One of the best read ideas of 2012 that's going to ignored...Time to close speciality training

A friend of mine, Dave Fiorella, published one of the most widely read paper in the radiology literature this year.  

Should neurointerventional fellowship training be suspended indefinitely? -- Fiorella et al. 4 (5): 315 -- Journal of NeuroInterventional Surgery

He argues that the world has enough of his own subspecialty, neuro interventional surgery (NIS), and that training programs should voluntarily close.  You may not have heard of NIS.  These physicians care for a small group of patients that typically need blood vessels in their brain opened or closed.  Examples include stroke patients (blocked vessels need to be opened) and aneurysms (diseased vessels need to be closed). People like Dave do their work by running a small tube, a catheter, from the groin up to the head and then inject things through these tubes to open or close the vessels-pretty cool stuff!  and a huge advance from 25 years ago.  Before NIS, neurosurgeons would open your skull, do their work, and close you up.  And now, Dave says we have enough.  Why?

After training (which included NIS) my first job was at a good, but smaller community hospital outside Seattle.  In part, I was hired to build a stroke program and grow neurosurgical services.  However, these skills require constant practice, and 6 months at this hospital I had only done a handful of cases.  As far as the professional requirements were concerned, I was competent to do these procedures.  However, deep down I wasn't so sure. Within 18 months I gave up doing these procedures, preferring to send patients to the university up the street.  

A coiled aneurysm.  The big ball is the aneurysm.  
Imagine pushing a wire into a basketball, replacing air  with wire.

My experience is similar to many physicians.  There simple aren't enough patients needing high end procedures to go around.  As a result, skills and quality suffer.  Unfortunately, hospitals want to compete.  Every center wants to be a stroke center or a chest pain center, a (you fill in) center of excellence.  In part this is done for branding, in part this is done for contracting.  Insurers want to simplify the process and get all the services they need from a few hospital partners.  The big loser here is the patient.  Many studies have documented a relationship between volume and outcomes (https://leapfroghospitalsurvey.org/web/wp-content/uploads/2012/03/Fact_Sheet_EBHR.pdf).

You or a loved one may need these services.  A physician will come to talk to you about the risks (you could die), benefits (the procedure may help you), and options (they hopefully mention other treatment alternatives, but they may not mention that you can go down the street to another facility).  Your outcome will be tied to the experience and volume the physician has done.

If there were fewer NIS physicians, there would be more cases/practitioner and better outcomes.  But the likelihood of programs are going to voluntarily shut down- that's not going to happen as long as hospitals are hiring.  There is a way out of this dilemma.

At the consumer level, you should ask the hard questions.  Doctor, how many of these have you done of these, when was the last time you did one of these?  Is there anyone else who has done more of these procedures in a 20 mile radius?  At the payer level, there should be a a requirement for a certain experience before paying a provider, and then there should be recertification, a certain number of on going cases to keep getting paid.  Ultimately, the payer should ask for outcomes from the provider, information about how their patients are doing 3, 6 and 12 months after the procedure.  

In short, Dave is right.  Practice makes perfect.  There just needs to be a business model supporting the desired (patient) outcome.

Why I use LinkedIn, and hope you do too....in the New Year, build your "hubness"

I am a Jew married to a Catholic.  Neither of us practice.  Next year we'll be married 25 years.  We have 3 children, all whom I am proud to call a friend.  But, I have this nagging feeling.  At the end, I'll get to the gate and be brought before (Jesus, Budda, Mohammed) who will ask why am I deserving.  Or at a minimum, with my last breath, I want to reflect on a life well lived.  That's why today I use LinkedIn.  Most people look at Linkedin and see a job board on the web or a professional Facebook.  I see something else: an accelerator of human potential.

Several years ago I read Malcolm Gladwell's Tipping Point.  He talks about the spread of ideas and how if you are lucky enough to meet a hub, the chance of your idea spreading to the next person, the right person, goes up exponentially.  At that moment, I realized that I wasn't getting any faster, or better looking and that senility was fast approaching. Though in spite of this inevitability, I knew that I could actively pursue my "hubness"… that I could become a connector.  When I met new connections I could learn about these people, what they were interested in, what they aspired to do, and file that information away until the day when I met their puzzle piece, the person who completed them.  Together, the two people could go on to accelerate human potential.

