Right Here Right Now: Ten Telehealth Pioneers Make It Work November 2008 Right Here Right Now: Ten Telehealth Pioneers Make It Work Prepared for California HealthCare Foundation Prepared by Jane Sarasohn-Kahn, M.A., M.H.S.A., THINK-Health November 2008 Right Here Right Now: Ten Telehealth Pioneers Make It Work   |  1 Acknowledgments Thanks to the following experts who generously shared their insights with me on the subject of health care online and unbound: Sandeep Agate, president and CEO, REACH Call Nicholas Augustinos, health care director, Internet Business Solutions Group, Cisco Systems, Inc. Ted Eytan, M.D., family physician and e-health expert; peer reviewer for this report Pramod Gaur, president, Healthanywhere, a division of IGEA Care Systems Joseph Kvedar, M.D., founder and director, Center for Connected Health Alex Nason, director of telehealth, Johns Hopkins Medicine Interactive Joseph Mondy, assistant vice president of IT Communications, CIGNA James O’Brien, director of product development, CIGNA Jay Sanders, M.D., president and CEO, Global Telemedicine Group Lawrence Sanders, M.D., radiologist Jonathan Schaffer, M.D., managing director, MyConsult, eCleveland Clinic Roy Schoenberg, M.D., president and CEO, American Well Sal Volpe, M.D., geriatric medicine, internal medicine, pediatrics About the Author Jane Sarasohn-Kahn is a health economist and management consultant who has worked with technology and medical device companies, educational institutions, pharmaceutical manufacturers and distributors, health care providers, payers, health plans, consumer products companies, nonprofits, and financial services firms for more than 20 years. In 1992 she founded THINK-Health, a strategic consultancy with a focus on issues at the intersection of health and technology. She blogs at Health Populi (www.healthpopuli.com). About the Foundation The California HealthCare Foundation is an independent philanthropy committed to improving the way health care is delivered and financed in California. By promoting innovations in care and broader access to information, our goal is to ensure that all Californians can get the care they need, when they need it, at a price they can afford. For more information, visit www.chcf.org. ©2008 California HealthCare Foundation 2  |  C alifornia H ealth C are F oundation Contents 4 Foreword 6 The Electronic House Call 8 A Norman Rockwell Kind of Doctor, v2.0 11 “Connected Health” Sees the Whole Person 13Winning Over Employers, Patients, and Providers 15 Telepresence Throughout Scotland 17Second Opinions— From Cleveland to 60 Countries 19 Medical Education Without Walls 21 Meet a Nighthawk 23 The Doctor Will See You Now 26 Expert Stroke Care, Anywhere 28 Endnotes Right Here Right Now: Ten Telehealth Pioneers Make It Work   |  3 Foreword This series of profiles complements Forrester Consulting’s 2008 study for the California HealthCare Foundation, “Delivering Care Anytime, Anywhere: Telehealth Alters the Medical Ecosystem.” The profiled organizations come to online health care from a var­­ ty of perspectives. They provide care to people in many differ­ ie ent settings: rural towns, urban centers, remote Scottish islands, Boston, Oahu, Singapore, Chile. They use an array of communica- tions instruments, from ordinary telephones and televisions to broadband connections and 3G-driven iPhones. They share at least two things in common—they are innovators and they have a goal of improving people’s health. These are some of the interconnected factors that have converged to enable them to do what they do, in the ways they do it: The world is getting flat. New York Times columnist and author Thomas Friedman popularized this metaphor to describe the leveling of the international competitive playing field thanks to the proliferation of new technologies. The concept is as true in health care as it is in business and socio-politics. It is happening because… Broadband technology is getting cheaper and ubiquitous. In cities, suburbs, and increasingly in rural America, broadband has become the norm for connecting to the Internet. In the developing world wireless connections have leapfrogged over hard-wiring as the basic telecommunications infrastructure. As a consequence… Telephones have emerged as useful health care delivery tools for providers and consumers alike. Phones are smarter and cheaper than ever. The camera in today’s mobile phone is more technologically advanced than a prototype that cost $12,000 just a few years ago. Reimbursement for online care is more available. No longer do telemedicine projects have to depend on foundation grants and government subsidies to seed a start-up or underwrite operations. Medicare, Medicaid, and private payers have begun to reimburse 4  |  C alifornia H ealth C are F oundation providers for teleconsults as the positive return on investment (ROI) has become unmistakable. Market drivers make telemedicine an obvious solution in many clinical situations. Providers are beginning to embrace remote care. Among early adopters of online health care have been radiologists, who increasingly provide remote coverage as “nighthawk” image readers for distant hospitals operating on a 24/7 basis. Forward- looking physicians are re-engineering care processes in recognition of the benefits that accrue when efficient, high-quality medical services are accessible to patients regardless of location. Consumers are benefiting. More enrollees in health plans and consumers who self-pay are accessing online care in innovative ways. Some have financial incentives to do so. Some are choosing new care models that fit with their time-pressed, mobile, technology-rich lifestyles. Still other consumers, especially those without health insurance, find that emerging online services give them access to care despite the lack of a regular medical home. The recent addition of “Walk-In Telemedicine Health Care” to Wal-Mart retail clinics, for example, will serve this consumer-driven market. Home can be the center of health care. Many online care innovators predict that the patient’s home will be the new hub of a person’s health and health care. As people take on more financial and clinical responsibility for health, the phrase “home health care” could take on new meaning. Jane Sarasohn-Kahn September 2008 Right Here Right Now: Ten Telehealth Pioneers Make It Work  |  5 1.The Electronic House Call Jay Sanders, M.D., Global Telemedicine Group Health services: In 1993, Dr. Jay Sanders worked with the Telemedicine; remote Medical College of Georgia and Georgia Tech to develop the first physician visits. home telehealth application in the U.S. The team called it the “electronic house call.” They used a standard television set as the Technologies used: Television sets; personal interface between the physician and the distant patient at home. computers. In the ensuing years, Sanders has consulted on telehealth projects with providers, medical schools, the World Health Organization, Lessons learned: NASA, the United States Air Force, the Army, and the Navy. Resistance to change by Following are three key insights he gleaned from these experiences. physicians can be overcome. The patient’s home is In designing the electronic house call, Sanders used the patient’s central to health. TV in their home and made the program fully interactive. “The reason we wanted to use the TV was we wanted it