According to Jonathan Linkous, CEO of the American Telemedicine Association, the latest version of the amendment would create a federal definition of a “valid prescription” covering all prescriptions, not just narcotics and other controlled substances.  And it would cover all pharmacies.  In part, it would require a patient to have had an “in-person medical evaluation” within the 24 months prior to receiving an online prescription.  To be “valid,” the prescription must meet a Controlled Substances Act definition requiring the patient to be at a hospital or clinic, or be issued by a newly defined “qualified offsite telehealth practitioner.”  The valid prescription must be based on an “instanteous” communication with the patient.  Jonathan suggests that those of us in the industry contact our lawmakers to register our concerns.

The bill’s sponsors are Sen. Diane Feinstein (D-CA) and Rep. Bill Cassidy (R-LA).  I think lawmakers, especially Senator Feinstein, have been looking for ways to prevent “Internet prescribing” which has proved fatal to some of its “victims.”  This occurs when physicians write prescriptions for people who merely fill out online questionnaires.  In these cases, the physicians don’t know if what the “patient” is telling them is correct.  They don’t even know if the “patient” is who he, or she, says they are.

The Journal of the American Medical Association recently published a study that violations of online professionalism are prevalent.  The study found that 63% of medical boards reported inappropriate prescribing by physicians who were either refilling prescriptions for or prescribing medications to patients they had not met.

Dr. Ryan Greysen, the leader author of the study and assistant professor of hospital medicine at UC-San Francisco, says he doesn’t believe these violations were intentional or malicious – just that doctors were misusing the Internet.  Dr. Robert Wachter, professor and chief of the Division of Hospital Medicine at UC-San Francisco, believes physicians should understand what constitutes professional behavior online.  Wachter told JAMA, “In nearly every situation, especially on the Internet, they should be wearing their doctor’s hat.”

No one doubts that using the Internet to put controlled substances and other potentially harmful drugs into the wrong hands is wrong and dangerous.  But Jonathan’s concern is that the language oversteps the problem and could likely interfere with legitimate telemedicine.  Even good meaning people sometimes don’t foresee the unintended consequences of legislation.  That’s why it’s important for us to draw their attention to potential problems before proposals become law.

For those of you attending the conference at the Grand Hyatt Hotel in San Francisco, Jay will be part of a panel at 11AM on May 24th.  The panel’s topic is: “How Will Cloud Transform Healthcare – the Rationale for Cloud Computing in Healthcare.”

Jay can explain how CONi™Services, GlobalMed’s cloud, can preserve both visible and invisible DICOM images in a secure PACS so that physicians can view them on their iPads, Android tablets, laptops or desktop computers as soon as they’re on the server.

The first product in the video is the Silhouette 3D Camera from ARANZ, a New Zealand firm.  Pretty amazing because it uses a system of three lasers to gauge distance at the bottom of a wound.  Then, you outline the wound’s margin by clicking (or in this case touching the HP Touchscreen monitor) until you have completed a circle.  The software then measures not only the width and area but also the depth of the wound.  The software features a reporting piece that shows healing progression.

After that, you’ll see the GlobalMed Transportable Examination Station, or TES™, followed by Midwest Account Manager Daniel Santiago as he puts our new TotalExamHD camera through its paces.

Jeff is the CEO of FuzeBox, a competitor of Cisco and Polycom in the “telepresence” arena.  He says that he had a conversation with members of a Fortune 500 company that spent millions of dollars on special rooms and equipment to do videoconferencing.  For those of you new to videoconferencing, this is the old business model where you build a special room with large screen TV’s mounted on the wall.  The table people are sitting around is mimicked by the people at the other end of the videoconference so it appears that you’re all sitting at the same table.

Even the 90-year-old chairman of the Fortune 500 company saw the limitations and unnecessary expense of that system and has decided to move to a “next-generation” videoconferencing platform from another provider. In Jeff’s post, “5 Reasons Cisco And Polycom Are In Trouble In Telepresence,” he says Cisco and Polycom are being outmaneuvered by more flexible, smaller companies (like his) with that “next generation” outlook.

