Transcript:
our next speaker probably needs no
introduction in fact in our first
meeting he told me that he’s actually
been in the telehealth world really
since before I was born
and I am no spring chicken believe me so
he spent his professional career working
with governments educational
institutions and businesses to address
the problems of cost quality and access
to health care today he’s going to
discuss be where we are today with
telehealth and the future of the
healthcare delivery system and the role
and impact on the per patient the
provider and the payer please join me in
welcoming the father of telemedicine and
a founding member of the ATA to the
stage dr. jay sanders
[Applause]
well you know I’d like to begin with a
huge thank you not simply from me but
from my professor of medicine dr. Ken
Byrd who told me about his idea of
telemedicine in 1967 when I was a
third-year resident in medicine at the
MGH and I was actually running the
emergency department a late summer day
standing out in front of the ER waiting
for the next usual Boston traffic
accident victim to come wheeling in from
EMS when all of a sudden the ER doors
opened wildly and they’re standing in
the door was my professor of medicine
dr. Ken bird red-faced and sweating and
looking upset and I knew exactly why
because Ken bird
like many Harvard professors in those
days as a full professor was making a
grand total of $8,000 a year and he was
moonlighting like every other Harvard
professor and he was moonlighting as
medical director at Logan Airport
Medical station
those of you who have ever been to
Boston before the two additional tunnels
from the airport to the center of the
city will know that it used to take a
minimum of an hour each way to go from
the airport to the MGH and Ken had to do
this every single day and this
particular summer day while parked under
the Charles River in the Sumner tunnel
because that was the only tunnel there
was no Callahan tunnel there was no Ted
Williams tunnel he got an idea and as he
came storming through the door he saw me
and he came walking up to me and he
grabbed my arm and he said J and I said
I know dr. Bert I know you got caught in
the traffic again he said yes he said
but I had this idea what do you think
about it he said what if I get two TV
cameras remember this is 1967 what if I
get two TV cameras and I put one here at
the MGH ER and one at Logan Airport and
I started to examine patients over this
TV system now you have to understand I
was a resident he was my professor I
thought this was a stupidest idea I’d
ever heard of in my life but I had
enough common sense to say gee dr. Byrd
that’s a very interesting idea by 1969
we had a fully functioning telemedicine
system and by the way there’s been a lot
of debate about where the origin of the
term telemedicine came from to me it’s I
don’t understand why people are
wondering it was dr. Byrd he looked at
me and he said well look we can’t call
this television medicine because that’s
what we had television cameras he said
let’s call it telemedicine that’s how it
started okay and in 1969 we had a fully
functioning telemedicine system in black
and white there was no color but
fascinatingly the chair of pathology dr.
Benjamin Castleman the chair of
dermatology dr. Tom Fitzpatrick very
quickly adapted to the grayscale so they
could tell whether something was there
with feminists or not simply by the
intensity of the grayness every clinical
chief of service started to use the
system we even had developed an
electronic stethoscope that seems
commonplace today it wasn’t then but it
was one chief of service who said this
will never ever work in my area and who
is that
that was dr. Tom Dwyer chair of
psychiatry now you might imagine my
professor and by the way please
understand Ken Byrd is the father of
telemedicine I’m not I’m just a good
student of his Ken bird came to Tom
Dwyer and said Tom you’re wrong and Tom
said Ken listen this cold mechanistic
technology will never ever be able to
reproduce at special ambience between
the psychiatrist and his or her patient
in the room together and Kenan was a
maverick Ken got some additional dollars
from the then general director of the
hospital dr. John Knowles who was the
equally Americ and they put another TV
camera out at the Bedford VA hospital
where Tom Dwyer and his faculty used to
travel everyday to see the VA patients
at the Bedford Roxbury VA hospital
three years later Tom Dwyer and his
entire faculty wrote a series of
articles they actually came out in 1973
on the incredible effectiveness of
telepsychiatry and what they found what
he specifically found was not only could
he reproduce that special ambience more
importantly he could manipulate the
ambience what he found was when he was
dealing with a patient
that he really wanted that patient that
think about what he just said he wanted
him to chew on it and swallow it he
would begin to pan remember these with
TV cameras and I saw that in your that
ability in your presentation he was able
to pan the camera in and this is what
TV TV directors movie directors tell you
well of course we create the emotions of
a scene not simply by the dialogue not
simply by the way the actors faces
appear but the way we shoot the scene
and when Tom Dwyer wanted this patient
to really think about what he just told
him he began to pan the camera in on his
face
so as the patient is watching him his
face is getting bigger and bigger and
