Telemedicine for all creatures great and small? Veterinarians debate.

Will veterinarians be covered by ongoing telemedicine legislation? This surprisingly became an issue with the New Jersey telemedicine bill [TTA 11 Aug] S.291 prior to signature by Governor Christie. The debate was whether “health care providers” covered under the licensing statutes in Title 45 of NJ’s Revised Statutes also included veterinarians in the “including but not limited to” language as well as the nature of the “proper provider-patient relationship” and “patient request”. Reportedly the Governor held his signature in order to sort this out, meeting with healthcare and veterinary representatives. The final bill does not appear to specifically address veterinary practice.

For its part, the American Veterinary Medical Association (AVMA) Practice Advisory Panel (AP) came out solidly in favor of non-inclusion in human laws like New Jersey’s in their January report. Their view of the patient-physician relationship is logically different because the animal patient cannot give consent, but an owner/client can, and that difference is not specified in human medicine laws. In the AP’s view, “telemedicine shall only be conducted within an existing VCPR [veterinarian client patient relationship], with the exception for advice given in an emergency care situation until that patient(s) can be seen by or transported to a veterinarian” which is increasingly not true of human telemedicine. Law firm Fox Rothschild’s animal law practice blog cited instances such as when a Texas veterinarian was found to have violated the state practice act by offering advice over the internet. 

Many veterinarians are calling for AVMA to seek guidance from organizations like the ATA to better codify animal telemedicine practice. ATA, for its part, has stayed apart from state debates while remaining generally supportive. The gap in veterinary practice is especially acute with a declining number of practitioners caring for food animals (livestock) and in rural veterinary practice. But who will care for the unicorns? Seriously, here is a gap that needs to be filled. mHealth Intelligence

Some reflections on ATA and a future CEO–your ‘nominations’ wanted!

This Editor and publication have had relationships at different levels with the American Telemedicine Association (ATA) since at least 2006. Our Readers know of TTA’s long-standing support of ATA’s annual meeting as a media partner. As a marketer, I’ve negotiated booths, sponsorships, and sent staff (including myself) to meetings, which makes this experience like many of our Readers.

It is worth reflecting that in 1993, when Jon Linkous took the ATA helm, few of us other than academics had email or used the Internet except in limited ways like IBMMail or Minitel. Once telemedicine, video consults, and vital signs data capture were the future and mostly theory. We went through the whiz-bang gadget phase, where every new one was going to change healthcare as we know it. Now we are past the buzzy cocktail party hangover into trying to make it work. We are in 2.0 and 3.0 where it’s all about integration of telemedicine and telehealth into patient engagement, behavior change, data analytics, predictive care, genomics, improving life for the aging and chronically ill population, managing the tsunami of patient data for better outcomes, smart pills, hacking and data security, EHRs, ACOs, meeting standards such as MACRA…and heavy engagement with national (Federal) and local entities. And always–getting paid enough to stay afloat!

As an organization, ATA faces an ever-expanding HIMSS, which has expanded far beyond its health information/IT/data analytics raison d’être to media properties, multiple health tech conferences, and now presence with early-stage companies through acquiring Health 2.0.

Dizzying changes, and more to come.

Who do you want to see at the helm of ATA? What will be the new CEO’s problems to solve? List your choices and thoughts in Comments below! (If you wish to be anonymous, email Editor Donna in confidence.)

Change at the top at ATA: CEO Jon Linkous departs after 24 years

The American Telemedicine Association’s CEO, Jonathan Linkous, has left ATA after 24 years as CEO. An ATA spokesperson cited personal reasons, according to MedCityNews. Sources told POLITICO Morning eHealth that Mr. Linkous “simply told the organization he was leaving the job effective immediately before its board meeting this week.” It was certainly an unusual departure, without the standard transitional period of months or even a year. The ATA release was short and concentrated on the ‘transitional period’.