His five reasons are:

1. Cost – These smaller companies can offer videoconferencing of about the same quality for 90% less than the big companies.

2. Cloud – Used to be a huge IT team was needed to keep systems up and running.  Now software can do make this much easier and less costly.  Online video meetings in the cloud can be recorded for viewing at your convenience.

3. Mobile – Polycom, Cisco and others have no app for the iPad.  And with downsizing the mantra for many companies, you can’t often get everyone in the same telepresence room.

4.  Interoperability – Used to be if you wanted to text someone you both had to be on the same mobile phone network.  That’s still the limitation for the big telepresence companies.  Polycom codec users can’t communicate with Cisco codec users.  The newer companies have engineered workarounds to connect with one another.

And 5.  Collaboration – You need more than just the ability to see and hear someone at a remote location.  You may want to share documents, video, audio, images and graphics and have the ability to add to the materials at either end.

Jeff doesn’t believe that big companies are ready to move forward into a more modern, competitive market because they’ve built their business around proprietary systems that can cost millions of dollars per installation.

You could easily substitute telemedicine models into this story because like telepresence there is a dated, fixed and expensive business model and a newer, more mobile, and more affordable model.  The older model accepts the Cisco and Polycom idea that you dedicate a room for telemedicine.  You have to bring the patient to the room to meet with the doctor.  The newer model doesn’t anchor the equipment to a room, but is portable, can move easily from room to room because everything is integrated, and works on one platform.  So instead, you bring the doctor to the patient.  This makes every room an exam room for in-person as well as telemedicine visits.

Some people see this as disruptive, but actually I think the old way is more disruptive because the doctor has to go to the Telemedicine Suite to do telemedical visits and back to the more traditional exam room to see patients in person.  Under the new portable model, the doctor goes to any room and sees patients, either sitting on the exam table or on the video screen.  That’s the model that GlobalMed embraced years ago and continues to work toward even more mobile situations.  In fact, when you went to the Cisco and Polycom booths at ATA2012 in San Jose, you didn’t see the old style of telemedicine/telepresence, but mobile telemedicine stations.  And had you visited the GlobalMed booth, we would have shown you how doctors now have the ability to view both visible and invisible light images on an iPad, just moments after they’re uploaded to the CONi™ Services cloud.  You would have seen not just one image from a CT Scan on an iPad, but the entire study with dozens of images.

When images are on the CONiPACS, first of all they are preserved in DICOM format with 256-bit encryption. Secondly, the CONiPACS is outside the hospital system so that physicians can view and manipulate images at a secure Web site.  The images are never resident on the iPad or other computer device, so there’s no chance of a HIPAA mishap.

For all we know, Jeff, Cisco and Polycom could be working on a new concept in videoconferencing.  Lord knows they have enough money to do it.  My advice is to keep looking over your shoulder.

Who wouldn’t enjoy the city, what we saw of it anyway!  And those of us who are desert-dwellers appreciated the crisp temperatures.

The smaller showroom floor wasn’t noticeable, despite a 20% increase in the number of vendors and organizations participating in the Expo Hall.  We were very pleased that so many visitors stopped by our two-story booth to learn about our new products and services and to attend the three presentations in the booth’s theater.  Meanwhile, the San Jose Convention Center provided adequate space for all of the educational programs and presentations.

One of the genuine surprises at the show was in our booth.  The Applied Research Associations New Zealand, or ARANZ, folks demonstrated their Silhouette Product Suite for advanced wound assessment and management.  In case you missed it, the SilhouetteStar is a small, handheld camera, about the size of a baseball with a third of it missing.  Around the perimeter of the camera lens are three lasers.  You aim the lasers at a wound and snap a freeze frame image when all three intersect.  The camera connects to a computer via USB and does not require batteries.  It gets its power from the computer.

SilhouetteConnect is the software application that processes images from the camera.  With it, you can measure the area, depth, volume and perimeter of wounds.  The images are saved in a database that contains a lot of patient wound information, including a reporting system that displays the healing progression on a chart.  Pretty clever, especially when used with an HP Touchscreen monitor.

