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UNITED STATES DEPARTMENT OF COMMERCE|
The Panel Conference took place in Room 4830 at the Department of Commerce, 14th and Constitution, N.W., Washington, D.C., Philip J. Bond, Under Secretary for Technology, presiding. PANEL MEMBERS PRESENT:DR. GEORGE ALEXANDER A-G-E-N-D-AWelcome & Remarks by Under Secretary Bond Topic One: The Innovation Side of Telehealth
Topic Two: The Demand Side of Telehealth
Topic Three: The Investment Side of Telehealth
P-R-O-C-E-E-D-I-N-G-S(9:16 a.m.)UNDER SECRETARY BOND: If everyone would go ahead and take their seats, and we will go ahead and get started. My name is Phil Bond, and I serve as the Under Secretary for Commerce for Technology, and also as the Chief of Staff to the Secretary. I want to welcome you all here on behalf of the Department and the Technology Administration. I want to take just a minute at the outset here to say a few special words of thanks to the expert panelists and to talk a little bit about why we are doing this and what we hope to achieve. But, first, by way of thanks, I want to thank our expert panelists for joining us. A number of you have come from out of town, and we appreciate the effort there. I especially want to welcome our friends from the Office of Homeland Security, the Department of Defense, HHS, and of course any others. Thank you for your participation. And we will be joined by Dr. Arden Bement. I would also like to thank private sector leaders and those from associations who have joined us in this important effort . . . working every day to make telehealth a reality. And of course guests from the Technology Administration who really did all the work to pull this off and make us all look good. I thank them. A few words about why this matters. Perhaps it is self-evident to most of you, but from our perspective, the Technology Administration, which includes the Office of Technology Policy headed by Bruce Mehlman which put this effort together. Our mission collectively is to maximize technology's contributions to our nation's economy, our society, and our overall competitiveness in an increasingly globalized economy. As the President stated in both his State of the Union and just last week when we met with a number of technology CEOs, technology is not just critical to the economy. It is critical to every primary mission of this Administration as far as national security and technology. Security is critical, and the same with Homeland Security. Anybody here who has had the pleasure to hear Governor Ridge report on this subject knows that he understands how critical technology is. It is interwoven into any successful execution of the mission of Homeland Security. Then there is, of course, restoring economic growth. Economic security is what we all desire for our fellow Americans. Telemedicine is an important component obviously having implications for our society and the delivery of services. For the economy to get more efficient, we need to deliver those services and create new and better jobs in homeland security, distribute information and health awareness, and so forth, and we will hear some of that today. So as obvious and significant economic, societal, and homeland security impacts, today what we would like to do is structure the discussions a little bit. As we move into different subject areas, we should try to see if we can achieve any kind of consensus at all on the state of innovation in the States right now, and what is the demand for these kinds of services, and what we see in terms of adjustment. Then last, but certainly not least, what is it that the government can do to help, or, to state it another way, what is it that the government can make sure that we don't do to hinder the development of this. What is government's role as to this. For your information, we do intend to post a verbatim transcript from the discussions today, and so you may get a tap on the shoulder every once in a while to make sure that you are close to a microphone so that the transcriber can pick that up. We also intend to create a listserv for future discussions so we can keep today's discussion going. We are working on a survey and a report that will include what we learned today, in addition to other information that the Office of Technology and Policy is gathering. And of course we welcome visits and additional input from any of you at any time here at the Technology Administration. So once again, let me say welcome. I want to turn to Assistant Secretary Bruce Mehlman for a couple of additional words, and by the time that he is finished, I am hoping that Dr. Bement will be here to say a word or two. Bruce. ASSISTANT SECRETARY MEHLMAN: Thanks, Phil. I will keep my remarks brief and not try to stall for the good doctor. I would reiterate Phil's welcome and thanks to everybody, and a special thanks to David Brantley, who is our TeleHealth Team Leader. He did the lion's share of work to make this great roundtable and all of this happen. He also has the lead on the report that we described, and as proof of his commitment, he is not even in the room yet. He is still outside sweating the details, and trying to help the last folks brave our security screeners in order to join us. Now, most of you probably know Senator Bill Frisk from Tennessee. What you may or may not know is that this world class surgeon spends his vacations from Congress in war-ravaged areas around the world performing surgery on folks who are in need or who are otherwise in bad shape. Probably nobody here knows Dr. Martin Knowski. Dr. Knowski is a general practitioner in Bethesda. He is also a service provider, but he lacks the resources of a Senator, and can't get away from his family or his practice quite as easily as Senator Frisk. One of the great promises of telehealth is its ability to allow doctors who are interested in answering the President's call to service to improve our nation and our world. It may soon allow the Dr. Knowskis to tend to the sick and needy in undeserved regions both in the U.S. and the developing world. The other point that I wanted to make is that the President also stated last week that it is important that we be aggressive about the deployment of broadband, high speed internet networks. And although freshly stated by the President, this priority is not new for the Administration, and our office has been working tirelessly to encourage broadband deployment and usage for almost a year now. The on-line delivery of medical goods, information, and services promises to significantly support broadband deployment and usage, and yet another reason for us to do all we can to facilitate its success. Perhaps the oxymoronic irony here is that health care may prove to be the "killer app" for consumer use and need for high speed connectivity at home. So, Phil, I have not successfully spoken until Dr. Bement got through traffic, but I also look forward to today's discussion. UNDER SECRETARY BOND: Thank you, Bruce, and given our late start, maybe it is a blessing as you described. Let's go ahead and get started, and launch into your programs, and see the order of discussions. Topic One is the "Innovation Side of TeleHealth," and we are especially privileged to have Colonel Ron Poropatich, the President of the American Telemedicine Association, and the Chief of Telemedicine over at Walter Reed. Colonel, why don't you open this discussion. COL. POROPATICH: Thank you very much, Mr. Bond. It is a pleasure to be here, ladies and gentlemen. I am very fortunate to be in a position where I can see how telemedicine meets some of the needs of the U.S. military, primarily the U.S. Army. Now, in my capacity as the President of the American Telemedicine Association, it's possible for me to see how we can also involve all the different civilian, military, and Federal programs doing telemedicine. We are fortunate today, I think, in having the past President and four board members from the American TeleMedicine Association here. UNDER SECRETARY BOND: Does the Association need to conduct any business while you are here? (Laughter.) COL. POROPATICH: We don't, but they are going to keep me honest. What I would like to open up with is with the unfortunate reality that in the military that we have been planning missions for 10 years now in Telehealth. Fortunately, that military mission has come home to meet the needs of our home healthcare issues as well. How can we leverage some of the Federal government initiatives in telemedicine in such a way that it makes sense to integrate those same technologies with the same simple processes into our overall telehealth delivery? The government's telemedicine R&D initiatives -- and this primarily focuses on some of the R&D issues -- is very active, and very robust. The Department of Defense, the Army, Navy, and Air Force, are very active in telehealth with dedicated budgets. The VA is represented here by Dr. Adam Darkins as well, who runs the VA Telemedicine Program which does 300,000 consults a year. Also represented are Health and Human Services, the Office for the Advancement of TeleHealth (HHS), NASA, and Agriculture. While there is a very strong representation here today of telemedicine R&D, there is no overarching Federal science technology plan bringing all these different Federal R&D programs together. I think that is one very important point. In the military, we put together a "joint science and technology plan." When we talk about moving clinical images between consultations, it is really much more than that. It is medical informatics and teleconsultations, and it covers a large gamut of health care issues. So I think that bringing all the different Federal government R&D efforts under one umbrella where someone can see how those efforts support homeland security would be very important. At the U.S. Army Medical Research Materiel Command, we are involved with almost $200 million a year in Congressional costs. But many of those projects that we are involved with were being looked at back in the October and November time frame. We categorized which projects really had an immediate role in addressing some of the homeland defense issues, and we put together a portfolio. I would be more than happy afterwards to share that portfolio with you all. The other priority is to take that R&D program and to elevate the capabilities of the healthcare team, starting with the consumer, the patient, the first responder, and, I would add to that a clinical specialist. I think the R&D effort needs to look at how we can put these technologies into use day-to-day, and not just when a disaster occurs. Then, find out what makes sense that we can insert right now then mobilize the full health care spectrum in our country to educate the consumer, the first responder on that EMT response team, and the specialist in the hospital taking care of that anthrax victim, for example. That is going to be a key. Whoever heads up this joint Federal Government R&D plan can say, well, this is where we can cover the different stakeholders by that health care team, to include medical modeling simulation, which is in a PC-based, management-based, virtual reality. These are all programs that are out there right now, with deployable telemedicine systems that we use in the military. Again, it is more than R&D. We have had this in place for five years now, and we are taking that same deployable system to Operation Joint Freedom in Afghanistan. How can we insert this kind of capability in our day to day peace time home care issues is going to be a challenge. Finally, I want to talk about standards or guidelines. Standards are very important and clinical guidelines are critical because without those types of clinical guidelines, we would not have interoperability. Interoperability is the goal that we all strive for, and interoperability will allow us to collect a network of networks, if you will, across this great Nation that will be web-based, will be teleconference-based, and twill be used for education as well as consultation purposes. We have within the ATA technology specialists looking at technology standards and telehealth, and we have got clinical standards being promulgated. VA and DoD are working on teleophthalmology standards, and this is very important because we need to not just say this is not how many pixels you need to do a telerenal image, but that you don't need to have a doctor look at the image the first time. There are clinical practice guidelines that will allow us to have a trained nurse or a trained Corpsman to look at the image and determine whether it is either normal or it is abnormal. If it is abnormal, then it goes to the specialist. If it is normal, forget about it and you triage out those 56 percent of normals, and you focus just on the abnormal . . . just like we do every day in our hospitals when you are screening patients. So this Federal R&D agenda to include developing a science and technology plan and identifying research metrics that we all agreed to as important to patient diagnosis, treatment, and evacuation, to avoiding evacuation, or other metrics. The most important research is not just clinical. For us in the military, it is the business case analysis, and where does this make sense. It is one thing to do great research for telemedicine, but you need to look at broader factors. What is the impact on our society, and what is the impact on that proprietary agency doing that research? I think the broader factors are, for us in the military, the bottom line. I may wear a uniform, but I am in business, and I am in the healthcare business and trying to reduce costs by using technology. This concept needs to be promulgated in this Federal R&D plan because the business dimension of telehealth is key. Let's take the best systems already in place and put them in key test sites to see if it makes sense from the metrics that we identify from this Federal R&D initiative. So, in summary, just a couple more points. Whatever we develop in this network of networks has to be used daily, such that it meets homeland defense needs during emergencies. Then we are not reinventing the wheel at a time when we don't have the luxury to learn how to use the system. We need to raise the standards of healthcare delivery across the whole spectrum of the healthcare team, starting with the patient, and ending with the consumer. Consultations and education as the key reasons to build a network. And then we need to leverage the collective build up of R&D efforts in telemedicine such that we identify a matrix and a innovation methodology. I would like to conclude with that, and kick off discussion and see where we go. UNDER SECRETARY BOND: Thank you. There are a lot of folks here to move the discussion on to, whether it is standards or whatever, but let me start with a question to you and to others to respond to as well on just the level of R&D, and this particular space. Please talk for a moment about the need for some coordination in terms of the level of coordination needed and if our coordination today is sufficient or insufficient. COL. POROPATICH: I think it