Fast forward to 2003: along comes Linkedin.  I had found the perfect tool.  Ii told me what people were doing, what they cared about, and when they changed paths.  It is the perfect tool for finding the missing puzzle pieces.

If you look at your world there are probably 20 people you see on a daily basis.  There is another 100 whom you like, respect and perhaps see every other year.  The is a larger circle beyond that, with some affiliation, but perhaps they have particular skills or knowledge.  With LinkedIn these secondary and tertiary circles become your world.

Today, I may spend as much time collaborating with people in my network as I do with people in my building.  I actively go through my network once a month, introducing people in my network simply because they should know each other.  Their pieces may fit, they may not, but I hope the world is a better place because of it. Of course in all honesty, I am the big winner.  I hear about interesting things people do, and sometimes join in the projects I helped catalyze.

Just imagine if each of us made it a New Year's resolution to build our “hubness”; to look for ways to bring strangers together so that they might call each other a colleague.  LinkedIn, or at least the process it enables, is one of the most powerful tools we have...we just need to use it correctly.

Shoe boxes should be for shoes, not medical records

If you ask a person coping with a chronic illness for their medical records, they may take out a shoebox with a neatly organized papers and CDs.  They hope the next doctor or nurse will open the box, look inside and help them.  This almost never happens.

What's in your box?

There is simply no time for providers to put this information into a meaningful story.  The provider tends to reorder labs, and begin from scratch.  

Patients and providers agree this is absurd.  Records should be immediately at the time of care.  This would enable better, more cost effective care.  Industry has spent decades trying to solve this problem, but it is a work in progress.

Centralized versus decentralized records.

In part, this failure reflects American healthcare's focus on the doctor and the hospital rather than the patient.  There is an expectation that others will care for us, rather than engage us.  Medical record solutions tend to pass centrally from patient, to doctor, to EMR, to a central clearing house (sometimes called an health information exchange, HIE).  

HIE, centralized healthcare records

HIEs sound like a great idea.  If the patient goes to 2 facilities or 2 different doctors, records would magically be collected and viewable by all participating facilities.  Unfortunately, HIEs are more concept than reality.  HIEs require high level collaboration from competing healthcare systems.  Further, there is first adopter risk.   Imagine buying the first fax- who would you send to? 

An alternative solution would centered around the patient.  In this case, the patient acts to collect data about themselves.  But rather than the shoe box, the information is organized so that others use it effectively. 

Google and Microsoft in fact took this approach and spent billions to create PHRs- this has largely been a failed effort  

Google Health shut down after several years

The medical apps industry is another approach.  Apps allow the people to collect all sorts of data about themselves (weight, blood pressure, physical activity) People can look at the information themselves or  present it to their practitioner.  As yet, industry has not achieve significant adoption or investor value.  

Both apps and PHR currently reach the wrong market. Apps and PHR tend to be used by the "super fit," the people trying to obtain that last little bit of potential immortality.  Although the super fit are a market, they are not the market insurers and providers are trying to reach.  The people who need PHR and apps, the sick, tend not to use them.  These people are typically older and less tech savvy, they tend to be less focused on their "wellness."  

Portal or PHR?

Hospitals are currently implementing portals, web based tools for patients and providers to see medical records. Healthcare systems view portal as an evolving service expectation, a chance to build customer loyalty.  However, this strategy is limited.  Portal is an extension of the hospital EMR.  Current portals do not aggregate records across the continuum or enable the patient to collect information about themselves.  

Would it be better if hospitals provided PHR?  This could be a card given to patients leading all providers, those from the hospital and their competitors, a web site where they could view and enter enter information for the patient.  Rather than centralize the information via an exchange, this would decentralize efforts around the patient.  At a minimum, this would allow providers to note that the patient received care and there are records to share.  Better would be an upload of records to the PHR; this is already possible via an accepted standard (CCD).  This would not replace EMR (which provide necessary documentation, scheduling and billing) but instead supplement care documentation.

