Thank you Mr. President

An inside game in Washington held every year by hundreds of the top lobbyists, consultants and association executives is to get some mention about their area of interest in the President’s State of the Union address. Last night, President Obama spoke of the importance of telemedicine as part of his proposal to deploy broadband, internet access and high-speed wireless coverage. In describing the benefits of such efforts the President stated: “It's about a firefighter who can download the design of a burning building onto a handheld device; a student who can take classes with a digital textbook; or a patient who can have face-to-face video chats with her doctor.”

As ATA past President Thelma McClosky Armstrong said in an email today: “We sure have come a long way.”

But mention in the State of the Union address is only a beginning. We need to make sure this idea is made real with specific policy changes. Also, allowing patients to make face-to-face video chats with a doctor takes a lot more than deploying broadband or other technology. Reimbursement, regulation and other policies will need to be addressed. ATA has identified six specific changes that the Administration can make immediately to improve the delivery of healthcare using telemedicine. They are available on the ATA website.

Over the past three months, we have been working with the White House and federal agencies to get these six fixes adopted. Our fingers are crossed on the outcome. Between health reform, broadband deployment plans and the President's speeches, the time for widespread use of telemedicine may be here soon.

More Evidence of Remote Monitoring Cost Savings

The results of new research, published in the January 2011 issue of Health Affairs (1), provide some interesting results that reinforce the importance of one aspect of remote monitoring: medication adherence. Compared to other studies, this one uses a more robust methodology, a larger sample size, demonstrates a strong link between adherence and reduced costs and directly refers to the benefits of remote monitoring. The study used data from 135,000 individuals with one or more of four chronic conditions, congestive heart failure, hypertension, diabetes and dyslipidemia. The article's conclusions provide an interesting perspective:

…“Our results indicate that despite higher pharmacy spending, medication adherence by patients with chronic vascular disease provides substantial medical savings, as a result of reductions in hospitalization and emergency department use. Benefit-cost ratios range from 2:1 for adults under age sixty-five with dyslipidemia to more than 13:1 for older patients with hypertension.

Given these findings, plan sponsors, government payers, and patients should consider participating in programs that improve medication adherence, as long as intervention costs do not exceed the estimated health care savings. Value-based insurance design, electronic monitoring devices, and pharmacist-led counseling are among the least costly alternatives. No matter what the intervention, actively encouraging medication adherence for chronic disease should be a top priority.”

The authors also stated that that the cost of an adherence intervention is directly related to the mode of delivery. Other studies that have assessed an intervention strategy involving heavy direct intervention by health professionals have not indicated results as strong as the ones reported here. The authors agreed with the results of an earlier study (2) that concluded: “Alternatives that require fewer resources—such as electronic monitoring devices and pharmacist-led patient counseling—have shown promise in improving patients’ medication adherence at less expense.”

(1)Roebuck MC, Liberman JN, Gemmill-Toyama M, Brennan TA. Medication adherence leads to lowerhealth care use and costs despite increased drug spending. Health Aff (Millwood). 2011;30(1
(2)Cutrona SL, Choudhry NK, Fischer MA, Servi A, Liberman JN, Brennan TA, et al. Modes of delivery for interventions to improve cardiovascular medication adherence: a systematic review. Am J Manag Care. 2010;16(12):929–42.

Telemedicine 2010 & 2011 Part 2 - TECHNOLOGY

Telemedicine has never been bereft of electronic wizardry and 2010 included a host of exciting developments with clever new devices that see, analyze, and intervene with any number of medical maladies, all at steadily reduced prices. Here are a few thoughts on two leading technologies: mHealth and video.

mHealth, clearly the hottest topic in telemedicine technology for 2010, has become a trendy term used for a perplexing array of activities. Its expansive definition now includes low cost cellular-based services for developing countries, consumer health-and-wellness digital phone products and wireless applications for the hospital and clinician. The number of downloadable cell-phone health apps exploded with over 10,000 such products now available, created by hundreds of new entrants to health care seeking a part of the trillion dollar healthcare market.

