Simply Breathtaking

New procedures are changing how we treat lung disease.

Heavy breathing is music to Carlos Remolina’s ears. No, it’s not what you think. Dr. Remolina is a man who takes breathing—all breathing—personally. As an asthma sufferer himself, he is in his third decade of practicing pulmonary medicine, treating diseases including chronic bronchitis, asthma, COPD, sleep apnea, pulmonary emphysema, lung cancer, pleural effusions, and other conditions. At Trinitas, Dr. Remolina is breathing new life into his field with procedures that are slashing the length of hospital stays, streamlining procedures and improving patient outcomes, and, of course, saving lives.

Photo credit: iStockphoto/Thinkstock

“It’s very important to me to make a diagnosis as early as possible to save a patient from having to undergo a major surgical procedure,” he says. “So the fact that we’re able to be on the cutting-edge and perform the procedures that are only being done in major medical centers is very rewarding.”

Dr. Remolina’s latest groundbreaking procedures is what he refers to as EBUS: an endobronchial ultrasound. “We can go right to a mass and then an ultrasound allows us to get inside the tumor itself and access areas of the lung we never could,” he says. By performing a bronchoscopy with the help of an ultrasound, he explains, patients need only undergo one procedure that will allow his team to diagnose and treat a bronchial condition—saving them from having to pay a visit to a surgeon and await the results of a biopsy. “The value of this procedure is that now not only can we make a diagnosis of cancer, but we can also stage it—we’ll know right away if the cancer is too advanced to operate and what the most effective method of treatment will be.”

Anyone admitted to Trintias in need of an endobronchial valve treatment can also rest assured that Dr. Remolina will spare them from unnecessary, painful surgeries; his endobronchial valve procedure enables doctors to perform a bronchoscopy and inflate a balloon to locate and stop a leak without the need for an uncomfortable chest tube insertion. “We send the patient home and six weeks later, they can come back to have the valve removed,” he says. “Hospitals are always focused on reducing the length of patient stays, so by taking away the need for patients to remain in the hospital in order for us to monitor a chest tube, we’re making it easier on the patient and preventing them from having to admit themselves for an extended hospital stay.”

Carlos Remolina, MD, FCCP, PA Chief/Pulmonary Diseases, Trinitas Regional Medical Center Director, Care One LTACH 908.241.2030

Dr. Remolina is working to ensure that the entire staff at Trinitas is trained to perform the latest in pulmonary medicine techniques. Among the hospital’s future plans, he says, is the acquisition of a navigational system that will enhance the capabilities of tools such as a bronchoscope. “It’s basically like a GPS that would allow us to find even the smallest tumor and do a biopsy,” he explains. “That way, we can detect cancer sooner and enable surgeons to operate more efficiently and with greater precision. Nobody else around here is doing what we’re doing…our ultimate goal is to provide the best pulmonary medicine in the area.” EDGE

Editor’s Note: Carlos Remolina, M.D., F.C.C.P., P.A. is board-recertified in internal medicine and pulmonary medicine. He currently serves as the division chief of pulmonary diseases at TRMC and medical director of Care One LTACH (Long Term Acute Care Hospital) at Trinitas. He completed medical school at the University of Medicine in Zaragoza, Spain before moving on to complete his residency at the New York Infirmary Hospital. Dr. Remolina completed his fellowship in pulmonary diseases at the New Jersey College of Medicine and Dentistry, Rutgers Medical School in Piscataway. His practice is located in Linden.

Fear Factor

The stigma attached to Alzheimer’s—and a dearth of clinical trial volunteers—may be slowing the development of a breakthrough drug.

When I was doing my post-doctoral fellowship, I was in the room with a neurologist who gave a patient an Alzheimer’s diagnosis and then left. I think the family forgot I was still in the room. The man turned to his wife and said, “We really need smarter people working on this problem.”

Well, in the two-plus decades since, there have been a lot of smart people working on it, and progress has been made. New drugs have come on the market: Cognex in 1993, Aricept in 1996, Exelon in 2000, Razadyne in 2001, and Namenda in 2003. In 2011, for the first time in 27 years, a revision of the initially proposed 1986 consensus criteria for Alzheimer’s Disease were established, which incorporate all of the data and technological and clinical advances that have been amassed over the past several decades of research. Since we now know that people suffering from Alzheimer’s have probably had plaques and tangles developing in their brains for decades, the emphasis on early intervention is greater than ever.

