Telemedicine Magazine Issue 6

CareKit's first apps are out. Now what?

Smith Island: A study in rural connectivity

Unity Stoakes: The leapfrog effect

Connected health starts in the kitchen

WWW.TELEMEDMAG.COM

THE BEST NEW TECH FOR EYE HEALTH PAGE 16

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

HOW ONE DATADRIVEN OLYMPIAN IS USHERING IN THE 'QUANTIFIED LIFE' A CONVERSATION WITH SKY CHRISTOPHERSON PAGE 40

ISSUE 6

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EXECUTE WITH CONFIDENCE 2

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Visit teladoc.com/healthsystems or call 1-844-798-3810 to see the Teladoc difference today.

telemedicine

WWW.TELEMEDMAG.COM ISSUE 6 / FALL 2016 Editor's Desk_4 Telehealth Regional News_6 ------telescope

Tele-ICU_9 Tele-Pharmacy_10 Tele-Fertility_12 Tele-Chronic Disease_13 Tele-Rehab_14 ------teletech

Gear Lab: CliniCloud_15 Tech Review: The latest in eye care_16 The Wired Home: The future of data collection may start in the kitchen_18 CareKit's first apps are out. Now what?_19 ------television

Alan Roga: Data driven strategies_21 Unity Stoakes: The leapfrog paradigm_23

pIsland Connections_Page 33 Maryland's remote Smith Island offers an important case study in rural telemedicine connectivity.

Larry Jones: Leave it to the programmers_24 Hollander: EPs are 'The Availableists.'_26 The AMA: Telemedicine's reluctant advocate._27 ------features

When to take the plunge as a 'doctorpreneur'_28 Telemedicine: By doctors, for doctors._30 Post-Mortem: When 'Better' still fails._32 Smith Island: A case study in rural telemedicine connectivity._33

p Groove founder Jennifer Aldoretta hopes an app can help bring womens' health out of the shadows.

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p Scott Jung reviews the industry's latest gadgets for ophthalmology and optometry.

16

p Physicians-turnedfounders, like Doctify's Stephanie Eltz, on how to balance business and medicine.

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Avera is building the ultimate telemedicine hub in South Dakota._36 From the velodrome to your home – how hi-tech athletes are ushering in a new quantified life._40 ------marketplace_44

---teleport

Did telemedicine inherit the right stuff?_50

www.telemedmag.com

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editor’s desk

Who Will Build The Highways?

logan plaster

editor-in-chief logan@telemedmag.com

Within minutes of arriving at the Smart Vision Labs office on Madison Avenue, co-founder Yaopeng Zhou had diagnosed my mild nearsightedness. (I blame the long hours staring at this layout in InDesign.)

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first became aware of Smart Vision Labs because of an editorial submission that landed in my inbox. A quick Google and I realized we were neighbors (by New York City standards) and so I set up a visit to see their latest gizmo, the SVOne, in action.

On the 16th floor of a blocky Madison Avenue behemoth overlooking Grand Central Station I met Smart Vision Labs co-founder Yaopeng Zhou. Zhou, an engineer who met his co-founder Marc Albanese at Boston University, guided me through a labyrinth of desks on a floor that had recently been turned into a co-working space for start ups and small businesses. Smart Vision Labs – about a dozen desks clustered humbly in the corner – have built a handheld, iOS-based tool that can measure vision imperfection and generate refraction in a matter of seconds. In other words, imagine no longer needing to schedule an eye doctor appointment when you're scrambling for contacts and need a new prescription.

Did I mention that their $4000 device replaces a machine that costs $20,000?

At this point, I was impressed. Zhou had tested the SVOne on me and within seconds told In addition to the me I was a touch nearsighted, but didn’t need challenges of server glasses just yet. But it wasn’t until Zhou took me into a smaller inner room that I really appreciated space and UX design, what they had accomplished. In this compact, these companies iron nondescript office, two men sat at desks care- out the complexities fully arrayed with frighteningly small machine of supply chain, parts. One man was designing new parts digitally custom factory buildwhich would then be built in a factory in Bosouts and material ton. These tiny metal pieces would, by a turn of engineering magic, eventually be able to measure shortages. distances within the eye at the micron level.

In a world of software services and algorithmdriven applications, a few companies stand out as truly inventing the hardware that will redefine healthcare. In addition to the challenges of server space and flat UX design, these companies iron out the complexities of supply chain, custom factory build-outs and material shortages.

There's nothing slight about what has been accomplished by software companies in the telemedicine space. In this issue we celebrate many of them, from Groove tele-fertility (page 20) to Rezoom tele-rehab (page 14) to Doctify, a specialist booking site (page 28).

These services are game changers, each it their own right.

Yet the question remains: who will build telemedicine's physical infrastructure? Who will fashion the new bridges and roads over which big – and bigger – data will travel? If you're on a remote island off the coast of Maryland what you need more than software is towers in order to improve bandwidth (read our report on Smith Island on page 33). And if you're manning an ICU in a rural hospital in North Dakota, you may need a tele-connected robot that can go on rounds with you (read our iRobot update on page 9).

In this, our sixth issue, we celebrate the inventors, the engineers and the programmers reimagining healthcare and building the tools to get us there. We look at the women and men inventing the machines which will gather data that has never been gathered before, at a price never before imagined.

As always, if you have an editorial pitch – or simply want to drop by our new Brooklyn offices to say hello – drop me a line at Logan@telemedmag.com.

telemedicine ISSUE 6 – FALL 2016

EDITOR-IN-CHIEF

Logan Plaster logan@telemedmag.com

Which tech icon would you most like to have lunch with?

Tim Berners-Lee, he invented the World Wide Web; would love to chat about what is next.

EDITORIAL DIRECTOR

Bill Gordon bill@telemedmag.com

Sen John Thune. Not because he is a tech visionary, but because he has done something practical to bring telemedicine to people who didn’t have it before through the REACH for Health Act.

EXECUTIVE EDITOR

Mark Plaster, MD

CONTRIBUTING EDITORS

Elon Musk, so I could convince him to have his next company focus on solving health challenges.

Rishi Madhok, MD Aneel Irfan Unity Stoakes

Mark Cuban! I think he'd offer insights on being forward thinking on tech trends.

EDITOR AT LARGE

Nicholas Genes, MD, PhD CONTRIBUTORS

Larry McClain Taja Whitted

Larry Ellison, the flashy founder of Oracle, has interests outside tech, like yachting and appearing in big-budget movies.

Scott Jung Vishaal Virani

Brian Roberts Jeremy Lacocque John Tyler Allen Michael Levin-Epstein

ILLUSTRATORS

Nicolet Schenck (cover) Maggie Chiang INDUSTRY ADVISORS

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

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

Haywood Hall, MD PACEMD

David Preznuk, Founder & CEO of Aerial Strategies LLC because drones will play a critical role in changing the telemedicine space for years to come.

Dr. Robert Park RelyMD Dr. Judd Hollander Jefferson University

ADVERTISING REPRESENTATIVES

Eliseo Rivera eliseo@telemedmag.com Aneel Irfan aneel@telemedmag.com

Telemedicine Magazine is published quarterly by M. L. Plaster Publishing Co., LLC. PO Box 121, Galesville, MD, 20765. Printed in the USA. Copyright ©2016.

To purchase a subscription, go to www.telemedmag.com/subscribe

The authors, editor and publisher are not responsible for any errors or omissions or for consequences from application of the information in this publication, which remains the professional responsibility of the practitioner. No part of this publication may be reproduced in any format or content without written permission of the publisher. The appearance of advertising in Telemedicine does not constitute on the part of the Publisher a guarantee or endorsement of the quality or value of the advertised products and services or the claims made for them by their advertisers. www.telemedmag.com

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telehealth

regional news

Regional Updates from the Consortium of Telehealth Resource Centers

NORTHWEST

SOUTHEAST

SOUTHWEST

NRTRC's sixth annual conference will be held in Seattle, WA, April 10-12, 2017.

This conference always kicks off with Telehealth 101 & 102, a 4-hour introduction to the industry. Our 102 session will cover all regulatory and legislative topics both from a national standpoint and also for each of our seven states in the Northwest.

The main conference kicks off Monday afternoon with our first general session, breakout sessions, and an amazing networking reception. Earlybird Registration begins September 4th 2016.

To help physicians make the transition to telehealth, technical assistance grants are available through the Wyoming Department of Health Office of Rural Health.

An application is available on the Telehealth Consortium’s webpage at uwyo.edu/wind/ wytn. When the application is filled out the staff at WIND reaches out to the provider to help identify which other clinics or hospitals they need to be linked to.

The Southeastern Telehealth Resource Center hosted their 5th Annual Alabama Telehealth Summit on August 11. The event was held at the UAB Hill Student Center on the University of Alabama Birmingham Campus in downtown Birmingham. It was a spectacular event with a great slate of speakers and over 200 in attendance.

Their next event will be the 3rd Annual Florida Telehealth Summit. This year’s event will be held November 17-18 at the Safety Harbor Resort and Spa in Safety Harbor FL. The statewide telehealth workgroups continue to be a catalyst in the advancement of telehealth across each state. Florida’s State Telehealth Advisory Council has been appointed with mandated surveys for licensed Florida practitioners and facilities now officially released. If you are interested in becoming a part of one of these workgroups, please feel free to reach out to SETRC director lloyd Sirmons.

The 2nd Telemedicine & Telehealth Service Provider Showcase in June in Phoenix was a smash hit, with nearly 400 attendees.

SWTRC expects SPS to continue to grow each year.

Another national resource and a corollary to SPS is the SWTRC online Telemedicine & Telehealth Service Provider Directory. The directory has reached 100 listings of clinical service providers offering services via telehealth technology. SWTRC is continuing its collaborative tradition with educational events including telegenetics trainings in Tucson, AZ, and Kent, WA, in August in partnership with the Western States Genetic Services Collaborative; a full-day, ATA-accredited training course with three northern Arizona partners in Flagstaff, AZ, Oct. 7; and webinars in partnership with the Western States Regional Public Health Training Center, the Arizona Center for Rural Health, and the ATA Technology Special Interest Group.

edited by aneel irfan

contact: bob wolverton

contact: lloyd sirmons

contact: kristine erps

aneel@telemedmag.com

bob@nrtrc.org

lloyd.sirmons@setrc.us

Sure signs of progress could be seen at the three 2016 TRC event stops on our first national tour. The CTN’s Summit in San Diego, the SWTRC’s provider showcase in Phoenix, and SCTRC’s Nashville forum all just about doubled in attendance this year.

These organizations continue to be at the forefront of telehealth awareness, creating hubs for dialogue on change. Look for video interviews from these shows on our website, www.telemedmag.com.

Keep up the good work, TRCs!

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kerps@telemedicine.arizona.edu

TEXLA

NORTHEAST

MID-ATLANTIC

HEARTLAND

The TexLa Telehealth Resource Center received notice of continued funding for FY2017. TexLa holds a quarterly Stakeholder Meeting to provide an open forum for anyone that wishes to join. Recent discussions and queries have centered on billing and reimbursement issues. The 2016 Rural Health at the Crossroads Conference was held June 20 – 21, 2016 at the Overton Hotel and Conference Center in Lubbock, Texas. In collaboration with AHEC, a telehealth track and community health worker track were offered.

Frontiers in Telemedicine, a one-of-a-kind training program for clinicians specific to telemedicine, started training January 2016 and has enrolled over 130 clinicians. The program focuses on competency-based learning and features a combination of online content and hands-on simulated learning. Visit the TexLa website, www.texlatrc.org, Facebook, Linked In or contact us via email.

CT: A June 2016 law now requires CT Medicaid to cover telehealth services.

ME: Medicaid adopted a telemedicine rule in April 2016 that removes priorapproval requirements.

MA: The MA tMED Coalition continues to bring together stakeholders in efforts to pass a telehealth parity law.

NH: A March 2016 law added NH to the Interstate Medical Licensure Compact, but we still await an updated Medicaid policy required by a 2015 law.

NJ: Limited reimbursement policies remain despite efforts to pass legislation this year, but interest continues is growing rapidly NY: The Office of Mental Health adopted new regulations governing telepsychiatry in August 2016, while NYS Medicaid works to finalize new reimbursement rules.

RI: Parity legislation was finally passed in June 2016 (requiring private payers to cover telemedicine), but limited Medicaid reimbursement policies remain.

If you were not one of the 358 attendees and 40 exhibitors at the MATRC 2016 Telehealth Summit in April 2016, access to screencasts of plenary sessions and handouts may be found at http://eventmobi.com/ matrc2016. Planning for the MATRC 2017 Telehealth Summit is underway with a focus on Clinical Quality and Innovation in Telehealth. If you would like to serve on a Planning Committee or would like to recommend a speaker, contact Kathy Wibberly. There are tentative plans to add a Telehealth Research Symposium to the Summit, to engage federal policy makers from across agencies in discussion about what type of research they most need to make sound telehealth decisions. If you are a researcher, stay tuned; exact dates and deadlines coming soon. To get our announcements, make sure you are either subscribed to the e-newsletter, have liked us on Facebook, or are following us on Twitter (@ katwibb).

Over the past couple years, Missouri has made big strides toward embracing the benefits of telehealth.

Legislators have passed bipartisan bills in support of expanding telehealth access, and Missouri became one of the first states to receive state funding for Project ECHO. However, up until recently, schools have struggled to fully implement telemedicine due to restrictions in how telehealth is defined in the state. Thanks to policy champions and new legislation, that is about to change. By allowing telehealth reimbursement in Missouri schools, students will be able to access specialists without having to leave school. This will improve diagnoses and treatment, as well as reduce the number of absences due to chronic diseases and other health conditions. SB 579 is expected to go into effect on August 28th. Once in effect, any Missouri school will be able to implement telemedicine and enjoy the benefits the service provides.

contact: becky jones

contact: andrew solomon

contact: kathy wibberly

contact: janine gracy

becky.jones@ttuhsc.edu

asolomon@mcdph.org

khw2k@hscmail.mcc.virginia.edu

jgracy@kumc.edu

www.telemedmag.com

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telehealth

regional news

SOUTH CENTRAL

CALIFORNIA

PACIFIC BASIN

UPPER MIDWEST

The SCTRC hosted the 4th annual South Central Telehealth Forum on August 1-2 in Nashville. Presenters and partners from across the country spent two days sharing tools, resources and techniques on how they drive quality health care via telemedicine and mHealth.

Mario Gutierrez, Executive Director, CCHP, discussed telehealth across the nation. Alan Morgan, Chief Executive Officer, NRHA, discussed telehealth in rural areas. Awards recognizing individuals who have made telehealth a focus in their communities were presented to Terry Eagleton (TN), Chip Templeton (MS) and Terri Imus (AR). Highlights were shown from a new SCTRC documentary, 'Underserved – Telehealth in America.'

The film shows how telehealth has the potential to change the lives of patients, caregivers and health care professionals. The event saw a record number of participants for the SCTRC.

California Telehealth Network (CTN), the State’s partnership for telehealth, announced it has received a USDA Rural Development Distance Learning and Telemedicine (DLT) grant award for $405,917. This grant will support the second phase of infrastructure enhancements to the CTN broadband network and videoconferencing service to ensure CTN can continue to provide state of the art service, speed and quality to partner healthcare providers. CTN also announced the selection of TeleConnect Therapies, a tele-mental health partnership serving rural health facilities throughout California, as a “Telemedicine Specialty Care Partner”.

On July 7, 2016, Hawaii Governor David Ige signed into law Senate Bill 2395: Relating to Telehealth as Act 226 (16). This Act requires the state’s Medicaid managed care and fee-forservice programs to cover services provided through telehealth. It specifies that any telehealth services provided shall be consistent with all federal and state privacy, security, and confidentiality laws. It clarifies liability insurance requirements as well as reimbursement questions. The Act requires written disclosure of coverages and benefits associated with telehealth services and ensures that telehealth encompasses store and forward technologies, remote monitoring, live consultation, and mobile health. To view the Act in its entirety, go to http://www.capitol.hawaii. gov/session2016/bills/ GM1328_.PDF

At its Educational Conference and Annual Meeting on August 11 in Effingham, the Illinois Rural Health Association presented its “2016 Rural Health Award of Merit” to the Illinois Telehealth Network (ITN), a network of 23 hospital members honored with this award. In July, Indiana scored a major win on the telemedicine legislative front. A new telemedicine state statute went into effect which expands the use of telemedicine together with certain prescribing rights (without an in-person office visit).

contact: wendy ross wross2@uams.edu

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contact: kathy chorba kchorba@caltelehealth.org

contact: deborah birkmirepeters

| info@pbtrc.org

contact: becky sanders bsanders@indianarha.org

tele

icu

On Rapid Response

telescope Telemedicine briefs across the medical universe --featuring ICU Pharmacy Fertility Chronic

robo rounds

New Directions In Tele-ICU Care For nearly a decade, Orlando Health has been a pacesetter in tele-ICU care. The central Florida health system has nearly 2,300 beds across six acute care hospitals. Dr. Jeffrey Sadowsky wears two hats at Orlando Health: corporate director for critical care and medical director for telehealth. Here are some of his thoughts on the rapidly evolving tele-ICU field as told to kristi labrum

“In the intensive care unit, things change every second.

