monitor group

Remote Health Services

A FUTURE SCENARIO AND ROADMAP

KNOWLEDGE INSIGHT ACTION

KNOWLEDGE INSIGHT ACTION
 Remote Health Services
A FUTURE SCENARIO AND ROADMAP

Remote Health Services (RHS) allow the patient to be treated

wherever he/she is or chooses to be. Instead of having to take a
trip to a doctor’s office or hospital to be diagnosed and treated by
trained professionals, they come to him/her, virtually, thanks to the
advances in information technology and telecommunications.

Also, this transformation is not restricted just to healthcare, but also health in
general. So, the consequences are far reaching. A generally held belief is that remote
consultation, monitoring, triaging, therapeutics, and diagnostics will change the
landscape of the health and healthcare industry.

However, many barriers remain. This is not just a technology show. The health-
care industry involves many stakeholders, all of whom do not share the same
vision, nor are they equally motivated to bring about such fundamental changes.
We need to put ourselves in the shoes of each stakeholder group and see
what the vision of RHS looks like from its perspective. What is the likely
A generally held
scenario? We need to examine if the behavior of each group is such that a
belief is that remote new “steady-state” can be achieved. If so, this would create one plausible
health services will to scenario; if not, an alternate scenario needs to be created. Also, is there a
change the landscape likely roadmap to get there from here? If not, then it may mean we are
right back to the drawing board.
of health and
Only by a comprehensive and rigorous analysis can one predict with some
healthcare industry.
confidence where RHS will end up. Only then can we evaluate what op-
portunities will surface by this rising wave and what risks will the present
themselves and when. This then becomes a guide book for many organizations and
corporations that are in the process of developing their own RHS strategy.

1
 This is a long process, but one that stakeholders need to initiate. This docu-
ment outlines the results of a workshop conducted by the Monitor Group in
partnership with HealthTech in which we began the process.

Workshop
In partnership with HealthTech, we conceived, designed, and conducted a
workshop to identify and describe a scenario for RHS, encompassing what
RHS could look like in 2016 from the perspectives of different stakeholders,
and how will we arrive there from where we are at the moment.

This was the third in a series of workshops Monitor has conducted in the
past year to develop a rich, multi-perspective view of the future of healthcare.
In this workshop, instead of developing various scenarios of the future of an
industry as we generally do, we decided to select a likely scenario and expand it
in greater detail. In the process, however, we identified key uncertainties, which
could provide the basis for a scenario planning exercise at a later date. Also, at
the back end, we created preliminary ideas for business models to investigate
the feasibility of the future we project. Although by no means complete, we
hope that this attempt serves to generate meaningful discussion on this very
important aspect of future health and healthcare.

Key Uncertainties and Scenario

The future of RHS will be shaped by many factors, ranging from policy and
regulations to payment models and incentives for everyone in the value chain.
The factors below were deemed noteworthy by the group.

2 KNOWLEDGE INSIGHT ACTION

 Factors
• Payment models and incentives for every-
one in the chain
• Distribution of providers
• Consumer demand
• Consumer acceptance
• Policy/regulation/legislation
• Technical feasibility
• Product distribution and logistics
• Provider attitude and acceptance
• Systemic adaptability by various cultures
• Health of health care
• National economy
• Innovative capacity
• Growth and efficacy of medical
interventions
• Digital divide of consumers
• Unforeseen events/consequences
• Fixed and variable costs
• Competition from non-traditional providers
• Political leadership
• Health professional shortage
• Level of variability of HC systems
• Telecom infrastructure
• Level of outsourcing
• User interfaces/human factors
• Data, information management
• Large employers acceptance
• Demonstrated significant utility
• Process and change management
• Resistance of the incumbent

Of these factors, we need to focus on those that have high impact on Remote
Health Services. The high impact factors having a high level of uncertainties
are used for creating alternative future scenarios while those factors having a
low level of uncertainty are included in all of the scenarios. Of the remaining
factors (i.e., the ones that create low impact) those with high level of uncer-
tainty are selectively used in scenario creation, while those with low level of
uncertainty (and impact) are not considered in the scenario planning exercise.
The chart below summarizes this classification of factors.

3
 High

Factors that
Factors that may be will primarily
selectively used in define scenarios
defining scenarios
“key uncertainties”

Uncertainty

Factors that are Factors that should

not important in be Incorporated
defining scenarios in all scenarios

Low
Low High
Impact

The group developed the following chart by multi-voting on each factor along
the two axes, level of impact and level of uncertainty.

Policy/Regulation/Legislation
High
Payment Models &
Incentives for Everyone
Demonstrated in the Chain
Significant Utility
Uncertainty

Provider Attitude &

Unforeseen Events & Consequences Acceptance
Resistance of the Incumbent
Digital Divide of Consumers User Interfaces/Human Factors
Level of Variability of HC Systems

Low
Low High
Impact

4 KNOWLEDGE INSIGHT ACTION

The results show several factors as important for developing the scenarios. Of
particular note are two factors: Payment Models and Policy/Regulations/Legis-
lation. It is not surprising that the future of RHS depends on these two. They
impact the pocket book issue of who will pay for what and how. There are
many uncertainties surrounding both these factors, as the stakeholders try to
quantify the cost benefits of RHS, as well as, grasp the liability issues.

