As we witness the remarkable and unprecedented acceleration of telehealth, our industry must harness emerging technologies to support new models of care. There is no better place to do this than from patients’ homes. How we provide acute and chronic care management, digital diagnoses, and aging in place services to patients from outside locations is now our key challenge.

Consider a 65-year-old patient with heart failure and pneumonia. Typically, we would admit this patient for vital sign monitoring and active treatments; all of which are now possible to do at home. Measuring the patient’s vitals as well as more sophisticated parameters, such as oxygen levels, work of breathing, weight, and fluid balance, can all be accomplished through digital devices from the more patient-centric approach at their home. Even treatments such as administration of oxygen and IV infusions are increasingly available to home health professionals. Yet, we face numerous technology infrastructure hurdles to conduct these in patient homes — WiFi, bandwidth limits, reliable data transmission, and the power required to run the devices.

To advance hospital-level care at home, we will rely on distributed sensing and computing devices, as well as the use of new telecommunication spectra. Wearables, biometric monitoring, and virtual health assistants can compute, analyze, and even act autonomously. New 5G networks, operating as much as 100x faster with more reliable data flow, will also play a significant role.

Fundamental advancements to enable sensors to operate collaboratively and cohesively with data collection and transmission innovations will evolve. In the meantime, health system leaders can prepare the groundwork through connected command and capacity centers, pilot deployments of IoT solutions in more traditional care settings (hospitals, clinics, etc.) as well as home. These efforts will also improve IT units’ knowledge and develop their expertise in emerging standards, electronics, and other device technologies.

As devices become more adaptive, integrated, autonomous, proactive, and patient-centric, organizations must prepare to receive and act upon enormous increases in volume and types of data.

Andrew Rosenberg MD, CIO, Michigan Medicine

Health systems tend to purchase patient monitoring and management devices in isolation. To manage a more complex integration of IoT and data transmission, they will need a more comprehensive plan. Where available, most health systems use devices with high information latency. Decisions tend to be made retroactively relative to when the information was first collected and knowable. The relatively few devices that could continuously monitor patients’ vital signs from home are often stand-alone, isolated by narrowly defined clinical intent, and often managed in a distributed fashion by non-enterprise IT. Often, these devices are based on an individual clinician’s specialty and rely on the limited 4G/LTE cellular transmission due to the inherent inconsistencies and lack of home WiFi networks.

As devices become more adaptive, integrated, autonomous, proactive, and patient-centric, organizations must prepare to receive and act upon enormous increases in volume and types of data. Both real-time data and analytics will evolve to predictive and prescriptive smart systems requiring dynamic capturing of patient event data, automating event-driven responses, coordinating critical workflows, orchestrating entirely new workflows, and engaging with the patient across care venues.

Gartner estimates 22B IoT devices will be connected by 2025. Healthcare IT leaders will need to blend new, best-in-breed devices with those that are more cohesively designed to work together even if they lack some features.

Driving innovation with machine-to-machine and other connected devices relies on the development of new telecommunication standards, electronics and infrastructure, and a wide range of network technologies. Real-time information sharing, location-aware, and edge-computing methods will allow a vast range of commercial and personal devices to change paradigms of care.

Speed coupled with much higher data capacity means 5G can support the additional capabilities required for home hospital care. Among these, the ability for IoT devices to process or pre-process data, perform advanced analytics faster and more accurately sense and respond with fewer errors; in a phrase to make ‘edge’ computing pragmatic and affordable.

The development and implementation of full-featured and more ubiquitous 5G is complex and will take years to be sufficiently mature across communities. The first standards for 5G released in 2018 by the international standards organization (3GPP and ITU) were the basis for the limited use of 5G by the largest commercial cellular providers. The second set of standards is anticipated for final release in Q4 of this year. Expect significantly more advanced features based on multimedia priority services, satellite access, LAN support, and network automations. Subsequent releases (Release 17) are planned for early 2022. It is estimated that 5G will still take 5-8 years for complete deployment.

