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

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.

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.”

Traditionally telemedicine has always involved real-time face-to-face communications directly between physicians or between doctors and patients. Meanwhile, teleradiology is a store-and-forward technology where doctors remotely read medical images sent to them from many facilities and provide their diagnosis. The question is whether there a way to combine these two and provide benefits not otherwise available?

Teleradiology Use Case Models

Here are several potential use cases that have looked promising over the years:

3-way consults – A three-way video consultation between a radiologist, a referring physician and a patient, with the ability to display a medical image. A variation of this could be adding a family member into the conversation. This would provide patients with a better understanding of their medical condition and help with their decision-making about a recommended procedure. The drawbacks: determining how physicians get compensated for this type of consultation and also a concern about the impact on radiologist productivity. Perhaps this is best left to academic medical centers.

doctor-to-doctor consults – A second use case is a physician-to-physician consultation to discuss critical findings. This capability has been demonstrated by Johns Hopkins at a recent RSNA meeting but has not yet seen a commercially viable implementation.

real-time consults during exams – Next is the combining of telemedicine and teleradiology primarily for live consultation between medical professionals during pathology, ultrasound and other radiology examinations. This is currently being done by the vendor Remote Medical Technologies. The disadvantage of replicating this model is the time and effort required to train technologists on ultrasound. It could also be improved upon by adding a camera in the exam room to provide much user guidance.

direct-to-consumer – The telehealth case now being introduced is for direct-to-consumer second opinion consultations.

Second Opinion Teleradiology: The Winning Model

In 2016, there were more than 1,250,000 online patient consultations¹.
Patients are becoming comfortable receiving medical information over their computers without having to make the trip to a medical facility which may be many miles away and pose challenges of transportation and long waiting room times. In a recent study², the Mayo Clinic reports that as many as 88 percent of patients seeking a medical second opinion received a new or refined diagnosis – changing their care plan and potentially their lives. Surely the potential of a second doctor’s opinion can help a patient facing an important medical decision.

This year at the American Telemedicine Association meeting, VSee, the telemedicine company for NASA Space Station, and Teleradiology Specialists, a leader in teleradiology, are announcing their partnership in offering direct-to-consumer Radiology Second Opinions and paving the way towards the marriage of telemedicine and teleradiology.

How Does Second Opinion Teleradiology Work?

With the new Radiology Second Opinions service, patients can now directly have their medical images viewed by another board-certified radiologist and receive a written report in just a few of days without going through delays in appointment scheduling and another trip to a provider.

First, a patient receiving an imaging exam (X-ray, Ultrasound, Mammogram, CT, MR) will need to request a copy of their exam from the imaging facility when they check out – usually provided on a CD or perhaps via a patient portal. (The provider is obligated to do this, although there may be a $5 charge for a CD.)

Then the patient uploads the image to Teleradiology Specialists from her home computer. The patient can also ask specific questions at the time she submits the study for a second opinion. The patient will be billed according to fee schedule based on the type of exam. Results are returned in one to three days.

With this second opinion teleradiology option, patients can quickly receive accurate image interpretations with thorough reports, and gain peace of mind. Patients can also take these results to their own physician for feedback. In the future, face-to-face consultation services may also be added.

Contact hreis@teleradiologyspecialists.com for additional information.

The numbers are staggering. Every day, in 2016, more than 115 Americans died after overdosing on opioids.^*1  The misuse of and addiction to opioids—including prescription pain relievers, heroin, and synthetic opioids such as fentanyl—is a serious national crisis that affects public health as well as social and economic welfare. A leading research group declares that this has become a $1 trillion problem for the United States^*2.

A recent excellent article in JAMA states, “not all well-intentioned approaches to addressing the opioid epidemic are good ideas. Some are based on evidence and experience, others on misunderstanding, blame, fear, or frustration. What’s needed in 2018 is the wisdom—and the courage—to tell the difference”

https://newsatjama.jama.com/2018/01/03/jama-forum-a-new-years-wish-on-opioids/

Can Telemedicine Help?

Robert C. Bollinger, MD, MPH, is a Professor of Infectious Diseases in the Department of Medicine of the Johns Hopkins School of Medicine and he identified four ways in which telemedicine can help to address the opioid epidemic:

1. Telemedicine can help to extend the reach of care teams. For example, Impact Healthcare — a SUD (Substance Use Disorders) treatment facility in Jackson, Tenn. — is using mobile technology to keep in touch with patients while also reducing the amount of time that they have to spend commuting to and from the office. This process is saving some patients hours of travel time

2. Leverage asynchronous technology — meaning that patients and providers can be “online” at different times — allows providers to use their time more efficiently.