We are currently in a better position to identify pre-symptomatic patients so that, if we had a disease-modifying medication, we could catch people early and possibly prevent the disease from progressing. There are a lot of companies looking for that breakthrough Alzheimer’s drug, which is why clinical trials are so important.

Ironically, the biggest obstacle right now in finding a cure for Alzheimer’s Disease may be the lack of participants in the studies being run on these new drugs and therapies.

Pharmaceutical companies are way behind in recruiting volunteers. Timelines for enrolling subjects are usually not met. This means critical data is coming out too slowly. We have not had an investigational Alzheimer’s drug get past Phase III in years.


The profile of a trial participant ranges from someone with cognitive impairment or concern to individuals who have received an Alzheimer’s diagnosis but are otherwise healthy. About half of the participants in the trials we run come through our clinic, the Cognitive and Research Center of New Jersey; these are people with whom we have already established trust and rapport. Others are referred by groups of neurologists, internists and gerontologists. We also get participants as a result of the public outreach I do personally. I am a big advocate of Alzheimer’s education and do a lot of speaking at churches, synagogues, senior centers, and other venues.

So why the lack of participants? Some are afraid that they’re agreeing to be “guinea pigs” for drug companies. That’s a valid objection, but people with this objection may not appreciate that these trials are very highly regulated by the government. It is very hard for a drug company to start a clinical trial. The FDA and other regulatory agencies have to be convinced that the potential benefits outweigh any risk; patient safety is concern number-one. Each trial has a set of strict criteria, and always errs on the side of safety.

There are other factors that make it difficult for clinics to find an adequate number of volunteers. Alzheimer’s trials have a high rate of screening failure. Even here—where we are highly specialized—the screening failure rate can range up to 50% after we’ve done urine, blood and EKG testing. Sometimes, people don’t meet criteria for a study because of preexisting medical conditions or medication regimens. There are always lists of medications that can’t be taken with the drug that’s being tested, and the patient can’t stop taking a particular medication.

Something else that impacts Alzheimer’s trials is that there will be a “study partner” involved. This is someone who knows the patient well and is in close enough proximity to acknowledge that the medication is being taken, and who can generate qualitative information, such as new symptoms, the level of caretaker burden, the patient’s mood and daily living skills—and just answering the question How are they doing? This is usually an immediate family member, but can also be a close friend. Without a committed study partner, it is unlikely an individual would be able to participate in an Alzheimer’s (or even a cognitive impairment) trial.

Finally, there is the stigma associated with Alzheimer’s, which I hope is changing. People think it’s a mental illness instead of a progressive medical disease. That could well be at the root of the recruiting problem pharmaceutical companies are experiencing in their trials. My perception is that a lot of people delay getting a diagnosis, mostly out of fear or perhaps denial. Incredibly, in fact, more than half the people who have Alzheimer’s never actually receive a diagnosis—even as they are being prescribed medications such as Aricept.


Among the major benefits of participating in a clinical trial is access to some of the better technology that is being developed. There are a number of procedures a patient’s insurance might not cover, including amyloid PET scans, which are very expensive. Thanks to this technology, we can actually detect microscopic changes in the brain that can give us a more concrete diagnosis.

All of the assessments a patient receives during a study are free. And sometimes there is a stipend for patients and their study partners.

Perhaps the most compelling reason to get involved in an Alzheimer’s study is the fact that people who are in clinical trials do better than people who are not—even those who are in the placebo group. Receiving attention from four or five specialists, talking about your condition, and receiving constant feedback is very therapeutic for the patient and for the study partner. In fact, most people who have completed one trial here want to get right into another.

The length of a clinical trial can vary from months to years. The length of each visit could take 45 minutes or four to five hours depending on what kind of evaluations are being done. Typically the clinic visits are more frequent at the beginning of a trial so that we can establish eligibility and collect baseline measures.

Whether volunteering for a clinical trial is appealing or not, families facing the prospect of a loved one with Alzheimer’s Disease need to take action. This disease is hard to deal with on your own, without support. The longer a family waits for a diagnosis, the sooner they’ll find themselves dealing with things in disaster mode.

The Alzheimer’s Disease Association estimates that 5.3 million Americans suffer from Alzheimer’s, and that number will continue to rise as the Baby Boomers age.

Unfortunately, right now less than half of these individuals are actually being told they have it. They don’t want to hear the diagnosis. So large numbers of patients and their families are suffering through the disease with no help.

