Telehealth for Healthcare Nirvana

AbstractTelehealth is transforming healthcare deliv-ery and administration in a significant manner. Our expectation is that ultimately, it will play an important role in helping human-kind attain ‘Healthcare Nirvana’ – high quali-ty universal healthcare for all. This whitepa-per provides an overview of the advance-ments being made by the telemedicine industry as well as the expectations. The future roadmap is intended to serve as a reference point for technologists to align their development pipelines, making them market ready before the need or competi-tion surfaces.

The drivers for these strides in telemedicine technologies have been different in different parts of the world. While in the developed world, it is being used to drive efficiencies and improve clinical outcomes, the motiva-tion in the developing world is primarily to provide access to affordable healthcare. This whitepaper explores these trends and use cases to provide insights to help prior-itize technology development choices.

In 1924, an American Magazine called Radio News, made telemedicine as its cover page story. It showed a patient, sitting at home, consulting a doctor in his surgery, through a television link. By 1960s this medico-technology fantasy materialized into reality. NASA built telemedicine technology into early spacecraft and spacesuits to monitor astronauts' physiological parameters. Ever since then, this amalgamation of health and technology, today called as telemedicine or telehealth has been touted as the future of the healthcare industry.

Today however, telemedicine has come of age. Thanks to the smartphone revolution, the cover-age, cost and outcome of healthcare has greatly improved. The enthusiasts believe that the telemedicine revolution is just round the corner. From an age where telemedicine was not reimburs-able, today 21 states in America mandate that telemedicine be compensated at the same rate as conventional care. The Veteran Administration has taken cognizance of the huge role telemedicine can play in elderly care and has embraced telemedi-cine. On the other hand, even private employers and the insurance companies are encouraged with the fact that now they are paying the doctors for the packages for care instead of per service. Conse-quently, telemedicine is being actively promoted even by the insurance providers.

The advancements in the field of technology has greatly ramped up the speed of telemedicine evolu-tion in America and elsewhere. From a simple video conferencing, we are today witnessing the inter-twining of health and technology through digitiza-tion of data, “Mobile”ization of data transfer, health on cloud, real-time access to medical records, health analytics on fingertips, and the list can go on.

However, data security has been considered one of the foremost challenges for telemedicine. The government has implemented a framework of laws and mandates to address these challenges. Tele-medicine, nevertheless, has reached an inflection point. Even while these challenges are getting addressed, the speed of its evolution has only accelerated. However, the true potential of telemedicine is yet to be uncovered.

Telemedicine: Evolution and the inflection point

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Healthcare is making great progress driven by the advancements made in pharmaceuticals, medical devices, and biotechnology. Centres of excellence within academic institutions as well as corporate R&D teams are pushing the envelope on what is possible. Heart transplants from a cadaver, devel-opment of vaccines to fight cervical cancer, 3D printing to create devices and percutaneous proce-dures to deliver implantables inside the patients’ bodies are just a few examples of what we have witnessed in the past few years.

On the flip side, we know that there is significant ground to be covered on the healthcare delivery front. The challenges around healthcare in general, and the United States in particular, have been a subject of analysis, theories and debates for long. In the United States, the healthcare ecosystem faces several challenges ahead. A growing and aging population, rising cost of healthcare, over-whelming co-pays, high deductibles, looming crisis of shortage of doctors are only a handful of the key issues this sector faces now, and in the near future. According to Association of American Medical College (AAMC) lobby for medical schools and teaching hospitals, the total physician demand is projected to grow by up to 17 percent as the popu-lation of baby boomers ages and the Affordable Care Act is implemented . Further, a Forbes report mentions that “the nation’s shortage of doctors will rise to between 46,000 and 90,000 by 2025 as the U.S. population grows, more Americans gain health insurance and new alternative primary care sites proliferate” .

Despite regulations and technology enablement, the quality of care varies from one provider to the next. Access to quality healthcare remains a chal-lenge across the globe, especially in the emerging economies. Taking the best advancements in healthcare to those in need is in fact the motivation of telehealth. The driver for innovation in telehealth is to a) provide universal access to healthcare; b) improve health outcomes through continuous or frequent monitoring of patients; c) reduce costs of healthcare delivery to sustainable levels; d) help alleviate the physician shortage (by increasing the physician utilization rate).

The context: Need-gap & motivation for telehealth

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The nation’s shortage of doctors will rise to between 46,000 and

90,000 by 2025.