3. Telemedicine can provide more information about a patient’s response to treatment, enabling providers to make data-driven decisions about his or her care plan.

4. Telemedicine provides a more timely response to problems with adherence and allows providers to more clearly identify exactly why, when, and where a patient has problems taking his or her medication without having to wait until they come in to talk about it.

Project Lazarus (https://www.projectlazarus.org/home) is a non-profit organization that provides training and technical assistance to communities and clinicians addressing prescription medication issues. Established in 2007, as a response to extremely high overdose mortality rates in Wilkes County, NC, Project Lazarus successfully and dramatically decreased Wilkes’ overdose mortality rate by devising and implementing what is now known as the Project Lazarus Model, a public health model based on the twin premises that overdose deaths are preventable and that all communities are responsible for their own health.  Using experience, data, and compassion they empower communities and individuals to prevent overdoses and opioid poisonings, establish effective substance use / disease of addiction treatment and support, and meet the needs of those living with pain.

One of the challenges facing Project Lazarus is that the process is labor intensive and it is difficult to reach all the rural communities in need of assistance. The Castleton Group (www.thecastletongroup.com) has worked together to create Project Lazarus 2020 (PL2020) based on Telehealth technology to overcome community replication challenges and scale Project Lazarus nationwide.

PL2020 streamlines replication, extends and delivers care utilizing a FDA approved, HIPAA secure cloud based Telehealth Platform. PL2020 is customizable to each community’s unique needs and eliminates capital equipment purchases for a nominal monthly subscription fee. Fred W. Brason II, Co-Founder, Project Lazarus identified the various areas in which telemedicine can reach community participants and expand the reach of their existing efforts.

Telehealth/Telemedicine Project Lazarus Model Utilization

PL 2020 is in discussion with several communities to establish a reference site for its efforts. Keep an eye out here for future developments and contact us directly if you know of a community looking for a tool to help battle this epidemic.

References
1 * https://www.cdc.gov/drugoverdose/epidemic/index.html

2 * https://www.behavioral.net/article/prescription-drug-abuse/opioid-crisis-now-1-trillion-problem?utm_campaign=Rx%20Summit&utm_medium=email&_hsenc=p2ANqtz-_y7l0mpYwe6uwIxfcb0efceBWX0OOBTGCY_G83qcNYo-qdFEMtF7sjB25Kx45ZeNQHXPK01C2KR1Bpo8MiXX28GsLscakYLQzWlXG8I8yPu8rWo2w&_hsmi=60710418&utm_content=60710418&utm_source=hs_email&hsCtaTracking=cc3a94b4-ad2e-4a86-88c6-feb657b61583%7C5c531e66-a66b-408a-afe9-2493be89475f

The industry has evolved and it’s still a confusing picture.  There are several key components of telemedicine including:

> Live Video Conferencing – between physician (or other healthcare practitioner) and patient (or physician and physician)

> Store-and-Forward – the transmission of a patient’s record or data to a healthcare provider

> Remote Patient Monitoring – the collection and transmission of a patient’s health and medical data in real time to a caregiver

> Mobile Health (mHealth)– using any mobile communications device, including smartphones and tablets, along with hundreds of software applications to support healthcare.

Let’s not debate the difference between telemedicine and telehealth, for this article they are one and the same.

In his just published cHealth blog, Dr. Joseph Kvedar of Partners Health care talks about the importance of adding Remote Patient Monitoring to a telehealth service:  https://chealthblog.connectedhealth.org. Simply put, “Remote monitoring is critical to move us from one-to-one models of care delivery to one-to-many.”

Telemedicine programs have evolved to support specific disease conditions such as diabetes and congestive heart failure.  Target populations include geriatric and pediatric patients. Specialties have emerged in areas such as tele-psychiatry, tele-pathology, tele-dermatology, tele-ophthalmology and my personal favorite, teleradiology.   By my count, there are over 120 commercial telemedicine/telehealth providers and close to another 100 teleradiology companies.

