1) Agree that the business case for adoption and use of telehealth by physicians must take into account current workloads, work processes and compensation models – it simply will fail otherwise. Such processes must account for follow-up with a patient as required, whether by phone, email, or other method. In speaking with Dr. Martin, Cleveland Clinic’s CIO, he related the example of a heart failure patient who, based on biometric readings, is collecting fluid around the heart, a common occurrence, for which a doctor would be able to prescribe a diuretic without the patient actually having to visit the clinic. Better service for the patient and eases the workload (no office visit) for the doctor. In such a case, the compensation model is of interest, but at this time, Cleveland Clinic is unwilling to go into the details of such models. We’ll have to wait and see.

To your point Michael, telephone triage is part and parcel of the complete program and will be the responsibility of the care team (physician(s), nurses, etc.) and not the sole responsibility of a single doctor.

2) So why do we believe there will be accelerated growth in telehealth? Two reasons:

a) The market for healthcare services is becoming more competitive with numerous entities (retail clinics, corp. campus clinics, medical tourism, online and telephone-based services, regional and national hospitals, the list goes on) all striving to get a piece of the action. For Cleveleand Clinic and other like-minded institutions, telehealth offers them an opportunity for differentiation providing healthcare with a higher “services touch” leading to higher customer retention and attracting new customers.

b) Microsoft has enormous resources at its disposal to push the concept and certainly has a vested interest to see this work. With some 50 devices now compliant with HealthVault, we now have a critical mass of device choices that previously were unavailable in the market, all networked through a common platform for data aggregation and subsequent push to a physician/care team.

And Microsoft is certainly not alone. In 2009 we will begin seeing a number of devices entering the market that are compliant with the Continua Alliance interoperability standards. This alone should provide a boost, but when coupled with the platform plays from either Dossia or Google Health (they both signed on to the Contnua Alliance in Oct.), we see something quite similar developing to what HealthVault is currently offering.

As both of you rightly point out, simply aggregating and pushing data into a physician’s EMR does not readily address workflow and compensation issues. While these are challenging and will take plenty of forethought, they are not insurmountable.

- The business case needs to be based on measurable evaluation data and be able to be extraplolated to estimate systemic impact, not just local elements.
- telephone triage was not mentioned and would seem to be a key issue to limit unnecessary clinician workload.
- In Australia where some 85% of GP’s have computers and a practice managment system (Medical Director, for example) the need is for seemless integration to the already established work flow.
- In public health jurisdictions there is no direct link between GP activity and hopsital avoidance as the two sectors are often funded separately.

Services like HealthVault will put pressure on the system and this is good. One ICT issue is when a patient comes to a GP and hospital with their USB key are demands upload.

1) Service redesign is the most important part of making telehealth work, and it takes a lot more than IT. I know what their CIO said, but did their COO/CFO commit to this too? What plans does Cleveland Clinic have in place not only to change their office visits, but also what happens in between? Imagine a physician who sees a patient’s blood pressure is too high – what enables that physician to easily take action (talk with the patient (either in person or through other means), increase the dose of the blood pressure med, get a prescription to the pharmacy, arrange for follow up lab tests) to address that high blood pressure reading? Furthermore, have they changed compensation for their docs so that their productivity is not reduced if they spend time on this instead of office visits? How does this work for patients followed by PCPs and specialists – who is responsible for managment?
2) There already are lots of studies showing that telehealth works when applied to the right patient population, even without EMR integration. Why do you think that another small study of fewer than 500 patients will make a difference?

It is possible to use telehealth to improve care for people with chronic illnesses, but it is going to take more than putting the vital signs readings in an EMR/PHR.