bigger to the patient this was like
coming from a much higher authority and
when he felt the patient wasn’t ready to
deal with the intensity of the moment
and he really wanted a sort of you know
sort of mitigate the intensity he would
sort of pan the camera back and he
became miniaturized in the patient’s
view as you know after teleradiology
probably the most frequent consultation
today is telling psychiatry you’ve all
seen this I’m sure but I show it all the
time because it’s genius
it’s pure genius and it still tells us
today what we need to do with our
technology the H I’m sure you know
stands for Hugo the yearly Writing
Awards in science fiction by the way are
called the Hugo Awards this is Hugo
Gernsback who is the editor of this news
magazine and it still tells us
everything we need to do with new
technology what is the technology being
used for this science fiction
telehomecare technology
it was the most intuitive technology
that existed in 1924 it was an
entertainment device think about that
it was an entertainment device it was a
radio TV hadn’t been invented and
commercialized until 1929
this is 1924 an intuitive technology
that was incredibly simple to use two
knobs controlled everything an on and
off switch which also controlled the
volume and a station changing knob so
you can go from your pediatrician to
your dermatologist to your cardiologist
just by changing a knob and what could
be less expensive than a radio and we
heard a lot this morning from speakers
about patient engagement look at the
young boys two friends they’re amused
they’re amazed by this
they are totally engaged in this this
was genius but science fiction is
science today and the only difference
between the two is time Hugo Gernsback
also thought about something we’re still
working on to perfect and that’s called
haptics the ability at the doctor at one
end to virtually touch feel the patient
at the distant end we started working on
this when I was at the Medical College
of Georgia and senior research scientist
at Georgia Tech with a bio engineering
division we started working on haptics
or work was actually first highlighted
in a very exceptional scientific journal
called Playboy magazine
and I’ll tell you that little vignette
if we have time for questions at the end
but haptics is still being developed and
will give us the ability for the surgeon
who feels I absolutely I can’t use
telemedicine I’ve got to be there and
feel that abdomen as if this device was
really sensitive at all or this device
and a stethoscope we’ll get to that in a
little bit what’s in a name the previous
panel said it all
and our speaker from MUSC really
underlined it for us the word
telemedicine was introduced by my
professor and if you were alive today
the one thing I would say to him that he
should never have done was to call it
telemedicine by the way folks I mean we
had telephone before we used those two
cameras at the MGH we never when I told
my patient take two aspirin I’ll see you
in the morning I mean I didn’t call it
telemedicine it was medicine we need to
get rid of the term telemedicine as a
matter of fact you don’t really hear
people talk about teleradiology anymore
it’s radiology yet 70% folks of
telemedicine is telling radiology that’s
where the big volume is but it’s so
commonplace to them now they don’t call
a teller radiology and that’s what we
need to do this is just healthcare and
I’m going to show you in some subsequent
slides why it’s so important for us to
understand that so it really doesn’t
matter who does it whether it’s
teledermatology or telepsychiatry it
doesn’t matter what technology actually
it does you have to use video
[Applause]
doesn’t matter where it’s done whether
its hospital the hospital or hospital to
home or physician primary care office to
another doctor specialist it doesn’t
matter whether it’s done in real time or
store-and-forward it’s just medicine
okay they’re really going to be four
themes that I want to underline in this
talk and let me also apologize ahead of
time because this is the same talk I
gave in 1996 at the National ATA
conference about the future of
healthcare and I’m just going to update
the future for you in this don’t laugh
at the technology but this was the most
up-to-date technology in 1991 by the way
my first grant in telemedicine was under
the National Science Foundation 1973 to
1976 at the University of Miami
don’t give up Tallahassee don’t give up
actually better give up knowing that our
house knowing the legislature of Florida
all right so between 1973 and 1976
I tested telemedicine under National
Science Foundation grant at the
University of Miami I started the first
nurse practitioner program in the state
of Florida in 1972 eight nurse
practitioners two of which were the Dean
and the Associate Dean of School of
Nursing and six ER nurses at Jackson
Memorial Hospital we took them through a
six month course certified them as nurse
practitioners used nurse practitioners
with telemedicine as the experimental
group versus board certified internist
physically on-site and what we found
after three years of study
was the nurse practitioners with
telemedicine did as well as and in some
areas did better than our board
certified internist who were physically
they are on site as opposed to nurse
practitioners who were there using
telemedicine for their consultations
that was 1976 and except for true story
the Shah of Iran and president mrs.
