## The Nightmare of Extracting and Interpreting Blood Pressure Data

Medical record data is full of hidden gotchas that a data professional can stumble into. My favorite example is Blood Pressure.

What Is Blood Pressure?

Blood Pressure is a measurement of force exerted by the heart on blood in order to move it through the body. It is a key indicator of heart health, made up of two measurements: Systolic Pressure (the pressure inside your blood vessels when your heart beats) and Diastolic Pressure (the pressure inside your blood vessels when your heart rests between beats). In its informative form, Blood Pressure is displayed to clinicians like this:

Systolic Blood Pressure / Diastolic Blood Pressure

To the untrained eye, this looks like a division math problem from elementary school. This string is an analyst’s nightmare!

• Do you take the top number and divide it by the bottom number, and utilize the quotient as the numeric representation of blood pressure?
• Can you consider Systolic or Diastolic Pressure numbers independently?
• If I clean this data by removing punctuation, I am left with one 5-6 digit integer. Can I use that?

Needless to say, it is confusing if you do not know much about medical data.

In What Way Is This Data Made Useful?

To help make this data more actionable, these two numbers are compared against reference ranges, sometimes stratified by age and gender. An elevated number for either reading can flag the whole blood pressure reading for a clinician, but a single normal reading does not indicate healthy blood pressure overall. The AMA guidelines for example:

This diagram sheds light into the utility of the two values independently. In SQL terms, our logic for categorizing and color-flagging blood pressure would look like this:

These are some analytic complexities when making blood pressure data actionable and useful, but let’s take it a step further and consider how we might see this data inside the underlying EMR data source.

How Do We See This Data Stored?

While a Blood Pressure reading’s useful form is as a string containing both systolic and diastolic readings, LOINC standards (LOINC Code 55284-4) note that it is inadvisable to report two observations in one record. Systems instead capture the data as two different integer readings, Systolic Blood Pressure (LOINC Code 8480-6) and Diastolic Blood Pressure (LOINC Code 8462-4). Now we know that the data tends to be stored as numbers, which should make an analyst jump for joy. This isn’t the whole story though.

Here are two common table structures modeled from EMR databases, both capturing vital readings:

System 1

System 2

Does anything pop out at you? These examples highlight a common EMR design trend for vitals data; it is not attributed its own primary key. Instead, it is logged in association with its encounter. Vital data is considered a subset of encounter information, rather than its own health data entity in and of itself. This introduces the concept of a vital set, which is the vital readings your doctor tends to do every time you visit (Height, Weight, Blood Pressure, O2 Saturation, Temperature, etc.). The vital set captures a specific set of vital readings, and allows for capture of 1 and only 1 reading per type.

Consider the Tilt Table Test, who’s data is recorded in the table examples above. During this test, a person lies on a table that rotates from vertical to horizontal. Their blood pressure is recorded at the supine position, then immediately monitored for the next minute once the table is rotated to the vertical position.

How would a system capture this information? System 1 creates a second vital set for the additional blood pressure reading. This approach allows the systolic and diastolic pair to remain closely associated to each other, but its association with other vital data captured during that encounter is now at the encounter level rather than vital set level. System 2 is in a long format and simply tacks on a new row. This model accounts for additional readings more fluidly, but the systolic and diastolic pair are not linked as closely. EncounterID, VitalTime, VitalPosition and any other columns available would need to be employed in order to make a systolic/diastolic link with confidence.

How Do We Match Vital Readings Together?

Now we see that while blood pressure data is most informative as a vital data pair, source systems do not store this data in its systolic/diastolic form. We as engineers need to come up with ways to confidently pair systolic and diastolic pressure readings when extracting this information from source systems.

Beyond pairing Blood Pressure data together, further complexity is introduced when considering that reference ranges for vital data are dictated by other patient information such as age, gender, or sometimes even from other vital data such as height or weight. Consider BMI, which is a calculated value from both height and weight. We may not expect height to change during the course of a visit, but we can reasonably expect weight to. This means that we have to account for the possibility that we will have as many calculated BMI values from a single encounter as there are weight measurements.

