Jonathan Linkous, CEO, American Telemedicine Association

(Music)

Mark Masselli: This is Conversations on Health Care. I am Mark Masselli.

Margaret Flinter: And I am Margaret Flinter.

Mark Masselli: Well Margaret, there was quite a firestorm last week over the
Susan G. Komen Foundation decision to pull funding for Planned Parenthood.
That announcement from the world’s largest organization dedicated to breast
cancer research really created a backlash across our society.

Margaret Flinter: It was amazing actually to see this become absolutely front and
center on the national stage and show just how much people care about these
issues. Social media played a large role I think in this national response but it
was all about the Susan G. Komen leadership announcing that they would
change their policies and withdraw financial support to any organization that was
under Congressional investigation. Unfortunately, they didn’t apply that policy
uniformly. The Komen leadership insisted that the move was not politically
motivated to appease their conservative supporters. But in the face of that
remarkable public outcry they reversed their decision, apologized for the
controversy, and I understand one of their lead strategists of that policy has just
stepped out.

Mark Masselli: Let’s hope these two organizations who do just such great work
for women’s health will now be able to continue their work in partnership and that
we can all move forward.

Margaret Flinter: Moving beyond the national scene to the global health front,
there was a joint announcement last week that may have a significant impact on
suffering around the world, a collaboration has been formed between the World
Health Organization, the Bill and Melinda Gates Foundation, a number of
countries, groups like the Lions Club and some of the big pharma companies all
with a single goal to eradicate 10 what they call neglected tropical diseases that
afflict millions in the Third World and have a profound impact on people’s ability
to survive and thrive in their home communities.

Mark Masselli: These conditions are very treatable with the right medications but
because these diseases like leprosy are not health concerns outside the Third
World there is very little political incentive for drug companies to tackle these 10
conditions.

Margaret Flinter: And Mark, we have been seeing for a while now that some of
these major investments by foundations, and certainly Bill and Melinda Gates is
one of them, may be able to do what NGOs and government have not been able
to do. They are pulling $800 million including a large commitment to the drugs

that are necessary to actually wipe out, not just reduce but wipe out targeted
illnesses the way we have approached smallpox in the world to allow people to
live productive healthy lives. And it seems it does take this kind of collaboration
beyond the NGOs and government to tackle these really big global health issues.

Mark Masselli: Well I am glad they are doing it. And one trend that is changing
the face of global health as well as health here in America is telemedicine,
medicine being delivered and engaged electronically, via digital technology like
smartphones or iPads and the Internet. Our guest today is the Cofounder and
CEO of the American Telemedicine Association.

Margaret Flinter: Jonathan Linkous has been analyzed in the world of
telemedicine since way back in the early 1990s, way ahead of the technology
explosion that has allowed so many of those early expectations to go from kind of
far fetched ideas to really pretty commonplace in health care today.

Mark Masselli: He will talk about some of the exciting new advances in mobile
health and telemedicine that have the potential to revolutionize how quality care
is delivered and how patients will become more empowered in their own health
outcomes through the use of this technology.

Margaret Flinter: Mr. Linkous will be discussing everything from the proliferation
of thousands of medical apps to the remote robotic medicine of the future. But
no matter what the story, you can find all of our shows and hear more about us
by Googling www.chcradio.com .

Mark Masselli: And as always, if you have feedback, e-mail us at
www.chcradio.com we would love to hear from you. Coming up our
conversations with Jonathan Linkous but first, here is our producer Marianne
O’Hare with this week’s Headline News.

(Music)

Marianne O’Hare: I am Marianne O’Hare with today’s Headline News. The
fallout continues from Susan G. Komen Foundation Planned Parenthood
Debacle last week in which the world’s largest breast cancer research
organization announced it was withdrawing its financial support to long time
partner and (04:00 inaudible) Planned Parenthood later reversing the decision
after a huge public outcry. Now the person thought to be responsible for the
withdrawal of support VP of Policy of Komen, Karen Handel resigned yesterday.
Since joining Komen in 2011, she has been strongly supportive of cutting off
funds to Planned Parenthood because of its abortion policies. Handel continues
to deny that the funding move was political in nature. Komen Foundation
leadership saying this week, they are learning from their mistakes.

