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How to Build an Effective Rural Virtual Care and Telehealth Strategy

Posted on October 10, 2018 I Written By

The following is a guest blog post by Lee Horner, CEO of Synzi.

Rural healthcare organizations are increasingly interested in implementing virtual care and telehealth solutions in order to better meet the needs of their facilities, staff, and patient population. In danger of closing their doors, rural hospitals are struggling to survive and thrive in a healthcare environment with razor-thin margins.

iVantage’s 2017 Rural Relevance Study reports that 41 percent of rural hospitals operate at a negative margin. Poor financial performance is impacting these hospitals’ ability to keep their doors open and serve rural communities. In fact, the National Rural Health Association (NRHA) reported that the number of rural hospital closures has risen to 87 in the last 8 years.

A rural hospital closure has significant impact to its community. These facilities provide fundamental healthcare services to nearly 57 million people across the country and are often an integral part of the local economy, providing jobs and a tax base for the community. John Henderson, CEO of the Texas Organization of Rural and Community Hospitals (TORCH) stated that hospitals are a critical element of a town’s survival: “Hospitals, schools, churches. It’s the three-legged stool. If one of those falls down, you don’t have a town.”

Virtual care technology can be a viable delivery option for healthcare facilities and residents in rural communities. To best build an effective virtual care strategy, rural healthcare organizations should short-list solutions which solve for limited bandwidth in rural areas, patient preference for mobile devices and communications, an organization’s current infrastructure and workflow, and security concerns.

Addressing Bandwidth Issues: Rural healthcare organizations may initially think that limited Wi-Fi and broadband availability will restrict telehealth adoption by a facility, a medical practice and/or the patients themselves. However, rural healthcare organizations can identify and implement solutions which work across any level of connectivity (whether cellular or Wi-Fi) to ensure that the providers and the patients can use the solution without issues. Various entities are actively pushing for continued investment in our nation’s broadband infrastructure and rural communities are a priority for future build-out.

Reflecting Patient Preferences: Patients are already using many devices – including smartphones, tablets, and/or computers – which also provide them with more convenient access to healthcare without requiring significant travel time and costs. Moving forward, rural healthcare organizations should prioritize solutions which are device-agnostic and should also ensure their patient communications work across any type of modality. Providers and patients already own many of these devices; a flexible virtual care platform will help organizations and individuals reap more benefits out of the investments they have already made in technology.

Optimizing Current Workflows: Healthcare organizations have ongoing clinical workflows, and may be wary of technology’s role in automating these processes. However, rural healthcare organizations’ existing workflows can be optimized by using a virtual care platform which ensures that the virtual care protocols are consistent with in-person protocols in terms of engaging at-home patients and/or reaching offsite specialists for a needed consult. The ideal solution should be intuitive and easy to use; providers will then be able to quickly incorporate virtual care into their practices.

Addressing Security Concerns: When exploring new technology, most healthcare organizations will initially question if a net-new solution meets safety and privacy standards. Rural healthcare organizations should prioritize solutions which are HIPAA-compliant and HITRUST-certified to ensure security, privacy and compliance. Although rural health providers will immediately understand the need to adopt a virtual care platform, IT departments and champions will also need to realize that the adoption of this new technology will benefit providers, patients, and ultimately, the sustainability of the healthcare organization. Virtual care technology is essential to rural healthcare as it helps close the time and distance gap in terms of providing patients with the care they need, when they need it – regardless of where the patients or the providers are located.

The rural population has noted gaps in both access and quality. An estimated one in five Americans live and work in rural areas across the nation, yet, there are 2,157 Health Professional Shortage Areas in rural areas compared to 910 in urban areas. Moreover, the Rural Health Information Hub reports that 19.5 percent of rural adults describe their health status as fair/poor vs. 15.6 percent of their urban counterparts. Virtual care technology can help address the gap in care by providing access to additional physicians and needed specialists at the click of a button. By leveraging external and/or associated hospitals and physician groups, rural hospitals strengthen their care within the vast populations and geographies they support.

The Win-Win of Today’s Telemedicine Technology for All Practices

Posted on March 22, 2018 I Written By

The following is a guest blog post by Sean Brindley, Product Development Manager, Kareo Telemedicine

The healthcare profession has been talking about telemedicine and its potential benefits almost as long as there have been phones. Over the last five years, adoption of telemedicine programs has increased steadily, but for some practices, particularly smaller, independent offices, the questions loom larger. How disruptive will adopting telemedicine be to office workflow? Will telemedicine overburden office staff? What are the risks involved in trying it? How will they get reimbursed for the investment? And, most important, what benefits can telemedicine bring to the individual practice that offset the impact of the learning curve?

Unlike even one or two years ago, today’s answers are mostly positive.

