Telemedicine and the Ukraine

Pregnant patient and Ukrainian refugee Sarah Misk using Sheba Beyond’s telehealth technology in Kishinev, Moldova, March 2, 2022. (Sheba Medical Center)

How Can I help?

Almost two months into the crisis in the Ukraine with no end in sight, its somewhat comforting to see the telemedicine/telehealth community rallying to try and do what they can to provide remote medical support to those still in the Ukraine, and refugees crossing the borders.  Now, telehealth companies are offering free digital health services to fill some of the healthcare voids created by the war.

This article discusses various ways U.S. clinicians can participate and how any reader can contribute to the clause.

VSee is a video telehealth platform with a 14-year history supporting health efforts in North America, the Middle East, Africa, conflict zones, the International Space Station, and refugee camps.  VSee developed Aimee, a telehealth app that “brings together more than 2,000 U.S.-based physicians to provide free on-demand doctor visits covering all medical specialties, including Emergency Room and trauma.” VSee is a video telehealth platform with a 14-year history supporting health efforts in North America, the Middle East, Africa, conflict zones, the International Space Station, and refugee camps.

VSee is the telehealth platform used by www.theteledentists.com. Thank you, Milton Chen, for all you do.  Read about it here:

https://conciergemedicinetoday.org/2022/03/14/cmt-spotlight-on-vsee-and-aimee-ukraine-fox-news-us-doctors-provide-free-telehealth-for-ukrainian-soldiers-civilians-refugees/

CTeL is a nationally recognized 501(c)(3) non-profit research organization focused on telemedicine and virtual care and has organized the Telehealth4Ukraine Coalition which is working to bring together telehealth providers to support virtual humanitarian healthcare efforts in Ukraine and the surrounding region. The goal of the Coalition is to produce a dynamic database of healthcare providers that humanitarian organizations can utilize for virtual care support.

https://www.telehealth4ukraine.org/

Dr. Irving Loh writes about his efforts working with CTel and a as co-founder and chief medical officer of an international healthcare artificial intelligence company based in Poland and the U.S

https://www.vcstar.com/story/opinion/columnists/2022/03/25/dr-loh-telemedicine-help-needed-ukraine-refugees/7155781001/

More International Efforts

Viveo Health, an e-health platform based in Estonia, recently announced it is focusing its Telehealth without borders initiative on Ukraine through its ViveoCares Foundation.

https://www.forbes.com/sites/debgordon/2022/03/21/amid-russian-invasion-new-initiative-launches-free-telemedicine-for-ukrainians-under-siege/?sh=22f47f804470

Using computerized systems built in Israel, physicians examine refugees on the Ukraine-Moldova border, check lungs, blood stats and even conduct prenatal ultrasounds.  The medical professionals are located at Sheba Medical Center, Israel’s largest hospital.

https://www.timesofisrael.com/doctors-in-israel-care-for-ukrainians-2000-km-away-as-tech-shrinks-world

Dr. Richard Simpson informed me about his efforts in working in conjunction Ina Burgstaller and her team at Bionabu (www.bionabu.com) in the UK. Bionabu has created an international Virtual Clinic for Ukrainian Refugees “Ukraine Refugee Virtual Clinic” (Likarnya Online) that provides direct doctor to patient mHealth triage and consultation services in Ukrainian and Russian through smart devices. U.S. physicians can sign up to participate on the website. Physicians and dentists globally can find more information and register to on-board and receive training at https://www.likarnyaonline.com/en.

Challenges

Some of the age-old challenges to telemedicine still exist.  There needs to be sufficient bandwidth, although anyone with a working smartphone can use these services.  Patients and providers need to be aware that services like these exist.  Fortunately, reimbursement is not a barrier as physicians are generously providing their services for free, but there is a great need for funds to support infrastructure and support staff.  There is a need for Russian and Ukrainian speaking physicians.  The use of translation services is possible but provides yet another barrier toward the delivery of care.

Joe McMenamin, a telehealth attorney who has been involved in several of these efforts writes, “For one thing, there’s a war on, and responding to American volunteers is not the (Ukrainian) MOH’s #1 priority. It is doubtless short-staffed from deaths and injuries inflicted by the enemy. For another, the providers we are able to reach over there say that what they need more than expertise from foreigners is pharmaceuticals and medical supplies”

On a personal basis

So, you think this is all brand new?

On December 7, 1988, an earthquake destroyed a significant portion of the Spitak Region of Soviet Armenia. The destruction resulted in significant death toll, building and infrastructure destroyed, and the displacement of hundreds of thousands of people. The entire local medical infrastructure was significantly damaged. Before the disaster, the space medical leadership of the United States and the Union of Soviet Socialist Republics were collaborating on joint activities in medicine and biology which resulted in the “Spacebridge to Armenia”.

The leaders of this collaborative effort devised an approach to support a disaster recovery utilizing telecommunications assets. I had the privilege of representing NYNEX Corp in discussion which resulted in participation from several major telecommunications companies as well as NASA.

https://pubmed.ncbi.nlm.nih.gov/10220470/

More than medical help is needed.  I want to applaud the work of Dan Abrams, a son of close family friends who is on the ground in Poland leading the effort for World Central Kitchen who is delivering over 100,000 meals a day to refugees.

https://mobile.twitter.com/wckitchen/status/1500223377860186118

How Can You help?

Through several of these links, clinicians can sign up to deliver their expertise. Many of these efforts are charitable organizations and financial contributions are most welcome.  Let others know about the good work being done by the telemedicine/telehealth community.  Contact me directly at hreis@healthepractices.com with questions, or if you know of other efforts I can share with this community.

Next Big Things

I have been blessed to have a career at the leading (bleeding?) edge of several exciting technologies.  From the early days of electronic banking and the early experiments in telemedicine, I have seen several innovations become mainstream.  What’s Next?  My focus for the past 30+ years has been largely healthcare.  I asked some industry leaders, and I am happy to share their answers.

First, what are the biggest problems to solve? Here’s a top 5.

High Cost of Prescription Drugs

  • Prescription drug prices in the United States are significantly higher than in other nations, with prices in the United States averaging 2.56 times those seen in 32 other nations, according to a new RAND Corporation report.

Unintentional Medical Errors

  • Frequently cited studies have placed the number of deaths as high as 250,000 deaths per year, which would make medical error the third leading cause of death, behind cancer and cardiovascular disease

Keeping up to date with current medical literature

  • Clinicians and researchers must keep abreast of new publications in their field. This represents a major challenge due to the exponential growth in the number of publications and the ever-growing availability of the internet favoring the emergence of online-only publications

Health Inequity

  • Health inequity refers to avoidable differences in health between different groups of people. These widespread differences are the result of unfair systems that negatively affect people’s living conditions, access to healthcare, and overall health status

Un-Integrated Electronic Medical Records

  • 40 years ago, I could access my bank account from almost any bank ATM, yet today two different hospital systems often can’t share my medical records, even in the case of an emergency.

So what technologies are being deployed to address these challenges?    One answer comes back, loud, and clear.  Artificial Intelligence (AI)!  Use cases abound.  Just a sampling includes:

  1. AI supports medical imaging analysis

– Image dependent specialties are the first to benefit including radiology, pathology, and dermatology

  1. AI can decrease the cost to develop medicines and can support drug discovery.

Supercomputers have been used to predict from databases of molecular structures which potential medicines would and would not be effective for various diseases.  AI algorithms can identify new drug applications, tracing their toxic potential as well as their mechanisms of action

  1. AI can forecast disease

In 2019, the Department of Veterans Affairs (VA) and DeepMind Health created a Machine Learning (ML) tool that can predict Acute Kidney Injury (AKI) up to 48 hours in advance

  1. AI contributes to cancer research and treatment, especially in radiation therapy

Automatic generation of clinical notes integrated with EHRs leads to a reduction of time spent by clinicians in managing patient treatment plans.

  1. AI supports health equity

The AI and ML industry has the responsibility to design healthcare systems and tools that ensure fairness and equality are met, both in data science and in clinical studies, to deliver the best possible health outcomes.

What are the other Next Big Things?