Medical data is a reflection of human health, thus mirroring its complexity in form and utility. We at Hart have come up with methods for extracting vital data as its own health data entity rather than as a child of an encounter, and pair it with other pieces of information to make it actionable for a clinician when viewed on the Compass Platform. Our knowledge of potential health data complexities, which can only be gained from deep experience with medical information, aids us in navigating every new source system we come across.

## Why Healthcare Should Look To Other Industries For Answers

True or false? There are no two similar snow flakes. (keep reading to find the answer)

Healthcare is a rewarding field to work in, our work directly effects lives and families. It is very easy to trace your work in healthcare and see how it improves others lives.

However when it comes to technology we often try to think that our own solutions are unique and can’t be addressed by any other means. While it is true we have very unique circumstances in healthcare from how we use data to how we input it to the uniqueness of each client and system, the reality is we can learn from other industries to solve 90% of our own technology shortcomings, the last 10% is what make healthcare rewarding.

## It has been done before

The fact of the matter is most challenges in healthcare IT have been seen before in other industries and those industries came out with solutions to address them. Here are just a few examples:

• Interfaces: In healthcare we got more interfaces than you can shake a stick at, and the other industries have responded with APIs, yes they don’t solve for every data type but it solves for a standard structure we can work with, that is half the battle
• Data Storage: We have lots of data, especially lab data, and in other industries the answer for this created Hadoop and a file store meant to handle large amounts of data (think Facebook)
• Software: In healthcare we still largely rely on one or two systems to run our workflows, in other industries this has ben decentralized and they are able to use the best of breed software for each scenario while still keeping data in sync, all the systems work in harmony together
• Architecture: In healthcare we still rely on a point to point rather than a Service Oriented Architecture which promotes the ability to be able to scale software and data as well as make it readily available much faster

## Learning from others mistakes

The best part about looking to other industries is not really about finding solutions it is more actually about finding out what their mistakes were.

See we are unique in healthcare and we will have different things to overcome than say another industry but the mistakes are more valuable than the success they had.

The mistakes can help us see our own pitfalls as we design and build systems so that five years later we are not stuck by our own decisions.

This allows us to make solutions that address challenges and not solutions trying to find challenges.

## Creative ideas to solve simple challenges

Some of the most heavily relied on technologies today (think: Hadoop, React, Cassandra, Node, etc..) were actually built to solve real-world challenges. In the business world sometimes we end up building software and then find a challenge it solves; however for software engineers this is rarely the case.

You see software engineers 99% of the time build software to ADDRESS a challenge, not because they are trying to find one. Which leads almost every innovation to creating a solution that addresses those challenges.

For instance Oracle database was sold on a business level before it was engineered however engineering had to create relational databases to solve their own challenge.

This leaves a trail of creative ideas that we can learn from.

## We are not unique and where we are

The answer to our trivia question earlier is: False. In 1988 Nancy Knight (USA), a scientist at the National Center for Atmosphere Research in Boulder, Colorado, USA, found two similar snowflakes.

If snowflakes can have identical then perhaps in healthcare there are similarities and lessons we can learn from other industries. Not just in software but also in business and operations.

We often diminish engineers in healthcare as not understanding our business and tell them to first shadow doctors and work in the system before trying to come up with solutions; the same should also hold true for doctors and those who work in healthcare, this is not the only way to solve a challenge, we must look into other industries.

## Your Analytics Software Is Creating Another Silo

In healthcare the current hottest trend we see is analytics software that seems to have the promise to do it all. Often times Integration Engines, HIEs and Population Health Management is also thrown into the mix to confuse things even more. Regardless of which you are looking at, we are going to call these “Analytics” software.

Don’t get us wrong we are not against any analytics software, however we are against the case for yet another silo to be created, but this can be managed!

## The Value of Analytics

Analytics comes in many flavors, and this post is in no means meant as a comprehensive cover of such. You have everything from Machine Learning, AI to specific needs such as SEPSIS or HEIDS measures.

