Insights Series Issue 24: "Redefining telehealth"

A thought leadership paper on "Digitalizing healthcare", driving growth through remote technologies. 

Insights Series Issue 24 digitalizing-healthcare . Stephen Bruin Adriana, Garcia Active Issues kapción of bug cancer Hypertension: Diabetes meter Rick Astest Blok GérerSES .......... Redefining telehealth Driving growth through remote technologies A thought leadership paper on “Digitalizing healthcare” SIEMENS Healthineers Preface The Insights Series The Siemens Healthineers Insights Series is our preeminent thought leadership platform, drawing on the knowledge and experience of some of the world’s most respected healthcare leaders and innovators. The Series explores emerging issues and provides you with practical solutions to today’s most pressing healthcare challenges. We believe that increasing value in healthcare – delivering better outcomes at lower cost – rests on four strategies. These four principles serve as the cornerstones of the Insights Series. Expanding Transforming Improving Digitalizing precision care patient healthcare medicine delivery experience Our Insights portfolio is an integrated collection of events, speaking engagements, roundtable discussions, and an expanding array of print and digital platforms and products all carefully curated to share ideas, encourage discussion, disseminate original research and reinforce our position as a healthcare thought leader. Please visit Executive Summary Hospitals are facing higher financial pressure than ever before.1, 2 While different institutions have vastly different factors contributing to their financial Remote technology can challenges, they all have a common foundation – bring efficiency to many increases in operating expenses are outpacing hospital departments growth in revenues. Many health systems have a traditional hub-and-spoke setup – a network consisting of an anchor establishment (hub) which offers a full array of services, complemented by secondary establishments (spokes) which offer more limited services.3, 4 While this traditional hub-and-spoke setup for hospital networks has increased patient out- reach, considerable inefficiencies exist in this model. Current inefficiencies in workforce, asset, and patient Emergency O flow management have reduced local hospitals to offering merely basic services to nearby patients. However, patients are becoming consumers and are Laboratory Radiology expecting faster and easier access to care. There needs to be a new way to strengthen ancillary locations to provide more advanced services so that patients can Inpatient receive care faster and closer to home. Expanding the use of telehealth makes it possible to Surgery Pathology create a new hub-and-spoke model. The current and most common use of telehealth replaces the brief interaction between patients and physicians during Pharmacy consultation. But the definition of telehealth is more than that. Telehealth means delivering healthcare at a distance with remote technologies. Applying remote technologies further down the patient pathway into diagnosis, therapy, and follow up can resolve current inadequacies to allow healthcare institutions to drive down costs and grow. Siemens Healthineers Insights Series · Issue 24 3 Remote technology can bring convenience to: Telehealth not only provides the convenience that patients are looking for today, but it also connects care Diagnostics imaging – remote scanning enables teams and empowers caregivers to deliver care in a more experts to guide advanced procedures in a different streamlined way. With a strategic use of telehealth location (example on p.8: University of Missouri technologies along the entire patient pathway, health Health Care, Advent Health) systems could reduce inefficiencies and achieve their growth objectives without increasing their footprint. Pathology – telepathology empowers pathologists to provide consultation from another site (example on pp.8-9: The Eastern Québec Telepathology Network) Clinical laboratory – remote data management supports laboratorians to manage multiple laboratories remotely (example on p.9: Turner Laboratories) Pharmacy – telepharmacy allows pharmacists to provide patient counseling to locations where there are otherwise no pharmacists present (example on p.10: Mount Isa Hospital and Nebraska Medical Centre) Surgery – remote surgery could make it possible for doctors to perform surgery from distance away (example on pp. 10-11: Apex Heart Institute) O Patient follow-up – remote patient monitoring can keep patients at home while proactively care for patients with worsening symptoms (example on pp. 12-13: Esse Health and The Heart and Diabetes Center North Rhine-Westphalia) 4 Issue 24 · Siemens Healthineers Insights Series Introduction Even before the COVID-19 pandemic, the healthcare