Reimbursement Is Real

Let’s tackle the big question first – reimbursement. Starting at the simplest point, most practices today give away a lot of practitioner time in telephone consults that are not reimbursable. Finding a way to generate revenue on even some of those would be a boon to most practices. But the news is far more positive than that. Thirty-five states, plus eight more pending, have enacted telemedicine parity requiring certain payers to pay for telemedicine consultations just as they would reimburse face-to-face visits. Private payers have been at the forefront of telemedicine adoption, likely recognizing telemedicine as a highly cost-effective delivery system for healthcare.  At the same time, a recent bill (The Creating High-Quality Results and Outcomes Necessary to Improve Chronic (CHRONIC) Care Act of 2017), has relaxed the restriction on Medicare reimbursements for telemedicine, and while Medicaid reimbursement varies substantially from state to state, there are places where the reimbursement practices go further than Medicare. All practices should carefully review the rules and regulations in their states. Parity doesn’t always mean parity. This is why it’s an advantage to have a telemedicine visit option that’s built into the EHR and practice management system, not a separate application. This ensures a smooth reimbursement process. For example, in Kareo when a video appointment is scheduled, the system automatically verifies that the patient is covered for telemedicine. This removes much of the burden from the office staff and greatly increases the chances that the telemedicine program will provide a revenue stream for the office.

What’s In It For Practices?

Beyond the potential for reimbursing telemedicine visits, how will telemedicine impact the operation of offices? First, telemedicine can increase the number of daily or weekly visits without increasing the practitioner’s work hours because visits conducted via most well-designed telemedicine systems take less time than an in-person visit. For example, a practice with three providers who each add two video visits per day, at an average reimbursement of $72, will earn an extra $103,680 in revenue over the course of a year. Telemedicine also greatly reduces the number of no-shows and cancellations. Patients with a telemedicine appointment are less likely to cancel because of work issues, transportation, child care, or just plain forgetting. An office appointment that has to be cancelled at the last minute can even be changed to a video visit, keeping the patient on track and not wasting the practitioner’s time. Having telemedicine available makes a practice more competitive against the rising number of “convenient” healthcare outlets like urgent care, walk-ins and on-demand care.

What’s In It For Patients?

Perhaps most important, telemedicine has the potential to improve patient health and increase quality outcomes since it provides an easy way to stay in ongoing touch with patients. The best use cases are for routine follow-up care where the appointment does not require a physical examination. For example, ideal cases for video visits are ongoing care for chronic conditions, observing treatment plans, reviewing slightly abnormal lab results, providing prescription updates, and discussing lifestyle changes for weight loss, smoking cessation and much more. Better quality outcomes also mean better reimbursement under today’s quality-driven healthcare system. Some of the specialties regularly using telemedicine are:

  • Primary Care
  • OB/GYN
  • Neurology
  • Nephrology
  • Mental/Behavioral Health
  • Gastroenterology
  • Endocrinology
  • Cardiology
  • Dermatology
  • Pulmonology
  • Infectious Disease
  • Urology
  • Hematology/Oncology

How Much Impact on Staff?

Traditionally, many providers have offered separate applications for telemedicine, which required additional steps and training for office staff, making it more difficult to implement, especially for small practices. However, telemedicine is now more feasible for all practices because new technology from Kareo integrates telemedicine seamlessly into the EHR platform. For example, our customers can schedule telemedicine appointments directly in their practice management system, maintaining current office workflow for scheduling, charting and billing with no extra steps or training required. The automatic eligibility verification removes much of the financial burden and produces on average 10 times the provider’s cost per visit.  Patients can request appointments online and conduct the visit through a mobile device or desktop.

Removing the Risk

In busy practices, all changes can feel risky in terms of impact on staff, patients and investment costs. The integration of telemedicine with popular EHR platforms removes much of the impact on staff. Since more than 64 percent of patients say they would be happy to have a telemedicine video appointment, the offering to patients is far more positive than negative. Finally, the investment risk has dropped to minimal. EHR providers that offer software-as-a service, such as Kareo, are now giving practices a chance to pay per telemedicine visit, thereby being charged only for what they use. These low per-visit fees reduce the start-up burden on small practices, so the financial risk drops to negligible. In this way the office can implement a telemedicine practice at its own pace, allowing reimbursements to keep pace with usage.

Chances are good that even the overworked independent practice can use today’s telemedicine technology as an opportunity to increase revenue, unburden staff, and enhance patient satisfaction with the most minimal of investments. After years of promise, telemedicine has become a win-win

About Sean Brindley
Sean Brindley is product development manager for Kareo Telemedicine. More information can be found on Kareo’s Go Practice blog.  Kareo is a proud sponsor of Healthcare Scene.

5 Drivers of Digital Change in Healthcare

Posted on January 29, 2018 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Hospital CIO (or as he prefers, CDO – Chief Digital Officer), David Chou, recently asked the question “What Is the Main Driver of Digital Health?” and then he shared this image from Cognizant.

These results are pretty interesting since the main driver of digital change in healthcare is the consumer. That’s right. Patients are asking for healthcare to go digital. However, health reforms, health insurance exchanges, and new risk accountability are influencing it pretty heavy as well.

While these drivers are interesting, the real message here is that digital change in healthcare is going to be required. The future consumer is not going to accept a healthcare organization that doesn’t embrace digital. This is going to be true in so many different forms.

For example, I can’t imagine my children going to a healthcare organization that doesn’t do telemedicine or that doesn’t support some sort of text messaging or similar digital communication. The idea of not communicating this way will be completely foreign to them. Those organizations that embrace it will be the big winners.

One thing that might hold this back is that in some cities healthcare organizations have near monopolies. Since healthcare is local, these near monopolies are really only competing with themselves when it comes to their digital health options. It won’t matter much that another hospital or health system across the country offers something better. Or will it matter?