Of course people were really impressed with our products as well.  Naturally, the TotalExamHD™ camera attracted a lot of people.  And they were treated to its images displayed in CapSure® 2, the more advanced version of GlobalMed’s image automation software that handles both HD and SD imagery.  A few steps away, we showed how easily CONi™ Services saves the images to CONiPACS, a HIPAA-compliant PACS and then makes the images available to a physician for secure viewing on an iPad, Android tablet, laptop or desktop computer outside a hospital’s network.

Two other telemedicine “stations” generated a lot of interest: the brand new FirstExam™ Mobile Telemedicine Station and TES™, the Transportable Examination Station.  People came away from both with an appreciation of the design and workmanship of these two products.  The FirstExam features lockable bins for peripherals whose cords are on retractable reels and out of sight.  And the work surface folds over and locks to secure the HP laptop.  TES is a carry-on size case containing an HP Elite notebook computer loaded with CapSure, a TotalExam™2 Examination Camera, a stethoscope, USB Otoscope and a ClearProbe ultrasound probe.

Dr. Hamilton Schwartz from Cincinnati Children’s Hospital presented his paper on a mobile telemedicine solution for emergency medical transport of patients.  This was funded by a grant and by his hospital to assess the efficacy of the TransportAV system by GlobalMed, which he couldn’t mention by name, but he had praise for both the product and our company for being easy to work with.  He said that during the brief period the TransportAV system was in use, there were 12 patients whose outcomes were definitely helped by the system.

But what most ATA2012 attendees will remember was the very entertaining conversation between ATA President Dr. Bernard Harris and Steve Wozniak, co-founder of the Apple which GlobalMed sponsored.  True, “the Woz” has had little to do directly with telemedicine, but as Dr. Harris, ATA CEO Jonathan Linkous and GlobalMed Managing Director Joel E. Barthelemy said in different ways, he has had a tremendous impact on the technology physicians use to treat their patients.  Joel described the impact Wozniak had on GlobalMed Director of Research and Development Mike Harris and him.  Both were early adopters of the Apple 2 personal computger.  That led up to Joel’s presentation of the first GlobalMed Impact Award to Wozniak.  Steve Jobs was the Apple marketing genius, but without Wozniak there would have been no iPod, iPad or iPhone.

One of the funny stories Wozniak told concerned a practical joke he played in college.  TV reception in a college dorm was sketchy.  Those of us over 50 remember using aluminum foil on rabbit ear antennas to try to improve the picture.  Wozniak built this system that would take a clear TV signal and make it unviewable and he could control it remotely.  When someone turned on the TV, he would make it so that the picture was nothing but “snow.”  At first, he would make it clear up when someone put his hand on the TV set.  When the person removed his hand, he would make it go back to “snow.”  Naturally, the guy touching the TV set had to stand in place (or so he thought) for everyone to see the TV.  Eventually, Wozniak would make people adopt strange positions in order to get a clear signal.  The high point of the spoof was when he had one person standing on one leg with his arms in the air just to watch TV.

At ten o’clock this morning, Dr. Ricardo Martinez, an emergency medicine physician from Atlanta, and the chair of the GlobalMed Advisory Board, will speak on “Redefining Regionalization in Emergency Care.”  He will repeat his presentation at 5:30pm.

Detelina Trendafilova and Manoel Coehlo, our International Business Development team, will discuss “Moving from International Pilot to Implementation.”  Dr. Phil Johnson, an emergency medicine physician from Summit Healthcare in Show Low, Arizona, will describe “A New Paradigm in Patient Care.”

Last night, we had a lot of people crowded around our booth, trying to get information on our new products: TotalExamHD, the FirstExam Mobile Telemedicine Station, and the Transportable Examination Station, or TES.  Plus, we were demonstrating how CONi Services saves images to a PACS and then allows a physician to view the images moments later on an iPAD – right here on the show floor.  Applied Research Associates New Zealand, or ARANZ, is demonstrating an amazing system in our booth.  Their 3D USB camera can capture images of wounds and measure the dimensions, including depth.  Remember the snack called a SnoBall?  The camera emulates that shape.  Three lasers help focus the camera on the wound depth.