Many of the remaining factors in the right hand top corner can be lumped
together into two mega-factors: Consumer Factors (user interface and human
factors, digital divide of consumers) and Provider Factors (demonstrated sig-
nificant utility, provider attitude and acceptance, resistance of the incumbent).
Once again, the development of RHS will be molded by these high impact
factors and the associated uncertainties in the way they will play out. Future
scenarios can then be developed by selecting various plausible combinations
of these four factors. The chart below shows one such selection that the group
believes is highly plausible.

PAYMENT MODELS
Consumer Paid Payor Paid

POLICY/REGULATION/LEGISLATION
Highly Favorable Highly Unfavorable

CONSUMER FACTORS
Consumer Demands Consumer Rejects

PROVIDER FACTORS
Provider Demands Provider Rejects

In this scenario, the payment model shifts more toward consumer payment,
while the policy and regulatory climate become slightly more favorable for imple-
menting RHS. In this scenario, the consumers demand RHS, as do the providers,
but not to the same extent. This situation could arise from clearly demonstrating
the value of implementing RHS and overcoming consumer resistance to being
treated and monitored remotely. This is certainly a plausible scenario, and there-
fore, selected for further investigation. The rest of the document describes how

5
 we think this scenario may play out….what RHS will look like from the perspec-
tives of the different stakeholders, what are the likely business models that would
make this scenario feasible, and how we may arrive there.

Future Scenario from Different Perspectives

Let us now discuss what the world of RHS under this scenario will look like
from the perspectives of the different stakeholders: healthcare providers, patients,
health delivery systems, and employers. For each discussion, we have selected one
or more archetypes to describe what they would see in year 2016. We discuss who
they are, what their health related needs are and how they are being met now that
RHS is in place, as well as, how the landscape has changed from the year 2006.

Healthcare provider

The first archetype healthcare provider is Sam, an individual who is a certified

Care Coordinator. He is a quick thinker with good people skills. Interestingly,
he is not trained as a clinician, but is a communications expert who can provide
customer service and perform triage. He is also technology savvy.

Sam’s needs are the same as his patients’, which are: 24/7 monitoring, two way
communications, coaching on prescription compliance, reminders, and good
technical experience. Sam’s patients require rapid interactions and interven-
tions. In other words, they need “human” touch and comfort, as much as they
do medical treatment.

Our healthcare provider can deploy an array of tools to meet these needs.
Sam has video and data lines (synchronous and asynchronous), a mobile PDA
linked to an intelligent processing unit that provides smart medical advice and
broadcasts alerts. Implanted sensors, home laboratory, and smart clothing allow
collection of patient data remotely. Everything is now wireless; the big boxes of
2006 are gone. Language is not an issue, this equipment automatically trans-
lates. The patients get reminders through e-mail or phone. There are online
support groups to guide and comfort them, the nurses and physicians are
always available as back-up, and transportation can be arranged as required.

6 KNOWLEDGE INSIGHT ACTION

An important difference from what our healthcare providers used to have in
2006 is that Sam gets a bonus every year based on his patient’s improvement on
the health standards test. Customers pay with Health Savings Account (HSA)
or Medicare vouchers, which can be cashed by Sam. He does not need to leave
home, as he is able to conduct virtual visits and even leave motivational video
messages based on continuously collected data. In this world, Telehealth is no
longer its own general field of expertise but has merged into the patients’ gen-
eral lifestyle; this is another major difference.

Another archetype of the healthcare provider is a Primary Care Provider (PCP),

Dr. Gupta, a geriatrician, schooled in Delhi. She is a Gen Y doctor with a wired
office, extensive referral network and over 10,000 patients! Gupta is highly
trained in emergency medicine, able to make rapid decisions, and has equip-
ment to perform basic surgery on an out-patient basis. She is networked with
24/7 intensivists or hospital based physicians.

In order for her to do her job she needs to be able to constantly monitor physi-
ological parameters and therapeutic compliance, and do a rapid assessment of
any changes. Dr. Gupta wants to keep her patients out of hospital by making
sure that they adhere to their medication regime and receive follow-up com-
munications. She needs to be connected with the right specialists at the right
time, while providing a one-stop shop for an extensive range of diagnostics.
Using RHS technologies, much like the ones described above, she is able to
meet these needs. She is also enabled by new devices that improve communica-
tions with her elderly patients.

Dr. Gupta finds the world quite different from when she started her practice
in 2006. She now needs to be extremely technology savvy and has received
a formal education in this arena. One third of her business involves remote
monitoring. Gone are the days of 40 patients per day…the new technology
allows her to connect with a lot more. Medicare Fee for Service (FFS) has now
disappeared to be replaced by pay for performance based on health performance
standards. She does not intervene in simple health issues; that is now attended
to by her fellow provider, Sam, described earlier.