We’d all love to have our normal doctor be the one doing our telemedicine visit. However, given the option of an in-person visit with our normal doctor or a telemedicine visit with a doctor across the country, I think we’ll start seeing many people opt for the later. We need a few more laws to change to make this a reality, but changes to those laws would certainly open up a new competition to own the online relationship with a patient.

What’s clear to me is that digital will dominate the future. What’s not clear to me yet is who will own that digital health relationship with patients. Will it be local? Will it be national healthcare organizations? Will it be some other large company?

What do you think about this digital change in healthcare? What’s making this a reality? How do you think this change will play out?

Key Articles in Health IT from 2017 (Part 2 of 2)

Posted on January 4, 2018 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site (http://oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

The first part of this article set a general context for health IT in 2017 and started through the year with a review of interesting articles and studies. We’ll finish the review here.

A thoughtful article suggests a positive approach toward health care quality. The author stresses the value of organic change, although using data for accountability has value too.

An article extolling digital payments actually said more about the out-of-control complexity of the US reimbursement system. It may or not be coincidental that her article appeared one day after the CommonWell Health Alliance announced an API whose main purpose seems to be to facilitate payment and other data exchanges related to law and regulation.

A survey by KLAS asked health care providers what they want in connected apps. Most apps currently just display data from a health record.

A controlled study revived the concept of Health Information Exchanges as stand-alone institutions, examining the effects of emergency departments using one HIE in New York State.

In contrast to many leaders in the new Administration, Dr. Donald Rucker received positive comments upon acceding to the position of National Coordinator. More alarm was raised about the appointment of Scott Gottlieb as head of the FDA, but a later assessment gave him high marks for his first few months.

Before Dr. Gottlieb got there, the FDA was already loosening up. The 21st Century Cures Act instructed it to keep its hands off many health-related digital technologies. After kneecapping consumer access to genetic testing and then allowing it back into the ring in 2015, the FDA advanced consumer genetics another step this year with approval for 23andMe tests about risks for seven diseases. A close look at another DNA site’s privacy policy, meanwhile, warns that their use of data exploits loopholes in the laws and could end up hurting consumers. Another critique of the Genetic Information Nondiscrimination Act has been written by Dr. Deborah Peel of Patient Privacy Rights.

Little noticed was a bill authorizing the FDA to be more flexible in its regulation of digital apps. Shortly after, the FDA announced its principles for approving digital apps, stressing good software development practices over clinical trials.

No improvement has been seen in the regard clinicians have for electronic records. Subjective reports condemned the notorious number of clicks required. A study showed they spend as much time on computer work as they do seeing patients. Another study found the ratio to be even worse. Shoving the job onto scribes may introduce inaccuracies.

The time spent might actually pay off if the resulting data could generate new treatments, increase personalized care, and lower costs. But the analytics that are critical to these advances have stumbled in health care institutions, in large part because of the perennial barrier of interoperability. But analytics are showing scattered successes, being used to:

Deloitte published a guide to implementing health care analytics. And finally, a clarion signal that analytics in health care has arrived: WIRED covers it.

A government cybersecurity report warns that health technology will likely soon contribute to the stream of breaches in health care.

Dr. Joseph Kvedar identified fruitful areas for applying digital technology to clinical research.

The Government Accountability Office, terror of many US bureaucracies, cam out with a report criticizing the sloppiness of quality measures at the VA.

A report by leaders of the SMART platform listed barriers to interoperability and the use of analytics to change health care.

To improve the lower outcomes seen by marginalized communities, the NIH is recruiting people from those populations to trust the government with their health data. A policy analyst calls on digital health companies to diversify their staff as well. Google’s parent company, Alphabet, is also getting into the act.

Specific technologies

Digital apps are part of most modern health efforts, of course. A few articles focused on the apps themselves. One study found that digital apps can improve depression. Another found that an app can improve ADHD.

Lots of intriguing devices are being developed:

Remote monitoring and telehealth have also been in the news.

Natural language processing and voice interfaces are becoming a critical part of spreading health care:

Facial recognition is another potentially useful technology. It can replace passwords or devices to enable quick access to medical records.

Virtual reality and augmented reality seem to have some limited applications to health care. They are useful foremost in education, but also for pain management, physical therapy, and relaxation.

A number of articles hold out the tantalizing promise that interoperability headaches can be cured through blockchain, the newest hot application of cryptography. But one analysis warned that blockchain will be difficult and expensive to adopt.

3D printing can be used to produce models for training purposes as well as surgical tools and implants customized to the patient.

A number of other interesting companies in digital health can be found in a Fortune article.

We’ll end the year with a news item similar to one that began the article: serious good news about the ability of Accountable Care Organizations (ACOs) to save money. I would also like to mention three major articles of my own:

I hope this review of the year’s articles and studies in health IT has helped you recall key advances or challenges, and perhaps flagged some valuable topics for you to follow. 2018 will continue to be a year of adjustment to new reimbursement realities touched off by the tax bill, so health IT may once again languish somewhat.

The Future Of Telemedicine Doesn’t Depend On Health Plans Anymore

Posted on December 6, 2017 I Written By

Anne Zieger is a healthcare journalist who has written about the industry for 30 years. Her work has appeared in all of the leading healthcare industry publications, and she's served as editor in chief of several healthcare B2B sites.

