Understanding Telehealth and Remote Patient Monitoring
Kent Dicks has been involved in providing technology for remote patient monitoring or RPM since 2006. Kent is a thought leader in the space and is currently CEO of Life365, a leader in RPM. Prior to that he founded MedApps, which was sold to Alere in 2012. In this episode Kent shares some common terms used in connected health and their definitions, how the segment has evolved, how consumer choice is effecting where medicine is and will be delivered, the role of remote patient monitoring, how RPM works from patient enrollment and training to use, how it’s implemented in a physician’s office, and the future of connected health.
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Episode Transcript
This transcript was generated using an automated transcription service and is minimally edited. Please forgive the mistakes contained within it.
Patrick Kothe 00:31
Welcome! Moving medical care out of the hospital or doctor's office and into the home has been happening for years, but it's really accelerated due to the pandemic. I think we all realize it's here to stay and provides some significant benefits, but will also probably disrupt some traditional relationships between patients, doctors, hospitals, IDNs and payers. I'm really happy to have Kent Dicks join us today to discuss connected health as he's been involved in providing technology for remote patient monitoring or RPM, since 2006. Kent is a thought leader in the space, and he's currently CEO of Life365, a leader in RPM. Prior to that, he founded MedApps, which was sold to Alere in 2012. Kent and I discuss some common terms used and connected health and their definitions, how the segment's evolved, how consumer choice is affecting where medicine is and will be delivered the role of rpm, and, and how it, it affects not only the patient, but also the physician, also the physicians, how RPM works, from patient enrollment and training to the use, and then how it's implemented and integrated into a physician's office. And then finally, we talk about the future of connected health. Here's our conversation. Kent, welcome. So happy to have you join us today.
Kent Dicks 02:12
Thanks for having me on today. I really appreciate it.
Patrick Kothe 02:15
So can I want to I want to take you back a little bit. Take you back to 2007 2007, the iPhone came out. But in 2006, you were rough believe running a staffing company running a recruiting company, and then formed a company in virtual care. So what happened there?
Kent Dicks 02:39
It's an interesting story. You know, I've always wanted to be an entrepreneur from being a little kid. I mean, my grandfather influenced me instead of my father. And I think I think my earliest entrepreneurial time I thought about it was when I started when I was seven, when I was mowing yards. And you know, I was also on weekends, but I was also at seven years old. It's eight years old, I was getting up at 430 in the morning, and delivering papers, right, you know, going down back alleys, the only thing i was scared of was dogs, right? You know, coming out. I wasn't scared of people or anything else from that, oh, I was scared about my brother stealing my paper out money, but that's about it. But you know, I, I went through, you know, into high school. And then I went into college, and thought I'm going to get a business degree right from that and went to work for Texas Instruments. I graduated with a computer information systems degree. And then eventually worked there for two years in Dallas and then went to American Express here in Arizona, and worked for 10 years for them as a programmer. I left American Express in 1996. And they call me back right away and said, you know, can you I'd left as a manager, can you come back and be a senior consultant for us. It only stay a couple of months, I ended up staying two years. But they also allowed me to start a consulting firm while I was at American Express. So I brought in, you know, 10 of my, my closest friends as consultants and, you know, brought in, you know, and lease them out to American Express as a consultant. When I left Americans press two years later, I had to leave because you know, the consulting business was really taking off. We ended up by the time we sold the business in 2008. We had put over 800 people right in placements. And we done over 60 to $70 million in business. We sold the business to another staffing company. But during that timeframe and like the 2001 2002 timeframe. We started transitioning over from just doing IT consulting, but doing top secret and secret engineers, right for orbital General Dynamics and other people. So as we're starting to put people in I started learning more because I was a FSO a field security facility security officer, including people I learned about where the military was headed. It's all declassified now, but they're gonna be heading into remotely monitoring people in theaters, you know, in different parts of the world. They wanted biometric information coming from soldiers. You know, from that standpoint, the soldier the future, drones are just now starting to be thought of in fact, one of our consulting gigs we got with the military and military contractors was up in my not North code, or where we're, we're we're actually recruiting kids that played video games, right to be the drone operators, right, because they were the best drone operators. So during that time, you know, we learned a lot about remote monitoring. And I started a, you know, I was approached by somebody about could you interface a Bluetooth device, medical device, to a smartphone, and I said, yeah, we'll do that. We'll work on it. And we did, and that's where it started become more interesting. We started working with McKesson, we started working with other people. And that's where med apps got formed. At the same time, I had my staffing company go. So we sold a staffing company and we went forward with med apps, we filed over 75 patents on the medical technology we created, we thought we're gonna go the direction of just interfacing medical device to a smartphone. So you talked about smartphones coming out in 2007. But then we quickly realize that these these smartphones are expensive. We wanted to go to underserved populations in rural locations. And we found that smartphones were getting stolen parked use for other things. You know, Napster was around at the time, they're downloading music instead of actually using it for, you know, for getting information from the smartphone. So we created a special device, I called it a non hackable device that was called the Health pal, and had a cellular chip in it, we built the hardware, we built all the firmware that went with it, we built all the firmware over the air, right to distribute it. And we talked to dozens of medical devices wirelessly on Bluetooth, we were one of the first IoT where they call iomt internet of medical things that's out there in the industry, we got significant amount of words significant amount of patents on that, we eventually were acquired by a publicly traded company, a layer, which was a $5.5 billion company, I became CEO of the layer connect division and my responsibility was to pipe and connect everything together from you know, the rapid diagnostics side of the business to the population health side of the business to the coagulation side to the diabetes side and feed it all into the HIE, the Health Information Exchange, that was our responsibility. We left in 2015 when avid and united or optim but parts of a layer and kind of split it up and filed another massive amount of pads because we knew the next generation technology was not going to be schlepping all this equipment around by scales and blood pressure and everything else. The next was going to be we needed to get to broader populations of patients in a very economical way. But with disposable sensors and patches and big data as a service to be able to go through and get data from the home to drive it through and look in AI systems so we can manage those large populations remotely right to do that. It's a lot of things we learned in the first company this company we learned, you know that you know, we call the first company RPM to Dotto remote patient monitoring to data. One Dotto was the boxes like Bosch is that Honeywell is the plugged into a phone line and were like $4,000 for the kit and you had to bring him in refurbishing RPM to Dotto as well. We as a company started with with med apps which is you know Intel went out and created a 23 pound box like a computer to monitor people we created an eight ounce device to monitor people. So we knew that devices needed to be smaller. And then RPM three Dotto is wearable sensors and patches that allow us to get to a large population of patients, but in a very economical manner. And that's where we're at today with light 335.
