
aura Brey holds encyclopedic knowledge on the many ways the access to care provided by school-based health centers can change a school and a community. She’s the Vice President for Strategy and Knowledge Management at the School-Based Health Alliance, and has worked in school-based healthcare for twenty-five years.
When school-based health is introduced, she says, “the whole environment of the school starts to change.” Students learn they can go to the school’s health clinic when they have an STD, maybe, or if there was no food at home for breakfast, and they’ll find an adult they trust. “It becomes a place where kids feel safe,” she said. The school-based health center then becomes a valuable tool for identifying issues like anxiety, depression, domestic abuse, and many other issues young people often face alone. “One of the things we’re able to determine pretty easily,” North said. “Is this the stomachache that comes every Tuesday, first thing in the morning before a spelling test, or is it a bigger issue that needs to be addressed? What is the child really seeking?” A communal approach, North stressed, is integral to their success. “We’re not just offering urgent care in the schools,” he said. “This needs to be part of the fabric of the health community.” Instead of replacing would-be primary care visits, the Health-e-Schools program aims to connect students with other comFor many families in munity healthcare providthe area, the Health-e- ers and, when necessary, Schools program was partner with these providers to better manage chronthe first regular access ic conditions. their children would It’s in this way that these have to a healthcare programs can lift an enprovider, and their only tire community, Brey said. opportunity to escape When kids are mentally a cycle of healthcare and physically healthy, and when other social needs no avoidance and longer go unnoticed, perpreventable emergency formance in school increasroom visits. es, school environments
improve, families migrate back to public schools, an educated workforce rises up, and the value of reinvesting in your community becomes evident. This seemed to be the way of things for Mitchell County. More than once I listened as someone unpacked for me how a single occurrence was invariably connected to everything else in the community. One story came from Amanda Martin. She had been visiting her grandmother in the hospital when a nurse stopped her in the hallway. “You run that computer doctor program for the schools?” the nurse asked. Martin braced herself for a skeptical healthcare professional’s diatribe on the ineffectiveness of telemedicine. “Once, I was working here at the hospital when I got a call from the elementary school that my son was sick,” the woman said. The school nurse had connected this woman’s son to a physician via a Health-e-Schools telemedical cart, they told her. Her son’s problem had been resolved and he had already returned to class. They were just letting her know. “That meant everything to me,” she said. “I didn’t have to leave work. And the hospital didn’t have to find someone to cover my shift. They didn’t have to pay someone overtime. Someone else didn’t have to come in unexpectedly. I didn’t have to find someone to pick up my other son. We didn’t have to sit in the pediatrician’s office with my sick kid, and my new baby wasn’t in there licking all the chairs and tables. He would have been sick another week…” “It had this ripple effect for her,” Martin said. And in one working-mother’s account of a single telemedical visit, it became evident just how deep into Mitchell County these doctors with cameras could reach. www.telemedmag.com
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the bottom line
Three essays on the business of telemedicine
The Race to Zero
Jon Pearce CEO, Zipnosis
“M
erry Christmas” – that was the first SMS message ever sent, back in 1984. Twenty-one years later, trillions of text messages whip around wireless networks all over the world. SMS’s rise in popularity foreshadows telemedicine’s evolution from traditional video/ phone-based encounters into asynchronous and technology-assisted virtual care. Along the way, the effective transactional virtual care costs will trend towards $0 – which is beautifully aligned with value-based care models that reward outcomes over encounters. This transition forward requires fresh thinking about who pays for virtual care. To spur this process along, I’ve mashed up non-healthcare models to see how we might unchain telemedicine from old-school PEPM + per visit fees.
get unlimited access via virtual visits through the season, but the “content” or access channels are titrated out based on the appropriate care protocols. In this way the tools (e.g. video/ phone/asynchronous) are free but patients pay for content pushed by providers.
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Hardware Unlocks Content:
Bundled Virtual Care Plans: analog: Wireless data plan: Individual or
description: With a proliferation of wearable
example: You walk into the Nike store and
--------Streaming Seasons of Care: analogs: Netflix, AppleTV, Hulu, Amazon description: Instead of buying the entire season
of Top Gear BBC, patients buy a “Season of Care” for a disease or care pathway. Individuals can build their own care networks on the fly by choosing from a menu of Seasons of Care. They Telemedicine
analogs: Television, radio
example: An employer purchases a lipid
management bundled payment plan. The bundled service includes 1-2 in person visits and unlimited virtual care encounters through the year.
|
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purchase a large block of interactions for a fixed price. The effective transaction price is technically not $0, but, like text messages or data usage, it trends towards that over time. Pricing is based on anticipated utilization across broad swaths of medical risk.
description: In this model, patients can
Issue 3
Type 2 Diabetes, purchases “Season 1 of Living with Diabetes” from Mayo Clinic. Each week he gets a new virtual care plan and access points across his devices. It might include scheduling a virtual visit to review his diet compliance and speak with a care coordinator about any open questions on his glucometer.
technology, remote devices and other healthenabled hardware, it is possible to use these to cover basic transactional costs. When you buy a TV, it comes ready to watch a handful of channels. The free content/channels are akin to basic care visits. Knowing that a vast majority of new hardware users are also potential new patients, providing content becomes a marketing expense to bring those into a system.