Additional hurdles for healthcare leaders to consider are increases in the security of using these networks, issues related to electromagnetic interference, intellectual property rights as well as unsubstantiated conspiracy concerns with 5G radiation.

The recent pandemic has no doubt accelerated virtual care models. These new models, and many others, require a solution that engages consumers, integrates with consumer health devices, and influences consumer-directed activities while being a seamless part of a provider’s existing care delivery systems.

There are numerous opportunities for novel care delivery through care at home capabilities. Patients want to be cared for at home, and the ability to extend the expertise and abilities of a real-time health system through some of these new technologies should be more commonly encountered. The fabric of IoT, edge computing, and 5G will undoubtedly be at the forefront of many of these efforts over the next years. IT leaders and their operational counterparts must create opportunities now for small pilots and experiments to do this with existing and emerging technologies in partnership with patients, payers, and policymakers.

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By Dr. R. A. Ramanujuan, MD Physician, Diabetic Care Associates, and
Dr. Anu Banerjee, PhD, MS MHM, Chief Quality and Innovation Officer, Arnot Health

M-health is a platform for the rapid exchange of abundant information about patient medical records. Accomplishing desirable health-related service should guarantee technological support for robust bidirectional transaction between patients and providers. It is often, distinctive to illness to espouse acceptance with perceptible value to stakeholders with information that is reliable to engage with commitment and confidence. Germane medical conditions where such streaming data conceptually, is attractive are those where numerical data extraction is critical to outcome; such as hypertension, diabetes and many of the cardio-metabolic disorders “Facilitative patient relay”. In the management of hypertension, diabetes, obesity and other cardio metabolic disorders, live stream facilitative patient-clinical care giver interaction is critical. Patient’s can securely access clinical information; such as blood sugar, blood pressure, weight, exercise, and cholesterol, through affordable devices. The process of data generation on health risk determinants directly from customers or by outsourcing through allied health care givers, allow better understanding of information collected at informal sites. It is possible to access and fuse this raw data from diverse locations at secure sites for validation, integration and dissemination.  Today’s Healthcare is assembled on a single, formal platform to react to signals generated during clinic visits and globally, the stream in clinic workflow is structured to react to medical issues associated with the subjective component and much less for those without any symptoms as with early cardiometabolic changes. Major cardiometabolic disorder-related complications are due to deficiencies in the integration of emerging changes in silent risk factors such as blood pressure, blood cholesterol, blood sugar, weight, smoking, race and gender and many more. Consequently, detection and clinical reaction in these conditions are delayed until there is significant biological damage to vital organs. Coronary heart diseases, stroke, chronic kidney disease, peripheral vascular diseases due to diabetes, cholesterol and hypertension are complications due to time-dependent cumulative changes.

We believe that m-health will allow under-served populations from all locations to engage with caregivers’ for synchronized clinical care.

Technology and analytics can integrate datasets as panels and detect the beginning of the rise in risk by sequenced segments to support early detection through device system behavior.  Factors like obesity, smoking, high blood pressure, diabetes, high cholesterol, exercise, gender, race, smoking, alcohol ingestion and socioeconomic stratum alone or in combination is a significant economic and health burden. The operation implementing risk-adjusted flow of information is similar to the preventive approach in the management of communicable diseases such as Tuberculosis and HIV.  Novel system behavior and analytical options can support similar preventive health care strategy in cardiometabolic disorders. In the future, it will be possible to integrate structured exercise performance measures through advanced system behavior.  In the technology arena, data access through affordable device, modifiable system behavior and analytical process hold promise to support primordial clinical care in cardiometabolic disorders. The development of supportive panels on relevant clinical data sets is important in the management of cardiometabolic disorders. There should be plans to support preemptive action plan in the management of cardio metabolic disorders.  Appropriate response measure is the integration of therapeutic lifestyle changes such as diet and exercise.  As we are aware, current electronic medical records known as EMRs are not equipped to support easily identifiable comprehensive and condition-specific linear data collection on risks.  The process of implementation and execution of operation will be a creative revolt that extent clinical care beholds.  It will be essential to reframe data acquisition sites from clinics to unfamiliar resource access instruments to develop this cultural change within the healthcare system. The accommodation of allied health forces and reforming external service integration will be a challenge and a cultural shift from office-based practice that providers are bound to practice today in healthcare. There is a huge data deficiency in integration between healthcare vendors and no standard formats exist today. Blood pressure, pulse and blood sugar values are not steady physiological values yet, decisions are based on observations made in confined clinical locations. This operation is incapable to reconcile ecological and contextual perturbations. Implementation of m-health based operation has become reality in practice and wider acceptance holds promise to the economic model of collaborative service with public health and clinic-based service.

