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Rheuban: Telemedicine: Full Discussion
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Rheuban: Telemedicine: Full Discussion
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Language: EN.
Segment:0 .
DR. ALI: I think maybe a neater approach, because I read your book which was a great read,
Segment:1 History of Telehealth.
DR. ALI: and I think you kind of touched upon the history, and I think we were just having a conversation about how cardiology, we're really some of the first, I think, verticals of physicians who actually were early adopters of remote monitoring. So, Holters, event recorders, but then in your book, I think you even talked about the American Civil War, or going way back where there is telegrams and--
DR. REHUBAN: Sure.
DR. ALI: Communicating.
DR. REHUBAN: Well, our telemedicine programs have been operational in the United States for more than 50 years. It's just the transformation of digital technologies has allowed us to really advance into everyday healthcare. And our program at the University of Virginia began 20-some odd years ago based on the premise that necessity was the mother of invention. We had patients who were remote from our institution, in rural locations who otherwise had no access in their community, so, it was driven by a need.
DR. REHUBAN: But fast forward to 2018, digital technology is here, consumers are demanding access to care over using convenient technologies and so it behoves us to establish high-quality programs that comport to the standards of care and improve access and have the policies align with what we're doing.
DR. ALI: Yeah, I agree. So, I think I agree with you that in 2018, now we have-- medicine was probably the slowest adopter of technology. I mean if you even look at electronic medical records, and since now we're in that era, I mean, you have digital banking, you can book your flights, your hotels, I mean, and people-- now, consumers are saying, "Well, why aren't we doing that in medicine?" And the consumers are driving this. It's not so much, I don't think medicine initially were the drivers.
DR. ALI: I think the consumers were saying, "Hey, I want healthcare when I want it, where I want it, and when I need it." And now the conversation, I think, is so, how do we start doing delivery care models-- and we're not just digital therapeutics, which is I think the new term-- of how do we start prescribing digital health apps to patients for chronic conditions or acute conditions. And we have the auspice on top of that, which is the Hippocratic Oath which is first, do no harm.
DR. ALI: So, how do we start using these digital technologies, but still, like you said, deliver high quality of care, and at what standards are we going to, as clinicians, hold ourselves when we have consumers saying, "I want care now." And how do we bridge that, and I think that's the fundamental question. And then, we need the support of clinical trials to show are these delivery models working? And also keeping at the high safety levels.
DR. ALI: And you're the expert as former ATA president. Just looking at where you've started back in, was it 2009?
DR. RHEUBAN: Well, 2009 as ATA president. More than 10 years behind, that's when we launched our program in the early to mid-90s. Which you guys were early adopters, if it was back in the mid-90s and I think now, we look at what is the current state. I mean we're seeing healthcare insurances now saying, "Hey, we can't ignore this anymore." "Our policyholders are demanding this so, we have no choice but to adopt it."
Segment:2 Barriers in Telemedicine.
DR. RHEUBAN: Where are you seeing the barriers right now in the telemedicine space?
DR. RHEUBAN: Well, there's a lot of elements that we need to advance. We absolutely need to develop the evidence, so, those are our trials. We want to provide high-quality care. We need to know and assure consumers. We need to assure providers. We need to assure payers. We need to assure regulators that we're providing high-quality care who advance legislation and policies that support telehealth.
DR. RHEUBAN: And healthcare is so heavily regulated that that has been a barrier in and of itself. Well-intentioned but sometimes slows us down. So, when we first started, technology was expensive. We didn't have the broadband networks. We didn't have provider understanding. We didn't have patients who understood. But as technology has evolved and the networks have evolved, you said it very articulately, people are using technology for everything else and they want to use it for healthcare.
DR. RHEUBAN: So, we need to make sure that we comport to the standards of care, that what we do aligns with the evidence and best practices and do no harm.
DR. ALI: Would you agree that-- I often get asked by consumers and even physicians, "So, what is telemedicine?"
Segment:3 Definition of Telemedicine.
DR. ALI: Like, what is it? And I usually respond that this is a way for two individuals, two parties, to communicate using video chat, right? But with the umbrella of it being HIPAA-compliant with the security and concerns of the patient-physician relationship and that interaction. Now, we're not doing it in person, we're doing it virtually, but I think the key concept here is can we provide the level of service at the standard of care that we would in person?
DR. ALI: And I think that's where a lot of state level and federal level, there is discussions and it hasn't been clearly defined. And I think that's where, as you said, that the data analytics, the trials need to be done, and I think the healthcare insurances-- I believe Omada and one of the healthcare insurances are working together on a program, for example, like Diabetes Prevention Program, just to give an example.
DR. ALI: And when I look at telemedicine, I try to break it down into four very broad categories. I look at acute care, I look at chronic care, I look at mental health because that is a very big area of telemedicine impact, and I think also post-care. So, when I talk about post-care, that could be post-partum, that could be after surgery, and so it's not really considered acute, it's not chronic, somewhere in between but it is post-care after an event, and that could become a chronic care condition.
DR. ALI: For example, after a stroke-- that's an acute event, and now there's a chronic condition that we have to deal with. And so, I think those are four very broad categories. There may be some other categories that you have in mind, but I think that is where the interplay of how do we take care of these patients, especially if they don't have access to great medical centers like you and I work in; there's a lot of remote towns and cities that, unfortunately, don't have enough access to care, and I think that's a big bridge that we can bring together through telemedicine and digital therapeutics.
DR. ALI: What's your thoughts on that?
DR. RHEUBAN: I completely agree. All of those buckets are totally appropriate.
Segment:4 Channels of Telemedicine.
DR. RHEUBAN: And then, you also want to consider the delivery mechanisms, which fall in sort of similar buckets, whether it's live interactive video-based services, or store and forward services-- store and forward meaning the asynchronous transfer of images and data for analysis by a provider with intervention to follow. And then remote monitoring tools which can sort of blend a little with store and forward as well, where biometric or physiologic data are sent from any number of settings-- primarily the home--to an entity, whether it's the hospital system, whether it's a company that manages the data, and then informs the provider.
DR. RHEUBAN: And then, there's mobile health which can include all of those systems or delivery mechanisms, and so, you can apply any of those to the various buckets you've identified and suddenly you have a really complex web of opportunity. And all opportunity, obviously, needs to be evaluated and done right.
Segment:5 Evaluation of Telemedicine.
DR. ALI: So, how do we do it right? What's your thoughts on that?
DR. RHEUBAN: Well, again, I think partnerships are really helpful. For me, in my own program at UVA, we have measured performance metrics, clinical outcomes metrics, but I think we're also, whether it's the payers including Congress as they look for federal government programs, need to understand what the financial outcomes are as well. And so, that's why I think partnerships with the payer community is most helpful because the keys to the kingdom often reside within those payer communities as well.
DR. RHEUBAN: So, we're all about partnerships to understand the outcomes of what we do. And I think the time is here and now, and actually 2018 is a great year for telehealth.
DR. ALI: Yeah, I think 2018 is a great year. I think one of the biggest barriers that I have seen just in practicing medicine as a whole, and I'm going to ask you about what your thoughts are about maybe future of where we're going with telemedicine, but-- And I'm going to premise it with this one statement: As physicians-- you're pediatric cardiology, I'm adult cardiology-- we know what we're doing, we have very great metrics for diagnosis and treatment, very evidence-based, appropriate utilization criterias, we have guidelines.
DR. ALI: We talk to patients, we make diagnoses and treatments. The biggest barrier that I see in medicine as a whole, where telemedicine, digital therapeutics can fill a void is behavioral changes, and compliance. I think compliance is a big area that up until now, physicians have not had the opportunity to monitor patients to see if they're actually taking our advice and moving that forward. So, I think one of the big opportunities we have right now in digital therapeutics,
Segment:6 Capturing Data & Patient Compliance.
DR. ALI: actually prescribing apps to patients, is to now capture data, and look at compliance, how do we work on behavioral changes.
DR. ALI: Just, for example, simply by doing push notifications. In fact, my mom, for example, I had initially just set up an alarm system for her to take her medications, now I've found a digital therapeutic app to do push notifications where she can notify her loved ones that, "Yes, in fact, I've taken my medications." What a simple digital therapeutic, right? And that's a very basic 101 concept, which is compliance.
DR. ALI: And then we start looking at behavioral changes. So, behavioral changes I think
Segment:7 Behavioral Changes in Telemedicine.
DR. ALI: is one of the biggest areas in telemedicine that we can push. So, I think one other bucket that I may have not mentioned is also, maybe in the chronic condition, but is wellness. And I think the wellness space is chock-full. As cardiologists, I think McGuinness from the NIH had done a study in 1990, 2000, 2010 and showed that the cause of death in America-- MIs, stroke, cancer, motor vehicle accidents, COPD, pulmonary diseases-- many of those are driven by behavioral changes.
