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.

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

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.



  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;


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

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

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

  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.

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.

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

Can Telemedicine Help My Mother?

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

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

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 (–L6VbGFkAccRb4J&index=3) but this assumes one can get on line.  Another advance has been new technology for hearing testing.  dB Diagnostics ( 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 would have made this much simpler, and I’m sure my friends at would have been happy to review the images and write the report.

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

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

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

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

Trip Report – Four Weeks, Four Conferences

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

NAOHP – National Association of Occupational Health Providers – Nashville Tennessee

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

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

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

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

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

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

SPS – Telemedicine & Telehealth Service Provider Summit – Glendale, AZ.

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

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

UCA – Urgent Care Association – Houston, TX

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

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

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

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

For additional information on any of the above, contact Howard Reis at

Telemedicine and Long-term Care Update

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

This is about to change.

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

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

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

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

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

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

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

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

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

Telemedicine in a Bronx Nursing Home

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

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

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

For additional information:

Finding a Way to Marry Telemedicine and Teleradiology – Radiology Second Opinions

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 for additional information.

Can Telehealth Help with The Opioid Abuse Crisis? Part Two

Last month we began the exploration of whether telehealth can help fight the opioid abuse crisis.  The statistics continue to overwhelm.  More deaths last year from opioid abuse (60,000) than in the entire Vietnam War.  An increase of 45% in overdose deaths in New York City between 2015 and 2016, 93% of these involve opioids. We shared findings from work being done at John Hopkins, a summary of which can be seen here:

Since then I have had an opportunity to do a deeper dive into the questions, especially with attendance this week at the AATOD (American Association for the Treatment of Opioid Dependence) conference.  There are more ways for telemedicine to help.  Here are just some of the ways.

  1. It takes a village. Combatting the opioid abuse crisis requires a multi-disciplinary approach.  Certainly, the patient, the family, the clinicians and the facilities.  Add in insurance companies, pharmaceutical companies, the schools and law enforcement.  Telehealth can create a community with enhanced communication enabled targeted at delivering positive outcomes.
  2. Access to resources. There is a disconnect between the geographic location of patients and the availability of professional resources who can help.  Telehealth can help fill this void.
  3. Transportation is an issue. Some patients in treatment need daily follow up visits and sometimes it takes hours just to get to appointments. Transportation usually involves significant cost and often involves additional individuals.  Telehealth can help.
  4. Coordinating the Clinics. Several organizations have opened multiple clinics to treat opioid patients.  The ability to use telehealth to load balance the clinical staff, enabling clinicians to serve multiple locations and reduce travel time is a significant opportunity
  5. Peer Support is essential and telehealth can be used in cases where it otherwise difficult for group members to gather in person.
  6. One of the final AATOD sessions was entitled “Prescribing Buprenorphine Using Telemedicine-Practical and Regulatory Issues.” The pharmaceutical industry has been identified as one of the villains in the fight against opioid abuse and here is an opportunity for them to step up into a leadership role.  Legal and regulatory issues also need to be explored.

Several “catch phrases” grabbed my attention in my learning about opioid abuse.

 Accidental Addicts – Patients developing addictions after taking the prescription given to them by doctors for a legitimate medical need.

Recovery programs utilize people in long-term recovery from addiction as Recovery Specialists and Patient Navigators to engage individuals reversed from an opioid overdose, putting an end to the “revolving door” where too many individuals endlessly cycle in and out of emergency departments and never connect to treatment or recovery support services.

Evidence-based treatment (EBT) refers to treatment that is backed by scientific evidence. That is, studies have been conducted and extensive research has been documented on a particular treatment, and it has proven to be successful.

Confidentiality Protection is essential for patients in recovery.  Removing the stigma of opioid abuse and treating patients with respect were common themes.

Government entities have recognized the crises and have begun to respond.  On the federal level SAMHSA (Substance Abuse and Mental Health Service Administration) is leading the charge and In New York State the charge is being led by OASES (Office of Alcoholism and Substance Abuse Services).  Treatment centers are expanding as depicted below.

All hands on deck.  Using technology, where appropriate, to spread the word and the good work being done by so many in the field is the one way I feel I can help.

What about you?


Can Telemedicine Help with the Opioid Abuse Crisis?

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”

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 ( 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 ( 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.

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The Future of Telemedicine – I asked the experts.

The Future of Telemedicine – I asked the experts.

Here’s what they had to say.


Jay Sanders, MD

President and CEO of The Global Telemedicine Group

Founding board member of the American Telemedicine Association, serves as President Emeritus.