Summary: We believe the future m-health operational systems can behave as a proxy to electronic health records and curate biological risk factors and set the standard for integration of condition-specific complex Marko’s mathematical algorithms through bioinformatics for mapping early detection and intervention both at individual and population level.

We believe that m-health will allow under-served populations from all locations to engage with caregivers’ for synchronized clinical care.  The proposed facilitative patient relay operation represents prudent participatory patient-centered efficacious intervention.  M-health visits can reduce office visits and permit continuous vigilant interaction between patients and providers in chronic disease conditions.

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By Elise Singer, MD MBA, Chief Medical Officer, CareLinx

Millions of our declining elderly need help in the home and 90% want to remain home to the end of life

According to Health Affairs, nine million community-dwelling Medicare beneficiaries—about one-fifth of all beneficiaries—have serious physical or cognitive limitations and require long-term services and supports (LTSS) that are not covered by Medicare. Nearly all have chronic conditions that require ongoing medical attention, including three-fourths who have three or more chronic conditions and are high-need, high-risk users of Medicare-covered services.

Unless the elderly are in poverty the government offers no in-home aid. Medicaid covers LTSS for very low-income Medicare beneficiaries, but only one-fourth of Medicare beneficiaries with serious physical or cognitive limitations are covered by Medicaid.

There is a known correlation between avoidable high medical spend in the elderly with significant cognitive and physical limitations. This gap in Medicare services leads to avoidable emergency department visits and hospitalizations and increases the risk of older adults’ ability to live independently leading to institutionalization in long-stay nursing facilities, which is paid by Medicaid. Consequently, costs often eventually simply swap government spending buckets.

Importantly, 90% of patients also prefer to remain at home through the end of life.

It’s complicated

It seems straightforward, if our health system could provide affordable supportive care in the home through non-skilled caregivers who also are enabled to pass on targeted, actionable information vital to optimal medical care, everyone would win. The elderly could remain at home and be happier, their health outcomes would improve and there would be fewer avoidable ED visits and hospitalizations. Fewer admissions provide governmental savings, whether Medicare or Medicaid, offsetting the cost of non-skilled caregiver services.

However, it is not straightforward. First, we will need to have 3 key components in place nationally: appropriate payment channels and incentives, system preparedness and a sufficient workforce.

Payment

Needless to say, payment in health care is complicated by 3^rd party payors, governmental involvement, lack of transparency due to contractual obligations and multiple key providers along the continuum of healthcare settings, and realities created by historical developments. Nevertheless, there are new federal rules expanding the definition of “primary health-related” benefits for Medicare Advantage plans beginning in 2019 that can allow for the coverage of the cost of non-skilled in-home caregivers.

The system

The most underrecognized complication is our healthcare system readiness itself.

Healthcare is like air travel at the busiest world airports. Almost around the clock, there are airplanes arriving and leaving every minute, a multitude of airlines, different languages spoken by pilots, 10s of runways, and unpredictable variables like weather. And mistakes can quickly lead to death. The right information at the right moment must be delivered to the right person. It works through a well-defined and coordinated interplay of highly educated people making decisions based on information given to them real time by technology systems crunching vast data sets based on algorithms and prioritizations. The system has been built over decades, iterated on for efficiency and has many interlocking systems and dependencies.

Healthcare systems are also a well-defined and coordinated interplay of highly educated people making decisions based on information presented to them real time by a system of integrated technology systems. The system is simultaneously efficient and complicated.

