Steve Case is on a mission. The cofounder of AOL wants to find a diamond in the rough – a start-up worth funding that hails from an unlikely location – i.e. anywhere outside of New York, California and Massachusetts.
Steve Case is on a mission. The cofounder of AOL wants to find a diamond in the rough – a start-up worth funding that hails from an unlikely location – i.e. anywhere outside of New York, California and Massachusetts.
Why are you succeeding where others may have failed?
Steve Cashman: I think we’ve developed a unique model that fits the clinical standards that are out there. And with those clinical standards, we’ve been able to garner a business model that’s built around reimbursement and the way healthcare works, versus trying to recreate the whole enchilada and argue about clinical standards. I think uniquely we have done something that is close to what happens in a traditional office or urgent care. We’ve just done it with technology.
From a services perspective, tell me why HealthSpot is unique.
Cashman: What makes us unique is that we’ve really given the doctor a new tool to do his job. We’ve replicated a full exam in an office setting with an existing doctor, with an existing payer relationship. We’ve just done that in a retail pharmacy using tele- medicine. And so we’ve really just kind of built the same standards and the same thing they look for into a telemedicine model. That’s given us the ability to really eliminate the overhead from the retail pharmacy that they would have in a traditional convenient care retail clinic. And it’s given the providers reach into a segment of consumerism without them having to get outside of the box in business model and other things. It’s the patient seeing them with the standard billable office rate. They’re examining them. They’re treating them just like they would in their office, but yet they’ve been able to use all this technology.
Where do you see the most potential growth for your company?
Cashman: We’re aimed at reinventing the retail clinic. So the 62,000 U.S. pharmacies is where you’re going to find HealthSpot for the near future. Why that is so significant is because when we look at chronic disease folks, they’re in retail pharmacies 20-plus times a year and they’re in their doctor’s office three times a year. As we try to do population health management, we need to take the care to where they are and not try to bring them to where we put care. That’s a fundamental shift.
The other thing is you saw we had an announcement with Samsung last week, we’re adding other services to the HealthSpot station, such as system-on-chip-blood testing. We’re going to allow the medical community to do more and more remotely by the integrated technology that we have within the footprint there. That neighborhood pharmacy is going to become a fully integrated extension in the local medical community and remain a consumer destination that now has other services in it because of our technology
What else do you have on the horizon? Who else have you partnered with?
Cashman: We’ve done a partnership with Rite-Aid. We opened up stores in Ohio in May and that’s been a big deal to give us a national player that we can grow with. The other partnerships that we are forming range from health systems to payers; but really just building an entire converged network, where the value is built around reinventing this care delivery.
Cox is a partner as well through the Vivre Health piece, which is an entity they’ve built around how we move healthcare into the living room. They’re the third-largest cable provider in the country. HealthSpot’s unique in that we’re really a software company. What we do with our software platform in managing doctors, records, claims, remote devices and then obviously all the care delivery video and audio and other things, the support that goes with that; our vision is to make that ubiquitous. As we look down the road, the same way we’ve created a rich telemedicine visit in a pharmacy in a kiosk, ultimately we want to use that technology to build a rich patient experience in the living room of everyone’s home.
How does your approach to creating a connected care network differ from other telemedicine companies?
Cashman: I think the majority of the telemedicine guys that are out there are just doing video. They have no biometric data, they have no way to help impact HEDIS and STAR measures. They have really no way to overall report on people’s total
health because they’re just getting a snapshot of a chief complaint that’s episodic.
Whereas what we’re doing in the model we’re building out is to really create a platform for population health management, where all the stakeholders: your payer, your doctor, your pharmacy where you get your script are all ultimately integrated and the consumer’s driving that. And so we’re really trying to build converged networks. All the way down to when we do a rollout, we go look at the payer data and say: Okay, where are the people that are disconnected from health care and are going to the ER? Where’s the nearest pharmacy to that ER? Who is the right doctor that we can get them into and really try to converge that?
What are the biggest stumbling blocks to making that happen?
Cashman: I think largely doing this at scale is the only way to try to create that convergence, right? With the amount of work that it takes to converge the data and educate the consumer and achieve the scale necessary such that I can walk into any store and get my doctor – and for that service to be ubiquitous near my work and home – we have to build large networks. It’s no different than what telecom went through when it wanted to launch wireless phones, right? They had to put up a bunch of towers so that you could actually make calls in your car. If it was point-to-point communication, it wouldn’t have worked. So we have to build large networks of providers and large networks of locations and work with the payers to then form large networks of consumers to where this becomes a standard level of care in what they do today.
What's the future of HealthSpot? Give me your prediction for 3 years, 5 years down the road.
Cashman: Five years from now HealthSpot will be in about ten to 15,000 pharmacies across the country. It will be as ubiquitous as getting a DVD from a Redbox, or cash out of an ATM. The things that you will be able to do in those pharmacies will far exceed what most people’s current expectation is, and that’ll largely be around things like the Samsung device. Things today that are expensive and inconvenient and require multiple days will instantly be turned into consumer satisfaction without the pain and wait, and with a ton of cost savings.
What we see is a network across the country that we can wander into, see the medical group that we’re affiliated with and quickly get diagnosis for basic things. As we look towards total population health, we’re going to walk in there and our payer is going to be able to flag: “Hey, we want to grab your blood pressure and your weight and a few other things,” just because we’re trying to keep track of overall health trends. And we’re going to reward you for improvements in these health trends.
What is HealthSpot going to look like when it’s fully baked, when it’s a huge company generating hundreds of millions of dollars in revenue?
