PODCAST

Kenton Williston: Welcome to the IoT Chat, where we explore the trends that matter for consultants, systems integrators, and enterprises. I’m Kenton Williston, the Editor-in-Chief of insight.tech. Every episode we talk to a leading expert about the latest developments in the Internet of Things. Today I’m talking to Dr. Richard Bakalar, Chief Strategy Officer at ViTel Net, provider of virtual-care platforms. Richard has an extraordinary career in telemedicine that stretches back decades, long before the concept was popularized. Now he’s focused on making telehealth an integral part of healthcare infrastructure, and helping care providers innovate with the latest technological advances. So, Richard, first and foremost, I want to welcome you to the podcast.

Dr. Richard Bakalar: Thank you very much. And look forward to sharing with you some of the experience that ViTel Net has had in the industry around telehealth and my colleagues as we’ve made this transformation over the last several years and, more importantly, over the last 18 months.

Kenton Williston: Fabulous. Can’t wait to hear it. What do you do in your role at ViTel Net, and what does ViTel Net do as a whole?

Dr. Richard Bakalar: ViTel Net has been in the industry for over 30 years and, most recently, ViTel Net has been able to leverage its experience in building a configurable platform that’s integrated into the health IT infrastructure, leveraging industry standards. But, more importantly, being able to support the continuum of care—from inpatient, outpatient, critical care, home, post-acute care, schools. The entire community can be supported on a single platform with multiple modules. And my role as Chief Strategy Officer is to help the leadership team define innovative opportunities for the future. More importantly, other than that, I work with my Chief Medical Officer, Rob Kolodner, as we work with customers to help them innovate their workflows around new delivery models—not only the ones that have been proven around stroke and behavioral health and the ones that everybody’s familiar with. But more these newer models—such as school care, post-acute care—a variety of new service lines that can be accomplished using the same technology, with minor modifications in the configuration of the software.

Kenton Williston: That’s great. And what did you do before this? How long have you been involved in telemedicine?

Dr. Richard Bakalar: My first job out of medical school and training was the Senior Flight Surgeon to the White House, and I had the opportunity to travel with the White House internationally, and really learned the challenges of being isolated, from a medical perspective, around the world. Later, I was at Oakland Naval Hospital during the earthquake in 1989, and found contingency operations—being isolated once again—when communication was impaired, and how to work with teams that are not necessarily the teams you normally work with. So, those were kind of early opportunities for me to be challenged as a clinician, and really understanding the value of remote care. Later, as I had the opportunity to lead the Navy’s telemedicine transformation in the 1990s, the Navy Surgeon General gave me a mission. He said, “Move information, not people. And bring specialty care to the deckplates”—was his mission statement to me.

And I had the opportunity to transform a variety of different platforms to use telemedicine in a way that it hadn’t been used before. We had everything from mental health to surgical specialties, dermatology—a variety of different specialties that really impacted the ability to provide the same quality care thousands of miles away from the United States at the deckplates in matter of minutes—as opposed to weeks or months, prior to the implementation of telemedicine on ships. That transformation of the Navy was really something that really helped me understand the value that could be employed—not only in the military, but also in the private sector as well.

Kenton Williston: This is a really impressive and long history with telemedicine, stretching back well before most of us were thinking about it. So, what are some of the lessons that you’ve learned along the way? And what are your thoughts on how that sector has evolved, growing from its initial implementation?

Dr. Richard Bakalar: Well, as I migrated from the military experience into the private sector, I had the privilege of being the president of the American Telemedicine Association in 2006, 2007, and worked with many of my peers, not only in the public sector, but in the private sector. And what we learned is that a lot of organizations had projects that were departmentally focused. Each of those projects independently created a capability as a proof of concept around how telemedicine could impact their care. What I learned early on is that you needed more of a programmatic approach. Because, in a project model, the project lead doesn’t usually continue beyond a few years, and then so the sustainability of a program is in jeopardy. In addition, the program offers the ability to cross different departments, similar to how radiology does.

If you think about radiology, you don’t have a separate radiology division within each medical specialty: you have one radiology department that supports the entire continuum of care within the health system. And, similarly, a telemedicine model could leverage that kind of a model for a program where we could take advantage of what’s available—from a protocol perspective, from a business perspective, and even a technology-infrastructure perspective—and just change those minor things that need to be changed to adopt specialty modules on a single platform.