Patrick Kothe 09:20
Well, it's been really a fascinating journey that we've all kind of taken over the years to, to get to this. This virtual care that we talked about a lot is has been talked about with telemedicine, telehealth and things especially just coming through this pandemic right now. But in general, how do you view this virtual medicine? How is it divided up in your mind?
Kent Dicks 09:49
Well, I'm going to I'm going to back up from now and then go backwards, right a little bit on this. Because one thing coming up with pandemic, the way that I kind of put the pandemic is It just accelerated everything that was on a glide path. Anyway, my from that. So it's not just healthcare that accelerated, we all know that the pandemic accelerated overnight telehealth, right, because that's the only way you can see your doctor. Right? RPM wasn't so fortunate, you know, and that because people are like the COVID-19 was happening so quickly, that you know, you couldn't use RPM to really to monitor RP COVID-19 patients, because trying to stop the equipment out and get it back and clean it up and give it to somebody else was a was a concern. But you could use it, right to try to keep people monitored and out of the hospital out of the emergency room that have multiple chronic diseases to try to keep them healthy and away from it. But not just a monitor that COVID patients, if that makes sense. We had everything set up from call centers, we have a relationship with AMR ambulance, their paramedics could go out and they could go install it, and they can monitor from the nurse call centers. But the hospitals were, there's a couple things that happened during the pandemic, the hospitals were so busy with inpatient that they already had, they really couldn't take on the outpatient side. That's why we bring AMR n. And the other thing they're complaining about is they just didn't have the money. Because they couldn't do elective surgery, COVID was costing them a lot of money in the space as well. So rpm, you know, really didn't take a real big foothold during, you know, during the COVID-19 phase. But it's starting to now. And the one thing I want to go back on to it since acceleration, like I said, is not just healthcare, it's how we eat food, how we have food delivered to our front door, how we get transportation to and from work or to, or to the airport, how are other places how we work Now all that is changed and accelerated, which I kind of call the new normal, right, that's out there we are seeing what we like, and how we exercised and how we ate and how we, how we participated in work and how we could just hop on sessions like this and get going right away, we didn't have to have destinations where we went to to be able to do it, we could do it from the comfort of our own home might do that as well. And that's what you're going to see more of. But the interesting part to just delve into this as well as well, shopping malls are changing, right, you know, the way we shop, you're seeing major shopping malls. And we saw that starting to occur five years ago, you know, you really don't go anymore to a shopping mall just to shop for clothes, you're doing that now a lot online shopping malls are now going to be restaurants, they're going to be anchored by commercial real estate on one end and residential real estate on the other end, they're going to have hospitals in the middle, they're going to have faith based organizations, they're going to have restaurants, they're gonna have clothing, it's going to be like little cities, right that you're going to have. And that's what they're gonna build more and more of, in the future, you're not just going to have destination shopping in the future. And healthcare has to be you know, part of that combination as well. Right. So you're connected, you can go physically to health care if you want in the location, or you can be remotely you know, monitored at work or at home or mobile.
Patrick Kothe 13:18
Let's, let's define a couple of terms that we hear out there quite a bit. Telemedicine, in your mind, what is telemedicine?
Kent Dicks 13:28
You know, that was I'm attending. I've been in this industry for 15 years, and I haven't had to go through my mind, you know, over the last couple years what the true definitions were. But I think they've gotten clear in my mind a little bit. I don't use the terms, I'll get to telemedicine in a second. I don't use the terms and health anymore. I don't use I mean, I talk about digital health, but that's just globally, everything that's out there could be Holter monitors, it could be remote patient monitoring could be telemedicine could be telehealth, other things. Telemedicine to me, you know, is a point to point solution, typically between providers, or it could be from a city CVS to you know, to a provider someplace, it could be a rural location to a provider, but typically using you know, equipment that is you know, more professional grade equipment to be able to do observations from one provider to another provider, could be to a video, you could be using OTA stoves, stethoscopes, you know ECGs anything that a doctor needs to be able to do an examination on you locally. That's where I see telemedicine, it could be like I said, a relocations, it could be on a ship, it could be on an airplane, but it's going typically for an exam from a physician from one location. The other telehealth is, in my mind is to a video, right that you're having, you know, like you and I are seeing each other right now that you can have a conversation with your doctor, as a patient to a doctor and have a title I help visit instead of going to the doctor's office, a lot of people lump in telehealth with remote patient monitoring as well, from now, because they're seeing vital signs, there is aspects in telehealth of getting vital signs in but that's the act of remote patient monitoring, remote patient monitoring is typically equipment that you are giving out to patients that are connected outside the point of care someplace, it could be mobile, it could be in the home, it could be the office, but then the data is sent to the cloud for something or someone to observe right from that. So when I started start saying something or someone it could be in the near future, right now, it could be machine learning, or AI or analytic systems that are over seeing you, and then just bring it to the attention of the doctor, right that there's an anomaly of your data, comparing your data to you, right from that standpoint, or it's just out of whack, based on parameters that have been set. virtual care, right is kind of to me the overall overarching, although digital health was, is the overall arching of creating a care situation, where you're actually virtually receiving care, either through telemedicine or remote patient monitoring or telehealth. And it could be prescribing medication, it could be titrating, your medication, it could be changing procedures or diagnostics. From that it's all that you are under the care of somebody, but you are creating a virtual care environment, it's done remotely or virtually,
Patrick Kothe 16:33
as you as you described it, we're not we're not going to talk much about the telemedicine side of things. Because what the way you describe this more pipeline between clinicians, the Telehealth is what what we just went through with, with the pandemic, changing some rules to allow it to be more used more, more frequently and easier. And I think those rules have been rolled back. Let's let's explore that a little bit about how that occurred within the pandemic. And you said that we were sliding and we're going in that direction to begin with, is that kind of accelerated and made it in people's mind to be a more commonplace scenario.