The value for analytics is broad and will largely depend on your needs as well as outcomes you are looking to resolve, which is exactly what it is intended for.

## The Shortcoming

However that being said there are a few challenges with analytics as they stand today and ideally you want to avoid making these mistakes as they cost time and money down the road. The major shortcomings are:

• Since there are so many options and each one takes a major integration effort to address, its hard to pick the right analytics software
• All of them create another silo for your data, but they have to in order to provide value to your organization

## Mind The Silo

In order for analytics to function most data needs to be transformed into whatever the solution requires in order to produce the results you need. This creates a silo for your data because the data goes in as one format and only to be stuck in another, the output is merely the process of that system.

This may sound okay, where it is not okay is that then we try to use that data for other things. Such as connecting an HL7 interface, or passing along data; which many of these systems will tell you they can do.

On the surface this all works well, however as you dig down to creating near-real-time data exchanges or try to do high volume transactions you will begin to run into a lot of issues, and in the process you have created yet another dead end silo for your data.

## How A Platform Helps

This is where a platform that helps direct your data in near-real-time really can show its true benefit. First and foremost it solves for the issue of which to choose. You can easily pilot 2 or 3 software systems at the same time without adding resource needs as the platform can easily manage and direct data to each system using proper security controls.

While you are still creating another data silo, you are not dependent on that one. Meaning the software can do what it does best then you can take that output and put it back into the platform to provide a full view of your data.

## Which Integration Method Is Right For You?

In healthcare it seems we are always talking about the latest type of connection you can use HL7, FHIR, ADT and the list goes on; what is even more comical is it changes based on who you are talking to Provider? Payer? Patient?

It feels like the fix for integration has been to create a new type of integration standard. However it is not all about these times of connectors or integrations, we can actually reduce down all this into 3 main areas to focus on.

Point-to-Point

These type of integrations are usually direct interfaces, like HL7, FHIR or ADT, that connect one system to the next. Information flows one way to share information and it is up to the Target system to decide what to do with it.

Point-to-Point is the most common type of integration in healthcare. You work with your vendors to establish a standard you will use, like HL7, and then make sure your schemas match and then test it.

This method leaves it up to each system to interact with any other systems to handle issues like EMPI or data flow or transformation.

Major hurdles with this integration type is each integration requires its own project timeline and you have to maintain each, we see our clients have 5k+ connections by the time we get start working with them.

On the plus side they are much easier to setup than most any other integration and require the least amount of software and/or license fees.

Health Information Exchange/Integration Engine

These types of integrations use Point-to-Point to move data to an Integration Engine that then forwards it to a target system. This is good for keeping a copy of the information, it is still up to the target system to decide what to do but in this case you can also handle a Point-to-Point reply from the target back to the Integration Engine and back to the Source.

Integration Engines are the second most popular and the most prevalent mostly thanks to the rise of Clinically Integrated Networks and ACOs as well as Population Health. However most of these systems are heavily under utilized and most clients report costs going up to maintain them as well as the team required.

This type of integration can automate the workflows required to talk to all your other solutions such as EMPI and data transformation.

Major hurdles with this integration is the team you will have to deploy and license it also does not eliminate the Point-to-Point connections.

On the plus side you get all you’re data is sitting in one place, its stale in the sense its one way and often transformed so it can work with a data viewer, however being in one place is great to be able to manage Population Health metrics and sharing data.

Near Real-Time Bi-Directional Platform

This type of integration is the most robust it offers you a reliable way to manage data moving back and forth from a Source to multiple Targets and back, it can also handle all your Integration Engine needs.

Unlike its counterparts this requires a platform that is able to handle data back and forth and also keep the data current and not stale, meaning minimal transformations or at least real-time transformations so you always have a copy of the live data.

The major difference of a platform is that it encompass multiple other solutions to bring everything holistically into one place.  So instead of having an EMPI, Integration Engine, HIE, API platform and so on a platform handles all this for you in one single place.