And so that was one of the lessons I learned early on, is that governance needs to be centralized, technology needs to be centralized, and leadership needs to be top down to provide strategic support for the program—both from a technical, administrative, and clinical perspective. But the innovation actually comes from the bottom up, from the end users in the field—in the deckplates, as we call it in the Navy, or deck plates—or in a hospital at the bedside, where a lot of those ideas about innovation can be brought up from the bottom, and support comes from the top. And when you have that kind of multidisciplinary approach in governance, telemedicine can scale very nicely and can be very effective.

Kenton Williston: So, this totally makes sense then, why you were drawn to ViTel Net. I know the key value that ViTel Net offers is a platform that you can innovate on top of. And I’m thinking—in comparison to what a lot of people have been doing, for example, during the pandemic—there were a lot of ad hoc solutions rolled out. Understandably so. People had to just make something work in short order. But there were all kinds of unique, single-purpose solutions rolled out that I think a lot of folks are trying to figure out now how to roll back into their larger practice. And I think that’s a challenge for a lot of folks. And I think this idea you’re putting forward—of starting with a platform first that’s broadly accessible, so that all the practitioners and all the experts can actually innovate with it—it really makes a lot of sense, especially in current context.

Dr. Richard Bakalar: One of the things that I think about—when you think of a platform, it’s not just the data. Obviously, data is very important, and documentation needs to be appropriate for the different delivery-service model that you’re going to apply. But the workflow needs to be integrated, and the reporting needs to be integrated as well. And that’s the challenge of using what I call an “app store approach” to telehealth or telemedicine—where you have lots of different single applications that are not necessarily linked together. Data doesn’t flow between them, the workflow is not totally integrated, and the reporting is not necessarily normalized across those different applications.

And so having a platform with modules allows you to normalize or harmonize the workflow, the reporting, as well as the data capture. And then also linking it back to the systems of records—such as the electronic health record, the PAC systems for images, and the business and related financial systems—that all needs to be in concert in order to provide a service of telemedicine. And I always recognize that telemedicine is not a technology; it’s a service. And I think that’s an important concept that organizations, as they grow their programs, need to think about. Everything you need to do for face-to-face care, that capability needs to be available in the telemedicine sphere as well.

Kenton Williston: Yeah, I agree. And I think it’s important to consider both sides of the experience, right? So it makes sense for the providers to have tools and workflows that make sense to them. But also from the patient perspective, there’s a real importance in having an experience that’s as close as possible to an in-person experience. Or really even, in some cases, I think telehealth can be superior to an in-person visit. And I’m interested in hearing, from your point of view, what would go into making for those really good experiences, from the patient perspective.

Dr. Richard Bakalar: Yeah, it’s a very interesting point. And I really like the idea that you said sometimes telemedicine or telehealth can actually be superior to a face-to-face experience. Having that convenience factor is one advantage, but a more important, I think, factor is getting the right data at the right time. And one of the challenges with a face-to-face is often there’s a lag between when a patient requests care or is scheduled for care, and when a patient has a problem. In the telehealth sphere you can actually synchronize those times and provide better context—the idea that the patient may be at home, and you may see some things in the background of the video, for example, that may show a compromised environment for the patient—that actually may not be available when the patient is seen in their clinic environment or the hospital environment.

And so the ability to get more context, to have it more timely, to have it more convenient, to be able to have more frequent evaluations, rather than once every quarter or once every half year to be seen in the clinic—I think offers a lot of flexibility, so that we can optimize the care schedule, as well as optimize the care environment for the particular situation. So, sometimes face-to-face is superior—where there’s a physical context required. Sometimes, when timing is sensitive, then a virtual visit may be a better option for that particular encounter.

Kenton Williston: Yeah. I love that point you’re making about having the context, right? I’ve even had this in my own personal experience, just not thinking to mention various symptoms or circumstances, because to me they were totally normal. Then a doctor managed to catch it at some point, and I went, “Oh, I didn’t even think to report that to you. But, okay, good to know that that was something I should be keeping an eye on.” So, yeah, that very much makes sense to me.

Dr. Richard Bakalar: One of the things that telehealth offers us is that we can bring in other health professionals that are not necessarily physicians that can add value using these capabilities, as well. So, let me give you a real-world example. We’ve been involved with the NETCCN project—The National Emergency Tele-Critical Care Network—that is sponsored by the US Army, and Health and Human Services. And one of their innovative projects was out in Southern Florida, where the EMS team was going into patients’ homes and providing them antibodies for those that are early onset of COVID, for example. And one of the challenges in that situation is that they need to be monitored for a period of time after the infusion of the medication.