  1. Asynchronous Remote Patient Monitoring
  • Asynchronous technology is one of four modalities in telehealth. Importantly, it can standalone for effective care delivery for hundreds of low acuity conditions, or can be paired with another modality of virtual telemedicine to streamline care, including synchronous telehealth, mobile health, or remote patient monitoring (RPM).
  1. Cancer Care Innovations
  • Technologies and innovations like CRISPR, artificial intelligence, telehealth, the Infinium Assay, cryo-electron microscopy, and robotic surgery are helping accelerate progress against cancer.
  1. Medication at Home
  • The COVID-19 pandemic turned lives upside down, and the social distancing guidelines in place have exacerbated the difficulty of the task of medication management for many.
  1. Population Health Management – Big Data
  • An effective population health program will automatically identify patient care gaps, using a combination of claims data and clinical data from multiple sources. It will also use automated messaging via phone, email, or text to alert patients with care gaps that they need to make appointments to see their providers.

What else?  How about hand-held (low cost) ultrasound?  Virtual Reality for rehabilitation? Stem cell cures for diabetes?  Immunotherapies? The possibilities are endless.  Also keeping an eye on the industry.  I suspect that we are in for more consolidation as there are over 250 telehealth companies and not room for all to be successful.  Keep a close watch on Amazon, Apple, Facebook, Google, and Microsoft.  Delivering healthcare to their own employees will lead to new strategies (and acquisitions).

And Beyond telemedicine and telehealth.  I have begun looking at new technologies for answering the climate change crisis, specially a app which will help large and small providers reduce carbon emission.  I hope to have more to report as we move into the new year.

Some Dark Clouds for Telehealth

 

Warning Signs:

As a 30+ year veteran of telemedicine (mostly teleradiology and teledentistry) I have always been one of its biggest fans.  I remain enthusiastic, but there are several warning signs that should be considered.

Telehealth usage peaked in the early days of the Covid-19 pandemic and has since stabilized.  The industry is guessing where usage goes from here as pundits debate the pros and cons of utilization going forward.  While claims compared to pre-covid levels have risen significantly, a plateau seems to have been reached.

This summer, Telehealth giant Amwell reported that they expect fewer telehealth visits through the fall and winter.

https://www.fiercehealthcare.com/tech/amwell-expects-fewer-telehealth-visits-fall-winter-as-delta-variant-creates-uncertainty

 

Investing in Telehealth

An investor would have been well advised to avoid the two largest telehealth companies, Amwell and Teledoc since the beginning of 2021.  Amwell shares are down 65% and Teladoc are down 30% through mid-October. One smaller company looking to take advantage of the SPAC phenomenon, Up Health Inc., has seen a decline of 85 % YTD.  Investors continue to pour money into the sector with digital health funding reaching $15B by the end of the second quarter.

https://www.fiercehealthcare.com/digital-health/telehealth-funding-soars-to-4-2b-record-shattering-2021

An investor would have been better advised to invest in one of the companies acquired by Amwell (Silver Cloud, Conversa) or Teladoc (Livongo, In Touch in 2000).

Industry News

Also of note, Google shut down its telehealth efforts (for the second time).

https://www.businessinsider.com/google-health-shutting-down-david-feinberg-leaves-2021-8.

Haven, the Amazon-Berkshire-JPMorgan venture to disrupt health care, is disbanding after 3 years

https://www.cnbc.com/2021/01/04/haven-the-amazon-berkshire-jpmorgan-venture-to-disrupt-healthcare-is-disbanding-after-3-years.html

Closer to home, at the end of June, now ex-Gov. Andrew Cuomo allowed New York’s executive orders regarding telehealth practice across state lines to expire.

https://www.timesunion.com/opinion/article/Expiration-of-telehealth-order-devastating-for-16420352.php

The potential for fraud continues to be a threat to telehealth growth:

https://news.bloomberglaw.com/health-law-and-business/doj-targets-telemedicine-fraud-in-1-4-billion-enforcement-spree

And the biggest threat may be challenges with cyber-security.

https://www.healthcareitnews.com/news/telehealth-biggest-threat-healthcare-cybersecurity-says-report

Reimbursement

Primary care doctors are also concerned about the sustainability of virtual care. If regulations and payment restrictions on digitally delivered care relaxed temporarily during COVID-19 are restored, 41% of clinicians say their practice may not be able to continue offering telehealth. Meanwhile, roughly a fifth of clinicians have already had to pull back their use of telemedicine since payments were reduced.

https://www.healthcaredive.com/news/quiet-suffering-primary-care-struggles-covid-19-telehealth/607996/

Telehealth/ telemedicine is here to stay and may succumb to the predictions of just being part of health or medicine while the industry looks for the “Next Big Thing”.  Any Ideas?  I’d love to hear from you.

 

Howard Reis

HEALTHePRACTICES

hreis@healthepractices.com.

 

 

 

How Do You Do Teledentistry? (Revisited)

Howard Reis, President, HEALTHePRACTICES

When I first started working as the CEO of The TeleDentists up until today when I continue working with them as an advisor and Board member, I continue to get asked one common question.  “How do you do teledentistry?”  The question is a natural one as most of us think of a visit to the dentist to include a cleaning, an X-Ray and (hopefully not) a cavity repair.  I can answer the question a bit better today having the benefit of being able to review close to 10,000 teledental visits.

The reasons patients contacted The TeleDentists remained quite consistent from the first time we measured the results.  They had toothaches, bleeding gums or broken teeth.  Parents had teething children.  Seniors had problem with their dentures.

The disposition of cases also stayed quite consistent.  We were able to prescribe (non-narcotic) medications and could also get the patient an appointment to see a local dentist if that was deemed necessary.

There has been some shift in the type of questions asked as the pandemic progressed.  Patients want to know if it is safe to return to the dentist’s office.  They also want help in finding a dentist as it has become more difficult to schedule an appointment due to closed offices and some limited hours.

I’ve also been asked, “What are things that can be treated with teledentistry” (and without entering the patient’s mouth).  Here’s just a partial list of what has been experienced:

  • Do I need ortho?
  • Whitening questions—what to use, how safe?
  • Cold Sores/herpetic infection
  • Canker Sores/Aphthous Lesions
  • Sensitive teeth
  • Dry Mouth—symptoms/solutions
  • “I have an appointment Monday, but swelling started and I can’t get ahold of my dentist” palliative care/intermediate help when someone has a dentist
  • Preventive Services that can be done by NP or Med Tech:
  • Fluoride Varnish application— “immunize against decay”
  • I need a dentist referral. Don’t know any.
  • Consultation with Diabetics about improving oral health/reducing A1Cs

And there’s more.

The TeleDentists recently connected with an Accountable Care Organization in Michigan to provide connectivity to three hospital emergency rooms (and soon three urgent care centers).  Also launched is The Virtual Tooth Fairy which connects a child to a hygienist for reassurance and instructions about taking care of their teeth.

TeleDentistry also combines the E-Commerce.  At The Marketplace on The TeleDentists web site you can find solution for Dry Mouth, TMJ, missing teeth, teeth aligners among other.  See https://www.theteledentists.com/marketplace.

Looking forward we expect to see Remote Patient Monitoring, and the incorporation of Artificial Intelligence to assist in the practice of teledentistry.  I do not believe teledentistry replaces dentists.  It helps them take better care of patients, especially patients who continue to find an office visit to be difficult.  And when an office visit is necessary, both the patient and dentist can be better prepared.

Contact:  Howard Reis hreis@healthepractices.com

David and Goliath and Telehealth

Having worked with several successful telemedicine/telehealth startups, I have long been captivated with the question of, “How does an ambitious new entrant company successfully do business with a much larger, well entrenched company?” This question applies to all start-ups, but my experience in telehealth/telemedicine provides some insights which can be appreciated by all companies.

Quick background.  I have held senior business development positions with two startup teleradiology companies and recently served as CEO of The TeleDentists, a startup teledentistry company.  Both teleradiology companies achieved the status of Inc. 5000 fastest growing private companies (three times each) and were acquired as part of successful rollups.  The TeleDentists may have a similar successful fate.

The TeleDentists is the only telehealth company with licensed dentists in all 50 states.  Since the start of the Covid-19 pandemic they have successfully delivered over 10,00 consultations for patients with toothaches, broken teeth, and bleeding gums.  Early pandemic collaborations with Cigna and Anthem were true telehealth David & Goliath success stories.  On August 1, The TeleDentists began delivering service to a major hospital system in Michigan where their service is available in three hospital emergency rooms and three ambulatory care facilities.  This is a significant milestone for several reasons.  While the American Hospital Association reported that 76% of hospitals used telehealth1, this will be the first major deployment of teledentistry in a hospital.  They are still waiting for permission to announce the alliance.