Marcos of the Philippines and the
Secretary of Department of Corrections
of the state of Florida there was
absolutely no other interest in
telemedicine until 1991 as much as I
tried and during those 15 years about
the only one I could talk to about
telemedicine was the reflection in my
mirror
in 1991 the governor of Georgia and Zell
Miller asked me to set up a statewide
telemedicine system in the state of
Georgia why we heard it from Tallahassee
in the previous talk because he
introduced himself initially to me as
Jay I am the governor of two states at
which point I looked at him somewhat
quizzically and he said yes I’m the
governor of Atlanta and I’m the governor
of the rest of Georgia and he said we
have everything we need here in Atlanta
and we don’t have everything we need in
the rest of Georgia and the most
critical thing for him was the fact that
most of the rural hospitals in Georgia
were closing they were going under
because their bed census was drastically
diminishing and why was their bed census
diminishing because the fundamental
reality of every rural community
in this country is that the medical
staff of most rural hospitals are made
up of general practitioners an
occasional internist a general surgeon
many times a circuit riding radiologist
at least in those days and if you came
in with a cardiological problem or
neurological problem you were
immediately transferred to an urban
facility or an academic medical center
that’s why the bed census was going down
but what the governor pointed out to me
was something I had never ever thought
about and that is the fact that when the
rural hospital went under in a Georgia
community the entire socio-economic
fabric of that community went under
within a three to five year period of
time because the hospital was a major
employer in town this was an issue of
jobs for the governor so we developed a
59 site statewide telemedicine programs
first statewide telemedicine program in
the United States 1991 three academic
medical centers connected to nine
comprehensive Community Hospital’s each
of those in turn connected to rural
facilities public schools nursing homes
freestanding AHEC facilities
cardiologists the Medical College of
Georgia examining a patient at a
hospital in Eastman Georgia 130 miles
away of course it wouldn’t matter
whether it’s a 13,000 miles away it
would matter if it’s Mars and if we have
time I can tell you about Mars but here
we have the patient where they live
being taken care of by a specialist 130
miles away and here is something I still
for some reason I don’t hear enough
about one of the greatest strengths of
telemedicine we often focus in on
great advantage it is for the patient
but very few people talk about the great
advantage it is to that primary care doc
in that rural community this is
real-time continuing medical education
in fact what we have found we actually
found this in the 1973 experiments that
were funded by the national science
medicine is that over a period of time
if you have an effective telemedicine
system the use of that telemedicine
system to rural communities will go down
for the best of reasons
now that primary care physician knows
that what that mitral valve click is now
that primary care physician knows what
that maculopapular rash is and doesn’t
need the dermatologist this is not only
a benefit to the patient it’s a benefit
to the provider in 1993 it dawned on me
why are we waiting until the patient
ends up in a rural hospital er why
aren’t I beginning to do what Hugo
Gernsback thought about as science
fiction in 1924 and why don’t I start to
try and see patients in their home so in
1993 we got a 1 million dollar earmark
from the federal government they still
did those things then and we actually
got a 1 million dollar earmark from
Tetrick from telemedicine Vance
Technology Center at Fort Detrick
Maryland and we developed the first
technology to go into the home we called
it the electronic house call and
interestingly enough we got a call as we
were developing this we had talked about
it a lot we got a call from the local
head of the cable company it was then
called Jones inter cable they’ve been
purchased since then and we had coaxial
cable we didn’t have fiber I wanted the
system to be totally interactive
but you couldn’t do it and they called
and they said well we can do it I said
how are you going to do that with with
coaxial cable I said well we can do that
we just had a reverse amplifier we take
it through an Ethernet bridge and you’ll
have interactivity so we went to the
hospital administrator and said who are
your 25 most revolving-door patients who
are your chronic disease patients who
are constantly being readmitted to the
hospital and we got those patients we
set up this system with Jones inter
cable by the way putting in the reverse