Decentralized, Collaborative PHR records could supplement EMRs.
Providers across the continuum  could add to the record for the patient.
Most PHR ask the patient to do all the work currently

Compassionate Capitalism- towards a sustainable business model for collaborative healthcare records 

As mentioned earlier, centralized health exchanges, with a centralized business models, have largely failed.  The return on investment ratio for the early adopters has not enabled wide spread adoption.  However, decentralizing the offering may have unique benefits for a healthcare system.  Registration in a system showing patients their hospital records, occurrences or records from other providers  as well as chance to record their own observations is value, something patients can't get or can't maintain (eg...the Microsoft and Google offerings) on their own.  Building brand through patient value equates to loyalty. Further, collaboration across the continuum, provides the necessary infrastructure for value based  cost effective care delivery.  This is not rocket science, but rather a repurposing of existing market tools.

To survive, radiology should become a horizontal

The future of radiology is bright, but its not so clear for radiologists....Lawrence Muroff, RSNA 2012

I attended the recent RSNA in Chicago this year.  Each year 60,000 people come to talk and sell all things imaging.  However, after years of short sighted, self destructive life style based decisions, radiologists have now successfully commoditized their specialty.  Although imaging will remain central to care, reimbursement for these services will likely change to align with the ACO/CIO agenda.  It remains to be seen if the specialty can reinvent themselves moving forward. 

Image isn't everything.

Radiologists are obsessed with the image.  This is understandable.  No other the speciality takes ownership of the quality and safety related to image production.    However, this focus on constant image improvement has to some degree been at the expense of image value for the patient. In the new world of value based care, every provider, every speciality will be measured against the patient's ultimate outcome.  Traditionally, radiology's relationship with the patient ends with the dictation.  There is no follow up.  Did the study decrease morbidity or cost of care?  Were care decisions influenced by imaging findings.  Were there differences between general and specialist interpretations influencing outcome or utilization?  This type of information, eminently obtainable via patient registries or directed personal health records, would add relevance to discussions with the payers moving forward.

Radiology as a “horizontal”

Radiologists and the imaging vendors can continue to ignore the the changes going on around them, or perhaps it is time to think about “creative destruction” of imaging.  These is a phrase coined by Eric Topol reflecting the rest of healthcare. 

Today, radiologists are paid for the transaction, the dictation.  Tomorrow we are paid for patient value.  How can we cross the chasm to this new world?

There is some good news.  There are some unique aspects of imaging services.  Unlike almost any other field in healthcare, radiology is a horizontal.  As opposed to neurology, obstetrics, surgery, relatively siloed verticals of care, imaging is required for all areas of medicine.  Radiologists have a broad understand of care across the continuum and could help navigate the patients course, suggesting appropriate next steps to arrive at cost effective diagnosis.  

(Radiology circa 1965...the reading room was the center of the hospital)

I am not suggesting the imaging subspecialists generalize themselves, but rather imaging services as a department begin to think of themselves as part of the care team, requiring and synthesizing clinical information to offer appropriate next steps.  Vagaries such as “stroke” or pain should not be accepted as clinical history.  Comparison studies should be found.  After an imaging study, there should be ownership of the outcome so that radiologists can effectively participate in utilization management.

These changes will not happen over night.  Currently, the IT tools supporting this type of practice are not offered- but markets respond.  If there is an ask, there will be product.  This is also anathema to the current practice patterns- aka, the referent is always right.  

Currently, it is almost like there is a sense of the “end of days,” make as much as you can now because the end is coming.  The end isn’t coming.  Imaging is here to stay.  Change is coming.  We can chose to plan for it and align with value, or deal with an abrupt, painful transition

Back to the Future- The New Black Bag, an iPad

In the early 60's, my father started in medicine making house calls.

He would carry his black bag from home to home.  It had all he needed to make a diagnosis and get the patient on the road to recovery.  Now, 50 years later, no one can lift this black bag.  It is too heavy with options. Improvements in care have meant more options, so much to know that no single person can have all the right answers.

Overall, Americans have benefited from medical advances.  We are living longer than in the 1960's.  But, it has also had the perverse effect of fragmentation.  Take the example of my mom, a quadriplegic.  

At times her care sounds more like a text on physiology.  There is someone for the lungs, the kidneys and the neurologic system.  Yet, no one is responsible for her.  In part, this is too much for one person, there is not speciality called "quadraplegia" and all that goes with it.  In part, this is how healthcare is reimburse- money is paid for problems, rather than wellness.

