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The HIMSS Flu

As usual HIMSS was an overwhelming whirlwind of meetings, opportunities, and information. We had a great show at Wellpepper, and were impressed by a few things. First we heard a lot less about wanting the EMR to do everything. People have realized that especially for all of the patient-facing digital experience, that there need to be interoperable solutions, that are designed with the needs of the end-user in mind. Another thing we noticed was less hype that any one technology (AI, blockchain) was going to be the savior of healthcare. It seems like the market is maturing and there’s an understanding that technology is a key underpinning but only when it’s solving real problems for patients and clinicians. John Moore from Chilmark, who was attending his 11th HIMSS has a great take on this.

Each year, we come away from HIMSS with something we didn’t expect. While it’s usually new leads, partnerships, or competitive intelligence, this year for me, it was the HIMSS flu. Being in a conference center full of technology to diagnose, manage, connect with, and treat sick people, made it seem like a solution should be close by. Ironically, I had meetings with a number of physicians who said that it looked like I had the flu, but couldn’t treat me because they weren’t licensed in Florida. Also, my primary care physician couldn’t help me for this reason as well.

After seeing CirrusMD tweet at my friend and fellow patient-centered care advocate Jan Oldenburg with an offer of a consult, I thought that telemedicine might be the answer.

MDLive came through with a visit code, and I signed up. The sign-up process was pretty painless although an option to clarify where I was physically versus where I lived might have been helpful.

Once I signed up, the app told me it would notify me when it found a physician. This was the slightly confusing part, as when I exited the app and opened it again there was no record that I was in a queue for an appointment, so I started trying to sign up again. Eventually, a video visit came through while I was trying to re-register.

My doctor looked like she was taking calls from home, from the video. Unfortunately, video didn’t work very well from the HIMSS floor—not surprising given the status of the network, so we switched to phone. After a 10 minute conversation, she concluded I had the flu (she was right), and prescribed Tamiflu.

As Jan also found out when she had her asthma attack, the pharmacies near the convention center weren’t actually pharmacies, that is they didn’t offer prescription medication. For Jan it was an expensive Uber to pick up her prescription. For me it was finding a pharmacy that would be open between Orlando and Tampa where were were headed for customer meetings on Friday. By the time I got the prescription, it was 7 hours later, and with Tamiflu the timing matters.

While I was thankful to get care, here are a number of points of friction that made it more difficult than it needed to be, and also show how healthcare really hasn’t adapted to the needs of people:

  • State-based licensure makes telemedicine prohibitive. It also means that you can’t get care from your primary care or other specialists if you’re traveling. Kind of ridiculous that because the patient is physically in Florida suddenly the physician is not licensed to practice.
  • Pharmacies need more delivery options. Even locally, I’ve ended up at pharmacies that don’t take my insurance. Driving around when you’re sick is annoying, and showing up in person when you’ve got the flu is unhelpful for everyone else there.

On the licensure, it’s slow going, but states are starting to have agreements to solve this. On the delivery options, Amazon-drone delivery can’t come fast enough. Overall, the experience wasn’t terrible, and the technology worked but it certainly wasn’t seamless or convenient, and I probably infected a bunch of people while trying to get care. I’d like to apologize to anyone I may have passed the flu along to. I’m not the type to work when sick, but when you’re on the road it’s hard not to.

Also, we’d like HIMSS and all conferences to consider pop-up urgent care. The bandaids in the first-aid room weren’t enough.

Posted in: Healthcare costs, Healthcare Disruption, Healthcare Technology, HIMSS, M-health, patient engagement, Telemedicine

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T2 Telehealth aka ATA 2017 aka ATA 23: Part 2, How Did We Get Here and Where Are We Going?

This was my second trip to Orange County Convention Center this year, so it was hard not to compare and contrast the annual American Telemedicine conference to HIMSS, the biggest health IT conference. As well, it was my third time at the ATA conference, back after skipping in 2016, and the gap made it easier to reflect on previous years as well.

The ATA annual is almost 10 times smaller than HIMSS, which makes it a lot less exhausting and easier to focus. There’s not a feeling that for every second you’re talking to someone you’re missing out on talking to someone else equally as interesting and valuable. (There is no shortage of interesting people, just a more manageable group.) The size also makes it a bit easier to talk to people as they’re not rushing off to walk a few miles across the convention center to the next session.

The first year I attended, 2014, the tradeshow floor was full of integrated hardware and software solutions, and Rubbermaid was even a vendor selling telemedicine carts. It was almost as though the iPad hadn’t been invented.  It was the year that Mercy Virtual launched their services as a provider of telestroke and telemonitoring for other health systems. A provider as a vendor caused a bit of a stir on the tradeshow floor.

By the next year, the integrated hardware and software vendors were dwindling, but talks were largely still given by academics and were focused on pilot projects that while showed success, talks often ended with a plea for thoughts on how to scale the program.

ATA evolved out of an academic conference and that’s still quite prevalent in the presenters who are often from academic medical centers, and reporting on studies rather than implementation. Data was important in all sessions, but measurement of value was inconsistent. In addition to academic medical centers, most leaders in telehealth seemed to be faith-based not-for-profits, like Mercy and Dignity, and as well as rural organizations where the value was clear.

That said, a welcome addition to this year’s content was two new tracks on Transformation and Value. I spoke in the Value track at ATA, along with Reflexion Health and Hartford Healthcare about the value of telerehab in total joint replacement, and we were able to share data points from real patient implementations, in addition to clinical studies. (If you’re interested, in the Wellpepper segment, get in touch.)

Although, harkening back to the day 1 keynote, the definition of value depended on the business model of the telemedicine platform being implemented. There’s no question that telestroke and neurology programs, and telebehavior programs deliver value especially in rural areas without direct access. At Wellpepper, we’ve seen definite results in post-acute care, both in recovery speed and readmissions.

