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On-demand healthcare apps are bringing house calls back
Some of the coolest wearables won't be available in stores
A day in the lives of five telemedicine physicians
Game on: Who will be telemedicine's next big winner?
telemedicine ISSUE #2
OUTSIDE IN How emotion-capture technology could augment telemedicine...starting with the treatment of PTSD 1
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p Adventure Capital 48
Let the Health Tech Games Begin
A Market in Search of a King
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www . telemedmag . com
A day in the lives of 5 telemed doctors Teladoc, MDLive, Doctor on Demand, HealthTap & American Well page 40
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Telemedicine briefs across the medical universe -------tele-psychiatry
Practice-changing gadgets and gizmos --------
Industry-shaping ideas and perspectives --------
google wearables
kristi henderson
empatica e4 wristband
jay parkinson
house call apps
samsung simband
mark plaster
veteran health
mc10 biostamp
judd hollander
apple researchkit best of start-up health
editor's letter 4 | contributors 5 | biz dev 46 | rock health run-down 49 | teleport 54 www.telemedmag.com
The Blurry Line Between Tech & Touch
logan plaster
editor-in-chief logan@telemedmag.com
No magazine launch would be complete without a cake. Thanks to everyone who came out to the Ace Hotel rooftop and made our launch event memorable.
Welcome back. This summer marked the 30th anniversary of Back to the Future, the franchise that promised us flying cars and hoverboards by the year 2015. We're still waiting for cars that fly – AeroMobil promises one by 2017 – but thanks to a strong Kickstarter campaign, Hendo might be bringing the world its first working hoverboard. Here's hoping it works on water. We all love a peak around the corner, a glimpse of what's next. That spirit of innovation was front and center at the American Telemedicine Association (ATA) annual meeting in Los Angeles, where we rolled out the inaugural issue of this magazine. On ATA's exhibit floor, sellers hocked a dizzying array of new gadgets and software platforms. There were consumer-facing gizmos like Tyto, the all-in-one at-home diagnostic tool with the sleek form-function of an iPhone. Tyto could arm a parent at home caring for a sick child with a range of intuitive medical-grade diagnostic tools, all for about $200. There were also industry-facing software services like HealthGrid, which allows doctors to use any video platform – even FaceTime – for a HIPAA compliant patient encounter. In the telemedicine market you can be forgiven for going a bit wide-eyed over such high tech wizardry. We geek out in this issue over two such products, and with good reason. There's 5CS, Will the killer the emotion-capture technology which charts telemedicine solution millions of data points on micro facial expressions (story on page 8). The technology has been be high touch or high available for more than a year, but only now is it tech? Synchronous or being trialed to aid in clinical psychiatry. The Em- asynchronous? Where patica E4 wristband, the research wearable used by on this spectrum will NASA and MIT, can detect stress with an electro- we find the balance dermal activity sensor. Scott Jung reviews this and between quality and three other sci-fi-worthy research wearables in his efficiency? tech review on page 18. But while we love our new, shiny toys, if a larger theme emerged from this issue, it was this: innovation is about more than adding complexity. Indeed, higher tech doesn't equal better healthcare. Sherpaa CEO Jay Parkinson lays down the gauntlet on page 24, eschewing video telemedicine in favor of patient encounters via text and email. Patients don't want high tech, high def video, says Parkinson (who has impressive usage stats to back up his claims). Sometimes, a little technology can help us go back in time – and get a lot more personal. Call it Uber for primary care – Medicast, TrueCare24, Orunje and Pager are all bringing back the old school house call (review on page 12). Just don't try to pay for the visit with a dozen eggs. Mark Plaster, in his essay on page 37, describes this dichotomy as "high tech" vs. "high touch". But wherever you find yourself on the spectrum, one thing is certain: the market is ripe for innovation. Digital health investment funding is at historic highs and no clear leaders have yet dominated the market. Will the killer telemedicine solution be old school or new? Synchronous or asynchronous? High touch or high tech? Where on this continuum will we find the balance between quality and efficiency? As with most things in life, the answer lies not at one pole, but in the murky middle. And this answer could do a lot more than make an investor millions. It could breath life into our healthcare system.
What book's currently on your night stand?
telemedicine ISSUE 2 – FALL 2015
Logan Plaster logan@telemedmag.com
Doctor in the House by Michael Burgess. It helps me visualize options for reforming healthcare."
Bill Gordon bill@telemedmag.com
I picked The Brothers Karamozov off the shelf in a fit of college nostalgia.
FOUNDER / EXECUTIVE EDITOR
Mark Plaster, MD EDITOR AT LARGE
Nicholas Genes, MD, PhD CONTRIBUTING EDITOR
Rishi Madhok, MD
I'm reading van Gogh's letters. I love how they communicate life's hardships and beauty.
Rebecca Calhoun Scott Jung Aneel Irfan John Tyler Allen
Mia Garchitorena Donna Cusano Jay Sanders, MD Scott Kozicki
INDUSTRY ADVISORS
Ting Shih ClickMedix Dr. Shiv Gaglani Quantified Care
Emotional Intelligence 2.0 by Travis Bradberry & Jean Greaves has taught me that success has more to do with management than intelligence.
Dr. Sylvan Waller Alii Healthcare Dr. Judd Hollander Jefferson University
Extraordinary Tales From a Rather Ordinary Guy by Ed Marx helps me reboot my work and personal life.
Jodi Lyons SeniorSherpa
I'm reading an autobiography of Mark Twain. Twain inspires me to keep design authentic.
Jon Pearce Zipnosis Jodi Lyons SeniorSherpa Dr. Robert Park RelyMD
Haywood Hall, MD PACEMD ILLUSTRATOR
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Telemedicine Magazine is published quarterly by M. L. Plaster Publishing Co., LLC. PO Box 121, Galesville, MD, 20765. Editorial offices located at 68 Jay Street, Suite 412, Brooklyn, NY, 11201. Printed in the USA. Copyright ©2015. To purchase a subscription, go to www.telemedmag.com/subscribe
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telescope Telemedicine briefs across the medical universe
"It's health care in your pocket. [Pager] saves health systems money whilst tapping into their practitioners and really providing the patient a personal experience." -Ashton Kutcher, on the Pager house call app, after his firm Sound Ventures helped them raise 14 million. page 26
tele-psychiatry –– hardware house calls –– veteran health www.telemedmag.com
EmotionCapture Video Takes Tele-Psych to Deeper Levels Future Life, Inc. hopes that their face-reading software will help detect and treat PTSD. by rebecca calhoun
Software developer Future Life, Inc. is redefining remote psychological counseling services with their new facial recognition software, 5CS. No matter the culture, all humans experience a range of emotions, which are registered in varying degrees of facial expressions. Through just a web cam, Future life's software aims to recognize and record these emotional responses with the hope of aiding in psychological care and counseling. Future Life's Vice President of IT and Business Development, Andrew Ramsey, describes the company as a "conceptual platform that allows clinicians to recognize facial emotions and look at them later for greater details and changes over time." Put in another context, it's as though Ramsey and his team watched the recent Pixar film "Inside Out" – in which the main character's emotions are vividly personified – and decided to bring the ideas to life with modern technology. The Future Life team just completed their third round of research, said Founder and CEO John Kilmer, in which they recorded and analyzed facial expressions of various veterans for one-hour sessions. With this research, Future Life hopes to help therapists reach accurate and timely remedies for patients who might suffer from PTSD. Future Life also keeps the software compatible with any computer interface for tele-therapy purposes.
About 5CS The technology behind 5CS software is based on Emotient and uses the iMotions Attention Tool. Future Life also applies acute analysis to the data by recording patients' facial expressions, analyzing each individual video, and developing emotional tracking algorithms from the data, said Ramsey. With continued development, the program will be able to rely on interpretations of micro expressions—which are emotional expressions that occur in the face of an individual for only fractions of seconds, even when the person is trying to hide those emotions. In the case of veterans and active duty soldiers, the 5CS software helps clinicians interpret the difference in facial expressions between non-PTSD and PTSD patients. Facial Recognition Technology Ramsey learned of facial recognition technology from psychologist Paul Ekman who began studying the correlation between emotion and facial expression in the 1970's. Ekman, as Founder of the Paul Ekman Group, developed the Facial Action Coding Units Manual (FACS)—a research tool for interpreting observable facial expressions. Paul Ekman Group now offers online training and workshops about manually reading micro expressions. Emotient and iMotions developed the initial eye tracking software that reads these facial expressions. Emotient's research focuses on helping advertis-
t The program will be able to rely on interpretation of micro expressionswhich occur in the face for only a fraction of a second, even when the person is trying to hide those emotions.
ers read emotional responses to marketing products—and Fortune spotted Emotient's work last year. According to a report presented at the 6th International Conference on Human System Interaction in 2013, the reliability of this kind of software is based on the accuracy of "complex algorithms of pattern recognition." Ramsey said Future Life spends a large part of their time and research trying to perfect these algorithms. Uses for 5CS Ramsey says 5CS can improve effectiveness in the niche market for TeleHealth counseling services because many veterans are at first more comfortable interfacing with a computer than a therapist. By collecting and analyzing facial action data over time and via webcam, therapists gain a deeper understanding of the emotional state of the patient and are better able to prescribe early treatment even if they cannot meet in the same room. This form of remote counseling can also benefit active duty soldiers by eliminating cost and geographical barriers. Future Life has not yet explored other sectors for facial recognition technology outside helping military patients, but they hope the software will eventually be useful to a wide range of remote counselors, first action responders, personality screenings with public safety officials, and even lie-detection. Future Life's Future Work While Future Life continues to conduct research and seek feedback from veterans and soldiers, Kilmer said the core 5CS software will officially launch sometime in July or August. Future Life hopes to one day make the software a public service, said Ramsey. But for now they are focusing on fine-tuning the program and applying the benefits to military patients through partnerships with military counseling services like Hope for the Warriors, Hidden Wounds, Armor Down, and SDV International.
5 Ways Tele-Psych Can Improve ED Operations A report of 300 ED directors found that 41% of EDs have a wait time of over two days to see a psychiatrist. Here are six reasons that on-demand tele-psychiatry might be part of the solution. 1. Shorten ED Wait Times According to Dr. Jim Varrell, Medical Director of InSight Telepsychiatry, on-demand telepsychiatry assessments are able to occur within about an hour of a request on average. Since psychiatric patients typically spend over 3 times longer in the ED than medical patients, telepsychiatry's timeliness means that psychiatric patients are able to move on to the next level of care much more quickly. This improvement results in shortened wait times for all patients within the ED. 2. Increase Hospital Revenue A study done on the impacts of psychiatric boarding found that boarders prevent an average of 2.2 bed turnovers which results in a lost opportunity cost for the hospital of $2264 per psychiatric patient. 3. Reduce Inappropriate Commitments South Seminole Hospital in Longwood, Florida implemented a telepsychiatry program in November 2014. According to the hospital's data, during the first six months of the program, one third of the involuntary commitments assessed by telepsychiatrists were rescinded. "Telepsychiatry allows us to make sure that the psychiatric patients in our ED move on to the most appropriate treatment, whether that is hospitalization or community-based care quickly," says Charles Webb, Manager of the ED at
South Seminole Hospital. 4. Improve Compliance with Joint Commission Standards Access to timely care means that hospitals are more likely to be able to meet standards for patient care set by regulating bodies like The Joint Commission who advocate that patient boarding times not exceed 4 hours. "When hospitals are able to reduce psychiatric boarding from say 14 hours to under 4, there are other financial benefits," explains Dr. Varrell. "The average sitter for a psychiatric patient costs $15 per hour. By cutting 10 hours from the time a psychiatric patient waits for care, that's $150 per patient saved on just sitter costs." 5. Empower and Support Onsite Staff At a more operational level, the implementation of a telepsychiatry program is reported to better empower onsite staff to handle psychiatric patients. For example, after a telepsychiatry program had been in place for several months at Chester County Hospital in Pennsylvania, the hospital saw an increase in their clearing and placing psychiatric patients without telepsychiatry because staff reported greater confidence in their abilities to assess difficult cases knowing that they had a specialist available for consult or assessment when needed. "Telepsychiatrists are most effective when they establish a rapport and teamapproach with the onsite staff," says Dr. Varrell. "The remote psychiatrists benefits from onsite staff sharing difficult-tocollect information like odor or agitation in the waiting room while the onsite staff benefits from having the expertise of a team of psychiatrists who they know and trust on-call."
-Olivia Boyce and Christopher Adams www.telemedmag.com
clinical quality will reduce the friction of adoption while keeping core clinical care in your network.