The “father” father of telemedicine

By 2025 telemedicine will be so commonplace for the provider and the patient that, hopefully, it will simply be called “medicine”. It will be a universally reimbursed service and the technology will be as integrated into our daily lives with the same ease with which we use our smart phone. But, perhaps, the biggest changes by 2025 will be the integration of A.I. (which I like to call Augmented Intelligence or Collective Intelligence, rather than Artificial Intelligence) into most telemedicine encounters and the ability, where needed, to continuously monitor patients in real-time by the use of biomedical sensors. And, finally do not be surprised that some of the most significant entities involved in these transformative changes in the delivery of healthcare will be Amazon, Google and Apple.

Ron Pion, MD

Founding Partner and Chief Wisdom Office, The Castleton Group

Founded the Hospital Satellite Network, the nation’s first daily satellite-delivered television service providing programming for hospital-based health professionals and patients.

The ‘grandfather” of telemedicine

Something I thought would have happened long ago is happening now. The TV set in the home would be the person’s screen. Vendors now have the ability to bring a nurse practitioner into the home at the touch of a button. And now the screen is also in the patient’s pocket. It’s here. And remember, without the patient, there is no $3 Trillion healthcare industry.

Roy Schoenberg

President and CEO of American Well

“Telemedicine will become the instrument of redistribution of healthcare services. It will democratize and humanize access, eliminate variations in quality and normalize cost and price of its services.”

Dale C. Alverson, MD

Medical Director, UNM Center for Telehealth

Past President, American Telemedicine Association

Telemedicine will become an integral part of healthcare by 2025. It will no longer be called “telemedicine” but just become an expected component of healthcare services, addressing the “Quadruple Aim”: 1) improving the patient’s experience with enhanced access, 2) improved population health and better outcomes, 3) reduced cost without sacrificing quality, 4) Improving the provider’s experience with enhanced options for practicing medicine with better continuity of care.

David J. Cohen, MD

Managing Director and Founder, Teleradiology Specialists

It’s been exciting to be involved in teleradiology for the past ten years as this became the first medical specialty to take advantage of telemedicine technology to deliver a commercially viable service. Going forward, I expect other image dependent medical specialties to follow our lead, for example dermatology, wound care, pathology and even ophthalmology. They would all have lessons to be learned from commercial teleradiology vendors, especially in the areas of image sharing, workflow process and especially quality assurance.

In closing, I wanted to add some additional observations.

1. Services become integrated (telemedicine/remote patient monitoring/apps/education)

2. Issues of reimbursement and regulation remain, but become less significant factors.

3. Telemedicine becomes cost justified as positive outcomes justify deployment.

4. The primary provider of telemedicine services will be the same companies who now offer electronic medical records.

5. International boundaries become less significant.

6. Telemedicine becomes an integrated tool in the areas of artificial intelligence, machine learning, personalized medicine and population health management.

I invite all our readers to add predictions of their own.

Telemedicine – Today

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: 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: 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,   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:

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 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  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”.

Telemedicine – Past

The concept of telemedicine is not new. A simple definition of telemedicine: The ability to practice medicine when the expert and the patient are separated by distance with the support of telecommunications technology.

One of the earliest telemedicine trials was in the summer of 1967 when Massachusetts General Hospital set up two TV cameras at Logan airport to examine patients and avoid the traffic which could make the 3.5-mile trip take up to two hours. The Telemedicine Spacebridge, a satellite-mediated, audio-video-fax link between four United States and two Armenian and Russian medical centers, permitted remote American consultants to assist Armenian and Russian physicians in the management of medical problems following the December 1988 earthquake in Armenia and the June 1989 gas explosion near UFA.

I personally participated in telemedicine trials in the early 1990s with NYNEX Corporation and four Boston Teaching Hospitals. In 1993, the American Telemedicine Association was established to promote access to medical care for consumers and health professionals via telecommunications technology (alternatively referred to as telemedicine, telehealth or eHealth).

In the year 2000 Nighthawk Radiology Services was formed as the first commercial teleradiology services. Reading Centers were set up in Australia and Switzerland so the U.S. board certified doctors could support nighttime emergency room radiology needs working during the day at new reading centers. The lessons learned in teleradiology are valuable to all disciplines using telemedicine today.
From the beginning, it was important to make a distinction from a-synchronous telemedicine which was a store-and -forward methodology (like used for teleradiology) to synchronous telemedicine which required real-time face to face consultation (like used in a tele-psychiatry session.)

While it is easy to identify the benefits of telemedicine for patients, providers and payors, no discussion about the early days of telemedicine is complete without a discussion of the barriers to wide-spread implementation. In addition to issues of regulation and reimbursement, there were issues of physician acceptance, bandwidth availability, system interoperability and comfort with the status quo. While progress has been made on all of these, new barriers continue to arise.