If someone has cardiac arrest, I can beam in quicker [with telehealth technology] than someone in the hospital who’s running to the code. I can also see patients at different facilities within 30 seconds.”

On Tele-ICU Workflow “A typical work flow for me would be to beam in, drive the telehealth device to the charge nurse, grab the respiratory therapist and then start doing multidisciplinary rounds. We drive to the patient’s bedside and the bedside nurse will give a report. I can take a close look at the patient and ventilator – and even see what setting the drips are on. Then we come up with our goals for the night.

If it’s a new patient, I’d do a whole physical examination.

I usually start with zooming in on the pupil. With the InTouch telehealth device, I can also listen to heart and lung sounds.”

On Tele-ICU Care Coordination “By being at the bedside quickly and continuously if need be, we can get people off the ventilator quicker and get them out of the ICU more rapidly. Therefore our length of stay is decreased. Our cases of ventilator-associated pneumonia have decreased – and our mortality rate has improved.

Our throughput time through the ICU has also improved.

With telehealth, we’re opening up ICU beds for new patients.”

On Tele-ICU Quality “The improvement in our quality issues and length of stay is

living la vita local VITA Takes Telepresence Robotics to the Next Level Jeffrey Sadowsky is the corporate director for critical care at Orlando Health as well as the organization's medical director for telehealth

because we have a small group of physicians that are working with standardized care. The daytime physician and nighttime physician do things the same way. We’re also available 24/7. We’re not a consultative service where someone beams in, gives recommendations and leaves. We’re actually the physicians of record. Even when I’m there virtually, they’re still my patients. I’m managing them.”

RP-VITA (Remote Presence Virtual + Independent Telemedicine Assistant) is the most recent offering from InTouch Health and iRobot. The robot, which stands about human height, can map its environment and move autonomously from bed to bed on rounds.

RP-VITA received FDA clearance in 2012 and is currently available at nearly 100 hospitals in the United States and around the world. s

On Family Rounding “My next step is to bring virtual health to family rounds.

On our day shift, we usually do family rounds between 3:00 p.m. and 4:00 p.m. We talk to the patient and family members at the same time. But some families can’t be there.

We have a lot of destination patients, and their families can’t be there. With telehealth, you can bring the family to the bedside.”

On Tele-ICU Productivity "With telehealth, one of the exciting things is that I can be at three different facilities at pretty much the same time. I can be at one facility on my iPad, another facility on my iPhone and another facility on my desktop. And I can take care of three patients simultaneously. That’s exciting.” www.telemedmag.com

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tele

pharmacy

more than a mirage

Telepharmacy Technology Helps Eliminate 'Pharmacy Deserts' Millions of Americans live in areas – both rural and urban – void of pharmacies.

Telepharmacy services are beginning to bridge the gap. by larry mcclain

To date, telepharmacy technology has been implemented mainly in two settings: in rural communities that are at least 10 miles from the nearest retail pharmacy and by health systems looking to improve service across multi-hospital, multi-clinic networks.

One of the largest telepharmacy networks in the U.S. is Catholic Health Initiatives’ Virtual Health Services in the upper Midwest, which connects 48 healthcare facilities with its 24-hour telepharmacy command center in Fargo, North Dakota.

Now telepharmacy services are coming to underserved urban locales. Just as low-income neighborhoods are sometimes dubbed “food deserts” because they lack supermarkets, many inner cities are “pharmacy deserts” because they don’t have a single retail or clinical pharmacy.

According to the public policy journal Health Affairs, about one million people in Chicago alone live in neighborhoods that are pharmacy deserts.

Large stretches of Baltimore are also considered pharmacy deserts – and residents’ troubles grew even worse in the wake of the 10

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Freddie Gray protests (when one pharmacy was burned to the ground and several others closed for weeks). To help alleviate the problem, the Baltimore Health Department allowed residents to use the 311 telephone service to obtain transportation to area pharmacies.

Federally Qualified Health Centers (FQHCs) are clinics that typically serve patients in pharmacy deserts – and many are interested in sharing the cost of a telepharmacy operation. With telepharmacy technology, an FQHC can dispense medications at the point of care in a way that’s more convenient and affordable for local patients.

FQHCs serve about 22 million Americans, and 33% are located in rural communities. There are FQHCs in all types of communities, like Penobscot Community Health Care in Bangor, Maine, which provides medication reconciliation and diabetes management. But only a handful of FQHCs have implemented telepharmacy programs. That could change in the year ahead, however, because the Affordable Care Act has provided $11 billion for FQHC expansion.

Q&A ADAM CHESLER, PHARMD Vice president of regulatory affairs for TelePharm -TM: What are the states where you currently support telepharmacies?

Chesler: We are currently providing the software for telepharmacies to operate in Illinois, Iowa, Wisconsin, Minnesota, North Dakota, New Mexico and Idaho. As regulations in various states are implemented or updated, we expect that number to increase significantly.

Many states are currently implementing telepharmacy language in order to address the

growing need for these services.

TM: Of the three growth areas for telepharmacies, where are you seeing the most growth and interest: rural communities, in or near health systems, or underserved urban areas?

Chesler: The main catalyst for growth of telepharmacy has been and continues to be rural communities. These are the areas most in need of access to a pharmacist.

tele

pharmacist on call

Telepharmacy Takes CPOE To the Next Level Does your hospital provide offsite pharmacist support at 3am?

In the era of CPOE, new telepharmacy services are helping to reduce medication errors. by brian roberts Ninety-seven percent of hospitals use hospital-based computerized physician order entry (CPOE) systems, thanks in part to a 2009 stimulus bill that tied funding to CPOE adoption. But while CPOE has been shown to reduce medication errors, a recent report by Castlight Health and the hospital rating organization Leapfrog Group, showed that CPOE systems failed to flag 13% of potentially fatal medication errors. In this increasing digital healthcare eco-system, what role can tele-pharmacy

TM: Are you currently doing work with any Federally Qualified Health Centers in underserved urban communities to solve the problem of pharmacy deserts?

Chesler: Some pharmacy owners are currently using TelePharm’s software to provide services in FQHCs in underserved urban communities. More and more healthcare professionals are realizing the need and benefit to providing services in all areas, including urban.

Telepharmacy is a great way

illustration by Maggie Chiang

play in helping ensure medication security and safety.

The problem has become all too common.

It’s the middle of the night and a physician working in the emergency department is entering orders into the hospital’s computer system. Because of the late hour, there’s no pharmacist on site, so the orders get transmitted directly to the cabinet where a nurse manager could override them. From a clinical perspective, this is asking nurses to take on the tasks of a pharmacist in addition to their patient care duties. This is both unwise and unfair to nurses.

Some hospitals have chosen to implement telepharmacy in conjunction with their CPOE system, to ensure that a clinical pharmacist is always verifying any medication orders as soon as they are prescribed.

Even when reviewed off-site, having a set of clinically trained eyes on these medication orders adds another level of security and safety for patients and providers. Thanks to expanding telepharmacy options, this can be a pharmacist in the hospital’s network who may be working from one central location but monitoring several ancillary sites during non-peak hours, or an external service provider. Although the majority of U.S. states today allow for this type of unique

to improve value-based care at FQHCs in urban areas.

TM: In the health system setting, who are the key decision-makers you need to reach to get telepharmacy implemented?

Chesler: Typically the key decision-makers include the C-suite executives, which vary depending on the size and scope of the organization. It is also very important that the Chief Pharmacy Officer and/ or Director of Pharmacy is involved with the discussion.

pharmacy

clinical support, it isn’t available in all states as the practice of telepharmacy continues to fight through some legislative roadblocks.

The regulatory landscape for telepharmacy varies widely from state to state – some states are highly regulated while others have nothing on the books. Professional organizations like the National Association of Boards of Pharmacy have tried to spur uniform legislation by developing a definition of the ‘practice of telepharmacy’ through its Model Pharmacy Practice Act, but regulation still remains inconsistent across state lines. As states look to develop their own guidelines, they sometimes fail to consider the full breadth of solutions and applications that exist under the umbrella of ‘telepharmacy’ and the differences between retail and hospital models. There are several models and technologies to leverage in telepharmacy – there’s no onesize-fits-all approach. Additionally, with the pressure on hospitals to bring value to patients increasing, we will see the lines between direct-to-consumer and peer-to-peer practice blur as telepharmacists help verify medication orders, but also perform discharge planning or additional patient facing activities that may help reduce readmissions or manage chronic illnesses.

With any technology implementation, it is important to engage the IT department early in the process as well.

TelePharm doesn’t need any significant IT resources to implement. However, it is important that the IT team understands how the system works and how it complies with security requirements as the discussions progress.

TM: How does TelePharm ensure quality and compliance?

Chesler: All prescriptions

processed in TelePharm utilize an image-based store-and-forward workflow for verification. During this process, images are captured of the stock bottle, vial, and physical product being dispensed. These images are sent to the pharmacist for verification, then stored permanently in a secure, online environment. Patients receive counseling via a HIPAA-compliant interactive live video connection before receiving their medications.

-Larry McClain

www.telemedmag.com

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tele

fertility

getting to know aunt flo

New App Hopes to Bring Fertility Out of the Shadows As many as one in seven couples struggles with infertility, yet so often they struggle alone, feeling the topic is taboo or not appropriate for conversation.

Jennifer Aldoretta (pictured), co-founder and CEO of Groove, hopes that her new mobile app can help bring these conversations into the light by providing high tech menstruation and fertility tracking. by jennifer aldoretta, as told to bill gordon I think specifically women’s health and women’s reproductive health is very much a taboo topic. Maybe not necessarily taboo but it’s just something that not a lot of people are not comfortable talking about. I think that that’s a big problem because there are so many couples who struggle with infertility. Between one in ten and one in seven couples will struggle with infertility, which is a huge issue.

I think we just need to have more of a conversation around women’s needs in general.

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Women’s bodies are very different. So the apps for women are going to look very different than the apps for men. Not necessarily from a design standpoint. But I think that women need to be very involved in the creation of these things; so that the apps are created with sensitivity and just from a place of a really deep understanding of the problem that’s being solved. That’s obviously not to say that a man can’t come in and work on this problem. But I think that having a very diverse team working on something is really important; so that you get input from people of all backgrounds, all experiences.

I am the cofounder and CEO of a company called Groove. We built a period and fertility tracker. But our big focus and our big mission is education because there are a lot of pitfalls when it comes to reproductive health education and sex education. So, we’re trying to tackle those.

So, our app is loaded with information about the female reproductive system and about menstruation and things that we feel are very lacking from the current sex education system. Part of the reason that women lack that confidence is because at a very deep level women are taught not to trust their bodies and that their bodies are mysterious. They just don’t have an understanding of what’s going on. I think that that affects women in their confidence and in their lives. So, we’re trying to overcome that and just teach women what’s going on in their bodies; give them that confidence that we’ve seen in people that use our app and use our products that will carry over into other areas of their lives and give them more confidence just in general.

The Groove website www.readytogroove. com is host to a library of information about womens health, educational material and guides on topics from cycle tracking to fertility tracking and hormone levels. It is all accessible via smartphone, which in may parts of the world is the only way people can access the internet. The app is available for both iOS and Android.

MARKET WATCH A few of the digital products shaping modern womens' health

s

willow health

Founded in 2015, Willow creates a virtual safe space for girls and young women to ask health-related questions. The mobile messaging app works by matching users with the right licensed health specialist who provides unbiased answers to their questions. price: Free

site: www.joinwillow.com

s

ovatemp

Using the fertility awareness method, Ovatemp goes beyond the traditional menstruation cycle charting.

A mobile app syncs to the ONDO Bluetooth thermometer to track the users temperature to pinpoint which days the woman is ovulating. price: $75

site: www.ovatemp.com

s

maven

Maven allows women to choose a practitioner and book a video appointment anywhere, anytime.

Designed to make healthcare for women simple and easy. price: Appts start at $18

site: www.mavenclinic.com

tele

chronic disease

sidle up

Ochsner’s "O Bar" Opens Up the Path to Improved Outcomes in Chronic Disease Modeled after the Apple Genius Bar, these consumer-oriented digital health hubs help patients take steps towards more comprehensive health tracking. by jeremy lacocque, do & nicholas genes, md, phd Lisinopril 20 mg once a day, an iPhone app, and a bluetooth blood pressure cuff might be the next prescription coming from primary care doctors at Ochsner Health System in Louisiana. That's thanks in part to a new initiative called "O Bar". Modeled after Apple’s Genius Bars, each O Bar features a helpful technology specialist and an array of smartphone-connected blood pressure cuffs, glucose monitors, scales, apps and Fitbits to help patients manage chronic diseases like CHF, hypertension and diabetes – with a modern twist.

Patients at the O Bar learn about managing their disease, and link their new devices to their smartphones. Apps and settings are configured so that they’ll beam information back to Ochsner, where care coordinators and clinical pharmacists will assess progress using CHF, hypertension and diabetes guidelines, and fine-tune their drug regimens accordingly.

Dr. Richard Milani, a cardiologist and Chief Clinical Transformation officer for Ochsner Health System, spearheaded the project in an effort to improve chronic

disease management, which accounts for so many emergency department visits, revisits, hospitalizations and deaths.

While sleek and modern, the O Bars themselves are not revolutionary – they are just an eye-catching front-end of a sophisticated operation. On the back end, based on patient data feeds, Ochsner has developed proprietary tools in their EHR to regularly report on those at risk. Patients whose blood sugars fall outside parameters, or CHF patients who are not sending new data from their wifi scales, are highlighted.

Ochsner mingles those updates with background information on their patients, from medical risk factors to health literacy. Even details about transportation capabilities and disposable income make it into the risk analysis. It’s all weighted and plugged into a calculation of who is most at risk, and who needs the most attention.

Every day, the Ochsner Digital Medicine team reviews the data feeds and reaches out to patients most at risk. Is there a technical issue blocking the flow of data? Is there a quick fix to explain why a patient’s numbers are off ? Care managers can help with prescriptions, transportation to clinics, and other things that may keep a chronically ill person off-balance. Health coaches can motivate, answer questions and assess progress on nutrition and fitness. And Ochsner’s clinical pharmacists can adjust medication dosing to help keep blood sugars, blood pressure and edema in check.

With these traditionally non-adherent

patients transmitting data and getting special attention, Ochsner Health said compliance with care management goals rises from 50% to 66% in just the first 30 days after an O Bar visit. Re-admissions in CHF patients sent home with wifi scales are down 44%, and improvements in diabetes and blood pressure control among patients have also been observed.

The O Bar, for all its preliminary successes, is losing money overall because of operating costs, but Ochsner thinks it’s well worth it considering the benefit to their patients and wider community. And then there’s the monies associated with meeting benchmarks and realizing incentive payments for keeping patients healthy and reducing exacerbations of chronic disease.

Regardless, patients using the O Bar can save money, because Ochsner negotiates with manufacturers; an app-controlled connected blood-pressure cuff sells for $40 at the O Bar, but at Best Buy or on Amazon it’d retail for $135.

Any hospital system willing to set aside a space in a clinic, staff it with a few friendly technicians and showcase an array of validated apps and devices can start a similar program. The biggest challenge will be developing the infrastructure to collect and process information from the apps and devices - and make sense of it. Coaching, managing and adjusting regimens based on data and risk – it’s those algorithms and practices that help Ochsner keep patients adherent and out of the hospital. www.telemedmag.com

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tele

rehab

rehab reimagined

New Apps are Making Recovery Less Painful There is a new category of telemedicine popping up called Tele-rehab in which physical rehabilitation services are provided via an app or web platform.