However, I see hope on the horizon.  Like Hermione's magical bag in the Harry Potter series, we can give our providers all that they need as they travel from house to house, or at least room to room.  Collaborative technologies can deliver the community, rather than strictly the provider, to the bedside.  In this world, the black bag is replaced by an iPad or other PDA.  The specialist is available for advice, supporting and reassuring the patient and local provider alike.  This is our future.  We need to learn to scale our healthcare ecosystem, to not rely on the best available locally but rather the the best available from anywhere in sustainable ways.  New economic incentives are accelerating these solutions.  Time to upgrade that old black bag, time to go back to the future.

Alan Pitt Health 2.0 - YouTube

There Are Points for Speed

I am radiologist, an MD specializing in CT and MR interpretation. When I was training, I had a Professor who would say "there are no points for speed."    What he meant was, if you missed something, the lawyers didn't care how fast you read the case, just whether you got it right.  Unfortunately, he is wrong.  Speed matters in medicine, a lot.

Doctors are paid for speed.  The current reimbursement system pays us on how much we do, not necessarily how well we do it.  There are metrics related to outcomes and complications, but they tend to be relatively infrequent outliers and disconnected from the care and reimbursement process.  

In the case of radiology, there is an expectation of a certain number of cases/day by each physician.  A radiologist’s productivity posted and often related to bonus pay.  

ED physicians are paid on the number of patients seen per shift.  Doctors have learned to order tests first, and then see the patient second- it is faster.  THis is one of the reasons there has been a 5 fold increase in CT for emergency room patients over the last decade.  Imaging has largely replaced the physical exam  (‎www.emedmag.com/PDF/043070006.pdf).  This results in over utilization of expensive imaging studies and lab work for the patient and for the payer.  

With bundled payments, hospitals are on the hook for this over ordering .  Hospitals are paid a set fee for diagnostic code (stroke, pneumonia, etc..)  irrespective of the number of studies ordered by the doctors caring for the patient.  Ultimately, it may be cheaper for hospitals to incentivize their physicians to slow down and make the right decisions rather than simply order another test.

The medical legal system, thought to protect the patient from mistakes (due to speed) perversely accelerates this process.  Doctors are rarely, if ever, sued for ordering tests.

Doctors are human.  They respond to individual incentives like everyone else.  If the system pays for volume, we will continue to get more volume.  If we want quality, intelligent decision making, incentives need to be aligned for quality.  Unfortunately, as long as there are points for speed, we'll all lose.

The Healthcare Pyramid- a view from the apex and the base

The Apex of Care

I am a successful physician at the Barrow Neurological Institute (BNI), the U.S largest hospital for neurological disease.  As a senior  radiologist, I have a good idea who are the best doctors and how to get things done at my hospital quickly.  Every year we take care of thousands of patients with brain tumors, epilepsy and spinal cord injuries to name a few.  There is process to care for these patients referred to as best practice.  We hope to optimize their outcome while they are in our care.  I am also the son of a quadriplegic, Sheila Pitt.  Danny Sands, a friend, thought it might be of general interest if I gave some perspective on her story, and my observations since her accident.

Here is some background on my mother.  She has always been a strong, independent person.  Growing up she successfully competed in women’s gymnastics.  She wanted to go into art, but that was not an acceptable career for a good Jewish girl in the 50’s.  Her father suggested she was better suited to be a teacher.  After marrying, she pursued a fairly traditional life as a spouse and mother.

After we moved to Arizona in the early seventies she developed a passion for horses.  She was an Equestrian.  She began riding in her 30’s and continued in the sport for over 35 years reaching a high level of competition.

In her forties she also went back and pursued her dream of becoming an artist.  She got her MFA at the University of Arizona.  She received tenure in her late forties and was made head of the printmaking department at the University of Arizona.  Her work has been shown at national and international shows.  She was also asked to advise the undergraduate studies program for the department, managing over 750 undergraduates.  She was elected to the Faculty Senate.  She is no wall flower.

The day of her accident was a bit bizarre.  I was participating in a new building dedication. Most of the neurosurgery department was in attendance.  Late Saturday morning, I got a call from my sister.  She wanted to tell me mom had an accident.  She had fallen from her horse and the paramedics were there.  I didn’t think much of it, but was able to reach another friend at the scene who put me through to the paramedics.  They were taking her by ambulance the hospital.  She was complete from the neck down.  I collapsed in front of 50 of my peers.

