The Latest in Remote Presence.

As health reform was being debated, many people theorized that hospital volumes would begin to drop as care was delivered at other points along the continuum. Well, it’s not a theory anymore. In fact, the numbers are a bit startling.

Health Management Associates (HMA) and Hospital Corporation of America (HCA), two of the nation’s biggest for-profit hospital chains, just reported big drops in first quarter admissions compared to the same period last year. At HMA, same-facility admissions fell by 8.8 percent. Across the country, both hospital admissions (and readmissions within 30 days) are steadily trending downward

Telemedicine is playing a key role in driving down hospital admissions. A remote stroke specialist can now examine patients in any robot-equipped ED, outpatient facility or ACO clinic. Telemedicine is also the ideal platform for ongoing patient monitoring that prevents unnecessary admissions in the first place – plus preventable readmissions that are now accompanied by hefty fines.

We’re just beginning to realize telemedicine’s true potential in disease prevention. It doesn’t take a genius to understand that a 340-pound patient who doesn’t exercise or make regular primary care visits is a prime candidate for a stroke or heart attack. Telehealth e-visits and follow-ups can go a long way toward eliminating the need for remote stroke consultations down the road.

Though volumes are decreasing, hospitals are still the primary funding resource for telemedicine initiatives across the entire care delivery system. Hospitals will still be the healthcare “hub” of the future because of their on-staff expertise and big IT budgets. But they’re likely to get a little quieter as expert care gets delivered in a variety of new settings.

Because of health reform, the U.S. healthcare system is bracing for the overnight influx of an estimated 20 million or more newly insured patients on Jan. 1, 2014. Balancing supply and demand will be tricky because as millions clamor for health services, there will be an estimated 200,000 fewer physicians nationwide to provide them. That’s why so many people are counting on telemedicine to be the Great Equalizer.

Here’s the demographic challenge: most of the fastest growing states in the U.S. are in the northern plains, an area that isn’t exactly a doctor magnet. (North Dakota is our fastest growing state because of the Bakken shale oil fields.) Meanwhile, populations in some eastern states like Rhode Island and Michigan are actually declining. With telemedicine, physicians who might be twiddling their thumbs in Providence and Kalamazoo can help care for some of those drillers in the Dakotas.

A report by the U.S. Census Bureau has revealed the top 10 states that have seen a population boom in 2012, seen in red, along with the worst, seen in blue.

States in the western U.S. and New England are the most “Obamacare-ready,” so they’re likely to see the biggest surge in demand. They could get help, however, from doctors in the 16 states that currently oppose Medicaid expansion (and probably won’t experience an immediate avalanche of new patients).

As Nirav Desai noted in a recent Hands On Telehealth post, matching healthcare supply and demand will depend in large measure on how well we utilize nurse practitioners and physician assistants. According to the Agency for Healthcare Research and Quality, there are about 56,000 NPs and 30,000 PAs practicing in the U.S. As Nirav points out, telemedicine could connect these mid-level practitioners with a physician in a central location. They could examine most patients on their own, and consult with the physician on more complicated diagnoses.

No other industry has ever faced a more daunting task than what awaits the healthcare field next year. If you sell tires or toothpaste, no one has ever thrown a switch and handed you 20 million new customers instantly. But telemedicine gives our overtaxed healthcare system a decent chance of being able to connect practitioners with patients, from Pawtucket, Rhode Island to the boom towns of North Dakota.

Yulun Wang, Ph.D., Chairman & CEO of InTouch Health and President-Elect of the American Telemedicine Association

By Yulun Wang, Ph.D., Chairman & CEO of InTouch Health

The need to provide high quality healthcare to everyone, while reducing costs, has reached a crisis level where it is a major focus at the highest government level.   More and more politicians and healthcare leaders are realizing that telemedicine is clearly a cornerstone of the solution.  This is tangibly seen by the increasing number of healthcare systems that are adopting telemedicine, by the growth of ATA, and by industry investing in telemedicine products and services.  I believe that telemedicine is now reaching an “inflection point” where the industry will grow at an exponential pace.  We are realizing that if one can bring the right clinical expertise, to the right place, at the right time, to make the right medical decision in a cost effective manner; quality can be improved while cost lowered.

