TTA’s week: CVS-Aetna’s implications, #MedMo17 report, Aussie Health Care Homes test

Is the CVS-Aetna merger heralding a new era, or an executional disaster in waiting? A lively #MedMo17 awards six startups. And Australia tries Health Care Homes for coordinated care.

Special to Alerts Readers: One free place at The King’s Fund Leeds meeting on 13 December. Last week! See offer below. And a reminder that you have one more week to 15 Dec to submit your project for the 2018 Digital Health Congress.


For our UK Readers: The King’s Fund has been kind enough to offer to our Readers one complimentary spot to their Wednesday 13 December ‘Sharing health and care records’ conference at the Horizon Leeds. If you would like to attend, email us by end of day Thursday 7 December at Extras@telecareaware.com with your name, title, and organization. Put in subject line of the email “KF-Leeds Ticket”. The winner will be chosen from best responses and notified by Friday 8 December.


Analysis of the CVS-Aetna merger: a new era, a canary in a mine–or both? (Are US healthcare execs in shock?)
#MedMo17: the conference, winning startups, Bayer, blockchain, and more (A lively conference report!)
Health Care Homes – treating chronic diseases in Australia (Coordinating care Down Under)

Does telemental care work?–the VA record. Secretary Shulkin moves forward on private care, Mayo’s Dr. Montori on care fitting into life. And HeyDoctor is Text 4 Doc.

OnePerspective: VA shows how technology can improve mental health care (Telemental health’s expansion chronicled in our new section)
VA’s Secretary Shulkin wants more private care options for veterans as part of reforms (Telehealth, private care coverage leading to better care)
Mayo Clinic’s Victor Montori MD calls for a ‘patient revolt’ for ‘careful and kind care’ (Expanding minimally disruptive medicine concept)
HeyDoctor! Come and get your diagnosis via text here! (Intriguing, but we see the downside)

Plenty of news before (US) Thanksgiving: NHS/Babylon Health’s London tests, Tunstall, Caribbean telemedicine. 

Rollout of second planned Babylon Health GP pilot for North West London scuttled (More unsettling news for Babylon’s model)
NHS, Public Health England testing multiple digital health devices for obesity, diabetes (Taking a year to do so with five suppliers)
NHS ‘GP at hand’ via Babylon Health tests in London–and generates controversy (Hits a GP brick wall)
Tunstall partners with voice AI in EU, home health in Canada, update on Ripple alerter in US (Changing their model, hopefully to profit)
A fistful of topical events (London Health Technology, NICE briefings, Planetary Health, RSM, DHACA, with a splash of Club Soda!)
Telemedicine comes to Saint Lucia–and the Caribbean (Seeking warmer climes doesn’t mean you leave telemedicine behind)

FDA’s approval of the first digital drug tracker. Reports on CES 2018, Aging 2.0. Looking forward to four conferences in NYC at end of November. Roundups on telehealth and companies. And Editor Charles cheerfully points out the difference between doers and advisors. 

Breaking: FDA approves the first drug with a digital ingestion tracking system (Proteus only took 16 years)
Telehealth roundups: Cuyahoga County (OH), BMJ systematic review, AAFP Forum (Telehealth results, PCP challenges)
Tender/Prior Information Alerts: North Yorkshire, North Ayrshire (Closing early 2018)
CES Unveiled’s preview of health tech at CES 2018 (5G, AI, VR, Extreme Tech, more)
BU CTE Center post-mortem presentation on Aaron Hernandez: stage 3 CTE (Can health tech even help?)
Some quick, cheerful updates from Welbeing, CarePredict, Tunstall, Tynetec, Hasbro, Fitbit
Themes and trends at Aging2.0 OPTIMIZE 2017 (Reinventing aging to thrive, not just survive)
A blogger’s lot is not a happy one (Editor Charles opines on the increasing disproportion between doers and advisers in the NHS) 


Having the ability to share health and care records digitally is essential to offering better, more co-ordinated care for local populations. But delivering the key benefits requires three things: the appropriate technology, the right governance structure and a culture of adoption. Learn about this at The King’s Fund’s 13 Dec full day conference at Horizon Leeds, where you will explore the different models that have been developed over the past few years and learn how local areas are overcoming these challenges. Click on the advert to register or here


Of continued interest….

Fall risk in older adults may be higher during warm weather–indoors (A counterintuitive surprise marks need for gait detection/analytics)
How does the NHS get funded and work? The King’s Fund pulls it together for you. (Graphics and video)
Public Health England: we’re hiring to expand digital initiatives (A hiring blitz of 9 openings, more to come)
A few short topical items: NHS Digital, DHACA, IET, more (Editor Charles’ update)

CareRooms: the perils of “Silicon Valley hype” when your customer is the NHS (Discretion is the better part of valor)
Tender Alert: advance notice for NHS England ACS-STP Innovation Framework (Another big part of this NHS initiative)
Will Japan’s hard lessons on an aging population include those with dementia? (Japan’s bellwether rings again)
CVS’ bid for Aetna–will it happen, and kick off a trend? (updated) (Where do payers, retailers go to expand?)