7
 Patient

Our first patient, Rosie, is an indigent wheelchair bound person living on the
3rd floor of an apartment in South Central Los Angeles. She is diabetic, has
cellulitis and requires wound care. However, she is mentally lucid and sharp.

Rosie prefers to be as mobile as possible and wants to avoid going to hospital.

She prefers to live an independent life in the neighborhood but would like to
have personal contact with Health Care Providers. She does not want to be
treated as a patient, but rather as a person who wants to live well and eat what
she wants.

In the future scenario when RHS is in place, Rosie’s needs are fulfilled. A
“smart” chair monitors her glucose, heart rate and other vitals. She gets coach-
ing from a care coordinator (Sam?), who uses an on-line disease management
system. The system connects her to a therapist and nutritionist (for culture
and cuisine), provides access to a healthcare provider, who can see pictures of

8 KNOWLEDGE INSIGHT ACTION

her wounds through a videophone. A dressing that can sense infection enables
quick intervention when needed.

Rosie is able to maintain her quality of life. An enlightened public payor sys-
tem (which pays for RHS) ensures that she does not have to worry about the
cost of her care.

Barry, our second patient, is an upscale baby-boomer living in Montana. He is

a post Myocardial Infarction (MI) patient, who does not want illness to domi-
nate his life. He wants to remain active, independent, and healthy. An active
participant in his own care, Barry wants to understand his illness and be well
informed of any new developments. He wants the world-class care of a New
York internist and cardiologist while living in Montana. Above all, he wants
peace of mind for his wife who worries about him.

Thanks to RHS, he can do what he wants. Barry interacts with online care
coach/coordinator through video camera, Voice over IP (VOIP), and wall
screens. His smart watch and shoes measure many of his vital signs, while his
smart fridge keeps a tab on what he eats. His heart rate, PO2, EKG, cardio
output, blood pressure, activity levels, and nutrition are all monitored. He
routinely uses Personal Health Records (PHR).

Interoperable technologies (wireless and broadband) are new and the issue of
licensing across state lines has been resolved. In this scenario, the payor takes
care of the service charges, while Barry pays for the “gadgets.”

9
 Health Delivery System

The first archetype in Health Delivery System, Fastcare, is a community based

ambulatory service to the chronically ill who need episodic care. A low cost
provider, who does not compromise on service, Fastcare focuses on customer
experience based on its understanding of healthcare delivery. Fastcare has to
respond quickly and efficiently. Its staff members require technology to fully
understand their patients’ needs and be able to offer different levels of service.

Data integration is a key element of fulfilling the needs of Fastcare. The raw
data from remote monitors and patient needs are converted to information
from which decisions can be made, enabling Fastcare to offer a tiered service.
Fastcare employees also can access coaches and navigators remotely so that
comprehensive care can be provided.

10 KNOWLEDGE INSIGHT ACTION

Fastcare is a dynamic, flexible, and accountable firm that has affiliations with
multiple hospitals. This is very different from what used to exist in 2006.

Midhealth, our second archetype in health delivery, is a large multi-hospital

system in the Midwest. Midhealth runs 10 hospitals and 12 outpatient centers.
Well known for cardiology and neuroscience, Midhealth has 35% market share
and competes vigorously with other powerful competitors in its primary service
area. Midhealth serves 2 million people, 80% urban and 20% rural. It is a mixed
income, multicultural slice of the Midwest population, with a disproportionate
number of aged patients. Midhealth serves patients with chronic diseases…obe-
sity, heart disease, diabetes, and joint deterioration. As the demand on their ER
goes up, Midhealth finds it more difficult to recruit skilled staff. The family
doctors have also started disappearing.

Midhealth wants to be able to retain patients even if they switch health plans.
It wants to increase the number of profitable hospitalizations and reduce the
number of money losing ones. Its staff members can provide a high level of
service to their patients through:

• A state of the art facility…integrated information technology systems

• An integrated network of outpatient centers

• Focusing on health, not just healthcare

• Providing holistic care

• A high quality pool of doctors, compliance and performance

How does RHS help Midhealth meet its needs? In a nutshell, RHS allows
Midhealth to use its resources much more efficiently and effectively. The hos-
pitals themselves are smaller than before, and they focus only on patients who
are ill. The physicians are “extended” through the use of IT support and by fo-
cusing on wellness as a means of preventing illness. The use of a tiered system
that does not promise the same level of service to everyone also helps increase
physician productivity.

Technology allows patients to get real time on-line consultation with the service
team they know and are comfortable. Real time devices tell patients how they

11
 are doing and send them to the hospital only when it is advisable. Well patients
are connected and, if they need to, can see a care provider virtually at home or at
a community center. Patients add to their own health records and control their
schedule with remote booking, reducing the overhead burden on hospitals.