It only took close to four years from initial conversation to implementation.  What took so long?

The good news is that The TeleDentists found on the hospital side a champion, an emergency room physician with a true vision of the potential for the program.  So often when working with a large organization, the champion leaves or gets re-assigned, and that was not the case here.  Even a visionary at the hospital cannot make the decision and commitment alone.  Administration, Legal, and IT were just a few of the departments which needed to be involved.  Contract negotiation, Security Audits, and Hospital Credentialing all needed to be included.  The Covid-19 crisis proved to be another hurdle as the hospital rightfully had other priorities during the crisis.

So, what are the crucial lessons learned? These are the first ones that come to mind.

  1. Need a champion with a vision, a good internal network, and a track record of prior success.
  2. Persistence and a belief that all hurdles can be overcome.
  3. Don’t put all your eggs in one basket. Look for other projects and opportunities with smaller customers that can keep you afloat while you are waiting for “the big one”.

What took so long?

  1. Contracting
    1. Lawyers – Every lawyer will have their say about a contract. One suggestion is to ask to use an agreement that the larger facility is already comfortable with.
    2. Insurance – It is understandable that the large entity wants to protect themselves, but they may require that the small entity carries types and levels of insurance that are difficult to financially justify.
  2. IT
    1. Security Audits – The larger entity will want to conduct a Security Audit. Wouldn’t it be nice if there was a way to do this once, and have an organization certify that all requirements are met?
    2. Integration – Each large hospital organization has their own EMR. Once you have performed an integration with EPIC, you have performed one integration with EPIC.  It may not be easier the second time.  Every EMR has their own unique requirements and if a hospital has undergone mergers, it may be necessary to integrate with multiple EMRs.
  3. Changes
    1. Over the course of a long negotiation, change in technology is likely. This may require re-doing steps that have already been completed.
  4. Covid-19
    1. It could not be anticipated that Covid-19 would play into the equation. Covid-19 hit Michigan especially hard.  It is still unknown how Covid will impact relationships between providers and vendors.
    2. A crisis is not necessarily a bad thing for a nimble startup company. My favorite quote during the pandemic was when our Cigna partner said, “we just got done in 6 days what usually takes us six months.”  Having the infrastructure in place to be able to respond certainly helped.

Going Forward

The challenges don’t stop with a successful initial implementation.  Training is essential and can be a challenge if done remotely.  It is essential to have a communications plan in place.  I have also seen where constant staff changes were a primary unexpected challenge in a nursing home telehealth implementation.  The hospital system has additional facilities and expansion is likely if the program is a success.

Other David and Goliath challenges.

In 220 Becker’s reported that there were 260+ telehealth companies3 and I suspect that the pandemic has launched many new ones.  It is the goal of many of these new entrants (Davids?) to be acquired by the larger ones (Goliaths?)   It certainly didn’t escape attention when Teladoc acquired Livongo for $18.5 billion just a year ago.4 If Teladoc is looking for billion-dollar deals, the startup telehealth companies have a long way to go to catch their attention.

Even partnerships can be a challenge.  If a company with $1Million in annual revenue looks to partner with a major medical distributor with $10Billion in annual revenue, the priorities may not be compatible.  A $250,000 revenue opportunity increases annual revenue by 25% for the smaller company, but only .0025% for the larger firm.  Certainly, the larger firm has other priorities to capture their attention and resources. (Please contact me a hreis@healthepractices.com to hear the details.)

The next time you hear about a David versus Goliath story, don’t think of an underdog. Think of a confident competitor who is more than happy to be underestimated.

I am also thrilled to write about the new David in my life as my grandson David turned one year old last month.  I look forward to being in his corner as he takes on the various Goliaths in his life.

Notes:

  1. https://www.aha.org/factsheet/telehealth
  2. https://www.healthcaredive.com/news/in-latest-merger-bid-beaumont-seeks-union-with-spectrum-health-to-create/602048/
  3. https://www.beckershospitalreview.com/lists/260-telehealth-companies-to-know-2020.html
  4. https://www.fiercehealthcare.com/finance/teladoc-finalizes-blockbuster-deal-livongo-less-than-three-months

3 Wishes for Telehealth

Thanks Seema Verma, then the CMS administrator, who in April 2020 declared, “the genie out of the bottle on this one”. 1

As a 30-year telemedicine veteran, now that the genie is out of the bottle, do I get my three wishes? Here’s what I would wish for.

  1. Interoperability – 40 years ago, I helped initiate home banking for both Citibank and Chemical Bank. This was on the heals of the installation of ATM machines around the country, and around the world. Soon thereafter your ATM card could access your bank account worldwide. Why is it today, 40 years later, two healthcare institutions across the street from each other still can’t share medical records? For telemedicine to be truly ubiquitous, institutions will need to share records much more easily than they do today.
  2. Collaboration – If integration is largely a Systems issue, Collaboration is mostly a personal one. Q1 2021 closed with $6.7B in US digital health funding, the most-funded quarter to date. 2  As investors pour money into all these startup companies, it is clear to me that no one company has all the answers. Collaboration will be a key to success. Here’s one example. The COVID-19 Telehealth Program provides$200 million in funding, appropriated by Congress as part of the Coronavirus Aid, Relief, and Economic Security (CARES) Act, to help health care providers provide connected care services to patients at their homes or mobile locations in response to the COVID-19 pandemic. 3 Thanks to the federal government and the funding that they are providing. Long Term Care has always been an attractive model for telehealth. Cost justification can often be achieved just by reducing the cost of transporting seniors to appointments which can readily be administered by telehealth. What’s missing is collaboration. Individual companies can provide services such as telepsychiatry, tele-ophthalmology, tele-dermatology and even teledentistry. What’s needed is one stop shopping. A single source that can be deployed which makes available a menu of services depending on demand. The most needed tele-service in nursing homes is mental health support. A next valuable service is the ability to remotely provide wound care.
  3. Integration – Do you want to provide a telemedicine solution to a hospital? It better integrate with the hospital’s EPIC system, or whatever EHR system that the hospital is using. And as the saying goes, once you’ve done one EPIC integration, you’ve done one EPIC integration. I’m all for standards and insuring the (data) quality of all connected systems, but this can also be an impediment to successful deployments.

Or can I use my last wish to wish for more wishes? 10 more wishes?

  1. Retire the term telemedicine – As Dr. Jay Sanders, known as the father of telemedicine, said, “We’re going to get rid of the term ‘telemedicine,’” Instead, remote care is going to become routine, which makes sense because the home is a better place for examining patients because clinics are sterile environments,” 4
  2. Reimbursement is still a challenge. While temporary relief has been available during the pandemic, widespread adoption is dependent on finally recognizing that telemedicine needs to be reimbursed on par with a regular doctor’s visit. And while we are at it, lets get rid of individual state licensing requirements which inhibit telemedicine’s growth.
  3. Celebrate our successes – Telemedicine can be lifesaving. Here’s just one recent example from Pacific Medical Centers. 5   More stories like this will convince our payors and legislators about the need for telemedicine.
  4. Vaporize the fraudsters – Two nurse practitioners who worked with Medicare patients in Montana admitted that they conspired to cheat Medicare of millions of dollars through exploiting Medicare’s telemedicine provisions. 6 As Telemedicine becomes ubiquitous, more stories like this are bound to emerge. They are headline-grabbing and can deter all the many benefits that can be provided.
  5. Consolidation of players – Becker’s Hospital Review identified 260+ telehealth companies in 2020 7 There are probably twice as many a year later as the pandemic saw dozens of start-ups. They can’t all survive, and consolidation will become the industry norm.
  6. Build the data – Cost savings! With a all these new telemedicine programs, outcomes become even more important. Let’s have a discussion about how to measure success of these programs, find the programs that are having successes, and figure out how to replicate.
  7. Telemedicine for All – There is a tremendous amount of good which can be provided to underserved communities. This is as true in rural America as it is in underdeveloped countries. While profitability still is elusive for even the largest of telemedicine companies, there needs to be a mechanism to provide telemedicine support in areas of need where the business case is still uncertain.
  8. Bandwidth – When I began my personal telemedicine journey (with Nynex Corp.) thirty years ago, sufficient bandwidth was an issue. Its still an issue today. Throughout pockets in the U.S. as well as around the world, telemedicine will never reach its full potential without the pipes and wires (and wireless) to ride on. Infrastructure? You bet!
  9. Encourage Innovation – Make funding available for startups with innovative ideas. Make is easier to work with large healthcare institutions that need this technology, but do not have the easy ability to work with small companies. Areas of great potential include the use of Artificial Intelligence, expanded availability of Remote Patient monitoring, and innovative ideas which are popping up all over and need to be explored.
  10. The Next Big Thing – I know its out there and I look forward to continuing to be in a position to see it when it comes.