In other sessions the value was not as clear and no one was able to fully refute the study that when offered the choice, patients used telemedicine in addition to in-person visits, thus driving up costs. In fact, the director of telemedicine for a prominent healthcare organization confirmed that patients were using televisits for surgical prep when they could have just read the instructions given to them. (Or interacted with a digital care plan like Wellpepper.)

As with every technology conference the voice of the patient was absent, with the exception of head of Mercy Virtual Randall Moore, MD who started all his presentations by introducing us to patient Naomi who was able to live out her life at home, attend bingo, and enjoy herself due to the benefits of the wrap-around telemedicine program that Mercy put In place. Oh, and it cost a lot less than the path of hospital admissions she’d been on previously. Sounds like triple aim, and what we all need to aspire to.

So, based on the keynotes, the sessions, and the show floor, I’d characterize this year’s conference as a world in flux, like what’s going on elsewhere. There was a sense of relief that the ACA had not been repealed. HIMSS took place before the proposed repeal and replace plan died, and there was a lot more fear and uncertainty. Vendors and providers alike are looking to strengthen the value chain. Unlike HIMSS, there was a lot less hype. Machine learning and AI were barely mentioned except in keynotes possibly because telemedicine is still largely a world of real-time visits, and extracting meaning from video is a lot harder than from records. We see promise, people want to do the right thing, but it’s not clear which direction will help us ride out the storm.

 

Still trying to figure out what this has to do with Telemedicine. Look better on realtime visits?

Posted in: Healthcare Disruption, Healthcare Legislation, Healthcare motivation, Healthcare Policy, Healthcare Technology, M-health, Prehabilitation, Rehabilitation Business, Telemedicine

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T2 Telehealth aka ATA 2017 aka ATA 23: Part 1, The Eye of the Hurricane

While there is a focus on transformation, value, and outcomes going on, if the keynotes are any indication it may be a rough road ahead for telemedicine.

“It’s the 23rd year for the American Telemedicine Association conference, why are we still talking about how to get paid?”, admonished Pamela Peele, PhD economist and Chief Analytics Officer of UPMC during the opening keynote of the annual conference of the American Telemedicine Association.

Pamela Peele at ATA2017

Pamela Peele at ATA2017

“Especially since, as this audience knows, telemedicine is the best thing since sliced bread?

Why indeed? Well, it’s complicated. The problem is that each person in the value chain, the payer, the physician, the healthcare organization, the patient, and the patient’s closest adult daughter (aka primary caregiver), only see the value of one slice of that loaf of bread, and we collectively as purveyors of telemedicine have to sell the entire loaf. There’s no clear solution to this problem. However, with unsustainable costs of healthcare, and increasing consumerization we have got to figure it out. The taxpayer is bearing the brunt of the costs right now, and Peele characterized the shift of baby boomers to skilled nursing facilities as a hurricane we are unprepared for. One way out is to keep people at home, and for that we need Medicare to fund a cross-state multi-facility study to determine efficacy, value, and best practices. Fragmentation of trials is keeping us from wide scale adoption.

The Adaptation Curve

The Adaptation Curve

“We have got to figure it out” was also the theme of best-selling author and New York Times columnist Tom Friedman’s keynote promoting his new book “Thank-You For Being Late.” Friedman claimed to be more right than the rightest Republican and suggested abolishing corporate taxes and at the same time more left than the leftist Bernie Sander’s supporter suggesting we need an adaptable safety net. His major thesis is that we are undergoing 3 climate changes right now: globalization, climate, and technological. To survive and thrive in this new world, we need to adapt and evolve, and take our cues from Mother Nature, not from some sort of top-down regulation. Like Peele on the previous day, Friedman also sees a hurricane coming and suggests that the only way to survive is to find the eye of the storm not by building a wall.

Adapting and evolving will come in handy with the harder times for healthcare investment ahead predicted by the venture investing panel in the day 3 keynote. Tom Rodgers of McKesson Ventures, and Rob Coppedge of the newly formed Echo Health Ventures pulled no punches, as they tossed of tweet worthy statements like “Don’t tell me you’re the SnapChat of healthcare” and “it seems like there are only 3 business models for telemedicine.” The later was Coppedge’s comment on walking the tradeshow floor. (The models are direct to consumer, platform, and as a combined technology and service.) Rodgers had no love for direct to consumer models or anything that targeted millennials who he deemed low and inconsistent users of services. Platform vendors were advised to surround themselves with services: video was seen as a commodity.

So where does that leave us? Value, value, value. The challenge is that the value is different depending on the intervention, the patient, the payer, and the provider. Preventing readmissions, aging at home, decreasing travel costs, all provide benefits to one or more of the key stake holders. Can we figure out how to reimburse based on slices of value? How do we get together to realize that value? And how do we do it before the hurricane hits?

Posted in: Behavior Change, Healthcare Disruption, Healthcare Policy, Healthcare Research, Healthcare transformation, Telemedicine

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Telehealth 2.0: Our picks for Orlando

File-2016-3478-2017_ATATradeshow_1920_25I am really looking forward to heading to Orlando for the American Telemedicine Conference, aka Telehealth 2.0. Seattle has been under a rain cloud this entire year, and I want to see the sun. I’m also looking forward to sharing our findings in using asynchronous mobile telehealth for remote rehabilitation with patients recovering from total joint replacement. I’ll be speaking with our colleagues from Hartford Health, Reflexion, and Miami Children’s Hospital on Sunday during the first breakout sessions. Hope to see you there!

In addition to the topics about legislation and regulations, it’s great to see these sessions on value, quality, and new treatment models. Here are some of Wellpepper’s picks for the conference.

Sunday

Monday

Tuesday

Now with all this great content, networking and a talk to prepare, when will I see the sun?