Telehealth can enable hospitals to shift the current industry was already facing profit margin pressure.5 business model and drive growth. Many hospital The pandemic has created further unprecedented networks have a flagship establishment that offers a financial pressures for hospitals and health systems full range of services in a central location, while smaller, because of additional costs associated with secondary facilities offer basic services for the local purchasing Personal Protective Equipment (PPE), communities. Yet asset and workforce inefficiencies with as well as cancelled appointments and surgeries.1 the traditional organizational model exist and they continue to impact the bottom line. Expanding the use of Telehealth was a lifesaver for patients who needed to telehealth, however, allows caregivers to work differently consult with doctors during the pandemic. As many as and more efficiently. Under this new model, community 46% of patients used telehealth in 2020.6 Some have hospitals that are close to the patients no longer serve defined telehealth as a combination of technologies and only as an outreach to direct traffic to flagship hospitals, devices to remotely gain information about a patients’ but remote technologies can empower spoke facilities to health status, and it helps to decide if there is a need or offer advanced services and deliver the care that patients urgency to intervene.7 This is how most people think of need closer to where they are. telehealth today: a patient is talking to a physician using a mobile device. Without a doubt, this is a leap forward in providing access to physician consultation. Yet more appropriately defined, telehealth is the use of technologies to provide care when the patient and the doctor are not in the same place at the same time.8 This means patients can receive the care they need from a distance, not just to determine if they need to come into the hospital, but to receive care remotely during diagnosis, therapy, and follow-up. Siemens Healthineers Insights Series · Issue 24 5 The challenge One of the major barriers to health system The global trend of urbanization poses additional growth today is workforce shortage. Hospitals are challenges as well. Staff shortages are particularly increasingly understaffed and there is a mismatch apparent in rural areas. Hospital networks have to in workforce demand and supply. United Kingdom- cover a widely spread-out region. Since it is particularly based publisher BioMed Central estimates a global difficult to find skilled medical professionals to work in shortage of more than 15 million healthcare workers rural areas, the capital investments made in these in 2030.9 The continually widening gap between the satellite sites often experience downtime which impacts increasing demand for healthcare due to an aging the bottom line. For example, approximately US$222,000 population, and the shortage of trained, qualified revenue could be lost per MRI scanner per year due to healthcare professionals makes providing care for missing experts.10 An alternative is to have skilled the communities ever more difficult. caregivers constantly spending time traveling to different sites to provide support, which also results in lost productivity. As a result, the ancillary locations usually offer only basic services and are not a major source of revenue. In fact, more than 470 rural hospitals have closed in the past 25 years in the U.S. alone.11 Yet studies have shown that 57% of people think that the most important factor to decide where to obtain care is the ability to receive timely care.12 There is a need to provide consistent, high-quality care across the region almost around the clock. To solve the myriad of challenges, hospital networks need to be creative in employing digital technologies to deliver more efficient care. 57% of patients think that the most important factor to decide where to obtain care is the ability to receive timely care. 6 Issue 24 · Siemens Healthineers Insights Series The solution Expanding the use of telehealth, or remote digital screening in emergency departments.13 Extending technologies, along the patient pathway to enable the use of remote technologies further to diagnosis, caregivers to diagnose and treat patients from therapy, and follow-up can reap even more benefits. another location offers the possibility of a new By leveraging on the expert support from anywhere, business model to gain greater efficiencies. Flagship ancillary sites can utilize their equipment fully and locations are often overcrowded and can be far away offer advanced services to care for patients in their from patients. Telehealth has already improved proximity. With improved patient management, patient flow and offers greater flexibility to providers hospitals can care for more patients and achieve by