Companies like Telespine, Simple Therapy, RespondWell and Rezoom are changing the way people access and utilize traditional services.

Reflexion Health has even created an at-home rehab service based on the Xbox Kinect. Here's a look at where this burgeoning field is heading. by bill gordon

When you have an ache or pain that won’t go away you head to the doctor who might prescribe physical rehabilitation as your treatment plan. This requires you to find an in-network therapist, go to an office and spend an hour or two there, all of which needs to be worked into your busy schedule and their availability.

Then there are the pains and injuries that don't even earn a visit to the clinic. Ninety percent of people will have low back pain at some 14

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point in their lives. Most people don't seek the care of a doctor until the pain has become chronic, but often this is too late.

Now with new telemedicine apps like Rezoom, RespondWell and Simple Therapy, there is a new way to approach rehabilitation services. These apps help those who have injured themselves find a step-by-step solution to their dysfunction/pain on their time in the comfort of their own home. The apps help you identify the source of your problem, and then puts you on the path to recovery using a combination of daily exercises and user feedback. Should you need the help of a medical professional they can even refer you to a local professionals for further medical assistance.

The most prevalent reason why people do not seek appropriate rehabilitation treatment is time and money. Tele-rehab solutions aim to remove both of these barriers.

In addition to at-home recovery, tele-rehab opens the door to more robust "pre-hab" – a concept which has emerged as a new area of focus in the rehab space. More and more healthcare providers and systems are conducting pre-surgical evaluations on patients where they determine strengthening exercises to be performed prior to surgery. This allows the development of end-to-end pre- and post-surgical care plans. Studies have shown that flexibility and strength prior to surgery is directly related to success rates after surgery. If someone is weak and tight prior to surgery, they are likely to be weak and inflexible after surgery, and this increases the risk that a person may damage other surrounding joints. Prehab can improve strength and flexibility prior to surgery to improve outcomes.

Tele-rehab is poised to be one of the next great frontiers in telemedicine. Whether these apps are utilized as stand-alone services or embedded into larger telemedicine service offerings like virtual doctors visits, there are millions of patients who can benefit from the technology. And as the Baby Boomer generation ages, the needs will only grow.

SPOTLIGHT REZOOM 1. Rezoom's proprietary user questionnaire helps determine whether or not a user will benefit from the app or if they need to be referred out to a therapist or doctor.

2. If the user is guided to stay within the system a custom treatment plan is created using a large bank of movement and exercise videos.

3. The system keeps tabs on how often you're logging in and provides daily reminders. Treatment assessment questions are provided along the way.

FOLLOW THE MONEY – Consumers can purchase subscriptions directly in order to analyze symptoms and use guided exercises – Doctors and physical therapists can work with Rezoom, paying to receive leads when users fail symptom analysis and are referred to local medical professionals.

– Employers and insurance providers can contract with Rezoom to provide quicker recovery for workers who have been injured on the job.

– Telemedicine doctors can provide access to Rezoom based on findings. In this scenario the Doctor pays a monthly license fee either per patient or for the entire practice allowing them unlimited access to the system for their patients.

teletech Practice-changing gadgets & gizmos --featuring At-Home Dx Ophthalmology Wired Kitchens CareKit

A combination of next gen infrared technology and Bluetooth connectivity allows users to take temperature without skin contact.

Thermometer scans the forehead and analyzes 12 separate recordings to identify the temporal artery temperature. Temperature is adjusted for ambient temperature conditions to ensure accuracy.

gear lab

CliniCloud's No-Touch Thermometer Raises the Bar for Consumer Home Diagnostics The Australian-born CliniCloud recently become a global name as it secured a partnership with Doctor on Demand and retail distribution in Best Buy. Here's how it works.

Integrated with telemedicine provider Doctor On Demand.

Accounts can be created for family members to track health.

This stethoscope designed specifically for use by consumers plugs directly into your smartphone.

Records lung sounds at 44.1kHz – more than 10 times the sampling rate of typical digital stethoscopes.

photo by Colin Strohm

www.telemedmag.com

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tech

eyes right

Eyes: The Window into the Future of Telemedicine When it comes to telemedicine, few medical specialties are more suitable than ophthalmology and optometry. The need is great: according to the World Health Organization, an estimated 285 million people worldwide are visually impaired. It’s an issue that affects all ages, genders, and ethnicities, and it places a difficult burden not only on the individual, but on the family, and often on society as a whole. But the prognosis is excellent: 80 percent of these visual impairments are treatable and can be prevented with access to even basic vision care services.

And compared to other specialities, the tools and technology are in abundance. “Ophthalmology has always been one of the most technology heavy medical specialties,” says Dr. Billy Pan, an ophthalmological resident at LAC+USC Medical Center in Los Angeles, California. “Recent decades have included tremendous advances in every sub-specialty within ophthalmology, from improved intraocular lens designs to advanced imaging in the form of optical coherence tomography (OCT), to name just a couple.”

Another common ophthalmology tool is one you probably already own. Mobile phone camera technology and internet adoption has reached the point where 3.6 million global cellular phone owners already possess a device sufficiently capable of addressing most basic eye and vision care needs. Here's a review of three new devices which use mobile technology to bring advanced eye care directly to consumers. by scott jung

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1 DigiSight One company that is leveraging smartphone technology to enhance vision care for doctors is San Francisco based DigiSight Technologies. For the physician, they’ve developed the Paxos Scope, a smartphone attachment and app that allows doctors to perform a routine fundoscopic exam practically anywhere. It consists of an adapter that houses a powerful light and a lens to illuminate and magnify the front and back of the eye. Images and video can be captured with the smartphone's camera, which can then be securely archived or sent to another party. Paxos Scope can examine both the posterior and anterior of the eye and provides a 56 degree field of view. And unlike many similar medical tools that utilize a smartphone camera, the Paxos Scope can fit practically any smartphone. By keeping the tools simple and affordable, Paxos is able to reach a greater number of eye care professionals who can in turn serve a greater number of patients.

2

3 Notal Vision Smart Vision Labs While empowering more ophthalmologists and optometrists with better tools will certainly improve access to vision care, it is often the patients themselves who are not motivated or are too busy to see their optometrist regularly.

Smart Vision Labs, based out of New York, has addressed this point with the recent launch of the SVOne Enterprise, a system that uses the company's smart autorefractor, the SVOne Pro, with a self-guided test to conduct eye examinations without the need for on-site doctors. The SVOne Pro, which Smart Vision Labs has already sold over 500 since its launch in 2014, is a handheld, iOS-based tool that utilizes advanced wavefront aberrometry technology to measure vision imperfection and generate refraction in a matter of seconds. Though it uses an iPhone camera and has a vastly smaller footprint than traditional tabletop autorefractors, the SVOne Pro has been shown to be just as accurate, with a measurement error of one percent compared to the gold standard.

And while the SVOne Pro itself can wirelessly print test results or archive them, the new enterprise component sends the data for analysis to a remote network of eye doctors who can write a digital eyeglass prescription for a patient within 24 hours or recommend a full eye exam. Smart Vision Labs hopes to place its systems in workplaces, schools, designer eyeglass boutiques, and even in countries like Haiti and Guatemala, where their SVOne Pro has already been used.

Even with tools that make vision exams more convenient for patients, there are some eye diseases that require constant monitoring. For many patients, this is a major inconvenience, and for some, like the elderly, it is not possible. For these patients, many who suffer from Age-Related Macular Degeneration or AMD, Notal Vision, a company based out of Tel Aviv, Israel, has developed a device that allows them to monitor the progression of AMD without leaving their home. Known as ForeseeHome, the device consists of a tabletop viewer with a standard computer mouse that runs a Preferential Hyperacuity Perimetry (PHP) test in which the patient moves a cursor to a specific location in his or her field of view. The test results are automatically sent to Notal Vision via land line or cellular phone service. If a statistically significant change in a test result is measured, the patient's physician will be notified so he or she can contact the patient for a follow up appointment. Doctors can view their patient's data at anytime and are automatically sent monthly reports. conclusion

Compared to other medical specialities, assessing a patient's basic visual health is relatively simple and doesn't require highly sophisticated sensors; in essence, a patient simply needs to capture a picture of his or her eye and look at a screen, something that the majority of cellular phones in the world are powerful enough to do.

Dr. Billy Pan thinks we’ll continue to see technological advancements in therapeutics as well: “We will likely see the maturation of many exciting new technologies including laser-assisted cataract surgeries, prosthetic retinal implants, gene therapy, and minimally invasive glaucoma surgery. All of these new devices have incredible potential for furthering our ability as ophthalmologists to provide sight-preserving and sight-restoring therapies to the population.�

www.telemedmag.com

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tech

the wired home

data dining

Smart Kitchens Help Consumers Cook Up An Ounce of Prevention As we continue our wired home series, we shift our focus to a critical area in any home, the kitchen! Smart kitchen devices are now commonplace in the internet of healthy things, with a whole host of connected accessories and appliances available. Here's a rundown of tech advances that will help keep consumers healthier longer.

by Aneel Irfan

1. Smart Utensils Smart forks and spoons are emerging on the market to help track and monitor eating habits while combating medical conditions or side effects. The most celebrated of these products is the HAPIfork, the flagship product of Hong-Kong based HAPILABS Ltd. The Bluetooth enabled HAPIfork itself was originally developed

by Slow Control for medical use. Using the Slow Control technology, the connected cutlery measures how many mouthfuls you take and buzzes and flashes if you're scoffing down your grub too quickly. Eating too quickly can lead to weight gain, digestive problems, gastric reflux and even postoperative complications. The mobile app and dashboard help tie it all together. You can see your meals in real time, check your time in between fork servings, download your fork data wirelessly, set workout challenges, 18

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track your progress and even score points with their HAPi Challenge. Though a direct-to-consumer product, the postoperative use cases can be utilized by physicians to monitor patient’s intake and avoid complications post surgery.

Liftware, a company out of California, has developed a stabilizing handle and a series of attachments from soup spoons to knives/forks to help people with hand tremor eat more easily. They work alongside clinics across the country to offer the product to patients. Google has invested in the parent company LiftLabs to fund the efforts. With many clinical trials under their belt, the Liftware smart utensil attachment may become a staple in the kitchen of the 10 million people worldwide affected with Parkinson’s.

2. Smart Cooking Ever think there would be a smart frying pan? Or even a smart cutting board? Well there is, among other kitchen essentials in your smart kitchen of the future.

The Pantelligent Smart Frying Pan when paired with their free app gives you stepby-step directions on cooking your favorite foods and real time temperature feedback to make sure you get that steak just right.

The Prep Pad by The Orange Chef tallies up nutritional info from the foods added to any bowl on its connected food scale. The information is then transferred to an iPad app so you know exactly how many carb, fat and protein calories are in your food. It then gives you an overview of every ingredient you put on Prep Pad throughout your week and logs that with your connected Jawbone Up to help you meet your health goals.

These advancements are great but what if you could 3d print your next meal? Many such concepts are hitting the market, products such as Foodini, The Green Onyx and The Genie are some to name a few. The Genie, developed by an Israeli company, White Innovations, is a uniquely shaped kitchen appliance of sorts which includes

ingredient capsules and a machine that prints those ingredients into edible foods.

The food capsules are designed to maintain a shelf life of up to five years, with no preservatives used. Each capsule is designed for a single serving and ranges anywhere from couscous to cake to muffins. The meals are available in both medium- and large-sized portions. So far, the Genie has options such as gluten-free and vegetarian as well. The company plans on tackling food waste and obesity with their invention. The Genie will initially be marketed to businesses, and then the company will consider marketing to households, with an estimated price tag of $1,000. According to the company’s founders, they have already seen a great deal of interest and are in the mass production stage. So far, the company has received thousands of orders from Israel, the US and Greece.

3. Smart Fridge Ideally I would like to see a fridge that orders food online automatically based off your grocery stock levels, but until then we have The Family Hub Smart Refrigerator from Samsung. The Family Hub Fridge is a new Wi-Fi enabled refrigerator that helps manage your groceries, connect with your family and entertain. The Family Hub has three built in cameras that take a photo ev-

ery time the door closes, you can use your smartphone to access the photos from anywhere so you always know what you have and what you're missing. The Wifi enabled touchscreen displays/coordinates schedules, interactive notes/reminders, shows off pictures, connects with a collection of apps for music streaming and even shopping for groceries online.

4. Smart Plate Probably the most interesting wired kitchen concept we’ve come across is the smart plate. If you're used to manually inputting all your caloric intake through various food tracking apps, then SmartPlate wants to make your life easier. The 10-inch plate is Wi-Fi and Bluetooth-enabled and, get this, it comes equipped with three mini cameras and weight sensors. Basically, your dish will be watching you – or in other words, figuring out what you're eating. If you serve yourself too much, the plate will alert you. There's also an app that syncs up with the plate to automatically analyze and keep track of every meal, and connects to MyFitnessPal and FitBit.

How it all comes together There are many ways healthcare practitioners will utilize the internet of things, and it is safe to say that much of that will begin in the kitchen. In time, the connected devices throughout the kitchen will talk to each other. Your Fitbit may send dietary information to your appliances to recommend the optimal meal to restore energy after your run; connecting the same FitBit to food printers can have food generated for you that is appropriate for that specific day. We are in the early stages of these smart kitchen devices because many of them don’t communicate with each other cohesively, something that is bound to evolve. As healthcare providers whose care continues to trend towards a patient centric future, it will be important to leverage these innovations to achieve positive health and wellness. illustration by Maggie Chiang

The first CareKit apps are out.

What's next? by nicholas genes, md, phd

T

he first apps that make use of Apple’s CareKit framework are now available for iPhone users, in the App Store. These apps focus on diabetes, depression, pregnancy and early parenthood, and post-op care management.

CareKit takes its place along HealthKit and ResearchKit, which Apple introduced to developers in 2014 and 2015. HealthKit was focused on fitness and nutrition, and provided a repository were users can visualize, enter and share their health data between apps.

ResearchKit gave investigators a common platform to remotely “e-consent” study participants for app-based trials, and securely collect their data Although HealthKit and ResearchKit were ambitious in their own right, CareKit has enormous potential (and also great potential for failure).

Apps that use CareKit help patients with five aspects of disease management: •Patients can track symptoms and monitor treatment effectiveness (an app called Start, for instance, lets users track their depression score over time, after starting new meds) •The app will prompt users for key tasks, such as medication dosing, wound care, or in the case of One Drop, logging food intake and checking blood sugar (some glucometers will beam the glucose levels directly into the phone).

•The “Insight Dashboard” helps patients learn from their reported symptoms and logs of medication adherence and other activities. An Insight may reveal a diabetic patient’s glycemic control suffers on weekend afternoons, or that poor medication adherence one week leads to worsening survey scores down the road, in a patient with depression.

•Patients can upload and store a Care Plan in their app (one presumably developed in conjunction with a doctor – like an asthma action plan or prenatal care guide).

•CareKit apps invite their users to securely share data with family members or healthcare providers, through the “Connect” module.

While standardizing care plan integration and symptom tracking is probably a useful contribution, it seems to me CareKit will really shine – or fade into obscurity – based on physician adoption of the “Connect” module.

Healthcare institutions and providers have already started partnering with app developers to collect patient-generated health data [like Ochsner health – see O Bar article on page 13]. Thanks to CCM from CMS, providers can now be reimbursed for reviewing remote data from chronically ill patients. Several studies have shown improved care and lower costs through remote monitoring, for CHF, COPD, and other disease states associated with frequent readmissions. Maybe CareKit and its “Connect” module will lead the way to more apps – and physicians – making use of this service.

More info via carekit.org or carekit.org/blog.html

www.telemedmag.com

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Learn more at zipnosis.com or call us at (612) 217-1083.

Telemedicine

vision

television Industry-shaping ideas & perspectives --featuring Roga Stoakes Jones Hollander

data driven

Teladoc Mines Mountains of Data for Strategic Insights Dr. Alan Roga, senior vice president and general manager of Teladoc's provider market, talks cost savings, utilization and why Teladoc has never been sued for malpractice.

Interview by Logan Plaster

telemedicine magazine:

roga

Teladoc has done more than 1.5 million patient visits as of today and you recently did a deep dive into that data. What's the most important lesson that you learned from investigating the data at this benchmark?

to take care of complex patients. So what we proved out by having no malpractice claims is that you’re able to take care of sicker patients through telehealth and do it effectively and have good satisfaction.

alan roga:

your 1.5 million visit data dive?