Major hurdles for this is usually cost and time to get up and running.

On the plus side most of the solutions in this space are fully managed by a vendor, cloud based, and once they are setup it is much easier to add connections and integrations by simply having your vendor follow a schema you have set in place for them.

What is right for you?

Rather than solving a need multiple times over and over it is time to re-evaluate your data integration strategy and see which option is best for you. Picking the best option will help you scale at a much more rapid pace than your competition.

And what is right for you is not right for all health systems, we still have clients that see the most value from Point-to-Point integrations. It really comes down to your needs and when is the right time to deploy it those needs.

There is also cost and scale challenges with each solution as well as implementation time. The first step to figuring out which option is right for you is to consider your current needs and your needs in the next 5 years, from there you can find the solution that fits both the needs and the budget.

Looking for a free evaluation of your integration strategy as well as which options are best for you? We are happy to help, and even if we are not the best option we will recommend one that is!

## Why Care Gaps Are Really Data Gaps

In healthcare you will often hear, or see in the news, talks about care gaps. Care gaps is used to describe when a link in the chain along the journey is not connected. Think of care gaps as a way to address a particular path/journey/experience in the same manner every time.

Addressing journey experiences is very important for systems and providers as it provides patients with a better experience overall, reduces risks and increases the success of each visit.

## White spaces

Care gaps live in white spaces, spaces that need to be addressed to resolve a particular initiative that is usually unique to addressing the unique population that provider/system serves. This is an important part, because you can’t have the same care gaps for every hospital be the same, although there are guides and standards people follow as a starting point most often you will see systems really take a unique approach to it which is important for them to stay innovative.

Strategic initiatives look at resolving these challenges at a high level; for example lets say a patient visits a doctor and then he is referred to a specialist and instead of making appointment on the spot the patient has to call a different number make an appointment. Then once the patient gets there the doctor does not have their information, this is a big care gap.

In this area is where care gaps work to solve the white spaces and they do this using workflows that can be followed consistently over and over again.

## Workflows

Workflows go hand in hand with care gaps. Care gaps identify the challenge we need to address and workflows is how we address those challenges. So if we were to take a look at it the flow goes from strategic initiatives to care gap identification to workflows.

Once workflows are identified then operations can begin executing those workflows and then we can measure the output of those and repeat the process or adjust until we find the right formula that provides consistent results

## Data Gaps not Care Gaps

When thinking of addressing care gaps what is always absent is the data gap. We have a larger data gap problem than a care gap problem. If we take our example of a basic referral for instance and ask the question is why is it missing? There are a few reasons that could be:

• Provider is not inside the 4 walls of the system OR
• Provider is using their own EMR system OR
• Provider is completely independent and even in another location/state

When you dig into all care gaps you will find it is often, if not always, a data gap issue that needs to be addressed – and any care gap or workflow built to work around this often ends in less than desired outcome.

## It’s time to look at data gaps to inform care gaps

When working through the customer journey or doing an experience map, it is vital that we use data gaps that we have to inform those care gaps rather than the other way around. Unfortunately we often come at it only from a care gap perspective leaving our IT team scrambling to identify where data gaps exist and how to fill them.

Often this results in workarounds that cause more work for providers than is needed. Instead we really should start looking at data gaps to help inform these care gaps, in fact if we look at our data gaps we can identify large gaps that we have and by solving those we would be informing care gaps about which gaps can be addressed and which are the biggest whitespace to fill.

This is where a platform comes in, platforms help you resolve data gaps quickly or at least offer a path to a solution quickly that does not require you to have to build out a team or projects with every single new identified data gap.

## Do We Really Need APIs In Healthcare?

When I talk to CEOs and CIOs often the first question I get is what are APIs and followed almost immediately by why do I need them? Perhaps, as I have come to learn, the root of the question is do I really need it? I mean after all we do have HL7 so why APIs and how are they different.

WHAT IS AN API?