Under this scenario, the health delivery system can rely on non-MD level staff
to provide superb medical care. Reimbursement has become more “even”, and
the fragmentation of care is gone. The focus on prevention, the integrated IT
solutions, the interconnected doctors, the patients driving priorities, and the
smaller physical plant are all new elements in this world.

A third archetype in health delivery is a large call center, Healthcall, which

offers different levels of subscription services to their members. A concierge
model is deployed; to navigate, guide, and connect the members to partner
health care services. Healthcall believes in providing absolutely first class
service to its members, thereby gaining customers for life. The tight relation-
ships it has formed with specialists and experts ensure that the members receive
on-going service of the highest order.

The focus is on the convenience features of PHR and an IT system that allow
24/7 virtual access. A service culture is created to ensure that the patients enjoy
human interactions, as much as, they do those with the machines!!

A final archetype is highly specialized acute care called Ritzcare. This is a part of
health delivery that provides highly specialized, expensive, and precise service.
They perform certain surgeries. Protected by regulations and paid by the fed-
eral government, Ritzcare is considered a national resource. Ritzcare is passive
on RHS, offering only limited virtual care. Ritzcare focuses on the highest
specialty tools and technologies.

12 KNOWLEDGE INSIGHT ACTION

Employer/Payor

Finally, let us look at RHS of the future from the perspective of employers and
payors. We will look at two archetypes, a large, self insured employer and a
small/midsize one.

The large employer, Bigstack, is a self-insured firm that provides both chronic
disease management and health/fitness on site, relying on outside enterprises
only for catastrophic situations. Bigstack needs its employees to have mini-
mum catastrophic coverage and offers optional comprehensive coverage. The
on-job injuries are covered by Bigstack and incentives are provided to become
safe employees.

The strategy relies on having a very good IT system that supports PHR and
provides decision support to both HR and employees. Health coaches and sup-
port groups aid in chronic disease management. There is an on-site pharmacy,
vending machines, and kiosks for basic healthcare. A third party manages the
on-site healthcare under a franchise. The entire system is easy to use.

What is gone here are the long waits for doctor visits, diagnosis, and treatment.
Employees become more productive and receive better care faster. They are

13
 increasingly empowered for their own well being through cost sharing and
financial incentives. There is no co-pay for on-site treatment, but the cost of
being covered outside the facility goes up.

A smaller employer, Smallstack, would like to provide the same level of ser-
vice as the larger employers. They have opened up some space to create a retail
outlet for healthcare. Since they do not have the heft of a larger employer, this
service is open to others as well, making it a profit center. A third party franchi-
see runs it, providing disease management and wellness programs using RHS.
A rating system for healthcare and wellness services assists the firm in selecting
the right franchisee.

The employees of Smallstack receive catastrophic coverage, but have to pay for
everything else, probably through a Health Savings Account (HSA).Their sal-
ary is increased as compensation. This type of service makes the chronically ill
more vulnerable. Also, regulatory and legal issues need to be resolved to make
this a feasible approach.

This is what the RHS of the future will look like.

14 KNOWLEDGE INSIGHT ACTION

To summarize, in year 2016, there are people like Sam, the Certified Care Coor-
dinator, more of a customer service specialist than a clinician, who depends on a
whole host of other healthcare providers to take care of his patients. Then there
is Dr. Gupta, who handles a tremendous number of patients from her wired of-
fice, all thanks to RHS.

There are also Fastcare, Midhealth, Healthcall, Ritzcare…different types of

health delivery entities, each leveraging RHS to gain a position in the health
and healthcare value chain. The patients have multiple choices and, by giving
up a one-size fits all model, the health delivery system is able to provide better
service than in 2006, using fewer resources.

There are also companies like Bigstack and Smallstack, with the ability to ser-
vice numerous health and wellness issues right on-site. They are able to strike a
balance between the quality of care their employees receive and the burgeoning
cost of health insurance, thanks to the ability of RHS.

In addition Rosie, the wheelchair bound diabetic, and Barry the post MI pa-
tient, can live their lives more independently then they do now while receiving
the best care possible at a reasonable cost.

For this vision to be true, it has to make financial sense for all of the stakehold-
ers, among other things. In order to do a quick “pressure test,” we generated
ideas on various business models the key stakeholders could deploy.

Potential Business Models

Healthcare Provider

Sam the certified care provider could have his own independent practice, or
be an employee of a business (remember Bigstack?) or a physicians’ practice.
He can also be a franchisee. If independent, his customers will pay a subscrip-
tion, much as they do to a fitness trainer or diet franchise. Other sources of
revenue for Sam are retail revenue for devices and supplies, referral fees, and
sponsorship fees from OTC producers. He accepts medical care vouchers and
performance payment/bonus from the payors. He could also contract with
health plans, physician groups, home care agencies, or hospitals.

15
 Sam runs a for-profit operation that accepts private payment and offers a no
hassle service. He has low fixed costs and the variable costs depend on risk. He
obtains his customers from multi-level marketing.