Acting as interim CEO will be Dr. Sabrina Smith, who joined last January as COO after senior VP/COO-level positions with the Regulatory Affairs Professionals Society (RAPS) and the American Academy of Physician Assistants (AAPA) after 12 years with MedStar Health, the largest health system in the Washington DC metro. MedCityNews quoted ATA board president Peter Yellowlees, MD that the search is expected to take about six months. This will take the search through ATA’s Fall Forum in October and well into the ramp-up for ATA 2018 in April. ATA is seeking “a vision for the future of healthcare” and “extensive knowledge of telemedicine”, so if you have it, step up! 

Jon Linkous, from the formation of ATA to yesterday, gained much recognition for telemedicine and telehealth, to where ATA presently has 10,000 members and 450 health system and industry partners, a leading annual conference, multiple events and educational programs. They have concentrated much (and successful) effort in gaining parity of payment for telemedicine, a state by state battle, though the POLITICO report (using a quote from a former HIMSS executive director now consulting for ATA!) did not think much of ATA’s influence in the Washington DC swamps. Another major change apparent over the past five years: as an association, healthcare technology has developed way outside ‘telemedicine’. Organizations like HIMSS have exploded in size through redrawing their definitional lines plus aggressive acquisitions in media and of competitors such as Health 2.0. The next chapters won’t be simple or easy for the new CEO. Also FierceHealthcare(Disclosure: TTA has been for many years a media partner of the ATA annual conference.)

ATA 2017 dispatch: The future is about business models and the consumer

Bruce Judson, our guest ATA 2017/Telehealth 2.0 reporter, is a bestselling author of books on business and technology issues in the evolving digital era. This is the first of several articles this week. Mr. Judson writes frequently for The Huffington Post. More on about him may be found in our review of his critique of the RAND telehealth study [25 Mar].

Orlando, April 24. Yesterday, the annual convention of the American Telemedicine Association (ATA) moved into full swing. At noon, Jonathan Linkous, ATA’s CEO, took a few minutes to talk with me. During our wide-ranging discussion, three notable themes emerged:

First and perhaps most important, Mr. Linkous believes that the future development of telehealth now stands with establishing viable business models. In his view, the speed of growth of the industry now depends on how the many participants in the healthcare system develop business models that lead to appropriate investments. He noted that this contrasts with the general focus on the evolving technology. Of course, the technology will continue to evolve and major advancements will occur for the foreseeable future. But, Mr. Linkous strongly believes that “the technology is here today.” In short, it’s now about how the technology is used and deployed. New advances will be incorporated into services and infrastructure as they occur. But, the past, telehealth is now moving into mainstream investment discussions. In his view, the leaders of every health organization are now assessing the role telehealth will play in the services they offer, and the investments they need to make now.  Now, it’s about making it work. We are no longer waiting for the technology to be viable.

Second, Mr. Linkous commented on the hype surrounding the industry. He was frank in recognizing that, as with all exciting, transformative industries, the hype cycle is in full swing. One telling comment: “Unlike the past, the industry now has real revenues,” with rapidly growing businesses. In short, we may not be past the hype, but the industry is quickly moving to fulfill realistic expectations.

Finally, Mr. Linkous concluded that the future growth of the telehealth industry would largely depend on the consumer. He cited a variety of factors: the growth of value-based care, the emerging influence of millennials who are comfortable with technology, and the overall consumerization of medicine.

Many industry participants have described themselves to me as B2B businesses. Undoubtedly, they are. It’s hard to refute Linkous’s conclusion: Ultimately, the growth of the industry, like the evolution of healthcare itself, will depend on consumer choices.

TytoCare remote diagnostics comparable to in-person exam results: study

click to enlargeA study of the Tyto Care remote diagnostic device, conducted by Schneider Children’s Medical Center and the Sackler School of Medicine, found that the quality of readings by Tyto Care was ‘on par’ with in-person medical exams using conventional otoscopes and stethoscopes. Ears, heart, lungs and throats of 137 children aged 2-18 seeking care from the emergency department of a tertiary care facility were examined first conventionally and then again by a second remote physician using exam data captured by the TytoCare all-in-one device and attachments. Using standard statistical methods, the results were compared and the study reported “good to excellent agreement for all exams conducted using TytoCare and conventional exam tools, with a p-value <.001.” The study also recorded a separate five-point measure of patient experience and results averaged 4.4 and 4.5 out of 5 (excellent). No adverse events were recorded.