Kent Dicks 17:16
Thank you. No, there was a there's a wave that was already occurring prior to the pandemic, what was a switch to consumer based care? You know, the one thing that we realize going forward is that in the future providers are really not going to be the people that make the decision on how care is administered, where how its administered, and where it's administered. Because the consumer is going to vote with their their dollars of how they receive care and where they received care. It's really going to be determined here in the future, it's already starting to be that way. And it started really with HSA is a lot as well, is that the payers and consumers will be the people that decide how healthcare is administered. And you can already see that people have voted in a certain way to go through and, and embrace embrace that a certain way. They they've got minute clinics, they've got, you know, ready clinics that are out there, CVS, Walgreens, you know, Walmart, you know, has clinics where consumers can choose, you know, to go there instead of going to the general, their, their PCP or their general practitioner. You know, companies like lemonade health are starting up, you know, hens and hers, Roman, you know, that's out there as well, these are, these are telehealth applications that are have been started up, because consumers demanded to be engaging with the health care providers a certain way. So this is what's making providers incredibly itchy. From the standpoint is because, you know, first of all, all this that we've been talking about so far is creeping outside the four walls of the hospital. So how do you control it outside the point of care? Second of all, you're telling me now that I have as a provider, I have no control of who I see and don't see, but I have still have to work be on call 24/7 and I still have to work 16 hour days, right? It's not a very pleasant experience for providers, and I really empathize with them. But you got to look and see the other trends that are occurring now to risk and value based care, you know, has been emerging as well. And, you know, I have this one chart I kind of show that shows these trillion dollar or multi 100 billion dollar channels that are emerging, you know, in the marketplace, they all kind of start with telehealth, but the telehealth companies are kind of aligning with the payers, right from this standpoint, and they're wanting to get closer to the consumer and they're wanting to cut out the provider in between and take control more of the cost, right associated, you know that a provider would normally have control over so instead of walking into a hospital I'm getting, you know, a bill for a million dollars for COVID they may have the ability to combat it for $20,000 based on their resources, right? So these trillion dollar channels you're seeing, like TelaDoc align with, you know, Livongo and you're seeing Humana, you know, aligning with he'll, you're seeing, you know, optim, United aligning with vivify. And, you know, Amazon with transparent you know, there's a lot of these channels Cigna with MD live, a lot of these channels that are emerging, they're not gonna share with each other patients, they're in competition with each other. They're right now doing more episodic care, than most right, they're going through like the TelaDoc are really still going through and saying, I'm going to treat colds and flus, they're really haven't made a big push into chronic care. Now vivifying United have but there are other channels really haven't got into the chronic care side, which is the reoccurring revenue side of the business, it's a bigger side of the business. But for them to be able to be able to do chronic conditions, they've got to get data and connectivity through the digital front door of the patient into the patient's home and connect to them on a regular basis to be able to do that. And to engage them and get regular vital signs and give early insights into what really is happening with cat decks right on a regular basis. I want some insights, right? Is he doing okay? Or not doing okay? So I see these marketplaces, as platforms that are going into communities to take to cherry pick and take off the best patients out of communities. Now, if you think of a provider, a provider, like I have a hospital two miles away from me, they typically get their patients from the surrounding area, right people will go I'll go to, you know, honor health at 92nd Street, because it's a it's two miles away from me, that's where I always go, I'm not going to go 20 miles away. Well, if you have the TelaDoc the world coming in, all these other guys come in, they're cherry picking out can dicks and you know, and Pat and other people, it's actually worse than we think they're cherry picking off the people that have the ability to pay, and leaving the people in the community that don't have the ability to pay. And those go to the hospital systems, right instead that are locally there. Sure, we're still going to go to hospitals, because we have needs, you know, from that standpoint, maybe I have to be in the hospital. But the trans current model, and the hospital models are going to change trans Karen went out and bought with Amazon went out and bought a surgery center that has over 300 Different surgery centers in it, and they send you to a surgery center to get your surgery and then they transition you home. Right instead, instead of transposition you into a hospital. So the hospital loses the surgery, the hospital loses all the aftercare from that as well. Where we have to get brilliant on us is that anything that would have been provided to me when I'm in the hospital, hospital now has to be transitioned to home. So hospital home needs to have food security medic, you know, whatever I get in the hospital now needs to start being at home under some of those initiatives. And that's where we see the growth opportunity. Once again, on the hospital side of it the provider side, I think they're in trouble part of his ego as well, too. I've heard Ben around a lot of you know, senior executives, and hospital systems that are just saying no, we'll be completely full, right from that standpoint for years to come. I don't necessarily see that's going to be the case, right from the US because the consumers have options, it's gone over to a consumer based economy, the telehealth companies are starting to cherry pick pipe people off. Other companies are starting to go at risk with population to take care of Ken Dix, trans Karen's going to go if you're under my program, you know, and I'm going to large self insured employers, I'm going to control the cost where you go, right, so I'm not going to send it on or help because they're gonna give me a million dollar bill, I'm going to send you to my surgery center, and I'm going to send you to an aftercare or to a sniff, to have pre negotiated rates on that, and then you're gonna go home, and I'm going to help you with that care at home. And it's gonna be a fraction of the cost, right, that we can say. So I think, you know, path is a big, big issue going to be coming up here real shortly.