amplifier and doing all of this free of
charge and I asked them why would you do
this they said Jay listen if this works
this is going to be like the movie
channel we’re going to call this the
Health Channel and we’re going to be
able to charge the consumer ten dollars
a month for the Health Channel either
way we can now do this on our Internet
able TVs and we had a graphical
interface on the TV screen we had a
picture of a stethoscope and if I wanted
to listen to that patients heart and
lung sounds all the patient had to do
and we heard this this morning all they
had to do was touch the graphical
interface stethoscope picture that
activated our stethoscope we could
listen the patient’s heart in lung
sounds but let me tell you the most
important thing that we learned when
putting in the system that we had never
ever thought about at the beginning and
I still don’t hear enough about this
when we started this mrs. Jones who
keeps getting readmitted and status
asthmaticus into our er intubated sent
to the intensive care unit given maximum
meds pulmonary function studies are
close to normal when she’s discharged we
see her at home 10 days later we do a
peak expiratory flow rate and by the way
since I have video interaction I can
watch her do the peak expiratory flow
rate so I know she her lips a purse
around the mouthpiece and I know she’s
doing it correctly and all of a sudden I
see an increase in her airway resistance
and then I realized my god why is she a
revolving door patient this is a woman
with asthma who’s sitting on a great big
puffy chair
okay she’s got thick rugs in her living
room
her husband is standing at the kitchen
door watching this whole thing with a
cigarette in his mouth and she’s giving
us her history as she’s petting her cat
for those non immunologists in the room
we started to find our patients with
hypertension who have been treating when
we took their blood pressure at home the
blood pressure was normal
what was great about this had nothing to
do with the technology had everything to
do with the recognition that the exam
room needs to be where the patient lives
not where the doctor works
under a NASA grant in 1996 or 98 we
developed a healthcare kiosk we now have
robots we now have beautiful kiosks we
now have our PCs we now have our
smartphones and now with all of this
technology we want to make 100% sure
that this never happens
luckily in Hazzard
okay now I’ve got to get serious I’m
gonna say something it’s going to
disturb everybody telemedicine is
potentially dangerous to your health
because we’re all Enthusiasm we all look
at this technology is being fantastic
and we all forget the most important
thing about what we’re doing the most
important thing about telemedicine is
not all the wonderful technology it’s
not all the telecommunications
infrastructure the most important thing
about telemedicine is the message if I’m
out-of-date and by the way I’m
out-of-date I’ll always be out of date
I’m a professor of medicine at Johns
Hopkins guess what I’m out of date I
can’t keep up not a single physician in
this room can keep up to date well if
the message I’m sending out is wrong
what in the world is good about the
technology it’s not and I hope we’re
going to hear about this a lot more from
a subsequent presenter
but I’ve got to get away from a single
physician at the bedside to collective
expertise in 1969 I started doing AI at
the MGH prodded by another professor who
was really known as the father of
computers in medicine dr. octo Barnett
but we didn’t have the computer
capability in the mid-80s MIT became the
center they also quickly found out they
didn’t have a computer capability today
we’ve got the computer capability and I
can take all the physician and all the
nurse knowledge that’s in this room now
with machine learning and AI and bring
it to the single patient’s bedside and
until we do that I will always say at
some point in time that telemedicine is
dangerous to your health I want to give
you a reference if you think I’m
exaggerating May 2016 British Medical
Journal senior author from Johns Hopkins
the third most leading cause of death in
the United States medical errors the
third leading cause of death diabetes is
the seventh medical errors is the third
we need to bring a I and I hate the term
artificial intelligence it’s not
artificial at all it’s augmented
intelligence its collective intelligence
and to my colleagues who think that I’m
pointing a finger at them and trying to
get rid of them I’m not you are all
remain as critical
when this is introduced as you are now
because each of our new observations at
the bedside each of our new observations
at the research bench will be
incorporated into the AI engine this is
a dynamic real-time living breathing
computer program that brings our