They need to be educated to plan for the future and understand changes in behavior, and to prepare for the practical and emotional issues of care they will face. When we conduct our initial neuropsychological evaluations, everyone leaves with a folder containing information about relevant resources. People may be hesitant to use those resources initially, but they are good to have on file. Also, individuals who get linked with resources fare much better than people who put off being evaluated.

The first step for many patients and their families is to deal with the overwhelming idea that once you have Alzheimer’s, there’s nothing anyone can do. The fact is there are things we can do. And the trials that clinics like ours are conducting hold great promise that soon we’ll be able to do much, much more.

Editor’s Note: Michelle Papka is a neuropsychologist specializing in Alzheimer’s Disease and mild cognitive impairment. For more information log onto or email


Hello Kidney

Renal Patients Learning to THRIVE Through Education & Intervention

The best-kept secret in Linden isn’t a chic boutique. It’s not a trendy eatery, nor is it a new after-hours hot spot. According to Joseph McTernan, it’s the Trinitas Renal Services Unit, which has made the difference in countless thousands of lives since opening in 1993.

“Right here in Linden, we offer world-class expertise in both the diagnosis and treatment of renal disease,” says McTernan, Senior Director of Community and Clinical Services for Trinitas Regional Medical Center. “Our renal program has won a national award for excellence in patient care, and our highly qualified physicians and staff boast years of experience. We have won a five-star rating from the Center for Medicare and Medicaid Services, which puts us in the top 10 percent of dialysis centers around the country. It’s a designation that affirms the strength of our renal care outcomes.”

Ruby Codjoe, Nurse Manager of the Linden Dialysis Center, Peggy Custode, Renal Clinician at the Dialysis Center at the Williamson Street Campus, and Dr. James Mc Anally, Chair of the Nephrology Division at Trinitas, regularly review patient cases. On a weekly basis, the Linden Center treats up to 90 Chronic Kidney Disease patients while the Williamson Street Renal Dialysis Unit treats up to 75 patients.

How does one measure such a thing? It’s a numbers game, says Dr. James McAnally, Chair of the Division of Nephrology: ER visits, hospital admissions, and infection rates. And the Trinitas numbers are indeed outstanding.

“Our patients require 40 percent fewer emergency department visits than the national average, and 43 percent fewer hospital admissions,” says Dr. McAnally.  “Our rate of infection is less than half of the national average.”

Besides its Linden location, which treats chronic patients, the Renal Services Unit also has a location at the main campus on Williamson Street and another at the New Point campus, both in Elizabeth.


  • Exercise regularly
  • Don’t overuse over-the-counter painkillers or NSAIDs
  • Control your weight
  • Get an annual physical
  • Follow a healthy diet
  • Know your family’s medical history
  • Monitor blood pressure & cholesterol
  • Don’t smoke or abuse alcohol
  • Talk to your doctor about getting tested if you’re at risk for chronic kidney disease
  • Learn about kidney disease

“If you have high blood pressure, diabetes, a family history of kidney failure, or are over age 60, the best thing you can do is to get tested for kidney disease annually by a doctor,” Sean Roach, Public Relations Manager for the National Kidney Foundation tells EDGE. “Usually, a urine test is all you need.”


Chronic kidney disease (CKD) is found in 26 million adults in the United States. The most common causes of CKD are diabetes and hypertension. Data shows that African Americans and Hispanics are disproportionately effected.

So, what’s the plan of attack to diagnose and treat all those who have chronic kidney disease?


“Education is a big part of what we do,” Dr. McAnally points out. “We teach patients how to take the best care of themselves. We have them meet with nutritionists and other professionals to make every day the best day possible.”

The first step on this journey toward living the best days possible is The High Risk-Intervention Via Education (THRIVE) Program at Trinitas, which Dr. Mc Anally founded more than 20 years ago. It addresses CKD in its early stages.  Dr. Mc Anally explains: “The goal of the THRIVE program is not only to educate and to empower patients regarding CKD and its various treatment options, but more importantly to develop strategies to slow the progression of CKD.

With the support of the National Kidney Foundation, Trinitas has conducted annual screenings to help community members become aware of the likelihood that they may develop CKD based on hereditary or lifestyle factors. “Through our efforts, we have reached more than 500 people who have participated in our Kidney Early Evaluation Program (KEEP),” explains Peggy Custode, Renal Clinician.

