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THE
VIRTUAL
DOCTOR
HOW DATA NETWORKS ARE EXTENDING THE
REACH OF MEDICAL CARE IN THE DIGITAL AGE
IN ASSOCIATION WITH:
CONTENTS
CONTENTS
The Virtual Doctor ................................................................................. 2
CASE STUDY: Ontario Telemedicine
CASE STUDY: InTouch
CASE STUDY:
Network ........................................... 6
Health Systems ...................................................... 7
C3O Telemedicine .............................................................. 8
CASE STUDY: Telepsychiatry ..................................................................... 9
CASE STUDY:
Boston Children’s Hospital................................................ 10
Acknowledgments.................................................................................. 11
THE
V I RT UA L D O C TO R
HOW DATA NETWORKS
ARE EXTENDING THE REACH
OF MEDICAL CARE
IN THE DIGITAL AGE
Thirteen years ago, a surgical robot named Zeus
made history when a team of physicians in New York
performed surgery on a patient in Strasbourg, France.
The Lindbergh Operation, as it came to be called,
represented a confluence of technical achievements,
namely the dexterity of the digital Zeus Robotic
Surgical System and a broadband transmission capability with optimized compression that limited the
time delay between the doctors’ commands in New
York and the resulting action in France.
We are not that far away from a future in which seeing a doctor does not require being in the same room
or even the same building, says Yulun Wang, founder
of InTouch Health and president of the American
Telemedicine Association. “I think telemedicine will
become the core methodology of healthcare delivery
in the future,” he says. “It has to, because that is where
we are going to get the efficiencies we need to meet
rising needs created by an aging population and provide affordable care.”
Since that breakthrough in 2001, the idea of treating patients remotely has touched almost every aspect
of healthcare. Neurologists can now “beam in” on
stroke victims to provide instant assessments that can
save lives. Patients recovering from surgery at home
can have the equivalent of an electronic house call
with a video link to their surgeon for follow-up
appointments. And, in one of the newest applications
of telemedicine, psychiatrists can create avatars to
meet patients in virtual worlds where they can act out
difficult scenarios.
One of the original imperatives for telemedicine
was to bring better care to underserved and remote
areas with few medical facilities or where there were
long distances between patients and doctors. But even
in well-served areas, there are compelling reasons to
incorporate telemedicine into many practices. There
are not enough specialists—neurologists, cardiologists,
dermatologists and psychiatrists, to name a few—to
meet rising demand. Someone suffers a stroke every
40 seconds on average in the United States, but there
is not always a neurologist available in the first few
2 | THE VIRTUAL DOCTOR
crucial minutes to provide a diagnosis. Telemedicine
can also reduce costs and improve outcomes. For
example, home health monitoring for people with
chronic conditions, such as diabetes, can mean
fewer missed appointments and hospital stays, not to
mention reduced travel time for patients.
These imperatives are driving unprecedented
innovation and entrepreneurial energy in the field of
telemedicine today. However, none of this innovation would work without a reliable network capable
of carrying a detailed image from one location to
another, or to control a robot miles away, or simply to
access an electronic record safely and securely.
New imaging systems, for example, save lives, but
they also create massive digital files. “The hospital has
to have a really strong network to take advantage of
this brilliant machinery,” says Tomas Yanez, director of
enterprise marketing at Comcast. “Everything may
work great at the main hospital facility, but at the edge
it,” says Yanez. “The network is behind the scenes, it’s
not in the lights where people are clapping. But the
connection is real, and critical to the performance of
any telemedicine application.”
Comcast Business Ethernet services dovetail well
with the needs of most healthcare providers. Ethernet
is a protocol that can run on both fiber and coaxial
cables, and it can be expanded with a single phone
call. So if a new imaging system starts producing files
that are choking the circuits, an existing Ethernet
service can be expanded exponentially without
digging new holes or laying new fiber.
