Telehealth Failures & Secrets to Success Conference 2017 by VSee Speaker: Homero Rivas Director of Innovative Surgery of Stanford University School of Medicine More info here: vsee.com/conference

1. “Will the next generation of doctors be ready
for Telehealth?”
Homero Rivas, M.D., M.B.A., F.A.C.S.
Director of Innovative Surgery
Section of Minimally Invasive Surgery
Stanford University School of Medicine
Stanford, CA
hrivas@stanford.edu
@mHealthSurgeon
Fremont, CA
September 20, 2017

2. Disclosures
• Nothing to disclose

3. Key Learning Objectives
• Learn why the business model of medicine is very inefficient
• Learn what are the characteristics of a successful innovation
• Learn what is the profile of successful innovators,
entrepreneurs and physicians
• We will identify challenges and opportunities for formal
education in Telehealth included in medical school curricula

6. Innovation of Delivery of Clinical Practice
• Health care reform
• Cost of US Health care 3
trillion/yr
• Nearly 18 % of US GDP

8. Evolution of Surgery
ImprovementsinPatientCare
Technology and Innovation
Open Surgery
Laparoscopy
Single Port Laparoscopy
Natural Orifice Surgery???
Endoluminal Therapies

13. Business Model
• Medicine in general has a very poor business model
• Not scalable
• Restricted by limited resources
• Academic and Preventive Medicine are at some degree limited
solutions
• DIGITAL HEALTH is the clear solution

17. Essential characteristics of a successful Innovation
• Simple
• Scalable, easily reproducible
• Cost effective
• It should make sense
• It should have a relative advantage
• Safe
• (Discrete)

18. Successful innovators
• High tolerance to failure
• Enthusiastic of risk
• Opportunistic mindset
• Eccentric personality, misfit, etc.
• Networking
• Open minded
• Persistence

19. Safe and Successful Physicians
• Focus oriented to never fail
• Risk averse. Always follow predictable risk
• Super specialized
• Cost insensitive
• Very secretive research. Rarely open source

20. Care providers as ideal adopters?
• Lack of medical school curricula
• Very slow FDA approval process not properly aligned to high
turnover of digital innovation
• Biggest hurdle is the change of mindset needed among care
providers

21. • In 2011, US Secretary of Health and
Human Services Kathleen Sebelius
referred to mHealth as “the biggest
technology breakthrough of our
time” and maintained that its use
would “address our greatest
national challenge.”

22. Promising Technologies
• Mobile Health, Telemedicine
• Online patient communities
• Wearable technologies
• 3D Printing
• Virtual and Augmented Reality
• Drones
• Artificial intelligence engines
• Others

23. AAMC Report, March 2015
The Complexities of Physician Supply and Demand
Projections from 2013 to 2025
• By 2025 the U.S. may be short 46,000 - 90,000 physicians
• 12,500 to 31,100 primary care
• 28,200 to 63,700 non-primary care - most notably surgery
https://www.aamc.org/download/426242/data/ihsreportdownload.pdf

24. !
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Year1Year2
Autumn Winter Spring
Year3,4,[5]
! Cells to Tissues
! Molecular Foundations of Medicine
! Applied Biochemistry
! Genetics
! Embryology
! Histology
! Anatomy
! Basic Cardiac Life Support
Scholarly Concentrations
! The Nervous System
! Immunology
! Microbiology & Infectious Diseases I
! Cells and Signaling in Regenerative
Medicine
! Human Health and Diseases I
• Introduction to Pathology
• Introduction to Pharmacological
Treatment of Disease
• Pulmonary System
• Cardiovascular System
! Human Health and Diseases II A
! Human Health and Diseases II B
! Microbiology & Infectious Diseases II
! Human Health and Diseases III A
! Human Health and Diseases III B
! Pharmacological Treatment of Disease A
! Pharmacological Treatment of Disease B
Transition to Clinical Clerkships
Pathophysiology Step 1 Study/
Clinical Problem- Early Clerkship Entry
Solving
Scholarly Concentrations
Reflections, Research, and Advances in Patient Care | Advanced Cardiac Life Support
Scholarly Concentrations
CLINICAL CLERKSHIPS
Practice of Medicine I Practice of Medicine II Practice of Medicine III
Practice of Medicine IV A & B Practice of Medicine V A & B
8 Weeks
Internal Medicine
Pediatrics
Surgery
6 Weeks
Obstetrics & Gynecology
4 Weeks
Critical Care
Family Medicine
Ambulatory / Emergency Medicine
Neurology
Psychiatry
8 Weeks
Selective I: Fundamentals of
Clinical Care
Selective II: Subinternship
6 Weeks
Electives
POM VI