There are several assumptions built into this model:

• Scope of practice can be articulated and regulated

• Certification program can be created (national?) and implemented

• Consumers accept the concept and the churn rate is low

• There are individuals (like Sam) with the requisite business, communica-
tions, and technology skills willing to undertake this type of profession

Such businesses can get started from many sources. For instance, nurse prac-
titioners at retail clinics could be the instigators. Existing consumer paid
health-related services could be the incubators. Legislation that gives Medicare
patients more control over spending money on health improvement, supported
by a campaign to educate the public on Telehealth, could provide a big boost.

16 KNOWLEDGE INSIGHT ACTION

For Dr. Gupta, the business model is somewhat different. She is a part of an
integrated healthcare system, which includes her, as a physician providing over-
sight, supported by NP, coach, PA, RN, medical technicians, and others. This
is to ensure that she can sustain her highly leveraged practice. She also needs
RHS providers. Perhaps a staffing company can source and train an overseas
provider to fit the bill.

Dr. Gupta’s primary revenue source is government entitlements and Medicare

vouchers. Given the leveraged model she is using, the revenue can be signifi-
cantly more than it would be otherwise. However, she also incurs substantial
cost in technology equipment (hardware and application software), staff train-
ing and recruitment, as well as, patient recruiting expenses. Perhaps she can
retain CMS or insurers to provide low cost capital (given that their costs will
go down because of deployment of RHS).

This model is predicated upon CMS expanding Medicare Advantage (special needs
plan) rather than cutting back, and having people like Dr. Gupta who are willing to
make an upfront investment in anticipation of increased revenue downstream.

This type of practice needs to be created from the ground up. Unless the pro-
cesses and network are designed to take advantage of technology, it will not work.
From the government’s perspective, developing and validating the risk versus
return investment in the Medicare risk plan will help, as will passing immigra-
tion reform to create an H1 program (merit based visa) for foreign doctors.

17
 Health Delivery System

Coming now to health delivery systems, let us talk about Midhealth, the large
multi-hospital system in Midwest.

Midhealth can make money by charging patients for enhanced service provided
through the use of RHS and focusing more on the chronic care patients rather
than those requiring acute care. The convenience of RHS may hook patients into
being long term customers and the family members may be willing to pay for the
advantage of not having to hospitalize an elderly family member. Other revenue
sources may be private label RHS products and services. Midhealth may be able
to reduce cost and/or increase its service level by regionally deploying tiered staff
and using an outsourced centralized center for data management.

All these benefits may not be sufficient to prevent RHS from initially being
a loss leader, to be covered under funds for demonstration projects. Also,
success of the business model depends on the patients seeing this as an added
value service for which they are willing to pay. They need to select hospitals
based on technology deployed rather than where doctors have relationships.
Additional assumptions are that the population is primarily insured and the
government regulations do not serve as a barrier to the deployment of RHS.

Midhealth can start the process of becoming an RHS empowered entity by

first having the enabling technology deployed (including integrating IT),
creating multi-level plans, and selling to select targets: Children of elderly
parents who need constant monitoring, baby boomers who may want such
service as a “life style” choice, and local employers.

Another potential business model for Midhealth is to create boutique RHS

centers (much like what Dr. Gupta is operating). These are pure retail centers
that attract patients by leveraging technology to provide low cost, high level
service. By networking with other components of the health delivery system
(e.g., ambulatory services), these centers offer a soup-to-nuts service. The
revenue sources are generated from the health system (for data/algorithms,
referral, marketing), the consumers (with some coverage by insurance), the
adult children of elderly folks (remote monitoring and making data available
to them), and other network providers (usage income).

18 KNOWLEDGE INSIGHT ACTION

The key assumptions in making this operation succeed are: there is consumer
demand for “Wal-Mart operations with a Nordstrom front,” the service fits into
the emerging network of health delivery operations, and it is able to operate 24/7.

Product/Service Vendor

The RHS will provide many opportunities for product and service vendors.
Let us take the example of a remote monitoring service provider. This vendor,
Highhealth Systems, provides health services through existing set top boxes for
consumers that require/want remote monitoring of their health. These are chroni-
cally ill people, post acute care patients, and those that are “worried well.” One can
subscribe to these services for a week, month or longer. A basic health channel is
created in co-operation with the cable company. This service fulfills a major need,
that of monitoring a patient’s compliance to a prescribed regime or therapy.

19
 The vendor can receive revenues from the healthcare providers, if they are the
ones who initiate the installation. If the service is able to achieve a higher level of
compliance, payors may be willing to contribute. Also, the worried well subscrib-
er may be willing to incur the cost himself, as long as the system allows him to stay
healthy. On the other side of the equation, the vendor may incur the cost for the
device, delivery, hardware and software support, and perhaps monetary incentives
to the patients. The devices would include remote monitoring instruments (smart
watches, rings, phones, etc.). Also, the ability to interpret data and recommend a
course of action based on the patient’s condition will have to be developed.

