Telehealth’s future is bright. Here’s what it’ll look like in 2025: COVID-19 could prove to be telemedicine’s watershed moment. Fast Company, Dec 2020
You’re sitting at the table eating dinner when you receive a notification. A woman wearing a light blue top fills the screen of your phone with a video message. “Hello, this is Diane in Dr. Halpern’s office,” the woman says. “The computer saw that your blood sugar and heart rate numbers went out of range yesterday and today. I’d like you set up a quick virtual visit, okay?”
That’s where telemedicine could be headed in the next five years or so. It won’t just be virtual—it’ll also be proactive, hyper-personalized, and data-driven.
Lots of people are having their first experiences with telemedicine right now as a result of the pandemic. They like it, and they’ll very likely expect to be able to continue accessing healthcare in this way after COVID-19 is long gone. The healthcare industry is notoriously slow in adapting new technologies, but COVID-19 may prove to be telehealth’s watershed moment.
“There honestly wasn’t much change from 2008 when I started . . . to really up until very recently,” says Doctor on Demand chief medical officer Ian Tong. “Then all of a sudden, not only have patients done this for the first time, but this is literally the first time that most doctors have had to even to think about it and were literally forced to change their models—in some cases overnight.”
With a new wave of investment likely flowing into digital health startups, including telemedicine providers, it’s a good time to ask how exactly telehealth will change the way we receive medical care. In short, the digitization of healthcare may change the whole paradigm where receiving care means going to where the doctors and all their magic tools are. Medicine might finally start coming to the patient, digitally.
BEYOND DR. ZOOM
When most of us hear the term “telemedicine” or “telehealth,” we imagine talking to our doctor on a laptop. But over time these terms might come to describe something far more fundamental.
American Well founder and CEO Dr. Roy Schoenberg sees telemedicine as the patient-facing front end of the healthcare system, where more interactions with patients will be digital.
WE’RE NOW LOOKING AT HEALTH IN THE SAME LENS AS WHEN PEOPLE BOUGHT BOOKS FROM AMAZON.”
DR. ROY SCHOENBERG
“We’re now looking at health in the same lens as when people bought books from Amazon, because that was the only thing Amazon was selling,” Schoenberg says. “But we completely failed to understand the dramatic impact of online retail, which was championed by Amazon. [Telehealth] is going to be for everything, so that’s the corner that we’re turning right now.”
In other words, the narrow set of things health providers can do for us via a Zoom call today will soon include a broad set of services that are delivered through things like apps and connected devices.
CONNECTED MEDICAL DEVICES
A doctor’s inability to listen to my heart during a virtual visit might be solved if I have my own digital stethoscope, an item that’s widely available now. The doctor might even be able to watch me take my own blood pressure during the virtual visit to make sure I do it right, then read the results I upload.
These kinds of connected medical devices are already here. The diabetes management company One Drop sells a kit and app for measuring blood sugar levels and reporting the data to a doctor or other caregiver. AliveCor’s Kardia device creates a medical-grade EKG that can detect atrial fibrillation, bradycardia, or tachycardia in 30 seconds, with some help from the company’s AI algorithms. A quick search finds FDA-approved connected otoscopes, which help physicians look inside your ear, as well as numerous blood pressure monitors, wearable blood glucose monitors, and many other connected health gadgets. Telemedicine platforms often review these devices and integrate with the ones they prefer.
These devices will get much more advanced in the next decade. “Just imagine the life of a diabetic patient where they’re carrying a skin patch or contact lens that measures their blood sugar,” Schoenberg says, “and how much more accurately you can treat them with insulin and with medications to make sure they don’t have all the complications of diabetes that come with poor control.”
REMOTE HEALTHCARE KITS
Telemedicine appointments where patients at home transmit diagnostic data to a caregiver is just one scenario. Many schools, workplaces, and remote clinics have someone with medical training on staff who can conduct diagnostic tests and pass them on to a remote doctor.
