NEWS &VIEWSSEPTEMBER I OCTOBER 2013

NRTRC’S VISION: Better health care for everyone

hoy, Shipmates! (Yes, it’s talk like a pirate day when I’m writing this.)

I just got back from the ATA Fall Forum, held outside the United States for the first time. The venue was Toronto, Ontario, Canada, and the National TRC group once again had a booth in the exhibit hall. We had quite a bit of traffic for a small venue like that and talked with a lot of Canadian Telehealth folks about operating north of the border. We ran into a few from the States, too, and had some good discussions about how to get them assistance or information. Consensus seemed to be that the event was a little smaller than usual, but until we get any official reckoning, we won’t know for sure.

We even managed to sneak out to Niagara Falls to see a lot of water fall a long way off a cliff. (It may be more than that, but after three consecutive soakings doing the touristy thing, I kind of got into a soppy mindset.)

This is the time of year for meetings,

there and we’ve got a pretty full agenda, discussing items that range from getting TRCs more visibility to methods for helping more networks grow and offer more services. The national group is a great bunch of folks all working toward the same goal NRTRC is, and we have a lot of fun and some great conversations. And, most importantly, we expand the amount of service available to Telehealth networks around the country.

In fact, we’ll soon be announcing formally a project that the Mid-Atlantic TRC and NRTRC are partnering in. We’re monitoring the startup of a coast-to-coast remote monitoring project to document the startup and growing pains of the new project. Our hope is to derive useful information that any of the TRCs can use to guide projects like this into the future without having to reinvent the wheel. It’ll be an exciting program.

Our reach doesn’t have to be coast-to-coast, though. If you have a project you’re starting, or are proud of one you’re running with, let me

know. I love to write up stories of successes closer to home, and we may be able to feature you in the Newsletter and on the website. We can also use your experiences and lessons learned to produce white papers that will help others go through the process you have gone through and avoid some of the pitfalls and pratfalls your project might have encountered.

Speaking of meetings (well, we were), the NRTRC Advisory Board is meeting in October. This is one of two annual face-to-face meetings of the Board (the other is in conjunction with the Annual Regional Conference). We’ll have a day of Board training, then work through our agenda and make plans to move NRTRC further along the road of helping bring health care to our underserved populations in the Northwest. If you have anything you feel the Board needs to discuss, let me know and I’ll get it on the agenda.

I don’t think I say often enough how much I appreciate all of you for bringing support, camaraderie and assistance to us here at headquarters, so thanks for being there. And, don’t forget that we’re here to help you find solutions to your challenges, provide information and networking opportunities and offer all the support we can, so feel free to contact any of the staff members to talk Telemedicine. n

MY 2¢ WORTH By Bob Wolverton,

NRTRC Program Director

it seems. We’re off to Tucson for an OAT-mandated Telehealth Resource Center meeting. All 14 TRCs will have personnel

NEWS &VIEWSSEPTEMBER I OCTOBER 2013

TELEMEDICINECONFERENCE

2014Portland, Oregon

March 24-26

NRTRC Announces Keynote Speakers for 2014 Conference

SPOTLIGHTBy Martha Nikides,

Administrative Assistant

NRTRC is pleased to announce the first three of five keynote

speakers for its 2014 Conference March 24-26, in Portland, Oregon.

The three speakers are:

JAY SRINI

Jay Srini is the Chief Strategist at SCS Ventures where she is working with international startup companies focused on HIT and other established organizations to help them with their business development, health care strategy and expansion. She is also CIO of an innovative Oncology Management firm KEWGroup. She has provided strategic visionary advice to CEOs of startups as well as for senior executives in companies such as Orion, Lockheed Martin, Emendo (sold to Mckesson) and Mmodal ( sold to Medquist). Jay’s prior experience includes her role as Chief Innovation Officer for UPMC (University of Pittsburgh Medical Center) Insurance Services Division as well as her role as Vice President of Emerging Technologies for UPMC Corporate. Her responsibilities as VP of Emerging Technologies included providing strategic direction and input regarding emerging technologies and solutions

to University of Pittsburgh Medical Center and their Insurances subsidiary. Jay was Managing Director for e-Health Initiatives at Internet Venture Works where she led technology and industry assessments of opportunities presented by strategic partners, investors and external sources and served in interim executive management roles for its’ portfolio companies before joining UPMC as VP of Emerging Technologies.