For as long as I can remember, the growth of telemedicine depended largely on overcoming two obstacles: bandwidth and reimbursement. Now, both are on the verge of melting away.

One, the availability of broadband, has largely been addressed, though there are certainly areas of the US where broadband is harder to get than it should be. Having lived through a time when the very idea of widely available consumer broadband blew our minds, it’s amazing to say this, but we’ve largely solved the problem in the United States.

The other, the willingness of insurers to pay for telemedicine services, is still something of an issue and will be for a while. However, it won’t stay that way for too much longer in my opinion.

Yes, over the short term it still matters whether a telemedicine visit is going to be funded by a payer –after all, if a clinician is going to deliver services somebody has to pay for their time. But there are good reasons why this will not continue to be an issue.

For one thing, as the direct-to-consumer models have demonstrated, patients are increasingly willing to pay for telemedical care out-of-pocket. Customers of sites like HealthTap and Teladoc won’t pay top dollar for such services, but it seems apparent that they’re willing to engage with and stay interested in solving certain problems this way (such as, for example, getting a personal illness triaged and treated without having to skip work the next day).

Another way telemedicine services have changed, from what I can see, is that health systems and hospitals are beginning to integrate it with their other service lines as a routine part of delivering care. Virtual consults are no longer this “weird” thing they do on the side, but a standard approach to addressing common health problems, especially chronic illness.

Then, of course, there’s the most important factor taking control of telemedicine away from health plans: the need to use it to achieve population health management goals. While its use is still a little bit lopsided at present, as healthcare organizations aren’t sure how to optimize telehealth initiatives, eventually they’ll get the formula right, and that will include using it as a way of tying together a seamless value-based delivery network.

In fact, I’d go so far as to say that without the reach, flexibility and low cost of telehealth delivery, building out population health management schemes might be almost impossible in the future. Having specialists available to address urgent matters and say, for example, rural areas will be critical on the one hand, while making specialists need for chronic care (such as endocrinologists) accessible to unwell urban patients with travel concerns.

Despite the growing adoption of telemedicine by providers, it may be 5 to 10 years or so before it has its fullest impact, a period during which health plans gradually accept that the growth of this technology isn’t up to them anymore. But the day will without a doubt arise soon enough that “telemedicine” is just known as medicine.

Measuring the Vital Signs of Health Care Progress at the Connected Health Conference (Part 3 of 3)

Posted on November 17, 2017 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site (http://oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

The previous segment of this article covered one of the crucial themes in health care today: simplifying technology’s interactions with individuals over health care. This segment finishes my coverage of this year’s Connected Health Conference with two more themes: improved data sharing and blockchains.

Keynote at Connected Health Conference

Keynote at Connected Health Conference

Improved data sharing
The third trend I’m pursuing is interoperability. If data collection is the oxygen that fuels connected health, data sharing is the trachea that brings it where it’s needed. Without interoperability, clinicians cannot aid patients in their homes, analysts cannot derive insights that inform treatments, and transitions to assisted living facilities or other environments will lead to poor care.

But the health care field is notoriously bad at data sharing. The usual explanation is that doctors want to make it hard for competitors to win away their patients. If that’s true, fee-for-value reimbursements will make them even more possessive. After all, under fee-for-value, clinicians are held accountable for patient outcomes over a long period of time. They won’t want to lose control of the patient. I first heard of this danger at a 2012 conference (described in the section titled “Low-hanging fruit signals a new path for cost savings”).

So the trade press routinely and ponderously reports that once again, years have gone by without much progress in data sharing. The US government recognizes that support for interoperability is unsatisfactory, and has recently changed the ONC certification program to focus on it.

Carla Kriwet, CEO of Connected Care and Health Informatics at Philips, was asked in her keynote Fireside Chat to rate the interoperability of health data on a scale from 0 to 10, and chose a measly 3. She declared that “we don’t believe in closed systems at all” and told me in an interview that Philips is committed to creating integrated solutions that work with any and all products. Although Philips devices are legendary in many domains, Kriwet wants customers to pay for outcomes, not devices.

For instance, Philips recently acquired the Wellcentive platform that allows better care in hospitals by adopting population health approaches that look at whole patient populations to find what works. The platform works with a wide range of input sources and is meant to understand patient populations, navigate care and activate patients. Philips also creates dashboards with output driven by artificial intelligence–the Philips IntelliVue Guardian solution with Early Warning Scoring (EWS)–that leverages predictive analytics to present critical information about patient deterioration to nurses and physicians. This lets them intervene quickly before an adverse event occurs, without the need for logging in repeatedly. (This is an example of another trend I cover in this article, the search for simpler interfaces.)

Kriwet also told me that Philips has incorporated the principles of agile programming throughout the company. Sprints of a few weeks develop their products, and “the boundary comes down” between R&D and the sales team.

I also met with Jon Michaeli, EVP of Strategic Partnerships with Medisafe, a company that I covered two years ago. Medisafe is one of a slew of companies that encourage medication adherence. Always intensely based on taking in data and engaging patients in a personalized way, Medisafe has upped the sophistication of their solution, partly by integrating with other technologies. One recent example is its Safety Net, provided by artificial intelligence platform Neura. For instance, if you normally cart your cell phone around with you, but it’s lying quiet from 10:00 PM until 6:00 AM, Safety Net may determine your reason for missing your bedtime dose at 11:00 PM was that you had already fallen asleep. If Safety Net sees recurring patterns of behavior, it will adjust reminder time automatically.

