Virtual Doctor

THE VIRTUAL DOCTOR

HOW DATA NETWORKS ARE EXTENDING THE REACH OF MEDICAL CARE IN THE DIGITAL AGE

IN ASSOCIATION WITH: CONTENTSCONTENTS

The Virtual Doctor ...... 2

CASE STUDY: Ontario Telemedicine Network ...... 6

CASE STUDY: InTouch Health Systems ...... 7

CASE STUDY: C3O Telemedicine ...... 8

CASE STUDY: Telepsychiatry ...... 9

CASE STUDY: Boston Children’s Hospital ...... 10

Acknowledgments ...... 11 T H E VIRT UAL DOCTOR

HOW DATA NETWORKS ARE EXTENDING THE REACH OF MEDICAL CARE IN THE DIGITAL AGE

Thirteen years ago, a surgical robot named Zeus We are not that far away from a future in which see- made history when a team of physicians in New York ing a doctor does not require being in the same room performed surgery on a patient in Strasbourg, France. or even the same building, says Yulun Wang, founder The Lindbergh Operation, as it came to be called, of InTouch Health and president of the American represented a con!uence of technical achievements, Telemedicine Association. “I think telemedicine will namely the dexterity of the digital Zeus Robotic become the core methodology of healthcare delivery Surgical System and a broadband transmission capa- in the future,” he says. “It has to, because that is where bility with optimized compression that limited the we are going to get the e"ciencies we need to meet time delay between the doctors’ commands in New rising needs created by an aging population and pro- York and the resulting action in France. vide a#ordable care.”

Since that breakthrough in 2001, the idea of treat- One of the original imperatives for telemedicine ing patients remotely has touched almost every aspect was to bring better care to underserved and remote of healthcare. Neurologists can now “beam in” on areas with few medical facilities or where there were stroke victims to provide instant assessments that can long distances between patients and doctors. But even save lives. Patients recovering from surgery at home in well-served areas, there are compelling reasons to can have the equivalent of an electronic house call incorporate telemedicine into many practices. There with a video link to their surgeon for follow-up are not enough specialists—neurologists, cardiologists, appointments. And, in one of the newest applications dermatologists and psychiatrists, to name a few—to of telemedicine, psychiatrists can create avatars to meet rising demand. Someone su#ers a stroke every meet patients in virtual worlds where they can act out 40 seconds on average in the United States, but there di"cult scenarios. is not always a neurologist available in the $rst few

2 | THE VIRTUAL DOCTOR crucial minutes to provide a diagnosis. Telemedicine it,” says Yanez. “The network is behind the scenes, it’s can also reduce costs and improve outcomes. For not in the lights where people are clapping. But the example, home health monitoring for people with connection is real, and critical to the performance of chronic conditions, such as diabetes, can mean any telemedicine application.” fewer missed appointments and hospital stays, not to mention reduced travel time for patients. Comcast Business Ethernet services dovetail well with the needs of most healthcare providers. Ethernet These imperatives are driving unprecedented is a protocol that can run on both $ber and coaxial innovation and entrepreneurial energy in the $eld of cables, and it can be expanded with a single phone telemedicine today. However, none of this innova- call. So if a new imaging system starts producing $les tion would work without a reliable network capable that are choking the circuits, an existing Ethernet of carrying a detailed image from one location to service can be expanded exponentially without another, or to control a robot miles away, or simply to digging new holes or laying new $ber. access an electronic record safely and securely. Most hospital systems need to connect multiple New imaging systems, for example, save lives, but locations, from the main facility to outpatient clinics, they also create massive digital $les. “The hospital has physician’s o"ces, imaging facilities and record to have a really strong network to take advantage of archives—all of which may be miles from one this brilliant machinery,” says Tomas Yanez, director of another. Any hospital system that relies on digital enterprise marketing at Comcast. “Everything may medical records needs to ensure constant access to work great at the main hospital facility, but at the edge those records, and that requires a reliable network

“The hospital has to have a really strong network to take TOMAS YANEZ, Director of Enterprise Marketing, advantage of this brilliant machinery.” Comcast

of the network, at the radiologist’s o"ce a few blocks across all locations with multiple paths and multiple away, it might not work very well at all if the network redundancies. isn’t robust enough,” he explains. Sending video $les takes even more bandwidth. At Inspira Health Network, which was formed in 2012 after the merger of South Jersey Healthcare “Everyone gets excited about the performance and and Underwood-Memorial Hospital, a Wide Area the glory of a new application that promises to make Network (WAN) connects three medical centers, two the patient experience better or make a hospital health centers and dozens of outpatient sites with a more competitive, but it won’t work unless there is combination of several di#erent Comcast Business a solid network foundation underneath to support Ethernet services. Physicians at any of Inspira’s facili-