DR. ALI: That's the effect, the cause is actually lack of exercise, not smoking, having good dietary habits and then actually using the preventative services that-- as played out by the United States Health Task Force. And so, those are the causes. The effect are heart attacks, strokes, COPD, right? So, these are behavioral changes in chronic conditions that we can change. So, I think we have an opportunity in the space of telemedicine and wellness to actually help those individuals focus on the cause of disease, and we know that a vast percentage, more than 50% of these diseases are modifiable.
DR. ALI: And now, finally, and I will shift the subject into actually how do we get paid for this because I think that's a big driver. I think technology is great but for adoption, we have to show metrics of success not just through these behavioral changes and data analytics, but to get adoption, the physicians have to get paid, the patients have to be provided for. So, what's your thoughts on this, I think it's a big elephant in the room in telemedicine, right?
DR. RHEUBAN: Sure, sure.
DR. RHEUBAN: So, you've covered the entire spectrum. I want to harken back first to what you talked about-- post-acute care and compliance and behavior change. Not necessarily-- The prevention piece is critical as well, but starting with that piece. Traditionally, patients were discharged from the hospital and they'd get their return appointment and they might come and they might not come. But integrating remote monitoring tools into that can affect compliance and can affect behavior change.
DR. RHEUBAN: So, in our experience in remote patient monitoring post-hospitalization, patients absolutely love it. I mean, I was amazed at the incredible positive feedback that we have gotten. And we've demonstrated a reduction in hospital readmission, as much as 70% in some conditions. On average, about 40%, but patients, they really need to know somebody is watching and somebody cares. And if there are outliers in physiologic data, somebody's calling in.
DR. RHEUBAN: That impacts the patient. The patient then can say, "Oh, I had too much salt yesterday, that's why I gained three pounds, and somebody noticed it", as opposed to waiting 'til they get more and more edema and heart failure and then come back in extremis. So, that's one really important piece; behavior change and compliance is huge. And we're looking at things like Apple watches to tell patients, the same thing-- to get prompts, push notification to say, "Take your medicine." Totally appropriate.
DR. RHEUBAN: Prevention is really important. We haven't really fully incentivized prevention, although employers are moving in that space as well. And there are incentives that can be provided not only to the providers but to the patients themselves, in terms of adhering to some of the recommendations in the wellness space. And smoking cessation and all the things that can add to the morbidity and mortality.
DR. RHEUBAN: So, payment for telehealth, that's a huge thing.
Segment:8 Payment and Metrics of Success in Telehealth.
DR. RHEUBAN: So, payment for telehealth has traditionally been either federal, through the federal government, like Medicare, or federal employee benefit plans do cover. Medicare is relatively limited in terms of their reimbursement. They have significant originating site restrictions under fee-for-service Medicare. In fact, in 2014, the data provided by the Center for Telehealth & E-Health Law provided to them by CMS, was that nationwide Medicare only reimbursed $14 million in claims, nationwide for telehealth services.
DR. RHEUBAN: So, there are more opportunities, and as we alluded to, 2018 is a really great year because there have been some changes
Segment:9 Changes in Medical Policies and Coverage.
DR. RHEUBAN: in Medicare, changes in the budget bill which incorporated the CHRONIC Care recommendations for expanding eligibility for acute stroke services to now rural and urban-originating site hospitals. That's critical. And we can talk about stroke in a minute. Also for dialysis patients, patients with end-stage renal disease who have challenges getting back to the clinic facility.
DR. RHEUBAN: In many cases, a lot of dialysis facilities are remote, but patients are even more remote. So, to enable telemedicine services to be provided. And then there's also expansion under ACOs and Medicare advantage programs, that was in the CHRONIC Care bill. So, that will hopefully expand adoption because there will be expanded payment. And then in the physician fee schedule for 2018, which really thrilled me, personally, because we're trying to build out remote monitoring is the new unbundled CPT Code 90...
DR. RHEUBAN: 90... 91... 99091, allows for unbundled CPT Code for remote monitoring. Suddenly we have a mechanism by which providers can be reimbursed to provide these services. So that's really important. And I'm hoping that there will be more payments for practice costs. If you have to invest in technology, it's one thing to be reimbursed a relatively small amount for reviewing 30 minutes a month, but it's another for the expense of the service provided to the patient, and what it takes to set it up in your own practice.
DR. RHEUBAN: So, I see that coming within the next year as well.
DR. ALI: Yeah, I think one of the examples that is prevalent today is actually the Diabetes Prevention Program. We just gave grand rounds at University of Texas actually yesterday, on this topic. So, I think that encompasses, actually, everything that we've spoken about, because in the Centers for Disease Control they did a trial where they looked at pre-diabetics. Now, pre-diabetes defined as a glucose of 100 to 125, and A1C that would be not your traditional, above 6.5% diabetes, but between 5.7 and 6.4. And we finally found out that a diabetic, if you quantify, if a pre-diabetic became a diabetic, it costs the healthcare system about $7,000 per patient.
DR. ALI: But if we were able to prevent those diseases, then now we're in a different era and we can actually reduce. So, the Diabetes Prevention Program showed through a trial that was done approximately seven years ago, that we could reduce the incidence of pre-diabetics becoming diabetics by up to 58% just by lifestyle choices, and that metformin actually did not do as well. It was actually non-inferior to lifestyle choices, so that it meant that if we prescribed lifestyle choices over a medication, we actually reduced the incidence of pre-diabetics going to diabetics.
DR. ALI: That's huge, so there is the opening for behavioral change and compliance. And now the CMS has given money to reimburse the physicians and the patients to get on board, to really look at their pre-diabetes, and I think the space for telemedicine is there. And actually, there's a company known as Solera that is looking at this pre-diabetic space and DPP and using digital therapeutics, and even in their own data, more patients would rather use a digital platform than go in person, and that was across the spectrum.
DR. ALI: And I think one area that we didn't even touch upon,
Segment:10 Patient Adoption of Telemedicine.
DR. ALI: is who's adopting this? Is it just young patients? Is it, you know-- I'm around my 40s now-- or is it patients above 65, which is when Medicare starts kicking in, where my mother would be, and we were talking about mothers earlier. So, what's your take on just the adoption, the age adoption of individuals in telemedicine?
DR. RHEUBAN: Oh, I think it's all age groups, actually. And, again, we were chatting about our mothers. My own mother is using the AliveCor device for management of her atrial fibrillation to identify-- and she adopted it without any challenge at all. And she just-- this generation, seniors are using FaceTime and Skype to be able to communicate. Their expectation is they'd like to be able to do so as well to their providers. It's a much more savvy older generation than one might have expected.
Segment:11 Future of Telemedicine and Government.
DR. ALI: Where do you think the next steps that we're going in telemedicine and I guess the big areas to me, 2018, which you alluded, this is going to be a big year, is parity laws which I think President Trump is now on board nationally through the Veterans Association, looking at parity laws. What's your take on the parity law? And then I think the next part is that we touched upon is the payer mix, and how insurances and device companies and digital therapeutics are working together to actually get telemedicine paid for.
DR. RHEUBAN: So, as we alluded earlier, the federal government plays a big role, certainly for the Veterans Health Administration, Department of Defense, Medicare, but the states play a huge role as well. And sometimes when there are roadblocks in Congress, especially because the Congressional Budget Office has to score these bills and when they are more expensive than what Congress would like, they push back, even though the evidence suggests that it should be less expensive. But at the state level, there's private pay parity laws and now more than 35 states have implemented private pay parity laws.
DR. RHEUBAN: And some are parity reimbursement itself with in-person. Others are not, just saying you have to pay for telemedicine services. And every state, you've seen one state, you've seen one state. Some say you have to pay for remote monitoring, some say you have to pay for E&M codes and visits. But the states have been very progressive, and one place the states have played a fabulous role in is with the Medicaid programs. So, the state Medicaid programs, again, you've seen one state, you've seen one state, but they have to manage larger populations, especially in those states that have expanded Medicaid, and to be able to have improved access and manage the patients better.
DR. RHEUBAN: And partnerships with the payers themselves, the managed Medicaid organizations who hold these contracts are very important. Again, they will hold the outcomes data, cost data, clinical outcomes data, from which we can then use as the evidence base to inform Congress and the Congressional Budget Office to advance Medicare reimbursement. I think one of the places we are also going well beyond fee-for-service is alternative payment methodologies.