Have a job to fill? Seeking a position? Free listings available to match our Readers with the right opportunities. Email Editor Donna.


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We thank our present and past advertisers and supporters: Tynetec, Eldercare, UK Telehealthcare, NYeC, PCHAlliance, ATA, The King’s Fund, HIMSS, Health 2.0 NYC, MedStartr, Parks Associates, and HealthIMPACT.

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Telehealth & Telecare Aware: covering the news on latest developments in telecare, telehealth, telemedicine and health tech, worldwide–thoughtfully and from the view of fellow professionals

Subscribe here to receive this Alert as an email on Wednesdays with occasional Weekend Updates. It’s free–and we don’t lend out or sell our list–no spam here!

Donna Cusano, Editor In Chief, donna.cusano@telecareaware.com, @deetelecare

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OnePerspective: VA shows how technology can improve mental health care

Editor’s note: This inaugurates our new series of ‘OnePerspective’ articles. These are written by industry contributors on issues of importance to our Readers and are archived under ‘Perspectives’. For more information on contributing an article to our OnePerspective program, email Editor Donna.

click to enlargeBy: Gigi Sorenson

The shortage of mental health professionals in the U.S. is becoming more acute for two reasons: 1) more health professionals are encouraging their patients to seek treatment, and 2) more people now have health insurance due to the Affordable Care Act.  A December 2016 assessment showed that over 106 million Americans live in areas where there are not enough mental health providers to meet the need. Because of this provider shortage, as well as the stigma attached to behavioral health treatment, roughly half of mental illness cases go undiagnosed or unaddressed.

However, telehealth could fill much of this gap, and the beginnings of this trend are already evident. A growing number of psychiatrists and psychologists are using video and audio teleconferencing to treat patients remotely. Patients have access to this “telemental health” either in clinics and medical centers or, in some cases, through their Internet-connected personal devices. Studies of telemental health have found that it is effective for diagnosis and assessment in many care settings, that it improves access and outcomes, that it represents a portable, low-cost option, and that it is well-accepted by patients.

VA Program Sets the Pace

The Department of Veterans Affairs (VA) began to deploy telemental health in the early 2000s, and the VA now has the largest and most sophisticated such program in the U.S. In 2016, about 700,000 of American’s 22 million veterans used VA telehealth services. In 2013, 80,000 veterans used telemental health services, and over 650,000 veterans took advantage of those services in the previous decade.

The VA system has trained more than 4,000 mental health providers in evidence-based psychotherapies for post-traumatic stress disorder (PTSD) and other mental health conditions.  It has expanded the use of telemedicine at its 150 medical centers and its 800 outpatient clinics.  It is relying increasingly on telemental health to serve its beneficiaries, partly because nearly half of the veterans of Iraq and Afghanistan live in rural areas. Mental health professionals are often unavailable in these regions, and it can be difficult for these veterans to travel to metropolitan areas where VA clinics and medical centers are located.

Telemental health can address these issues.

(more…)

NHS ‘GP at hand’ via Babylon Health tests in London–and generates controversy

click to enlargeThe GP at hand (literally) service debuted recently in London. Developed by Babylon Health for the NHS, it is available 24/7, and doctors are available for video consults, most within two hours. It is a free (for now) service to NHS-eligible London residents who live and work in Zones One through Three, but requires that the user switch their practice to one of the five ‘GP at hand’ practices (map). Office visits can be scheduled as well, with prescriptions delivered to the patient’s pharmacy of choice.

Other attractive features of the service are replays of the consult, a free interactive symptom checker, and a health record for your test results, activity levels and health information. 

While the FAQs specify that the “practice boundary” area is south of Talgarth Road and Cromwell Road in Fulham, and north of the River Thames, it is being advertised on London Transport (see advert left and above taken on the Piccadilly Line) and on billboards.

Reviewing the website FAQs, as telemedicine it is positioned to take fairly routine GP cases of healthy people (e.g. colds, flu, rashes) and dispatch them quickly. On the ‘can anyone register’ page, it’s stated that “the service may however be less appropriate for people with the conditions and characteristics listed below”. It then lists ten categories, such as pregnancy, dementia, end of life care, and complex mental health conditions. If anyone is confused about these and other rule-outs, there is a support line. 