Rosy forecasts abound. But, market watchers have reported that the mHealth industry is evolving into a more concentrated market. Further, the sheer pace of innovation has resulted in some consumers taking a wait-and-see approach before making a purchase. Last June I wrote about how mHealth is close to the top of the hype cycle (It’s mHealth but will it be a Revolution?). We may be due for an industry shakeout soon, termed by Gartner as the “trough of disillusionment,” which will pave the way for broader adoption. In 2011, mergers and acquisitions in mHealth are sure to be news.

Although many business plans appear to rely on consumer and third party buyers, it is important to note that 90 percent of direct healthcare purchases are made by individual doctors and health administrators. Most successful mHealth technologies, like the rest of telemedicine, will be those that integrate and mainstream with traditional healthcare. MobiHealth News recently profiled nine hospitals dabbling with mHealth applications (http://mobihealthnews.com/special-edition-9-mobile-health-hospitals). Many more are starting to look. A few applications are starting to get wide-spread adoption by individual providers. For example, Epocrates, providing drug information and interactions over a digital phone, is now used by over a million health professionals. Of particular interest will be the interplay between the next-to-nothing cost of some mHealth applications and the remote monitoring industry.

Video conferencing technologies were also a buzz in 2010. On the high end, telepresence applications became closer to mainstream with many large institutions. Also in 2010, high definition video became the de facto standard for videoconferencing. A lingering concern that may be addressed next year is interoperability between both high-end and medium level videoconferencing technologies. Customers are looking for it and it appears vendors are moving toward it.

On the other end of the spectrum, webcams powered by free or almost free software is now in use by tens of millions of consumers worldwide and has started to pick up steam for medical services such as telemental health. Last year a series of discussions about privacy and HIPPA compliance for such devices and applications created confusion in the market (for the record, there is no official HIPPA certification for technology; it’s how you use it not what you use). The new videoconferencing application for 4G and Wi-Fi cell phones may be a potential game changer for some telehealth services starting next year. A series of two-way video calls from my cell phone while I was in China to the ATA offices in Washington, DC this December still astounds me.

Also of Note –There has been a series of amazing innovations in robotics, micro technology and automated clinical decision making, which may also start to have a broad impact on health delivery in 2011.

Telemedicine - 2010 & 2011 - Part 1 Public Policy

Here is the first of three pieces on where we have been in 2010 and where we are going next year for telemedicine. My comments throughout reflect the gobalization of the field. The focus here is on two critical public policy issues that have received worldwide attention: healthcare and broadband:

1. Since 2004, healthcare spending has been the single largest part of the national government’s budget in the U.S. as well as most industrialized countries. Thus, reform efforts attracted huge attention throughout the world. For telemedicine, 2010 appears to have been a watershed year - the point when many in charge of government healthcare programs finally started to seriously consider the benefits of such technology. Speeches in 2010 by the head of Medicare in the U.S. and Ministers of Health in Australia, China, England and Russia all included serious declarations on the importance of telemedicine. Its role in reducing hospital readmissions and the costs of chronic care have been highlighted as well as its ability to improve services for remote areas and even for special circumstances such as postoperative care. But the gulf between pronouncements and action is still there, with spending on telemedicine and integration of telemedicine into health systems in its infancy.
   
   2011 will be the critical year when we find out whether leaders in Washington and other world capitols will follow-through with specific actions. Despite the positive press, telemedicine has been caught between lingering fears over the costs of medical technology and the enormous attention directed to electronic records. For next year, the most important factors affecting the deployment of remote health services will be an increased emphasis on both provider and regional decision making, continued outcomes from comparative effectiveness studies and practice guidelines. The outlook is brighter than ever but still not certain.



2. Plans to aggressively expand broadband access were unveiled by several countries in 2010. In the United States, the Federal Communications Commission announced in September its National Broadband Plan: Connecting America (http://www.broadband.gov/). The plan includes federal policies, financial incentives and other activities to “ensure every American has “access to broadband capability.” In December, 2010 China announced that its next Five Year Plan would include a nationwide broadband backbone for the exclusive use of healthcare. Also in 2010, Australia started to roll out its National Broadband Network and broadband policy was a major issue in that country’s national elections.
   
   We will wait and see in 2011 what effect how the governments’ plans will actually have on accelerating broadband deployment. Our attention will be on 1) how much and where government dollars will be spent to support broadband deployment and 2) how much of the available broadband infrastructure will really be used for healthcare.