Telemedicine for the Rio Olympics;

GlobalMed: Telemedicine for the Rio Olympics;

The 2016 Olympic Games were fast approaching and Manoel Coelho, Director of Global Business Development at GlobalMed, knew this left him with very little time to accomplish his goal: taking telemedicine technology and services to the Rio de Janeiro Olympic Games in Brazil, his home country. Telemedicine offered opportunities for delivering high-quality data sharing, diagnosis, video consultation, and treatment decisions in real time to patients and clinicians who were separated by physical distance. Coelho recognized that successful application of telemedicine for Olympic athletes and spectators could amplify exposure and accelerate its worldwide adoption. Coelho’s more specific near-term goal was to keep GlobalMed, based in Scottsdale, Arizona, USA, in the line of sight as the telemedicine vendor of choice for the Olympics. Exposure during the Games could potentially offer worldwide brand awareness for the company. GlobalMed’s longer-term goal was to gain a foothold in the Brazilian market, which offered significant opportunities for telemedicine penetration and a springboard for growth into South America. The following hypothetical scenario, a composite of several real stories, describes how GlobalMed officials envisioned the role telemedicine could play at the Games:

A badminton player representing Japan suffers an eye injury from a fast-moving shuttlecock in one of the early rounds of women’s doubles competition during the Rio Olympics. She is pulled from play. Medical personnel located on site conduct preliminary exams using a portable telemedicine station and convey results to a Rio hospital, where ophthalmologists specializing in retinal injuries review photographic and ultrasound images. The player is transported to the Rio hospital, where additional images and diagnostic tests are run. Brazilian specialists make the decision that the eye injury is too serious for the player to continue participating in the Games. This news is communicated somewhat awkwardly through an interpreter. The badminton player is devastated by the ruling—she has trained for 15 years with Olympic competition as a lifetime achievement goal. Understanding her distress and the far-reaching implications of the decision, her family helps her connect with a renowned retinal specialist in Kyoto. He contacts the ophthalmologists in Rio and requests all images and records be conveyed to him via the encrypted, cloud-based telemedicine system. He also conducts a virtual, live exam and speaks with the player using the telemedicine unit’s video capabilities. Upon careful review and consultation with his colleagues in Kyoto, he determines that the injury should not exclude her from participation in remaining Olympic matches if she adheres to a short-term treatment regimen, along with the recommendation that she wear protective eyewear. He advises that her eye condition should be monitored carefully before, during, and after each match to ensure that it is stable, and communicates his need to be fully connected via telemedicine for all of these tests. Based on the as- sessment from Kyoto, the Brazilian ophthalmologists reverse their decision, and the player is allowed to continue competing. A telemedicine unit, fitted with special-purpose cameras, an ophthalmoscope, and an eye ultrasound monitor, is used courtside three times during each match to assess the eye condition, which does prove to be stable. The player continues with her doubles partner through the remainder of the competition, and they finish with a silver medal. This allows her to achieve her life’s dream, and also sets her in motion to compete in her home country in the 2020 Tokyo Olympics. The story could have ended very differently without the support of telemedicine, which facilitated a rapid, accurate, and thorough response with real-time input from specialists in the athlete’s home country.”

Coelho worked closely with Dr. Antonio Carlos Marttos, a fellow Brazilian and world-renowned expert on medical trauma who was based at Jackson Memorial Hospital’s Ryder Trauma Center in Miami, FL, USA. Marttos was the chief spokesperson selling the telemedicine concept to Olympic officials. As Marttos envisioned it, the Rio Olympics project would place about 11 portable telemedicine units in competitive event sites, to serve both athletes and spectators, as well as an ad- ditional portable unit in the Athletes’ Village. Given the critical nature of health to an athlete’s performance and career, access to personalized medical care was essential, and sometimes had been a missing link in previous international athletic events. Additionally, the technology would offer major benefits to spectators who might experience medical emergencies while at- tending events. Exhibit 1 shows a GlobalMed portable telemedicine unit similar to the ones proposed for use in the Rio Olympics.