At least two digital health companies are building full kits of connected diagnostic devices that can be paired with more traditional telemedicine. GALE from Silicon Valley-based 19Labs looks like a small medical chest with a number of connected medical devices hidden inside, including a stethoscope, pulse oximeter, digital thermometer, and otoscope. A built-in display shows remote doctor visits and recorded how-to’s for using the equipment and treating specific illnesses. Similarly, New York-based TytoCare makes a handheld health monitoring device with attachments that transform it into various diagnostic devices. Data collected by the device is sent in real time to a doctor video-chatting with you on a companion smartphone app. The kit sells for $300 at Best Buy, and works with most of the major telemedicine providers, including American Well and TelaDoc.
Diagnostic testing could be approached in other ways. The health system Ascension is starting to test mobile labs to bring X-ray, ultrasound, and blood work screenings to patients at their own homes. The test results would then be transmitted to virtual doctors, who can use them to inform diagnosis and treatment. Such a remote clinic might use Butterfly Network’s smartphone-connected ultrasound device, which is meant for use only by trained health practitioners.
APPS, APPS, APPS
There’s also a growing wave of digital health apps that rely on smartphone features to collect diagnostic data. The Australian company ResApp Health makes a number of apps that use a smartphone to record and transmit the recording of a cough. Tel Aviv-based Healthy.io makes an app that uses the smartphone’s camera to measure aspects of a patient’s urine. Researchers at the Centre for Eye Research Australia (CERA) developed a tablet app that uses computer vision to recognize early signs of Alzheimer’s in the eye of the user.
The more these devices and apps can do, the more digital doctor visits may be able to replace in-office visits. Expect to see much more investment in startups that advance these digital health devices and find new ways to transmit more kinds of higher-quality clinical data to healthcare providers.
Doctor on Demand’s Tong says this work will accelerate as more doctors become involved in developing the technology. “Because now you have a lot of physicians who were otherwise not putting much thought, or health systems that were not putting enough investment or thought, behind their virtual care capabilities—and now they have to,” he says.
AFTER THE EXAM
Doctor on Demand’s Tong says that follow-up appointments, which are one of the healthcare industry’s biggest and costliest pain points, are an obvious opportunity for telehealth. Treatment plans often go off the rails when patients skip follow-up appointments, and many of them end up returning to the clinic, or worse, showing up at the ER.
PEOPLE ARE GOING TO BE MORE APT TO DO THOSE FOLLOW-UP VISITS FROM THE CONVENIENCE OF THEIR HOME OR AT WORK.”
“What happens in reality is most people start taking those meds, they feel better, and they don’t follow up with that visit with their doctor simply because it’s an inconvenience, it’s another missed day of work,” Tong tells me. And that’s when patients often stop taking their meds, stop monitoring their symptoms, or return to normal habits too soon, and end up getting sick again.
“I think with telemedicine in the future people are going to be more apt to do those follow-up visits from the convenience of their home or at work,” Tong says. That not only allows the physician or hospital to capture the revenue for the follow-up appointment, but it keeps the patient on track with their treatment.
BEYOND THE “WEALTHY AND WELL”
To this day, caregivers have precious little vision into the lives of their patients between office visits. Medication adherence has been a well-known problem for decades, and there’s still no standard way of knowing if people are following the directions on the pill bottle.
But in the future, a digital health integration with a pharmacy system might inform a doctor if a patient has failed to fill a prescription. Modern smartwatches have gradually added data-collecting sensors that could be potentially useful to caregivers. But unfortunately it’s been mainly the so-called “wealthy and well” who have embraced wearing such devices every day, not people like the diabetic and obese factory worker with a history of heart trouble.
However, that could change, especially if that patient sees wearable devices as a natural extension of their doctor’s stethoscope. That’s when the crucial wellness and preventative potential of digital health can happen. “When those devices detect that something is going the wrong way, the clinician shows up on your phone within a matter of a minute and says, ‘Hey, we just detected that you have an arrhythmia, and this is what we’re going to do about it,’” Tong says.
