Transcript Telehealth - Evalueserve

Telehealth and Remote Patient Monitoring:
Landscape report
January 2013
Methodology
Project objective
This report aims at providing an understanding of the telehealth landscape with respect to the market, its
dynamics and the business models of various stakeholders.
Project methodology
Client Shared Files
Evalueserve Secondary Research
and Analysis
Expert Interviews
Profiles of experts interviewed
Telehealth Landscape Report
Market overview
Market dynamics
Business environment
CEO, Telehealth Start Up, US
Director, Telehealth, Leading Network Provider, US
Business Development Manager, Telehealth Consortium, UK
Novartis telehealth strategy
Senior mHealth Analyst, US
GP Director, Clinical Research Facility; Pharmaceutical
Consultant , UK
1
Table of Contents
Telehealth: Introduction
The Market
Market Attractiveness
Industry Overview
Trends
Drivers and Deterrents
Macroeconomic Conditions
Switching Costs
Unmet Needs
Pharmaceutical in Telehealth
Telehealth in COPD: Case Study
Abbreviations
2
Telehealth Introduction
3
Introduction
Specialized softwares and devices are aiding remote monitoring of patients
Telehealth refers to the transfer of medical data between a patient and a healthcare professional via
telecommunications technologies1.
eHealth
Telehealth: Remote
patient monitoring1
Home monitoring of
vital parameters, drug
ingestion
Patient
Device
Telemedicine2
Telecare3
Involves activities such
as patient follow-ups
and remote surgery.
Example:
Monitoring of patients
who have Cardiac
Pacemakers
Monitoring of changes
in an individual’s
lifestyle.
Examples: Fall
detectors, movement
sensors
Doctor
Source: 1. 120229_Novartis_LINK_Final_Report; 2. NHS Alliance 2011 ; 3. 1108 WSD Protocol
4
Information flow in a typical RPM set-up
A step-wise process with a regular feedback system is the essence of any telehealth
service
Information Flow1
Patient
Measuring
Device
Gateway
Telecommunication
Call center/
Information
Management
Healthcare Provider,
Pharma Company,
hospitals, funding
sources
Responding to escalation
“The three telehealth benefits– Compensation, Confidence, Convenience.”
–CEO, Telehealth start-up
Source: 1. E&Y LINK II Telehealth in COPD; 2. Evalueserve expert interviews
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The Market
6
Features on the telehealth market
The telehealth market is growing but difficult to define………
Key points that are important while understanding this market:
• The market is small and fragmented
• There is no clear market definition (based on our analysis of different reports)
• Terms like telehealth and RPM are used interchangeably
• Overlap between products and services provided by stakeholders in the market
• No standardized sales database to draw information from (unlike drug sales where IMS database is used)
In this study, we have defined the market based on two reports, exemplifying the points mentioned above:
Reference
report
E&Y,
Kalorama
Report
InMedica
Report
Includes
Monitoring devices for home
healthcare, hospitals, nursing
homes, other healthcare
organizations
Only home-use health
monitoring devices
Excludes
-
Devices and services
for professional
application.
Mobile health devices
and applications.
Primary Diseases
Global
included
Market size
CHF, COPD,
USD 10.4
Diabetes, Asthma, billion
Cancer
(2010)
CHF, COPD,
Diabetes,
Hypertension,
Mental health
disorders
USD 190
million
(2011)
Source: 1. Evalueserve analysis
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The Market
The US is the biggest market for remote patient monitoring and was valued at USD
6.9 billion in 2010

The graph below depicts the growth rate of market comprising wireless and remote patient monitors, patient data
processing equipment and applications, and EMR data transfer equipment and applications. The key customers
include hospitals, home healthcare, nursing homes and other healthcare providers (research institutions,
physicians offices, military applications)1.

The diseases conditions in the market primarily comprise COPD, asthma, CHF, cancer and diabetes1.