Don't Re-Create, Integrate While the promise of telemedicine is tantalizing, the challenges of system integration are often daunting. Here are three integration strategies to keep in mind when expanding your practice into remote care. By Jon Pearce
When I was in high school I was not exactly beating back hordes of potential girlfriends. So I did what any desperate 16-year-old male would do: install an aftermarket stereo system in my car! As I had no money, I bought the cheapest components possible, re-using anything I already had sitting around. Then I toiled for hours fuming over electrical tape, blown speakers and wires strewn everywhere. Adding telemedicine services to your current medical practice or system has the potential to attract a wide spectrum of patients. But as with my stereo, there is the right way to integrate telemedicine and, well, the suboptimal way. Here are three areas to consider when plotting out your integration plan. Patient Access – Get Specific Answering the access question requires you to first ask who you want accessing telemedicine. If your primary objective is to service existing, chronically ill patients, the access point should be done in a way that ensures patient identification, ease of repeated use and deeply coordinated care points. If your access is geared towards younger, healthier patients, you cannot bury it behind firewalls and cumbersome portals. Instead of trying to build some10
thing for everyone (which results in nothing for everybody), consider targeting a specific demographic or clinical cohort with an optimized access plan. That specificity will promote a patient-centered solution while helping filter out the noise of options. Clinician Experience – Address Day-to-Day Impact The data is scathing on the impact EMRs have had on clinician satisfaction. Adding telemedicine services to workflows and systems that already degrade clinician productivity only increases clinician anxiety and burnout. Establishing a small focus group of clinicians to set standards and expectations for clinician workflow in treating patients via telemedicine is essential. One tempting alternative is to outsource telemedicine services. In some cases this may be necessary (like radiology or physicianto-physician communication), but for primary or core specialty care areas, consider the long-term implications of using a third party. It may seem daunting to engage recalcitrant physicians today, but you will likely find a small group of progressive physicians who are willing to engage in open dialogue. Using these innovative clinicians as a starting point to address the key questions of day-to-day impact, reimbursement and
Technology Integration There tends to be two approaches to telemedicine technology integration at this stage. One is to simply extend the EMR's capabilities. The second is to buy a service from a vendor. Either way, the technology must support the patient access and clinician experience standards you set. If you are considering extending an EMR, pay close attention to two costs: actual costs and opportunity costs. Most EMRs are not designed for patients. So you will likely need to improve the core technology. That's the real cost: paying contractors, internal IT, etc. Then you need to consider market pressures and dynamics. If your EMR build is 6 months late, does that mean you miss open enrollment and essentially lose a year of business? If you are considering buying from a vendor, evaluate how serious they are about truly integrating their technology into your systems. Is their medical record interface an after-thought or something core to their mission? Does their technology make it easier or more cumbersome to support over time? Technology should not drive the telemedicine choice. It should support frictionless patient access and a stellar clinician experience. As you step into offering Telemedicine, pay attention first and foremost to the patients you want to attract. Be intentional about designing a sustainable, positive clinician experience. Then use technology to achieve those goals as cost-effectively as possible. For those readers over 15 years old, it will not be shocking to learn that I failed to woo any living female with my rattling trunk and gangsta rap music. I also managed to completely destroy my car. If I had simply asked whom I wanted to date and what I wanted that experience to be, I might have skipped the bailing wire and box cutters in favor of some dance lessons and a new shirt. A lesson we can all integrate into our lives.
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t MediCast provides an Uber-like realtime view of on-call provider status and location.
uber convenient
On-demand healthcare apps are bringing the house call back by mia garchitorena
San Francisco's TrueCare24, Chicago's provided house call services 24/7. Doctors Orunje, and Miami-based Medicast conwould arrive at patients' homes in 45 minnect patients to a network of health care utes to two hours after a patient placed a providers that supply anything from stitchrequest. Each visit cost $99. es to prescriptions in the comfort of one's The organization shifted from a directhome. to-consumer model to helping hospitals Is this the direction that telemedicine is and healthcare systems train and send out heading? That's the bet being made by comtheir own doctors for house calls. The reapanies like Orunje. "I never thought I'd be son for the switch? CEO and founder of ordering shampoo and have it delivered to Medicast Sam Zebarjadi said that the move my home," said Dr. Pardeep Athwal, CEO helped expand Medicast's services to a naand founder of Orunje. "Now I order everytional and international level. thing off of Amazon. I think home health "We don't have to worry about the is going to be similar." burden of sending out doctors These house call apps and ourselves," said Zebarjadi. websites allow doctors "We're working with hosAn estimated to establish a stronger pitals and we're tapping 12,000 doctors relationship with painto a very large set of across the country are tients than a typical providers. They deterparticipating in concierge telemedicine service mine which doctors medicine, or about five allows, all while makare fit to go do house percent of all primary care ing care more convecalls." doctors in the U.S. nient, at a relatively And soon, if Ze-Concierge Medicine low cost. barjadi has his way, Today Two companies that Medicast will be availhave paved the way for the able abroad as well. The digital-based start-ups are Pagcompany hopes to have its first er and Heal. Oscar Salazar, foundinternational partner by the end of ing architect of Uber and Pager, used the this year. driving service model to bring doctors to For Russian-born Leonid Popov, founder patients' homes. His New-York based app of TrueCare24, the idea for a house call app raised $14 million in July, totaling $24 milcame from the old country. When he first lion in funding, according to MobiHealtharrived in the United States, Popov was disNews. This year, Los Angeles-based Heal appointed in the inability to get a doctor to raised $5 million in funding, racking in a come to his home. total of $8.7 million. "In Russia, especially for pediatricians, These apps aren't only being used by payou can easily request a doctor that will artients. Hospitals and health care systems rive at your home pretty fast. I know how across the country have been using Mediconvenient it is and how efficient it is." cast's platform in order to expand the netPopov was aware that house calls were work of doctors doing house calls. not uncommon in the U.S. before and so he Medicast's initial model, which launched decided to bring the service back with his in Miami in January 2013, consisted of a app. small network of recruited physicians who Chief Technology Officer and co-found-
in profile
er of TrueCare24 Bimohit Bawa said that house calls allow doctors a chance for better diagnosis because they are treating patients in a comfortable setting. "Just by knowing where the patient resides and what kind of dynamics are in the environment, a doctor can suggest immediate measures to bump up the heat in the house or to do small things that would otherwise go unnoticed," he said. In collaboration with ER Direct, an urgent care house call service, Popov and his team of five will connect nearby physician assistants and nurse practitioners to patients in the San Francisco area. TrueCare24 will launch in August. Radiology resident and founder of Orunje Dr. Pardeep Athwal said that it is important to push doctors outside of their comfort zone when it comes to treating patients in their own home. Training physicians to be ideal house call doctors is part of Athwal's screening process. He said that he had to reject many applications from physicians who lacked compassion or proper bedside manners. "A good house call doctor is someone that is compassionate and someone that is willing to go to the patient, understand what's going on, and really spend time trying to make them better," he said. Orunje differs from Medicast and TrueCare24 in that it provides X-rays, ultrasounds and lab work the same day as the home visit, and at no extra charge. Both patients and physicians have responded positively to the service since its launch in June. Athwal said that this is because house calls benefit the doctor as much as the patient. "We're not asking you to leave your regular job. We want you to see additional patients without feeling rushed or having back-to-back visits," he said. "It makes medicine more human and it gives doctors more satisfaction."
medicast
orunje
truecare24
Sam Zebarjadi, a father of two small children, always found himself in the middle of the night deciding whether he should rush his sick child to the ER or wait until the next day to book an appointment. Zebarjadi and his two co-founders, Nafis Zebarjadi and Dr. Sahba Ferdowsi, discussed the problems that physicians faced in health care, concierge care and house calls and ways to bring immediate service to patients. They decided to tap into the on-demand industry and scale out the house call service with the help of technology.
About two years ago, Dr. Pardeep Athwal couldn't find the time to schedule a physical for himself. His hectic 7 a.m. to 6 p.m. schedule as a resident at the University of Connecticut made it difficult for him to access a physician after hours. This experience helped him come up with the idea for Orunje, in which patients connect with physicians and nurse practitioners within two hours at an affordance price. He also wanted to give doctors a chance to spend quality time with patients without the hassle of taking notes.
When Leonid Popov came to America from Russia as a student, he was disappointed that doctors didn't make house calls like they did back home. So he decided to create TrueCare24 to remedy the situation. The platform consists of exclusively nurse practitioners and physician assistants because their services would be more affordable to patients, his team would be able to hire more providers and they could provide faster care.
The price point for Medicast's initial direct-toconsumer model was $99 per visit by a physician. Appointments could be made via app 24/7. Now, all prices are determined by different hospitals that use Medicast's platform.
Patients pay $99 for nurses and $169 for physicians. $20 is kept by Orunje so nurses make $79 and physicians $149. Payments are cash reimbursements or wired directly to the provider's account.
Single visits will cost $150-$199 initially. There is also a $15/month subscription plan which allows patients to have unlimited access to health care providers via phone, video and messaging. Plus, subscribers get $99 off for each house call visit.
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While the Veterans Health Administration might not be the first place you'd look for cutting edge technology, the last decade has seen the VA take bold steps in groundbreaking telemedicine solutions. To learn more, we sat down with Paul Costello, VP of Marketing at Viterion, which has been at the center of the VA's Telehealth program. By Donna Cusano Out of 2 million patient visits in 2014, the VA estimates that telemedicine has led to savings of nearly $2,000 per patient while maintaining an 85 percent patient satisfaction rate. At the center of this telehealth system is Viterion Digital Health, which has been an authorized supplier to the Veterans Health Administration for its Care Coordination/Home Telehealth (CCHT) program for more than a decade. Paul Costello, Viterion's VP of Sales and Marketing, discusses the impact the VA Home Telehealth program has had on the industry as a whole. How did the VA's telehealth program act as a proof of concept for the industry? The VA's VISN 8 regional pilot (Florida, south Georgia, Puerto Rico and the USVI), with 800 veterans during 2000-2003, demonstrated the value of basic telehealth monitoring which reduced days of care, hospital readmissions and hemoglobin A1c, maintaining high levels of patient satisfaction. This became the model for the national Care Coordination/Home Telehealth (CCHT) program starting in 2003, which targeted veteran patients at high risk of entering longterm institutional care by focusing on in-home care management assisted by monitoring technology. At the time, the VA's major care challenge was the growth of the aging veteran population; between 2000 and 2010, the number of 80+ veterans tripled. We've heard that the VA's telehealth program was successful. Give us the straight numbers. By any metric, the VA Telehealth Services program has succeeded in expanding its scope and outcomes. 690,000 patients—12 percent of the veteran population—experience 2,000,000 visits annually (FY2014). They now receive services including Clinical Video Telehealth (real time videoconferencing), Store & Forward (clinical imaging) and Home Telehealth (home-based acute and chronic care
690,000 Veterans provided with remote care by VA in fiscal year 2014 55% Percentage of veterans receiving remote care who live in rural areas 12% Percentage of veterans receiving telemedicine care in 2014 2 million+ Total number of telehealth visits in the VA system in 2014
VA Deploys Targeted Telemedicine Programs to Improve Vet Services
wounded, wired warriors
Home Telehealth alone has grown from 43,000 patients in FY 2010 to 156,000 in FY2014
management via technology). About half of veterans receiving telehealth services live in rural areas with limited access to VA care. Home Telehealth alone has grown from 43,000 patients in FY 2010 to 144,520 patients in FY2013 and 156,000 in FY2014, as it becomes an increasingly attractive option for veterans. Home Telehealth has improved patient outcomes and saved money, results remarkably consistent since the VA's first national survey in 2007. By FY2014: •	Bed days were reduced by 42 percent •	Hospital admissions were reduced by 34 percent •	Patient satisfaction was maintained at 85 percent •	The VA also estimated that Home Telehealth saved $1,999 per patient per year in FY 2013. Home Telehealth has also succeeded in achieving the VA goal of keeping veterans living independently in their communities. During FY 2013, 41,430 patients—over 28 percent—were supported by Home Telehealth to live independently in their homes, versus being transferred to long-term institutional care. Describe more specifically how home telehealth developed with the VA It took time, but the VA and Viterion developed methods for their care teams to utilize this newly-generated patient data in optimizing care coordination of large populations. These patients may have multiple chronic conditions—hypertension, diabetes, COPD, heart failure and obesity—or be in transitional care. Telehealth assists not only in clinician monitoring of patient vital signs, patient self-management, health promotion and disease prevention (HPDP), but also in alerts to changes in condition, reports, analysis and EHR integration. The goals are to enhance patient health, prevent decompensation and to reach the patient with the right care at the right time. Vital signs monitoring uses medical continued on page 47 www.telemedmag.com
Introducing GoToPills, the ground breaking health IT that increases patient safety and decreases liability for healthcare providers by delivering offlabel alerts to patients and providers.
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Along with a free consumer app GoToPills will be rolling out a suite of off-label prescribing tools for healthcare providers.
Keep a look out for our forthcoming collaboration with Walgreens.
teletech Practice-changing gadgets and gizmos
"I think the cross-pollination that is emerging by bringing everyone together from around the world is ultimately going to create better (and unexpected) solutions." -Unity Stoakes Co-founder of Start-Up Health page 26
google –– empatica -- samsung mc10 –– apple -- start-up health www.telemedmag.com
research wearables
WEARABLES 2.0 Tech companies race to launch a new breed of wearable devices that aid in medical research by Scott Jung
The Empatica E4 is the updated version of the E3, an Italian-designed wearable that was considered to be the most accurate health tracker by NASA, MIT and Microsoft. It uses light and electrodermal sensors to track a range of subtle health metrics.
Wearable health devices are currently one of the hottest trends in technology. By some estimates, the wearables industry will reach $50 billion over the next few years, and it seems like every day, there is a new device that encourages you to exercise more, slouch less, or breathe deeper. When used dutifully, these wearables can offer beneficial advice to help meet a user's personal health goals. But can wearable devices also help solve some of the world's biggest health problems? Over the last year, major tech companies like Google and Samsung have developed wearable devices - stuff never before intended to be worn on consumers' wrists. These devices contain medical-grade sensors in conjunction with cloud computing and sophisticated algorithms to collect large amounts of extremely accurate biometric data. And they're available exclusively to researchers to better understand disease and engineers to create better medical devices.
Turn the page to read about some notable examples of companies using wearables to address health on a global scale.
Google Cardiac & Activity Sensor The Silicon Valley search giant made a statement last month that it wants to get more involved with your health with the release of its cardiac and activity sensor. Developed by Google's life sciences team and available only to researchers as an investigational device, this wrist-worn wearable contains sensors to track a continuous stream of biological data, such as pulse, activity level, skin temperature, and an ECG. It also contains sensors to capture environmental data, such as noise level and light exposure, providing useful contextual information about the user's health. According to Google, the goal of the device is to discover which sensors working in parallel provide the most relevant data to the physician. From there, Google hopes that researchers can not only better study the progression and treatment of a disease, but can also help develop and build better wearable sensors for larger disease populations. It's all part of Google's mission to "move health care from reactive to proactive".
