"The Virtual Doctor is In!" Ed Brown and Will Falk, Ontario Telemedicine Network and PWC, Breakfast with the Chiefs 15 November 2012

1. The Virtual Doctor is In!
Ed Brown and Will Falk
Breakfast with the Chiefs
November 15, 2012

2. What is vHealth?
2

3. Virtualization: The Future is Now…
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4. Topol on Virtualization (@HealthAchieve)
Consumer Demands + Game Changing Technology =
The Creative Destruction of Medicine (CDoM)
“The idea of going down to your doctor’s office is going
to feel as foreign as going to the video store”
– Sean Ahrens
4

5. Berwick on Virtualization (@HealthAchieve)
AFHCAN Telemedicine Cart utilized in
rural Alaska:
– Travel reduced 70 %
– Turnaround 24 hours
– ROI > 10:1
ECHO (Extension for Community
Health Outcomes):
– Rural primary care physician to specialist
virtual consults
– Treats 6-8 x more patients than traditional
telemedicine
5

6. Global Examples of Virtualization of
Healthcare
Who How What
Kaiser • Secure email • 26% reduction in in-person
Permanente • Scheduled telephone visits visits
Veterans Affairs • Two-way messaging devices for • Reduction in diabetes-related
diabetic patients hospitalizations and clinic visits
Specialists on • 24/7/365 access to highly qualified • Increased tPA administration
Call neurologists rate for qualified stroke patients
• Guaranteed 15-minute response time • 1.5 to 1.8 day reduction in
ALOS for stroke victims
eICU (Philips) • One intensivist and two nurses cover • 10% of U.S. ICU patients
120 ICU beds • Approximately 300 hospitals,
• Supports intensive care units (ICU), 40+ health systems across 34
emergency rooms, trauma, rapid states
response
“Consumers ready to adopt mHealth faster than health industry ready to adapt”
- PwC mHealth Global Survey
6

7. Virtualization is Broader and More
Transformative than “m-” or “e-”Health
vHealth
– Virtual Health Care Delivery: any care process
which is delivered remotely using information and
communications technology (ICT)
• mHealth
– Mobile Health: use of mobile and wireless devices to improve
health outcomes, healthcare services and health research
• eHealth
– Digitization of Health Records: Our decade long journey to
move the infrastructure supporting healthcare delivery
2011 BWTC we said: “25% of care and the majority of
diagnostics will be vHealth by the end of the decade”
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8. The vHealth Transition
This shift to vHealth will be as dramatic as the shift in the
1980’s and 90’s from inpatient to ambulatory care; requiring
major transformation and restructuring of people, assets, and
care processes
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9. Virtualization Can Be…
Virtualization connects people in a multitude of ways and
both synchronously and asynchronously:
Typology Example
Consumer to • Mobile technology, web portals, social networks
Consumer (C2C)
Provider to Consumer • Structured email, telemedicine, video conferencing
(P2C)
Provider to Provider • Electronic transfers, eReferral, eConsult, care
(P2P) collaboration tools
Multiple Providers to • Process of care models and case management tools
Consumer (PxP2C)
Machine to Machine • Cardiac rhythm monitoring, dialysis, diabetes
(M2M) management, body area networks
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10. Virtualization Will Improve…
Virtualization will improve health system access, quality,
productivity, and sustainability:
Access Quality Productivity Sustainability
• Deliver care over • Auditability of • Automated • Avoidance of
long distances decisions scheduling greenhouse gases
• Reduced travel • Use of • Elimination of • Ability to substitute
and wait times manufacturing, “politeness time” lower cost care
• Re-distribution of QI, and QA • Asynchronous providers
HHR – access to techniques consultations • Auction pricing
scarce • Lower infection • Ability to mechanisms
specialties rates/ Infection aggregate • Artificial
control volumes Intelligence
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11. What’s happening in Ontario and
what’s next?
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12. The Ontario Telemedicine Network
An independent not-for-profit corporation funded
by the Government of Ontario
Members include 1,000 health care and
education organizations
Delivery partners include:
– e-Health Ontario
– Keewaytinook Okamakanak
Telemedicine
– Canada Health Infoway
Page 12
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13. OTN Vision
Telemedicine will be a
mainstream channel for
health care delivery and
education.
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14. OTN “Virtual” Channels
1. Healthcare Office 2. Acute Care
3. Learning 4. Home and Community