Although the concept of telemedicine is simple and elegant, implementing telemedicine can be complex and messy.  This is not unexpected as fundamental change in any industry is never easy and without obstacles.  As one works to implement telemedicine in order to benefit from this enabling technology, one quickly uncovers the many challenges in actually building telemedicine programs.   Barriers created by existing payment structures, regulatory policies, IT architectures, corporate boundaries, resistance to change, and technology limitations, all need to be overcome.   It is these barriers or challenges, coupled with the significant potential value that can be created, which makes telemedicine ripe for innovators and entrepreneurs.   I believe that with persistent innovation, usually accompanied with the risk of capital, entrepreneurs can overcome these barriers and unleash the benefits of telemedicine into our healthcare delivery system.

To succeed in creating positive change I believe in the “divide and conquer” theory.  Trying to orchestrate a singular fundamental change to our healthcare delivery system to incorporate telemedicine systemically is too monumental a task, and will likely fail.  The pathway for entrepreneurs to innovate successfully is to find appropriately sized healthcare workflow challenges which can benefit from telemedicine solutions, and then work to gain adoption by healthcare providers.   With adoption, the entrepreneur can continue to build on that success and expand the vision and market opportunity.

As the telemedicine industry grows, applications are partitioned into two broad categories differentiated by the health status and location of the patient.   The first category we call “acute care telemedicine”, in which telemedicine is used to enable remote clinicians to immediately diagnose and treat sick patients.  These patients may be very sick and require immediate help from a specialist who is difficult to access.   The second category can be called “chronic disease management telemedicine”, where telemedicine is used to periodically and regularly monitor and manage a person’s chronic illness.

The needs of the telemedicine solution and the economic model vary greatly across these two categories.    Telemedicine solutions for acute care must enable a remote clinician to be interactively present in the patient environment and gather pertinent medical information through examination and data access to form a medical decision. Often, this decision can have significant (e.g. life or death) consequences.   If the remote clinician is the physician-in-charge, then the system must enable the physician to lead and establish dominion over the complete environment.  Conversely, telemedicine for chronic disease management generally does not require acute medical decision making, and the interactions are more coaching and mentoring in nature.    These solutions often connect healthcare providers into patient’s homes and therefore must scale cost effectively to a single patient/single system mode.

Telemedicine entrepreneurs should identify opportunities where they can innovate manageable-sized solutions that create significant value for the healthcare providers.  Still change is always difficult, particularly in the field of medicine where process and procedures are honed and perfected over decades to insure every patient receives consistently high quality care.   Therefore the solution must solve the problem in its entirety for adoption to occur.  For example, solutions should not be limited to technology alone, but rather need to be coupled with clinical protocols, business plans, training and implementation services, regulatory assistance, and even the ongoing monitoring and measuring of the solutions impact.  The level of multi-disciplinary depth and detail required to facilitate a change can tax even the most persistent entrepreneurs.

Healthcare is in a seismic state of transition that hasn’t been seen for many decades.  The fundamental goal of changing from “fee for service” to “fee for value”, and competitive pressures re-aligned to drive continued improvement of the quality/cost value curve, is enabling telemedicine to transition from a research topic to mainstream medicine.   Generational changes like these happen infrequently, and should be embraced by adventurous entrepreneurs.  We are at a time when the need for innovation and entrepreneurism in telemedicine is at a maximum!

Accountable Care Organizations and telemedicine have a common purpose: expanding access to improve care. According to a recent CDC report, 80% of adults who visit the ER do so because they lack access to other providers. Telemedicine not only provides that access, but it makes it easy to provide the post-visit patient monitoring so vital to the ACOs’ main mission: managing high-risk populations.