Personal health monitoring may have started with wrist wearables, but there is a growing list of options. In the future, we’ll very likely see things like hearing aids that also listen to heart rhythms, finger rings that monitor skin temperature and other vitals, and clothing with built-in sensors for monitoring body temperature, heart rate, and other metrics.
A NEW APPROACH, WITH AI
As wearables generate more precise measurements, we’ll likely see more startups that specialize in receiving, analyzing, and presenting the data to caregivers via a dashboard. Their software products might even integrate biometrics data with other patient information from the electronic health record, then apply AI to the data set to look for patterns. Insights from this analysis might trigger a proactive video call to a patient’s phone before they realize something’s wrong.
Tong says this sort of biometrics-driven remote patient monitoring might be handled by a non-physician member of the care team, which could free up doctors to spend more time with patients who are sick and need in-person care.
While this vision for the future of telehealth is one many startups are betting on, it depends on something outside their control: a healthy broadband infrastructure. And it remains true that in some of the least healthy parts of the country, accessible mobile and fixed-line broadband service is a real problem. Videoconferencing with a remote doctor is a high-bandwidth application that requires a steady signal. And some of the things we will ask digital health to do in the future—like transmitting high-resolution medical imagery—may require even faster, commercial-grade connections.
“We’ve heard from some patients that even when other modalities are available, they prefer to have a video visit with their provider,” says Dr. Lauren Broffman, research scientist at the telehealth provider Ro. “For telemedicine to become a truly comprehensive service where people can be treated holistically for their needs, the technological infrastructure needs to be there.”
Fast Company Senior Writer Mark Sullivan covers emerging technology, politics, artificial intelligence, large tech companies, and misinformation. An award-winning San Francisco-based journalist, Sullivan’s work has appeared in Wired, Al Jazeera, CNN, ABC News, CNET, and many others. More
Built for places where doctors are far away, 19Labs’s Gale “clinic-in-a-box” contains sensors, interactive guides, and on-demand video access to health care pros.
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The Gale high-tech first-aid kit was born on a terrifying night in Mexico.
Its creator, Ram Fish, who once led the iPod group at Apple, was on vacation with his wife and three young daughters in a small town in Baja called Los Barriles. At 10 p.m. one night, one of his daughters, Tali, started having trouble breathing while she slept.
As she struggled to get her breath, her parents become more and more frightened. “We were saying ‘What do we do? Is there a local clinic? How do we diagnose it?” Fish remembers. Little villages in Baja are great for getting away from it all—but if someone gets sick, then health care is far away, too. Fish and his wife soon learned there was no clinic nearby.
“So we called Kaiser, and luckily there was somebody running it who spoke English,” Fish says. The nurse at Kaiser was able to provide some help identifying the cause of the young girl’s breathing problem. She was having a chronic obstructive pulmonary disease (COPD) episode, probably due to an infection. Most of the time, COPD episodes sound more dangerous than they really are, Fish told me. His daughter was wheezing loudly that night, but she was still getting enough oxygen.
“Everything ended up being fine, but it was a horrible night, looking at only the most primitive diagnostic tools,” he says. “You usually just leave them sleeping, but if it gets serious you need to give them steroids, and if that doesn’t work you need to intubate.” If the COPD attack had been more serious that night in Baja, Tali could have been in real trouble.
That got Fish thinking. “Everybody is focusing on doing things in the cloud, but the place where you really control the experience is the endpoint,” he says. He began to think that focusing on tools that people could keep on hand—especially for those who live far from a clinic—could improve patient outcomes. And it might make for a solid business, too.
A CLINIC TO GO
Fifteen months of hard work later, Fish had a startup called 19Labs, and a new product called the Gale “clinic-in-a-box.” (The name of the product derives from Florence Nightingale, the founder of modern nursing.)
Gale is a breadbox-size chest containing diagnostic tools in the bottom drawer and medications and supplies in the top drawer. On the top is a pop-up touch screen that displays various interactive treatment guides. The guides can walk a user through the process of assessing all kinds of health problems from snake bites to ankle sprains to heart trouble. “If you are a parent, or a secretary in a school, or have a senior,” Fish says, “without any health care education you can make an assessment.”