After the two hour program last night, I met up with the ATA Pediatric Special Interest Group, then went with Manoel Coehlo to the Polycom offices in Santa Clara where he presented the TES to visitors at the OMANTEL show in Oman via videoconference  from 10pm to about 1:30am our time.  Since Oman is 11 hours ahead of PDT, it was 9am to 12:30pm there. One of the visitors to their booth was the Sultan of Oman. 

Judging from last night’s turnout, we expect a large crowd in the Expo Hall today.  Many people like to fly in to spend the day and then depart on Tuesday morning.

The GlobalMed two-story booth is up and really looks good.  You get an idea of the scope of the hall from the second floor.  Because it’s the only two-story booth, you can’t get that view anywhere else.

Yesterday, I took in the Telemedicine 101 course and was amazed at the number of people there.  I arrived about five minutes before the course was scheduled to start at 9am, and had only three or four seat options.  I ended up hugging the wall on the left for the morning session.  After lunch, I sat in the very front row because that was the only place open.

I did a rough count and figured there were about 300 people in the room.  A show of hands indicated this was the very first ATA meeting for about 95%. And I’d say about 10% were from outside the country.

In one sense, I felt like the “wolf in sheep’s clothing” because the talk in the afternoon turned to vendors in the Expo Hall.  Some of the panelists “warned” the audience about us.  “Telemedicine is not about the technology,” one of them stated.  Not to argue the point, but actually, it is.  Without it, there would be no telemedicine.  For that matter, none of them would have been invited to share their ideas about how to set up a telemedicine practice.

I didn’t expect panelists to be cheerleaders for GlobalMed because this was a certificate course for CME.  But when government-sponsored agency folks promote their own services as being the real authority on telemedicine, then I think that’s going beyond the bounds of the course. 

Today, we’ll attend the Joint Institutional/Industry Council Luncheon, and the topic will be “The Business Case for Telemedicine.”  If any aspect of telemedicine has been elusive it is the case for Return on Investment, ROI.  I hope to glean some essentials from it.

Of course, Monday is a full day of Expo Hall and presentations for those of us at the GlobalMed #535 booth.  We will have nine stations set up to demonstrate the range of new products we’re introducing at ATA 2012.  Please make plans to attend one or all three of the presentations in the booth theater.  Dr. Ricardo Martinez kicks things off at 10am by “Redefining Regionalization in Emergency Care.”  He will repeat his presentation at 5:30pm.  Manoel Coehlo and Detelina Trendafilova, our GlobalMeda International Business Development team, will speak on “Moving from International Pilot to Implementation” at Noon.  And Dr. Phil Johnson will address telemedicine in the emergency room in a talk, titled “A New Paradigm in Patient Care” at 2:15pm.

And please, if you stop by our booth, allow me the pleasure of meeting you.

The Convention Center is downtown, a couple of blocks from our hotel.  There’s a nice park in the center of downtown that encourages you to walk around.  The city is expanding the Convention Center, and the new area will open next year.  Good thing, because the Expo Hall, at 143,000 square feet is smaller than the Tampa Convention Center, the 600,000 square foot home of ATA 2011, and tiny compared to the one-point-three million square foot Henry Gonzales Center in San Antonio which was the site of ATA 2010.  And yet, the ATA has jammed about 20% more vendors into this year’s show.

This is the first time I’ve seen the hall before workers begin setting up all the booths.  It will be interesting to see the place transformed into a visitor friendly place.  Workers began putting our new two-story booth in place about an hour ago.  We expect them to have most of it up by late this afternoon.

I ran into Gary Capistrant, the ATA’s Senior Director of Public Policy, in the empty lobby as we were registering for the tradeshow and getting our badges. Gary has been working on generating support for Senator Tom Udall’s proposed bill that would create a tandem medical license.  If approved, the bill would remove one major barrier to doing telemedicine across state lines.