Cashman: I think we’re starting to become more like our core, which is a software company. The combination of everybody’s data is going to help us know what care we need today, and where it should be provided. That may be right on your Smartphone. It may be in the living room of your home or it may be coming to a pharmacy to do more advanced diagnostics. Or it may be even going into a medical facility. HealthSpot will be the ubiquitous application that’s helping deliver that; reinventing the patient experience to what is the right care at the right place at the right time, based on what you have going on, what we know about you and what sensors we need to ultimately determine what the root problem is. We will become something that is ubiquitous to the consumer where they work, where they travel, where they live and where they shop.
And we’re on our way. In our first 90 days at roughly 25 Rite Aids, we saw nearly 10,000 people. That’s a lot of biometric data; a lot of people and consumers that we now have a relationship with and that’s in a short window of time.
Written by Bill Gordon
Everyone’s heard of the 80/20 rule. In healthcare it goes like this: 80% of the money is spent on 20% of the patients. This means that the sickest of the sick, the folks who have significant health issues, are accountable for 80% of the dollars spent. A quick Google search will tell you that the amount spent on healthcare in the United States in 2014 was between $3.5 and $3.8 trillion dollars. For the purposes of this article we will use the $3.5 trillion figure, quoted by numerous sources.
So, 80% of $3.5 trillion is $2.8 trillion. That’s the amount of money spent on 20% of all patients treated in 2014. That is an astonishing – and tantalizing – number. But chasing that number could kill your business. Here’s why.
The 80% sector may only be responsible for 20% of health spending, but here’s the catch – that’s about $700 billion, and this sector of the population is more likely to spend their own money for products and services. These folks are more apt to be the early adopters, which means these are the people telemedicine companies should be targeting with their marketing programs. The high-spending 20% might look tantalizing, but anyone who overlooks this $700 billion sector is focused on the wrong things. One percent of that market is $70 million. I know a few CEOs who would love to have that on their P&L.
Many start-ups have been operating under the premise that the 20% high spenders are their target market because that is where the outcomes of their services will show the greatest impact. They are trying to prove that their solutions will cost payers less in payouts, show better care results and ultimately be better for the consumer by making them healthier and creating higher satisfaction levels. Sound familiar? It’s a page ripped right out Meaningful Use legislation and all the financial analyst briefings on healthcare that have been published for the last decade. The problem is that it requires that a company prove their solution by targeting one of – if not the hardest – market to succeed in. Why not target the 80%, the much larger portion of the population, where consumers/patients have shown that they will spend their own money on healthcare innovations? All you have to do is look at any of the players in the connected Diabetes market. There has been over $100 million of venture capital invested in this market and not one of those players have made a significant splash. Not one has gone public and not one has reported statistically significant revenue to date. Not Telcare, not Livongo, not Glooko, not Entra. Why? They are going after the 20%.
Until recently payers have resisted large-scale mHealth or telemedicine deployments. They hadn’t been proven and no one was really sure that they actually worked. Fast forward just a couple of months and we now see the momentum shift we have all been waiting for. United Healthcare announced that they would offer telemedicine visits to everyone in their payer network via three service providers. This is ground breaking. Why would United offer this service system wide? Because the 80% want it, will use it and it will ultimately lower United’s operational costs.
Want more proof ? Fitbit clearly targeted the 80%, they went after the healthy and those who want to be healthier. These are people who spent their own money (for the most part) on a product that they believed would help them improve in some way, shape or form. I believe that this same populace would also buy BP Monitors, Blood Glucose Meters, connected weight scales as well as other connected healthcare related devices. Why? For the simple fact that people want to be in charge of and have command over their information. Plenty of weekend warriors, bike riders, half marathon runners and triathletes have medical issues like diabetes, high blood pressure or just want to optimize their performance. Marketed properly, mHealth tools like connected peripherals will enhance their experience and provide better results. Why does that bike rider buy new pedals? They want a better experience or an advantage. Why does the runner buy new shoes? They want faster times or a better fit. It’s all about perspective.
We live in a “take the services to the people” society. People no longer want to have to go and find things; they want them served up where they want it, when they want it. It would be easier to list the things you can’t do utilizing apps rather than listing the things you can. With this kind of mindset prevalent among the 80%, telemedicine and mHealth service providers should be racing to capture this market sector. They have money to spend, have shown that they will keep spending it as long as they are receiving a quality product and experience.
Finally, remember that todays 80% will eventually be tomorrow’s 20%. Want to create loyal telemedicine customers? Get them while they’re young.
The 9th Annual Health 2.0 Conference convened this October in Santa Clara, California. With more than 1,000 attendees and keynotes ranging from Chelsea Clinton to Dr. Vivek H. Murthy, the Surgeon General of the United States, and a swarm of innovative start-ups, it was a dynamic year that signaled some important trends. Here are a few takeaways spotted by the StartUp Health team:
In years past, the stage and exhibition floor were filled with point solutions and feature sets. This year, discussion was elevated from feature sets to more comprehensive solutions and established industry partnerships signaling the next wave of progress and maturation of the market.
New players and talent were circling the conference this year, from electrical engineers and software developers to nuclear submarine mechanics and political figures, all with solutions to problems in the healthcare system. Big name consumer players like Under Armour were also present.
Many international delegates (especially Nordic and Japanese innovators) are hoping to break into the U.S. market for capital and customers. There were nearly 30 startups from Finland alone in attendance with a diversity of solutions.
So many more sensor types—ranging from rings, to beds and pillows, to shirts and hats tracking blood pressure, sleep, EEG, ECG, and heart rate and activity. The wearable, “nearable,” and embeddable market was a huge theme this year.