 

Notes:

  1. https://www.beckershospitalreview.com/telehealth/the-genie-s-out-of-the-bottle-on-this-one-seema-verma-hints-at-the-future-of-telehealth-for-cms-beneficiaries.html
  2. https://rockhealth.com/reports/q1-2021-funding-report-digital-health-is-all-grown-up/
  3. https://www.fcc.gov/covid-19-telehealth-program-invoices-reimbursements
  4. https://medcitynews.com/2016/03/father-of-telemedicine/
  5. https://www.pacificmedicalcenters.org/news/parents-use-telemedicine-to-get-daughter-life-saving-care/
  6. https://www.natlawreview.com/article/united-states-department-justice-scores-another-victory-exposing-telemedicine-fraud
  7. https://www.beckershospitalreview.com/lists/260-telehealth-companies-to-know-2020.html

TeleDentistry – After the Masks Come Off

I’m feeling pretty good. It’s two weeks past my second Covid-19 vaccine. It’s gotten me thinking. When will I no longer need to wear my mask in a crowd? And what will this mean for teledentistry?

For the Patient

According to Becker’s Hospital Review1 in March 2020, 19.5 percent of Americans had a telehealth appointment, whereas 61.05 percent had in March 2021. This is also true for teledentistry where most patients have now had a previous telehealth experience, and almost always a positive one. In March 2020, 65.6 percent of Americans doubted the care quality provided in telehealth appointments, but in March 2021, 87.82 percent wanted to continue using telehealth services after the pandemic subsides. Patients do not want to always travel for their medical appointments, and they do not want to wait in a (crowded?) waiting room.

Benefits are also significant for the patient population, or specific classes of patients. The great benefit of telehealth has always been improved access. This is especially true in rural areas where a visit to the dentist may mean a trip of many hours.   The elderly, and patients with disabilities or special needs are most likely to benefit the most from a remote visit.   There are cost reductions for patients, especially those without insurance. Insurance companies benefit by keeping patients out of the emergency room. Oral hygiene can be improved reducing more serious diseases which are likely to occur if oral health issues are ignored. A visit with a teledentist is much less intimidating for a patient who has always been afraid of what may happen in the dentists’ office.

For the Dentist

While the greatest impact of Covid-19 on dental practices has been a drop in revenue, At least one study has reported that the drop was less than had been anticipated.2 In any case, teledentistry can help to make up the difference.

Teledentistry provides great benefits for individual dentists.

  1. Use teledentistry to screen patients and maximize chair time with those patients that need a procedure.
  2. Attract and meet new patients using teledentistry and meet them face-to-face and not behind PPE.
  3. Integrate teledentistry into your practice management system and provide patient education and scheduling reminders.
  4. Create the ability to consult with a specialist in real time, and with the patient included.

One expression that many dentists hear now is ‘mask mouth.’ The phrase refers to a range of symptoms associated with wearing a face mask around your mouth for long periods. It’s not an official diagnosis, but it’s become a common phrase used to describe the rise in dental problems that have resulted from increased mask-wearing. There may also be specific procedure (like teeth whitening) that become even more popular as patients no longer “put off” procedure and plan to return to their regular routines.

There are also benefits for specific groups of dentists, namely those recently retired or dentists who have become disabled. What a great way to continue to use the skills developed over a lifetime of practice without the burden of managing an office.

For the Future

Teledentistry is one of a variety of technologies that have been identified (by MedCity News) as having the most likely ability to shape the future of dentistry over the next ten years. The list also included 3D Printing, Artificial Intelligence, Digital Dentistry, Tooth Remineralization and Augmented Reality. You can read the whole article here:
https://medcitynews.com/2021/04/trends-in-the-dental-industry-dental-technology-in-the-next-decade/

 

More immediately, 2021 will see expansion of teledentistry in areas are medical-dental integration, e-commerce (via the expanded selling of dental products to patients and dentists), electronic claims processing and further integration with electronic health records. The TeleDentists will be leading the way.

 

Notes:

  1. https://www.beckershospitalreview.com/telehealth/how-american-attitudes-on-telehealth-have-changed-since-the-start-of-the-pandemic.html
  2. https://www.dentistryiq.com/practice-management/industry/article/14200344/in-2020-dental-practice-revenue-declined-6

Tele-Dentistry – The State of The Union

Teledentistry is the union of dentistry and telehealth (or telemedicine). The State of the union is very strong.

The Telehealth industry is booming. The Covid-19 virus changed everything. Research by McKinsey & Company reveals that while only 11 percent of consumers used telehealth in 2019, 46 percent were using these remote services by May of 2020 to replace canceled office visits. [1] McKinsey went further to predict that the telehealth industry could grow to a quarter of a trillion dollars. (2) Telehealth investment, according to the Mercom Capital group venture finding in digital health in 2020 came to $14.8 billion. 3 Telemedicine was the top funded category and led VC funding activity with $4.3 billion, a 139% YoY increase compared to $1.8 billion in 2019.

Last year presented unprecedented circumstances for the dental industry. From the threats of the global pandemic, to a complete shutdown, to a staggered reopening approach across the country, dental practices faced many challenges. Figuring out how to triage patients without the face-to-face option, bring in revenue, and maintain staffing levels are just a few of the issues that dentists experienced. Spending on dental care fell by up to 38% in 2020 the ADA projects. Of dentists surveyed by the trade group, more than 46% said their patient volume was down at least 15% from usual levels during the week of Oct. 5. 4 The market size of the Dentistry industry is $138.8bn in 2021. 5

Teledentistry is the use of information technology and telecommunications for dental care, consultation, education, and public awareness. One industry study said the global size of the teledentistry was expected to reach $2,214.5 Million by 2027 compared to $667 Million in 2019 6. Becker’s Dental, a leading publication identified 13 market leaders in 2020. 7 Most of these provide software for dentists to provide teledentistry to their own patients. A very few have established a network of providers.

Services provided by teledentistry are remediation, e-prescribing, and scheduling on-site appointments if necessary (usually the next business day). Conditions which can be addressed include broken teeth, lost fillings, canker sores, clear aligner monitoring, bleeding gums, parents with teething children and senior with problem dentures.

Covid-19 significantly accelerated the growth of teledentistry. Reimbursement codes for teledentistry consults were approved for the first time. As much of the population experienced their first telehealth experience, the idea of receiving telehealth support for a dental problem was no longer a foreign concept.

There are several key indicators which represent growth opportunities for teledentistry including:

  • In 2018, 39% of the US population did not see a dentist. For most people, it takes an average of 3 years for them to go into a dental appointment. That’s about 125 million people today who need dental help.
  • 8 million work and school hours were lost due to a need for dental care in the US.
  • There are more than 2 million visits every year to hospital emergency rooms for dental pain. Most emergency rooms (ER) do not have dentists on staff to provide dental treatment so patients are typically prescribed painkillers or antibiotics ,8 Visits to the ER for dental pain are costly and can range from $400 to $1,500 compared to a much less expensive visit to a teledentist.
  • 1 in 3 parents feel the pandemic has made it harder to get preventive dental care for their child; families with Medicaid may face greater barriers. 9

Several key new initiatives will accelerate teledentistry in 2021 including increased consumer awareness, integration with electronic medical records, automated claims processing, medical-dental integration, expanded e-commerce with the ability to promote dental products (both prescription and non-prescription based) and the first steps into remote patient monitoring via the availability of an innovative intra oral camera. Future innovation will incorporate the use of Artificial Intelligence (AI) and international expansion.