Jay has a Master’s Degree in Computer Science from New York University and a Master’s Degree in Business Administration from Bucknell University and her executive education from the Kellogg School of Management at Northwestern University. She serves on the board of Medrespond, Icache and PRHI. She also serves on the advisory board of several entrepreneurial companies, nonprofit healthcare organizations and serves as one of the commissioners at CCHIT (Certification Commission of HealthCare Information Technology) in addition to her role as adjunct faculty at the University of Pittsburgh.

She is an internationally known speaker in HIT and has chaired several national and regional HIT conferences in the US.

• • • • • • • • • • • • • • • • • • • • • • •

ERIC ARZUBI, MD

Dr. Eric Arzubi is a child and adolescent psychiatrist at the Billings Clinic in Billings, Montana. He is also an Assistant Clinical

Professor at the Yale Child Study Center, providing remote supervision to child and adolescent psychiatry fellows there using telemedicine equipment. Dr. Arzubi is especially passionate about crafting innovative models to deliver mental health services to youth in the K-12 school setting. He is a member of the Schools Committee of the American Academy of Child and Adolescent Psychiatry and he is a board member of the Billings Chapter of the National Alliance on Mental Illness (NAMI).

• • • • • • • • • • • • • • • • • • • • • • •

ANA MARÍA LÓPEZ, MD, MPH, FACP

Dr. López is the founding Medical Director of the Arizona Telemedicine Program. She is a medical oncologist, researcher and educator who has dedicated her work to the amelioration of health care disparities. She has a long standing commitment to underserved populations and is dedicated to increasing access to high quality medical specialty care to all communities. Her academic and clinical interests are focused on cancer prevention, specifically in the area of women’s malignancies, and in the development of outreach programs. Dr. Lopez is the principal investigator of several clinical and health service research studies.

• • • • • • • • • • • • • • • • • • • • • • •

Watch for the announcement of the final two keynote speakers

later this month.

Registrationopens

December 2

NEWS &VIEWSSEPTEMBER I OCTOBER 2013

e have spent the past two and a half years working to develop a

mobile wound care app called WoundMap®. Like a lot of ideas, WoundMap® began as a sketch on the back of a napkin. A group of wound care providers were sitting around a table during a break between lectures at a wound care conference. The discussion turned to technology and the, as of yet, unreleased Apple iPad II. Rumors suggested that the new iPad would have a forward and rearward facing camera. There was, we agreed, the potential for a tool like the iPad to be used in wound care. The process of our app development was never formally thought out or discussed. None of us had

WoundMap® The Anatomy and Development of a

Mobile Healthcare App

SPOTLIGHT

By Tom Richards, MD/MSGuest Writer, NRTRC Board Member

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Screen shot of WoundMap app on an iPhone

ever built an app before. We have found our way by trial and error. We have pushed forward partly from sheer determination and partly out of ignorance of the amount of work this would be. Along the way we’ve been blessed with incredible good luck and timing. This article is a summation of our experiences and lessons learned in developing an app on the Apple iOS platform. I’ll follow a format of first discussing general concepts of mHealth and app development and then how those ideas played out in the case of our app, WoundMap®. Hopefully it will provide some insights into the process of mobile health development.

SO, YOU HAVE AN IDEA FOR AN APP?

Congratulations! Your idea may propel you to fame and fortune or at least be a meaningful contribution to whatever your area of interest is. Over one million apps have been submitted to the Apple App Store since it launched in 2008. Android’s Google Play store has also reached the one million app mark. To call the market explosive is an understatement. Before you join the thousands of other app hopefuls already in the market you should understand that app development, particularly in the medical field, is time consuming and expensive. Some time spent developing your idea, studying the market, building an app development team, and thinking through the strategy of implementing your app will be time well spent.

