Trends in Telehealth

Alex Gerwer
Principal Partner
AKN
The Big Picture
Changing Needs

1900-1950 Infectious Diseases

1950-2000 Episodic Care
2000-2050 Chronic Care

Partnership for Solutions

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Chronic disease is gaining increasing
global attention....
 The Impact of Chronic Disease
Chronic, disabling conditions cause
Eight out of ten older Americans are
major limitations in activity for more
living with the health challenges of one
than one of every 10 Americans, or 25
or more chronic diseases.
million people.
Source: http://www.cdc.gov/chronicdisease/resources/publications/AAG/aging.htm

People with chronic disease cost 3.5 times as much to serve compared to others, and
account for 80% of all hospital bed days and 96% of home care visits.
Source: Nobel J, Norman G. Emerging information management technologies and the future of disease management. Disease
Management. December 2003, 6(4): 219-231.
 9 Chronic Disease Megatrends

MAGNITUDE: We are just scratching the surface of chronic disease
challenges.

INTEGRATION: The 50 year tide is shifting toward integration, away
from specialization.

MEDICARE: While Medicare has endorsed the need for chronic
disease management, disappointing results from recent demo
projects make future direction unclear.

PROVIDERS: Care providers have woken up to DM opportunities and
threats; they are promoting the Chronic Care Model and the medical
home.

MAKE, ASSEMBLE, BUY? Fewer are buying as health management
becomes increasingly strategic.

TECHNOLOGY: DM in your home and your pocket.

BEHAVIOR CHANGE: DM is moving from a medical to a social model;
behavior change has become the Holy Grail.

CLINICAL AND ECONOMIC ROI: Round one is over, DM wins; Round 2
has just begun.

WILDCARDS!
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 Technologies are Converging
CONSUMER TECH eHEALTH APPLICATIONS
Electronic Health Records (EHRs)
INFRASTRUCTURE Personal Health Records (PHRs)
Remote patient monitoring
Internet
Fitness/wellness/prevention
Smart houses
Self care support
Personal communications devices --
PDAs, cell phones, etc. Physician/patient secure messaging
Broadband -- cable, DSL, satellite Home telehealth/telecare
Digital cameras, video Decision support systems
Wireless -- 802.11, Bluetooth, RFID, etc. e-Prescribing
Voice recognition e-Disease Management
etc. e-Clinical Trials
Predictive modeling
Computerized Physician Order Entry
Quality evaluation web sites
Patient reminder systems
etc.
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 Focal Points for Convergence
Home Networks, Smart Phones, EHRs
CONSUMER eHEALTH

Home
Network
PHR/
Smart EHR
Phone

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Future Care Delivery Models Will Be Integrated Around
Patients’ Homes & Communities

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The Most Significant U.S. HAH Initiative
is at Johns Hopkins

9
 The $30 Billion Potential DM Market is
Barely Penetrated
Disease Management Market Penetration
(millions) CCIP Expansion
Healthplans and Self
CCIP Phase 1
Funded Employers
$40,000
$35,000 FEHBP Plans Start
$30,000 Adding DM
$25,000 Medicaid Market
$20,000 Opens with FL
$15,000
$10,000
$5,000
$0
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Available Market Industry Revenues
Source: Chris Selecky, President of DMAA and Chair, Lifemasters, 2005
Available Market based on Wachovia Capital Markets Formula
 Definition of Telehealth
• Telehealth can be considered the act of connecting
consumers to healthcare providers through the use of
a collection of technologies with the goal of meeting a
diversity of healthcare needs in a wide variety of
settings across a population, thereby improving access
to healthcare services within the community where it is
applied.
Telehealth vs Telemedicine

Source: Dena Puskin; HRSA

 Telehealth vs Telemedicine
“Telemedicine is the use of medical information
exchanged from one site to another via electronic
communications to support
• Medical diagnosis
• Ongoing patient care
• Remote patient monitoring

“Telehealth” encompasses a broader definition of remote

healthcare that does not always involve clinical services
• Health-related distance learning
 Definition of Telemedicine
• Healthcare services provided at a distance
• Only the service moves, neither the patient
nor the health professional moves
• It involves secure transmission of medical data
and information, through text, sound, images
or other forms needed for the prevention,
diagnosis, treatment and follow-up of
patients.
• Wide variety of telemedicine services:
teleradiology, telepathology, teledermatology,
teleconsultation, telemonitoring, telesurgery
and teleophthalmology
Teleradiology to Home Monitoring
Years to mainstream adoption

Benefits
high

moderate

low

Source: Gartner, Hype Cycle for Telemedicine, 2008

(June 2008)
 Drivers for Telemedicine

Source: Triple Tree mHealth Report; Q1, 2010

“Techy” Consumers are Connected
“Techy” Consumers are Connected
 Clinicians Engage in Telemedicine
USAGE