Several firms have raised tens of millions of dollars to develop and promote their services.  Here is a list of 11 top companies:  http://www.healthcareitnews.com/news/comparing-11-top-telehealth-platforms-company-execs-tout-quality-safety-ehr-integrations. One Teledoc (TDOC) is publicly traded (but still not profitable).  Most of these target insurance companies who now offer telemedicine to their clients and recent data shows that 70% of larger employers offering telehealth as a benefit (although utilization remains low).   I’m happy to represent one below-the-radar company with an outstanding feature set, www.myhealthconnection.tv.   Telemedicine has been shown to provide great clinical benefits to under-served populations (third world countries and rural areas) but economic justification remains elusive.  Here is a recent article describing 8 reasons why telehealth is gaining momentum right now: http://www.healthcareitnews.com/news/8-reasons-why-telehealth-gaining-momentum-right-now

Many hospitals now offer telemedicine services with a major focus on reducing hospital re-admission to avoid Medicare penalties.  Most hospitals use a teleradiology company to cover overnight shifts, but that trend has shifted somewhat as radiology groups are reorganizing to capture lost revenue. Barriers to telemedicine acceptance exist including those of regulation and reimbursement but through lobbying and educational efforts, those are finally changing (as now most of the states have parity laws for the reimbursement of telemedicine).  Medicare remains a stubborn hold out. The annual American Telemedicine Association meeting in 2017 had over 6000 attendees.

On a personal note, in conjunction with www.thecasteltongroup.com we have just submitted a proposal to be considered as part of the “First 1000 Days on Medicaid Initiative sponsored by the New York State Department of Health. See https://www.health.ny.gov/health_care/medicaid/redesign/first_1000.htm.  We have proposed five telemedicine pilots as part of this program and we should know the status by the end of this month.  Stay tuned.  And stay tuned for next month’s “The Future of Telemedicine”.

The global market for telemedicine was valued at approximately $18.20 billion in 2016 and is expected to reach approximately $38.00 billion by 2022.¹  The global teleradiology market was valued at approximately $ 1.91 billion in 2016 and is expected to generate revenue of around $ 4.75 billion by end of 2022. ²

By my count, there are 87 commercial teleradiology companies in the U.S., most of which are providing nighttime (nighthawk) reading of radiology exams for U.S. hospitals with more than 50% of hospitals using this service.  One company has found an interesting and profitable niche.  With all those nighthawk companies competing why not offer a “dayhawk” service to clinics, imaging centers, mobile medical companies and specialty physician practices?  Teleradiology Specialists has done just that.  Their niche?  Urgent Care Centers.

There are 7,357 urgent care centers in the U.S., according to Urgent Care Association of America’s 2016 Benchmarking Report. The number marks an increase from 2015’s count of 6,707 (+ 10%).  As of September 1, 2017, Teleradiology Specialists is reading exams for more than 1,600 centers (> 20%).  While just about all urgent care centers provide x-ray services, they do not have a radiologist on site.  Very few provide advanced imaging and several are beginning to offer ultrasound exams.  Net, net that’s a lot of x-rays.  On a busy Monday (Monday is always the busiest) Teleradiology Specialists can expect to read 7500 exams from centers in 44 states.  That’s done with a group of 85 radiologists who like reading x-rays (not all radiologists do). Not all doctors are on the schedule every day, and scheduling is a critical component as a doctor needs to have a license in the state where the study originates.

Teleradiology Specialists was just named to the Inc. 5000 list of fastest growing companies in the U.S. (# 758) with a reported revenue in 2016 of $13.4 million.  With that 20% market share, this would project to a market size of about $ 60 million, just a niche within a niche of the global telemedicine market.

Establishing this niche market didn’t happen by accident.  Here are the steps that made this happen.

1. Find a well-respected client that can act as a reference.
2. Deliver outstanding service.
3. Learn the niche through participation in industry events such as conferences and trade shows.
4. Identify key differentiators which make you different from the competition.
5. Identify key decision makers and industry influencers and educate them about your value added.
6. Identify the key target customers and develop a strategy to pursue them.
7. Price competitively – pursue market share before profits.
8. Partner with other industry vendors who deliver complimentary products and services.
9. Identify and develop value added services.
10. Build a team that has shared vision and goals.

But wait, there’s more.
11. Prepare for a Long Sales Cycle, especially with large customers
12. Listen to your early adopters if they ask you to iterate or pivot

Now comes the next challenge.  Growth!  Do you find new market opportunities while protecting your base, or find new products and services to sell to existing clients?  Or both?

1. Sarasota, FL, March 31, 2017 (GLOBE NEWSWIRE) — Zion Market Research has published a new report titled “Telemedicine Market (Tele-Education, Tele-Training, Tele-Consultation, Tele-Monitoring, Tele-Care, and Tele-Surgery) for Neurology, Orthopedics, Cardiology, Dermatology, Emergency Care, Internal Medicine, Gynecology, and Other Applications: Global Industry Perspective, Comprehensive Analysis and Forecast, 2016 – 2022”.  

