Guest post by Donald Voltz, MD, Aultman Hospital, Department of Anesthesiology, Medical Director of the Main Operating Room, Assistant Professor of Anesthesiology, Case Western Reserve University and Northeast Ohio Medical University.
Telemedicine is about reaching out to patients in remote locations, but limited to videoconferencing between patients and health providers. It is similar to a face-to-face service with the exception that the patient and primary care provider are not physically together. Such efficiency is limited in term of scope and only addresses the geographical challenge and scarcity of physician availability, a far cry from what CMS wanted for its Chronic Care Management Services (CMS), which would fundamentally change telemedicine as it is practiced.
CCM services bring the telemedicine definition to the next level – a quiet continuous monitoring and collaboration from all care services to the patient, given the ability to anticipate and engage in care issues. Such ability not only curbs care costs, it would also increase care provider bandwidth, giving them the ability to cover more patients with better efficiency. The challenge is not on the requirements part of CCM services, but the lack of an IT solution to really address all CMS guidelines, including its intent to enforce the concepts through the healthcare industry.
The New England Journal of Medicine has covered the major challenges from the new CCM guidelines, touching on all the major shortcomings in today healthcare IT offerings. Healthcare providers recognized that the fee-for-service system, which restricts payments for primary care to office-based visits, is poorly designed to support the core activities of primary care, which involve substantial time outside office visits for tasks such as care coordination, patient communication, medication refills, and care provided electronically or by telephone.
The time has come for a paradigm shift to re-engineer how we deliver care and manage our patients. To arrive at a new plateau requires rethinking the needs of our patients and how to meet these needs in an already resource constrained, proprietary, inoperable systems. Unless we develop solutions that both integrate with and enhance the technologies currently available and those yet to be realized, we will not realize a return on health IT investment. That has now changed since one Healthcare 2.0 innovator has been able to connect the CMS guideline dots.
Huge Market Opportunity
According to the 2010 Census, the number of people older than 65 years was 40 million with increasing trends to 56 million in 2020 and not reaching a plateau until 2050 at 83.7 million. With two-thirds of Medicare beneficiaries having two or more chronic conditions while one-third has more than three chronic conditions according to CMS data, putting the number of patients who qualify for CCM services at 15 million. This number is predicted to continue on an upward trend until 2050.
The World Health Organization (WHO) recognized the growing burden this trend in chronic disease places on the healthcare system and addressed the need for innovative solutions in their 2002 report. While the potential market is huge, in the billions of dollars yearly, healthcare organizations have been struggled to address the CMS guidelines with key requirements from CMS. We can no longer afford not to address the needs of patient with chronic medical conditions along with engaging them in their healthcare decisions.
The CMS guidelines are as follows:
24×7 access to clinical staff
Patient care continuum
Collaboration, coordination between primary care providers and other care services
Electronic management of care transition among care providers
Coordination between home and community care services
Here is how these guidelines are now being addressed:
Guest post by Christina Richards, vice president, AOptix.
In recent years, the healthcare industry has experienced a Renaissance of sorts with the development and adoption of mobile and connected technologies. As a result, healthcare facilities the world over are increasingly making use of smart technologies to drive better patient outcomes, track equipment, and support overall operations. In addition, the developing practice of telemedicine is becoming increasingly commonplace for doctors in healthcare settings across the United States, which is raising new concerns about the infrastructure needed to support these real-time doctor-patient experiences.
Although the development of these digital technologies for healthcare applications is only in its infancy, we are already beginning to see their wide range of benefits, including the potential to help organizations achieve the Institute for Healthcare Improvement’s (IHI) Triple Aim of bettering the patient experience, improving population health standings and reducing the cost of healthcare. For instance, a 2014 study by Dale H. Yamamoto of Red Quill Consulting, Inc. found that that the average estimated cost of a telehealth patient consultation was $40 to $50 per visit, compared to the average estimated cost of $136 to $176 for in-person acute care.
