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please stand by for realtime captions >> karenrheuban thank you for being here. i am, the professor of the address at the universityof virginia and the director for the center of telehealth. telehealth programs have servedas a innovative tool for the delivery of care linking patients and providers separated bygeographic and/or socioeconomic barriers. all the while navigating specialty workforceshortages. through an explosion of advanced technologiesand the significant federal investment in telehealth programs and rod brand infrastructure,many lives of americans and likewise patients around the world now benefit from care providedthrough telehealth. telehealth programs are entirely aligned witha -- the aims of cms -- better care, better

health, and lower-cost. with the passage of recent affirmation ofthe affordable care act, we are now at a strategic inflection point in our efforts to furtherintegrate telehealth into mainstream everyday healthcare. we must ensure that contemporarypublic policy alliance with these goals. over the next two days, we hope to furtherdelineated evidence base for telehealth and highlight special applications for rural andunderserved populations, but also for all patients regardless of location. we will discussion actions to be undertakenby hhs, the state, and the payers and also hear from consumers.

this is our opportunity to identify issuesthat warrant further study by the institute of medicine. i would like to thank the colleagues here-- dr. wakefield, dr. morris, and [indiscernible] for their leadership role in advancing thisprogram nationwide. and for funding this workshop. a special thanks goes to the planning committee-- dr. tom nesbit,, the doctor at partners healthcare, dr. spero manson, and dr. pruitt,the office of telehealth. in addition, i want to thank dr. tracy lustedwho coordinated this and for colleague, samantha [last name indiscernible] . >> our scheduleis tight this morning and we encourage people to move about if they need to. when the timecomes for questions and answers, flip the

switch on the microphone and we encourageaudience participation. no food or drinks are allowed in the auditoriumsince it is brand-new and renovated. these turn off your cell phones and pagers. now,it gives me great leisure to introduced cheryl lynn pruitt -- she will introduce her colleague,dr. mary wakefield dr. >> thank you, karen. i am honored to introduced the next speaker,dr. mary wakefield. when i saw her this morning, i asked how she went to be introduced. shesaid keep it short and leave more time for content. i will honor her request. beforei do, i want to tell a story. i joined the office in 2006 and i intended a meeting ofthe rural health information network. this meeting was led by dr. wakefield. i saw herand i thought who is that lady? she hasn't

so much energy and enthusiasm. she is brightand she can control the room. i was very impressed by her. when i heard she was going to be theadministrator here, we were all excited. she knows telehealth and rural health and anybodywho is interested in rural communities and the medically underserved populations, weare blessed to have her as the administrator. i would like to introduce our administratorand iom member, dr. mary wakefield dr. thank you very much. as you can tell, cheryllynn is associated with the office and they are a bit of a [indiscernible] group. theypretend that they take direction from me, but they go and do what she does. they notand say yes and they go off and do what they should be doing which is great -- paid noattention to the administrator. i am just

joking, of course. the health resources andservices administration has a set of programs. it is a delight for me because of where icome from to deal with the terrell office of rural health policy. i have a long standinghistory with tom moore 17 there. we have fabulous employees across the entire agency. theseare certainly some of the best. and to all of you with [indiscernible] -- steve hirschis also here and will speak later.. thank you karen for your willingness to serve inhelping to coordinate and lead this particular meeting. we go way back -- she is from theuniversity of virginia and i have spent some time myself in some of the university infrastructureof the state of her gender. i appreciate the opportunity to talk with all of you todayabout what i think is an incredibly important

topic for the meeting -- focusing on how wecan for the meeting -- focusing on how we can dr., telehealth technology in an evenmore robust fashion to improve patient outcomes, especially for people in isolated geographicareas across the united states. and how we can harness telehealth technology to expandthe reach of what our scarce health resources in rural america are. at hr as they and acrosshhs, we have been looking forward to this meeting for quite some time with the hopeof a report that will provide us with your great thinking about how we can really catalyzethis agenda going forward. the six members of the planning committee-- a special shout out to each of you who are willing to dissipate in the meeting. alsoyou will be participating in terms of helping

to perl the content together on the back andwith the iom. it is nice to see familiar faces in the audience. i know we are broadcastingthis as well and that it will be available archived. for those of you here and why no,we have worked collectively a number of bus in this rural landscape for now decade. theissues that we are talking about today we'll he -- really resonate with me today. i ama resident of the state of north dakota. i commute for my job. it is still home for me.obviously, you don't have to look to too many states that are more rural than the stateof north dakota. these issues we are talking about -- ensuring access to healthcare resources-- play a way for me and family members who reside in rural parts of that state. and,frank, for as long as i have been in healthcare

for decades -- rural issues have been a partof what i have focused on. in that context, i see a promise and potential impact and alsosome of the challenges that we have had in deploying telehealth -- not just in northdakota, but in other parts of the united states. in my home state, though, telehealth technologyand its hardest thing has been a key player in helping to make available access to healthcareservices. i think that is the ability to capitalizeon technology, especially from and through a rural lands, probably gets its start ina rural communities that are often shy of a full array of resources. in places likenorth dakota, i like to think about those communities -- rural healthcare leaders -- thatreally do necessity is the mother of innovation.