The growth of telemedicine has some roadblocks to expansion chief among them
being the inability of doctors licensed to practice in one state being able to treat a
patient across state lines. New Mexico Senator Tom Udall is crafting a bill that
would address that issue. The bill would streamline licensure portability to make
it easier for doctors to practice in more than one state. The bill would create a
unified set of licensure data that would allow physicians to sign up for a national
license. Opponents of the measure including the Federation of State Medical
Boards worry it will undermine oversight and a state’s right to censor bad
practices. The bill is expected to be presented in April.

The FDA is revising its recommendations on administering vaccinations for the
HPV virus or Human Papillomavirus which has been recommended for
preadolescent girls since 2006. The virus is largely responsible for cervical
cancer. But recent studies also show a link between the virus and head and
neck cancers as well. They are now recommending the vaccine for all
preadolescent boys and catch-up vaccines for 30 to 21 year old males moving
forward. I am Marianne O’Hare with this Headline News.

(Music)

Mark Masselli: Today, Margaret and I are speaking with Jonathan Linkous, Chief
Executive Officer of the American Telemedicine Association, the largest global
non-profit organization dedicated to fully integrating telemedicine into
transformed health care systems to improve quality and affordability of health
care throughout the world. Mr. Linkous, welcome to Conversations on Health
Care.

Jonathan Linkous: Glad to be here, thank you.

Mark Masselli: Jon, you are a veteran in the field of telemedicine policy
development and you launched the American Telemedicine Association back in
1993 way ahead of the technology curve. Now with the explosion of technology
applications I imagine you are seeing applications in place that you could have
st
only imagined 20 years ago. Tell us about telemedicine in the 21 century and
how is it different from what you envisioned years ago?

Jonathan Linkous: It is certainly different, we always said, I said in 1993 that the
implementation of telemedicine around the country is just around the corner and
it was a much bigger corner than I thought. But it is not only more widespread
but it is very different than we had anticipated back in ’93.

Telemedicine was largely a big video conferencing box and people thought of it
as something that a large hospital could use to see a patient in a rural area
occasionally and the used this high fangled high cost technology called video
conferencing and now it’s everything from handheld mobile devices to data

streams to imaging and everything in between. It’s becoming so ubiquitous it’s a
great part of life these days.

Margaret Flinter: Jon, you recently wrote about the seven biggest trends in
telemedicine that we are likely to see in 2012 and I would like to ask you if you
could maybe focus on two of them, you could pick any two. But the two I would
ask you to focus on, one that addressed cost, the shift away from fee-for-service
reimbursement as a trend and the second, telemedicine actually becoming the
standard of care in some clinical areas. Tell us about these trends and how soon
do you think they go from trend to accepted normal practice.

Jonathan Linkous: Well, the traditional way we all get paid of course is fee-for-
service. Now in terms of physicians or other health providers, they submit a bill
to the insurance company, have a little code on it called a CPT code or couple
different types of codes and they get paid according to that service. And the
problem with that system and the fee-for-service system is the more times you
see the doctor the more he is going to get paid. There is lot of incentive for
doctors to see the patients more and more often and do a lot of other types of
activities that all generate revenue. This subtle shift away from fee-for-service to
managed care or capitated care or other types of medical homes, different ways
of calling it but a different way of paying for it, you are paying for the health of the
person rather than for the service delivered each time. It’s a radical change
probably more of a change in our health care system than anything else that’s
going on because it changes the perspective. You are no longer eager to see a
patient come in to provide a service to them, to bill for it, you are eager to have
your patient get well. They are on their own in some ways to figure out the best
way to provide care for that patient, to make sure the patient is well and gets
better as they are supposed to do. And that means for telemedicine we are
shifting away from having to fight these battles with the folks in terms of is this an
allowable cost, is this an appropriate technology, it’s now to the providers who
really should be making the decision.

Mark Masselli: Let me pull the thread a little on that. You see telemedicine
providing an opportunity for tremendous new growth on the business side of
health care and one of those areas will be the rise of the independent remote
clinical enterprises. It’s already being done successfully in certain disciplines like
teleradiology and patient scans and x-rays are being analyzed by clinicians in
other locations. What are some of the other promising growth areas that will not
only provide better patient service through telemedicine but offer new business
models for health care industry as well?