Babylon Health is well financed, with a fundraise of £50 million ($60 million of a total $85 million) in April for what we profiled then as an AI-powered chatbot that sorted through symptoms which tested in London earlier this year. This is a full-on telemedicine consult service with other services attached.

Now to the American view of telemedicine, this is all fairly routine, expected, and convenient, except that there’d be a user fee and a possible insurance co-pay, as more states are adopting parity for telemedicine services. We don’t have an expectation that a PCP on a telemedicine consult will take care of any of these issues which Babylon rules out, though telemental health is a burgeoning and specialized area for short and long-term support. But the issues with the NHS and GPs are different.

First, signing up to ‘GP at hand’ requires you to change your GP to one in that program. US systems are supplementary–a telehealth consult changes nothing about your other doctor choices. This is largely structural; the NHS pays GPs on a capitation basis.

mHealth Insight/3G Doctor and David Doherty provide a lengthy (and updated) analysis with a critical view which this Editor will only highlight for your reading. It starts with the Royal College of GPs objections to the existence of the service as ‘cherry-picking’ patients away from GPs and creating a two-track system via technology. According to the article, “NHS GPs are only paying them [Babylon] £50 a year of the £151 per year that the NHS GP Practice will be paid for every new Patient they get to register with them” which, as a financial model, leads to doubts about sustainability. Mr. Doherty advises the RCGPs that they are fighting a losing battle and they need to get with mHealth for their practices, quickly–and that the NHS needs to reform their payment mechanisms (GPs are compensated on capitation rather than quality metrics).

But there are plenty of other questions beyond cherry-picking: the video recordings are owned by Babylon (or any future entity owning Babylon), what happens to the patient’s GP assignment if (when?) the program ends, and patients’ long-term care.

Oh, and that chatbot’s accuracy? Read this tweet from @DrMurphy11 with a purported video of Babylon advising a potential heart attack victim that his radiating shoulder pain needs some ice. Scary. Also Digital Health.

Telemedicine comes to Saint Lucia–and the Caribbean

click to enlargeThe wide world of telemedicine! It’s hard to get away from the internet (see The Telegraph’s digital detox list of countries and areas with little to none, like North Korea), but your Editors have found that telemedicine is reaching far away places like the small, volcanic Windward Island of Saint Lucia. For those who are considering a winter holiday or are resident in this eastern Caribbean Commonwealth-member island with a dual French and British history, you can take advantage of Bois d’Orange’s Easycare Clinic‘s telemedicine services. These include real-time video consults, answers to healthcare questions, creation and maintenance of PHRs, vital signs tracking, and full access to a health network. Registration is free at www.easycare-stlucia.com along with the app. St. Lucia Times

Elsewhere in the Caribbean, a report from the Bahamas tells us that that the Princess Elizabeth Hospital A&E department is now covering Fresh Creek Community Clinic in Andros and Marsh Harbour in Abaco (the ‘family islands’). According to Edward Stephenson, a healthcare consultant in the Caribbean, telemedicine has been established privately in Turks & Caicos, Haiti, Dominican Republic and St. Vincent. The VA’s Home Telehealth program was established in Puerto Rico and the USVI, although in what present condition after two hurricanes is unknown. The University of the West Indies has had a telehealth program for Trinidad and Tobago since 2004 and works with The Hospital for Sick Children (SickKids) in Toronto in a program that includes that country as well as the Bahamas, Barbados, Jamaica, St. Lucia, St. Vincent and the Grenadines.

ATA has had a long-standing Latin America and Caribbean Chapter (ATALACC) which also is affiliated with the University of Arizona’s well-known Arizona Telemedicine Program–which in turn is affiliated with Panama’s Proyecto Nacional de Telemedicina y Telesalud. Readers’ updates welcome on this subject!

Distance concierge medicine: telemedicine connects US doctors to Chinese patients

Another ‘burden shift’ in medical care. As we in the US wrestle with the issues of telemedicine, cross-state consults, and payment parity, companies are finding a niche in cross-border international virtual consults. A startup in NYC, Docflight, now connects Chinese patients to a claimed several hundred US doctors from prestigious medical centers: Dana-Farber Cancer Center, NYU Langone, Brigham and Women’s Hospital, Massachusetts General, New York-Presbyterian, and others. Founded by Sally Wang, an attorney with a MPH, she developed the idea after negotiating the US healthcare system for her mother with breast cancer and considering how difficult it would be in China to do the same.

The patients pay an upfront fee of about $2,000 in what is essentially long-distance concierge medicine. Docflight first screens the patient, then recommends an appropriate specialist. Once matched, Docflight collects the patient’s medical records (machine translated then human reviewed) and schedules the consult time. The US doctor then advises their Chinese patient on health issues and performs a virtual visit, often with an attending Chinese doctor, and offers recommendations for treatment in an average 45 minute session. The doctors cannot prescribe, perform treatments or procedures. 