Most hospital systems need to connect multiple
locations, from the main facility to outpatient clinics,
physician’s offices, imaging facilities and record
archives—all of which may be miles from one
another. Any hospital system that relies on digital
medical records needs to ensure constant access to
those records, and that requires a reliable network
“The hospital has to have a really strong network to take
advantage of this brilliant machinery.”
of the network, at the radiologist’s office a few blocks
away, it might not work very well at all if the network
isn’t robust enough,” he explains. Sending video files
takes even more bandwidth.
“Everyone gets excited about the performance and
the glory of a new application that promises to make
the patient experience better or make a hospital
more competitive, but it won’t work unless there is
a solid network foundation underneath to support
TOMAS YANEZ,
Director of Enterprise Marketing,
Comcast
across all locations with multiple paths and multiple
redundancies.
At Inspira Health Network, which was formed in
2012 after the merger of South Jersey Healthcare
and Underwood-Memorial Hospital, a Wide Area
Network (WAN) connects three medical centers, two
health centers and dozens of outpatient sites with a
combination of several different Comcast Business
Ethernet services. Physicians at any of Inspira’s facili-
COPYRIGHT © 2015 FORBES INSIGHTS | 3
ties can access test results, surgery notes, home health
visits, diagnostics and other data as they move from
one patient to the next. Instead of juggling paper
files, doctors can spend more time with their patients.
Patients are also benefiting from the network via a
dedicated portal where they can review test results,
pay their bill, schedule classes and access a library of
health care information.
“The more services we run over the network, the
more we can reduce the cost of those services,” says
Thomas Pacek, vice president and CIO of Inspira
Much of telemedicine takes place over the public
Internet. “The Internet is inexpensive, it’s nearly
ubiquitous, and you don’t need to program anything,”
explains Yanez. Those qualities have laid the groundwork for the growing ubiquity of telemedicine. For a
doctor answering an emergency call by logging on to
a mobile device or paying a virtual visit to a patient
in a remote location, the public Internet is the only
option that makes sense.
But security is still a real concern. “What could
happen when you pass medical records around over
“The more services we run over the network,
the more we can reduce the cost of those services.”
Health Network. Inspira is “collapsing everything
onto the network,” he explains, from cardiology
equipment to the medical records of physicians’
offices associated with the hospital. With so much of
the daily workload moving over the network, reliability
is key. “The more we become electronic with our
records—and everything we do related to patient care
is becoming digital—the more we can’t afford to have
any downtime,” says Pacek.
Security and privacy matter as well. Healthcare providers have to meet HIPAA requirements to protect
patient privacy. A psychiatrist speaking with a client,
for example, can’t use standard free videoconferencing
applications to hold a session. Instead, they must use
an application with HIPAA-compliant architecture
that comes with a host of security features. Patients,
for example, might enter a virtual waiting room and
then be invited into a virtual exam room that can be
opened only by the room’s owner.
4 | THE VIRTUAL DOCTOR
THOMAS PACEK,
Vice President and CIO,
Inspira Health Network
the Internet?” asks Yanez. Data is handed off from
one network to another, exposing the sender to the
possibility of an embarrassing security breach.
That is why many hospital systems use private
networks that don’t traverse the public Internet. With
the explosion of mobile devices and the growing use
of telemedicine, some of them are able to extend
their networks to include the homes of their healthcare providers through such services as “Ethernet at
HomeSM.” This service, offered by Comcast Business,
provisions off the healthcare facility’s existing infrastructure without going over the Internet, just as it
does at the other locations on a hospital network. It
is one more way that telemedicine is breaking down
the boundaries of distance and time to provide better
outcomes for patients and healthcare providers.
COPYRIGHT © 2015 FORBES INSIGHTS | 5
CASE STUDY:
ONTARIO TELEMEDICINE NETWORK
CANADIAN PIONEER
Edward Brown, chief executive officer of the
Ontario Telemedicine Network, connects doctors
and patients across a province that is bigger
than Texas and California combined. Because
of the network’s size, there is great potential for
collaboration and experimentation. And because
of the network’s long history, Ontario has been
ahead of the curve at every stage of telemedicine’s evolution.