In 2013, before Google announced a wearable for the study of disease, and before Apple redefined the iPhone as a robust tool for clinical research, there was Empatica. Based out of Milano, Italy, Empatica developed the E3 wristband. Devised from a sensor that was originally designed to detect seizures, the E3 was promoted as the most accurate health tracker and could count MIT, NASA, and Microsoft as some of their customers. Since then, they've released an updated tracker, the E4, which contains a 3-axis accelerometer, photoplethysmography sensor to track heart rate, electrodermal activity sensor to monitor factors related to stress, and an infrared skin thermometer. It was designed specifically for use by researchers in clinical research studies, as the E4 only provides raw data meant to be interpreted with 3rd party software or programs written with Empatica's API's. Empatica is also seeking FDA clearance as an approved medical device, a rarity among health wearables.
Samsung Simband While Samsung has had modest success with its consumer-oriented line of Gear Fit trackers, they've been using technology to improve our health in other ways as well. Their latest contender is the Simband, a wearable that's based on Samsung's Gear watch design and contains various sensors to measure a user's bio-
metric data. While this sounds like basically every other wearable fitness band out there, Simband won't be commercialized. Simband is meant to be a platform that will allow wearables developers to build smarter devices. Developers can use the Simband's sensors to ensure that they are accurately collecting data. Some of the sensors included are an accelerometer, gyroscope, ECG, galvanic skin response
sensor, multiple optical sensors to measure pulse/heart rate, and a skin surface thermometer. In turn, companies can use the measured data to make better apps and devices. The benefit is that wearables companies can be confident that they are developing on Samsung's open and universal platform, and are collecting data using highly accurate and reliable sensors.
MC10 Biostamp One of the most technologically-advanced wearables being developed is one that attempts to mimic a type of artwork that goes back thousands of years. Known as the BioStamp, this wearable in development from Cambridge, Massachusetts based MC10, can best be described as an electronic tattoo. The basic BioStamp is about the size of a quarter and is built out of technologically advanced stretchable circuits supported by a thin sheet of rubber, making them practically unnoticeable to the wearer. They're waterproof and breathable, costs only a few dimes when manufactured at scale, and lasts a week before the normal shedding of skin cells causes it to fall off. BioStamp, described as an "electric tattoo," can detect anything from brain signals to body temperature. The thin, circuited wearable is still being tested by MC10.
The BioStamp is actually a flexible platform; while all the models have a similar form factor and utilize NFC for power and telemetry, MC10 is developing sensors for the BioStamp that can measure body temperature, light exposure, pulse rate, blood-oxygen levels, sweat, blood pressure, and even signals from the brain. Most recently, MC10 teamed up with the University of Rochester to test the BioStamp in clinical settings and help develop disease-specific algorithms for smarter predictive health analytics. They're hoping that the BioStamp's smaller footprint and more versatile form factor can collect more accurate biological information from parts of the body other than the wrist.
Why A.I. is the Future of Telemedicine by Jay Sanders, MD
Apple ResearchKit While we wrote about Apple's ResearchKit previously, Apple since has shared significant updates on the success of its official venture into health technology. As a refresher, ResearchKit is an opensource software framework that allows medical researchers to leverage the technological power and popularity of the iPhone to create apps that gather data and help them gain further insight into various diseases. Study participants can sign informed consent documents, perform active tasks, and complete questionnaires and surveys all on the iPhone or iPad. Since launching in March, thousands of iOS users have signed up for the half-dozen apps developed using ResearchKit. Stanford's "MyHeart Counts" app reportedly received more than 11,000 signups less than 24 hours after ResearchKit was first announced. Other ResearchKit apps include Sage Bionetworks'/University of Rochester's "Parkinson mPower" app to study Parkinson disease using voice and mo-
tion analysis, and Massachusetts General Hospital's "GlucoSuccess" app to learn more about diabetes (editor's note - I'm intimately involved with Mount Sinai's Asthma Health app, which was announced alongside these other ResearchKit apps). Most recently, UCSF kicked off a groundbreaking, first-of-its-kind study with an app called "PRIDE Study" to learn more about the health of LGBTQ people. There are some concerns about the iPhone collecting inaccurate data due to rogue button taps or someone else using the phone, and some claim that iPhone owners are better educated and have higher incomes than Android owners, which could lead to potential bias. But ResearchKit is open-source, so one can assume Android versions can be developed. And the framework for e-consent that's now gained traction will allow many future research apps to be released on smartphone platforms. Finally, the iPhone's enormous popularity will undoubtedly allow researchers to tap into populations and collect amounts of data that with traditional research methods would be impossible.
Have a medical device or app that we should review in these pages? Email logan@telemedmag.com or reach out on Twitter @telemedmag
"There need to be standards for history-taking in the healthcare delivery system. How in the world do you know that the history the doctor's taking is complete? You don't. And in fact, we know that doctors don't take complete histories. As a matter of fact, the majority of doctors take the histories based upon their particular specialty. And that's been proven by taking actor-patients and giving them a chief complaint and then having them go into four different board-certified physicians' offices and they come out with four different histories. Because each of those board-certified physicians are board-certified in a different specialty. Gastroenterologist, endocrinologist, cardiologist – they ask the questions based upon their thought framework, not based upon your chief complaint. The answer? Artificial intelligence. It will contain the collective expertise of all of the experts and it will be a dynamic system. So that when I make a new observation at the bedside or the research bench, it will be programmed into the machine." -as told to Logan Plaster www.telemedmag.com
start-up health
Go East Young Man
10 Years, 1000 New Health Tech Companies. Can They Do It? Unity Stoakes co-founded StartUp Health with an audacious goal – help 1000 health start-ups disrupt the market in one decade. They're bringing innovative energy to the East Coast, and getting a little attention from the Whitehouse along the way.
Unity, we understand that you and your partner Steven Krein got to discuss the StartUp Health concept with Obama himself in the Oval Office. What was that like? Meeting with the President about our vision to transform healthcare by organizing an army of entrepreneurs to rebuild every aspect of the system was like being paused in time. We could feel the great history of the office surrounding us, and at the same moment there was a sense of optimism and momentum about the future. We thanked the President for making health reform a priority and he thanked us for focusing on rethinking what's possible in healthcare. It was truly one of the most amazing experiences of my life and gave us a meaningful launchpad for StartUp Health. You say you want to help build 1,000 digital health start-ups. Is that a marketing ploy or do you really think you can get there? Something incredibly powerful happens when you combine the power of the network effect with a group of inspired and passionate Healthcare Transformers. It's one thing to help build a bunch of compa24
nies all dedicated to fixing something that's completely broken, but when you organize them and create a community that is working together, something magical happens. The cycles of innovation speed up the all sorts of unexpected collaborations emerge. We already have over 100 companies in the StartUp Health family and we're tracking over 7.500 startups around the world. It's less about the number of 1,000 companies, and more about the impact our community can make collectively over the coming years.
cross-pollination that is emerging by bringing everyone together from around the world is ultimately going to create better (and unexpected) solutions.
What makes StartUp Health different from other similarly positioned incubators?
East Coast v. West Coast?
StartUp Health is unique because we're the only organization focused on supporting entrepreneurs over the long-term over many years through every stage of growth from startup to ramp up to speed up. We're not about demo days and quick sprints. We're building a community of innovators and healthcare transformers who believe that by working together we can make the biggest impact. StartUp Health is also global with our companies spanning 10 countries and 50 cities and I think the
What's the vibe like at S.U.H.? We're a big family at StartUp Health. Building a great company over many years is often times a lonely and painful process so it's just more fun to do that with a big group of people who are as passionate and committed to the mission of transforming healthcare as you are.
The true innovation is happening across the globe and in all of the cracks in between. While there's a lot of money on the West Coast, and tons of exciting innovation happening on the East Coast, there truly is a "rise of the rest" as our investor Steve Case has termed it. Not only are exciting ideas coming from everywhere, but it's easier to get capital and to build anywhere too. The East Coast / West Coast rivalries will be left to Tupac and Biggie.
105 Down, 895 To Go Start-Up Health has so far helped more than 100 companies gain their footing in the market. Here are three standouts.
CAREPREDICT
BREATHRESEARCH
SKINDROID
What It Is A wearable device designed for to help caregivers of seniors detect declines in health. Precursors manifest as changes in behaviors that are only noticed by continuous observation. The device provides continuous observation that tracks activities of daily living, from waking up, bathing, sleeping, quality
of sleep, to brushing teeth, eating, drinking, cooking and more.
What It Is BreathResearch is building a wireless mobile headset and vital signs monitor with advanced respiratory pattern recognition and heart rate monitoring for personalized exercise testing and early detection of heart and lung decompensation. The BreathResearch headset will come with a mobile app with
cardiorespiratory assessments and guidelines, and a data service for providers and clinicians to easily track patient assessments and compliance.
What It Is Skindroid lab-on-a-chip platform is a wearable Basic Metabolic Panel monitor. Skindroid's technology allows non-invasive remotemonitoring of Chem-7 'blood chemistries' without the need for actual venipuncture, physical facilities or laboratory staff. Using skin-interfacing sensors, skindroid can detect
and transmit real-time serum chemistries to care-givers, whether on the same floor or halfway across the globe.
Who's Behind It Founders Satish Movva and Dr. Krishnatej Vedala Stage of Development Completed Seed funding round in June 2015 Product in pilots in large Senior Living facilities
Who's Behind It Founder/CEO Nirinjan Yee Stage of Develop Seed funded, raising next round
Who's Behind It Founders Winston Capel, MD; Somair Riaz, MD & Abigail Peterson Stage of Development (Patent-pending) Prototype + Initial funding + B2B custom-
Team Size 6 Five Years from Now... CarePredict would like to be "a global product company with a continuous observation platform on the wrists of seniors and other vulnerable populations everywhere."
Team Size 5 5 Years From Now... We want to be the point of care respiratory pattern tracking tool for early detection of heart and lung disease and for optimizing cardiorespiratory performance worldwide.
ers & pilot partners Team Size 10 Five Years from Now... There will be 6 Billion Mobile users worldwide in 5 years and 3 Billion of those will be smartphone users. In 5 years, Skindroid aims to be the wearable clinical lab for all of them, as a mobile accessory.