The THRIVE program is based on the five “E’s” of rehabilitation:

  1. Encouragement. The THRIVE team gives patients with impending kidney failure the encouragement they need to adopt a positive attitude toward rehabilitation.
  2. Education. The THRIVE team gives patients and their families the education they need to handle the sometimes profound life changes associated with chronic illness, including coping strategies for successful adaptation.
  3. Exercise. Gradual decline in muscle strength and endurance is a result of inactivity. THRIVE patients are encouraged and counseled about exercise. There are many levels of activity to fit varying degrees of functional ability, from vigorous workouts for the otherwise healthy patient to stretching exercises for the chairbound.
  4. Employment Referrals. Occasionally there is a need to alter the work environment to address healthcare needs. The THRIVE staff assists patients in meeting these needs.
  5. Evaluation. Identifying patients early and educating them about kidney disease—and how to comply with a treatment plan—enables them to manage their own health, which will improve outcomes.

These 5 E’s of rehabilitation work.  As a result of the THRIVE program, most patients begin renal therapy electively in an outpatient setting.  “Such therapy has been associated with decreased morbidity, decreased mortality and lower costs overall,” reveals Dr. Mc Anally.

“Our mission isn’t simply helping patients survive,” McTernan adds. “It’s about showing them how to thrive.”


How prevalent is kidney disease? Sean Roach of the National Kidney Foundation says that 26 million American adults—nearly one in 10—have kidney disease. “And, most don’t know it,” he says. “That figure is projected to climb to 14.4% in 2020, and 16.7% in 2030.”

Dr. McAnally says the current diabetes epidemic is largely to blame for the increasing number of kidney disease cases. Diabetes is one of America’s leading killers, as well as the number-one cause of kidney failure. Also, signs and symptoms of kidney disease are often nonspecific. That means they can be caused by other illnesses. And because kidneys are highly adaptable and able to compensate for lost function, signs and symptoms may not appear until irreversible damage has occurred.

“Dr. Mc Anally’s professional career has been devoted to nephrology and to teaching patients how to manage their kidney disease,” says Joe Mc Ternan. “He has encouraged people who have hypertension or diabetes to take responsibility for their renal care before they experience significant kidney failure.”

Patient, Heal Thyself

Will your house become a virtual doctor’s office?

by Caleb MaClean

In November 2017, the Food and Drug Administration approved Abilify MyCite, the first “digital” pill. The pill, made of silicon, magnesium, and copper, contains a sensor no bigger than a grain of sand. It communicates with a patch worn by the patient, which then trans its medical data to a smartphone app, which in turn uploads it to a database that’s accessible to a patient’s doctor (and also family members). The sensor is activated when it interacts with stomach acid and transmits the time the pill is taken, as well as the dosage.

Abilify is a medication that treats bipolar disorder, depression, and schizophrenia, all of which demand that a patient stay on schedule with medication. The digital pill makes for easy monitoring by a third party. Although there are some inherent privacy issues that will probably need to be worked out, the big picture for healthcare is big indeed: By some estimates, the improper or unnecessary use of medication costs the industry $200 billion annually. To wrap your head around that number, consider that the total amount of property taxes paid by New Jersey homeowners in 2018 will probably be about $30 billion. With that much money on the table, you’d better believe a flood of digital pills is on the horizon.

This is just the beginning of a revolution that will move more and more elements of traditional medicine into the home—to the point where, one day, more doctoring will be done through digital housecalls than in medical practices. Which is why, in 2017, the FDA created a new unit devoted entirely to digital health.

It is being staffed with engineers well-versed in software development and artificial intelligence, who are able to deal with the steadily growing flow of medical technologies that require FDA approval. While certain parts of the federal government maneuver at a snail’s pace, the FDA is changing its culture to deal with the day in the not-too-distant future when machines will be monitoring and regulating a huge part of the healthcare industry. The FDA has long considered medical “apps” outside of its purview and thus the vast majority are currently unregulated. As more and more traditional medicine moves out of the doctor’s office and into our bedrooms and living rooms, that will need to change. And soon, for all of our sakes. 

The digital pill is, in its own way, a forerunner of how our homes will become part of the pharmaceutical industry  Within a few years, 3-D printers will be integrated into millions of American homes, plugged right into our smartphones and laptops. At the moment they are novelty items, but the capability to “print” pills on an as-needed basis may make them as common as home-testing machines for blood glucose or coagulation levels. Besides the cost savings and the convenience factor, this technology could also create pill shapes that release medications at different rates. For patients who need medications “tweaked” regularly, 3-D printers would be a godsend.