is really insufficient. There are VA and DoD collaborations under way, and we are working together on some of these telehealth issues together. What I am trying to promote within the ATA is bringing standards and guidelines together, and developing an archiv. We need to use what is already out there. Health and Human Services and NASA are very active right now, through Dr. Dena Puskins's efforts in the Office for the Advancement of Telehealth, in developing clinical practice guidelines and standards. But what I would love to see us do is develop a central archive of technical standards, clinical standards and R&D, and then learn from those standards. We all need to start doing it the same way. If we don't, we are not going to accomplish what we are trying to accomplish. UNDER SECRETARY BOND: What about on the Federal side and what about on the private industry side? COL. POROPATICH: I think that there is a lack of a common vision that we are moving towards. I think whether you are Federal, or civilian, academia or industry there is that gap. I feel that our responsibility in the ATA as a non-profit professional organization is bringing all these together. It is something that we all desperately need, and I see that as a way to bridge industry, academia and government. UNDER SECRETARY BOND: Does anybody else want to comment? MR. SIMMONS: I am Scott Simmons from East Carolina University. A couple of comments on Ron's presentation. I think part of the current problem is that we still seem to have a kind of narrow definition of telemedicine, or telehealth. I look at it as more health informatics and telemedicine. I don't see people here from the medical informatics industry, and there is a whole issue. One of the limitations of telemedicine right now is that there is no integration of electronic medical records. There are several organizations that make telemedical records that don't integrate into medical records systems, and it is very difficult to get data from clinical telemedicine sessions into your EMR that you have in your facility. That is one issue. Another one is that part of the problem with the industry developing is that it is not a technology problem. The real payoff for telemedicine and telehealth is the re-engineering the way we do health care. It is not taking the technology and adding it on top of the existing processes. Today we develop telemedicine by replicating the face-to-face visit, or we replicate the nursing care that we bring to the home right now. There are reimbursement issues, for example, and the military gets around this because they are not faced with the same reimbursement issues. They can do their store-and-forward telemedicine, and in the dermatology unit at Walter Reed, they have done some real innovative work in web-based teledermatology. We can't get that reimbursement in the private sector is my understanding. DR. PUSKIN: A couple of comments. Unfortunately, I didn't hear all of Ron's comments, but I think I am fairly familiar with them. I am Dena Puskin, and we have had the good fortune of funding telemedicine and telehealth projects since 1988 at the Department of Health and Human Services. And I would like to echo some of the comments and then perhaps add something to them. Number One, I think that the Federal Government can help drive the development of standards and guidelines by being in essence a large purchaser, and having a lot of influence on the purchasing decision. Without that, we will not see this field take the next large step. I have over and over again seen communities and projects have a very difficult time deciding how to step off the curb because while there are standards out there, they are not implemented shall we say in the same way. And in some ways we have too many standards, and people have a very difficult time when they actually go into the field and try to gain interoperability. They make an investment, and the investment essentially is not as well-integrated as perhaps their legacy investment. It then becomes a very difficult decision to step off the technology curb. I think with some guidelines and standards that are based essentially on what purchasers are doing, the Federal Government can take the lead very much here in its own purchasing position. You can see in the video field costs it made a major difference when purchasers made decisions about what to purchase. In terms of some of what Scott said, it is the human factors that make a difference whether in fact this works or does not work out there. It is matching the right technology for the right need or purpose. Often we have not quite -- and I will be honest with you, we have not quite figured that out. We are still not there. So we are in the area often of demos, especially as we push the envelope. We are doing speech therapy, and we are doing occupational therapy with it, and doing a lot of things, and what relevance does it have? As we push the envelope, we are learning from working day to day in the field, and that is the key to what we are learning as we deal with the situation. So I think that we have to recognize, and some people I think don't at this point, that we are at least in some ways very much in the demo area, that broad-based demo, and not the little things, but figuring things out on a wide sphere. We have done a lot of little things. The question is now how does that move from what I call the little things to the wide sphere. We have to carefully look at that. I hate to say it but, in a sense, September 11th gave us the impetus to look at this much more critically and seriously. I think we need to do that. In terms of management, it is very hard to manage people, and we have to recognize that. One often starts with the familiar. Start with trying to mimic what is going on, and the re-engineering follows. If you start with saying to people that we are going to change everything you do, you get an automatic "We are different." If you look at how computers diffused everything that we do, the whole system of how we do much of our commerce and much of our health care has been infused by such a change with telehealth care. The role of industry I think is to look at health care a little differently. In the past, the video conferencing world said -- and I will use that as an example, but the industry early on, because health was just a small portion of their business, said we will move on to some other things, and essentially we will market to the health care community, but we won't think of health first. As such, there often was not a good fit. There is one vendor, for example, a business that made a terrible business decision to essentially get rid of some ports that allowed data and other kinds of video transmissions in their next iteration of equipment thereby making all their previous iterations essentially legacy systems unless you invested a large amount of money for an add-on. So, I think the other issue probably from a business side is to begin to look at the health care market a little bit. I have one final point, in terms of the electronic medical record. We are funding quite a few projects that are looking at the electronic medical record integrated into sort of a process, and including telemedicine. I think the issue there is a very serious one. There are not standards for the electronic medical record and for good reason. That has been difficult to achieve. When offices start and think that we are going to start with the electronic medical record, we have been starting with the electronic medical record for a long time. The question is now we have a billion medical records, and we have about 3 or 4 major purveyors of medical records. UNDER SECRETARY BOND: Let me go to Dr. Sanders first, and just a request, which is hard to do, but these things are all seamlessly connected. Let's try to focus on the innovation side. DR. SANDERS: With respect to both the issue of standards relative to technical and clinical standards, I totally agree with what has been stated relative to medical standards. I will give you a little vignette. In 1973, I had a National Science Foundation grant to do telemedicine in Dade County, Florida, at the University of Miami. And one of the technological devices that we used in 1973 was a device called the fax machine. Within 24 hours of our using it, I called our budget manager at the National Science Foundation, Mr. Al Shannon, and said, Al, we have already done our evaluation of the fax machine and it is useless! Now, you are saying the fax machine is useless. What are you talking about? Well, very simple. Unless the person that I was faxing to had exactly the same name, model, of fax machine that I had, they wouldn't talk to each other. And, number two, it took 4-1/2 minutes to send 8-1/2 by 11 sheet of paper, and then, when the paper came out, you had to take an iron and literally iron it to put it in your file. So it was very clear that the fax machine wouldn't work. And it was right around that same time that the industry started to get together, because all of them had this great new thing out that everyone wanted to be the first in the field. The reason was that they were making such proprietary types of technology that nobody would talk to anybody else. And it was when the fax industry got together and said, look, we are killing each other, and let's stop with all of these non-standard and proprietary approaches, and let's have a common language that the fax industry literally exploded. And that is really what has to happen in this industry. I think that is an issue which we can talk about later with respect to the electronic medical record, and which is really the guts and the starting point for all of us. The issue of clinical standards. We are just incredibly naive about the issue of clinical standards. I can go on the record and say we have absolutely no clinical standards in healthcare. And that is the example that I always use, and I think it is a good example. I always ask folks in the room how many of you have had physical exams in the last few years, and everybody raises their hands. And I said how many times did your doctor listen to your heart and lung sounds, and everybody raises their hands. And then I ask them how many of you have asked your doctor when did he have his last hearing test, and everybody laughs about it. But the fundamental reality is that I take a hundred stethoscopes, all of which have the same technological standards, and they give me exactly the right decibel level that I need for the softness diastolic nerve, or the heart diastolic murmur. And I take a hundred stethoscopes and I put them into 200 different ears, and what is perhaps more important, the hearing that is between the two ears. So I think we have got to look a little deeper when we talk about clinical standards. DR. DARKINS: My name is Adam Darkins and I am from the Department of Veterans Affairs. Before I make a brief comment I would like to say that unless explicitly stated otherwise the opinions I will give are my own and should not be taken as the position of the Department of Veterans Affairs. A distinction that I find useful to use when looking at telecommunications infrastructure in relation to telemedicine development is to use the analogy of the railroads in the mid to late 1800's We have the fiber in place for the network and this equates to having the railroad tracks laid down. What is of pressing importance is establishing the telemedicine traffic that is going to travel on these tracks (fiber) and making sure that all the tracks are compatible and interoperable. The traffic on the network, whether it is rail or telecommunications, is what provides the revenue to sustain the network. I feel we need to worry less about the tracks and more about the rail cars that is going to be transported in them Standards should be with a view to encouraging the volume of traffic on the network. With the growth of the railways we saw the establishment of new communities, new products, new professions and new trades. From my perspective I would say that our focus needs to be on more than just developing standards per se for the fiber network (tracks), I think it needs to be aimed at developing the metaphorical rail cars and the goods these will carry. These are what will generate the revenue that is needed to sustain these telemedicine networks long-term. In the end if patients don't use telemedicine, we wont get the revenue traveling through the system. I will limit my initial comments to this, but I think as we move through our discussions it may be useful to make the tracks versus railcars distinction again, particularly when it comes to looking at the potential value/return of any investment we suggest is made . UNDER SECRETARY BOND: Dr. Bement. DR. BEMENT: It is very rarely that I can sit in and say what standards of guidelines that are mentioned, and coming from a Federal Agency where our life's blood is standards and guidelines. With regard to information exchanged, and information standards, and formats, I could see that there could be a lot of commonality on the input side and on the exchange side. I wonder about the output and the formatting side, and whether there are some real barriers to the commonality and with formats that we even know about it in order to set the standards, and I am curious to know what your views would be on those kinds of barriers. MR. WALKER: My name is Craig Walker, and I am the Vice President for Public Policy, at HealthCare Computer Corporation, and I just wanted to respond that as an individual representing part of the industry, I think there are some standards that are recognized already with regard to -- and common events. And I think to the extent that those are espoused and usually integrated with telemedicine applications, it is required from a systems standpoint using the analogy of a hospital system, and that information be linked up to records (inaudible), and it is our goal, particularly with our projects, to ensure that the information that is transmitted is seamless. And to the extent that we can assist health care providers and improve demands for that information on the patient populations, you will see a better outcome in (inaudible). MR. MORRIS: I am Richard Morris with the Office of Public Health Preparedness. I just wanted to add a couple of comments and kind of supplement what has been said before about the standards. My understanding is that as of September 11th, when we started preparing for civilian terrorists, the ball game really changes because now we need to move health care in all respects out of the clinic and out of the current context, and that means that many of our existing data standards, in spite of all of the good work that has been done, now needs to be extended to serve a public health objective. I also think that what Ron said about needing to put a whole new set of professionals in the loop in medical decision making is inherent, and that also makes the issue of this infrastructure of data standards much more imperative, and we have got to do much more work than was anticipated in the patient-doctor