The global remote monitoring industry is expected to triple in the subsequent four years2. The largest remote
patient monitoring market was identified to be the US, while the UK and Germany dominated Europe. The US
market was found to be growing at a faster pace than the world market2.
Market sizes in USD billion
Forecast:
2011-2015
Global growth
rate: 26 %
US growth rate: 28 %
Europe growth rate: 24%
The market size for 2011 on the basis of the exact number of installed bases and the subsequent revenues (for home
healthcare only) are detailed in the next slide.
Source: 1. Global market based on MibilHealthNews article; Kalorama Information- Remote and Wireless Patient Monitoring Markets
2. US/EU estimates: 120229_Novartis_LINK_Final_Report (USA estimations based on Kalorama Report 2010; Europe estimations based on CSMG
analysis on Mobile Technology for Healthcare Report 2010) 3. .Evalueserve expert interviews
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The Market
The revenues from the sale of home healthcare units will reach USD 854.8 million in
the next five years

The graphs below depicts the estimated growth in the telehealth market by the number of installed bases. The
patient numbers and revenues include devices and services for home monitoring only1.

The diseases conditions in this market primarily comprise of CHF, COPD, diabetes, hypertension, mental health
disorders1.

The telehealth installed base increased by 22.2% from 2010 to 2011 with the number of patients enrolling
worldwide reaching 241,2001.

This translates to revenues (device and service for home healthcare) worth USD 190.0 million in 20111.
Number of Patients (000s)
Revenues (USD million)
Source: 1. InMedica (IHS Research)
9
Market Attractiveness
10
Market Attractiveness-By geography
US, UK and Germany are the most attractive geographies
“I would put my money in the US to start with. Having said that, India and China cannot be ignored looking at the
mobile phone penetration and chronic disease burden…”
–Senior mHealth Analyst, US
USA, UK and Germany–most promising
markets1:

Favourable regulatory environment and
reimbursement rules

High healthcare expenditure (as % of GDP)

High market growth rates

Larger number of initiatives

Better infrastructure availability
Source: 1. 120229_Novartis_LINK_Final_Report; 2. Evalueserve expert interviews
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Market Attractiveness-By therapy area
Chronic conditions have great potential for telehealth applications
Immediate need in chronic conditions1:

