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Creating Large Scale Telehealth Networks : A Perspective from the USA

Adam Darkins MBChB, MPHM, MD, FRCSVice President of Innovation and Strategic Partnerships, Medtronic Plc

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Historical Perspective

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Telemedicine• DeBakey Houston

and Bird Boston

• eHealth• mHealth

• Connected Care• ?Next

Internet• ARPA

• CSNET• Public Internet• eCommerce• Streaming media• Social Media• Internet of Things

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Darkins A. The Growth Of Telehealth Services in the Veterans Health Administration between 1999 and 2014: A Study in the Diffusion of Innovation. Telemedicine and eHealth Volume 20. 2015

• Serving a population of 6.6 million people, predominantly male.• Primary reasons for programs addressing challenges with access, cost,

quality.• Implemented in network of 152 hospitals and >600 other sites of care.• Covered 44 clinical specialities, including Tele-ICU, often in “shortage

specialities”• Three modalities home telehealth, store-and-forward and clinical

videoconferencing, including directly into the home• Sustainable revenue predominantly from realizing efficiencies/cost

avoidance• Two thousand-fold increase to 760,000 patients per year and 2.2 million

annual consultations (not including teleradiology).

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Building Telehealth Networks by Design, not Chance• Its does not begin with the technology.• Start with population health need and geographic distribution served.• Networks are initially built on high volume low cost applications not

low volume high cost.• Set out to solve challenges that affect patients.• Need “multi-media” patient record.• Money “follows patients”.• Requires building and standardizing clinical, technology and business

underpinnings.• Clinical, technology and business champions are important, but you

cannot scale if systems are based on “relationships”.• If a serious proposition and going to succeed “its for life”.

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Operational Issues Building Telehealth Networks • Clinical models of care with clinical pathways.• Clear accountability for clinical, technology and business processes.• Associated systems for governance.• Training of staff – interdisciplinary teams (logical to train virtually)• Quality management with metrics.• Program accreditation.• Privacy and Cybersecurity.• Help desk support• Risk management and continuity of operations plans.• Coding of activity with workload capture.• Measurement of clinical, technology and business related

outcomes.• Ongoing development to avoid becoming ones own “legacy

system”

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Academic Considerations

• New ways of assembling evidence in a rapidly changing environment.

• Clinical, technology, social science and policy considerations.• Lack of evidence for legacy systems.• Is the future about incremental change in status quo or

transformation?• Need clear vision for the future not nostalgia for the past.

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The Future: Value-Based Care

CMS - Medicare Advantage Value-Based Insurance Design• Aside from lower cost-sharing, plans in the demo can offer

supplemental benefits, such as telehealth or nonemergency transportation to doctor visits.

Omar Ishrak, CEO Metronic, in sponsoring a collaboration between Harvard Business Review and the New England Journal of Medicine on Discussing Value-Based Care:“Today in our service-based systems, we pay for each step in patient care regardless of outcome; however, it’s becoming increasingly clear that we must collaborate to shift this to a model that focuses on and rewards patient outcomes”.