For clarity sake lets all get on the same page about APIs. For starters API stands for Application Programming Interface(s). Better way of thinking of APIs is to think of power sockets. Around the world as you travel you find different sockets depending on which country you are in. To use those sockets you buy an “adapter” that converts your plug, for whatever gadget you have, to that countries specified plug. This is exactly what an API does. It allows an application that has one type of socket to use an adapter (API) that then connects to the other type of socket you need to connect to.

WAIT THIS SOUNDS LIKE HL7!

In many ways HL7 is a great, sort of, API that we have in healthcare that is taken largely for granted. However it is really important to note that a lot of the challenges of HL7 are really due in part to how the software provider configured HL7 and due to the complexity of HL7 there are many deployments of it.

Before I go any further though I would like to point out that APIs have the same challenge as HL7. There is no ultimate governing body and we have to rely on developers. Yes, there is, a widely accepted specification format for displaying such as JSON however how it comes out and how it is deployed is NOT standard.

Retrospectively HL7 has more of a standard than APIs as it forces a set of guidelines for how data should be displayed and more specific how data should be displayed in healthcare.

WAIT BUT WE NEED STANDARDS

Absolutely. Maybe. Perhaps.

The answer to this question is just as tough as figuring out how to solve it. The challenge with any standard is restriction of how something flows; thus why we get specifications. However then the challenge is in how its implemented across the industry.

What I would like you to consider is that instead of focusing on standards we focus on specifications that lay a general guideline and then use the least complex method to get that data in and out.

APIS WILL SOLVE EVERYTHING THEN?

No.

The first step is to shift away from talking about “interoperability” and start talking about data liquidity. After we refocus and redefine our approach and accomplish that we can then put APIs on top to help people access the data faster and help build great experiences.

However the greatest challenge lies beyond data liquidity, the merger of the experience, consumer and the clinical workflow.

## How is Hart Connecting the Missing Pieces of CHOC’s Data Puzzle?

Building jigsaw puzzles is a favorite pastime of many, young and old. Not only are there proven benefits to puzzle building, but seeing an image come together with each piece can be one of the most satisfying exercises, knowing you’ve reached the end as you place that one last piece. Yet, the moments of frustration when pieces are lost or are mixed in other puzzles somehow.Similarly, in today’s healthcare industry, a patient’s care team consists of multiple touch points with various specialists, imaging centers, pharmacies and beyond. Collaboration is key when it comes to continuity of care, but it does not always mean connectivity. With the various systems in place, sources from each facility often do not communicate with each other. One patient may be manageable, a handful may be as well, but for hospitals caring for thousands of patients with multiple levels of data details, there exists a complicated puzzle the healthcare industry has long been trying to solve.

At Hart, not only do we love to build puzzles, but even more so, we love to solve them. When Children’s Hospital of Orange County shared their challenging data puzzle, we were motivated to ensure improved care for their pediatric population. Hart and CHOC’s mission is to place patients’ well-being at the center of everything we do. We couldn’t wait to get started.

Healthcare data is at the core of our mission, our day-to-day currency that feeds the healthcare engine. We ensure that hospitals that maintain a close partnership with more than a dozen prominent clinical institutions within a community work together to improve access to care and to make a difference in their patients’ outcomes.

In the words of CHOC, “This problem derives from the use of different EMR systems, forcing patient records to be spread among incompatible systems, and preventing valuable information from being easily transferred and accessible across the healthcare system.”

As an extension of CHOC, we went to work seamlessly linking the differing EMRs and clinical systems, by way of our bidirectional API platform. Occurring in near real time, the most current set of data is collected, merged and redistributed into CHOC’s population health tool (Cerner’s HealtheIntent), filling in the missing pieces of information that can potentially play a determining role in a diagnosis.