Bruce Jaspen in Forbes accessed from: http://www.forbes.com/sites/brucejapsen/2013/12/22/oba-macare-doctor-shortage-to-spur-2-billion-telehealth-market/

Bruce Japsen in Forbes accessed from: http://www.forbes.com/sites/bruce-japsen/2015/03/03/u-s-doctor-shortage-could-hit-90000-by-2025/

Telehealth, a rapidly advancing domain within healthcare, offers a big piece of the affordable, accessible healthcare puzzle. Telemedicine, or “Telehealth,” enables remote access to a physician or care provider through a range of mechanisms, starting from email based consultation which is asynchronous to real time vital signs monitoring through wearables.

The global telehealth market was valued at $736 million in 2011. The industry is expected to grow to a mammoth $17 billion by 2020. The innovators are seeing fund flowing in as well. 2014 YTD has already seen 130% more funding into the telehealth space than in all of 2013.

The Solutions

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Investments in Telehealth overthe past years (Source: CBInsights)

Global Telemedicine Market Outlook 2020 accessed in Sep 2015 from: http://www.prnewswire.com/news-releases/global-telemedicine-market-outlook-2015-2020-for-the-17-billion-industry-with-mckesson-philips-healthcare-ge-healthcare-and-cerner-dominating-504372191.html

https://www.cbinsights.com/blog/telehealth-�nancing-record/

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2007 2008 2009 2010 2011 2012 2013 2014

JUNE 2012American Well raises $37M in �nancing

MAY 2013Health tap raises $24M series Vled by Khosla Ventures

JAN/FEB 2014Specialist on Call and MD live receive $55.6M in aggrigate funding

AUGUST 2014Doctor on demand raises $21M series a led by Shastra Ventures, Venrock and Richard Branson

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Depending on the kind of technology used, Telemedicine can be broadly categorized as synchronous or asynchronous. Synchro-nous programs occur on a real time basis, with two-way consulta-tion between a patient and a specialist at a distant site. Asynchro-nous programs, on the other hand, are “store and forward” distance applications, and involve delayed communications. Such programs include transfer of diagnostic images or videos for viewing. This can then be followed by synchronous programs for a consultation.

Based on their usage, telemedicine can be grouped into 3 basic categories, namely, real time or interactive, store and forward and remote patient monitoring.

Telehealth technology evolution:Yesterday, today & tomorrow

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CATEGORY FEATURES BENEFIT

Real Time/Interactive

Store andForward

RemoteMonitoring

Includes a live call, non-voice, voice or video between the patient and the provider

The provider, patient and specialist can communicate together on a real-time basis

Patients can be shifted to home with remote observation and monitoring

Patient’s history, current condition, radiology images, pictures and videos can be attached to the message which can help the provider in diagnosis

Seamless transfer of medical history which can help in diagnosis and further treatment plan. Not necessarily real time

Best for disease management, post-hospital care, assisted living

Video based consultations and advice are the new face of telemedicine. It includes the use of live video conferencing, transmission and/or remote collaboration of static images and videos received from diagnostic equipment and remote monitor-ing.

Smartphones, on the other hand, have made this shift even faster than one would have anticipated. Real time visual inspection, discussion of the condition with the physician or specialist as well as prescription and medical records are all being delivered through mHealth applications.

There has been a recent surge of opportunities in Healthcare Systems Strengthening. It includes Healthcare Practitioner Support applications which are expected to have the largest share, with about 5% of the total mobile health market opportunity (US$ 1.1 billion). Others that follow are include administration, healthcare surveillance support, and emergency response.

Some very interesting applications such as online dermatology app, Spruce Health, has found venture backers such as Kleiner Perkins Caufield and Byers (KPCB). There are several others going the mHealth way for other healthcare domains. Noteworthy players are Doctor on Demand, Tela-doc, MDLive in the USA as well as Chunyu Yisheng and Lybrate from China and India respectively.