COPYRIGHT © 2015 FORBES INSIGHTS | 3 ties can access test results, surgery notes, home health Much of telemedicine takes place over the public visits, diagnostics and other data as they move from Internet. “The Internet is inexpensive, it’s nearly one patient to the next. Instead of juggling paper ubiquitous, and you don’t need to program anything,” $les, doctors can spend more time with their patients. explains Yanez. Those qualities have laid the ground- Patients are also bene$ting from the network via a work for the growing ubiquity of telemedicine. For a dedicated portal where they can review test results, doctor answering an emergency call by logging on to pay their bill, schedule classes and access a library of a mobile device or paying a virtual visit to a patient health care information. in a remote location, the public Internet is the only option that makes sense. “The more services we run over the network, the more we can reduce the cost of those services,” says But security is still a real concern. “What could Thomas Pacek, vice president and CIO of Inspira happen when you pass medical records around over

“The more services we run over the network, THOMAS PACEK, Vice President and CIO, the more we can reduce the cost of those services.” Inspira Health Network

Health Network. Inspira is “collapsing everything the Internet?” asks Yanez. Data is handed o# from onto the network,” he explains, from cardiology one network to another, exposing the sender to the equipment to the medical records of physicians’ possibility of an embarrassing security breach. o"ces associated with the hospital. With so much of the daily workload moving over the network, reliability That is why many hospital systems use private is key. “The more we become electronic with our networks that don’t traverse the public Internet. With records—and everything we do related to patient care the explosion of mobile devices and the growing use is becoming digital—the more we can’t a#ord to have of telemedicine, some of them are able to extend any downtime,” says Pacek. their networks to include the homes of their healthcare providers through such services as “Ethernet at Security and privacy matter as well. Healthcare pro- HomeSM.” This service, o#ered by Comcast Business, viders have to meet HIPAA requirements to protect provisions o# the healthcare facility’s existing infra- patient privacy. A psychiatrist speaking with a client, structure without going over the Internet, just as it for example, can’t use standard free videoconferencing does at the other locations on a hospital network. It applications to hold a session. Instead, they must use is one more way that telemedicine is breaking down an application with HIPAA-compliant architecture the boundaries of distance and time to provide better that comes with a host of security features. Patients, outcomes for patients and healthcare providers. for example, might enter a virtual waiting room and then be invited into a virtual exam room that can be opened only by the room’s owner.

CANADIAN PIONEER

Edward Brown, chief executive o!cer of the “Last year, because of telemedicine, patients Ontario Telemedicine Network, connects doctors avoided about 260 million kilometers of travel,” and patients across a province that is bigger says Brown. “That’s the equivalent of going than Texas and California combined. Because to the moon and back 330 times.” The private of the network’s size, there is great potential for network is particularly important for reaching collaboration and experimentation. And because remote places where there are no doctors—and of the network’s long history, Ontario has been no Internet. “We deal with a lot of rural areas ahead of the curve at every stage of telemedi- that may never have good Internet access.” cine’s evolution. But the bold new frontier for Ontario is con- The buildout started in the late 1990s as a necting directly with consumers via their device private network, before the public Internet was of choice. One example: people with chronic equipped to handle either the kinds of telemedi- diseases can stay healthier and avoid crises cine applications Ontario wanted to use or the by learning to self-manage their conditions. populations Ontario needed to reach. About 15 Patients send vital signs to their healthcare pro- years ago, the network moved to IP video con- viders, and nurses coach them through routine ferencing with hardware-based devices at all care and diet as well as monitoring compliance. the end points—3,400 at last count—in every “We are reducing hospitalization by about 50% hospital and many mental health, primary care for patients with congestive heart failure and and rural care facilities across the province. chronic lung disease. These are people who visit “We probably had the biggest IP video network the hospital often, and we are keeping them at in the world at that time,” explains Brown. This home,” he adds. Telemedicine is also a boon to was before popular services such as Skype and post-surgery and complex care. “We are starting Facetime took o". Now, with the availability to give people apps so they can communicate of higher bandwidth and greater Internet cov- with a nurse if they have an issue, so they don’t erage, Ontario has rolled out PC and mobile have to visit the emergency room,” he says. videoconferencing that’s integrated with the private network.