to be totally intuitive for the person,” explains Sanders. “The patient didn’t view this as something ‘new,’ but rather, ‘just my TV.’” To access the program, the patient would change the channel, find the interactive health channel, and see the doctor or nurse at 30 frames per second. “We added some medical peripheral devices that were simple to use, and a graphic interface on the screen that “We wanted it to showed, for example, a stethoscope. We’d ask the patient to touch the icon, and that would activate the electronic stethoscope.” be totally intuitive This was the first system of its kind, and American Telecare of for the person.” Minneapolis developed the second. “That’s what started this industry,” says Sanders. Home Is Where the Health Is “Over the past five years there’s been a realization that the exam room is wherever the patient is,” adds Sanders. “As we began to examine patients in their home, it was obvious: Why do we wait for the patient with congestive heart failure to come to the hospital? If we’d been able to pick this up a week earlier we could have prevented the acute admission to the hospital. It dawned on some of us that home is where the exam room has to be.” Sanders emphasizes that providing convenience and access is only part of the benefit to having patients remain in their own setting. For examinations, “the doctor’s exam room is often the wrong place,” he says. “Taking the person’s blood pressure at home where 6  |  C alifornia H ealth C are F oundation they live and at the office where they work is a better way to assess their BP throughout the day than my taking it in my office where a patient can have ‘white coat syndrome’ (a higher-than-usual reading caused by the stress of being in the doctor’s office).” Sanders is convinced that medical care must migrate away from episodic or periodic evaluations to continuous evaluation—the “same way our car’s dashboard continually reminds us about the engine operation.” Patients are typically more likely than their doctors to embrace telehealth programs, according to Sanders. “While the technology has evolved from boxes that we had to build, to equipment that is now available in every Best Buy and Circuit City store, we haven’t been able to effectively address the resistance to change in a lot of physicians’ minds.” Sanders acknowledges that technology cannot substitute for all health care delivery. Nevertheless, he says, “Telehealth does help us deal with the access challenges that currently exist.” Right Here Right Now: Ten Telehealth Pioneers Make It Work  |  7 2.A Norman Rockwell Kind of Doctor, v2.0 Sal Volpe, M.D., Staten Island, NY Health services: Dr. Volpe is board certified in pediatrics, Remote physician visits; internal medicine, and geriatrics. He describes himself as a Norman electronic medical records Rockwell kind of doctor. “Patients in our practice feel like they’re access; continuing medical on the set of Cheers,” Volpe says. “Everybody knows your name.” education; e-prescribing; His practice prides itself on treating patients like family, and part of and alerts. what makes that possible is an array of technology that is essentially Technologies used: invisible to patients. Personal digital assistants (PDAs); smartphones. Volpe has been at the forefront of the wired physician practice since he first researched practice management systems for his office in the Lessons learned: late 1980s. His only alternative in those days was a UNIX-based The mobile phone can system—which he found to be “rock solid,” he recalls. be a powerful tool for He later moved to Hewlett-Packard handheld PDAs with physicians and consumers QWERTY keyboards, which he used initially for billing when in health care. he made hospital rounds in the early 1990s. “You didn’t have to walk around with index cards to track your visits,” he explains. Volpe was an early adopter of e-prescribing on PDAs. As he followed the trends in information technology and health care, he recognized that cellular phones were becoming more sophisticated. “It was only a matter of time before you could get a Palm-based Centrino for $100 or less, and now for just a little more you can “Once you’re used get phones running pretty good operating systems like Windows to using a tool 6.1. The Nirvana these days is the iPhone, which is running a version of the Apple computer operating system on a handheld you will want to use and is incredibly powerful.” it for the rest of your life.” Telehealth applications have been rapidly growing in number and variety since 2006. Thomson Research estimates that almost a third of physicians had adopted smartphones in practice in 2008. TDG, a market research firm, forecasts that 70 percent of active physicians will wield Internet-enabled smartphones by 2011. After switching to a smartphone for e-prescribing, Volpe loaded in diagnostic software including Harrison’s Practice. Today he owns a Windows-based Samsung handheld smart device. “Now I can look up anything I want,” he says. “I’ve got Epocrates and other e-textbooks.” He expects before long to be able to view his appointment schedule and phone messages received at the office. But his goal is to access a complete set of EHR functions. 8  |  C alifornia H ealth C are F oundation “You’ll be able to look into the continuity of care they may correctly say no,” Volpe continues. That’s record and, if you want, to do (virtual patient) visits because the doctor didn’t ask specifically if the with the handheld.” In fact, Volpe is working closely patient was taking any supplements. Furthermore, with the New York City Department of Health to the physician may not in fact know that St. Johns help the agency deploy EHRs throughout the five wort can work as an anti-platelet agent. metropolitan boroughs. The problem of screen size on handhelds, which Saving Time and Improving Care has been a barrier to physician acceptance, is Bringing the phone into the exam room with a being addressed with the newer phone designs and patient can actually enhance the value of the inter- software, notes Volpe. “With Opera 8.65, or the action, Volpe says. He sees patients every 12 to 16 Safari browser that runs on the iPhone, you can minutes. If an issue arises during the patient exam zoom in on sections of the screen. It’s not as sexy as that he wants to research, he can avoid the three- a 21-inch screen, but you can get a lot done on a minute walk to his office and the additional three handheld device.” Such productivity improvements or so minutes to look up the research—which will attract more physicians to use the instruments, would eat up 50 percent of the exam time. “With he predicts. my handheld and hypertext, I can link into the Skyscape Suite or Epocrates. If I look up asthma Younger physicians are naturally embracing hand- and recommend albuterol, I can then click on helds for health care, Volpe notes. They have albuterol and read the pharmacy description of the generally experienced game systems such as medication. Then I can check and see if it interacts Nintendo and Playstation, and “they’re very familiar with the patient’s beta blockers. You’re leaping in with the idea of navigating a screen by hitting fractions of a second from one reference section to certain control buttons.” Today’s students at medical another. You can do a lot for a patient in a short schools have been given PDAs in their third