Adoption and Awareness

Source: Triple Tree mHealth Report; Q1, 2010

Telemedicine: Unit Growth
Telemedicine: Revenue Growth
Strong Growth for mHealth
 The Home Telemedicine Model
ELDERLY CARE HEALTH TELEMONITORING
Goals: Goals:
• Feel secure, independent @ Home • Help patients with chronic illness to
• Stay active in society manage their disease(s)
• Quality of Life • Reduce the need for and cost of medical
• Better healthcare care (e.g. avoiding hospitalization or
Main requirements: emergency care)
• TV-centric solution • Real-time clinical feedback
• video call with doctor, family members, • Overcome mobility issues
friends, … Main requirements:
• Personalized diseases-based packages at
• home-assisted caregiver (e.g. video home (e.g. cardiac, asthma, diabetic,
call center) etc.)
• Video chat & infotainment • Video call with doctor/nurse
• personalized packages at home • Home assisted caregiver (e.g. video call
( e.g. cardiac, asthma, diabetic, center)
etc.) • Chronic diseases management (CDM)
• safety and security (e.g. tools
motion & gas sensors) Economization of
Stay longer health cost by
autonomously prevention &
at home follow-up of
diseases
 The Concept
– Mass deployment of home-based services for elderly and ill people
– Automatic capture and storage of vital signs at home & update of medical information with
patient-specific alerts
– Integrates broad-range of medical devices and home control & surveillance with End-user or
remote control capability
– Safety and secure online services
– Modular and simple line of products, non-invasive devices ready-to-use packs, able to be sold
on retail as packs and to be installed at home by the End-user him-/herself (or by e.g.
nurse/caregiver)
– Easy accessible medical records for doctors
– Videoconference on TV with doctor, nurses as well as loved ones
 Remote Patient Monitoring

Targets
•CHF
•Diabetes
•Hypertension
•COPD/Asthma
•Obesity
•Alzheimer’s disease
 Parameters Monitored at Home

Source: J. John W. Clark, et al.; Medical Instrumentation: Application and Design, 3rd ed., JG Webster , Ed.; J Wiley & Sons, New York, 1998
Home Monitoring Devices
Home Monitoring Devices
 Home Monitoring Devices

Source: Park Associates

 Health Peripheral & Home Devices
Example of Future Packages

Chronic Patient
cardiac, asthma, diabetic, ... Health Blood Weight
Home GW EGG Scale Spirometer
HUB Pressure

Family & Elderly Packs

General range for check-up +
Regular monitoring + Home GW Health Blood Weight Panic
online daily support on TV HUB Pressure Scale Button

Options
for any pack Video Surveillance
Set-top Box Surveillance Sensors PDA Cell phone
 Benefits of Telemedicine

Patients
– Timely access to locally unavailable services
– Improved triage when patient transfer required
– Improved quality of care
– Reduced readmission for same diagnosis
– Improved chronic disease management
– Spared burden and cost of unnecessary travel
 Benefits of Telemedicine

Health professionals
– Access to consultative services
– Each consultation is inherently educational
– Access to continuing medical education
– Reduces sense of isolation
 Benefits of Telemedicine
Rural communities
– >85% of patients remain in local community
– Care in the community (lower cost) environment
– Enhanced healthcare and local economic
development
Society
– Lower cost of care
– Improve outcomes
– “Green” technology
 Benefits of Telemedicine

Source: Triple Tree mHealth Report; Q1, 2010

 Challenges to Telemedicine
• Reimbursement/initial costs / funding (anti-Stark Law)
• Infrastructure / network costs
• Re-engineering practice / clinical acceptance
• Evaluating cost effectiveness / value added
• Financial sustainability
• Malpractice
• Licensure / credentialing / privileging / practice scope
• HIPAA / data privacy / security
• Interagency alignment related to policies / regulatory
• Integration with EMRs / health information exchange
• Over-abundance of information about telemedicine
• Health reform, ARRA
• Outcomes / best practices
 Challenges to Telehealth

Source: Triple Tree mHealth Report; Q1, 2010

 Does Telemedicine “Work?”
• Answer depends on clinical service, setting, and
implementation
• We believe that telemedicine:
• can improve access in rural communities
• can improve quality of care
• does not necessarily improve productivity (depends
upon the workflow design)
• has been shown to be cost-effective in closed
systems, such as the VA, Kaiser, and in limited small
studies of non-closed systems
Remote Monitoring and Telehealth

Source: Darkins A, et al. Care Coordination/Home Telehealth: The Systematic Implementation of Health
Informatics, Home Telehealth, and Disease Management to Support the Care of Veteran Patients with Chronic
Conditions, Telemedicine and e-Health. 2008, 14(10): 1118-1126
Remote Monitoring and Telehealth
• 10% of Medicare beneficiaries account for 66% of
Medicare costs

• VA Care Coordination and Home Telehealth

• 19% reduction in readmission for the same
diagnosis
• 25% reduction in length of hospital stay
Savings Due to Telemedicine
Consumer Willingness to Pay
 Business Overview
Payer
Pays for the health contracted
services to the The Provider on
behalf of End-user. I.e.
health insurances

Telecom/ The Provider

IT Provider
Provide
telecommunications
infrastructure for End-users,
Content Provider and 3rd
Party Service as well as
hosting the application
Integrates the health/care knowledge
platform
Operates the service on
technical and business level, i.e.
End-user
including the acquisition/partner- Consumer or patient at
ship of/with other players services home participating in the
and handling the commercial items care program paid by the
for the end-users. Payer. He/she uses the
services provided by The
Provider.
and technology modules for business
communication and community
services.