It is clear that doubling the incoming flight volume or adding in helicopters, that have a completely different landing pattern, couldn’t be successfully accomplished without significant planning. The systems need to accept or integrate the new data stream and the air controllers need to know what information is relevant and how to react based on that information.

Today, in healthcare, 95+% of a patient’s time is spent at home, or outside of medical interactions. Yet there is little data from this “home setting” to the healthcare systems or professionals. With a few exceptions, all of health care data in existence today comes through outpatient physician visits punctuated by data from high acuity settings or through informal means. Some patient-reported data from the home setting is occasionally shared, typically in paper format during a medical appointment on paper or visually noted by the nurse or doctor from the patient’s smartphone. This data doesn’t reliably enter the medical record in a discrete usable fashion.

In order for data from the “home setting” to be ingested by the healthcare system, it must be relevant, dependably accurate and timely and the health system must be able and prepared to receive it.

Workforce

Lastly, we need a sufficient supply of trustworthy in-home workers along with visibility into their hours and actual work. Issues of worker availability, accountability and reliability as well as dependable and defined mechanisms to guard against fraud and abuse are critical. Sufficient wage levels according to local markets are critical to maintaining this workforce.

The next step

Extending health care into the home via connected caregivers should be a national priority. Huge majorities of people strongly prefer to age in place, there isn’t sufficient national infrastructure to institutionalize seniors in need of functional support and it is unsustainable financially privately and publicly. Perhaps most importantly, health outcomes could improve while overall health spending decreased: connected caregivers can improve preventive care in the home through scripted prompts, provide thoughtful functional support in the home and send real-time medical data that is monitored by skilled healthcare resources leading to timely intervention opportunities and fewer avoidable hospital admissions.

With the 2018 Medicare Advantage programmatic supplemental benefit expansion, the necessary payment reform has taken an important step forward. When offered to the appropriate patient segments coupled with proper pricing, functional caregiver support tied into the medical system should be expanded to the entire Medicare population.

The caregiver workforce is readily available in most parts of the country, whether engaged informally or formally. Several franchised businesses and a marketplace offer successful channels to support an expanded need for in-home support.

In order to accelerate the health system readiness process, “connected caregiver” service lines in existence today offer a supply of high quality, trained caregivers coupled with a HIPAA compliant technology platform built for this use that can integrate with hospital and payor technology systems.

It is time to truly extend health care into the home through an affordable connected caregiver workforce deeply integrated into our medical system.

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By Molly Menton, Director, Clinical Delivery, Evolent Health

Technology has changed our lives in every imaginable way. Every industry, every sector, and every consumer has been irrevocably changed by the digital revolution. 50 years ago, it would have been only in the Jetsons cartoon that people would make purchases without paper money, go shopping without going to the mall, and call a cab without using a telephone. But here we are; we’re living our space-age dreams from childhood (I’m still waiting for my flying car…) and we’re continually finding ways to redefine our known experiences. There is one industry that has lagged. One of our most powerful industries yet one that is often a lumbering beast with minimal agility: healthcare.

Of course, no one is suggesting that the healthcare industry is still stuck in the days of bloodletting and lobotomies, we’ve managed to adopt many technological advances that have improved patient outcomes, patient safety, and clinical delivery models. We’ve (reluctantly) accepted that EMRs are here to stay and that digital imaging systems really are far better than looking at x-ray films in a crowded hallway. Yet somehow the healthcare industry has been slow to embrace the idea of telemedicine as a modality that can be both high-tech and high-touch.

High-tech healthcare doesn’t have to sacrifice high-touch relationships

There is often a collective gasp when I tell people that the future of telemedicine does not lie in better video capabilities but instead in the virtual space, without cameras. True innovation for telemedicine will mean fewer “face to face” meetings with providers for common medical concerns (think: UTI, Conjunctivitis, URI, etc.) and far more asynchronous interviews in which a condition can be diagnosed and treatment can be prescribed using adaptive interviews and branching logic. The technology will aid in clinical decision making, especially in urgent care and primary care settings. Of course, I’m not suggesting that patients with serious, rare, or life-threatening conditions would benefit from a “virtual visit” but a patient that gets a UTI once a year and simply needs a routine course of antibiotics would benefit greatly. She gets her diagnosis, prescription, and be on her way within minutes without having to leave her home or make an appointment.