Telemedicine-driven ACOs hold a lot of promise, but that didn’t stop several Harvard University pundits from prematurely proclaiming their demise.

In a recent Wall Street Journal article titled “The Coming Failure of Accountable Care,” Harvard prof Clayton Christensen and colleagues painted a gloomy picture. But they were quickly countered by Joseph Kvedar, MD from the Center for Connected Health. After careful reflection, we agree with Dr. Joe.

In Kvedar’s view, the Harvard gang incorrectly labels ACOs as “latter-day health maintenance organizations.” But HMOs were driven primarily by health plans that lacked the tools for delivery reform. In contrast, ACOs are provider-driven, offering a fresh vision for population-based care delivery and reimbursement.

The Harvard gang feels that doctors’ attitudes won’t change enough to make ACOs successful. But Kvedar notes that many physicians are weary of the fee-for-service grind, and are very receptive to things like shared savings, bundled payments and full capitation.

However, Kvedar and the Ivy Leaguers agree on one key point: to fulfill the promise of ACOs, patient attitudes must dramatically change. Many Americans still don’t feel compelled to hit the gym and avoid the cheeseburgers to rein in the cost of preventable, chronic illness. Millions of us cling to a sedentary lifestyle, then expect the healthcare system to fix us. That mindset will obviously have to change for ACOs to have a fighting chance.

Christensen and his Harvard associates are like baseball fans who write their team off in May. But, hey, the season is still young – and both telemedicine and ACOs have bright prospects. Dr. Kvedar feels that they could be the healthcare equivalent of the Baltimore Orioles: an unexpected success. Telemedicine-empowered ACOs can win the hearts and minds of physicians – and they can make money.

As every sports fan knows, you just have to believe.

By fostering greater hospital partnership, the Affordable Care Act is already showing early signs of success. CMS notes that the national percentage of 30-day hospital readmissions – which was stubbornly stuck at

Health reform is providing both carrot and stick to make collaborative healthcare a reality.

19% for years – is finally starting to come down.  It’s now at 17.8%, and health reform and telemedicine deserve a lot of the credit.

Some telemedicine-based programs are getting far better results than the national average. For example, Geisinger Health Plan has implemented a telehealth program that has already cut hospital readmissions by a whopping 44%.

Obviously, the more collaboration between healthcare organizations, the better the results. Spurred by health reform, nearly 60% of hospitals are now part of a broader system. The ACA funded one of the most successful so far: 26 “Hospital Engagement Networks” (HENs) that work with more than 3,700 hospitals to coordinate patient care. According to the Advisory Board Company, the largest of the HENs has reduced its average 30-day readmission rate across 450 hospitals from 11.2% in 2010 to 10.2% by late 2012. That’s encouraging news for the folks in the Big Henhouse at 1600 Pennsylvania Avenue.

Last October, CMS began fining more than 2,000 hospitals with high readmission rates, imposing the maximum penalty of 1% in reduced Medicare reimbursements for 300 of them through the remainder of this year.

There are, of course, other factors driving hospitals to join larger systems: increasing margin pressures, plus the need to find economies of scale to improve care quality. But it’s clear that health reform is providing both carrots and sticks to make collaborative healthcare a reality.

If health reform and telemedicine continue to boost quality and rein in costs, it will be a nightmare for legislators who opposed them. Their biggest fear was that these things would actually work – and that people would love them so much that there would be no turning back.

As more success stories like these come rolling in, the president may soon be proud to call his program “Obamacare.”

Malcolm Gladwell, author of bestsellers like The Tipping Point and Outliers,  has brilliantly documented how hard-working early adopters (the outliers) help bring about pivotal social change (the tipping points). Telemedicine advocates can take heart from one of Gladwell’s most famous examples: The Beatles.

Similiar to musical revolution ushered in by the Beatles in the 1960s, telehealth has reached a tipping point.