With every piece of data weighing significantly for each patient, it is increasingly gratifying to be part of patients’ paths to recovery. After equipping the immunologists of CHOC with a holistic data plan for 150,000 patients, the outcomes started to speak for themselves. Not only was there a financial impact on managing the pediatric population by saving the hospital over \$1,000,000, over the course of 8 months, the data collection and reallocation helped increase the distribution of Asthma Action Plans by 30%, resulting in 18% fewer unexpected visits to the Emergency Room. That’s 27,000 children that can be busy playing with puzzles instead of being rushed to a hospital yet again.Collectively, our teams acknowledge the importance of fluid data operations and we look forward to continuing our collaboration with CHOC and completing the puzzle for each patient, big and small. We want to make physicians feel confident so communities can thrive with healthy children running around in that California sun.

## Telehealth is great. So why isn’t it everywhere already?

A lot of people don’t know this but Hart got its start in telehealth. Well, actually, we started with medication adherence and the more we worked with clients, the more we discovered how important remote patient monitoring (RPM) is to medication adherence.

RPM is one form of telehealth by which devices are sent to a patient’s home to monitor chronic conditions. This is especially useful in a post-hospital situation to maintain quality of care and reduce the chances of the patient ending up back in the hospital.

At its core, that’s what telehealth really is — and should be — about: Providing convenience, delivering excellent quality of care, minimize a patient’s need for unplanned hospital visits and just generally making it easier to improve a person’s overall health.

So if telehealth is so great, why isn’t it everywhere already?

I can answer that question and others for you. But before we dive into the conversations currently surrounding telehealth, let’s add some context.

### “Tele-what?”

When “tele-” is used to describe something, it means there are electronic means involved so that two or more parties can accomplish something without having to be in the same room.

When you see “tele-” used with “health” or “care,” it means care provided over electronic means so that the two people — usually a clinician and/or patient, or in some cases, multiple clinicians — can interact without meeting face to face. The idea is that telehealth can allow providers, hospitals and health technology companies like Hart to extend tools and resources to patients; and it can allow patients to receive more instantaneous answers to their health questions.

I’ll give you some examples to help clarify. Let’s look at a few forms of telecare that exist today.

Telehealth is used to broadly describe health information services, education and care services delivered electronically. It’s a term that umbrellas everything that happens under it.

Telemedicine is often confused with telehealth, or the two are wrongly used interchangeably. But telemedicine is more defined in that it specifically refers to using telecommunications technology to provide remote clinical services to patients. Examples include digitally transmitting medical images, doing remote diagnostics (like RPM) and/or video consults (think FaceTime). These interactions may be with your primary care physician; in other cases, they may be with a remote team that will ultimately keep your doctor in loop.

Teletherapy is the practice of therapy done via telemedicine, for example, personal therapy, family therapy or even addiction therapy.

Telecare involves a team of doctors, nurses and others taking care of patients remotely. This allows a patient to maintain his or her independence and quality of care while staying at home.

Just a heads up that I’ll be using “telehealth” throughout the rest of this post to keep things simple. But it’s good for you to have some knowledge of the subtle differences between the related terms.

### “How is this technology used?”

Because this technology has such a broad application across so many areas in healthcare, it can offer greater convenience and faster care to everyone. Here are some specific examples.

#### Remote Care

Arguably the most exciting area is our ability to extend care to people we were not able to reach before. Imagine having doctors providing care to patients in other countries, remote areas or even disaster areas. This significantly improves the care someone receives and can actually help eliminate the need to travel long distances just to receive care.

#### Remote Patient Monitoring

As I mentioned, Hart began in the RPM area. A great service that allows a care team to remotely take care of a patient after he or she has been discharged from a hospital, RPM enables the patient to enjoy the comforts of home, safely. Plus research has shown patients may heal better and faster when they are surrounded by familiar settings and, in particular, their loved ones.

#### Consults

Another major way this technology is being used is to provide consultation between specialists and caregivers. For example, maybe your doctor wants a specialist’s opinion on one of your medical images in order to make an intelligent diagnosis. Instead of referring you to the specialist and making you do a lot of back and forth with additional appointments and paperwork, your doctor could use telehealth to get instant feedback, saving everyone time and money.