On the touch screen, a user first chooses from broad categories like “Stings and Bites” and “Concussions in Children.” The guides then help the user narrow down to a specific problem through a series of questions and answers. The text and images in the guides were developed by researchers at Stanford and licensed by 19Labs. A voice agent is always reachable to help users with questions about the treatment guides.
The touch screen is also used for placing video calls to physicians and other caregivers, including doctors from telehealth provider Amwell. The large button on the front of the Gale box can be preprogrammed to place a telemedicine call with a finger press. Alternatively, it can be set to immediately dial 911 or a health call center.
After using the guides, a user can call on a series of diagnostic, sensor-based instruments to get at the objective facts of the problem. The drawer on the bottom front of the Gale box holds some of the most important ones, including electrocardiogram patches, an AliveCor EKG and stroke detector, a blood sample tool, a digital thermometer, a fingertip oximeter (for measuring pulse), an otoscope (inner ear exams), and a spirometer (measures lung ventilation), among others.
“The amount of stuff that’s coming up in sensor technology is just amazing,” Fish says. Gale may one day integrate data from other, less clinical, sensors like sleep monitors or health and fitness wearables, Fish says.
When a Gale user calls into a call center or telehealth service, the data collected by the sensors can be transmitted to a caregiver. Fish is careful to point out that Gale doesn’t try to replace the human caregivers. Rather, the device seeks to assist in the assessment of a problem then help get the patient connected with the right health professionals when needed.
Gale incorporates a 4G cellular radio to stay connected from remote places, and sports a large battery to ensure that it’ll have power when medical help is needed. “You can imagine one in every school, every workplace, every office,” Fish says. “In the beginning it will be public places, and in a couple of years I think we’ll see more and more things like this at home.”
Fish isn’t ready to talk about how much Gale will cost yet, but says that the idea is to drive the price tag down by leveraging consumer electronics-like economies of scale and making money from ongoing services rather than just selling boxes. 19Labs, which now has 12 employees, hopes to finish pilot programs in South Dakota and Canada this year, then begin to make Gale more widely available to clinics. It plans to sell the Gale hardware for an initial cost that will include basic medical supplies and sensor instruments. A monthly fee will cover the device’s cellular connectivity and access to a cloud-based device management and health content platform.
SOAKING UP SRI’S MOJO
19Labs is housed in a small office in a long, thin, two-story building located on the campus of SRI International in Menlo Park, California. SRI, originally known as the Stanford Research Institute, is the place where the very first internet packet was sent back in 1969. Hundreds of tech inventions have been created there over the years, such as the AI assistant that became Apple’s Siri. Numerous small tech companies, and a few high-profile venture capital firms have gathered themselves around the campus, as if to soak up some of that historic mojo.
When I walk in Fish is on a video conference call with a couple of his engineers, his medical director (and former astronaut) Dr. Scott Parazynski, and a developer from one of the country’s largest research hospitals. The hospital has developed a technology that could be integrated into Gale. Fish is rapidly and loudly throwing questions at the developer about everything from core technologies to business model to integration specifics to marketing tactics. The developer is keeping up pretty well.
The more you see the product, the more you can see the technology, design, and product marketing lessons Fish has brought not only from Apple but also another former employer, Samsung, where he worked on the Simband health wearable.
“From every company I worked at I took a few great ideas,” Fish says. He absorbed Apple’s obsession with quality and its desire to “surprise and delight” customers. At Samsung, he learned from the company’s culture of very hard work at high speed to deliver products before anybody else.
“The secret as a leader is to then apply these themes selectively, and balance the inherent conflict between those great ideas,” he says. “Companies tend to get religious—dogmatic around specific ideas—and at Apple, quality became one such dogmatic idea. Quality is critical, but perfection exists only in our dreams. Reality is never perfect. So aspire, but don’t get dogmatic about it, and know when to compromise.”
