Telemedicine Holiday Wish List

I was recently asked what the “Reis Telemed Program” would look like, especially regarding Senior Care.

Given the season, I present my Telemedicine Holiday Wish List.

The package arrives in the mail just before your 65th birthday.  The package consists of a tablet (with a handle) and a peripheral device along the lines of an MedWand https://www.medwandsales.com/ or a Tytocare https://www.tytocare.com/ .  You plug the tablet in, and it works right out of the box with a welcome screen.  It can be voice activated with a touch screen option.  Security features include biometrics like an eye scan or a fingerprint with two factor authentication.

The main screen resembles something like the following (I need a real designer to make this, but you get the idea.)

The main screen is customizable by the patient, with on-line customer service available 24/7 to help.

Vital Signs includes a dashboard of all applicable medical information, all collected through Remote Patient Monitoring.  Any major changes are highlighted (with alerts sent to an appropriate healthcare provider.  This section also includes access to all medical records from all providers without the need to log into multiple systems.  Test results are also available here.

Friends and Family addresses one of the major concerns of the elderly, loneliness.  Easy links are provided for identified family members and can be accomplished by phone, video, text, or email.  Interest groups are also available for group chats or advice.

Current News is customizable based on items of interest to the individual patient.  News can be delivered by video, text, or alerts.

Healthcare Information contains searchable articles about diseases and conditions with the ability to receive the information at various levels of complexity.  There is a strong emphasis on “wellness” and suggestions for how to best avoid getting sick.  Gamification is included with incentives for healthy behavior.

 

The handle permits the patient to transmit EKG information.  Perhaps two handles are necessary.

Also included:

  • Automated scheduling of appointments and appointment reminders
  • Billing and tracking of bills and co-payments
  • Information about clinical trial availability
  • Easy to use directory about healthcare providers and their specialties
  • Notification if anyone has attempted to access personal information

 

Here’s a pet peeve:  By taking this tablet to any healthcare provider or appointment, information can be transmitted so that the patient never needs to fill out a clipboard again.

The system is free to the patient.  Funding for the system is provided by non-Medicare patients who want to participate, limited targeted advertising and actual product sales.  A non-advertising version is available for an additional fee.  Assuming the patient opts-in, data is available to third parties.

Clearly defined metrics is a key to success.  My hypothesis is that patients who monitor their care will be healthier and therefore incur lower medical bills.  Studies will need to prove this.  In 2021, the average Medicare cost per beneficiary in the US was $15,671, an increase of 9% or $1,323 from 2020.  How much will this system bring down these costs?  It remains to be seen.

In their recent book, Dr. Jay Sanders and Michael Gorton write about the Digital Medical Home (DMH), a living platform that can be fed the right data continuously to enable a care team to provide the next generation of healthcare.  As that data is fed into the DMH, Artificial Intelligence (AI) can monitor and watch for unusual blips, suggest interventions, coordinate care outreach, and support clinical decision making.  I believe this will be an important component of a successful system

All these components are available today.  The key is tying them all together into an easy-to-use system.

I welcome suggestions for additional feature functionality as well as identifying existing systems which meet most of this functionality.  Anyone want to help build this?

 

Telemedicine and Controversy

I have had the privilege to be involved in telemedicine for forty years.    Then, and now I view this as mostly a very good thing.  The doctor with expertise does not have to be in the same geographic location to help a patient.  While Telemedicine has evolved in so many positive directions, it has been fascinating to observe how telemedicine has become embroiled into some of the most controversial issues of our days, and has managed to create some major issues of its own.