I wouldn’t say that there was one lesson that was more important than the others, but there were things we found in the data that were great to see. For instance, we learned that our prescribing rate is in line with an in-office visit. Also, we learned that the average user is a 36-yearold female and that 44 percent of the time they actually have a comorbidity. So our patients aren’t just college kids with pink eye.

We looked at 12 comorbidities, including diabetes, high blood pressure, COPD; so, 44 percent of our patients actually have one or more of these.

tm: Were you surprised at the profile of a typical Teladoc user? roga:

If you look at the data out there, like the Department of Labor studies, they show that 80 percent of the healthcare decisions are made by the female head of the household. So when our data showed that 63 percent of our users were female, that simply validated what’s already been seen out there.

The fact that our average user is 36 is probably reflective of the market and the dynamics. The telehealth space was very much born in the employer space because they were the ones originally saying: We want to see more cost effective measures for care delivery.

And then it migrated to the payer space.

And now you’re really seeing it move into the hospital space because the dollars are being shifted. So I think the fact that our user is a 36-year-old female is reflective at some level of the stage of the market. tm: Will that knowledge impact your strate-

gic direction? roga:

I think that the industry itself will migrate very much from an acute care to a more longitudinal care model – being able

tm: What other insights did you glean from

roga:

We have seen our adoption dramatically increase. We had a 93 percent growth between 2014 and 2015. And we are on target for 945,000 consults for 2016. So you’re seeing tremendous upslope in adoption rates. And I think that it comes down to two things: one is the market is maturing.

And the other is we are really very good at consumer engagement.

The question for telehealth has been: What are the real savings? Well, we commissioned a group out of Harvard led by Dr. Niteesh Choudhry, who did a longitudinal study on claims data from very large employers and what they found was there was a slope that was increasing on spend.

Post-implementation of Teladoc, you could see a statistically significant decrease in the slope of the spend to the tune of $21 per member per month.

As a frame of reference, most insurance carriers are looking for tools that will decrease a dollar or two dollars per member per month. We were able to show $21. This was an independent study. It looked at longitudinal claims data. And really the cost savings was due to reduced ER, primary care, hospitalizations and prescriptions. So while a lot of companies out there will tout the overall benefits of the program, this was quantifiable. We reduced ER visits by 2.1 per thousand and hospitalizations by .7 per thousand and office visits by .9 and spend by $21. That’s big. That total is almost $387 million in savings for our collective book of business. So I love that study. I think that study is really powerful.

Another question has been: Is it safe?

We’ve proven that it is. Zero malpractice claims, no bad outcomes. tm: To what do you attribute Teladoc’s com-

www.telemedmag.com

21

vision

roga

plete lack of malpractice claims? Even good doctors giving good care can end up in court occasionally. roga:

It starts organizationally and structurally. Teladoc is not only the market leader as far as size but I would say we are the leader as far as quality as well. At the board level, Dr. Bill Frist, who is not only a lung and thoracic surgeon but also was a two-time US Republican Senator and Senate Majority Leader; chairs the Teladoc Patient Safety and Quality Committee. It starts at the board structure with governance and leadership saying: Quality and safety first and foremost. We developed over a hundred proprietary telehealth guidelines for safe practice.

They’re unique in the industry. Nobody else has them anywhere. Also, we mandate that our physicians pass a full training program before we allow them to perform a consult.

We review 10% of all consults every month and 100% of all consults for new physicians for the first 90 days or 10 consultations. So we manage the processes well and not only in training the physicians but oversight on their chart review. If you look also on the outcome side, the patients are generally happy; 95 percent patient satisfaction… So if patients are happy, they don’t typically sue. tm:

But let’s just take for granted that you’re doing all of these things to promote patient safety and excellence. Zero claims out of a million-and-a-half sounds like an outlier. roga:

It’s high satisfaction. So the number one reason why somebody sues their doctor is because they’re dissatisfied. It’s medical liability. It’s part of doing business in healthcare. tm:

You’ve described Teladoc as being a nimble organization because of its dedicated business unit focused on hospital system integration. You don’t usually hear the largest company in a space declaring themselves to be the most nimble in terms of being able to shift direction. Tell us more about that.

roga: All I do all day long is talk to hospi22

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We commissioned a group out of Harvard [to do] a longitudinal study on claims data from very large employers . . .

Post-implementation of Teladoc, you could see a statistically significant decrease in the slope of the spend to the tune of $21 per member per month. tal systems. And that’s all our team does all day long. We work with our hospital clients and potential clients and we see what the market trends are. And that allows you to be focused and very specific and that really does allow us to be very, very nimble in our capabilities there because of the focus and dedication of the team.

Essentially every system gets a separate instance of the platform in a separate environment. As an example, one opportunity that we were competing on essentially came to us and said: We need a specific workflow on this type of user role. We were able to deliver in six weeks a module that they were working on for six months with a competitor and weren’t able to even have it delivered. tm:

What are some notable advantages to being the largest player in the market? roga:

What often gets overlooked by a health system is the technology is just one piece of the program. You’re developing a strategic asset that is going to touch multiple service lines in your hospital. If you were going to build an Urgent Care, you wouldn’t just hire a contractor to pour the cement and hire a bunch of doctors and set them free to practice. You’d make sure that it was

integrated into logistics and pharmacy and billing and nursing and all of those features.

I think sometimes systems look just at the technology and that’s just the tip of the iceberg. So what’s underneath the water is all of the operational support you need. We’ve got a 75,000 sq. ft. operations center in Dallas, Texas; it houses an army. You know, there are 400 people there of call center and clinical operations and marketing and technology; so that we’re able to do a visit every ten seconds that’s seamless. tm:

We ran an interview with Jay Parkinson, head of Sherpaa, a few issues back.

One of the things that he felt was a killer component of Sherpaa was that their physicians were in a room together and that if they needed to, they could actually bounce things off each other and gain some of that both important and enjoyable collegial back and forth. Would Teladoc ever consider, given your volume, employing doctors full time at a central hub? roga: I think it’s an interesting idea. I think

it’s probably more around life cycle of the company. And I’m not sure about the concept of trading knowledge because we’re all in the same room makes us better, really actually flies for the current market dynamics. tm:

It’s kind of a lifestyle question. Are we working towards a future where I practice medicine from home in my pajamas? Or am I working towards a future where I come into a hi-tech facility with ten colleagues and we take calls on screens and we discuss them with each other? roga:

I suspect it’s much more the former than the latter. It does provide a wonderful lifestyle for many physicians: physicians nearing retirement; physicians with young children; physicians on disability. As long as they’re professionally dressed and in a private environment. Doctors huddled in a room is more likely a response to current state of the organization and the amount of volume that they’re seeing.

leapfrog

The Ricochet Effect and Why The World's Most Underserved Markets Will Lead Us Forward Ten years from now, telehealth will be an integral part of every American’s health experience. Remote monitors will seamlessly collect our health information from home, routine check-ups will be as easy as a Facetime call, and rural health centers will simply patchin the world’s best specialists for meaningful consultations as-needed.

But it will be the world’s most underserved markets that will increasingly lead the telehealth revolution, driven by the necessity that fosters innovation and a unique set of conditions that are rapidly accelerating global adoption and encouraging progress.

by Unity Stoakes

illustration by Maggie Chiang

It used to be that newest health care solutions required heavy infrastructure and billions in investments to gain traction. But the near-ubiquity of mobile technology around the world has changed that equation. There are already billions of people using mobile phones and connected to the internet globally. And over the next decade, billions more will only experience a connected-life, a group the entrepreneur Peter Diamandis coined “the rising billions.” These people are increasingly becoming the future of our global economy.

Sadly, these are also billions of people who have little or no access to quality health care.

A unique combination of extreme demand, mobile ubiquity, affordable tech, and less regulation will enable the world’s most underserved markets to propel the next wave of telehealth innovation. Efficient solutions, with new business models, perfected in the developing world will create a ricochet effect, ultimately paving the wave for increased adoption of telemedicine into every aspect of the U.S. health system.

From villages in Africa to remote farms in Mexico, entrepreneurs, doctors and technologists are exploring new ways to leverage mobile technology to bring health care to those with limited access.

Entrepreneurs, local health professionals and in some cases governments and global leaders in some emerging markets will drive this revolution because, very often, the alternative is no care at all. The scarcity of medical services makes these markets ripe for

innovation. In the U.S., there’s an average of 2.45 doctors for every 1,000 patients; in stark contrast, Zimbabwe only has 0.08 doctors for every 1,000 patients. Telemedicine can augment and amplify medical care in rural areas. And as new affordable cognitive tools and platforms enter the market, they will quickly fill in the gaps where there are not enough health practitioners for everyone in need.

In resource-poor settings, entrepreneurs will need to find a way to operate with limited or no budget. These lean telehealth solutions will foster a leap forward with business models that emphasize efficiency while keeping costs low. Moreover, the telehealth solutions forged in the developing world will create a new type of healthcare model - one in which providers and technology are able to distribute basic care and services more evenly across large territories and populations.

Telemedicine innovation in the West is continuing to advance rapidly, but the pace of adoption will be quickly surpassed globally because of a myriad of regulatory barriers. In the United States for example, innovators must grapple with not only federal regulations, but also regulations that vary state-by-state. Because of this, we are seeing some investors and entrepreneurs looking beyond U.S. borders for the next wave of telemedicine innovation.

Ultimately, those low-cost solutions will ricochet back to the Unites States and other highly-developed markets, and their adoption will drastically drive down costs and improve efficiencies. This leapfrog innovation will proliferate rapidly, slicing through our current infrastructure because of undeniable cost savings and improved outcomes especially for the underserved. These new telehealth technologies will become standard features of our lives, just as Skype and WhatsApp are now standard features for billions.

The door is wide open for globally-minded entrepreneurs and organizations to bring the much needed telehealth revolution to patients all over the world.

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jones

rebel on rails

Larry Jones: Telemedicine's Next Wave Belongs to the Programmers According to Larry Jones, CEO and founder of Telacare, telemedicine is in need of a backend overhaul. A computer programmer by training, Jones wants to fundamentally rethink the software backbone for how digital health gets delivered. as told to Logan Plaster

Telacare has about 30 employees and utilizes a network of about 750 providers, with an additional 1500 available if we need them. We cover every state where telemedicine is permitted, plus Puerto Rico.

We approach telemedicine differently.

In my opinion, telemedicine is nothing but technology. I mean, the whole term tele is referring to technology of some sort. I think the key points to remember with telehealth today: if you don’t have a strong technology base, you’re not going to be able to deliver to your clients.

On Entering the Telemedicine Market

I had brushed by a company that was offering Telemedicine. I got to see what they were doing and how they were doing it. And 24

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there was just such a huge issue with the way it was being delivered and utilized. There were actually no biometrics. There were no units. There were no measurements. One of my curiosities was: How do you tell if I have a fever? How do you tell if I’ve got respiratory issues? There was no answer to that question. No offense, I could be faking it.

Once I got a chance to see what was under the hood of their car, I sat down and talked to the telemedicine company about what they needed to change. Once they decided it was something they weren’t ready to do yet, it just made me say: You know what?

This is a great service. You don’t want to do it then I’m going to go do it.

The first thing I did before I even entered the telemedicine arena was actually go start working with biometric units and seeing about the connectivity and what could we use and what could we not use for a case setting inside a business.

On Telacare's current biometrics offerings

We currently have whole sit-down kiosks in pharmacies. We also have wall-mounted units, which are about 10.5 inches deep and about 2.5 feet wide with locked doors for the biometric units, which connect to a flat screen and a drop-down board. We came out with those years ago.

On gathering biometrics at home

We’re actually kind of excited about this.

We’re coming out with something this year, fourth quarter, which is going to enable the patients at home to plug a home kit into their computer for consultations with us.

Home has always been an expensive venture for telemedicine companies because you would have to get the mom or the dad or somebody to actually purchase the kit. But I think if you could get a low-cost enough kit, you’re still going to get into some of these homes.

On competing in a crowded telemedicine market

First off, we have zero venture capital. We don’t have to answer to a board. We don’t

have to answer to people who aren’t familiar with telemedicine and just gave us money.

So, we can still think outside the box. We are a free-thinking telehealth company. If something’s new, something’s inventive or something’s going to push the envelope in the telehealth arena, we can get up the next morning and start building it. If I’m a Teladoc or an MDLive, those innovations can easily get stuck on the drawing board.

What we see is these bigger telemedicine companies seem to be copying each other.

MDLive bought Breakthrough. Now the former CEO of Breakthrough is the head of psych for Teladoc. To me, if they’re going to keep copying each other, they’re not going to advance. We don’t care what they do. Telacare only cares about what’s the newest, the greatest and the hottest thing in telehealth. Teladoc just acquired HealthiestYou for $125 million, but they were only earning ten million a year and their app was built on third party APIs – there was nothing proprietary.

Also, what you’re going to find is that the Teladocs and American Wells and the MDLives are 90 percent made up of insurers and large Medicaid/Medicare companies and probably only ten percent general businesses. I, on the other hand, have no Medicaid/Medicare business or any insurance companies. I’m 100 percent made up of small to medium size businesses and consumers.

On Telacare's market differentiators

Our strength over the competition is in utilization. We have 40 percent utilization.

Compare that to some of the biggest players in the market, who are hitting around four percent utilization (rough estimate).

On Telacare's pricing structure

The big telemedicine players in the market have been competing on who could sell their services the lowest. Those guys were in the market saying: Well, I’ll do it for a quarter less. What they’re finding out now – thanks to Teledoc’s public data – is that this pricing structure might not be such a

good idea.

When we sold telemedicine, we said: Look, flat out, we have a minimum. Our minimum is five dollars. And people said: Oh, well, gosh, I can get it from Teladoc for two. And my response was: Get it. And in six months let’s see what your utilization is.

That’s what people did and that’s why they started coming back. Because they said: Look, you’re right. It’s not worth it. At two bucks if nobody uses it, I’m throwing two dollars out the window. I might as well pay three more and guarantee utilization.

On scaling up

Our current user base is in the seven figures, but everyone wants to be larger. My focus has never been on how many lives we can get, and “I’ve got more than you.” My thought process has always been: Am I doing it better than the other guys? Am I doing it right? And am I getting the results for my customers?

So in terms of scalability, yes, I would love to have ten million, 15 million, 20 million members; providing that I can still deliver the same great utilization and service that I do now. If I can’t, then no, I don’t want it. Because then all I’m doing is becoming another one of those giants who’s saying: Look at me, I’ve got all these big numbers but I’m still making no money and I’m not producing the service or the solution that I’m promising these people.

If my customer wants something tomorrow, I’ll build it. I guarantee it’s going to take many board meetings and discussions and roundtables before the big guys even get to the same spot to start building something. I’ll wake up tomorrow and tell my guys: Build the damn thing now. And we’ll build it. I’m still hungry and even after seven years haven’t lost that thought.

So I guess it just depends. Can I continue to do what I’m doing? I think yes. I think we can scale larger. And I think we can continue to deliver. We are profitable. We’re proud of that. We don’t have any venture capital.

I’m absolutely proud of that. We took on no debt. And for a telehealth company to be profitable, that means I have to be charging

We don’t have to answer to a board. We don’t have to answer to people who aren’t familiar with telemedicine and just gave us money. So, we can still think outside the box. We are a freethinking telehealth company. If something’s new, something’s inventive or something’s going to push the envelope in the telehealth arena, we can get up the next morning and start building it.

something and doing something correct.

On having a CEO with a tech background

I don’t think it matters if you went to Harvard or Chico State University. I think the determination, the drive, your vision is what matters. What makes me different?

I don’t have to do what you say. I have to do what my members say. And if my members say that they want it to be easier to sign up on the back-end, that’s what we’ll do.

When we built our systems, we made it so that it was a single sign-on, so that people didn’t have to worry about checking a box or looking in the spam folder or anything.

It’s simple things like that that I have the ability to take further than the other guys.

Customers need the KISS method. And as a tech guy, I can look at the KISS method and immediately see that we have a problem. We

are constantly evolving. We’re constantly changing. And I don’t think I sleep much because I’m always sitting there thinking: What can I do to make mine better or easier or more appealing? Because every day I have to go out and compete.

Put your company in the hands of an actual developer and let them have free creative reign. What you’re going to see is them continuously coming out with new products, new systems. Because a developer does not know how to sit still and they also sure don’t know how to let stuff get stagnant. They’re always trying to improve upon something that they have built. That’s just the mentality we have.

