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!

Accountable Care Organizations and telemedicine have a common purpose: expanding access to improve care. According to a recent CDC report, 80% of adults who visit the ER do so because they lack access to other providers. Telemedicine not only provides that access, but it makes it easy to provide the post-visit patient monitoring so vital to the ACOs’ main mission: managing high-risk populations.

Telemedicine-driven ACOs hold a lot of promise, but that didn’t stop several Harvard University pundits from prematurely proclaiming their demise.

In a recent Wall Street Journal article titled “The Coming Failure of Accountable Care,” Harvard prof Clayton Christensen and colleagues painted a gloomy picture. But they were quickly countered by Joseph Kvedar, MD from the Center for Connected Health. After careful reflection, we agree with Dr. Joe.

In Kvedar’s view, the Harvard gang incorrectly labels ACOs as “latter-day health maintenance organizations.” But HMOs were driven primarily by health plans that lacked the tools for delivery reform. In contrast, ACOs are provider-driven, offering a fresh vision for population-based care delivery and reimbursement.

The Harvard gang feels that doctors’ attitudes won’t change enough to make ACOs successful. But Kvedar notes that many physicians are weary of the fee-for-service grind, and are very receptive to things like shared savings, bundled payments and full capitation.

However, Kvedar and the Ivy Leaguers agree on one key point: to fulfill the promise of ACOs, patient attitudes must dramatically change. Many Americans still don’t feel compelled to hit the gym and avoid the cheeseburgers to rein in the cost of preventable, chronic illness. Millions of us cling to a sedentary lifestyle, then expect the healthcare system to fix us. That mindset will obviously have to change for ACOs to have a fighting chance.

Christensen and his Harvard associates are like baseball fans who write their team off in May. But, hey, the season is still young – and both telemedicine and ACOs have bright prospects. Dr. Kvedar feels that they could be the healthcare equivalent of the Baltimore Orioles: an unexpected success. Telemedicine-empowered ACOs can win the hearts and minds of physicians – and they can make money.

As every sports fan knows, you just have to believe.

In telemedicine, it’s imperative for all mobile devices to conform to HIPAA guidelines.

Like most professionals, physicians enjoy using mobile devices. By some estimates, 90% of doctors are already using them at the point of care. And while they like smartphones, they love tablets like the iPad and iPad mini. The latter is rapidly becoming physicians’ mobile tool of choice because its roughly 8 x 5 inch dimensions make it easy to slip in a pocket, yet it’s far better for data entry than a smartphone.

This stampede toward tablets goes by two names in healthcare IT circles: bring your own device (BYOD) and corporately owned/personally enabled (COPE) devices. Most hospitals, long the domain of intranets and bulky laptops, are finally giving physicians what they want…which leads us to the trendiest acronym of all: mobile device management (MDM), where vendors and IT folks support multiple user profiles and secure document sharing.

Unfortunately, many do-it-yourself telemedicine programs and telecom companies have bypassed MDM altogether – and that can be disastrous in healthcare. It’s imperative for all mobile devices used in telemedicine to conform to HIPAA guidelines for patient privacy and secure messaging and imaging.

We’ve all seen media reports about celebrities whose smartphones have been hacked. Imagine the scandal that would erupt if Brad Pitt’s MRI results were suddenly available on the Internet – or if an aging star like Jack Nicholson received a telestroke consultation that went public. HIPAA has a very formal (and no doubt expensive) protocol for reporting these kinds of embarrassing data breaches. The reputation of a hospital system or large practice could be irreparably tarnished overnight.

The easiest way to avoid this trouble is to use only mobile devices and technologies that fully meet HIPAA guidelines – and all InTouch products do, including our new ControlStation app for the iPad and iPad mini.

Some do-it-yourself telemedicine programs are forgetting that if you’re lax on mobile security, it’s going to bite you eventually. Why open the door to compliance fines, PR crises, and potential lawsuits?

Few would argue that the Mayo Clinic is the gold standard in healthcare research. The facility’s main campus in Rochester, Minnesota has been around since the 1890s and employs more than 32,000 people. So when Mayo recently published a study on the cost-effectiveness of telestroke care, hospital CFOs across the country paid close attention.

The study, published last month in Circulation: Cardiovascular Quality and Outcomes, concludes that telestroke programs indeed offer financial benefits, not just societal advantages. 

Using data from both the Mayo Clinic and Georgia Health Sciences University telestroke networks, researchers estimated that a rural hospital would save more than $100,000 annually compared to a hospital without telestroke capabilities.

“The upfront costs associated with setting up the telestroke technology are quickly offset by the financial gains that result from a higher proportion of patients receiving clot-busting drugs and the reduced stroke-related disability and subsequent reduced need for rehabilitation, nursing home care and assistance at home,” says Bart Demaerschalk, M.D., director of the Mayo Clinic Telestroke Program and co-author of the study. 

Most people assume that Mayo operates geographically close to its famous headquarters, but it also has a large footprint in Florida and Arizona. Mayo began using telemedicine technology in 2007 after research revealed that 40 percent of Arizona residents lacked local stroke expertise. Since its inception, the Mayo Telestroke Network has conducted more than 1,500 emergency consultations across the state.