Posted in: Adherence, Behavior Change, Health Regulations, Healthcare Disruption, Healthcare Legislation, Healthcare Policy, Healthcare Research, Healthcare Technology, patient engagement, Telemedicine

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Every Patient Has a Story

I have just returned from my first Beryl Institute Patient Experience Conference 2016 (PX2016), and I’m inspired. At Wellpepper, we are focused on empowering the patient to feel ownership and accountability to participate in their healthcare journey. The Beryl Institute and their members are doing the same and it was great to connect with so many like-minded people. The PX2016 conference is just one way they bring together this community.

PX2016 is 6 years young and attended by mostly caregivers, nurses, doctors, regular people who were touched by a personal health experience and now are in the field, and patients. With only 1000 attendees, it’s possible to form relationships. There was lots of hugging, sharing, pictures and overall excitement to be in Dallas. I met several newbies and like me, they were inspired too.

The conference opened up with a real life patient story. Les, a heart attack survivor, told his story of how he was participating in a sculling exercise and went into cardiac arrest in the middle of the water. The following chain of events happened that allowed him to be standing in front of us to tell his story. A retired nurse was on board and jumped into action to do CPR (she was filling in for her friend who couldn’t make it), the bowman had his cell phone to call 911 (typically he doesn’t bring it on the boat), another rower in his own boat happened to be near the dock gate and had a key to unlock the gate (usually locked because it was 5:30AM) which allowed the paramedics to get to Les. If there was one break in that chain, Les would not be with us. He went on to share his experience about his care at UCLA Medical Center and how every touch point from the people on the boat, to paramedics, to the care team made a difference in his recovery. By this time, there was not a dry eye in the place. It was all about why we in this profession of healthcare really do want to make a difference in the patient experience.

This lead to the theme that every patient has a story. From the other keynotes to the sessions I attended, this theme was pervasive. The focus of PX 2016 is to share stories, best practices and ideas on how to bring together interactions, culture and perceptions across the continuum of care.

In the session, Removing Complexity from the Post-Acute Care Patient (one of our passions at Wellpepper), it became clear that the long term care model needs to be reinvented for simplicity. True simplicity comes from matching the patient’s experience with the patient’s expectations. As an example, The New Jewish Home is renaming its post-acute rehabilitation to The Rapid Recovering Center which supports setting a different tone for the patient and ultimately in their experience. When a patient is sent to a post-acute rehabilitation center it can suggest a long and difficult recovery. But, naming it the Rapid Recovery Center aligns with the patient’s expectation of wanting to get better as soon as possible.

Another session that hit close to Wellpepper’s core values was how University of Chicago puts family and patients first in their patient experience strategy. Enhancing Patient Experience and Engagement through Technology Innovation by Sue Murphy, RN, Executive Director- Patient Experience and Engagement Program and Dr. Alison Tothy, Associate CMO – Patient Experience and Engagement Program at University of Chicago suggest the ability to capture real-time opportunities for engaging patients in their care and in their service expectations with innovative technology and techniques can lead to overall happier patients. Such technologies like rounding, discharge call centers and interactive patient care have led to substantial outcome improvements. However, just implementing technology did not solve the patient experience challenge. A culture shift in the staff was required which inspired them focus on individualized care for each patient. Combining a culture shift with innovative technology has allowed the University of Chicago to increase patient satisfaction scores, reduce readmission rates and improve outcomes. Furthermore, leadership is engaged and excited about the power of technology to improve the patient experience.

To bring it to a close, we were inspired by another personal patient story from Kelly Corrigan. She is a New York Times best-selling author who shares her most personal stories, including her health challenges. She has had more than her share of health encounters between herself and her family. She read an excerpt from her book, The Middle Place, where her and her Dad where both diagnosed with cancer in the same year. It was a compassionate and funny rendition of when she just starting her chemotherapy sessions and her Dad came across country for support. She talked about how in the middle of crisis, magnificent can happen. She was amazed to witness how all the people around her, including herself, able to conform into the new reality – cancer. Although a happy ending for her, not so much for her father. He passed away last year. She emphasized how at the end of her father’s journey, she made a point to thank all the caregivers for they really did make a difference in a very difficult time. Then looking out at all of us in the audience at that moment, almost with a tone of authority, she challenged us to hold on to the feelings of why we went into healthcare.

For some of us, it was a personal experience. For others, it was the opportunity to make a difference. Regardless, as Kelly so eloquently put it, people want to feel as if they have been felt and be a good listener because every patient has a story.

Posted in: Behavior Change, chronic disease, Healthcare transformation, Managing Chronic Disease, patient engagement, Patient Satisfaction

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Did HIMSS deliver on its Charter? Transforming Health through IT

HIMSS Annual Conference
February 29-March 4, 2016

Another HIMSS has come and gone for me. I will not brag about how many times I have attended this conference, but I will brag about it being the first time with Wellpepper. Overall, the level of activity exceeded our expectations and validated the need for innovative patient engagement technologies like ours.

Being with a new company gave me a whole new perspective on the HIMSS annual event. Reflecting back, years of HIMSS events can blur together and it can seem like the same old same old. This year was different: the healthcare ecosystem is going through a profound change and the providers and payers know this. Health systems are beginning to understand that the model is moving away from a passive engagement with the patient, to a model where the patient is taking more initiative to include their own wants/needs to participate in their care delivery.

With that, comes a whole new set of demands from the patient consumer and that I believe is where HIMSS is trying to make the transformation.  For the second year, HIMSS has partnered with HX360’s Innovation Pavilion to showcase pioneering health IT solutions that are addressing these challenges. As a start-up company, we can often get lost in the maze of vendors at a large conference such as HIMSS (estimates suggest more than 1200 exhibitors). The HX360 Innovation Pavilion provides an opportunity for entrepreneurial health IT companies to shine… and that we did.

Along with this venue, HX360 sponsors an Executive Program that runs concurrent with HIMSS. These educational sessions attract leaders such as Chief Innovation Officers, Nursing Informatics Officers and Vice Presidents of Digital Health who are looking for innovative solutions from companies like Wellpepper. Because of this venue and opportunity, we were able to have meaningful conversations with IT and executives that are looking to get a head of the curve and provide innovative solutions for their patients and systems.