There are a lot of players trying to crack the code on patient engagement with clever solutions to connect, funnel, reward, entrench, socialize, and gameify their way to the top. Patient engagement remains one of the most popular areas of focus, and one that hasn’t found a clear winner yet but with lots of good contenders.
This Brooklyn-born start-up positions itself as a companion service for members already insured with traditional health plans. Sherpaa coordinates and streamlines access to health care for its members, who sign up through their participating employer. Sherpaa members may consult a physician via web or app, and Sherpaa physicians resolve about half of all cases remotely. All doctor-patient communications are documented, free of the time constraints of an office visit, and physicians are able to search the literature as needed, resulting in a malpractice rate one-third of that of a traditional office-based physician.
Because Sherpaa provides easy access to physicians, its members can use the company’s physicians to receive diagnosis and treatment for common complaints and ailments. Consultations with Sherpaa physicians are not billed to patients’ traditional insurance plans, ultimately resulting in very low (≤2%) premium increases for clients.
by Rishi Madhok, MD
Seed investors can be from friends and family or regional or state grants. Those initial investors often care more about the person behind the concept – or the potential for job creation – than they do the actual business value. A VC on the other hand is very clear in what they expect from investing: significant returns within a 5-10 year period on a business that can scale quickly.
VCs invest in both a business and the people behind it. Small start-ups do not have the ability to compensate for bad hires or poor management dynamics. As a result, some of those intense, driven personalities drawn to start-up culture can drive away talent and eventually investors as well. One toxic partner or bad seed money can be fatal to getting VC funding and closing your Series A.
The old mindset of getting a product 95% “right” before taking it to market is gone. This style of development leads to a product that is outdated before it even reaches its users; making changes expensive or impossible. Don’t underestimate the power of getting the idea 50% right and improving on the 50% wrong. Get users, learn from mistakes while its easier to change, show growth, and bridge the valley of death.
Written by Nicholas Genes, MD, PhD
It’s been said that the very first phone call, in Boston on March 10, 1876, (“Mr. Watson, come here! I want to see you”) was actually a request for medical assistance. In his autobiography, Thomas Watson recounted Alexander Graham Bell had spilled bat- tery acid on himself on that fateful day, and was simply calling for help (Bell never told stories of the first phone call, and Watson’s au- tobiography was published years after Bell’s death).
While details of that day will probably never be certain, it’s clear Alexander Graham Bell often had medicine on his mind. Bell taught elocution to the deaf, his mother and wife were both deaf, and his interests in telephony developed alongside his interests in helping the deaf communicate.
What’s generally credited as the first telemedicine encounter came just a few years later, as Bell’s inven- tion proliferated. In 1879, an anonymous writer in the Lancet reported a case where a mother phoned their family doctor in the middle of the night, concerned that her baby’s cough was the croup. The doctor asked to “lift the
child to the telephone and let me hear it cough.” He then proclaimed, “That’s not the croup.” The family was relieved and reportedly slept well.
Alexander Graham Bell was also involved in an early example of high-tech bedside diagnostic testing, in 1881. President Garfield had been shot near the lumbar spine. His surgeons had trouble locating the bullet, despite multiple attempts at probing the wound (worse yet, Lister’s sterile technique was not in widespread use). As days turned to weeks, Bell applied his telephone’s amplifier to another of his inventions, called the Induction Balance, creating a functional metal detector. When the device passed near metal, users would appreciate a ringing sound, transmitted through an earpiece.
Bell tested the device on Civil War veterans with known lodged bullets, and a side of beef in which a bullet had been hidden. It worked, but in the White House it failed to find the president’s bullet (Garfield’s doctor limited the search to avoid moving the patient too much; autopsy later showed they were looking on the wrong side). Garfield eventually died – not from the initial injury but from the resulting infection.
Bell died in 1922. On the day of his funeral, at 6:30pm EST, all telephone service in the U.S. and Canada was shut down for a minute – the 13 million phones in use at the time went silent. Nearly a hundred years later, it’s hard to imagine anything stopping, or even delaying, so much instantaneous communication – even a telemedicine consult.
Written by Jodi Lyons
As the telemedicine market opens up, patients will be exposed to even more unverified, unhelpful information than they already are. Many of you have had patients show up to your offices with “evidence” printed off of some random website and demanding a particular “medical” treatment. “Dr. Internet” is a popular physician who never went to medical school and doesn’t know the patient, yet dispenses “not- quite-but-awfully-close-to-medical” advice. Whether it’s coconut oil for Alzheimer’s Disease or krill oil for cancer, patients are sure to get upset when you tell them that their requested treatment is quackery.
Patients therefore are forced into an odd dichotomy – a balance between buyer beware and buyer have faith. “Buyer have faith” – credat emptor – is a term that describes the scenario in which the buyer should ethically be able to trust the advice and expertise of the “seller” – in this case, the person providing medical information or care. To quote an old commercial, “an educated consumer is our best customer.”
This challenge is only going to get worse as the telemedicine market opens up and web-based applications “replace” human-to-human interaction between medical professionals and patients. The art and science of medicine can be supported by, but not replaced by, an algorithm. It is important to preserve the instinct, training, education, experience, and compassion that medical professionals bring to the table so that the diagnosis and treatment plan don’t take place in a vacuum. The analysis of data is only one part of the equation.