Notes:

 

 

Stress and Teledentistry

We live in unprecedented stressful times. There is a global pandemic with no announced cure. Unemployment in the U.S. is at historic levels. Working parents need to supervise remote learners while trying to do their own jobs remotely. Racial tensions have gripped the country. Adult children with parents in nursing homes may not be able to visit. A national election is days away with a tremendous amount of anxiety on all sides. The list goes on.

High levels of stress have been linked to a number of severe conditions, including high blood pressure, anxiety, depression, stroke, irritable bowel syndrome and a weakened immune system. Stress can also be a major factor for dental health causing conditions like bruxism (teeth grinding) dry mouth, gum disease and TMJ/TMD.

Dentists are not immune. Studies reported in dental literature confirm that dentists are subject to a variety of stress-related physical and emotional problems. These problems included an alarmingly high incidence of cardiovascular disease, ulcers, colitis, hypertension, lower back pain, eye strain, marital disharmony, alcoholism, drug addiction, mental depression and suicide.

The Covid-19 pandemic has led to a new stressful event for both patients and dentists. Going to a dental office. Appointments are more difficult to schedule. Patients are afraid that they will be subject to infection. Dentists are afraid that not enough patients will visit, and their practices have suffered.

The TeleDentists Can Help!

There are several ways The TeleDentists can help relieve these stressful situations.

  1. Video Consults. Patients can see a licensed dentist from the comfort of their own home within 10 minutes of clicking on a link with their computer or phone (theteledentists.com). If needed, medication can be prescribed and sent to a local pharmacy.
  2. Sponsored Products. The TeleDentists are promoting several products which can directly help a patient with specific conditions. (https://www.theteledentists.com/#Sponsored%20Ads)   Speed2Treat provides treatment for head, neck and jaw pain. SaliPen is a leading-edge medical device which treats dry mouth naturally.
  3. MY TeleDentist gives any practice the ability to add teledentistry to their own practice offering. https://www.theteledentists.com/myteledentist.html.
  4. If you don’t have a dentist, we can help you find one.

We do not pretend to have solutions to all the problems which are causing stress today. However, if those problems are leading to dental issues, we are here to help.

A New Dimension for Telehealth > E-Commerce

Telemedicine has been with us for sixty years.1 The Covid-19 pandemic of 2020 has brought this capability to the forefront as it is now an accepted component for the delivery of healthcare expertise.

Where do we go from here?

So many new opportunities. With Teladoc’s recent purchase of Livongo there will be more incorporation of remote patient monitoring. The largest telemedicine companies are actively raising money and more acquisitions are to be expected. I expect to see more collaboration with companies developing Artificial Intelligence tools and with academic medical centers focused on population health.

There’s been another aspect of telemedicine/telehealth which has been partially under the radar. You can use the technology to sell things, especially things which require a prescription.

Simple Contacts allows you to order contact lenses online: https://www.simplecontacts.com/

Several companies offer online birth control:

https://www.nurx.com/

https://www.simplehealth.com/

Other offer solutions for Erectile dysfunction and hair loss:

https://www.getroman.com/

 

So, what about dental products? Certainly, companies are offering teeth aligners:

https://smiledirectclub.com/

https://www.invisalign.com/

 

The TeleDentists (www.theteledentists.com) has a network of 300 dentists providing virtual consults for patients 24/7/365. These dentists can all write prescriptions. We are about to start working with Saliwell (https://saliwell.com/) to provide the SaliPen, a leading edge medical device that treats dry mouth. Another partner is providing Speed2Treat (https://www.speed2treat.com, a home healing kit for patients with head, neck and jaw pain. We are also starting a pilot program with Proctor & Gamble for their SmileAdvisor program (https://smileadvisor.com/) which is looking to match millennials with dental professionals and also promote P&G products. We have also spoken with a company which is using 3D printing for denture replacement.

 

Where does the industry go from here? Medical products and devices targeted to specific diseases or age groups.   Online wellness and education either for sale or bundled into offerings from insurance companies and medical groups. New opportunities emerge regularly, and it will be exciting to be part of future offerings.

 

Contact

Howard Reis, CEO, The TeleDentists

  1. In 1959, the University of Nebraska used interactive telemedicine to transmit neurological examinations, which is widely considered the first case of a real-time video telemedicine

How Teledentistry Has Changed – In the Past 30 Days

What has changed for teledentistry since the onset of Covid 19? In a word, everything.

For Patients

Patients can no longer visit their dentists as most offices have closed or are only seeing emergency patients. Patients can no longer go the Emergency Room for dental pain as they are standing on long lines or getting turns away. Patients are still getting toothaches. Many are finding The TeleDentists at www.theteledentists.com where they can see a dentist, usually within 10 minutes, who can remediate the problem, get a prescription sent to a local pharmacy, and get information about local dentists whose offices are open for emergencies.

For Dentists

Many have closed their offices in compliance with the American Dental Association recommendation that dentists nationwide postpone elective procedures in response to the spread of the coronavirus disease.

See: https://www.ada.org/en/publications/ada-news/2020-archive/march/ada-recommending-dentists-postpone-elective-procedures

Dozens of dentists have found The TeleDentists to be able to remotely provide service to their own patients, or patients of The TeleDentists.

For The Telehealth Industry

Established telehealth/ telemedicine providers have seen a substantial increase in patient volume especially as President Trump and Vice President Pence have extolled the benefits of telemedicine in their daily briefings and announced relaxed regulation and expanded Medicare benefits.

https://www.cms.gov/newsroom/press-releases/president-trump-expands-telehealth-benefits-medicare-beneficiaries-during-covid-19-outbreak

https://mhealthintelligence.com/news/feds-ok-interstate-licensing-paving-way-for-telehealth-expansion

Among the new policies, the CMS Fact Sheet listed these key takeaways:

  • For the duration of the emergency, Medicare will pay for telehealth services furnished to beneficiaries “in all areas of the country in all settings” at the same rate of as regular, in-person visits.
  • HHS will not conduct audits to track whether there was a prior patient-physician relationship for claims submitted during the public health emergency.
  • Patients must initiate services, but physicians may inform their patients on the availability of telehealth services.

In addition,

  • States are allowing license flexibility

The general policy regarding medical licensure and telehealth is that the physician must be licensed in the state where the patient is located at the time of treatment. The AMA telehealth guide notes that CMS has waived this requirement for Medicare patients and that states may request a waiver for Medicaid patients.

  • “Discretion” on HIPAA rules

The OCR, the HIPAA-enforcement arm of the HHS, announced that it will exercise “enforcement discretion” and would not impose penalties for noncompliance with regulatory requirements during the “good faith provision of telehealth” services during the COVID-19 national public health emergency.

·         Prescribing of Controlled Substances

The Drug Enforcement Agency (DEA) published a COVID-19 Information Page on the Diversion Control Division website, providing guidance relating to the COVID-19 public health emergency, including the ability to prescribe controlled substances via telemedicine without a prior in-person exam.

Some Telehealth companies have been forced to let patients know to expect delays. This notice was found on the web site of a major provider:

We are experiencing longer than normal wait times due to the COVID-19 pandemic.

For The TeleDentists

Significantly increased patient volumes, hundreds of interested dentists, new business opportunities, very little sleep.

We have signed agreements with two multi-state DSOs (dental service organizations) and will be implementing service for their dentists and patients this week. We are also in discussion with several major insurance companies who want to provide relief for their patients during the crisis. Our dentists have stepped up significantly. Our partners have been understanding. Our technology vendor has been able to handle the increase in volume.

Is this the turning point we hoped for which will put teledentistry on the map?

Possibly mention what is happening in Maine and Texas, and our response?

 

We at The TeleDentists are amazed and humbled by the response from healthcare workers and support staff around the country and are hoping to do our part. We pray that readers of this blog and their families are healthy and safe. We’re all in this together.

Howard Reis, CEO, The TeleDentists

 

Would You Recommend the TeleDentists to a Friend or Family Member?

The TeleDentists stepped up during the Coronavirus pandemic providing an important service during a time of critical patient need. Dental offices closed, but patients continued to get toothaches. Patients found relief by looking for solutions on the Internet or were guided to our site by two major insurance companies, Cigna and Anthem.

For most patients, this was their first experience with teledentistry, in fact it was their first experience with telehealth of any kind. We had promised our partners that we would be able to see patients in 10 minutes or less and we met that metric 99% of the time. But we also wanted to make sure our patients were satisfied with the experience. So, we asked them.