Current state of technology

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https://capsite.himssanalytics.org/assets/Uploads/Telemedicine-Study-TOC.pdf

Video based consultations and advice are the new face of telemedicine

57.8%

55.5%

44.1%

43.1%

35.5%

31.3%

30.3%

26.1%

19.9%

4.3%

TWO WAY VIDEO. WEBCAM

IMAGE SHARING TECHNOLOGY

E-MAIL

PARTNER PORTAL

VIDEO CONFERENCING [ GROUP]

MEDICATION MANAGEMENT TECHNOLOGY

SCHEDULING TOOL

REMORT PATIENT MONITORING

SMART PHONE [ PICTURE, TEXT, APP]

OTHERS

HIMSS SURVEY 2014: MOST WIDELY USED TELEMEDICINE TECHNOLOGIES

According to a report by Frost and Sullivan, telemedicine was forecasted to have the maximum impact on the digital healthcare market in the next five years. The report gave the forecasts for the years 2014-2019. The segments leading the pack included Home and Disease Management through remote patient care, video telemedicine, mHealth applications and telemental-health.

The real paradigm shift is being brought by remote vital signs monitoring. It makes real time data capture and predictive analytics possible. Mobile Cardiac Outpatient Telemetry (MCOT) technologies from Cardionet and Life Watch are examples.

Patients wear a simple portable device on their body which captures vital parameters continuously and relays to the patients smartphone (or a differ-ent device) using energy efficient Bluetooth proto-cols.

Future readytelehealth technologies

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The real paradigm shift is being brought by remote vital signs monitoring which make real time data capture and predictive analytics possible.

Source: Frost & Sullivan

Thereafter, the data can be transmitted using data connection/Wifi to centralized servers where the visualization and analysis of data happens. SOS calls, arrhythmia and other cardiac event detection is possible. Some devices also help detect fall which can be particularly helpful for providing care to ageing patients living alone. Not only are such devices helping in patient monitoring, but they are also being deployed as part of clinical trials. Inde-pendent Diagnostic Testing Facilities or IDTFs are adopting these technologies to make continuous monitoring of patients viable both physically and economically.

Apart from the technologies used above, there are also some top disruptive technologies with poten-tial high economic impact:

Mobile internet: Wireless technologies for care service delivery Internet of things: Wireless and NFC based technologies for Remote care Video diagnostic consultation: Activity Monitoring Psycho-social well-being apps Personal emergency responses systems (PERS) Retail tele-health

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http://www.statista.com/chart/3370/wearable-device-forecast/

While according to the Centres for Medicare & Med-icaid Services, the defining feature of telemedicine is real-time video communication, there are certain critical features which are a priority to ensure that a telemedicine application is easy to use, works reliably, and gets the job done. This could mean customizable screen layouts, borderless video pictures to simulate a closer, more personal inter-action for building trust with patients. To make the initial investments in telemedicine productive and profitable for providers, it is important to support features like interoperability i.e., compatibility with other systems (software, hardware in the market) than limiting to proprietary systems, and use tech-nologies to manage multiple feeds from various video cameras and devices.

Providing selective multi-monitoring where in the uses two different screens to view the information and conduct a telemedicine call with his patient, could be one of the ways to ensure privacy and security. Use of VOIP technologies to provide features like facilitating the patient to be reached for a telemedicine consultation, even if the patient is not online but can receive an incoming call, is key to making the solutions effective.

Hence choosing ISVs/ vendors with capabilities and competencies in relevant technologies to provide not just video communications solutions but the above, as well as security, mobility, and perfor-mance is a critical step for providers to successfully implement telemedicine solutions.

Technology features which enable effective telehealth solutions

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Maintaining privacy could also mean ability to provide selective multi-monitoring so that the provider can view information securely on one monitor while conducting a telemedicine call on another screen.

In developed countries like U.S. and continental Europe, telemedicine focused primarily on improving patient outcomes. In the process, it also achieves cost-efficien-cy and elevates the patient’s quality of life.

However, in the developing and third world countries, there are other factors that make telemedicine a much desired medium.

While telemedicine is most evolved in the developed nations, it has a maximum impact in the developing world. With limited access to specialists, doctors, Tele-medicine can revolutionize the healthcare ecosystem. With a trained healthcare professional who can be the eyes, ears and hands of a distant doctor, healthcare would become more affordable and accessible in the remotest of the corners. A specialist can help diagnose a problem and suggest a line of treatment while sitting miles away from the patients. Since the basic telemedi-cine initiatives can be established with low start-up costs, it brings benefits to everyone involved. The specialists are able to extend their services, local doctors get the opportunities to learn from more expe-rienced physicians across the globe and the patients receive immediate and better care and treatment.