Products based on symptom checkers and the like present a particular challenge. Think of how many diseases or adverse reactions to medications manifest themselves in “flu-like symptoms.” Another challenge is mimicking symptoms: is it a GI bleed or a side effect of bismuth sulfide? How are patients to know if they have a serious problem or not? How do they know who or what to trust? Consumer education is vital as is a clear means of differentiating between reliable sources and quacks. Most professionals understand the difference between scientifically validated information with peer review and the information found in a chat room where no one has any medical expertise. Many consumers don’t know the difference.
It also is important to differentiate between “real” telemedicine and “there’s an app for that” faux telemedicine. The telemedicine industry needs to thoroughly educate the consumer base so that the distinction between legitimate telemedicine practices and quacks are more easily identifiable. This is vital for patient protection– buyer beware.
The second side of the equation is “seller beware.” Medical professionals face a particular challenge if they don’t have a preexisting, face-to-face relationship with the patients before embarking on a telemedicine relationship. That is the “danger” of relying on patient self-reported symptoms and allergies. While similar challenges exist when enrolling a new patient even in a traditional office visit, the online-only world raises the stakes. There is limited data on the patient, and that data often is patient self-reported. How is the practitioner supposed to know if or how much the patient is cognitively impaired? A drug user/abuser? Confused? Misunderstanding the questions or situation? Doctor-shopping? Lonely and just needing someone to talk to? A hypochondriac? It is often easier to “see” these challenges face-to-face.
Particularly in the world of geriatrics, it is important in both face to face and telemedicine interactions to perform some sort of cognitive and mood screening that identifies executive functioning and decisional capacity, not just a test of short-term memory. This allows the medical professionals a chance to decide whether or not to trust the patient’s self-reporting, to know if the patient truly is able to understand the medical recommendations, to identify whether or not the patient is capable of adhering to the recommendations, and to decide whether or not to treat the patient. There are evidence-based, scientifically validated cognitive assessment and mood screening tools that can be administered in 15 minutes or less in-person, online, or over the phone even over asynchronous care. Using them protects both the patient and the medical professional. Short-term memory retention only tells a small part of the story and tests like the MMSE don’t give enough guidance to the practitioner.
Additionally, as the population ages, it becomes even more important to understand the psychosocial and practical implications of the medical interaction. If the medical practitioner calls in a prescription, does s/he know if the patient is able to get the medication and take it properly? Does the practitioner need to know or have they done their job just by calling in the prescription? Is there a need for follow up? Who arranges the follow up?
The expanding world of telemedicine and web-based medical advice creates many opportunities to expand access to medical care, especially to those who are not well- served by “traditional” means. Yet, just as patients need to beware of bad information on the Internet, medical professionals need to beware of bad information from the patients. Buyer and seller, beware!
Written by Scott Jung
One of the hottest trends in the computer industry is augmented and virtual reality, a computing environment which partially or completely skews reality with computer- generated imagery. Somewhat like a primitive version of Star Trek’s “holodeck”, this technology allows a user an escape from real life with immersive sound, lifelike visuals, and interactive, gesture-based interaction.
While virtual reality is finding itself increasingly in the next generation of video games, both augmented reality, in which images and information is superimposed over real-world images, and virtual reality, in which one’s entire field of view is completely computer-generated, is also being trialed in the healthcare industry, namely medical education.
While an experienced doctor is still absolutely essential, “augmented medicine” and other new technologies are allowing them to extend their talents even further and learn even more about the human body and disease. For patients, this could mean reduced costs and better outcomes for surgical procedures and treatments.
Here’s our list of notable technologies that you might someday see in a medical school or doctor’s office near you.
Ever since the launch of Google Glass in 2013, the tech industry has eagerly speculated about how each field of medicine would embrace it. In August 2013, a surgeon at the Ohio State University Medical Center wore Google Glass during an ACL repair as medical students watched the live-stream on laptops in another area, and since then, a number of doctors have started using Google Glass to stream and record their surgical procedures for educational purposes.
Google Glass was officially discontinued in its current form in early 2015, but some are still hopeful that smartglasses might still be the next revolution in surgery technology. One company, Pristine, has developed a program called EyeSight to stream and record live video and photos from the smartglass user’s point of view. This content can be shared with a colleague with a simple voice command.
Another company, inSight Augmented Medicine, has developed a similar app called Telepresence that can transmit the smartglass user’s point of view to a remote user’s tablet. The tablet user can annotate the video or picture with their finger, and the video feed with annotations, drawings, and text is transmitted back to the smartglasses and seen through its display.
Both EyeSight and Telepresence were developed for multiple smartglass platforms, so Google Glass is not required.
One gadget that could prove beneficial during surgery may already be sitting next to your TV. Microsoft’s Kinect motion-sensing camera has already shown itself to be a useful tool to help surgeons view and manipulate medical images. Within the sterile field, surgeons are usually unable to operate a mouse, keyboard, or even a touch screen with their hands. The Kinect makes viewing and manipulating images and patient data as simple as waving their arms.
Moreover, the camera in the Kinect is sensitive enough even to detect subtle changes in a patient’s skin color. An additional Kinect device could theoretically be aimed at the patient being operated on to monitor a user’s heart rate or track radiation exposure from x-rays or CT scans.
Brain surgery has always been a risky undertaking. Not only because the brain is the control center for the entire body, but also because it contains a dense network of blood vessels and anatomical features that are unique for every person and extremely delicate to navigate.
One company, Surgical Theater, took inspiration from flight simulation technology and developed a platform which integrates CT and MRI scans and traditional x-rays to create a highly detailed three-dimensional model of the part of the brain being operated on. These models can be manipulated and used for planning the best entry/ incision point, the best path around the patient’s vasculature and the minimum amount of skull bone needed to be removed to facilitate faster healing. Recently, Surgical Theater received approval in the EU to incorporate virtual reality headsets for enhanced navigation and planning.
