The Latest in Remote Presence.

Yulun Wang, Ph.D., Chairman & CEO of InTouch Health and President-Elect of the American Telemedicine Association

By Yulun Wang, Ph.D., Chairman & CEO of InTouch Health

The need to provide high quality healthcare to everyone, while reducing costs, has reached a crisis level where it is a major focus at the highest government level.   More and more politicians and healthcare leaders are realizing that telemedicine is clearly a cornerstone of the solution.  This is tangibly seen by the increasing number of healthcare systems that are adopting telemedicine, by the growth of ATA, and by industry investing in telemedicine products and services.  I believe that telemedicine is now reaching an “inflection point” where the industry will grow at an exponential pace.  We are realizing that if one can bring the right clinical expertise, to the right place, at the right time, to make the right medical decision in a cost effective manner; quality can be improved while cost lowered.

Although the concept of telemedicine is simple and elegant, implementing telemedicine can be complex and messy.  This is not unexpected as fundamental change in any industry is never easy and without obstacles.  As one works to implement telemedicine in order to benefit from this enabling technology, one quickly uncovers the many challenges in actually building telemedicine programs.   Barriers created by existing payment structures, regulatory policies, IT architectures, corporate boundaries, resistance to change, and technology limitations, all need to be overcome.   It is these barriers or challenges, coupled with the significant potential value that can be created, which makes telemedicine ripe for innovators and entrepreneurs.   I believe that with persistent innovation, usually accompanied with the risk of capital, entrepreneurs can overcome these barriers and unleash the benefits of telemedicine into our healthcare delivery system.

To succeed in creating positive change I believe in the “divide and conquer” theory.  Trying to orchestrate a singular fundamental change to our healthcare delivery system to incorporate telemedicine systemically is too monumental a task, and will likely fail.  The pathway for entrepreneurs to innovate successfully is to find appropriately sized healthcare workflow challenges which can benefit from telemedicine solutions, and then work to gain adoption by healthcare providers.   With adoption, the entrepreneur can continue to build on that success and expand the vision and market opportunity.

As the telemedicine industry grows, applications are partitioned into two broad categories differentiated by the health status and location of the patient.   The first category we call “acute care telemedicine”, in which telemedicine is used to enable remote clinicians to immediately diagnose and treat sick patients.  These patients may be very sick and require immediate help from a specialist who is difficult to access.   The second category can be called “chronic disease management telemedicine”, where telemedicine is used to periodically and regularly monitor and manage a person’s chronic illness.

The needs of the telemedicine solution and the economic model vary greatly across these two categories.    Telemedicine solutions for acute care must enable a remote clinician to be interactively present in the patient environment and gather pertinent medical information through examination and data access to form a medical decision. Often, this decision can have significant (e.g. life or death) consequences.   If the remote clinician is the physician-in-charge, then the system must enable the physician to lead and establish dominion over the complete environment.  Conversely, telemedicine for chronic disease management generally does not require acute medical decision making, and the interactions are more coaching and mentoring in nature.    These solutions often connect healthcare providers into patient’s homes and therefore must scale cost effectively to a single patient/single system mode.

Telemedicine entrepreneurs should identify opportunities where they can innovate manageable-sized solutions that create significant value for the healthcare providers.  Still change is always difficult, particularly in the field of medicine where process and procedures are honed and perfected over decades to insure every patient receives consistently high quality care.   Therefore the solution must solve the problem in its entirety for adoption to occur.  For example, solutions should not be limited to technology alone, but rather need to be coupled with clinical protocols, business plans, training and implementation services, regulatory assistance, and even the ongoing monitoring and measuring of the solutions impact.  The level of multi-disciplinary depth and detail required to facilitate a change can tax even the most persistent entrepreneurs.

Healthcare is in a seismic state of transition that hasn’t been seen for many decades.  The fundamental goal of changing from “fee for service” to “fee for value”, and competitive pressures re-aligned to drive continued improvement of the quality/cost value curve, is enabling telemedicine to transition from a research topic to mainstream medicine.   Generational changes like these happen infrequently, and should be embraced by adventurous entrepreneurs.  We are at a time when the need for innovation and entrepreneurism in telemedicine is at a maximum!

Franklin, North Carolina is a town with just 4,000 residents, located on the historic Appalachian Trail in the southwest corner of the state. The town is famous for its gem mining, including rubies and sapphires. But this community has found something far more valuable: a life-saving connection to the Mission Health telestroke network.

Mission Health reached a major milestone recently when Dr. Alex Schneider, the program director in Asheville, used a remote presence robot dubbed “IC4U” to conduct the network’s 100^th telestroke consultation. The patient was at a facility in Franklin, a 90-minute drive from the hub hospital. Without access to a telestroke network, that patient would have lost 180 million brain cells just getting to Asheville.