Family.
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example: Jim, who was recently diagnosed with
purchase the latest workout shirt with embedded sensors that monitor pulse, respirations and perspiration. The shirt comes with free virtual visits for simple conditions for as long as you own the shirt and regularly upload biometric data. The advent of SMS was facilitated by powerful technology innovation. But it was adopting an “unchained” economic model that allowed it to proliferate. Like SMS, the tide of technology is pushing telemedicine towards lightweight, zerocost virtual care transactions. Now it’s time to get unhinged in devising new economic models that allow virtual care to explode.
Telemed’s Ultimate Turf War Scott Kozicki Managing Director, Brentwood Capital
T
he telemedicine sector is quickly turning into an arms race. Several companies have raised very large rounds of investment and one even went public, managing to keep above its IPO price despite a very volatile market this summer. Most of these players are what we like to call Direct to Consumer (D2C) plays, in that they are focused on marketing and delivering a service that you pay for out of pocket with little or no intermediary. But the battle lines aren’t just being drawn between competitors. There is another battle playing out as the established care delivery industry reacts to these telemedicine upstarts and the new capabilities that they represent. The million dollar question is whether the establishment will react quickly – and intelligently – enough to fend off the D2C challengers. It’s silly to think that the established care delivery system (let’s call it Healthcare Inc.) will sit and do nothing while a bunch of startup rebels whisper lots of 21st century smartphone nonsense into the ears of consumers about how conveniently their health care should work. For Healthcare Inc. is strong with the force (of hundreds of billions of dollars in combined revenue). Just like many of our favorite good-versusevil stories, it’s not always easy to tell the good guys from the bad. Companies like Doctor On Demand, MDLive and Teladoc are all very focused on the consumer experience and spend a lot of money marketing directly to the consumer in order to create ‘pull’ for their services with employers and payers. It’s not as simple as saying they are all D2C players. Some of their revenue comes from payers and employers, who are the ones writing the biggest checks in the health care landscape in the United States. In our last issue, we argued that these D2C players are creating the first consumer healthcare brands and they’re creeping on existing Healthcare Inc. brand’s turf. But Healthcare Inc. is massive and in many cases already a trusted brand. Mayo Clinic, Cleveland Clinic, HCA, the vast network of Ascension hospitals; all of these provider
organizations have tremendously valuable brands and have been dabbling with various components of telemedicine for years. There are some telemedicine companies who are geared more as platforms for existing players to utilize than their D2C competitors. In this way, there’s no need to use a rebel startup such as MDLive, when you can finally get access to UCLA Health from anywhere in the country via a company called Zipnosis. Zipnosis is the leader of the pack of B2B providers of telemedicine. Their platform allows any Healthcare Inc. provider brand to add telemedicine capabilities as if by the stroke of their hand. Why is that important? Healthcare Inc. brands are known quantities with consumers. They already have the infrastructure and institutional expertise of not just getting your visit covered by insurance, but how to arrange for follow up care (such as physical therapy, or imaging procedures), and perhaps the most important piece of the puzzle: data. That’s right, they probably already have some clinical data on you, and that enables them to do a much better job of driving positive outcomes, both clinical and financial. So who will win this battle? It appears that the D2C rebels have raised a lot of money and have been the darlings in the press about bringing the health care experience in line with the rest of our mobile lives. But unless they use that money to offer deeper delivery options such as brick and mortar experiences, then they will simply be another channel to access care. A channel is generally not a rich margin business long term (just ask anyone who sells DSL for internet access). It’s much more likely that Healthcare Inc. will use B2B platforms as part of their broader marketing strategies to keep their mighty traffic numbers within their brand experience. It will be very hard for the D2C companies to compete with the infrastructure of the Healthcare Incs of the world. And it enables Healthcare Inc. brands to wage war with each other outside their existing territories. Mind you, this story isn’t over. Healthcare’s startup rebels are still a force to be reckoned with, and won’t go down without a fight. www.telemedmag.com
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the bottom line
Three essays on the business of telemedicine
Getting Creative with Revenue Models Models
Nathaniel Lacktman, Esq Foley & Lardner LLP