being an effective and safe alternative to in-person growth without additional real estate investment. Figure 1: Expanding telehealth along the continuum of care Telehealth today mainly complements the consultation between patients and physicians. Expanding the use of remote technologies to different disciplines in diagnosis, therapy, and follow-up can bring more convenience to patients and efficiencies to caregivers and help hospitals grow. Emergency Diagnostic Pathology Clinical Pharmacy Surgery Inpatient care and room imaging laboratory follow-up visits E-consultation Remote Telepathology Remote data Telepharmacy Remote Remote patient scanning management surgery monitoring Diagnosis Therapy Follow-up Siemens Healthineers Insights Series · Issue 24 7 Diagnosis Remote scanning assistance in diagnostic imaging sites, Advent Health sees its revenue from cardiac examinations since the introduction of remote scanning Diagnosis with medical imaging impacts greatly on support grow by 35%. patient outcomes. Yet highly qualified staff are hard to come by, making radiology departments a potential bottleneck in care delivery.14 To address this, the use Telepathology of remote scanning in radiology is on the rise across the globe. Telepathology is the practice of remote pathology through the exchange of digital pathology images. University of Missouri (MU) Health Care in the U.S. offers It can be used for remotely rendering primary diagnoses, a full range of advanced diagnostic imaging in central second opinion consultations, and quality assurance,15 Missouri. Three radiology imaging sites have been set which is especially useful for areas with limited access up to offer services for patient coming from this wide to equipment and expertise. One example is in the geographic area. Appointment availability, however, province of Québec, Canada. There was a lack of is limited to only the sites where expert technologists pathology services for its remote area with a population or supervisors are present. Senior technologists have to of 1.7 million people spread over a vast territory. It is constantly travel between locations to align protocols difficult to recruit pathologists and some departments and provide support as not all technologists have the only have a part-time pathologist or none at all. expertise to perform all examinations. To tackle this challenge, the Québec ministry of Health To overcome this inefficiency, the radiology network of funded The Eastern Québec Telepathology Network.16 MU Health Care employs a solution for remote scanning This network comprises of 24 hospitals providing that allows medical staff to connect remotely to scanner oncologic surgery, of which seven have no pathology workplaces and assist personnel at a different location. laboratory and four have a pathology laboratory but no The expert technologists can support complex pathologist. With this initiative, each site is equipped procedures remotely and eliminate the need to travel to with a macroscopy station, video conferencing devices, different locations, which makes it easier to manage a drawing tablet, and a digital whole slide scanner with bottlenecks and offer support to on-call technologists. images saved on a dedicated telepathology server to It also simplifies training support of less-experienced allow pathologists to interact with any sites. The net- technologists. Having the ability for expert technologists work now enables expert opinion, intra-operational to be virtually connected whenever and wherever consultations, urgent biopsies, neuropathology, macro- needed, patients can choose to go to any of the three scopy supervision and has a tele-autopsy capability. sites, greatly improving access for patients across the The success of this network leads to plans for expansion state of Missouri. In a similar approach, Advent Health in to other regions, as well as offering tele-autopsy for Orlando also expanded its service by using remote remote regions so the body does not always have to scanning to support sites located in Altamonte Springs-, be transported to Québec City.17 Telepathology can Apopka-, and Celebration Hospital from a single location. provide patient-centered pathology closer to With advanced examinations accessible across three communities as it is much easier to move an image 8 Issue 24 · Siemens Healthineers Insights Series than to move a patient or physician. It also facilitates analytics and access instruments remotely for better organization of clinical work in a vast territory maintenance and troubleshooting, laboratory staff with a shortage of pathologists. can have full oversight and control of multiple laboratories from anywhere. Remote data management for clinical laboratory Dr. Gustavo Dip, technical director of Turner Laboratories in Rosario, Argentina, tells us that they expanded