Professional Documents
Culture Documents
SK MH Telemedicine
SK MH Telemedicine
DOI: 10.1089/tmj.2016.29007.skk
M A R Y A N N L I E B E R T , I NC . VOL. 22
INTERVIEW
curriculum by Judd Hollander. Do you see telehealth as a separate course, or as integrated into every curriculum?
Well, at the risk of getting kicked out of any academic society that still lets me in, I will say that we are, in essencenot
just in this area, but in other areasdoing a great job of creating doctors who will be great in the 1980s. It starts with how
we choose doctorswe still accept students based on science
GPA and MCATs and organic chemistry grades, and then were
shocked when doctors are not more empathetic, communicative, and creative.
So here is the answer to your question about curriculum.
There is a 100.0% chance that I will have an augmented intelligence being next to me, because there is no human brain
that will be able to memorize every genomic sequence. And
the only thing that I bring to the table is the human skillsthe
ability to communicate, the ability to see versus observe. That
means that spending the first 2 years re-memorizing the Krebs
cycle makes absolutely zero sense from a physician point of
view. That is all stuff that can be done online.
We need a longitudinal curriculum around not just telehealth, again, but around technology so that the people who
get out of medical school really understand how technology
can help them communicate with patients, some of which will
be telehealth. As an example, when doctors have the ability to
understand healthcare disparities, so many things are possible. How can telehealth actually get to communities that do
not have access to care or to traditional care? And its not only
communication with patients. How can we transform communication with other doctors and team members to solve
disparities?
We are moving from a business-to-business model to a
business-to-consumer model, and we are going to have to
teach our medical students to exist in that very different environment. In this model, how do they interact when they are
not right next to a patient, how they interact with telehealth
assistance, telehealth associates, and I think it will be part of
the entire longitudinal curriculum.
Switch from the changes that will occur to doctors to the
changes that occur to the Blockbusters of the medical world.
How can medical centers, clinics, and even hospitals find an
economic benefit in something that could be very disruptive
to the Blockbuster model of medical center buildings?
That is a critical question because it so easily rolls off our
tongue when we say, Oh, we are moving from volume to
value. Well now get paid for keeping people healthy at home,
not just treating the sick in a hospital. Id love to say thats
true in 2016. The problem is that what we get paid for is paid in
the old way. Were in the Twilight Zone of healthcare.
I hear CEOs saying, I am really glad to see Steves investment in telehealth. Hurray for Steve, and I am sure that the
next CEO will enjoy taking over after Steve gets fired if he
cant prove his telehealth ROI [return on investment]. But I am
going to continue having patients come to my inefficient,
expensive emergency room because thats how I get paid.
Some of their argument is true. We are in the Twilight Zone
of healthcare. We are in a situation where we are partly feefor-service and partly moving to value. But if you are not
preparing for reimbursement models based on value, you are
not going to be able to turn on that switch.
So today, Michael, we already have one accountable care
organization with 100,000 Medicare shared savings plan lives
where health really matters, where it matters to keep those
patients out of the ER [emergency room]. It matters both from
the patients perspective and what they pay in premiums, and
it matters from my revenue point of view, because I am capitated.
So I think the folks who think that they are going to be able
to flip a switch from fee-for-service to capitated care can be
too far behind. All it takes is one disruption. If joint replacements become an outpatient procedure and they have not
prepared for that Netflix model of getting care out to where it
should be the easiest and most efficient place for the patient,
those hospitals are going to be dead.
You know, we go to conferences around the country where
they say there will be 25% fewer beds needed. But how many
places do you see actually decreasing their beds? You can still
see cranes building new inpatient beds.
Until it was way too late, there were still new Blockbuster
stores being created. And then they said, Oh, gosh, you know,
maybe we should get in the Internet business. Too slow. And I
think the same thing will happen with the folks who are
laughing about telehealth and Netflix strategy as a model for
growth. If you think this is a gimmick, I think 3 years from
now you will go, Wow, I really missed that boat.
Back to joint replacements. Our colleague at Healthcare
Transformation, Associate Editor Dr. Antonia Chen, has had
success using a combination of telemedicine and video to
help people recover at home after knee replacement and
finds it is just as good as making them come back to the
center for training and physical therapy for the new knee.