and amount of time.” fourth years, as have residents in training. Phones, however, aren’t yet viable as telehealth tools for Doctors can, in fact, earn CME credit at the same all doctors, Volpe notes. “As we get older, we get time. For example, ReachMD offers credit via presbyopia. So it’s hard to look at a small screen, the Apple iPhone or the iTouch. As of late 2008, even with bifocals.” there were CME courses covering a broad range of conditions, such as bipolar depression, colorectal Cornerstone of Patient-Centered Care cancer, and functional bowel disorders. Consumers, too, are adopting self-care applications on phones. Blackberry devices have offered a long Volpe believes the most important function of the list of health tools since 2006, including Epocrates’ handheld is enabling drug-drug interaction checks. drug reference software, Skyscape’s medical text- “We should not trust our memories; there are way books, and Thomson Healthcare’s medical software too many drugs prescribed,” he warns. There is even, titles. The advent of Apple’s iPhone has significantly he adds, a version of Epocrates that incorporates expanded the marketplace for both physician- and herbal supplement interactions. If a patient is using consumer-facing health applications. St. Johns wort as a substitute for a selective serotonin reuptake inhibitor (SSRI), for example, it can affect In the future, Volpe predicts, the handheld/phone platelet function. “If a person is bleeding and you will be the cornerstone of patient-centered care ask them if they’re taking any other medicines, in the patient’s home and mobile health applications Right Here Right Now: Ten Telehealth Pioneers Make It Work  |  9 (“mHealth” in shorthand). The two market drivers for this will be adequate reimbursement for these services and broad penetration of 3G phone standards. Advanced phones will enable two-way interactions between patients and doctors, each of whom will have a handheld device with camera. The doctor and patient can talk and video- conference, and the patient can zoom in with the camera on a skin rash or other visible symptom. In the meantime, Volpe foresees an accelerating adoption of phones in clinical practice. “Once you’re used to using a tool,” he says, “you will want to use it for the rest of your life. I now have one device I use as an email checker, cell phone, drug reference tool, entertainment console, and for loading audio books.” In his spare time he uses his cell phone to catch up on what his kids have been reading. You could say he is a Norman Rockwell kind of doctor, v2.0. 10  |  C alifornia H ealth C are F oundation 3. “Connected Health” Sees the Whole Person Joseph Kvedar, M.D., Center for Connected Health Health services: Joseph Kvedar, M.D., wanted to know if Remote physician visits; telecommunications could enhance care for skin disease patients, home-based care. so he initiated research to evaluate the potential of teledermatology. The study called for patients’ skin problems to be photographed Technologies used: Internet; telephone and stored in a database so that clinicians could access and (wired and mobile); text examine them from another location. The technology for the messaging; cameras. study consisted of a one-megapixel camera that, 14 years ago, cost $12,000, Kvedar recalls. Compared to today’s technology, he says, Lessons learned: “it wasn’t as good as a camera phone.” Not only did the images Remote clinician-patient prove to be a good substitute for an in-person dermatologic exam, consultations can result Kvedar concluded, but there was another, unexpected outcome: in optimal, and often A physician was easily able to review 37 cases in only three hours. improved, health outcomes. Connected health can The researchers “discovered an efficiency here,” Kvedar says. “And expand access and it dawned on me that, for some conditions and procedures, if improve efficiencies in care delivery. we separated the doctor and the patient we could actually improve the quality of care as well.” But when he made that argument to the physician community, “people kicked us out of the room,” he quips. Nevertheless, “we believed that we could eliminate some of the bottlenecks inherent in our health care system as it is designed now, in which the clinician drives all health care trans- actions. We are proposing a fundamental change in concept: The patient doesn’t have to come into the office for every blood pressure check.” “For some conditions and procedures, if we Kvedar bases his concept of redesign on what he calls “connected health.” It is focused on a three-part value proposition: expanding separated the doctor and access, raising quality, and enhancing efficiency. Since 1994 Kvedar the patient we could has tested and grown his ideas at the Center for Connected Health, actually improve the a division of Partners HealthCare, the integrated system founded quality of care.” by Brigham and Women’s Hospital and Massachusetts General Hospital. The Center (then known as Partners Telemedicine) established a program with the two hospitals to provide second opinions to patients and physicians anywhere in the world. At the time, there was a growing capacity challenge in the health care industry, which pointed toward the usefulness of monitoring and messaging technologies to improve case management and extend the same provider workforce across more patients. In Right Here Right Now: Ten Telehealth Pioneers Make It Work   |  11 particular, it was important to better manage chronic is no point in giving someone a technology that illnesses like hypertension and diabetes. Kvedar and he or she is going to completely ignore.” his team saw a significant opportunity to apply the strategies being developed by the Center to this The Center has launched several programs in the problem. By extending better care into the patient’s Partners network, as well as one with a large home and conserving hospital resources for the Massachusetts firm to help employees manage most acute and complex cases, the Center could hypertension. Numerous research programs are advance the three-part access-quality-efficiency value always under way. Kvedar and his colleagues are proposition. highly encouraged by the number of patients who sign up for programs, but concerned about those Two Synergistic Principles who do not. “The patients who are not enrolling Kvedar says that better management of patient for connected-health programs may be the ones populations is dependent on using two synergistic who need it the most,” he worries. “How do we principles: attract people to a connected-health solution? We are pretty good for patients who can use a Web browser 1. ollecting physiologic information about a patient C and have an Internet connection.” To address the over time keeps everyone honest, empowering the challenge of engaging more reluctant adopters, patient and clinician to make better decisions; and the Center is continuing to develop mobile phone 2. oaching, augmented by clear, objective, measur- C modules. able data, can create behavior change over time. Kvedar is hopeful about the role that connected- The Center has applied these connected-health health strategies can play in managing chronic principles in a broad range of clinical areas disease and promoting access, efficiency, and quality. including hypertension, diabetes, heart failure, He warns, however, that