television Industry-shaping ideas and perspectives
"Telemedicine is a part of our business development at the state level. When a company comes [to Mississippi], I can have healthcare for their employees in the workplace, so they don't have to worry about where they physically locate their business... No matter where you go in Mississippi, I've got healthcare for you." Kristi Henderson Chief Telehealth & Innovation Officer University of Mississippi Medical Center page 26
kristi henderson –– jay parkinson mark plaster –– judd hollander www.telemedmag.com
action Jackson
Can Mississippi Emerge as the South's Next Health Tech Hub? Due to the leadership of pioneers like Kristi Henderson, Mississippi – a state which has struggled mightily against poor health trends – has emerged as a telemedicine leader. Now, Henderson and others want to share this success with the nation, while turning Jackson into the South's hub for health tech innovation. Interview by Logan Plaster
Some have described the Mississippi telehealth program as the best statewide telemedicine system in the country. How did you get where you are today? kristi henderson:
More than ten years ago I was helping run the emergency department, the trauma center here at University of Mississippi Medical Center (UMMC). The chairman of our department and I were brainstorming: How do we impact outcomes of patients that are needing emergency care in rural areas of the state? They're getting transferred to us but having bad outcomes because they didn't have an intervention done sooner. Over a period of time we sketched out a telemedicine plan. It ultimately took us three years to get through regulatory boards to allow us to do it the way we wanted to do it. In 2003 we started with three community hospitals, connecting them 24 hours a day to unscheduled episodic emergency care. Little did we know that was the hardest area to start. We could have started with something more controlled like tele-dermatology, but instead we jumped into emergency medicine because that's where we knew the need. I think, looking back, that played a
big piece into the success and the model that we've continued to replicate. It's based on the need. We're not coming up with a project and shoving backwards. We're having people say: Help us. Here's our need. And we look for innovative programs, which happen to use technology. What were those early days like, starting with episodic care in these initial spoke site? henderson:
First, we said: Let's find out who the clinicians are in those towns, instead of trying to use temporary help or flying in people that are going to not be a part of the community. We didn't think that was a good and sustainable. Most of those communities had nurse practitioners or family physicians who were also covering the emergency department around their day job. So we went in and offered a training program that was a series of clinical and didactic training for the generalist: the family practitioner, whether that was a nurse practitioner or a physician. They got trained in how to recognize emergencies and how to treat the patients in emergency rooms. Then we gave them 24-hour video access – audio and video – to our UMMC I L LUS T R AT I O N BY N I C O L E T SCHEN CK
emergency physicians that are board certified. So when they did see those high risk but low frequency patients – the poisoned child or the near drowning or the multi-vehicle car accident – we were there for them. What was interesting was that when we did this, the communication between the two sites led to a collegial relationship. Discussions went beyond trauma and medical emergencies and become good collaborative care, a team approach where people bounced ideas and treatments off of one another. What we found was that the care that was being given at these tertiary sites became comparable to what was being given at the academic medical center. And we've done studies to prove it. Take cardiac arrest, where unfortunately the rate of death is higher in a rural area because of lack of resources and transportation challenges. We were finding that we were having the same outcomes with the patients in those areas now just by having that kind of team approach to healthcare, using telemedicine. We started with those three sites in 2003, not knowing what in the world was going to happen, and then word of mouth led to more and more hospitals wanting to do it because they were challenged with keeping their hospitals open. We grew to eight or nine hospitals, and then it was time for us to do a deep dive study. I went and did a pre and post analysis on lots of things, one of which was cost. We found that not only were these sites saving money but they were also having an increased number of admissions to their local hospital, which was critical for them to stay open. And that was because they now were not sending inappropriate patients to us. They were able to really stabilize them, get a second opinion and determine that they could keep them in their local hospital. So now they had a decrease cost to staff their emergency department, even with the telemedicine, and an increase in local admissions. So it was a win-win to say the least. And then what we were getting in our trauma center was now more appropriate. We weren't getting the things that needed
to stay in the community hospital that were backlogging our waiting room. We were now getting more appropriate patients to utilize the tertiary and quaternary services. We didn't start with some grand scheme to launch a statewide telehealth program. When I started my background was clinical emergency medicine – I had been a nurse practitioner for years, had been an administrator of an ER. But it worked. And then it snowballed and the tertiary sites said, "Could you also give us psychiatry? What about derm? And cardiology?" And then it just slowly kept evolving to where it is today. Some of the greatest challenges in telemedicine surround the reimbursement issue. How did you make sure that you got paid appropriately for your services? henderson:
A pivotal point in the whole process was when we worked out the reimbursement issue. For sustainability of this program, I have to work in the policy realm and the reimbursement world and regulatory space to make sure all those different angles are addressed so that it's easy for the healthcare community to adopt and use this and it's one financially we can sustain. Little did I know how much I would live in that space. And so I began working with the Governor to change legislation that would require insurance companies in the state to pay for this the same as they would for in-person care. We got unanimous support and it went into law in 2012. We followed it with additional legislation to expand it into the home. In 2003 we were completely dependent on grant funding but eventually the contracted revenue sustained us. And now we have a robust statewide program because we have reimbursement for it and we have a business plan with our contracts that sustains it. How do you handle the extensive logistical challenge of having so many spoke sites connecting on one network? From connectivity
to hardware to software, telemedicine presents a daunting operational challenge. henderson:
Ours really is a turnkey solution. We manage all the equipment, all the endpoints. We do the support and maintenance. We are on call 24 hours a day so nobody has to worry about how to understand telemedicine or how to deal with equipment, the network or connectivey when it doesn't work in the middle of the night. We handle all of that. If anybody in the state wants our services, they can call and customize our program to their needs. So they may be a small hospital and they need pediatric services or they need all the way up to a connected EICU type model. We come up with an a la carte program basically, we develop the technology solution that's the best fit to match all their needs; so that they don't have redundant or duplicated efforts in their technology solution. We do all the IT assessment, put all that recommendation together. We purchase the equipment. We put it there. We manage it and maintain it. And then they pay for only the services that they need. It really makes it very easy for them. One of the pieces is that we keep up to date with all the regulatory and privacy and security issues that they just don't have the capacity to do. It's hard enough for me. They already had a shortage of medical people. Well, guess what? They have a shortage of technology and legal folks and compliance folks and everything else. So we basically become the hub for all that type of information and we take the worry out of that. You started in 2003 with 3 sites. Give us a snapshot of where you are today. henderson: We currently have 176 sites in
the state, all linking to UMMC. And we're not that big of a state. We have 2.9 million people in the state, and we're signing contracts every week. And it's not just hospitals and clinics. We're in schools. We're in community colleges and four-year colleges. www.telemedmag.com
We're in businesses and in the home. We even have a mobile van, and we're in the prison. We're trying to create a web. How has the impact of telemedicine gone beyond healthcare to the health of communities as a whole? henderson:
These small communities and towns are dying. And if they have to close their hospital, the business community leaves as well. But for them to stay alive maybe they don't need a hospital. Maybe they need a telehealth access point that brings the needed healthcare to them, but it's at the right size that they can sustain financially. We're asking: What does the healthcare model need to look like for our state and for each city? We have to think about the economic driver side of healthcare, which is essential if our state's going to turn anything around and continue to bring businesses into the state. So telemedicine is a part of our business development at the state level. When a company comes here, I can have healthcare for their employees in the workplace, so they don't have to worry about where they physically locate their business. Because that's always a piece of that assessment: What's the education system, the healthcare system and the workforce look like? I'm going to take a piece of that puzzle out of there and say that no matter where you go in Mississippi, I've got the healthcare for you. Given how large this system is, describe for me what the center of the wheel, the hub, looks like. How does UMMC take care of these 176 sites? henderson:
Last year we expanded and are off-campus from the medical center because we needed more space. But in our hub operation, there are administrative, clinical and technical folks. And the center runs 24 hours. When you come in, there are several nurses that are interacting with patients. I have nurses that are doing the home remote patient monitoring program. Then I have nurses that are monitoring EICU beds and stepdown beds of patients that they need to 30
by the numbers What Success Looks Like In the emergency program we've seen a 25 percent reduction in the emergency room staffing costs. There's been a 20 percent reduction in unnecessary transfers to the academic medical center. We see 8,000 patients per month and our outcomes in these rural areas are now matching those of an academic medical center. I talk a lot about our chronic disease program that we're doing around diabetes in the Mississippi Delta. We're still in the middle of the study but on the first hundred patients, we took a snapshot of where they are in the program and what the impact has been
on them. We enrolled people that were all uncontrolled diabetics, and who had every challenge you can imagine from poverty to health literacy. We sent tablets home with them so that we have daily interaction with them and educate them. We monitor their health on a daily basis instead of waiting for them to come in for a check-up to say: Oh, for the last six months, you've not had your disease controlled and it's damaged your kidneys and your eyes and your heart. Now we're interacting on a daily basis and we're health coaches and we're motivators and we're reminding them about their medicine. And what we've found is is that nationally the average compliance with medication is somewhere on a good day
monitor. So it looks like an air traffic control with screens everywhere. And we even do remote telemetry monitoring; so there's lots of monitors and activity and video conferencing going on. And then I have nurse practitioners that are doing all of our corporate telehealth, employee health. So they have workstations where they are interacting with patients here as well. If somebody wants to call for an appointment for telemedicine or schedule even education via our telehealth network, they call in and we schedule them for a provider. If they need a psychiatrist or a pediatric child development specialist, we schedule them into virtual clinics. We're the connec-
around 60-62 percent. Ours is at 96 percent. And of those hundred patients – these are people that had been bouncing in and out of the hospital and the ER – not one of them has been admitted to the hospital for a complication of diabetes since we started the program last year – not one. What we're doing is looking at the cost to manage their care before and after and what did their health look like. Patients are so excited about the program that they're going to the public library and getting on the American Diabetes Association website and blogging about the program. And these people don't own a phone. They don't have a computer at home. They don't even have a car. And they're doing this.
tor between the healthcare provider, the physicians and the patients. If they need an acute service like ER, stroke or neonatology, that happens immediately. We connect it and push it to the on call physician for that service. In the beginning, medical providers had to work physically in the center. But then we decided that that provision defeated the purpose of telemedicine. So now the ER has a dedicated space that's off of the main emergency room in our trauma center. We can pull in the trauma doc or the surgeons if we need to. But with any of the other physicians that do telemedicine, we get into their workflow, rather than the other
way around. We typically have a telemedicine workstation for them in their existing clinic, in their office, and a lot of them in their home. If it's a service like a stroke neurologist, they have an iPad mini in their pocket so that they don't have any delay in connecting. We're trying to be just as user friendly and accommodating to our physicians as we are to our customers. We have a master grid of who's on for what at what time. And we're the connector that makes that happen and schedule them or connect them immediately if it's an emergency. Looking back over the last decade, what would you have done differently? henderson:
I wouldn't have done anything differently. Of course, I say that now because it's worked. But the challenge that we continue to have is just integration of information and sharing of information. So whether that be an image or an entire electronic medical record, that is still a challenge. We do not have one consistent way to do that because our customers don't have one consistent workflow. We still have people on paper systems, so I can't integrate with them. So how do I get that information to provide coordinated care that also creates a lifetime clinical record for the patient, that is in one place? It's still a work in progress. I also wish that there had been more communication and discussion when the health information network was being set up for our state. I think now it's a little different, but when we first started the business, there was still a lot of distrust between health systems and sharing of information. I mean, information and data is power and money and so people don't want to give it up. There's things that we could have done much better and set up in a more coordinated fashion and saved money; instead of having fragmented systems that we're going to now have to try to reconnect. So I think data sharing is the biggest challenge. Our health information network and our partnerships around the state have a good
process for sharing data, but it's still very time-consuming and very costly when these systems don't want to talk to each other and then you have to pay for the interfacing and everything else. What made a huge difference was centralizing telehealth for our institution. So doing that sooner would have allowed there to be a more organized strategy to roll this out statewide. But you know, it's working now and I would say that I'd recommend that for any other institution that you centralize those efforts. To the customer it's confusing if pathology, cardiology and radiology departments are all selling them different telemedicine solutions. I can assure you they're buying equipment that's redundant and duplicative, that would not have happened if you had coordinated through a central office that can keep up to date with all of that. What are some of the best ways that you have found to get providers and consumers on board with telehealth? henderson: It's interesting. When we went
to pass the legislation for this, at first representatives and senators were concerned that they didn't need it. But we'd been touching lives around the state for years, so I'd say, "Go back to talk to your constituents." It was a grass roots effort that we didn't know we'd created. So the power and the voice of the individuals when they're touched by this is very powerful. So having the consumer of these services be your champion and advocate is extremely powerful. So I would say that's one of the most successful things that we have; is that we have people that are telling their story, that people are coming and doing documentaries on our program and they want me to take them places. They want me to fly them to Washington to tell people about what this has done for their life. And that's far more powerful than me sitting up there doing a PowerPoint slide presentation about how this is going to change the world. When somebody with tears in their eyes says, "This saved my child's life," that's huge. But I think that the education piece has
to go from every angle; from the political side, regulatory boards, medical community, health system administrators. And so our strategy has been to just knock on all of those doors and share the message. And once they hear it and word of mouth travels fast; so then all of a sudden you're doing that every day. But I would say we can't underestimate the need for the education; that until we create the value of this to whoever, whichever spoke of this audience we're talking about, you won't get the adoption and use and you'll have a great idea that doesn't get adopted. How have you successfully gotten buy-in from local legislators? henderson:
The Governor formed the Mississippi Telehealth Association and one of their main objectives is education. I serve as the executive director for that program. One of the things we did was when the legislative session was about to begin, we polled what the agenda items were for all the representatives and senators. Then we went and had a dinner to talk about how telehealth can play a part in education; how it can play a part in prisons; you name it. Whatever the legislative agenda was, I could connect it to telehealth. It's just eyeopening. You spoke in front of a Senate committee a few months ago and explained the need for more federal support for these kinds of programs. What came of those hearings? henderson:
I've done two now. The first one was to the Senate commerce committee and that one was really about advocating for continued funding and support of broadband connectivity because this can't be done without the broadband connection. Then the next one was to approach the committee on the appropriations around rural healthcare. And my message there was very similar but to point out the fact that at the federal level we need to clear regulatory barriers to reimbursement and adoption of telehealth. And I know the concern www.telemedmag.com
at the federal level is: We'll go broke doing this and there's no true outcomes. Well, I'm here to tell you our Mississippi story, that we cleared those same barriers at the state level. And not only did we not go broke, we started improving our health and we lowered cost of care. So use us as your example to magnify the impact that this could have at a federal or national level. So I think the biggest thing was that from the first one, the momentum built up to where I got invited to come back again just a few weeks later to testify to another group. And now I sit on several committees – the National Governor Association and National Council of State Legislators workgroups on telehealth – to continue to try to give the information that's needed to the right folks so that policy can be changed.
got telemedicine. Poof, it's going to work. It takes nurturing. It takes relationships and partnerships. And you've got to have buy-in across the key stakeholders. And so it's not an easy journey but it can be done. We did it here and we're being asked to go and help other states all over the country replicate. And people are flying here from all over the world to look at what we're doing. And I wish that there were some really magical secret thing that I could say: Go do this and you'll have it. It takes time to build the necessary relationships with the citizens of the state and the key stakeholders.
What are the legislative hold-ups? What's the pushback?
henderson: Yeah, that is an impediment
henderson:
The biggest pushback is around reimbursement. There are I think 75 codes that reimburse for telemedicine, but there's geographic restrictions on it. Because their thought is that we just need to do this in areas where they don't have access. Well, anybody in an urban area can tell you how hard it still is to get in to a healthcare provider and it's still inconvenient and so people don't go. And so I think the misconception is that there's not challenges in the urban areas to access to care. The other challenge is that they think people will abuse this and it'll cost more money. If we give them access, they're just going to spend more money and want to stay at the doctor all the time. Well, that's just not the reality that we've seen. How unique do you think Mississippi is? Or is this something that really can be replicated easily in most places? henderson:
It can be replicated. It's not about the technology. It's about people and process. And so somebody has to take the time to go a little bit deeper than just buying a piece of equipment and saying: You've 32
Does there need to be a single dominant healthcare entity within the state to really be the hub? If there are too many players, is that an impediment? and it's something I'm dealing with now. We knew we had to clear barriers for our program to be able to flourish. But when I clear those barriers, that opens a great playing field for anybody in the entire world to come do telemedicine in Mississippi. And so of course the dollar signs are going off in people's minds. Competition is good. The challenge with that it dilutes the effect because people don't know who is what. Let's say we have a hospital that I'm providing services to and then another group comes in and sells them a piece of telemedicine equipment. Now, who knows which one is for what? And the end user gets confused and so then they get frustrated because they can't remember if this piece of equipment goes to UMMC cardiology or if that one is for dermatology. I don't want people to create another network and put more equipment out there when the equipment's already there. So, I've pulled back and made my network an open platform. So you don't have to use our clinical services but use our technology and our infrastructure and don't duplicate that and waste money. Clearly, there's still technology vendors that are going to want to compete and run it themselves. But I do worry
that there's different levels of quality. There are some that don't care and it's just about the money; they are going to start tainting the reputation of telehealth if we don't set a minimum standard. So at a national level, you know, I do worry. Do we need to have some kind of minimum standard for telehealth service providers? Does there need to be one central location? Not necessarily. There could be multiple hubs and multiple spoke sites that still share. But there needs to be some type of strategy led at a state level. You bring up the idea of competition. And this is certainly a hot market with hundreds of small businesses jumping in. Are there some emerging technologies that you're particularly excited about in terms of their ability to help what you're doing? henderson:
They're a dime a dozen coming out. It feels like every day. We're actually building a new building that'll open next year that'll be our Center for Telehealth and Innovation. And a piece of that is a Living Lab where we're going to let start-ups bring their product into a real life telemedicine scenario so that they can test it in a robust model. One of the benefits of being in the program for this long is I can tell you where there's still gaps and things aren't good enough. And so working with the technology vendors to help address that puts us on the forefront to keep our competitive edge and keep us delivering the best solution at the lowest cost and has the most mobility and inner-operability and all those things that are important. We want those companies and start-ups in our space, testing things, working through, brainstorming with us; so that we become a hub of innovation. Right now the target date is July of 2016 that we'll move in, and we hope you'll join us. Innovation doesn't all have to happen in Silicon Valley.