DR. RHEUBAN: And that's where I think wellness plays a great role as well, to incentivize providers and systems to incorporate wellness in for the populations that they serve. So, that's another great opportunity. We're not quite there fully with alternative payment methodologies so fee-for-service still lives here today. And it's very important to get it right. And for me, I work in a large health system, and our investment in telemedicine, in staffing and technology, is by the CEO of the hospital.
DR. RHEUBAN: So, I need to be able to show her there is a return on investment in terms of better outcomes, fewer penalties for readmission with remote monitoring, and better management of patients. The stroke world is huge. You as an adult cardiologist, that's now-- standard of care is using telemedicine technologies for access to stroke neurologists for early, timely administration of tPA and thrombolytic agents and methodologies.
DR. RHEUBAN: In our own experience and that of Dr. Lee Schwamm from Mass. General, who's really set the stage for this nationwide, it has leveled the playing field. We know that in our state, which I think-- I'm so proud of my colleagues in stroke neurology-- if you present to a critical access hospital in a rural community that might be, if you're lucky, a three to four-hour drive just to UVA, and maybe you can fly, and maybe you can't in bad weather, the actual tPA administration rates through telemedicine are exactly the same as the administration rates if you showed up de novo as a citizen of the city of Charlottesville and you show up in our emergency department.
DR. RHEUBAN: That's transformational. We're saving lives, saving brains.
DR. ALI: Yeah, I mean just imagine that-- we were talking about our mothers but one of them had a stroke and were not able to get to a hospital, and loses the window-- there's a window of time that they could get the tPA. And James Grotta from University of Texas has put an imaging MRI, actually, on the back of an ambulance, where they can pull up to your doorstep, get the imaging and be able to use telemedicine to communicate and initiate the tPA, and stabilize them and bring them back to the university.
DR. ALI: So, I think that was the bucket that we talked about-- acute care shifting over to chronic care-- hypertension, diabetes, smoking, obesity as well, which also goes into the wellness space. I think there's huge opportunities to help cost-cutting and savings, not just from an economic side, but also for great patient outcomes. And I think that you hit upon it, we as a whole for telemedicine-- I think American Telemedicine Association is the biggest driver right now-- trying to get all of these states, and all of these parity laws, and the whole nation under one umbrella to say, "Hey, let's all get together, collect the data, do the data analytics." And I think that's what it takes to really drive the insurance companies and the adopters to say, this is a standard of care of delivering healthcare.
DR. ALI: I think what we need to define are what are the areas that we feel comfortable as physicians-- again, first, do no harm-- in the telemedicine space, and what are the areas that do need to be seen in person. And I think that will only be answered through industry and academic centers, working together and in unison, and to bring that data together and present in forums. For example, I think, both of us have been at the American Heart Association, American College of Cardiology.
DR. ALI: I think these are huge topics. Again, going back to cardiologists, who've been early adopters of telemedicine and information from remote-- for example, Holter monitors, event recorders-- and so, I think every industry in medicine, whether you look at dermatology, where pictures can be taken and looked at. Again, still more data needs to come out on which lesions need to be seen and do they need to be palpated.
DR. ALI: I think there's a number of different verticals in our fields. I think from some very prime examples as you had explained about CARDIA, there's a group that I've been discussing in Houston, who have taken-- they don't make any devices, but what they've done very smartly is taken all of the devices in sleep, including EEG, even for daytime somnolence, and putting that into an API in a dashboard, and reducing the costs.
Segment:12 Telemedicine Reducing Costs.
DR. ALI: I think the biggest driver that will bring telemedicine into the forefront, which I think it is now, but really in the forefront, is showing the data analytics that we're reducing cost.
DR. RHEUBAN: Absolutely.
DR. RHEUBAN: That this is no longer a fee-for-service type of industry. This is based on outcomes, improvement in healthcare, improvement to access of care, and all of that being driven to reduce healthcare cost with improvement in care. And delineating what areas, that we as a group of physicians, first doing no harm, are able to put together, that will be the driving force. And I think there's so many examples, and I'll go back, we'll cut out the DPP because I want to go back.
DR. RHEUBAN: It's actually a very important point. So, I'm just going to bring another example, back to the example of Diabetes Prevention Program. Can't state that enough because one-third of Americans,
Segment:13 Diabetes Prevention Program.
DR. RHEUBAN: that's over 85 million Americans, have pre-diabetes. And we know that if those pre-diabetics become diabetics, it costs the healthcare system, annually, $7,000. So, if we can prevent those patients in the Diabetes Prevention Program, which was put out by the CDC, that showed that lifestyle interventions reduced the transformation of that pre-diabetic to a diabetic by about 57%, which was much better than prescribing a very common medication called metformin, as you're very aware of.
DR. RHEUBAN: So, lifestyle interventions actually improved the decrease in diabetes. And the point of that is that we can use telemedicine in the two big areas that we talked about-- behavioral changes and having the patients adopt and actually being compliant. And so I'll give you a very prime example of Diabetes Prevention Program. So, a company called Solera Health has been working with companies like Omada, like a company that I work with, Fruit Street and even Lark, which is an AI application for Diabetes Prevention Program, and they've actually shown that if you allowed the consumer to go through a screening process to see if they qualify of being a pre-diabetic, that they can choose an in-person or a digital engagement.
DR. RHEUBAN: So, whether that's AI, or that's telemedicine, or that's using a digital therapeutic, that a majority of patients would actually choose using a telemedicine service. And it makes sense-- it goes back to convenience, and being able to actually talk to a provider and not having the burden to drive through the traffic or miss an appointment. But they found that, in about 40,000 patients, there's a non-inferior response to whether you did it in person or through a digital therapeutic.
DR. RHEUBAN: I think that's huge, and I think that is what is needed as the driving force to really push telemedicine. I will tell you in the Diabetes Prevention Program, it really equals, as a cardiologist, to cardiometabolic risk reduction and weight loss. And here's a perfect example: you have to lose 5% of weight to be paid for the service-- there's four stages, but ultimately to get the entire amount of payment.
DR. RHEUBAN: What a perfect example that puts together what we're talking about today. We're looking at delivering better healthcare that's convenient; that is modifying patients' diseases so they don't go into diabetes; where they're getting weight loss, you have the wellness component; cardiometabolic risk reduction, so, now you have the chronic care management; that we have payments for that to the healthcare industry; and that the CDC and CMS are recognizing it.
DR. RHEUBAN: And on top of that, they're paying for that using a digital engagement. What a perfect example. So I think the Diabetes Prevention Program will be one of the driving forces in 2018, as more data is collected and outcome measures are being shown. I think another big area in the CDC is chronic care management, and that also will show in the bucket of what we talked about-- chronic care conditions-- that we can manage chronic care conditions remotely, and again, showing those outcome datas will push the CDC and CMS to say, "We recognize, we see the value, we see the value for the physician and, ultimately, the healthcare system." Your thoughts about that.
DR. RHEUBAN: Completely agree. Earlier you talked about the various advocacy organizations. When you think about the context you've just discussed,
Segment:14 Rural Communities and Telemedicine.
DR. RHEUBAN: the National Rural Health Association has also been incredibly supportive of telehealth as a tool to empower our rural communities.
DR. ALI: Absolutely. We know that rural hospitals are closing at unprecedented rates, leaving patients in communities with no access to care, whether it's emergency services or inpatient services. Suddenly telehealth is yet another tool that will improve that access and allow rural patients to avail themselves of these very same opportunities. The prevalence of diabetes is even higher in rural communities. And a host of other conditions certainly prevalent in rural communities. We haven't really talked about mental health access, substance use disorders, really important.
DR. ALI: In our program we provide services in the UVA telemedicine program in more than sixty, 6-0 different clinical specialties and subspecialties with more than 100 projects in development. So, clinicians are engaging and the patients are very much accepting it.
Segment:15 Mental Health in Telemedicine.
DR. ALI: But mental health still remains our number one demand in request for services. So, we have a long way to go to address the workforce shortages and the malalignment of providers who tend to stay in urban areas and not be in rural communities.
DR. ALI: So, telemedicine is a fabulous application. Just like you mentioned, which I really loved the discussion about, pre-diabetic patients are more happy to use telemedicine than perhaps driving across town to be face-to-face. In many cases, for mental health, it's easier for patients to be able to communicate virtually, than be in that space. We've demonstrated fewer missed appointments in mental health services using the telemedicine technologies, because it's there, locally, and it's a great alternative.
Segment:16 Substance Abuse Disorders in Telemedicine.
DR. ALI: And we're facing gigantic prevalence of substance use disorders and we need to think of creative solutions that will empower patients and providers to be able to access some of these services and I know that is a priority for this administration, as it was for the last, and I'm hopeful that we'll have greater improvements in policies that will enable us to be able to use these technologies for substance use disorder. I think those are two hot topics right now dealing with mental health disorders and opioid addictions and pain addictions.