GlobalMed: History and Performance
GlobalMed was founded in 2002 by Joel E. Barthelemy,1 whose previous entrepreneurial endeavors were in integrated learning systems and semiconductor quality control. His experiences had enlightened him about the broad potential for using remote cameras to virtually diagnose technology problems in the semiconductor quality process, and he recognized that the concept had applications in the growing telemedicine industry. A camera, on its own, would not be enough to create a robust and comprehensive telemedicine system. Full function would require an integrative software platform to support numerous pieces of diagnostic and communication hardware, a state-of-the-art IT system for capturing and transmitting images and data, high-level data security, and a network of trained medical professionals who would make the entire system work.

Barthelemy funded GlobalMed with his own resources for the first seven years of the company’s existence, and later added supplemental funding from six angel investors. By 2014, the company had over 100 employees. It had generated substantial profits,2 and had been recognized for rapid growth by several entities.3 For example, Inc. 500 ranked GlobalMed in the top 100 fastest-growing U.S.-based companies, and seventh in healthcare for 2012. Deloitte’s Technology Fast 5004 ranked GlobalMed 58th for growth in 2012, up from 122 in 2011. Revenues were $32 million in 2012 and $27.4 million in 2013. This revenue decline, the first in the company’s history, was caused primarily by a budget stalemate in the U.S. Congress that delayed until 2014 some major purchases of GlobalMed equipment. New contracts in the U.S., Latin America, and the Middle East indicated that 2014 would be a banner year for sales. Nonetheless, revenue trends made clear the importance of establish- ing a broader international portfolio of clients.
In 2014, GlobalMed executives recognized that a well-crafted international expansion strategy was needed to sustain positive momentum. Brazil, the market focus for the Rio Olympics project, was one of several key areas for global expansion. According to Detelina Trendafilova, Director of International Business, other high-priority geographic areas included Chile in South America and Romania in Europe. Chile’s economic strength and its linear geographic layout made it a logical location for extension beyond Brazil. Romania represented an attractive target because, according to Trendafilova, it already had one of the most advanced telehealth systems in Europe and had committed to wider-scale adoption. This focus on global expansion was consistent with the company’s stated mission: “To transform healthcare globally by developing and integrating secure, efficient health delivery systems that improve access and quality of care, while eliminating unnecessary costs.””

Organizational Structure
GlobalMed’s structure (see Exhibit 2), designed to foster cross-functional interaction, was flat and informal. The company applied a matrix approach in which initiatives ran horizontally through the various functions, and employees were assigned on a temporary and part-time basis to serve the changing needs of GlobalMed’s project portfolio. The organization was too small and the portfolio too broad to allow for full-time team assignments to individual projects. Brad Schmidt, Director of Strategic Accounts, played a central integrating role in coordinat- ing efforts across departments for major initiatives, such as the Rio Olympics.”

GlobalMed’s Competitive Differentiators
GlobalMed was one of a multitude of players in the telemedicine industry. No single player was able to provide everything necessary to make a telemedicine unit operable, so collaborative partnerships were prevalent. GlobalMed assembled fully functioning telemedicine stations that combined some of its proprietary equipment and services with equipment and services from other companies. GlobalMed executives believed they had created competitive advantages that were responsible for the company’s rapid growth within the industry.

First, according to Coelho and Schmidt, a major differentiator for GlobalMed was its commitment to quality and regulatory compliance. As a matter of policy, GlobalMed worked diligently with regulators during the full development lifecycle of new technologies and product modifications. The company had eight people5 assigned full time to these areas, which represented a proportionately larger allocation of resources than any of its competitors. The company was an ISO6 13485: 2003-registered medical device manufacturer. Additionally, GlobalMed had sought and maintained International Electrotechnical Commission (IEC) 60601 Ref. 3 cer- tification, also from the International Organization for Standardization (ISO), making it one of the few in its industry to possess this global qualifier.

A second competitive strength was GlobalMed’s capacity for integration. When fully assembled and activated in the field, a GlobalMed station brought together all functions seamlessly. For example, its secure, cloud-based systems offered the highest level of data and image security while allowing for integration across a wide range of information systems. This was important for the array of organizations that would be connected through a telemedicine network because it eliminated the need for file conversion across platforms. Further, GlobalMed’s
manufacturing arm had the expertise to customize as needed and assemble all technology into one unit, allowing for turnkey deployment upon delivery to the customer. Also along the lines of integration, company officials felt confident that GlobalMed’s eNcounterTM software provided a better, more medically specific interface than any of the more general applications its competitors offered. Yet another aspect of integration was the training and service GlobalMed offered as part of its contractual relationships with companies purchasing its equipment. Training was an area where GlobalMed was expanding its offerings as part of its strategy to ensure closer, long- term relationships with clinical end users.