their It is estimated that about 70% of medical decisions are clinical laboratory testing service with such an approach. based on laboratory results.18 Factors such as an aging Serving a city with over one million inhabitants, Dr. Dip population, increased disease surveillance and screening, had to expand his testing service to accommodate the a rise in new strains of infectious diseases, as well as the growing demand. In addition to the central main epidemic spread of chronic diseases are making labora- laboratory in the city center, Turner Laboratories acquired tories busier than ever before. Patients need quick and two new sites that are more than seven kilometers away near accessibility to testing, yet laboratories in smaller from the center. Experienced laboratorians are difficult to communities may not have the capacity to offer a full find in Argentina, yet Dr. Dip was able to manage the portfolio of diagnostic tests. Much esoteric or specialized additional workload without hiring more senior medical testing needs to be done in centralized laboratories that technologists. The medical technologists can work from could be far away, making clinical laboratory testing any location remotely to review exceptions that require another potential bottleneck in the continuum of care. attention. The number of remote workers has increased from 2% to 40% after implementing remote data Remote technology for data management allows management. The resulting turnaround time also laboratorians to manage the increasing demands in decreased because this eliminated the need to transport testing and offer more convenience to patients at the patient samples during peak hours to the central location same time. Additional testing sites can be set up in local in the city center. The remote capabilities made a communities to serve nearby clinics. With the help of difference to ensure the operations kept running during laboratory automation, local technologists can perform the pandemic. pre- and post-analytical processing while remote data management technology receives the work orders from the Laboratory Information System (LIS), downloads test orders to the instruments, intelligently processes them based on algorithms fitting the laboratory standards and then uploads results back to the LIS automatically. Remote data management software can also review results based on user-defined verification rules and automatically release results so that senior laboratorians only have to attend to exceptions or abnormal results that require manual review. With the ability for staff to view real-time data Siemens Healthineers Insights Series · Issue 24 9 Therapy Telepharmacy who obtained drugs via the internet at home. In Spain, this service was offered to HIV (Human Immuno- Pharmacies are important as they can serve as the first deficiency Virus) patients and was managed by hospital level health care access points where qualified health pharmacists.22 Patients benefit from telepharmacy by professionals such as pharmacists can give advice to saving time and money, and health systems can reduce patients on drug regimens and safety. As in other costs by having one pharmacist covering multiple sites disciplines, pharmacists are in shortage and there is across a wide area that otherwise would require a higher an unequal distribution of pharmacists in urban and number of pharmacies. rural areas. Hospital networks can adopt telepharmacy to provide Remote surgery pharmaceutical services to underserved areas. Tele- pharmacy means pharmacists and patients interact Surgery is perhaps the most difficult part of the patient while being in different locations from one another care journey to deliver remotely, but it was already using information and communication technology (ICT) explored in the 1970s with the goal to treat astronauts facilities. The Mount Isa Hospital in Australia and the in space.23 Telesurgery can eliminate long distance travel Nebraska Medical Centre in the Midwest region of the for patients, which may not be feasible because of U.S. have deployed a remote pharmacist intervention to financial restraints and travel-related health risks. support underserved hospitals to ensure safe treatments Telesurgery also has the potential to provide greater for hospital inpatients.19, 20, 21 Telepharmacy can also access to patients especially in the rural areas as the support patients with services such as medication supply of specialists there is 31% lower.24 selection, order review and dispensing, patient counselling and monitoring. In many hospitals, the Despite the promising advancements in surgery and implementation of telepharmacy has led to a decrease telecommunications, there are several hurdles to of medication error rates.19 adopting remote surgery. Latency, or the time delay in transferring auditory and visual