Interview

Healthcare Transformation: The Future of Telemedicine

tinker, we cannot incrementalize. For example, I think we have to stop talking

about telehealth. John Sculley (former
Apple CEO) said telehealth is going to be
s the President of Philadelphiahealth. We do not talk about telebanking
based Thomas Jefferson University
anymore. We talk about banking.
and CEO of Jefferson Health,
Its bigger than tele, its really about
Stephen K. Klasko, MD, MBA, is
home. We have to start thinking about
known nationally as a champion for transforwhat are the modalities that will make
mation in healthcare delivery and education.
health go home. You know, at Jefferson
He has fought for change as university
we say healthcare delivery is going from
president, as dean of two medical colleges,
Blockbuster to Netflix. The thing about
and as CEO of three academic health cenNetflix is, it is not just DVDs in your
ters. This year he publishes his new book,
Stephen K. Klasko, MD, MBA
mailbox or, if you are too lazy to go your
2016s We CAN Fix Healthcare in Amermailbox, on your TV. But talking about the future, maybe
ica. In 2015 he launched the journal Healthcare Transformawe will be too lazy to turn on our TV. Netflix will be a chip in
tion, as Editor-in-Chief, both with Mary Ann Liebert, Inc.
our brain.
A native of Philadelphia, he returned to the city to lead Jefferson
I think we will have the same transition with telehealth, that
and quickly transformed the historic institution from a threeit will be a totally different experience that will bring health
hospital system to an 11-hospital system. He renamed Jefferson
home. And all we have to do is look to the Millennials, who
Medical College for donors Caroline and Sidney Kimmel, who gave
really have very, very little loyalty to the old way of doing
$110 million for disruptive innovation in education. And, he is
things, and it is going to be all about convenience.
proposing a merger with Philadelphia University, which would
So what do I see? I see that when we talk about a Comcast or
give Jefferson an undergraduate partner and pipeline.
a Verizon subscription, there will be a whole subscription to
For Dr. Klasko, this means creating the university and health
health, and that there will not be any kind of LensCrafters
system of the future. When the mergers are complete, Jefferson
store; that I will be able to look into my TV, it will do my eye
will have revenues of $4.8 billion, 28,000 employees, 7,800
exam, and then I will, same day, have a drone drop off my new
students, 6,000 physicians and clinicians, and 4,000 faculty.
glasses based on what I have chosen.
At a time when many people have become pessimistic about
Whats behind it is the ability to access specialists any place
the future of healthcare, Steve Klasko takes the exact opposite
in the country, or the world. As you know, Michael, we are
position. He is wildly optimistic that the disruptive trends we
actually talking to Jordan about how we might be able to work
see in healthcare today will actually help us create a rewarding
with them. I think well use technology underlying telehealth
and transformed future.
to overcome language barriers, so that in 2030, when I talk to a
patient in Jordan, what she hears is in her own language.
Lets jump into the future, since you enjoy bending the
To me, the idea of Is it not cool that you can actually have a
spacetime continuum. Where do you see the future of
video chat with a doctor? is very 90s. We are already over that.
telemedicine in 2030?
We need healthcare not only to join the consumer revolution,
but in some respects to eclipse the consumer revolution that
Thank you. I use a history of the future to set what I think
exists in relatively simple arenas like ordering from Amazon.
are then realistic goals. When you start with 2030, you think:
Why incrementalize? Why wait until 2029 to begin to create
So if that is the case, then is it not time to introduce this into the
an ideal healthcare world in 2030? Why not now?
curriculum in medical schools? We had an article in Healthcare
Thats what I see that happening in healthcare. We have
Transformation in the first issue with a comprehensive
been so far behind the consumer revolution that we cannot
President, Thomas Jefferson University
CEO, Jefferson Health