Net Promoter Score (NPS) is a management tool that can be used to gauge the loyalty of a firm’s customer relationships by asking a single question. According to the June/July 2020 issue of Fortune Magazine, it is a tool which is used by 2/3 of the Fortune 1000 companies.

But it can be easily used by small companies such as ours. The question we asked,

“Would you refer a friend or family member to The TeleDentist service?”

Patients were asked to rate us from 0 (not very likely) to 10 (very likely). Results can range from -100 to +100. Our results were “off the charts” positive as we scored an 82.

Companies are usually compared to others in their field, and below is a chart of average NPS by industry with a range of 27 to 71.

This article from 2017 says that the average NPS for dental providers is “1”.

https://www.dentistryiq.com/practice-management/patient-relationships/article/16365771/survey-says-dental-patients-are-dissatisfied-solving-the-patient-experience-problem

This article says that Teledoc has an average NPS of “9” and that we even beat the very highest ranked companies, Costco and Starbucks.

https://customer.guru/net-promoter-score/teladoc-inc

 

Many companies, when reviewing the results of their first NPS survey are in a position off asking themselves, “How can we do better?”. We, the TeleDentists are in the fortunate position of asking, “How do we keep doing what we’re doing?”. We are very conscious of the fact that the results are largely a factor of the ability of a qualified dentist to provide expert relief at the time of patient need. Delivering a service which is valued by its customers is one way that a small company becomes a larger one.

 

Telemedicine for Millennials

The Millennial generation is the biggest in US history—even bigger than the Baby Boomers.  They value (among other things) Innovation, Convenience and Experiences. Has telemedicine found the demographic group which will make this delivery system a ubiquitous component of medicine?    Several new service offerings suggest that perhaps it has.

Slingshot – https://www.slingshothealth.com/ – Is a marketplace which allows you to book an appointment online with a doctor near your location at a price you are willing to pay.

Uberdoc – https://uber-docs.com/ – Gets you a guaranteed appointment with the best specialist for you, without being put on hold, needing a referral or waiting many weeks

XpertCare – https://xpertcare.online/ – Is a network of Pediatric Subspecialists who provide e-Consults to pediatric primary providers and is about to launch its direct-to-the consumer service.

Millennials (anyone) can currently purchase:

A recent count showed over 220 active telemedicine/telehealth providers happy to provide online assistance to parents looking for immediate attention to their children’s medical needs.  For example, a child is teething in the middle of the night? The parent can See The Teledentists at www.theteledentists.com

91% of employers are expected to offer telemedicine by 2020, according to a First Stop Health survey of midsize to large employers.

Earlier this year, Healthcare IT News reported on a new study that showed millennials rate telehealth as “extremely or very important” to their choice of medical provider.

Media Logic suggests that some of the most salient statistics on millennials and their comfort level with telehealth include:

  • 74% prefer a telemedicine visit to an in-person appointment.
  • 26% would switch current doctors over one that offers telehealth.
  • 71% want to be able to book their appointment through a mobile app.
  • 75% that have used telehealth rated it as superior to a traditional on-site office visit.

This study says millennials are the age group most likely to use telehealth, especially for mental health:

https://static.americanwell.com/app/uploads/2019/08/American-Well-Consumer-Survey-Age-18-34.pdf

That’s not to say that there won’t be hurdles.

While the vast majority of midsize to large employers offer a telemedicine benefit, less than 2% have used the service, according to Willis Towers Watson’s 2018 Annual Changes Ahead Survey.

Visibly (formerly Opternative) was forced to recall its online vision test https://www.optometrytimes.com/news/visibly-formerly-opternative-recalls-online-vision-test

The California Dental Association was instrumental in passing a law that offers protections for patients using teledentistry (for tele-orthodontia).

https://www.ada.org/en/publications/ada-news/2019-archive/october/california-passes-law-strengthening-teledentistry-requirements

So, with additional popularity comes controversy.  If the services are cost effective, easy to use, and available on a mobile phone, it looks like they are here to stay.

How Do You Do Teledentistry?

When speaking to former colleagues in telecommunications, teleradiology, or telemedicine about my new opportunity in teledentistry, often the first question I get is, “How do you do teledentistry?”

Good question. A prospective client recently asked, “What are things that can be treated with teledentistry” (and without entering the patient’s mouth).

The TeleDentists (www.theteledentists.con) replied:

  • Tooth eruption
  • Do I need ortho?
  • Whitening questions—what to use, how safe?
  • Cold Sores/herpetic infection
  • Canker Sores/Aphthous Lesions
  • Gums bleed when brushing teeth
  • Sensitive teeth
  • Dry Mouth—symptoms/solutions
  • “I have an appointment Monday, but swelling started and I can’t get ahold of my dentist” palliative care/intermediate help when someone has a dentist
  • Oral Health Assessment Survey (available online or at the clinic) Education from a dental specialist about improving your score.
  • Preventive Services that can be done by NP or Med Tech:
  • Fluoride Varnish application— “immunize against decay”
  • I need a dentist referral. Don’t know any.
  • Consultation with Diabetics about improving oral health/reducing A1Cs

And there’s more.

The TeleDentists will shortly launch a service to provide Dental Second Opinions for patients which have been told that they need extensive and expensive dental work and would like an independent third party to provide them with confirmation.

As with telemedicine, there is no clear definition of what to include under the teledentistry umbrella.

SmileDirectClub, a company which providers aligners via telemedicine recently filed their IPO.

https://www.prnewswire.com/news-releases/smile-direct-club-files-registration-statement-with-sec-for-proposed-initial-public-offering-300902903.html

This was not without controversy as the American Dental Association filed a complaint with the FTC against SmileDirectClub.

https://www.cda.org/news-events/ada-files-complaint-with-federal-trade-commission-against-smiledirectclub

Going forward, there are several Artificial Intelligence (AI) companies which are looking to see how their software can assist in the practice of remote dentistry.

https://www.hellopearl.com/index

https://www.videahealth.io/

In any case……Expanding oral health access via telecommunication is essential to overall public health and wellness, and teledentistry is a critical piece of this industry transformation.

 

And Now, TeleDentistry

Teleradiology?  Main stream.1 Tele-Psychiatry – Common practice and being used for 50 years.2 Tele-Stroke and Tele- ICU have found their place in hospitals across the country.  And now the emergence of companies dedicated to sub-specialty telemedicine.  Teledermatology, Telecardiology, Tele-orthopedics, Telepathology, Tele-ophthalmology, Tele-obstetrics, Tele-pediatrics. And now, Teledentistry.

Teledentistry is the use of information technology and telecommunications for dental care, consultation, education, and public awareness.

Maria Kunstadter, DDS, co-founder of The TeleDentists who has been in practice for more than 35 years, says, “We are solving an unmet market need. Nearly 6 million people annually experience an urgent dental problem and lack access to a regular dentist or are unable to find a dentist who can see them quickly.” Emergency department (ED) dental visits are a significant, costly public health problem. A study documents more than 2 million annual emergency department (ED) visits in the United States for nontraumatic dental problems.

It must be “a thing” as next week I will be attending a conference dedicated to teledentistry.3

How much do you need to see inside the mouth?

Here’s an answer from the FAQ section on the TeleDentists web site: 4

Reaching a preliminary idea about what’s happening in your mouth starts with a discussion. You tell what it feels like, we ask questions, we see you on the video, and then we can discuss various possibilities and outcomes. Definitive treatment will happen when you see your new dentist.

I see four primary ways in which teledentistry will be delivered:

  1. Providing dental expertise via existing telehealth solution providers
  2. Providing fixed site solutions to hospitals, clinics, FQHCs, and employer health centers
  3. Enabling existing dental practices to offer a service to existing (and future) patients for after-hour, emergency, or consultative support without requiring a visit to the office.
  4. Direct to the consumer via dedicated web site and enhance mHealth tools.

Which one of these will prevail?  Next week I am privileged with the task of having to figure this out as I become CEO of TheTeleDentists.