Upon my travels home, I felt optimistic this shift to value-based healthcare will really drive innovation and allow companies like Wellpepper to part of the conversation and solution. The future appears to be bright and full of opportunity.  It is an exciting time for both the healthcare community and the consumer.

So, did HIMSS hit their mark? In part, yes. HIMSS is making great strides to keep up with the changing landscape of healthcare. No longer is it just about the EMR, servers, networks and storage in the IT back room. It’s about patient facing solutions that provide ownership and accountability for the patient while securing that brand loyalty for the provider.

The transformation of healthcare is now. Healthcare does not take to change lightly. But, companies like Wellpepper will continue to pave the way to innovation and the industry will take notice.

Posted in: Healthcare Technology, Healthcare transformation, M-health, patient engagement, Telemedicine

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Digital Health and the Influence on Healthcare: Wearables, Telehealth, & Treatment

Things are looking up in the world of digital health at least this was the view from “Digital Health and the Influence on Healthcare: Wearables, Telehealth, & Treatment.” The WBBA held their last event of the season with a panel on digital health, hosted by Russell Benaroya, CEO of Everymove, and featuring Dr. John Scott, Director of Telemedicine at UW Medicine, Davide Vigano CEO and co-founder of Sensoria, Mike Blume, independent healthcare consultant, and myself. I’d characterize the overall event as being optimistic and realistic, both from the panel and the attendees.

Digital health event

It was a dark and stormy night

No one said that the road to digital health was easy or fast, but the consensus that things like moving to the cloud, and the acceptance and adoption of patient-driven digital care is reaching a turning point.

Both Sensoria and Wellpepper’s business models are made possible by the cloud. For Sensoria this was the ability to process millions of datapoints coming from their wearable technology. For Wellpepper, this is our ability to rapidly implement solutions working with department heads facing a particular challenge in patient engagement and outcome tracking and improvement. Dr. Scott remarked on the dramatic drop in the cost of telemedicine solutions over the years he’s been an advocate and solutions due to both Moore’s Law and cloud computing over his tenure running telemedicine at UW.

Sensoria's Quantified Socks

Sensoria’s Quantified Socks

As well, although Dr. Scott highlighted how telemedicine was limited by arcane reimbursement models that did not allow for patients to receive telemedicine consults in their homes, he and other panelists discussed that they were not waiting for billing codes to do the right things in using technology to deliver better care. As usual, the Affordable Care Act was seen as a big driver as patient-centered and digital care.

Possibly because there were two ex-Microsoftees on the panel (Davide and me) a cloud-based platform approach was touted as the best way to both collect, analyze, and sort the data that came in directly from patients. In the case of Sensoria and Davide, this was to look for trends and patterns coming from sensor-integrated clothing, and in the case of Wellpepper it was to collect patient outcomes in the context of care and compare these across patients, procedures, and healthcare organizations.

This view led to a discussion about the proliferation of data, and everyone agreed that digital health has the ability to overwhelm health systems with data that they are currently not prepared for. EMRs are not set up to include sensor or patient-reported data, and as Dr. Scott pointed out, physicians are not looking for every data point on a patient, only the anomalies, like glucose out of range.

One audience member asked about whether healthcare organizations had an overall data strategy, and whether digital health data should be collected as part of that. It’s an interesting idea to consider but it seems like it’s still a long way off in healthcare. Does your organization or CIO have an overall data strategy? It seems that quality measures and the need for patient reported outcomes are introducing new requirements for data, but this is at the departmental or initiative level. Grappling with questions like this will be important as connected devices, digital, health, and patient reported outcomes enter the mainstream.

Posted in: Health Regulations, Healthcare Disruption, Healthcare Policy, Healthcare Research, Healthcare Technology, Healthcare transformation, M-health, Outcomes, Telemedicine

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This Month [August] in Telemedicine

This Month [August] in Telemedicine

Moderated by:
Jonathan Linkous
Chief Executive Officer,
American Telemedicine Association

Gary Capistrant
Chief Policy Officer,
American Telemedicine Association

This month in Telemedicine webcast was interesting because more than once was the ATA sentiment geared towards realizing the big picture of telemedicine: To help patients. Unless you are lucky enough to work directly with patients that utilized telemedicine on a daily basis, I think sometimes, including myself, we get caught up in the bureaucracy/methodological side of things. Sometimes it takes talking with patient or clinician in order to make me grasp how HIT is improving lives, my life too! So I appreciate the reminder John! At the end of the webcast he asked if you have a personal story of how telemedicine helped you or a loved one ATA needs to hear it, please email John Linkous -jlinkous@americantelemed.org

The main highlight of the first 20 minutes of this webcast focused on the positive trend of telemedicine utilization. Not surprising the younger crowd just beginning their careers in medicine strongly support the use of telemedicine; Medscape conducted a survey and found out that 70% residents had no problem consulting via telemedicine. And maybe because I am of the ‘younger’ crowd (bahaha) I think this is ingenious: the Colorado medicine board is doing away with the rule that patients need to see doctors face to face before utilizing telemedicine; ok so how many times have you gone all the way to the doctor’s office only to get a referral or need blood work done before they can give you a diagnosis/treatment?! Genius! Other interesting facts: 20% of American adults use some technology to track health care (counting steps, migraine triggers & heart rate, etc.) and 57% of households with children access one health portal per a month. Finally big employers are seeing the benefit of telemedicine to cut back on insurance costs; 75% of large employers will be using telehealth as a benefit next year.

Licensure compacts. Ok guys really? Every “This month in telemedicine” webcast talks about this. What is the hold up?! It is so frustrating to me that if I get ill on vacation in Hawaii (ok dreaming, who gets sick in Hawaii?) I cannot get a consult from my doctor over the phone or the internet. This is silly people and it was clear to me that John thinks so as well. He underscored the importance that ATA supports the federation’s compacts in principal, but has some concerns… it is estimated that it will cost 300 million for the 21% of physicians that have more than one state license. Oh money, yea ok that’s the same old hold up every time. Next time they talk about state licensure compacts I am just going to put a dollar sign in my post… you’ll understand.