Once the procedure is planned, the details can be imported into another Surgical Theater program which allows the surgeon to see the 3D model and plan in real time from inside the operating room.
Tablet computers have transformed the computing industry because of their portability and ever-increasing processing power.
Fraunhofer MEVIS research center in Germany has harnessed the power of the tablet computer and developed an augmented reality app to assist with liver cancer surgery. CT scans are used to create a model of the liver and its cancerous site to assist with preoperative planning. However, instead of being sent to a stationary computer monitor, the model is sent to a tablet computer. As a result, a surgeon can superimpose the exact locations of important blood vessels and anatomical features during a procedure when the tablet is held over the patient’s actual liver. The liver can be filmed with the built-in camera, and the tablet can be operated as normal with touch gestures.
This technology helps ensure that the surgeon doesn’t make any unnecessary cuts, can make adjustments quickly and flexibly, and completely remove the cancer.
Like the Kinect, the Oculus Rift is another gaming device that is dabbling in the medical technology industry. The Oculus Rift is a virtual reality headset that displays a fully immersive 3D experience that makes you feel like you are actually in the middle of an environment. Motion sensors detect when you move your head and change your perspective accordingly. Now owned by Facebook, Oculus Rift is still looking for its niche in gaming and consumer media, but it’s already been used as an immersive medical learning tool.
Last July, a surgeon in France wore a GoPro Dual Hero camera system on his head as he performed a total hip replacement surgery. The cameras created a stereoscopic 3D video that could be viewed through the Oculus Rift. Moreover, the sensors in the Oculus Rift allowed the viewer to move his or her head and focus on different aspects of the procedure, such as the surgical site or the assistants. The team behind the surgery hopes that doctors anywhere in the world would someday be able to observe a surgical procedure by simply donning an Oculus Rift. They believe that the headset can be a revolutionary learning tool for both new and experienced surgeons.
Doctors aren’t the only ones that have all the fun when it comes to Oculus Rift, however. They’re also being evaluated in patients as a form of virtual reality therapy (VRT). Dr. Albert “Skip” Rizzo of the University of Southern California’s Institute for Creative Technologies has developed an Oculus Rift version of the Virtual Iraq/Afghanistan PTSD Exposure Therapy System that he created in 2005 to help treat war veterans suffering from PTSD. The system uses virtual reality to recreate combat situations to help alleviate fearful associations linked to traumatic memories and has been shown to significantly reduce PTSD symptoms. According to Rizzo, the lower price point of the Oculus Rift will make it much more affordable for clinics and allow for research to expand to other areas of mental health.
“Merry Christmas” – that was the first SMS message ever sent, back in 1984. Twenty-one years later, trillions of text messages whip around wireless networks all over the world. SMS’s rise in popularity foreshadows telemedicine’s evolution from traditional video/ phone-based encounters into asynchronous and technology-assisted virtual care. Along the way, the effective transactional virtual care costs will trend towards $0 – which is beautifully aligned with value-based care models that reward outcomes over encounters. This transition forward requires fresh thinking about who pays for virtual care. To spur this process along, I’ve mashed up non-healthcare models to see how we might unchain telemedicine from old-school PEPM + per visit fees.
Analog: Wireless data plan: Individual or Family.
Description: In this model, patients can purchase a large block of interactions for a
fixed price. The effective transaction price is technically not $0, but, like text messages or data usage, it trends towards that over time. Pricing is based on anticipated utilization across broad swaths of medical risk.
Example: An employer purchases a lipid management bundled payment plan. The bundled service includes 1-2 in person visits and unlimited virtual care encounters through the year.
Analogs: Netflix, AppleTV, Hulu, Amazon
Description: Instead of buying the entire season of Top Gear BBC, patients buy a “Season of Care” for a disease or care pathway. Individuals can build their own care networks on the fly by choosing from a menu of Seasons of Care. They get unlimited access via virtual visits through the season, but the “content” or access channels are titrated out based on the appropriate care protocols. In this way the tools (e.g. video/ phone/asynchronous) are free but patients pay for content pushed by providers.
Example: Jim, who was recently diagnosed with Type 2 Diabetes, purchases “Season 1 of Living with Diabetes” from Mayo Clinic. Each week he gets a new virtual care plan and access points across his devices. It might include scheduling a virtual visit to review his diet compliance and speak with a care coordinator about any open questions on his glucometer.
Analogs: Television, radio
Description: With a proliferation of wearable technology, remote devices and other health-enabled hardware, it is possible to use these to cover basic transactional costs. When you buy a TV, it comes ready to watch a handful of channels. The free content/channels are akin to basic care visits. Knowing that a vast majority of new hardware users are also potential new patients, providing content becomes a marketing expense to bring those into a system.
Example: You walk into the Nike store and purchase the latest workout shirt with embedded sensors that monitor pulse, respirations and perspiration. The shirt comes with free virtual visits for simple conditions for as long as you own the shirt and regularly upload biometric data.
The advent of SMS was facilitated by powerful technology innovation. But it was adopting an “unchained” economic model that allowed it to proliferate. Like SMS, the tide of technology is pushing telemedicine towards lightweight, zero-cost virtual care transactions. Now it’s time to get unhinged in devising new economic models that allow virtual care to explode.