China has a burgeoning middle class and an aging population, which in combination with the hospital-based system of care in China means that individual patients receive little time with a physician, don’t have a personal relationship with one or more doctors, and don’t expect much of a personal relationship with their doctor. Their government is trying to swing the balance to a primary care model, but with 1.4 bn people that will take awhile. Telehealth and remote patient monitoring is one avenue being explored [TTA 12 Oct 16] but for acute care, a different model is needed. For the Chinese middle class, Docflight is an alternative to medical tourism, a time-tested safety valve for the affluent commonplace for patients from Canada, Latin America, the Middle East, and Asia to international medical centers, though Docflight will arrange such trips to the US.

It’s reasonable that healthcare crosses borders to increase access and overcome language barriers. We’ve previously profiled Mexico’s Salud Interactiva, which provides telephonic consults within the country plus select services through partners ConsejoSano (US) and Konsulta MD (Philippines) [TTA 16 Aug]. Dictum Health, an early-stage health tech company dual-headquartered in Dubai and Oakland, Calif., provides telehealth/telemedicine services long-distance to clinics in Costa Rica, refugee camps in Jordan, and oil rigs [TTA 19 Sep]. Crossing borders to burden-shift care and using technology to facilitate it is a trend to watch for in 2018. NBC News (video)Bold Global Media (video)Crunchbase  Hat tip to reader Jeanmarie Tenuto of Healthcare Technical Solutions.

Medtronic, American Well mega-partner for telehealth + telemedicine for chronic care

Boston-based American Well and Dublin-based Medtronic announced this week a partnership to integrate telemedicine and telehealth for chronic care management, targeting complex, chronic and co-morbid patients. Under the agreement, American Well’s telemedicine services will integrate into Medtronic Care Management Services (MCMS) video-enabled telehealth platforms for remote patient monitoring and video consults. The goal is to provide more information so that clinicians gain a more complete view of a patient’s health status when making care decisions, thus reducing the cost of care and improving patient outcomes. Care for patients with multiple chronic conditions accounts for over 70 percent of healthcare spending, according to an AHRQ study.

American Well is currently partnered with 250 healthcare partners in the US and more than 750 health systems and 975 hospitals, along with most major health plans. MCMS has two video telehealth platforms including the mobile NetResponse and the LinkView Wi-Fi tabletop. Their most recent activity is with the Midwest’s Mercy healthcare system for data sharing and analysis to gather clinical evidence for medical device innovation and patient access. MCMS platforms are also being integrated into the VA’s Home Telehealth program [TTA 6 Feb and 15 Feb]. It indicates that Medtronic is seeking to grow its telehealth device business, which has largely (except for VA) been a backwater in the immense Medtronic empire.

This is a very logical and in this Editor’s estimation, overdue type of partnership between a telehealth provider to enhance telehealth and RPM. (An easy bet: expect Teladoc to follow with another telehealth provider)

American Well/Medtronic release, Healthcare Informatics, MassDevice

Improvements in telehealth reimbursement, interstate coverage urged in Florida

Florida is one of the 34 states (plus the District of Columbia) to have legislated telehealth commercial insurance coverage, usually termed ‘parity’, for telehealth (telemedicine) virtual visits. It’s also the headquarters of many telehealth related companies, which makes it surprising that it took till 2016 for legislation to pass. In the law was the formation of a Telehealth Advisory Council within Florida’s Agency for Health Care Administration (AHCA) to report on the actual performance of insurers in paying for telehealth services. This Advisory Council recently met to review a draft copy of a 32-page report that will be sent to Florida’s Governor and Legislature later this month. That report contained some aggressive recommendations based on their provider survey, such as:

  • Establishing a practitioner/patient relationship through telehealth alone, without a prior in-person visit
  • Real parity in insurance company payment with in-person visits–in other words, payment at the same rate, which is explicitly stated in regulations in only three of the 34 states with telehealth ‘parity’ legislation
  • Amend Medicaid rules to give provider reimbursement for more telehealth services–currently, Medicaid provides for reimbursement of live video conferencing only
  • Authorize participation in interstate “compacts” that enable cross-state licensure for telehealth services. This was in the Florida House version of the bill in 2016 but dropped from the final version approved by both chambers.

The Advisory Council’s survey prior to the draft report showed lower than the national usage of telehealth: 6 percent of practitioners versus nationally 16 percent. 45 percent of Florida hospitals used telehealth, below the 52 percent of hospitals (with another 10 percent in the process) found in a 2013 national poll. For practitioners, the key barrier was financial in three areas: required investment, adequate reimbursement for services, and a financial return.