Employer

Bigstack, a large self-insured employer described above, can build a viable busi-
ness model for an RHS enabled on-site facility. A third party franchisee can
operate the facility. In exchange for the installed base of patients, the franchisee
will be asked to recruit people outside the firm to join and use the facility. That
way the cost will be reduced. Under this model, Bigstack gains because of im-
proved employee health, reduced cost, and reduced down time incurred when
employees travel to outside facilities. For employees, the convenience is hard to
beat. This way, everyone gains!

20 KNOWLEDGE INSIGHT ACTION

For this model to work, one needs to ensure that Stark (Physician Self-Refer-
ral) Regulation is not violated. Of course, the conjecture that the employees
will find this service desirable needs to be tested. It will probably take a highly
visible employer to say “I have had enough” about the healthcare costs and
establish such a facility. That would be the tipping point.

Payor

Finally, a payor, a typical health plan called Payum, can develop a business
model around RHS. Their members will be encouraged to use RHS and
reduce hospital visits. The members availing themselves of this option will be
offered incentives (coupons, premium discounts). Medication compliance and
reward for healthy behavior will generate a win-win situation. The focus will,
once again, be on members who are chronically ill. The question is what incen-
tives to provide the healthcare providers to use such model. Some revenue
sharing may be needed …“because this is a good thing” may not be enough.

Should Payum wait for CMS to make a move or be bold and move without
them? One option is to build and see!

21
 So, there are a lot of possibilities. RHS has the power to alter health and health-
care at a fundamental level, permitting the development of different business
models. However, the business models need to fit together. A cursory over-
view, as described above, has found that many pieces of this puzzle do indeed
fit. It appears that Sam and Dr. Gupta can live with Midhealth, Bigstack and
Payum. However, this needs to be examined further, not only from a stake-
holder alignment perspective, but also from the regulatory, liability, and policy
viewpoints. That is the topic of a future workshop!

So far we have been painting a picture of the future, what does RHS look like
in 2016 and how does it all work? We now need to look into how do we ar-
rive from here to there? What technologies, products, and services need to be
developed? What financial models need to come into place? What regulatory or
policy changes are required? When?

These are the questions addressed next.

Roadmap to the Future

An important element of any future scenario exercise is to see if there is a fea-
sible way to get to that future vision from where we are today. What will need
to happen in what time frame? Does it look reasonable?

Here are three roadmaps describing the timelines in technology, products/ser-

vices, and financial/regulatory/policy needed to achieve the vision outlined.

22 KNOWLEDGE INSIGHT ACTION

ROADMAP TO THE FUTURE — Technology

Higher speed, dependable
wireless broadband
(available everywhere),
broadband penetration 40%
Secure communication (as
in financial services), the
encryption penetration 15%
of video health
Mobile device/implant
pairing
PHR interoperable, links to
EMR and patient pays for it.
Patient portals
ER system fragmented
Connection to schools &
churches
Dicom- image: SNOMED,
ICD10, HL-7 (standards)
Video to the desktop
Ultra low power body area
network
Almost all telephones mobile
Asynchronous multi-media
mobile communications
Inexpensive high bandwidth
wireless applications
All applications web based
Fun software for adults
that focus on wellness and
compliance
Easily portable software for
mobile devices
Biometric access/
authentication
Reliable voice recognition in
widespread use
Commercial EMR companies
sell their tech on an ASP
basis to providers
The cell phone becomes the
portal for medical services
Privacy, security issues
resolved, encryption
penetration 40%
Increased safety allow better
penetration of HC technology
Wireless access of all
peripherals
Voice driven mobile-search
location enabled
User friendly interfaces
Smart wireless Band-aids
RHIO ED integration with
EMRs
32 frame/sec broadcast
quality video.
Complete (geographical) wireless
coverage with non-provider
dependent integration
Mobile UDED technology 1:many
Ubiquitous remote
physiologic sensing
Software as service
Closed loop insulin delivery
(artificial pancreas)
Technology interoperability of
different brands of devices
Hospital clinical information
systems are commoditized
Handheld based entry to PHR
Interoperable “searchable”
electronic health records”
Intelligent algorithms for
decision support

2006 2007 2008 2009 2010

Wireless high speed >100mbps wireless Virtual coach using Artificial pancreas Artificial intelligence Diabetes is cured
penetration reaches mobile broadband automated video linked wirelessly to systems either with closed loop
60-70% wireless Broadband access in software provider portal insulin or biological
Integration of consumer all homes 90% of patients replacement
electronic devices and Continua interoperability connected via PHR Heart disease is cured
wellness info into EMR moves into low cost through low cost
Integration of EMR and disposable home labs replacement or new
remote devices drug therapies
Potential applications
Patient centered PHR of nanotechnology, Integrated systems plug
such as imaging, are & play allowing creation
Data storage access of knowledge from data
authentication implemented
management PHR/EMR
adoption>40%
iPod access