With the widespread adoption of any new technology however, there is a learning curve to ensure that they can be effectively integrated into existing operations to capture the greatest benefit without compromising the level of care. But what does this entail?
As healthcare facilities become more connected through the Internet of Things, adoption will continue across a broad spectrum of devices and sensors—from wearable tech that monitors patient location and vital signs to analytics platforms that track staff movements and create more efficient workflows. While these devices span a variety of applications, they all share a universal purpose, which is the constant collection and analysis of data.
Likewise, video conferencing and other mobile approaches to telehealth are highly data-intensive, requiring the transmission and processing of large amounts of information. As a result, many healthcare administrators have encountered the need for far more robust mobile networks in their facilities to support the massive amounts of data traveling across their systems.
In considering other data requirements on the horizon, take the case of rapid genomic sequencing. While the new technology allows researchers to quickly determine the complete DNA sequence of an organism to predict disease susceptibility and drug response, the process requires the transfer of massive amounts of data. To make this information more widely accessible, one company, NantHealth, is looking into a method of compressing the data into a more manageable size so it can be shared with other facilities through high-capacity wireless connections, rather than strictly relying on fiber. With ever-growing levels of data becoming necessary in the healthcare system, new technologies and methods for managing it across various networks will become even more important.
Although life in rural communities offers many advantages, the rural healthcare system in America faces challenges not seen in urban areas, for obvious reason: population loss, poverty and access to healthcare have been problematic in recent years.
Taking a look at Pennsylvania, which is the sixth most populous and ninth most densely populated state in the US, based on information from the United States Census Bureau from 2010 and 2013, as a state it hosts a significant amount of rural areas. According to the Pennsylvania Rural Health Association, 48 of its 67 counties classified as rural, and all but two counties have rural areas. More than one quarter of Pennsylvanians live in rural counties.
Thus, it’s as good a place as any to examine some of the unique issues facing rural communities, who even though they may be within driving distance to some of the best medical care in the world, they are unable to access it each day without some sort of life altering obstacle.
In general, residents of rural communities in the U.S. are less healthy than those in urban environments. According to Unite for Sight, “rural residents smoke more, exercise less, have less nutritional diets and are more likely to be obese than suburban residents.” Already against the odds, residents in rural Pennsylvania face several specific problems that jeopardize the state of healthcare in the area.
Between 2000 and 2010, the Pittsburgh Post-Gazette reported that rural Pennsylvania counties grew by 2.2 percent while urban counties grew by 3.9 percent. However, the small increase in rural counties was only because of the eastern counties. Western rural counties decreased by 0.9 percent, and by another 0.5 percent from 2010 to 2012.
In some places, the situation is bleak. The newspaper highlights the population loss in Taylor Township, a part of Lawrence County that experienced a 13.6 percent population loss from 2000 to 2010. “Of its 1,052 residents, more than twice as many are over age 65 as under 18. That ratio is practically unheard of among municipalities and doesn’t bode well for the township’s future.”
Today’s physicians face an increasing array of non-clinical demands on their time, from filling out paperwork to sorting through insurance denials. As a result, the amount of time doctors have to actually see patients has been reduced.
The combination of decreasing number of physicians, increasing demand for quality care, and rising costs of healthcare has created a challenging environment for both patients and healthcare professionals.
Nearly all of us have experienced long wait times at a physician’s office, often for minor ailments or routine follow-ups. These lengthy wait times are causing more and more patients to skip follow-up visits or turn to unreliable online medical services and websites for information. This not only erodes the doctor-patient relationship, but it puts patient health at risk. Furthermore, the information is not properly shared with the patient’s actual physician.
Today’s ultra-connected world has a solution that can bring the doctor-patient relationship into the 21st century: telemedicine.
Telemedicine is a suite of technology solutions that enables doctors to communicate with and treat patients via text, video and audio – and it can be used by physicians, nurses, office staff, any healthcare professional and, of course, patients. Telemedicine allows physicians to provide more convenient, real-time interactions with their own patients, for triaging acute issues and for quick follow up visits that can save the entire health system time and money.