On the challenges of having a software developer at the helm

We’re stubborn. We would take longer sometimes because it’s never really done for us. Think about Steve Jobs, who took forever to come out with the Macintosh. That he wouldn’t go to market with it and he kept spending more money was one of the reasons he was let go. And of course what did they do later? They brought him back because they couldn’t make it work. Having a developer at the helm did pose a problem, but as a developer, you know when it’s ready and you know when it’s not. It’s not all about being first to market.

On Telacare's client base

My smallest client has five employees.

Two of the biggest telemedicine providers had told them they were too small, that they couldn’t help them. They called us and I said: I don’t care if you have one employee.

I’m happy to help you. At the end of the day, I don’t think people realize that two plus two does become four.

On Telacare's end game

I’m not going anywhere, I can tell you that. I sure as hell ain’t selling. I’m not hurting for money. I’m a happy guy. I got my wife and my three kids. And I enjoy getting up every day and doing what I’m doing. So, it really doesn’t matter what they want to offer me. www.telemedmag.com

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vision

hollander

the new normal

Let’s Own It – Emergency Physicians Are “The Availableists” EPs need to stop eschewing nonurgent medicine and embrace our role in modern healthcare as the docs who can truly handle anything at any time.

by Judd Hollander, MD

Do you remember the essay you wrote when you applied for medical school? It probably had little to do with emergency medicine (most people don’t know their specialty at that time) but it probably had a lot to do with helping people. It probably did not have a lot about what you want to be doing but rather had more to do with how you could help other people achieve their goals.

Do you remember the essay you wrote when you applied for residency? I remember mine (and I may actually have read yours). Most of you focused on learning to be a great clinician while developing the skill set to do some research and teach others. Almost all of you talked about how you will give back to others after training.

Now is your chance – the world of health care is changing.

First, there is a lack of concordance between when patients want care and when most health care providers want to deliver care. Emergency medicine is the only 24/7 26

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specialty without any screening process.

Anyone comes, any time. No-one prescreens them. We are always available.

Second, the payment models of the past are changing. There is movement from fee for service to value based care. Depending upon whether you are a glass half full or glass half empty person, you can see a future of shared risk or shared savings. In either case, it seems clear that health systems and providers will face increasing financial scrutiny for the quality of care they deliver and the cost associated with it.

Consumers buy products that they want, when they want them. Patients are purchasing acute care at a growing rate. Despite federal initiatives designed to improve linkage of patients to primary care providers, primary care visits are falling, while emergency department, urgent care and retail clinic visits are growing. Everyone has a smart phone and telemedicine is projected to be a 30 billion dollar industry within 4 years. There is survey data clearly demonstrating that cost and convenience is a higher patient priority than seeing their own primary care provider. Being open and available is the winning ticket. Being affordable adds more value.

Waiting for an appointment a couple days away does not excite the current consumer of health care.

I would like to suggest that emergency physicians are the solution to this problem.

We already control the most expensive decisions ever made – to admit (maybe tens of thousands of dollars) or discharge (less than a thousand dollars). Unfortunately, we don’t typically make that decision until patients have become more than a little sick. Were you ever on a shift when you wondered why someone did not intervene sooner? Why was this patient not able to be seen by someone else a couple days ago, even though they had primary providers? Even though they were insured? No one else was available. I believe we have a unique opportunity to be more available. Let’s go back to the ideals expressed in our essays. Let’s give patients what they want. Let’s be the Availableists.

We should never have another discussion about “inappropriate” visits. A health care

We should never have another discussion about “ inappropriate” visits. A health care system should provide health care. If large health systems don’t want to, the retail clinics will be happy to fill that niche . . . These non-life threatening visits are not inappropriate – they are totally appropriate for the patient trying to navigate a system that does not provide them with other options.

system should provide health care. If large health systems don’t want to, the retail clinics will be happy to fill that niche. CVS is the largest provider of health care in the US. Walmart wants that spot. These non-life threatening visits are not inappropriate – they are totally appropriate for the patient trying to navigate a system that does not provide them with other options. In fact, from a patient centered point of view it is smart. Mary was not fired from her job because she did not miss another day of work – she received her care in the ED after the work day ended. George came in at 3 in the morning – it was his “lunch hour” and he knew it would be less crowded than after his shift, when he needed to get his kids off to school. Although these were logical decisions for Mary and George, it is not very smart for the health care system to not provide any low cost options at the times convenient for patients.

How can we do this? At Jefferson (sorry about a little marketing, but I left my old job to do this, so I believe it is important), we have created the JeffConnect wheel.

Brendan Carr likes to call the left side of the wheel, the “pre-acute care” phase. Instead of waiting until people are sick or desperate enough to come to the ED, we can provide low cost care options that provide high value to patients. A combination of on-demand video visits with emergency physicians who are on call 24/7/365 and specially trained and dedicated to providing video based evaluations combined with conveniently located brick and mortar urgent care centers has provided the “little sick” with alternatives to the ED. In fact, less than 15% of our telehealth visits seek further care for that injury or illness and the majority of those referred to the ED receive a procedure or admission. Most patients never have to leave home or work. It costs less than one third of an ED co-pay.

I believe the true core competency of an emergency physician is being available.

Sure, we do critical care. Yes, we are experts at resuscitation. We also evaluate and treat ingrown nails, bronchitis, and sprains and strains. Our application essays said we wanted to help people. Even in the ED, the need we fill most is being available for everyone who needs us, most of whom don’t have a true medical emergency.

We now have a unique opportunity – the shift in patient priorities and payment reform has given it to us. We have always been available in the emergency department.

Now we should be available not just in the emergency department, but where our patients want us. It turns out that is increasingly likely to be in their backyards (urgent care or retail clinic) or on their phone (telemedicine). We should not define ourselves only in the acute care space. Let’s be also available in the pre-acute care phase when patients are just a “little sick”. While we are at it, there is ample opportunity to play a role in the post-acute care space. After all, we are always open, always available. We should never be asleep at the wheel. We are The Availableists.

The AMA, Telemedicine's Reluctant Advocate by aneel irfan

T

he American Medical Association (AMA) has had an up and down relationship with telemedicine. This tension was palpable at the association's annual meeting in June. On one end, AMA President James Madara, MD, made waves by stating that the tsunami of digital health tools and apps flooding the market amounted to modern day snake oil. He warned of the danger of developers who aren’t concerned or don’t know the potential health risks of these "un-validated toys.” Yet by the end of the meeting the AMA had passed a set of telemedicine ethical guidelines, thereby sanctioning the field in its own way.

Since 1847, the AMA has promoted scientific advancements in medicine, improved public health and made investments in enhancing the doctor/patient relationship. Throughout its history, the AMA has been actively involved in a variety of medical policy issues, from Medicare and HMOs to public health and climate change.

Between 1998 and 2011, the AMA spent $264 million on lobbyists, second only to the American Chamber of Commerce. Though many may say the AMA has lost a lot of its clout to state associations, the AMA’s influence is undeniable. Yet until recently, the AMA was lukewarm about using that influence in support of telemedicine.

Some of that hesitation came from the AMA's concern over the erosion of the doctor-patient relationship. Just a few years ago, the AMA's official position was that doctors must be physically present to provide proper care. Yet little by little, these positions have evolved.

The AMA now states that an in-person patient relationship must be formed before telemedicine can be used as a form of healthcare delivery. They also evolved their stance on providers having to be licensed in the state in which the patient is located.

In 2014 the AMA voted to approve a list of guiding principles for ensuring the appropriate coverage of, and payment for telemedicine services. The principles aimed to help foster innovation in the use of telemedicine; protect the patient-physician relationship; and promote improved care coordination and communication with medical homes. The guiding principles stemmed from a policy report developed by the AMA's Council on Medical Service addressing coverage and payment for telemedicine, which provided a robust background on the delivery of telemedicine.

It also outlined current coverage and telemedicine payment rules, a summary of specialty society practice guidelines, position statements on telemedicine, and case studies. All of these actions were solid movements forward for telemedicine; a sign the association is listening, learning and evolving their policies.

The AMA's Ethical Guidelines for Telemedicine At its annual meeting on June 13, the AMA adopted ethical guidelines for the use of telemedicine, affirming the organization’s support of the use of telemedicine technologies within the confines of certain ethical principles. The guidelines were adopted after several years of debate and solidify AMA’s support for providing medical care via telehealth technologies. Here are the recommendations from the proposed guidelines: Managing Conflicts of Interest •Physicians should disclose any financial or other interests in the telehealth/telemedicine application or service used by the physician and should manage or reduce potential conflicts of interest.

•Physicians should provide objective and accurate information when producing content for mobile health applications or services.

CONTINUED ON PAGE 43

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start - ups doctorpreneurs

W so doc, you want to be an entrepreneur?

by Dr. Vishaal Virani

Medical students and doctors typically plan out their career time lines as meticulously as Big Ben chimes on the hour. Though in a year when Big Ben has taken a break for some restoration work, perhaps it is time for entrepreneurial medical professionals to also take some time out to re-think their career goals.

hat happens when you medical career is progressing perfectly well but one day you get bitten by a bug. An entrepreneurial bug. This bug leaves a stubborn and lingering itch that seemingly will only be relieved with a dose of career uncertainty, and an injection of risk-taking behavior.

Doctors and medical students are increasingly encountering this bug, as it sweeps from Silicon Valley Eastwards. However, they are reacting in a variety of ways, and the lack of strict treatment guidelines is disconcerting for many. Some doctors get the entrepreneurial bug and immediately swap the scrubs for sweatshirts, the stethoscope for software programming. Some doctors get the bug and react by gradually building their startup whilst clutching reassuringly to the financial safety net of clinical work.

Others still stoically ignore the bug, and focus wholeheartedly on their first love of medicine, trying to fend off the philandering advances of this so-called entrepreneurial bug.

The reality is that there is no universal, one-size-fits-all answer to the big question of if and when to quit your clinical career to focus on a healthcare startup. The comforting truth, however, is that there are a number of successfully proven approaches to tackling this dilemma that is afflicting an increasing number of doctors. The common thread in all the stories below is that if you get the entrepreneurial bug, you will succumb to it. The real question is whether you succumb full-time or part-time.

In order to exemplify the variety of career paths taken by doctorpreneurs (doctors turned entrepreneurs!) here are several case studies to satisfy the medical profession's obsession with evidencebased decision making:

Doctorpreneurs, Unite! Doctorpreneurs is a global community for medical entrepreneurs based in the UK. Find interviews of doctors-turned-entrepreneurs, jobs in startups for doctors and medical students, as well as a regular podcast. www.doctorpreneurs.com 28

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Should you wade in to entrepreneurship part time or leap head first?

Here's what a few doctorpreneurs had to say: Stephanie Eltz, Founder of Doctify (photo opposite) has managed to continue her work as an orthopaedic surgeon whilst running a startup.

Jim Gray is an orthopaedic surgeon, Clinical Director of an NHS hospital, and Founder of Tuberosity.

Though he doesn't find three to be a crowd.

Jessica Mann, Co-Founder of TrialReach and ex-cardiologist, values her years in specialty medicine but now focuses exclusively on her startup.

"As a doctor, you have a duty towards your patients and your clinical work has to be prioritised above everything else. I would never compromise on that. I am 150% focused at the hospital. You have to be very organised and compromise on your life outside of work [to balance clinical and startup work]. Say goodbye to your friends and the pub. Investors will be concerned when you talk about balancing a clinical career and driving your business.

It’s not unusual for med tech companies at all but you have to make sure your absence is covered and that you add as much value as your full-time startup colleagues."

"The balance I have between my clinical, personal and my business life is complementary. I see the business as a hobby not a chore so I’ve got a healthy balance. I look forward to weekdays as Mondays bring emails about our startup [alongside a long list of patients and hospital management duties no doubt...]"

"It depends on how much sleep you need...but I think if you have a passion for either of them [medicine or your startup], at one point you will need to make a choice. I do think that you should be putting in a few years of seeing patients in the specialty you like because that is going to make you able to empathise with patients’ needs."

-Joshua Landy, Co-Founder of Figure 1 (photo opposite), says his Critical Care job adds crucial credibility to his startup.

"Yes, continuing to practice medicine is very important to me, both personally and professionally. I practice two weeks per month, so I essentially split my time between Figure 1 and the hospital.

Working side by side with an interdisciplinary team in the hospital, I learn how my colleagues work and what tools might be developed to help them. I definitely think that’s beneficial for Figure 1. It provides an important dimension to my role as Chief Medical Officer."

--Rupert Dunbar Rees, Founder of Outcomes Based Healthcare, has technically left medicine but says founding a healthcare startup is 'still doing medicine, just of a different kind' "A lot of us have been in that big dilemma around whether you leave medicine or not.

I eventually did [after working in general practice for several years]. On the team I’m the only one who has got that far down the line to leave medicine. Would I say I’ve left medicine? Probably not. I’d argue that we are all still doing medicine, just of a different kind. I got a long way down the track before I noticed that I was unhappy in my clinical medicine. My biggest piece of advice is, if you are having these feelings early, listen to them. There are lots of people who are very unhappy in medicine even though they are doing wonderful jobs. I personally would listen to those feelings."

Sean Duffy, Co-Founder of Omada Health, left medical school and went 'all-in' to his startup venture.

"So at first I paused my medical training, took a year off, and took another year off, and I had to make a choice.

Everything worth doing in life is harder than you imagine it to be, once you get going. As an entrepreneur you’re just fighting gravity each and every day, so it requires an all-in, full-in, dedicated approach I think."

-Jamie Wilson, Founder of HomeTouch and exPsychiatrist, valued the financial safety net that part-time medical work offered in the early days of his startup career.

"If you give up your other job [as a doctor] and then start a new company, and you have problems raising money, and you’re not bringing in sales, then you quickly arrive in a financially difficult position.

My advice would be, if you

possibly can, find some niche whereby you can continue earning some regular income, whether that’s locuming [parttime clinical work] or doing other work such as advisory work, that gives you flexibility.

Remember that most nonmedics do not have this option, so you are giving yourself an advantage.

Thom van Every, serial healthcare entrepreneur and ex-obstetrician, advises seizing the moment whilst still practicing medicine. Carpe Diem!

There is rarely a perfect moment to launch your entrepreneurial idea and you never have perfect information. But we are so lucky that we can do locums [part-time medical work] and earn income while developing our plans. Don’t delay!"

-Neil Bacon, ex-Nephrologist and Founder of iWantGreatCare, didn't want to merely 'dabble' with startups; he left medicine after practicing for several years to enter the startup world full-time.

"I'm not a believer in doing things on the side – in dabbling. From my perspective, you can’t mess around if you really want to make something happen. If you want to really do something properly, change the way things are done, it takes all your time and effort. Half-measures won’t cut it."

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start - ups trailblazers

telemedicine built by doctors, for doctors In Virginia, a medical society chooses a different path towards telemedicine, one which places a uniquely high priority on the value of the physician. But can their bootstrapped experiment in non-profit telemedicine survive in a crowded marketplace? by logan plaster

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hen Claudia Tellez moved from the north side of Chicago to the north side of Virginia to become the executive director of the Medical Society of Northern Virginia (MSNVA), she had no idea where the job would take her. The move to Virginia was driven in part by the desire to be nearer to family as her own family grew, but she was also seizing an opportunity to impact healthcare access for low income families by managing the MSNVA’s charitable foundation. What Tellez didn’t know nearly eight years ago was that this position would lead her to help start a trailblazing digital health program, DoctorsTelemed, the first telemedicine platform architected by a medical society as a service for its members.

When Tellez started her job with MSNVA, she recalls, it felt more like a social organization than anything else. She sat down with her board to look at how healthcare was changing and together they crafted a 10-year roadmap aimed at making the MSNVA a more proactive, service-oriented organization. Had they a crystal ball, that roadmap would have included the creation of remote care pathways and telemedicine 30

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solutions, but that would have to come later.

The turning point happened a couple years ago when Tellez and her team began to be asked to review telemedicine contracts.

Members of the MSNVA were slowly beginning to consider signing on with major telemedicine companies, such as Teladoc, American Well and MDLive. When Tellez dove into the fine print of those contracts, she was shocked at what she found.

“For us, it was appalling to see how much of the profit the big telemedicine providers were taking,” says Tellez. “We realized that a lot of the business models currently on the market are either based on taking income from the physician or are predicated on insurance reimbursement. Which we all know has been diminishing over time. We couldn’t’ turn a blind eye to this and just say that this is the way things are. There had to be another solution.”