“Complete” is a term in neurosurgical terminology meaning the patient isn’t moving below a certain level- neck, chest ,waist- and really isn’t supposed to move ever again- they are complete.

There were a series of tests and stabilizing care given in Tucson.  Within 8 hours I had her helicoptered to my hospital 100 miles north. By midnight she was in the operating room with one of my close friends and best spine surgeons in the country, Dr. Nick Theodore.  I honestly believe my mother’s functional status would not be as high without this prompt intervention.

As a senior physician at the BNI, I was able to guide much of my mother’s course through the ICU, step down and rehabilitation facility.  Another friend, Dr Rick Su, prevented her from requiring a tracheostomy by patiently monitoring her respiratory status at a critical time.  This procedure involving a breathing tube inserted into her neck, would have meant several months of additional recovery.

When she arrived at the rehab floor, Mom had minimal movement in one shoulder, but could breathe on her own.  She began a course of aggressive therapy.  Therapists  worked on her limited strength and function most days.

Occupational therapy was perhaps one disappointment.  We wanted to have Mom trained to use voice recognition on the computer.  This would enable her to read and respond to email, in essence, get her closer to reintegration with activities of daily living.  We were told they did not have the staff to train her on the computer and would only offer skills for her to type the keys with a pencil.  We arranged for a local high school to volunteer.   Students would offer computer assistance with the software program in exchange for volunteer hours at the facility with my mother and other patients having similar injuries who asked for help.  It would be a win-win.  This opportunity was passively refused by the hospital occupational therapy supervisor.

She spent several months there with some gains.  She was able to push up her glasses with one arm.  However, after a while, she wanted to go back to Tucson.  Her husband and friends were there.  Phoenix was not her home.

The Base

As a quadriplegic the only place in Tucson meeting her medical requirements and that her insurance would pay for was the county nursing home.  This is a clean but rather Spartan facility.  The staff was nice but limited, and the physician rarely seen.   She was placed in a room with roommate.  This woman had been in a chronic vegetative state (most would call it brain dead) for 15 years with no chance of recovery.  All Mom could hear was the in and out of the breathing machine.  Although she said this was a plus (she didn’t have to be bothered by idle conversation), I know this wore on her.

It felt like a dream to me.  She showed tremendous strength.   One minute she was a professor in front of students.  A horse stumbles and she is unable to move or reach a call button.  The person next to her was one in name only.  After another month, custom changes to her home were completed.  She left the nursing home and remains at home today.  She has 2 care providers on any given day.

Whereas I could monitor and optimize my mother’s care at the BNI, in her new surroundings I am largely reduced to a family member.  Certainly other care providers make themselves available to me.  However, largely her care is reduced to the base – self driven and self monitored with no real “captain” of her ship.  She has a multitude of providers – a urologist, a neurologist, a physiatrist.  Each deals with individual issues they are comfortable handling.  There is no individual overseeing the care process.  This is largely the responsibility of my mother and her husband.  Like most people with chronic illness, they have discovered their own solutions, ways to solve problems they encounter with drugs, services and insurers.  She has a marker board for her list of medications and appointments.  Although we all have financial worries, hers seem somewhat more acute and ever present.

After much cajoling, she returned to work last September.  She teaches a full class at the University of Arizona on printmaking (see picture below).  She asked for and received a student helper in the classroom and one to assist her in making art in her studio from the university’s disabilities resource center.  She has had to be creative in the process.  She participates in the process but needs to be collaborative.  I have asked her to write a piece on how the process of art has changed for her – both as an able bodied person and now as one with disability.  She is thinking about it.

Her health remains good.  She deals with occasional spells related to body temperature regulation and hypotension, but overall has not had common complications of many quadriplegics.

I would like to make one final comment regarding quadriplegia. The word “complete” is a misleading term that should be abandoned. On hearing this term, many of the nurses we met at the Barrow gave up on my mother assuming she would never get any further recovery.  Patients with cord injuries are not complete or incomplete.  They are transected (the cord has been cut) or they have an injured but intact cord remaining.  There is no way to know at the time of an acute event whether the cord is cut or simply injured without advanced imaging.  For those that are not transected, like my mother, every day is a chance to get a new skill, to recover lost functionality.  Hope is a powerful motivator.