#### Employers

I’ve already written about companies establishing on-site clinics for their employees. Sometimes those clinics are criticized by people who point out that remote employees or out-of-town family members are left out. But telehealth allows those individuals to visit with the very same doctors and care team as the on-site employees do. Interacting with familiar faces can be important to retention since many patients perceive these individuals to be more fully involved in their care.

I’m sure you can see and think of many other areas in which we can use these types of services. We’re seeing their numbers grow rapidly and I enjoy learning about new telehealth services that are springing up all the time.

### “What are the benefits?”

All of this sounds great but in my opinion there are benefits to telehealth beyond just the ability for tele-visits. Nothing is more important than getting the right answer quickly from your doctor, however, there are other things to consider here that offer amazing value to us as patients, and of course, there’s also value for the physician.

#### Convenience

No one can argue how convenient telehealth services are. Compare the traditional method of trying to make a doctor appointment to just picking up your smartphone. In the latter scenario, you can access your doctor’s office so much faster. Or if you use voice commands to your Echo or your Google Home device, then your access is even faster still. It might take 5 to 20 minutes to get a member of your care team up on your screen.

Teladoc, a leading provider of telehealth (that just surpassed 2 million telehealth visits), advertises an average wait time of 22 minutes. All things considered, that’s not bad. That’s how long it takes most of us just to schedule an appointment with our primary doctor over the phone. That’s 20-some minutes not to be seen but just to be scheduled.

#### Engagement

If you have a telehealth app on your smartphone, you now have a way for a care team to communicate with you. That’s a great opportunity for engagement, whether it’s before or after your visit — maybe even right after your appointment while you’re waiting for a call back. And in the event you’re an RPM patient, you actually have a device that’s collecting information 24/7 from the medical devices you’re using. All of these are touch points that are ripe for engagement and can allow your care team to better facilitate your overall health.

#### Prevention

The best part about telehealth services is that they’re not just for those who are sick. There are many times when we need to go see the doctor for simple things that could be accomplished via telehealth technology. And with more and more providers doing this, now we can.

At this point you might be thinking, Wow, this could save all of us a lot of time and money and also make those quick cold flus go away much faster. Why isn’t this widely used already?

### “Are there laws to regulate telehealth?”

The general premise of laws is that they’re there to protect us as a society and uphold certain values. But in some cases, such as telehealth, the law can’t keep up with the industry’s changes and ultimately hinder growth and innovation.

The freedom to post anything on the internet and reach anyone instantaneously is great. Medicine, however, is something special and, let’s be honest, requires guardrails. When it comes to taking care of you, it’s important that the doctors who are giving you an opinion are board-certified. After all, you don’t want just any random person trying to give you advice about a condition you might have — or end up using Mr. Google, which sometimes ( often) leads to information with a disclaimer that says a condition can result in X, Y, Z “… or death.” Not very comforting.

#### Not All Laws Are Created Equal

In the U.S., when it comes to healthcare, each state has its own medical board and laws that define things such as:

• Proxy (the ability to see someone else’s record, for example, your child’s)
• Lab releases (what kind of labs you get and when)
• Abortion (perhaps the most controversial of all)

Each state has its own laws for telehealth too. This means a doctor can’t practice across state lines unless he or she is licensed in that state. You can see how this can get tricky where telehealth is concerned.

#### What This Means for You

There are a couple areas where this hinders the adoption and rate at which this technology can grow. This could mean a few things for you:

• Not every doctor will do this
• You can’t always get a doctor right away
• Slow growth of adoption due to certifications and legal drawbacks

Over time we’ll see this change and there is a lot of movement already on this from a law perspective to allow transportability between state lines. While this will take time, it will gradually get better and better. A great thing about technology companies is that they can adapt quickly, so they should be able to adapt swiftly along with any law changes

I’ll fill you in on the answer. It’s time to explore the other side of telehealth, the one where telehealth meets the law.

### “I’m sold, how much does this cost?”

Of course, patients usually like the sound of telehealth but wonder whether it will cost them more or less than what they’re already paying for healthcare. The reality is, it actually costs less than what most people would think, especially when you consider costs associated with your time, gasoline, and the wear and tear on your car.