2. Zion Market Research has published a new report titled “Teleradiology Market by Category Type (Hardware, Software and Telecom and Networking), Modality Type (X-ray, Computed Tomography, Magnetic Resonance Imaging, Ultrasound, Nuclear Medicine and Fluoroscopy) and Region: Global Industry Perspective, Comprehensive Analysis and Forecast, 2016 – 2022”., growing at a CAGR of around 16.5% between 2017 and 2022.

Maybe I’m naïve.  But I did hear Thomas Friedman state, “Naivety is the new reality” in his keynote address last month at the American Telemedicine Association annual meeting in Orlando, Florida.  So naïve to believe the best in people and to be amazed when I see their intellectual talents trying to defraud, rather than to be used for good.

As this blog goes to press, Ransomware has become headline news due to recent attacks.  Over the course of less than 30 days, even my small business has become a target.

First an email which came in the name and headline from my largest client.  I was owed a payment and they were asking for confirmation of my account information.  The “tone” of the email was somewhat suspicious, as I had previously received hundreds of emails from the same person.  I supplied my account information.  When the next email asked me to transfer funds to them, I knew something was wrong.  A phone call confirmed my fear and I immediately closed my bank account.  Fortunately, no major harm done.

Next came this email with a Virus warning.

DO NOT CALL THIS NUMBER!  They will offer to fix a computer virus, help a family member with a drug problem, relieve you of major issues with the IRS, just give them a credit card number…….  Who are these people?

Next while visiting a website for what I thought was a new Urgent Care center, I received a pornographic image with an audio warning, Do Not Shut Off Your Computer!  I shut off the computer, disconnected from the network, rebooted and hoped for the best.  Again, I was lucky, the ransom threat has not reappeared.

We’ve all heard the warnings, but I engaged some industry experts for additional advice.

Why Healthcare?

I spoke to William Mee, President of https://www.securehim.com/,  a firm dedicated to changing the security culture of healthcare through implementing health IT security training, education, assessments, and security consulting.  Here is some information from a Ransomware Module they are creating.

Healthcare practices are the perfect mark for Ransomware. Physicians and healthcare providers rely on up-to-date information. Providers often respond immediately by shutting down large portions of its network. Staff typically cannot access email or a database of patient records.

Without quick access to accounting and other information, patient care can get delayed. A practice manager is more likely to pay a ransom rather than risk delays that could result in lawsuits.

Providers typically do train their employees on security awareness. Their primary concern is HIPAA compliance and ensuring that employees meet the federal requirements for protecting patient privacy.

Hayley Dezendorf, Chief Compliance Officer for Teleradiology Specialists offered this advice:

Mailing lists make great marketing tools….

We’re growing, we’re building our Client base, we need Rads to read more studies… that makes it so tempting to click on the email that comes in offering access to the database of thousands of Urgent Care Centers looking for a teleradiology provider, or Radiologists looking for teleradiology work…. Don’t Do It!  Don’t get caught in a phishing net!

Advice?

Even though your computer is behind a locked door it can be hacked while you are on the Internet. Here are some tips to protect yourself, courtesy of Byron Hurlock of Computer Blue Technologies.

1. Make sure your Microsoft Windows updates are running and up to date – type in Windows update at your search bar next to the start button
2. Make sure you have a paid anti-virus on your computer. Examples include McAfee, Norton Internet Security, or Kaspersky. Free ones are OK but paid ones are always updating their definitions 24/7 – 365. If you are on Windows 10 turn on Windows Defender, it’s free and effective.
3. Add a secondary Malware scanner – the reason for this is there are companies whose only business is protecting against malware. Malwarebytes is a secondary scanner that protects against zero-day attacks
4. Be careful what you click on. This malware was distributed by phishing emails. You should only click on emails that you are sure came from a trusted source
5. Be sure to back up all your computing devices. Regularly backing up your devices helps you recover your information should your computer become infected with ransomware

Taking the above precautions will keep your machine better protected while you work in cyberspace. Not sure what to do, reach out to info@computerbluetech.com or visit their website www.computerbluetech.com

And now to “John Becker” who called my 89-year-old mother this week congratulating her sweepstakes victory if only she will share her bank account number so they can make an account transfer.  There is no lower form of life than someone who is looking to make a living preying on the most vulnerable among us.  Mom is well coached, told Mr. Becker that she is hard of hearing and would he please call her son.  I wish he had.  Even better, I wish I had the opportunity to speak with his mother.

So, in the immortal words of Sergeant Phil Esterhaus of Hill Street Blues:

As I started an engagement with a new consulting client that plans to read medical images using artificial intelligence (deep learning) some interesting questions needed to be answered.