Telepsychiatry for Hospitals Crisis Telepsychiatry
On-Demand Access to Psychiatry InSight is the leading national telepsychiatry service provider company with a mission to increase access to behavioral health care. InSight specializes in crisis telepsychiatry and can provide on-demand psychiatric evaluations and care within an hour of a request on average.
Impacts of Telepsychiatry
- Lower Inappropriate Admissions - Reduce Length of Stays - Decrease 1:1 Evaluations - Reduce Risks and Liability - Increase Regulatory Compliance - Improve Employee Retention - Improved ED Throughput - Improve Consumer Satisfaction InSight providers collaborate with onsite resources to augment and enhance the existing system of care, finding the most appropriate and least restrictive level of care for each consumer who receives a psychiatric evaluation.
InSight's crisis telepsychiatry services providers are available to evaluate consumers within one hour of a request on average. After preforming a psychiatric exam, the provider collaborates with onsite resources to jointly determine appropriate disposition. Documentation is promptly returned to the hospital via secure electronic transmission immediately following each encounter. InSight crisis providers can serve as a consultant or prescribe medication directly.
Inpatient Telepsychiatry
InSight's telepsychiatry services can be used to support an inpatient medical setting for weekend rounding, crisis response or afterhours admission services. An InSight telepsychiatrist integrates into the onsite system of care to expand the facility's psychiatric capacity.
Urgent Telepsychiatry
InSight can serve medical or surgical floors as a consultation services to hospitalists or other physicians to provide expertise on the behavioral health concerns of medical patients throughout the hospital. Telepsychiatrists are also available to directly interview and assess consumers via video.
Phone Consults, Questions and Orders
InSight's telepsychiatrists are available 24/7 for phone consultations with physicians, nurses, social workers and case managers for encounters that don't require the initation of a video session.
ED Rounding for Follow-Up Care
Supplement a facility's behavioral health capacity by providing follow-up psychiatric consultations to consumers who have already been seen via videoconferencing but who are still awaiting placement. These services can be provided during designated time periods each day or can be requested as needed with a 4-hour response time on average. "In the emergency department, the availability of specialty services is always difficult. We were finding that the availability of psychiatrists was increasingly more difficult, because of their professional load in their offices. The immediacy that we needed just wasn't there. Our hospital turned to InSight for their telepsychiatry services which have been very successful. We're not waiting for a psychiatrist to come in when his office hours are over. The physicians are very skilled, and the patients like that it's private. You almost forget in today's world that you're talking on videoconference. " -- Betty Brennan, Director of Emergency Services Chester County Hospital
www.InSightTelepsychiatry.com
856.797.4772 www.telemedmag.com 33
Telemedicine: Is Sherpaa able to deal with complex cases or is it mainly geared towards minor health issues? How quickly do cases get punted to the ED?
let's talk about text
Sherpaa Bets Big on Asynchronous Care Delivery If you think Sherpaa is just another entrant into the national telemedicine market, look again. Between snubbing synchronous video and insisting that telemedicine providers work in a central office, it's clear that this Brooklyn-born start-up plays by a different set of rules. Telemedicine sat down with Sherpaa founder Jay Parkinson – dubbed 'The Doctor of the Future" by Fast Company – to learn more. Interview by Logan Plaster
dr. jay parkinson: We've been around for a little over three years now and we've pretty consistently been able to handle about 65 percent of things in-house. That means 35 percent of the time you actually need to have hands laid on you. But 65 percent of the time we can order tests, take a history and we can get those results back and treat. But occasionally we say: Well, you know what? Somebody needs to listen to your lungs or press on your belly. We're trying to practice the safest medicine. Doctors are by nature ridiculously conservative. I mean, nobody's a renegade here. In terms of your patient population and the age group, I'm assuming this is a younger, healthier group who's adopting this early? parkinson: Yeah, but I'd push back on "healthier." I think it's a different sort of disease profile than your 80-year-old with cancer. We definitely don't have those. But 30 to 40 percent of people in this age group have a chronic illness: a lot of mental illness – anxiety, depression. There's allergies, asthma, acne. There's Crohn's Disease; there's diabetes. These aren't critical emergencies, but I have a little bit of a chip on my shoulder about the term worried well. Everybody needs a doctor at some point and I think that's a really important concept to get out there. What is Sherpaa's ability to handle trauma? How will that impact emergency departments? parkinson: We take a history and send them to the radiologist around the corner; get the results back in half an hour. It's way faster than going to the ER, and X-ray is the gold standard. I've read what you've written about texting versus video. You
make the argument that it isn't natural to have a video conversation with a stranger. As an asynchronous platform, Sherpaa has a lot riding on this supposition. What will happen when it does become natural? parkinson: It's just a big assumption. It's like saying we might have flying cars. That dream has been alive for 80 years. But it's not come to fruition because I think people are less comfortable flying cars. You argue that it's uncomfortable to talk to a stranger face-to-face. But people have gotten used to being examined by a doctor that they've never met before. parkinson: That's going to be just a tiny fraction of care. What that means is that doctors are going to be comfortable chatting with you over video. And then patients are going to be comfortable chatting. If a doctor can make more money by seeing you in person, they're going to see you in person. If reimbursement is the same for video or less for video, they're going to do both – to meet with the person anyway. There's a lot of big assumptions around video. I just don't believe that people will ever get comfortable with it besides with their family or their girlfriend or kids. It's just weird. But is it really any weirder than going to a new doctor and talking to a stranger? parkinson: Yeah. Definitely. Video is weird. Have you ever done a customer service video before? What about physician gestalt, the physician's ability to look at the patient over video and say: I'm not sure what's going on here, but you are not well. parkinson: The issue isnt about accesss to video. The issue is synchronous versus asynchronous. I could say, "Hey, move your ankle in this way. Here's the YouTube video of how to do it. Record it. And then up-
give a group of people access to Teladoc and American Well, only about two to three percent of people will use. I mean, that's crystal clear to me that consumers actually don't want video. However, people will absolutely do email on a regular basis. What are Sherpaa's usage rates?
The issue isn't about access to video. The issue is synchronous versus asynchronous. I could say, "Hey, move your ankle in this way. Here's the YouTube video of how to do it. Record it. And then upload it." I mean, to me, that's what people would want. load up." I mean, to me, that's what people would want. In our three years of operating, it's been very clear when you need a physical exam. It's not ever a question. You could do an exam through video. Sometimes you've got to have the patient jump up and down. But at the same time, why not just ask the patient, "Can you jump up and down?" I don't need a document about it. And why would you lie? So do you think asynchronous is the direction that telemedicine will go? Or do you think that these big companies like Vidyo and VSee are going to make synchronous video the industry standard? Where do you think the industry is going? parkinson: You can't force the behavior on a consumer group. If consumers don't want to do something, they're not going to do something. I mean, that's why when you
parkinson: We're getting about 85 percent of client companies registered and about 65 percent of those become regular yearly users. It's game changing in that sense. I saw recently that you received over 6 million in capital investment? What's the next expansion? parkinson: Basically it's for signing up more companies, so it's really just beefing up the sales team. We just hired the VP of Sales from TriNet, so that was a big win for us. Cheryl Swirnow, Sherpaa's co-founder and I don't have a ton of experience with sales. So it was more about getting the right people in here to build up the sales team. I know you pride yourself in organic growth as the needs arise. Do you see that as in any sort of conflict with this sort of big raising of capital for growth? Are those two things at all at odds? parkinson: No. I mean, you have your challenges whenever you receive that kind of funding; they want to maximize growth. But our process is simple: essentially we just put doctors on the end of an email for free, paid for by the employer. We just saved one of our self-insured companies something like $500,000 last year. That means they can hire more people and grow. Especially with self-insured companies, we can see the direct result of having Sherpaa. What kinds of companies are you going after? parkinson: We're focusing on companies with between a hundred and a thousand employees.
What role will medical wearables and remote monitoring play in Sherpaa's future? parkinson: I'm always looking for interesting ways to put a test in somebody's office building. Things like Theranos are extremely exciting. You can have walk-ins and get a test result any time. It's amazing. I want to see how well they execute. Will you be encouraging people in your system to be wearing any medical wearables? parkinson: Not really. It's a heartrate. That's about it. If you're worried about a heartrate at this point, you're going to get a holter monitor, not an Apple watch. They're cute wearables, but they're not really medical diagnostic devices. I'm sure they will be someday in some element. But heartrate, oxygen saturation? If you're that sick you need to be in the ER. But would it be helpful for you to have more data points for the patients you're serving? parkinson: Our model is pretty simple. It's not like we're going to use a ton of technology. Every once in a while we need to get your heartrate. We can do that in various ways. We can tell you about those apps that you put on your finger or the flash that detects your heartrate. Those are pretty accurate. Do you have favorite apps that you suggest to people? parkinson: Yeah, absolutely. It just depends. There are some great headache diary apps. The vast majority of this type of medicine is just taking a good history and that's where I think we excel. Right now healthcare's just oral. It's in an exam room. And I'm asking you questions and you're giving me answers. Those are lost data points traditionally. But we've created about 175 questions. Based around your complaint; if you come at us with a sore throat, we basically just fire up the sore throat questions. www.telemedmag.com
And those questions are evidence-based, designed to give us the actual diagnosis but also to draw out the back stuff. Now what's cool about that is eventually with enough data, you're going to say like: Alright, given the way you answered this, here's your most likely diagnosis. Tell us a little about your medical background. You were trained in pediatrics? parkinson: And preventative medicine. Are there specific things about that particular type of practice that informed how you run Sherpaa? parkinson: Healthcare is a process. And in that process it's sort of designed and it's going to design itself. Nobody ever sat down and said: What's the most efficient way we can do this? We've just had the same tired process since doctors invented it a long time ago. So I just sat down and analyzed the process of healthcare really from the outpatient perspective and said: Can we inject some internet here? We have all this stuff. Can we inject some technology in this stuff ? And basically I just tried to simplify the processes as much as possible. It helps to be a doctor to understand the details of the processes. But at the same time, I don't know if you need to be. These processes are broken and it doesn't take a rocket scientist to figure it out. I wrote something five months ago and it asked: Why aren't there more doctor entrepreneurs? It's very fascinating when there's about 600,000 practicing doctors in America and there's so few that are actually creating cutting edge businesses. Doctors just follow the straight and narrow. That's part of what we're trying to address with Telemedicine Magazine. It's trying to bring physicians into the fold and utilize their experience in what needs to be a physician-driven healthcare revolution. parkinson: Well, they're good people. They're just stuck in a system that encourag36
Many telemedicine companies don't have dedicated physicians. Those doctors, for some reason, have free time. I'd be worried about a doctor with free time. Hiring doctors to be on staff allows us to own your health issue from beginning to resolution.
es them to continue the same tired process. Do you still see patients? parkinson: Not so much. I mean, we hire doctors and they work full-time for us. Do you miss any of the physician experience, the interaction with patients? parkinson: Being a doctor is a full-time job. And it's not to be taken lightly. And I don't think you should be doing it an hour here and an hour there. People's lives are in your hands.	How many people in the office here are physicians taking questions from patients? parkinson: We have about eight doctors now. Each doctor can handle about 5,000 people. What's interesting about this is that a traditional way of dealing with patients is to be focused on one patient at a time. But our asynchronous model allows our providers to increase their efficiency. Who do you see as your primary competition? parkinson: Nobody's doing what we're
doing at all. Unfortunately, people lump us into the video visit category. But they charge a ridiculously low rate and get companies signed up because nobody uses it. You know, we have to charge much more because people actually use Sherpaa. If people don't use it, you shouldn't exist. You're just like a fake little company. And you're definitely not going to move the needle on healthcare. I mean, our goal is to fundamentally change how healthcare is delivered. Cigna offers Teladoc for example. Okay, great, nobody's going to use it. That's our whole selling point. We are a solution that people use. And because people use us, we can move the needle on your healthcare costs. So typically what that means is, no joke, a 50 percent reduction in healthcare costs. Can Sherpaa users come back and build a relationship with the same provider over time? parkinson: Yeah. Many telemedicine companies don't have dedicated physicians. Those doctors, for some reason, have free time. I'd be worried about a doctor with free time. Hiring doctors to be on staff allows us to own your health issue from beginning to resolution. It's not just 15 minutes on the clock. It's, 'Hey, let's deal with this on a regular basis. Let's check in every two weeks.' It's a totally different experience. Because we hire our doctors, we can deliver that continuity. Within the community of emergency physicians, there's a big group of burnt-out docs who just need a little bit of a break. What about these docs taking a day per week to work from home to increase their quality of life? parkinson: I mean, without being able to own the issue from the beginning to the end, you're just making money. That's all you're doing. If you can't solve the problem over a video and you say: Well, you need to go see a doctor and you're on your own. Plus, you have doctors doing things that nurse practitioners have been doing, which
to me, if you're a doctor, it's a little insulting. But if you want money, sure, it's fine. Would you ever move towards having one of your providers at home with the whole system set up? parkinson: No, because it's such a collaborative thing. Whenever a case comes in, the doctors here have a conversation with each other. That is the heart of what our doctors love about what we do. It's super collaborative. Some people ask, Don't your doctors miss the face-to-face communication? They still have that. They're with each other. They don't have it with the patients so much. Occasionally they have to jump on a phone. Is this self-limiting to say we need to be in a physical location together doing telemedicine next to each other? parkinson: I think the value over time is going to persist, versus a decentralized customer service model. One of the things that I did not like about being a doctor, especially when I was out on my own, is that I was out on my own. I didn't have anybody to bounce things off of. It sounds like you're saying that these other telemedicine companies are competing on efficiency while you guys are trying to compete on quality? parkinson: Absolutely. I mean, the theory between conventional telemedicine is there's a couple hundred doctors in America that have some free time. And if we can leverage their free time to do nurse practitioner-level work, you can make that as efficient as possible. But you're still a doctor with free time doing nurse practitioner stuff. Last question: Where is Sherpaa going next? parkinson: Just more space. More doctors, more companies. That's about it.