Telemedicine providers are zealous advocates for change and shift in healthcare delivery. Yet these same innovators often fail to apply that same mentality when developing their business models and contractual arrangements. They devise something new, exciting, and disruptive, only to lament a lack of existing reimbursement for the innovation they just created.
The concept of government-funded, fee-for-service payments (i.e., traditional “reimbursement”) is becoming increasingly criticized (even by the Department of Health & Human Services itself ) as an outdated, less than ideal payment model for 21st century healthcare. CMS already announced plans to make at least 30% of Medicare payments through non-FFS alternate payment models (e.g., ACOs, bundled payments) by the end of 2016, increasing that percentage to 50% by the end of 2018. The remaining FFS payments would be tied to quality or value under programs like the CMS’ Hospital Value-Based Purchasing Program or the Hospital Readmissions Reduction Program.
With all these signs of change, why do some telemedicine providers expect their breakthrough approaches to care would (or even should) easily align with an old payment model? Rather than wait on the sidelines focusing on regulatory hurdles, the most successful telemedicine providers we work with (whether physicians, hospitals, or start-ups) are those who shift their mindset from reimbursement to revenue. When that happens, a world of payment opportunities presents itself.
To succeed in the developing market, telemedicine providers must structure their business models and contracts using the same creativity and innovation they devote to their care and technology offerings. In doing so, companies can build scalable, sustainable telemedicine programs extending well beyond the realm of grants, pilots, loss-leaders, and demonstration programs.
By no means an exhaustive list, here are a few concrete examples of telemedicine revenue- generating business models outside the traditional “reimbursement” box. There is no one-size-fits-all approach. And while any healthcare offering must be tailored to comply with state and federal laws, providers should not allow perceived regulatory complexities to prevent them from building something great. Remember: there are no problems – only solutions.
An Academic Medical Center with a surplus of talented specialist physicians can leverage that expertise to patient markets outside the zip codes surrounding its brick and mortar location. The AMC could enter into contracts with rural hospitals or other institutions across the world in need of on-demand specialty expertise. Compensation methodologies will be driven by specific business factors and contract design, including whether the AMC’s service is peer-to-peer consults or direct patient care (or both), and if there will be any billing of third-party payors (and if so, any reassignment of collections). The parties could utilize a monthly rate, a hybrid payment, a fee schedule menu of different specialist services, or even a cafeteria model to encourage multi- specialty utilization. Fundamentally, this model can be built as a professional services agreement without dependence on external FFS reimbursement to drive the revenue.
Even among those forward-thinking providers who have embraced change to build ACOs . . . only approximately 20% have incorporated telemedicine.
Even among those forward-thinking providers who have embraced change to build ACOs (there are 20 Pioneer and 333 MSSP ACOs in the United States), only approximately 20% have incorporated telemedicine technologies into their operations. It may be no a surprise, then, that only 27% percent of ACOs achieved cost and quality scores sufficient for to trigger financial incentive payments in 2014. Strong opportunities exist for telemedicine technology companies (particularly those with and population health software functionalities) to contract with ACOs and use virtual care as a means for ACOs to realize the quality and cost improvements needed for them to receive Medicare incentive payments next year.
A provider with a network of primary care physicians can offer telemedicine-based care to the workforce of an employer through a combination of an on-site kiosk and an online app. The employer would realize benefits of increased presenteeism and workforce health, reduced direct care costs in the short term, and reduced overall workforce health costs in the long term, among other benefits. The provider could negotiate with the employer a variety of different compensation approaches, including but not limited to a per-encounter fee, a base services rate combined with a reduced per-encounter fee, a fully capitated per employee per month payment, a shared savings fee model (whether paid on an encounter, capitated, or hybrid basis). Different choices in the contract terms and compensation methodologies will significantly impact the employee utilization of the offering, so all these factors should be considered and tailored to the parties’ specific goals. The payment could be made by the employer’s self-funded plan, the employer’s third-party payor administrative services organization, or even the employer itself as an out-of-pocket cost.
These are just a few examples of what can be achieved when a telemedicine company applies the same level of creativity to its healthcare business models and contracting. Providers should reject the notion that the traditional FFS reimbursement system is immutable or that they must wait for someone else to change policy. Telemedicine companies have already rejected traditional care approaches in favor of something better, so while the business and legal “how to” may be unfamiliar, the “why” is nothing new to these thought leaders.
When the telemedicine and virtual care market matures and the dust settles, the successful and surviving providers and companies will be those who are innovative not only in what they offer patients and the healthcare industry, but in how they offer it.
PokitDok is a cloud-based application program interface (API) platform that powers healthcare interoperability. Third-party developers such as payers, health systems, and digital health companies who license the PokitDok platform can easily create new apps to streamline healthcare transactions, with the intention of creating better experiences and bending the cost curve down. PokitDok CEO, Lisa Maki, says that there are over 2,400 applications on their platform today. “That’s what excites me,” says Maki, “people pulling these services together in ways that we can’t even imagine.”
Financial transparency and savings are a significant aspect of the PokitDok mission. Maki recently announced that all clearinghouse transactions on PokitDok’s X12-compliant API, such as preauthorizations and submitting or checking claims, would be completely free of charge, effective immediately. With modern technology and cloud services, the cost of moving data from point A to point B is now “close to zero,” she said. “So we want to start passing that savings back to all of you.”
STOP WORRYING about appearing as an outsider in your field and focus on your strengths (most Silicon Valley seed-stage startups are filled with young men in their twenties). Focus on what you can affect—your idea, pitch, team, tech, and timing. You’ll make a difference by executing and succeeding. If you are a woman and your target audience is too, use that to your advantage. No one knows your audience better than you do.