when i think of innovation and our abilityto better meet these needs in our rural and frontier parts of the country, i certainlybuy into that thinking more effective deployment of telehealth technology. prior to my current position, i served onthe commonwealth commissions find. this was on a high performing healthcare system. ibrought the commission people from across the united states -- i brought them to northdakota to look at innovation in healthcare. central to the conversation was the deploymentof telehealth technology. that state, in particular, we were talking about tele-pharmacy were youdo not have a arm assist in every single rural community and yet you have a lot of peoplewho are relying on the knowledge and availability

-- of pharmacy. i am well aware of the importantwhere role that technology can play in rural frontier states and even through that tele-pharmacyproject is well underway there. when i came to hrsa, i became more aware ofthe importance of oral health. as karen indicated, any isolated communities. the point wouldbe that some of our most isolated communities in some respects are actually in some of oururban inner-city areas. i know that because i've seen it in my current capacity as recentlyas a week and a half ago. i visited an incredibly medically underserved part of this districtof columbia -- a stone's throw from -- a stone's throw from the nation's capital. so, that is the orientation that we bringto this set of issues around really alighting

on the promise and opportunity of telehealthtechnology with an obvious recognition of some the challenges we have yet to overcome,but frankly i cannot think of a better time than right now for us to be focusing in onthis conversation. it's about the role that telehealth can play in what is really a rapidlyevolving healthcare environment. the importance of telehealth and its potential will, i believe,and many of you believe it too, the importance of this will continue to grow, especiallyas more and more people in rural and isolated areas across the united states are able toseek a full complement of healthcare services. in no small part part this will be a partof the affordable care act including provisions lies like health insurance exchangeable reachout the availability of access to health insurance

coverage. also, the availability without co-payof preventive healthcare services. without out-of-pocket costs. another set of servicesthat individuals will not have caused barriers to in terms of accessing as well as some ofthe new medicare and medicaid payment models. we have a lot of new opportunity that we cantake advantage of and i think telehealth technology is a key player when we think about theseisolated populations. we all know that when it comes to isolatedpopulations we have real challenges in rural parts of the nation. the rural populationin this country -- nearly 20% of the us population -- is spread across about 80% of the nationscountryside. the landmass. this is a population that is widely dispersed and calls up themedia challenges in terms of connecting healthcare

am a not just emergency care, but preventivehealth services as i alluded to a minute ago with populations that reside in very ruralparts of the country. we also know that rural communities and the older. an older population.we know that rural communities tend to have people with lower incomes and we know thatin sharp contrast to some of the myths that we have higher rates of three -- certain chronicdiseases in rural areas. because of this, chronic disease, low in, -- low income, andthis creates additional barriers to our helping individuals to obtain healthcare servicesin real-time. we also know that in rural areas we have challengeswith attracting and retaining healthcare providers. physicians, pharmacists, physical therapists,nurses, and others. that can be for many of

the rural communities a difficult challenge.we know that a lot of the for a lot of the health-care industry, particularly some ofthe smallest hospitals, today they are operating on the thinnest of margins. we have a lotof challenges, but i would say also opportunities of which telehealth technology applicationscan be a part, not entirely, but part of the solution. so, at hhs we are addressing these issuesas we think about the future of health care across the united states and we are payingattention -- paying attention to healthcare challenges -- some that i mentioned and otherstoo numerous to mention. rural communities and populations will face these. as a result,we are looking forward to the ideas that come

from this meeting. ideas that will take usto concrete steps to think about how we can leverage what our limited resources are inmany circumstances and how we can advance this area rural focused agenda. as many of you know, this administration hasmade rural america a high priority. this has been made clear by the president via a numberof initiatives that he has advanced and i would say while it is not an initiative, frommy perspective, one of the most important and periodically i am summoned to talk aboutthis -- one of the most important steps that i think the president has taken that helpsadvance for rural america's agenda is by naming the secretary that he named to head the usdepartment of health and human services -- secretary.