The digital housecall will be commonplace years before the printed pill. Ask people who work in the tech industry and they’ll tell you it can’t come soon enough. Besides the new FDA unit, there is already a trade organization promoting digital medical consultations, the American Telemedicine Association. Several insurance carriers either cover, or say they plan to cover, webcam exams and consultations. At the moment, digital housecalls are being conducted primarily in rural areas, via smartphone and Skype. The visual component is key; according to health insurance giant Aetna, the error rate is one-fifth that of voice-only doctor consultations.

Actually, the digital housecall is nothing new. It’s around 10 years 

The initial driver was distance. In places like Maine, where a single hospital may cover hundreds (or even thousands) of square miles, keeping patients off the road is a huge priority. Maine, in fact, was one of the proving grounds for telemedicine. Doctors there used telemedicine in a wide range of situations, including burn and trauma cases, where victims had to be helicoptered in for emergency treatment. They found they could begin “treating” those patients en route or, in some cases, on the scene.

Going forward, the driver of telemedicine will be cost (or more to the point cost savings). A doctor can see more patients digitally than in an office, which creates money saving— and money-making—efficiencies. Patients, on the other hand, benefit financially, too. They save time and money by staying at home or at work during a medical consultation. The necessity of hands-on contact is certainly an issue, but as more “connected” monitors and diagnostic devices come online, the need for doctors and/or medical staff to be in the same physical space as their patients will decline. Right now, insurers estimate that only about 20 percent of visits to a GP actually require a GP. Think about your last visit to the doctor’s office: How much physical contact did you have with your doctor? How much of your check-up was off-loaded to a nurse of staff member? Much of what a doctor does is ask a series of questions and listen carefully to your answers—which can be done on a screen.

So how exactly will this work?

Based on what already works in the places that telemedicine has a track record, it’s not difficult to paint a realistic picture. Patients will register online with the primary care physician or medical group that currently serves them, or possibly with a hospital center such as Trinitas. Though the particulars are likely to vary somewhat from insurance plan to insurance plan, patients will make appointments to interact with doctors (or other healthcare workers) in a space in their house or apartment where they can see and hear each other, and where the patients have access to biometric devices that plug into a smartphone or computer. Given that most of the equipment in a doctor’s office—and for that matter in a hospital—already “talks” to computers, there is no reason why simpler, cheaper home versions couldn’t be made available to patients with chronic illnesses or other conditions that require periodic monitoring. Right now, people with artificial heart valves already test their own blood weekly in order to tweak their Warfarin dosage (a famously moving target) and report PT/INR levels to their cardiologists. Five years ago, the home equipment was expensive and cumbersome; most patients had to drive to a lab to get their blood drawn and tested. Now the device is the size of a Game Boy. Five years from now, or perhaps much sooner, the next generation of these monitors will feed data directly into the cardiologist’s computer.

As hospitals cross the digital divide, they are likely to find telemedicine a force-multiplier, as well as a profit center— especially if they offer distinct specialties. For example, there are patients who travel many hours multiple times a week from surrounding states to see the wound-healing specialists at Trinitas. Not all of those trips are related to procedures performed on-site; a fair number are progress-checks and dressing changes that could conceivably be conducted without a patient leaving the home.


If you think about it, the reduced need to physically visit a doctor’s office cuts both ways—if the patient can stay at home, why not the doctor? Your digital housecall may be conducted by a physician working remotely, too—perhaps from his or her own home or home-office. There are, in fact, thousands of doctors who already work this way. Many are part of existing telemedicine groups. These companies treat hundreds of thousands of patients and are constantly tweaking how their platforms deliver healthcare to under-served or isolated communities.

At the moment they are kind of like virtual “Doc-in-a- Boxes,” bringing basic diagnostic services into homes. But make no mistake about it…they have their sights set on a bigger piece of the pie.

MDLive, which began offering digital housecalls almost a decade ago, recently added dermatology to its roster of services. It did so by partnering with an existing company called Iagnosis, an online skincare company that developed a platform called DermatologistOnCall. “Teledermatology” (they need to work on that name, by the way) makes sense on a lot of levels. 