6 | THE VIRTUAL DOCTOR CASE STUDY: INTOUCH HEALTH SYSTEMS

HOW TO BE IN TWO PLACES AT THE SAME TIME

Yulun Wang, founder of InTouch Health Systems, To avoid the latency and frozen screens is an engineer by training who worked on the that plague the free video chat services most surgical robot technology that is ubiquitous in consumers use, InTouch developed and deploys operating rooms today. But in 2002, he saw how a highly e!cient cloud-based computing system robots and the ability to control them remotely that utilizes bandwidth optimization techniques, could change the delivery of healthcare through- compression and decompression algorithms, out the hospital. and various optimization strategies to give the clinician the best possible experience. “When “Having experienced telesurgery, I thought a doctor starts moving a robot, the image may we would be able to generalize that concept be lower resolution initially in order to keep up using the Internet as the backbone,” says Wang. with the movement, but then resolves to high “And with remote presence robots connected resolution when more stationary and examining to a cloud-based network, I thought we would a patient,” says Wang. be able to better utilize the clinical resources we have.” The typical InTouch customer is a healthcare system looking for a better way to leverage its Wang saw the possibilities of building on another specialists across a wider range of locations. “We crucial element underlying the explosion of sell the hospital the InTouch Telehealth Network, many telemedicine innovations: the movement which is layered on top of the hospital system’s to electronic medical records. “Once medical backbone infrastructure,” explains Wang, “and information is electronic, it becomes portable,” the hospitals generally provide the physicians he explains. “Now a remote physician can not who use it.” only interact with the patient, sta" and family from afar, but he or she can also get pertinent For doctors, controlling a robot is “like having an medical information like lab reports, CT scans avatar that can interact in another environment,” and physician notes,” says Wang. “Now you can he says. Telemedicine used to be about provid- truly deliver care remotely.” ing access. “But in the future, we might use it to see a patient down the hall—like the way we Some of the InTouch robots are like giant com- text someone in the other room now. It’s a more puter tablets on wheels, with video cameras e!cient way to get your work done.” and other monitoring equipment that can be operated by the doctor on some models, or by a nurse in the room on others. The patient sees the doctor’s face on screen while the doctor can pull up medical ﬁles, sort through the readings and direct the nurse, all while examining the patient via video and other remotely enabled diagnostic equipment.

DOCTORS ON DEMAND

Herb Rogove is founder of C3O Telemedicine, mimicker, like low blood sugar. And if there is a a service that specializes in providing physicians neurologist on duty in the emergency room, but for the delivery of care to critically ill patients. someone in cardiology has a seizure, a physi- Doctors in the C3O network work primarily cian in the C3O network might be able to beam with patients in cases where there may not be in faster than a specialist on another floor. “You a specialist available for a face-to-face diag- have only 60 minutes if a patient is eligible to nosis in the first crucial minutes when a stroke get a clot buster,” explains Rogove. “It can mean is suspected. the di"erence between being paralyzed for life or being able to resume some kind of normalcy.” His experience running an intensive care unit at a large university-a!liated hospital inspired him When the call comes, a doctor in the C3O to find a way to use technology to speed diag- network will usually respond within five min- nosis. “We would often get patients from smaller utes—three minutes if a stroke is suspected. In facilities,” he explains. “They would come to our southern California, where C3O is based, that hospital for resuscitation, but a large percentage sometimes means doctors are pulling o" the of them died. We were too late to help them.” freeway and booting up their tablets on what- ever network is available. “So we are connect- Rogove founded C3O in 2007 to deliver physi- ed through one channel to examine a patient cian services on demand. He recruited doctors remotely, usually with a nurse and the from university hospitals and large tertiary care family present,” he says. Then the doctor accesses facilities like UCLA. Most of them, like Rogove, patient records through the physician portal— are critical care intensivists used to working in a di"erent process in each of the 20 hospitals an ICU setting with patients on ventilators or with which C3O works. gun-shot victims. “Eight years ago, we saw a decrease in the number of intensivists and C3O specialists use a robotic system onsite to realized we could leverage telemedicine to help examine patients. “The quality is so good that us care for patients,” he explains. “For hospi- you can beam in on a patient’s pupil to see if it tals that don’t have the expertise or who can’t dilates when a light is shined, or look through the get a doctor in fast enough, we can beam in to hair on someone’s arm to see if there is a rash,” assess a patient,” he says. “We’re not replacing he says. Some stroke patients can be treated any doctors, we are just providing a service the before they even reach the hospital—in emer- hospitals can’t o"er.” gency vehicles equipped with CT scans and with the help of a physician beaming in. Even in a well-sta"ed hospital, there may not be a neurologist available in the emergency “We are seeing technology creep into every as- room if a patient comes in with signs of a stroke. pect of acute medicine, from skilled nursing to For an ER nurse, for example, “we can be their home healthcare,” says Rogove. “It’s not science doctor buddy,” to help them determine whether fiction anymore.” or not they are witnessing a stroke or a stroke

