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VIRTUAL DOCTOR

THE

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

CONTENTS

2 | THE VIRTUAL DOCTOR

Thirteen years ago, a surgical robot named Zeus made history when a team of physicians in New York performed surgery on a patient in Strasbourg, France. The Lindbergh Operation, as it came to be called, represented a con!uence of technical achievements, namely the dexterity of the digital Zeus Robotic Surgical System and a broadband transmission capa-bility with optimized compression that limited the time delay between the doctors’ commands in New York and the resulting action in France.

Since that breakthrough in 2001, the idea of treat-ing patients remotely has touched almost every aspect of healthcare. Neurologists can now “beam in” on stroke victims to provide instant assessments that can save lives. Patients recovering from surgery at home can have the equivalent of an electronic house call with a video link to their surgeon for follow-up appointments. And, in one of the newest applications of telemedicine, psychiatrists can create avatars to meet patients in virtual worlds where they can act out di"cult scenarios.

We are not that far away from a future in which see-ing a doctor does not require being in the same room or even the same building, says Yulun Wang, founder of InTouch Health and president of the American Telemedicine Association. “I think telemedicine will become the core methodology of healthcare delivery in the future,” he says. “It has to, because that is where we are going to get the e"ciencies we need to meet rising needs created by an aging population and pro-vide a#ordable care.”

One of the original imperatives for telemedicine was to bring better care to underserved and remote areas with few medical facilities or where there were long distances between patients and doctors. But even in well-served areas, there are compelling reasons to incorporate telemedicine into many practices. There are not enough specialists—neurologists, cardiologists, dermatologists and psychiatrists, to name a few—to meet rising demand. Someone su#ers a stroke every 40 seconds on average in the United States, but there is not always a neurologist available in the $rst few

HOW DATA NETWORKS

ARE EXTENDING THE REACH

OF MEDICAL CARE

IN THE DIGITAL AGE

T H E V I R T U A L D O C TO R

COPYRIGHT © 2015 FORBES INSIGHTS | 3

crucial minutes to provide a diagnosis. Telemedicine can also reduce costs and improve outcomes. For example, home health monitoring for people with chronic conditions, such as diabetes, can mean fewer missed appointments and hospital stays, not to mention reduced travel time for patients.

These imperatives are driving unprecedented innovation and entrepreneurial energy in the $eld of telemedicine today. However, none of this innova-tion would work without a reliable network capable of carrying a detailed image from one location to another, or to control a robot miles away, or simply to access an electronic record safely and securely.

New imaging systems, for example, save lives, but they also create massive digital $les. “The hospital has to have a really strong network to take advantage of this brilliant machinery,” says Tomas Yanez, director of enterprise marketing at Comcast. “Everything may work great at the main hospital facility, but at the edge

of the network, at the radiologist’s o"ce a few blocks away, it might not work very well at all if the network isn’t robust enough,” he explains. Sending video $les takes even more bandwidth.

“Everyone gets excited about the performance and the glory of a new application that promises to make the patient experience better or make a hospital more competitive, but it won’t work unless there is a solid network foundation underneath to support

it,” says Yanez. “The network is behind the scenes, it’s not in the lights where people are clapping. But the connection is real, and critical to the performance of any telemedicine application.”

Comcast Business Ethernet services dovetail well with the needs of most healthcare providers. Ethernet is a protocol that can run on both $ber and coaxial cables, and it can be expanded with a single phone call. So if a new imaging system starts producing $les that are choking the circuits, an existing Ethernet service can be expanded exponentially without digging new holes or laying new $ber.

Most hospital systems need to connect multiple locations, from the main facility to outpatient clinics, physician’s o"ces, imaging facilities and record archives—all of which may be miles from one another. Any hospital system that relies on digital medical records needs to ensure constant access to those records, and that requires a reliable network

across all locations with multiple paths and multiple redundancies.

At Inspira Health Network, which was formed in 2012 after the merger of South Jersey Healthcare and Underwood-Memorial Hospital, a Wide Area Network (WAN) connects three medical centers, two health centers and dozens of outpatient sites with a combination of several di#erent Comcast Business Ethernet services. Physicians at any of Inspira’s facili-

“The hospital has to have a really strong network to take advantage of this brilliant machinery.”

TOMAS YANEZ, Director of Enterprise Marketing, Comcast


ties can access test results, surgery notes, home health visits, diagnostics and other data as they move from one patient to the next. Instead of juggling paper $les, doctors can spend more time with their patients. Patients are also bene$ting from the network via a dedicated portal where they can review test results, pay their bill, schedule classes and access a library of health care information.