By law, the Advisory Council must complete its report by December 1, 2018, but it appears they are well ahead of schedule. Health News Florida (WUSF). Background from law firm Foley on the original legislation 14 March 2016

Proposed rule issued for ‘VA Anywhere to Anywhere’ telehealth cross-state care

The Department of Veterans Affairs ‘Anywhere to Anywhere’ program, which would enable VA doctors to treat VA patients across state lines via telehealth and telemedicine, yesterday (2 October) published in the Federal Register the required Federal proposed rule. There is a mandated 30-day comment period (to 1 Nov). In the Federal government, these rules move faster than any legislation. From the rule: “VA has developed a telehealth program as a modern, beneficiary- and family-centered health care delivery model that leverages information and telecommunication technologies to connect beneficiaries with health care providers, irrespective of the State or location within a State where the health care provider or the beneficiary is physically located at the time the health care is provided.” PDF of rule.

VA Home Telehealth has both doctor-to-patient telemedicine and vital signs remote monitoring components. While VA is fully able to waive state licensing requirements if both the physician and the patient are in a VA clinic, because of state telemedicine laws they have not been able to provide the same care for veterans at home. VA also has a care distribution problem, with many veterans living in rural areas, at great distances from VA facilities, or with limited mobility. What this will enable is VA hiring in metro areas primary care and specialist doctors to cover veterans in rural or underserved areas and the expansion of mental health care. It also will facilitate the rollout of the VA Video Connect app for smartphones and video-equipped computers now in use by over 300 VA providers [TTA 9 Aug].

The VETS Act (Veterans E-Health and Telemedicine Support Act of 2017, S. 925) would permanently legislate this, but in the US system this type of Federal rule, in this circumstance, moves faster.  Fierce Healthcare, Healthcare Finance, mHealth Intelligence 

Tender Alerts: Staffordshire’s £70m contract, Yorkshire and The Humber test

Susanne Woodman, our Eye on Tenders, alerts us to two tenders, the first which will definitely pique our UK Readers’ attention with its size and duration. The second is for a proposal using TECS and telemedicine as an alternative to emergency services.

  • Staffordshire: This is a huge seven-year contract to create the Support For Independent Living In Staffordshire (SILIS) Service to enable older and disabled adults to age in place in their current homes. “A key aim of the Service is to help Individuals to make changes to their home environment that will prevent the need for more costly interventions, such as admission to hospital or residential care, following life crises.” The Service will improve upon existing services in Assistive Technology (AT) including referral to telecare providers.

There are six borough and district councils involved, with the potential for use by nine more. The contract is valued at £70 million to start April 2018 with renewal points, ending in March 2025. Deadline is Wednesday 1 November at noon. Much more information (you’ll need it) on TED EU-Tenders Electronic Daily

  • NHS Greater Huddersfield & North Kirklees CCG: This tender is for the provision of a technology-assisted, rapid access service offering an alternative to hospital-based A&E services. Market test site is in Kirklees for residents of a care home. Requirements are:
    • A 24/7 clinical teleconsultation service delivered via secure video link into residential/ nursing homes, that is utilized instead of patients having to be taken to the local A&E department.
    • A service that provides clinical consultation not a logarithm based approach like 111.
    • A fully managed technical service utilizing bespoke laptops with HD cameras and with 4G SIM or broadband.

The CCG may also commission an accountable care organization (ACO) for this care in future, to which this contract would transfer. Deadline is 5pm on Friday 20 October to brenda.powell@greaterhuddersfieldccg.nhs.uk. More information on Gov.UK.

Want to know effectiveness of telehealth, interoperability? NQF reports take their measure.

There’s been an increase in doubt about the efficacy of telemedicine (virtual visits) and telehealth (vital signs monitoring) as a result of the publication of two recent long-term studies, one conducted by the University of Wisconsin and the other by CCHSC for Telemonitoring NI [TTA 13 Sep]. These follow studies that were directionally positive, and in a few cases like the VA studies conducted by Adam Darkins, very much so, but mostly flawed or incomplete (low N, short term, differing metrics). What’s missing is a framework for assessing the results of both. In an exceptionally well-timed announcement, the National Quality Forum (NQF) announced their development of a framework for assessing the quality and impact of telehealth services. 

In a wonder of clarity, the NQF defines telehealth’s scope as telemedicine (live patient-provider video), store-and-forward (e.g. radiology), remote patient monitoring (telehealth), and mobile health (smartphone apps). Measurement covers four categories: patients’ access to care, financial impact to patients and their care team, patient and clinician experience, and effectiveness of clinical and operational systems. Within these categories, NQF identified six areas as having the highest priority for measurement: travel, timeliness of care, actionable information, added value of telehealth to provide evidence-based practices, patient empowerment, and care coordination. Finally, the developing committee identified 16 measures that can be used to measure telehealth quality.