We chose this booth design for a couple of reasons.  It enables us to display our newest products (more on them in a moment), and to have a quiet area we can use for presentations.  This year, Dr. Ric Martinez, the chair of the GlobalMed Advisory Board, will present.  His topic is “Redefining Regionalization in Emergency Care.”  And Dr. Phil Johnson will speak on “A New Paradigm in Patient Care.”  The title of the presentation by Manoel Coehlo and Detelina Trendafilova, our International Business Development team, just back from the Med-e-Tel Meeting in Luxembourg, is “Moving from International Pilot to Implementation: The Road to Cost-Effective, Accessible Healthcare.”  The second floor of the booth provides guests with an opportunity to have a place away from the crowd to meet with our sales team and discuss our solutions.

Here’s what you will see if you stop by our booth, #535.  We will have our i8500 Series Mobile Telemedicine Stations at various locations to demonstrate our new solutions, beginning with TotalExam™HD, the first true HD examination camera for telemedicine.  It is a 1080p camera that can provide video at 60 frames per second.  The resolution is, in a word, incredible, and it’s perfect for dermatology!  This is the same video quality that has only been available in TV studios.  The 12 bit per pixel camera can display billions of colors, compared with millions of colors from an SD, or standard definition, device.  TotalExamHD features include automatic focus, automatic color control, and automatic frame analysis when freezing the video.  The camera analyzes 17 video frames and chooses the clearest one.  For richer color in an image, you can select a different frame rate by simply pushing a button on the camera.

At the recent HIMSS show in Las Vegas, we had a ton of visitors wanting to see TES™, the Transportable Examination Station.  This is a telemedicine station inside a carry-on size case.  It fits in an airline overhead bin, and has a handle and wheels just like your other carry-ons.  Inside is an HP Elite notebook computer for videoconferencing and is loaded with our CapSure® image automation software for storing and forwarding patient images.  Also included is our TotalExam™2 Camera, a stethoscope and a USB otoscope.  A control panel  allows you to connect any medical device that is USB.  The HP Elite is 3G/4G ready, you just have to select a carrier, but it can also connect via WiFi, broadband or SAT phone.

People have asked us if we could provide them with a mobile telemedicine station that would fit better in an office or clinic where space is a premium.  At ATA 2012, we will show for the first time our new FirstExam™ Mobile Telemedicine Station.  It has a smaller footprint than the i8500 Series stations.  Everything, cords, cables, peripherals are all contained with the unit in either the central column or in four lockable compartments.  The only cords you will see on the outside are the AC cord to power the unit and charge the medical grade battery and the CAT-5 Ethernet cable, and both are on retractable reels.  FirstExam can have different monitor configurations for videoconferencing, but the unit uses an HP ProBook laptop that is hidden away when not in use.  Loaded on the laptops will be our latest version of our image automation software, Capsure®2, which can display both HD and SD video images.  I could go on and on about CapSure 2, but you really need to see it in action.

CONi™ Services and EMDTransfer™ will also be on display.  These are GlobalMed’s cloud applications that work with both visible and invisible light images.  Once patient images in DICOM format are uploaded to the secure CONiPACS, an email can be automatically sent to a physician, alerting him to images that are ready for his viewing.  Using an iPad, notebook, laptop or desktop computer, or his smartphone, he can go to the secure CONiView Web site, and view the images.  He can manipulate them and write reports on them that are saved with the images in the patient’s EMR.  The CONiView portal also allows patients to sign in and view their medical images with a secure passcode system.  No longer does a patient have to maintain their medical images somewhere at home.  And access to them is not dictated by office hours or a doctor’s office workload.

EMDTransfer is the emergency arm of CONi  Services.  It allows an emergency department to upload CT Scans and x-rays to the cloud for timely collaboration between an emergency room physician and a remote specialist on the care of a patient.  This collaboration can confirm that the patient needs to be transferred to a higher level of care.  The specialist doesn’t have to wait for the arrival of the patient and the study, and can begin preparing his team for the case.  The availability of CT scans and x-rays from the originating hospital eliminates the need to do a redundant study at the receiving hospital, thus preventing the patient from receiving another dose of radiation.  On the other hand, the EMDTransfer consultation could help decide that the patient need not be transferred from the originating hospital, thus saving the healthcare system thousands of dollars in emergency transporation.