With telehealth, there are currently two models for payment:

• User Pays: You cover the cost of the visit.
• Insurance Pays: Your insurance covers the cost of the visit.

#### User Pays

Among the leading telehealth providers, the price for visits ranges between \$49 and \$99. All things considered, that’s a fairly economical price range so long as you aren’t calling the doctor every day. Or what if it were the middle of the night and your child were crying and you had no idea what was going on? That price would most certainly be worth the immediate answers and peace of mind.

Most of these companies have online signup or even mobile apps — just register and you’re ready to go. Some companies have a subscription model which requires you to pay a yearly fee in exchange for a lower price per visit or several free visits over a certain period of time.

#### Insurance Pays

A lot of insurance companies are still catching up to this, however, great strides have been made. If you use your insurance, the cost will vary depending on your plan type and your co-pay.

In order for a telehealth company to take insurance, it has to make a contract with each insurance plan provider, which can take some time to get in place. That’s one reason why a company may not presently take insurance or insurance by a specific plan provider.

Most likely you’ll see that by the end of 2017 all insurance plans will have some form of coverage for telehealth. It’s in their best interest, after all, as it lowers their own overall costs when insured customers make use of telehealth.

Additionally, an employer or another sponsor can choose to pay for the entire cost or subsidize the cost of a visit.

#### Sometimes You Need a Doctor Right Now

There are other companies that allow you to call a doctor to make a house call on demand. While that’s not telehealth, it’s still using digital technology to summon a doctor to your doorstep — kind of like back when your parents were children and the doctor used to visit their homes. The prices for these vary and there are also options for both payment models.

### “Why doesn’t my doctor do this?”

By now you’re probably excited about this type of technology. And if you’re like me, you’re probably wondering why your own doctor might not do this yet. Remember the state laws and insurance complications I mentioned? While some aspects of telehealth have evolved rather quickly in response to consumer demands, the area of contracts with doctors is still a work in progress.

Simply put, not all doctors can get paid for this type of service … yet. This is changing more and more as insurance companies are seeing the benefit. Today doctors still requires you to come in so they can bill the insurance company , that’s how they make money. Unfortunately, they can’t yet bill for telehealth visits in all areas or all states.

#### New Laws

It’s not just telehealth that’s evolving — the healthcare industry as a whole is undergoing many changes. That includes changes in how we pay for value, and there are new laws being put in place to focus more on the value than the fees. Hence, it’s becoming more prevalent to see your health system and/or doctor offering telehealth services.

#### Operations

There are also other complications to consider, such as balancing the doctor’s schedule — after all, some people still need to go see the doctor in person, as not everything can be addressed via video.

These changes in workflows and operations will take some time to work through, however, I see the industry making great strides and I’m very excited for the next few years in care.`

### “What if I still have questions?”

We never talk about anything in healthcare without these questions coming up:

• Is it safe?
• Is it secure?
• How do I trust the service?

The short answer is: Yes, it is safe; yes, it is secure. However, all that said, you should do your research and go with a reputable company.

#### You’re Not Being Recorded

By law, the encounter you have with the doctor is only between you and the doctor — same as when you visit with your doctor in person. Once the video connection is made, that video connection is secure, private and never preserved as part of your medical record. Regardless, do your homework. Check the privacy terms just as you would for any service you use. And keep in mind that laws can change, so review those terms often.

#### This Isn’t the End of Going to the Doctor

This is a great question and the answer is no. There are still many cases in which you will need to visit a doctor due to either laws or just the nature of practicing medicine. These include but are not limited to:

• Getting certain prescriptions or renewals
• Physicals
• Critical care
• Surgery

Maybe in time all of these and others will be possible over tele-means, without the patient ever leaving home. I would argue, however, that there will always be a reason to see the doctor in person. My biggest reason for it?

Simply put, we like the interaction of being with others — we are, after all, social beings.