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.

A recent New York Times story chronicled the downside of hospital and physician practice consolidation. The article noted that employed physicians are facing increasing pressure to admit patients only to the hospital that signs their paychecks – often for procedures that aren’t truly necessary. This is causing some hospital systems to be the overwhelmingly dominant player in their area, which allows them to slowly drive up prices. And it often forces patients to drive up to 40 miles further for treatment – something that stroke patients can ill afford to do.

This is obviously not the intent of healthcare reform – and telemedicine is helping to level the playing field while actually lowering costs and providing better, more timely care.

Here’s how it works in the telestroke field. A family practice physician examines a man who’s showing signs of a mild stroke. She immediately sends the patient to the nearest telemedicine-equipped hospital, which isn’t the one she works for but is 20 miles closer. A remote specialist quickly determines that the patient needs immediate tPA administration, so medical necessity is documented on the spot. The result: faster treatment at a lower cost than what the “preferred” hospital can provide.

No patient wants to be a pawn in a battle between sparring health systems – or to undergo needless tests and hospitalization. That’s why the Office of the Inspector General and other regulators are stepping up efforts to stop these practices.

Telemedicine lets us rise above the health system turf wars that threaten to undermine the collaborative spirit of health reform. Remote presence technology can help put an end to this Hatfield and McCoy squabbling so that patients get the highest level of care, delivered impartially at a lower cost. That’s where the reform caravan needs to be heading.

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.

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.

As you might expect, American Telemedicine Association CEO Jon Linkous has many insights on telemedicine’s biggest challenges and its winning strategies. This blog will examine one of the challenges, and next week we’ll look at the unlikely allies who are helping advance the cause of telemedicine.

When we spoke to Jon recently, he felt that poorly informed state medical boards constitute telemedicine’s biggest hurdle at the moment. They’re still basically clueless about many aspects of telemedicine, and that’s why the rules concerning multi-state licensure are still in the Stone Age.

But Linkous rightly maintains that medical board bureaucrats (like all bureaucrats) can eventually change their minds if they get the proper education and persuasion. The key here is consistent, ongoing outreach to medical boards – and we all have a role to play.

Be an advocate for telemedicine at your state’s next medical board public meeting.

Every state medical board (and some states have more than one) hosts a monthly meeting open to the public – with schedules released far in advance. So it’s quite easy for telemedicine advocates to get on the agenda in their respective states. Like Woody Allen once said, “Ninety percent of success is just showing up.”

It’s really that simple. First, find out what your state board’s telemedicine policies are by clicking on this link: http://www.fsmb.org/pdf/grpol_telemedicine_licensure.pdf

Then use the link below to find the address and meeting schedule for your state board:

http://www.fsmb.org/directory_smb.html

Many of the board officials know less about bandwidth than your teenagers, so be patient. You may encounter people who think that if Hippocrates didn’t need telemedicine, neither should we. But don’t forget that many modern legislative miracles – like the Americans with Disabilities Act – were the result of many years of persistent plugging and nonstop education.

We all need to double-down in our efforts to educate state medical boards. This is one battle that can’t be won by giving it a “tele” prefix. You must be present to win.

When patients hear the diagnosis “cancer,” the first response is often to panic. They’re ready to drive or fly anywhere to get a second opinion or learn more about the latest clinical trials and treatments.

But with telemedicine, they can get those expert opinions and therapies without ever leaving their local hospital. For example, the Trinity Health system in Michigan is now using remote presence technology to rapidly get second opinions from oncology experts throughout the region.

It all began with some creative thinking at St. Joseph Mercy/Port Huron, which adapted its telestroke robot to do double-duty for oncology. Physicians there discovered that some cancer patients were driving 120 miles round-trip to get second opinions – making a highly stressful situation that much worse.

“This is a very difficult time for patients,” says Kanu Dalal, an oncology MD at the Port Huron facility. “Using telemedicine for a second opinion can ease some of those fears – and it really expedites things when it comes to choosing and starting a treatment.”

Research shows that patients battling cancer prefer to be treated locally, yet they understandably want access to cutting-edge treatment. Remote presence can bring the best surgeons, oncologists and radiologists right to the bedside, ensuring that the patient gets expert advice without spending hundreds of dollars in travel costs.

Because the Port Huron Hospital is part of the Michigan Cancer Center Consortium, patients have access to every national clinical trial and treatment in use today. So they don’t necessarily have to book a flight to MD Anderson Cancer Center in Houston. (From Port Huron, you’d need to drive an hour to Detroit, where round-trip plane fares to Houston for two people would run about $1,000.)

Getting a cancer diagnosis is one of the toughest blows imaginable. The last thing a cancer patient wants to do is start calling travel agents. Remote presence brings a team of experts right to the patient’s home hospital and that’s truly a blessing. No second opinion needed.