5% of chronic patients generate 75% of healthcare
expenditure

RPM for chronic diseases will create revenues
worth USD 84 million 2016
Chronic
therapy
area
Diabetes
Acute
therapy Cardiac
conditions
COPD
Number of chronic disease patients1 (US,
millions)
Emergency
situations
Source: LINK II report
Asthma
Chronic
heart
failure
Number of monitored individuals
(Chronic disease management)2
2011-2016
Source: 2011 Juniper report
2012
51
2013
25.5
2014
North America
Mental
conditions
119.4
78.1
35.9
15.6
9.6
188.6
68.2
41.8
2015
“Diabetes , CHF and COPD are the
hottest therapy areas to launch a
telehealth system in.”
–CEO, Telehealth
start up, US
2016
Total (Global)
Source: 1. E&Y LINK II: Telehealth in COPD: Telehealth in COPD; 2. Juniper Mobile Market Report; 3. Evalueserve expert interviews
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Industry Overview
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Information flow and stakeholder segments
Stakeholders from various industries, from medical device manufacturers to IT
companies, contribute to the development of a successful telehealth service
Information Flow1
Patient
Measuring
Device
Gateway
Call center/
Information
Management
Telecommunication
Healthcare Provider,
Pharma Company,
hospitals, funding
sources
Responding to escalation
Activity mapping to key stakeholders
Key stakeholders2
Patient
Measuring
device
companies
Gateway
providers
Network
Providers
Information
Management
Providers
Pharma
Company,
Hospitals
Payer,
funding
sources
Interoperable System/
Device Providers
Source: 1. . E&Y LINK II Final Report: Telehealth in COPD; 2. Evalueserve analysis
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Information flow and stakeholder segments
‘Business Model Generation’ handbook, written by Osterwalder & Pigneur to
understand how the organization creates, delivers, and captures value
Value Proposition
Customer Segment
Key Resources
Channels
Key Activities
Building blocks1
Customer Relationships
“Each stakeholder in the workflow
is different. If one wants to
understand this market, knowing
how each stakeholder is modeled
is important.”
–CEO, Telehealth
start up, US
Key Partnerships
Revenue streams
Cost structure
Patient
Measuring
device
companies
Gateway
providers
Network
Providers
Information
Management
Providers
Pharma
Company,
Hospitals
Payer,
funding
sources
Interoperable System/
Device Providers
Source: 1. Business Model Generation’ handbook; 2. Evalueserve analysis
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Business Canvas
While there are some commonalities in the building blocks of the stakeholders…
Customer
Segment
Channels
Customer
Relationships
Revenue
streams
• Clinical trials
and pilots
• Conferences
• Self or
investor
funded
• Government
funded
Key
Resources
Cost structure
Interoperable
System
Network
Providers
Information
Management
Providers
Pharma
Company,
Hospitals
• Patients
• Physicians
• Device
• Mobile
phones
• Networks
(3G/4G)
• Dependant
on activities
• Patents
• Infrastructure
• Manpower
• Cost of
device
• Cost of R&D
• Activity
dependent
costs
Payer,
funding
sources
Source: 1. 120229_Novartis_LINK_Final_Report; 2. Evalueserve expert interviews; 3. Evalueserve analysis
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Business Canvas
…key differences lies in their value-adds, activities and subsequent partnerships
Value proposition
Key Activities
Key Partnerships
Interoperable
System
• One-stop solutions
• Low-cost benefits
• Clinical trials and pilots
• Network and communication
companies, government
initiatives
Network
Providers
• Communication solutions
• Improved reach
• mHealth initiatives
• Across stakeholder groups
Information
Management
Providers
• Database management
solutions
• Data entry automation
• Digitization of medical data
• Mostly with hardware
providers
Pharma
Company,
Hospitals
•
•
•
•
• Deliver healthy outcomes
• Increase access
• Offer complete care solutions
• IT medical device companies
Payer, funding
sources
• Provides telehealth start-ups
with seed money
• Funding health IT initiatives
• IT companies, telehealth
start-ups, hospitals
Medical know-how
Solid corporate image
Reach to rural areas
Increase awareness
Source: 1. 120229_Novartis_LINK_Final_Report; 2. Evalueserve expert interviews; 3. Evalueserve analysis
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Trends
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Trends
The environment is evolving socially, culturally, politically as well as socio-economically to catch
pace with the evolution of telehealth technologies
“A standardized ecosystem will emerge, with a standard operating protocol, communication protocol and management
protocol. These protocols will run through the fabric of telehealth.”
–Director, Telehealth at a leading network provider in the US

Increase in government-driven telehealth initiatives

Growing burden of aging patient populations
 Increasing healthcare costs

Trends1-5
Better perception among patients and physicians
 Increasing willingness to use telehealth services
Societal and Cultural
Trends

Evolution towards approval of devices and software in
medical use
 Faster adoption in the US as compared to the EU
 Crisper reimbursement guidelines

Greater involvement of telecoms

 Collaboration amongst various companies 
 Interoperability through system integration 
 Expansion of 3G and 4G networks

Source: 1. Juniper Report 2011; 2. PWC Healthcare Unwired report; 3. Kalorama Report; 4. European Remote
Patient Monitoring Markets, 2008 - Frost & Sullivan; 5. Evalueserve expert interviews
Role of tablets and smart phones
Miniaturisation and mobilisation
Automation
Electronic Prescribing
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Drivers and deterrents
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Key drivers and deterrents
While the increasing incidence of chronic diseases will drive the market, the high setup cost will inhibit the growth