Content Provider/
3rd Party Service
Provide customized services for the
End-user on behalf of and under
supervision of
The Provider.
Application Overview
Conceptual Model: Base Features
The Provider’s services:
• Personal Health Record (PHR)
• Physiological database
• Chronic Disease Management (CDM)
• Other online services (web-based)

Health Link Care Plan

Health Link

API
• Physiological data
Clinical Portal • Security / Automation data
 Requirements
• Applications:
a) Remote Patient Monitoring
b) Browser-based applications
c) Video-call application
d) Customer Management System
e) Personal Alarm System (home security
& safety)
• Devices:
a) Health sensors (e.g. blood pressure,
weight scale, etc.)
b) Set-top box & home gateway
c) Home security devices (e.g. gas
sensor, surveillance cameras, etc.)
• Platform:
a) Multi-services platform allowing hybrid services, i.e. support of home- & network-centric
applications
b) Allow 3rd party service implementation/integration, e.g. where the service interface is
exposed as a remotely accessible interface
c) Infotainment & entertainment platform
The Telemedicine Market is Migrating...

• From
– High unit prices rooted in the industry's early focus on medical device markets
and business models
– Proprietary devices, proprietary IT, non-interoperable data
– Low unit volume, moderate margins per unit
– Competition based on vendor lock-in through high switching costs
• To:
– Low unit prices as the technology evolves toward consumer markets and
consumer business models
– Interoperable devices, common IT platforms, and interoperable data
– High unit volume, low margins per unit
– Competition based on value-adds and service

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Persistence Impacts Telemedicine
• Persistence refers to the
always on / always
connected nature of
networked devices
• Persistence creates new
opportunities for service-
based businesses
– Real-time data
– Add-on sales
– Software updates
– Device diagnostics
– Usage statistics
– Community
• Central to business model
 New Infrastructure: Telemedicine
• Telemedicine infrastructure would ideally provide:
• A standards-based home network gateway which serves as a
“wireless base station” for any in-home healthcare device
• Limited roaming charges for mobile networked devices to “stay
connected” anywhere in the world
• A platform that gives developers access to families of devices and
allows them to write applications that integrate with these devices
• A way to bill for services which allows all service providers to share
in revenues
• The evolution of this infrastructure is being driven by several different
forces
• A variety of companies are developing home gateways
• Several Mobile Network Operators are developing robust
development platforms to support networked devices and
associated services
• It is believed that individuals efforts will ultimately result in best
practices and standards
Sensor Interface Architecture
Functional Requirements:
Communications
• Allows system node to
connect with other external
nodes in support of:
– data communications
– person-to-person
communications
• Should accommodate a range
of devices and formats
• Should manage bandwidth
for other resources in system
node:
– separate details of what to
communicate from how to do
this
– support demand-driven
allocation of bandwidth
 Extending Hospital-Like Connectivity
Centralized
Applications
Key Requirements:
• Multiple applications & devices
- data, voice, video, medical device
- no user retraining
EMR • HIS • Voice
• Meets security requirements for
HIPAA compliance

• Non-technical staff installable

Distributed
Users • WAN & LAN transport
independent

• Can be remotely managed

Physicians • Clinics
 Remote Access Points

WAN LAN
Plug-Play Client Local Connectivity

Client Enterprise
VPN
PEF Secure
Wi-Fi
To Datacenters Distributed
Policy Enforcement Enterprise
Firewall Engine Secure
Wired
LAN/WAN/Internet

Access Forwarding Priority

Per User/Device/Session
Dynamic Policies via Controller
 Solution Architecture

Source: www.ibm.com/developerworks/websphere/techjournal/1001_hanis/1001_hanis.html
 Community Architecture

Source: Dena Puskin; HRSA

Consumers Want Single Source
mHealth Companies Look to MNOs
• Technology resources
• Device management and diagnosis
• Managed services
• One-stop global deployment
• Commercial resources
• Participate in the sales and marketing of services
• Finance sales with up-front subsidies
• Design connectivity fees to match the nature of the
particular offering
• Facilitation of systems
• Accommodate patient mobility
• Manage device and service diversity on a network level
Provider of Choice for Consumers
 Who Will Drive Adoption?

Source: Triple Tree mHealth Report; Q1, 2010

 Enhancing Telemedicine Adoption
 Eliminate the rural requirement under Medicare

 Fund remote monitoring and home telehealth

 Fund store and forward telehealth in lower 48

 Eliminate the credentialing barrier under Medicare

 Ensure Medicaid coverage across the states

 Ensure that any plan receiving federal dollars covers

telehealth
 Thank You

Alex Gerwer
asg_akn@yahoo.com
(562)726-4256
www.linkedin.com/pub/1/264/32b