The technology is available and as healthcare becomes less authoritarian and more consumer-driven, we must accept that patients will expect and seek out options that allow for quick, uncomplicated diagnosis and treatment for routine medical issues. By embracing adaptive interviewing technology in the virtual space as a complement to current clinical practice versus a supplement, we are signaling to patients that we understand their needs and we respect their time. Gone are the days when patients will keep the same provider for 30 years; patients are now more focused than ever on efficiency, cost, and convenience. I’ve worked with several health systems who have struggled with patient retention and loyalty and the million-dollar question was always “how do we get them to come in?” The answer lies in providing the patients with enough convenience options for non-acute, routine conditions that they are willing to use the same system when they have serious medical needs. Consider the retail industry; many brick and mortar stores are dying on the vine while virtual retailers are blossoming. Why? Because virtual retailers filled a need for customers and in turn, those customers now buy nearly everything online (think: Amazon). According to Pew Research, 79 percent of Americans make purchases online, up from 22 percent just 18 years ago. It doesn’t mean that customers have deviated from brand loyalty, they just buy their products virtually. Imagine if in the next 20 years nearly 80 percent of patients received care online? Is your health system ready for that level of demand?

It is time to accept the fact that the next generation of patients are savvy and although they want relationships, they want relationships on their own terms. By offering user-friendly, cost-effective virtual care options, the health system is demonstrating an understanding that high-tech options meet a specific need for patients. And by meeting that need, you are in turn demonstrating that you care about their needs thus creating a relationship (even if the patient has never set foot in your building) that will build brand loyalty in the future.

High-tech healthcare doesn’t have to sacrifice high-touch relationships. Both things can co-exist and provide the patient with meaningful experiences that allow them to be equal partners in their health care. By accepting that medicine will not always be a face-to-face experience and leveraging technology to provide the patient with virtual care, we are moving with the times instead of fighting against the future. Think about it: had Blockbuster saw the writing on the wall and bought Netflix when they had the chance, things would have turned out very differently for our now nostalgic video store. As healthcare leaders, it is up to us to push the envelope and ensure that traditional medicine welcomes telemedicine warmly so we can continue to take care of our most important charge, our patients.

Note: The opinions expressed in this article are those of the author and do not necessarily reflect those of Evolent Health.

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One can imagine early uses of the telephone involving discussions about patient care between hospitals or a small town contacting a doctor in the city about a patient.

Today, we view telemedicine as the digital exchange of medical information from one site to another with the intended purpose to improve patient care and access. This is achieved through a wide variety of applications, devices, and services. These include things like two-way video, smartphones, email, tablets, peripheral exam devices, and many other mobile tools. All of these tools create a continuum of telemedicine technology complexity.

By leveraging the appropriate telemedicine technology based upon the use case, all of these groups can potentially converge to achieve the quadruple aim by providing better outcomes at lower cost, while, at the same time, improving both the patient and clinician experience.

Telemedicine helps to improve access to care in a way that has the potential to revolutionize the healthcare industry. This is more important than ever as healthcare systems continue to expand their footprint. Enacting telemedicine programs makes location of both patient and facility less important, and allows healthcare providers to expand their reach in ways never previously thought possible. In this article, we will review various telemedicine technologies with regard to complexity and appropriate use in specific cases.

Show patients and providers the benefit these technologies can afford them

In assessing the appropriate technology for a specific telemedicine use case, one must consider budget, use case requirements, and workflow. For basic interactions between provider and patient, mobile devices such as smartphones or tablets work extremely well and are commonplace among both providers and healthcare consumers. These devices allow for secure real-time audiovisual communication from any location with an Internet connection (Wi-Fi, 4G, LTE, etc.). There are multiple mobile-based, HIPAA compliant telemedicine platforms for use on mobile devices that can meet the needs of solo practitioners all the way up to regional healthcare organizations. Secure mobile video carts can also be used in conjunction with mobile devices to allow for similar communications from a health care facility to external locations using stable Wi-Fi or Ethernet connection. These carts provide better quality video than mobile devices as they function over stable internet connections and have a mounted camera that helps to steady the video feed.