What is lacking in the release are the diagnoses of the young patients, but presumably those results will be presented with the final study. Formal presentations will be at the Israel Society for Clinical Pediatrics (HIPAK) meeting on 8 February in Tel Aviv and at the American Telemedicine Association (ATA) conference 23-25 April in Orlando, Florida. This positive report on efficacy will also aid their rollout with American Well, announced at the end of 2016 [TTA 2 Dec]. Harry Wang at Parks Associates in their blog also named TytoCare one of the two standouts of CES 2017–and the other, Partron (Croise) is not yet on the market.

The growth of telehealth, and the confusion of terminology (US)

Becker’s Health IT and CIO Review has written up a US-centric review of recent advances in telehealth and telemedicine but kicks it off with the confusion level between the two terms. Internationally, and in these pages, they are separate terms; telehealth referring primarily to vital signs remote monitoring, and telemedicine the ‘virtual visit’ between doctor and patient, between two clinical sites, or ‘store and forward’ asynchronous exchange (e.g. teleradiology). Somehow, in US usage, they have been conflated or made interchangeable, with the American Telemedicine Association (ATA) admitting to same, and American Well simply ‘just doing it’ in relabeling what they provide. On top of it, the two are incorporating elements of each into the other. Examples: TytoCare vital signs measurement/recording into American Well’s video visit; Care Innovations Health Harmony also providing video capability.

Of particular interest to our international readers would be the high rate of US growth in telemedicine utilization from 7 to 22 percent (Rock Health survey). Teladoc, the largest and publicly traded provider, passed the milestone of 100,000 monthly visits in November and the ATA estimates 1.25 million from all providers for 2016 (Teladoc release). Other US competitors include the aforementioned American Well, MDLive, and Doctor on Demand, the latter two also selling direct to consumer. They also compete against doctor-on-house call services like Pager and Heal. Reimbursement remains an issue both privately and publicly (Medicare and Medicaid) on a state-by-state level, with telehealth experiencing significant difficulties, as well as internet access, speed, and usage by older adults.

The difficulty in differentiating telemedicine and telehealth

Our Editors have always tried to cleanly define the differences between telemedicine, telehealth and telecare, even as they blur in industry use. (See our Definitions sidebar for the latter two.) But telemedicine, at least on this side of the Atlantic, has lost linguistic ground to telehealth, which has become the umbrella term that eHealth wanted to be only two or three years ago. Similarly, digital health, connected health and mHealth have lost ground to health tech, since most devices now connect and incorporate mobility. And there are sub-genres, such as wearables, fitness trackers and aging tech.

Poor telehealth grows ever fuzzier emanations and penumbra! Now bearing the burden of virtual visits between doctor and patient, doctor-to-doctor professional consults, video conferencing (synchronous and asynchronous), remote patient monitoring of vital signs and qualitative information (ditto), and distance health monitoring to treat patients, it also begins to embrace its data: outcome-based analytics, population health and care modeling. Eric Wicklund accumulates a pile of studies from initial-heavy organizations: WHO, HIMSS, HHS, Center for Connected Health Policy (CCHP), ATA, TRC Network. All of which shows, perhaps contrary to Mr Wicklund’s intentions, how confusing simple concepts have become. mHealth Intelligence

Payer reimbursement for telehealth, telemedicine gains in Delaware, Connecticut (US)

Two states–Connecticut and Delaware–are now requiring private commercial insurers to cover telemedicine and telehealth services at parity with in-person visits. Connecticut was first, signed into law on 22 June but not starting till 1 January 2016. It covers not only video consults but distance care delivered both synchronously and asynchronously, such as store and forward transfers, and covers remote patient monitoring. It specifically omits audio-only consults, email, texting and fax (!). The Connecticut law also requires parity of payment with in-person visits to prevent lower reimbursements. Delaware’s law was signed 7 July to take effect immediately, and based on the summary is similar in breadth to Connecticut’s. Delaware is now the 29th state to enact telehealth/telemedicine reimbursement legislation. Articles written by members of the Foley & Lardner law firm. JD Supra, Lexology