encounter that was restricted to the doctor's office or hospital. COL. POROPATICH: Well, again, we are talking about formulating a different health care and trying to focus this new wave health care only within the last 10 years extremely active, to a process that will improve -- and I think we have had this discussion before. Who will take the pictures, and who reads the pictures, and these are all things that we have not quite figured out, and if we want to change the standards and guidelines, it makes no difference to me. What are the standards and guidelines now, and nobody knows. And we are getting beyond technical issues and pixels, and that is a technical issue, and you start talking wireless, and you get into a whole another area where the wideband issue is a very hot topic right now in commerce, and (inaudible) to raise that level of conscious, and make sure that we actually implement it more broadly, because right now it is just impossible, and the whole concept is the peanut butter concept on a piece of bread. You can have a lot of peanut butter here and there, and making this whole telehealth work, and we want to spread it out and to standardize the basis. And I really think the consumer is an issue and we need to be coming up with success stories to educate the consumer, and why aren't they asking if there was an emergency what would they want. What could we offer. I think that these are the hard questions that we are trying to come up with, and educate consumers, and to help push this faster, and past all the barriers, whether it is electronic medical records that we referred to, human factors, and these issues are still going to remain. And with this opportunity now after September 11th, and with the Homeland security issues, has elevated the pace, and it is not acceptable to go with the current pace that we have been operating under for the last 10 years. It is now time to evaluate the pace. CPT BAKALAR: Richard Bakalar, U.S. Navy. A couple of comments. Having worked with Ron Poropatich for the last seven years, we have seen a shift in the last several years from a focus on technology infrastructure, and to an emphasis on improving the accountability and friendliness to the consultants. And one of the things that we are seeing over the last several years is that our capacity for consultants has been diminished because of the increasing demand in the hospital for the local health requirements, as well as the telehealth requirements. And so the efficiency gained needs to be -- because the infrastructure is shrinking in the clinical world, and our radiologists, for example, are less available, both in the private sector, as well as in the military, and the ability to take advantage of the infrastructure that has been deployed is diminishing because the systems are not very friendly using different information systems that are available. So the efficiencies have to be improved -- MR. WATERS: My name is Bob Waters. I am counsel to the Center for Telemedicine Law, and, a member of the Board of the American Telemedicine Association. I understand this section ofof this part of the program is focusing on research in the broadest sense, the government and the private sector have spent a lot of money investing in telemedicine technology. I am reasonably confident that the technological tools and toys will be there and our economy will produce these products. I agree with the previous speakers regarding interoperability and the electronic based record. These are really key points. However, there are additional areas that have not been mentioned where we are probably under-invested. One is the whole area of service delivery research. What is it that causes the doctors to use telemedicine? We need to spend more time and energy on what really works in the field, and how do people behave, and what behaviors make it more likely that they would embrace these new technologies. Secondly, I am becoming more and more enamored with the benefits of investing more money into the technological transformation of medical education. Visualization and simulation tools can have a tremendous impact, not only the way that we educate physicians in the first instance, but also in how we check their proficiency down the road. Jay's question about your doctor's hearing is a perfect example. The physician could listen to a hundred hearts over the phone using his electronic stethoscope as part of a proficiency test. You could determine whether or not the doctor could hear, and whether or not he needs to get a new hearing aid, or whether hearing isn't the issue and it is a question of whether he could properly diagnose a patient. An investment in medical simulation and proficiency tools could do a tremendous amount in terms of improving the quality of health care in this country. I don't think the private sector will make that investment. I am doubt the academic health institutions have the resources to do it by themselves. This is an area where the government should step up to the plate and make a significant contribution. DR. RICCI: Mike Ricci from the University of Vermont, another ATA Board Member as well, and as I am trying to focus on innovation and apply it to some of what I would think are some innovations that we have done in Vermont, our innovations grew out of the need, and we need to define need. If you receive a set of injuries here in Washington, and when you get that set of injuries in Pottstown, New York, your chances of dying from those injuries is roughly twice what it is in Washington. And what we discovered was that there was higher mortality in rural America from trauma. And nobody really knows why that is. Is it an educational issue, or is it a training issue, but the outcome is worse. So we used the technology to deliver our trauma specialists high volume doctors relevant to the rural communities into those Emergency Rooms. So our success in that area came out of the need for health care for those patients. We combined it with education that first responders and physicians, as well as 7/24 clinical care. In terms of Jay's comments about the stethoscope and the standards, I think the end point, Jay, isn't whether he has had a hearing test, or whether he is able to treat your angina properly. And it is not uncommon as a surgeon for patients to ask me how many of these have you done. Nobody is asking me to hold my hand out and see if it is shaking or not. But they often ask if I had a good night's sleep. But there are standards out there. For instance, in trauma, with the pre-hospital trauma life support course, and the ATLS course, and the standards that exist, while admittedly imperfect, we tried to apply to our existing trauma program, and we have had success. MR. NEWBURGER: Mark Newburger here Apollo Medicine. Just three comments and they all have to do with the current state of medical delivery, versus adding telemedicine to it. We have run into some problems when we are dealing with implementing telemedicine from a standards and guidelines perspective. We just can't look at telemedicine overall. We have to look at the different solutions for varying specialties. Each medical specialty has its own standards for how to make a diagnosis for treatment, and whether it is pathology and radiology, gastroenterology, dermatology, there are different needs. So, whereas in radiology, you may need a very high resolution still image, in pathology, you actually need a low resolution for a motion picture. In developing standards and guidelines and talking about interfacing with medical information systems, we have a problem, in that we all want to do it, but at the same time the perceptions due to HIPAA and privacy concerns is that nobody wants to do it, because everybody wants to keep the information very secure. And so that is kind of a major hurdle or even a wall if you will for entering into medical information systems. And then with regard to the comment, and I don't remember who said it, and I apologize, but with the ATA looking at trying to see why patients aren't asking for this technology. A patient doesn't ask the doctor to make a telephone call. What the patient asks is maybe I need to get a second opinion. So whereas with -- I think the technologies really are there, and it is really a format that they are being marked if you will to both the patient and the health care professional population to expand its limitations. UNDER SECRETARY BOND: We need to go ahead and wrap up this session. Sumit. MR. NAGPAL: I am Sumit Kumar Nagpal, President and CEO of Wellogic, Inc., and we are a technology provider focusing since '92 on telehealth and health applications, and it is really great to be here and listening to you all speak. And what I am hearing here sounds like page 1 through 35 of a requirements document for HUD, and I could address a lot of the issues that you are bringing up around interoperability and around the features of the products mean to me. What I will touch on at this moment is just the area of clinical standards, and highlight, on the innovation side, one initiative where we are actually succeeding at getting the major vendors to collaborate in creating a vehicle for standards around clinical guidelines. We did a not-for-profit institute call IMKI, the Institute for Medical Knowledge Implementation, and we have gotten Siemens, IDS, Columbia Informatics, Stanford Informatics, a full- fledging of these vendors, to actually come together around the creation of a tool set and a library of clinical guidelines that each one of those vendors would then adopt into their products. That is one of the areas where we are very focused on increasing interoperability across systems, and we are actually succeeding in getting these vendors to work together to, one, design a product that they are all willing to then adopt the output from. And then, two, to actually then imbed the outcome into their systems and cause clinical decisions and support to happen in their very different systems, all following the same guidelines that are all about. So there is proof in this industry that, yes, a lot of these large vendors, or most of the large vendors, are islands unto themselves, but the problems around patient safety, and patient privacy are forcing some of these vendors to actually begin to talk to each other, and begin to look for solutions. DR. MCCRARY:My name is Victor McCrary, and I am the Chief of the Convergent Information Systems Divisions in the Information Technology Lab at NIST. We deal with every day in our division looking at the (inaudible) content, and in a lot of those areas, where we have worked in areas like electronic pulse and biometrics. While we are there we try to facilitate standards interoperability, because in many of the industries that we work with typically (inaudible) and these different structures are needed. But there are also going to be the same things that you are going to need in health care because you are going to make this, whether it is telehealth, or telemedicine, or health care infomatics, along this vertical, you need to implement infrastructure standards as you see in the entertainment industry, and these standards are extremely important for the medical and publishing industries involving electronic standards for electronic files and publishing. I just want to point out that if that is to happen in places like NIST, as well as in other agencies, we need to try and coordinate and help facilitate these standards, because not only are you going to have issues as far as a quality format -- for example, to develop tools that would carry images which would carry images and there are computers still having to bring up PDA. And some people would look at mobile health care deployment, but issues like network security, and issues of interoperability among different (inaudible), and when you talk about electronic formats, and interoperability, and what kind of data, you may have to describe it, for example, in XML. One of my colleagues is here, Mark Skull, who is the Chief of our Software Performance Testing Division. And he can get a lot with the standards of just XML. So I would just point out that while we talk along this vertical issue of standards and interoperability, this infrastructure, and again whether it is entertainment or health care, we are going to have these (inaudible). And I also agree with you that the bottom line is the business case. We can have great technology, and if we build it, they may come, but they might not show up. It is extremely important that we have that. And I guess also my other interest in this is just personal interest because some number of years ago I was -- UNDER SECRETARY BOND: And just to state the obvious, of course, NIST is to facilitate, rather than dictate, standards. Scott, and then we will wrap up with the Colonel, and get a couple of thoughts here. MR. SIMMONS: I believe Michael was next. DR. FITZMAURICE:Two comments. I am Michael Fitzmaurice, from AHRQ, HHS, and we undertake research and quality, and one of the things that we do is provide (inaudible) practice reports. So if you are considering practice guidelines, we don't do guidelines. But what we do do in the practice reports is synthesize all the control trials out there in the research to be used in telehealth guidelines. Secondly, the role of the Federal Government is to provide for the welfare of the people through innovation and to the quality of life. I see from the background in here that we have the Department of Defense, and we have defensive reasons and we have private sector reasons for pushing innovation. But in the United States, a lot of the innovation has come through defensive purposes. There are a lot of things that we can do for defensive purposes that lead the way. Defense has excellent lines of communication, and the ability to do partial research, and manpower to test new applications for defensive purposes, and that technology is often transferred into the private sector. The private sector, however, is reluctant to spend its own money to pave the way because they have to be concerned with the bottom line, and their own viability. So for telehealth, some of the first things that we need to find out is whether a technology is medically effective. If it is, does it have efficacy, and does it work in an ideal setting; and secondly, does it work in a community where you and I get health care. In the past if those tests are effective, then is it efficient. Is it the best place to spend our money, and do we get the results that we want. If it is, then we have to move on to how do we integrate technology, the technology that we already have, and to the technology that is proven, through research and through pilots, to move us forward with existing infrastructure and legacy system. And then finally we have to be concerned with access to this technology. Most all of us get our health care paid by a health plan; maybe a military health plan, maybe a private sector health plan, and maybe through a Federal health plan. And as you invent new technologies, it gives more and more access to people. There are