Wearables 2.0

Tech companies race to launch a new breed of wearable devices that aid in medical research
by Scott Jung

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.

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”.

Empatica E4 Wristband

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 biometric 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.

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.

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 open-source 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 motion 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 or reach out on Twitter @telemedmag

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

1. TelaDoc

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.

2. Doctor On Demand

The Doctor: Dr. Aditi Joshi is board certified in emergency medicine and practices full-time with Doctor on Demand.
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.

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.

3. HealthTap

The Doctor: Dr. Zachary Veres is board certified in family medicine and practices at Family Practice Physician at Veres Group in Warren, OH
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

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.

4. American Well

The Doctor: Dr. Lauralee Yalden is board certified in family medicine and practices full-time with American Well’s Online Care Group
The Basics: Employer and direct-to-consumer 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 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.  

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 not-safe 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. 

5. MDLive

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.
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

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.

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.

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 days a week. The nice thing is, you can set your pace, you can decide.

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 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.

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.

Do you maintain ongoing relationships with patients?

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.

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. It’s very, very important to us.

MDLive: We’re moving in the 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 Godfathers of Telemedicine

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.

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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

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 Editorial Director 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 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 face-to-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 farfetched 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 product 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.

Can Mississippi Emerge as the South’s Next Health Tech Hub?

Due to 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, all 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 teledermatology, 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 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 connectivity 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. 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 is 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 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 connector 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 eye opening.

You spoke in front of a Senate committee a few months ago I understand 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 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 work groups on telehealth – to continue to try to give the information that’s needed to the right folks so that policy can be changed.

What are the legislative hold-ups? What’s the pushback?

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 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.

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?

HENDERSON: Yeah, that is 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 UMC 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 there. So, I’ve pulled back to say my network is 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 startups 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 startups 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.

Jonathan Javitt on the Future of Direct-to-Patient Connectivity

Former White House healthcare adviser and TelCare founder Jonathan Javitt casts a vision for telemedicine’s future, and explains why connected devices are just the beginning.
Interview by Mark Plaster, MD

Telemedicine: Tell us a bit about the health IT work you did for the Bush administration.

Jonathan Javitt: First of all, I didn’t join the Bush Administration in order to computerize medical records. I joined the Bush Administration because I was so shocked and outraged on 9/11 2001 that I felt like it was time to join the fight. And I actually spent the first 18-24 months of my time in the Administration in the National Security Health Policy Center, working on stuff that had nothing to do with Health IT but was all about preventing the next bioterrorism attack. At the end of that stint, the President’s chief domestic policy advisor came to me and said: We’d really like you to consider doing something in the civilian health care sector. And we talked about a number of different opportunities. I said: Well, you know, the thing I’ve always wanted to do is get the paper out of the health care system and move the United States in the 21st century when it comes to medical records and Health IT. And they said: Well, that’s not on our agenda. Why are you talking about that? I said: Well, here’s the problem. We’re going to spend $2 trillion on health care next year. And right now the only options on the plate are either deny care to patients or pay less money to doctors in the hospitals. Or both. If you deny care to patients, you run the risk of killing people. And if you reduce payments to doctors in hospitals, we’re at the point where they just go out of business. So the only third alternative is to make health care more effective and more affordable. And the only way I know to do that is with Health IT.

Even before we’d done anything, [Bush] put a line in the State of the Union saying: Electronic medical records save lives and save money. And people were scratching their heads and saying: Where did that come from?

So we convened a task force. The President appointed me as the Chair of the Health Committee of the President’s Information Technology Advisory Committee. And we started listening. We started doing town halls all over the country. I went to HIMSS and did a couple of town halls and talked to people in industry and really started listening and understanding: Well, what can electronic medical records do and how do you deploy them? And over and over again we started hearing: Well, until you really connect the patient to the electronic medical record, at best you’ve taken something that could be done on paper and put it into a computer. But the minute you connect the patient, now you can create magic. So that was the surprising outcome of the process in which we engaged. And it’s really what led directly to TelCare.

Telemedicine: How do you feel about the current state of Health IT?

JJ: I’m not satisfied with the direction and pace of electronic health records. Then again, I’ll spend my life being dissatisfied. It’s never fast enough for me. It’s never comprehensive enough for me. That’s why I’m always pushing.