Patrick Kothe 24:24
So the, the old the old model is you go to you choose your physician, you go to the physician and the physician and the physician chooses to use technology to do that what you're saying is that that choice of it, the initial choice of physician may not be in in the consumers hands anymore.
Kent Dicks 24:41
It no I think consumers are gonna choose the physician, right? I mean, I think that the consumers have their their ability to do that. I think they're gonna give, they're going to give the payer is going to give them a certain amount of money, almost like HSA and they can go choose their physician right from from that standpoint, but it may be within Network, right from that perspective out networks probably going to be a lot more expensive. But I still think the consumer is gonna be able to change to choose their, their physician, I personally have changed a little bit, but my wife and I, probably seven, eight years ago fired our general physician, because they're making us come in to get an exam, come back to get test, and then come back in to get test results. And that because that's how they got paid. And you and I know, both of you and I both don't have the time, because we're not we weren't in town long enough to be able to when we're traveling, to be able to go back for three separate, you know, three separate occasions, so guess what happens, you don't get the test, you don't get you know that that slip of paper that the doctor gives you to go get the test or whatever stays in the back of your car on your desk for months before you go do it. And it's just not healthy for you to do. So, you know, we fired the physician and we ended up going at that time minute clinics or, you know, if we had, you know, the cold or flu or whatever, we went to a Minute Clinic instead. But we still had our specialist, right, my wife still had her specialist, and I still had my specialist like cardiologist and, and others, their author of cardiologists mainly. So I think the cardiologists are going to be are the specialists are going to be a fairly protected class of individuals. You know, I think they're even better if they're not associated with a health system. Right from that standpoint, if they're more independent, but I think there are good classes citizens, I think the doctors are going to be the ones are the general GPS and PCPs are going to be the ones that are going to be hurting. And I think they're going to have to transition over to telehealth, they're going to have to, you know, go through and start taking in ZocDoc helps with it, but they're gonna have to start taking in telehealth visits, to be able to fill up their practice. i That's just my, my thinking because a lot of consumers, especially when you're starting to talk about millennials, Millennials don't give a whinge right about if they go to the same GP CP that's out there. Right, they want to make sure it's cost effective. And they want to make sure that you know, they get care, right from that standpoint. And as long as it's going to somebody that's reputable, you know, and they do what they want them to do. That's the key, they do what they want them to do, then, you know, they're going to go probably to be very comfortable with a telehealth visit. Maybe the older population isn't as comfortable with a telehealth visit. But you know, and I'm talking about a population that's 8070 8090 years old, I'm 60. But I've grown up with this, and I've grown up with technology as well, I am demanding that I sit behind my computer screen and I have a conversation with my PCP or with my specialist on a regular basis, and then maybe go in once a year, right or it could be twice a year, but once a year, or as needed to do an in person visit. But the rest of the time with technology and being able to phone in your blood pressure or, you know, or track your blood pressure or your glucose or other things that you can be part of the electronic health record. I think it can all be done hybrid. It's going to be done hybrid in the future.
Patrick Kothe 28:19
We kind of had a grand experiment over the past year where there was a lot more telehealth visits than there were previously. And data was drives change. Have we seen the data that has come back from that experience?
Kent Dicks 28:35
The only thing I've seen initially it was like initially in March of 2020. We went from like a 12 to percent penetration of telehealth to a 70%. Like almost overnight, right from that. I mean, telehealth companies were scrambling to if you had telehealth, you're getting installed, right, they're scrambling to get installed. Out there, it went back down to about 40 or 45%. But that's still a huge jump year over year from 12 to to 40 or 45%. That signals that not only the doctors got comfortable with that the consumers got comfortable with it. Right as well. And it's interesting. You know, I just heard this the other day that with one of our health systems, we're working with the doctors we're kind of fighting tooth and nail and March of 2020. Right about doing telehealth visits are like we can't give the best care to our patients because we need to see them in person. But it was the only way they could do that. Now today, that's the only way they want to see him. They want to see him virtually unless they need to see him face to face.
Patrick Kothe 29:40
Right. So what were the changes during COVID? There's changes to reimbursement there's changes to licensing across states. What are the changes were were made?
Kent Dicks 29:50
So we're under the Ph. D. Right? The Public Health and Health Emergency and the public health emergency. You know, I'm not an expert on this, but I'll just try to do the best I can. If I Under COVID situations under remote patient monitoring, under typical remote patient monitoring, you had to have 16 days of readings to get reimbursed right, for a chronic condition, at least two chronic conditions, at least using one wirelessly or connected device, right that goes to the cloud, you be able to be reimbursed for connectivity be able to be reimbursed for the first 20 minutes of monitoring a patient during the month in the next 20 minutes. But you had to have 16 readings coming out under the PhD with COVID. And it was COVID. Related, it only required two days. Right of reading. That was it. But also to your point, licensure was extended, right? There are already I think 35 states that had compacts between them so that they could share nursing resources and between states to be able to do that, but a lot of the other states signed waivers to be able to, to talk with with patients remotely. So our the RPM side of it, the reimbursement codes, we thought we'd go up this year, they went up a little bit, you know, in 2021. And I believe they're going to be about the same in 2022 as of January 2022. But the bigger thing that's occurred that's coming out is our TM codes. So remote therapeutic codes, those are similar to rpm code or RPM codes, but they're not related to vital sign biometric data, they're related more to engagement and adherence, compliance, right from that. So anyway, to be able to engage a patient or get a compassion compliant, like med reconciliation, right to be able to do that for the medication, you know, is billable under the RTM codes, right. But, you know, I can talk loosely about this right now, because they really haven't figured out, you know, completely what those codes look like, until January 1, I personally wrote a letter of opinion to CMS, you know, to be able to go through and give our opinion on what the code should look like. And a lot of thought leaders in the space that as well.