PREPARE by educating yourself on incorporation, funding, operations, and everything else about your company. You will need to be able to answer questions about your company in any period of time and in any order, so do yourself a favor and learn it in your bones. Or, as my sensei sometimes required when we practiced sparring, pitch blindfolded.
DON’T FOLLOW the herd and don’t worry if your “raise” doesn’t look as large or come as quickly as that of others (don’t chase an outcome you can’t realistically achieve). Focus on investors who will evaluate you and your business outside of the flash funding lens and on the merits of your team, tech, and timing.
LEARN TO JUDGE people quickly and well. I have amazing women on my team who move mountains every day to build our company. Three of our advisors are women who dominate their field. However, the only people who have invested their money in our company, and in me, are men. Men are not our enemy, they are our allies. Find the good ones, male or female, and discard the rest. And never waste time on anyone who wastes your time.
Written by John Tyler Allen
There’s an understanding in Mitchell County, North Carolina: if you miss your shift at the factory for any reason, don’t bother showing up tomorrow. “You don’t get to miss work and still have a job,” one Mitchell County resident told me. “You can’t leave and go to a doctor’s appointment. You can’t call in sick. It’s harsh.”
The zero tolerance policies common to the factories are made possible by what feels like compounding misfortune. Deep down, Mitchell County is an Appalachian mining community where the ground produces quartz and feldspar in unusual abundance and purity. The small mines that used to dot the mountainside were owned and worked by locals. Now, the conglomerate Unimin is the largest mining operation and third-generation miners hope for work. An assortment of manufacturing plants, the area’s second-largest industry, was, until recently, a buoy for the local economy. But in a recent six-year period, one town of two thousand lost a total of two thousand jobs when their work was outsourced to cheap labor. With unemployment still surging to fifteen percent, the community has yet to recover.
The offence feels more personal, though. For a working parent, something as common as a first-grader’s sore throat and the resulting call from the school nurse can mean choosing between a paycheck and medical care for a sick child.
“You have to weigh that carefully,” Amanda Martin said. “Can I leave to go get my kid? You put your job at risk every time you do that.” Martin is the executive direc- tor of the Center for Rural Health Innovation in Mitchell County. The center, a nonprofit with a mission to “apply innovative technologies to improve access to healthcare in rural communities” came out of Dr. Steve North’s work providing care in a school-based health center at the north end of Mitchell County. In addition to the isolation and the poverty, the shrinking job market and the stifling work schedules, North noticed that parents weren’t able to get their kids in to see primary care physicians. The schools, North said, were looking at unusually high absentee rates due to health problems that, otherwise, wouldn’t warrant missed class time.
The connection, he said, was obvious, and he soon began assessing other health data in the area. In a state where eight in ten counties are rural, Mitchell ranked 89th out of 100 in clinical care access. With only 15.6 physicians per 10,000 resi- dents, it had been designated a Health Provider Shortage Area by the Health Resources and Services Administration. School officials said sixty-five percent of students utilized the free and reduced lunch program, which meant it was likely as many families depended on Medicaid. Finally, what was perhaps most telling, North said: in the previous year, seventy-five percent of daytime emergency department visits
for children ages five to eighteen had been for non-emergent issues.
This was a community that had been subjected to the failings of a porous, incomplete healthcare system. North was determined to find an answer. A year later, he founded the Center for Rural Health Innovation and launched the Health-e-Schools program,
which equipped three schools with a crude telemedical cart – general exam camera, digital stethoscope and otoscope, and a high-definition camera for imaging bruises, rashes, and the like – taught existing school nurses to operate the equipment, and gave them remote access to a physician and on-call nurse practitioner. Five years later, Health-e-Schools carts now feature fully integrated state-of-the-art diagnostic equipment and access to a cloud-based server that allows parents with access to a camera – a smartphone, perhaps – to conference in to their child’s visit.
“That kid got care they were not going to get. And it may mean that parent keeps their job. That’s a game changer for that family.”
For many families in the area, the Health-e-Schools program was the first regular access their children would have to a healthcare provider, and their only opportunity to escape a cycle of health care avoidance and preventable emergency room visits. “We’re able to evaluate and treat their child, send them home with follow-up instruc- tions, and a prescription has been called in to a pharmacy that is open late,” Martin said. “That means that kid got care they were not going to get. And it may mean that parent keeps their job. That’s a game changer for that family.”
“Sick kids are the number one reason parents in America miss work,” North added. Last year, the Health-e-Schools program expanded to the neighboring McDowell County. Of the first one hundred visits they conducted at McDowell schools, only four students had to be sent home. “Previously, at least half of those kids, their parents would have needed to come pick them up and take them to the doctor,” North said.
Laura Brey holds encyclopedic knowledge on the many ways the access to care provided by school-based health centers can change a school and a community. She’s the Vice President for Strategy and Knowledge Management at the School-Based Health Alliance, and has worked in school-based healthcare for twenty-five years.
When school-based health is introduced, she says, “the whole environment of the school starts to change.” Students learn they can go to the school’s health clinic when they have an STD, maybe, or if there was no food at home for breakfast, and they’ll find an adult they trust. “It becomes a place where kids feel safe,” she said.
The school-based health center then becomes a valuable tool for identifying issues like anxiety, depression, domestic abuse, and many other issues young people often face alone.
“One of the things we’re able to determine pretty easily,” North said. “Is this the stomachache that comes every Tuesday, first thing in the morning before a spelling test, or is it a bigger issue that needs to be addressed? What is the child really seeking?”
