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  1. 1. Overview of Telemedicine Program December 16, 2009
  2. 2. Management Team CEO and Founder Chief Medical Officer Chief Financial Officer VP, Business Development VP, Operations Paul I. Bulat, M.D., FACEP Daniel J. Shea, M.D., FACEP Maureen Petersen, CPA Sam Shen M.D., M.B.A, FACEP Brenden Hayden, EMT-P
  3. 3. Overview- Challenges Across the nation, skilled nursing facilities face similar challenges. Patients Nurses Physicians Skilled nursing facilities Hospitals Access to real time medical consultation Timely access to physicians for non-urgent, urgent, and emergent clinical issues during off-hours. Responsibilities span office visits, nursing home visits, and on call coverage limiting availability Regulatory compliance, unnecessary transfers to local Emergency Departments Readmissions
  4. 4. Overview- Demographics The elderly population is expected to grow dramatically relative to other age groups. By 2050, the over 75 age group will comprise 12% of total population Source: Chartbook on trends in the Health of Americans, Health, United States, 2005 % of population
  5. 5. Limitations There are limitations in the current model of physician coverage at Skilled Nursing Facilities <ul><li>Limited supply of primary care physicians, especially geriatricians </li></ul><ul><li>Response times to clinical questions in SNF can range from hours to days </li></ul><ul><li>Physician consultation over the phone is constrained by: </li></ul><ul><ul><li>Limited time of the provider </li></ul></ul><ul><ul><li>Limited knowledge of the patient </li></ul></ul><ul><ul><li>Lack of visualization of the patient </li></ul></ul><ul><ul><li>Lack of access to medical records </li></ul></ul><ul><li>Consultation results in blind diagnosis or unnecessary transfer to the Emergency Department </li></ul>
  6. 6. Solution PhoneDOCTORx is an innovative company targeting the growing medical needs of the nursing home population <ul><li>Physician coverage service for skilled nursing facilities in New England </li></ul><ul><li>Utilize existing telemedicine technology to perform physician consultation with patients </li></ul><ul><li>Implemented at our first trial site in June 2006 in a 154 bed SNF in New Bedford, MA </li></ul><ul><li>Currently in 3 sites, expanding to 6 facilities January, 2010 </li></ul><ul><li>Operational 7 days/week </li></ul><ul><ul><li>5pm-11pm Mon-Friday </li></ul></ul><ul><ul><li>10am-7pm Sat., Sun. </li></ul></ul><ul><li>Staffed by Board Certified physicians in Internal Medicine, Family Medicine, and/or Emergency Medicine </li></ul>
  7. 7. Technology Solution <ul><li>Wireless cart is portable and self-contained </li></ul><ul><li>Tandberg equipped camera </li></ul><ul><li>High definition capability </li></ul><ul><li>Camera operated remotely by physician at call center </li></ul><ul><li>Additional wound/dermatology camera available </li></ul><ul><li>Battery operated </li></ul><ul><li>Ability to bring multiple providers on screen to patient </li></ul><ul><li>3 process patents and 2 patents pending </li></ul>
  8. 8. Overview- Operations Clinical Process <ul><li>Clinical question or concern arises at a SNF </li></ul><ul><li>SNF nurse contacts PhoneDOCTORx at our call center </li></ul><ul><li>Medical triage assistant prioritizes call </li></ul><ul><li>Physician pulls up patient records electronically </li></ul><ul><ul><li>Discharge summary </li></ul></ul><ul><ul><li>Medication list </li></ul></ul><ul><ul><li>Progress notes </li></ul></ul><ul><li>SNF nurse discusses case with physician by phone </li></ul><ul><li>Nurse rolls telemedicine cart to patient room to initiate consultation </li></ul><ul><li>Physician writes orders as needed and electronically transmits progress note of encounter to SNF </li></ul>
  9. 9. Clinical Benefits PhoneDOCTORx can improve quality of care and life at skilled nursing facilities: <ul><li>Reduce time delay in responding to clinical problems at SNF </li></ul><ul><li>Visualization of patients can provide physicians more information to make better decisions </li></ul><ul><li>Access to medical records allows better decision-making </li></ul><ul><ul><li>Review labs, XRays, medications </li></ul></ul><ul><li>Assist in stabilization of emergent patients being transported to the ER </li></ul><ul><li>Documentation of clinical encounters ensure better continuity of care </li></ul><ul><li>Address pain/behavioral issues immediately </li></ul><ul><ul><li>Adjust pain medications </li></ul></ul><ul><ul><li>Control agitation without restraints </li></ul></ul>