2011 2012 2013 2014 2015 2016

23
 ROADMAP TO THE FUTURE — Products and Services

Video Kiosks for health Retail health centers in
services medical centers
Patient centered online Chain drug stores add medical
disease management clinics to all their stores in
program, adapt to order to increase number of
multiple disease states, customers
links to coach, health
Video telephone medical visits
education & positive by mobile phone
reinforcement.
Can buy different levels of
Separate glucose monitor
home monitoring.
and insulin pumps
Emergence of installers
and integrators for home
deployment of RHS
Location based
applications/services
HIPAA compliant quality
of service
“Smart appliances” for
the home
Cell phone based fitness
devices
Affordable devices with two
way communication capability
Formalized program for valet/
concierge medical services
Mobile specialist van for home
visits- hospital at home
Medicine vending machine at home
Continua begins to provide
telemedicine work site care.
Industry/provider joint ventures to
bring products to market
Managed health care partners with
retail clinics/outlets
Emergence of retail care
coordinator (weight watchers)
Community health workers for
chronic disease mgmt
(adoption 10%-15%)
Custom programmed vital signs
monitoring sensors to provide data
to web server
Smart mat for weight
Cell phone based medical devices
Voice recognition devices
Low cost sensors with built in
communication functions.
Data gathering to auto uploads to
analysis to synthesis to action
Consumer health
improvement franchises
like “Weight Watchers”
Peer to peer platforms
take off, communities and
patients advise patients
New businesses spring
up combining concierge
services and employee
health management
Miniaturized laboratory
testing
Integrated basic vital sign
devices are less than $100
in consumer outlets
Retail clinic proliferation
Radiology, lab medicine
and pathology mostly
done offshore to lower
cost
Expansion of personalized
medicine
Smart cigarettes
Sharing of technology
and products between
industries
Less contact vital sign
acquisition UWB/radar

2006 2007 2008 2009 2010

Personalized medicine 40% adoption Patient becomes Acceptance and 10 terahertz iPod video Personalized medical
prescriptions of Telemedicine PCP. Primary care implementation of phones under $200 “iPod”
More than 40% (synchronous or goes away, physician international nurse Wildcard: stem cell
of stroke care via asynchronous) specialty replaced by call centers therapy
Telehealth from Primary care based networks/teams of
designated Stroke community health health extenders
Centers workers Continuous glucose
Care coordinator Continuous video meters with activity
supplants physician as monitoring at home tracker
lead contact Homes sold with Continua announces
Wildcard: gene eMonitoring devices in the shipment of the one
replacement walls, appliances millionth interoperable
device
Sub clinical airway Invisible mini monitors/
resistance monitor sensors Idiot proof devices that
self repair
Left ventricular end Basic lab devices for
diastolic pressure home use are sold Pharmaceutical patch
sensor on implantable below $100 in retail and other delivery
device. broadcasts outlets devices
wirelessly to decision Implant drug delivery
algorithm systems

2011 2012 2013 2014 2015

24 KNOWLEDGE INSIGHT ACTION

ROADMAP TO THE FUTURE — Financial/Regulatory/Policy

$84 trillion unfunded Invest: $ for innovation
liability in Medicare programs -initiative
Medicare parts A, Deployment of services for
B, D provide limited (1) demand management
coverage for RHS (2) demand enhancement
system.
Employer onsite
physician for employees Employer drives to new
and their families technology because of
Open listed food financial reasons
ingredients Insurance coverage
that provides patient
incentives for improved
health – Points for Health,
discounts, MSA, etc.
Resource regulation
for NHII is provided by
legislation
FCC telecom act reopened
Evidence based care
protocols
Dissemination of
knowledge education
related to technology
Health coach curriculum,
under development
HSA/ HRAs on universally
accepted debit/credit cards.
FSA/ HSA health information
authentication leading to
secured transactions
GM files for chapter 11
blaming healthcare costs
Reimbursement model
conducive
Various models to choose
from: levels of complete
coverage and catastrophic
Employees increasingly held
accountable for health and
expenses
Active lobbying for
de-regulation
Outlaw trans fats
Medical device standard-
Continua
Closed loop systems
approval
Culture change of clinicians
to obtain buy-in
Happiness and positive
lifestyle training, yoga,
education training, organic/
vegetarian
Education directed to payors
Government investment in
rural EMR
Mobile virtual cash transactions
Mobile banking
CMS initiates a parallel program of
P4P for patients
Medicare standards for pay for
performance
Medicaid reimburse patient/
provider for their savings from
avoiding transportation costs to HC
facilities
Equivalency of virtual and in person
encounter
CMS demos produce positive
results on the RHS disease
management trials
Employers abandon paid health
benefit for HSAs
Accepted “standards of care” for
various chronic diseases
Standardization of electronic
devices
The FCC uses the universal service
fund to deploy broadband networks
in all states
Certification program created/
designed for “health coach”
Nursing/PA/MD training in next
generation technologies.
National and universal coverage
CMS requires all providers
to have EMR or that are not
reimbursed
Home bound status is no longer
required by CMS + payor
Third party payors pay for
devices
CMS payments for eHealth
widespread
Care coordination reimbursement
takes off
Major payors supporting online
disease mgmt.
CMS moves from demonstrations
to risk based reimbursement. For
chronic care, P4P
Incentives move from treatment
to prevention – e.g. Medicaid
/Medicare vouchers for health
improvement services
Employers offer RHS but pushes
cost to employee, baby boomer
demand/ lobbying
Multi-state licensure simplified
Critical mass of Medicare special
needs plans
Medical specialty support
through visionary leadership
Fast track ACGME/RRC program
requirement