Who owns medical images?

Is it the patient, the provider, the imaging vendor (or someone else?). As medical images become part of searchable databases, do the rules change? Does the information need to be anonymized? Does “research” have any special exemptions? Is there any case law in this area? Does the debate over genomic data provide a precedent?

Answer: you can look but not touch.

I found my answer in an article from the Journal of the American College of Radiology, Feb. 5, 2014.

Confusion often arises amongst patients as to the ownership of radiologic images and the extent to which they possess rights over their images. Authors Jonathan L. Mezrich, MD, JD, MBA, LLM, of the University of Maryland in Baltimore, and Eliot Siegel, MD, also of the University of Maryland, clarify the confusion.

“In general, the facility that performs imaging maintains ‘ownership’ rights,” they wrote. “Individuals have a right to inspect their images and obtain copies but may not have medical records modified or stricken.”

Don’t worry, your doctor isn’t trying to hide anything from you. In fact, HIPAA does give the patient the right to access their own images (in most circumstances). However, there may be delays and costs incurred by the patient in their quest to obtain copies. Each state may also regulate the maximum costs for patient access.

Can the facility use my image for anything it wants to?

Imaging facilities have rights to use images beyond treatment purposes, including for educational training, quality control, and research, though these uses are subject to HIPAA requirements, according to Mezrich and Siegel.

What about my medical record? Who owns medical records?

Here it gets a little trickier. The question about medical record ownership (patient, provider, facility or patient?) varies by state. This link will help you understand what your state has to say (or not say) with regard to medical record ownership.

http://www.healthinfolaw.org/comparative-analysis/who-owns-medical-records-50-state-comparison

Is a medical image part of the medical record?

A medical image is not protectable by copyright law, and therefore, a medical practitioner can claim rights to the medical image. Copyright is defined generally as “original works of authorship fixed in any tangible medium of expression, now know or later developed, from which they can be perceived, reproduced, or otherwise communicated, either directly or with the aid of a machine or device.” 17 U.S.C. § 102. The U.S. Copyright Office has stated in the U.S. Copyright Office’s Copyright Compendium that “the Office will not register works produced by a machine or mere mechanical process that operates randomly or automatically without any creative input or intervention from a human author.” U.S. Copyright Office, Compendium of U.S. Copyright Office Practices, Third Edition, Section 313.2 (available at https://copyright.gov/comp3/chap300/ch300-copyrightable-authorship.pdf) (last visited Mar. 15, 2017). Examples of such works include “medical imaging produced by x-rays, ultrasounds, magnetic resonance imaging, or other diagnostic equipment.” As such, “ownership of medical images, is governed either by state statute or by agreement between the patient and the healthcare provider, and not based on federal copyright law” said George Likourezos, an intellectual property attorney with Carter, DeLuca, Farrell & Schmidt.

Who owns my genetic data and is that a precedent for my medical images?

It seems intuitive to many of us that each person owns his or her genetic data and therefore should control access. But the reality is more complex. The Supreme Court’s verdict that companies cannot patent naturally occurring genes told us who doesn’t own our genes—that’s a start. Depending on circumstance, genomic information may or may not be considered protected health information under HIPAA. That means sometimes there will be a number of barriers between you (or anyone) and that information, and other times it will be freely accessible, but in ways that supposedly prevent anyone from knowing whom the data comes from. Not too much of a help for the medical imaging question.

What is my medical image worth?

It used to be that you could sell an analog x-ray film to recover the silver, but that was before the world turned digital. Last month it was reported that here are 106 Artificial Intelligence startups in healthcare https://www.cbinsights.com/blog/artificial-intelligence-startups-healthcare/

All of these firms are in need of large volumes of data perhaps giving radiology groups the opportunity to monetize the vast number of images they have been storing to comply with regulatory requirements. In August of 2015, IBM bought Merge for $1 Billion to gain access to 30 billion images. That’s $30 per image. I’m happy to share my recent medical image and perhaps I can sell the same image multiple times.

Diagnosis?

Howard Reis X-Ray;

Alexis Gilroy, Partner at Jones Day, and on the Board of Directors at The American Telemedicine Association adds the following questions:

If an image is produced and reviewed solely by a machine per AI capabilities is it still the practice of medicine? If so, by whom? If not, then is it still a medical record subject to HIPAA and the state specific rules around medical records, after all these are specific types of records and data developed on the basis of the presence of a provider/patient relationship. Without the presence of that relationship isn’t the production of the image the mere production of a business record between the company who owns the AI and the consumer?

I look forward to exploring these questions as the field evolves over the next several years.