high tech v. high touch
A Physician's Defense of Asynchronous Telemedicine by Mark Plaster, MD In the world of direct-to-patient telemedicine there are two schools of thought. One is synchronous, or what I have dubbed for the sake of comparison as "high touch." The other is asynchronous, a.k.a. "high tech." Synchronous care, exemplified by real time audio or audio/video conferencing between the patient and a provider, has certainly captured the majority of this emerging market. It was an easy transition in that a telephonic exchange between a physician and patient is similar to the on-call situation that doctors have always handled except that the patient is new to the provider. The only new wrinkle is that the provider is limited to whatever preliminary information that a screening tool provides and whatever information he can obtain in the interview. Further, the provider does not have any previous relationship or information about the patient. Of course, this might be the same situation that a provider in a large practice would find themselves in as well. Adding high definition video to the patient encounter has helped to address the factor upon which most practitioners rely
heavily, and that is the gestalt. I would dare say that most experienced practitioners will gain a significant amount of information from their first 30 seconds of seeing a patient. For example, the patient who is awoken out of a deep sleep and then promptly reports a pain scale of ten out of ten. Or conversely, the middle aged patient with "moderate abdominal pain" who happens to appear pale, sweaty, and lethargic. In both situations, a picture is truly worth more than a thousand words. Another significant difference is that instead of being a free service of a private practice, this is a fee-for-service or subscription on-call situation. Even so, patients with high deductibles or co-pays have seen this as an advantage, not just for convenience, but because it may lower their out-of-pocket expense for a standard office visit. And insurers have seen this as a potential advantage if it keeps patients out of the higher cost venues such as urgent care or emergency rooms. But insurers also fear that the highly convenient physician access could encourage patients to overutilize the service if it did not have a significant co-pay built in. One limitation to direct-to-patient telemedicine has been the provider's discomfort with dealing with more complex medical problems that carry with them a larger liability exposure. This is about more than simply not being able to physically examine the patient. There is a "time vs. compensation" component at play – which is similar to what takes place during live encounters. Most providers will agree that 95% of diagnostic problems can be solved if one simply asks enough questions. But "time is money" both for the provider and patient. So whether the doctor is talking to the patient on the phone or video, to make the encounter affordable, we must keep the encounter brief by limiting the service to problems that are simple, low risk, and easily resolvable. Everything else gets referred to an in-person encounter. And for these cases, the initial telemedicine encounter has added little but cost and delay to the situation. Consequently, real time direct-topatient care has been limited, for the most www.telemedmag.com
Asynchronous care does a better job of generating a real time record of words and pictures that can be shared with consultants or sent to providers who will provide subsequent care. This record then becomes searchable for the purposes of quality assurance, risk assessment, research and billing.
part, to the most minor of ailments; cold symptoms, acne, sunburn, etc, conditions for which most patients seek over-the-counter remedies. The real potential for expansion of directto-patient care, in my estimation, is through solving this last problem of obtaining a more cost effective complete history. And that problem can be largely solved by a more "high tech" or asynchronous approach. The service is asynchronous in that the patient never interacts with the provider in real time, or does so only when all other asynchronous avenues of information gathering have been exhausted. These services start with a brief encounter between a patient and a provider or intake "navigator" who takes the chief complaint and the briefest of histories. Then the patient is sent a more exhaustive set of questions, based on the chief complaint. This exchange might go back and forth several times, refining and expanding the answers to the initial and subsequent questions. Even the physical exam can largely be performed by asking the patient to do specific tasks and report the findings. For instance, a patient with the complaint of an ankle sprain might be asked all the questions related to the Ottawa ankle rules to determine if a diagnostic X-ray would be indicated. A patient with abdominal pain would be asked to do a heel bump and report the results. When everything has been done that can be done asynchronously, then the case is reviewed by a clinician and the decision is made whether a real time audio/video encounter is needed. Physical exam findings that require a trained eye or hands would obviously require referral to some type of provider, possibly a retail clinic or ER depending on the nature of the problem. But some of these could be accomplished using phone-based video chat or the use of diagnostic add on tools available to the consumer market, such as an otoscope attachment or an app. Disposition is then made to refer the patient for further diagnosic studies, prescriptions, or referral to a subspecialist – the same capability as the synchronous model. The point is that the asynchronous care
model provides a mechanism of obtaining a more extensive history and some physical exam elements that will allow experienced clinicians to feel more comfortable addressing more complex medical problems. I've heard complaints that this type of asynchronous care is too high tech, to the point of being cold, remote and mechanistic. And that patients will not tolerate this lack of human touch. Certainly, if the question cascades are maddeningly repetitive, irrelevant or obtuse – similar to talking to a robotic customer service rep at your phone company – patients will not stay with it to the end. But there is also something to be said for the feeling of privacy a patient has when "talking to the computer". Studies have shown that a patient is more willing to be honest with a computer questionnaire than with a live doctor, whom they might feel would be more judgemental. Asynchronous care also does a better job of generating a real time record of words and pictures that can be shared with consultants or sent to providers who will provide subsequent care. This record then becomes searchable for the purposes of quality assurance, risk assessment, research and billing. These records would also be available to providers caring for patients at subsequent visits, whether virtual or physical. Using "autofill" functions, the subsequent histories would only ask the patient to verify information given at a previous visit to the service. The biggest advantage of this type of asynchronous care is the efficiencies that it would make available to the provider. In my emergency department I am expected to see approximately two to 2.5 patients per hour. That is the time allowed to take a history, examine the patient, record the history on the computer, write any necessary prescriptions, or make referrals. That's between 20-25 minutes per patient. On my last specialty board exam, I was expected to read a summary of findings in a complex history and make a disposition every 90 seconds. Somewhere between these two is the ideal efficiency for a trained physician. This gap is where the time/ cost efficiencies of the future can be found.
dors need to address to get the telehealth world on the road to success.
the buyer's perspective
My 2015 Telemedicine Wish List After seeing dozens of demos by telemedicine vendors, I'm convinced we're not reading the same road map. Here are the 12 things telehealth companies need to know if they really want to solve my company's problems. by Judd E. Hollander, MD If you work with information tech vendors, terms you have likely learned to despise probably include "roadmap" and "parking lot". These terms are commonly used to inform you that they will not provide you with what you want in the near term. I became all-too-familiar with these responses as I helped launch JeffConnect, a new telehealth platform by Thomas Jefferson University. I've met with and seen demos from many different up-and-coming telehealth vendors. Each one likes to say they have the best "solution" for our program. The truth is that most have a very reasonable product, but most have limited ability to customize and less ability to adapt. I have often heard how I can achieve my goals using a "work around". I have heard how great ideas will not be available in the version we can purchase, but they will be placed on the roadmap. I have heard how some great ideas are not feasible in the next version but they will be placed in the "parking lot". Frankly, I'm tired of being stuck in the parking lot. Here are the 10 needs that ven-
1. Customization in development process. I am not supposed to be buying an off-theshelf product. I want your product to be my solution. Obviously, not all providers need the exact same solution. Please help solve my unique problems rather than just the same things your last customer survey suggested. 2. Electronic medical record integration If I cannot put the medical record in the patient's medical records, it does not help the patient or provider. Please make this happen easily. 3. Care coordination I want to be able to email the patient and their providers a copy of the visit with me at the conclusion of the call. That is a fundamental component of care coordination. 4. Compatibility with all common devices. I don't believe in limited care based upon whether patient has an iOS or android device, tablet, phone or desk top. It is 2015 and you are a technology company. Please make this happen. 5. Ability to send prescriptions electronically to the pharmacy. This should be part of the core package. Please don't ask us to pay extra for it when you already have done the integration many times. 6. On demand and scheduled appointments. We need a solution that allows patients to access care as they want – either through a scheduled appointment or using our ondemand service. 7. Multiparty capabilities Providers speak with patients and their families. Providers consult other providers. Making families be physically together or
not allowing multiple providers to interact with patients simultaneously defeats the advantages of telehealth. It is not reasonable to make the patients' daughter go to their house before the call. Virtually all videoconferencing technologies enable multiparty calls. We all do it all day long. Why can't we do it for medical care? 8. Automatic functionality with all browsers. Patients want to see the physician. They don't feel well. They don't want to download video upgrades first. They don't know the restrictions on each different piece of technology. As a provider, I am not trained to be tech support. Patients did not call me to trouble shoot their computer. They don't feel well. Please don't make them feel worse by having them wrestle with their computer. 9. Accessible by new and established patients. We want to care for patients already in our system as well as patients who might be utilizing our services for the first time. 10. Ability to see what's coming next. As a physician, I need to know how many people are waiting. I can spend more time with my current patient if the next scheduled one is late. If I have three people in my waiting room I need to manage expectations. We all have text alerts and calendars in our hands all day long. Please help me see what is happening on mine. I don't really want to buy your product. I want you to provide a "solution" to my problems. The solution is ideally not to help me find a work-around within your pre-packaged product. Please, please don't try to placate me by telling me you have my concern on the roadmap for the future or you think it is a great idea and you will place in the parking lot. If you want to be our "solution", please solve our problem. I have given you the roadmap out of the parking lot. Now start your engines! www.telemedmag.com
A Day in the Life of a Telemedicine Physician A billion-dollar valuation, a claim of 100 million members, $50 million funding rounds, app downloads in the millions, and a host of Fortune 500 partnerships are only a few of the highlights coming from the five largest telehealth providers and their race to capture the industry's fastest growing market. They've all claimed to be the largest provider of virtual consultations, and each approaches telehealth with slightly different guiding principles. We rounded up five of their docs to get their take on providing care in this yet undefined landscape. These are their experiences. by John Tyler Allen
the doctor Dr. Timothy Howard is a board certified family practitioner and a Senior Medical Director at Teladoc. the basics Offer services via employers and health plans, 11 Million+ members, 1,100+ board-certified physicians, recent IPO saw $1 Billion valuation, partnership with HealthSpot Stations allows employers to offer on-site clinics via private kiosks. claim of fame "Founded in 2002, Teladoc is the nation's first and largest telehealth provider with approximately 11 million members." -From July 1, 2015 Press Release
How did you get started? It was a postcard that basically said, "Are you interested in trying to earn some extra income as a physician?" I was in practice for 20 years. I said, let's just see what happens. Then I realized, oh my goodness, what we're doing to supplement income was actually able to replace it. I was looking to put my kids through college. Could all physicians expect to replace their income practicing telemedicine? No. It's different for every individual. Was there any logistical training? We have to go through how to do a consult. Logistically, how to work their website. You have somebody assigned to you on staff that walks you through that. Your consultations are $40 per visit? That's everything. When I do a consultation, I get a portion of that. Many industry and insurance companies will underwrite a lot of it. The great majority of patients end up paying $5 to $10. How was your first video consult? I had a child over in Barcelona doing study abroad and we'd use Skype a lot. It wasn't anything earth shattering. How was your confidence level? Understand that because you take away the physical exam, you have to use your listening skills a lot more. I learned that a long time ago while being on call. You listen to how they come across. Is there panic in their voice? And then base that on what you're hearing, as far as their symptoms go.
the basics Direct-to-consumer and corporate services; in-network visits for UnitedHealthcare; 1,400+ physicians; co-founded by Dr. Phil McGraw; backed by Google. claim of fame "For our urgent care services, we have over 1,400 primary care physicians on staff, making us the largest primary care telehealth provider in the country." -November 20, 2014 blog post Tell me about your first visit. Looking at a patient and talking to them, it only took about thirty seconds to realize, Okay, this is just like me talking to a patient.
the doctor Dr. Aditi Joshi is board certified in emergency medicine and practices full-time with Doctor on Demand.
It's been a smooth transition? Yes. I had online training with CEO Adam Jackson. We'll offer suggestions, "Hey, maybe we should try this." I've seen the platform change and have minor tweaks that have really helped. How are you compensated?? We are paid per patient. However, if the number of patients is low, as it was early on, there is a base rate per hour. Did you have to learn to be comfortable providing medical care with limited faculties? It's more about being honest about limitations. I'll tell patients, "I can't listen to your lungs so if you have this symptom or you feel uncomfortable, you need to go get this checked out." Being very honest with them makes them feel comfortable. What about abdominal pain? If they have a family member available – a lot of times they do – I'll have the family member lay them flat and palpate for me. Asking where the pain is and where it hurts when they push tells me a lot. Obviously, if it's an area I'm more concerned about, I'll say, "This
is something serious, you need to go to an urgent care or ER to get a full abdominal exam. How often do you send people to the emergency room? Only a handful of times. There was a sixty-year-old gentleman having shortness of breath and chest pain. I told him, "You need to call an ambulance right now." Sometimes people just need information. Is it serious enough that I need to go to the hospital? People will call me and say, "I Googled this. Is it ALS?" Are online consults more often a convenience or a necessity for patients? More of the former. I've had people waiting in their cars or in the waiting room of urgent care and they'll say, "The wait here is four hours. Can you help me?" Are patients looking for the most human connection possible? The ones who call and are afraid of something or they've gotten a diagnosis and they're asking for a second opinion – they are. If someone knows what they have and they need a prescription – not necessarily. But they are looking for some sort of compassion. Everybody is.