the path to success will weight management, and medication adherence. likely not involve new reimbursement codes for Kvedar’s team has learned a great deal about how distinct monitoring services. The important thing, patients respond to different clinical prompts, health he says, is re-engineering health care delivery in a information, and resources. For example, a recent way that takes the whole person into account— study evaluated the role of a personal text message as home life and technology preferences, personal a daily reminder to use sunscreen. The findings values, and motivations. were remarkable. At baseline, participants were only 60-percent adherent to their sunscreen regimen; despite daily reminders, the adherence rate never exceeded 60 percent. “This tells us that some people are just not respon- sive to reminders,” concludes Kvedar. However, he adds, after a period of six weeks, those who received no reminders showed adherence of only about 20 percent. Those in the group who were reminded achieved a persistent 60-percent compliance rate. “This indicates that 40 percent of folks are very responsive to simple reminders,” says Kvedar. “The study gives an early glimpse into how we will need to segment our consumer/patient populations…There 12  |  C alifornia H ealth C are F oundation 4. inning Over Employers, Patients, W and Providers CIGNA and RelayHealth Health services: CIGNA was an early adopter of online virtual Remote physician visits. house calls as part of what it terms a “convenience care strategy.” Explains Joe Mondy, assistant vice president of IT commun- Technologies used: ications, “The member is going to receive an additional level of Internet access. convenience. She doesn’t have to wait in line for an appointment Lessons learned: or leave work to see the doctor.” CIGNA was among the first Consumers don’t have health plans in the country to reimburse physicians for remote to be “tech-savvy” to consultations. adopt virtual visits. Provider resistance can The online visits are powered by RelayHealth, a unit of McKesson, be overcome through a secure Web-based messaging service. To engage in by proving ROI. online consultations with their physicians, plan members log on to a password-protected Web site and answer a series of questions about their illness and medical history. The doctor then responds online. If the physician thinks it advisable, an office follow-up visit is scheduled. Before signing on with RelayHealth, CIGNA vetted the technology application with its own doctors to make certain only clinically appropriate cases were being treated online. “Many enrollees with lower educational “This isn’t an email system into which you can write free-text,” attainment have had notes James O’Brien, CIGNA’s director of product development. just as good pick-up RelayHealth incorporates an algorithm that provides a kind of triage: If patients report symptoms that are inappropriate for of the program.” the online consult (i.e., a higher than routine level of acuity or urgency), they are routed to their physician for a face-to-face appointment or, in emergencies, told to call 911. Cost-effective Care For employers, a positive return on investment is emerging, according to O’Brien. The $25 virtual visit is considerably cheaper than a typical office visit, and there are economies through increased productivity as well. He says the service “is more cost-effective and more cost-transparent” than conventional visits. Right Here Right Now: Ten Telehealth Pioneers Make It Work   |  13 Patient acceptance is not automatic, cautions efficiency-enhancing applications, including O’Brien. However, CIGNA found through e-prescribing and refilling, e-delivery of lab test consumer research that once an enrollee gets over the results, and appointment scheduling and referrals. initial hump—unease in interacting with a physician online—there is a high percentage of repeat “The biggest learning we’ve had goes directly to utilization. In fact, O’Brien reports, “people get the network effect issue,” observes O’Brien. CIGNA comfortable quickly.” To win over patients, CIGNA expanded its four-state pilot (Arizona, California, emphasizes the convenience of refilling prescriptions Florida, and the Tri-State/New York region) online. “Once tried, this channel for pursuing health nationwide in order to make the service more care is very effective and clinically appropriate; compelling to large-employer customers. As these furthermore, it meets the needs of today’s busy subscribers recognize the value, more of their workforce,” he adds. members will be given access to the service and therefore more physicians are expected to sign up. CIGNA hypothesized, when it piloted the service “This in turn will make the service more valuable to in California, that the earliest users would be employers,” says O’Brien. “It will create a ‘virtuous highly educated and technologically sophisticated cycle’ for e-visits.” workforces, but over time it has found that “many enrollees with lower educational attainment have had just as good pick-up of the program,” says Mondy. The bulk of patient symptoms that prompt calls into the system are associated with low-acuity diagnoses, reports O’Brien. Primary care issues predominate, and pediatricians have been among the earliest adopters of the service. But specialists are also attracted by the ease of scheduling and e-prescribing. A “Virtuous Cycle” The lack of assured reimbursement, which has been a key barrier to the growth of virtual physician consults, has eased somewhat with the American Medical Association’s adoption of a CPT-4 code to legitimize payment for remote interactions. CIGNA emphasizes to physicians that not only will they be reimbursed for an e-visit, but they will also benefit from the fact that the service reduces staff time on the telephone. The average cost to sign on to RelayHealth is approximately $100 a month for a physician practice. CIGNA reimburses $25 per e-visit. Therefore, if a physician handles at least four visits a month, the entire cost of the service is recovered. In addition to Web consultations, participating doctors enjoy a broad suite of 14  |  C alifornia H ealth C are F oundation 5. Telepresence Throughout Scotland Cisco HealthPresence Health services: Many countries are struggling with a growing Extending clinician expertise imbalance between the demand for health care services and a to remote areas. physician workforce—particularly specialists—who are unevenly distributed geographically. The aging of the population exacerbates Technologies used: The Internet; IP-enabled the problem. medical devices. Scotland faces an especially daunting challenge bringing Lessons learned: high-quality, affordable health services to the one in five Scots Networking technology who live in remote rural areas or on islands. In January 2008, the can help scale health Scottish Centre for Telehealth and the National Health Service services to patient and launched the world’s first trial of Cisco HealthPresence, a telehealth clinical demand. Nodes of delivery system. It was developed by the Cisco Internet Business care should be located Solutions Group (IBSG), the firm’s global strategic consulting arm. where the patients are: The system combines video, audio, and medical information to shopping malls, create schools, workplaces. a virtual face-to-face experience