DOI: 10.1089/tmj.2016.29007.skk

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curriculum by Judd Hollander. Do you see telehealth as a separate course, or as integrated into every curriculum?
Well, at the risk of getting kicked out of any academic society that still lets me in, I will say that we are, in essencenot
just in this area, but in other areasdoing a great job of creating doctors who will be great in the 1980s. It starts with how
we choose doctorswe still accept students based on science
GPA and MCATs and organic chemistry grades, and then were
shocked when doctors are not more empathetic, communicative, and creative.
So here is the answer to your question about curriculum.
There is a 100.0% chance that I will have an augmented intelligence being next to me, because there is no human brain
that will be able to memorize every genomic sequence. And
the only thing that I bring to the table is the human skillsthe
ability to communicate, the ability to see versus observe. That
means that spending the first 2 years re-memorizing the Krebs
cycle makes absolutely zero sense from a physician point of
view. That is all stuff that can be done online.
We need a longitudinal curriculum around not just telehealth, again, but around technology so that the people who
get out of medical school really understand how technology
can help them communicate with patients, some of which will
be telehealth. As an example, when doctors have the ability to
understand healthcare disparities, so many things are possible. How can telehealth actually get to communities that do
not have access to care or to traditional care? And its not only
communication with patients. How can we transform communication with other doctors and team members to solve
disparities?
We are moving from a business-to-business model to a
business-to-consumer model, and we are going to have to
teach our medical students to exist in that very different environment. In this model, how do they interact when they are
not right next to a patient, how they interact with telehealth
assistance, telehealth associates, and I think it will be part of
the entire longitudinal curriculum.
Switch from the changes that will occur to doctors to the
changes that occur to the Blockbusters of the medical world.
How can medical centers, clinics, and even hospitals find an
economic benefit in something that could be very disruptive
to the Blockbuster model of medical center buildings?
That is a critical question because it so easily rolls off our
tongue when we say, Oh, we are moving from volume to
value. Well now get paid for keeping people healthy at home,
not just treating the sick in a hospital. Id love to say thats

338 TELEMEDICINE and e-HEALTH M A Y 2 0 1 6

true in 2016. The problem is that what we get paid for is paid in
the old way. Were in the Twilight Zone of healthcare.
I hear CEOs saying, I am really glad to see Steves investment in telehealth. Hurray for Steve, and I am sure that the
next CEO will enjoy taking over after Steve gets fired if he
cant prove his telehealth ROI [return on investment]. But I am
going to continue having patients come to my inefficient,
expensive emergency room because thats how I get paid.
Some of their argument is true. We are in the Twilight Zone
of healthcare. We are in a situation where we are partly feefor-service and partly moving to value. But if you are not
preparing for reimbursement models based on value, you are
not going to be able to turn on that switch.
So today, Michael, we already have one accountable care
organization with 100,000 Medicare shared savings plan lives
where health really matters, where it matters to keep those
patients out of the ER [emergency room]. It matters both from
the patients perspective and what they pay in premiums, and
it matters from my revenue point of view, because I am capitated.
So I think the folks who think that they are going to be able
to flip a switch from fee-for-service to capitated care can be
too far behind. All it takes is one disruption. If joint replacements become an outpatient procedure and they have not
prepared for that Netflix model of getting care out to where it
should be the easiest and most efficient place for the patient,
those hospitals are going to be dead.
You know, we go to conferences around the country where
they say there will be 25% fewer beds needed. But how many
places do you see actually decreasing their beds? You can still
see cranes building new inpatient beds.
Until it was way too late, there were still new Blockbuster
stores being created. And then they said, Oh, gosh, you know,
maybe we should get in the Internet business. Too slow. And I
think the same thing will happen with the folks who are
laughing about telehealth and Netflix strategy as a model for
growth. If you think this is a gimmick, I think 3 years from
now you will go, Wow, I really missed that boat.
Back to joint replacements. Our colleague at Healthcare
Transformation, Associate Editor Dr. Antonia Chen, has had
success using a combination of telemedicine and video to
help people recover at home after knee replacement and
finds it is just as good as making them come back to the
center for training and physical therapy for the new knee.
So question: The definitions of the words shift from telemedicine to telehealth. Obviously, only a doctor can practice
medicine, so in theory only a doctor can practice telemedicine. But the word telehealth means, to me, a team.

MARY ANN LIEBERT, INC.

