A National Perspective on Technology

Garret SpargoDirector, Telehealth Technology Assessment Center

This ‘telephone’ has too many shortcomings to be seriously considered as a means of communication.

William Orton, 1876 …

President of Western Union …

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There is practically no chance communications space satellites will be used to provide better telephone, telegraph, television, or radio service inside the United States.

T.A.M. Craven, 1961 …

FCC Commissioner …

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There is no reason for any individual to have a computer in his home.

Ken Olsen, 1977 …

Founder, Digital Equipment Corporation …

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Cellular phones will absolutely not replace local wire systems.

Marty Cooper, 1981 …

‘Father’ of the Cellular Phone …

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There’s no chance that the iPhone is going to get any significant market share.

Steve Ballmer, 2007 …

Microsoft CEO …

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Overview

• What is TTAC?• A Telehealth Overview

• Some New Trends• The Same Old Problems

telehealthresourcecenters.org

• Links to all TRCs

• National Webinar Series

• Reimbursement, Marketing, and Training Tools

What Does TTAC Do?

17 Camera Bodies18 Light Configurations9 Evaluation Image SubjectsMultiple Lenses Per CameraMultiple Distances From Each Subject

~3500 Images

Telemedicine

Delivery of billable, interactive clinical services performed at a distance.“

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Telehealth

Telehealth is the use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration.

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• Hospitals & SpecialtiesSpecialists see and manage patients remotely

• Integrated CareMental health and other specialists work in primary care settings (e.g., PCMH’s, ACO’s)

• Transitions & MonitoringPatients access care (or care accesses patients) where and when needed to avoid complications and higher levels of care

Value proposition varies across types18

Types (Domains) of Telehealth

• Hospitals & SpecialtiesSpecialists see and manage patients remotely

• Integrated CareMental health and other specialists work in primary care settings (e.g., PCMH’s, ACO’s)

• Transitions & MonitoringPatients access care (or care accesses patients) where and when needed to avoid complications and higher levels of care

Technology requirements vary across types19

Types (Domains) of Telehealth

• Live Videoconferencing (Synchronous)Live, two-way interaction between a person and a provider using audiovisual telecommunications technology.

• Store-and-Forward (Asynchronous)Transmission of recorded health history through an electronic communications system to a practitioner, usually a specialist, who uses the information to evaluate the case or render a service outside of a real-time or live interaction.

• Remote Patient Monitoring (RPM)Personal health and medical data collection from an individual in one location via electronic communication technologies, which is transmitted to a provider in a different location for use in care and related support.

• Mobile Health (mHealth)Health care and public health practice and education supported by mobile communication devices such as cell phones, tablet computers, and PDAs. Applications can range from targeted text messages that promote health behavior to wide-scale alerts about disease outbreaks, to a name a few examples.

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Types (Domains) of Technology

Videoconferencing

Live, two-way interaction between a person and a provider using audiovisual telecommunications technology.“

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Hardware Endpoints

Facetime – The Rise of Consumers

Software Options

Simple Addition(s)

• Scopes with Video Outputs• Scopes with USB Outputs• Electronic Stethoscopes

VTC – Peripherals

New Stuff – Rooms, Carts, Robots

New Stuff – Software You Host

New Stuff – Software You Host

• Do you need to control the infrastructure?• How far do you want to extend your “edge”?• Do you need to work with standards-based

systems?• Do you have the resources to provide sufficient

support to your users?

New Stuff – Software in the Cloud

New Stuff – Software in the Cloud

• Do you have a reliable service provider?• Can you handle the risks of “the cloud”?• How will you control access, monitoring, logging?• Do you need to work with standards-based

systems?

Store-and-Forward

Transmission of recorded health history through an electronic communications system to a practitioner, usually a specialist, who uses the information to evaluate the case or render a service outside of a real-time or live interaction.