And the ability to use telehealth protocols and technology infrastructure to be able to do that, and allow the EMS teams to go to the next house. And yet have the patients being monitored for a period of time, and then reengage the health system if the patients were to do poorly, reassure the patients if they’re not doing poorly, and provide a scale that’s much greater than it would’ve been if the patients had to travel or be seen elsewhere.

Kenton Williston: Yeah. This calls to mind what you were saying earlier—about radiology, and how it’s a cross-functional, cross-departmental service that’s being offered to whoever needs it. And in much—in the same way, you’re laying out this scenario where different specialties, people who are in the field, people who are back in the clinic, can collaborate together—really add some value you just can’t get any other way. So, I think a key question in my mind is, why has this little integration and collaboration been so difficult in the healthcare industry? And what needs to happen to break down those barriers?

Dr. Richard Bakalar: Like I mentioned, we have a fragmented approach in the private sector, primarily by departments. And so each individual department has a separate project officer or a separate technology—that data is siloed. There’s not a business model yet, because reimbursement has been very limited and very focused on what the payers felt was important—not necessarily what was providing the best clinical outcome. And so I think during COVID we learned a lot, and I think that’s expedited our transformation from the business-as-usual, to now new opportunities to see. We know that it can work. We found that it worked when we had to increase from a 5% utilization to a 30% to 80%, depending on where you were during the COVID pandemic.

And so now the challenge is, how do we transform the governance, the technology infrastructure, the business-reimbursement models, the regulatory barriers that have been up in the last 10 or 15 years, and getting the adoption and acceptance by the patients. And, more importantly, by the providers, who have been hesitant to adopt this capability because, two reasons—one is they were very busy with face-to-face care; when COVID came, they didn’t have that—patients weren’t coming into the clinics or the emergency room. And they had to use the technology to be able to access their patients. They recognized the value of it. Now the issue is going to be there’s going to be more patients than they have availability for, and we still have problems with access. And so how can they better utilize limited resources—physician resources, ancillary health resources, other staff resources—to be able to provide better care to more people, more equitably, around the health system?

Kenton Williston: Yeah. That’s quite a cluster of challenges. Some of those, organizations can address internally. Some of those, though, are external factors—regulatory factors, reimbursement factors. Do you see those things going in a direction that will make these hurdles less onerous?

Dr. Richard Bakalar: I absolutely do. And I think the reason for optimism, I think, right now, is the fact that the patients have seen the value. They’ve used video conferencing for their work, they’ve used it for entertainment during this pandemic. And they say, “Why can’t I use it for my healthcare services as well?” So the patients are going to demand better access to telehealth services going forward. The payers have seen that it can actually save money for them in the long run—especially when it’s used for chronic conditions, especially when it’s being used for the high-cost services in the hospital health system. And so episodes of care can be less expensive, even if individual encounters may be more expensive until the infrastructure has been scaled.

I think health systems are going to recognize that they’re understaffed in a lot of cases, and telehealth can be more efficient. So it provides a lot of opportunity for them. I don’t think it’s going to be consistent and 40% to 50%, 60% level of transactions. I think it’s going to settle out at the 25%, 30% perhaps, once it’s all optimized. And when I say optimized, there has to be that governance I was talking about—centralized support, training, protocols—consistent across specialties. Infrastructure needs to be integrated with electronic health records and other platforms.

And the key there is if you have multiple apps, it’s very expensive to maintain those interfaces. However, if you have one platform that has multiple modules, maintaining that interface with the electronic health record and the data warehouses and the financial systems is much easier to maintain—especially if you’re using industry standards. And so the centralized governance and organization and programmatic approach to telehealth will allow us to scale and be sustained at that 25% to 30%, once it’s integrated into our health system. If it’s going to continue to be siloed as separate applications and separate departmental approaches, I think it’ll revert back to the 5% or 10%. And so I think that’s one of the things that organizations have to make some investments and decisions on how they want to proceed going forward.

Kenton Williston: Yeah. So, a lot of positive things there. One thing I want to touch on a little bit more in detail is the question around electronic health records. So, this has been an area where there have been visions of streamlining and unifying the medical industry for a long, long time. And it’s just been very, very challenging, right? You’ve ended up with different flavors of EHR systems that just don’t talk to each other. And, like you said, different interfaces; and it’s been very difficult to manage. So, where do you see the state of affairs now? And how do you see a platform like ViTel Net addressing those issues?