information between Home drug delivery (HDD) is a recently developed way the two distant locations, is one of the major drawbacks of medicine delivery consisting in dispatching medicinal because it can increase chances of inaccuracies. products directly to the home or workplace of patients. Even the most experienced teleoperator cannot perform Remote pharmacists provide counselling for patients with acceptable accuracy and efficiency when the 10 Issue 24 · Siemens Healthineers Insights Series latency time is greater than two seconds.25 The suitable performed by Dr. Patel from inside the Swaminarayan latency time is 300 milliseconds, with less than 200 Akshardham temple located in Gandhinagar. His partner, milliseconds being ideal for remote surgery.26 Legal and Dr. Sanjay Shah, was in the room with the patient at the billing issues related to remote surgery also need to be Apex Heart Institute. The success of this study is an considered as laws and policies differ across state and encouraging sign that large-scale, long-distance country borders. telerobotic platforms may soon be a realistic option for surgical procedures. Remote technology such as this The good news is that patients seem to be receptive could dramatically improve patient access for both to the idea of remote surgery. In fact, 77% of patients elective and emergent percutaneous coronary would consider robotic surgery27 and the use of robotic- interventions in rural and underserved populations, assisted surgery has increased more than three-fold over as well as reduce time to treatment for procedures the past decade and the U.S. is the largest market for such as heart attack or STEMI (ST-Elevation Myocardial this technology.28 Emergent technologies are also Infarction). promising to overcome the current hurdles to remote surgery. For example, the theoretical maximum speed of the fifth generation (5G) internet is a hundred times faster than 4G. High speed 5G internet incorporation with telesurgery will reduce the current latency period of 270 to 10 milliseconds.29 The demand for specialized and timely access to care in India prompted Dr. Tejas Patel, Chairman and Chief Interventional Cardiologist of the Apex Heart Institute, to pioneer a telerobotic intervention study. In 2018, he conducted the world’s first percutaneous coronary intervention (PCI) from a remote location outside of the catheterization lab. Five patients located at the Apex Heart Institute in Ahmedabad, Gujarat, underwent an elective PCI procedure from a distance of roughly 20 77% of patients would miles (32 km) away.30 Each procedure was remotely consider robotic surgery Siemens Healthineers Insights Series · Issue 24 11 Follow-up Remote patient monitoring for optimizing The Heart and Diabetes Center North Rhine-Westphalia inpatient care in Bad Oeynhausen, Germany is also using innovative remote care service to manage patients with cardio- Telehealth has been useful for keeping patients at vascular diseases. The program, known as “HerzConnect”, home to avoid spreading infection during the COVID-19 is aimed at health insurance companies that want to pandemic. Remote patient monitoring takes this offer improved treatment for policyholders with chronic advantage even further by not only moving more heart failure32. The patient gets a certified mobile healthcare out of the traditional settings and to where measuring device which records selected vital signs people live and work. It also has the ability to gather a and other patient parameters around the clock, and constant stream of data that provides a much clearer transmits this data via a Smartphone app and a secure picture of the patients’ health. Not only are patients more data connection to the institution. Data is analyzed engaged with their health, but keeping non-high-risk both automatically and by specialists using specially patients at home avoids overcrowded emergency rooms developed algorithms, so that treatment can then be and allows caregivers to focus on more critical cases, systematically optimized to suit each individual patient.32 leading to lower readmission rates. Continuous monitoring and remote care programs such as this will enable faster response times if unusual Esse Health, one of the largest independent primary care parameters are detected and ensure improved adherence groups serving patients in Missouri and Illinois in the U.S. to treatment, all of which will ultimately result in better saw increasing demand on care resources, yet it was not quality of life for the patients and lower the rate of financially sustainable to hire more staff. To solve this unplanned readmissions. challenge, Esse Health uses remote patient monitoring tools to support caregivers to manage heart failure, Telehealth is also a great tool for cancer patients. chronic obstructive pulmonary disease (COPD), diabetes, It benefits frail patients who cannot travel and makes it or hypertension patients posing various levels of risks.31 easier for patients to obtain a second opinion. With The care team focuses on the top 5% of high-risk patients remote monitoring tools, cancer patients can report who requires hospitalization, while using device-based symptoms, respond to questionnaires, and communicate remote patient monitoring platform to categorize with their care team as often as they would like through patients to high-, medium-, or low-risk groups. When a a mobile device. With this capability, care teams can patient is identified as experiencing worsening collect highly specific, detailed information tailored to a symptoms, an alert is triggered, and a care manager then patient’s diagnosis and treatment type for more informed proactively contacts the patients to address the signs and decision making, and the automatic patient prioritization symptoms.31 This allows care teams to focus their efforts can inform caregivers to intervene with patients who on patients who need them most, saving time and have the most critical need.33 As remote patient energy while allowing them to reach more patients. monitoring might be handled by a non-physician Using this strategy to monitor and provide care member of the care team, it could free up doctors to proactively, one care manager can care for 15 times more spend more time with patients who are sick and need patients while emergency room visits was reduced by in-person care. nearly half.31 12 Issue 24 · Siemens Healthineers Insights Series Esse Health can reach 15x more Medicare Advantage patients using remote monitoring technology V 100 1,500 Patients being cared for by one High- and rising-risk patients care manager without the help while maintaining high of remote technology satisfaction Siemens Healthineers Insights Series · Issue 24 13 Conclusion Inefficiencies in workforce deployment, asset Finally, by expanding the use of telehealth in patient utilization, and patient flow management impede engagement during follow-up, it allows caregivers growth for many healthcare institutions. The to give timely, proactive care to patients for better convenience that we experience from telehealth, outcomes. By keeping patients in their homes, hospitals however, has tremendous potential to overcome can reach and care for more patients at the same time, these existing barriers to business growth. The while reserving hospital beds for critical patients who current use of telehealth gives patients the ease and need caregivers’ focused attention. The increase in accessibility to obtain consultation remotely, but revenue more than covers the cost of telehealth remote technologies can considerably impact how investment. There are also operational expenditure caregivers deliver care by overcoming challenges (OPEX) purchasing models available for many digital such as geographical distance and expertise health offerings which decreases the demand for capital shortages posed by the traditional hub-and-spoke expenditure (CAPEX). setups. As the number of patients grows, it is no longer sufficient for regional community hospitals to Clearly, licensing regulations between countries or offer basic services and direct patients to flagship between states can hinder the availability of some locations, but they need to be able to offer advanced services. For successful implementation of telehealth and specialized care to patients as well. services, data security needs to be taken as a top priority. Yet with many obstacles to telehealth adoption being Using remote technologies for various disciplines, removed, now is an opportune time for healthcare hospitals can leverage experts across the whole leaders to evaluate their business objectives and network and give patients access to diagnosis early. determine which area can be streamlined by remote With the advent of telepharmacy and remote surgery, technologies. The challenge posed by geographical patients do not need to receive treatment and advanced boundaries is no longer as daunting as before. Expanding care by specialists only in main campuses, but close to the definition and use of telehealth offers the potential where they live and work as well. The cost savings from for healthcare institutions to grow and serve patients more productivity from highly skilled caregivers and closer to their homes. assets can contribute to improved profitability. 