  10. 10. Overview- Additional Benefits Providing our telemedicine service creates real benefits to the patients, clinical staff, physicians, and SNF <ul><li>Provide higher level of acuity of service at SNF </li></ul><ul><ul><li>Our physicians provide immediate care and manage the spectrum of acuity </li></ul></ul><ul><li>Reduce unnecessary transfers/readmissions to hospitals </li></ul><ul><ul><li>2007 New York Study by Grabowski approximates 31% of inpatient admissions avoidable </li></ul></ul><ul><li>Increase admissions and occupancy </li></ul><ul><ul><li>Marketing opportunities to community/family/hospitals </li></ul></ul><ul><li>Attract PCPs with large practices </li></ul><ul><ul><li>Decrease the burden on PCPs during afterhours/weekends </li></ul></ul><ul><li>Improve nursing recruitment & retention </li></ul><ul><ul><li>Nursing satisfaction very high with program </li></ul></ul><ul><ul><li>Provides real-time support to nurses </li></ul></ul>
  11. 11. Unnecessary Hospitalizations Reducing nursing home hospitalizations is an area of cost savings based on recent study “ Costs and Potential savings associated with Nursing Home Hospitalizations” by David Grabowski, (2007) <ul><li>In New York State, between 1999-2004, spending increased 29% on nursing home hospitalizations </li></ul><ul><li>During that time period, $972 million in aggregate spending </li></ul><ul><li>Total cost per hospitalization $12,160 (2004) </li></ul><ul><li>40% deemed avoidable admissions based on diagnosis </li></ul><ul><li>This results in $223 million potential cost savings </li></ul><ul><li>Admissions result in increased iatrogenic disease and delirium </li></ul><ul><li>Conclusion “…policies directed at decreasing nursing home hospitalizations may generate major cost savings for Medicare program” </li></ul>
  12. 12. Overview Telemedicine program is a platform for additional/future services PhoneDOCTORx Service Increased access to physicians Specialist consultation Family conferences Education <ul><li>Continuing medical education </li></ul><ul><li>Lectures/seminar via telemedicine </li></ul><ul><li>Discussion with family </li></ul><ul><li>Wound care </li></ul><ul><li>Psychiatry </li></ul><ul><li>Real-time medical consultation </li></ul>
  13. 13. Clinical Summary: Overview <ul><li>There have been over 10,000 documented encounters between June 1, 2006 and present at three sites </li></ul>
  14. 14. Clinical Summary: Disposition For all encounters, the majority of patients remain in the skilled nursing facility while a minority (5%) are transferred to the Emergency Department.
  15. 15. Clinical Summary: Chief Complaints There is a wide distribution of cases seen during the first year.
  16. 16. Clinical Summary: Transfers
  17. 17. Clinical Summary: Transfers
  18. 18. Clinical Summary: Overall Benefits How do you value the service PhoneDOCTORx provides? Value PhoneDOCTORx Access Fee Potential cost savings from unnecessary ED transfers Access to care/improved care Marketing tool Staff retention/recruitment $/month Patient/family satisfaction Additional benefit Financial breakeven point $ Physician recruitment Regulatory compliance
  19. 19. Legal Concerns <ul><li>Received support from Massachusetts Department of Public Health </li></ul><ul><li>Operating as covering physicians for primary care physicians </li></ul><ul><li>No impact on malpractice premiums for telemedicine physicians </li></ul><ul><li>Telemedicine consult enables a more thorough and informed evaluation versus status quo </li></ul>
  20. 20. Business Model The market size is approximately $3 billion in the United States per year. Nursing Homes 17,000 Skilled Nursing Facilities United States Massachusetts 456 Skilled Nursing Facilities
  21. 21. Barriers to Adoption There are several real and perceived barriers to adoption of our program Costs Nursing homes bear cost of program with limited resources <ul><li>Subsidize costs by insurers/government </li></ul><ul><li>Senior whole health </li></ul><ul><li>Medicare </li></ul>Barriers Solutions New technology Healthcare slow to adopt new technologies <ul><li>Demonstration projects </li></ul><ul><li>Marketing </li></ul><ul><li>Consumer driven demand </li></ul><ul><li>Policy changes </li></ul>
  22. 22. Expansion Strategy <ul><li>After successful trial at existing sites: </li></ul><ul><li>Market to local and regional nursing home chains </li></ul><ul><li>Market to physician groups that provide nursing home care </li></ul><ul><li>Partner with third party payers </li></ul><ul><ul><li>Regional payers (SCO’s) </li></ul></ul><ul><ul><li>Large private/government payers </li></ul></ul><ul><li>Market to large national nursing home chains </li></ul><ul><li>Academic prospective study with Grabowski, Professor, Harvard University </li></ul>
  23. 23. PhoneDOCTORx Services <ul><li>SNF </li></ul><ul><li>Consultation services to develop customized telemedicine programs for individual sites </li></ul><ul><li>Implementation of telemedicine program </li></ul><ul><li>Hospital </li></ul><ul><li>Consultation services for customized “30 day readmission” program </li></ul><ul><li>Coordination of SNF/Hospital continuum of care </li></ul>
  24. 24. Questions? 1-866-539-PDRX