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Telemedicine providers are zealous advocates for change and shift in healthcare delivery. Yet these same innovators often fail to apply that same mentality when developing their business models and contractual arrangements. They devise something new, exciting, and disruptive, only to lament a lack of existing reimbursement for the innovation they just created. The concept of government-funded, fee-for-service payments (i.e., traditional “reimbursement”) is becoming increasingly criticized (even by the Department of Health & Human Services itself ) as an outdated, less than ideal payment model for 21st century healthcare. CMS already announced plans to make at least 30% of Medicare payments through non-FFS alternate payment models (e.g., ACOs, bundled payments) by the end of 2016, increasing that percentage to 50% by the end of 2018. The remaining FFS payments would be tied to quality or value under programs like the CMS’ Hospital Value-Based Purchasing Program or the Hospital Readmissions Reduction Program. With all these signs of change, why do some telemedicine providers expect their breakthrough approaches to care would (or even should) easily align with an old payment model? Rather than wait on the sidelines focusing on regulatory hurdles, the most successful telemedicine providers we work with (whether physicians, hospitals, or start-ups) are those who shift their mindset from reimbursement to revenue. When that happens, a world of payment opportunities presents itself. To succeed in the developing market, telemedicine providers must structure their business models and contracts using the same creativity and innovation they devote to their care
and technology offerings. In doing so, companies can build scalable, sustainable telemedicine programs extending well beyond the realm of grants, pilots, loss-leaders, and demonstration programs. By no means an exhaustive list, here are a few concrete examples of telemedicine revenuegenerating business models outside the traditional “reimbursement” box. There is no one-size-fitsall approach. And while any healthcare offering must be tailored to comply with state and federal laws, providers should not allow perceived regulatory complexities to prevent them from building something great. Remember: there are no problems – only solutions.
Three non-traditional telemedicine business models 1. Institution-to-Institution
An Academic Medical Center with a surplus of talented specialist physicians can leverage that expertise to patient markets outside the zip codes surrounding its brick and mortar location. The AMC could enter into contracts with rural hospitals or other institutions across the world in need of on-demand specialty expertise. Compensation methodologies will be driven by specific business factors and contract design, including whether the AMC’s service is peer-topeer consults or direct patient care (or both), and if there will be any billing of third-party payors (and if so, any reassignment of collections). The parties could utilize a monthly rate, a hybrid payment, a fee schedule menu of different specialist services, or even a cafeteria model to encourage multispecialty utilization. Fundamentally, this model
---------
Even among those forward-thinking providers who have embraced change to build ACOs . . . only approximately 20% have incorporated telemedicine.
can be built as a professional services agreement without dependence on external FFS reimbursement to drive the revenue.
--------2. Telemedicine and ACOs
Even among those forward-thinking providers who have embraced change to build ACOs (there are 20 Pioneer and 333 MSSP ACOs in the United States), only approximately 20% have incorporated telemedicine technologies into their operations. It may be no a surprise, then, that only 27% percent of ACOs achieved cost and quality scores sufficient for to trigger financial incentive payments in 2014. Strong opportunities exist for telemedicine technology companies (particularly those with and population health software functionalities) to contract with ACOs and use virtual care as a means for ACOs to realize the quality and cost improvements needed for them to receive Medicare incentive payments next year.
3. Employer Workforce Offering
A provider with a network of primary care physicians can offer telemedicine-based care to the workforce of an employer through a combination of an on-site kiosk and an online app. The employer would realize benefits of increased presenteeism and workforce health, reduced direct care costs in the short term, and reduced overall workforce health costs in the long term, among other benefits. The provider could negotiate with the employer a variety of different compensation approaches, including but not limited to a per-encounter fee, a base services rate combined with a reduced per-encounter fee, a fully capitated per employee per month payment, a shared savings fee model (whether paid on an encounter, capitated, or hybrid basis). Different choices in the contract terms and compensation methodologies will significantly impact the employee utilization of the offering, so all these factors should be considered and tailored to the parties’ specific goals. The payment could be made by the employer’s self-funded plan, the employer’s third-party payor administrative services organization, or even the employer itself as an outof-pocket cost. These are just a few examples of what can be achieved when a telemedicine company applies the same level of creativity to its healthcare business models and contracting. Providers should reject the notion that the traditional FFS reimbursement system is immutable or that they must wait for someone else to change policy. Telemedicine companies have already rejected traditional care approaches in favor of something better, so while the business and legal “how to” may be unfamiliar, the “why” is nothing new to these thought leaders. When the telemedicine and virtual care market matures and the dust settles, the successful and surviving providers and companies will be those who are innovative not only in what they offer patients and the healthcare industry, but in how they offer it.