Circa 1934. Broadcast to Webcast; Radio Technology to Wireless Telegraphy… and now just ‘wireless’. http://www.cio.noaa.gov/rfm/index.html

Frustration was also heard in John’s voice about the FCC Telecommunications Act of 1996. The last Telecommunications act was in 1934, 62 years it took to write a revision, and it looks like it will take another 62 years at the rate they are going! ATA continues to be disappointed in the Act; the FCC estimated there would be a 400 million a year in spending on broadband linking rural healthcare, last year they approved for 200 million. They have only deployed 100 million; only spending a quarter on what the program was supposed to spend- “they need to step up.” Why John? They have 62 years to spend that!

A big note: telemedicine care for post discharge (knee and hip replacements) isn’t expanded out to Physical and Occupational Therapy for Medicare patients. CMS has waived two of Medicare restrictions: allow any Medicare beneficiary to provide services regardless of where they reside but somehow does not include health innovation- “we will be commenting to CMS” and so they did in a letter dated 9/8 strongly urging CMS “…to allow for PT and OT to provide rehabilitation by telehealth means, otherwise covered by Medicare…”

The ATA Fall Forum is next week (9/16-18) in Washington D.C. (and yes I put in D.C. being from Washington state!) with the highest registration rate ever and the exhibits have sold out. They actually have a ATA meeting mobile app for those of us that cannot make it. With a conference that has “Tele” in the name, I see this as the most logical and sensible way to attend.

Posted in: Healthcare Technology, Healthcare transformation, Occupational Therapy, Physical Therapy, Rehabilitation Business, Telemedicine

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This month [May] in Telemedicine

American Telemedicine Association: This month [May] in Telemedicine
June 2, 2015

Presenters:
Gary Capistrant, Chief Policy Officer, American Telemedicine Association
Jonathan Linkous, CEO, American Telemedicine Association

John commenting on the heat in Washington, D.C.

John commenting on the heat in Washington, D.C.

The annual ATA conference in LA last month had the largest attendance rate that ATA has seen in 20 years. It featured over 500 presentations; the video recordings of every presentation is available for purchase. Our own Wellpepper CEO, Anne Weiler, went to the conference and you can read her blog here. Also in May there were some big changes at ATA; a new president, new officers and members of the board of directors were elected. Their backgrounds are all impressive, thank goodness because we need them!

Telehealth’s exceeding advantages in both entrepreneurial and patient health naturally have lead to several new organizations popping up every year (or every month it seems) that use clinical consultations over the internet/phone. And where there is money to be made and quite literally lives at stake, legality is involved. The Texas medical board ruling prohibiting use of telehealth without previous relationship with patient, or a healthcare professional being present with patient when telehealth is being utilized (Huh, how is that telehealth?) lead to Teladoc filing a lawsuit against TX. Consequentially last Friday the Federal court ‘temporarily’ stopped TX medical board ruling. With that said ATA provides accreditation for online consultation sites to make sure sites are open/transparent, adherence to all relevant laws and regulations and promotes patient safety; however Teladoc isn’t accredited by ATA.

For those of us waiting for a particular practice guideline from ATA, there are now 10-12 Telehealth practice guidelines available on the ATA website and six active workgroups are under development; Teleburns, teledermatology, child mental health, general pediatrics, remote health and data management and telestroke. Please contact ATA if you would like to be involved in a workgroup, it is practicing professionals like you that make these guidelines viable.

If your state has a Telemedicine Parity Law, kudos, but 23 still do not. To be positive, we are getting there, a new milestone was achieved in the laws; Minnesota, Nevada and Indiana this week alone have added their own parity laws. Also in state news ATA added the highly awaited and much needed resource, the ATA State Telemedicine toolkit titled “Working with Medical Boards: Ensuring Comparable Standards for the Practice of Medicine via Telemedicine”. Again this is a call for involvement!

Congress or digress? The three letter difference is slight! But hey three new bills were introduced to Congress since the last webcast that will be interesting to watch; Telehealth Enhancement Act 2015, Amendment to Social Security Act to expand access to telehealth stroke services under Medicaid, and the VETS Act of 2015. The VETS Act of 2015 would permit U.S. Department of Veterans Affairs health professionals to treat veterans nationwide with a single state license. I cannot help but speculate the motives of introducing this bill; are they using the VA as a pilot for licensure compacts for ‘civilian’ physicians, etc.? Let’s hope so and more importantly I hope it goes well and only reaps benefits.

The announcement of a new Distance Learning and Telemedicine Grant from the USDA was mentioned and I wanted to make note of it in case any of our readers qualify. Please check it out here.

The next ‘This month in Telemedicine’ will be announced shortly on the ATA website and as always is free to watch.

Posted in: Healthcare Policy, Healthcare Research, Healthcare Technology, Telemedicine

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Session Picks for 2015 American Telemedicine Meeting

We can’t promise to get to all these sessions and blog about them for you, but here are a few that caught our attention at the American Telemedicine Association Annual meeting coming up in Los Angeles next week.

Monday May 4th

Establishing a Program to Reduce Readmissions and Costs in the Ambulatory Setting: A California Success Story

Telehealth is proven to decrease costs without sacrificing quality for many scenarios.

Learning Opportunities from Large Scale Telemedicine Initiatives

An interesting mix of private and public sector initiatives across disciplines including pediatrics and psychiatry.

Improving Commitment, Quality, and Outcomes

We love outcomes, and this session also feature’s Seattle’s own Carena.

It’s a Small World After All: Approaches in Neonatal ICU Care

Cute title, serious results with examples across pediatric care.

A New Model for Remote Diabetes Care Best Practices

One of the biggest issues facing our healthcare system so new models welcome!