TelaDoc It would be hypocritical for us to say we want to the patient to be with their primary care physician and then say we want you to use our service again and again with this particular doctor.
HealthTap Yes. When you log in, there's an icon area that lists all the people who have requested to be your patients. I've had multiple people who have called me quite frequently.
Do you maintain ongoing relationships with patients?
the basics What you need to know: Direct-to-consumer services, 71,000+ physicians, 100 Million+ users, robust online knowledgebase created, curated, and edited by HealthTap physicians, lab tests via Quest Diagnostics. claim of fame "HealthTap [is] the world's largest, most trusted digital health hub…" -June 30, 2015 press release
the doctor Dr. Zachary Veres is board certified in family medicine and practices at Family Practice Physician at Veres Group in Warren, OH
Did HealthTap provide any training? We had to do a lot of webinar training to be active: how to perform the consult, how to set up your computer. When you initially set up their software, it would tell you exactly what they wanted, what kind of connection you needed, what would best work for the live video consults, things like that. You seem to maintain more hours than most on HealthTap. I usually have at least four hours a day. I've been driving down the road when I got a text notification that a patient was requesting a live consult. With LTE and Wi-Fi, you're pretty much always available if you want to be. How much of your day goes to HealthTap patients? I maybe get one consult a day. But if you're more active answering the free random questions and interacting with the other doctors, you get more patient exposure. I try to answer questions at night while I'm watching TV. With the state of healthcare, telemedicine is going to be more prominent in the near future. I'm trying to get on board early. I'm actually in the process of being credentialed on MDLive and Teladoc, too. I'm going to be on as many of them as I can.
How are you paid? A standard price per consult or per inbox, or per live text. How does that compare to private practice? There's a lot less hassle, less headaches. You don't have any overhead. Add it up; the numbers are pretty close. Not all physicians think telemedicine is a good idea. They're missing the boat. Traditional medicine in the United States is dead or dying. People can interact digitally for probably 70% of their healthcare needs, and at a cheaper rate than carrying insurance. This won't replace emergency rooms, but it may replace primary care. How long will that take? The writing is on the wall. It could be as early as ten years. How many people go to the emergency room who don't really need to be there? Probably 80%. I very rarely see actual emergencies. If they make me president, I can fix the healthcare problem.
Doctor On Demand There are some patients I've seen three or four times. Most of them are calling me for urgent issues. We have a feature where you can follow up with us in a few days to see how it's going, or to see if it's worsening. American Well Absolutely. A lot of these things we do in collaboration with the patient's primary care doctor. Continuity of care is really important to be a good primary care doctor. We love to see our patients over time and monitor our progress, and get to know our patients and their families. MDLive It's very, very important We're moving in the to us. direction where we can
possibly provide more continuity of care. But we always try to get people back to their primary care doc for ongoing problems.
the doctor Dr. Lauralee Yalden is board certified in family medicine and practices full-time with American Well's Online Care Group
You provide telephone and video consults? We actually made a decision as a group that video is involved one hundred percent of the time when prescribing. That's not to say that we don't do telephone consults. But we made a decision that, in order to be comfortable prescribing, we want that extra level of communication. Did you receive any training? Before we go to see our very first patient, there was a lot of training and practice involved together with the team. We practiced amongst ourselves, just like we did in internship. Sometimes you'll play the patient; sometimes you'll play the doctor. We needed to figure out what an online consult would be like and how we would want to handle it. Any uncertainties going into your first visit? Sure, I needed to adapt and make sure I was getting all the information needed to optimize the consult. There's a learning curve, just like you're practicing anything new.
the basics Employer and direct-toconsumer services, in-network visits for UnitedHealthcare and Anthem, 700 physicians, 1.5 million mobile users, AW8 app allows physicians to integrate telehealth services into their existing practice. claim of fame "American Well, the nation's largest telehealth service, has delivered healthcare into the homes and workplaces of patients for close to a decade." -June 22, 2015 press release
You're part of an Online Care Group for AmWell. What does that entail? Every month we meet together and review our protocols. Last night, one of our docs reviewed medications in pregnancy. We put together a list of safe and notsafe medications, and things we may or may not feel comfortable managing online. Sometimes we refer back to the OB or physician in the community. We're actively creating telehealth-specific guidelines to manage pregnancy as well as acute and chronic diseases. What skills have you had to develop? You have to have a certain comfort level working with patients online. In a brick and mortar setting, you're really doing everything yourself. But the patient online is very actively involved in gathering information. Patients love it. They're like, "Oh, I've never done this. I've never looked at my tonsils." You can have patients pressing on their belly, sinuses, lymph nodes, etc. How are Amwell physicians compensated? I'm compensated like any other full-time doc, by salary, with all the great benefits: CMEs, bonuses, PTO, vacation time, malpractice, etc. There are also contracted docs. There are doctors that have a part-time employment relationship with Online Care Group. We have physicians who treat their own patients using the platform – they're paid by patients and/or insurers. www.telemedmag.com
the basics Provides service via employer, health plans, and direct-to-consumer app; 5 million+ members; partnered with Walgreens to provide virtual visits via in-store kiosks. claim of fame "MDLive, the nation's leading provider of telehealth services and software..." -November 11, 2014 press release
the doctor Dr. Haywood Hall is a Fellow of the American College of Emergency Physicians and the Fellow of the International Federation of Emergency Medicine.
What prompted telemedicine? I was commuting [from Guanajuato, Mexico to the U.S.], doing eight shifts a month, a series of nightshifts. That was getting pretty tiring. I got a recruitment email. I followed up on that and slowly started building up steam. It's worked out pretty well.
days a week. The nice thing is, you can set your pace, you can decide.
What was training like? That's what I'm doing now – I monitor a series of calls for our new docs. We discussed how well I was managing cases and areas I could have improved. The platform was mostly intuitive.
What were your feelings going in? You're practicing medicine differently. You're trying to intuit a bit more than you would in a normal clinical situation. At first you're like, Ok, this is a little different. I don't have a nurse describing the problem. I don't have the formal medical triage. We have to keep our threshold pretty low for possible problems that could get complicated.
How do patients access you? It's a call system. Patients are pre-registered and there's a person who screens the calls, and then channels them in different directions depending on who they are, what licenses are required, who's available. How are you compensated? We get paid per patient, typically. Between 11 P.M. and 7 A.M., you might get 30% more. You could see six people an hour. You're probably not going to see that, but over time, it can add up and you can see a few hundred people a month. There are people out there who might make as much as they would in their regular practice if they agreed to be on the phone twenty-four hours a day, seven 44
Do you remember your first consult? I think it was a sore throat or something. It wasn't anything very dramatic. I was more trying to figure out the platform.
What skills have you had to develop? I think it's been said that 70% of diagnosis is history, so you need to be able to take a good history. You may have to ask people questions about physical exam issues that, if you were actually seeing a patient, you would be able to assess yourself. I have seventy- or eighty-thousand patients of experience, so when I listen to people, I'm cross checking to see where that fits within my experiences. I still feel like a doctor when I'm doing this.
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Leaving Your Legacy The digital age of clinical care is upon us; the reach of care is extended like never before, redefining healthcare as we know it. It is a unique moment in medicine, one in which physicians have an opportunity to leave a lasting legacy. What role will you play in medical history? by Aneel Irfan
Unlike some recent medical advancements, like electronic health records, telemedicine isn't being force-fed to clinicians. In many cases, providers have options for how to creatively deploy new systems. What they're finding is that the possibilities are diverse and rewarding, with the promise of increasing reimbursements and improving care. Telemedicine's true early adopters will gain significant notoriety by building the first ever national remote care networks. These pioneers will solve the physician shortage and become leaders in their respective fields through forward-thinking. Our world rarely sees such disruptive innovations, and it begs the question: Who will lead the revolution? History tells us that in these critical moments we need relentless innovators who have an obsessive vision for the future. Steve Jobs could be called a modern day Cornelius Vanderbilt, who opened new trade routes with his Grand Central Railroad. John D. Rockefeller used these railroads to transport his fuel to light up America with his kerosene lamps, which was later challenged by J.P. Morgan and Thomas Edison with the birth of electricity. From the industrial revolution until today, bold steps of technological 46
innovation have been led by brave pioneers who sparked a domino effect within society, changing the course of history. This doesn't happen often. You may have one moment in your career when you get a glimpse of the future and have an opportunity to have a role on the leading edge. And it's not all about the money. Sure, Vanderbilt, Rockefeller, Morgan and Jobs made a few dollars. But they also changed the world, creating industries and practices that never existed before. They revolutionized how life was lived for hundreds of years after their lifetime. That's what I call a rewarding and undeniable legacy! This is the opportunity that you as a clinician can have now in telemedicine. This industry has been building slowly and there is still time to become a forefather in shaping how it will look for years to come. There is no better time to position yourself on the ground floor of this evolving landscape. The widespread adoption of telemedicine will only happen once. Before long it will be the norm and the open call for innovation will be over. In fact, new study statistics show that the number of telehealth visits is projected to grow from 350,000 in 2013 to 7 million in 2018. Moreover, the worldwide revenue for these services is also expected to reach $4.5 billion. So what are some ways you can get start earning revenue while making history? Join a Telemedicine network This is an easy way to start taking telemedicine consultations and creating additional revenue. Several platforms are now available in which the telemed companies contract physicians to take consultations from their subscriber base. Reimbursements vary from state to state and from one company to another but an average visit takes about 11 minutes. That is time spent with the patient and doesn't include reviewing the medical history before connecting with the patient. An average of $30 a consult can be earned which varies depending on what
New studies show that the number of telehealth visits is projected to grow from 350,000 in 2013 to 7 million in 2018. Moreover, the worldwide revenue for these services is expected to reach $4.5 billion.
company you work with, but a doctor can do 4-5 consults an hour, which comes out to about $140 an hour. A lot of times a doctor can log into the system at any time if they have a spare hour or set up scheduled shifts. These networks are sometimes a great option as a lot of them take the burden of billing, credentialing and malpractice coverage off the physicians. Start a Telemedicine Network Nowadays the technology is available to license a compliant telehealth platform and white label it to your practice. This gives you the tools needed to start conducting telemedicine consultations. For providers licensed in several states it gives you the flexibility to establish a hub and spoke model, providing access to your care in the other states you're licensed in. This option takes a bit more planning when it comes to technology selection, reimbursement by state, workflows and staffing, but the rewards in automony are great. Start a Remote Monitoring Program Physician pay schedules have been introduced for continuously monitoring chroni-
V.A. LEADS THE WAY // FROM PAGE 15
cally ill patients and developing care coordination plans utilizing telehealth. The options are robust and capabilities are truly remarkable with this newfound ability to impact patients suffering from chronic diseases. You can now take your care to the home of patients you treat, which has already shown many positive outcomes in managing chronic diseases such as diabetes, while earning a monthly reimbursement per patient. For this type of program you need to deploy the devices necessary to monitor the patients remotely. The options available on the market are diverse and even though they essentially all do the same things in regards to collecting vital signs data, the higher tiers of monitoring devices can do much more. Devices can give you an uploaded customized series of survey questions to gauge the patient's daily condition, medication adherence reminders, educational materials such as exercise and diet suggestions along with live video capability, all in one unit installed into the home. Provide Mobile Diagnostics Mobile diagnostics or imaging is an avenue a provider can champion and build a business off of as well. The global mobile imaging services market was valued at USD 10.7 billion in 2013 and is expected to grow at a CAGR of 3.2% from 2014 to 2020, to reach an estimated value of USD 13.3 billion by 2020. The telemedicine tools are now available, but the catalyst for massive change will come from those with credentials, with years of education, these vital knowledgeable few who have been entrusted to care for us. I dare you to embrace the revolutionary journey of becoming a telephysician and shaping our clinical world for centuries to come.
devices to monitor blood glucose, blood pressure, pulse, pulse oxygen, weight, temperature, peak flow and pain level. These connect directly to the current V100 desktop unit, or the patient or caregiver may enter results manually. Patient answers to customized health questions provide qualitative information for the clinician. Integrated into daily checks are medication reminders and patient education tips preset for their condition(s) which reinforce healthy behaviors. Clinicians can enroll patients, assign DMPs, establish monitoring schedules with reminders, easily set up vital sign risk levels and alerts when patients are out of range or measurements aren't taken, and can see their patient grouping with status at a glance on their home page. Viterion's platform also facilitates individual patient and population reports, analysis and risk stratification through a wide range of queries and filters. Results are also integrated into patient records in VistA, the VA's EHR. How will a new, younger veteran population change the VA's telehealth landscape? Younger veterans—Cold War, Vietnam, Gulf War, Bosnia/Kosovo, Iraq and Afghanistan—are now part of or entering VA care. These veterans are often substantially more mobile and technologically sophisticated. Viterion's new tablet, the Vitacast 1000, was designed to meet their needs. A 7" touch screen tablet with its own platform, it has wireless capability (3G/4G/ Wi-Fi), Bluetooth/USB-A medical device connectivity and a rechargeable battery. Its screens, menus and icons are large, bright and intuitive; audio cues, text-to-speech option and stylus assist those with motor, hearing and visual impairments. The new technology enhances not only vital signs monitoring but also reminders for medication and appointments; patient education and qualitative measurements such as pain
assessment; and indicators that help with care for PTSD and brain injury patients. What is next for the VA's telehealth program? The VA is piloting a digital wound management system, integrated with VISNET and VistA, where patients or caregivers take digital photos of their wounds at home, wirelessly uploading them to their patient record. Clinicians can instantly view and assess images, then document patient progress over time, increasing access to care for mobility-restricted or rural veterans. How will the VA system's lessons impact the broader telemedicine landscape? Viterion Digital Health is now using the lessons learned over 12 years with the VA in new partnerships with ACOs, hospitals, health systems, long term care organizations and health plans. A significant and positive change for telehealth this year is CMS' introduction of a reimbursement program for chronic care management (CCM). Eligible for this are Medicare FFS patients with two or more chronic conditions, who are often the sickest and most costly to manage. For providers implementing CCM, meeting CMS' rigorous reimbursement requirements--successfully establishing, coordinating and managing comprehensive care plans for these patients, integrating non-face-to-face patient care, documentation through existing practice/hospital EHRs and management systems--can be extremely important to their bottom line. It presents a new opportunity for private CCM/TCM providers to integrate telehealth as part of remote care, which can lead to improved patient outcomes, convenience, satisfaction and avoidance of unnecessary care costs, as proven by our extensive history and experience with the VA.