also people without health insurance and they get more and more access through the future use or the current use of the telehealth. But if you think of it in terms of an increased dollar amount, or a fixed percentage, then that new technology can crowd out services to some people. If you extend it to the poor and to people who don't have health care, somebody else is going to be crowded out. There has to be some logical thinking about the human factors involved and where we use this telehealth, and how do we help input the welfare of our people. I don't have the answers to the questions, but I think we need to think about events and its innovations in technology, and we need to transfer that to the private sector for what is needed for the standards and guidelines, and then how we use it in the private sector, with some guidance from above, as well as through the marketplace. MR. SIMMONS: I know that we are running late, and so I will attempt to be brief. On the standards issue that we talked about today, Victor brought up a really good point, and I think we need to look outside the health care and in the traditional way of developing standards through the computer industry and the entertainment industry, and how they developed standards, and how they are able to interoperate and still be competitive. And the model that I am thinking of is that if I am filling my telemedicine system, I would like to be like -- and I believe that Windows 2000 will do this now, and I know that my MAC will. But I buy a PC, and I want a HP printer, and I want so-and-so's digital camera, and so and so's other peripheral. I can pop these all in and they automatically recognize each other off the shelf. Try to do that in medicine now, and that is one area of doing it in. And just to get back on the topic about this kind of network of networks concepts. We talked a lot about interoperability at kind of the device level, but we need to talk about internet based applications. So right now, because of the ubiquity of the internet a lot of the developing applications are of the internet protocol, and IP based on TCP/IP, and I know that at least in video conferencing that TCP/IP is great for transferring, for messaging and transfer of files, and error checking and that, but it is not designed for video conferencing. There are a lot of networks that are moving in to the TCP/IP realm to do video conferencing, and we are doing a lot of IT telemedicine right now, and the only way you can do this with existing networks, is that we found like a 20 percent traffic mode that that crashes our video conferencing to a level that is clinically significant. So things like quality-based quality of service is something that we really need to look at, especially if we are talking about a network of networks. And if certain event A happens, who gets priority on the network; is it fire, police, EMS, clinical telemedicine. That is a big area, because right now the quality of service factor has worked really well within my own campus. But as soon as I get outside the campus, then there is this negotiation that has to happen, because I might say that all telemedicine video packets are the highest priority, and as soon as I touch somebody else's network, they may disagree with that. So, QS is another one, and security is another one, when it comes to software. COL. POROPATICH:(Off microphone) I just want to get back to the third question on the pamphlet, which says how can government help overcome some of those barriers, because there is a big barrier with infrastructure. I heard Ken Kizer of the National Quality Forum here in town saying that one-third of public health processes in America don't even have e-mail. So every town in America has a public health office, and if one-third of them don't have e-mail, there is an infrastructure issue. I have also heard that half to two-thirds of the hospitals in America lost money last year, and that is a significant number of hospitals that lost money. So how can they even afford to build an infrastructure if they are already losing money. And at that meeting there was a comment made by CMS that said, well, why don't we do this. Why don't we take DRG costs and give 5 percent of that cost and give that to the hospitals, and use that 5 percent to increase their IN/IT industry. If you get that from the government, then from that hospital, and it talks about population studies outcomes, and how well these sorts of information systems are helping us make decisions on pharmaceuticals, et cetera, and it covers the whole gambit. So the challenge I think is that the Department of Commerce would take the lead in coordinating with CMS and with the FCC, because the infrastructure issues I know are very helpful, on how the FCC can use some of their $400 million or so a year to build infrastructure, and a process that is now burdensome that is perceived from a lot of users. So there are things out there right now that we can help build an infrastructure, whether it is the FCC, or whether it is Congress buying into it, and funding DRG, Federal payments, to hospitals to help build this infrastructure. All of these things have to be happening at once, and I think that Commerce could help be that catalyzing force to bring some of these issues together, with the intent that that infrastructure helps with these types of issues. UNDER SECRETARY BOND: (Off microphone) Let me see if I can offer a couple of things here by way of wrap-up here, and pose another question and forewarn my homeland security guests here, and then have a quick comment. Let me see first of all a show of hands from folks who think that the innovation stage of telehealth, that the biggest challenge is actually technology and capability, versus a show of hands from those that think the problems really are more of interoperability (inaudible)? So, number one, I would like a reaction from the homeland security folks on how they react to hearing that, that the biggest challenge is the interoperability and standards, and the hobbling of the technology that is available (inaudible)? And then kind of pose the question to the group by way of closing what tangible near-term steps we could take on sort of -- and to touch on one again, we have touched on a lot of very key issues. Change the payment systems, and the Federal Health Care System, and change the way that we educate, long term transformation that is under way, and all of which are big, big challenges. Changing public policy on the way that different groups interact and who pays for what. Those are heavy issues. So I want to try to focus on some near-term practical steps that we might take away from this, and I am sure that the folks at NIST would take a crack at this. And let me first turn to the omeland security folks and get their reaction and response. First, the CIO, Steve Cooper, and then Dr. Alexander. MR. COOPER: Phil, thank you very much. This has been very, very helpful to me. Let me share with you why and what my task is very simply. Governor Ridge and the President have basically given me two objectives. The first is to integrate the Federal agencies, all relevant agencies, with regard to the sharing of essential information for homeland security. When I get done with that, then I have to effectively do the same thing among and between Federal, State, local, and private sectors. Now, that is a big challenge, but let me tell you what is interesting and what I think I would offer and kind of back you all, because I need a lot of help on this obviously. What is interesting to me, and what I find, is that I have a technology background, and I am out of the private sector, and I spent a lot of years with Eli Lilly as one of their senior folks, senior executive in IT. And therefore I do have some reasonable knowledge of what we are talking about, but I don't pretend to be a medical or health care expert. But what I find interesting is that this conversation is a very, very valuable and highly relevant conversation. But let me ask a couple of questions before that. Where is the voice of the customer? The discussion at the moment I think, you have got telemedicine, and think of it as an industry or a sector. It is in its infancy. Ten years is a drop in the bucket if you think about industry, and the first circle of customers or consumers for the services are the medical professionals, the health care professionals. Somebody mentioned the fact -- and I think it was the gentleman -- and forgive me, as I can't remember his name, but the counsel mentioned the thing about the service delivery mode. Well, I would argue that begins to get at what is really going on here, because the value is going to have to eventually be seen by the patient, by the collective consumers of health care services. And I don't think they are in the game yet. They are not involved. There are a significant number of people -- and I don't know the exact number -- who actually do go to the internet for health care information. But that is a very, very important percent, but it is not enough. I don't think that the patient yet sees any different delivery.I think right now the paradigm is still I go to my physician, or to my health care facility, and until the health care professional begins to change that model paradigm of health care delivery, I am not sure that telemedicine is really going to catch hold. Now, mind you, this is just an opinion and an observation. It is not necessarily a fact. Now, should one then go into this, the second part of Phil's question, and short term types of things. One of the things that I think would be extremely important is that part of what your discussion is focused on is about interoperability and technology standards, and things like that. A suggestion is to go to the folks who have already solved the problem, and let me give you some examples. The financial industry has solved the problem. You can take your Master Card or Visa Card and use it anywhere in the world. Now, as a consumer, that is all you care about. All you care about is you can plug your card in and you get money back. Well, that network already exists, and it is fairly secure for the types of information that would be moot for health care purposes. Why not key that one, and why not engage, for example, the financial industry in riding on their network? Why make a duplicative investment in new network technologies solely for the purposes of telemedicine? I am not sure that it makes sense to me. Another group that has done it all over the world, some of which you can access and some of which you can't, is DoD. You have got networks going everywhere. Again, why not build upon and create a partnership, and you are going to get the information where you need to get it. One of the best examples, believe it or not, is the National Guard across America. Now, they clearly don't reach outside the borders of the United States, but the Guard and Guardnet has over 3,000 locations already. Now, think about the role that the Guard is going to increasingly play in homeland security, and I would argue that you would begin to form a pretty interesting partnership if you sat down and talked with the National Guard about, hey, help us with telemedicine. Just a couple of thoughts, a couple of comments, and I am happy to continue the dialogue after. MR. ALEXANDER: Thank you, Mr. Bond, and good morning ladies and gentlemen. I am George Alexander from the Office of Homeland Security. Mr. Bond asked a question -- well, first of all, the core question is how can telehealth help support homeland security. Well, certainly I agree with essentially everything that has been said around the table. Within the last decade, numerous advances have been made in the field of telemedicine. I think to answer your question, sir, about what are the issues, I would refer to the gentleman who made the comment there are different specialties who have different needs. And I think that is the key, whether you are talking telemedicine, whether you are talking telehealth, whether you are talking health infomatics. Each of these individuals or each of these groups have different needs. And in order to come together, I agree that the infrastructure issue is paramount, and through efforts of core groups and panels such as this, one can forge ahead to address these concerns. With respect to having an industry identify the problems and try to resolve it, I think that is an excellent approach. With respect to homeland security, I would like to make a comment. Part of Governor Ridge's initiatives and the President's initiatives deal with defending against biological terrorism. And one of those primary strategies is to improve the public health infrastructure in this country. We have heard from the Colonel how several years ago many health departments didn't even have fax machines. Well, clearly telemedicine can play a role in homeland security. When you talk about improveming the public health infrastructure, you are talking about essentially three things:
With respect to communicating rapidly this is something that is important and communication plays a role. So clearly telemedicine can certainly play a role in improving homeland security. With respect to questions about how this is funded, I wanted to ask Dr. Sanders. He mentioned that he had gotten a grant from maybe a decade or two ago, and I was just curious where his funding was then, and probably there weren't many interested in funding telemedicine, but I am sure that there is probably more money available today. I am not sure if that was from the NIH or another organization, but clearly as the need arises and the point was very well taken that that academia alone could probably not do this, and perhaps some future Federal monies is an excellent suggestion. There was the comment about how do you go about doing all of this, in terms of clinical standards. I think that education is the key, particular medical education, and perhaps involving the American Association of Medical Colleges, and the education component, and teaching our young future physicians of tomorrow would certainly be a place to start also. So, ladies and gentlemen, what I am saying is that due to the collaborative efforts of everyone in this room, and the Federal Government, I think we can move forward with this very exciting area, and the potential for contributions are tremendous. And as far as I am concerned, I deal with the public in medical issues involving homeland security, and I think that the sky is the limit. We have seen in the past that there can be problems with interoperability, but if there is a way, there is a will, and I am confident that with the bright minds that are around this table that this issue can be solved. And so we commend your efforts with regard to this entire endeavor. UNDER SECRETARY BOND: Thank you very much. Let me close by sharing some of my initial takeaways from this, because again I want the conversation to be ongoing. But with interoperability and the standards being two of the main things in the next stage, and with the criticality of homeland security, I guess my initial takeaways are, one, clearly that Commerce, and NIST, and NTIA, that we have the ability to work on interoperability and standards, and have the experience to do that, having done that in other sectors of the economy. And so that is one take-away that Dr. Bement and I will share on this. The other though is looking at our grants across the Federal Government in this space in light of homeland security, because as was observed, there is a rich tradition, starting with the -- well, not starting with, but certainly including the Internet itself, using the critical Federal mission to expedite development and deployment of technology, which would then get the wild factor to drive some of the demand, and what Steve talked about. And in fact I need to thank Steve for providing the perfect segway into the next section that we will have to start focusing on sooner, and on the health care delivery professionals, too, in terms of discerning what is the demand, and that will really create hope to go along with some of the innovation, and to get to interoperability and standards. And to hold that innovation true to route delivery to the American public. So with that, I want to turn to Steve Brown, and he can kick off this section, and Steve, the floor is yours. MR. BROWN: Thank you for inviting me to speak at this prestigious roundtable dealing with the important and timely topic of improving our healthcare system and homeland security through telehealth technology. It is an honor to be asked to introduce Topic Two, the Demand Side of Telehealth. I will speak broadly about some of the market drivers, drawing upon specific examples from my experience as the founder and CEO of Health Hero Network, a developer of remote health monitoring technologies and solutions for disease management and public health surveillance. In the last session, Steve Cooper recommended that the healthcare industry look to industries such as financial services for successful models, and that we even should explore the idea of riding on the networks that they have already built. I agree that it is helpful and instructive to look to the models of other service industries that have already adopted "tele-technology", and financial services is a good starting point. . How many of you can remember the last time you waited in line for the privilege of a face to face encounter with your banker or stockbroker? Personally, I can't, and it is not just because my wife does the accounting at home and the company has a CFO at the office. They both do it on-line. In most service industries, demand for the "tele-technology" of the industry has been driven by two primary forces: consumer demand for better and more convenient services, and business competition to deliver those services at ever lower costs. In this room, we all know that health care is different, and the same rules don't apply. The enabling technologies exist and the infrastructures exist. The technologies might not all work together yet, but that is not the primary barrier. Consumer demand is a little bit more muted in health care because consumers don't pay directly for their care. Third parties pay for their care. So consumers have less of a voice and fewer choices. In addition, by the time that most people really think about demanding better healthcare services, they may have already gotten a disabling disease. So it is not the same early adapter consumer profile that most of the consumer technology industry responds to with new product and service ideas. Healthcare consumers have special needs. What will drive demand for telehealth technology? The traditional sale for a technology company is usually that the technology enables better and more convenient services and higher productivity in delivering those services. That is the traditional information and communications technology value proposition . But if a doctor primarily gets paid for face-to-face encounters, increased productivity means more encounters per hour. In healthcare, increased productivity does not mean better service with fewer face-to-face encounters as it does in financial services and other industries. In addition, if a health care provider makes a profit on hospital admissions, there may be few incentives to deliver more effective care that reduces or prevents the need for those admissions. Health care is a complex market, and rather than being driven by consumer demand for better service and internal competition to deliver those services, the changes that we are beginning to see are largely driven by external forces and stresses on the system that require change. I am going to talk about two of those forces today. The first is demographic trends. The aging population and the resulting rise in chronic disease is forcing us to change the way that we think about the health care delivery system, which was originally built for acute care. Chronic disease doesn't get better by itself. It only gets worse over time. As a result, remote monitoring and care management using telehealth technology has great promise in redefining the health care encounter, and creating a better delivery system for chronic care. Telehealth technology can improve our ability to educate patients, support patient behavior change, and identify problems early, which all are fundamental prerequisites to higher quality care at lower cost in an aging population where the primary needs are chronic. The other fundamental stress on the system is the threat of infectious disease, which for centuries has been the primary stress on the system, but in the past few decades we have taken it for granted. Whether it is existing treatments not working anymore for the old infectious diseases, or it is the advance in biotechnology leading to the risk that that technology will be used for harm rather than for good, or it is the threat of bioterrorism, infectious disease is a long term threat and stress to the health care system, and it is not going away anytime soon. Telehealth technologies can play a role in training the medical community to look for the latest threats. Perhaps even more importantly, telehealth technology can help public health and homeland security officials systematically collect data from points of care and from the population at large in order to proactively monitor, prepare for, and investigate, unusual patterns of illness. In an infectious disease outbreak, time is the enemy, and in our highly diverse and mobile society it is hard to imagine how we can effectively monitor and manage this threat without well thought out solutions involving telehealth technologies. These twin needs of an aging population and the threat of infectious disease will translate into a market for telehealth technologies primarily as a result of government actions. The demand for innovation in health care is being led by government agencies that recognize the need to be enlightened payers, and who must drive modernization in order to respond to these new stresses and threats to our healthcare system. I am going to give three examples from my own experience that will illustrate this point. The first examples are the new models of disease management that the Veterans Health Affairs and the Department of Defense have been developing, investigating and assessing with some pretty amazing results. Some of the results -- and I know that Adam Darkins has been involved in some of these efforts -- were presented at the American Telemedicine Association Meeting earlier this month. The Veterans Health Affairs care coordination program lead by Dr. Marlis Meyer in Florida and Puerto Rico, with the support of Dr. Robert Roswell when he was director of VISN 8, reported a 60 percent reduction in medical costs over the past two years from over 700 patients involved in telehealth care management programs, and we have been honored to be a partner in these programs. The second example of government leadership in telehealth comes from Congress, where legislation is currently being considered that could open health care to telehealth technology by starting to change the reimbursement paradigm to include remote services and disease management. One example is the Medicare Remote Monitoring Services Coverage Act, which is Senate 1607, sponsored by Senator Jay Rockefeller and Senator Olympia Snow, and House Resolution 3572, sponsored by Representative Richard Burr and Representative Anna Eshoo. The Medicare Remote Monitoring Services Coverage Act establishes parity between remote monitoring services and face-to-face, encounter-based monitoring services, using existing codes. It is a baby step towards starting to change the definition of what constitutes an encounter to include encounters enabled by telehealth technologies. If the Secretary of Health determines that the data is comparable from a remote encounter, then why not reimburse it the same way using the same code. The bill is budget neutral by construction, but in fact it could save billions of dollars if it is implemented in the manner being demonstrated by the Veterans Affairs VISN 8 down in Florida. If remote monitoring services become adopted by Medicare, then the rest of health care will follow, and a marketplace for the enabling technologies will thrive. The third example is homeland security, where we have seen leaders and innovators from around the country become involved out of their desire for public service. At Health Hero Network, we have also tried to answer the President's call to get involved and figure out how we can help. We started by developing and piloting a new model of disease surveillance to link public health departments and the local medical community to ensure consistent syndrome reporting and real time data analysis. The system, called BASIICS, is one of the first truly proactive electronic disease surveillance systems to be piloted, and we hope it will help show how telehealth technology can improve our homeland security. We then reached out to public health departments and hospitals around the country and worked with a number of these to submit a proposal to the Defense Threat Reduction Agency in response to a Request for Proposals that was looking for for ideas and models for enhanced disease surveillance. I don't see DTRA here at this table, but it is interesting to see the variety of agencies that are involved looking at the same thing and the convergence that clearly is starting to occur. We are very interested in partnering with the Office of Homeland Security and other agencies in disease surveillance. In conclusion, to create demand for telehealth technology, industry leaders need to work with Federal Agencies and with Congress to increase the awareness and understanding of what is possible through telehealth innovations that can be applied to care delivery, public health, and homeland security. In-turn, the government agencies who pay for and regulate health care have a vital responsibility to take the lead in supporting innovation so that American enterprise can help respond to these new threats and stresses to our system. The resulting government actions and policy changes will create a marketplace for the enabling technologies, in which private industry can compete on innovation and quality of service. UNDER SECRETARY BOND: Thank you very much. COL JANCZEWSKI: I am Dr. Mark Janczewski, and I am with the Clinical Information Technology Program Office in the Department of Defense, Health Affairs. I would like to amplify or expand on Steve's remarks. He mentioned the Medical Remote Monitoring Act. I think another part of the barrier puzzle that we have is a policy issue of reimbursement to physicians for provision of teleconsultative services. If the physician is not going to get reimbursed, it is a disincentive to using teleconferencing technology. In the military, we have a similar or parallel problem with workload credit. If I am a dermatologist at Walter Reed, for example, and I get a whole stack of teleconsults from various bases or posts, and I am not going to get credit for them( which the "bean counters" take a look at), then I am not going to do them. Instead, I am going to devote my time more towards hands-on and face-to-face patient care, even though dermatology in particular can be more efficient timewise if it is done in a teleconsultative fashion. The other problem, which is more related to the civilian health care sector, is the legal barrier that is imposed by having individual State licensure for positions. If I am a specialist provider in West Texas, and a primary care friend of mine in New Mexico wants to refer a patient to me in a teleconsultation, if I am not licensed in New Mexico, legally I can't provide those services. We ought to be able to address this issue, because that is indeed in my opinion a big policy barrier. MR. BROWN: I think it is critical that we find the small practical steps and start to redefine encounter. Most of the rules are written around very specific definitions of encounter, and defines out of existence most of the technologies, and ideas, and innovations that we are talking about. But as we look for baby steps, and I am sure that there are some very important things that could be done if it is a State issue. But on the other hand, a lot of health care is local. Most health care or all the health care is local at this point, and so it is just even getting from the local doctor being able to monitor the local heart failure patient before that patient ends up in the hospital. And without even crossing State lines, that is a baby step, and what we are trying to be involved with obviously is that as you develop better methods of care delivery, then you want to model those areas. MR. BROWN: I think it is critical that we find the small practical steps and start to redefine notion of a doctor-patient encounter. Most of the rules are written around very specific definitions preclude most of the technologies, ideas, and innovations that we are talking about. While there are some very important things that could be done regarding the inter-state issue, most of health care is local. We need to look for baby steps that will enable the local doctor to monitor the local heart failure patient before that patient ends up in the hospital. MR. WATERS: I have a couple of comments. First of all, on the reimbursement side, I think Mark's point is critically important. I have worked on a number of those projects. I remember one that received a substantial amount of Federal funding to put the equipment in place, and only to find that they could not get any Medicare reimbursement for the doctors who use it. It's as if they had been given a bright new shiny car, but no gasoline to run it. Federal regulators would then remark "Gee, you don't seem to take your car out for a spin very often. Don't you like it?" We have got to find a way for the Medicare program and other funding agencies to play a constructive role in terms of physician reimbursement. It seems like a huge part of the Federal focus has been to avoid costs. Everyone is being very careful in order to avoid expenditures. While we don't want to open up the