“The more services we run over the network, the more we can reduce the cost of those services,” says Thomas Pacek, vice president and CIO of Inspira

Health Network. Inspira is “collapsing everything onto the network,” he explains, from cardiology equipment to the medical records of physicians’ o"ces associated with the hospital. With so much of the daily workload moving over the network, reliability is key. “The more we become electronic with our records—and everything we do related to patient care is becoming digital—the more we can’t a#ord to have any downtime,” says Pacek.

Security and privacy matter as well. Healthcare pro-viders have to meet HIPAA requirements to protect patient privacy. A psychiatrist speaking with a client, for example, can’t use standard free videoconferencing applications to hold a session. Instead, they must use an application with HIPAA-compliant architecture that comes with a host of security features. Patients, 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.

Much of telemedicine takes place over the public Internet. “The Internet is inexpensive, it’s nearly ubiquitous, and you don’t need to program anything,” explains Yanez. Those qualities have laid the ground-work for the growing ubiquity of telemedicine. For a doctor answering an emergency call by logging on to a mobile device or paying a virtual visit to a patient in a remote location, the public Internet is the only option that makes sense.

But security is still a real concern. “What could happen when you pass medical records around over

the Internet?” asks Yanez. Data is handed o# from one network to another, exposing the sender to the possibility of an embarrassing security breach.

That is why many hospital systems use private networks that don’t traverse the public Internet. With the explosion of mobile devices and the growing use of telemedicine, some of them are able to extend their networks to include the homes of their health-care providers through such services as “Ethernet at HomeSM.” This service, o#ered by Comcast Business, provisions o# the healthcare facility’s existing infra-structure without going over the Internet, just as it does at the other locations on a hospital network. It is one more way that telemedicine is breaking down the boundaries of distance and time to provide better outcomes for patients and healthcare providers.

“The more services we run over the network, the more we can reduce the cost of those services.”

THOMAS PACEK, Vice President and CIO, Inspira Health Network


CASE STUDY: ONTARIO TELEMEDICINE NETWORK

CANADIAN PIONEER

Edward Brown, chief executive o!cer of the Ontario Telemedicine Network, connects doctors and patients across a province that is bigger than Texas and California combined. Because of the network’s size, there is great potential for collaboration and experimentation. And because of the network’s long history, Ontario has been ahead of the curve at every stage of telemedi-cine’s evolution.

The buildout started in the late 1990s as a private network, before the public Internet was equipped to handle either the kinds of telemedi-cine applications Ontario wanted to use or the populations Ontario needed to reach. About 15 years ago, the network moved to IP video con-ferencing with hardware-based devices at all the end points—3,400 at last count—in every hospital and many mental health, primary care and rural care facilities across the province. “We probably had the biggest IP video network in the world at that time,” explains Brown. This was before popular services such as Skype and Facetime took o". Now, with the availability of higher bandwidth and greater Internet cov-erage, Ontario has rolled out PC and mobile videoconferencing that’s integrated with the private network.

“Last year, because of telemedicine, patients avoided about 260 million kilometers of travel,” says Brown. “That’s the equivalent of going to the moon and back 330 times.” The private network is particularly important for reaching remote places where there are no doctors—and no Internet. “We deal with a lot of rural areas that may never have good Internet access.”

But the bold new frontier for Ontario is con-necting directly with consumers via their device of choice. One example: people with chronic diseases can stay healthier and avoid crises by learning to self-manage their conditions. Patients send vital signs to their healthcare pro-viders, and nurses coach them through routine care and diet as well as monitoring compliance. “We are reducing hospitalization by about 50% for patients with congestive heart failure and chronic lung disease. These are people who visit the hospital often, and we are keeping them at home,” he adds. Telemedicine is also a boon to post-surgery and complex care. “We are starting to give people apps so they can communicate with a nurse if they have an issue, so they don’t have to visit the emergency room,” he says.


CASE STUDY: INTOUCH HEALTH SYSTEMS

HOW TO BE IN TWO PLACES AT THE SAME TIME

Yulun Wang, founder of InTouch Health Systems, is an engineer by training who worked on the surgical robot technology that is ubiquitous in operating rooms today. But in 2002, he saw how robots and the ability to control them remotely could change the delivery of healthcare through-out the hospital.

“Having experienced telesurgery, I thought we would be able to generalize that concept using the Internet as the backbone,” says Wang. “And with remote presence robots connected to a cloud-based network, I thought we would be able to better utilize the clinical resources we have.”