Jonathan Linkous: Couple of examples, stroke care. There are so many
emergency medical rooms are in existence around the country that don’t have a
trained neurologist on staff but when you come in, someone comes in with a
stroke it’s really important to identify what type of stroke it is and identify what is
the appropriate action to take whether it’s administering a drug or other types of

medications. You need a neurologist make those assessments and if you don’t
have one on staff, you are up to the guess of someone who is maybe a very
competent physician but not one who is trained in neurology. The work of
telemedicine and tele-stroke care or tele-neurology allows all emergency rooms
to have access to a shared neurologist who can see the patient at the time they
come in. This has been around for about five or 10 years. There are hundreds
of stories of people whose lives have been changed. Lives have been saved
because they have had a very simple activity in emergency room where they can
hook them up to a neurologist.

The same type of thing is being done with intensive care units. The hospitals
around the country now, their ICUs are being looked at by an intensivist,
someone who is trained in the study of taking care of patients who are in the ICU.
Studies by several major groups including Leapfrog which is a national group of
employer healthcare providers, and others, have said that if you use intensivist,
the outcomes for patients in the intensive care unit dramatically change, their
chances of survival and their chances of a good outcome are dramatically better.
But not every hospital can afford an intensivist or not everyone can afford an
intensivist 24X7. Not surprisingly, a lot of hospitals, even all the major hospitals
in the country are now moving to share intensivist among a number of facilities.
All of these sharing a specialist is not only cost efficient but it makes a real
difference in patients’ lives and that’s what we are really talking about with
telemedicine.

Margaret Flinter: Jon, when we interview folks like yourself that really have their
finger on the pulse of these innovations I am often struck by what a gap there
seems to be between sort of the general public’s awareness of what's going on
with these innovations and the tremendous progress that’s being made in
another area, the increasing emergence of robotics as part of medicine and as
part of telemedicine. So where robotic surgery has become pretty commonplace
in hospitals, we are also seeing some success using robotics in other areas as
part of telemedicine and particularly in people’s homes. Where do you see
robotics fitting into telemedicine beyond the operating room and how deep is the
research on their effectiveness and achieving the kinds of outcomes we would
like to see?

Jonathan Linkous: I think in the next five years I think we will see a dramatic
change in that area and people’s lives will be changed as a result of that as well.
When I first started in telemedicine this idea of robotic surgery was just being
experimented with. And in the speeches I would give I would say, well sometime
in our lifetime maybe we will have some of this actually deployed in some
hospital. Well as you know, hundreds and hundreds of hospitals around the
country are using robotic surgery all the time. Now there are robots where a
physician can go grand rounds, can see patients in multiples places even though
he is at home or she is at home or in some other location. They use a portable
robot that moves down the hall and has their picture in the frame and they are

seeing a patient on the bedside and they turn to go to the next bedside. We are
seeing robots that are used in ambulances to provide instant care to people on
their way to the hospital. Surprising to me most of them out-of-the-box have
been pretty cost effective. It's a type of technology that’s still new, still being
developed. Some of the robot companies that are working on things like
cleaning your rug, there is a company that does that with a little robot, some of
them are being used in health care field as well now. So we are seeing a lot of
integration among different types of robotics and I think you are right, I think
that’s going to be moving into the home in a much bigger way in the next couple
of years. We already have remote vital sign monitoring in the home that’s
becoming pretty standard in a lot of cases particularly people with chronic care.
So I think it's only a matter of time that we are going to have other types of
robotics that will move quickly into every place we are located.

Mark Masselli: Today, we are speaking with Jonathan LInkous, CEO of the
American Telemedicine Association. Jonathan, the ATA is advising Congress, the
administration and numerous organizations domestically and globally on policies
that will promote the integration of telemedicine into health care systems. In fact,
you predict the advances being made in telemedicine technologies are going to
make health care a globally integrated business. What does globalization mean
for a typical practice or a patient here at home?

Jonathan Linkous: I think the globalization is already here in many ways. For
example, in radiology, almost every hospital now in United States now uses
teleradiology. And increasingly the radiologist doesn’t have to be located not only
in the hospital, not necessarily in the same community, not even in this country.
If you were in the hospital in Billings Montana in the middle of the night and you
have a broken leg and you have x-ray being done and it’s 03:00 in the morning
and you don’t have a radiologist there, a group of radiologists in Sydney,
Australia will do the read.