Patrick Kothe 32:12
remote patient monitoring, let's dig into that a little bit. What exactly is being monitored
Kent Dicks 32:17
on an RPM side of it. I mean, we we have a system that that interfaces, over 300 different medical devices. And, you know, when I talk about medical devices, you know, it's we integrate to scales and blood pressure and pulse ox and glucometers. And, you know, ECG, like, we're the only company that interfaces to a live core cardio mobile, ECG and spirometers. You know, from that thermometers. So you know, why 300, because there's different brands and different quality of data, right, that's out there, you may see some RPM companies that have five devices, they may have a scale of blood pressure, pulse, ox, and glucose and a thermometer. And that's all they offer, right as five devices from one manufacturer, maybe from China. And when we get to a health system, a physician will go, I don't like the quality of data coming out of those devices give me something different. And they may be more comfortable with Masimo and D non and you know, and such right, that's out there. And so our Omron so we can actually give them another maybe a more high quality device to be able to use to give their quality of data. Let me just talk about quality of data just for a second. Because it's really super important. A lot of times people will go through and say I need the most accurate data there is, you know, to know Pat's heart rate is that heart rate is Zach, blood pressure is Zach glucose. And some applications of healthcare do need to have that exact quality of data and accuracy of data. Others, there's an opportunity to do exception based processing and actually comparing Pat to Pat, right. So you could use potentially a little bit less accurate device still FDA cleared, that maybe as with off within 2%, or 3%. And some of the less expensive devices will will be that way. It's a tolerance by the FDA. But you're only comparing that number, you're not showing it to the patient, you're not showing it to the clinician, you're showing it to AI or machine learning and going, okay, he's trending now, right on this kind of stuff. And he's trending up by 10% per day, even if it's off by 2%. We should let somebody know and then use an FDA device to truly measure them. Right. And that's where I think that you get opportunities, right to measure greater populations of patients by using a tier one and tier two approach. Tier one is living give them a less expensive medical device. It could just be one right a pulse oximeter. And in fact, we did that with my mom. We did a poll six numbers, she was always 9293 9293 and then one night she was 75. And why was she 75 Because COVID Right COVID took her down to 75, we didn't have to have any other parameters right there out there, instead of just that one. From that, that's what we we worried about. So, you know, I could have a long dissertation about quality of data and everything else, but we want to be able to give clinicians of choice to choose from from it. And we want to be able to scale to larger populations, economically, with different qualities of data. So when we're doing RPM, you know, and all those devices that are going on with it as well, we can put them come combined together to go after certain disease states that are costing, you know, a significant amount of money. So it could be congestive heart failure, where, you know, providers are getting dinged for 30 day readmission, it could be diabetes, it could be hypertension, it could be COPD, asthma, you know, those are traditional hypertension, the traditional frequent flyer, once a typically can put you into the hospital and exacerbate and cost more down the road, but they're not limited to that they can be used with oncology could be used with kidney care. You know, in fact, you know, we're seeing a big, you know, update or uptick in kidney care right from that because kidney care as of January 1, nephrologists are going to be more on the hook, you know, for reimbursing for sorry, more on the hook for risk, right when they get reimbursed right from that. So they want to make sure people are are staying out of the hospital, right, on a regular basis.
Patrick Kothe 36:33
So Kathy, those devices are connected how.
Kent Dicks 36:37
So the devices that we typically have the three or 400 we're talking about are typically wireless Bluetooth, that talked to a smartphone, they could have embedded cellular inside of them, right. So we have scales and blood pressure and glucometers that have Siler built inside. On some of you know, you got to look at, you know, the situation of when you're going into monitor population, when we typically go into a population, most people don't care about the brand of scale, the brand of glucometer, the brand of pulse oximeter or thermometer, but they do care about the brand of glucometer. Right? A lot of times, people you know, it could be the VA, it could be other other organizations that are out there have already contracted with the large glucometer makers. And sometimes they give him the most the cheapest glucometer and the cheapest strips that are out there. And it might be that they have no connectivity other than a connected wire, right from it. So in that case, we have to plug in a wire to the glucometer and then either plug it into the back of our system, or we have to convert it to Bluetooth with a little dongle. Right to have it connect to the phone from it. So you know, it's typically Bluetooth, but it can also be serial wired as well.