The American Stroke Association estimates that only 3 to 5 percent of those who suffer a stroke reach the hospital in time to be candidates for thrombolytic treatment. But the Mission Health program has an astounding 43 percent success rate.

“Treating our 100^th telestroke patient represents a momentous milestone for Mission Health,” says Schneider. “It’s evidence of the strides we are making in bringing timely, expert care to rural neighborhoods throughout western North Carolina.”

In its long history, Franklin, North Carolina has been home to Cherokee Indian councils and colonial era gem miners. But no sapphire discovery can compare to a program that offers Franklin residents an eight-fold greater chance of receiving timely t-PA treatment.

The Mission Health telestroke network serves Franklin, North Carolina, using a remote presence robot with this custom license plate.

The first chapter in telemedicine was about providing care where it was urgently needed, especially in under-served rural communities. But now we’re seeing breakthroughs in how care is delivered, where remote specialists work closely with onsite clinicians as if they were actually present in the room.

Team-based care requires technologies that are seamless and easy to use. And our new RP-VITA remote presence robot is taking ease of use to the next level with its environmental awareness and autonomous capabilities. Simply by tapping a tablet screen, a clinician can select a destination (such as the ICU) and RP-VITA undocks and goes there independently.

Upon arrival, RP-VITA coordinates the care provided by a multidisciplinary team – some local, some remote. Not only does RP-VITA transform collaborative care, but it adds a new layer of clinical value by serving as a force multiplier to existing onsite staff. In short, RP-VITA brings healthcare’s long-sought triple aim into reach: improving healthcare access to entire populations, reducing per-capita costs, and dramatically enhancing the patient experience (both quality and satisfaction).

Here’s an example of how RP-VITA coordinates care in the ICU:

At 7:25 a.m., a clinician taps an iPad screen and RP-VITA automatically undocks and moves on its own to the ICU. The robot displays patient data to the onsite nurse, respiratory therapist and case manager – and makes that same information available to a remote critical care physician and pharmacist. Soon a radiologist joins in the collaborative effort as the team details daily goals. RP-VITA then moves independently to the next patient, and eventually returns to its charging station.

RP-VITA is helping to ensure that technology, people and processes are all “on the same page,” delivering superbly coordinated care that leads to better outcomes and lower costs.

To see a video animation of the RP-VITA coordinating the delivery of multidisciplinary team-based care at a hospital sometime in the near future, click here.

Hoboken, New Jersey, USA – October 31, 2012

After Hurricane Sandy, we heard plenty of stories about heroic first responders from police and fire departments, not to mention the tireless utility crews. But there were plenty of tele-responders, too.

One New Jersey doctor went the extra mile to do a remote presence telestroke consultation – and there’s a man who probably owes him his life.

In the aftermath of Sandy, neurologist Robert Felberg was stuck without power at his Morristown. N.J. home. About the only thing working was his land line, and the call he received was urgent: an elderly patient at Holy Name Medical Center in Teaneck had just suffered a stroke and the ED doctor needed a teleconsultation.

Although Felberg was only 32 miles from the hospital, it might as well have been 3,000. Downed trees and power lines made travel impossible. So Dr. Felberg jumped in his pickup truck and started zig-zagging through neighbors’ yards. He finally found a strong enough 4G signal to do the teleconsultation. Felberg confirmed the on-site physician’s decision to initiate tPA. Within 48 hours, the patient was doing well enough to be discharged.

The InTouch Telemedicine System can be used from virtually any location.

Both Holy Name and Felberg’s own hospital (Overlook Medical Center in Summit, N.J.) never lost power during or after the storm because they planned ahead, making sure there was ample power from generators. “If there’s an award for bravery for prevention, these guys should get it,” he said.

That’s a theme echoed in a paper entitled “Tele-ICU During A Disaster” by Dr. H. Neal Reynolds and colleagues that ran in the Nov. 2011 issue of the journal Telemedicine and e-Health. The paper chronicled how an intensivist was able to stay in close communication with on-site hospitalists and nursing staff following a series of blizzards in Baltimore in 2009-10.

The article concludes that if a health system already has a telemedicine network in place, the organization can simply extend those capabilities to disaster support when needed. But the key is to be prepared. If Holy Name hadn’t established a remote presence network in the first place, Dr. Felberg’s gallant efforts would have fallen short.

As police and firefighters know, bravery will only get you so far. Teleheroes – like all first responders – need to be ready in advance.

To read a full account of the story in the New Jersey Star Ledger, click here.

Colin Angle, CEO iRobot

Colin Angle, chairman and CEO of iRobot, doesn’t like to get too future-struck when there are marvels all around him. The RP-VITA platform that iRobot helped create is indeed an astonishing achievement, so he’d prefer to savor that for a moment before speculating on the future of telemedicine robotics.