On the Federal front, Representative Mike Thompson (D-CA) and three other members of the House of Representatives introduced H.R. 2948, the Medicare Telehealth Parity Act of 2015. It would remove the current geographic restrictions for telehealth (in the Federal definition including telemedicine), expand services, expand telehealth/RPM for additional chronic conditions and expand home care service into hospice and dialysis. It is a rework of last session’s H.R. 5380 and is at very early days having gone to a Congressional committee. Unfortunately its passage has a snowball-in-July chance with Govtrack.us giving it zero chance of enactment. Rep. Thompson’s website, FierceHealthIT, ATA-Jonathan Linkous support statement.

Previously in TTA: Telehealth reimbursement makes legislative progress in Texas, US House

Home telehealth now focused on the ‘superusers’ of healthcare

A noticeable trend in telehealth has to do with focusing less on the generic virtues of at-home vital signs monitoring for routine patient care and more on managing specific high-cost populations to avoid or reduce costs. Some of the impetus in the US has come from new regulations by CMS (Center for Medicare and Medicaid Services) intended to move Medicare fee-for-service (FFS) patients into a reimbursed chronic care management (CCM) model. Banner Health is Arizona’s largest private employer (which does say something about Arizona as a retirement haven) and since 2006 has been experimenting with remote monitoring since 2006. Starting in 2013 Banner piloted Philips‘ post-discharge program now called ‘Hospital to Home’ as Banner iCare, combined with Philips Lifeline PERS, but made it available to those only with a stunning five+ chronic conditions–the top 5 percent that is reputed to account for 50 percent of healthcare spend. Banner combined the tech with intense support by a multi-layered care team. At ATA they announced the following results with the initial cohort of 135 patients, now up to 500:

  • 27% reduction in cost of care
  • 32% reduction in acute and long term care costs
  • 45% reduction in hospitalizations

The article in Forbes is a bit breathless in profiling the program and the ‘superusers’ of healthcare (with a windy but false analogy from John Sculley) but provides a level of detail in the program that most articles do not. One wonders how Philips makes money on supplying what is at least $2,500 worth of kit, with peripherals that must all be Bluetooth LE. It’s also not stated, but the TeleICU and TeleAcute programs also appear to be Philips’. Video

ATA trend #1: Is a sustainable RPM infrastructure fact or fiction?

Guest columnist Dr Vikrum (Sunny) Malhotra attended ATA 2015 last week. This is the first of three articles on his observations on trends and companies to watch.

The advancement of remote patient monitoring is a visible trend from the American Telemedicine Association’s 2015 meeting, with care moving from the doctor’s office and being shifted to the patient’s home. A more diverse range of data is being collected for patients to facilitate more informed decision making at the patient visit and after the patient is away from the practice. As information is being collected and monitored on a more comprehensive basis, we have seen creative modalities to view a broad array of data points that would typically have been collected in a doctor’s office with the hopes of early diagnosis and preventive care, versus reactive care.

Patient autonomy has now come to the forefront and network infrastructure is being built to support that shift. Wearables, implantables and home based lab/ urine diagnostic kits are becoming smaller, cheaper, less invasive, wireless and cloud-based so that patients can be monitored without interfering in day to day living. (more…)

ATA announces award winners, Strategic Summit companies

ATA announced the six winners of their Annual Awards recognizing innovators in telemedicine and telehealth for significant contributions, along with six new members of the ATA College of Fellows. One of the more intriguing winners (Innovation in Remote Care) is the US/UK company Sentrian which has built intelligent predictive data models (‘Remote Patient Intelligence’) that can monitor disease and co-morbidity in thousands of patients with the goal of preventing hospitalization and readmissions. Release. ATA has also selected 30 emerging companies to participate in the Telemedicine Investor and Strategic Summit  (more…)

A mélange of short subjects for Tuesday

ATA accredits American Well, Apple ResearchKit, diabetic contact lenses, Hackermania Falls on Indiana, patent trolls get a haircut, and more