for patients and caregivers who may be hundreds of miles apart. The system “allows you to distribute the expertise,” explains Nick Augustinos, global health care solutions director for Cisco IBSG. “You can expand the reach of specialists into remote communities.” The program is based on the company’s TelePresence platform, which was released in October 2006. Because the The technology transmits life-size, high-definition images and encounter “feels” live, audio. Augustinos says the result “is as immersive as an in-person meeting.” Because the encounter “feels” live, he adds, it it is particularly is particularly appropriate for health care delivery. appropriate for health care delivery. Here Come the Pods The trial, which will assess clinical efficacy as well as patient and caregiver satisfaction, is taking place at Aberdeen Royal Infirmary. There physicians are using the Cisco technology to monitor vital signs such as blood pressure, temperature, pulse rate, and pulse oximetry. They are also examining images from scopes that can be focused on a patient’s ear or throat by an attendant working with Right Here Right Now: Ten Telehealth Pioneers Make It Work   |  15 the patient in a HealthPresence “Pod.” The Pods can be configured in a variety of ways—for example, as a fully self-contained structure that offers privacy, or as a panel that incorporates an array of medical devices and can be placed in an existing room. Pods can be located in a wide range of settings, including public spaces such as shopping malls or libraries. Cisco is also developing new workflow processes and a business model that can scale. “We believe fundamentally that the health system does not scale fast enough or in a way that is fiscally viable,” say Augustinos. “We have to be smarter in how we scale to meet demand. Financial considerations and technology allow us to challenge [conventional] health care delivery models as the world is becoming flat.” The ultimate goal, says Augustinos, is to bring Cisco HealthPresence into the home. “Then,” he says, “home will become an integral part of the continuum of care.” 16  |  C alifornia H ealth C are F oundation 6. econd Opinions—From Cleveland to S 60 Countries eCleveland Clinic’s MyConsult Health services: Since its founding in 1921, the Cleveland Second opinions from clinical Clinic has been known for the expertise of its multispecialty group experts; remote consulting practice. In the mid-1990s, C. Martin Harris, M.D., chief infor- direct-to-consumer for nutrition mation officer, began talking with his colleagues about ways and other services. to make that expertise more widely available through telecom- Technologies used: munications. Harris outlined a series of HIT solutions he believed The Internet; telephone; could provide a number of benefits: improve patient care, enhance electronic health records; operational efficiency, reach out to community physicians, create Picture Archival Communications new knowledge, and provide people with many of the tools they Systems (PACS). need to manage their own health. The result was the creation of eCleveland Clinic, which was facilitated by an organization-wide Lessons learned: transition from a paper-based to a digital medical record system. Physicians can effectively cooperate when operating Harris and his staff recognized that people were constantly faxing between community and emailing the Clinic for advice—in particular for second and consulting institutions. Patients and caregivers opinions concerning serious illness. Of approximately 6,000 can feel comfortable possible diagnoses, notes Jonathan Schaffer, M.D., the questions providing personal health received concerned only about 5 percent of them. Nearly all information concerning of those fell into what he categorizes as “the life-threatening, life-threatening illnesses life-altering diagnosis set.” To respond to this demand, the Clinic over the Internet. developed a second-opinion service, MyConsult. The program makes the clinicians’ backup expertise available to citizens of 48 states (the exceptions are North Dakota and California) and more than 60 foreign countries. Schaffer, who also holds an M.B.A., serves as managing director. How It Works “We are the WD-40 MyConsult has a dedicated clinical operations team led by nurses with many years of experience in the most relevant clinical areas. of health care.We want to The nurses interface between Clinic physicians and the e-patients. take the squeaks out The service is straightforward for patients or their providers to of the system.” initiate. They register on the MyConsult Web site, complete the forms online, submit data based on the diagnostic checklist, and pay for the service (via their own credit card or their employer’s benefit plan). The MyConsult staff nurse reviews the submission and assures that the patient’s file is complete, then routes the case to the most appropriate consulting physician. Right Here Right Now: Ten Telehealth Pioneers Make It Work   |  17 The consultant’s opinion is published to a secure Collegiality is, in fact, a hallmark of the Cleveland portion of the Web site that the patient can access. Clinic, which may give the organization a competi- In 48 hours the nurse on the case contacts the tive edge in providing second-opinion services. patient to see if there are any additional questions to All of the 1,800 doctors in the multispecialty group refer to the consulting physician. Once those have practice are salaried. “We all have annual professional been resolved, a hard copy of the patient’s report is reviews and those determine our compensation sent to the patient and the responding physician(s). for the year,” explains Schaffer. “That’s our key to The consult is recorded in the Cleveland Clinic success. If I call up somebody in infectious disease electronic medical record system and all digital to discuss a patient with total joint problems, and if images are stored in the Clinic’s PACS. I phone someone in vascular medicine as well, the three of us work together seamlessly. The cost is reasonable, Schaffer notes, especially since the average airfare into Cleveland is $650, “We are the WD-40 of health care,” he says. while an e-consult costs $565. “It’s a no-brainer,” “We want to take the squeaks out of the system.” he says. If an e-patient ultimately decides to visit the Clinic, he adds, there’s a further payoff in that all the information about the case has already been registered in the Clinic’s electronic medical record system. Collegiality Pays Off The MyConsult second opinions differ from the first opinions about two-thirds of the time, according to Schaffer. Sometimes it is the diagnosis that is deemed incorrect. In other cases the Clinic physician believes there are insufficient data to support a definitive diagnosis. In such instances the Clinic physician contacts the patient’s community doctor to discuss the case. Almost invariably, says Schaffer, both physicians involved in these discussions have maintained a “very collegial” relationship. “We give them some specifics,” he explains. “It’s all based on data.” 18  |  C alifornia H ealth C are F oundation 7. Medical Education Without Walls Johns Hopkins Medicine Interactive Health services: Located in Baltimore, Maryland, Johns Continuing medical education; Hopkins School of Medicine and Hospital are not part of a remote consults and major