In a recent interview, Angle noted that in many ways, the future has arrived with RP-VITA. “It’s the first robotic system in telemedicine that offers environmental awareness, self-navigation and autonomy – and that’s a huge leap forward,” he said.

Just a decade ago, creating a system that makes long-distance collaboration “better than being there” seemed out of reach. Now it’s here with RP-VITA, where real-time patient data and sophisticated networking make it possible.

“We’re just beginning to tap the potential of a system that enables the world’s top specialists to consult with physicians in small hospitals anywhere in the world,” said Angle.

Because RP-VITA creates almost limitless possibilities, we couldn’t resist asking Colin a few questions about robots’ future role in healthcare.

In Colin’s view, there’s no reason why robots can’t function like today’s medical assistants, escorting people to waiting rooms and taking vitals. And he predicts that robots’ embedded sensing capabilities will improve dramatically in the years ahead. “Humans have thousands of sensors in their fingers that provide very good qualitative data,” he said. “But a robot with even fifty sensors can provide very useful quantitative data to make diagnoses more accurate.”

But enough with the crystal ball. We don’t want future-gazing to steal the spotlight from today’s achievements. By making robots autonomous, RP-VITA is a major milestone in the history of telemedicine.

At first glance, Skype would seem like a wonderful medium for telemedicine. There are now about 180 million Skype users worldwide taking advantage of its free communications capabilities. People rave about its ease of use. So why not use this popular tool for telemedicine?

Before you hop on the Skype bandwagon, here are some great reasons to avoid it like the plague in a healthcare application:

It’s a lawsuit magnet – Skype isn’t HIPAA-compliant, so it doesn’t meet the federal requirements for ensuring the confidentiality of patient data. If you use Skype in a healthcare setting, you’ll soon be hearing the click of attorneys’ briefcases.

Risk of losing or abusing patient data – If hackers delight in stealing celebrities’ smartphone photos, think how much fun they’ll have hijacking their lab results.

No oversight – Information passed back and forth on consumer platforms like Skype and Tango can’t be effectively documented and managed by a hospital CIO or quality leaders. And if healthcare data can’t be integrated and shared, doesn’t that defeat the whole purpose of team-based care?

The technology is unsafe – More worms and spyware infect computers via Skype than any other source except for music file-sharing. You may get some successful teleconsultations under your belt, but is it worth the risk of crashing your entire network?

The connection is low-grade and unreliable – Skype doesn’t offer interoperability with other video programs, and transmission quality is sometimes poor.

Risk of impersonation – Although Skype uses digital certificates for log-in, there’s no guarantee that the person you’re speaking with is really a doctor. So theoretically, an actor from Scrubs could approve your next surgery.

Those are some pretty serious drawbacks in an industry as litigious and regulated as healthcare. Skype might be a great medium for business meetings, but it’s a toxic tool for telemedicine.

The city of Craigavon in Northern Ireland is synonymous with “new” because it was built from scratch in the 1960s to lure business away from Belfast. It’s Northern Ireland’s equivalent of Portland, Oregon, with greenways and bike paths abounding. Perhaps that’s why Craigavon was receptive to another great innovation: remote presence technology.

The RP-7  serving Craigavon Area Hospital is the UK’s first telemedicine robot – and it’s helping improve care at Daisy Hill Hospital 20 miles away.

It’s part of a new healthcare blueprint called “Transforming Your Care” compiled by John Compton, CEO of Northern Ireland’s Health & Social Care board. This forward-looking plan aims to dramatically improve “high dependency care” for patients who are very ill but not quite ICU material. And that’s where the RP-7 comes in.

Dr. Charles McAllister and other intensivists at Craigavon are using the RP-7 to closely monitor patients in Daisy Hill’s 10-bed high dependency unit. That means that fewer of them need to be transported to the Craigavon ICU.

Dr. Shane Moan at Daisy Hill was skeptical at first, but now he’s a big fan of remote presence technology. “You can get a huge amount of information from the robot,” he says. “You get realtime information from the monitor, and you can see the patient up close in high definition. You can also listen to the patient’s lungs and heart through a stethoscope at the back of the robot.”

Dr. McAllister reports that patients have quickly warmed to the RP-7. “They understand that having an intensivist virtually at the bedside is a real benefit to them,” he said.

“The remote presence robot is at the cutting edge of innovation in our health service,” says health minister Edwin Poots. “And it makes the best use of our health resources.”

Northern Ireland’s population is aging, and remote presence helps deliver the highest quality care while keeping transport to a minimum. It’s probably just a matter of time until local celebrities like 67-year-old rock legend Van Morrison start using it.

To see BBC coverage of the remote presence intensivists care at Daisy Hill Hospital, click here.