The DICOM (Digital Imaging and Communication in Medicine) standards adopted across GlobalMed’s stations, via its CapSure®7 and CapSure Cloud®,8 offered a third competitive differentiator. These technologies allowed fully encrypted images from every GlobalMed telemedicine station to be transmitted with all related patient data embedded in the files.”

“Distributed Sales Model
GlobalMed had developed strategic alliances with several companies, including HP, Lifesize, Microsoft, Avaya, Cisco, and Polycom. These companies and their channels offered some of the physical components, IT products, and system support necessary for telemedicine units. A significant part of initial sales contacts came through these partner organizations, which then contacted GlobalMed and began working with a member of the GlobalMed sales team to create a proposal. The major players in GlobalMed’s partner network often had their own resellers who might actually be the point of contact for customers, so the length of the sales chain could put GlobalMed at a significant distance from end-user customers. By 2013, the company had begun to engage more actively in efforts to create name recognition with institutional end users in the U.S. Moreover, GlobalMed’s international expansion strategies were moving toward direct connections with clinical customers, and the company planned to build its global sales force and ongoing revenue streams accordingly.”

GlobalMed’s Products, Services, and Markets
GlobalMed’s telemedicine stations, supported by customized back-end software, facilitated real-time interactions between patients and doctors, allowing patients to be examined through the use of GlobalMed’s DICOM- compliant software, exam cameras, stethoscopes, vital signs monitors (including pulse oximeters), spirometers, ophthalmoscopes, otoscopes, ultrasound devices, EKG monitors, and a variety of other devices that could be integrated into telemedicine stations. (Appendix A describes these devices.) Hard-ware sales represented 85% of GlobalMed’s revenues, with the remainder coming from recurring fees for ongoing support and maintenance.
As of January 2014, GlobalMed’s installed base of full-featured telemedicine stations totaled over 3,000, and the company had about 300 orders either con- firmed or in the pipeline. Approximately 90% of installed stations and future orders were for U.S. locations; however, international sales had tripled in the previous two years. Most international sales were small-scale deployments designed to gain market entry. According to Neal Schoenback, Director, North American Busi- ness Development, this mirrored the growth strategy that had worked well in the U.S. market. Beyond its full-featured units, GlobalMed had sold several hundred mobile units and many more of its clinical components, including medical exam attachments and over 10,000 of its general exam cameras for use in telemedicine units sold by other companies. An example of a typical full-featured telemedicine station is shown in Exhibit 3.

GlobalMed’s most substantial sales relationship was with the U.S. Veterans Administration (VA), where more than 1,600 of its telemedicine stations were installed in satellite clinics in rural communities and connected to major VA facilities. The telemedicine stations facilitated virtual face-to-face exchanges and remote diagnosis, both for patient-to-clinician and clinician-to-clinician interac- tions.9 Based on VA data, the number of telemedicine consultations exceeded 1.4million in 2012, and GlobalMed estimated there were over two million consultations in 2013. This was the largest telemedicine deployment in the world, to date, and it had attracted attention and new sales from many international government entities.

Another successful GlobalMed partnership was the Telestroke program that linked stroke specialists at Mayo Clinic Hospital, Phoenix, Arizona, with 13 rural and remote hospitals in Arizona, Missouri, and New Hampshire. The 24/7 service provided rapid assessment, diagnosis, and emergency treatment decision-making, which were critical to long-term outcomes and quality of life for patients with stroke, and the Telestroke program had delivered very positive clinical outcomes.10

GlobalMed also had made inroads with the U.S. Corrections System, where a mobile telemedicine station could be taken directly to an inmate’s cell, reducing the risks and costs associated with transferring a patient to a clinic inside the facility or to a hospital outside the facility. As of early 2014, the company had sold 41 units to the State of California, 17 to the State of Oregon, and five to the State of Florida.