PART OF A SYSTEM
A common theme you’ll hear repeated by venture capitalists these days is the idea that products should be vertically integrated, providing as many layers of a given service as possible. VCs like companies that own hardware, software, and services. For instance, Apple controls the iPhone hardware, the operating system and many major apps, and services such as the App Store, iCloud, and Apple Music.
But that holistic approach can be difficult for startups, because it requires multiple internal groups focused on very different technologies, yet all working closely together on an integrated experience. Fish favors a different approach. “It’s smarter to play to your own strengths than to try to do something vertically,” he says. “And that’s a mistake that a lot of VCs in the Valley make when they tell startups ‘don’t give a damn, go transform the industry, take out the existing player, do everything from A to Z,’ rather than saying ‘No, build the things that you’re good at and then empower others.’”
Fish’s philosophy is to build a tech platform that can then pull in the best-in-class sensor products from companies like AliveCor. Rather than creating the medical supplies or sensor devices that come with Gale, 19Labs makes Gale into a platform for selling those products. If the Gale box finds its way into many clinics, schools, or homes, it could become a valuable distribution channel for partner companies.
Fish promoted this idea when he worked at Samsung, too. Samsung brought Fish in to lead the creation of the Simband. But rather than selling a one-size-fits all device including a few sensors that would fit the needs of most people, Fish (with Samsung executive Young Sohn) decided to make the Simband a prototype on which developers could create custom wearable devices with a specific set of sensors.
Since 19Labs hopes to sell Gale to health care providers—not consumers—this approach makes sense. Some health organizations may require specific or more specialized devices. A big part of 19Labs’ job is to make sure the hardware, software, and sensors all work together, and integrate with health providers’ systems.
While 19Labs is starting out by selling Gale to health clinics in far-flung places, Fish believes health care providers might eventually decide to buy the “clinic in a box” for homes, schools, and community centers.
By doing so, a provider might save money in the end, because patients would be able to utilize health services at the right times. “For the health care company, if they bring somebody too late to the hospital it can cost tens of thousands of dollars,” Fish says. “And if they keep them in the hospital it’s thousands of dollars a day more.”
Gale could help health care companies assess and deal with a problem before it becomes severe, and more difficult and costly to treat. It could also save money by enabling earlier hospital releases. “A mother might be able to bring her baby home sooner, if the family has the technology to monitor it,” Fish says.
ABOUT THE AUTHOR
Fast Company Senior Writer Mark Sullivan covers emerging technology, politics, artificial intelligence, large tech companies, and misinformation. An award-winning San Francisco-based journalist, Sullivan’s work has appeared in Wired, Al Jazeera, CNN, ABC News, CNET, and many others.
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The home turns a wheelchair ramp into a central design feature, and in doing so acknowledges the needs of the mixed households of the future.
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When a family in China approached architectural firm AZL Architects to create a house that could accommodate four generations, they probably didn’t expect that a wheelchair ramp would become the main design element.
But that’s what they got with Song House, a modern three-story, five-bedroom home made of concrete in the rural town of Nansong, China. The house was designed for four generations: a 50-something couple and three older relatives, some of whom occasionally need wheelchairs. There’s also space for the couple’s daughter, her husband, and their child.
The key feature is a smoothly sloped ramp that goes around the home’s exterior perimeter (similar to the ramp that wraps around the inside of New York’s Guggenheim Museum), giving the home’s wheelchair users easy access between the bottom floor and the first floor. The bottom floor has private quarters for one of the older relatives, and the first floor has three bedrooms. The second floor belongs to the granddaughter and features a bedroom and play space.
According to the architects, the idea is that everyone can feel connected when they want to, but enjoy privacy when they don’t. As populations age around the world, this AZL Architects design offers a compelling model of the future of housing: homes designed not just for able-bodied, nuclear families, but for the different needs that span multiple generations.
Jesus Diaz founded the new Sploid for Gawker Media after seven years working at Gizmodo, where he helmed the lost-in-a-bar iPhone 4 story. He’s a creative director, screenwriter, and producer at The Magic Sauce and a contributing writer at Fast Company.