DR. ALI: I think that it's a great opportunity for telemedicine to fill that void. I completely agree. It's access, access, access. And individuals don't necessarily want to drive to a physical location. There's a lot of reasons for that, but to be able to do that at the comfort of your home, with very serious conditions that they may not otherwise want to go seek help, but may from the comfort of their home, and having easier ability to access to go get that help, I think, should be and I think is a big focus in the ATA and telemedicine.
DR. ALI: I think we have a great position to fill that gap, and I think that is a great focus in the acute and chronic care buckets that we talked about.
Segment:17 Future of Telemedicine and Digital Therapeutics.
DR. ALI: Where do you think the future-- I think it's one of the questions I wanted to pick your mind, have some ideas-- but where do you think the future of this-- it's such a Wild West, in a way, right? This whole digital therapeutics, telemedicine, all the verticals we talked about, but where do you see the future play with telemedicine digital therapeutics?
DR. RHEUBAN: Well, you know what, I like to think that it's not going to be telemedicine. It's just going to be healthcare, this is how we deliver healthcare. This is how we bank, this is how-- And assuming we can work out the regulatory challenges and appropriate, you know-- regulations addressing licensure, credentialing and privileging, patient privacy, evaluating outcomes, this will be everyday healthcare.
DR. RHEUBAN: And we do have a long way to go in terms of making that happen because there are so many different silos right now that impact telemedicine providers, but this will be everyday healthcare. Health information exchange, that's another thing. We have great electronic medical records, we're an Epic system.
DR. ALI: Interoperability with that.
DR. RHEUBAN: Interoperability is absolutely key. I don't need to be getting faxed requests for telemedicine, services coming from a facility with faxed medical records. We don't need that anymore in the digital era. So, we just have to work out all of these elements to make it seamless and integrated. We have a distributed network in telemedicine within our health systems. So, every provider has a secure video conferencing portal available to them. And Epic is our electronic medical record, and we have incorporated telemedicine into Epic, but we still have a long way to go, in terms of that health information exchange.
DR. RHEUBAN: And then it's the digital health tools. There are peripheral devices that can be used in the home setting that will allow us to comport with the standards of in-person care. That's important. So that when a provider is seeing a patient, they're not just talking to somebody without using some of the very tools that we might use in our office. So, I see the digital transformation as here and now and it behooves us to gather the evidence and show that it is effective, and that we align with the triple aim of improved access, that you referred to, improve access, improve quality, and lower cost of care.
D. ALI: From a standpoint of the future of telemedicine, I look forward to the day that you pick up your phone, and you hit an app, and you get to see a physician when and where you want to, that the barriers of access are removed and it is as simple as banking, booking a flight, booking a hotel, or seeing a clinician for your medical care. I see the day that when a patient comes to see me physically in the office, that I'm really auditing their numbers, I'm actually no longer having a discussion for the short period of time that I'm allowed to, but really looking at the data analytics of compliance and behavioral changes and really working on that.
D. ALI: So, I look at the hardware that we've prescribed them that integrates and it's interoperable with my EMR, that I have a dashboard that I get to see, "What have you been doing over the last three months?" And my conversation with you is an audit of that information. And then the subsequent treatment is actually tweaking the digital therapeutics on you and saying, "In the next quarter that I see you, these are the items that we're going to work on." And by the way, my opinion on the matter is that healthcare is not practiced at the time that I'm seeing the patient.
D. ALI: Healthcare is practiced between the office visit. Telemedicine and wearables is that bridge. It helps us bridge the behavioral changes as well as the adoption of this information. I think those barriers are being reduced as industry and academics work hand in hand together. And I think the vision is really the prescription of digital therapeutics in the future. I think that-- go ahead.
DR. RHEUBAN: I wanted to comment on one point you made when healthcare is as easy as hitting an app and connecting to a physician, wherever possible, within the context of the medical home, whether it's the primary care medical home, or the specialty medical home, so we don't have fractionated care.
DR. ALI: That's right. I mean, how frustrating is it that--
Segment:18 Physician Interaction and Patient Data.
DR. ALI: I don't know how many hours you spend a day, just trying to get the physicians to talk to each other, and I think that the driver, again, is going to be the consumer, that the consumer is going to have the access point, and allow us to, as individual physicians, to look at their data, and as easy as sending me a HIPAA-compliant form that I can tap and then access their information, and share that information within the home health nurse, the physicians, the NPs, the PAs, the mid-levels, that we're all on the same board.
DR. ALI: I mean, how many medical mistakes are being done right now, just through number of pharmaceuticals that different physicians may be prescribing because no one knows what each other is talking about. And I think the consumer's going to be the biggest driver. The consumer needs to, especially now that we have Cloud systems, we have the ability to really push out data across the spectrum, physicians and the mid-levels and all of the healthcare communities that are affecting that patient will be able to access that data.
DR. ALI: I also think that the future of telemedicine needs to be
Segment:19 Collection of Patient Data.
DR. ALI: where the patient doesn't even know that their data is being collected, gives access to be able to collect that data. I'll give you just an example of some ideas that have been floated out there. Your commute. I don't know if you're on the subway or if you drive a car-- but as simple as this, if you're driving a car, for example, you sit down in the car-- there's your weight.
DR. ALI: You put your seatbelt on, it's going right over your chest, right? So, we can have your EKG. We can put monitors on the steering wheel to measure your pulse ox. Now, there are glucometers that just need sweat or skin access, so I can actually measure your glucose after you had your breakfast this morning, right? All this data can be collected, aggregated. There's AI apps, there's data analytics and where the patient or the consumer doesn't even know that data is being collected, but wants that data collected, right?
DR. ALI: And wants to be able to give that access to the people that need to see that access. And so I think there is even talks about when you use the restroom, right?
DR. RHEUBAN: Oh, sure.
DR. RHEUBAN: That we can access your urine analysis. We can check for occult bloods in your stool that could be a predictor for colon cancer. That could be simple sensors that are put into, as simple as a toilet system. And we can talk about sleep, sleep apnea which is a big chronic condition that is a definite chronic condition that affects the heart as not only the lungs when you sleep. And I think that's a big area of interest right now in digital therapeutics, is sleep apnea.
DR. RHEUBAN: So, the point is that as things move forward, where you look at the house, again going back to the apps that we talked about, banking, and booking flights and hotels. You have apps that let you in your door at home. You have Nest that lets you access your air conditioning before you get home. I see that there's a whole healthcare industry that can be integrated in our day-to-day routines, that we don't even have to think about it.
DR. RHEUBAN: That that data is being collected as you manage your life, and that your physician gets access so when you're doing that quarterly review, it's more of an audit of that information, rather than having you have to actively collect that information.
DR. RHEUBAN: And I think you made a really good point about this is not just about physicians. This is about an entire workforce, right, in healthcare that are engaged because there's going to be so much demand. It's advanced practice nurses, physician's assistants, training nurses, training LPNs and CNAs and community health workers to be part of this evolution in healthcare. And there's going to be a lot of data to be analyzed and mined, and we just have to make sure we do it right, and train everyone to work collaboratively and certainly at the top of their license.
DR. RHEUBAN: So, this is very exciting.
DR. ALI: It's very exciting. 2018 I think is going to be a big year for all of us. And I look forward to actually collaborating and working with you, actually.
DR. RHEUBAN: I feel the same way, this is great.
DR. ALI: Because I think you kind of represent a lot of the academia, and I kind of represent a lot of what where industry is going.
DR. RHEUBAN: The innovators, yeah.
Segment:20 American Medical Association in Telehealth.
DR. RHEUBAN: And I want to also give a plug to the American Medical Association. So, the AMA has really transformed in terms of its engagement in telehealth. They have convened the AMA's Digital Medicine Payment Advisory Group, because as we speak to what is going to incentivize systems and providers, we still have to work out the solutions and how it's integrated. So, the AMA has been extremely positive, and I'm grateful for that.
DR. ALI: Absolutely. I attended a number of lectures at the AMA and they do seem like they're really pushing to be a driver. They do recognize that this paradigm shift between fee-for-service and value-based systems, and I think they look at everything that we've talked about, from acute care to chronic care conditions, especially in the cardiometabolic world, we can make a big impact. And I think telemedicine and wearables, and digital therapeutics are going to be a big driving force.
DR. RHEUBAN: And "augmented" intelligence, "artificial" intelligence, however we want to--
DR. ALI: AI, data analytics.
DR. RHEUBAN: Machine learning, right.