Medisafe also gives users the option of recording the medication adherence through sensors rather than responding to reminders. They can communicate over Bluetooth to a pill bottle cap (“iCap”) that replaces the standard medicine cap and lets the service know when you have opened the bottle. The iCap fits the vast majority of medicine bottles dispensed by U.S. pharmacies and costs only $20 ($40 for a pack of 2), so you can buy several and use them for as long as you’re taking your medicine.

On another level, Mivatek provides some of the low-level scaffolding to connected health by furnishing data from devices to systems developed by the company’s clients. Suppose, for instance, that a company is developing a system that responds to patients who fall. Mivatek can help them take input from a button on the patient’s phone, from a camera, from a fall detector, or anything else to which Mivatek can connect. The user can add a device to his system simply by taking a picture of the bar code with his phone.

Jorge Perdomo, Senior Vice President Corporate Strategy & Development at Mivatek, told me that these devices work with virtually all of the available protocols on the market that have been developed to promote interoperability. In supporting WiFi, Mivatek loads an agent into its system to provide an additional level of security. This prevents device hacking and creates an easy-to-install experience with no setup requirements.

Blockchains
Most famous as a key technological innovation supporting BitCoin, blockchains have a broad application as data stores that record transactions securely. They can be used in health care for granting permissions to data and other contractual matters. The enticement offered by this technology is that no central institution controls or stores the blockchain. One can distribute the responsibility for storage and avoid ceding control to one institution.

Blockchains do, however, suffer from inherent scaling problems by design: they grow linearly as people add transactions, the additions must be done synchronously, and the whole chain must be stored in its entirety. But for a limited set of participants and relatively rate updates (for instance, recording just the granting of permissions to data and not each chunk of data exchanged), the technology holds great promise.

Although I see a limited role for blockchains, the conference gave considerable bandwidth to the concept. In a keynote that was devoted to blockchains, Dr. Samir Damani described how one of his companies, MintHealth, planned to use them to give individuals control over health data that is currently held by clinicians or researchers–and withheld from the individuals themselves.

I have previously covered the importance patient health records, and the open source project spotlighted by that article, HIE of One, now intends to use blockchain in a manner similar to MintHealth. In both projects, the patient owns his own data. MintHealth adds the innovation of offering rewards for patients who share their data with researchers, all delivered through the blockchain. The reward system is quite intriguing, because it would create for the first time a real market for highly valuable patient data, and thus lead to more research use along with fair compensation for the patients. MintHealth’s reward system also fits the connected health vision of promoting healthy behavior on a daily basis, to reduce chronic illness and health care costs.

Conclusion
Although progress toward connected health comes in fits and starts, the Connected Health Conference is still a bright spot in health care each year. For the first time this year, Partners’ Center for Connected Health partnered with another organization, the Personal Connected Health Alliance, and the combination seems to be a positive one. Certain changes were noticeable: for instance, all the breakout sessions were panels, and the keynotes were punctuated by annoying ads. An interesting focus this year was wellness in aging, the topic of the final panel. One surprising difference was the absence of the patient advocates from the Society for Participatory Medicine whom I’m used to meeting each year at this conference, perhaps because they held their own conference the day before.

The Center for Connected Health’s Joseph Kvedar still ran the program team, and the themes were familiar from previous years. This conference has become my touchstone for understanding health IT, and it will continue to be the place to go to track the progress of health care reform from a technological standpoint.

Measuring the Vital Signs of Health Care Progress at the Connected Health Conference (Part 2 of 3)

Posted on November 15, 2017 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site (http://oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

The first segment of this article introduced the themes of the Connected Health Conference and talked about the importance of validating what new technologies do using trials or studies like traditional medical advances. This segment continues my investigation into another major theme in health care: advanced interfaces.

Speaker from Validic at Connected Health Conference

Speaker from Validic at Connected Health Conference

Advanced interfaces
The compulsory picture of health care we’re accustomed to seeing, whenever we view hospital propaganda or marketing from health care companies, shows a patient in an awkward gown seated on an uncomfortable examination table. A doctor faces him or her full on–not a computer screen in site–exuding concern, wisdom, friendliness, and professionalism.

More and more, however, health sites are replacing this canonical photograph with one of a mobile phone screen speckled with indicators of our vital signs or thumbnail shot of our caregivers. The promise being conveyed is no longer care from a trusted clinician in the office, but instant access to all our information through a medium familiar to almost everyone everywhere–the personal mobile device.

But even touchscreen access to the world of the cloud is beginning to seem fusty. Typing in everything you eat with your thumbs, or even answering daily surveys about your mental state, gets old fast. As Dr. Yechiel Engelhard of TEVA said in his keynote, patients don’t want to put a lot of time into managing their illnesses, nor do doctors want to change their workflows. So I’m fascinated with connected health solutions that take the friction out of data collection and transmission.

One clear trend is the move to voice–or rather, I should say back to voice, because it is the original form of human communication for precise data. The popularity of Amazon Echo, along with Siri and similar interfaces, shows that this technology will hit a fever pitch soon. One research firm found that voice-triggered devices more than doubled in popularity between 2015 and 2016, and that more than half of Americans would like such a device in the home.