In 1962, the music world was dominated by folk musicians and balladeers like Dean Martin. But in a tiny nightclub, four lads from Liverpool laid the groundwork for what would become the juggernaut of progressive rock. They didn’t fret about “tipping points” in musical tastes. They were the tipping point.

In a recent Hands On Telehealth newsletter, Nirav Desai (who’s fond of quoting Malcolm Gladwell) puts it beautifully: “You are part of the paradigm shift, not just through your awareness of telehealth but also your ability to bring about awareness, adoption and usage. As Mahatma Gandhi said: Be the change you wish to see in the world.”

Nirav adds that telemedicine actually has three tipping points that are occurring simultaneously: awareness, adoption and usage. And there are geographic pockets where these things are bubbling faster than in other regions. The parallel once again is to 1962 England, where The Beatles were part of a coalescing scene that included The Who and many others.

Just as Beatlemania was fueled by a music-hungry Baby Boom generation, telemedicine is being spurred by the aging of that same group (along with a shortage of physicians to care for them).

All the factors at the center of the see-saw – telemedicine reimbursement, cross-state licensing, and interoperability – are shifting steadily toward that proverbial tipping point. What Nirav urges us to do is add our individual bounce to help make it happen.

That’s the kind of energy that turns emerging trends into world-changing breakthroughs.

Pan/Tilt/Zoom (PTZ) cameras have been around for quite a while, mainly in the security field. They’re used every day in Las Vegas casinos to zoom in on blackjack players to make sure they’re not cheating. But now they’re being used widely in telemedicine – not to eavesdrop but to connect patient and doctor with greater intimacy.

By controlling a PTZ camera, a physician can assume the same distance from a patient that feels right in-person. If the doctor needs an extreme close-up of a stroke patient’s pupils, no problem. The camera can then adjust for a full-body view. If the patient is tearful, the doctor can empathetically edge a bit closer.  And the tilt feature comes in handy when physicians need a sideways view, even for routine things like throat or ear checks. Best of all, PTZ technology eliminates the fixed gaze of a TV anchorman, making the patient/physician encounter much more office-like.

The RP-7i utilizes a dual-camera system to obtain both the greatest field of view for driving and the maximum zoom capability during telecommunication interactions.

Many telemedicine companies offer PTZ camera technology, but the sophistication varies widely. Some high-end PTZ cameras offer features you’d probably never need in a hospital, such as the ability to block out images from the apartment complex visible from the patient’s window. To find the best match for your application, you need to see them in action. That’s why it’s virtually impossible to compare telemedicine products using a checklist. And that’s true for all the features canvassed, not just camera finesse.

On paper, many telemedicine products seem to offer comparable functionality. But a patient may clearly feel more comfortable using System A rather than System B.  When it comes to something as subjective as the patient/doctor relationship, there’s only one way to truly assess the trust-building qualities of a telemedicine product: experience it.

A recent New York Times story chronicled the downside of hospital and physician practice consolidation. The article noted that employed physicians are facing increasing pressure to admit patients only to the hospital that signs their paychecks – often for procedures that aren’t truly necessary. This is causing some hospital systems to be the overwhelmingly dominant player in their area, which allows them to slowly drive up prices. And it often forces patients to drive up to 40 miles further for treatment – something that stroke patients can ill afford to do.

This is obviously not the intent of healthcare reform – and telemedicine is helping to level the playing field while actually lowering costs and providing better, more timely care.

Here’s how it works in the telestroke field. A family practice physician examines a man who’s showing signs of a mild stroke. She immediately sends the patient to the nearest telemedicine-equipped hospital, which isn’t the one she works for but is 20 miles closer. A remote specialist quickly determines that the patient needs immediate tPA administration, so medical necessity is documented on the spot. The result: faster treatment at a lower cost than what the “preferred” hospital can provide.