14 Issue 24 · Siemens Healthineers Insights Series Suggested follow-up on • Siemens Healthineers Insights paper issue 12: This changes everything – The COVID-19 pandemic leads to a significant acceleration of digitalization in healthcare. Available at: siemens-healthineers. com/insights/news/accelerate-digital-health- transformation.html • Siemens Healthineers Insights paper issue 16: Who are the leaders in digital health and what can we learn from them in times of COVID-19? Available at: news/leaders-in-digital-health • Siemens Healthineers Insights paper issue 21: Turning data into value; A thought leadership paper with Dr. Hee Hwang from Seoul National University Bundang Hospital on his strategic approach to data integration. Available at: turning-data-into-value Information The Siemens Healthineers Insights Series is our preeminent thought leadership platform, drawing on the H. knowledge and experience of some of the world’s most respected healthcare leaders and innovators. It explores emerging issues and provides practical solutions to today’s most pressing healthcare challenges. All issues of the Insights Series can be found here: Contact For further information on this topic, or to contact the authors directly: Dr. Ralph Wiegner Global Head of Digitalizing Healthcare [email protected] Siemens Healthineers Insights Series · Issue 24 15 References 1. Hospitals and Health Systems Face 7. Galiero R, Pafundi P, Nevola R, Rinaldi L, 14. [Internet]. Insightsimaging. Unprecedented Financial Pressures Due Acierno C, Caturano A et al. The 2021 [cited 4 June to COVID-19 | AHA [Internet]. American Importance of Telemedicine during 2021]. Available from: Hospital Association. 2021 [cited 4 June COVID-19 Pandemic: A Focus on 2021]. Available from: Diabetic Retinopathy. Journal of track/pdf/10.1186/s13244-020- guidesreports/2020-05-05-hospitals- Diabetes Research. 2020;2020:1-8. 00941-z.pdf and-health-systems-face- unprecedented-financial- 8. What is telehealth? | 15. Farahani N, Pantanowitz L. Overview pressures-due [Internet]. 2021 of Telepathology. Surgical Pathology [cited 4 June 2021]. Available from: Clinics. 2015;8(2):223-231. 2. New analysis reveals daunting scale of financial challenge facing health understanding-telehealth/ 16. Têtu B, Perron É, Louahlia S, Paré G, and care post-COVID | The Health Trudel M, Meyer J. The Eastern Québec Foundation [Internet]. The Health 9. [Internet]. Human-resources-health. Telepathology Network: a three-year Foundation. 2021 [cited 4 June 2021]. 2021 experience of clinical diagnostic Available from: [cited 4 June 2021]. Available from: services. Diagnostic Pathology. and-comment/news/new-analysis- human-resources-health. 2014;9(S1). reveals-scale-of-financial-challenge- facing-health-care-post-covid s12960-017-0187-2.pdf 17. Building a telepathology network [Internet]. 3. The hub-and-spoke organization design: 10. Assumptions: Average reimbursement 2021 [cited 4 June 2021]. an avenue for serving patients well for complex MRI examinations = $854 Available from: healthcare-in-europe. [Internet]. BMC Health Services and 5 complex examinations (e.g.: com/en/news/building-a- Research. 2017 [cited 17 July 2017]. Cardiac MRI, MRI Prostate, MRI Brain telepathology-network.html Available from: bmchealthservres. Perfusion/CSF (Cerebral Spinal Fluid), MRI Breast, MRI Pediatrics, 18. Rohr U, Binder C, Dieterle T, Giusti F, s12913-017-2341-x Spectroscopy) skipped per week due to Messina C, Toerien E et al. The Value of missing experts for advanced scans. 52 In Vitro Diagnostic Testing in Medical 4. Meinhardt R, Staehr H. How does working week x 5 examinations x $854 Practice: A Status Report. PLOS ONE. Finland's healthcare system contribute $220,040. 2016;11(3):e0149856. = to the nation's happiness?. Siemens Healthineers Insights Series. 11. Rural Healthcare Facts [Internet]. 19. Baldoni S, Amenta F, Ricci G. 2021;(15). 2021 [cited 4 June Telepharmacy Services: Present Status 2021]. Available from: the-hospitalist. and Future Perspectives: A Review. 5. Fitch: Healthcare pricing, profit margin org/hospitalist/article/125213/rural- Medicina. 2019;55(7):327. pressure will persist in 2019 [Internet]. healthcare-facts Modern Healthcare. 2021 [cited 4 June 20. McFarland R. Telepharmacy for remote 2021]. Available from: 12. 2020 Patient Access Journey Report | hospital inpatients in north-west Kyruus [Internet]. 2021 Queensland. Journal of Telemedicine 20181130/NEWS/181139995/fitch- [cited 14 June 2021]. Available from: and Telecare. 2017;23(10):861-865. healthcare-pricing-profit-margin- pressure-will-persist-in-2019 access-journey-report 21. Sankaranarayanan J, Murante L, Moffett L. A Retrospective Evaluation of Remote 6. Meinhardt R, Staehr H. Unlocking the 13. Rademacher N, Cole G, Psoter K, Kelen Pharmacist Interventions in a digital front door. Siemens Healthineers G, Fan J, Gordon D et al. Use of Telepharmacy Service Model Using a Insights Series. 2021;(19). Telemedicine to Screen Patients in the Conceptual Framework. Telemedicine Emergency Department: Matched and e-Health. 2014;20(10):893-901. Cohort Study Evaluating Efficiency and Patient Safety of Telemedicine. JMIR Medical Informatics. 2019;7(2):e11233. 