I recently covered a health care challenge using Amazon Alexa that demonstrates how the technology can power connected health solutions. Most of the finalists in the challenge were doing the things that the Connected Health Conference talks about incessantly: easy and frequent interactions with patients, analytics to uncover health problems, integration with health care providers, personalization, and so on.

Orbita is another company capitalizing on voice interfaces to deliver a range of connected health solutions, from simple medication reminders to complete care management applications for diabetes. I talked to CEO Bill Rogers, who explained that they provide a platform for integrating with AI engines provided by other services to carry out communication with individuals through whatever technology they have available. Thus, Orbita can talk through Echo, send SMS messages, interact with a fitness device or smart scale, or even deliver a reminder over a plain telephone interface.

One client of Orbita uses it platform to run a voice bot that talks to patients during their discharge process. The bot provides post-discharge care instructions and answers patients’ questions about things like pain management and surgery wound care. The results show that patients are more willing to ask questions of the bot than of a discharge nurse, perhaps because they’re not afraid of wasting someone’s time. Rogers also said services are improving their affective interfaces, which respond to the emotional tone of the patient.

Another trick to avoid complex interfaces is to gather as much data as possible from the patient’s behavior (with her consent, of course) to eliminate totally the need for her to manually enter data, or even press a button. Devices are getting closer to this kind of context-awareness. Following are some of the advances I enjoyed seeing at the Connected Health Conference.

  • PulseOn puts more health data collection into a wrist device than I’ve ever seen. Among the usual applications to fitness, they claim to detect atrial fibrillation and sleep apnea by shining a light on the user’s skin and measuring changes in reflections caused by variations in blood flow.
  • A finger-sized device called Gocap, from Common Sensing, measures insulin use and reports it over wireless connections to clinical care-takers. The device is placed over the needle end of an insulin pen, determines how much was injected by measuring the amount of fluid dispensed after a dose, and transmits care activity to clinicians through a companion app on the user’s smartphone. Thus, without having to enter any information by hand, people with diabetes can keep the clinicians up to date on their treatment.
  • One of the cleverest devices I saw was a comprehensive examination tool from Tyto Care. A small kit can carry the elements of a home health care exam, all focused on a cute little sphere that fits easily in the palm. Jeff Cutler, Chief Revenue Officer, showed me a simple check on the heart, ear, and throat that anyone can perform. You can do it with a doctor on the other end of a video connection, or save the data and send it to a doctor for later evaluation.

    Tyto Care has a home version that is currently being used and distributed by partners such as Heath Systems, providers, payers and employers, but will ultimately be available for sale to consumers for $299. They also offer a professional and remote clinic version that’s tailor-made for a school or assisted living facility.

A new Digital Therapeutics Alliance was announced just before the conference, hoping to promote more effective medical devices and allow solutions to scale up through such things as improving standards and regulations. Among other things, the alliance will encourage clinical trials, which I have already highlighted as critical.

Big advances were also announced by Validic, which I covered last year. Formerly a connectivity solution that unraveled the varying quasi-standard or non-standard protocols of different devices in order to take their data into electronic health records, Validic has created a new streaming API that allows much faster data transfers, at a much higher volume. On top of this platform they have built a notification service called Inform, which takes them from a networking solution to a part of the clinicians’ workflow.

Considerable new infrastructure is required to provide such services. For instance, like many medication adherence services, Validic can recognize when time has gone by without a patient reporting that’s he’s taken his pill. This level of monitoring requires storing large amounts of longitudinal data–and in fact, Validic is storing all transactions carried out over its platform. The value of such a large data set for discovering future health care solutions through analytics can make data scientists salivate.

The next segment of this article wraps up coverage of the conference with two more themes.

Measuring the Vital Signs of Health Care Progress at the Connected Health Conference (Part 1 of 3)

Posted on November 13, 2017 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site (http://oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

Attendees at each Connected Health Conference know by now the architecture of health reform promoted there. The term “connected health” has been associated with a sophisticated amalgam of detailed wellness plans, modern sensors, continuous data collection in the field, patient control over data, frequent alerts and reminders, and analytics to create a learning health care system. The mix remains the same each year, so I go each time to seek out progress toward the collective goal. This year, I’ve been researching what’s happening in these areas:

  • Validation through clinical trials
  • Advanced interfaces to make user interaction easier
  • Improved data sharing (interoperability)
  • Blockchains

Panel at Connected Health Conference

Panel at Connected Health Conference

There were a few other trends of interest, which I’ll mention briefly here. Virtual reality (VR) and augmented reality (AR) turned up at some exhibitor booths and were the topic of a panel. Some of these technologies run on generic digital devices–such as the obsession-inducing Pokémon GO game–while others require special goggles such as the Oculus Rift (the first VR technology to show a promise for widespread adoption, and now acquired by Facebook) or Microsoft’s HoloLens. VR shuts out the user’s surroundings and presents her with a 360-degree fantasy world, whereas AR imposes information or images on the surroundings. Both VR and AR are useful for teaching, such as showing an organ in 3D organ in front of a medical student on a HoloLens, and rotating it or splitting it apart to show details.