Expanding Telehealth to Improve Hospital-wide Readmission Rates

Readmissions and care transitions, so important.

Mainstream Medicine Moves into Direct to Consumer Health

Mercy, a Catholic Health System from St. Louis, is a quiet leader in telehealth. Find out why they dedicated an entire new building to for their telehealth practice. Plus a case study from Cleveland Clinic. Whew, that’s a lot of great content.

Tuesday May 5th

Utilizing Interactive Voice Response (IVR) and Telemonitoring to Reduce Hospital Admissions and Readmissions for Heart Failure Patients

Heart failure is a patient group where readmissions can be prevented with better communications, which telemedicine and remote monitoring can provide.

A Large Provider Focuses on Consumers: The Experience at Kaiser Permanente

With large deductibles, patients are increasingly making decisions as consumers.

Implementing Successful Clinical Specialty Programs: Burns, Infectious Diseases, and Genetics

Telemedicine helps scale specialists, especially from centers of excellence and to rural areas.

Using Community Health Models to Enhance Patient Performance and Outcomes

Another great benefit of telemedicine is to empower community health workers through remote support from specialists.

Posted in: Behavior Change, Health Regulations, Healthcare Technology, Healthcare transformation, M-health, Telemedicine

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Wellpepper’s Top Healthcare Blog Posts of 2014

We had quite an amazing year at Wellpepper and are really looking forward to great things in 2015. We’re looking forward to more changes and disruption in mobile health and telehealth, as well as new business models, billing codes, and proof of the efficacy and effectiveness of mobile health.

As we look forward, we thought we’d spend a few minutes to recap our most popular blog posts of 2014. In order of popularity they are:

Misfit Shine

Jewelry? Hmm.

A Tale of Two Sensors: Misfit Shine vs FitBit Zip

Not surprisingly given the hype around sensors in 2014, our post comparing how the two stacked up was our most popular blog post.

The Future of Mobile Health is Like a Warm Marshmallow

We read somewhere that your favorite tweet is not destined to be your most popular. This blog post has a warm space in our heart as it was a surprise to see mobile health as mainstream as a heartwarming Disney film.

Forging Ahead With Telehealth: A Roadmap for Physical Therapists

Our conference recaps are always popular, and this one was especially popular as all healthcare professionals are champing at the bit for billing codes that reflect the innovative new ways they want to practice.

Healthcare Is Part Of Our Supply Chain: The Boeing Company

Boeing is really pushing the payers and providers to deliver cost-effective outcome-driven care, so we are chuffed to see this one at the top of the list. Which other employers are going to take the mantle for 2015?

Post or Perish: Disseminating Scientific Research and the Kardashian Index

This recap of a talk on social media and popularity as important to scientific research made our top 5, and while the advice was great, and the debate on popularity vs credibility is important, we suspect it may have something to do with the mention of the “K” word.

Posted in: Behavior Change, Healthcare transformation, Lean Healthcare, M-health, Rehabilitation Business, Telemedicine

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Support for Telemedicine in Rehabilitation

Recognized barriers to telemedicine in rehabilitation, for example, the need for hands on intervention, a lack of billing codes, and not enough studies on cost-effectiveness, did not damper the enthusiasm for the potential of the field and the inevitability of future interventions at American Congress of Rehabilitation Medicine annual conference in Toronto. Presenters in numerous sessions demonstrated the many benefits of tele-rehabilitation for patients, providers, healthcare systems and payers.

Two sessions we attended, “Use Of Telemedicine In Spinal Cord Injury And Pressure Sore. A Pilot Project “ and “Tele-rehabilitation: A New Frontier In Geriatric Rehabilitation” debunked many of the common myths of telemedicine including:

  • Concerns about patient privacy
  • Ability of seniors to use telemedicine
  • Diminished care quality

Instead what they showed was:

  • Patients were more than willing to invite the video into their homes
  • Seniors and people with severe disabilities can use technology with the right support
  • Care quality can be improved by telemedicine

However, even with solid data presented in all of these sessions, presenters joked that telemedicine still largely suffers from a disease called “pilotitis”, that is never progressing past the pilot stage and a proliferation of pilots.

The Use of Telemedicine In Spinal Cord Injury And Pressure Sore: A Pilot Project

Norwegian Health SystemThis session showcased another great example of an interdisciplinary team, common at this conference. This team was from Norway, as they called it “land of trolls and polar bears.” Norway has a total area of 385,252 square kilometres and a population of 5,109,059 people (2014). 84% of the population has smart phones. Like most countries other than the US, they also have socialized medicine. Telemedicine was first introduced in Norway in 1980, so the fact that this project was still a pilot points to some of that “pilotitis.”

The driver for this particular project was two-fold: improve patient care by enabling patients to stay in their home, extend the reach of specialists to rural areas. Both are common reasons for telemedicine, and also can help lower healthcare costs in this case by decreasing transportation of the patient to a medical center located a few hours away. This particular intervention focused on helping Paraplegic patients manage pressure ulcers. Due to both cost and patient preference, patients with spinal cord injuries are being released earlier from hospital. However the risk of developing a pressure ulcer is greater and local healthcare support often does not have the expertise needed.

In this case, a team from the hospital would check in with the patient via video conference through a web camera at the patient site. Now, here’s where we debunk the myth of patient privacy. The patient in this case was so happy with the remote support and care he received that he agreed to have the recording of his sessions shown at the conference. For those unfamiliar, pressure ulcers occur in intimate locations like the buttocks. The team did a great job of showing how they manage to capture high-quality video over speeds as low as 256k and keep the privacy of the patient protected by positioning the camera only on the ulcer with no identifyiable patient visuals. (The video presented in the session was not for the faint of heart though.)