door to inappropriate utilization, we should not go to the other extreme. On Mark's other point, the local barriers, the licensure barriers, we at the Center for Telemedicine Law have tracked those developments for some time. The interstate issue is a real issue if you really believe in the vision of telemedicine. If you really want returns on our nation's investment in a national medical infrastructure, you need telemedicine. Our medical centers of excellence, like NIH, and the Mayo Clinic, and Hopkins should be accessible to anyone. Ultimately, we will find a way to make that possible. I am an optimist. Notwithstanding the politics involved, many of the barriers will fall because the consumer will demand it. Patients will not want to get in their car or board a plane to receive medical care when they can conduct every other transaction electronically. Why should they have to get in a car to drive across State lines to have that encounter? But the consumer has to see that that telemedicine is an option. I am not sure that they really see that today. I am troubled by recent developments Some States are now requiring physicians to have hands-on experience with the patient before they can diagnose or treat them. This has been in response to some of the more nefarious types of entrepreneurial endeavors that have occurred over the Internet to sell "lifestyle" drugs such as Viagra, and and Propesia and Xenium. The gut reaction by States is that you shouldn't prescribe anything over the Internet. This has a very negative impact on the dividends from telemedicine. We are kind of asleep at the switch on that one. We are letting the Boards get out in front of us on it, and I think we need to play a more constructive role to fashion rules that are reasonable but provide clear protection for the consumer. UNDER SECRETARY BOND: Lots of folks; one, two, three. DR. PUSKIN: Okay. In looking at making comments that might add to the discussion a little bit. On the demand side, we have a tremendous amount to learn about what works and what doesn't, in terms of the technical use and some of the clinical uses of these technologies through the VA and the military. But I do want to remind people that there is a huge difference when you go from closed systems to open systems, and most of our health care is delivered in open systems. That is, people don't work for the same employer, and they have all these issues, and so as we look at the lessons learned, in some ways we have lessons learned from the closed systems, and you must remember that we have to very carefully look at the deployability in open systems. That is one thing. The second point, in terms of homeland security, I work not just for HHS, but I work for the Health Resources and Services Administration, HRSA, and that is the folks that give you the National Health Service Corps, and the community health centers, et cetera. And our mission is really looking at underserved populations, and we are about to embark with East Carolina University on essentially doing an inventory, which I hope will feed into the ATA's efforts and the ATA linkage of our own grantees, beyond my own, which are the leaders in our agency in terms of telehealth. But we actually have varied telehealth throughout our agency, which is quite large. It is probably about 3,500, to look essentially at the capabilities of that infrastructure out there, and to look at telehealth, and it does build on some of the good things or work that has been done. And the reason that I mention that is because we have an assumption here that we have got that infrastructure out there, and it is easy enough to make up. I think that in some ways we are doing it, and in many ways we don't, and I think we need to start knowing what is out there, and get a good sense of what is out there, especially in our most vulnerable communities. And so this is the first step and I am hoping that we will encourage other agencies to do that through the joint work we do on telemedicine. I don't know how many of you are familiar with the Joint Working Group. It is an interagency Federal group that works with cross-agencies to essentially to -- and has been in existence since 1995, to essentially keep the agencies together on the same sort of wavelength, at least to what each of us is doing. And I just say that I think that the homeland security activities have maybe gotten a little skewed, and so I think we are going to try to bring them together again. Another point was on consumers that was raised earlier. I do agree that the ultimate consumer is often the patient or the patient to be. But what drives the system, at least right now, are the clinicians. However, it is synergistic activity, and at least in one population we are trying something to get consumers more involved, and this may be a model for other people. We are looking at children with special health care needs, and they are a very special subpopulation, and that is fairly well organized in terms of consumer activity, and they have group family voices which speak for the families of these children. And we are trying to get them involved and helping us to identify in places where they already have telehealth systems to address those children's needs, and what is working and what they would like to see. And I would suggest that we have opportunities that we have not taken advantage of through our own Federal activities and private sector activities to really reach the consumer through focus groups and other activities to see what works and what doesn't work. A couple of words on specialties, and the needs of the guidelines and the issues for specialty differences. We have developed guidelines that are very preliminary for about 11 or 12 specialty areas that follow a lot of others. I think there is this enormous opportunity, however, to look at the commonalities. When you look at the banking industry, banks have different products and different services, but they have certain common needs for when they develop a system. And I think it is important to step back in telehealth and look to see what do we have in common and functionality, and to cut the pie a little differently, and to see if we get at these standards in a slightly different way. In terms of licensure, we have worked on this for a very long time, and we collaborated with Commerce on one report on telehealth, which included issues of licensure in 1997 and then in 2001, we submitted another report to Congress, which basically said that the situation has not gotten better, but it has gotten worse in terms of State activities. However, I also agree that this may not be part of the elephant that you want to address first. But there is through homeland security an opportunity to essentially furrow into this very difficult problem, and it is not simple. And that is that in homeland security, you have to have among the States some commonality and agreement that in the wake of a national disaster that we are able to call upon anyone anywhere, and while States do have some provisions, they do vary, and it is time perhaps to harmonize it under Federal imperatives. And to harmonize some of these standards to allow for under the major public health challenges or whatever, and then to harmonize the same. Finally, in terms of reimbursement, Medicaid is an area that we have not looked at. There is tremendous opportunities in the Medicaid program and they are substantial, but we only have about 22 to 24 States that actually cover telemedicine, and they cover it in many different ways globally. And it is an opportunity to address that, and in large part many of the States have managed-care plans, and where the incentives would be more in line with trying to get efficiency in telemedicine, but we have not addressed the private sector, and I think in terms of an investment -- and I know that the ATA is doing a study on private sector reimbursements. But it is an opportunity to the powers of industry to look at this and say is it not time to look at this in terms of pressuring insurers to cover freedom of choice, and I think it is, and there may be roles that Commerce that play in that. UNDER SECRETARY BOND: Paul, Jerry, and Adam. MR. OLENICK: Yes. I am Paul Olenick, and I am from CMMS, the Center for Medicare and Medicaid Services. I just wanted to respond a little bit and make a few comments about the Medicare payments and the inability to use the new car. I think it is fair to say that over the years, because we take our directions from Congress, that over the years that we and Congress have taken probably a series of baby steps with respect to telehealth, and BIPA had specified to change the payment system somewhat, and they were going to be paying for telehealth, but we still only paid for, you know, a half-a-dozen types of services. And there were restrictions on where the patient has to be located, et cetera, but one thing that you would probably be interested in is that BIPA gave the Secretary the authority to set up a process under which the Agency would be able to decide whether to cover new or other services under telemedicine. We have a proposal to do that, and I am not at liberty to talk about that today, the reason being that this proposal is included in our annual notice of proposed physician fee schedule which is due to come out any day, and that document will review our proposals with respect to this process, and that will be looking at those and coming up with a final process. Hopefully there is eventually going to be a couple of drivers that can at least get in the car and sit in the front seat. UNDER SECRETARY BOND: Richard Morris. MR. MORRIS: Yes. I just wanted to reinforce about three themes which I think are really critical to your discussion on the demand side. Steven already mentioned infectious diseases, but I wanted to emphasize that the reason there is a need for a sustained sense of urgency about this topic is not just because of bio-defense, but because of the emergence and re-emergency of infectious diseases, and that problem is going to be with us regardless of what our foes might do. It is the reason that we need to turn our attention to technology development, all of which in the future will be dual use technology, and I also think that part of that discussion is that we can project when we are preparing to bolster the informatics infrastructure relevant to public health, and it is an open system as Dena said, because we are serving civilians. And not all models, although many do, but not all models are DoD, or others which might apply here. The second theme that I want to emphasize is who is the customer. And the context for my opinion on this is couched in the fact that two weeks ago the Secretary released $1.1 billion for infrastructure development in public health preparedness, and the role of the States according to well thought out, and very detailed, and facetiously reviewed proposals. And about a quarter of that investment in the States will go for IT infrastructure. We really need to take measures to make sure that those people who are making those choices at the State, city, and county level know what they are buying. And that they are investing in laboratory information management systems, and when they worry about issues of conductivity between the county health department and the local hospital. Right now that consumer needs to be educated. That customer, or the CIO in the county health department, needs to be supported to avoid this being a vendor-driven exercise. The final message that I wanted to make is that I think we need to have the term de facto in this discussion. I think that there are ways that we talk about very aggressive, high quality standards for activities without compromise to the end-user requirements. But industry can be very much in the drivers seat with the government guidelines, and I am going to betray the fact that I used to work at NIST and as part of HHS, by just calling attention to the fact this office really wrote the book on de facto standards and ways that industry can be in partnership with government to identify and defuse standards, and it not just in health care or anyplace else. We have got the programs in place, and through past experience, we really have gotten -- UNDER SECRETARY BOND: Adam. DR. DARKINS: I think that that Steve Cooper made an excellent point about consumers. I don't want to get into the complex issues of who are the consumers of health care in terms of the relative roles of patients and practitioners. However this does lead us in the direction of thinking about what are the telemedicine "products". I think the telemedicine "products" are going to be different from what have been the traditional "products" in health care. . To return to my analogy of rail cars and railroad tracks the products we should be looking toward is not the telecommunications fiber or the software systems but the goods and services these are going to carry. In my opinion the products that are going to sustain the telemedicine networks, whether they involve homeland security or routine health care delivery. Will involve health care decision-making. Making health-care decisions remotely is going to be a valuable product. One of the features of health care up until now has been that decision-making has been tremendously variable. There has been very little no quality control in the decisions that are made. In many instances patients have had to accept the quality of medical advice that is available to them locally. Just as before the railroads the goods and produce that were available to people who lived inland were those that were made locally. So I think the great benefits of telemedicine networks will be the widespread exchange of medical decision-making. In order to develop these new products the relationships of telemedicine networks to academic medical centers is very important because these are where so much of this expert knowledge and expertise in health care currently resides. So I think the future of academic health care is bound up in the development of telemedicine networks. I foresee a huge potential demand for health care decision-making, both nationally and internationally, and I will come back to that in a second. In the Veterans Health Administration (VHA) the use of telemedicine is not constrained by State licensure barriers. We have a closed national system in which the use of telemedicine is expanding rapidly. We have two programs that I should briefly mention that give credence to the idea that medical decision-making will be valuable commodities on a telemedicine network. These programs involve the care of patients with Multiple Sclerosis and Parkinson's disease. VHA has implemented a national network of Centers of Excellence for the surgical treatment of Parkinson's Disease. We are attempting to join these together using telemedicine so that these services are widely accessible to veteran patients. A second program,that we are developing is that of having 2 nationwide centers of excellence for research and care for veteran patients with multiple sclerosis. This will mean that veterans