Telemedicine and Abortion

Medication abortion now makes up the majority of abortions in the United States, according to data released by the Guttmacher Institute, a reproductive rights organization.

https://abcnews.go.com/GMA/Wellness/majority-abortions-us-now-pills-data-shows/story?id=83075210

According to the New York Times, women in states with abortion bans are turning to Telemedicine.  The misoprostol pill is used to terminate early pregnancies.

https://www.nytimes.com/2022/11/02/briefing/abortion-pills.html?searchResultPosition=1

Telemedicine abortions just got more complicated for health providers. In the U.S., more than a dozen states severely restrict access to abortion, and almost as many have such laws in the works. Across the country, since Roe v. Wade was overturned, clinics that do provide abortions have seen an increase in demand. Many clinics rely on help from physicians out of state, who can alleviate some of the pressure and keep wait times down by providing services via telemedicine.

https://www.npr.org/sections/health-shots/2022/09/26/1124360971/telemedicine-abortion-medication-ban

 

Telemedicine and Gun Control

Telemedicine became part of the dialog regarding Gun Control this past June when U.S. Senators reached a bipartisan compromise on gun violence and school safety that includes new federal investments for mental health services and telehealth.

https://www.fiercehealthcare.com/providers/bipartisan-gun-violence-deal-supports-major-investments-behavioral-health-telehealth

While the agreement does not include the outright bans on semiautomatic assault rifle purchases or age restrictions backed by most Democrats, it does introduce new scrutiny for buyers under 21 years of age, stiffer penalties for illegal straw purchases of firearms and grants for states to implement red flag laws.

Also core to the proposed deal are “major investments” in mental health and supportive services delivered through community behavioral health centers and schools.  Further supporting these investments would be additional funds aimed at increasing mental and behavioral telehealth accessibility “for youth and families in crisis,” the senators said.

Telemedicine and Opioid Abuse

There has been increased use of Telehealth for OUD Services During COVID-19 pandemic associated with a reduced risk of overdose.

https://nida.nih.gov/news-events/news-releases/2022/08/increased-use-of-telehealth-for-opioid-use-disorder-services-during-covid-19-pandemic-associated-with-reduced-risk-of-overdose

 

But prescribing controlled medications online is controversial. There’s a concern that fewer safeguards will lead to more abuse. Should it be OK to prescribe controlled substances via telemedicine? Limits on virtual addiction treatment may soon return, making care harder to access.

https://www.npr.org/sections/health-shots/2021/12/30/1064818982/telehealth-addiction-treatment-prescribing#:~:text=This%20is%20why%20virtual%20prescribing%20of%20controlled%20medications,the%20R%20Street%20Institute%2C%20a%20free-market%20think%20tank.

 

How Are Telehealth Laws Intersecting with Laws Addressing the Opioid Overdose Epidemic?

Opioid-involved drug overdose deaths have been a growing concern in the US for several decades. The Centers for Disease Control and Prevention identified several strategies to address the opioid overdose epidemic, including increased availability of and access to medication-assisted treatment and guidance on safer opioid prescribing practices. Telehealth offers the potential for increasing access and availability to these strategies, and laws governing telehealth have implications for their utilization.

https://www.cdc.gov/phlp/publications/topic/telehealth.html

Telehealth fraud

Recent federal crackdowns on Medicare fraud linked to telehealth have raised concerns in Washington that virtual care introduces new opportunities for criminals to defraud vulnerable patients. But lobbyists and researchers say risks aren’t necessarily greater than in-person, and warn that fear could drive lawmakers to make virtual care harder to access

 

https://www.statnews.com/2022/08/08/telehealth-fraud-doj-risk-hhs/

 

Telehealth’s Limits: Battle Over State Lines and Licensing Threatens Patients’ Options

If you live in one state, does it matter that the doctor treating you online is in another? Surprisingly, the answer is yes, and the ability to conduct certain virtual appointments may be nearing an end.

Telehealth visits for medical care took off during the worst days of the pandemic, quickly becoming commonplace. Most states and the Centers for Medicare & Medicaid Services temporarily waived rules requiring licensed clinicians to hold a valid license in the state where their patient is located. Those restrictions don’t keep patients from visiting doctors’ offices in other states, but problems could arise if those same patients used telemedicine.