I haven’t yet mentioned the popular buzzword “telehealth,” because it’s subsumed under the larger goal of connected health. I do use the term “artificial intelligence,” certainly a phrase that has gotten thrown around too much, and whose meaning is subject of much dissension. Everybody wants to claim the use of artificial intelligence, just as a few years ago everybody talked about “the cloud.” At the conference, a panel of three experts took up the topic and gave three different definitions of the term. Rather than try to identify the exact algorithms used by each product in this article and parse out whether they constitute “real” artificial intelligence, I go ahead and use the term as my interviewees use it.

Exhibition hall at Connected Health Conference

Exhibition hall at Connected Health Conference

Let’s look now at my main research topics.

Validation through clinical trials
Health apps and consumer devices can be marketed like vitamin pills, on vague impressions that they’re virtuous and that doing something is better than doing nothing. But if you want to hook into the movement for wellness–connected health–you need to prove your value to the whole ecosystem of clinicians and caretakers. The consumer market just doesn’t work for serious health care solutions. Expecting an individual to pay for a service or product would limit you to those who can afford it out-of-pocket, and who are concerned enough about wellness to drag out their wallets.

So a successful business model involves broaching the gates of Mordor and persuading insurers or clinicians to recommend your solution. And these institutions won’t budge until you have trials or studies showing that you actually make a difference–and that you won’t hurt anybody.

A few savvy app and device developers build in such studies early in their existence. For instance, last year I covered a typical connected health solution called Twine Health, detailing their successful diabetes and hypertension trials. Twine Health combines the key elements that one finds all over the Connected Health Conference: a care plan, patient tracking, data analysis, and regular check-ins. Their business model is to work with employer-owned health plans, and to expand to clinicians as they gradually migrate to fee-for-value reimbursement.

I sense that awareness is growing among app and device developers that the way to open doors in health care is to test their solutions rigorously and objectively. But I haven’t found many who do so yet.

In the next segment of this article continues my exploration of the key themes I identified at the start of this article.

The Healthcare IT Field is Unique, Yorktel Discovers

Posted on September 11, 2017 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site (http://oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

Health care professionals love to vaunt the uniqueness of the medical industry, and tend to demand special, expensive treatment on that basis. Reformers tend to discount this special status. (For instance, the security problems in health care are identical to those in other industries, and are caused by the same factors of insufficient investment and training.) Yet telecommunications in hospitals and clinics really is special, and video giant Yorktel has spent the past five years adjusting to that reality. On September 5, Yorktel announced that it has enhanced its solutions for patient telemedicine with Univago HE that includes robust video connections, monitoring, and analytics as a service.

To learn how the company enhanced their video teleconferencing for healthcare, I recently talked to Peter McLain, Senior Vice President of Healthcare, and John Vitale, Senior Vice President of Project Management. They disassembled the various features of Univago that deal with hospital environments, which require reliable 24/7 connectivity, deal with a good deal of noise (both audible and electronic), and demand fast, faultless authorization to protect privacy.

Directional audio

The triangular table-top sets, familiar to so many of us from business teleconferencing, are omni-directional in order to facilitate use by people seated around the table. In a hospital, they pick up the whirr of carts going by, the chatter in the hallway, and the beeps and gurgles of machines in the patients’ rooms themselves. So Yorktel had to substitute directional microphones.

Camera positioning

Remote monitoring requires much more detail than talking heads in a teleconference. For instance, a remote nurse may want to check whether an IV bag is getting empty. So the person on the remote end of the video connection can direct the camera at particular points in the room and zoom in. Originally offering joystick-like controls for this purpose, Yorktel found them too confusing and cumbersome, so they created a system where a user can just double-click on her own screen to focus in on the place she indicated.

Infrared cameras

Remote monitoring takes place continuously, including when the room is dark. The staff don’t want to wake the patient while monitoring him, so Yorktel cameras support the display of scenes scanned from infrared light. A mild alert, such as a soft buzz, lets an awake patient know that he’s being monitored, without disturbing a sleeping patient.

Integration with dashboards

Yorktel software can be seamlessly integrated with other applications so that staff can see vital signs and other data while in a video call. The developers have made the systems adhere to relevant standards, including Skype, Web RTC, and H.323.

Robustness

Conventional business teleconference systems are used for a few hours each day; hospital systems are used 24/7 and must promise long mean times between failures. Yorktel addressed this on both a hardware and a software level. In hardware, they broke down large, integrated components into modules that would be easy to replace. In software, they built a custom operating system on Unix, feeling that would offer maximum reliability. They use artificial intelligence techniques to detect whether the camera has frozen (a common failure) and reboot the system before it interferes with a video session. Components can still fail, but McLain says they can be replaced within 15 minutes instead of 3 to 6 hours.

Security

Yorktel has hardened its authentication and authorization process to make sure that no one at random can dial into a system and see a patient in his bed. At the same time, they have integrated that process into mobile devices so the physician can check in from home or the road in case of an emergency.

The systems follow industry best practices, as specified by the ISO 27001 security standard and HIPAA. In order to expand into UK’s National Health Service and the European Union, Yorktel achieved Privacy Shield certification. They also get penetration testing from a third party expert, and incorporate anti-microbial technology into their systems. The systems are pending approval as Class 1 medical devices (the most reliable level of use) by the FDA.