Let the Health Tech Games Begin Direct-to-consumer telemedicine brands are raising millions. Is it a tech bubble, or are they reshaping the nation's entire healthcare landscape? by Scott Kozicki
e have a new arms race and it is called Telemedicine. Doctor on Demand and MDLive, within days of each other, both announced $50M funding rounds. Teladoc's IPO closed with value of $1 billion with a "B". American Well has amassed more than $125M in funding over the years. You can be sure that Ping MD, Spruce, Maven, Sherpaa, and others are not just admiring themselves in their video cameras. Battle lines are being drawn. Alliances are being forged. The sabers are rattling. Much like the cold war, there appears to be two distinct philosophies pitted against each other in the telemedicine space. There is very much a direct to consumer model, as practiced rather purely by Doctor on Demand, MDLive and a few others. A lot of the financing action is currently here. But there's also a platform or business to business model as well, versions of which are practiced by Zipnosis, Teladoc, and American Well. The differences are subtle. They both get patients to clinicians in a virtual encounter. But they are two very different paths in terms of who is paying, what you are building, and where it goes next. I'm going to talk about the direct to consumer (D2C) model this time and the platform model (B2B) model next issue. The D2C model is predicated on one simple truth: make a visit to a primary care physician work just like how everything else in my life works – through my smart phone. I can manage almost all of my life through apps on my phone. Travel. Banking. Entertainment.
Shopping. Dining. Even dating. All have been remade and scaled via smart phone. Except health. Health is still a laggard when it comes to this evolution. Then arrives D2C telemedicine. There is no single bigger use case to the parent of a small child than the power of tapping an app on your phone at 11pm on a Friday night when said child has an ear infection or fever. Being able to engage with a quality physician for a reasonable price without having to go anywhere in this situation is nirvana far easier to reach than all those yoga classes. When we pitched this concept to the C-suite at Verizon in 2011, the resounding comment around the table was "when can I have this?" Let's get one thing straight: this NEEDS to happen. It's been BEGGING to happen for about a decade. All the perfect storm elements are now finally in place and it is definitely happening. Having a low friction consumer driven experience where practitioners can open larger markets for themselves all while driving volume and quality is like a dream come true. And this is precisely why investors are flocking and dumping truckloads of cash into these brands. Few things in life make so much sense. One can argue that these huge raises and large valuations are just the sign of the times. We're in a bubble! Equities are expensive! My competitor did it so I should too! But there's something else going on here. The D2C telemedicine model is fundamentally reshaping the delivery system. In short I L LUS T R AT I O N S BY N I C O L E T SCHEN CK
order, the process of finding a physician who accepts your insurance, booking an appointment, waiting days or weeks to arrive in a lobby, where you will wait for what feels like days and weeks before finally seeing that physician, only for them to shuffle you to the nurse in 7 minutes or less are over. Of the approximately 1 billion encounters that occur in the US between a patient and clinician each year, an ever increasing share can and will be had virtually within the next 5 years. In the process of accomplishing this, D2C platforms will essentially be building the first nationwide delivery networks – and brands! We will see the first consumer brands that are health care specific come out of this wave of investment. Doing that is expensive but it's a good thing. No mat-
ter where you live or travel, you'll have a brand experience that is consistent and you can trust. Given that access to primary care is literally the wheelhouse in which $2.7T of spend is directed, investing $50M to try and capture the hearts and minds of consumers in this space is just an entrance fee. The reality is that there will need to be a brick and mortar component to this at some point. For all the sizzle and flash of virtual visits, there are a lot of those billion encounters that literally need hands on to facilitate. Consumers using biometric devices to gather data that the clinician will then use to make decisions will help, but at some point, you actually need to touch a human being to treat them in a lot of situations. The difference is that they will be branded centers coming from the virtual
delivery networks. Not HCA. Not Mayo. Not Cleveland Clinic. New brands that are focused on delivering a great experience for consumers by organizing the labor force of practitioners around the country. That is really what the D2C model philosophy is and why the capital requirements are going to increase. This means war! Of course, for every action there is an equal and opposite reaction. Existing brands in the health care delivery space are not stupid nor are they sleeping. They are answering. And that will be our next topic.
A Market In Search of a King Hundreds of millions of dollars have been poured into the telemedicine industry, yet no clear frontrunner has emerged. Will there be another FitBit windfall, or is the hyperactive telemedicine market at risk of being the next tech bubble to burst? by Bill Gordon
According to the MERCOM Q1 2015 Healthcare IT Funding and M&A Report an astonishing $437 million across 98 deals was invested in just the first quarter of this year in consumer centric companies focusing on mobile healthcare, telehealth, scheduling/rating/shopping and personal health. That is an amazing amount of money for a sector that has yet to fully realize its potential. Many of the companies are start-ups who are still trying to create the perfect app or groundbreaking solution that will drive user adoption levels into the millions. So my question is, where is all the money going? Where are the widely publicized successes? Why are VCs still investing billions of dollars in a market that has yet to produce it's all-star? The answer is because it takes just one win 50
to justify the investments being made. Fitbit is an example of one of those big winners. Fitbit raised $66 million over four rounds of investment starting in 2008. With its recent IPO the company has achieved a valuation of over $6.6 billion (as of this writing). This is a huge win for those VCs who took a chance on a wearable fitness device and app which is now integrated with many of the top telemedicine and mHealth solutions. But I would call this the exception and not the rule. Where is the rest of the money? Fitbit's venture capital raise was considerable but many others have raised far more and produced much less stellar results. Take Telcare for example. Telcare has what is said to be the worlds first FDA 510K-cleared cellular-enabled blood glucose meter and a robust platform supporting both clinicians and end users/consumers. This is a well-developed and tested solution. I should know; I used to work for the company. Telcare has raised over $63 million in venture capital yet there has been no big market splash to date. If you Google "Telcare" you will find a few articles about trials or investments in the company but not much else. One of Telcare's competitors, Livongo (formerly EOS) has a cellular driven blood glucose meter and an application/platform for end user and clinician access to data as well, and they too have raised significant venture capital. They have raised $30 million in less than one year driven by Glen Tullman the former CEO of Allscripts. Another player in the diabetes management space, Glooko, has raised an additional $16.5 million in venture capital. That is close to $110 million in venture capital across three companies in the diabetes management arena. All three companies state that they have customers or corporate partners yet none of them have reported significant revenue. Their investors are betting that one of these companies will crack the code and become the next Fitbit, making their multimillion dollar investments worth their while. Diabetes management costs increase year over year – in 2012 over $245 billion was spent
on diabetes management and care in the United States. There is a lot of money to be made in this market and the investors see a path to capturing market share with their investments. Is one of these companies the next big winner? The concept of "doc in a box" or a true telemedicine visit is another of the all-star markets in venture capital investment. Companies like American Well, Teladoc and MDLive have raised millions of dollars in venture capital. Teladoc has raised over $74 million since 2009; MDLive has raised over $23 million and American Well has raised over $128 million since inception. That is over $220 million in venture capital across these three companies. Now Teladoc is in the middle of a patent infringement suit with American Well, but they have also filed for their IPO. This could be the "one" out of this group or it could be a bust, only time and the market will tell. This may be the most important and revenue generating of all the telemedicine or mHealth categories due to its acceptance and adoption by both CMS for ACO Advantage plans starting in 2016 and large payers like United Healthcare who will reimburse for telemedicine visits at the same rate as faceto-face visits in the near future. To date, no one telemedicine visit company has shown over-the-top performance yet there are millions (approaching billions) of dollars to be made in this market. The last category I will touch on is what I call the fantasy product category. These are devices or solutions that seem far-fetched but should one become a reality, will be true disruptors and game changers. An example is SCANADU who is developing a Tricorder (the Star Trek medical device that hovers and scans for issues and vitals) device that will perform multiple tests/ functions. They are competing for the X Prize and have raised over $49 million in investment and venture capital to date. This is a huge amount of money for something literally out of a TV/Movie. If successful it could very easily be a billion dollar prod-
uct and company. On the opposite side of the spectrum you have a company called Cloud DX which is a true start-up and has raised $2.6 million in angel investment to date. They too are pursuing the X-Prize for the creation of a Tricorder along with their core heart rate, blood pressure and heart anomaly detection device. An interesting side note, the CEO of Cloud DX, Robert Kaul, coined the phrase "Cloud Diagnostics®" and owns the trademark to it. And then there is the monster (my terminology) of the group, Proteus Digital Health. They have raised an astonishing $309 million in capital since 2003 with the majority coming since 2009. They have a system based on an ingestible sensor that patients take with their daily medications that syncs to a patch worn on the abdomen. Bluetooth connects the device to a smartphone or tablet and transmits valuable data on medication adherence and effectiveness to the cloud for clinician use. This is the stuff that science fiction writers have been talking about for decades and it exists today, just waiting for mass adoption. With all of this investment and all of the moderate successes being achieved, you would think there would be much more fanfare and notoriety amongst the players in the telemedicine or mHealth world, yet there isn't. Not yet. It will take billions more in capital investment and mass adoption from players such as CMS and the large private payers before we see a "Fitbit" success story in telemedicine. I have listed approximately $690 million in venture capital investments in this article, yet all it takes is the next "one" to justify all of these investments. To answer my own question from the opening paragraph: "Where is all the money going?" It is going out on large corporate bets that one of the companies developing these technologies will turn a 10% ownership stake acquired via venture capital investment into a Fitbit-sized return.
With all of this investment and all of the moderate successes being achieved, you would think there would be much more fanfare and notoriety amongst the players in the telemedicine or mHealth world, yet there isn't. Not yet. It will take billions more in capital investment and mass adoption from players such as CMS and the large private payers before we see a "Fitbit" success story in telemedicine.
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The Godfathers Dr. Jay Sanders – often called "The Father of Telemedicine" for his work introducing telehealth in the Southeast in the 1970s – can remember the day that telemedicine was concieved, and by whom. To Sanders, the true father of telemedicine is Dr. Kenneth Byrd. Here's his story.
It was late summer, 1967.
I was working as a senior resident in medicine at Massachusetts General Hospital in Boston. In those days there was no emergency medical specialty. The senior resident and the surgical senior resident rotated two 12-hour shifts, running the emergency room. I was out front in the emergency department waiting for the next Boston traffic accident victim to come through the doors when the doors swung open and in came my professor, who was red-faced and upset. I knew exactly why he was upset. These professors of medicine at the Massachusetts General Hospital were making a grand total of about $8,000 a year. So many of them moonlighted. One of the jobs that Ken Byrd was doing was moonlighting as the medical director at Logan Airport Medical Station. Anybody who knows Boston knows that the Airport's only 3.5 miles away from the Mass General, except for one problem: the traffic. In those days, there was only one tunnel under the Charles River, not three like there are today. And every day he would have to go
back and forth 3.5 miles to Logan Airport to see airport employees or travelers who got sick. And every day he would get stuck in terrible traffic in the Sumner Tunnel. It would literally take him an hour each way. He got so frustrated this one day in 1967 that he came through the MGH doors with an idea. Since I was the first one he saw, he came up to me and he grabbed my arm and he said: "Jay!" I said, "I understand, Dr. Byrd. I know you got caught in traffic again." And he said, "No! I did, but I had this idea! What if I bought two TV cameras and put one at Logan Airport and one here in the MGH ER and I began to examine patients over TV? What do you think?" Now I have to tell you I thought it was the stupidest idea I'd ever heard of in my life. But I had enough common sense to realize he was my professor. I was a resident and I said, "Gee, Dr. Byrd, that's a very interesting idea." And I've been working on his stupid idea ever since. -As told by Jay H. Sanders, MD President and CEO of The Global Telemedicine Group
JeffConnect is putting health .in the palm of your hand. V
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Jefferson is bringing doctors and patients together.
Whenever and wherever. Through JeffConnect TM, our comprehensive telemedicine initiative, Jefferson is creating new ways to improve the health of our community. Whether it's attending a doctor visit on your smartphone, connecting a son in San Francisco to his mother's bedside in Philadelphia, or by creating one of the largest telemedicine networks in the world, we're using technology to bring the expertise of Jefferson health care to you. As JeffConnect continues to expand, we are hiring a range of positions – from ED physicians to telehealth assistants. If you are interested in the innovative world of telehealth, we would like to connect with you. Contact Judd Hollander or Kate Fuller at the email addresses below. JeffConnect. Helping to reimagine the future of health care. Kate Fuller
Judd E. Hollander, MD
Telehealth Program Manager | Jefferson University Hospitals
Associate Dean for Strategic Health Initiatives | Sidney Kimmel Medical College Vice Chair for Finance and Healthcare Enterprises | Department of Emergency Medicine | Thomas Jefferson University
kate.fuller@jefferson.edu
judd.hollander@jefferson.edu
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Telemedicine Magazine Issue 2
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