Replacing the shoebox and other issues for the future

Along with my clinical responsibilities, I do research related to the nexus between humans and computers, asking how data and process can be captured to improve care.   I have a particular interest in tools enabling patients to participate in the process of wellness.  I find it more than a little ironic that my mother continues to use paper and a marker board to manage her care. My mother’s experience reflects some of the basic problems with the current approach to healthcare delivery.  In particular, her care was optimized during the acute phase, but is relatively disorganized now that she is coping with a chronic disability.  Further, patient and family efforts to optimize care are not supported by participatory tools.

The current administration is spending billions of dollars to improve the healthcare infrastructure.  There is an expectation that within 5 years every medical practice, from large hospitals to small clinics will be using some form of electronic record.  This should improve care and hopefully reduce costs.  However, in many ways, this is more of the same, an effort focused on the provider, the apex.

Patients and their families need a similar effort that is directed at helping them care for themselves.   Currently, a shoe box is the best we’ve got.  This “box,” full of notes from previous hospitalizations and clinic visits along with CD’s of images, is all too common.  The patient comes to clinic, hands over the box and expects the provider to make sense of the records and arrive at a plan moving forward.  With most appointments no more than 30 minutes, this is not going to happen.  There are a number of companies offering to digitize records.  This is not the answer.  Providers need relevant summaries, dashboards, of how the patient has been doing.

There have been some recent signs of change.  In 2006 the FDA suggested “observations of daily living” (ODL) become part of new drug and device evaluations.  It makes sense to ask the consumer (and not just the researcher) how they are doing with products.  The private sector has also made efforts.  Microsoft, Google, and Relay Health have all introduced solutions that capture information about and from patients.  However, these are not simple to use or significantly relevant to merit sustained traction.

Solutions need to be transparent.  Many people with chronic illness are from a generation that is not comfortable with the internet.  Even cell phones are a bit foreign.  My father-in-law often uses his cell phone as a one way device.  He makes calls and then turns it off to save the battery.  My mother is willing to participate, but the process has to meet her workflow.  My personal belief is that the TV will be the final common device.  Everyone can work a remote.  It will work with other devices in the home through Bluetooth.  It will remind us when to take pills.  It will allow us to meet with our doctor while at home.

The cable box is not a one way device.  I Skype with my mother, but she has to turn on the computer, start the application, turn on the camera.  She should meet me and others on her healthcare station.  Voice recognition software also needs to improve.  It is designed for business, but there are other large markets.  The software needs to be hands free.  She uses it, but not without assistance.  Later this year she and I will be experimenting with a new box from Cisco that should get us closer to this vision.

Solutions need to consider the patient’s ecosystem rather than their illness.  My mother and I don’t care about quadriplegia, but rather living with quadriplegia – how she copes with the various difficulties in her effort towards wellness.  Most approaches do not consider ways to leverage the family and related opportunities or local resources to stay well.

I was told a story by a father of a juvenile diabetic.  His daughter had slipped into coma several times in the past.  Out of concern, he found himself calling her once a week at odd hours to check on her.  The daughter viewed these calls as an intrusion on her independence.  A solution that called out to the father, but only when there was something wrong, would have provided a margin of safety for the daughter while addressing her family’s concerns.

Similarly, advanced electronic platforms message or alert a nurse if the patient’s weight, blood pressure or sugar is abnormal.  Why are family members not included in the messaging layer?  Families are cheap and the most vested in the patient’s well being.

My mother has to find solutions to problems on her own – where to find goods and services, how to deal with common problems.  Google Maps can find and rate a restaurant or the nearest gas station.  Why not use local based services for physicians, wheel chairs, etc.? I raised this issue with Google Health two years ago…nothing yet.

The patient is the largest untapped resource in the healthcare debate.  After all, they are the most vested party, the one with the illness.  Providers are merely a part of the process along the way.


If you ever feel like life has overwhelmed you please visit my mother's website
sheilapitt.com

Telemedicine- Are We Hammering the Right Nails?

As early adopters go, I am on the right of the curve, not quite a geek, but close.  I tend to buy technology based on impulse rather than value.   Not surprisingly, I am a telemedicine supporter.  I believe in the promise of better care through improved access. But, I have a confession.  To date, it appears my late adopter friends have been more right than wrong.  Expensive projects with limited value, telemedicine's promise of remains largely unfulfilled.  For the technology to reach a tipping point, a routine tool rather than a novelty, several things have to change.  The technology will continue to improve, but perhaps importantly, the telemedicine proponents should change their message and learn to talk the talk of the late adopters.