Mark Masselli: I should note on that that they still need the state license, the
state license is still trumping globalization.

Jonathan Linkous: Absolutely. Every physician that’s involved in this providing
care to patients in United States must be fully licensed and if they are in a
hospital, credential and privileged in that hospital, that’s beyond doubt. But
United States is not only receiving care from physicians outside, we are providing
care to other countries. Now this has been going on for a long time. In the
Middle East, there are several companies that are providing not only radiology
services but a variety of medical services. Typically, United States has been the
source of providing medical services to people around the globe who have come
here, traveled here to get medical services but now we are being able to export
our expertise around the world and obviously other countries could provide here
as well.

Margaret Flinter: Jon, you have I am sure seen literally thousands of tech
gadgets and applications come and go in your years and I like the term the gold
st
rush that you referred to of the 21 century with all the products that are being
rushed into development and you also make the seasoned comment that a lot of
them won’t make it into the mainstream health care marketplace. But what will
characterize the winners?

Jonathan Linkous: Well I think for many parts of telemedicine we are still at the
top of the hype cycle and if you are familiar with that the next step is the trial of
disillusionment. Now unfortunately, we are going to be there with some of these
and there is going to be some products that seem wonderful but will fall off the
landscape. Largely, the innovators in telemedicine include a variety of
technology firms and experts and various types of telecommunications or
technologies but you have got to be aware of the health care market. Health
care payment systems as you well know are very different from buying something
at a retail store. I think the products and the services that are aware of the way
that health care is provided and can seamlessly integrate themselves into the
delivery of care are the ones that are going to make it. The role of the
government is in variety of areas from regulation of devices through the Food
and Drug Administration to payment of services through Medicare. And just the
general consensus of where we are going in terms of health care and medicine
even the state medical boards and various activities that are functioning in terms
of the Federal Trade Commission all of these are going to be playing a role in
terms of shaping the health care delivery system of the future.

Mark Masselli: You know another area that’s going to shape the growth of all this
technology and there is a real explosion out there but it seems to be one of the
Achilles’ Heel might be around intellectual property and patterns for certain tech
applications that could ostensibly make developers lot of money and there is
nothing wrong with that but how do we balance the rights of the inventors with
the underlying goals of promoting science and better health for the general
population?

Jonathan Linkous: Well you have put your finger on something that’s an
emerging issue and concern in telemedicine. There has been a variety of folks
out there who have decided they would get a patent on something as very
fundamental as seeing a patient on a video conference, not different from a lot of
emerging industries where you have this. And we are going through that period
of figuring out the intellectual property and who owns it and what makes sense to
move for the industry. But yes, we do have that concern right now because there
are people who have got great inventions and they need to be protected. On the
other hand, there is a lot of telemedicine that is growing and we need to have the
innovation continue without being fettered with someone getting a patent that’s a
global patent and trying to enforce it by really just cherry picking off of the market
that’s out there now.

Margaret Flinter: Jon, I am a big fan of telemedicine as a great strategy to
eliminate waste and waits and delays in connecting patients especially patients
seen in primary care with specialists and other services. But I have to tell you
those barriers are pretty formidable. Mark referenced the issue of a state like the
one that we are based in that requires that the provider making a diagnosis
radiologically hold a license to practice in the state but another one is just that the
variation between the states and Medicaid in particular which makes up its mind
on a state-to-state basis about the services it will cover is going to cover
telemedicine. So you have got enormous challenge in front of I would think in
terms of bringing some standardization and while each state is its own both
laboratory for innovation and its own set of laws and regulations. What are you
doing as an organization to try and get some consistency across the states so it
can really make telemedicine efficient? So maybe you can just comment on what
you are working on nationally.