OUR APP Wound care is a large and growing market with an identified need for a mobile solution. We focused on building a bed-side, point-of-care tool that could be used by nurses, physical therapists, and doctors to standardize and streamline the wound assessment and treatment process. The app helps streamline and objectify the process of wound evaluation by using the camera built into the mobile device and a novel, patent-pending photography and measurement system. The system has built into it the ability to evaluate both patient specific risk factors for wound development and wound specific factors to develop a care plan. It also builds a clinical assessment document while the provider is evaluating the wound and tracks pertinent findings (wound dimensions, exudate, undermining, etc.). It automatically graphs these assessments over the course of continuing examinations. Photographs are recorded for review or time lapse play back. The information is recorded and data stored using consistent nursing terminology and

coding. The clinical assessment document can be printed as a PDF, e-mailed in a secure, encrypted HIPAA compliant format, or pushed to an EMR. Later iterations of the program will allow multiple users to review patient info in real time and wound care experts to consult when needed. When we first started work on the app there wasn’t a single app dedicated to wound care on the Apple

App Store. Today, if you search the Apple App Store you’ll find 24 iPad apps and 38 iPhone apps.

We chose to build our app on the Apple iOS platform because Apple mobile devices are the most frequently used in health care. What began as an idea on a napkin has grown over the past two and a half years to involve a growing list of wound care experts, software engineers, graphic designers, and business developers who have all worked to make the idea on that napkin a reality. The result is our award winning software program WoundMap®.

BUILDING (AND PAYING FOR) A DEVELOPMENT TEAM.

The next step, after researching your idea and the market you will be providing it to, is to find the people with the necessary skills to build the app. Building a medical app requires three critical components. The first is an expert knowledge base within a narrowly defined area of medicine. Why do I suggest a narrow focus? Because there are thousands of medical apps already on the market. Many of these are focused on exercise and wellness or very common medical problems. There are 466 iPad and 914 iPhone apps just for diabetes. Your app is more likely to be successful if it is focused

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on an underserved niche rather than trying to break into an already crowded field. Then you need expert programming knowledge. Unless you have specialized medical knowledge or experience in programming you’ll need to add people with this expertise to your team. The final component is the time and persistent effort required to translate that knowledge into a mobile app that health care providers will want to use. Medical experts and software programmers don’t usually work for free so you’ll also need to decide early on how they’ll be paid. Your app will also probably require ongoing work to address bugs in the software and for updates to reflect changes in the field. You can sell your app on The App Store. Apple takes a 30% bite for marketing it on The App Store, collecting payments, using their servers, etc. for your app is very widely adopted you may be able to generate revenue from ads on a free app. Paying your team members an hourly rate or giving them some ownership of the final app (and a percentage of the profit) are two options for reimbursing partners or employees. One way or another app development requires initial and ongoing funding.

OUR APP We chose to focus on the niche wound care market. Wound care is a very visual field and improvements to the cameras built into mobile devices made this an attractive choice. We also had the good fortune of finding wound care experts Marta Ostler and Dr. Karen Zulkowski. Marta Ostler organized the conference where the idea was first hatched. She has over twenty years of wound care experience and runs the wound care clinic for Sheridan Memorial Hospital. Dr. Zulkowski is a nationally recognized wound care expert and researcher, an Associate Professor of Nursing at Montana State University, and a past member of the National Pressure Ulcer Advisory Panel (NPUAP). She co-authored parts of the current NPUAP/EPUAP guidelines that CMS references for pressure ulcer evaluation and management as well as consulted on the Agency for

Healthcare Research and Quality (AHRQ) “Pressure Ulcer Toolkit for Acute Care”. Our lead programmer, Dr. Todd Guion, has over twenty years of programming experience and has been developing software for the Apple iOS platform since 2007. He is currently a consultant to Apple Computer for the iTunes Mobile Team. He had to take our ideas for content and

make them work seamlessly.