First, it is a very visual branch of medicine, from training to practice, so it lends itself to a camera and screen. Second, how long do you have to wait to see a dermatologist on your current insurance plan? California-based SnapMD, a relative newcomer to the industry, just launched an app that enables Spanish-speaking patients to communicate with doctors who don’t speak Spanish, and vice-versa. Wall Street is watching companies like these very carefully, trying to divine where the “tipping point” is for the industry. Some believe it is coming in the next year or two.


Homebuilders also are paying close attention to this space. They are already partnering with tech innovators on ways to make their homes “smarter” and recognize that, as Baby Boomers age, telemedicine will become a part of their lives. Some builders, in fact, may be thinking really big: Not only will future housing units double as doctors’ offices, by incorporating medical hardware and software, they may double as “doctors,” 

The first group to break ground on this idea was a research team at the University of Rochester. Back in the early 2000’s, they initiated a project called the Smart Medical Home. Its goal was to develop interactive technology for home healthcare. It brought together doctors and engineers from the university, Rochester Medical Center and the Center for Future Health. Over the next few years they designed living spaces that actively assisted patients with dementia and Parkinson’s. A Personal Medical Monitor was built into one of the walls. It featured an avatar that interacted with residents and answered questions about medication and symptoms of illness. Sensors located around the structure were designed to monitor the resident and could alert his or her doctor if it detected a change in vital signs.

The home-as-doctor concept has continued to pick up steam in the ensuing years, as computing power and artificial intelligence have doubled, doubled again and doubled again. In 2015, a story in Healthcare IT News on smart medical homes reviewed a number of machine-tomachine (M2M) health devices in development for home use, including monitors built into footwear that can detect a limp or shuffle that may be a symptom of a more serious illness—and transmit this information through the home. In 2017, the same Center for Future Health in Rochester received funding for the development of tiny, wearable health monitors that transmit data to a base station in the home. The monitor incorporates “predictive” health software that can spot developing health issues, manage daily routines and intervene in the case of an emergency. The system constantly evaluates activities, motion, breathing, the sound of the wearer’s voice and how they all intersect.

It is not just the home and health industries that are working toward this goal. At the 2018 Consumer Electronics Show in Las Vegas, CNET held a forum entitled The Invisible Doctor. A panel of tech, medical and insurance industry experts explained how everyday items—from smartphones to home appliances—could potentially be part of a health-monitoring network keeping us connected to our doctors through our smart homes.

Some things, however, simply must be done in a doctor’s office or hospital setting. So the digital housecall will never replace brick-and-mortar medicine. That’s not the idea, anyway. The goal is to make the “front line” of healthcare more time- and cost-efficient and to make doctors more accessible to more people in more places.

Just as important is the byproduct of that goal: To give doctors access to patients before small problems become big ones.


Telemedicine has the potential to play a major role in disaster relief efforts. One of the first things that happens in stricken areas is the collapse of the healthcare infrastructure. Hospitals may keep their doors open and restore power during a crisis—they are built to do this— but are unlikely to be able to cope with the ensuing spike in demand from scores of the sick and injured. In these cases, access to virtual doctors and diagnostic services would prove invaluable in coping with the patient surge at brick-and-mortal hospitals. Down the road, these relationships could conceivably extend to remote surgical procedures, performed by surgeons in daVinci pods like the ones at Trinitas, working on patients in OR’s thousands of miles away.


One of the great debates around digital doctor visits is how easily older patients will take to the new paradigm. The implication is that individuals over a certain age are intimidated by technology, or are total Luddites. That may be, but balanced against the comfort level of seeing your own doctor in your own home, it may be less of an issue than critics claim. As home/medical technology advances it will, by definition, become simpler to use, with fewer buttons to push and procedures to follow. You can already get a TV remote you can talk to…biometric devices that follow voice commands can’t be too far behind.


For digital medicine to become fully integrated into the healthcare system, two major challenges will have to be continually addressed. While the hardware end of the business will become faster, better and cheaper, the software may struggle to keep up—and not just the software that runs diagnostic tools. As is currently the case with in-office visits, everything a doctor does will have to be coded and entered into a database used for billing, coverage eligibility, deductibles, referrals, and reimbursements. If you’ve ever peeked behind your doctor’s reception desk at the wall of paper files, you know how much information is kept on patients. Which bring us to the second major hurdle: With all that information digitized for digital doctor visits, just how safe will it be? Federal HIPAA laws create high standards for record-keeping, but can HIPAA regulations anticipate the legal and technical loopholes that digital medicine will almost certainly create?