Telemedicine: Why did you launch TelCare?

JJ: So our focus is on using connected medical devices to join doctors and patients around improving care for chronic illness. And right now our first product is a connected blood glucose meter. Every time you test your blood sugar, the data goes up to the cloud. You get immediate feedback. And we’ve got a published study showing that that seemingly simple innovations – we didn’t invent the blood glucose meter; we didn’t invent the cell phone. All we really did was take a couple of chips out of the cell phone and put them inside the blood glucose meter. That little intervention seems to double or triple adherence to blood sugar testing. And at least from one study it’s reduced the cost of care by 50 percent. The real reduction is you’re spotting the people who are running sugars of three, four, 500 on a daily basis before they wind up in the hospital. These are people who wind up in the hospital in hyperosmotic coma. These are people who stroke. They wind up with gangrenous toes. All of that’s avoidable. The product is commercial. It’s been FDA cleared for more than two years now. We’ve put out 50,000 units in people’s hands.
Telemedicine: Where do you see the greatest opportunities for remote monitoring?

JJ:  I think the low-hanging fruit for avoidable hospital admission is people with diabetes. It’s people with pulmonary disease. Cardiology is a little tougher. Cardiac event monitoring is technically more difficult. And building the device that lets you really spot the events is more difficult. Although I’ve seen one interesting technology for people who have sort of chronic unstable chest pain and getting cardiac enzymes drawn on a regular basis; I’ve seen a pretty nifty electronic device that’s almost as good as enzymes. But if you just attacked diabetes and pulmonary disease, that’s a lot. You don’t have to go the whole enchilada to make a huge difference. You could start out by putting the history gathering and review of systems gathering tool in the front room of the ER.

Telemedicine: How has your recent move to Israel impacted your med tech ventures?

JJ:  For me Israel is just the world’s greatest medical start-up environment. Part of what makes it so exciting is if you show up with $100,000, the Chief Scientist for the State of Israel will match it with $500,000. That’s why Israel is ten percent of the NASDAQ. That’s amazing. As I drive from my house to the university where my wife teaches, I pass Qualcomm and Google and Yahoo and Microsoft and Intel. Pretty amazing start-up environment. Oh, and GE and Phillips.
I’m part of a venture fund over there as well. We just did an IPO. I’m passionate about what TelCare is doing, but I’m passionate about the whole field. So, for instance, in the last three months we’ve had two IPOs out of Israel. One’s a company called ReWalk. It’s an exoskeleton that lets people with quadriplegia walk for the first time since their injury. The second one’s a company called Check-Cap. It’s a capsule you swallow with a camera in it and it’ll show you the small bowel. The problem is once it gets down towards the cecum, it can’t see through the fecal stream. So that’s the end of its usefulness. So Check-Cap has a capsule with a very small X-ray emitter in it. It’s doing the same kind of reflectance X-ray as the body scanners in the airports and images the entire large bowel for you. It passes through and you poop it out. It’s a prep-less colonoscopy.
Telemedicine: What are telemedicine’s greatest hurdles moving forward?

JJ: I don’t think the hurdles are political. First of all, the payers are terrified of opening one more spigot for reimbursement. That to their way of thinking is always going to be additive to everything else.

A big hurdle is that, until recently, the technology wasn’t there. I mean, if you walked around the ATA ten years ago, you would have seen pretty clunky old modems; I mean, real Rube Goldberg stuff. You know, TelCare is the first product where somebody ever took a state-of-the-art cellphone chip and put it inside a medical device and said: This is seamless. All you got to do is stick your finger, put a drop of blood on the strip, pull the strip back and it transmits. Nobody ever saw that before. Even now most scales, you know, you got to pair it with an iPhone. Well, that’s a frustrating process. It stays paired until your phone pairs to your car. And then all of a sudden it knocks off the Fitbit. The whole Bluetooth thing to is very unstable. I think you’re going to see cloud-connected devices.

Telemedicine: What about the challenge of health data security?