Patient benefits

Telemed costs

 

 

 

 

 

 

 

 

Benefits that the team saw were:

  • Cost-savings from decreased hospital stay
  • Decreasing travel exhaustion for the patient
  • Supporting the nurses in the community and helping them improve skills
  • Time-saving as the patient was always ready at the exact appointment time
  • Continuity of care, although interestingly, summer vacations caused some discontinuity and showed that this is not ensured simply by having Telemed.

Some best practices they identified included making sure that all introductions were completed for context, safety, and dignity before starting the examination, excluding personally identifiable information from sensitive video, and working with an interdisciplinary team to deliver results.

 

Tele-rehabilitation: A New Frontier In Geriatric Rehabilitation”

This session reinforced the need for telemedicine to support patients in their own homes. Dr. Helen Hoenig from Veterans Affairs described the gap between what the patient was able to do in the hospital and what they were able to do at home. For example, one veteran was released from the hospital proficient at using a walker but had no way of getting into his house because of the large number of steps. Having the veteran capture photo and video and send it for review (a method known as “store and forward” or “asynchronous telehealth”), enables staff at the hospital to provide advice and programs that are more applicable to the veteran’s real home situation.

Another example was of a patient who was given a shower chair and taught to use it during occupational therapy sessions at the hospital. When he returned home, it was obvious that the chair didn’t fit in the shower, and needed to be replaced with a bench. During the next video telemedicine session, the veteran practiced getting in and out of the shower using the shower bench while the occupational therapist coached remotely. (Unlike our Norwegian example, this person was fully clothed on the video.)

Veterans Affairs spends up to $6000 per person on home renovations for disabled veterans who need it. Having occupational therapists who are able to see the home remotely and help the veteran navigate it, as well as provide suggestions for modifications can help maximize the benefit of spending this money.

Our favorite part of this session was the presentation by Nancy Latham from Boston University who shared preliminary results from their study using Wellpepper and FitBit to keep activity levels high for people with Parkinson’s. People with Parkinson’s often see a dramatic decline in activity levels. However, the healthcare system has little or no support for long-term exercise needs. This randomized control trial had one group receiving the usual care condition which was an in-person visit and exercise prescription. The m-health group received an in-person visit but their exercise program was assigned using Wellpepper for their program with custom video, reminders, and messaging with a physical therapist. They were also given a FitBit. The results are extremely positive for exercise adherence, self-efficacy, patient satisfaction, and most importantly outcomes, judged using the 6-minute walk test. Stay tuned for early 2015 when we’ll have the final results to share with you. If you’d like to see the preliminary results, contact us.

Posted in: Health Regulations, Healthcare Disruption, Healthcare Technology, M-health, Rehabilitation Business, Telemedicine

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Best Practices in Healthcare Software Usability from the American Telemedicine Conference

BaltimoreA few weeks ago, Wellpepper took a road trip to the American Telemedicine Association conference in Baltimore. In addition to exhibiting and presenting at the venture summit, we also had the opportunity to attend a couple of the pre-conference sessions, which had some excellent content. In particular, one topic that we wanted to highlight was the Human Factors in Telemedicine session.

The session was presented by  Patrick Boissy, PhD, Neil Charness, PhD, and Elizabeth Krupinski, PhD. The focus of this session was on HCI (Human-Computer Interaction) and usability – some of the key tenets that we’ve held from the beginning while we built Wellpepper. Based on some of the healthcare-focused software we’ve seen, there is lots of opportunity here. It’s a shame the session wasn’t better attended, but in fairness it was also at 8am on a Sunday.

Dr. Boissy started by illustrating the importance of Human Factors Engineering with two case studies. First he examined Healthcare.gov. He pointed out many engineering failures that have been well documented in the press, the biggest of which was the limited end-to-end testing, which in some cases didn’t even happen until after the launch. Second, Dr. Boissy walked through a study by Desroches, C.M. et al (2013) on EHR adoption. Looking through the taxonomy of barriers to adoption, Human Factors issues are some of the most-cited barriers to technological acceptance of EHR systems. Essentially: doctors and nurses have trouble using the systems.

While EHR and EMR systems are certainly solving a difficult problem, there seems to be a cognitive disconnect in a world where you can go to an Apple Store and buy an iPhone that is easy enough for 2 years olds to use. If highly educated clinicians have trouble using Healthcare IT, what hope is there for the rest of us?

One theme that emerged throughout the morning is that usability is not something can be added on later – it’s infused throughout the software engineering process. This starts at requirements gathering, includes frequent iteration with user feedback, and may culminate in formal user-centric measurements of acceptance.

One practical technique that was shared is Contextual Inquiry – essentially sitting down with the user in a room, watching them perform tasks with prototypes or functioning software, and using this as an opportunity to understand the user’s thought process and conceptual model. It’s also a good opportunity to gather quantitative metrics like time-to-task, enabling you to measure improvements in your product as you iterate.

It’s a deceptively simple idea, but ever since I started using CI during my time at Microsoft, I can attest that it’s a wonderfully powerful technique that almost forces you to build user-centric products. At Microsoft, we had fancy usability labs with cameras, eye trackers, and one-way mirrors, but the technique can be applied simply, and frankly most effectively when you just get out and go visit users. Even just a few users can make a huge difference. I recall one time where my team and I had spent several weeks building a super-smart machine-learned recommender system, but when we put it in front of a user for the first time and gave them a task, they said something to the effect of “okay… but why do I want this?”. Back to the drawing board. This is actually pretty typical. As software professionals, regardless of how well we think we understand the problem, the first time we put a prototype in front of users, I’m never surprised to hear something that causes a big reset because it’s so easy to make false assumptions early on in the design process. One hint: always capture video when you do CI – it’s amazing how much depth you can extract from an hour-long conversation.

Dr. Charness went on to describe some of the specific challenges of building usable patient-facing healthcare solutions. He argued that even something as simple and pervasive as the pill bottle can be hostile to users, and is emblematic of the usability issues in healthcare IT. “Pill bottles seem fine when you have 20/20 vision, good fine-motor control, and are in a brightly lit office. But what about the diabetic patient who lives in a trailer with a single 60W lightbulb?” This is an area where pharmaceutical retailers like Target have been innovating.