Dr. Richard Bakalar: The challenge with electronic health records is that they’re such a dominant role in the care delivery and workflow, that there’s a lot of demand for organizations to make the modifications in those electronic health records to support new delivery models and new documentation requirements as payment requirements change, and as regulatory changes, and so forth. So, telemedicine has gotten a backseat, so to speak, in its ability to be included into the electronic health record in the past. That’s changing now, because of the dominance of telemedicine over the last year, year and a half. But that still doesn’t change the fact that EHRs were primarily designed to be true transactional systems. They were not designed to be customizable, configurable workflow engines that can meet the demands of a remote or virtual visit that telehealth requires.

Where ViTel Net can play is that we are very agile. We can make very rapid changes in our platform and then link into—using the industry standards—and share the critical components with the transactional system. Both at the front end—pulling in demographic information, historical information, and then sending back the results of an encounter, summarized—and put that back into the system of record, the electronic health record, at the end of a transaction, and provide that continuity of care that’s needed for both face-to-face and virtual care. So we can help with the virtual visits, provide the video conferencing, the language processing—a lot of the details that are required for a virtual visit that electronic health records were not suited to do, and provide that information back and forth to the electronic health records.

Kenton Williston: Interesting. Interesting. I wouldn’t have imagined that that would be such an incredibly huge barrier. But I can see your point—how a system that’s built purely to be transactional would not really offer you the greatest level of agility. One thing I am wondering—we’re talking about adding onto existing systems, rather than starting from scratch, which, again, I think makes a lot of sense. One of the things that people have been talking about a lot in the past couple of years and increasingly going forward, I think, is how to take this existing data and make better use of it through things like AI and machine learning. And I just heard you mention, for example, language processing—which I think is an important part of that, right? Having some bots be able to handle some of the initial interactions. So, where do you see the role of these technologies today, and where do you think they’re going in the near term?

Dr. Richard Bakalar: One of the challenges is all of the virtual visits that have been done over the last several years have been absent from those data warehouses. And so let me give you some examples. When I was in my prior role at Microsoft, we tried to use the electronic health record to be able to predict, when a patient came in the ER, who would be readmitted in the future, and who needs to be admitted, and who needs to be sent home with more supportive care. And one of the challenges we found is that if you only use the data in the electronic health record—particularly the inpatient record—you’re only going to get a 70% to 80% predictive model, because you don’t have the right data that you need to make that algorithm more accurate.

One of the things that is missing is when you’re doing 20% or 25% virtual visits and that data is not incorporated in your data warehouse, then you’re missing the opportunity to take advantage of that important information. Now, why isn’t it in the data warehouse? And the reason is because most of the transactional systems, the electronic health records, don’t code for telehealth. Because in the past it’s been a very small fraction of their business, and they really haven’t taken the time to even code for it. Or these siloed applications aren’t even tied into the electronic health record; they’re standalone systems.

At the 5%, it wasn’t a big deal. It’s kind of a rounding error, so to speak, of their business. And those cases were typically single events, they weren’t continuity-care events; and it wasn’t a problem. But now, as we move into chronic care and predictive models and automation going forward, those virtual-visit requirements are going to be even more and more critical to getting accurate analysis of not only patients, but population health. And so the ability to code things properly, to be able to include them into the data warehouses, and have a complete and more comprehensive view of the patient—it’s going to be more critical to get more accurate machine learning and artificial intelligence going forward. And that’s why it’s so important not to let the latency of getting this into electronic health records be a barrier to more advancements using some of the new analytics that’s coming down the pipe.

Kenton Williston: Yeah, and that makes sense. It’s the “old garbage in, garbage out,” right? If you don’t have the right data from the real world that you’re trying to predict against, you’re never going to get to the predictions that you want to have come out the other end. The other thing that strikes me here, is if there’s a role here for things like natural language processing for translation services—some more of those sorts of real-time, patient-facing services—if you see an important role, especially in the telehealth domain, for those sort of things.

Dr. Richard Bakalar: Well I think there absolutely is. I think you’re using the KISS principle. Starting at the very rudimentary level of language processing, recognizing that not everybody has English as their first language, not everybody can communicate as well as we would like—particularly when you start having an outreach to more of our diverse population. As our population becomes more and more diverse with time, and access becomes improved, both patients and their family members and extended health networks need to be able to communicate with the health system more effectively. And so one of the things we incorporate into the telehealth platform is language services—both video as well as audio, and in multiple languages—and make it very easy for a provider to bring those on very quickly. And not only bring on the language-services capability, but also bring in other family members of their extended network so that the patients can feel more comfortably supported, and actually help get better compliance and adoption of recommendations because family members provide that family support for that to happen.