The next level of complexity in telemedicine technology is the addition of connected peripheral devices to the audio-visual stream to provide more information for the clinician on the receiving end. The most high-yield and commonly used connected device is the stethoscope, which allows for real-time or store and forward transmission of heart and lung sounds. There are many different types of connected stethoscopes that vary in terms of form, function, and obviously price. Despite variations in price, the costs to implement such a program are not prohibitive to smaller practices or even individual providers. These types of systems can provide large amounts of useful information for a relatively low overall cost. Other connected peripherals include spirometers, otoscopes, ophthalmoscopes, high-resolution cameras, real-time ultrasound probes, EEGs, and various other real-time scopes. Usage of these types of peripherals is dependent upon the needs of the use case.

Also in the category of low complexity telemedicine technology are home monitoring solutions, which includes devices such as blood pressure monitors, scales, glucometers, pulse oximeters, vital sign monitors, wearable fitness devices, and medication dispensers. These devices can provide instant feedback for patients, and allow them to feel more in control of their health while at the same time allowing clinicians to remotely monitor them. Data from these devices can be synched to software platforms with algorithms to alert for certain events or findings. This information can then be sent along to the native electronic health record to allow clinicians to view this information in-line with the comprehensive medical record. Included in home monitoring devices are also cardiac telemetry devices that allow for remote intermittent or continuous monitoring of cardiac status. Aside for providing comfort to the patient, these devices can reduce the need for in-hospital monitoring in stable cardiac patients. With the emergence of new mobile solutions within this market, cardiac telemetry devices are more accessible than ever as they have cut down on previously cumbersome remote options.

As we approach higher complexity telemedicine technology, we start to see more of an “all in one” approach with devices that have enhanced mobility and can perform multiple aspects of a physical exam via telepresence technology and connected peripheral devices. Peripheral integrated carts are often used in hospital settings as they offer reliable video quality and a robust suite of peripherals and add-ons. Some models can even be driven remotely so that providers can “round” from a remote location. On the other hand, mobile integrated telemedicine kits allow either patients or health care providers to perform remote physical exams using mobile devices that have a variety of add-on attachments that allow for capture of various physical exam elements. These units are becoming more commonly used as they are affordable, allow for flexibility, and are relatively easy to use. There are various offerings of these kits that are targeted to different use cases: rugged for field use (disasters, EMS, etc.), small and compact for consumers, and those with increased durability and higher quality parts for healthcare professionals.

Atop the mountain of telemedicine technology complexity are the emerging technologies of AR and VR. VR platforms allow for creation of a completely immersive auditory and visual environment to create a world that can be based in reality or devoid of physical laws governing space, time, mechanics, etc. VR’s ability to manipulate the user world can be helpful in post-stroke/rehab care, various psychiatric treatments, and simulative learning. It also holds promise for telemedicine application in surgical procedures, radiology, and neuropsychological assessments/rehab. AR functions differently in that it augments the real world with virtual computer-generated objects that appear to the user to coexist in the same space as the real world. This allows for natural movement in the physical world and interaction in the augmented world through gaze, gesture, and voice commands. While the applications of AR are similar to those of VR, it differs significantly in that it is a more natural fit for the clinical workflow as users can still interact with their surroundings.

In order to decide what technology is most appropriate, providers and organizations need to first assess the requirements of the specific use case and then work within their budgeted funds to find the best overall fit to meet the workflow. In doing so, it is vital to do the following when implementing telemedicine technologies:

1. Listen to your staff!
2. Focus on need first, and not simply what is available or cutting edge.
3. Don’t force technology.
4. Adapt to current workflows as closely as possible.
5. Involve staff early and often.

And perhaps most important is to minimize the pain of implementation, while maximizing the gain. Show patients and providers the benefit these technologies can afford them by meeting them somewhere within their comfort zone so that you can then take them out of it.

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