throughout the country will have local access though their own local neurologist or internist to excellence of care from these centers of excellence via telemedicine. Imagine if you will a health care system where for example a homeless veteran in Colorado, a veteran who farms in Montana or a veteran who is works in the fishing industry in Alaska can get health care in the remote part of the country where they live from a world expert in a academic center elsewhere to help guide the treatment they receive locally. With this you begin to see a very different kind of health care system developing. I think the vision of what this might be, if extended to other areas of care is fairly obvious. In my opinion a big driver outside the federal system for this development of telemedicine networks to enable medical decision-making is going to be a huge international market for this.. I think we are going to see it happening especially in the Pacific Rim. I foresee a major driver of where telemedicine moves in the future is going to involve meeting the demands of these international markets. Again I would like to reiterate that I do not think the current limitation on this happening is telecommunications bandwidth I feel it is the development of the products. What types of health care decisions can be traded and how will they integrate into the delivery of care? When the products are right I believe these telemedicine networks will develop very rapidly. I therefore think that standards development should be focused on how high quality health care decisions that can be traded on telemedicine networks are developed. Decisions that improve the health of the populations they serve. We should remember the lesson from the VHS versus the Betamax competition that played out with video recorders. We could spend a lot of time developing what may seem wonderful and very elaborate standards only to find that what will eventually drive the widespread adoption of standards will be what supports high volume delivery of health care to patients. I will leave with my comments there. ASSISTANT SECRETARY MEHLMAN: Well, since I last worked at Cisco Systems, even asking this question, as opposed to taking it on faith, is probably heretical. But I am curious. I have not heard any data with respect to two, three, or four groups here. One is patients and the other is doctors, and specifically is this a method by which -- and I assume it is, but is this a means by which patients want to receive medical advice, and perhaps treatment, and it is a method by which doctors want to deliver it, and the antidotes are good, and the statistics are even better. I am particularly curious on the patient side, because the folks who probably need the most medical care and treatment generationally are the least inclined to be on the Internet, and the least comfortable with new technologies. And at the same time for doctors, I think your intentional point is great, and I believe it and make it all the time, but I kind of wonder that if I am a doctor, do I really want to try to treat folks who can't afford the drugs that I am instinctively and likely to prescribe, and perhaps can't get some of the treatment. Does this create some real medical care challenges that I am not prepared, equipped, trained, and have spent the last 30 years, able to do? MR. WATERS: I think in response to the issue of consumer demand, and whether the patients really want it, I would look in two places. First, take a look at the Internet. There is ample data in terms of consumer demand for health information over the Internet If a patient is diagnosed with a disease, there is a voracious appetite for related information on the Internet. Second, telephone call centers. Health plans now have 24-hour call-a-nurse centers. They are extremely popular with patients. If you could hook a video along with that, I think it would be even more popular. Call a nurse 24 hours a day. Their job is to be there and to help answer your questions. If we are mining for data as to popularity and responsiveness, we should look in those areas where the tools are brought right to the patient. Where they have a point of access, they respond very positively. The other comment that I would make was that in interstate cooperation. It may be more possible than you think. We have some 19 States now that have adopted the Interstate Nurse Licensure Compact. If you are licensed in one of the participating States, then your license will count in other States. If they reach a critical mass of 25 or 30 States, you are going to have really good national coverage. What is the Federal role? The Federal Government can provide a carrot to State licensure boards to convert their systems, because they are taking a risk. These Boards don't know other States will comply. If you give them a modest amount of financial assistance, more of them may move forward. The medical Boards are the same way. They are looking for ways to harmonize the administrative requirements for data collection. The carrots that can be offered are not expensive, but that would help promote interoperability on the licensing front. UNDER SECRETARY BOND: Let's go down this way. Michael. DR. RICCI: (Off microphone) We have in telemedicine research always included patient and physician surveys and useability analyses, and some of that has been published. The patients universally accept the technology, and age is not an issue. In fact, they are most appreciative if in my practice that they don't have to drive for 2 or 3 ours, and so patients accept it. The consulting physicians -- and we saw this particularly in our recent trauma project, but that consulting physicians, about 90 percent, are saying this improves care. In fact, with the consulting physicians, the percentage that felt that this was useful and improved care was higher than the physicians at the academic medical centers. And maybe they expected more, or felt that they weren't doing enough to help. So in our experience it has been excellent. In terms of the way that a physician would view this, we just want to take care of patients, and this is just the tool to help us take care of patients, and if it works, it makes us more efficient, and helps us take care of patients. DR. SMITH: I am Philip Smith and I work with the Indian Health Service, which is one of the agencies within HHS. I was trying to figure out how I could interface in the discussion, because our issues are very parochial, in the sense that we are dealing with a very set group of people in the United States. You know, we have about 2.5 million Native Americans and the Indian Health Service takes care of about 40 percent of them. And we have issues which are being addressed here in many ways, and I was thinking of two thoughts that I would like to throw forth. And one of them centered around the issue that people have said, saying that often times you look at what the country is like, and like how it deals with those that are the most vulnerable, and how they take care of those who can't afford things, and those who really need things. And I think in the area of telehealth we sort of got on the table really early, mainly because of DoD's interest, and NASA's interest in transmitting information from remote locations; in Alaska, and we have facilities there in Nome and the Army facility was nearby, and they wanted to see how images from there could come back to Walter Reed. And Georgetown got involved in that, and so we found the real practicality of use in that, and one of the things that we have also done is we have always focused on physicians in the private sector when we found that we could not get someone to practice, and there are people there, and you can't bring very many cardiologists to Nome, or you can't even bring an internist or pediatrician to Arizona right in the middle of anywhere. And as result, we didn't have a lot of family practice physicians, and primary care professionals, and nurse practitioners, and physician's assistants, who came into play and who we found were really in the area of addressing those two issues. And I think that the issue that was brought up earlier about the acceptance by the people, this is almost standard. You go into, say, a community out in the middle of nowhere, and where there is no road. The nearest road is maybe a hundred miles away, and you have to get in by dog sled and occasionally some bush pilots, and you have a small clinic there, and the patients who go there are ones that have the images sent back. One of the other interesting things about that is that the issue of -- well, I think in terms of medicals, and that's what I would like to make a point on, is that the images are the same. The dialogue is the same. The linkage is there, and it is a question of what you recommend in terms of what be done. And the key for us has been the involvement of the academic centers as they work with the Federal institutions, and I think that I would like to really encourage that cooperation as the Federal Government puts out resources there and that they involve the academic centers, and not just focus on just the rural areas, but also looking at the frontier settings. I think that our experience has been such that because of our increase in chronic disease, our tracking of diabetes is really shown tremendous progress in terms of just looking at how many entities there are now, as opposed to or before these things were instituted. And I think there have been real changes, and while one may be saved, and it might be the village chief whose life was saved, and really impacted the people in a small community. And I just wanted to encourage the academic standards, and not be lowered just because they happen to be in a frontier setting, because the images and the linkages that come back to institutions are still the same, and the standards should be maintained. UNDER SECRETARY BOND: Jay. DR. SANDERS: Yes. Addressing Bruce's concern and question, and echoing what Michael Ricci said about patient receptivity, and probably the verbiage that was stated about consumer receptivity. That is one of the areas that I want to comment on later. But the fundamental reality is that nearly every study that has been done with respect to the receptivity on the part of the consumer patient, that this technology that it has been overwhelmingly positive, including of course from 1973 to 1976 on that NSF grant. There is absolutely no question that the consumers, once exposed to it, love it. And one of the realities is that it provides the same sort of convenience to them as Steve Cooper mentioned, in terms of our ATM machine. Now the bank comes to us, and now the examination room is where the patient is, and not where the doctor is. It is a more appropriate location. And, number two, what it has proven, and further studies will need to be done to collaborate this, but if it does collaborate it, it will have an incredible impact on both the quality of health care and the cost of health care. And that is that when you come into that patient's home with your telehealth system. And the compliance rate on the part of the patient, which is a hundred-billion dollar a year problem in our health care delivery system, and the compliance rate on the part of these patients, in terms of taking their medications, and taking the right medications. And not taking every other doctor's medications that they saw over their lives, along with the present medications, and that compliance rate and that education level goes up dramatically. Where we do still have a barrier is in physicians my age. If the professor who didn't grow up in this era, and who doesn't feel familiar with new technology, and the irony of this, and this is not flippant comment, we are now finding the medical students teaching the professors of medicine this type of technology. You know, if I talked to anybody 15 years ago about e-mail, and using the Internet, they would say what's that, or it's a little embarrassing, and I don't have that yet, you know. Today, you look at it, and you wonder how did I ever do this before. I mean, this is unbelievable. I mean, we don't even use the fax machine anymore because it is too slow. Perhaps it is just a matter of time, and the next generation of providers will wonder why in the world did they have this conference today on barriers, in terms of provider receptivity. And you ask most general practitioners today why are they using e-mail. Their patients push them to use it. That is the reality of it, and that's the way that it is going to mature. UNDER SECRETARY BOND: Let's try to wrap up this session. CPT BAKALAR: In the same way from what Jay was saying, one of the things that we learned in the Navy is that one of the ways to test drive this car is using medical education once again, and of course then we have the Naval Reference Site, which we have had on-line for seven years now, and it is running a hundred percent per year, and it is used by 140,000 users of interest. It is primarily a great reference site. However, 40 percent of the users are Navy and DoD, and 40 percent are private sector, U.S., and 20 percent are international. So we actually have all the data on the website for the last seven years in which they have participated. One of the things that we have also found is using -- UNDER SECRETARY BOND: Do you have the demographics on the folks who are using it? CPT BAKALAR: Mostly by the Its, and we actually have done studies on the military side, but not on the other side. The other aspect is in medical ground rounds, and it is a way of test driving video conferencing for those people who have the barrier to modernization. So medical education can be a segway, and also there is no licensure issues with education, and so that is another short way, short term way of getting into the industry without having to worry about those barriers that may have long term implications. MR. SIMMONS: I would just like to echo the comments of several people in terms of patient satisfaction. We have a similar problem at East Carolina University with physicians. We are responsible for a big service area, and basically all of North Carolina east of I-95, and there are not a lot of specialists in these small towns. So we have got pediatric cardiologists, for example, and both of them are based in North Carolina in the Greenville area near the University. In the past they had to drive around and make rounds at different rural hospitals. They don't have to do that now, and so it really comes down to convenience, and I think that is the word that Jay actually used as well. And when we talk about consumerism, the problem is that consumerism applies to choice, and a lot of people don't have a choice right now, and they don't know that there is any alternative. So what it comes down to is convenience, and the patient costs are not factored into any cost models that we look at. One of the cost models for telemedicine or where we demonstrate savings is in the prison population, because it is very expensive. Transportation costs are expensive, and security,a nd all those things, and