integrated delivery system with scores of regional affiliates. grand rounds. Nevertheless their reach extends across the country and to places Technologies used: as distant as the Middle East, Asia, and Latin America. The Videoconferencing; the Internet. organization has built a network of affiliations through Johns Hopkins Medicine International, a subsidiary dedicated to Lessons learned: promoting knowledge exchange and clinical learning by linking Don’t assume broadband Johns Hopkins clinicians with others worldwide. According to is available everywhere yet— Director of Telehealth Alex Nason, telehealth activities going on but it can be found and used every day in many global markets are hosted in clinicians’ offices in the community-at-large, on the Baltimore campus. such as in cafés. Health care delivery and JHM International offers two main types of global telehealth knowledge transfer is education: the GlobalAccess Lecture Series, in which Hopkins globalizing. faculty deliver live lectures on a health topic; and Colleague Information Exchange, where physicians based overseas engage in real time with Hopkins clinicians to discuss patient cases, research, and treatment options. These global telehealth relationships have grown organically, physician-by-physician, says Nason. Hopkins clinicians who want to reach out internationally often travel to an overseas provider “I try to get people site as a first step. They establish local relationships and then, after to stop thinking about their returning to Baltimore, rely on telehealth solutions to enhance and reinforce that collegial link. The Hopkins physician might walls and start thinking make subsequent annual site visits to work with local physicians about their community.” and engage in educational colloquies. The telehealth programs are “what happens in between the visits,” Nason observes. In addition to live remote patient consultations, international telehealth activities include transmitting grand rounds in various departments and telecasting lectures on a broad range of clinical topics. JHM International undertakes more than 250 video events a year at hospitals around the world. Live video- conferencing has taken many forms. In one example, a Hopkins oncologist established a virtual tumor board with an oncology program in the United Arab Emirates. Such liaisons enrich case discussions on behalf of patients. Right Here Right Now: Ten Telehealth Pioneers Make It Work   |  19 The Bandwidth Barrier One of the key barriers to service is inadequate bandwidth for high-speed audio and video applications in many parts of the world. Half of videoconferences require ISDN lines that many local environments lack. Limited by constraints on the receiving end, Hopkins’s telehealth solutions often embody fairly simply technology. “If you look at the local environment,” says Nason, “you can deliver services and not make a massive investment.” In one scenario, an overseas provider who lacks the necessary bandwidth on campus might rent out a nearby Internet café with broadband access in order to host a Johns Hopkins education session. “I try to get people to stop thinking about their walls and start thinking about their community,” Nason says. As a complement to its global medical education effort, JHM International manages hospitals in the United Arab Emirates and has affiliations in Chile, Istanbul, Lebanon, and Panama. It is now working with the health service of the Republic of Trinidad and Tobago to expand that country’s infrastructure capacity for care delivery and medical education. And, back home in Baltimore, the Johns Hopkins Hospital welcomes patients from more than 100 countries annually. 20  |  C alifornia H ealth C are F oundation 8. Meet a Nighthawk Lawrence Sanders, M.D. Health services: Nighthawk Radiology Services started up in 2001 Teleradiology coverage on a to fill the void for hospitals lacking 24/7 radiologist coverage. 24/7 basis. It provides off-site teleradiology, which includes both nighttime emergency department coverage and daytime subspecialty radiology Technologies used: The Internet and broadband. coverage. The company employs American-trained radiologists who are all board-certified by the American Board of Radiology. Lessons learned: Round-the-clock teleradiology As of 2008, almost one in four U.S. hospitals employs the service, services can be cost-effective as do 700 radiology groups through a distributed network of image and can provide access readers in the U.S., Australia, and Switzerland. Radiologists in the in underserved areas. latter two time zones can work during daytime hours to provide The only barrier to national nighttime coverage in the U.S. coverage is licensure. Larry Sanders is a Nighthawk radiologist specializing in body MRI and cardiac MRI. After three years as what he calls “a traditional radiologist,” Sanders left his practice in Hollywood, Florida, to join Coeur d’Alene, Idaho-based Nighthawk in 2006. He is now credentialed at 800 hospitals across the U.S. and is licensed in nearly all of the 50 states. To help with the licensure requirements for each state, Nighthawk has a large, dedicated internal staff “Radiologists, like most that facilitates applications for the company’s doctors. In addition to obtaining a license for every state from which a doctor receives physicians, want better images, he or she must go through the hospital credentialing lifestyles. We don’t want to process for each institution for which they will consult. be awake at night.” Five Evolutionary Stages In the last 25 years, telehealth has changed the work of radiologists. In a 2008 article in the journal Radiology, William Bradley, M.D., Ph.D., described the early 1980s as the “wake up and drive to the hospital” era for off-site radiologists.1 Each nighttime call from the emergency department resulted in at least two hours of lost sleep for the on-call radiologist. By the mid-1980s, continued Bradley, radiologists entered the “wake up and read from home” phase. They could look at transmitted images on a video unit in their homes, but they were still roused from their beds. Stage 3 involved a “stay up at night and cover ED radiology cases internally” scenario. One radiologist Right Here Right Now: Ten Telehealth Pioneers Make It Work   |  21 representing a group would remain on duty in a Two factors will expand the opportunity for hospital overnight to read images referred there from outsourced radiology: readily available technology a group of institutions. This was done via expensive and a limited labor supply. The technology to enable T1 lines to the “mothership” institution where the radiologists to work from home is fairly ubiquitous; radiologist was headquartered. This process was most American homes have reasonably priced access the model in the mid-1990s. Stage 4 on Bradley’s to broadband cable and/or telecommunications timeline was the era of “outsource nighttime lines. At the same time, the demand is large. coverage to another U.S.