Wang saw the possibilities of building on another crucial element underlying the explosion of many telemedicine innovations: the movement to electronic medical records. “Once medical information is electronic, it becomes portable,” he explains. “Now a remote physician can not only interact with the patient, sta" and family from afar, but he or she can also get pertinent medical information like lab reports, CT scans and physician notes,” says Wang. “Now you can truly deliver care remotely.”

Some of the InTouch robots are like giant com-puter tablets on wheels, with video cameras 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.

To avoid the latency and frozen screens that plague the free video chat services most consumers use, InTouch developed and deploys a highly e!cient cloud-based computing system that utilizes bandwidth optimization techniques, compression and decompression algorithms, and various optimization strategies to give the clinician the best possible experience. “When a doctor starts moving a robot, the image may be lower resolution initially in order to keep up with the movement, but then resolves to high resolution when more stationary and examining a patient,” says Wang.

The typical InTouch customer is a healthcare system looking for a better way to leverage its specialists across a wider range of locations. “We sell the hospital the InTouch Telehealth Network, which is layered on top of the hospital system’s backbone infrastructure,” explains Wang, “and the hospitals generally provide the physicians who use it.”

For doctors, controlling a robot is “like having an avatar that can interact in another environment,” he says. Telemedicine used to be about provid-ing access. “But in the future, we might use it to see a patient down the hall—like the way we text someone in the other room now. It’s a more e!cient way to get your work done.”


CASE STUDY: C3O TELEMEDICINE

DOCTORS ON DEMAND

Herb Rogove is founder of C3O Telemedicine, a service that specializes in providing physicians for the delivery of care to critically ill patients. Doctors in the C3O network work primarily with patients in cases where there may not be a specialist available for a face-to-face diag-nosis in the first crucial minutes when a stroke is suspected.

His experience running an intensive care unit at a large university-a!liated hospital inspired him to find a way to use technology to speed diag-nosis. “We would often get patients from smaller facilities,” he explains. “They would come to our hospital for resuscitation, but a large percentage of them died. We were too late to help them.”

Rogove founded C3O in 2007 to deliver physi-cian services on demand. He recruited doctors from university hospitals and large tertiary care facilities like UCLA. Most of them, like Rogove, are critical care intensivists used to working in an ICU setting with patients on ventilators or gun-shot victims. “Eight years ago, we saw a decrease in the number of intensivists and realized we could leverage telemedicine to help us care for patients,” he explains. “For hospi-tals that don’t have the expertise or who can’t get a doctor in fast enough, we can beam in to assess a patient,” he says. “We’re not replacing any doctors, we are just providing a service the hospitals can’t o"er.”

Even in a well-sta"ed hospital, there may not be a neurologist available in the emergency room if a patient comes in with signs of a stroke. For an ER nurse, for example, “we can be their doctor buddy,” to help them determine whether or not they are witnessing a stroke or a stroke

mimicker, like low blood sugar. And if there is a neurologist on duty in the emergency room, but someone in cardiology has a seizure, a physi-cian in the C3O network might be able to beam in faster than a specialist on another floor. “You have only 60 minutes if a patient is eligible to get a clot buster,” explains Rogove. “It can mean the di"erence between being paralyzed for life or being able to resume some kind of normalcy.”

When the call comes, a doctor in the C3O network will usually respond within five min-utes—three minutes if a stroke is suspected. In southern California, where C3O is based, that sometimes means doctors are pulling o" the freeway and booting up their tablets on what-ever network is available. “So we are connect-ed through one channel to examine a patient remotely, usually with a nurse and the family present,” he says. Then the doctor accesses patient records through the physician portal— a di"erent process in each of the 20 hospitals with which C3O works.

C3O specialists use a robotic system onsite to examine patients. “The quality is so good that you can beam in on a patient’s pupil to see if it dilates when a light is shined, or look through the hair on someone’s arm to see if there is a rash,” he says. Some stroke patients can be treated before they even reach the hospital—in emer-gency vehicles equipped with CT scans and with the help of a physician beaming in.

“We are seeing technology creep into every as-pect of acute medicine, from skilled nursing to home healthcare,” says Rogove. “It’s not science fiction anymore.”


CASE STUDY: TELEPSYCHIATRY

THE CYBER PSYCHIATRIST

Peter Yellowlees, a professor of psychiatry at UC Davis, has helped pioneer the field of tele-psychiatry. He held his first remote session via video conference in 1992. Since then, he has treated thousands of people using telemedicine. Part of his work involves better understanding of how people respond in virtual space. “Are there certain groups of patients who would be better treated remotely than in person?” he asks. “Or certain techniques that would be better to use in a virtual setting?”