Different markets, different drivers

DEVELOPED ECONOMIES

Bringing the cost of administration down (faster discharges frees

infrastructure)

Better healthcare outcomes because of the ability to predict adverse

events

Preventive healthcare to decrease the overall cost healthcare delivery

EMERGING ECONOMIES

Access is the primary need which is being served. Access to physicians

within the country and from overseas

Access at affordable costs given the low penetration of health insurance and the generally lower per capita

income levels

Preventive healthcare given the sedentary lifestyle the younger

populations are pursuing

Value proposition of Telemedicine in different contexts

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Telemedicine today faces several challenges which can be converted into opportunities with the right technology tools with focus on deliver-ing value to its end consumers without changing the behavioural patterns.

Consumers: Due to lower levels of trust between the providers and their patients, the distance created by technology can further make the patient feel distanced. Considering the fact that face-to-face communication is considered to be one of the important aspects of diagnosis by both the provider and the patient, using technol-ogy faces a big stumbling block. Especially for elderly population which may feel overwhelmed by the technology, adopting telemedicine can be a big hindrance in reaping full-fledged benefits. The concerns regarding the privacy and security of data and consultation creates uncertainty, which further adds to the apprehensions.

Providers: Clinicians may lack the technical skill needed to embrace the technology. Moreover, it could significantly change or further complicate the face-to-face consultations which can affect the diagnosis and treatment. With a similar hesi-tation from the patient’s end, the health care providers then factor in the risks returns on the investment made in telemedicine.

There are several prohibitive regulatory policies that hinder the widespread use of telemedicine.

Stringent laws in many states limit or completely prohibit the practice of telemedicine. Mentioned below are four major impediments which restrict a wider uptake of telemedicine. Today in the US, more than 100 telemedicine bills are before state legislatures, many of them deal with matters of reimbursement but some of them include verbi-age about telemedicine licensure.

State licensing: According to an update from Federation of State Medical Boards (FSMB) in Janu-ary 2015, 47 state boards require physicians to be licensed in the state where the patient is locat-ed, and only 13 state boards issue a special purpose telemedicine license for telemedicine practice across state borders

Reimbursement coverage: Consultations and treatments given over telemedicine are yet not defined in coverage policies.

Quality/scope: A larger policy level decision is needed which can outline the types of medical services that can be offered via telemedicine.

HIPAA compliance: Privacy and security of patient information remains a primary cause ofconcern for telemedicine.

ChallengesRegulation andStandardization

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Telemedicine is potentially “flattening the world” by bringing the experts and the needy patients together and also allowing for experts to collabo-rate amongst each other. Examples are abound where complex procedures such as transplants and genetics based cancer therapy involves collaboration between the patient, local surgeons and overseas experts. The converse, viz., patients from developed economies seeking consultation from experts in emerging economies, for elective procedures not covered by insurance (example plastic surgery) is also happening. Therefore, while the priority of benefits may be different, telemedicine is disrupting healthcare delivery and taking us closer to healthcare nirvana!

From the providers standpoint too, telemedicine is a boon as it helps them expand their care deliv-ery, use it as a tool for medical training as well as reduce the cost of providing care. An important aspect for providers to implement telemedicine is to do so by engaging product companies or Inde-pendent Software Vendors (ISVs) that can provide holistic telemedicine solutions, which also simpli-fy adoption by patients/physicians.

Conclusion

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About AdroitentAdroitent Inc. is a global Health IT solu-tions provider with decades of experi-ence of working with industry leading clients, including those who feature in the Fortune 500 list. Our expertise includes delivering solutions for imple-menting telehealth solutions, incorpo-rating compelling UIUX and interopera-bility features, healthcare insurance exchange (HIX), health information exchange (HIE), electronic medical records (EMR), and health data analyt-ics leveraging Big Data frameworks. In addition, we have delivered state of the art IT solutions for population health, health data security (viz., HIPAA) and mHealth, keeping pace with how the industry is evolving.

The advantage we bring forth is our ability to work with companies at all stages – be it a rapidly growing, high potential startup which looks for agility and achieving its next development milestone, as well as larger corpora-tions, who require scaling of their IT infrastructure, trans-formative solutions or high-end support. Having traversed the journey ourselves, growing into a large team of ~400 professionals, we have first-hand perspective on how to adapt our services and solutions to different customer needs. We think of ourselves as multiple startups within a growing company.

With Adroitent as your technology development partner you get three things at once: a) foremost, a reliable partner who takes ownership of your projects in the true sense, b) a technology team which has the versatility and experience to deliver solutions best for you and c) a partner with processes in place (SEI-CMMi), which helps you experience a reliable product development experience.