The NQF also issued a similar framework for interoperability, a bête noire that has led many a clinician and developer to the consumption of adult beverages. Again there are four categories: the exchange of electronic health information, its usability, its application, and its impact—on patient safety, costs, productivity, care coordination, processes and outcomes, and patients’ and caregivers’ experience and engagement. And it kept the committee very busy indeed with, from the release, “53 ideas for measures that would be useful in the short term (0-3 years), in the mid-term (3-5 years) and in the long-term (5+ years). It also identified 36 existing measures that serve as representative examples of these measure ideas (sic) and how they could be affected by interoperability.”

Both reports were commissioned and funded a year ago by the US Health & Human Services Department (HHS). We will see if these frameworks are extensively used by researchers.

NQF release, Creating a Framework-Telehealth (download link), Creating a Framework-Interoperability (download link), Mobihealthnews 

Equivocal long term telemonitoring studies released by Telemonitoring NI, U. of Wisconsin

The HSC Public Health Agency for Northern Ireland and Queen’s University Belfast have released an evaluation of the six-year (2011 – 2017) Remote Telemonitoring Service for Northern Ireland (RTNI). The Centre for Connected Health and Social Care (CCHSC) launched the Telemonitoring NI project in 2011, which enrolled over 3,900 patients with COPD, diabetes, weight management, stroke, heart failure and kidney problems in both telehealth (vital sign) and telecare (behavioral) monitoring. The study period was through 2015, but the program continues to be implemented by all five NI Health and Social Care (HSC) Trusts across a range of chronic conditions. 

The Northern Ireland findings were at best equivocal. While the qualitative data gathered from patient, carer, and clinician focus groups and interviews were positive in terms of engagement and on reassurance–to be able to carry on with their lives as usual–the quantitative data did not confirm gains in effective care.

Although there were a number of testimonials from the participants in the patient focus groups regarding
reduced hospitalisations and a reduced need to attend outpatient clinics, this did not carry through to
the data obtained in the effectiveness aspect of the current evaluation. In general terms, the number
of hospitalisations, length of hospital stay and outpatient clinic attendance (and therefore overall cost
of healthcare provision) did not differ between the quasi-control ‘never installed’ group and any of the
groups who received some amount of telemonitoring. The results, where they were statistically
significant, were largely driven by an anomalous result for the heart failure ‘never installed’ group. (page 17)

The Executive Summary, Telehealth, and Telecare Reports are available for free download on the HSC R&D Division website. Many thanks to former TTA Ireland Editor Toni Bunting for the information, summary, and researching the previous TTA coverage below.

This is the second discouraging study on the long term effectiveness of patient monitoring released in the past month. A five-year, 140,000 patient/90 provider study conducted by the University of Wisconsin found that giving patients the option of telemedicine, instead of being more convenient for the provider, created new issues. It increased office visits by six percent, added 45 minutes per month of additional visit time to practices, and reduced the number of new patients seen each month by 15 percent. For the patient, the researchers found “no observable improvement in patient health between those utilizing e-visits and those who did not. In fact, the additional office visits appear to crowd out some care to those not using e-visits.” The study suggested that the telemedicine visits could be made more effective by structured questions prior to the visit. (This approach has been taken by telemedicine provider Zipnosis with adaptive online interviews and patient triage.) Mobihealthnews

Previous commentary by TTA’s Editor Emeritus Steve Hards on the procurement of the NI Remote Telemonitoring Service:

http://archive1.telecareaware.com/the-long-and-winding-road-that-leads-to-your-doorin-northern-ireland/
http://archive1.telecareaware.com/african-elephant-ecch/
http://archive1.telecareaware.com/remote-telemonitoring-northern-ireland-service-tender-long-list-mystery/
http://archive1.telecareaware.com/short-listed-companies-rtni-service/
http://archive1.telecareaware.com/northern-ireland-remote-monitoring-servicegoes-to-tf3/

 

Can unused “TV white spaces” close the rural and urban broadband–and telehealth–gap?

click to enlargeThe digital divide comes one step closer to closing. Microsoft’s release of its white paper proposing an alternative to the expensive build-out of the US broadband network deserved more attention than it received in July. The Rural Broadband Strategy combines TV white spaces spectrum (the unused UHV television band spectrum in the 600 MHz frequency range which can penetrate through walls, hilly topography, and other obstacles) with fixed wireless and satellite coverage to economically deliver coverage to un/under-served areas versus fiber cable (80 percent savings) and LTE fixed wireless (50 percent).