-based group working at Hospital emergency departments—even in remote night.” And this led logically to stage 5— “outsource areas—must have 24-hour coverage, and the number nighttime U.S. coverage to a group working offshore of specialty-trained radiologists is limited. More (where it is daytime).” radiology companies are expected to move into this space to serve a marketplace where professionals This is the stage that has made Nighthawk’s business will be in short supply—and where those who are model viable. And although the company began in the current supply are eager for a better work-life operations by targeting the niche of overnight balance. radiology coverage, today its doctors study images around the clock. Nighthawk has competition. According to the Radiological Society of North America, there are at least 41 teleradiology companies that provide nighttime coverage, daytime coverage, subspecialty coverage, or all of them. More than half of U.S. hospitals rely on an outsourced nighttime service. Regaining Work-Life Balance “I’m a much better radiologist than I was before, because of this model,” Sanders says. “I spend less of my time commuting. There’s flexibility built into the schedule I keep. I submit what days and times I want to work. I have a lot more opportunity now to structure time and schedule so I can keep up on my radiology training. When I worked six days a week at my previous job, I had no time to keep up and stay current and broad-based. “Radiologists, like most physicians, want better lifestyles,” he adds. “We don’t want to be awake at night. All of us want to spend more time with our families.” 22  |  C alifornia H ealth C are F oundation 9. The Doctor Will See You Now Roy Schoenberg, M.D., American Well Health services: Drs. Roy and Ido Schoenberg started a Virtual physician-patient comprehensive, Web-based “personal health management” consultations. company called CareKey in 2001, when personal health records (PHRs) were in their infancy. Five years later, they founded Technologies used: The Internet and Web browser; American Well, again pioneering in a largely unexplored market a Web camera if available niche—this one focused on physician visits online. and desired; a telephone if the Internet is not accessible; American Well bills itself as the Online Healthcare Market- software accessed from place™. It offers a platform from which consumers can launch a American Well online. visit to a physician remotely, pay for the visit with a credit card (if self-paying) or through a health plan, and interact with a doctor Lessons learned: of their choice by voice, Web camera, or telephone. The traditional barriers to physician acceptance of “It is as simple as watching a YouTube video,” American Well telemedicine—medical advertises. liability and the cost and availability of technology— can be overcome. The first commercial application of American Well was in Hawaii, under the auspices of the Hawaii Medical Service Association (HMSA) of Blue Cross/Blue Shield of Hawaii. The state’s population is scattered across eight islands. While Oahu has significant population density (1,650 people per square mile), the state’s average overall density is just 187 people per square mile—among the lowest in the nation. HMSA will deploy American Well to serve enrollees in the sponsoring plan as well as all Hawaiians without health coverage. “We have the scars from the PHR industry, so we A Disruptive Force know that you need to When American Well’s Online Health Marketplace began operation in June 2008, it stirred a flurry of media attention. deliver actions, not just a Stories appeared in major news outlets including The Wall Street remote hard drive to Journal, MSNBC, USA Today, and a host of technology and health put some stuff in.” industry media. Observers within and outside of the health care field saw the concept as a disruptive force. With its founders’ roots in the development of personal health records, American Well sees the patient visit as an information-rich encounter; diagnostic and clinical information must be recorded to enable good follow-up and care management. Thus, the company is collaborating with Microsoft’s HealthVault to integrate patient Right Here Right Now: Ten Telehealth Pioneers Make It Work   |  23 data generated through Online Health Marketplace Automatic inclusion of all plan physicians also visits into HealthVault’s PHR repository. Patients can lowered the barrier to physician adoption. access this confidential information at a later date “We have allowed physicians to step in at their and provide it to their physician during a subsequent own pace, to do as much consulting online as they in-person visit—or the American Well physician like,” says Schoenberg. “If they do one transaction, can access the data from within the platform. their fee for the visit appears in their bank account. The insurance and claim management system is “When you are interacting with the physician seamlessly, transparently built into American Well.” inside the American Well system,” Schoenberg Physicians can try out the system; if they like using explains, “your PHR information is presenting it, they can do more. This option could be attractive along with you.” Schoenberg recalls from his work for physicians at different points in their careers, with CareKey, which did not include the capability says Schoenberg. to do a transaction between the patient record and the physician’s, “We have the scars from the PHR The problem of medical liability is also mitigated industry, so we know that you need to deliver by a creative plan developed with AIG, the global actions, not just a remote hard drive to put some insurance company. The cost of malpractice stuff in.” insurance is folded into the reimbursement for each online visit. Assembling a Physician Network An early question for American Well was how to Future Directions build a physician network that consumers could To understand how online care will impact health access. The company considered enrolling patients plans, American Well has been working with the within a certain geographical area and pre-enrolling actuarial company Milliman, which has a long physicians in that market. Then questions arose history of developing clinical care guidelines for about how to assure that participating physicians are health plans. Milliman has been studying the sufficiently trained and comfortable with technology. domains in health care that lend themselves to online care. A patient with acute chest pain, for example, The company has been working with health plans should immediately go to an emergency room— to solve these issues. In the case of HMSA, all whereas a person with peptic discomfort, headache, physicians who are in the plan’s network are eligible or a chronic condition may be a good candidate to participate on the American Well platform. for online care. Milliman assisted American Well in Enrollees can therefore access physicians in existing sorting out the applicability of online care, as well provider networks. As Schoenberg explains, as quantifying its fiscal impact on a health plan’s “This brings it back in parallel with the online con- bottom line. sumer tools of Health 2.0. You can browse a book in a Barnes and Noble store, and then you can buy Schoenberg says the future growth of the company the same book on Amazon. This was one of our could move in several directions. Initially, online ‘aha!’ moments.” physician visits were expected to be best suited to the relatively technology-savvy patient, perhaps a busy professional parent with young children. Paradoxically, Schoenberg says he has learned from conversations with companies and policymakers that the American Well model could positively impact, 24  |  C alifornia