collective expertise to that patient’s
bedside telemedicine has to be married
to AI I would point out I’ll say this
again in my next slide that there’s
going to be another industry that’s
going to beat us to it and as a matter
of fact please understand that
telemedicine and AI in the medical space
don’t any of you think that this is
revolutionary we are so far behind the
times it’s amazing every other service
industry figured out how to do this long
before we did have any of you ever
bought a book on Amazon Amazon brings
the shopping mall to us do any of you
have Netflix Netflix brings
entertainment to us have any of you done
online banking all these service
industries bring their services to us
telemedicine and AI will bring these
services to us in the healthcare space
and by the way those industries are
going to beat us to it because I’m going
to at the end talk to you about some of
my come recent conversations with Amazon
and they’re 1492 unit do you know if you
heard about Amazon’s 1492 unit this is
their strategic initiative very
hush-hush unit
okay so telemedicine very important AI
even more important continuous
unobtrusive monitoring more important
than the previous two I hope none of you
actually go in for a yearly physical
exam that’s the most ridiculous thing in
the world and by the way let me tell you
those of you in the room who have been
told you’re sick you’re lucky because
the rest of you who’ve been told you’re
normal you have not the slightest idea
whether you’re normal or not and why
would I say something that sounds as
ridiculous as that for the simple reason
that laboratory tests that we all use
that we say oh you’re fine every all of
your tests came back in the normal range
how do we get normal ranges we take
millions of people and statistically
grind them into normal ranges is the
only one thing wrong with that it has
nothing to do with you let me just give
you two examples I my wife doesn’t like
this but I always use her as an example
my wife’s blood pressure normal blood
pressure is 90 over 60
okay most women in this room
collectively have a lower blood pressure
than most men in this room that’s why
you guys
longer than we do so she’ll go in next
year for her ridiculous annual physical
exam and her blood pressure will be 95
over 65 and what do you think her
internist tells her oh mrs. Sanders your
blood pressure’s perfectly normal and
then the following year it’s a hundred
over 70 then it’s 110 over 75 then it’s
115 over 80 what do you think her
internist has told her for the last five
years oh well your blood pressure’s
perfectly normal because the normal
range is 120 over 80 and below that’s
the most ridiculous thing in the world
she’s been hypertensive ever since she
went above 90 over 60
her shearing pressure within her a order
is denuding vascular endothelial cells
she’s clumping platelets she’s
developing atherosclerosis
but no no she’s normal look the blood
pressure is below 120 over 80 if you
came into my office today with a fasting
blood glucose above 125 I would make an
immediate diagnosis you’re diabetic
guess what
I could have demonstrated that you were
insulin resistant 10 to 13 years ago
because your normal fasting glucose is
75 then the following year was 80 then
it was 85 then it was 90 then it was 95
I had to wait till you got to this magic
125 to say you’re diabetic that’s
ridiculous you were insulin resistant 10
years ago continuous monitoring is going
to give us an identification of exactly
when we started to get sick
I’ve told the number of automobile
manufacturers BMW in particular that
look you need to develop a medical
dashboard in the car
the minute you sit in the seat folks
I’ve got your weight whether you like it
or not the minute you put your hands on
the steering wheel
I’ve got your pulse your rhythm strip
I’ve got your RR variability and the
minute you take your seat belt and plug
it in I’ve got your respiratory rate
your respiratory volume and with some
neat signalling processing I’ve got your
mean arterial blood pressure why don’t I
have a medical dashboard in my car and
now when I get angry at this guy next to
me is just trying to cut me off I can
watch my PVCs starting mid-1990s this
shirt called the vive metric shirt was
developed it was paid for by DoD it was
used up at Natick mass great shirt
measures 42 physiological parameters
wirelessly great technology bad business
people they went out of business but
great technology watches tattoo
developed by MIT and some work we did
with NASA in the mid 90s you shine the
appropriate polarized light on that and
will give me your blood electrolytes
hopefully ten years from now when you
walk into the doctor’s office if there’s
a nurse there coming at you with a
syringe a needle to take some blood run
go to another doctor because this is the