34 million Americans lack broadband connection to the internet. Some of these are voluntary opt-outs, but 23.4 million live in rural areas without access, with huge economic consequences estimated in the hundreds of billions. TV white spaces can also expand coverage in small cities and more densely populated areas, including usages such as within buildings. This effort also presses the FCC, which in turn has pressed for broadband for two decades, to ensure that at least three channels below 700 MHz are kept unlicensed in all markets in the US, with more TV white spaces for rural areas.

The first part, the Rural Airband Initiative, builds on Microsoft’s present 20 programs worldwide, and is planned to connect 2 million people in by July 4, 2022, with 12 projects across the US running in the next 12 months. Much of the connectivity is dedicated to nonprofit efforts like 4-H’s digital literacy program and ‘precision agriculture’ in New York State and Washington. Microsoft is also granting royalty-free access to 39 patents and sample source code related to white spaces spectrum use in rural areas.

A positive move for telehealth’s spread. Rural healthcare providers pay up to three times as much for broadband as their urban counterparts. Telemedicine increasingly connects for consults between hospitals in rural areas and city-based health systems for specialty coverage and to provide assistance in specialized medical procedures. Telemedicine and telehealth remote monitoring has difficulty spreading with poor internet coverage; this has already been a barrier to patients in rural ACOs who can be 1-2 hours from the doctor’s office and notably for the VA in providing rural veterans with home telehealth support. Paramedics increasingly rely on internet connections and dropped connections lead ambulances to go to hospitals at a greater distance. If the FCC cooperates and Microsoft’s partners can find a way to profitably execute, broadband can finally achieve that promise about closing the ‘digital divide’ made back in the Clinton Administration. A Rural Broadband Strategy: Connecting Rural America to New Opportunities  The Verge, mHealth Intelligence, Becker’s Hospital Review

Weekend Big Read: will telemedicine do to retail healthcare what Amazon did to retail?

Updated. Our past contributor and TelehealthWorks’ Bruce Judson (ATA 2017 coverage) has penned this weekend’s Big Read in the HuffPost. His hypothesis is that telemedicine specifically will disrupt location-based care, followed by other digitally based care–and that executives at health systems and payers are in denial. More and more states are recognizing both parity of treatment and (usually) payment. Telemedicine also appeals to three major needs: care at home or on the go, with a minimal wait; maldistribution of care, especially specialized care; and follow-up/post-acute care. His main points in the article:

  • Healthcare executives are being taken by surprise because present digital capabilities will not be future capabilities, and the shift to virtual will be a gradual process
  • Telemedicine will address doctor shortages and grow into coordinated care platforms embedding expertise (via connected diagnostics, analytics, machine learning, AI) and care teams
  • Telemedicine will eventually go up-market and directly compete with large providers in urban areas, displacing a significant amount of in-person care with virtual care
  • Telemedicine will start to incorporate continuous feedback loops to further optimize their services and move into virtual health coaching and chronic care management
  • Telemedicine platforms are also sub-specializing into stroke response, pediatrics, and neurology
  • Centers of expertise and expert platforms will become larger and fewer–centralizing into repositories of ‘the best’
  • Platforms will be successful if they are trusted through positive patient experiences. This is a consumer satisfaction model.

Mr. Judson draws an analogy of healthcare with internet services, an area where he has decades of expertise: “A general phenomenon associated with Internet services is that they break activities into their component parts, and then reconnect them in a digital chain.” Healthcare will undergo a similar deconstruction and reconstruction with a “new set of competitive dynamics.”

It’s certainly a provocative POV that at least gives a rationale for the sheer messiness and stop-n-start that this Editor has observed in Big Health since the early 2000s. A caution: the internet, communications, and retail do not endure the sheer volume of regulatory force imposed on healthcare, which tends to make the retail analogy inexact. Governments monitor and regulate health outcomes, not search results or video downloads (except when it comes to net neutrality). It’s hard to find an industry so regulated other than financial/banking and utilities. FierceHealthcare also found the premise intriguing, noting the VA’s ‘Anywhere’ programs [TTA 9 Aug] and citing two studies indicating 96 percent of large employers plan to make telemedicine, also with behavioral health services, available, and that 20 percent of employers are seeing over 8 percent employee utilization. (Under 10 percent utilization gave RAND the vapors earlier this year with both this Editor and Mr. Judson stinging RAND’s findings with separate analyses.)

Analyses of New Jersey’s new telemedicine regulations

click to enlargeWith New Jersey’s telemedicine regulations now signed into law by Governor Christie to be effective 21 July, both providers and payers are adjusting to what the expansion means for those covered by Medicaid, Medicaid managed care, commercial health plans, and NJ state-funded health insurance. Our 27 June article reviews key points, and they are largely positive for expanding telemedicine in the (now official) Garden State. However, the payment parity part was diluted in the final version, with the in-person reimbursement rate set as the maximum ceiling for telemedicine and telehealth reimbursement rates.