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the list
teleSCOPE ----Coalfire www.coalfire.com 877.224.8077 page 10 Atlas Health Technologies www.atlashealth.com 615.854.7001 page 10 Proficio www.proficio.com 800.779.5042 page 10 FortyCloud www.fortycloud.com 781.269.7190 page 10 GoToPills www.gotopills.com mail@gotopills.com page 13 ScriptPro www.scriptpro.com 800.606.7628 page 13 KitCheck www.kitcheck.com 786.548.2432 page 13
inSight Augmented Medicine www.augmedicine.com contact@augmedicine.com page 19 Microsoft Kinect www.microsoft.com 786.548.2432 page 20 Surgical Theater www.surgicaltheater.net 216.452.2177 page 20
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Oculus Rift www.oculus.com support@oculus.com page 21
Fresh Air Sensor www.freshairsensor.com info@freshairsensor.com page 40, 41
teleVISION ----QualComm Life www.qualcommlife.com page 24
Pop Biotechnologies www.popbiotech.com jrsmyth@popbiotech.com page 40, 41
Capsule Technologie www.capsuletech.com 978.482.2300 page 24 HealthSpot www.healthspot.net 855.585.7768 page 26 Start-Up Guide ----STEMP www.getstemp.com support@getstemp.com page 35 Tympani www.mytympani.com page 35 Kinsa www.kinsahealth.com page 35 EmbraceFamily Health www.embracefamilyhealth.com 844.463.6272 page 36
teleTECH ----Pristine www.pristine.io 855.545.3777 page 19
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The companies and brands mentioned in this issue.
Telemedicine
Sherpaa www.sherpaa.com 844.283.3979 page 37 PokitDok www.pokitdok.com 877.564.5029 page 38 Features ----Sisu Global Health www.sisuglobalhealth.com 906.370.3975 page 40, 41
ShapeU, LLC www.shapeu.co info@shapeu.co page 41 Sonavex, Inc www.sonavex.com 443.797.2584 page 40, 41 Edessa www.edessaclean.com 443.797.9799 page 41 SmartPlate www.getsmartplate.com 844.438.3485 page 41 Life.io www.life.io help@life.io page 41 MyOnCallDoc www.myoncalldoc.com 855.362.3278 page 42 Doctor on Demand www.doctorondemand.com 800.997.619 page 47 MDLive www.mdlive.com 800.657.6169 page 47 American Well www.americanwell.com 617-204-3500 page 47 Zipnosis www.zipnosis.com 612.424.0443 page 47
Sponsors ----Avizia www.avizia.com 571.267.2999 page 2 TEAMHealth www.teamhealth.com 800.342.2898 page 8 Salus Telehealth www.salustelehealth.com 866.892.9493 page 11 CaptureProof www.captureproof.com info@captureproof.com page 22 TeleSpecialists tele-specialists.com info@tele-specialists.com page 28 MyOnCallDoc www.myoncalldoc.com 855-362-3278 page 42 ATA www.americantelemed.org 202-223-3333 page 50 IMST Innovations www.telehealthsuppliers.com 954.774.4138 page 51 Teladoc www.teladoc.com 800.835.2362 page 47 JeffConnect www.hospitals.jefferson.edu 215.955.6840 page 56
National Fingerprint 888.823.7873 www.nationalfingerprint.com page 51
learn more at www.telemedmag.com
New Year, New Opportunities
From expanded circulation to an online buyers guide, Telemedicine Magazine offers a range of new ways to build your brand in 2016.
1) bonus distribution In 2016, in addition to its circulation of 30,000, Telemedicine will be distributed at major conferences around the world, and through multiple telehealth resource centers. Here is our current list of meetings. Contact us to arrange custom distribution at your event or place of business.
CES January 6-9 Las Vegas, NV
TEDMED February 15-19 Vancouver, Canada
ATA May 14-17 Minneapolis, MN
J.P. Morgan Healthcare Conference January 11-15 San Francisco, CA
HxRefactored April 5-6 Boston, MA
mHealth + Telehealth World July 25-26 Boston, MA EuSEM October 2-5 Vienna, Austria
Health 2.0 January 13 San Francisco, CA
Health Evolution Summit April 13-15 Dana Point, CA
HIMSS February 29–March 4 Las Vegas, NV
ICEM 2016 ACEP S.A. April 18-21 October 15-18 Cape Town, South Africa Las Vegas, NV
•
The Buyers Guide In 2016, Telemedicine advertisers will be included in an exclusive digital buyers guide, where each brand will have the opportunity to share product details and relevant contact information.