sibilius -- from kansas -- she can match justabout anyone in conversing about the special needs in the rural communities that she wasresponsible for helping to govern across the state. through that appointment, we have anincredibly tireless advocate and a very knowledgeable individual who cares about and manages acrossscores of issues, but who never in any conversation i've ever been a part of with her has lostsight of some of the unique challenges and opportunities for rural communities in ruralhealthcare infrastructure. in addition, the president created the white house rural council-- the first council of its type -- focusing on rural with an eye toward the economic healthof rural communities. and eating that in mind. this is a council that hhs interfaces within no small part to the federal offices in

a council that is been very active in dancingissues in agriculture and other areas and very much a dancing health care issues, too.then, coming on the heels of that we have the affordable care act. i mentioned thisearlier. it brings a special tool and opportunity and benefits from our vantage point to ruralpopulations, too. starting to help the rural communities face long-standing challenges.just a few of these benefits the point -- they play specific to the rural communities ina positive way. so, for example, expanding insurance coverage and increasing access tocare -- in places where frequently you do not find it -- individuals that go withoutinsurance or are underinsured is not uncommon in rural areas. once insurance is expanded,that benefits those individuals and clearly

benefit the providers who are providing theservices as well. the affordable care act also focuses on improvinghealthcare quality through team-based patient centered care. telehealth has a role in leakingmembers of teams. you can see the alignment, if you will, of this focus on telehealth andhow we engage more fiber link the full skill set that teams bring to care of individualsand communities. in addition, the affordable care act is focused on addressing health disparitiesand improving public health. these are important but praise to benefit rural areas. it focuseson -- sharply -- and we own a lot of work in this area -- focuses on increasing thenumbers and deployment of healthcare providers. much of this occurs in rural communities goingforward. as a result of the affordable care

act, we have 16 million americans living inrural areas that a longer days like time limits on -- in terms of dollar amounts -- on theirhealth benefits. about half of all of the workers that live in our remote communitiesacross the united states are employed by small firms that followed by four tax credits thatcan help them provide coverage and make it more affordable for their employees. as thisis more fully implemented, we will see a dramatic increase in the numbers of americans withhealth care coverage. this reaches right into and across rural america. we will also be at a critical juncture interms of the implementation of electronic health records is a part of the push towardmeaningful use. by 2014, we will also be starting

to finish off the work that we have been engagedin fully in the expansion of our community health centers, infrastructure, and the investmentsin the growth and number of primary care providers that i was talking about earlier. also, wewill be winding down by 2014. we have been building a platform already and we have gotelected he still underway. all of which should accrue in a favorable way as i mentioned torural communities. we will also continue to focus on improvingcare quality through a range of initiatives supported through the affordable care act-- partnership for patients that we have an especially working hard with cms to workingout and into an engaging world hospitals and other rural healthcare infrastructures allthe way to some of the new initiatives that

cms is supporting through cmm i -- the centeron medicare and medicaid innovation. some of their new initiatives have been supportedthrough the innovation center and focus sharply on quality, access, and reducing cost. asan aside, two mornings ago in my spare time -- i took the time to go through about 100+abstracts of all of the cmm i innovation initiatives that were just relatively recently funded.it was exciting for me to see -- i mentioned frequently -- and rural. also exciting forme to see -- telehealth technology. you see this picking up from local levels that werecompeting for the funds and harnessing of the technology -- not just for rural areas,but certainly in many instances for rural areas. all by way of saying that i think telehealth,given this backdrop, can in some ways has

already started to play an even more importantrole in what for us is clearly evolving landscape in healthcare. especially as we move awayfrom the traditional fee for service system to work new models of care and putting accountablecare organizations and patient centered strategies and re-engineered designs focusing on outcomesmuch more sharply than focusing on quantity of care for example. >> at the same time,the cost of technology associated with telehealth like the cost of a lot of these types of technologies,is also dropping. and products in the telehealth -- technology world -- are becoming easierto use, either even for someone like me who did not grow up with this and at least wheni was in graduate school thought that computers were a passing fad and did need to learn awhole lot about the use.

more widely prevalent in the marketplace andaccessible. consequently, a set of tools, then, that we can bring into play in an eveneasier fashion than perhaps even five or 10 years ago. just last week -- for example,secretary. sibilius announced the launch of a new initiative called to care for life.big is an evidence-based program that will deploy mobile technology and mobile texting,specifically, to improve retention and care and to improve medication adherence for hiv-positiveindividuals. in hiv world -- retention in care and adherence to medication usage asprescribed i clinicians are tough challenges. right here at a center of part of the responseroute to that topic set of challenges, technology applications. this initiative will focus onsouthern states, for example. it is a two-year

project and they were developed a messagelibrary for delivering phone text notifications of both bush and spanish for appointment remindersand medication reminders and so on. it is a great harnessing of technology and we lookforward to this. some of the rest -- the other activities -- notnecessarily from the federal government but other places -- some of you may have hearda few days ago about the exam red will fight but for each 140 pound telemedicine robot.this robot is being tested and piloted in emergency rooms to help patients get morerapid treatment from specialists. especially at night when hospital staff tends to be lower.that robot allows physicians and others to visit patients in distant locations and alsoallows them to carry on conversations and