And it’s far from the latest medical fad. Telemedicine is already one of the fastest growing segments in healthcare. According to the American Telemedicine Association, half of all U.S. hospitals now use some form of telemedicine. Similarly, Health Affairs has predicted an increase in domestic telehealth revenue by almost 20 percent per year, to $1.9 billion by 2018.
Connecting to patients, anywhere and anytime
Clearly, these solutions have ushered in a new age of medicine. Technology can also provide real-time data on patient vital signs, blood sugars and other information to improve the monitoring of chronic conditions, reducing readmission rates and keeping our patients healthier outside of the hospital.
Factors fueling the growth of telemedicine are as follows: a shortage of physicians in rural and remote areas, the high prevalence of chronic diseases, growing elderly populations, increasing numbers of smartphone users and the need for improved quality of care.
Telemedicine solutions fall into two broad categories: remote patient monitoring and online/digital communications. Remote patient monitoring links home healthcare equipment (heart monitors, dialysis equipment, etc.) to the internet and then securely reports patient data back to a healthcare provider.
Telemedicine initiatives may have a promising future within the American healthcare system, and could alleviate the shortage of general practitioners, increase reliable access to basic and preventative care, and reduce overall costs. Despite potential positive outcomes of telemedicine platforms, patients remain dubious about this remote option and the quality of diagnosis made during virtual appointments.
According to a nationwide study conducted by TechnologyAdvice Research, nearly 65 percent of respondents said they would be somewhat or very unlikely to choose a virtual appointment, while only 35.4 percent stated the opposite. Approximately 75 percent of people reported they either would not trust a diagnosis made via telemedicine, or would trust this method less than an in-doctor visit.
“This is perhaps the largest issue that telemedicine vendors and healthcare providers will need to overcome,” said Cameron Graham, managing editor at TechnologyAdvice and the study’s author. “If patients don’t trust the diagnoses made during telemedicine calls, they may ignore the advice given, fail to take preventative steps, or seek additional in-person appointments, which defeats the point of telemedicine.”
Telemedicine is a newer technology in the medical industry, with greater lack of familiarity, but data from the study shows that younger patients may be less skeptical. Only about 17 percent of 18- to 24-year old respondents, and 24 percent of 25- to 44-year olds, said they wouldn’t trust a virtual diagnosis. Also, 65 percent of respondents said they would be somewhat or much more likely to use a virtual appointment system if they had first seen the doctor in-person.
Sherpaa connects employees directly with doctors and insurance guides online to reduce healthcare costs. Founded in 2012, Sherpaa has redefined the healthcare experience for companies and employees across the country. Sherpaa powers its medical practice in the cloud with dedicated board-certified physicians and insurance navigators. It saves time and money by solving 70 percent of issues without routing them through the traditional healthcare system – fewer interactions with the healthcare system means greater efficiency for the individual and savings for the employer, Sherpaa currently “takes care” of more than 120 companies including Tumblr, Etsy and GLG.
Sherpaa was co-founded by Dr. Jay Parkinson MD, MPH, trained in pediatrics and preventive medicine at St. Vincent’s and Johns Hopkins. He’s given talks for TED and The Clinton Global Initiative. He’s been referred to as “The Doctor of the Future.”
We are a B2B company selling into the HR and C-suite. Our founders are a doctor and an experienced HR expert leading up a proven sales team. We know firsthand what companies need, how they make decisions, and how to sell into them. As one of the few employer-driven healthcare services actually founded by a physician, our thought leadership in the space enables us to speak at conferences, produce interesting content, and truly have a respected voice in what the future of healthcare looks like.
Our sweet spot is companies with 100 to 1,000 employees. Every single company of this size is struggling with out of control healthcare expenses without the in house resources to do anything about these skyrocketing costs. They’re being sold wellness plans that don’t work to control costs and traditional telemedicine services that can’t control costs when only 3 percent of a company uses them. They need a better solution that people will actually use. Without meaningful usage, costs can’t be contained. Unfortunately we’re lumped into the telemedicine space and people confuse us as being in competition with TelaDoc, American Well, Doctor on Demand, and MDLive. Sure, they sell into the same HR departments, but offer a service that nobody uses, and therefore can’t move the needle on healthcare costs. Presently, there is no other service in America available to companies that operates like Sherpaa, gets 70 percent of a company to use our services, and delivers the kind of results that we do.