Jonathan Linkous: Well you know diseases don’t pay attention to state
boundaries and actually the practice of medicine doesn’t really pay attention to
state boundaries. Every physician is granted an MD using the exact same test
around the country. There has to be a lot more interaction among medical
institutions, physicians and patients no matter where they are located. If you are
in upstate New York why can't you see a specialist who happens to be in Atlanta
if that’s the best way of getting you care and also the more efficient way. Why
would you have to hop on a plane to go down and see him if you can get the care
there? So all of these things are a big challenge you are right. We are working
with Congress to look at legislation. We are working with the states to try to look
at various ways of providing reciprocity. Certainly there are differences in the
way not only physicians and other health care providers are licensed but also
how you view the practice of medicine. I think there is a lot of education that
needs to done in terms of what is available now. I think a lot of the state
regulators need to listen to their kids, what they are doing. There is just so much
available now. And it's a big fight but I am very confident.

Mark Masselli: Speaking about listening to our kids certainly you would have to
be thinking about mobile health and smartphones and talk to us a little bit about
the difference between mHealth and telemedicine. Certainly telemedicine is one-
to-one relationship between the patient and the doctor and mHealth seems to be
one-to-many but how would you describe it in what are you doing as you move
into that new arena?

Jonathan Linkous: Well mHealth is the latest craze in what I consider just really
a component of telemedicine because the telemedicine is just providing health
care remotely using telecommunications and if it’s a handheld device or if it’s a
wired device to your desktop it doesn’t really matter. Now mHealth is allowing
types of services that we couldn’t provide before but it's all part of a continuum of
providing remote health care. So it's a great new way of allowing people to have
access to health information, to have access to their physicians to send in vital

signs not just home based but work based, when you are on the subway based,
anywhere you happen to be. But the real challenge for mHealth as for other
technologies is to fit into the health care system. Now there is a lot of
misperceptions among mHealth that it can be a consumer device that works
almost outside of what you are doing when you see the doctor or going outside of
the hospital and certainly it frees people, it empowers the consumer in many
ways but you still have to somehow figure out how this fits into the overall system
of getting health care. And so many applications that we see, I have been in
telemedicine for 20-30 years are now just using handheld devices as another
way of providing the care.

Margaret Flinter: Jon, we like to ask all of our guests this one final question.
When you look around the country and the world what do you see in terms of
innovation and who should our listeners at Conversations be keeping an eye on?

Jonathan Linkous: Certainly, the academic medical centers here are all
experimenting with different approaches. But I think we are seeing in the Silicon
Valley area and some of the technology companies that have led the way in the
telecommunications world and consumer health are starting to get into this area
as well and so I think we are going to see applications that come out of very, very
different places, retail outlets, I think we are going to see entertainment industry
get involved in the health care world. I think there is a lot of different ways that
surprise me everyday in terms of where to turn for the next innovation.

Mark Masselli: Today, we have been speaking with Jonathan Linkous, CEO of
the American Telemedicine Association. Thank you so much for joining us today.

Jonathan Linkous: Thank you.

Margaret Flinter: Each week Conversations highlights a bright idea about how to
make wellness a part of our communities and everyday lives.

Mark Masselli: One of the directives of the Obama Administration’s Health Care
Reform Act requires pediatricians and health insurers to begin screening kids for
obesity, a condition afflicting one in three American children, the problem what to
do with those children who are identified as being overweight or obese. It's tough
enough for adults to lose weight even with multiple programs at their disposal.
There are relatively few programs available to overweight children and their
families that aren’t expensive or hospital based. UnitedHealthcare has teamed
up with the YMCA to create a program for community-based weight loss sessions
for kids and teens launching the pilot program in Providence, Rhode Island. The
kids accompanied by a parent joined in a group session that are fun but also
informative. Kids are educated about the calorie counts of food, learn about
Body Mass Index and the importance of exercise on a daily basis. At the end of
the 16 week program, the overweight kids lost an average of 3.5% of their body
fat and the bonus, the parents and the rest of the family often lost weight too.

The pilot program is inexpensive, kid-directed and life changing. And with follow-
up as part of the program, these kids know they will still be challenged to keep up
with healthy lifestyle changes. Helping kids tackle obesity cheaply and in a
community setting that works for kids and their families, now that’s a bright idea.

Margaret Flinter: This is Conversations on Health Care. I am Margaret Flinter.

Mark Masselli: And I am Mark Masselli, peace and health.

Conversations on Health Care, broadcast from the campus of Wesleyan
University at WESU, streaming live at www.wesufm.org and brought to you by
the Community Health Center.