The buildout started in the late 1990s as a
private network, before the public Internet was
equipped to handle either the kinds of telemedicine applications Ontario wanted to use or the
populations Ontario needed to reach. About 15
years ago, the network moved to IP video conferencing with hardware-based devices at all
the end points—3,400 at last count—in every
hospital and many mental health, primary care
and rural care facilities across the province.
“We probably had the biggest IP video network
in the world at that time,” explains Brown. This
was before popular services such as Skype and
Facetime took off. Now, with the availability
of higher bandwidth and greater Internet coverage, Ontario has rolled out PC and mobile
videoconferencing that’s integrated with the
private network.
6 | THE VIRTUAL DOCTOR
“Last year, because of telemedicine, patients
avoided about 260 million kilometers of travel,”
says Brown. “That’s the equivalent of going
to the moon and back 330 times.” The private
network is particularly important for reaching
remote places where there are no doctors—and
no Internet. “We deal with a lot of rural areas
that may never have good Internet access.”
But the bold new frontier for Ontario is connecting directly with consumers via their device
of choice. One example: people with chronic
diseases can stay healthier and avoid crises
by learning to self-manage their conditions.
Patients send vital signs to their healthcare providers, and nurses coach them through routine
care and diet as well as monitoring compliance.
“We are reducing hospitalization by about 50%
for patients with congestive heart failure and
chronic lung disease. These are people who visit
the hospital often, and we are keeping them at
home,” he adds. Telemedicine is also a boon to
post-surgery and complex care. “We are starting
to give people apps so they can communicate
with a nurse if they have an issue, so they don’t
have to visit the emergency room,” he says.
CASE STUDY:
INTOUCH HEALTH SYSTEMS
HOW TO BE IN TWO PLACES AT THE SAME TIME
Yulun Wang, founder of InTouch Health Systems,
is an engineer by training who worked on the
surgical robot technology that is ubiquitous in
operating rooms today. But in 2002, he saw how
robots and the ability to control them remotely
could change the delivery of healthcare throughout the hospital.
“Having experienced telesurgery, I thought
we would be able to generalize that concept
using the Internet as the backbone,” says Wang.
“And with remote presence robots connected
to a cloud-based network, I thought we would
be able to better utilize the clinical resources
we have.”
Wang saw the possibilities of building on another
crucial element underlying the explosion of
many telemedicine innovations: the movement
to electronic medical records. “Once medical
information is electronic, it becomes portable,”
he explains. “Now a remote physician can not
only interact with the patient, staff and family
from afar, but he or she can also get pertinent
medical information like lab reports, CT scans
and physician notes,” says Wang. “Now you can
truly deliver care remotely.”
Some of the InTouch robots are like giant computer tablets on wheels, with video cameras
and other monitoring equipment that can be
operated by the doctor on some models, or by a
nurse in the room on others. The patient sees the
doctor’s face on screen while the doctor can pull
up medical files, sort through the readings and
direct the nurse, all while examining the patient
via video and other remotely enabled diagnostic
equipment.
To avoid the latency and frozen screens
that plague the free video chat services most
consumers use, InTouch developed and deploys
a highly efficient cloud-based computing system
that utilizes bandwidth optimization techniques,
compression and decompression algorithms,
and various optimization strategies to give the
clinician the best possible experience. “When
a doctor starts moving a robot, the image may
be lower resolution initially in order to keep up
with the movement, but then resolves to high
resolution when more stationary and examining
a patient,” says Wang.
The typical InTouch customer is a healthcare
system looking for a better way to leverage its
specialists across a wider range of locations. “We
sell the hospital the InTouch Telehealth Network,
which is layered on top of the hospital system’s
backbone infrastructure,” explains Wang, “and
the hospitals generally provide the physicians
who use it.”
For doctors, controlling a robot is “like having an
avatar that can interact in another environment,”
he says. Telemedicine used to be about providing access. “But in the future, we might use it
to see a patient down the hall—like the way we
text someone in the other room now. It’s a more
efficient way to get your work done.”