In a video session, there is a lot of eye contact and you can have very intense conversations, he explains. At the same time, there is a little more distance. “From a clinical point of view, that can be a good thing because you can observe more objectively.” For agoraphobic or para-noid patients, or for patients who might be ag-gressive or dangerous—or for children who are used to video chats—a virtual session may be a better option.

The professor is also working on some futuristic applications: helping with the creation of avatars

that interact in virtual worlds. “The military has already done a lot of work on this with a view to providing therapy to veterans,” he explains. A veteran can create an avatar and be inside an Iraqi souk or driving a vehicle when an IED goes o". They can re-experience some of the horrors of war but in a virtual setting with a real therapist.

The next step: virtual therapists. Yellowlees has worked on an artificial intelligence project pioneered by Albert “Skip” Rizzo at the Univer-sity of Southern California to create an avatar therapist, trained to respond in certain ways to certain cues. The project began by taking hours of videos of patients and then bringing in psychiatrists such as Yellowlees to analyze the movements and cues of patients, capturing doc-tors’ reactions and then programming cartoon avatars to respond appropriately to patients’ cues. The avatars are not being used yet, but when they are, they could combine the collec-tive knowledge of psychiatrists with many years of experience and training into a completely virtual doctor.


CASE STUDY: BOSTON CHILDREN’S HOSPITAL

MY FIRST ROBOT

Naomi Fried, chief innovation o!cer at Boston Children’s Hospital until last December, and her colleagues have had to be more creative than their counterparts at most other hospitals. “Pediatrics is a small market,” she explains. “Kids are generally healthy, so it’s hard to get the attention of big device manufacturers or drug makers to work on pediatric problems. That’s why you see our doctors and clinicians really pushing the envelope in a way that you wouldn’t see in a typical adult hospital.”

Boston Children’s Hospital has one advantage when it comes to adaptation: children love technology. And they really love robots. One of the hospital’s pilot programs sent kids home with mobile robots after urological surgery to facilitate virtual video visits instead of requiring them to come back for a follow-up visit in person. During a video visit, the robots could accompany the kids to the bathroom when the doctor needed to see what was going on. Doctors could connect with the patients virtu-ally and in a mobile way that was far less in- timidating to the kids and more convenient for parents. Many young patients named their robots, and some cried when the robots had to go back to the hospital.

The hospital also piloted a novel approach to a persistent problem: children were missing their follow-up appointments after being diag-nosed with a concussion. “It’s very important

at the six-week mark to make sure it’s safe for kids to return to sports or other activities,” says Fried. “When we o"ered the follow-up visit as a virtual visit, compliance was much less of an is-sue,” she says. “It’s much more convenient for parents and much safer for children than no visit at all.”

Another pilot program tested asynchronous teledermatology. Asynchronous applications are already common in radiology. Digital imaging was one of the original examples of telemedi-cine and one of the first to employ asynchronous diagnostics. Whenever a technician takes a PET scan or CT scan and sends the image to a spe-cialist to read or a diagnostician to interpret or to the practitioner who will be treating a patient, this is asynchronous telemedicine in action.

At Boston Children’s Hospital, primary care doc-tors who participated in the teledermatology pi-lot program could take a picture of a rash and send it to a dermatologist. Patients and their parents got the information back quickly from their primary care doctors without the need for a follow-up visit to a specialist. In most cases the primary care doctor could treat the problem, saving weeks of waiting to see a specialist.

“I think in a few years we won’t be talking about telemedicine anymore,” says Fried. “It will just be how we practice medicine, and we won’t even think about the fact that it’s virtual.”

ACKNOWLEDGMENTS

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

Edward Brown,

Naomi Fried,

Thomas Pacek,

Herb Rogove,

Yulun Wang,

Tomas Yanez,

Peter Yellowlees,


ABOUT FORBES INSIGHTSForbes Insights is the strategic research and thought leadership practice of Forbes Media, publisher of Forbes magazine and Forbes.com, whose combined media properties reach nearly 75 million business decision makers worldwide on a monthly basis. Taking advantage of a proprietary database of senior-level executives in the Forbes community, Forbes Insights conducts research on a host of topics of interest to C-level executives, senior marketing professionals, small business owners and those who aspire to positions of leadership, as well as providing deep insights into issues and trends surrounding wealth creation and wealth management.

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