No patient wants to be a pawn in a battle between sparring health systems – or to undergo needless tests and hospitalization. That’s why the Office of the Inspector General and other regulators are stepping up efforts to stop these practices.

Telemedicine lets us rise above the health system turf wars that threaten to undermine the collaborative spirit of health reform. Remote presence technology can help put an end to this Hatfield and McCoy squabbling so that patients get the highest level of care, delivered impartially at a lower cost. That’s where the reform caravan needs to be heading.

In telemedicine, it’s imperative for all mobile devices to conform to HIPAA guidelines.

Like most professionals, physicians enjoy using mobile devices. By some estimates, 90% of doctors are already using them at the point of care. And while they like smartphones, they love tablets like the iPad and iPad mini. The latter is rapidly becoming physicians’ mobile tool of choice because its roughly 8 x 5 inch dimensions make it easy to slip in a pocket, yet it’s far better for data entry than a smartphone.

This stampede toward tablets goes by two names in healthcare IT circles: bring your own device (BYOD) and corporately owned/personally enabled (COPE) devices. Most hospitals, long the domain of intranets and bulky laptops, are finally giving physicians what they want…which leads us to the trendiest acronym of all: mobile device management (MDM), where vendors and IT folks support multiple user profiles and secure document sharing.

Unfortunately, many do-it-yourself telemedicine programs and telecom companies have bypassed MDM altogether – and that can be disastrous in healthcare. It’s imperative for all mobile devices used in telemedicine to conform to HIPAA guidelines for patient privacy and secure messaging and imaging.

We’ve all seen media reports about celebrities whose smartphones have been hacked. Imagine the scandal that would erupt if Brad Pitt’s MRI results were suddenly available on the Internet – or if an aging star like Jack Nicholson received a telestroke consultation that went public. HIPAA has a very formal (and no doubt expensive) protocol for reporting these kinds of embarrassing data breaches. The reputation of a hospital system or large practice could be irreparably tarnished overnight.

The easiest way to avoid this trouble is to use only mobile devices and technologies that fully meet HIPAA guidelines – and all InTouch products do, including our new ControlStation app for the iPad and iPad mini.

Some do-it-yourself telemedicine programs are forgetting that if you’re lax on mobile security, it’s going to bite you eventually. Why open the door to compliance fines, PR crises, and potential lawsuits?

A bill before the Indiana state legislature requires Medicaid to reimburse for telemedicine services provided to all rural health clinics.

For those of us who’ve been waiting for meaningful telemedicine legislation at the state level, there’s cause for celebration. Eight states and the District of Columbia have already introduced bills this year aimed at expanding telemedicine reimbursement from both Medicaid and private insurers. And the ATA estimates that another ten states will follow suit in coming months.

Much of the proposed legislation draws heavily from the ATA’s recommendations for what constitutes a model telemedicine bill. This succinct document gives lawmakers some statehouse-friendly language on how to expand telemedicine coverage by health plans, HMOs, Medicaid and home health.

Legislators in Mississippi and New Mexico deserve kudos for introducing two new bills, presumably to widen the discussion to ensure that the final bill is comprehensive. The bills would require all health insurance plans to cover telemedicine services to the same extent as those provided in-person.

In Florida, House bill 499 would require both health insurers and Medicaid to provide coverage for telemedicine services, and would extend Medicaid telemedicine coverage to home care. A bill in Indiana goes a step further, requiring Medicaid to reimburse for telemedicine services provided to all rural health clinics.

Proposed legislation in the state of Washington would greatly reduce hospital compliance requirements when granting privileges or associations to telemedicine physicians. And the South Carolina bill has language requiring both individual plans and HMOs to provide telemedicine coverage.

It’s looking like 2013 will indeed be a watershed year for far-reaching telemedicine legislation. You can feel the momentum in states both red and blue. Politicians are very sensitive to the winds of change, so now’s the time to contact your state legislators and keep the pressure building. This could be our year!