8 | THE VIRTUAL DOCTOR CASE STUDY: TELEPSYCHIATRY

THE CYBER PSYCHIATRIST

Peter Yellowlees, a professor of psychiatry at that interact in virtual worlds. “The military has UC Davis, has helped pioneer the field of tele- already done a lot of work on this with a view psychiatry. He held his first remote session via to providing therapy to veterans,” he explains. video conference in 1992. Since then, he has A veteran can create an avatar and be inside treated thousands of people using telemedicine. an Iraqi souk or driving a vehicle when an IED Part of his work involves better understanding of goes o". They can re-experience some of the how people respond in virtual space. “Are there horrors of war but in a virtual setting with a certain groups of patients who would be better real therapist. treated remotely than in person?” he asks. “Or certain techniques that would be better to use in The next step: virtual therapists. Yellowlees a virtual setting?” has worked on an artificial intelligence project pioneered by Albert “Skip” Rizzo at the Univer- In a video session, there is a lot of eye contact sity of Southern California to create an avatar and you can have very intense conversations, he therapist, trained to respond in certain ways explains. At the same time, there is a little more to certain cues. The project began by taking distance. “From a clinical point of view, that hours of videos of patients and then bringing in can be a good thing because you can observe psychiatrists such as Yellowlees to analyze the more objectively.” For agoraphobic or para- movements and cues of patients, capturing doc- noid patients, or for patients who might be ag- tors’ reactions and then programming cartoon gressive or dangerous—or for children who are avatars to respond appropriately to patients’ used to video chats—a virtual session may be a cues. The avatars are not being used yet, but better option. when they are, they could combine the collec- tive knowledge of psychiatrists with many years The professor is also working on some futuristic of experience and training into a completely applications: helping with the creation of avatars virtual doctor.

MY FIRST ROBOT

Naomi Fried, chief innovation o!cer at Boston at the six-week mark to make sure it’s safe for Children’s Hospital until last December, and kids to return to sports or other activities,” says her colleagues have had to be more creative Fried. “When we o"ered the follow-up visit as a than their counterparts at most other hospitals. virtual visit, compliance was much less of an is- “Pediatrics is a small market,” she explains. “Kids sue,” she says. “It’s much more convenient for are generally healthy, so it’s hard to get the parents and much safer for children than no visit attention of big device manufacturers or drug at all.” makers to work on pediatric problems. That’s why you see our doctors and clinicians really Another pilot program tested asynchronous pushing the envelope in a way that you wouldn’t teledermatology. Asynchronous applications are see in a typical adult hospital.” already common in radiology. Digital imaging was one of the original examples of telemedi- Boston Children’s Hospital has one advantage cine and one of the ﬁrst to employ asynchronous when it comes to adaptation: children love diagnostics. Whenever a technician takes a PET technology. And they really love robots. One scan or CT scan and sends the image to a spe- of the hospital’s pilot programs sent kids home cialist to read or a diagnostician to interpret or with mobile robots after urological surgery to the practitioner who will be treating a patient, to facilitate virtual video visits instead of this is asynchronous telemedicine in action. requiring them to come back for a follow-up visit in person. During a video visit, the robots could At Boston Children’s Hospital, primary care doc- accompany the kids to the bathroom when tors who participated in the teledermatology pi- the doctor needed to see what was going on. lot program could take a picture of a rash and Doctors could connect with the patients virtu- send it to a dermatologist. Patients and their ally and in a mobile way that was far less in- parents got the information back quickly from timidating to the kids and more convenient their primary care doctors without the need for for parents. Many young patients named their a follow-up visit to a specialist. In most cases robots, and some cried when the robots had to the primary care doctor could treat the problem, go back to the hospital. saving weeks of waiting to see a specialist.

The hospital also piloted a novel approach to “I think in a few years we won’t be talking about a persistent problem: children were missing telemedicine anymore,” says Fried. “It will just be their follow-up appointments after being diag- how we practice medicine, and we won’t even nosed with a concussion. “It’s very important think about the fact that it’s virtual.”

10 | THE VIRTUAL DOCTOR ACKNOWLEDGMENTS

Comcast Business and Forbes Insights would like to thank the following executives and ex- perts for sharing their time and expertise:

Edward Brown,'LMIJ)\IGYXMZI3J½GIV3RXEVMS8IPIQIHMGMRI2IX[SVO

Naomi Fried, :MGI4VIWMHIRXSJ1IHMGEP-RJSVQEXMSR-RRSZEXMSRERH)\XIVREP4EVXRIVWLMTW &MSKIR-HIG JSVQIVP]'LMIJ-RRSZEXMSR3J½GIV&SWXSR'LMPHVIR´W,SWTMXEP

Thomas Pacek,:MGI4VIWMHIRXERH'LMIJ-RJSVQEXMSR3J½GIV-RWTMVE,IEPXL2IX[SVO

Herb Rogove,*SYRHIV'38IPIQIHMGMRI

Yulun Wang,*SYRHIV-R8SYGL,IEPXL7]WXIQW

Tomas Yanez,(MVIGXSVSJ)RXIVTVMWI1EVOIXMRK'SQGEWX&YWMRIWW

Peter Yellowlees,4VSJIWWSVSJ4W]GLMEXV]9'(EZMW

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