2006 2007 2008 2009 2010

Medicare sponsored HSA’s
More rigid evidence based on
cost effectiveness analysis
of existing and new products
and processes
Opening of H1 visas to
foreign doctors
First boomers turn 65
Replacement of credentialing
based on training only by
requiring demonstrated and
verified competence
New training for PCPs
(technology, business
management )
Widespread consumer demand and direct payment Medicare modernization act Open borders -Rx National medical
Critical mass of health savings account of 2012 locks in P4P, SNP’s licensure
and gives consumers more
State system contract for care management control over spending $
Healthcare is 20% of GDP Increase public pay for RHS
Medicare officially bankrupt Employer not responsible
State mandates for universal coverage reaches for employee health
critical mass coverage
Low income coverage paid by the government
Small co-pay for all services
Wide spread public and private converge of RHS
Provider payment aligned to spread of adoption
All patients given true costs of care
Payment for virtual visit extensive
FCC telecom act closed

2011 2012 2013 2014 2015

25
 Closing
This report summarizes the results of a workshop on Future of Remote Health
Services jointly sponsored by the Monitor Group and HealthTech. It describes
a scenario of Remote Health Services in the year 2016, and what it will look
like from the perspectives of the various stakeholders. This scenario is tested by
examining if there are potential business models that would make the stake-
holders behave in the way we have postulated, and if there is a roadmap for
arriving there from here. These are prerequisite steps in an attempt to decide
what opportunities are going to be created by RHS, what risks will be posed,
and what should the strategy be to manage both.

The scenario described here is an optimistic one and it makes sense; the parts
seem to fit together. That is the good news. There is no real bad news but a
word of caution. There are many challenges that need to be overcome before
the bold predictions of the roadmap come to pass, and the future scenario be-
comes a reality. Here are some of them:

• We still do not have a good handle on patient experience and acceptance.

How will we drive the cultural shift? How can we establish a living labo-
ratory? (Can a wired hotel be a living laboratory, for instance?)

• We need leadership…we have too many parties working independently.

Who will lead? Government? Employers? Empowered consumers?

• We need to create public awareness and acceptance regarding RHS. We

need real world examples…real patients, real testimonials. We need edu-
cation, even for the healthcare community, let alone the consumers. (Is
the anti-smoking campaign a good model for promoting the new value
proposition?)

• How do we cross the chasm from the innovators to the majority users?

• How do we enable, encourage, and entice the healthcare industry to

reach out and partner across other industries? The emerging vision can
not be accomplished just by the usual suspects. The North American
healthcare industry needs to work with many other entities. These in-

26 KNOWLEDGE INSIGHT ACTION

 clude, on the one hand, healthcare communities around the world, and
on the other hand, firms such as those involved in IT/telecommunica-
tions/computer HW/SW.

It is the responsibility of a diverse group like the one we convened for the
workshop to make things happen and to move forward. “Who else is going to
try it?” We all concur that RHS will play a critical role in the future of health
and healthcare, but we need commitment and accountability. We need to move
quickly…try out a few models and receive feedback.

Now is the time.

Many thanks to all the workshop participants who

contributed to the ideas in this paper:
Speranza Avram, Richard Bakalar, Benton Baker, Nicole Barnett, David Bass,
Nancy Bitting, Ashok B. Boghani, Steve Brown, Laurie Bubby,
Rhonda Chetney, Steve DeMello, Matthew Deveney, Hank Fanberg, Jenna
Fischer, Naomi Fried, Jim Fulkerson, William Halverson, Nancy Harrison,
Ateret Haselkorn, John Haughom, Beverly Jones, Don Jones, Joseph Kvedar,
Sebastiaan la Bastide, Michael Magliaro, Colin McKee, Horst Merkle, Wayne
Mills, Chris O’Connor, Randy O’Steen, George Panigiotopoulos,
Cynthia Perazzo, Mario Quintanilla, Ken Riff, Patti Runyan, Jay Sanders,
David Sandrich, Mary Kate Scott, Bob Spencer, Michael Ward, Don Weissman,
Dave Whitlinger, Nancy Wright, Scott Young, and Rick Zall.

Additional thanks to: Julia Frenkle, Karen Long, Maria Taborszki, and the staff at
HealthTech for their help in converting the workshop output into a paper.

27
28 KNOWLEDGE INSIGHT ACTION
monitor group
KNOWLEDGE INSIGHT ACTION

Monitor Group For more information, please visit: or contact:

Two Canal Park www.monitor.com Nicole Friel
Cambridge, MA 02141 617-252-2197
617-252-2000 nicole_friel@monitor.com