“Previous studies have demonstrated that a hub-and-spoke telestroke network is cost-effective from the societal perspective,” adds Demaerschalk. “For a relatively small amount of money, [it] can save quality years of life – so it’s a bargain really.”

The Mayo study isn’t the first one to document the financial benefits of telestroke technology. But it’s nice when one of the best-known “brands” in American healthcare weighs in with its own convincing evidence.

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.

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.

We’ve all seen Clint Eastwood westerns where the sheriff says, “We can’t treat him here…the closest doctor is in Dodge City.”

Without telemedicine, that’s the future we’re all facing. In little more than a year, some 30 million new patients will enter the U.S. healthcare system – the equivalent of every man, woman and child inVenezuela. Meanwhile, the Association of American Medical Colleges (AAMC) predicts that the physician shortage in America will reach 130,000 by 2025.

Legislative caps on residency funding will only worsen the current physician shortage.

One of the main reasons for the shortage is that the federal government has capped its funding for doctor residencies. Because there are so many deficit hawks in Congress now, it’s unlikely that the cap will be increased anytime soon – and efforts at private funding have stalled. You know we’re in trouble when a Congressman named “Price” (Tom Price, R-Ga.) bemoans the price of training physicians, but can’t muster the votes to change things.

Atul Grover, the AAMC’s chief public policy officer, recently said that “we’re going to have to find ways to see more patients with fewer physicians” to handle the increased volume.

And that’s exactly what telemedicine is doing. While politicians dither and medical schools stay in no-growth mode, telemedicine is enabling the doctors we do have to extend their reach. In fact, telemedicine solves one of today’s thorniest problems: the need for doctor relocation. These days, a young doctor can improve the quality of care in rural communities without ever leavingPhiladelphia or San Francisco.

Like a storm blowing through a western town in that Clint Eastwood movie, there’s a perfect storm on the horizon: millions of new patients, not enough doctors. That storm may be strong enough to blow away all remaining barriers to telemedicine.

Some hospitals mistakenly think that you can create a telemedicine program as easily as someone can build a patio by going to Home Depot.

Good luck with that.

These healthcare do-it-yourselfers make two big mistakes from the get-go: they underestimate the complexity of the job and they overestimate what their IT departments can deliver.

For starters, any hospital that tries to jimmy-rig its own telemedicine system is automatically considered a manufacturer by the FDA. In its 2011 MDDS ruling, the FDA made it crystal-clear that devices that perform active patient monitoring are Class II devices requiring far greater regulatory scrutiny. It’s very costly and time-consuming to get FDA clearance – and why on earth would a hospital want to assume that kind of liability exposure?

Secondly, many hospital IT folks think that creating a telemedicine network is as simple as connecting two tin cans. They fail to realize that telemedicine technology is vastly different from videoconferencing. In telemedicine, a hospital must manage outside networks where there’s no on-call IT person. And the endpoints aren’t static, like in a boardroom-to-boardroom video conference.  But that doesn’t stop many overconfident hospital IT people from biting off more than they can chew.

Starting up a telemedicine program is far more complicated than most hospitals ever expect.

When hospitals try do-it-yourself telemedicine, their IT staff often gets so befuddled by technical issues that clinical workflow becomes an afterthought – and the end result is a system that clinicians hate to use.

We’ve all had neighbors who thought they could build a deck or patio worthy of Town & Country magazine – only to wind up with something that looks like a bomb site. That’s why we urge hospitals to avoid the temptation of do-it-yourself telemedicine. Let the pros do it.

When we recently spoke with the ATA’s CEO Jon Linkous, he said there are plenty of unlikely allies helping to champion telemedicine. On the surface, some of these alliances are head-scratchers. But if you reflect for a moment, you’ll see that telemedicine companies share a common cause with these groups:

NOBEL/Women – No, this isn’t a group of prize winners like Madame Curie. The acronym stands for the National Organization of Black Elected Leaders/Women. They come from the ranks of both state and federal government, and they’re passionate about improving the quality of health care in urban communities. Many people assume that telemedicine mainly benefits rural patients, but many inner-city folks are equally underserved. Many NOBEL women are already sold on the benefits of telemedicine, and they know how to get things done in the halls of power.

Trial lawyers – They’re not the most beloved group inAmerica, but they’re quickly helping to establish telemedicine as a standard of care. In Linkous’ view, attorneys’ efforts may ultimately be more fruitful than trying to get laws passed. Several large hospitals have already had to make large out-of-court settlements because attorneys argued that by not offering telemedicine, the facilities didn’t provide the needed level of care to stroke patients.

Hospitals that do national branding – Linkous notes that highly regarded health systems like The Cleveland Clinic and the Mayo Clinic Care Network are promoting their telemedicine programs in national branding campaigns. When prestigious organizations start practicing and promoting telemedicine nationwide, the rest of the healthcare field takes notice.

If you’re a telemedicine crusader, it’s easy to feel like the Lone Ranger sometimes, but take heart.  You have a host of powerful new allies.  Reach out to them, and be grateful for their help.