Key drivers1-7








Current and future economic burden of chronic diseases
Large and growing ageing population
Shortage of skilled healthcare practitioners
Need for increased medication compliance in chronic conditions
Technological development
National eHealth strategies introducing telehealth as a key objective
Positive clinical outcomes data
High set-up cost of telehealth devices and services
Lack of large-scale evidence base
Lack of standardisation in terms of reimbursements–The current reimbursement models
favour a face-to-face visit to the physician
Lack of knowledge and inclination to telehealth adoption in healthcare practitioners
Key
deterrents1-7
“We did a study where we offered diabetes patients an RPM device at the cost of a T-shirt, @ USD 15. We realized that
people would not even pay this much for telehealth if a face-to-face consultation is fully reimbursed..”
–Director, Telehealth at leading network provider, US
Source: 1. Juniper Report 2011; 2. 120229_Novartis_LINK_Final_Report; 3. PWC Healthcare Unwired report; 4. Kalorama Report; 5. Global
mHealth Survey; 6. Telehealth_IMD MBA_April 2012; 7. Evalueserve expert interviews
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Macroeconomic factors
22
Macro-economic factors driving telehealth adoption
Countries with relatively higher healthcare expenditure, are identified as strong
telehealth adopters
GDP, and country’s healthcare expenditure1,2
Total expenditure on healthcare
(%age of GDP, 2010

Investment in telehealth initiatives is related to the
economic condition of a nation and its expenditure on
healthcare

US, France and Germany were among the highest
spenders on healthcare

US and Germany were found to be stronger in telehealth
initiatives
Information and communication technology Infrastructure3

Investment in telehealth initiatives are related to the economic condition of a nation and its expenditure on healthcare.

Modern ICT infrastructure is considered as a pre-requisite to launching telehealth services

US: Strongest supporting infrastructure

UK, Sweden and Denmark: Strong telecom infrastructure

Developing countries: SMS and voice based services
“In my opinion, the economy of a country is a measure of its preparedness to adopt new technologies.”
–Business Development Manager, Telehealth Consortium, UK
Source: 1. WHO Report; 2. CIA World Fact Book; 3. 120229_Novartis_LINK_Final_Report; 4. Evalueserve Analysis; 5. Evalueserve
expert interviews
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Switching costs
24
Switching costs
High technology implementation cost is important while considering a transition from
face-to-face consultation to a telehealth based set–up
High Cost of implementation is inclusive of1:

Nurse hiring

Nurse training and protocol development

Demonstration programme

Technology setup

Physician loss of reimbursement

Reduced productivity losses

Reduced hospital stay expenditure

Reduced travel costs

Reduced physician consultation fee

Technology set-up cost vis-à-vis reduced productivity loss

Telehealth consultation cost much lower than face to face consultation in the US
“A lot of times physicians ask – ’What is in it for me?? Answering this question with crisp benefit is key.”
–Business Development Manager, Telehealth Association, UK
Source: 1. 2011-01-12__Updated_I-Meds_Final_Presentation; 2. A systematic review and an analysis of economic evaluations, Journal of
Technology Assessment in Health Care; 3. HSJ Media Release; 4. Evalueserve Analysis; 5. Evalueserve expert interviews
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Unmet needs
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Unmet Needs
While it is essential to know the importance of evidence to support cost effectiveness
to engage more physicians…
Unmet needs1-5 (1/2)
Need for 100 % reimbursement for
telehealth services
Presence of multiple
state bodies
increases ambiguity
Need for easy-todecode
information,
security of data
and reduction in
misinterpretation
Single federal
regulatory body
Complete
reimbursements
Appropriate
standards
Comprehensive
backend care
Engagement of
the healthcare
providers
Increase awareness of
outcomes among
physicians
Stakeholder
engagementPharmaceuticals
Sufficient evidence
to support cost
effectiveness
Lack of
standard
delivery,
reimbursement
processes and
policy
structuring
Need for more
studies to
demonstrate cost
benefits
Need to tap the potential of pharmaceutical
company’s know-how and customer reach
Source: 1. NHS Paper. Telehealthcare Interoperatability; 2. Wearable sensors/systems and their impact on biomedical engineering. IEEE Eng Med
Biol Mag; 3. Telehealth research and evaluation: implications for decision makers. Medical Technology Symposium; 4. Evalueserve research and
analysis; 5. Evalueserve expert interviews
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Unmet Needs
…identifying customer needs and delivering patient-centric solutions is key
Unmet needs 1-4(2/2)
The true value of teleheatlh
solution can be seen only if
the target population is well
defined
Focus should be on patient-specific
clinical conditions and co morbidities
Identification of
the right patient
segment
Appropriate and
continuous
training
sessions to
facilitate the
efficient use of
telehealth
devices
Patient-centric
solutions
Device mobility
Training on device
use
Mobile
penetration in
rural areas
Easy availability of
mobile phones and
network to increase
telehealth access
Patients want
small and
wearable
systems
Easy-to-use
interface and
easier analysis
User friendly
systems for faster
adoption, accurate
data collection
Source: 1. Wearable sensors/systems and their impact on biomedical engineering. IEEE Eng Med Biol Mag; 2. Telehealth research and evaluation:
implications for decision makers. Medical Technology Symposium; 3. Evalueserve research and analysis; 4. Evalueserve expert interviews
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Pharmaceuticals in Telehealth
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Current role of pharmaceutical companies in the telehealth
system
“The pharmas are not there yet.. Failing to act on this opportunity will drive a wedge between the pharmas’ participation in the
patient journey.”
–Business Development Manager, Telehealth Consortium, UK
“The IT companies just make chips, they have no idea what the disease is. But you in pharma do.” 2
–Prof. Russel Wynn, Hertfordshire GP
The Missing Pharma Link1