Many early teleradiology programs were supported by government grants and sustainability became an issue when grant funding terminated. There has been a continual need to prove a Return-On-Investment for telemedicine programs and a need to create reliable business models to support implementation. There has been a constant turnover of vendors looking to penetrate the market as a review of the list of exhibitors at the early American Telemedicine Association meetings bears little resemblance to the companies that show up today.

A Niche in a Niche – Providing Teleradiology Services to Urgent Care Centers

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.

Sing a Song of Telemedicine

(To the tune of When I’m Sixty Four)

When I get older, thinking of health, just two years from now
Seeing my doctor via video chat, manage my vitals, ten seconds flat

Hey Dr. Dermo is this a mole? Or is it something more?
Manage my bills, reminders for pills, when I’m sixty four

You’ll be older too. And if you click right here, this can work for you.

Videos for exercise and good things to eat, keep me fit and trim
Feeling kind of sickly at a quarter to three, need that prescription waiting for me.

Asking an expert is it sleep apnea? Or just a very bad snore?
Manage my plans, sharing my scans, when I’m sixty four.

Phished, Hacked, Held for Ransom

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,  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!


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 or visit their website

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:

Bringing a New X-Ray Product to Market

One of the great privileges in life has been to see the birth of a new child.  Ok, now I’m working on grandchildren and that’s a great privilege too.  In my professional life, I’ve had the privilege to observe the phenomena of bringing a new product to market.  There are similarities.

Source-Ray Inc. (SRI) ( is a developer, supplier and the largest American manufacturer of diagnostic portable imaging equipment.  They were finding that established entities were not overly interested in portable systems.  Then they came upon the Urgent Care Market.  Various studies have identified approximately 10,000 Urgent Care centers today, and the market value is projected to grow from $23.5 billion in 2013 to a projected $30.5 billion by 2020, according to a new report from Transparency Market Research (TMR).  With no single dominant equipment vendor in the market, this seemed like a great opportunity for SRI.

There has been much talk about the “triple aim” in healthcare:  improving the patient experience of care (including quality and satisfaction); improving the health of populations; and reducing the per capita cost of health care.  SRI set off to create a solution that met all three.  Create a quality product at a lower price point combined with clinical efficiency.  The primary differences were to create a unit which required less electrical power (5kw compared to other 30kw systems) and minimal lead shielding so that it could be utilized in existing (rather than purpose-built) exam rooms.  The result is the Source-Ray UC-5000.

Here’s a much simplified graphic of a process which took just over a year:

Highlights included:
·    Dozens of revisions to all aspects of the product including electrical, mechanical, ergonomic and aesthetics.
·    In preparation for FDA (510K Medical Device Authorization) approval, working with Underwriters Lab (UL) and EMC for Electromagnetic Compatibility Testing
·    Completion of literally two feet of paperwork and a >150 item check list.
·    Submission to and approval from FDA in 29 days!

Lesson learned, do your homework in advance and get an experienced consultant to guide you through the process to assure that the FDA filing is 100% correct!

As the product approached the market ready state, SRI wanted the endorsement of a radiologist with regard to image quality of the x-rays.  Who better than Dr. David Cohen, Founder and Chief Medical Officer of Teleradiology Specialists, the leading x-ray over reader for urgent care, serving over 1000 centers nationwide?  According to Dr. Cohen, “I find the quality remarkable considering the images were produced by a lower power unit”.

Selling the product will be driven by John Schaumberg, Director of Business Development.  John is a passionate product champion who has been careful not to “sell” the product before it was approved and ready, but who has nurtured the cause from the onset.  One of the strong selling points is that the new system will require significantly less room preparation costs than all of its competitors…it is both a clinical and business solution.  According to John, “It’s not selling, its’s not marketing, it’s education”.

The product will have its coming out party at the UCAOA (Urgent Care Association of America) convention and Expo which takes place beginning April 30 at National Harbor in Maryland.  As urgent care centers continue to expand, as cost continues to be a consideration, and as urgent care owners learn about the benefits of this new device, it will be exciting to see how the market reacts.

Who Owns (my) Medical Images?

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.

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 (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

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.


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.

Telemedicine and Life and Death

Telemedicine and Life and Death

There is (virtually) no aspect of life which cannot be positively impacted by the addition of telemedicine.