So began a months-long search for a telemedicine platform that could be harnessed

by MSNVA for the benefit of its members. What they found was CloudVisit, a telemedicine software company located in picturesque town of Beacon, New York.

CloudVisit founder Daniel Gilbert, the son of a physician, appealed to Tellez and her team for his personal grasp of the modern medical practice.

“He really understands the challenges that independent practitioners face now days,” says Tellez.

Together, MSNVA and CloudVisit decided to build DoctorsTelemed, an in so doing laid down the gauntlet for medical societies everywhere.

Here’s how it works. DoctorsTelemed is a non-profit direct-to-consumer telemedicine service built for MSNVA members – who number about 1600 – and community physicians. The only telemedicine platform designed specifically by and for a medical society, DoctorsTelemed allows providers to join the platform and then offer DoctorsTelemed as a “service of convenience” to their patients.

Using the platform is similar to many

other direct-to-consumer telemedicine experiences. Patients create an account, fill out a medical history questionnaire and then find a doctor. Patients have control over which provider they want to access by scheduling a consult specifically with a physician of their choice. And if your clinician isn’t a part of the program, DoctorsTelemed encourages you to ask them to join, rather than simply using another physician online.

Once they’ve found a doctor, patients go through a payment portal. DoctorsTelemed doesn’t charge a registration fee for patients, relying instead on a credit-based fee structure for revenue. Patients can purchase credits (1 credit = $55) in advance or at the time a consult is requested. Most consults cost 1 credit, but can be more depending on the nature of the consult and the specialty requested.

All consults are stored safely for later access, and doctors can gain appropriate access to the medical record. In order to measure quality, patients are sent satisfaction surveys to fill out following each consultation. The results are analyzed for trends at least four times per year.

So far, you could be forgiven for confusing this product with others on the market.

The real differentiator comes on the backside of the visit – in reimbursement. DoctorsTelemed gives 95% of the income generated on the platform back to the physicians, and they’re currently charging no sign-on fee.

When asked if a 5% administrative fee was going to be sufficient and sustainable, Tellez was adamant.

“It’s totally sustainable. You can run the numbers. It’s no secret. If you do 10 visits times 10 doctors, at $55, there’s substantial income to be had,” says Tellez. “Since we don’t have shareholders, we don’t have to pay out dividends. Anything that is made is going to be reinvested in improving the product.”

The question remains whether this experiment will work in practice. DoctorsTelemed soft launched in January 2016 and then offi-

One of the greatest challenges for DoctorsTelemed has been directto-consumer engagement. They recently trialed a new bus stop campaign in the hopes of building consumer awareness.

cially rolled out the program in late May. In that time they’ve garnered only 15 patient subscribers and hosted 25 live sessions. According to Tellez, the goal for participation is 100 physicians by the end of 2016, with each conducting an average of four consults per week. If they hit their goal, those 1600 patient encounters will bring in approximately $4400 per month in administrative fees. Whether they can hit these targets, and whether these numbers can sustain operations, only time can tell.

“We have a timeline,” says Tellez. “We have two years of this. We’re going to give it our best shot.”

One the biggest challenges that Tellez has faced came as a surprise: marketing.

The initial plan for spreading the message focused on word of mouth – each board member was responsible for educating their peers. But Tellez quickly found that there was a startling lack of understanding among providers of telemedicine in general, and DoctorsTelemed in particular.

“When I say, like Facetime, their faces light up,” says Tellez. “Then they ask if they can use Facetime, which the answer is no.”

Because of this general lack of understanding, Tellez is monitoring the organizations marketing messages closely.

“We’re finding out that that has to be a very tight partnership between the providers and us. It’s not enough for them to just sign up. We need to be proactive, pushing

the solution to their patients. If this were a capital venture, they would have been ready with all of those tools and resources, but we are learning as we go. We need to help our physicians market the service. They can’t do it on their own.”

What is that marketing message? It comes down to one word: “Convenience.”

“We’ve tried several sound bites, but we’ve learned that people love the word convenience. You really have to convey the idea of convenience to people. Let’s think about the mom tied up at home with one sick child and one in the hand. When will she have time to get to the doctor? You have to spell that out for the patient. That’s a challenge we hadn’t anticipated, but it’s been a wonderful learning experience.”

Currently DoctorsTelemed is putting energy behind two marketing campaigns, including a bus shelter campaign and participation in community events.

When asked why it was advantageous for a telemedicine company to be run by a medical association, Tellez said it came down to one main concept: Trust.

“Patients trust their physicians,” says Tellez. “Physicians need to have a vehicle to maintain that trust. The differentiating factor for DoctorsTelemed is that, since we are regionally focused, if a patient wants to see their doctor in person, they can. If you sign up for Teladoc or American Well, you never know where the provider will be. You might

get a doctor from a different state or region.

On a related note, continuity of care is also a big deal. When our doctors sign up, they can make use of community labs and local hospitals. That’s a big differentiator. It’s not just a one-off consult.”

While sign-ups have been slow, and the team is small, MSNVA has a unique leg up as a non-profit – access to grant funding. DoctorsTelemed received a shot in the arm from a recent grant for charity care, designed to help them extend telemedicine services to patients with the greatest financial needs in Northern Virginia.

“Those little victories are really energizing our members.”

The question remains as to whether this pathway for telemedicine adoption is superior to the more market-driven, for-profit offerings in the industry. And, by extension, is the MSNVA’s lead one that other medical societies should follow? When asked this directly, Tellez responding that starting a telemedicine company wasn’t for everyone, but that most medical societies did need a change in perspective.

“I think medical societies need to change the way they’re doing business,” says Tellez.

“I think they cannot be social in nature anymore. They cannot spend more than 60% of their focus on policy, because policy is in flux, and I don’t know how much impact doctors have on policy, because of the AMA’s grip in that area. If medical societies want to survive, they need to be more invested in delivering a real service. It doesn’t have to be the same model that we have, but it has to include very strong information to educate physicians to take the right path for them. How do you maximize your time as a provider? If organized medicine isn’t carrying that message I think they’re doing a disservice to their members. Sure, technology is intimidating, but they need to dive a little deeper beneath the surface and get with the program.”

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start - ups post - mortem

sometimes being 'better' still isn't good enough The health tech start-up Better seemed to be hitting all the right notes. Backed by a starstudded cast of founders and partner institutions, Better aimed to help consumers manage the complexities of the healthcare system. So why did they have to close their doors in 2015? by rishi madhok, md

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ver the past years, there have been a flurry of successful healthcare and insurance start ups working directly with consumers to help cut through the jargon and difficulties of insurance and accessing healthcare. We’ve seen many of these early companies raise hundreds of million dollars in funding and have been successfully in getting buy-in from key healthcare institutions as well as patients.

It makes sense. Take the convoluted, outdated, high touch structure of medicine and provide experts, technology, and resources to improve the experience. This approach improves outcomes, introduces efficiency, all while meeting the demands of reducing cost.

It's almost too obvious of a solution. Are you not palm to face right now asking “why didn’t someone think of this sooner?”

Of course someone did. The focus of this post-mortem is Better, a health care start up based out of Palo Alto, which tried just that and unfortunately shuttered its digital doors in 2015.

Let’s take a closer look at what Better offered. From their original press release, 32

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t 'Better' CEO and founder Geoffrey Clapp had all the right ingredients, from concept to collaborations to cash. But he lacked one critical element: Good timing.

Better staked their territory as “a consumer health start-up which offers a Personal Health Assistant service for people to manage the complexity of healthcare in order to focus on being well." In collaboration with Mayo Clinic, Better was built to offer tailored advice to users – on demand and mobile friendly. "Blending world-class medical expertise with technology and design, Better's founding team includes executives from some of the world's most successful health technology and consumer Internet companies” Seems to make sense. As their CEO and founder, Geoff Clapp, described: Better wanted to be the AAA of healthcare. The message was right. Their partnership, and investment came from the Mayo Clinic venture arm and Social + Capital Partnership.

Clear vision: check. Solves a present problem: check. Technology in place: check. Initial funding: check. Strategic partnerships: check.

So far it all looks good. Maybe this was a leadership issue? However, Geoff Clapp was no stranger to healthcare or start ups. In fact, he co-founded Health Hero Network, one of the earliest telehealth service providers that was acquired by Bosch in 2007 and continued to operate until 2015.

Strong leadership and direction: check Perhaps this was a case of startup hype: over promising services and a solution that they were not ready to meet. It doesn’t seem

so in Better’s case. A review from their LinkedIn page is one of many examples of how Better met its promise, if not exceeded it. On discussing Better’s service, one user reported using the Personal Health Assistant for "Recommending activities and books to nurture my toddler; Finding a pediatric dentist for my daughter; Making doctor appointments on my behalf; Finding weekend running clubs for myself; Researching Paleo Diet and answering questions; Researching apps that provide accurate nutritional information; Assessing my nutrition and designing a meal plan; [and] finding dance classes for my toddler."

In fact, Better’s customers seemed loyal, happy, and eventually heartbroken when they ceased their service.

So what happened?

Better’s problem was simply one of Timing. When Better launched their service they were solving a problem in a market that had not yet defined itself. It’s value could not be quantified. It had nothing to compare itself to and so further investment pitches were met with lack luster interest.

Investors and partners understood that Better was on to something, but could not grasp what that something was and more importantly its true value. In the end, despite having so much going right for it, Better fizzled because the market just wasn’t ready for it. When interviewed, one of Better’s investors described the reaction to Better’s pitch as “crickets” when meeting with potential investors. Fast forward to today, perhaps the story would be very different.

connected communities

Smith Island, which sits 12 miles off the coast of Maryland in the Chesapeake Bay, has no bridges or air strip, making medical transfers both expensive and time-consuming.

Smith Island Offers a Case Study in the Challenges of Rural Telemedicine Development A unique partnership seeks to bring telemedicine to one of America's most remote island communities. The biggest challenge so far has been supplying fast, reliable internet connectivity at a price a small town can afford. by michael levin-epstein

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n 84-year-old woman was experiencing dizziness and, according to her daughter, literally bouncing off the walls. So the daughter called Kerry Palakanis, DNP, NP-C, head of the Crisfield Clinic, who was aware of the mother’s history. Palakanis immediately became concerned that the 84-year-old woman had had a stroke.

Under ordinary circumstances, providers in Palakanis’s situation would have asked the daughter to bring her mother to the clinic as soon as possible. But these were photo by Patrick J. Hendrickson / Highcamera.com

hardly ordinary circumstances. The mother and daughter lived on Smith Island (population 276), 10 miles offshore in the Chesapeake Bay in Maryland, which is reachable, even in the best of circumstances, only by boat or helicopter. Once in Crisfield, patients still need to find a taxi or other vehicle to get them to the clinic, which then could lead to a possible consult with a physician in Baltimore.

But because of gale-force winds and ice, the circumstances were less than ideal. If Palakanis had the requisite telemedicine

equipment available at the clinic, she would have been able to adequately evaluate the patient and, if the weather had cleared, determine whether to request a helicopter to transport her. As it turned out, it took three days for the weather to improve enough for the mother to be able to get on a boat to cross the bay. The woman, in fact, had had a stroke, and Palakanis was forced to deal with its tragic aftermath.

Palakanis was determined to do everything in her power to make sure that this kind of situation didn’t occur again. She began a partnership with Ellumen, an Arlington, Virginia-based IT company specializing in developing medical imaging for health care systems, and University of Maryland Medical Center’s Telehealth Office, to secure telehealth equipment for the clinic and establish an Internet link to the island (see box, page 34).

With the proper telehealth equipment and optimal broadband capacity, Palakanis would have been able to better manage the case of the stroke victim, and deal with more routine care situations, says Ellumen project manager Dan Bray. Smith Island residents could be trained to take blood pressure readings and engage in video consultations, he says, in a variety of settings.

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dermatologists to examine spots on the skin to determine if they are cancerous.” In addition, telehealth carts provide the ability to conduct more complicated procedures, such as sonograms. “All of this can be done without anybody having to leave the island and that’s really significant when weather prevents patients from getting off the island in the first place,” he adds.

A Work in Progress

The project to bring telehealth to Smith Island is still a work in progress. When completed, the project is expected not only to reduce costs but provide better service to all residents while serving as a model for telemedicine in other remote areas, according to Bray.

The project is far from completion principally because of a pesky bandwidth issue.

“It’s not so much a question of needing more bandwidth,” Bray explains, but “its reliability.” The Smith Island bandwidth experience provided Ellumen with an understanding of what many resident in rural areas experience every day—having to deal with cable and telephone companies that can be as much as part of the problem as the solution. “We were able to go in and help straighten out Dr. Palakanis’s network inhouse at the clinic, but that led to us identifying problems with the actual cable and landline providers,” he notes.

“You’d think running cables or putting up a wireless link at Smith Island would be relatively easy,” says Bray. However, he says, it’s not that simple. The locals — including the mayor, city manager, and zoning authorities — have been “extremely helpful,” he explains, but the regulatory issues have remained problematic.

Built-In Inefficiencies

There are built-in inefficiencies in our current telecommunications regulatory rubric, asserts Bray. Although the bandwidth is available, it’s too costly to implement 34

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origin story

How the Smith Island Project Got Underway The Smith Island Telehealth Project began several years ago when Ellumen CEO Bill McCollough moved to rural Virginia, explains company president Art Carroll: “Bill also happens to be our chief scientist and he assumed that when he moved there, he’d be able to continue conducting his research remotely from home.

But he couldn’t get a strong enough Internet connection. During this same time period, Bill and Mary (Vogel) had a meeting at the Mid-Atlantic Telehealth Resource Center (MATRC). It just happened, that the MATRC representatives that they met with that day, had just gotten off the phone with Dr. Palakanis, who then put Mary in touch with Kerry. That’s how this project was launched.”

Kornak explains how the University of Maryland Medical Center became involved in the project: “Our Department of Psychiatry has been integrating more telemedicine to pediatric primary care offices where we would ultimately provide equipment into the primary care office, as well as be able

to extend services. About three years ago we placed equipment in Kerry’s Crisfield office where patients or children could ultimately have a telemental health session with our child and adolescent behavioral health group remotely over telemedicine, so that the patients wouldn’t have to drive the couple hours in. We placed that equipment in Crisfield. We worked with the local IT groups, to make sure that we had a decent connection.

We did experience some video and audio issues during those sessions.

So we inevitably work with Kerry on trying to get that fixed. And obviously, that’s being fixed now with the work with Ellumen. Basically, University of Maryland Medical Center was going to provide those psychiatry services for this program, once it kind of rolled out. And there’s obviously been some issues around regulatory as well as some school-based telemedicine initiatives with the Maryland Health Care Commission as well as the Department of Mental Health and Mental Hygiene, which Kerry is continuing to strive and have interesting conversations with certain individuals to try to get these issues and problems worked out.”

and the project managers are continuing to work with regulators to find an acceptable financial solution.

“In rural areas, where you don’t need extensive service, it’s very expensive to buy at a high volume,” Bray explains. “So we’re looking at how to stitch together different locations, thinking beyond just solving this link out to Smith Island—trying to afford to buy the bandwidth that makes it all work for everybody—“Bray says. The project’s long and winding journey has had less to do with technical issues, and more to do with the regulatory situations in rural areas, emphasizes Bray. The bottom line: “It’s been a learning experience. If it were easy to do, it would have already been done.”

To accentuate the point about technology, Bray refers to the fiber optic backbone in Crisfield that goes right through the center of town. The fiber backbone literally runs adjacent to the clinic. This backbone was built primarily with federal grant funds under the policy of extending broadband capacity.

Unfortunately, Bray says, the cost to get her hooked up to Internet is prohibitive.

“If you’re only buying a small slice of bandwidth, it’s expensive. But if you’re buying a lot of bandwidth, it’s a much less costly proposition."

follow the money

Who’s Paying for Smith Island's Telemedicine?

John Kornak and the University of Maryland Medical Center worked with Kerry Palakanis and the Crisfield Clinic and a video teleconferencing vendor to investigate grants, including a Department of Agriculture distance learning and telemedicine grant, which was awarded several years ago. Palakanis is paying for the bandwidth/Internet connections from her own funds. She acquired the telemedicine equipment grant from the USDA DLT grant, which provided the equipment not only for the Crisfield office, but for Smith Island and six schools in the county. She’s using the AMD telemedicine carts for the project. Ellumen has paid out of pocket for supporting the investigation and plan for the Internet connection.