16 Issue 24 · Siemens Healthineers Insights Series 22. Margusino-Framiñán L, Cid-Silva P, 28. Childers C, Maggard-Gibbons M. Castro-Iglesias Á, Mena-de-Cea Á, Estimation of the Acquisition and Rodríguez-Osorio I, Pernas-Souto B et al. Operating Costs for Robotic Surgery. Teleconsultation for the Pharmaceutical JAMA. 2018;320(8):835. Care of HIV Outpatients in Receipt of Home Antiretrovirals Delivery: Clinical, 29. Management Articles, Journals, Events, Economic, and Patient-Perceived Quality Directory | Analysis. Telemedicine and e-Health. [Internet]. 2019;25(5):399-406. 2021 [cited 4 June 2021]. Available from: 23. Mohan A, Wara U, Arshad Shaikh M, healthmanagement/issuearticle/5g- Rahman R, Zaidi Z. Telesurgery and opens-the-future-of-telesurgery. Robotics: An Improved and Efficient Era. Cureus. 2021. 30. Patel, T., Shah, S. and Pancholy, S., 2019. Long Distance Tele-Robotic- 24. Lacking specialist access drives health Assisted Percutaneous Coronary disparities [Internet]. Modern Intervention: A Report of First-in-Human Healthcare. 2021 [cited 4 June 2021]. Experience. EClinicalMedicine, 14, Available from: modernhealthcare. pp.53-58. com/providers/lacking-specialist- access-drives-health-disparities 31. Scaling Deviceless Remote Patient Monitoring at Esse Health [Internet]. 25. Korte C, Sudhakaran Nair S, Nistor V, 2021 [cited 4 June Low T, Doarn C, Schaffner G. 2021]. Available from: caresignal. Determining the Threshold of Time- health/ Delay for Teleoperation Accuracy and Efficiency in Relation to Telesurgery. 32. Expansion of telemedicine in Bad Telemedicine and e-Health. Oeynhausen to improve care for heart 2014;20(12):1078-1086. patients [Internet]. Corporate.siemens- 2021 [cited 4 June 26. Xu S, Perez M, Yang K, Perrenot C, 2021]. Available from: corporate. Felblinger J, Hubert J. Determination of the latency effects on surgical releases/pr-20190613022shs.html performance and the acceptable latency levels in telesurgery using the 33. Noona | Varian [Internet]. dV-Trainer® simulator. Surgical 2021 [cited 4 June 2021]. Endoscopy. 2014;28(9):2569-2576. Available from: software/care-management/noona 27. Patienten würden sich auch vom Roboter operieren lassen [Internet]. 2021 [cited 4 June 2021]. Available from: porsche- pressemitteilungen/detail/patienten- wuerden-sich-auch-vom-roboter- operieren-lassen-1/#image-1 Siemens Healthineers Insights Series · Issue 24 17 About the authors Joanne Grau Dr. Ralph Wiegner Thought Leadership Manager Digitalizing Global Head of Digitalizing Healthcare Healthcare at Siemens Healthineers at Siemens Healthineers Joanne Grau focuses on current trends and thought leader- Ralph Wiegner and his team engage in thought leadership ship content for Digitalizing healthcare. Prior to this role, and portfolio-related activities for Digitalizing healthcare. Joanne has had ten years of marketing experience in Earlier, he worked as head of Improving patient experience, Siemens Healthineers as marketing director for the head of Marketing Strategy and in global key account diagnostics division based in New York and as Head of management. Prior to joining Siemens Healthineers, Marketing for ASEAN countries based in Singapore. Ralph worked for several years in the Banking and Asset Joanne graduated from UCLA with a degree in Molecular, Management practice of McKinsey & Company on various Cell, and Developmental biology. Before joining Siemens European and international assignments. Ralph holds a Healthineers, Joanne was a research scientist in Quest Ph.D. in Theoretical Physics from University of Erlangen, Diagnostics (formerly Celera) and has authored multiple Germany, with several research engagements at the publications. Joanne is also currently a faculty member in Oklahoma State University, USA. Union University of California. 18 Issue 24 · Siemens Healthineers Insights Series At Siemens Healthineers, our purpose is to enable healthcare providers to increase value by empowering them on their journey towards expanding precision medicine, transforming care delivery, and improving patient experience, all enabled by digitalizing healthcare. An estimated five million patients worldwide benefit every day from our innovative technologies and services in the areas of diagnostic and therapeutic imaging, laboratory diagnostics and molecular medicine as well as digital health and enterprise services. We are a leading medical technology company with over 120 years of experience and 18,500 patents globally. With about 50,000 dedicated colleagues in over 70 countries, we will continue to innovate and shape the future of healthcare. Siemens Healthineers Headquarters Siemens Healthcare GmbH Henkestr. 127 91052 Erlangen, Germany Phone: +49 9131 84-0 Published by Siemens Healthcare GmbH · HOOD05162003209173 · online · 0721 · © Siemens Healthcare GmbH, 2021

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