Telehealth’s current focus has been:
―
Monitoring devices and diagnosis
―
Data collection and transmission
Payers and healthcare providers are realizing the importance of greater engagement of pharmaceutical
companies to achieve the main aim of telehealth– delivery of healthcare
Why should Pharma engage in Telehealth3
Benefits to telehealth system:
 Best disease know-how
 Greater access to patients
 Strong corporate image among
physicians
•
•
•
Better defined protocols and
alarms
More specific questionnaires
Share loyalty from physicians
and patients
Source: 1. IHS Healthcare Blog; 2. Pharmatimes Telemedicine Article; 3. Evalueserve expert interviews
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Future business model for a pharmaceutical company
What is in it for a Pharmaceutical company?
Benefits to pharmaceutical companies1
Typical pharma
business model
Telehealth
service

Additional revenues from telehealth
services

Direct and indirect benefits in business :
–
Cost reduction in clinical trials
–
Improved patient adherence
–
Improved Market Access efficacy
–
Strengthened relationship with payers
and healthcare providers
Market entry business model1
Participation in telehealth
initiatives

Novartis: eBreezehaler,
Proteus collaboration, and
MS adherence program in
Italy
Participation in telehealth
pilots

Sanofi: Integrated care
program for diabetes.
 GSK: Diabetes management
program
Creation of a telehealth
subsidiary



Bayer – Viterion
Roche – Emminens Conecta.
Pfizer’s – Pfizer Health
Solutions
Source: 1. 120229_Novartis_LINK_Final_Report; 2. Evalueserve research and analysis; 3. Evalueserve expert interviews
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Telehealth in COPD: Case Study
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Telehealth Application Area: COPD (Case study)
Clinical trials have demonstrated a positive impact of RPM on COPD related
outcomes….
Market1
• The number of telehealth patients with COPD is projected
to grow strongly as telehealth focus continues to expand
to respiratory diseases.
Number of Patients (000s)
• The successful results of the Whole System Demonstrator
(WSD) programme in the UK are likely to pose as strong
evidence base for the benefits of telehealth for COPD
patients.
• There are estimated 3 million people in the UK with COPD
with a total cost of GBP 800 million per annum to the
healthcare system.
Information flow in COPD monitoring2
Intervention
Positive Impact on the Clinical Endpoints
in Trials2
Physician
Patient at
home
Drug and
smart device
Payer
Platform
Monitoring Tools
Adherence, Spirometry,
Exacerbation
Information
Management
Site
Sources: 1. inMedica (IHS Research); 2. Telehealth_IMD MBA_April 2012; 3. Clinical Trials Registries;