COPYRIGHT © 2015 FORBES INSIGHTS | 7
CASE STUDY:
C3O TELEMEDICINE
DOCTORS ON DEMAND
Herb Rogove is founder of C3O Telemedicine,
a service that specializes in providing physicians
for the delivery of care to critically ill patients.
Doctors in the C3O network work primarily
with patients in cases where there may not be
a specialist available for a face-to-face diagnosis in the first crucial minutes when a stroke
is suspected.
His experience running an intensive care unit at
a large university-affiliated hospital inspired him
to find a way to use technology to speed diagnosis. “We would often get patients from smaller
facilities,” he explains. “They would come to our
hospital for resuscitation, but a large percentage
of them died. We were too late to help them.”
Rogove founded C3O in 2007 to deliver physician services on demand. He recruited doctors
from university hospitals and large tertiary care
facilities like UCLA. Most of them, like Rogove,
are critical care intensivists used to working in
an ICU setting with patients on ventilators or
gun-shot victims. “Eight years ago, we saw a
decrease in the number of intensivists and
realized we could leverage telemedicine to help
us care for patients,” he explains. “For hospitals that don’t have the expertise or who can’t
get a doctor in fast enough, we can beam in to
assess a patient,” he says. “We’re not replacing
any doctors, we are just providing a service the
hospitals can’t offer.”
Even in a well-staffed hospital, there may not
be a neurologist available in the emergency
room if a patient comes in with signs of a stroke.
For an ER nurse, for example, “we can be their
doctor buddy,” to help them determine whether
or not they are witnessing a stroke or a stroke
8 | THE VIRTUAL DOCTOR
mimicker, like low blood sugar. And if there is a
neurologist on duty in the emergency room, but
someone in cardiology has a seizure, a physician in the C3O network might be able to beam
in faster than a specialist on another floor. “You
have only 60 minutes if a patient is eligible to
get a clot buster,” explains Rogove. “It can mean
the difference between being paralyzed for life
or being able to resume some kind of normalcy.”
When the call comes, a doctor in the C3O
network will usually respond within five minutes—three minutes if a stroke is suspected. In
southern California, where C3O is based, that
sometimes means doctors are pulling off the
freeway and booting up their tablets on whatever network is available. “So we are connected through one channel to examine a patient
remotely, usually with a nurse and the
family present,” he says. Then the doctor accesses
patient records through the physician portal—
a different process in each of the 20 hospitals
with which C3O works.
C3O specialists use a robotic system onsite to
examine patients. “The quality is so good that
you can beam in on a patient’s pupil to see if it
dilates when a light is shined, or look through the
hair on someone’s arm to see if there is a rash,”
he says. Some stroke patients can be treated
before they even reach the hospital—in emergency vehicles equipped with CT scans and with
the help of a physician beaming in.
“We are seeing technology creep into every aspect of acute medicine, from skilled nursing to
home healthcare,” says Rogove. “It’s not science
fiction anymore.”
CASE STUDY:
TELEPSYCHIATRY
THE CYBER PSYCHIATRIST
Peter Yellowlees, a professor of psychiatry at
UC Davis, has helped pioneer the field of telepsychiatry. He held his first remote session via
video conference in 1992. Since then, he has
treated thousands of people using telemedicine.
Part of his work involves better understanding of
how people respond in virtual space. “Are there
certain groups of patients who would be better
treated remotely than in person?” he asks. “Or
certain techniques that would be better to use in
a virtual setting?”
In a video session, there is a lot of eye contact
and you can have very intense conversations, he
explains. At the same time, there is a little more
distance. “From a clinical point of view, that
can be a good thing because you can observe
more objectively.” For agoraphobic or paranoid patients, or for patients who might be aggressive or dangerous—or for children who are
used to video chats—a virtual session may be a
better option.
The professor is also working on some futuristic
applications: helping with the creation of avatars
that interact in virtual worlds. “The military has
already done a lot of work on this with a view
to providing therapy to veterans,” he explains.
A veteran can create an avatar and be inside
an Iraqi souk or driving a vehicle when an IED
goes off. They can re-experience some of the
horrors of war but in a virtual setting with a
real therapist.