I feel somewhat uniquely qualified to do this.  I certainly know more about dentistry (as a patient) than I did about radiology when I dove full time into teleradiology 12 years ago.  I have helped two separate teleradiology company achieve the status of a place in the Inc. 5000 list of fastest growing private companies.  In addition to the nuts and bolts of telemedicine (licensing, credentialing, scheduling, recruiting), I have seen first hand what it takes to make a telemedicine operation successful:

  1. A dedication to Quality service (thank you Dr. David Cohen, founder of Teleradiology Specialists)
  2. A team of support staff dedicated to the operation as well as patient care
  3. Flexibility to adjust to the needs of the market

I walk into this with the knowledge that a start-up company faces many challenges and that there are more failures than successes.  I am confident that there is a market need.  While there are dozens of teleradiology companies and almost as many tele-psychiatry companies, no one else has built a network of dentists ready to perform this task.

Stay tuned.

 

Notes:

  1. According to a recent Research and Markets report, the global teleradiology market is on the upswing and is forecasted to reach $8.2 billion by 2024
  2. In 1969, Massachusetts General Hospital (MGH) provided psychiatric consultations of adults and children at a Logan International Airport health clinic. During the 1970s-80s it became increasingly common, expanding to most diagnostic and therapeutic interactions.
  3. Rochester teledentistry conference; https://www.urmc.rochester.edu/dentistry/education/continuing-education/teledentistry-conference.aspx
  4. https://www.theteledentists.com/faqs.html

 

Im-Patient Portals (and Im-Perfect EHRs)

I recently had a medical imaging exam.  The procedure went smoothly and the results (report and images) were soon available to me on the patient portal established by the radiology provider.  The referring physician, of course had their own portal with a separate log-in and user interface.  Fortunately, I know to request of a CD from the imaging center, otherwise the referring physician would not have (without my permission) access to my images.  If I needed hospitalization, here too would be a challenge of report access and easy interoperability.  There must be a better way.

Here’s my list of what I would like to see in a Patient portal:

  • Single sign on across all my providers
  • Appointment scheduling – Reminders (who’s frequency I can control)
  • Ability to provide access to any physician at my choosing
  • Ability to share with caregiver
  • Billing information included and accessible
  • No more clip boards!
  • Complete medical history
  • My medications
  • Access to medical information – conditions, medications, alternatives, reviews
  • Reports in understandable English
  • Image sharing
  • List of recommended physicians – on or off my plan
  • Integrate chat – see https://conversahealth.com/

Is this a pipe dream, or might I actually see this in my lifetime?  And I’m not even talking about video conferencing with my physician (or an available physician) after hours with the ability to record the conversation and include access to it through the portal.

So where did all this come from?  A concept called Meaningful Use.

The American Reinvestment & Recovery Act (ARRA) was enacted on February 17, 2009. ARRA included many measures to modernize our nation’s infrastructure, one of which was the “Health Information Technology for Economic and Clinical Health (HITECH) Act”. The HITECH Act supported the concept of electronic health records – meaningful use [EHR-MU], an effort led by Centers for Medicare & Medicaid Services (CMS) and the Office of the National Coordinator for Health IT (ONC). HITECH proposed the meaningful use of interoperable electronic health records throughout the United States health care delivery system as a critical national goal.

As a core measure of Stage 1 Meaningful Use, eligible professionals had to provide patients with the ability to view online, download, and transmit their health information.  There are however, well documented problems with EMRs.

  1. Burnout – The American healthcare system is going through a burnout epidemic and EMRs have been identified as one of the causes. See

https://www.beckershospitalreview.com/ehrs/6-stats-on-ehr-related-physician-burnout-and-7-tips-to-combat-it.html

  1. Bankruptcy – EHR system cost has contributed to bankruptcy at several hospitals. Here’s one example:

https://ehrintelligence.com/news/ehr-system-costs-contributed-to-bankruptcy-at-3-mi-hospitals

  1. Interoperability – In March of 2017 it was reported that there were approximately 1,100 EHR vendors – and there has not been much market shakeout. Each market vertical (hospital, urgent care, long-term care, specialty practices, university clinics…) have their favorite.  And they don’t talk to each other.  Here are some charts that highlight the issue.

https://www.healthcareitnews.com/news/why-ehr-data-interoperability-such-mess-3-charts

I don’t see the situation getting better anytime soon.  Microsoft and Google had tried to introduce personal health portals, without much success.  They haven’t given up and Apple has entered the field, especially as they explore uses of Artificial Intelligence and Data Mining.

https://ehrintelligence.com/news/how-google-microsoft-apple-are-impacting-ehr-use-in-healthcare

I suspect Amazon and Facebook won’t be far behind.

Can Telemedicine Help My Mother?

Mom turned 90 this year.  She is in relatively good health with no life-threatening illnesses.  She lives in a well-appointed independent living facility about 30 minutes from my home.  In the past few weeks I have taken Mom on several medical appointments and having been involved in telemedicine for close to 30 years, I ask the question, could telemedicine help?

Mom is not computer savvy, not that she doesn’t want to be.  Dad was the user of the family computer until he passed away ten years ago.  If he had taught Mom how to use his computer, we wouldn’t be in the situation we are in in today.  I have tried to get Mom on line with both the PC and a tablet.  Poor hand-eye coordination and a shrinking attention span have made this task impossible.    She uses a flip phone rather than a smart phone and likes the Jitterbug from Greatcall (https://www.greatcall.com/) because “it has big buttons and a big display”.

Mom has several medical conditions that need regular attention.  She has macular degeneration in her eyes, a severe hearing loss, and an increasing complex orthopedic condition with both feet.  Let’s see how telemedicine could help.

Mom gets regular injections to prevent her macular degeneration from getting worse.  No telemedicine there.  But tele-ophthalmology is now becoming an available service.  In New York City, Columbia Ophthalmology is taking the fight against the leading causes of blindness out of the traditional clinic and onto the streets. The Department’s new mobile tele-ophthalmology unit will be serving neighborhoods with populations at high-risk for eye disease.   https://www.columbiaeye.org/Tele-Ophthalmology.

Mom has been wearing hearing aids for the past two years and it’s been a struggle.  The biggest challenge has been learning how to properly put in the hearing aids.  An on-line video showing how to install the hearing aids is available (https://www.youtube.com/watch?v=XmlIJCIF-ys&list=PLAEwIo2bHQMwzpOQK–L6VbGFkAccRb4J&index=3) but this assumes one can get on line.  Another advance has been new technology for hearing testing.  dB Diagnostics (http://www.dbdsys.com/) is a startup that has developed a hardware/software system that enables medical providers to test their patients for hearing loss.  If hearing loss is caught early-on, learning the proper use of hearing aids would be most beneficial.

To help treat her orthopedic condition, she needed to go to a nearby imaging center for x-rays of her feet.  While the local radiologists were happy to send the podiatrist their report, they didn’t want to send the images.  I asked for a CD with the images and hand delivered it to the podiatrist.  An image sharing service like https://www.lifeimage.com/ would have made this much simpler, and I’m sure my friends at www.teleradiologyspecialists.com would have been happy to review the images and write the report.

Even though Mom is surrounded by many peers at the Independent Living facility, she still misses her family.  A telemedicine system should easily enable video visits, cut down on transportation for medical appointments and enable remote monitoring should a condition become chronic.

So, here’s my wish list for Mom, or for other mostly independent seniors who could use a technology boost:

  • An easy to use system that perhaps uses her home television as the primary screen with a very easy to navigate user interface (touch screen?)
  • Easy ability to include family members in on-line visits.
  • Ability to schedule appointments with all her providers and the ability to speak to them on-line when needed.
  • Appointment reminders.
  • A list of her current medications which can be shared electronically with a new provider when an appointment is made.
  • Medication reminders.
  • No more clipboards!
  • Ability to monitor her apartment and send an alert in case of a fall.
  • An individual physically in her facility that is comfortable with the technology and can provide on-site assistance when necessary (not sure who pays for this)
  • An on-line assistant who can guide her through any technical issues.
  • A complete revision of out-of-date Medicare regulations regarding telemedicine reimbursement (because CMS will actually be saving money when systems like this are in full use.)

I am confident that this service will be in place within the next ten years.  Perhaps not is time to help my mother.  Surely in time to help me navigate an increasingly complex medical system as my own needs continue to change.

Trip Report – Four Weeks, Four Conferences

I have just returned from a whirlwind of travel, attending four conferences in four weeks, all related to the fields of telemedicine and medical imaging. I am sharing some brief observations.