The ATA (American Telemedicine Association) has gained more than 200 applications for their US-only Accreditation Program for Online Patient Consultations [TTA 17 Dec 14]. First past the post in accreditation is American Well’s Amwell virtual visit app, which will shortly be listed on the ATA consumer website SafeOnlineHealth.orgRelease, MedCityNews….Stanford University, one of the five academic centers using the Apple ResearchKit, had a mind-boggling 11,000 signups for a heart health study–in 24 hours. The downside is that they may not be representative of the whole population [TTA 10 Mar, see 11 Mar update] including us Android users. 9to5Mac….The Google-Novartis glucose-measuring contact lens [TTA 17 July 14] for diabetes management just gained some Canadian competition–Medella Health in Kitchener, Ontario, founded by a team of (more…)

American Telemedicine Association (ATA) 2015

2-5 May 2015, Los Angeles Convention Center, 1201 S Figueroa Street, Los Angeles, California 

ATA’s annual meeting for 2015 connects like-minded telemedicine, telehealth, mHealth professionals and entrepreneurs from around the globe. With over 6,000 attendees, 13 educational tracks and the largest telemedicine trade show in the world, the ATA meeting is a premier forum to learn and network, featuring:

For more information and to register, see our special link here. Telehealth & Telecare Aware is pleased to be again an official media partner of this year’s ATA. 

Telemedicine’s boffo year? Some confirmation. (US)

Big bets were made on telemedicine (video doctor-patient consults) in 2014. This Editor closed her 18 December article with ‘telemedicine providers received a $200 million+ vote of confidence from tough-minded investors. We’ll see if 2015 results fulfill these whale-at-Monte-Carlo wagers.’ Here may be the start of a tipping point. New York State’s new law requiring insurer reimbursement for telehealth services went into effect 1 January, making NY the 22nd state to require payers to pay up for virtual visits. Permitted providers are physicians, dentists (!), physician assistants, psychologists and social workers. This provider list is considerably broader than Medicare’s new rules applying telehealth for patients with two or more chronic conditions, which is tied to physicians’ offices and contracted third parties. Also cheering the industry are that Indiana, Iowa and Tennessee are holding hearings on potential legislation, with Missouri at the legislative bill stage. (more…)

Looking back over Telehealth & Telecare Aware’s predictions for 2014, part II

click to enlargeEditor Charles has treated you to a look back on his 2014 predictions, daring Editor Donna to look back on hers. Were they ‘Decidedly so’, ‘Yes’, ‘Reply hazy, try again’ or ‘My sources say no’? Read on…

On New Year’s Day 2014, it looked like “the year of reckoning for the ‘better mousetraps’”? But the reckoning wasn’t quite as dramatic as this Editor thought.

We are whipping past the 2012-13 Peak of Inflated Expectations in health tech, diving into the Trough of Disillusionment in 2014.

There surely were companies which turned up ‘Insolvent with a great idea’ in Joe Hage’s (LinkedIn’s huge Medical Devices Group) terms, but it was more a year of Big Ideas Going Sideways than Crash and Burns.

Some formerly Great Ideas may have a future, just not the one originally envisioned. (more…)

2015: a few predictions (UK-biased)

As intimated in our review of last year’s predictions, we feel little need to change course significantly, however some are now done & dusted, whereas others have a way to go. The latter include a concern about doctors, especially those in hospitals, continuing to use high-risk uncertified apps where the chance of injury or death of a patient is high if there is an error in them. Uncertified dosage calculators are considered particularly concerning.

Of necessity this is an area where clinicians are unwilling to be quoted, and meetings impose Chatham House rules. Suffice to say therefore that the point has now been well taken, and the MHRA are well aware of general concerns. Our first prediction therefore is that:

One or more Royal College/College will advise or instruct its members only to use CE-certified or otherwise risk-assessed medical apps.

The challenge here of course is that a restriction to CE-certified apps-only would be a disaster as many, if not most, apps used by clinicians do not meet the definition of a Medical Device and so could not justifiably be CE-certified. And apps are now a major source of efficiencies in hospitals – (more…)