when we look at health care, the person who has to take their kid out of school, and take a day off from work, and drive several hours, and basically miss a whole day, maybe without pay, and that whole thing is not factored into that. So we look at this convenience model that I just mentioned, the school model, and the other thing is when you look at lost work time. I have seen estimates that somewhere between -- that for every dollar in health care costs that a company outlays that somewhere between $2 and $4 are spent on lost productivity. So if I can stay in my office and go down and see my physician, or at least schedule my appointment in advance for them to be ready when I get there, and they have all of my insurance information and medical history, that really breaks down some of those barriers. COL. POROPATICH: I just had another comment regarding an important point on patient providers and where we are having some impact. And one of the things that we need to be careful of is that we don't become victims of our own success, and I call this the skybox phenomena. If you go to a sporting event and you see those that have these beautiful seats and you know that business, or industry, or whatever, provides those, and those of us who sit in the cheap seats on top watching down on a small playing field. And I think that the health care field needs to be mindful that there is a growing trend among providers that I don't want to travel between 3 and 4 hospitals. I am killing myself working 12 and 14 hour days and going to all these different hospitals. And I know that there is a segment of society willing to pay for my time and close access. Boutique health care they call it, and it will be coming more prevalent. You see it promoted in the news now, in terms of news stories. And I think we ought to be careful that we don't develop this boutique health, and it may happen just because of market trends. We have people that have the discretionary income, and for example those that receive botox injections every four months, and I am going to spend 200 bucks to take the wrinkles out of my forehead, and that's fine. People are going to have that kind of discretionary income patients who are going to put down their credit card, and go to a kiosk somewhere and get that health care, and pay 50 or a hundred bucks. And you are going to have docs that are willing to limit their 6,000 patient base down to maybe 250 or 500, and have the same income and a better quality of life through technology. And it is just like the radiology community adapting to that, and there are already radiology centers throughout the country. So I think the skybox phenomena could very well happen. The question is what will the government have; is this a good thing or a bad thing, and if we don't do anything and just let market forces take its toll on them. UNDER SECRETARY BOND: If there is a market out there. COL. POROPATICH: If there is a market, right. It is still too early to tell, but I just wanted to bring that up. UNDER SECRETARY BOND: There are a lot of problems in that particular market. MR. WALKER:(Off microphone) I just wanted to say that as we reflect on this particular topic, because of the advances in telehealth and the kind of current and future trends, one of the things that I think that Commerce could look at doing, particular with regards to technology, is the encouragement of the development (inaudible), and not necessarily specific to health care. But we have got some projects in Texas, and we have a rural community with a population of 6,500 people, and the whole community is connected to the library, the school, the hospital, and we have a telemedicine project down there, and telemedicine is no longer a noun. It is a verb. You can walk into that community and run into somebody, and they will say, oh, yeah, my little boy was sick, and I told the nurse to telemedicine it over, because she was not able to leave her employer in time to go and drive 40 miles to pick up her child, and to wait for 2 hours in a clinic to see the doctor. And what we are finding in our research is that it is incredible, and that they now see telemedicine through telemedicine, and that their child can see a doctor immediately. And what we are seeing is the community now, the whole community, is cognizant of telemedicine, where they have now redefined it, and they see the value of in the community. And so I think that is one of the things that Commerce could look at doing, and providing an expertise, and hearing back some of the things that you need to evaluate, and your assessment. Secondly, I agree with Bob, that I think that Commerce could definitely provide a kind of -- well, make it the carrot and the stick with State's medical rules, and looking at how homeland defense and licensure for telemedicine -- really, there is an onerous there that we need to start to address, the interstate licensures as it relates to telemedicine with consultations. Because I think that ultimately we have seen legislative efforts, like through the emergency management assistance COMPACT, which allows National Guard contiguous States to share resources, and the nursing licensure COMPAC. So I think that through those similar kinds of relations that we could have something specific to homeland defense perhaps as it relates to those types of situations, and where those contiguous States, or even interstates, where they are separated by one or two, could be able to leverage medical expertise with that licensure being -- DR. BEMENT: Let me ask you a question. With regard to systems as you point out, I am curious to know how these systems get designed, and who sets the requirements, and how all of this comes together from a design point of view. MR. WALKER: Right now in Texas, we have a fund that generates about $200 million in capital a year in revenue that is going out to fund various infrastructure initiatives, and at the present juncture there is no expertise. One of the things that we are doing -- I sit on the technology board for this agency, and we are trying to come up with standardized approaches to the design. I know that there are a lot of companies -- you know, a lot of vendors like Cisco, who offer an enormous amount of expertise because of the design work. But it is not without its flaws. For example, at Crowels (phonetic), they initiated a wireless network through their electronic medical records, the billing, as well as the telemedicine systems, using an 80211 technology. Unfortunately, that technology, even though it was sold to Victor, they did not disclose to us that there were issues with regard to multi-districts. And so that is where we are wanting to grow out that infrastructure, and to pick up school districts where they don't even have a school nurse. We are having to go back to the design table, and we have to learn from some of our woes, and try to prepare for the future. But there is nobody at this point that can come in off of that expertise and infrastructure development, and I think that would be an excellent place for Commerce to provide some best practice examples. UNDER SECRETARY BOND: Steve. If you could wrap up. MR. BROWN: This has been a very interesting discussion, and I want to summarize and touch on a few of the points that were raised. Jay Sanders' comments revealed that solutions are possible. I would like to add that these results have not just been in closed systems like the DoD and VA, but these results are consistent with other programs in open discussions, which we didn't discuss as much here. There are solutions and they are possible. Several of you have talked about the fact that consumers do like these solutions, and consumers do like the convenience. But it does remain a fact that the people who need care the most are the least empowered in our society, and it is not just the elderly as Bruce Mehlman mentioned. Adam Darkins gave a very telling and relevant example about the homeless veteran, who is not an elderly person, but clearly one of the least empowered members of our society, and who has a most urgent need for better services. This brings us to a point that Dena Puskin brought up, which is how essential the human factors are. We need to make these systems work and make them practical for the people who need them the most. There is tremendous consumer interest in health care information on the internet as we all know, but consumers really get interested after they have already gotten some kind of disease. We need to find a way to reach out to people before they end up in situations where it is too late. This is really going to start with creating a framework that enables physicians to get paid for disease management and remote monitoring services designed to enable intervention before conditions become more complicated and acute, and we talked about that. Scott Simmons mentioned the need for integrated cost models, so that we actually take a full counting of what constitutes the true cost for the care, including measures of lost productivity and lost time on the part of the patients. I would argue that with the first step that we should be making before that is with the cost models and scoring systems used by our own government, where you don't get credit for hospitalizations you save for an intervention. We need an integrated cost model across the board to account for the true cost of care so that we can really understand the benefits of these new technologies. Homeland security is not new, but it is a current urgent stress on the system. The system is already stretched with the aging population and the increased demand for services , and the hospital system is already stretched. Infectious disease threats, bioterrorism, and terrorism in general, places a new stress on the system that we need to prepare for. And when you look at the interoperability and standards issues that we talked about, the homeland security issue reveals the critical needs and vulnerabilities more than any other issue that we talked about. In homeland securing, it is not just an interstate issue, but an inter-county, inter-city issue, and even itra-county and intra-city issue. We have had the privilege of dealing with a number of counties looking at infectious disease surveillance. Within individual counties there may be 6 to 12 hospitals, and they don't have common systems to talk to each other. I am sure that if one of these infectious disease outbreaks happens that it is going to cross county lines, but many neighboring counties don't yet share data . So the homeland security issue places a new stress on the system and it reveals our needs and vulnerabilities in healthcare in general. If we can fix that, then we will have fixed a lot of other problems in our health care system as well. UNDER SECRETARY BOND: Steve, let me thank you for your contributions, and we obviously have a consensus that there is a huge demand out there, whether it is consumers and providers, or local officials in terms of a homeland security plan, and managers. And certainly not to be overlooked here, just the budgeters in this town, and that there are very real pressures that make the numbers add up. And that there is more work for all of us to do. The driver in a lot of this in making reality though is going to be money, and investments, and Bruce Mehlman, who is the Tom Cruise of Technology Administration, says, "Jay, show me the money." So why don't we talk about the investment side of telehealth. DR. SANDERS: I will be Steven Spielberg now. UNDER SECRETARY BOND: There you go. DR. SANDERS: Well, I first need to begin by saying that this is somewhat of an anniversary for me this month, as it will be 35 years ago this month that I was first introduced to a concept called telemedicine. And in a institution where Senator Frisk got his cardiovascular training in, a little hospital called Massachusetts General Hospital in Boston. I also must say that literally everything that has been stated up to this point in time I have heard before, and this is a deja vu for me, including having this discussion in this building. And the first time we had this discussion was in 1976, where all the grantees who had had three years of funding from the National Science Foundation, and what was then called HEW, got together to discuss the results of their telemedicine initiatives. One of those initiatives was into the inner-city, in terms of pediatric care, and one of those into a rural group practice, and one of those into a correctional health care arena, and one of those in the Indian Health Service, in terms of NASA's Papago Indian Reservation projection. Perhaps the most important thing for me to say is that not a single one of those projects exists, and not a single one of them was sustainable. All of us used the excuse that these were, quote, demonstration projects, and we really assessed them to be not sustainable, when in our hearts all of us wanted them to be sustainable. Why in the world am I sitting here 35 years later asking the same question of where is the business and where is the success factor, and where is the sustainability, and why isn't this being used in the same way that the technology that I threw out in 1973 has gone through a huge upswing in use, and everybody in society uses it. And now we have actually gone down the downswing for the best of all reasons because improved technology has come along. The fax industry was a good business. I guess if I had the answer to that I wouldn't be here. UNDER SECRETARY BOND: That's a good question. DR. SANDERS: Someone once called me -- and he is not sitting in the room, and I am glad he is not here, but he said, Jay, other than your consulting business do you know anybody else who is making money in the telehealth field. And I first laughed, and then my laugh took on a little bit of a sardonic nature to it, because the fundamental reality is that you can really count on the payments in your hand, and the companies that adventure capitalist would evaluate and say, okay, that is a viable business. I think that the government has done a tremendous amount, and don't you for one moment wring your hands and in any way feel guilty about what you haven't done. You have done a tremendous amount. On the flip side, you are also part of the problem for what you have done. I have said in the past that probably the best way for a telehealth program to begin is that the best thing for them to do is to never get government help, or don't get government help at the beginning. Now, I know that you said, Secretary Bond, that this is going to be recorded, and so I am going to get a lot of comments from my colleagues out there who are applying for grants, but until very recently -- and it really has been an initiative that Dena and her office has taken, has anybody ever asked for something called a business plan to be submitted with their grant proposals?We have become so dependent on the anticipated monies coming from the Federal Government in the form of grants that we have not gone through the normal process that anyone starting up a business would do who was seeking money. < |