Unique parts of the NJ bill require:

  • Telemedicine or telehealth organizations operating in NJ to annually register with the Department of Health
  • Submit annual reports on activity and encounter data, which will include patient race and ethnicity, diagnostic and evaluation management codes, and the source of payment for the consult (final details determined by succeeding legislation)
  • A seven-member New Jersey Telemedicine and Telehealth Review Commission
  • Mental health screeners, screening services, and screening psychiatrists are not required to obtain a separate authorization in order to engage in telemedicine or telehealth for mental health screening purposes

Full reviews of the legislation are available from law firms Foley & Lardner and in the National Law Review by an attorney from NJ firm Giordano, Halleran & Ciesla.

VA unveils several ‘anywhere’ new telehealth services for veterans

The new Veterans Affairs Secretary, David Shulkin, has wasted no time since his appointment in introducing several technology and mobile-based services at the VA, all of which are long overdue in this Editor’s estimation:

  • Anywhere to Anywhere VA Health Care will authorize telehealth consults and cross-state care for veterans no matter their location and regardless of local telehealth restrictions. VA is already the largest provider of telemedicine services (called VA Telehealth) in 50 specialties to 700,000 veterans annually. This new regulation will enable VA to hire primary care and specialist doctors in metro areas to cover veterans in rural or underserved areas. 
  • Rolling out nationally over the next year is the VA Video Connect app where veterans can use their smartphones or home computers with video connections to consult with VA providers. At present 300 VA providers at 67 hospitals are using it.
  • The Veteran Appointment Request (VAR) app will also roll out from its test. It will enable veterans to use their smartphone, tablet or computer to schedule or modify appointments at VA facilities nationwide.

Dr. Shulkin advocated these programs while undersecretary, especially ‘Anywhere to Anywhere’, which required advice from the Justice Department. VA’s technology is also being supported by the American Office of Innovation to improve care transitions between the Defense Department and VA. 

President Trump participated in the announcement with Dr. Shulkin and sat in on between Albert Amescua, a 26-year Coast Guard veteran at a VA clinic in Grants Pass, Ore., and Brook Woods, a VA internist in Cleveland. VA announcement with videos, POLITICO Morning eHealth, HealthcareITNews

Can Google Glass’ enterprise iteration solve the patient documentation crisis?

click to enlarge“Glass is a hands-free device, for hands-on workers.” What a marketing position! Google Glass finally arrives at where it should have started–not a techie toy or a social snooper banned from bars, but a tool for specific work needs that solve specific but important problems. This is not only ‘on trend’, but also the ‘professional case’ is steak on the grill as a powerful way to lend legitimacy to a new product (the classic is Tang ‘orange drink’ going into space in the early ’60s). The recent announcement of Glass Enterprise Edition (EE) marking its emergence from stealth mode was a refreshingly low-key (for Google and parent Alphabet) surprise. Even the revamped look is sturdy and utilitarian in full glass mode (left) or in clip-on (and also serves as eye protection). 

Their on-trend position for healthcare is to reduce the amount of time that doctors spend charting and documenting patients. Augmedix, a Glass partner, built the documentation automation platform for Sutter Health and for Dignity Health that captures the information from the interaction between patient and doctor via a ‘remote scribe’. Jay Kothari, the Glass project lead, quotes data from Dignity that it reduces clinician daily documentation time from 33 percent to less than 10 percent,  The Sutter Health estimate is two hours per day. Out of the gate this is extremely valuable because it improves the clinician-patient face-to-face (and presumably virtual) visit in eye contact, reduces the break in taking notes, and reduces time pressure generated by post-visit review. Netherlands-based swyMed concentrates on facilitating virtual visits, and is testing a home visit pilot with Loyola University Health System practitioners in Maywood, Illinois. Others, like John Nosta, have been continuing to use Glass in business. Our Readers may want to check out these partners as that is how Google is making the Glass available, not directly. SF/Boston-based partner Brain Power wasn’t mentioned in Mr. Kothari’s blog, but their AI/VR applications for brain conditions such as autism and TBI, as well as other uses such as clinical trials and care for older adults. mHealthIntelligence interviewed Augmedix’s CEO Ian Shakil, who notes that Glass still needs improvements in battery life for the hard work of documenting patient visits.

Update: An interesting comment on this via Twitter. The paper is from 2015 but the regulatory and privacy questions around recording patients and information remain. Augmedix does state on its website that it is HIPAA compliant.

 
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