•
Weekly Email Briefing Each week Telemedicine will curate the latest breaking news in digital health. Get into the inboxes of our exclusive distribution by becoming our email sponsor.
•
Get Social @telemedmag Join us on social media for all things Telemedicine.
2) digital opportunities In addition to Telemedicine’s unique print offering, 2016 will see the introduction of multiple digital channels to expand your brand’s footprint online.
3) events Announcing the first mHelath Tool Box – a collaboration between Telemedicine Magazine and the faculty from the iLab at Weill Cornell Emergency Department.
Take part in the inaugural mHelath Tool Box, a hands-on digital health workshop taking place in conjunction with the International Conference for Emergency Medicine (ICEM) in Cape Town, South Africa. Unique sponsorship opportunities are available. For more information, contact Diana London at diana@telemedmag.com.
contact Diana London: Diana@telemedmag.com www.telemedmag.com
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teleport
1875
1903
1931
1959
1987
2015
Saved by a Bell Sure, new smartphones and tablets, with their ever-improving cameras and sensors, represent dizzying possibilities for telemedicine. But it’s worth remembering the humble telephone is still the communication mode of choice for the majority of telemedicine transactions in the world today. by Nicholas Genes, MD, PhD
I
t’s been said that the very first phone call, in Boston on March 10, 1876, (“Mr. Watson, come here! I want to see you”) was actually a request for medical assistance. In his autobiography, Thomas Watson recounted Alexander Graham Bell had spilled battery acid on himself on that fateful day, and was simply calling for help (Bell never told stories of the first phone call, and Watson’s autobiography was published years after Bell’s death). While details of that day will probably never be certain, it’s clear Alexander Graham Bell often had medicine on his mind. Bell taught elocution to the deaf, his mother and wife were both deaf, and his interests in telephony developed alongside his interests in helping the deaf communicate. What’s generally credited as the first telemedicine encounter came just a few years later, as Bell’s invention proliferated. In 1879, an anonymous writer in the Lancet reported a case where a mother phoned their family doctor in the middle of the night, concerned that her baby’s cough was the croup. The doctor asked to “lift the child to the telephone and let me hear it cough.” He then proclaimed, “That’s not the croup.” The family was relieved and reportedly slept well. Alexander Graham Bell was also
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involved in an early example of high-tech bedside diagnostic testing, in 1881. President Garfield had been shot near the lumbar spine. His surgeons had trouble locating the bullet, despite multiple attempts at probing the wound (worse yet, Lister’s sterile technique was not in widespread use). As days turned to weeks, Bell applied his telephone’s amplifier to another of his inventions, called the Induction Balance, creating a functional metal detector. When the device passed near metal, users would appreciate a ringing sound, transmitted through an earpiece. Bell tested the device on Civil War veterans with known lodged bullets, and a side of beef in which a bullet had been hidden. It worked, but in the White House it failed to find the president’s bullet (Garfield’s doctor limited the search to avoid moving the patient too much; autopsy later showed they were looking on the wrong side). Garfield eventually died – not from the initial injury but from the resulting infection. Bell died in 1922. On the day of his funeral, at 6:30pm EST, all telephone service in the U.S. and Canada was shut down for a minute – the 13 million phones in use at the time went silent. Nearly a hundred years later, it’s hard to imagine anything stopping, or even delaying, so much instantaneous communication – even a telemedicine consult.
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Jefferson is bringing doctors and patients together.
Whenever and wherever. Through JeffConnect TM, our comprehensive telemedicine initiative, Jefferson is creating new ways to improve the health of our community. Whether it’s attending a doctor visit on your smartphone, connecting a son in San Francisco to his mother’s bedside in Philadelphia, or by creating one of the largest telemedicine networks in the world, we’re using technology to bring the expertise of Jefferson health care to you. As JeffConnect continues to expand, we are hiring a range of positions – from ED physicians to telehealth assistants. If you are interested in the innovative world of telehealth, we would like to connect with you. Contact Judd Hollander or Kate Fuller at the email addresses below. JeffConnect. Helping to reimagine the future of health care. Kate Fuller
Judd E. Hollander, MD
Telehealth Program Manager | Jefferson University Hospitals
Associate Dean for Strategic Health Initiatives | Sidney Kimmel Medical College Vice Chair for Finance and Healthcare Enterprises | Department of Emergency Medicine | Thomas Jefferson University
kate.fuller@jefferson.edu
judd.hollander@jefferson.edu
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www.telemedmag.com