Following security by design principles, Yorktel maintains no information for a patient. A physician finds the right room through an external service and calls that room. (If the patient wants to be called, he presses a button by the bedside, and a message is sent through some appropriate alert, such as a text message or a flashing screen.) No information on the traffic is preserved, and the call records have no personally identifying information.

Specialized services

Each department in a hospital has different needs, and Yorktel has provided specific enhancements to make their systems more useful in various settings.

For instance, family visits are an excellent use case for videoconferencing. A session can be shared with family members who can’t get in to the hospital. It can also be recorded and saved by the hospital (as mentioned earlier, Yorktel does not preserve session traffic) so it can be viewed again or brought out to prove that the hospital fulfilled its responsibility. To enable family visits, Yorktel allows the staff to designate members of the call as guests. The visitors are called “guests” because they have no control over the systems, but can see and hear what goes on during the session.

For general use in medical settings, Yorktel also allows sidebar conversations. The patient can be put on hold while physicians discuss treatment candidly and privately among themselves.

Via these enhancements targeted at hospitals and clinics, Yorktel has expanded its business in health care. It started with a common application, remote monitoring in the ICU, but expanded to telestroke care, family health, behavioral health, and translational services. They also knew that hospitals already have expensive, dedicated systems for many of these tasks, and don’t want to throw them away, especially if the outcome is to be locked in yet again to some proprietary system. Hence Yorktel’s dedication to standards.

Currently, video conferencing in the hospital is so expensive that it tends to be restricted to ICUs and a few other applications. Ultimately, Yorktel’s subscription plans should offer systems at a low enough cost that they can be deployed universally in hospitals and clinics.

What can other technology developers, outside of two-way video, learn about health care from the Yorktel experience? Most of all, go into the environments where you want your systems used and get to know the needs and workflows of the participants. Systems must be flexible, because each user is different. The systems must also be secure from the ground up, robust, and conformant to standards. Cost is also an important issue in most settings, particularly given the cuts in reimbursement that are widespread.

As it designs systems to interact along standards with other vendors, Yorktel’s strength in software has grown exponentially. This parallels trends throughout many industries, from manufacturers through retailers. Marc Andreessen famously said in 2011 that software is eating the world, and along these line, many analysts say that all companies will soon be software companies–or be drowned by their more agile competition. In this sense, we can all learn from Yorktel.

Both US And International Doctors Unimpressed With Govt Telehealth Adoption

Posted on May 25, 2017 I Written By

Anne Zieger is a healthcare journalist who has written about the industry for 30 years. Her work has appeared in all of the leading healthcare industry publications, and she's served as editor in chief of several healthcare B2B sites.

A new survey by physician social network SERMO has concluded that both US and foreign physicians aren’t impressed with national and local telehealth efforts by governments.

The US portion of the survey, which had 1,651 physician respondents, found that few US doctors were pleased with the telehealth adoption efforts in their state. Forty-one percent said they felt their state had done a “fair” job in adopting telehealth, which 44 percent said the state’s programs were either “poor” or “very poor.” Just 15 percent of US physicians rated their state’s telehealth leaders as doing either “well” or “very well” with such efforts.

Among the various states, Ohio’s programs got the best ratings, with 22 percent of doctors saying the state’s telehealth programs were doing “well” or “very well.” California came in in second place, with 20 percent of physician-respondents describing their state’s efforts as doing “well” or “very well.”

On the flip side, 59 percent of New Jersey doctors said the state’s telehealth efforts were “poor” or “very poor.” New York also got low ratings, with 51 percent of doctors deeming the state’s programs were “poor” or “very poor.”

Interestingly, physicians based outside the US had comparable – though slightly more positive — impressions of their countries’ telehealth efforts. Thirty-eight percent of the 1,831 non-US doctors responding to the survey rated their country as having done a “fair” job with telehealth adoption, a stronger middle ground than in the US. That being said, 43 percent said their country has done a “poor” or “very poor” job with adopting telehealth programs, while just 19 percent rated their countries’ efforts as going “well” or “very well.”

As with state-by-state impressions in the US, physicians’ impressions of how well their country was doing with telehealth adoption varied significantly.  Spain got the best rating, with 26 percent of physicians saying efforts there were going “well” or “very well.” Meanwhile, the United Kingdom got the worst ratings, with 62 percent of doctors describing telehealth efforts there as “poor” or “very poor.”

Of course, all of this begs the question of what doctors were taking into account when they rated their country or state’s telehealth-related initiatives.

What makes doctors feel one telehealth adoption program is effective and another not effective? What kind of support are physicians looking for from their state or country? Are there barriers to implementation that a government entity is better equipped to address than private industry? Do they want officials to support the advancement of telehealth technology?  I’d prefer to know the answers to these questions before leaping to any conclusions about the significance of SERMO’s data.

That being said, it does seem that doctors see some role for government in promoting the growth of telehealth use, if for no other reason than that that they’re paying enough attention to know whether such efforts are working or not. That surprises me a bit, given that the biggest obstacles to physician telehealth adoption are generally getting paid for such services and handling the technology aspects of telemedicine delivery.

But if the study is any indication, doctors want more support from public entities. I’ll be interested to see whether Ohio and California keep leading the pack in this country — and what they’re doing right.