DR. RHEUBAN: All of these things putting together and accessing, I think it's an exciting time in the telemedicine space.
Segment:0 .
DR. ALI: I think maybe a neater approach, because I read your book which was a great read,
Segment:1 History of Telehealth.
DR. ALI: and I think you kind of touched upon the history, and I think we were just having a conversation about how cardiology, we're really some of the first, I think, verticals of physicians who actually were early adopters of remote monitoring. So, Holters, event recorders, but then in your book, I think you even talked about the American Civil War, or going way back where there is telegrams and--
DR. REHUBAN: Sure.
DR. ALI: Communicating.
DR. REHUBAN: Well, our telemedicine programs have been operational in the United States for more than 50 years. It's just the transformation of digital technologies has allowed us to really advance into everyday healthcare. And our program at the University of Virginia began 20-some odd years ago based on the premise that necessity was the mother of invention. We had patients who were remote from our institution, in rural locations who otherwise had no access in their community, so, it was driven by a need.
DR. REHUBAN: But fast forward to 2018, digital technology is here, consumers are demanding access to care over using convenient technologies and so it behoves us to establish high-quality programs that comport to the standards of care and improve access and have the policies align with what we're doing.
DR. ALI: Yeah, I agree. So, I think I agree with you that in 2018, now we have-- medicine was probably the slowest adopter of technology. I mean if you even look at electronic medical records, and since now we're in that era, I mean, you have digital banking, you can book your flights, your hotels, I mean, and people-- now, consumers are saying, "Well, why aren't we doing that in medicine?" And the consumers are driving this. It's not so much, I don't think medicine initially were the drivers.
DR. ALI: I think the consumers were saying, "Hey, I want healthcare when I want it, where I want it, and when I need it." And now the conversation, I think, is so, how do we start doing delivery care models-- and we're not just digital therapeutics, which is I think the new term-- of how do we start prescribing digital health apps to patients for chronic conditions or acute conditions. And we have the auspice on top of that, which is the Hippocratic Oath which is first, do no harm.
DR. ALI: So, how do we start using these digital technologies, but still, like you said, deliver high quality of care, and at what standards are we going to, as clinicians, hold ourselves when we have consumers saying, "I want care now." And how do we bridge that, and I think that's the fundamental question. And then, we need the support of clinical trials to show are these delivery models working? And also keeping at the high safety levels.
DR. ALI: And you're the expert as former ATA president. Just looking at where you've started back in, was it 2009?
DR. RHEUBAN: Well, 2009 as ATA president. More than 10 years behind, that's when we launched our program in the early to mid-90s. Which you guys were early adopters, if it was back in the mid-90s and I think now, we look at what is the current state. I mean we're seeing healthcare insurances now saying, "Hey, we can't ignore this anymore." "Our policyholders are demanding this so, we have no choice but to adopt it."
Segment:2 Barriers in Telemedicine.
DR. RHEUBAN: Where are you seeing the barriers right now in the telemedicine space?
DR. RHEUBAN: Well, there's a lot of elements that we need to advance. We absolutely need to develop the evidence, so, those are our trials. We want to provide high-quality care. We need to know and assure consumers. We need to assure providers. We need to assure payers. We need to assure regulators that we're providing high-quality care who advance legislation and policies that support telehealth.
DR. RHEUBAN: And healthcare is so heavily regulated that that has been a barrier in and of itself. Well-intentioned but sometimes slows us down. So, when we first started, technology was expensive. We didn't have the broadband networks. We didn't have provider understanding. We didn't have patients who understood. But as technology has evolved and the networks have evolved, you said it very articulately, people are using technology for everything else and they want to use it for healthcare.
DR. RHEUBAN: So, we need to make sure that we comport to the standards of care, that what we do aligns with the evidence and best practices and do no harm.
DR. ALI: Would you agree that-- I often get asked by consumers and even physicians, "So, what is telemedicine?"
Segment:3 Definition of Telemedicine.
DR. ALI: Like, what is it? And I usually respond that this is a way for two individuals, two parties, to communicate using video chat, right? But with the umbrella of it being HIPAA-compliant with the security and concerns of the patient-physician relationship and that interaction. Now, we're not doing it in person, we're doing it virtually, but I think the key concept here is can we provide the level of service at the standard of care that we would in person?
DR. ALI: And I think that's where a lot of state level and federal level, there is discussions and it hasn't been clearly defined. And I think that's where, as you said, that the data analytics, the trials need to be done, and I think the healthcare insurances-- I believe Omada and one of the healthcare insurances are working together on a program, for example, like Diabetes Prevention Program, just to give an example.
DR. ALI: And when I look at telemedicine, I try to break it down into four very broad categories. I look at acute care, I look at chronic care, I look at mental health because that is a very big area of telemedicine impact, and I think also post-care. So, when I talk about post-care, that could be post-partum, that could be after surgery, and so it's not really considered acute, it's not chronic, somewhere in between but it is post-care after an event, and that could become a chronic care condition.
DR. ALI: For example, after a stroke-- that's an acute event, and now there's a chronic condition that we have to deal with. And so, I think those are four very broad categories. There may be some other categories that you have in mind, but I think that is where the interplay of how do we take care of these patients, especially if they don't have access to great medical centers like you and I work in; there's a lot of remote towns and cities that, unfortunately, don't have enough access to care, and I think that's a big bridge that we can bring together through telemedicine and digital therapeutics.
DR. ALI: What's your thoughts on that?
DR. RHEUBAN: I completely agree. All of those buckets are totally appropriate.
Segment:4 Channels of Telemedicine.
DR. RHEUBAN: And then, you also want to consider the delivery mechanisms, which fall in sort of similar buckets, whether it's live interactive video-based services, or store and forward services-- store and forward meaning the asynchronous transfer of images and data for analysis by a provider with intervention to follow. And then remote monitoring tools which can sort of blend a little with store and forward as well, where biometric or physiologic data are sent from any number of settings-- primarily the home--to an entity, whether it's the hospital system, whether it's a company that manages the data, and then informs the provider.
DR. RHEUBAN: And then, there's mobile health which can include all of those systems or delivery mechanisms, and so, you can apply any of those to the various buckets you've identified and suddenly you have a really complex web of opportunity. And all opportunity, obviously, needs to be evaluated and done right.
Segment:5 Evaluation of Telemedicine.
DR. ALI: So, how do we do it right? What's your thoughts on that?
DR. RHEUBAN: Well, again, I think partnerships are really helpful. For me, in my own program at UVA, we have measured performance metrics, clinical outcomes metrics, but I think we're also, whether it's the payers including Congress as they look for federal government programs, need to understand what the financial outcomes are as well. And so, that's why I think partnerships with the payer community is most helpful because the keys to the kingdom often reside within those payer communities as well.
DR. RHEUBAN: So, we're all about partnerships to understand the outcomes of what we do. And I think the time is here and now, and actually 2018 is a great year for telehealth.
DR. ALI: Yeah, I think 2018 is a great year. I think one of the biggest barriers that I have seen just in practicing medicine as a whole, and I'm going to ask you about what your thoughts are about maybe future of where we're going with telemedicine, but-- And I'm going to premise it with this one statement: As physicians-- you're pediatric cardiology, I'm adult cardiology-- we know what we're doing, we have very great metrics for diagnosis and treatment, very evidence-based, appropriate utilization criterias, we have guidelines.
DR. ALI: We talk to patients, we make diagnoses and treatments. The biggest barrier that I see in medicine as a whole, where telemedicine, digital therapeutics can fill a void is behavioral changes, and compliance. I think compliance is a big area that up until now, physicians have not had the opportunity to monitor patients to see if they're actually taking our advice and moving that forward. So, I think one of the big opportunities we have right now in digital therapeutics,
Segment:6 Capturing Data & Patient Compliance.
DR. ALI: actually prescribing apps to patients, is to now capture data, and look at compliance, how do we work on behavioral changes.
DR. ALI: Just, for example, simply by doing push notifications. In fact, my mom, for example, I had initially just set up an alarm system for her to take her medications, now I've found a digital therapeutic app to do push notifications where she can notify her loved ones that, "Yes, in fact, I've taken my medications." What a simple digital therapeutic, right? And that's a very basic 101 concept, which is compliance.
DR. ALI: And then we start looking at behavioral changes. So, behavioral changes I think
Segment:7 Behavioral Changes in Telemedicine.
DR. ALI: is one of the biggest areas in telemedicine that we can push. So, I think one other bucket that I may have not mentioned is also, maybe in the chronic condition, but is wellness. And I think the wellness space is chock-full. As cardiologists, I think McGuinness from the NIH had done a study in 1990, 2000, 2010 and showed that the cause of death in America-- MIs, stroke, cancer, motor vehicle accidents, COPD, pulmonary diseases-- many of those are driven by behavioral changes.