INTERVIEW

How do you see the shift, just like volume to value, from
medicine to health? What happens to physical therapists?
That brings up a couple issues. I just got out of giving a talk
to 200 global leaders of one of the largest medical device
companies in the world, and they were asking some of the same
questions: How do we need to think of ourselves in the future?
And I said, stop thinking of yourself as a medical device
company, and start thinking of yourself as a solutions company. How are you helping both the patient and the provider
provide better care at a lower cost? And if you are not doing
that, somebody will be able to commoditize your business.
I think the same thing is true from our perspective. If you
think about postacute care, in a bundled payment model, now
all of a sudden you are getting X amount of dollars from 6 weeks
before the hip replacement to 6 months after the hip replacement. What you did not mention, Michael, is that that difference
in costand, as you mentioned, they had better outcomeswas
not a difference of 10%. It was a difference of an average of
something like $4,000, which is what it would cost for both inhome and outpatient rehab, versus a new cost of $400. That
means there is $3,600 that Dr. Chen or colleagues can regain to
lower their cost to compete and to create new solutions.
I think the other part of this is that patientsand again, I will
speak to the Millennialsare just going to demand that. They
are going to say, I want telehealth, I want these technologies to
help me be healthier the way that I want to do it, not the way
that some doctor or hospital thinks that I ought to. That is
happening in academics, also, where students are saying, You
know, that is really cute, that this is how you want to teach me,
and this is what you have decided my major should be. But I
want to take these 10 courses, and I want to learn it this way.
As you know, Michael, we started an Institute for Emerging
Health Professions, saying, What jobs are going to be needed
10 years from now that might not exist today, and how should
we teach them? So we are trying to get in the minds of students and patients and not think of the way that we do it as the
provider.
Are you optimistic about this? You have just published a
book on how we can fix healthcare. Do you see this as exciting, or do you see this as a catastrophe for doctors?
It doesnt have to be a catastrophe if youre willing to look
ahead. I look at it like the computer industry in the very early
2000s and late 1990s. It was a catastrophe for Gateway. It was
a semicatastrophe for Dell. Apple, on the other hand, did well.
Apple stopped thinking like a computer company and started
thinking like a digital health company. And at the end of the day,

we have to stop thinking like a hospital. I am optimistic, because

at Jefferson, we were a 192-year-old academic medical center
that, frankly, acted our age, and now we are acting like a startup
company.
So the book you mentioned, it was originally called I Messed
Up Healthcare in America: Put Your Name Here, because the
concept is, we tend to blame everybody else, and then we feel
good that it cannot get better. We tell ourselves: Look, we were
right, its gotten worse. The concept of the book is what if there
was a science-fiction event with a blackout where everybody
involved in healthcare had to look in the mirror? The book
ranges from patients to CEOs of pharma to providers to CEOs of
health systems. And after many conversations with those people, we came up with 12 disruptors for the demise of the old
healthcare that were so compelling that they became the platform for both the Republican and Democratic National
Committees.
Now, before any of you readers actually guffaw about Republicans and Democrats collaborating for a great future in
healthcare, our publisher Mary Ann Liebert had a great comment. My first book was about a woman medical student who
gets abducted by aliens, and Mary Ann said, You managed to
come up with the one premise that has less of a chance of
happening than your first book.
But the fact is that when you look at those 12 disruptors for the
demise of the old healthcareand you should all buy the book; it
is published by Liebert Publishingliterally those 12 disruptors
are things we could all agree on, and it has nothing to do with
who is paying for it. It really gets down to how do we get
healthcare to act like a consumer-centered, innovation-driven
model the way that retail has, the way that travel has, the way
that almost every other consumer entity has done?
As somebody who loves science fiction, who thinks about
these things along the spacetime continuum, what have we
not considered? What are the possibilities for health that
another generation may have?
I think what we have not really talked aboutwhere do we
really need docs? I think you are going to see some DIY (do-ityourself) healthcare. I mean, we may never get to the point of
DIY major surgery. There are always going to be invasive
procedures that need another human. But I think we will select
and train much more empathetic physicians, using powers
unique to humans, not artificial intelligence.
That means docs will go from being captain of the ship,
which has a hierarchical mentality to it, to members of teams
that include communication experts and geneticists and all
sorts of folks to help people navigate the system. But most