So that’s kind of the first level of language services—is just a basic communication. Now, I think what you’re referring to is the ability to take verbal or audio language, or even video. And one of the things we’re starting to see now is that you can take audio files and start looking for evidence of depression, for example—which is very interesting—or mental health issues. Now, one of the challenges in doing that is having the right context. So, a person could be anxious for a number of reasons. It may not be because they’re depressed or anxious, but maybe because something’s going on. So the ability to have that contextual background with audio files is very important. And so I think there’s great opportunity to integrate systems—to leverage some of these new technologies that are going to be available that haven’t been invented in healthcare, but can be leveraged by healthcare—as the entertainment industry, as the retail industry, and other financial industries have done the heavy lifting, and we can leverage their experience and those capabilities in healthcare.

Kenton Williston: So, something that strikes me here is we really covered a very broad swath of capabilities. And this is potentially a pretty big commitment for a healthcare organization to make—to choose a platform, choose a partner, to try to undertake all of these advancements on how they deliver care. And that leads me to wondering what healthcare providers should be looking for in a partner, and how they can have confidence that they’ve chosen a partner that’s going to be reliable, trustworthy—who’s going to be able to deliver on this broad spectrum of capabilities they’re trying to embark upon.

Dr. Richard Bakalar: That’s a great question. And I think the good news is that telehealth is kind of the third wave down this path of digital transformation. It started with PACS in the early 1990s and beyond, and then the electronic health record, and now telehealth platforms—which may, again, leverage those platforms, but also nevertheless be a similar type of a challenge in that transformation.

One of the things we learned in PACS and learned in electronic health records is you want an organization to partner with that’s going to co-invest. They’re going to share risks, they’re going to be reliable, they’re going to be dependable, they’re going to be innovative. And, most importantly, and probably the most important, they’re going to provide the kind of support you need—not only for the onboarding and for the initial implementation, but the ongoing innovation going forward, and the ongoing training and support that’s going to be necessary to make that investment a value going forward. And so one of the things that we often see is that there’s a lot of new flashy technology that’s coming out, but the organizations that provide that capability don’t have that longevity in the field. They don’t have the ability to customize it or configure it, as we describe it, in a way that’s going to be useful to the end user immediately. But, more importantly, down the road—so that you don’t have to have throwaway technology going forward as well. And, more importantly, how do you integrate that with the other systems?

Kenton Williston: This overlaps with another question I wanted to ask you, which is, again, we’re talking about a lot of different potential avenues for healthcare organizations to explore. So, do you have some thoughts on where healthcare organizations should start, broadly speaking, as they’re embarking on this greater digital transformation journey—making telehealth more central to their offerings? What are some of the first considerations they should make to set themselves up for success?

Dr. Richard Bakalar: So, first and foremost, there needs to be centralized programmatic support for this. And it doesn’t have to be a telemedicine program—it could be an innovation program, of which telemedicine may be one of the early use cases for that program. But, nevertheless, centralized governance with top-down support. And I always like to ask the Why: “Why are you doing it?” Not so much the How. The How is actually very easy today, because technology is abundant and very robust.

What’s not so apparent all the time is why you’re doing it, and what kind of problems are you trying to solve? So I think that’s a big part of it: the senior leadership needs to define the objectives, the goals, the Why of using telemedicine for their organization at this particular time. And how do they want to leverage it going forward? So that’s step number one, is that governance piece. The next is to have the multidisciplinary team assembled. So that you can have representation of not only the technologists, but also the operational folks who have to fund and support this from an investment perspective and also a business-model perspective. And then the clinicians need to be on board at the early part of the process, so that they can tell you what’s practical, and what’s needed, and where the pain points are that need to be solved using this capability. So that multidisciplinary approach and ongoing support is going to be critical.

Kenton Williston: Well, Richard, I just want to say it’s been a real pleasure talking to you. This is really exciting to hear your vision—all the things that are possible, and some practical thoughts on how we’re going to get there. So I just want to thank you so much for your time today.

Dr. Richard Bakalar: Thank you very much, and it’s been a pleasure, and I really appreciate the opportunity to share that with your audience.

Kenton Williston: And thanks to our listeners for joining us. To keep up with the latest from ViTel Net, follow them on Twitter at @ViTelNet and on LinkedIn at ViTel Net. If you enjoyed listening, please support us by subscribing and rating us on your favorite podcast app. This has been IoT Chat. We’ll be back next time with more ideas from industry leaders at the forefront of IoT design.

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