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    5.2 Telehealth

    It’s here. Finally.

    Telemedicine is a perfect illustration of the famed Gartner Hype Cycle. [1] Developed by the advisory firm Gartner, Inc., the Hype Cycle provides a graphical and conceptual presentation of the lifecycle of emerging technologies through five phases.

    The “Technology Trigger” for telemedicine happened in the late 1960s with government-funded research, and finally became practical in the 1980s with the advent of personal computing. By the mid-1990s, several hyped pilots were in motion and a “Peak of Inflated Expectations” had been achieved. In the early 2000s telemedicine began its slide down into the “Trough of Disillusionment.” Stumbling pilots, legal anxiety, and poor adoption led most to doubt the return on investments in telemedicine technology.

    All that has changed in the last five years. The combination and near-synchronous rising trends of smartphones, internet connectivity, cheap sensors, and payment reform have created the needed force to push telemedicine onto the “Slope of Enlightenment.” It has also gathered a broader, better name: “Telehealth.” Now few doubt its viability and there is widespread awareness of its benefits, risks, and applications.

    Here are the specific changes that prove that this paradigm shift is here to stay:

    • The government thinks it’s legitimate. In January 2015, CMS issued a new provider reimbursement code (CPT 99490) for non–face-to-face health care services for patients who have chronic medical conditions. It allows an approximately $40 payment for 20 minutes of non-face-to-face chronic care management (CCM) services per patient every month. That non-face-to-face part is what legitimizes telehealth as something the government thinks is worth paying for. The payment may sound trivial, but do the math: the average PCP has around 1,500–2,000 patients under care annually. Even if only 500 of those are eligible for CCM, there is an annual payment of $20,000 per physician on the table for remotely monitoring and interacting with patients. There are catches to this deal, of course. Patients have to explicitly agree to be in the CCM program and shell out a monthly $8 co-pay. This is the start of a torrent of federal money that will germinate the long-sown seeds of telehealth, just like what the HITECH Act did for the EHR industry.
    • Big vendors and deals are emerging. The top four players (Teladoc.com, MDLive.com, AmericanWell.com, DoctoronDemand.com) have continued double-digit growth and multi-million-dollar funding. Teladoc has blazed the path and even went public in early 2015. The official bonds these companies have formed with health insurers is what really underscores future viability. Multiple deals have been struck with big names like United Healthcare, WellPoint, Aetna, Cigna, and CVS Health to offer telehealth as either as an optional-and-charged service or as an included-and-free service. When traditional insurers start offering telehealth, it’s time to pay attention.
    • Regulatory forces are moving fast. In April 2014, the Federation of State Medical Boards (FSMB) adopted a model policy to guide state licensure boards in evaluating the appropriateness of using telehealth in care delivery. [2] 2015 saw more than 200 Telehealth-related bills introduced in 42 states. [3] Medicaid programs in almost all states (49 actually) and the District of Columbia already have some coverage for Telehealth. In June 2015, the Texas Medical Board stated their disapproval of virtual visits with physicians who have not previously seen patients in-person and ruled that a provider-patient relationship can’t be established remotely. Dallas-based Teladoc, in turn, sued the Texas Medical Board for being anti-competitive. The analysis of all this legal wrangling shouldn’t predict winners or losers. A more important takeaway is that there is continuous movement. The legal landscape is shifting, and evolving faster than ever before.

    If care interactions are not restricted to a physical location, the aspects of such virtualization open up many chances to create viable businesses. Existing online technology infrastructure around audio, video, mobile, security, payment, reviews, marketplaces, and on-demand services will all need to be customized for telehealth applications. In that sense, healthcare is now starting to experience the early years of ecommerce and online transactions. Emerging services like Telepathology, teledermatology, telepsychiatry, and telestroke will transform their conventional, real-world parent fields.

    Wearables

    The popularization of wearable devices is a trend that further proves the ongoing maturity of the remote monitoring phenomenon, albeit from a non-clinical perspective. Innovations from Fitbit, Misfit, Garmin, Apple, and others have helped create a mass awareness (and acceptance) of wearing sensors that detect some physiological metric(s) about the user’s body. Deriving continuous insights from the gathered data and connecting services (running coach, for example) is going mainstream too.

    Imagine the traditional medical device industry at one end of a spectrum and the consumer electronics industry at another. Players at the ends of that range are constantly yearning to stretch their product appeal toward the opposite side. Medical device makers are trying to create more apps and mobile add-ons to help them appear consumer-friendly. For example, take the surge in smartphone-compatible glucometers. On the flip side, retail players like Samsung and Apple are getting serious about the health-related value propositions of their devices. That’s why one can find banal activity monitors now marketed with heart-health buzzwords.

    With the medical establishment opening up to Telehealth and consumers understanding the concept of remote monitoring at the same time, the future is getting exciting. Before long, a significant quantity of medically-relevant data will be collected outside of clinical settings, often before any medical need arises.


    [1] Gartner. Interpreting Technology Hype. Accessed April 25, 2016.
    [2] Federation of State Medical Boards. Report accessed on April 25, 2016.
    [3] National Conference of State Legislatures. White paper accessed on April 25, 2016.