I haven’t even begun to tell you about the Teleaudiology solution that will be on display or the laptop that will show… Oops!  I’m not supposed to say anything about 3D, so please forget all about it!

If you can stop by, please do so.

Then there’s the colon cancer patient dismissed from the practice of an oncologist because the patient lost his healthcare insurance.  Dr. Brawley saw the man and discovers the first doctor was using a chemotherapy regimen that “we” stopped using 15 years earlier.  I don’t know if Dr. Brawley meant him and his staff or the royal “we,” all of medicine.  But he calls the first doctor “greedy.”

In the first two situations, the blame rests with insurance companies and doctors.  He blames the patient in the third example for wanting unnecessary chemo treatment for her colon cancer because she had the money to afford it.

Tara quizzes him about the breast cancer patient as to what he was “trying to tell us with that example.”  Dr. Brawley said he saw a lot of things in her background that were “lessons for society about what we need to do if we want to defeat breast cancer.”  One aspect he cites is a “little bit of denial.”  Personally, without knowing much more than the interview, I’d say there was a LOT of denial.  But Dr. Brawley decides the real culprit here is insurance because she dropped her policy when it became expensive.  And she failed to seek care from Dr. Brawley until 9 or 10 years later when her breast fell off.  At that time, when she was uninsured, she received free care from the hospital and lived for about two years more.  Dr. Brawley gets mad at the insurance company and the healthcare system, but not at the patient?!?!?  Who provided the free care  when she no longer had insurance and extended her life another two years after she made incredibly poor choices?

Dr. Brawley describes the doctor who treated the colon cancer patient with a dated chemo regimen as an oncologist with a “wonderful reputation as a doctor to the rich and famous in Atlanta.”  We don’t know how the man “lost his insurance,” or why “the oncologist basically dropped him” (sounds like a simplification of what happened), but at least the man did the right thing and went to his public county hospital for treatment.  Dr. Brawley says the chemo drugs the oncologist tried allowed the doctor to “get a substantial markup and make a substantial amount of money by selling them.” If insurance covered the treatment, how did the doctor get a substantial markup?  Insurance companies are notoriously stingy.  If the oncologist received more than he should have in reimbursements, this is fraud.  And if he was going to charge the patient more for being his patient, (remember, he is the “doctor to the rich and famous in Atlanta”), perhaps the patient should have looked for another doctor.  This was the doctor Dr. Brawley claims was using a dated regimen for colon cancer.

By the way, I hope Dr. Brawley reported his concerns to the Georgia Medical Board if this incident happened when he was Medical Director of the Georgia Cancer Center for Excellence at Grady Memorial Hospital or Deputy Director for Cancer Control at the Winship Cancer Institute at Emory University.  I would hope that he would feel a duty to report a colleague who fell below the standard of care whether or not there was a state law in Georgia requiring it.  Judging from what he says about the oncologist, this should have been a medical board investigation leading to discipline.  The medical board could have suspended his/her ability to practice until passage of a competency exam.

Looking at the final case involving the doctor-shopping female colon cancer patient, Dr. Brawley blames her for ultimately getting chemo from another doctor after he told her she didn’t need it.  So, if I understand what happened, he chastises the patient in the interview (and in the book) for seeking a second or third opinion?  Hey, if Doctor A and even Doctor B tells me (1) I have colon cancer, and (2) I don’t need chemo, I want to make darn sure.  If I accept his diagnosis and treatment plan, then find out that later research says I should have had chemo, my options are greatly reduced.  And if I have the money to spend, I use it to be sure in my mind.  Meanwhile, this is ONE (1) patient, and Dr. Brawley uses this and the other TWO (2) cases to make a broad general characterization to “blame patients…blame doctors…blame hospitals…blame drug companies.”  Who else is left?  The government.