Finding these experts who were interested in the project and willing to devote time to it was key to our success. The initial seed money to develop our WoundMap® app came from a small projects grant from the Northwest Regional Telehealth Resource Center. The $10,000 grant seemed like a lot of money at the time. We have, to date, invested many times that initial amount. The WoundMap® team won first place in the Office of the National Coordinator for Healthcare IT sponsored “Mobilizing Data for Pressure Ulcer Prevention Challenge”. The first place award of $60,000 will be used to partially offset further development costs.

BRINGING THE APP TO MARKET.

After your app is built you’ll need to make it available for people to download. In the case of Apple this is done in the Apple App Store by submitting the app to for review. The review process can take a month or more. Once the app is cleared by Apple it can be sold through the App Store. Now you need to tell the world about your app and convince users to download it. Focusing on a defined market, an initial “beach head” entry market is a critical step. Early adopters of your app can be a source of valuable feedback about what is good and not so good about it. User feedback is the best way to guide future development. Despite your best efforts to make

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the app work flawlessly there will still be bugs to fix and improvements to make. Apple’s App Store has a well defined mechanism in place to update your app and push those updates out to the people who have already purchased your app. Depending on what your app does (and doesn’t do) it may or may not require FDA clearance. At the time of this writing the rules and regulations for mHealth apps have yet to be completely defined. I will be providing a webinar next month (October 24) through the NRTRC on the topic of mHealth regulation. Please tune in for further information.

OUR APP We’re currently in the process of redesigning our user interface to be more attractive, user friendly, and intuitive. Beyond just being useful we are focused on making the app “sticky” so that once a user tries the app they will want to

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Our ‘Mobilizing Data for Pressure Ulcer Prevention’ is the first challenge we’ve funded at the ONC specifically for nursing. The challenge winner, the WoundMap® app, uses consistent nursing terminology for wound care to enhance continuity and quality of care across the nursing care continuum. With the WoundMap® a patient moving from one hospital system to another or from one level of care to another, a hospital to long term care facility for instance, can be assessed using the same tool and described using the same terminology.

Judy Murphy, RN, FACMI, FAANDeputy National Coordinator for Programs and PolicyOffice of the National Coordinator for Health ITWashington, D.C.

“

Tom Richards MD/MS is an ED physician at Sheridan Memorial Hospital and is the CEO of Apollo Telemedicine LLC and MobileHealthware LLC. He is a member of the advisory board for NRTRC. He can be contacted at trichards0445@me.com or 307-752-1665.

keep on using it. We’re contacting potential users in beach head markets including skilled nursing facilities, assisted living, home health care, and hospice providers. We’re also currently researching what federal regulations we will need to comply with. Beyond the technical, work flow, and scalability issues there are issues that are common to all small businesses – marketing, intellectual property protection, insurance, and contracts to name a few. For those issues I again advise you to find someone with some business experience. Here again we were lucky. We’ve contracted with a business development specialist with over thirty years of experience starting up, developing, running businesses. He has a background in the skilled nursing, assisted living, and home heath market. We hope to have the app in the App Store in November 2013.

Selecting a Mobile App for Clinical Usage

SPOTLIGHT

NEWS &VIEWSSEPTEMBER I OCTOBER 2013

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obile health apps provide an interesting challenge to organizations looking to provide a controlled,

organized technology deployment to their staff and patients. Due to the ubiquity of cell phones and tablet devices, an organization will have to determine how to best integrate existing personal devices with newly purchased, program-specific applications.

At TTAC, we’re committed to teaching professionals to evaluate their own unique telehealth technology needs. The steps to do this are universal, and in this article we’ll apply them to clinical mHealth app selection.

Assessing your needs is the first step in selecting an mHealth app. What problem are you trying to solve? Are your providers looking for readily available patient data outside of the office? Is your clinic looking for patients to track and communicate their own health metrics? What mobile apps are on the market that might meet your needs? Are your patients and staff comfortable with mobile technology? Are the apps available for multiple mobile platforms (Android, iOS, etc.)?