15. 1. Virtual Health Care Office

16. Videoconferencing and Electronic
Medical Devices

17. Clinical Specialties in Telemedicine
• Cardiology • Oncology
• Dermatology • Ophthalmology
• Endocrinology • Orthopedics
• ENT • Pediatrics
• General Surgery • Physiotherapy
• Mental Health & • Rehabilitation Medicine
Addiction • Speech Pathology
• Nephrology & Dialysis • Teleradiology
• Neurology • Telestroke
• Occupational Therapy • Urology
… And 30 others

18. 2011/12 Clinical Utilization
Annual Growth
Patient Events 204,058 52%
Consultants 1,685 13%
• Physician 1,208
• Allied 477
Regular User 1,046 22%
Consultants
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19. eConsult
(AKA “Asynchronous” or “Store Forward” Consultation)
Send questions, patient data and/or pictures to a
specialist for advice or a full consultation
Current uses: dermatology, ophthalmology,
wound care
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20. Avoided Travel in Northern Ontario
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21. 2. Acute Care
Provincial 24/7 On-call:
Tele-stroke
Sign language services
Tele-burn
Regional Programs:
Crisis psychiatry
Trauma
Critical care
Long-term care
Page 21
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22. 3. Learning and Meetings 2011/12
Events* Annual Growth
Education 13,967 20%
Meetings 16,529 26%
*Includes videoconferences, webcasts & webconferences
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23. http://learning.otn.ca/

25. 4.Telehomecare for Chronic
Disease Management

26. Telehomecare/ CDM Study Outcomes
Self-reported data from 813 enrolled patients with
CHF and COPD
64 – 66 % decrease in hospital admissions
72 – 74% reduction in emergency department visits
16 – 33% decrease in number of primary care physician
visits
95 – 97% reduction in walk-in clinic visits
High levels of patient and provider
satisfaction
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27. OTN’s Job
1. Support a single, harmonized,
collaboration model
2. Catalyze adoption
• Providers – Organizations – Programs
3. Simplify the process of organizing and doing
telemedicine
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28. Directory – Used to find specialists and
programs

29. Directory – Used to find sites to host a
patient near their home

30. 30

31. What Have We Learned?
1. Telemedicine videoconferencing:
• Works at scale to reduce travel and improve access
• Enables new, innovative models of care
2. Telehomecare technology is a powerful tool
when part of a good CDM program
3. eConsult has enormous potential
• Provider efficiency
4. We have not fully addressed patients’ virtual
health care needs
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32. World of Virtual Clinical Great Firewall of
Collaboration Ontario #1
Great Firewall of
Ontario #2
Specialty Care Primary /
Community
Care
People +
Carers

33. Patient to Provider 2013
Communication
• Ask a question eConsult
• Video visit
• Prescription refill
• Appointment request
View personal health information
Personal Digital Health Care (for CDM)
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34. Provider to Provider 2013
Referring Clinician Consulting Clinician
eReferral
4. eConsult (ask a question)
Primary Care 3. eConsult (full assessment)
Family Health Teams
Community Hospitals 2. Clinical Videoconference
Cancer Centres
First Nations Communities 1.Face-to-Face
Psychiatric Hospitals
CCACs Specialists’ Offices
Mental Health Facilities Regional Hospitals
Federal and Provincial Prisons On-Call Emergency Physicians
Rural Nurse Practitioners Public Health Units
Long-Term Care Homes
34 Mental Health and Addiction Treatment Centres

