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?
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