Telemedicine for Pediatric Care

In May 2001 Dr. Ken McConnochie began delivering Telemedicine care to five inner-city Rochester child care sites and today virtual care is available in all Rochester City Schools. (see brief video here: )

Telemedicine for Elder Care

There has been a recent focus on using telemedicine to support elder care.  There will be a special area at the upcoming American Telemedicine Association annual meeting in Orlando in May devoted to Elder Care.  (Register here or contact  for a free exhibit hall pass.)  Keep tuned for a major announcement coming soon about a major telehealth initiative with one of the largest Nursing Homes in NYC coordinated by

There have also been interesting developments in telemedicine at the “End of Life”.  ResolutionCare works with healthcare providers and payers to provide Palliative care to people where they live and on their own terms. Dr. Michael Fratkin, founder of ResolutionCare, has developed a program including teams comprised of physicians, nurses, social workers, clergy, and support staff focusing on bringing greater quality of living and greater quality of dying using telehealth technologies.  See

Two Telemedicine Pioneers

Dr. Ron Pion is a physician (Ob/Gyn), visionary, and business professional. Among many other major accomplishments, Dr. Pion founded the Hospital Satellite Network, the nation’s first daily satellite-delivered television service providing programming for hospital-based health professionals and patients.  I am privileged to call Dr. Pion a friend and a partner and recently had the opportunity to discuss how telemedicine will impact “end of life”.  According to Dr. Pion, “I want to celebrate life rather than worry about death.”  He also wants to reinvigorate the conversation about death and feels that it is important to talk about death with children at an early age, not just when there is a teachable moment like the death of a family member or close acquaintance. “We know that everyone is going to die.” Dr. Pion suggests a focus on prevention rather than just treating acute illness which has been the focus of other telemedicine initiatives.

Dr. Pion also pointed me to a wonderful article about Ideo’s attempt to redesign death in America.  Anyone with an interest in this topic will appreciate reading the full article here:

Dr. Lisa Thompson created in order to provide patients, families and caregivers with resources to empower them to have the best possible quality of life while living with serious illness. Her dream is to make high quality palliative care accessible to everyone. For the past four years, Dr. Thompson has been providing online medical consultations to patients via telemedicine.

Can telemedicine save a life?

There are plenty of examples of live-saving telemedicine ranging from rapid support of stroke patients in rural areas, to transmission of vital signs from an ambulance to a hospital, to the use of home-monitoring devices to transmit daily weight, blood pressure, and other biometrics to their doctors for patients suffering from COPD, diabetes and other chronic conditions (see With just a click of a button, a doctor may conference in with a patient and provide rapid triage and medical decision-making that can save hours in a world where minutes make all the difference.

Can telemedicine save the healthcare system?  With the promise of lower costs, better patient care and improved patient satisfaction it goes a long way to helping achieve the triple aim of healthcare.

Delivering Radiology Reports into the Electronic Health Record

One of the biggest changes in teleradiology operations over the past two years has been the demand and the ability to deliver radiology reports directly into the EHR (Electronic Health Record) of the Urgent Care Center.

Teleradiology Specialists has always provided electronic access to teleradiology reports through a secure web portal.  Previously firms faxed their reports to the centers which scanned the reports and attached them to the EHR.  As centers began to see at least five x-ray patients a day, that method became time consuming and prone to error.

There were two primary drivers for centers wanting to receive their reports automatically downloaded into the EHR.

  1. Electronic delivery increases efficiency, cuts down on errors and reduces administrative time.
  2. In order for a provider to qualify for the CMS EHR Incentive Program (Meaningful Use), they were required to use computerized provider order entry (CPOE) for radiology orders directly entered by any licensed healthcare professional who can enter orders.

The connection between a radiology PACS (Picture Archiving and Communication System) and the EHR is most frequently accomplished by an HL-7 interface.  Health Level-7 or HL7 refers to a set of international standards for transfer of clinical and administrative data between software applications used by various healthcare providers.  There are two types of interfaces

Unidirectional interface – results only are transmitted via HL7 to the EMR

Bidirectional Interface – Orders come in and results go out streamlining the process

In most cases, a unique interface must be established for every individual client.

“One of the greatest benefits of adding an HL7 interface into your workflow is improved patient care” according to Hayley Dezendorf, Interface Project Coordinator at Teleradiology Specialists “workflow is more efficient, results are in the EHR quicker without extra steps, and oftentimes the potential for human error is decreased when submitting orders” according to Hayley.

Many of Teleradiology Specialists clients have their reports electronically transmitted into their EHR.  All clients using the Practice Velocity EHR, can take advantage of a single interface which sends results into their EHR.  Other EHR vendors where clients have interfaces include DocuTAP, eClinicalWorks and eMDs.  More are scheduled for 2017.