DR. ALI: That's the effect, the cause is actually lack of exercise, not smoking, having good dietary habits and then actually using the preventative services that-- as played out by the United States Health Task Force. And so, those are the causes. The effect are heart attacks, strokes, COPD, right? So, these are behavioral changes in chronic conditions that we can change. So, I think we have an opportunity in the space of telemedicine and wellness to actually help those individuals focus on the cause of disease, and we know that a vast percentage, more than 50% of these diseases are modifiable.
DR. ALI: And now, finally, and I will shift the subject into actually how do we get paid for this because I think that's a big driver. I think technology is great but for adoption, we have to show metrics of success not just through these behavioral changes and data analytics, but to get adoption, the physicians have to get paid, the patients have to be provided for. So, what's your thoughts on this, I think it's a big elephant in the room in telemedicine, right?
DR. RHEUBAN: Sure, sure.
DR. RHEUBAN: So, you've covered the entire spectrum. I want to harken back first to what you talked about-- post-acute care and compliance and behavior change. Not necessarily-- The prevention piece is critical as well, but starting with that piece. Traditionally, patients were discharged from the hospital and they'd get their return appointment and they might come and they might not come. But integrating remote monitoring tools into that can affect compliance and can affect behavior change.
DR. RHEUBAN: So, in our experience in remote patient monitoring post-hospitalization, patients absolutely love it. I mean, I was amazed at the incredible positive feedback that we have gotten. And we've demonstrated a reduction in hospital readmission, as much as 70% in some conditions. On average, about 40%, but patients, they really need to know somebody is watching and somebody cares. And if there are outliers in physiologic data, somebody's calling in.
DR. RHEUBAN: That impacts the patient. The patient then can say, "Oh, I had too much salt yesterday, that's why I gained three pounds, and somebody noticed it", as opposed to waiting 'til they get more and more edema and heart failure and then come back in extremis. So, that's one really important piece; behavior change and compliance is huge. And we're looking at things like Apple watches to tell patients, the same thing-- to get prompts, push notification to say, "Take your medicine." Totally appropriate.
DR. RHEUBAN: Prevention is really important. We haven't really fully incentivized prevention, although employers are moving in that space as well. And there are incentives that can be provided not only to the providers but to the patients themselves, in terms of adhering to some of the recommendations in the wellness space. And smoking cessation and all the things that can add to the morbidity and mortality.
DR. RHEUBAN: So, payment for telehealth, that's a huge thing.
Segment:8 Payment and Metrics of Success in Telehealth.
DR. RHEUBAN: So, payment for telehealth has traditionally been either federal, through the federal government, like Medicare, or federal employee benefit plans do cover. Medicare is relatively limited in terms of their reimbursement. They have significant originating site restrictions under fee-for-service Medicare. In fact, in 2014, the data provided by the Center for Telehealth & E-Health Law provided to them by CMS, was that nationwide Medicare only reimbursed $14 million in claims, nationwide for telehealth services.
DR. RHEUBAN: So, there are more opportunities, and as we alluded to, 2018 is a really great year because there have been some changes
Segment:9 Changes in Medical Policies and Coverage.
DR. RHEUBAN: in Medicare, changes in the budget bill which incorporated the CHRONIC Care recommendations for expanding eligibility for acute stroke services to now rural and urban-originating site hospitals. That's critical. And we can talk about stroke in a minute. Also for dialysis patients, patients with end-stage renal disease who have challenges getting back to the clinic facility.
DR. RHEUBAN: In many cases, a lot of dialysis facilities are remote, but patients are even more remote. So, to enable telemedicine services to be provided. And then there's also expansion under ACOs and Medicare advantage programs, that was in the CHRONIC Care bill. So, that will hopefully expand adoption because there will be expanded payment. And then in the physician fee schedule for 2018, which really thrilled me, personally, because we're trying to build out remote monitoring is the new unbundled CPT Code 90...
DR. RHEUBAN: 90... 91... 99091, allows for unbundled CPT Code for remote monitoring. Suddenly we have a mechanism by which providers can be reimbursed to provide these services. So that's really important. And I'm hoping that there will be more payments for practice costs. If you have to invest in technology, it's one thing to be reimbursed a relatively small amount for reviewing 30 minutes a month, but it's another for the expense of the service provided to the patient, and what it takes to set it up in your own practice.
DR. RHEUBAN: So, I see that coming within the next year as well.
DR. ALI: Yeah, I think one of the examples that is prevalent today is actually the Diabetes Prevention Program. We just gave grand rounds at University of Texas actually yesterday, on this topic. So, I think that encompasses, actually, everything that we've spoken about, because in the Centers for Disease Control they did a trial where they looked at pre-diabetics. Now, pre-diabetes defined as a glucose of 100 to 125, and A1C that would be not your traditional, above 6.5% diabetes, but between 5.7 and 6.4. And we finally found out that a diabetic, if you quantify, if a pre-diabetic became a diabetic, it costs the healthcare system about $7,000 per patient.
DR. ALI: But if we were able to prevent those diseases, then now we're in a different era and we can actually reduce. So, the Diabetes Prevention Program showed through a trial that was done approximately seven years ago, that we could reduce the incidence of pre-diabetics becoming diabetics by up to 58% just by lifestyle choices, and that metformin actually did not do as well. It was actually non-inferior to lifestyle choices, so that it meant that if we prescribed lifestyle choices over a medication, we actually reduced the incidence of pre-diabetics going to diabetics.
DR. ALI: That's huge, so there is the opening for behavioral change and compliance. And now the CMS has given money to reimburse the physicians and the patients to get on board, to really look at their pre-diabetes, and I think the space for telemedicine is there. And actually, there's a company known as Solera that is looking at this pre-diabetic space and DPP and using digital therapeutics, and even in their own data, more patients would rather use a digital platform than go in person, and that was across the spectrum.
DR. ALI: And I think one area that we didn't even touch upon,
Segment:10 Patient Adoption of Telemedicine.
DR. ALI: is who's adopting this? Is it just young patients? Is it, you know-- I'm around my 40s now-- or is it patients above 65, which is when Medicare starts kicking in, where my mother would be, and we were talking about mothers earlier. So, what's your take on just the adoption, the age adoption of individuals in telemedicine?
DR. RHEUBAN: Oh, I think it's all age groups, actually. And, again, we were chatting about our mothers. My own mother is using the AliveCor device for management of her atrial fibrillation to identify-- and she adopted it without any challenge at all. And she just-- this generation, seniors are using FaceTime and Skype to be able to communicate. Their expectation is they'd like to be able to do so as well to their providers. It's a much more savvy older generation than one might have expected.
Segment:11 Future of Telemedicine and Government.
DR. ALI: Where do you think the next steps that we're going in telemedicine and I guess the big areas to me, 2018, which you alluded, this is going to be a big year, is parity laws which I think President Trump is now on board nationally through the Veterans Association, looking at parity laws. What's your take on the parity law? And then I think the next part is that we touched upon is the payer mix, and how insurances and device companies and digital therapeutics are working together to actually get telemedicine paid for.
DR. RHEUBAN: So, as we alluded earlier, the federal government plays a big role, certainly for the Veterans Health Administration, Department of Defense, Medicare, but the states play a huge role as well. And sometimes when there are roadblocks in Congress, especially because the Congressional Budget Office has to score these bills and when they are more expensive than what Congress would like, they push back, even though the evidence suggests that it should be less expensive. But at the state level, there's private pay parity laws and now more than 35 states have implemented private pay parity laws.
DR. RHEUBAN: And some are parity reimbursement itself with in-person. Others are not, just saying you have to pay for telemedicine services. And every state, you've seen one state, you've seen one state. Some say you have to pay for remote monitoring, some say you have to pay for E&M codes and visits. But the states have been very progressive, and one place the states have played a fabulous role in is with the Medicaid programs. So, the state Medicaid programs, again, you've seen one state, you've seen one state, but they have to manage larger populations, especially in those states that have expanded Medicaid, and to be able to have improved access and manage the patients better.
DR. RHEUBAN: And partnerships with the payers themselves, the managed Medicaid organizations who hold these contracts are very important. Again, they will hold the outcomes data, cost data, clinical outcomes data, from which we can then use as the evidence base to inform Congress and the Congressional Budget Office to advance Medicare reimbursement. I think one of the places we are also going well beyond fee-for-service is alternative payment methodologies.