25. Accreditation Council for Graduate Medical
Education (ACGME) “Milestones” 2009
• Designed to secure six core competencies
– Patient Care
– Medical Knowledge
– Professionalism
– System-based Practice
– Practice-based Learning and Improvement
– Interpersonal and Communication Skills

27. The Future of Graduate Medical Education
“Simply adding more doctors to the current mix is not a
thoughtful solution to workforce challenges.”
Pizzo et al., May 2015

28. THIS GAP IS KNOWN
• In 2016, the American Medical Association adopted a
policy “aimed at ensuring medical students and residents
learn how to use telemedicine in clinical practice”
• 32 schools are working together to "incorporate the
newest technologies that will help prepare future
physicians to practice in the changing health care
environment and better provide health care services to
underserved populations.”
https://www.ama-assn.org/ama-encourages-telemedicine-training-medical-students-residents

29. CURRENT PROJECTS AND
PROGRAMS
• University of Hawaii Medical School
• Developing a telemedicine curriculum that will be taught via
telecommunication technology
• University of Arizona College of Nursing
• Telehealth training program
• University of North Dakota School of Medicine and Health
Sciences
• Using telemedicine and simulation technology to teach skills
in helping rural communities
https://www.ama-assn.org/ama-encourages-telemedicine-training-medical-students-residents
http://telemedicine.arizona.edu/blog/ua-college-nursing-launches-telehealth-training-students

30. CURRENT PROJECTS AND
PROGRAMS
• East Carolina University School of Medicine, Center for
Health Sciences Communication
• Advanced telemedicine training designed to “increase
the understanding of operational, technical and
administrative issues associated with on-line learning
and remote healthcare delivery"
• University of Texas Medical Branch at Galveston
• Open Gates Tele-training Institute (not-for-profit)
• Offers many comprehensive courses on telemedicine
ranging from a 2 day to 5 day program
http://ieeexplore.ieee.org/stamp/stamp.jsp?arnumber=769925

31. UC SAN DIEGO MEDICAL
EDUCATION AND
TELEMEDICINE CENTER
• Provide telemedicine education and
practice as well as instruction and
practice in latest surgical techniques
• Funding:
• “Half of the funding to build the new
Medical Education and Telemedicine
Center comes from Proposition 1D,
a bond initiative passed by California
voters in September of 2006 to
expand and enhance medical
education programs with an
emphasis on telemedicine.”
https://health.ucsd.edu/news/2009/Pages/11-20-medical-telemedicine-education.aspx
http://www.som.com/FILE/18243/ucsd_medicaled_sustainable_1400x800_cesarrubio_01.jpg

32. DIGITAL HEALTH CENTERS
• UMass Medical School
• The Center for Digital Health
• University of California, San Francisco
• Center for Digital Health Innovation at UCSF
• Stanford University
• Center for Digital Health
http://centerfordigitalhealthinnovation.org/what-we-do/
https://www.umassmed.edu/news/news-archives/2016/11/new-center-for-digital-health-launched-by-umass-med

33. DIGITAL HEALTH PROGRAMS
• Brown Alpert Medical School
• Offers a course on Digital Health (BIOL 6677) for medical students
• Tufts University School of Medicine
• Students can earn a Certificate in Digital Health Communication
• John Hopkins University School of Medicine
• Informatics and Digital Health course (four-day course)
• Indiana University School of Medicine
• Teaching medical students how to use electronic health records (EHRs)
using de-identified data
• This training is now being implemented at other medical schools
http://publichealth.tufts.edu/Academics/HCOM-Program/Certificate
http://www.hopkinsmedicine.org/som/curriculum/genes_to_society/curriculum/year_one/time_informatics_digital_health.html
https://www.brown.edu/academics/medical/education/biol-6677-digital-health

35. Photo by Mathieu Plourde @mathplourde

39. Opportunities
• Unique platform for networking of students
from different geographical and professional
backgrounds
• Great source of talent for entrepreneurs,
investors, organizations, etc.
• Scalability of delivery of Healthcare