This is an exciting time in healthcare. The field is changing in terms of how and where care is delivered, who is providing those services, even how the care is financed. As the world around us becomes increasingly digital, the medical industry needs to keep up. I believe patients deserve convenient access to the best doctor for their particular case, no matter where that doctor is located. They deserve personal attention and a firsthand look at the images and results their doctor sees.
This is why I was honored to join other national telehealth leaders in the HX360 panel discussion, the Telehealth Turnabout, during HIMSS15 in Chicago. The group brought together divergent perspectives on the future of telehealth, including market opportunities for new entrants, novel opportunities for providers to extend care, capture new patients or establish a new revenue stream using telehealth.
At Optimized Care Network (OCN), we are challenging the healthcare industry to imagine having every world-class specialist available in one office — no matter where you are located. We are moving the industry and the people we serve away from reliance on brick and mortar offices.
Personalized digital healthcare is the future of quality medical care. New developments in technology are making healthcare providers more accessible than ever before. As the digital domain grows, providers and patients alike must be clear on the differences between telemedicine and personalized digital health. Telemedicine can involve seeking treatment over the Internet via a video conference, and personalized digital healthcare enhances your traditional office visit by adding state-of-the-art image sharing equipment and lifelike communication linking the patient in one location with the doctor who could be hundreds of miles away. The digital healthcare delivery offered in an Optimized CareSpace takes digital healthcare to the next level by personalizing it. You meet with a nurse, look your doctor in the eye via exclusive video technology, and you can see the medical images your doctor sees, giving you, the patient, a complete view of your healthcare.
At HIMSS this year, multiple speakers laid out visions for a future where parents could consult with a pediatrician via a telemedicine encounter during the middle of the night, take their children to receive immunization shots at a retail clinic, and have all of this information aggregated in their primary care provider’s record so that providing an up to date immunization record at the start of the next school year is as simple as logging into the PCP’s patient portal and printing out the immunization record. In short, multiple speakers presented visions of a truly interoperable future where patient information is exchanged seamlessly between providers, healthcare applications on smartphones, and insurers.
While initiatives such as the CommonWell Health Alliance, Epic’s Care Everywhere, and regional health information exchanges attempt to address the interoperability challenge, these fall short of fully supporting the future vision described above. Today’s solutions do not address smartphone applications and still require manual intervention to ensure that suggested record matches truly belong to the same patient before the records are linked. This process is costly but manageable in an environment where a low volume of patient records are matched between large provider organizations. In a future world where patient data is available from a multitude of websites, smartphone applications and traditional healthcare organizations, it would be cost prohibitive to manually review and verify all potential record matches.
Of course, one solution to this dilemma would be to improve patient matching algorithms and no longer require manual review of records before they are linked. However, for this to be possible, a standard set of data attributes would need to be captured by any application that would use or generate patient data. In a 2014 industry report to the Office of the National Coordinator for Health Information Technology, first name, last name, middle name, suffix, date of birth, current address, historical address, current phone number, historical phone number, and gender were identified as data attributes that should be standardized. Many of the suggestions in this report were incorporated into the Shared Nationwide Interoperability Roadmap that the ONC released in January 2015.
Deb Dahl, vice president of patient care and innovation at Banner Health, discusses her experiences managing the telehealth program for the health system. Banner Health is a nonprofit health system based in Phoenix operating more than 20 hospitals and specialized facilities. It is the second largest employer in Arizona, providing emergency care, hospital care, hospice, long-term care, outpatient surgery centers, labs, rehab services, pharmacies, and ambulatory clinics, which include Banner Arizona Medical Clinic and Banner Medical Group.