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importantly, people will recognize that they need to be

responsible for their health, and a lot of this they can do
themselves.
Far into the future, its easy to see a scenario with wearables
where even while you are sleeping, everything is being evaluated, much like your car. I see a future with nanotechnology
where literally I have little Fantastic Voyage spaceships going
through my bloodstream constantly looking and zapping
cancer cells. I see a future where nobody is ever taking insulin
again. You know, you literally just keep, like you would do
with your cars oil, you just keep it refreshed.
And by the way, the interesting thing about that is that is
not that science fiction-y. Almost everything that I just said is
being developed today and has every chance of actually existing within the next 10 or 15 years.
That means that some academic medical centers and hospitals will start to embrace that mentality. Ten years from now,
if somebody comes from Andromeda and says, Where is
Jefferson Health?, people will look at them like they are
crazy, because they will say, Do you mean, where is Jefferson
on my TV; or where is Jefferson, these various urgent care
centers; or where is Jefferson, the Netflix model? Where is
Jefferson at my home? You know, if you are talking about the
place where really, really, really sick people go, that is in
Center City, Philadelphia.
But that is the model we are moving toward, and I would say
I am probably in the minority of health system CEOs who feel
that way. On a competitive basis, I feel good about that. And
not that I am comparing myself, but when Apple came out
with the iPod, reviewers laughed (you can look it up): What?
Steve Jobs is going to build this company around 200 mp3s?
And I think what he was uniquely able to do was to say, Look,
I see where things are going 10 years from now, and I am
willing to put my company in it today.
By the way, everything I have talked about, every single
health system CEO would agree, Yeah, that is where it is
going 10 years from now. You know, when I ask them, Okay,
what are you doing today? Oh, nothing. What are you doing
next year? Oh, no, we are just going to keep doing what we
are doing. So the issue is not disagreeing on the progress we
are going to make toward a consumer-driven system, it is
disagreeing about the skill sets or what to do today to make my
organization be successful.
And let me just say one other thing. I think telehealth has
become such a controversial subject because it is the first front
in this transformation. It is the first front of something real
that takes control out of the hospital and takes control in some
respects even away from the provider, where the patient can
get on her iPhone and say, Hey, what kind of provider do I

340 TELEMEDICINE and e-HEALTH M A Y 2 0 1 6

want? What kind of information do I want? And are you there

for me, Steve, on the other end?
And by the way, I know it sounds trite, but I think we will
have both a real and a virtual Uber-ization of healthcare, I
mean, to the point where if somebody has an issue, they will
get on theirwhatever phone or mobile device it is, and they
will access me. And I will either take care of the problem and
virtually prescribe something, or I will ensure there will be
somebody literally there within 2 minutes to pick them up to
take them to wherever I am sending them and take them back.
There is zero chance that that will not be the future.
And that place could be retail health or somewhere that isnt
a traditional medical center?
I was with 130 deans when the first drugstore starting
seeing patients, and those deans all laughed: What a stupid
business idea. What they missed is the fact that there was not
this huge outcry for patients to see nurse practitioners in a
drugstore. Instead, there was a huge need for convenience and
speed. If your kid was a little sick and crying all night, would
you wait for a doctor versus being able to go to a pharmacy,
have a nurse practitioner see you, give you drops? And then
you can stop for a bottle of Tempranillo, so when your kid is
actually sleeping you can have a glass of wine, as opposed to
being up all night. That was the need.
And when you think about it, we all laughed at it, but if we
had just kept our office hours open from 6:15 a.m. to 1:15 a.m.
with the same nurses who actually left us to go to Walgreens
and CVS, we would have been able to maintain that $15 or $16
billion in our own pockets.
So I think those are the kind of choices that people who run
healthcare systems are going to have to make. You can laugh
at telehealth, you can say it is a gimmick, you can say, You
know, my job is to run an academic medical center or a hospital. That is where my job ends, and I think you will be
looking the way that Blockbuster or Gateway did.
Examples, Steve? Where is the future happening now?
I would give threenone perfect, all a chance to learn. At
Jefferson, we started a pilot with virtual rounds. If you think
about it, in 2016, if you have a parent in a cancer center, an NCI
[National Cancer Institute] cancer center, and let us say you and
your brother are in different towns, but neither is where your
mom is. In 2016, with all the technology that exists, you are still
calling your mom and saying, What did the doctor say? And
she is saying, I do not know. You know, he came in at 5:30 in the
morning. With all my medicines, Im not sure I really woke up.