H ealth C are F oundation among others, enrollees in Medicare and Medicaid plans as well. Since the Medicaid population is a significant user of crowded emergency departments, the American Well platform could, for example, provide a lower-cost and more accessible health care gateway for these enrollees. “What we will find is that there are some unpre- dicted areas in health care where online care will play a role,” Schoenberg says. Specifically, he believes the platform could serve as a bridge toward universal health access. “What we are humbly doing through technology is opening up the notion of getting health care for the nominal cost of one transaction,” he explains. “A person without health insurance can go on to the system through the public site of a health plan that offers online care, and with an ATM card, can get in front of a credentialed, live physician.” With online care technology, Schoenberg says, “we have opened up access to the health system to those who have none.” Right Here Right Now: Ten Telehealth Pioneers Make It Work  |  25 10. Expert Stroke Care, Anywhere REACH Call, Inc. Health services: Stroke ranks third as a cause of death in the Telemedicine for stroke. United States, after heart disease and cancer. Americans suffer some 780,000 new and recurrent strokes each year, and more than Technologies used: 150,000 die. Personal computer; Internet connection; software intelligence built The American Heart Association/American Stroke Association into an ASP model. (AHA/ASA) created the “Get With the Guidelines” program, which publishes performance indicators for health care providers. Lessons learned: A key indicator for preventing deaths is the administration of tissue Providing specialty health plasminogen activator (tPA) to patients diagnosed with an ischemic care services to even stroke within three hours of the onset of symptoms. However, the remotest area is possible only a fraction of Americans for whom it is appropriate receive via generic, off-the-shelf tPA within that timeframe. (Close to 90 percent of strokes are hardware and an ischemic—characterized by a clogged vessel.) Internet connection. David Hess, M.D., of the Medical College of Georgia (MCG) in Augusta, is only too familiar with this situation. The state has one of the highest rates of stroke in the country—46th out of 50.2 Professor and chairman of neurology at MCG, he and his colleagues had long observed that in too many instances rural hospitals in Georgia are unable to provide stroke care quickly enough in their EDs because there is no neurologist on staff. Many “Dr. Hess drove into a of these stroke patients are transferred to MCG for treatment— Taco Bell, opened up often too late to benefit from tPA. the wi-fi connection, and Telemedicine off the Shelf treated a stroke victim To respond to this critical problem, MCG launched what it calls who’d been admitted to a its “REACH” system in 2003. This 100-percent Web-based small rural hospital in protocol uses generic, off-the-shelf hardware to enable a neurologist and a community- or rural hospital-based physician to engage in East Georgia.” an online consultation. All that is required of the nonspecialist is a personal computer, a mouse, and an Internet connection. The software-based intelligence is built into the Web server through which the clinicians connect. The REACH tagline, appropriately, is “Stroke Care Anywhere™.” In 2006, the system became commercially available through REACH Call, Inc. By August 2008, the program had facilitated more than 900 stroke telemedicine consults—saving an estimated 26  |  C alifornia H ealth C are F oundation 200 lives. Operational in seven states, REACH documentation on-demand in real time immediately has demonstrated onset-of-treatment times that after the encounter is over.” The consultation can are among the fastest nationwide. Hess and his be coded as a 99244 CPT code or higher, the same team have published this research in peer-reviewed as a conventional emergency department consult. journals such as Stroke and Lancet Neurology. “It is the same coding as if the patient were physically present,” he emphasizes. The REACH approach addresses several of the hurdles that have hampered adoption of telemedicine Once Medicare reimburses for a clinical service there applications. First, the cost of hardware acquisition is typically a domino effect, with commercial payers and maintenance is low because the turnkey quickly following suit. In a growing number of states service is driven by the PCs that health providers Medicaid programs now cover telemedical consults. already own. As an application services provider However, Agate warns, “we still have a long way to (ASP), REACH Call has made the investment in go with respect to telemedicine reimbursement.” hardware, data storage, and the Web-based tools and algorithms that power the system. Users pay The short supply of neurologists is driving the on a monthly basis; the fee is fixed regardless of the demand for REACH Call’s services, observes Agate. number of cases they submit. The need in rural areas is especially acute. He relates an incident that happened to Dr. Hess in When a health system signs up for the service, it one such area. designates a “hub” institution to provide neurology consulting services to “spoke” hospitals. Each “If you’ve ever been on the road to nowhere,” Agate spoke hospital has installed a REACH cart in its says, “it’s on Route 25 in rural Georgia, miles from emergency department equipped with a laptop, everywhere. One evening, Dr. Hess, who had his monitor, keyboard, mouse, and camera. The cart laptop in his car, drove into a Taco Bell, opened up is battery-powered and wireless-enabled. It can the wi-fi connection, and treated a stroke victim be located anywhere in the ED, but is mobile. who had been admitted to a small rural hospital in Physicians at spoke hospitals connect through the East Georgia. After the consultation, he continued cart’s laptop via a wireless communications link to a his trip. When he reached his destination, he logged neurologist at the hub institution when they need on to the system to check on how the patient was to initiate a consult. doing.” The system works well at the 10-bed Jenkins County While the stroke module has been REACH Call’s Hospital in rural Georgia, according to Sandeep flagship product, the company also offers a general Agate, CEO of REACH Call. “The patient in rural telemedicine consultation module and plans to add Georgia has access to the same level of care” as a treatment modules for cardiology, acute psychiatric patient at the 400-bed academic medical center in episodes, and other acute conditions. Augusta, says Agate. Recently the health service in Singapore called on No More Nowhere REACH Call. Stroke is the third leading cause of Reimbursement for telemedicine is a work in death there, too. progress. Medicare has reimbursed two-way radio and video consultations since May 2006, provided The world is flat. there is complete clinical documentation. “Because we’re a Web application,” notes Agate, “we produce Right Here Right Now: Ten Telehealth Pioneers Make It Work  |  27 Endnotes 1. ff-site Teleradiology: The Pros, Radiology, Volume 248, O Number 2, August 2008, pages 337-341. 2. eart Disease and Stroke Statistics 2008 Update, American H Heart Association. 28  |  C alifornia H ealth C are F oundation