Patrick Kothe 37:58
So every every patient is going to have different internet, different technology. skills. How do you how do you go about training somebody to use it and and assessing whether they're capable of using? Yeah, so
Kent Dicks 38:15
that's, that's a really super good point. And that is the main friction point, I'll talk about friction points, you know, in this industry, friction points are things that cause things not to scale. Right, especially from an RPM perspective. There's a couple of different friction points. friction points are, if a clinician has to put in an order for an RPM solution then has to decide which one to deploy to a patient, like who's going to be able to use it, who's not going to be able to use it, you may not get ordered, right? If you have to decide how it gets distributed to the patient. That's another friction point. If you have to see the data in another system, it doesn't flow back into the clinical system. That's another friction point. If you have to engage the patient separately to use it. That's another friction point. So the more that you can go through and this is what we try to do, the more you can go through and eliminate those friction points, get automatic order entry, try to use machine learning or artificial intelligence to try to align the right solution with the right patient to get the right outcome at the right cost. Right, engage them in the care then put the data back into the clinical back end system. That's going to cause you to start scaling right from this. So how do you go through, get all styles of users and types of users to try to engage and it's no easy task. That's why we've gone through and offered what we call a BYOD or an app that you can download and connect to 100 different medical devices. Well, that app may be okay for me or for you or for millennials that are out there to use that maybe it's not okay. It wasn't okay for my dad. My dad didn't have a smartphone. My dad wasn't on the grid. It could be a certain user doesn't, it's just too techie for them to pair devices. And, you know, and try to use it. So that's great. There's the next level we go to, which is cellular enabled devices. And all we have to do on that is ship a scale or blood pressure or glucose meter out to the patient, no app, no phone, it just arrives, and it's connected and says the data and the clinical backend system, that's easy as can be. So you decide the case with my dad, like, we'll put them on that, right instead, an option three is a hub that we use, and we have a neat little one that's coming in now that you can actually wear around your neck, it also acts as a purse device. But it's also an Android probe, I Android program with Bluetooth on it, that can run our connected device program, and talk to all the medical devices around it and send the data automatic to the cloud from a hub, no hands on no phone, no nothing. So what was the difference between Seiler and between the hub because the hub can talk to 300 Different devices with our program, the sailor only has three devices that it's embedded into. And then the fourth one is our tablets solution, which is you know, ability to have to a video on it, you know, survey questions interface to 300 different medical devices. And that's more for people that just want complete systems to be able to talk to their doctor totally hands off. It's you know, it's already bundled into a kit, we make this easier with the reduce their friction points, by taking all this equipment and don't just shove it into a brown box, we put it into a nice kit, a carrying case kit that has a scale of blood pressure, pulse ox and tablet or hub that's inside of it. And so it can easily be stored and put away if you want to most the time they're gonna keep it out, or it can be returned back to us. The fifth option is wearable devices and sensors, right so that we can go through and be able to connect with patients through wearable devices, you know, that they can wear as a wristband, or they can have a patch that goes on their chest, or they can have a sensor that's located on them somewhere, you can talk to other devices, you know, it can talk us a patch could talk to wearable, wearable device, but we want to make it as easy as possible to deploy that technology with a patient. From my perspective, I don't mind the doctor having an examination saying you know, on discharge are all we want you to go home, but we're going to give you this patch to where and for the next 72 to 96 hours, you know, our telemetry system, our nurses are going to be monitoring from home, but don't worry about it, just wear the patch, right? Go in the shower, if you want to do your normal thing, you don't have to step on anything, we'll we'll be watching you from a distance. And then after 96 hours, we'll call you and you can take the patch off and throw it away. That gets him outside of the golden hour of returning back to from a readmission to hospital. So it's not easy to go back to your original thing. It's been the problem with scaling in this industry. But I think that AI and machine learning and alignment of the right solutions is going to be a really true help in the future.
Patrick Kothe 43:09
So we've discussed, what what's going on it from the patient's location, what's going on at the physicians location, what does that dashboard? What does that software look like there? And how does it integrate into into their systems.
Kent Dicks 43:24
So the positions are crazy busy in their practices, a lot of times the physician themselves, an average physician has about 2000 patients in their practice maybe 2500 a value proposition, you know, of going through and saying hey, we can deliver another 500 to 1000 patients for you to into your practice by monitoring them sometimes is attractive from a revenue perspective, but daunting from a workload perspective, right? So you know, the progressive physician practices that are out there, know that they have to switch over to virtual care. They just know, that's the only way they're going to get new patients coming in, especially if your GP specialists are different, but GPS. And if they set it up correctly, they would have medical assistants or physician's assistants to be the people that are responsible for two or 300 patients each, right and monitor them, you know, on a daily, weekly or monthly basis. Right, and then they can bill for it. Right. So I think the average they've shown is that pa that takes in, you know, two or 300 patients extra into a can generate another potentially up to another half a million dollars in revenue for the physician practice. So that should not if it's set up correctly, that should not cause a lot more concern to the physician. Right from a workload perspective. They would only intervene if they needed to like they normally would. If the PA couldn't handle it right or the MA couldn't handle it. They don't bring them the perception based on So it's disruptive to their practice. But so where electronic health records right as well. And so as telehealth, I really say that physicians want to get more to the Uber model. And the Uber model is they want to turn on and off, to go see their kids soccer game, right and not be on call and be able to, you know, go out for two hours, and then come back and maybe go back online for another three hours in the evening. If they have time. Once they put the kids to bed, they want to choose their hours when they were, it's not always possible, right in their practices to be able to do that. But when you become a telehealth doc, a lot of times it is. So that's why you're seeing people switch over to become telehealth Doc's right because they can go on and off when they want to put time into it. The biggest complaint we saw when we worked with quit with Mayo Clinic, is that they love the fact that, you know, they can connect to people on platforms outside the community and bring in diverse populations and bring in, you know, people, you know, that need to have care. But their physicians are already overloaded. And the average physician spends 80 minutes a night, updating the electronic health record with notes from the day, they're already overburdened, you know, even when they're not on the clock. They're overburdened at night, just trying to complete their records, right. So they don't miss somebody. Their biggest fear also, is that they get over 500 emails a day. Right? Maybe it's an exaggeration, but that's what they tell me. And they don't know which one's the critical one to look at. Now, there are systems out there, there's software that's being made. So it could actually go through and learn from the emails and try to bump it into a top of the queue to try to get it there. But it really worries them that something stuck in the queue, and they they're not able to get to it right in a timely manner.