The next step: virtual therapists. Yellowlees
has worked on an artificial intelligence project
pioneered by Albert “Skip” Rizzo at the University of Southern California to create an avatar
therapist, trained to respond in certain ways
to certain cues. The project began by taking
hours of videos of patients and then bringing in
psychiatrists such as Yellowlees to analyze the
movements and cues of patients, capturing doctors’ reactions and then programming cartoon
avatars to respond appropriately to patients’
cues. The avatars are not being used yet, but
when they are, they could combine the collective knowledge of psychiatrists with many years
of experience and training into a completely
virtual doctor.
COPYRIGHT © 2015 FORBES INSIGHTS | 9
CASE STUDY:
BOSTON CHILDREN’S HOSPITAL
MY FIRST ROBOT
Naomi Fried, chief innovation officer at Boston
Children’s Hospital until last December, and
her colleagues have had to be more creative
than their counterparts at most other hospitals.
“Pediatrics is a small market,” she explains. “Kids
are generally healthy, so it’s hard to get the
attention of big device manufacturers or drug
makers to work on pediatric problems. That’s
why you see our doctors and clinicians really
pushing the envelope in a way that you wouldn’t
see in a typical adult hospital.”
Boston Children’s Hospital has one advantage
when it comes to adaptation: children love
technology. And they really love robots. One
of the hospital’s pilot programs sent kids home
with mobile robots after urological surgery
to facilitate virtual video visits instead of
requiring them to come back for a follow-up visit
in person. During a video visit, the robots could
accompany the kids to the bathroom when
the doctor needed to see what was going on.
Doctors could connect with the patients virtually and in a mobile way that was far less intimidating to the kids and more convenient
for parents. Many young patients named their
robots, and some cried when the robots had to
go back to the hospital.
The hospital also piloted a novel approach to
a persistent problem: children were missing
their follow-up appointments after being diagnosed with a concussion. “It’s very important
10 | THE VIRTUAL DOCTOR
at the six-week mark to make sure it’s safe for
kids to return to sports or other activities,” says
Fried. “When we offered the follow-up visit as a
virtual visit, compliance was much less of an issue,” she says. “It’s much more convenient for
parents and much safer for children than no visit
at all.”
Another pilot program tested asynchronous
teledermatology. Asynchronous applications are
already common in radiology. Digital imaging
was one of the original examples of telemedicine and one of the first to employ asynchronous
diagnostics. Whenever a technician takes a PET
scan or CT scan and sends the image to a specialist to read or a diagnostician to interpret or
to the practitioner who will be treating a patient,
this is asynchronous telemedicine in action.
At Boston Children’s Hospital, primary care doctors who participated in the teledermatology pilot program could take a picture of a rash and
send it to a dermatologist. Patients and their
parents got the information back quickly from
their primary care doctors without the need for
a follow-up visit to a specialist. In most cases
the primary care doctor could treat the problem,
saving weeks of waiting to see a specialist.
“I think in a few years we won’t be talking about
telemedicine anymore,” says Fried. “It will just be
how we practice medicine, and we won’t even
think about the fact that it’s virtual.”
ACKNOWLEDGMENTS
Comcast Business and Forbes Insights would like to thank the following executives and experts for sharing their time and expertise:
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Naomi Fried, :
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&MSKIR-HIGJSVQIVP]'LMIJ-RRSZEXMSR3J½GIV&SWXSR'LMPHVIR´W,SWTMXEP
Thomas Pacek,:MGI4VIWMHIRXERH'LMIJ-RJSVQEXMSR3J½GIV-RWTMVE,IEPXL2IX[SVO
Herb Rogove,*SYRHIV'38IPIQIHMGMRI
Yulun Wang,*SYRHIV-R8SYGL,IEPXL7]WXIQW
Tomas Yanez,(MVIGXSVSJ)RXIVTVMWI1EVOIXMRK'SQGEWX&YWMRIWW
Peter Yellowlees,4VSJIWWSVSJ4W]GLMEXV]9'(EZMW
COPYRIGHT © 2015 FORBES INSIGHTS | 11
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