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• “Asynchronous” to VTC’s “Synchronous”– Suffers from a bit of a branding problem– Medical email with tools for workflow

management, patient management, and data capture

– Workflows may vary depending on specialty and preferences• On-call or scheduled S&F time

Store-and-Forward – Concept

• Traditionally viewed as a cart-based solution– PC, monitor, medical

peripherals– Custom software that

transmitted and stored data

Store-and-Forward – Hardware

• Scopes with Video Outputs• Scopes with USB Outputs• Electronic Stethoscopes• Digital Cameras• Scanners• Vital Signs Monitors• Blood Pressure Monitors• Audiometers• Electrocardiogram• Memory Cards / Storage Media

Store-and-Forward – Peripherals

Remote Patient Monitoring

Personal health and medical data collection from an individual in one location via electronic communication technologies, which is transmitted to a provider in a different location for use in care and related support.

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• Synchronous or asynchronous• Physician to physician or patient to clinician• Often have built-in alerting– Synchronous connections• Medical devices stream to central monitoring station(s)

– Asynchronous connections• Medical devices periodically send data to central

monitoring system

Remote Patient Monitoring

• Synchronous or asynchronous• Physician to physician or patient to clinician• Often have built-in alerting– Synchronous connections• Medical devices stream to central monitoring station(s)

– Asynchronous connections• Medical devices periodically send data to central

monitoring system

Remote Patient Monitoring

• Base station at patient site– Wireless or cellular connection

• Peripheral devices– Blood Pressure– Scale– Glucometer– Spirometer– Pulse Oximeter

RPM - Hardware

• Patient-oriented– Interface for wellness questions– Dashboard for patients and caregivers

• Physician-oriented– Triage and review screen for patient population– Often reviewed by case manager, with cases of

concern brought to attention of appropriate provider

RPM - Software

• Challenges– Data management– Managing relationships between monitoring

clinicians and on-site clinicians– Interoperability between RPM systems and EHRs– Patient compliance with asynchronous systems– Reimbursement

Remote Patient Monitoring

mHealth

What is ‘mHealth’?

mHealth – Some Definitions

To date, no standardized definition of mHealth has been established

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Mobile health (mHealth) is […] the provision of health services and information via mobile technologies such as mobile phones and Personal Digital Assistants (PDAs)

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mHealth is the use of mobile and wireless devices to improve health outcomes, healthcare services and health resources

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[…] medical and public health practice supported by mobile devices, such as mobile phones, patient monitoring devices, tablets, personal digital assistants (PDAs), and other wireless devices

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mHealth - TRCs

Health care and public health practice and education supported by mobile communication devices such as cell phones, tablet computers, and PDAs. “

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Sub-definitions, from Garret

Delivery of healthcare services in any of three distinct use cases:• Provider-Centric Data Capture• Patient-Provider Communication• Patient-Oriented Data Capture

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• A rapidly growing market segment– Health and wellness trackers– Medical devices that talk to a phone– Programs that offer patient education via SMS or

multimedia messaging– Epidemiology and disease tracking– Mobile applications that interface with

videoconferencing systems or S&F software

mHealth - Concept

• Basic components– Mobile phone– Software “app” for phone– Peripheral medical devices– Centralized server for storing and sharing data

mHealth - Components

• Challenges– Interoperability– Variable quality of the software applications– Questions of privacy and security– Patient engagement

mHealth

• The technology is changing– Staying on top of the right technology is hard– Selecting the right technology is critical

• The healthcare environment is changing– EHRs, mobile devices, and broadband– New models of care, new models of payment

• The necessary skills are changing– Technophobia is not a long-term strategy for most

Overall Trends

• The lines are getting increasingly blurred– What can’t you do on a mobile phone?

• The rise of the “API”– Application Programming Interface

• One app to rule them all?– The growing battle for consumer health

• Three basic components– Hardware, software, servers

mHealth, Home Health, or RPM?