Kirt Beck Director, National Telehealth Technology Assessment Resource Center (TTAC)

Donna Bain Telehealth Technology Assessment Specialist, National Telehealth Technology Assessment Resource Center (TTAC)

Step 1 INFORMATION GATHERING

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If so, is the look and feel of the app similar enough to make training patients and staff relatively seamless? How key is the data being stored?

Once you’ve defined your user group and clinical needs, you’re ready to define your minimum requirements. A list of your minimum requirements will narrow down the scores of mobile apps on the market, and will streamline the testing step. Examples of minimum requirements may include the ability of an app to facilitate data sharing between the patient and provider, whether or not medical data can be stored on the device or on the cloud, and if the app is available for use with multiple mobile operating systems. Is it enough for an app to simply store blood glucose levels, or will the provider also require data on exercise, blood pressure, diet and weight?

Once minimum app requirements are determined, you’ll need to decide if your organization will purchase new devices for employees or you’ll support personal devices already in use by employees. There are difficulties in either scenario, and each must be weighed appropriately.

Existing devices owned by employees have a couple of benefits, namely that the organization does not need to purchase new equipment, and employees will already be familiar with the product. However, complexities can arise regarding patient privacy, network security, and operating system discrepancies. Clear usage and security policies must be set for

personal devices to mitigate these concerns.

TESTING

Selecting an app, or any technology for that matter, requires pre-deployment testing in its native environment. In other words, it is not enough to just read or rely on the developer’s claim that interoperability exists. For example, if your app needs to be available for use on multiple mobile-platforms, secure devices of various screen sizes using each operating system to ensure that the functionality and display is to your satisfaction. If an app must allow for manual data entry versus only allowing data syncing from a medical device, ensure that each version of the app will accommodate this.

At TTAC, we make a grid using our minimum requirements and a list of the products being tested. In this way, when we’ve concluded several hours or days of testing, we can easily look back and compare raw data. Usually one or two products rise above others, making a deployment decision that much easier.

DEPLOYMENT

Once the app is identified or obtained, provide an area to stage and train it on the same devices that will be used clinically. This will help ensure that support issues are initially addressed by getting users familiar with app use on each phone

or tablet, and will allow your team to address any differences in how the apps behave on each device before they are used.

The National Institute of Standards and Technology discusses many issues and questions related to the deployment and support of mobile solutions in the workplace. You may find this document in our resources section of our 2012 mHealth toolkit.

SUPPORT

After verifying that the apps and their devices will work for your needs, ensure that there are instructions available to those attempting to utilize the app. A basic level of setup and troubleshooting documentation will result in reduced service calls, and this documentation can serve as a guide should issues arise. Don’t assume that an app that appears simple to you will be intuitive to other staff or patients.

Before problems occur during use, determine who is responsible for providing app support. Who in the organization will be prepared to train and support staff and patient users? Will the app developer be available to the organization to address problems? Clarifying these issues up front will streamline the support process.

Finally, duplicity is imperative as mobile apps are first introduced to patients and providers. Ensure successful training and verify data before relying entirely on mobile app solutions for your clinical needs.

Step 2

Step 4

Step 3

Our TTAC Team Kirt Beck is our TTAC Director. Donna Bain is our Telehealth Technology Assessment Specialist Want to know more? Visit the TTAC website at: www.TelehealthTechnology.org.

The National Telehealth Technology Assessment Resource Center 3900 Ambassador Drive, Ste 102 Anchorage, AK 99508 Main: 907-729-4703 Fax: 907-729-2263 Toll Free: 877-885-5672

NRTRC Board Welcomes Two New Members

The NRTRC advisory board welcomed two new members this past month –

Dr. Wesley Valdes from Utah and Christie Artuso from Alaska.