Building Your Own Towers?

The partnership is trying to solve this problem by thinking outside the box.

“We’re examining building our own towers to link to Smith Island because no one has put any money into the current infrastructure for half a century. But we really can’t afford to do that, unless we’re buying enough bandwidth to make it cost effective,” says Bray. That’s why this issue is bigger than just an Internet link. “If there were jobs for technical professionals who were using the bandwidth, you could get the price down, but you can’t get those people to come to Smith Island until you have the bandwidth,” he explains. “That’s the chicken-and-egg problem.”

Ellumen views this as a kind of a pilot program, Bray says. “We’re not aware of anyone who has cracked the code. There are wireless ISP providers delivering service in

photo by Patrick J. Hendrickson / Highcamera.com

rural areas — but not at a price point and a reliability standpoint that meets the modern needs.”

The Role of the Feds

The Federal Government can be a major player in this space. The Federal Trade Commission and the Department of Agriculture are investing millions of dollars to encourage businesses to service rural areas, says Mary Vogel, Vice President. Client Solutions, at Ellumen.

In Maryland last year, for example, the Feds used only $30,000 of the millions available in grants for that purpose. “And if that doesn’t point to something that’s just totally screwed up, I don’t know what else would.”

The grants are administered through the Universal Service Administrative Company (USAC), explains John Kornak, Telehealth Director at the University of Maryland Medical Center. USAC provides about $400 million worth of funding annually to develop cheaper broadband, Internet, telecommunication services in rural healthcare locations, schools, and libraries.

“If there’s grant money available, and yet you can’t get people that can put together the right combination of solution to the economic, technical and regulatory environment, there’s something that needs to be changed in the way it’s structured,” says Bray. Finances are clearly an issue, the partners in the project all agree.

It’s been a while since the incident with the stroke victim, but the telehealth solution is still a top priority for Palakanis. She provides a current example: “A Smith Island resident with a cardiac history was visiting friends near Annapolis and experienced a cardiac event. He went to the hospital when he was seen by a cardiologist or pulmonologist, is back down in my community, which is about two hours away on the island. He had his testing done, while he was up there and he needs to go back up this week for a follow-up. And I explained to him that he really shouldn’t have to get in the car and drive two hours for follow-up, which could be performed by telemedicine. The telemedicine equipment has the ability for that cardiologist and pulmonologist to evaluate him on the island, if we can create that link.

Follow-ups are a classic point of access for patients when the higher-level testing like CAT Scans or nuclear stress tests have been performed in a hospital facility. And this is a patient that’s coming in after the fact for either routine follow-up or follow-up for recording and testing. They don’t necessarily have to be physically present with that provider. My peripherals allow for EKGs and spirometry and a stethoscope that enables cardiac and pulmonary assessment.”

Palakanis concludes: “All of that can be done by telemedicine and could be instrumental in keeping people out of readmission situations, as well as preventive healthcare.”

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curs because we are licensed in their state and also credentialed and privileged in their hospitals. In all instances we are able to respond to emergent conditions as they arise. tm:

The eHospital: Avera Sets Out to Build the Ultimate Telemedicine Hub After entering the telemedicine arena in 1993 with a service called eConsult, Avera has grown to be one of the nation's most robust telemedicine hubs, servicing 31 hospitals through eight distinct service lines – including eEmergency. Telemedicine caught up with Dr. Brian Skow, executive medical director of the eCare hub in Sioux Falls, South Dakota, to learn about Avera's operations. interview by logan plaster

magazine: Describe your eCare “hub”. This is a somewhat novel concept, even in the telemedicine space. telemedicine

brian skow:

Here at our eCARE hub, our service lines consist of eEmergency, eICU, ePharmacy, eLongTermCare, which is our nursing homes; eCorrections, which is prisons; our eSchoolNurse, our eConsultative service and AveraNow, which is our direct to consumer play, partnered with American Well. tm:

Tell us a bit more specifically about eEmergency skow:

eEmergency is our largest service line. We use high definition audio and vi36

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sual equipment and it links emergency departments across our nation to board certified emergency physicians and in addition, emergency certified nurses at a centralized hub called eCARE. By pushing a red emergency button, the rural hospitals have immediate access to our eCARE staff for collaborative and peer-to-peer support for their local rural providers. And this occurs 24/7. Once our eEmergency video feed is live, our local rural emergency department determines what level of involvement they would like. They request the type of support they need for each patient. Our eEmergency physicians then can render decisions regarding what type of treatment when the local provider is not yet present.

We can work with the nurses. And this oc-

What makes Avera’s eCare unique in the telemedicine market?

skow: It’s our suite of services. We have a team of 20 telemedicine board certified emergency physicians. And we’re providing support and guidance on patient care and we’re using our high definition cameras that have 20 times zoom capacity. Over the camera we can read an EKG from across the room; we can zoom into a GlideScope screen. We have the capacity even to read your iPhone if we needed from across the room. In addition we have a remote control where we can preset monitors. So for example if we’re on live with the facility, we can lock into a Lifepak, a vital signs monitor, their airway and just a broad view of the room through our camera with the push of a button. We’re also logged directly to their EMR. So in real time we can review labs, patient information. In many cases we’re alerted to a critical lab just by logging into their EMR. We can alert the providers and nurses that we need to treat something. In addition we’re logged in directly to their Xray machines. So we review images in real time shortly after the X-ray or CT is completed. tm:

That’s eEmergency. What are some of the other services that you offer? skow:

One thing we offer which is quite popular in the rural setting is our nursing documentation. This allows the local nurses to stay at the bedside and treat the patient while we perform all the documentation for them directly. We can directly enter it into their EMR or we can fax or scan it to them.

At the end of the call they have all the documentation. What will happen is during a code, they’ll yell out where the IV’s going, what the bolus is, what meds are given in our nurse’s to document for them on our end. [Read a full rundown of eCare's service lines in the box on page 37].

on the menu

tm:

How do you handle privacy concerns when you talk about basically live-streaming every patient encounter?

skow: None of the video calls are recorded.

So we’re documenting just by listening to the audio, in addition to seeing what they’re doing. For example if they’re placing an IV in the right antecubital, we can see that over the camera. In fact we can zoom into the IV, see what color it is and document what gauge it is on their documentation. tm:

What long does it take for a spoke site to get up and running? skow:

Before we go live, we perform a full site assessment. We send a team to the rural hospital and collect all their contact information, their typical transfer patterns, what flight services do they use. We go through their entire emergency department and determine what equipment they have already and what they may need in the future. We also look what medications they have so that we’ll have it all on file during a video consultation. We also look at lab capabilities, because not all labs can get a lactic acid.

In those situations where we have a septic patient, we don’t even ask if they can get it because we know they can’t. And then we look at their ancillary services, including CAT Scan, ultrasound, anesthesia; to see what do they have available to call in if we need it. tm:

Why aren’t more regions doing this?

I’m guessing the barrier to entry is the complexity of stitching together this whole ecosystem. How were you able to create the holistic system? skow: We have 31 hospitals that are associ-

ated with our main hospital and the majority are critical access hospitals. We started off seven years ago just with three sites. We asked: “What can we do to keep patients in their local facilities, to be admitted there?”

Typically patients do better in their hometowns. And how can we keep them in their local hospitals by assisting the rural hospitals? This also increases their revenue by keeping their patients local. So it all started

A Sampling of What Avera Offers Its Rural Hospital Partners TRANSFER SUPPORT When we have a sick patient, we can call in the rotor-wing or the fixedwing to support them.

We have our log books, where we know typically what flight service they use; what their preference is; where there’s a transferring facility. We can call in the rapid transfer support even prior to the patient arrival to their emergency department.

In addition to calling in the transport vehicle, we’ll also contact an accepting physician for them at the local trauma center. We can give the accepting physician the full story. And we can get the name of the accepting physician and directly over the camera give them the name for their transfer form.

BEHAVIORAL ASSESSMENT The behavioral assessment team is available 24/7 to evaluate psychiatric patients. Over the camera, our counselors will come in and determine if the patient would require in-patient or out-patient therapy.

When they do require

in-patient – or maybe they’re suicidal and on a hold – the next step is finding a bed. What we can do on our end is look at the geographical map of all the behavioral health centers that have an in-patient facility, determine which is closest, call them and see if they have a bed. Many times they’re full and it takes multiple phone calls, calling multiple facilities and occasionally this process can take up to two to three hours.

TEST INTERPRETATION We can zoom in on the EKG monitor and I can read an EKG before it pops off on paper. I can determine if it’s a STEMI or not just by zooming into the screen. In addition we assist with X-ray interpretation, CT interpretation. If a site would like us to review a CT prior to getting the virtual or vRad read, we can give them a wet read.

Because sometimes it’ll take up to 30 minutes, up to an hour to get a read back.

PROCEDURAL ASSISTANCE We provide procedural assistance for the local providers: the nurse practitioners, the PAs. This includes airway management, chest tube placements, central line placements, joint reduction, conscious sedation, to name a few. We also have quality initiatives set up so they can meet all of their CMS guidelines.

Some of our quality initiatives include: chest pain, stroke, sepsis and airway. We’re involved in the NEAR study, which is a national emergency airway registry. Our goal is to improve the first pass attempt of intubation at our rural facilities.

TELE-BURN We have the capacity to provide burn center referrals. We can three-way camera in a burn surgeon.

We’re partnered with a major burn center. And we can give the burn surgeon the opportunity to evaluate the burn in real time. Occasionally they’ll determine if it would meet a burn center criteria and give recommendations on how to CONTINUED ON PAGE 39

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as a need that we found in our local rural hospitals. tm: Talk to us about the reimbursement/fee

structure.

skow: It’s a monthly fee model, per facility.

We didn’t want to limit the button pushes.

For example, we’re happy to take a look at a rash at 4:00 in the morning. If we charged on a per click model, that rash might not make the cut. But what if the patient also had a fever and it happened to be meningococcemia? Well, that could potentially be a lethal rash. If we’re limiting button pushes by having the local facility pay per button push, we might have missed that case. It’s a fee per month and there’s no limitation on how many times they can push the button.

However, what we’ve found is that throughout our 140 eER sites and 255 cameras that we have out there, the sites are really using us appropriately. We’re typically involved in five percent of their total census volume. So, they’re pushing the button only for the sickest of the sick patients. The monthly cost is based on the facility and typically not off of volume, because for example a facility that sees 12,000 a month might only use us two to three percent of the time while a facility that sees 5,000 a month might use us ten percent of the time. However we do have grants available and the majority of our rural hospitals do receive grant funding initially. We receive a lot of support through the Leona M. and Harry B. Helmsley Charitable Trust.

tm: What kind of numbers do you have showing specific cost savings? skow:

They can put it on their Medicare cost report, which reduces the annual expense by 30 percent. In addition we’ve found that the billing for hospitals that utilize eEmergency increased from a range of 100 to 200 per visit and also increases ancillary services. So we look at an annual impact per site of revenue of $15,000. We also reduce the transfers; 25 percent is our average for reduced transfers. Which in these cases an annual net revenue can be cal38

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culated around $25,000. We also are seeing workforce retention. When our eEmergency board certified docs are in consultation with nurse practitioners and PAs, there’s less burnout because they have backup. In fact, we’ve had PAs and nurse practitioners that have worked in our facilities and when they’ve left and gone to a facility that doesn’t have eEmergency, one of their first questions is: When are they getting it? It’s similar to vRad. When a radiologist goes out and interviews, they want to make sure they have that nighttime coverage. So through eEmergency we can provide that similar support. tm:

Physicians in other regions might say that they want this support, but they might not have the charitable trust. How critical is that element? skow:

We’re able to sell it to rural facilities without the grant support. It’s approximately the cost of one full time nurse. And just through our nursing documentation piece alone, that’s almost a full nurse FTE. In addition, we’re providing the physician support also.

tm: Is this a sustainable business outside of the grants and the charitable trust? skow:

Yep. When we first started eEmergency, one of the goals is we had the support of the trust but we wanted to get to a point where we were supporting ourselves.

And to get to that point, we needed to be established in at least 60 to 80 eEmergency facilities and we’re above that now. So without the support to get there, to that point, that was kind of our breakeven area.

tm: And how long did it take to reach that sustainability marker?

skow: It took three to four years.

tm: How big would you guys like to get?

How far beyond the region do you want to expand? skow:

Typically what we do is we look at a

critical access hospital map and say: Where are the most critical access hospitals? In addition to the Midwest we are also in New Hampshire and Vermont, as our furthest East location. In regards to expansion, we’re open to expanding to wherever the need is at. tm:

Do you also expand by dropping in local eEmergency centers for providers? Or do you just have one main facility for that?

skow: That’s a good question. How we’ve structured it is we have a centralized eEmergency hub, where all of our physicians and nurses work. So we have the capacity with a number of physicians and nurses here in Sioux Falls to continue growth to multiple states.

tm: As a work environment, the eEmergency hub that you’ve created seems really unique. Emergency physicians and emergency nurses coming to work in a high-tech non-hospital environment, where they’re dealing with physicians over video but they themselves are in a room somewhere else.

That’s sort of a new healthcare paradigm.

Do the physicians get to collaborate on cases with one another? What would you say are some of the unique aspects of that hub environment?

skow: There are many unique aspects in regards to collaboration at the eCare hub.

We’ve had for example a case where our long-term care facility, staffed by fellowship-trained geriatricians had a case in a nursing home where a patient had fallen and hit her head. She’s on Coumadin and went unresponsive. So we saw that case over the camera. That case was transferred to the local rural emergency department, where we have cameras. So now it went from long-term care to an eEmergency call. So we determined that we needed rapid airway assessment, intubated, got our flight team there. From that point, she went from the rural critical access hospital to our main campus, where we also have a camera in our trauma room. So this is her third camera interaction. So now she’s in eEmergency

more from the avera e-care menu of services camera number two, where we assist with the nursing documentation for the trauma code. When she was stabilized in the ER, she is transferred up to our intensive care unit; where our eICU intensivist was on board. So in one building we were able to give direct hand-off from geriatrician to ER physician to the intensivist and we’re all communicating under one roof.

tm: And there’s actually communication offline? Do physicians get up and talk to one another during these cases? skow:

Absolutely. We’re just a few steps away in the one building here. You can just take a few steps over and give the short story or do it over the phone if you’re busy at that point. tm:

How many people work in your hub facility? skow: We probably have over 200. tm:

How do you find the clinicians feel about that work environment? skow:

Telemedicine isn’t for everybody.

When we interview our partners, what we look for is what we call a telepresence: somebody that interacts well in front of the camera and is aware of their visual cues.

We also offer media and camera training for our staff before they go live because not everybody is always a good fit. In addition, there’s really a big customer service piece for our facilities that you may not see as much in the main ER. In addition, we don’t take new graduates. We wait until you’re board certified and typically at least three to four years out of training. We want you to get your feet wet before we put you in front of the cameras. tm: Any recent memorable cases? skow:

Recently we had a button push for a rattlesnake bite and this was in our Badlands of South Dakota, near the Mt. Rushmore area. It was a young mother and her daughter that were on a afternoon hike when they

CONTINUED FROM PAGE 37

treat the burn in their local facility.

E-PHARMACY We have ePharmacists on staff. The pharmacists help us here in the ER for consultations for toxicology cases, titrating drips, things like that. We just recently had a calcium channel blocker overdose, where we had to titrate an insulin drip up above 100 units an hour and start a D-70 drip and transfer the patient to a major center that has ECMO.

CRITICAL INCIDENT STRESS DEBRIEFING What we found early on is that many times these small communities know all the patients in the town. So when a death, a cardiac arrest, a pediatric trauma comes into the ER, a lot of times they’re related or they know

them quite well. Following a disaster and major trauma, or death, we can call the critical incident stress debriefing team in 24/7 to assist. We’re able to bring our pastoral care in and go ahead and debrief them and provide them the support that they need.

DISASTER TREE ACTIVATION We have a list of all of the staff at the hospital in our computers. Where we used this most recently was when we had a tornado tear through one of our local rural facilities and we were able to go through the disaster tree activation and call the people in that needed to come to assist.