New Tech Enables New Demands

• Providers want access to more data and systems over a broader geographic range

• Organizations need to work with more partners and providers

• Patients demand access to their records and/or providers

• Regulators have put out clarified rules and begun levying greater fines

Telehealth Will Be Assimilated

• EHRs growing in functionality

• Interfaces are developing more rapidly

• Consumers becoming more technically savvy

• The cost of entry has been greatly reduced

HIPAA

Old Concerns – Privacy & Security

Disclaimer

[I am not a lawyer]

Disclaimer

[I am not Your lawyer]

Old Concerns, New Era

• What Changed: Omnibus– Final rule released January 25, 2013– Covered entities and business associates needed to comply

by September 23, 2013– Clarified roles, responsibilities, and fines

• HIPAA defines …– Covered entities– Business associates– Conduits

Old Concerns, New Era

• PHI is much broader than most people realize

1. Names2. Geographic subdivisions < states3. All elements of dates (with qualifiers)4. Phone numbers5. Fax numbers6. Email addresses7. SSN8. Medical Record Number9. Health Plan Beneficiary Numbers10. Account Numbers11. Certificate / License Numbers

12. VINs, Serial Numbers, License Plates13. Device Identifiers and Serial Numbers14. URLs15. IP Addresses16. Biometric Identifiers17. Full Face Photos18. Any other unique number, characteristic,

or code

Old Concerns, New Era

• PHI is much broader than most people realize

1. Names2. Geographic subdivisions < states3. All elements of dates (with qualifiers)4. Phone numbers5. Fax numbers6. Email addresses7. SSN8. Medical Record Number9. Health Plan Beneficiary Numbers10. Account Numbers11. Certificate / License Numbers

12. VINs, Serial Numbers, License Plates13. Device Identifiers and Serial Numbers14. URLs15. IP Addresses16. Biometric Identifiers17. Full Face Photos18. Any other unique number, characteristic,

or code

45 CFR Part 164 (§ 164.402)Definition of a Breach

An acquisition, access, use, or disclosure of protected health information in a manner not permitted …[and] is presumed to be a breach, unless the covered entitycan demonstrate that there is a low probability that the PHI has been compromised”

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Old Concerns, More Breaches

http://www.hhs.gov/ocr/privacy/hipaa/administrative/breachnotificationrule/breachtool.html

Old Concerns, More Breaches

To paraphrase a talk from the FDA and OCR…It is not a matter of if you will be breached, but a matter of when you will be breached and how you handle it.“

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Old Concerns, New Tech

• Need to balance the CIA– Confidentiality– Integrity– Access

• Need to have policies and procedures in place– Not enough to document – must follow your process– Get a BAA (but know it isn’t enough on its own)– Be prepared to get breached

Q.o.S.

Old Concerns – Performance

• Quality of Service– Fixed in the past with dedicated pipes, controls– Impossible to control on the public Internet

• How do we handle QoS?– Select technologies that tolerate low bandwidth– Implement QoS where you can– Establish minimum requirements for endpoints– Consider “overprovisioning” your bandwidth

Old Concerns – Performance

• There is no silver bullet that increases the scope of your access while maintaining the reliability of your connectivity

• New tools exist, more are on their way

• Procedures and policies should be in place to clarify what to do when connections fail

Old Concerns, New Tech

Available Resources

• Telehealth Resource Centers– www.telehealthresourcecenters.org

• American Telemedicine Association– www.americantelemed.org

• https://www.telementalhealthcomparisons.com/apps

• http://telehealth.org/video/

Available Resources

• Telehealth Technology Assessment Center– www.telehealthtechnology.org– (844) 242-0075– (907) 729-4704– gspargo@anthc.org

• 15 toolkits– Desktop Videoconferencing, Digital Cameras – DSLR, Digital Cameras

– Point & Shoot, Electronic Stethoscopes, Home Telehealth, mHealth, mHealth App Selection, Mobile Blood Pressure, Patient Exam Cameras, Technology Assessment 101, Tympanometers, Videoconferencing, Videoconferencing Bridges, Videoconferencing Endpoints, Video Otoscopes

Garret Spargo(907) 729-4704gspargo@anthc.orgwww.telehealthtechnology.org