JJ: Some patients will say: Well, is this HIPAA compliant? Or is this secure? And you’ll say: Well, here’s the data that says it is. And that’s the end of the conversation. People are worrying more about their bank accounts being hacked than their health records being hacked. I’ve known a number of people who were killed or injured because their health information was not available to somebody when it needed to be. I’ve never met anybody who was killed, injured or even inconvenienced because their health information was improperly made available to somebody it shouldn’t have been. HIPAA is a great law. Being able to put somebody in jail for invading somebody else’s private information is a really good thing. So, I’m not suggesting for a minute that that’s not a good legal remedy. But normal levels of encryption are more than adequate to deter all but a committed thief.

And if you’re going to be a committed thief, you’re better off spending your time invading somebody’s bank account.

Telemedicine: How do you see payment reform and capitated care driving med tech?

JJ:  Once you’re doing capitated care, then the government policymakers say: It’s not our problem anymore because we pushed the risk down to the care system. If med starts capitated and they can do half as many visits, they will. I just spent time with a young man today who’s built a little company around normal low risk OB. And they put a box together that costs a couple hundred dollars with a scale and a blood pressure cup and some nifty apps. And they’ve got OB groups who are taking a $3,000 global fee for labor and delivery. And they’re saying: Gee, by deploying this and we’ve got a daily weight and a daily blood pressure we can cut our number of prenatal visits in half. So the Med Star OB Group is paying a couple hundred dollars per woman for this product and service because they’re saving $800 per woman. So capitation does drive the stuff in the right direction. Now the problem you run into of course is some bright guy will say: Well, why don’t we do a study because maybe we’re seeing people twice as often as we need to? So rather than paying this nice little start-up company a couple hundred dollars for their box, let’s just cut the number of prenatal visits in half and see if anybody suffers. That’s what’s going to happen.    


A Med Tech Magazine About People

Better, faster, cheaper.

That’s the mantra being chanted quietly from the C-Suite and the halls of government in response to today’s healthcare crisis. We want better outcomes, shorter wait times and lower insurance premiums.
Healthcare providers in the trenches are caught in the middle, squeezed from all directions. One proposed solution? Become more “meaningful users” of healthcare technology. But for many, this rings hollow. After all, who can worry about hot new apps and gadgets – let alone a cumbersome new EMR – when there’s a line of sick folks weaving out the door?

On one hand, they are correct in that the patients will always matter most. No one knows that more than the docs on the ground. On the other hand, any physician who bucks against digital healthcare innovation has missed an important fact: The only way for healthcare to ever become faster and cheaper (occasionally even better) is through remote, digitized patient encounters – i.e. telemedicine.

It is into this world – this tension – that we introduce the premier issue of Telemedicine Magazine. Telemedicine will chart healthcare’s digital future in a way that links practicing clinicians – the backbone of our healthcare system – with the tech innovators who are turning that system on its head. We’ll publish three issues in 2015; pick yours up at

In his essay on page 32, Editorial Director Bill Gordon describes 2015 as telemedicine’s tipping point. The technology has arrived, the evidence base is growing and legislation supporting its practice is (slowly) working its way through the pipeline (read Rock Health’s legislative run-down on page 47). Not to mention that investors are dropping millions to get a piece of the pie (Scott Kozicki covers investment trends on page 43). According to Ron Gutman, the CEO of HealthTap, there’s even been tidal shift in Silicon Valley. Now instead of flocking to gaming and social media, the best tech talent in the industry are turning to medical tech start-ups (read the full interview on page 28).

But telemedicine is about a lot more than who acquired whom or what new app came out of The Valley. Telemedicine is about the actual delivery of healthcare, from a doctor to a patient. That’s why, in the end, Telemedicine Magazine is as much about people – innovators and practitioners – as it is about technology and gadgets. It’s about stories of progress, and how we can all play a part. That’s one reason we’ve chosen to publish this magazine in print in an age when so many are flocking to digitally incessant blogs and news feeds. We hope the tactile experience of holding these stories in your hands will help you take the time to slow down and ask big questions. What do you want the future of healthcare delivery to look like? How can the right technology be applied at the right time, in the right way . . . by the right people?

Perhaps you’ll find answers to these questions on the pages ahead. Or perhaps the people and ideas you encounter here will spark your own fresh contribution. Either way, I hope to hear from you. If you have comments or queries – or would like to pitch a story – email me at

Logan Plaster // Editor-in-Chief