The health system is a long-time user of telehealth technology, which has had a profound positive impact on providing patient care and is seen as a major benefit to the organization.
Have you used telehealth services in your practice to provide care?
Yes, we have had a long standing relationship with Philips collaborating on telehealth programs, using a “technology, people and process” approach to healthcare. We started with a single facility in 2007, and our telehealth program now reaches more than 400 beds at 18 facilities in Arizona, Colorado, Wyoming and Nebraska with plans to cover our Fairbanks, Alaska, facility and Nevada site some time in 2015. Across these facilities we utilize telehealth in the intensive care unit, acute care, skilled nursing facility, and ambulatory space (patients at home). We use a command center approach, which allows a dedicated team of physicians, nurse practitioners, nurses, pharmacists and social workers. We provide coverage to more than 400 ICU beds in five states, more than 200 medical/surgical patients, neuro and behavioral health ED coverage, 500 complex chronic members at home, as well as simple low acuity on demand home visits.
What’s it like? Is it all it’s cracked up to be?
Yes, we went live with our first 50 ICU beds in 2006. With our program growth, we’ve experienced great results: in 2013 our ICU results were among the top three in the U.S. Using APACHE as the actual to predictive model Banner saved more than 33,000 ICU days, 47,000 hospital days and 1,890 lives in 2013. We are expecting similar results for 2014.
PipelineRx is a telepharmacy company offering remote and SaaS pharmacy services to rural hospitals, as well as larger integrated delivery networks (IDNs). For smaller hospitals, PipelineRx offers 24/7 staffing during nights and weekends, verifying medication orders remotely to promote patient safety. The SaaS technology platform allows larger IDNs to essentially create their own telepharmacy, using one of their own pharmacists to staff additional locations.
CEO Brian Roberts has spent most of his career focused on healthcare services and staffing. Prior to co-founding PipelineRx, he was the president of Canopy Healthcare until it was acquired in late 2008. Canopy Healthcare was the leading allied healthcare staffing firm on the West Coast. Prior to Canopy Healthcare, Roberts was the EVP of business development at CHG Healthcare Services, a $600 million leader in diversified healthcare staffing which supplied physicians, pharmacists, nurses, and allied healthcare professionals to hospitals nationwide.
Here, Roberts discusses his firm and its capabilities, technology developments he’s seeing, telemedicine challenges and trends we’ll see in the coming year.
Tell me more about yourself and what inspired you to found PipelineRx?
I spent the first half of my career as a venture capitalist investing in early stage healthcare services and healthcare IT companies. I spent the second half of my career building companies from the ground up as an entrepreneur. I love the operations and technologies that are critical for building a sustainable business model. After building two successful medical staffing companies, I figured out that we could “staff” hospitals using remote pharmacists that work from home. The labor arbitrage of enabling one pharmacist to work on multiple hospitals drove on average a three to one return for hospitals. This all was enabled by creating a technology that allowed interchange between PipelineRX and hospital pharmacy information systems and EHRs.
We now have an amazing management team bringing more than 100 years of experience in building pharmacy technology companies.
Tell me more about your desire to lead a telepharmacy company? Who uses this service? How is it growing and how has it changed?
Leading PipelineRx is exhilarating each and every day. Overcoming challenges are what makes it interesting and trying to apply cloud based technology to a service that must be completed (pharmacy verification services).
Hospitals of all sizes use the service. From the small side, critical access hospitals with 25 beds use the service for long stretches, say 6 p.m. to – 6 a.m. and 24 hours on the weekends. Our service allows them to save significant costs yet have world class medical coverage of their hospital. We can also fill in if an employee pharmacist calls in sick or if there is a big snow storm and the employee pharmacist can’t make it to work. We also work with larger hospitals and hospital systems that are looking to optimize their staffing levels. While pharmacies traditionally were staffed like a firehouse with ample coverage, PipelineRx allows the hospital to staff to the median levels and then use our staff for peak or overflow. It’s been an amazing journey to see hospital administrators and C-suite’s understand that we assist in moving traditional fixed costs to variable costs through our unique service.