I just got a grant- now what?

        In part,  telemedicine's failures start with funding.  As with many disruptive innovations, early telemedicine required big thinking and big budgets.  The technology was first developed by the military to treat wounded service man and woman remotely. A laudable goal, but the not easily transferred to the private sector.   After the military, academic centers became the primary owners.  Telemedicine fit well with "centers of excellence" looking to provide care at a distance.  Funding came through grants, rather than sustainable business models.  Unfortunately, many (if not most) of the projects live and die by grant support.  Typical programs do not generate enough clinical revenue to stand on their own.  Clinical providers often engage out of a sense of mission to care for the underserved.  However, attempts efforts to expand efforts to broader provider communities often meet with limited success.  Without revenue, altruism goes only so far.

Come to my beautiful room

        Historically telemedicine has been about the best possible image rather than good enough for a particular use case.  Traditional telemedicine is a room with expensive equipment connected to another (expensive) room.  Each end point requires capital and operational budget.  Almost as importantly, these special rooms require care and feeding.  Rural partners struggle justify the expense as well as retaining qualified technical support staff. Once deployed, these rooms are by definition fixed end points often away from the clinical work spaces.  Care providers must break away to use the room.  Once there, the traditional workflow (front desk, nurse, chart, see the patient) is not incorporated.  As a result, the providers often views this activity as a necessary evil, part of their clinical responsibilities, rather than part of their clinic.

Can't I just use Skype for that?

        Well, no.  Although Skype is widely available (and free), it does not support the regulations related to HiTech, FDA and HIPAA for medical care in the cloud.  However, supported cloud based technology has evolved to leverage common browser based devices (iPhones, android, iPad, laptops) along with public internet (encryption without VPNs).  Workflow, optimizing the expensive care provider expense, can be incorporated, enabling a sustainable business cases.

Learning to talk to laggards

        Fortunately, early adopters (EA) are typically not put in charge of budgets.  Responsible adults requiring a business plan and a return on investment write the checks for most healthcare organizations.  Although frustrating for the EA, the typical CXO has a responsibility to keep the hospital lights on.  Referral (eg...remote stroke care) often does not make business sense, or if it does, the data is convoluted with a long list of assumptions for profitability.  Further, referral requires a number of partners to come together and participate in telemedicine.  This includes the outside facility (who often views the effort with some level of skepticism. after all, they are often asked to pay for infrastructure to lose (via transfer) potential clinical revenue).   The tertiary facility has to pay for infrastructure and align the clinical staff to provide services for another external coverage activity. Finally, the clinical staff on both ends have to be paid and trained to participate in this foreign activity.  All in all, this is not an attractive business case.

        Referral, the basis for point to point telehealth, is a nice to have for most hospital administrators, but not a have to have.  It is weighed against other business opportunities for revenue generation.  Typically at most hospitals there is no director of telemedicine getting up every day looking to build business around referral.  At best, it is one of a number of responsibilities for an over taxed business development person.  

        However, ubiquitous telemedicine  (common devices, common networks) allows the conversation to become a must have for the CXO.  At every hospital, there is at least one person, if not a team, who are focused on throughput, length of stay (LOS), and transition care.  These topics familiar administrators.  These are concepts that fit on spread sheets and are carefully measured on a weekly, if not daily basis.  A tool that addresses these issues can be supported.

        As we move from point to point telemedicine to ubiquitous collaborative care, it is incumbent on the EA to speak in the administrator's language, to lead with the business case rather  than the technology, and to address problems that are the focus of most administrators.  When the telehealth community begins to hammer at these central issues (LOS, transition care), telemedicine will reach a tipping point.  Opportunities for access and referral will be a natural extension of the existing infrastructure

        Frankly, I have abandoned the term telemedicine whenever possible.  There is too much baggage associated with the image of big, clunky devices.  I prefer to talk about enabling medical collaboration.  Ultimately, both EA and laggards need to be included in the vision of better care via collaboration, removing the tele from telemedicine. 

What do you think is more likely to help you or your family- a limited problem like managing stroke remotely, or a way to bring the right person at the right time to the bedside, for whatever ails you?