Patrick Kothe 46:58
So let's talk about regulation for a second. Life 365 health, are you in a regulated medical device? Product? Where are you integrating regulated medical devices,
Kent Dicks 47:10
so light three C five health itself by providing hubs and smartphones and tablets, you know, and wearable devices that are out there that act like a hub falls under the MdDS, the American Cares Act, right, it's out there that we are conduit, we are not, although we have a quality system that we work with him, we do not have to be FDA cleared, we use FDA cleared devices, but we don't have to because we're not going through and changing the data, or making a correlate, you know, algorithm to the data to point it out to the physicians, all we're doing is going through and saying when the doctor says, Tell me when their weight gets above 200 pounds, just let me know, we let them know the weight got about 200 pounds. We're not saying anything more than that.
Patrick Kothe 47:58
So the physician is setting setting the limits, and they're looking for outliers. But as you describe, you know, some of the AR and AI and machine learning stuff. That's kind of where the gold is, isn't it that that's, that's where you're gonna start looking at at changes is is that still within life? 365? Or is that something that's in the physician's side?
Kent Dicks 48:24
Yeah. So Well, I mean, I see us as a tool or an aid to the position right from that. So ultimately, it's going to be a tool that helps them do their job better, or alert them to do their job better. When I see you know, machine learning or artificial intelligence, obviously, it needs a massive amount of data to be smart. But a lot of people use it to do more in the predictive analytics side of the business to go through and say, you know, Ken, Texas had three regular, irregular heart rates over the last, you know, four days. Last time we did this, He, God forbid, he had a heart problem, right from it. That's, that's going to be FDA cleared. Right? That that's going to have to if you're making those type of correlations. When we start talking about the machine learning and AI side of this, I'm talking about using data insights and data that flows through our system, D identify data that learns, you know, the difference between what engages Pat, to be engaged in his care versus can't. And that doesn't have to be FDA cleared, because I'm just doing insights to go through and say, Well, I'm going to recommend a smartphone app to Ken right from there. So I'm going to recommend a tablet or a wearable to Pat because based on his demographics and everything he's doing, and its compliance ratio, I think he would do better from an inherence basis than Kentwood.
Patrick Kothe 49:45
Let's talk a little bit about the business side of things and RPM. Who owns the devices? Does the patient buy the devices is that the physician on it is a lease model what's the model look like?
Kent Dicks 49:56
The answer is yes. Right to that because it really depends on the customer and how they want to structure projects or programs. The one thing I will say about rpm, and where we've got to today, we've actually crossed that prefaces that breach that boundary, where devices are becoming so economical now that it doesn't warrant going and picking them up and and refurbishing them and sending them back out to another patient in the in the initial days of RPM, when things were costing a lot more money. I mean, a pulse oximeter used to cost me $450, right Bluetooth one years ago. But now it costs 30. You know, if you talk about having to go out, ship it out to a patient 30 bucks to do that, ship it back, 30 bucks, cleaning it up 70 bucks, right to do it and put it back in inventory, it's not worth it to do that, it's better to just leave it with the patient, and say, This is great. This is yours, right? Depends on the program. If you have programs that are 30 day readmission programs, and they turn around pretty tightly and pretty quickly, and you're only going to be monitoring for 30 or 60 days, it's it's not that economical to do some of this stuff. But if you know the economics between congestive heart failure patient, you've got to look at the longer cycles, like a congestive heart failure patient, you as a hospital system may be worried or a payer that they're going to readmit back in the next 30 days, and you get disincentive through HEDIS rating star ratings reimbursement that's out there. And you're only going to monitor for those 30 days, that a typical congestive heart failure, patients probably going to go back to the hospital for four times during the year, or have episodes and you want to try to at least eliminate one or two of those along the way or get early insights to try to eliminate that. So instead of giving equipment to somebody, and then bringing it back, and then giving it back to them, bring it back, just let them have the equipment, right, leave it connected, let them do self management with them. And then the times that are in between, monitor them live from that to keep them connected. So it could be a lease program that our clients pay for with us as a PMPM or per member per month. It could be they're buying the equipment, and then paying us connectivity fee, there's a whole host of things that they could do. It could be they're looking at the data in our portals, right? It could be that they're, we're sending data into their electronic health record through an interface into the EHR into, you know, epic are all scripts, and they're looking at the data in their system. Or it could be that we're sending it through API's into another clinical system, right from that standpoint. So it really depends on the customer, what kind of program they're putting together,
Patrick Kothe 52:36
approximately how much reimbursement to some does a physician get for RPM patient?
Kent Dicks 52:43
So you know, there, I have the exact codes here, but I'm just I'm just gonna say briefly, there's, you know, there's one code that allows you to get training code, right. So if you give out the equipment at your office and give it to a patient, you can get a trading code. And I think that's $19 9019 for a one time code. There's another code which is, you know, 99 9454, which allows for connectivity, that's the one that requires 16 days of readings, to chronic conditions, you know, one at least one medical device, and it's $63. I think the right number is $63 a month for that. But then you got to subtract 20% copay. So the net amount is roughly around 50 $51 That is netted out of there. From that to the I mean, the whole $63 is netted to the physician, the $20 20% for copay, but also the $51 for connectivity. But what a lot of RPM companies do is they'll walk in and say, Okay, let's we'll get paid out of 99 for five for you keep the 20% copay on that we'll take the rest of it the $51 you know and that pays for the equipment, the connectivity, the shipping, everything that kind of goes with it all in one right. And then on 99 457 and 458 that is you know, reimbursement codes for facility and non facility. And you know, it ranges anywhere from 45 to $50 per 20 minutes segment. If you did a right and this and bundle with other codes like 99 494 or five, four and 99 091 I believe it is you could bill up to about $150 per month, right for a single patient including connectivity and and the minutes spent with a patient.