MARY ANN LIEBERT, INC.

INTERVIEW

We asked, tell us with whom you would like to communicate. Well send the software to your son in Denver or your
daughter in Miami, and well text them when we are making
rounds. It is a huge, huge, huge difference from a patient
morale point of view, from a family morale point of view. So I
was excited about that. I was also depressed because I realized
there is no new technology that made this happen. We could
have done it 3 years ago with FaceTime, 5 years ago with
Skype, and 15 years ago with the telephone. What changed?
That is an example of starting to think the way patients think
and then using telehealth or technology to change that.
My second example is a policy perspective, the issue of
increased access to care through Medicaid expansion. The
government began to give all these people a ticket, if you will.
They go from being uninsured to having Medicaid, but they
have no idea how to access the system. So many of them end
up in the emergency room, which is much more expensive
with much worse care.
So we need the ability to use virtual triage for somebody who
has just gotten his or her Medicaid card and say: Here is how
we can get you careand by the way, it might not be a doctor. It
might be a nurse practitioner. If the patient says, Oh, for the
first time I am covered, and I want to look at contraception
alternatives, you know, you can see a nurse practitioner. We
need to use technology to get people to the right resource.
And then the third example is starting to look at how
technology and new ways of delivering care can make change
without huge investment. Re-admissions in this country are a
huge problem. Why not use technology for modeling outcomes? At Jefferson, we partnered with a mathematical
modeling company that does modeling for sports, to help us
understand who is going to be at high risk for coming back for
congestive heart failure, for example, for re-admission, which
in some hospitals costs them 5 or 6 million dollars a year.
But just as importantly, were starting to get to the point
where hospitalists can virtually go out of the hospital and see
those patients for 90 days. It means when those patients leave

an academic medical center, they still have access to those

hospitalists. What we have in a lot of hospitals is too often, the
family doctor is not allowed in that hospital, and the hospitalists are not allowed out of the hospital.
So those are just three examples that do not require huge
investments: virtual rounds, virtual triage, and the concept of
extensivists with two-way electronic communication. Those
three will provide greater access and greater quality at a lower
cost and break the iron triangle of access, quality, and cost.
This is not science fiction. This is stuff you can do today
with telehealth programs that exist, with virtual rounds programs that exist, and with virtual triage programs that exist.
Which goes back to how we train the next generation
of healthcare professionals.
Yes. At Jefferson, with our Institute for Emerging Health
Professions, we have started one of the first national telehealth academies. What new professionals will be needed?
Logistics folks, health coaches, trusted health advisors,
training associates?
In academics we are so hierarchical that even if you think this
is what we need in the future, by the time you start the cycles of
getting the degrees and doing the internships, you really have
to start today to get that workforce ready for 10 years from now.
And very, very, very few universities are doing that.
We have actually now merging and partnering with a top-10
design university. Why would a health science university and a
design university get together? Well, think about design of
patient experience. Think about the design of how you organize
a telemedicine or telehealth or virtual experience. Human design in healthcare is going to be all about that consumer experience and teaching people to be ready for that fundamental
change in how healthcare is delivered. And thats exciting.

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Interview by Michael Hoad, MA

Executive Editor, Healthcare Transformation

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This article has been cited by:

1. Doarn Charles R., Merrell Ronald C.. 2016. Moving ForwardPast the White Picket Fence. Telemedicine and e-Health 22:5,
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