Now states are rolling back many of those pandemic workarounds.

https://khn.org/news/article/state-medical-licensing-rules-threatens-telehealth-patient-options/

I have hope that the benefits of telemedicine will prevail and that unscrupulous operators do not take advantage of the telemedicine’s capabilities for their own well being.  HHS reported that there were 52.7 million Medicare telehealth visits during the pandemic.  Patient satisfaction was extremely high.   Delivering better patient care shouldn’t n be controversial.

I welcome your thoughts and comments.

License, Locums and Telehealth

One of the biggest challenges faced by healthcare providers in the post pandemic environment is in hiring and maintaining qualified staff. More than 30 percent of hospitals are reporting that they can’t locate enough candidates to fill open positions, and all are feeling the effects of staffing shortages.1

Staffing and Locum Companies have stepped up to help providers deal with the shortage. Telehealth has helped providers extend their reach geographically. This paper deals with some of the issues involved.

Licensing and Credentialing of Telehealth Programs

Licensing and credentialing telehealth providers can pose challenges to expanding telehealth programs. Licensing refers to the process of securing the authority to practice medicine within a state. Credentialing refers to the process of verifying the provider’s license, education, insurance, and other information to ensure they meet the standards of practice required by the hospital or healthcare facility. Virtually all states require physicians providing telehealth services to be licensed in the state of the patient receiving care. Further, every site delivering telehealth services must fully credential the physician.

State licensing policies

Almost every state has modified licensure requirements/renewal policies for health care providers in response to COVID-19, including out-of-state requirements for telehealth.

For emerging updates and the latest requirements for each state, see:

The Interstate Medical Licensure Compact is an agreement among participating U.S. states to work together to significantly streamline the licensing process for physicians who want to practice in multiple states. It offers a voluntary, expedited pathway to licensure for physicians who qualify.

The Compact currently includes 34 states, the District of Columbia and the Territory of Guam. In these jurisdictions, physicians are licensed by 46 different medical and osteopathic boards. Other states are currently in the process of introducing legislation to adopt the Compact.

Physicians, even those who practice telehealth, must obtain medical licenses for the states  where they wish to practice. Each state has different licensing requirements, timeframes, and fees. Some states have a reputation for making the process simple and affordable, while for others, it can take anywhere between three and nine months and more extensive costs.

With ongoing demand for telehealth services and a need for flexible staffing models, locum tenens can be a strategic and cost-effective way to enhance your telehealth program.

A case study sponsored by www.Axuall.com found that by reducing unnecessary delays in practitioner onboarding, health systems can capture services revenue that would otherwise be lost.  An in-depth analysis of one large health system indicated it will save $74,000 per physician by integrating real-time digital credentials into its processes.

Fingerprinting

According to the Federation of State Medical Boards, 56 state medical boards require fingerprints as a condition of initial licensure

 

And now, tele-fingerprinting

 

TeleFingerprinting.com, is an innovative U.S.-based biometrics company formed as a spinoff corporation from National Fingerprint, Inc. (NFp) an industry leader in expediting FBI criminal history checks required by licensing laws and privacy regulations.

TeleFingerprinting provides the only secure, patented, and scalable remote fingerprinting solution for batch submission to licensure authorities from anywhere in the world.

TeleFingerprinting™ is a one-time, virtually witnessed, end-to-end encrypted HD video collecting of fingerprints, ID credentials, attestations, and biometrics comparison standards for Privacy compliance. Certified Enrollment Agents ensure accurate fingerprint self-captures that comply with Chain of Custody and all other regulatory requirements from your isolated location

To discuss how tele-fingerprinting can benefit your organization, contact hreis@healthepractices.com.

 

  1. https://go.beckershospitalreview.com/10-top-healthcare-staffing-challenges-and-how-to-solve-them

Something Old, Something New – TeleFingerprinting

In ancient Babylonia and China, thumbprints and fingerprints were used on clay tablets and seals as signatures. The idea that fingerprints might be unique to individuals dates from the fourteenth century. Fingerprints weren’t used as a method for identifying criminals until the 19th century. In 1858, an Englishman named Sir William Herschel was working as the Chief Magistrate of the Hooghly district in Jungipoor, India. In order to reduce fraud, he had the residents record their fingerprints when signing business documents. Sir Edward Henry, commissioner of the Metropolitan Police of London, became interested in using fingerprints to nab criminals. In 1896, he created his own classification system based on the direction, flow, pattern, and other characteristics of the friction ridges in fingerprints. In 1901, Scotland Yard established its first Fingerprint Bureau. The following year, fingerprints were presented as evidence for the first time in English courts. In 1903, the New York state prisons adopted the use of fingerprints, followed later by the FBI.