NAOHP – National Association of Occupational Health Providers – Nashville Tennessee

Occupational health is a field of health care made up of multiple disciplines dedicated to the well-being and safety of employees in the workplace. It has a strong focus on injury prevention and employee education. Occupational health services include employee wellness, pre-placement testing, ergonomics, occupational therapy, occupational medicine, and more. Ryan Associates hosts a professional conference for Occupational Health providers.

I attended representing Teleradiology Specialists. Of significant interest to attendees was the ability to provide B-Reads. The B-reading is a special reading of a standard chest x-ray film performed by a physician certified by the National Institute for Occupational Safety and Health (NIOSH). The reading looks for changes on the chest x-ray that may indicate exposure and disease caused by agents such as asbestos or silica.

There are a limited number (< 200) of B-readers nationwide and the four employed by Teleradiology Specialists promise to deliver their results within 24 hours at very reasonable prices.

PATH – Partnership for Artificial Intelligence and Automation in Healthcare – Washington, D.C.

https://pathhealth.com

First conference for this new organization created by Jonathan Linkous the founding CEO of the American Telemedicine Association and Mary Ann Liebert, founder, president, and CEO of Mary Ann Liebert, Inc. is one of the world’s best known and most respected publishers of scientific and medical books, journals, and digital information in fields such as telemedicine, health transformation, big data, and CRISPR.

If you are looking for the Next Big Thing in telemedicine and medical imaging, this is it. Artificial intelligence is the rage and hot topic of many conferences right now (even bigger than Block Chain) and the organizers assembled an all-star group of speakers to help the audience understand the nuances of machine learning, deep learning and how this might all work in conjunction with robotics and medical imaging. Dr. Eliot Siegel, Professor and Vice Chair at the University of Maryland School of Medicine is worth the price of admission at any conference where he is on the agenda.

SPS – Telemedicine & Telehealth Service Provider Summit – Glendale, AZ.
https://ttspsworld.com

Organized by the Arizona Telemedicine Program, SPS is a national conference focusing on linking telemedicine and telehealth service provider companies with hospitals, healthcare systems, clinics and others who need their services. SPS is about bringing better healthcare to patients, communities, and populations; improving outcomes; and reducing costs. It is about helping hospitals and healthcare systems to thrive through partnerships with telemedicine providers.

One unique feature of this conference was “lighting rounds” with all the (40?) conference vendors which were two-minute interviews form the trade show floor broadcast into to conference auditorium where the (400?) conference attendees could hear the vendor pitches between scheduled speakers and could decide which vendors they wanted to visit during the breaks. The interviews were conducted by Dale C. Alverson, MD, FATA, FAAP Medical Director, Center for Telehealth, University of New Mexico Health Sciences Center and Elizabeth A. Krupinski, Professor and Vice Chair of Research Department of Radiology and Imaging Services, Emory University School of Medicine.

UCA – Urgent Care Association – Houston, TX

https://www.ucaoa.org

UCA is the largest, most notable trade and professional association in urgent care with more than 3,300-member centers representing urgent care clinical and business professionals from the United States and abroad. This was the last fall conference as the organization is switching to a once-a-year event starting in April of 2019.

Attending with Teleradiology Specialists, it is always a pleasure to meet with so many customers at the meeting. While there is always an opportunity to hear what we can do better, generally speaking all clients continued to be thrilled with the support and service they are receiving.

Always on the lookout for new opportunities, it was exciting to hear about companies making great strides in concussion management, rule-based scheduling, and once again, artificial intelligence for radiology interpretations (chest x-rays). Please contact me directly for additional information on any of these.

Next up, RSNA – Radiological Society of North America, the largest medical trade show in the U.S.

http://www.rsna.org/

For additional information on any of the above, contact Howard Reis at hreis@healthepractices.com

Telemedicine and Long-term Care Update

In 30+ years of exploring the benefits and challenges for widespread adoption of telemedicine one barrier has been prevalent from the beginning. Reimbursement for telemedicine has been steadily improving by most payers including individual State Medicaid programs and major insurance companies with one significant exception-Medicare remains a major obstacle. This has been particularly inhibiting for long-term care as seniors are almost universally dependent on Medicare for their healthcare coverage and Medicare has regulations in place that prevent access to healthcare services via Telemedicine. Medicare limits access to healthcare provided through Telemedicine based on a narrow rural designation that in affect prevents access to critically needed healthcare for seniors throughout the country.   Most long-term care facilities do not meet the Medicare “rural designation” and therefore these seniors are prevented from accessing physicians and other healthcare providers via Telemedicine whereas a resident with only Medicaid would be allowed such access to care.

This is about to change.

CMS’ proposed 2019 Medicare Physician Fee Schedule and Quality Payment Program includes coverage of telehealth-based check-in services and support for remote patient monitoring programs. The proposals would also benefit providers who want to use virtual health technology to consult with a patient instead of an in-person visit. CMS’ plan to increase the use of virtual care focuses on three procedures. Under the proposed rule changes, CMS will begin reimbursing for virtual check-in services and remote evaluation of recorded image and video submitted by patients, as well as expanding reimbursement opportunities for “prolonged preventive services.”

  • Public comments on the proposals are due by September 10.

The Castleton Group (TCG) is especially encouraged by these developments. TCG has established a Telemedicine demonstration center at Grand Manor Nursing Home in Bronx, New York with plans to replicate components of the program in other nursing homes in New York State and beyond. At Grand Manor, the telemedicine pilot program is being used for resident admissions, pulmonary and cardiac evaluations as well as, access to additional physician specialists. The trial pilot program will soon expand and include St. Barnabas Hospital; Bronx, New York whose, primary goal is to reduce unnecessary post-operative surgical visits to physician offices and clinics, and when a patient is discharged to a skilled nursing facility for the provision of subacute rehabilitation services.

TCG has identified several additional program components including remote medication management and access to mental health professionals (telepsychiatry).

The benefits of Telemedicine for the patient, the provider and the payer remain consistent

  • Timely access to health services
  • Improved patient satisfaction
  • Reduced patient readmission
  • Lower costs (especially for patient transport)
  • Improved communication for facilities with multiple locations
  • Improved quality scores (and value) for the facility
  • Improved staff education and morale
  • Improved recruitment and retention of providers
  • Most importantly -Better Patient Care

These benefits can be quantified for individual locations. And now, with the new proposed fee schedule, reimbursement can be calculated on a procedure by procedure basis.

According to CMS, “We now realize that advances in communications technology have changed patients’ and practitioners’ expectations regarding the quantity and quality of information that can be conveyed via communications technology.

“A facility operator faces multiple challenges in today’s environment and Telemedicine is just one of them.” according to Skip Rodenbush CEO of TCG.     Telemedicine represents an opportunity to meet and exceed requirements. The winners will be those that embrace experts in Telemedicine in coordination with their own individual facilities.”

Telemedicine in a Bronx Nursing Home

Grand Manor Nursing & Rehabilitation Center has initiated a Telemedicine Pilot Program. The main goal of this DSRIP funded Telemedicine pilot is to increase quality of care for the residents through timely physician consultation visits via telemedicine.

Changes in a resident’s physical condition can necessitate the need for an immediate assessment and additional actions to be taken by a physician. This pilot program allows for physicians to consult with the resident, via the telemedicine system avoiding unnecessary transfer to the hospital. A nurse at the patient site who participates in the telemedicine consultation can assist in providing the physician with additional information that at times a physician lacks when conducting a visit in their office and or clinic setting.

The Telemedicine Pilot Program implementation is supported by The Castleton Group, telemedicine carts were provided and implemented by AMD Telemedicine and a non-invasive cardiac monitor was provided and implemented by My Health Connection. Some elements of the telemedicine pilot program are being used for resident admissions, pulmonary and cardiac evaluations as well as, access to additional physician specialists, not easily accessed within a skilled nursing facility.  The trial pilot program will soon expand and include St. Barnabas Hospital; Bronx, New York whose, primary goal is to reduce unnecessary post-operative surgical visits to physician offices and clinics, and when a patient is discharged to a skilled nursing facility for the provision of subacute rehabilitation services. For additional information, contact Lowell Feldman at lowellsfeldman@gmail.com

For additional information:

www.thecastletongroup.com

www.amdtelemedicine.com

www.myhealthconnection.tv


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