Mortality

Exacerbations

Activity and exercise capacity

Quality of life

Healthcare utilization (reduced hospital
visits)
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Telehealth Application Area: COPD (Case study)
RCTs support the effectiveness of telehealth in COPD…
*Click to View Sources
The table below gives an overview of studies in Telehealth/RPM in COPD and the effects of the intervention on
outcome measures. There is a growing body if clinical evidence that Telehealth in COPD improves outcomes in
most of the trials and large scale evidence base is required to verify earlier findings:
Overview of Key Outcomes Data*
Mortality
Exacerbations
•
•
•
•
Activity and exercise
capacity
Quality of life
•
Healthcare utilisation
•
•
•
No significant difference between telecare and usual care (Odds ratio 1.05)1
Higher in patients receiving telecare, versus usual care (Relative ratio 1.21)2
Significant reduction in readmission rates in ”hospital at home” compared to a
“inpatient care” for acute exacerbations of COPD (Relative ratio 0.76)3
14.6 % reduction in significant COPD exacerbations versus pre-telemedicine period4
Improvements in 6-Minute Walk Distance (6MWD) similar with telecare (+81 m) and
standard outpatient care (+82 m)5
• Favourable effects in some studies6,7
• Systematic reviews showed:
−
mean difference in SGRQ score vs. usual care 6.571
−
similar to or better than usual care2
46 % reduction in unscheduled hospital visits4
50 % decrease in hospital admissions9
Systematic reviews showed:
−
−
reduction in patients with ≥1 ED visit over one year (Odds ratio vs. usual care
0.27)1
reduced hospitalisation rates and emergency visits versus usual care2
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Telehealth Application Area: COPD (Case study)
…while nationwide initiatives have demonstrated initial positive results
US: Care Coordination/Home Telehealth1
The program:

National program

50,000 patients

Many chronic disease
Results in patients with COPD:

Decreased potential patient resources utilization
by 20.7 %
Denmark: COPD Funen1
The program:

Regional Program
COPD Funen pilot (2 years):

800 patients per year


Focus on COPD
Decreased early readmission for exacerbations by
10 %, early readmission for other causes by 14 %
COPD Funen program:

Reduced beds used for COPD patients by 30 %
Sources: 1. 120229_Novartis_LINK_Final_Report
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Telehealth Application Area: COPD (Case study)
Current methods require customisation based on patient needs, understanding of the
disease and patient history
Issues in COPD Telehealth
systems1,2
Opportunities in COPD
Management1,2



Improvement in treatment adherence
in smoking cessation support ,
pulmonary rehabilitation and
therapies

Countering false alarms

Facilities to monitor co-morbidities

Ambient medical devices
Daily follow up on symptoms and
exacerbations after discharge from
hospital–eventually reduce hospital
stay and readmission

Early disease prediction models

Personalized monitoring system

Easy-to-fill patient assessment,
sensitivity of questionnaires
Quick intervention in case symptoms
go out of hand
Telehealth Systems
in COPD
“Having the physician involved is the key. Up to now, people have promised too much and focused on complex gadgets.
The key, however, lies in a simple and clinician driven approach.”
–GP Director, Clinical Research Facility; Pharmaceutical Consultant in the UK
Sources: 1. Expert Interviews; 2. 120229_Novartis_LINK_Final_Report
37
Abbreviations
•
GP: General physicians
•
eHealth: Electronic health
•
RPM: Remote patient monitoring
•
EHR/EMR: Electronic health/medical records
•
COPD: Chronic obstructive pulmonary disorder
•
CHF: Chronic heart failure
•
USD; US Dollar
•
GDP: Gross Domestic Product
•
mHealth: Mobile Health
•
IT: Information Technology
•
SMS: Short messaging servce/Text messages
•
MS: Multiple sclerosis
•
GSK: GlaxoSmithKline
•
ED: Emergency department
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Thank you for your attention.
39
Evalueserve Disclaimer
The information contained herein has been obtained from sources believed to be reliable. Evalueserve
disclaims all warranties as to the accuracy, completeness or adequacy of such information. Evalueserve shall
have no liability for errors, omissions or inadequacies in the information contained herein or for interpretations
thereof.
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