The RP-7 allows intensivists to treat more critical care patients at multiple hospital locations.

Information provided by the U.S. Centers for Disease Control and Prevention.

We’re all aware that the number of strokes per year in the U.S. is about to cross the 800,000 threshold, but it’s shocking to see how much of that is concentrated in the Southeast region.

Just take a look at this map of the “Stroke Belt” to see how bad it’s gotten in Dixie. It makes you wonder what folks in Phoenix, Minneapolis, and Albany are doing right – and why that success can’t be repeated in the South.

When you take a closer look, you’ll see that many of the nation’s stroke “hot spots” are in underserved areas like northern Maine and in rural parts of the Pacific Northwest. But the South is where you see ample evidence of a double-whammy: a large number of rural communities that don’t have access to advanced stroke care, plus the nation’s highest rates of obesity and high blood pressure.

You’d think that most hospitals in the Southeast would be staffing up on stroke specialists left and right, but many simply can’t afford the high cost of on-site neurointensivists. That’s why telemedicine has such a huge role to play in turning the Stroke Belt into the Southern Success Zone.

Although some sections of the country are more stroke-prone, that doesn’t diminish the need for telestroke capabilities in every community. New Mexico may have enviable stroke statistics, but that doesn’t mean much to someone experiencing a possible stroke in a small town like Portales or Hobbs. Survival trumps statistics every time.

This map makes one thing crystal-clear: hospitals in the South must implement telestroke programs with an urgency akin to D-Day. This year, the number of stroke deaths will be enough to fill two NFL stadiums. That’s totally unacceptable. It’s time to declare war on stroke, with telestroke programs leading the charge.

The first-ever WIRED Health Conference in New York last week was an ideal forum for spreading the word about the latest innovations in telestroke and teleICU programs. ITH’s Charlie Huiner spoke at the conference, along with Yulun Wang (via RP-VITA) from Santa Barbara.

You may be sick of that overused phrase “thought leader,” but that’s exactly the type of person this conference draws. Most of the attendees could have easily worn badges saying “guru” or “visionary.” So there’s no better place to change the hearts and minds of the world’s healthcare elite.

Yulun and Charlie shared the stage with some notable names like genomics pioneer Craig Venter and Harvard’s Nicholas Christakis. But their mission there was not to bask in the limelight but to amplify the conference theme: using realtime data to drive healthcare decision-making.

InTouch Health’s RP-VITA

The InTouch presentation was something of a coming out party for RP-VITA, showcasing its environmental awareness capabilities. The ITH presenters noted that coordinated care at most hospitals remains elusive, and demonstrated how RP-VITA can help make it a reality.

Each year in the U.S., 100,000 lives are lost due to medical errors and miscommunication. By providing team-based care and easy documentation, RP-VITA can dramatically reduce those errors and missteps.

Conference attendees marveled at how RP-VITA can undock automatically and glide to a bedside on its own – all from a tap on an iPad. (Don’t forget that most of WIRED’s editors like Steven Levy are longtime fans of R2-D2.)

Thanks to the InTouch presentation, the WIRED world has a clearer understanding of how telestroke and teleICU programs can make healthcare decision-making faster, more accurate and less expensive. Click here to see the live stream of the InTouch presentation.

Telemedicine can help unclog crowded Emergency Departments.

There are basically two ways to run an Emergency Department. Most are designed like the Department of Motor Vehicles where you sign in and wait for service. The emerging way is to use the Grand Central Station model, where the ED is the service hub. People don’t hang out at Grand Central; they get quickly routed to the places they need to go.

Today’s most innovative EDs are using this hub approach to better serve patients – and remote presence plays a vital role in that process. For too long, Emergency Departments have seen themselves as the hospital’s front door, not the center of the entire enterprise. But a hub-style ED offers a host of benefits: more efficient workflow, better resource utilization, greater throughput, and higher quality care.

In a hub-style ED, the idea is to quickly triage and route each patient to the most appropriate care setting. How does telemedicine help? For starters, it provides better service for the ED’s most frequent users: behavioral health and pain management patients, plus those who rely on the ED for routine primary care. Because those patients aren’t in critical condition, they often sit for hours waiting to be seen. But with remote presence, they can get high-quality care without clogging up the ED. A remote physician can quickly make an assessment through devices like the RP-7i robot. That means that ED physicians have more time for patients with life-threatening emergencies.

It’s obvious that the most expensive resource in today’s ED is the provider. Highly trained ED physicians and nurses have more pressing things to do than treat sinus infections or try to determine whether a patient is depressed (especially when a behavioral health professional can be reached quickly with remote presence).

So the choice is clear: your ED can either be a plodding DMV or a fast-paced hub capable of delivering higher throughput and better care while improving the hospital’s bottom line.