DR. RHEUBAN: And that's where I think wellness plays a great role as well, to incentivize providers and systems to incorporate wellness in for the populations that they serve. So, that's another great opportunity. We're not quite there fully with alternative payment methodologies so fee-for-service still lives here today. And it's very important to get it right. And for me, I work in a large health system, and our investment in telemedicine, in staffing and technology, is by the CEO of the hospital.
DR. RHEUBAN: So, I need to be able to show her there is a return on investment in terms of better outcomes, fewer penalties for readmission with remote monitoring, and better management of patients. The stroke world is huge. You as an adult cardiologist, that's now-- standard of care is using telemedicine technologies for access to stroke neurologists for early, timely administration of tPA and thrombolytic agents and methodologies.
DR. RHEUBAN: In our own experience and that of Dr. Lee Schwamm from Mass. General, who's really set the stage for this nationwide, it has leveled the playing field. We know that in our state, which I think-- I'm so proud of my colleagues in stroke neurology-- if you present to a critical access hospital in a rural community that might be, if you're lucky, a three to four-hour drive just to UVA, and maybe you can fly, and maybe you can't in bad weather, the actual tPA administration rates through telemedicine are exactly the same as the administration rates if you showed up de novo as a citizen of the city of Charlottesville and you show up in our emergency department.
DR. RHEUBAN: That's transformational. We're saving lives, saving brains.
DR. ALI: Yeah, I mean just imagine that-- we were talking about our mothers but one of them had a stroke and were not able to get to a hospital, and loses the window-- there's a window of time that they could get the tPA. And James Grotta from University of Texas has put an imaging MRI, actually, on the back of an ambulance, where they can pull up to your doorstep, get the imaging and be able to use telemedicine to communicate and initiate the tPA, and stabilize them and bring them back to the university.
DR. ALI: So, I think that was the bucket that we talked about-- acute care shifting over to chronic care-- hypertension, diabetes, smoking, obesity as well, which also goes into the wellness space. I think there's huge opportunities to help cost-cutting and savings, not just from an economic side, but also for great patient outcomes. And I think that you hit upon it, we as a whole for telemedicine-- I think American Telemedicine Association is the biggest driver right now-- trying to get all of these states, and all of these parity laws, and the whole nation under one umbrella to say, "Hey, let's all get together, collect the data, do the data analytics." And I think that's what it takes to really drive the insurance companies and the adopters to say, this is a standard of care of delivering healthcare.
DR. ALI: I think what we need to define are what are the areas that we feel comfortable as physicians-- again, first, do no harm-- in the telemedicine space, and what are the areas that do need to be seen in person. And I think that will only be answered through industry and academic centers, working together and in unison, and to bring that data together and present in forums. For example, I think, both of us have been at the American Heart Association, American College of Cardiology.
DR. ALI: I think these are huge topics. Again, going back to cardiologists, who've been early adopters of telemedicine and information from remote-- for example, Holter monitors, event recorders-- and so, I think every industry in medicine, whether you look at dermatology, where pictures can be taken and looked at. Again, still more data needs to come out on which lesions need to be seen and do they need to be palpated.
DR. ALI: I think there's a number of different verticals in our fields. I think from some very prime examples as you had explained about CARDIA, there's a group that I've been discussing in Houston, who have taken-- they don't make any devices, but what they've done very smartly is taken all of the devices in sleep, including EEG, even for daytime somnolence, and putting that into an API in a dashboard, and reducing the costs.
Segment:12 Telemedicine Reducing Costs.
DR. ALI: I think the biggest driver that will bring telemedicine into the forefront, which I think it is now, but really in the forefront, is showing the data analytics that we're reducing cost.
DR. RHEUBAN: Absolutely.
DR. RHEUBAN: That this is no longer a fee-for-service type of industry. This is based on outcomes, improvement in healthcare, improvement to access of care, and all of that being driven to reduce healthcare cost with improvement in care. And delineating what areas, that we as a group of physicians, first doing no harm, are able to put together, that will be the driving force. And I think there's so many examples, and I'll go back, we'll cut out the DPP because I want to go back.
DR. RHEUBAN: It's actually a very important point. So, I'm just going to bring another example, back to the example of Diabetes Prevention Program. Can't state that enough because one-third of Americans,
Segment:13 Diabetes Prevention Program.
DR. RHEUBAN: that's over 85 million Americans, have pre-diabetes. And we know that if those pre-diabetics become diabetics, it costs the healthcare system, annually, $7,000. So, if we can prevent those patients in the Diabetes Prevention Program, which was put out by the CDC, that showed that lifestyle interventions reduced the transformation of that pre-diabetic to a diabetic by about 57%, which was much better than prescribing a very common medication called metformin, as you're very aware of.
DR. RHEUBAN: So, lifestyle interventions actually improved the decrease in diabetes. And the point of that is that we can use telemedicine in the two big areas that we talked about-- behavioral changes and having the patients adopt and actually being compliant. And so I'll give you a very prime example of Diabetes Prevention Program. So, a company called Solera Health has been working with companies like Omada, like a company that I work with, Fruit Street and even Lark, which is an AI application for Diabetes Prevention Program, and they've actually shown that if you allowed the consumer to go through a screening process to see if they qualify of being a pre-diabetic, that they can choose an in-person or a digital engagement.
DR. RHEUBAN: So, whether that's AI, or that's telemedicine, or that's using a digital therapeutic, that a majority of patients would actually choose using a telemedicine service. And it makes sense-- it goes back to convenience, and being able to actually talk to a provider and not having the burden to drive through the traffic or miss an appointment. But they found that, in about 40,000 patients, there's a non-inferior response to whether you did it in person or through a digital therapeutic.
DR. RHEUBAN: I think that's huge, and I think that is what is needed as the driving force to really push telemedicine. I will tell you in the Diabetes Prevention Program, it really equals, as a cardiologist, to cardiometabolic risk reduction and weight loss. And here's a perfect example: you have to lose 5% of weight to be paid for the service-- there's four stages, but ultimately to get the entire amount of payment.
DR. RHEUBAN: What a perfect example that puts together what we're talking about today. We're looking at delivering better healthcare that's convenient; that is modifying patients' diseases so they don't go into diabetes; where they're getting weight loss, you have the wellness component; cardiometabolic risk reduction, so, now you have the chronic care management; that we have payments for that to the healthcare industry; and that the CDC and CMS are recognizing it.
DR. RHEUBAN: And on top of that, they're paying for that using a digital engagement. What a perfect example. So I think the Diabetes Prevention Program will be one of the driving forces in 2018, as more data is collected and outcome measures are being shown. I think another big area in the CDC is chronic care management, and that also will show in the bucket of what we talked about-- chronic care conditions-- that we can manage chronic care conditions remotely, and again, showing those outcome datas will push the CDC and CMS to say, "We recognize, we see the value, we see the value for the physician and, ultimately, the healthcare system." Your thoughts about that.
DR. RHEUBAN: Completely agree. Earlier you talked about the various advocacy organizations. When you think about the context you've just discussed,
Segment:14 Rural Communities and Telemedicine.
DR. RHEUBAN: the National Rural Health Association has also been incredibly supportive of telehealth as a tool to empower our rural communities.
DR. ALI: Absolutely. We know that rural hospitals are closing at unprecedented rates, leaving patients in communities with no access to care, whether it's emergency services or inpatient services. Suddenly telehealth is yet another tool that will improve that access and allow rural patients to avail themselves of these very same opportunities. The prevalence of diabetes is even higher in rural communities. And a host of other conditions certainly prevalent in rural communities. We haven't really talked about mental health access, substance use disorders, really important.
DR. ALI: In our program we provide services in the UVA telemedicine program in more than sixty, 6-0 different clinical specialties and subspecialties with more than 100 projects in development. So, clinicians are engaging and the patients are very much accepting it.
Segment:15 Mental Health in Telemedicine.
DR. ALI: But mental health still remains our number one demand in request for services. So, we have a long way to go to address the workforce shortages and the malalignment of providers who tend to stay in urban areas and not be in rural communities.
DR. ALI: So, telemedicine is a fabulous application. Just like you mentioned, which I really loved the discussion about, pre-diabetic patients are more happy to use telemedicine than perhaps driving across town to be face-to-face. In many cases, for mental health, it's easier for patients to be able to communicate virtually, than be in that space. We've demonstrated fewer missed appointments in mental health services using the telemedicine technologies, because it's there, locally, and it's a great alternative.
Segment:16 Substance Abuse Disorders in Telemedicine.
DR. ALI: And we're facing gigantic prevalence of substance use disorders and we need to think of creative solutions that will empower patients and providers to be able to access some of these services and I know that is a priority for this administration, as it was for the last, and I'm hopeful that we'll have greater improvements in policies that will enable us to be able to use these technologies for substance use disorder. I think those are two hot topics right now dealing with mental health disorders and opioid addictions and pain addictions.