35. Predicting the future is always tricky…
35

36. Reaching the Point of Critical Mass and
the Steep Part of the “S-curve”
• 200k+ visits
through OTN
• 50% YoY
growth rate
• Monthly growth
rate is now >
50%
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37. Adoption Rates Are Accelerating for
vHealth as they have for other
technological advances…
http://cdn.theatlantic.com/static/mt/assets/business/
technology%20adoption%20rate%20century.png
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38. We Have Been Through Similar Shifts
Before…
1992…
More people leave
hospital after procedure Virtual
than remain overnight Care
Outpatient
Care
202X?…
More virtual visits than
Inpatient physical visits
Care
Each transition involved people, process, and technology changes. Major
shifts in how we organize our care delivery services and assets
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39. Where Are We Headed…
Primary Care:
• Increased # of
virtual visits
• Decreased # of
Patient-Doctor Personal Video in-person visits
Structured Email/ Conferencing • Improved patient
Messaging Virtual Visits experience
• Enhanced
patient access
How Do We Know:
• Kaiser Permanente – 26% in physical visits
• Ontario’s FHTs
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40. Provider to Provider eReferral 2013
will allow very different patient and
information flows…
1. Quick Question
(e-message or phone)
Depending on the
specialty, between
2. e-Consult 20% and 60% of
e-Referral visits can be
(structured delivered remotely
& secure) 3. Videoconference (mix varies by
specialty)
4. Face to Face Visit
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41. Where Are We Headed…
Regional Specialist Hubs (aka Virtual Group Practices)
• Increased Primary Care Capacity
Primary (e.g., Project Echo)
Regional
Care • Increased Access (e.g., AFCAN
Specialist
Hubs Cart)
“Franchised” • Increased Access (e.g.,
using Ontario Specialists On Call)
MD and OTN • Decreased Costs (e.g.,
Hospitals Infrastructure Emergency Neuro Image Transfer
System - ENTIS)
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42. Technical “prescriptions” will be made
along with pharmaceutical prescriptions
Pharma Rx vs.Tech Rx App Formulary
• UK – Cambridge
Healthcare – “Europe’s
Pharma Retail First Health-App
Formulary Pharmacy Store” developing
certification process
for apps it sells.
Remicade • US - Happtique –
Diagnosis market-leader in health
apps published set of
standards to certify
Crohn’s App Virtual apps:
Formulary Pharmacy • Operability
• Privacy
• Security
myIBD • Content Reliability
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43. “Bespoke eHealth” will involve the
physician, other care providers, the
patient and family Apps Pharmacy not Apps Store
Tech Rx
Take 2 Apps and
Call Me in the
Morning Apps Formulary
AliveCor Cardiac
Withings Blood Pressure
bant Diabetes
Pain Squad Pain Mgmt
MyIBD Crohn’s Disease
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44. Mobile Health (using “phablets”) will be a key
part of a low cost infrastructure. A variety of
approaches exist…
Ottawa Hospital
• “Walled Garden”, Speed & Scale
• Expensive but comprehensive
Hamilton Health Sciences
• “BYOD “Access to Integrated Care Record
• Integrated and inexpensive
University Health Network
• Cultural Revolution, “Let a Thousand Flowers Bloom”
• Innovative Research not operational (yet)
Mount Sinai Hospital
• Replacing the Clinical Interface
• Intuitive but disruptive
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45. What Now? Rx for Ontario’s Future
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46. This is a Big Change
“In times of profound change, the learners inherit
the earth, while the learned find themselves
beautifully equipped to deal with a world that no
longer exists.”
-Al Rogers
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47. OTN Plans
Continue OTN’s work to make it simpler for
providers to “find each other, organize and do”
virtual health care and education
Work with key partners across the eHealth
ecosystem to advance eConsult and eReferral
Work with LHINs and other organizations to
expand personal digital health care use in
chronic disease management
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48. Challenges
New, collaborative way of working among
providers required
– Mutual commitments
– New workflows
Provider / physician payment
New technology solutions need to be
implemented
– P2C – local solutions
– P2P – regional or provincial solution(s)
Community Leadership
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49. What Leaders Can Do Now
Get providers to sign up for OTN’s Personal
Videoconferencing Portal in Q4
Bring your provider network together to plan
virtual health care
Hospitals and Primary Care/FHTs have special
leadership roles:
– Build your community of practice for eConsult and
“virtual ward”
– Motivate and arm primary care to deliver virtual health
to their patient populations
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50. THANKS!
@OTNTELEMEDICINE AND
@WILLFALK