But how has fingerprinting changed since the 19th century?

The Henry system finally enabled law enforcement officials to classify and identify individual fing­erprints. Unfortunately, the system was very cumbersome. When fingerprints came in, detectives would have to compare them manually with the fingerprints on file for a specific criminal (that’s if the person even had a record). The process would take hours or even days and didn’t always produce a match. By the 1970s, computers were in existence, and the FBI knew it had to automate the process of classifying, searching for and matching fingerprints. The Japanese National Police Agency paved the way for this automation, establishing the first electronic fingerprint matching system in the 1980s. Their Automated Fingerprint Identification Systems (AFIS) eventually enabled law enforcement officials around the world to cross-check a print with millions of fingerprint records almost instantaneously.

That changed in 1999, with the introduction of Integrated AFIS (IAFIS). This system is maintained by the FBI’s Criminal Justice Information Services Division. It can categorize, search, and retrieve fingerprints from virtually anywhere in the country in as little as 30 minutes. It also includes mug shots and criminal histories on some 47 million people. IAFIS allows local, state, and federal law enforcement agencies to have access to the same huge database of information. The IAFIS system operates 24 hours a day, 365 days a year.

But IAFIS isn’t just used for criminal checks. It also collects fingerprints for employment, licenses, and social services programs. When all these uses are taken together, about one out of every six people in this country has a fingerprint record on IAFIS.

Covid-19, Fingerprinting and Telemedicine

A long-standing tenet of telemedicine requires physicians to be licensed in the state where the patient presents. Radiology, which was the first medical specialty where telemedicine was widely used, often saw physicians in need of multi-state licenses. In was not unusual for a radiologist to carry 25-30 (even 50) individual state licenses. All states require fingerprints as part of the licensing process. A radiologist would go to the police station, sheriff’s office, or the office of a commercial fingerprint service. Documents often got lost in the process.

Then came Covid-19. Telemedicine blossoms with more than 300 commercial telemedicine or telehealth providers, all with growing staffs of physician needing to expand their staffs and their licenses. And many of those places where physicians could previously get their fingerprints scanned were closed due to the close contact required with examiners. Locum Tenems Companies thrived, many of which proving physicians to facilities experiencing staffing shortages. This too required an efficient solution. A new breed of company emerged with private equity backing emerged which enables facilities to outsource much of the credentialling process. See www.axuall.com and www.medallion.co.

Stay at Home!

A new solution has emerged, TeleFingerprinting!

International Fingerprint, Inc (IFP), dba TeleFingerprinting.com, is an innovative U.S.-based biometrics company formed as a spinoff corporation from National Fingerprint, Inc. (NFp) an industry leader in expediting FBI criminal history checks required by licensing laws and privacy regulations. TeleFingerprinting™ provided the only secure, patented, and scalable remote fingerprinting solution for batch submission to licensure authorities from anywhere in the world. TeleFingerprinting™ is a one-time, virtually witnessed, end-to-end encrypted HD video collecting of fingerprints, ID credentials, attestations, and biometrics comparison standards for Privacy compliance. Certified Enrollment Agents ensure accurate fingerprint self-captures that comply with Chain of Custody and all other regulatory requirements from your isolated location.

Beyond healthcare, clients include multiple components of the financial services industry, law firms, on-line gaming, international outsourcing and multiple additional vertical markets. Anywhere that multi-state licensing is essential, and time is a critical factor.

To find out how TeleFingerprinting can benefit your organization, contact hreis@healthepractices.com

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.