GlobalMed kept itself on the cutting edge of technical development with a strong R&D team led by Mi- chael Harris. Harris and his team worked continuously to develop new products and refine existing ones. The R&D team collaborated with the Product Management group, led by Ashley Droege. Droege and her team had responsibility for discovering new customer needs through their activities in the field. Miniaturization was a key part of GlobalMed’s product development strategy. For example, the company was developing diagnostic hardware and software to work with “MyCapSureTM,” a new smart phone medical photo-sharing application. The GlobalMed interface would allow encrypted patient data to be transmitted to a clinician, who could then provide feedback to the patient about what he or she should do under certain conditions. Many smart phone applications were appearing in the market, but none could promise the data security GlobalMed would offer. Miniaturization and smart phone applications offered the potential to move telemedicine into the home, reducing the requirement for a patient to travel to a clinic. It also offered potential for expanding the reach of telemedicine in international, multi-venue sporting events such as the Olympics.”

The Rio Olympics Project
The 2016 Rio Olympic Games offered a significant opportunity for GlobalMed. With over 10,000 athletes from 244 countries competing in 28 sports across 306 events, the chances for injuries and ailments were significant. Dr. Marttos played the central role in pitching the telemedicine idea to the Brazilian and International Olympic Committees. As Marttos emphasized in a May 2013 speech to the American Telemedicine Association (ATA), if an injured athlete could connect with a specialist in his or her home country, language and cultural barriers would be diminished as obstacles to diagnosis. Moreover, home-country doctors, familiar with the athlete’s medical his- tory, career goals, and personality, could offer a more holistic perspective. So, although any country hosting the Olympic Games was likely to have its own trained specialists with the highest ethical standards and best interests of the athletes in mind, connecting with doctors from an individual’s home country presented great appeal.

Marttos also emphasized the role telemedicine could play in reducing spectator concerns about the avail- ability of healthcare services in medical emergencies. He argued that the assurance of available care and virtual connections to home-country doctors could increase the number of Olympic visitors. This had become an especially significant issue in light of the 2013 Boston Marathon bombing incident that killed three people and injured nearly 300 others,11 and the 2013 Russian suicide bombings during the weeks leading up to the 2014 Winter Olympics.12 Underscoring Marttos’ concern about medical care at international sporting events was a January 2014 communication from the U.S. State Department warning spectators planning to attend the Sochi, Russia, Winter Games about potential inadequacies in the region’s medical system.13
Telemedicine offered the potential to reduce the strain on Rio’s 10 major hospitals serving a population of 6,000,000. The city’s medical establishment, challenged to meet existing demands,14 would have difficulty accommodating the increased load created by an influx of the 1,500,000 tourists projected to visit Rio for the Games.15 But, even if additional medical personnel were imported for the two-week event, there was no guar- antee the right specialist would be in the right place at the right time. Telemedicine could deliver expertise on short notice, an important consideration in a city whose transportation system was navigated through numerous water inlets and granite peaks via congested tunnels, bridges, and narrow roadways that created some of the most bottlenecked traffic in the world.

The Rio Olympics were viewed as a jumping-off point for GlobalMed’s plans to enter the Brazilian market and gain first-mover advantage in telemedicine there. Brazil, with the world’s fifth largest population,16 fifth larg- est land mass,17 and sixth largest gross domestic product,18 made sense as a strategic target.”

GlobalMed’s Activities Leading Up to the Rio Olympics Initiative
GlobalMed had worked toward the Rio Olympics project for several years, making progress that would draw it closer to winning the bid as the telemedicine vendor of choice. For example, Coelho closely followed the 2011 Pan American Games when telemedicine, involving video-conferencing only, was implemented there under Dr. Marttos’ leadership. It was effectively used several times, including one instance where a gold-medal volleyball player injured her spine in a fall. A team of specialists in Brazil, in collaboration with Dr. Marttos, shared se- cure image and data files, and made treatment decisions that ultimately allowed her to sustain the viability of her career. For the 2012 London Olympics, Dr. Marttos and the University of Miami selected GlobalMed to provide a portable telemedicine unit to support the Brazilian team. This represented a landmark in Olympic Games history because it was the first time a fully integrated telemedicine unit, complete with medical device attachments, had been used in the Games. The unit proved itself valuable in multiple instances. For example, the ultrasound device on the mobile unit was used ringside in boxing events several times to test for damage following major abdomen blows.