NEWS &VIEWSSEPTEMBER I OCTOBER 2013

Dr. Wesley Valdes has served as the Telehealth Services Medical Director for Intermountain Healthcare since November of 2011. Since his arrival, Intermountain Healthcare has launched an online physician service, hosted demonstration booths at HIMSS, ATA, and mHealth conferences, and engaged in building software solutions for inpatient remote monitoring. Dr. Valdes has helped get telehealth reimbursement language adopted with Select Health which is the healthcare insurance company owned by Intermountain Healthcare. Dr. Valdes works in collaboration with Intermountain Healthcare’s Healthcare Transformation Lab and helps guide the organization regarding how to adopt telehealth strategies and technology to support the organizations mission and values.

Christie Artuso, Ed.D., RN, CNRN, SCRN is the Director of Neuroscience Services at Providence Alaska Medical Center. She leads a specialized team of nurses, technicians and support staff, in collaboration with physicians to provide outstanding neuroscience services and quality care to patients. The Neuroscience Division includes a nationally-accredited stroke program, a nationally-certified concussion program, a nationally-accredited sleep disorders center, neurodiagnostic testing, and both inpatient and outpatient services for patients with neurologic and neurosurgical disorders. She has more than 32 years of educational and leadership experience in university-affiliated hospitals with recognized clinical expertise in emergency services and critical care.

Artuso currently serves as a member of the NorthWest Affiliates Stroke Task Force for the American Heart Association/American Stroke Association and previously served on the American Association of Critical Care Nurses (AACN) Certification Corporation Board of Directors. She is the president of the Alaska Collaborative for Telemedicine and Telehealth and a past-president of the South Central Alaska Chapter of AACN. She earned a diploma in Nursing from Geisinger Medical Center School of Nursing in 1979 and later earned a Bachelor of Arts in Nursing at The University of the State of New York in 1986. She went on to earn a Master of Arts in Nursing at New York University in 1989, a Certificate of Advanced Graduate Study from Nova Southeastern University in 2007 and completed a Doctorate of Education in Healthcare Education from Nova Southeastern University in 2009. She is a nationally recognized speaker and an expert in the field of cardiovascular and cerebrovascular health and has published on numerous topics related to critical care and emergency medicine.

Upcoming Events OCTOBER 2013By Martha Nikides

National Telehealth Resource Centers Monthly Webinar

October 17, 2013Integrating Telemedicine

and the EHR

For more information on upcoming events, please go to www.nrtrc.org.

EVENT SUBMISSIONSPlease forward event information to martha@nrtrc.org

ARTICLE AND PHOTO SUBMISSIONS If you would like to write an article or provide photographs for this publication, please contact Cathy Britain (csbritain@gmail.com or 541-910-7366)

NEWS &VIEWSSEPTEMBER I OCTOBER 2013

About UsThe Northwest Regional Telehealth Resource Center leverages the collective expertise of 33 telehealth networks in Alaska, Idaho, Montana, Oregon, Utah, Washington and Wyoming to share information and resources and develop new telehealth programs.

NRTRC Services• Provide technical assistance for new programs and applications• Increase exposure to telehealth as a health care delivery tool• Improve access to specialty care through regional collaboration• Develop information on best practices and telehealth toolkits• Provide current information and facilitate discussion of regional regulatory, policy and reimbursement issues

Northwest Regional Telehealth Resource Center1233 North 30th StreetBillings, Montana 59101888-662-5601 or 406-237-8665

NRTRC StaffBob Wolverton Program DirectorSara Rivera Social Media SpecialistMartha Nikides Administrative AssistantDoris Barta Principle Investigator

NRTRC Board MembersAlaska: Cynthia Roleff, Christie ArtusoHawaii: Joe Humphry Ex officio Idaho: Tom Hauer, Neill Piland Montana: Doris Barta, Thelma McClosky-Armstrong Oregon: Cathy Britain, Doug RomerUtah: Patricia Carroll, Weslty ValdesWashington: Cara Towle, Nancy VorheesWyoming: Jim Bush, Tom Richards

NRTRC Open-MicWebinar:

October 24, 2013App Development