EDUCATIONAL SUPPORT We have a cloud-based site that covers a range

stumbled across a den of rattlesnakes. The mother was bitten multiple times in the lower extremity. The daughter was able to help drag her away from the snakes; called 911. And at that point the red button on the wall was pushed. She arrived. She is unstable. She was in shock. We went ahead and administered the anti-venom, the Crofab. And she went into full-blown anaphylaxis. Over our cameras we are able to see the airway – our Glidescopes are attached directly to our cameras – just as if we were there intubated ourselves. Unfortunately, the patient’s airway completed swelled shut. It was a failed airway. We were unable to intubate. At that point, we had our flight team and two family practice doctors

of topics. Approximately 300 clinicians throughout our footprint access our educational cloud monthly. In addition we have what we call a simulation truck, which is essentially a large semi that is loaded with educational equipment; some simulation dummies and computers. When we identify that a site may want more education on airway or chest tube placement, we can take the sim truck and drive it to the state that they’re in and train the local staff.

We tailor all these educational opportunities for each site. Let’s say we have a nurse practitioner who hasn't done a chest tube in five years and wasn't as familiar with the procedure on her last pass as we would have liked.

We can offer them that educational opportunity.

– each of whom have the capacity to do a trich but hadn’t done one in multiple years.

Using our handheld camera, we were able to peer right above the neck and identify landmarks and essentially walk them through a complete cricothyroidotomy. We were able to get the airway in the patient. The patient was flown to our facility and she walked out of our hospital just a few days later, completely neurologically intact.

And these are some of the procedures that we’re able to assist with over the camera; that we’re experienced in, that the local providers, nurse practitioners or PAs just don’t get that exposure to like we do from our training.

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from velodrome to home: how one datadriven olympian is ushering in the 'quantified life' In Conversation with Sky Christopherson

by John Tyler Allen

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the quantified life

In 1996, Sky Christopherson was one of the promising young cyclists in Project ’96, the ambitious development program built around Lance Armstrong and expected to redeem USA Cycling’s embarrassing performance at the ’88 and ‘92 Olympic games. In 2009, with his Olympic-level intensity now focused on building an Internet startup, he worked himself into the back of an ambulance with a tightness in his chest and pain in his shoulder. Two years later he broke a track cycling world record in the 200-meter sprint, a physiological coup made possible by an experimental program leveraging health tracking and data analytics.

I

n the just-released documentary Personal Gold, Christopherson convincingly proves the program reproducible when he leverages the same data-rich approach to help a ragtag women’s pursuit team win the first USA Cycling medal in twenty years. Soon, he says, his digital health and performance consulting company, OAthlete (short for Optimized Athlete), will make the same analysis available in an app capable of turning our mountains of self-quantifying data into meaningful insights.

On a recent August evening, Christopherson took a call from his office outside Los Angeles and, starting from the beginning, outlined his plan to optimize our health like never before.

-------“I left [cycling] very frustrated with the doping problem. It was so apparent on our team. At that time – that was in the late 90s to 2000 – you could tell, night and day, who was doping and who wasn’t. It www.telemedmag.com

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the quantified life

was really frustrating because when you’re not, you’re getting sick and injured. Quite a few of us retired really frustrated and just put sport behind us.

“I started an Internet company up in Seattle. I dove into that with blinders on, pushing the limits in every way we could: thirty-six hour coding sessions, pulling all nighters, all these things that are worn as a badge of honor in startup culture. After two years of doing that, my body just started falling apart. I ended up in an ambulance thinking I was having a heart attack. I went to the hospital and they did the full heart attack CT scan with contrast and all this. And even though it ended up being stress, they couldn’t differentiate it from heart attack symptoms.

“The doctor who I met with in a couple minutes – literally, it was a two-minute conversation – had a list of drugs I could use: ‘Here’s how to lower your blood pressure, here’s how to lower anxiety….’ I felt like I was right back where I was when I left sport. This guy was standing here saying, ‘Here’s some pills to solve these things.’ And I thought, there’s got to be a better way, here.

“It was serendipitous that, a month later, I went to San Diego and saw Dr. Eric Topol giving this TEDx Talk about this data-driven health revolution. I was literally on the edge of my seat. I talked to Dr. Topol afterwards. I wanted to do a one-year experiment where we re-prioritized sleeping, nutrition, and exercise.

“I not only got my health back, but started training again, hitting times that were better than when I was in my twenties. I decided to go for a world record that was held by a guy who had a lifetime ban for drugs. I broke that record that fall. That’s really when I thought, wow, this data can impact the way we train and the way we make decisions every day in a way that, I think, can get the most unique potential out of each individual.

“I connected with my old teammate Jennie Reed and she basically said, ‘Hey, I’m putting this pursuit team together, we’re going for a medal.’ They had never ridden in the Olympics together before. We talked and I said, yeah, let’s give it a shot, let’s try to set you guys up with some of the same data.

“The British team, before London, had – it was rumored – custom beds made, and they were shipping the beds around with them.

And they had different devices they were using to computer model the surface of the track. Being on a budget, we had none of that. We only had consumer-available devices. And, in a way, that was kind of beautiful.

“For example, we had no way to understand sleep quality, so we used the Zeo sleep managing headband, which pulled the EEG activity from the forehead. In the case of Jennie, especially, we saw way better performance the next day when she was hitting better deep sleep numbers when we cooled her mattress with a water-circulated pad.

“But our data was siloed. Each device had its app and a database.

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Our focus is really on using data to leverage the natural strengths of our bodies.

-Sky Christopherson

Ultimately, the most important thing was getting [the data] out of those silos, getting it into a personal data model for each athlete.

[Big data analytics company] Datameer, created a circular relationship diagram for us, which is a beautiful visual way of seeing how different lifestyle areas affect one another. These are like puzzle pieces.

We were getting a new kind of data and putting that into a model, looking at it in this unified, holistic way, and then making interventions for each individual. That’s the key model, right there.

“We’re now looking to impact a much broader population, and, of course, that’s going to mean people outside of elite sport. We’re doing market research and seeing a huge gap. Consumer devices like FitBit, they’re doing step tracking really well. MyFitnessPal tracks diet really well. A lot of the other apps are made by engineers in Silicon Valley, and there’s this gap in taking this data and figuring out how it’s relevant to human performance or human health.

“With OAthlete, we’re developing an app that utilizes data from FitBit, Misfit, Jawbone, Withings, all these accessible consumer devices…and making recommendations, giving people insights about what that data means in terms of their lifestyle, their daily routine, and what they can change. Sometimes it’s simple stuff. You like eating pizza or a big meal? Ok, you usually eat that for dinner. Just move that and eat it after your workout where you need this glycogen replenishment and have a smaller meal before bed. Or, you usually go for a walk in the afternoon to get sunlight? Move that walk to the morning where we see sunlight in the eyes impacts your hormones and your sleep patterns, your circadian rhythms. Simple things like that can have huge improvements in people.

“When you look at the numbers, the people who were utilizing pharmaceuticals not just for essential disease management or acute issues – I would call it life doping, where people want better performance and more energy…Putting the ethical part of drugs aside, you look at its impact on systems in the body. You’re always going to have side effects. You’re going to have your body adjusting to things. In a sense, you’re weakening your body’s own natural systems by adding, exogenously, these substances. Our focus is really on using data to leverage the natural strengths of our bodies.

“If we could have doctors, in a sense, prescribing an app like this, it

would be so powerful. Sometimes doctors become resigned or cynical about the daily lifestyle choices of their patients. I understand behavior change is a hard thing and some of these patients are dug in and it may not work – it depends on the patient.

“An n=4,000 study was the biggest, most recent look into how people are using these digital health apps. The biggest percentage of longer term engaged app users right now are people who had a recent health scare or have gone into the hospital, right? They go in and they get scared, and they suddenly get motivated to take real action. They’re like, ‘Screw this, I’m not going back to this bed again.

What do I have to do?’

“These people are hungry, they’re motivated. If we can address that group, if the doctor can prescribe the app and then finally get answers about those everyday puzzle pieces…. We call it the four pillars: sleep, exercise, nutrition, and wellbeing or happiness. Our app, basically, is a circular interface, twenty-four hours a day, and it shows

ama

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Privacy and Security •The telehealth application or services must have appropriate protocols to protect the security of patient information and prevent unauthorized access to such information both throughout the electronic encounter and during any subsequent provision of care.

Patient Information •Physicians should inform users about any limitations resulting from care being provided via telemedicine, advise patients on how to arrange for follow-up care when medically indicated, and encourage users to inform their primary care physicians about the telemedicine consultation.

Standards of Care •Physicians should uphold the standards of professionalism expected for in-person interactions and adhere to applicable law governing the practice of telemedicine.

•Physicians should be proficient in the use of relevant technologies.

•Given the inability to conduct a physical examination, physicians should ensure that they have sufficient information to make well-informed clinical recommendations.

you right there when you should eat a meal and what you should eat. When should you exercise and what should you do? Let’s say you get a bad night’s sleep, do you take a nap? When do you take a nap? These are the daily decisions, as athletes, we’re trying to figure out. As a patient, if you want to prevent disease or be healthy, it’s the same equation, the same puzzle pieces…. We hope, by building this app and using the existing data people are getting, we’re able to actually share these insights and recommendations that, currently, are just really scarce in the market right now.

“We have an alpha [version]. We’re talking with investors about our first seed round. The film is finished, the narrative is established, and we feel as though the technology is finally there in ways it wasn’t four years ago when devices were less accurate, harder to use, APIs maybe didn’t even exist yet. This is the time. We’re looking at a seed from an investor in Silicon Valley and we’re going to get the first version built sometime next year”

•Physicians should be “prudent” in carrying out evaluation or prescribing medications by confirming the patient’s identity, confirming that telemedicine services are appropriate given the patient’s circumstances and medical needs, evaluating the appropriateness and safety of any prescription, and documenting the diagnostic evaluation and prescription.

•When physicians would otherwise be expected to obtain informed consent, physicians should tailor the informed consent process to provide information about telemedicine features.

•Physicians should promote continuity of care and information sharing with the patient’s primary provider or other specialists.

Professional Organizations/Health Care Institutions •Through their professional organizations and health care institutions, physicians should support refinement to telemedicine technologies, advocate for policies to •Improve access to telemedicine services, and monitor the telemedicine landscape.

Which brings us to The AMA’s most important recent stance, the recommendation of the requirement of telemedicine training in medical schools. The disconnect has been that our upcoming healthcare workforce usually do not receive any

training on the emergence of digital health tools like telemedicine in their everyday clinical work or how to leverage them correctly in practicing medicine. Most of them are not learning how to work with patients virtually. Specifically, the nuances, the best practices, the rights, the wrongs and most importantly, the rules. These best practices exist – teaching institutions, much like telemedicine itself, have just not fully achieved widespread adoption into their curriculum. It’s not just at the medical school level either. Nursing students, health IT & and other healthcare workers are usually not receiving telehealth training or basic understanding either. Telemedicine organizations and some medical boards have been working to build this educational backbone, but this new institutional support from the AMA is pivotal.

It is vital to collectively make the push for this increased access to this evolving type of education for all stakeholders. So one day, there will be technology clarity, proof in the validity of our tech offerings, with clear, defined, widely accepted guidelines for providers and AMA’s skepticism towards telemedicine turned to trust.

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Telemedicine

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the list

teleSCOPE ----Orlando Health www.orlandohealth.com Page 9 telePHARMACY ----Catholic Health Initiatives www.catholichealthinitiatives. org/telemedicine Page 10 Castlight Health www.castlighthealth.com Page 11 teleFERTILITY ----Groove www.readytogroove.com Page 12

The companies and brands mentioned in this issue.

Respond Well www.respondwell.com Page 14 Reflexion Health www.reflexionhealth.com Page 14 Rezoom www.irezoom.com Page 14 teleTECH ----Clinicloud www.clinicloud.com Page 15

Digisight www.digisight.net Page 16

Willow Health www.joinwillow.comww.j Page 12

Smart Vision Labs www.smartvisionlabs.com Page 17

OvaTemp www.ovatemp.com Page 12

Hapifork www.hapi.com Page 18

Maven www.mavenclinic.com Page 12

The Genie www.genie.cooking Page 18

teleCHRONIC DISEASE ----Ochsner Health System www.ochsner.org Page 13

SmartPlate www.getsmartplate.com Page 19

teleREHAB ----Telespine www.telespine.com Page 14 Simple Therapy www.simpletherapy.com Page 14

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teleVISION ----Teladoc www.teladoc.com Page 21 Telecare www.telecarecorp.com Page 24

Features ----Doctorpreneaurs www.doctorpreneurs.com Page 28 Doctify www.doctify.co.uk Page 29 Figure 1 www.figure1.com Page 29

Sponsors ----Teladoc www.teladoc.com Page 2 Zipnosis www.zipnosis.com Page 20 National Fingerprint Inc. nationalfingerprinting.com Page 44

Outcomesbasedhealthcare www. outcomesbasedhealthcare. com Page 29

NuPhysicia www.nuphysicia.com Page 44

Omada Health www.omadahealth.com Page 29

Avera Health www.avera.org Page 45

I Want Geat Care www.iwantgreatcare.org Page 29

JSA Healthcare www.jsahealthcare.com Page 45

Cloud Visit www.cloudvisittm.com Page 30

Mhealth Toolbox www.mhealthtoolbox.com Page 46

Doctors Telemed www.doctorstelemed.org Page 30

IMST Telehealth Resources www.imsttelehealth.com Page 47

Ellumen www.ellumen.com Page 34

CirrusMD www.cirrusmd.com Page 47

Avera Health www.avera.org Page 36

Ellumen www.ellumen.com Page 52

O Athlete www.oathlete.com Page 40

learn more at www.telemedmag.com

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Service Provider Showcase June 21-22 Phoenix, AZ

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South Central Telehealth Summit August 1-2 Nashville, TN

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contact Eliseo Rivera: Eliseo@telemedmag.com www.telemedmag.com

49

tele

port

Inheriting the Right Stuff Before there were Fitbits and Teladocs there was Apollo 13 and Skylab. If you want to gain some perspective on the future of wearable health tracking, take a look back at the industry's high flying pioneers.

by Nicholas Genes, MD, PhD

W

earable trackers of vital sign and activity levels. Data streams. Doctors on demand to deliver remote diagnoses. The future of digital medicine may look a lot like the space program's past.

Remote biometric monitoring was a part of the first missions beyond Earth’s atmosphere – back when it was an open question whether humans could survive the stresses of a launch and re-entry, or if we could properly function in microgravity.

Starting in 1961, the Mercury astronauts had hundreds of readings of blood pressure, pulse, respiration and EKG tracings collected during their brief missions. Astronauts also held regular "private medical conferences" with ground-based physicians, on a separate channel from Mission Control – a policy NASA has continued through today.

With Gemini, the missions grew longer – and the medical monitoring increased. Sleep, balance and nutrition tracking began, and the first medical experiments were conducted on astronauts.

In the Apollo missions, health tracking was facilitated by a biosensor harness that delivered near-real-time telemetry back to Mission Control. It was these harnesses that first indicated the urosepsis fever experienced by Apollo 13 astronaut Fred Haise (he downplayed the symptoms to Mission Control's flight surgeon).

As Apollo gave way to Skylab, then the Space Shuttle, monitoring and telemedicine capabilities grew more sophisticated.

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The Shuttle's Telemedicine Instrumentation Pack was a carryon-sized computer that facilitated remote physical exam, including the capture and forwarding of eye and ear images, and heart, lung and bowel sounds.

Telemedicine capabilities developed for space travel have been turned toward Earth-based emergencies, such as earthquakes in Mexico City (1985) and more significantly, Armenia (1988) where NASA leveraged its satellite network, A/V equipment and clinical protocols to permit US clinicians to see and treat hundreds of earthquake survivors.

Still, you'd be hard-pressed to come up with many insights into the future of earthbound digital medicine based on decades of monitoring astronauts. After all, most astronauts are healthy, fit, and relatively young individuals. Even in an environment that causes motion sickness, headaches related to fluid redistribution, renal colic, and UTIs, astronauts seem to experience medical emergencies well below the rate of the general population.

Maybe the best thing the space program's medical experience can give us is perspective. As new telemedicine services are rolled out across the country, as the data collected by consumer fitness trackers and wearable monitors continues to grow, we may take some solace. Whatever questions we still have about digital medicine's safety, effectiveness, accuracy, or reliability pale in comparison to the challenges facing NASA engineers, and the risks faced by the astronauts. Sometimes we have to remember, pushing forward requires not just planning and study but bravery, and maybe just a bit of the right stuff.

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