DR. ALI: I think that it's a great opportunity for telemedicine to fill that void. I completely agree. It's access, access, access. And individuals don't necessarily want to drive to a physical location. There's a lot of reasons for that, but to be able to do that at the comfort of your home, with very serious conditions that they may not otherwise want to go seek help, but may from the comfort of their home, and having easier ability to access to go get that help, I think, should be and I think is a big focus in the ATA and telemedicine.
DR. ALI: I think we have a great position to fill that gap, and I think that is a great focus in the acute and chronic care buckets that we talked about.
Segment:17 Future of Telemedicine and Digital Therapeutics.
DR. ALI: Where do you think the future-- I think it's one of the questions I wanted to pick your mind, have some ideas-- but where do you think the future of this-- it's such a Wild West, in a way, right? This whole digital therapeutics, telemedicine, all the verticals we talked about, but where do you see the future play with telemedicine digital therapeutics?
DR. RHEUBAN: Well, you know what, I like to think that it's not going to be telemedicine. It's just going to be healthcare, this is how we deliver healthcare. This is how we bank, this is how-- And assuming we can work out the regulatory challenges and appropriate, you know-- regulations addressing licensure, credentialing and privileging, patient privacy, evaluating outcomes, this will be everyday healthcare.
DR. RHEUBAN: And we do have a long way to go in terms of making that happen because there are so many different silos right now that impact telemedicine providers, but this will be everyday healthcare. Health information exchange, that's another thing. We have great electronic medical records, we're an Epic system.
DR. ALI: Interoperability with that.
DR. RHEUBAN: Interoperability is absolutely key. I don't need to be getting faxed requests for telemedicine, services coming from a facility with faxed medical records. We don't need that anymore in the digital era. So, we just have to work out all of these elements to make it seamless and integrated. We have a distributed network in telemedicine within our health systems. So, every provider has a secure video conferencing portal available to them. And Epic is our electronic medical record, and we have incorporated telemedicine into Epic, but we still have a long way to go, in terms of that health information exchange.
DR. RHEUBAN: And then it's the digital health tools. There are peripheral devices that can be used in the home setting that will allow us to comport with the standards of in-person care. That's important. So that when a provider is seeing a patient, they're not just talking to somebody without using some of the very tools that we might use in our office. So, I see the digital transformation as here and now and it behooves us to gather the evidence and show that it is effective, and that we align with the triple aim of improved access, that you referred to, improve access, improve quality, and lower cost of care.
D. ALI: From a standpoint of the future of telemedicine, I look forward to the day that you pick up your phone, and you hit an app, and you get to see a physician when and where you want to, that the barriers of access are removed and it is as simple as banking, booking a flight, booking a hotel, or seeing a clinician for your medical care. I see the day that when a patient comes to see me physically in the office, that I'm really auditing their numbers, I'm actually no longer having a discussion for the short period of time that I'm allowed to, but really looking at the data analytics of compliance and behavioral changes and really working on that.
D. ALI: So, I look at the hardware that we've prescribed them that integrates and it's interoperable with my EMR, that I have a dashboard that I get to see, "What have you been doing over the last three months?" And my conversation with you is an audit of that information. And then the subsequent treatment is actually tweaking the digital therapeutics on you and saying, "In the next quarter that I see you, these are the items that we're going to work on." And by the way, my opinion on the matter is that healthcare is not practiced at the time that I'm seeing the patient.
D. ALI: Healthcare is practiced between the office visit. Telemedicine and wearables is that bridge. It helps us bridge the behavioral changes as well as the adoption of this information. I think those barriers are being reduced as industry and academics work hand in hand together. And I think the vision is really the prescription of digital therapeutics in the future. I think that-- go ahead.
DR. RHEUBAN: I wanted to comment on one point you made when healthcare is as easy as hitting an app and connecting to a physician, wherever possible, within the context of the medical home, whether it's the primary care medical home, or the specialty medical home, so we don't have fractionated care.
DR. ALI: That's right. I mean, how frustrating is it that--
Segment:18 Physician Interaction and Patient Data.
DR. ALI: I don't know how many hours you spend a day, just trying to get the physicians to talk to each other, and I think that the driver, again, is going to be the consumer, that the consumer is going to have the access point, and allow us to, as individual physicians, to look at their data, and as easy as sending me a HIPAA-compliant form that I can tap and then access their information, and share that information within the home health nurse, the physicians, the NPs, the PAs, the mid-levels, that we're all on the same board.
DR. ALI: I mean, how many medical mistakes are being done right now, just through number of pharmaceuticals that different physicians may be prescribing because no one knows what each other is talking about. And I think the consumer's going to be the biggest driver. The consumer needs to, especially now that we have Cloud systems, we have the ability to really push out data across the spectrum, physicians and the mid-levels and all of the healthcare communities that are affecting that patient will be able to access that data.
DR. ALI: I also think that the future of telemedicine needs to be
Segment:19 Collection of Patient Data.
DR. ALI: where the patient doesn't even know that their data is being collected, gives access to be able to collect that data. I'll give you just an example of some ideas that have been floated out there. Your commute. I don't know if you're on the subway or if you drive a car-- but as simple as this, if you're driving a car, for example, you sit down in the car-- there's your weight.
DR. ALI: You put your seatbelt on, it's going right over your chest, right? So, we can have your EKG. We can put monitors on the steering wheel to measure your pulse ox. Now, there are glucometers that just need sweat or skin access, so I can actually measure your glucose after you had your breakfast this morning, right? All this data can be collected, aggregated. There's AI apps, there's data analytics and where the patient or the consumer doesn't even know that data is being collected, but wants that data collected, right?
DR. ALI: And wants to be able to give that access to the people that need to see that access. And so I think there is even talks about when you use the restroom, right?
DR. RHEUBAN: Oh, sure.
DR. RHEUBAN: That we can access your urine analysis. We can check for occult bloods in your stool that could be a predictor for colon cancer. That could be simple sensors that are put into, as simple as a toilet system. And we can talk about sleep, sleep apnea which is a big chronic condition that is a definite chronic condition that affects the heart as not only the lungs when you sleep. And I think that's a big area of interest right now in digital therapeutics, is sleep apnea.
DR. RHEUBAN: So, the point is that as things move forward, where you look at the house, again going back to the apps that we talked about, banking, and booking flights and hotels. You have apps that let you in your door at home. You have Nest that lets you access your air conditioning before you get home. I see that there's a whole healthcare industry that can be integrated in our day-to-day routines, that we don't even have to think about it.
DR. RHEUBAN: That that data is being collected as you manage your life, and that your physician gets access so when you're doing that quarterly review, it's more of an audit of that information, rather than having you have to actively collect that information.
DR. RHEUBAN: And I think you made a really good point about this is not just about physicians. This is about an entire workforce, right, in healthcare that are engaged because there's going to be so much demand. It's advanced practice nurses, physician's assistants, training nurses, training LPNs and CNAs and community health workers to be part of this evolution in healthcare. And there's going to be a lot of data to be analyzed and mined, and we just have to make sure we do it right, and train everyone to work collaboratively and certainly at the top of their license.
DR. RHEUBAN: So, this is very exciting.
DR. ALI: It's very exciting. 2018 I think is going to be a big year for all of us. And I look forward to actually collaborating and working with you, actually.
DR. RHEUBAN: I feel the same way, this is great.
DR. ALI: Because I think you kind of represent a lot of the academia, and I kind of represent a lot of what where industry is going.
DR. RHEUBAN: The innovators, yeah.
Segment:20 American Medical Association in Telehealth.
DR. RHEUBAN: And I want to also give a plug to the American Medical Association. So, the AMA has really transformed in terms of its engagement in telehealth. They have convened the AMA's Digital Medicine Payment Advisory Group, because as we speak to what is going to incentivize systems and providers, we still have to work out the solutions and how it's integrated. So, the AMA has been extremely positive, and I'm grateful for that.
DR. ALI: Absolutely. I attended a number of lectures at the AMA and they do seem like they're really pushing to be a driver. They do recognize that this paradigm shift between fee-for-service and value-based systems, and I think they look at everything that we've talked about, from acute care to chronic care conditions, especially in the cardiometabolic world, we can make a big impact. And I think telemedicine and wearables, and digital therapeutics are going to be a big driving force.
DR. RHEUBAN: And "augmented" intelligence, "artificial" intelligence, however we want to--
DR. ALI: AI, data analytics.
DR. RHEUBAN: Machine learning, right.
DR. RHEUBAN: All of these things putting together and accessing, I think it's an exciting time in the telemedicine space.
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