A communal approach, North stressed, is integral to their success. “We’re not just offering urgent care in the schools,” he said. “This needs to be part of the fabric of the health community.” Instead of replacing would-be primary care visits, the Health-e-Schools program aims to connect students with other community healthcare providers and, when necessary, partner with these providers to better manage chronic conditions.
For many families in the area, the Health-e-Schools program was the first regular access their children would have to a healthcare provider, and their only opportunity to escape a cycle of healthcare avoidance and preventable emergency room visits.
It’s in this way that these programs can lift an entire community, Brey said. When kids are mentally and physically healthy, and when other social needs no longer go unnoticed, performance in school increases, school environments improve, families migrate back to public schools, an educated workforce rises up, and the value of reinvesting in your community becomes evident.
This seemed to be the way of things for Mitchell County. More than once I listened as someone unpacked for me how a single occurrence was invariably connected to everything else in the community.
One story came from Amanda Martin. She had been visiting her grandmother in the hospital when a nurse stopped her in the hallway. “You run that computer doctor program for the schools?” the nurse asked. Martin braced herself for a skeptical healthcare professional’s diatribe on the ineffectiveness of telemedicine.
“Once, I was working here at the hospital when I got a call from the elementary school that my son was sick,” the woman said. The school nurse had connected this woman’s son to a physician via a Health-e-Schools telemedical cart, they told her. Her son’s problem had been resolved and he had already returned to class. They were just letting her know.
“That meant everything to me,” she said. “I didn’t have to leave work. And the hospital didn’t have to find someone to cover my shift. They didn’t have to pay someone overtime. Someone else didn’t have to come in unexpectedly. I didn’t have to find someone to pick up my other son. We didn’t have to sit in the pediatrician’s office with my sick kid, and my new baby wasn’t in there licking all the chairs and tables. He would have been sick another week...”
“It had this ripple effect for her,” Martin said. And in one working-mother’s account of a single telemedical visit, it became evident just how deep into Mitchell County these doctors with cameras could reach.
The telemedicine sector is quickly turning into an arms race. Several companies have raised very large rounds of investment and one even went public, managing to keep above its IPO price despite a very volatile market this summer. Most of these players are what we like to call Direct to Consumer (D2C) plays, in that they are focused on marketing and delivering a service that you pay for out of pocket with little or no intermediary.
But the battle lines aren’t just being drawn between competitors. There is another battle playing out as the established care delivery industry reacts to these telemedicine upstarts and the new capabilities that they represent. The million dollar question is whether the establishment will react quickly – and intelligently – enough to fend off the D2C challengers.
It’s silly to think that the established care delivery system (let’s call it Healthcare Inc.) will sit and do nothing while a bunch of startup rebels whisper lots of 21st century smartphone nonsense into the ears of consumers about how conveniently their health care should work. For Healthcare Inc. is strong with the force (of hundreds of billions of dollars in combined revenue).
Just like many of our favorite good-versus-evil stories, it’s not always easy to tell the good guys from the bad. Companies like Doctor On Demand, MDLive and Teladoc are all very focused on the consumer experience and spend a lot of money marketing directly to the consumer in order to create ‘pull’ for their services with employers and payers. It’s not as simple as saying they are all D2C players. Some of their revenue comes from payers and employers, who are the ones writing the biggest checks in the health care landscape in the United States. In our last issue, we argued that these D2C players are creating the first consumer healthcare brands and they’re creeping on existing Healthcare Inc. brand’s turf.
But Healthcare Inc. is massive and in many cases already a trusted brand. Mayo Clinic, Cleveland Clinic, HCA, the vast network of Ascension hospitals; all of these provider organizations have tremendously valuable brands and have been dabbling with various components of telemedicine for years. There are some telemedicine companies who are geared more as platforms for existing players to utilize than their D2C competitors. In this way, there’s no need to use a rebel startup such as MDLive, when you can finally get access to UCLA Health from anywhere in the country via a company called Zipnosis. Zipnosis is the leader of the pack of B2B providers of telemedicine. Their platform allows any Healthcare Inc. provider brand to add telemedicine capabilities as if by the stroke of their hand.
Why is that important? Healthcare Inc. brands are known quantities with consumers. They already have the infrastructure and institutional expertise of not just getting your visit covered by insurance, but how to arrange for follow up care (such as physical therapy, or imaging procedures), and perhaps the most important piece of the puzzle: data. That’s right, they probably already have some clinical data on you, and that enables them to do a much better job of driving positive outcomes, both clinical and financial.
So who will win this battle? It appears that the D2C rebels have raised a lot of money and have been the darlings in the press about bringing the health care experience in line with the rest of our mobile lives. But unless they use that money to offer deeper delivery options such as brick and mortar experiences, then they will simply be another channel to access care. A channel is generally not a rich margin business long term (just ask anyone who sells DSL for internet access). It’s much more likely that Healthcare Inc. will use B2B platforms as part of their broader marketing strategies to keep their mighty traffic numbers within their brand experience. It will be very hard for the D2C companies to compete with the infrastructure of the Healthcare Incs of the world. And it enables Healthcare Inc. brands to wage war with each other outside their existing territories.
Mind you, this story isn’t over. Healthcare’s startup rebels are still a force to be reckoned with, and won’t go down without a fight.
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.
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.
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.
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.
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 firstname.lastname@example.org or reach out on Twitter @telemedmag
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 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.
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.
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.
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.
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.
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
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.
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.
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.
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 www.telemedmag.com.
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 email@example.com.
Logan Plaster // Editor-in-Chief