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Cloud-based retinal telemedicine pays primary care to achieve Triple Aim

By Dr. Dennis Schmuland, Chief Health Strategy Officer, U.S. Health and Life Sciences, Microsoft on August 29, 2016

Filed under Health

Telemedicine isn’t a new idea.  It’s been around for over 40 years–and most of the industry agrees on the advantages: improved access to primary and specialty care, speed, convenience and reduced cost of care and complications.  With so many compelling advantages, you’d think that, by now, telemedicine would have gone mainstream in primary care, right?  But it hasn’t.  And there’s a good explanation.

Because telemedicine rarely pays for itself when the bulk of compensation to providers is in the form of fee for service payments.  The problem is that the nearly 95% of payments to providers today are still in some form of discounted fee for service.  Under fee for service, providers are paid to deliver care, not improve the access or speed of care, or, reduce the cost or need for care—the value that telemedicine typically delivers.  So there’s no reason to expect telemedicine to go mainstream in primary care until the majority of payments to provider come in some form of fee for value.

That is, unless there’s a telemedicine service that pays for itself regardless of whether the bulk of provider payments are in the form of fee for service or fee for value.   Last month while on the road meeting with partners and customers, I found one when I ran into IRIS, short for Intelligent Retinal Imaging Systems.  It’s retinal telemedicine — high resolution retinal photos taken in primary care clinics, enhanced, and interpreted by remote retinal specialists.  During my road trip, I sat down with Jason Crawford, the CEO of IRIS to look further into why so many primary care practices are integrating retinal telemedicine even while the bulk of their payments are fee-for-service.  Below is a transcript of my conversation with Jason.

Schmuland: Jason, how is it possible that retinal telemedicine is a win for all three stakeholders–providers, health insurers, and patients—regardless of whether the patient’s health plan is a fee for service or fee for value payment model?

Crawford: With retinal telemedicine, every stakeholder involved in the care value chain benefits–and the benefits that each stakeholder realizes is in weeks, not years.  Primary care providers benefit because they get reimbursed to do in-office evaluations and their quality performance metrics improve because more of their diabetic patients actually get their required annual retinal examinations.  Ophthalmologists, retinal specialists, and optometrists benefit because their volume of appropriate referrals goes up because the patients referred to them are pre-screened in advance of their appointments.  Health insurers benefit from improved margins because they can achieve five-star HEDIS ratings and reduce their costs related to treating retinal disease since early conservative treatments cost much less than later stage interventional treatments.

“Everything is handled and processed in Azure because the wealth of tools available in Azure has eliminated any need for us to maintain our own servers or software.  This means we have zero infrastructure on premise.  And when I say zero, I really mean zero.”

Of course, diabetic patients are the biggest winners because they can avoid blindness altogether through early detection and treatment.  Today only about 50 percent of at-risk diabetic patients undergo retinal evaluation largely because of the barriers of cost, inconvenience, lack of awareness, and even procrastination.  Primary care retinal screening removes these barriers because patients can easily get this done while they’re visiting their primary care doctor for any reason.

Schmuland: Operationally speaking, what does the workflow look like for retinal telemedicine in a primary care setting?

Crawford:  For each primary care clinic we offer a customized turn-key arrangement.  Our team creates the workflows, documents the processes, and installs the best practices we have developed from over 125 health systems we’ve worked with.  The customer selects the high definition camera that works best for their environment, we provision it, and, from there, we provide the end-to-end service—everything from image transmission to expert interpretation, report and recommendation.  Any staff member can administer the simple automated exam process and the findings and referral recommendations are transmitted back to the originating primary care physician and directly into their EHR within hours.
Schmuland: The concept of remote retinal imaging for early detection of diabetic retinopathy has been around for well over a decade– but the technology has always been a bit bulky and costly.  What have you done to make it practical and pay off for primary care?

Crawford:  Retinal telemedicine wasn’t practical or cost-effective for primary care in the past because of regulatory barriers and the cost of setting up and financing the camera was high and the end-to-end process of sending the image for expert interpretation, getting the report and recommendations back, and taking action on those reports  was all done manually using paper-based processes.  We’ve removed the regulatory barriers by being the first FDA-cleared cloud-based Class II Medical Device for retinal telemedicine.  We’ve commoditized retinal scanning by removing the costs of labor and paper and then automating and taking responsibility for the end-to-end multi-point process in the cloud.  Now the loops are closed and the clinician gets the report back in their EHR as a consultation report for review and action.

Every time a CISO asks us how we’re going to protect their PHI, we tell them that we are drafting behind Microsoft’s world class expertise and experience in cybersecurity, privacy, and compliance for the health industry– and that alone was won their confidence every time.

Schmuland: Wait a minute.  This sounds like a systems integration nightmare.  Are you saying that, for every clinic you have to install and wire up the camera, send the images to specialists for interpretation, send the reports back to the primary care clinic and upload each report into the primary care clinic’s EHR?  How have you managed to automate all this and remove the usual points of failure?  What does your IT infrastructure look like?

Crawford:  Our infrastructure is 100% Microsoft Azure.  Everything is handled and processed in Azure because the wealth of tools available in Azure has eliminated any need for us to maintain our own servers or software.  This means we have zero infrastructure on premise.  And when I say zero, I really mean zero.

And with the enterprise agreement we have with Microsoft, we can pay as we grow.  There’s no need for us to build or even anticipate our future capacity needs.  Plus, the other big advantage that comes with Azure is Microsoft’s cybersecurity and privacy reputation, HIPAA business associate agreement (BAA), trusted and compliant cloud documentation in the Microsoft Azure Trust Center and their Guide to designing secure health solutions for developers.  Every time a CISO (Chief Information Security Officer) asks us how we’re going to protect their PHI, we tell them that we are drafting behind Microsoft’s world class expertise and experience in cybersecurity, privacy, and compliance for the health industry– and that alone was won their confidence every time.

Schmuland:  You selected Microsoft Azure in the early days of your company.  What were the factors back then that convinced you that Azure was the platform that would best meet your needs as an early stage growth company?

Crawford:  There were three things that sold us on Azure.  First, affordability.  I recently saw a study that showed that Microsoft Azure partners realize almost 20 percent higher margins than those of the next closest competitor.   Second, flexibility.  Our first customer was blown away when we went from design to production in just 3 months on Azure.   One of the great things about Azure is that it not only gives us high availability but it also scales from a POC to a mission critical app that serves millions of customers.  Our CIO can partition the infrastructure and hand off a copy of our infrastructure to a developer — and say, “Here’s your instance of our infrastructure — go use it, push it, break it and then when you’re done let me know so I can turn it off and Microsoft won’t charge me for it. And last, Azure is a complete platform for developers.  We use just about one of everything in in Azure — web apps, SQL Azure, virtual machines, service bus, service fabric, and the list goes on. We have all of these services at our fingertips, which means we don’t need ANY infrastructure.

Schmuland:  What gets you up in the morning for this business?

Crawford:  By 2050, the prevalence of diabetes is projected to increase from 25 million to 125 million Americans.  This means that in the not too distant future, the number of patients with diabetes requiring annual retinal evaluations will far exceed the capacity of ophthalmologists.  Half of them will develop diabetic retinopathy.  With IRIS, primary care providers can prevent blindness for nearly every one of their diabetic patients and, in the process, reduce the total cost of care and complications.  There are very few ways that primary care physicians can achieve the triple aim now and get paid to do it today.  Retinal telemedicine is one of them.  But what gets me up in the morning is knowing that we’re making a profound difference in the lives of people by preventing blindness from ever occurring.

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