Patrick Kothe 54:41
Can I want to focus just a couple minutes on the future. Many of us have devices already. Call it health and wellness devices are worried well devices people can have their own ECGs they can wear a Fitbit they can wear an Apple Watch. You talk About the devices becoming cheaper in the in the professional category that you're in, as we make our way up from being a health and wellness into chronic situation or an acute situation and have professional management of that there's really a crossover of the devices, there's crossover the data, what do you think that that's going to look like in the future?
Kent Dicks 55:27
Well, I think the the biggest thing that's going to have to happen, it's going to have to be incredibly passive, right, it's going to have to be lay in the background. And I think a lot of people are moving that direction. You know, the Apple Watch, you know that does is going to do blood pressure here in the next couple of years. They'll say it doesn't now but it's not FDA cleared SPO two ECG it already does. Like an all in one device that's out there. Having an all in one devices is awesome, right to be able to do. But Will people be willing to pay for, you know, that device, if it's more expensive, and prices will most likely come down right from that as well. But it's going to have to be, it's going to have to be past passive in the background to be able to do stuff, I think, you know, it's the right direction for us to get rid of these kits that have you know, scales and blood pressure, and all that kind of stuff. And to go to a wearable device that is all in one, like an Apple Watch, or Samsung, or Google or whatever, or that's out there, that makes a whole heck of a lot of sense to me. But I think it's going to have to even get by the time I think I leave this earth, I think that we will probably have a little tiny BB sensor that's implanted in us that does all of it, that you know, it just radiates out. And then you've got big concerns, you know, about here's your data already out to spewing out to everybody and is that a big HIPAA and privacy and everything else that kind of goes with it, I don't have a problem with it. Because I know that it'll be on encrypted channels, right and only talking to my smartphone, but people will have a problem with data flying through the air. It does that today. So my big thing on that it's going to have to be it's going to have to be passive. The other thing to kind of consider is generally consumers will not invest in their own health. They just won't.
Patrick Kothe 57:23
they'll invest in their own sickness, but they won't invest in their own health. Right?
Kent Dicks 57:27
Correct. And there's still a mentality, especially in this country, and I think I don't want to get political, but I think that's where it's going to have to change is, you know, people have to be more responsible for their outcomes. If I decide to eat a cheese pizza every single night and go up to 350 pounds and have clogged arteries, we automatically expect the insurance company to be there and pay for it, even though it's a consequence of our own actions, right from that. And I think you're going to see, you know, more and more that just like you do with a car, if you don't drive responsibly, your rates go out. Right from that. Right. So, you know, again, I don't want to be political, but you know, the people that decided not to get COVID-19 shots that are out there, you know, when once they do get COVID? Should the insurance company really pay for them? Right, even though they paid into it? So, you know, I think there's gonna be a lot of accountability from that perspective coming up.
Patrick Kothe 58:28
Well, Kent, this has been a fascinating discussion. And I really appreciate your perspective on here. Is there anything that you any any message that you'd like to deliver to the fellow medical device, people that are out there,
Kent Dicks 58:42
just and I always say that, just because you build it, they may not come right, you know, when you're building something, you know, make sure you know who's going to use it, who's going to pay for it, this is not an industry, where you go through and try to just build something and try to get people to use it. But if you generally have to find a need, right? To that you're serving, and it has to be economic, right as well to make sure that it gets somebody is going to pay for it and gets paid for some way. The other thing I would just say really quickly, with entrepreneurs that are coming into this is this industry doesn't adopt fast, right from that. So you have to be in the investors know that. And the industry doesn't necessarily like to think broad, either. It doesn't like to think about platforms, even though there are health care platforms out there. It likes to think very narrowly about a disease state and about an economics around a disease state and go to market and how it's delivered. And it's going, that kind of mentality is going to have to change right over the next several years. Because the only way we're going to get economies of scale and to reduce friction points that we talked about, is to now start leveraging platforms that are broader aspects. Have you know of the system, right to be able to do that. And people have to open up to that level of openness and rest.
Patrick Kothe 1:00:09
Some people are all about the device. And some people take a broader perspective. Kant is obviously one of those people who takes a broader perspective is not just a device guy. He's deeply connected to the way that medicine is delivered, and who is and will be delivering it in the future. So this much broader perspective is going to keep him and his company relevant. A few of my takeaways, first, the definitions, and I think that this is really interesting, because we talked about connected health, telemedicine, telehealth remote patient monitoring, and this is an evolving field. And each one of these definitions has been evolving in the past as well. So I guess, one thing to keep an eye on is if you're in a field that is evolving, don't assume that you're talking about the same thing, when you're throwing out terms, make sure that you validate that you're both on the same page when you're discussing a term. The second thing is, I was really struck by when when he talked about the accuracy of the device may not be the most important thing. As we're developing products, we think that we know what what the customer really needs and wants. And accuracy in the medical device field is really been one of those things that we're really honing in on when we're developing product. But in this particular aspect, and this particular product, the accuracy is not the most important thing early on, it's really monitoring changes. So I guess the question I got for you is, you know, have you really defined exactly what the needs are not necessarily what you think the needs are. The final thing is, he discussed friction points. And he defined it as you know, friction points or points that cause things not to scale. And I thought that this was really interesting as well because he defined each one of those those friction points and then remove them systematically to be able to provide the best product. So what are your your friction points. And if you when you identify those, just attack each one of those because they're an obstacle to your success. As you continue to attack them remove one at a time, one at a time, you're removing the friction to adoption. Thank you for listening. Make sure you get episodes downloaded to your device automatically by liking or subscribing to the mastering medical device, podcast and Apple podcast, Spotify or wherever you get your podcasts. Also, please spread the word and tell a friend or two to listen to the mastering medical device podcast as interviews like today's can help you become a more effective medical device leader. Work hard. Be kind
