Overview of Telemedicine ProgramOverview of Telemedicine Program

December 16, 2009December 16, 2009

Management TeamManagement 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

Overview- ChallengesOverview- 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

Overview- DemographicsOverview- 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

0

10

20

30

40

50

60

<18 18-54 55-64 65-74 >75

2000

2004

2050

Source: Chartbook on trends in the Health of Americans, Health, United States, 2005

% o

f p

op

ula

tio

n

LimitationsLimitations There are limitations in the current model of physician coverage at Skilled Nursing Facilities

• Limited supply of primary care physicians, especially geriatricians

• Response times to clinical questions in SNF can range from hours to days

• Physician consultation over the phone is constrained by:• Limited time of the provider• Limited knowledge of the patient• Lack of visualization of the patient• Lack of access to medical records

• Consultation results in blind diagnosis or unnecessary transfer to the Emergency Department

SolutionSolution

PhoneDOCTORx is an innovative company targeting the growing medical needs of the nursing home population

• Physician coverage service for skilled nursing facilities in New England

• Utilize existing telemedicine technology to perform physician consultation with patients

• Implemented at our first trial site in June 2006 in a 154 bed SNF in New Bedford, MA

• Currently in 3 sites, expanding to 6 facilities January, 2010• Operational 7 days/week

• 5pm-11pm Mon-Friday• 10am-7pm Sat., Sun.

• Staffed by Board Certified physicians in Internal Medicine, Family Medicine, and/or Emergency Medicine

Technology SolutionTechnology Solution

• Wireless cart is portable and self-contained• Tandberg equipped camera• High definition capability• Camera operated remotely by physician at

call center• Additional wound/dermatology camera

available• Battery operated• Ability to bring multiple providers on screen

to patient• 3 process patents and 2 patents pending

Overview- OperationsOverview- Operations

Clinical Process

1. Clinical question or concern arises at a SNF2. SNF nurse contacts PhoneDOCTORx at our call center3. Medical triage assistant prioritizes call4. Physician pulls up patient records electronically

• Discharge summary• Medication list• Progress notes

5. SNF nurse discusses case with physician by phone6. Nurse rolls telemedicine cart to patient room to initiate

consultation7. Physician writes orders as needed and electronically

transmits progress note of encounter to SNF

Clinical BenefitsClinical Benefits

PhoneDOCTORx can improve quality of care and life at skilled nursing facilities:

1. Reduce time delay in responding to clinical problems at SNF2. Visualization of patients can provide physicians more information

to make better decisions3. Access to medical records allows better decision-making

• Review labs, XRays, medications4. Assist in stabilization of emergent patients being transported to

the ER5. Documentation of clinical encounters ensure better continuity of

care6. Address pain/behavioral issues immediately

• Adjust pain medications• Control agitation without restraints

Overview- Additional BenefitsOverview- Additional Benefits

Providing our telemedicine service creates real benefits to the patients, clinical staff, physicians, and SNF

1. Provide higher level of acuity of service at SNF• Our physicians provide immediate care and manage the

spectrum of acuity2. Reduce unnecessary transfers/readmissions to hospitals

• 2007 New York Study by Grabowski approximates 31% of inpatient admissions avoidable

3. Increase admissions and occupancy• Marketing opportunities to community/family/hospitals

4. Attract PCPs with large practices• Decrease the burden on PCPs during afterhours/weekends

5. Improve nursing recruitment & retention• Nursing satisfaction very high with program• Provides real-time support to nurses

Unnecessary HospitalizationsUnnecessary 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, et.al (2007)

• In New York State, between 1999-2004, spending increased 29% on nursing home hospitalizations

• During that time period, $972 million in aggregate spending• Total cost per hospitalization $12,160 (2004)• 40% deemed avoidable admissions based on diagnosis• This results in $223 million potential cost savings• Admissions result in increased iatrogenic disease and delirium• Conclusion “…policies directed at decreasing nursing home

hospitalizations may generate major cost savings for Medicare program”

OverviewOverview

Telemedicine program is a platform for additional/future services

PhoneDOCTORx Service

Increased access to physicians

Specialist consultation

Family conferences

Education• Continuing medical education• Lectures/seminar via telemedicine

• Discussion with family

• Wound care• Psychiatry

• Real-time medical consultation

Clinical Summary: OverviewClinical Summary: Overview• There have been over 10,000 documented encounters between June 1, 2006 and present at three sites

Clinical Summary: DispositionClinical 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.

ER 5%

Nursing Home95%

Overall Disposition Distribution

Emergency Department

Nursing Home

Clinical Summary: Chief ComplaintsClinical Summary: Chief ComplaintsThere is a wide distribution of cases seen during the first year.

Distribution of Chief Complaints

Medication13%

Psychiatry/Behavioral4%

Pulmonary8%

Radiology2%

Endocrine2%

Orthopedic3%

Opthalmology0%

Cardiac3%

Laboratory23%

Infectious Disease/Fever

2%

GI7%

Gynecology0%

Neuro3%

Other10%

Skin8%

Trauma7% Allergy

0%

GU4%

ENT1%

Allergy

Cardiac

Endocrine

ENT

Gastrointestinal

GU

Gynecology

Infectious Disease/Fever

Laboratory

Medication

Neuro

Opthalmology

Orthopedic

Other-see comments

Psychiatry/Behavioral

Pulmonary

Radiology

Skin

Trauma

Clinical Summary: TransfersClinical Summary: Transfers

Clinical Summary: TransfersClinical Summary: Transfers

Clinical Summary: Overall BenefitsClinical Summary: Overall Benefits

How do you value the service PhoneDOCTORx provides?

Value

PhoneDOCTORx Access Fee

Potential cost savingsfrom unnecessary ED transfers

Access to care/improved care

Marketing tool

Staff retention/recruitment

$/month

Patient/family satisfactionAdditional benefit

Financialbreakeven point

$

Physician recruitment

Regulatory compliance

Legal ConcernsLegal Concerns

• Received support from Massachusetts Department of Public Health

• Operating as covering physicians for primary care physicians

• No impact on malpractice premiums for telemedicine physicians

• Telemedicine consult enables a more thorough and informed evaluation versus status quo

Business ModelBusiness Model

Chains52%

Independent48%

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

Chains52%

Independent48%

Barriers to AdoptionBarriers to Adoption

There are several real and perceived barriers to adoption of our program

Costs Nursing homes bear cost of program with limited resources

Subsidize costs by insurers/government• Senior whole health• Medicare

Barriers Solutions

New technology Healthcare slow to adopt new technologies

• Demonstration projects• Marketing• Consumer driven demand• Policy changes

Expansion StrategyExpansion Strategy

After successful trial at existing sites:

• Market to local and regional nursing home chains• Market to physician groups that provide nursing home care• Partner with third party payers

• Regional payers (SCO’s)• Large private/government payers

• Market to large national nursing home chains• Academic prospective study with Grabowski, Professor, Harvard

University

PhoneDOCTORx ServicesPhoneDOCTORx Services

SNF• Consultation services to develop customized

telemedicine programs for individual sites • Implementation of telemedicine program

Hospital• Consultation services for customized “30 day

readmission” program• Coordination of SNF/Hospital continuum of care

Questions?Questions?1-866-539-PDRX1-866-539-PDRX

www.phonedoctorx.comwww.phonedoctorx.com