So question: The definitions of the words shift from telemedicine to telehealth. Obviously, only a doctor can practice
medicine, so in theory only a doctor can practice telemedicine. But the word telehealth means, to me, a team.
INTERVIEW
How do you see the shift, just like volume to value, from
medicine to health? What happens to physical therapists?
That brings up a couple issues. I just got out of giving a talk
to 200 global leaders of one of the largest medical device
companies in the world, and they were asking some of the same
questions: How do we need to think of ourselves in the future?
And I said, stop thinking of yourself as a medical device
company, and start thinking of yourself as a solutions company. How are you helping both the patient and the provider
provide better care at a lower cost? And if you are not doing
that, somebody will be able to commoditize your business.
I think the same thing is true from our perspective. If you
think about postacute care, in a bundled payment model, now
all of a sudden you are getting X amount of dollars from 6 weeks
before the hip replacement to 6 months after the hip replacement. What you did not mention, Michael, is that that difference
in costand, as you mentioned, they had better outcomeswas
not a difference of 10%. It was a difference of an average of
something like $4,000, which is what it would cost for both inhome and outpatient rehab, versus a new cost of $400. That
means there is $3,600 that Dr. Chen or colleagues can regain to
lower their cost to compete and to create new solutions.
I think the other part of this is that patientsand again, I will
speak to the Millennialsare just going to demand that. They
are going to say, I want telehealth, I want these technologies to
help me be healthier the way that I want to do it, not the way
that some doctor or hospital thinks that I ought to. That is
happening in academics, also, where students are saying, You
know, that is really cute, that this is how you want to teach me,
and this is what you have decided my major should be. But I
want to take these 10 courses, and I want to learn it this way.
As you know, Michael, we started an Institute for Emerging
Health Professions, saying, What jobs are going to be needed
10 years from now that might not exist today, and how should
we teach them? So we are trying to get in the minds of students and patients and not think of the way that we do it as the
provider.
Are you optimistic about this? You have just published a
book on how we can fix healthcare. Do you see this as exciting, or do you see this as a catastrophe for doctors?
It doesnt have to be a catastrophe if youre willing to look
ahead. I look at it like the computer industry in the very early
2000s and late 1990s. It was a catastrophe for Gateway. It was
a semicatastrophe for Dell. Apple, on the other hand, did well.
Apple stopped thinking like a computer company and started
thinking like a digital health company. And at the end of the day,
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INTERVIEW
INTERVIEW
We asked, tell us with whom you would like to communicate. Well send the software to your son in Denver or your
daughter in Miami, and well text them when we are making
rounds. It is a huge, huge, huge difference from a patient
morale point of view, from a family morale point of view. So I
was excited about that. I was also depressed because I realized
there is no new technology that made this happen. We could
have done it 3 years ago with FaceTime, 5 years ago with
Skype, and 15 years ago with the telephone. What changed?
That is an example of starting to think the way patients think
and then using telehealth or technology to change that.
My second example is a policy perspective, the issue of
increased access to care through Medicaid expansion. The
government began to give all these people a ticket, if you will.
They go from being uninsured to having Medicaid, but they
have no idea how to access the system. So many of them end
up in the emergency room, which is much more expensive
with much worse care.
So we need the ability to use virtual triage for somebody who
has just gotten his or her Medicaid card and say: Here is how
we can get you careand by the way, it might not be a doctor. It
might be a nurse practitioner. If the patient says, Oh, for the
first time I am covered, and I want to look at contraception
alternatives, you know, you can see a nurse practitioner. We
need to use technology to get people to the right resource.
And then the third example is starting to look at how
technology and new ways of delivering care can make change
without huge investment. Re-admissions in this country are a
huge problem. Why not use technology for modeling outcomes? At Jefferson, we partnered with a mathematical
modeling company that does modeling for sports, to help us
understand who is going to be at high risk for coming back for
congestive heart failure, for example, for re-admission, which
in some hospitals costs them 5 or 6 million dollars a year.
But just as importantly, were starting to get to the point
where hospitalists can virtually go out of the hospital and see
those patients for 90 days. It means when those patients leave
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