Posted in: Healthcare Technology, Healthcare transformation, Telemedicine

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Dispatches from the 2014 American Telemedicine Association Conference

BaltimoreWe just returned from the 19th annual American Telemedicine Conference in Baltimore, MD. It was an amazing opportunity to network, meet telemedicine pioneers, and get energized about the opportunities to improve patient care. While there are still some major barriers to care, first in the way of billing codes and second in the way of cross-state licensing, speakers were confident that these legislative issues will be solved for a number of reasons: telemedicine is effective, it’s what patients want, and it can improve access to care and decrease costs.

Telehealth in Practice: Chronic Disease Management

Similar to what we’re seeing in all healthcare, a one-size fits all approach does not work when it comes to telehealth either. For some patients it works extremely well, and for some even the most rudimentary telehealth (i.e. phone calls) doesn’t work. We heard many discussions about green, yellow, and red patients. Green are those that are able to take care of themselves and their recovery. Yellow are those that have some risk, particularly of hospital readmissions. Red are those who are a definite readmissions risk. While Red patients often cost the most money, they may not be the best candidates for the cost savings of telehealth. One speaker pointed out that the most challenging of “red” patients often move without notice or have their phones cut off which makes even the simplest intervention, either a phone call or a house call impossible. This speaker suggested that while the healthcare system needs to figure out a solution for these patients, they are often used as examples of why telemedicine doesn’t work. Using this as the standard will definitely set us up for failure as the benefits for those green and yellow patients are real.

Congestive Heart Failure is the number 1 reason for hospital readmissions, and not-surprisingly a number of sessions dealt with follow-up care for this population. As well, repeated CHF readmissions also lead to long-term mortality. In practice ensuring follow-up visits reduced readmissions, however, in-person follow up visits are both expensive and inconvenient for patients. Carolinas Healthcare Systems started a telehealth follow-up program for CHF in June of last year, and are already seeing results for their Heart Success Virtual Clinic. First, patients have been saved over 3,900 miles and 380 hours of travel. Second, the follow-up rate for virtual visits is >95% compared to 70% at the in-person clinic, and the no-show rate is 3% compared to 10%. Telehealth visits are more convenient and as one speaker pointed out “it’s hard to miss a visit that’s in your house” so no-shows decreased as well. While the study hasn’t been completed yet, they are expecting a 50% decrease in readmissions for the patients that are participating in telehealth visits.photo 2

The University of Arkansas Center for Distance Health also saw positive results for CHF by using a call center to manage 30-day post-discharge follow-up coupled with an EMR. While on the phone with the patient, an RN verifies whether the patient has been seen by a nutritionist, is on a special diet, is managing fluid intake, has been in touch with a patient educator, and has scheduled a 1-week follow up appointment. Patients were instructed to call the hotline with any questions, concerns, or worsening symptoms. During the pilot from May-July of 2013 the program saw a 31% decline in readmissions resulting in $60,000 in cost savings to the organization (this did not include the costs of any Medicare fines). When the program was rolled-out to the entire patient population in Q1 of 2014, 34 readmissions were prevented with a total cost savings of $418,000.

Other examples from the conference involved care team and peer support for patients. A bariatric program run by DPS Health included patient discussion groups that were moderated by healthcare professionals. Moderators were present to guide the discussion and ensure that patient questions were answered, but they did this by prompting patients to answer each other’s questions rather than having the moderator jump in. This peer support helped participants achieve an average weight loss of 4-5%.

Sensors and Information Overload

It seems that the greatest promise for telemedicine though comes at the convergence of patient self-care, collaborative team care, and access to information, and patient provider communication. Patients can take more responsibility for their care outside the clinic using monitoring, apps, and sensors. However, the best results were seen when those patients were able to communicate remotely with healthcare professionals, and when those healthcare professionals also had access to information. However, none of this should come at the expense of care. While sensors were a hot topic, tools must be developed to help healthcare professionals deal with the influx of data. They need to be able to triage the information and get to the relevant and actionable information. One physician said that we don’t have a primary care physician shortage, but due to the extraordinary demands of documentation, we do have a shortage of physician time. Trackers and sensors should not increase this burden if they want to have an impact on care.

At the conference we saw sensors for just about everything, including a few questionable brain scanners. The sizes of scanners ranged from ankle bracelets to band-aids, and from flashy consumer designs to highly clinical. One speaker was adamant that disposable sensors are the future, citing the “razor/razor blade” model. While disposable are appealing in that they are usually designed to be worn under clothes and are small, we’re not sure about the analogy as the software that comes with sensors is usually free. However, given the number of FitBits we’ve had to replace at Wellpepper due to loss, the idea of a cheap disposable sensor is highly appealing.

What Patients Want

We’ve know since we founded Wellpepper that patients want information, convenience, and access to support from healthcare providers everywhere. It was heartening to see this echoed throughout the conference. Perhaps the most interesting was the data presented by Carena on what happened when a major employer in Seattle moved to a high deductible plan: the total number of PCP visits decreased 52% and the remaining shifted to telehealth. If this doesn’t prove without a doubt that patients are cost-conscious consumers, we’re not sure what does, especially since we happen to know that major employer pays pretty well. It also probably shows that if services are unlimited, people will overuse them.

This was really just a small glimpse of an extremely busy conference. On the one hand, it’s heartening to see all the passion about change, however, it’s also sobering to realize that this was the 19th year for this conference, and yet we still are debating the merits of telehealth, and some states do not allow telehealth. Hopefully though between patient demand, increased access to technology, and the need to reevaluate both the costs of care and how to support population health, this will change.

We will definitely see you next year at ATA 2015, and are looking forward to see how small the sensors have become and how much more ubiquitous telemedicine has become.

Posted in: Health Regulations, Healthcare Disruption, Healthcare Technology, M-health, Telemedicine

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