40. “CLOSE ENCOUNTERS, DISTANCE
LEARNING BY TELEMEDICINE”
• Understand the value proposition of telemedicine, and how mobile
and wireless platforms can be leveraged to responsibly and safely
improve the efficiency, quality and extent of global delivery of
healthcare and medicine.
• Identify important deficiencies in using telemedicine and learn skills
to overcome these challenges
• Be able to think critically about using technology in healthcare and
propose simple solution for health issues
• Meet and network with key players in the telemedicine market.
Develop with them potential academic, social or entrepreneurial
collaborations

43. SCALING ACCESS TO CARE IN
RURAL MEXICO VIA DIGITAL
HEALTH, TELEMEDICINE AND
DRONES.
Funded by Center for Innovation in Global Health Seed
Grant

44. PI:
Homero Rivas, MD, MBA, FACS,
FASMBS.
Assistant Professor of Surgery
Stanford Department of General
Surgery
hrivas@stanford.edu
Co-investigators:
Sharon Wulfovich, B.A.
Stanford University
sharonws@stanford.edu
Thomas Boillat, PhD
tboillat@stanford.edu
Micaela Esquivel, MD
Resident Physician and Research
Fellow
Stanford Department of General
Surgery
mesquive@stanford.edu
Katarzyna Wac, PhD
Associate Professor
Department of Computer Science
University of Copenhagen, Denmark
Invited Professor and the Quality of
Life Technologies lab leader at the
Center for Informatics
University of Geneva, Switzerland
Visiting Scholar
Stanford University, School of
Medicine
wac@stanford.edu
M. Carolina Jimenez, MD
Instructure and Researcher
University of Toronto, Department of
Surgery
Strategic Allies:
Dr. Eduardo Diaz Juárez
Health Secretary of Durango, Mexico
Pedro Matabuena
Founder and CEO, Dialipso
Consultant for Airdronix
Jordi Munoz
Founder and CTO, 3D Robotics

45. PROJECT
DESCRIPTION
Inequities of access to medical care represent a universal
problem, which is especially evident in countries with
large socioeconomic differences. Our pilot project centers
on the use of technology to bridge access to medical care
in marginalized communities. We will focus on Mezquital,
a highly marginalized municipality of Durango, Mexico.
We propose the use of “drone telemedicine units”. Such
“unmanned aircraft vehicles” could be equipped with
basic, yet advanced digital health systems, that could
reach people in remote or isolated areas with otherwise
very limited access to medical care. This study would
evaluate the feasibility and scaling of prompt access to
care by means of digital health, telemedicine and the use
of drones in rural Mexico. More specifically, we would like
to evaluate its potential value for acute, subacute, and
chronic medical problems, in geographical locations
where there is a paucity or absence of healthcare
providers, and a lack of an adequate infrastructure to
deliver prompt medical care when needed.

46. CLINICAL
APPLICATIONS
• Scorpion bites (need antiserum)
• Allergy (need epi pen)
• Any medical emergency

47. TELEMEDICINE PLATFORM
Google Pixel Phone
https://madeby.google.com/phone/ https://vsee.com
VSee for Video Telemedicine Calls

48. DIGITAL HEALTH DEVICES
Wireless Wrist Blood Pressure Monitor One Digital Stethoscope
https://ihealthlabs.com/blood-pressure-
monitors/wireless-blood-pressure-wrist-monitor/
http://www.thinklabs.com

49. DIGITAL HEALTH DEVICES CONT.
https://ihealthlabs.com/fitness-devices/wireless-pulse-oximeter/
Wireless Pulse Oximeter Portable Ultrasound
http://www.healcerion.com/product/ultrasound/sonon-300c/
Mobile EKG Monitor
https://store.alivecor.com

50. BUILDING
THE DRONE

51. LANDSCAPE

52. LOADING THE DIGITAL HEALTH AND TELEMEDICINE UNITS

53. FLIGHT
PLAN

59. TELEMEDICINE
AND DIGITAL
HEALTH
DEVICES
CHALLENGES
• Explaining how to use the devices
• Non-reliable measurements
• Setting up everything
• Syncing – especially if any additional
interactions are needed
• Possible intereference with the drone and
the bluetooth and wifi

63. Barriers for adoption
• Economic
• Technological
– Battery life
– Encryption/privacy
• Mindset
– Health care providers
– Patients
• Universal access

64. Solutions
• Open source models in medicine and science.
• Medical Schools, medical boards, allied health, postgraduate
programs should lead implementation of telehealth
• Involvement of othe key stakeholders
• Patient centric strategies
• Patients to lead the adoption of Innovation

65. hrivas@stanford.edu
@mHealthSurgeon
Thank you!