technology of tomorrow everybody heard
of the body area network the body area
network
the FCC knows about it the FCC has
developed spectrum for your body area
network where all your wearable embedded
and circulating sensors I were one of
the things I do as I head up a
scientific a Medical Advisory Committee
for National Science Foundation nano
system Center where we’re developing
self powered sensors that’ll either be
worn be embedded or there’ll be less
than seven microns and they’ll be
injected circulating around and you will
be constantly monitored and totally
unobtrusively monitored and in the cloud
will be your vital signs yours
individually so if you have a blood
pressure of 90 over 60 when you go up to
a hundred over seventy an alarm will go
off and to prove to you everybody knows
what this is right how many Trekkies
aren’t there any Trekkies in the room
yeah it’s a tricorder
this is 1.0 tricorder and by the way I’d
like to announce as of yesterday late
yesterday the FDA approved a technology
from a company called butterfly that is
an ultrasound on a chip going into a
smartphone by the way do you know who a
year before he died got the patent to
collect medical physiological data from
body worn sensors into a smartphone
Steve Jobs
brilliant except for himself he’d be
alive today if he listened to his
physicians this device is my electronic
black bag this device is your exam room
you remember about two years ago there
was a big business announcement between
Apple and IBM guess what’s going into
your smartphone folks Watson and the
sensors will communicate by bluetooth
into the smartphone and if AI is not in
your smartphone will be in the cloud
that’s my collective intelligence that’s
my AI in the cloud with my sensors
knowing exactly when I became insulin
resistant exactly when my blood pressure
became hypertensive for me today with
this device without the butterfly
ultrasound on a chip I’ve got a
microscope I’ve got a stethoscope
thumb and index finger I’ve got an EKG I
have everything I need with this and
with the photonics soon I’ll get old
blood electrolytes
final the issue of who will be the
primary care physician of tomorrow folks
it’s us it’s you and I the big problem
that we have today in our health care
delivery system as much as we’d like to
point a finger at the government at our
insurance company at our provider we
need to begin to point the finger in the
direction it always should have been
pointed right here because I can know
everything about myself that I’m
overweight that I don’t exercise that I
smoke and if I still do all of these
things that lead to this doesn’t matter
how good all of our technology is it’s
not going to work but guess what I’m
sure you all heard who won the Nobel
Prize in Economics Richard Thaler who
wrote a book nudge with his co-author
Cass Sunstein both University of Chicago
professors of law many of you read nudge
you need to read it good for you
you need to read nudge it talks about
behavioral economics so let me tell you
what I was talking to Amazon about
behavioral economics basically
encourages you to do the right thing
from an economic standpoint so one of
the things I called them about was Alexa
you all know Alexa and you all know the
fact that Amazon recently bought Whole
Foods and I suggested to them that with
Alexa and AI integrating the patient’s
electronic medical record into that if
the patient now orders food from Whole
Foods and they’re diabetic and the food
that they’re ordering is inappropriate
for their diabetes Alexa would say look
we would suggest you choose this
instead of the food you ordered and by
the way if you do order the right food
we’ll charge you less for that think
about the behavioral economics of that
think about who then becomes the
physician in that setting
it’s that behavioral economics and are
going to change patient’s behavior
I’m not sure that’s going to do it and I
just want to remind you and ending that
there are certain human instincts that
are going to be very very difficult to
change although I think the economics
will I want you to know that resistance
to change has been more of a problem
today with my colleagues than it really
has been with the public because look at
the public every single one of you has a
smartphone in your pocket every single
one of you
I’ll bet does please take a moment to
read this I know I’m just slightly over
time but it’s important for you to read
this this appeared in the London Times
in 1834 in which the Royal Society of
Medicine who are the authors of this
quote the most prestigious medical body
in England at the time said this new
technology will never ever work it comes
between the doctor and the patient
the first step to scope the best way to
end this is to leave you with this quote
from Ralph Waldo Emerson thank you very
much
[Applause]