Beyond the international sporting event industry, GlobalMed’s pioneering work with offshore oil platforms in Brazil had offered the company a vehicle for gaining Brazilian government approvals for its devices, and for obtaining precedent with import licenses. Telemedicine was a valuable tool on oil platforms; on-site diagnosis of an injured worker could reduce the number of unnecessary helicopter transports, which were both dangerous and expensive. In another Brazilian application, many victims of the January 27, 2013, Santa Maria Night Club fire, that claimed 236 lives and injured over 100 others, were screened and treated on site, 606 miles (975 km) south of Sa~o Paulo, with the help of the GlobalMed portable station that had been used during the London Olympics in 2012. The technology facilitated remote assessment of burn damage to inform decisions by physi- cians at Albert Einstein Hospital in Sa~o Paulo about whether and where victims needed to be transported, or how they could be treated on site.19 These success stories added to GlobalMed’s credibility and offered proof of concept for telemedicine with the Brazilian government and with the Brazilian Olympic Committee.”

Financial Considerations
GlobalMed had donated its time, equipment, or expertise to support pilot tests of telemedicine in both the 2011 Pan American Games and the 2012 London Olympic Games. However, for future events, the company expected client investments. If the equipment were sold at going rates, about $20,000 to $30,000 apiece, the 12 units, accompanied by annual charges for support services, estimated at about $5,000 per unit after the first year of operation,20 would produce a relatively small amount of revenue.

Assuming GlobalMed were selected as the telemedicine vendor for the Games, the official ROI for the project was likely to be low or negative. However, potential media exposure could offer great value. GlobalMed could not afford the cost of official Olympic sponsorship, so the company would not be able to mention the Olympics in its advertising and would need to rely on and facilitate exposure in the news media to achieve its brand recognition and market penetration goals.”

Scope of Work for the Rio Olympics Telemedicine Project
The Rio Olympics project would involve a complex set of interrelated tasks, many of which would require support from global partners. An important consideration was the Brazilian cultural propensity for last-minute decision- making.21 GlobalMed officials anticipated the final decisions about whether to adopt telemedicine and which vendors to select would occur within three to six months of the start of the Games. Consequently, an important aspect of GlobalMed’s project strategy would involve being ready to deliver as soon as it had an official order. Capacity for quick delivery could be the key factor in the Brazilian Olympic Committee’s decision about which company to select as the telemedicine provider.”

Coelho and Schmidt, along with the informal cross-functional team they had assembled, spent some time brainstorming a preliminary set of activities for the project, but they acknowledged they might have missed some important elements. They also recognized that some of the items on their list could be considered major deliv- erables, and others were detailed tasks that might need to be clustered together under a higher-level deliverable category. Examples of activities the team identified for the project included the following:

Activities    Background
Product development
GlobalMed’s R&D team needed to ensure that when the time came for a vendor decision, its equipment was the most state-of-the art and simple to use. The equipment’s functionality and capacity to meet the needs of a major sporting event would be important deciding factors.

Supply chain    Vendors would need to be selected and orders placed for components not produced by GlobalMed. Some of these components would have lead times exceeding the potentially short lead time the Brazilian Olympic Committee was likely to give the chosen vendor.

Training practioners:
Brazil and athletes’ home countries    Telemedicine represented a new application for nearly all of the doctors who would potentially be involved. Part of the training would be technical, but part of it would be aimed at increasing acceptance among practitioners. Dr. Marttos articulated the most important challenge: “You can buy the equipment, but the human network is the most important thing.”1 The Ryder Trauma Center, under the direction of Dr. Marttos, had already begun training teams of nurses and doctors from Rio de Janeiro in intensive two-week telemedicine programs in Miami
Transporatation of devices to Brazil    The units would have to be shipped in a safe, secure, and timely manner and would need to arrive far enough in advance of the Games to allow time for clearing Brazilian Customs, testing, training, and installation.

Repair and maintenance    Repair manuals would have to be available in Portuguese, and Brazilian repair personnel trained for quick response. Additionally, a cache of spare parts would be necessary.

On-site support team for the Games.     GlobalMed would need to select, train, and deploy a support team to attend the Games and be on hand to assist with use of the equipment. This would ensure that the GlobalMed units were working to their maximum potential, and would also allow for discovery of media opportunities.”

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