take information in real time. so, the pace of innovation is less expensiveand it has been it is also accelerating. we think this will have important implicationsfor the workforce, two, and the quality of services and efficiency of delivery. certainlyit can have applications for the cost of healthcare services and the availability of healthcareproviders in remote areas. also, it has implications for the type of and training of the healthcareproviders as well. the types of training that they will need in order to acquire proficiencyin deploying and using the technology in their space. >> in this rapidly changing environment,then, your ideas and recommendations for leveraging these technologies to improve health outcomeshave isolated and underserved populations

will be extremely important. especially ifwe are to successfully reduce health disparities between rural and urban populations and betweenpeople with higher incomes and lower income and reduce disparities among people that seemto be tenaciously clinging to ethnicity and age and gender and race and so on. these arethe disparities that we far find far too frequently. while this is not a panacea, we can thinkabout how this can help us reach farther to minimize and ultimately eliminate those kindsof disparities. in the next couple of days you will discussand hopefully have ideas emerging from the meeting that will populate from our vantagepoint a roadmap for us that will help us better meet some of the challenges ahead and takea vantage of the opportunities that we know

exist right now. in that context, some ofthe opportunities have already become fairly clear. for example, there is a growing bodyof evidence that shows the potential for health information technology to improve care qualityif it is used properly to maximize the databases and so on. it is possible to generate qualitymeasures with the use of technology that improves clinical outcomes that can contribute to timelyand understandable feedback for safety net providers and other members of clinical teams.hig derived information is critical for performing a quality improvement strategy. everyone inthis room knows that and it is especially important when individuals are participatingin patients under medical homes and accountable care of innovations that don't just reachacross writer types, but also sectors of the

healthcare delivery systems. harnessing thetechnology is critically important. it is our hope that you will bite us with your bestinsight on how to move forward across a range of issues and topics from telehealth technologyand link to payment and telehealth technology a link to care ordination and links to healthprofessions training and so on. within hhs and across the government we have been makingfairly significant investments in telehealth technology. we are moving on his agenda, orhave not fast enough, but we do have a few initiatives that i think i'd a bit of a platformeven going forward. this might inform your thinking. we have a new cross federal workgroup on telehealthcalled bad tell. -- fed tell. they share knowledge

and identify a collaborative opportunities.there are now 26 federal agencies and offices across the government with an interest inor an investment in telehealth technologies. they are partners within this new entity -- fedtell. for example, we have signed a memorandum of understanding with the indian health serviceto develop a joint quality strategy. this strategy has enabled and has been designedto improve the quality of care. along with aligning the goals of that initiative withthe national quality strategy. the -- it has been an innovator in the field giving thegeographic challenges that they face in getting healthcare services out to some of our mostrural and remote populations. we have also been working closely with cms to include measuresof a proposed rule for stage ii of meaningful

use that reflect underserved and vulnerablepopulations served by the grantees. these include measures on oral health, behavioralhealth, rural populations, material and prenatal care, for example. shifting to another read of activity -- thenational library of medicine funds projects to leverage this technology to improve healthcareoutcomes. we are now seeing innovative projects in telehealth through the work of the beaconprograms nested in the office of the national coordinator for hit. and of course some of the unique projectsthat i mentioned, an out of the centers for medicare and medicaid innovation. telehealthis an area of focus from the white house world

health council not just through the work ofhhs, but also the veterans administration and the fcc to identify ways to work togetherto design and prove access to care for the veterans residing in rural and remote partsof the country. the department of defense, too, invest heavily in this technology andthe department of agriculture and commerce have also focused heavily on expanding broadbandcapacity which is integral to pushing out the utilization of this technology. >> laterin the workshop you will hear from the department of veterans affairs and the indian healthservices about their experience in this area. our work in picking about veterans and harnessingtechnology can also be seen in the federal office of rural health policy initiative -- theveterans health-care access program. this

program is using telehealth technology toincrease access to mental health care services for veterans that are returning from iraqand afghanistan and living in rural areas. currently we have 3 grantees being funded.-- they are alaska, montana, and virginia. they all provide mental health services includingcrisis intervention and detection of posttraumatic stress disorder. they care for patients withdramatic rain a jury and other injuries that veterans have suffered. within this we haveestablished a series of programs to promote the expansion. this includes a focus of thelicense for portability issues that support state professional licensing boards to developand element policies that are designed to reduce the statutory very jurors -- areas-- i remember a couple of years ago thompson

to me that from his vantage point somethinglike it was easier for us to extend the reach of medical services across the pacific andacross california state lines with neighboring states. that has always stayed with me. so,this focus on license for portability is important. we also have a telehealth network grant programand a resource center that we support through the federal office of rural health policy. what is the point of sharing this informationwith you? the point is to let you see a net of what we have available right now and abit of what we can build off of great it doesn't all come from the federal government, forsure, but a lot of activity is unfolding there right now. that provides a context, hopefully,for some of your thinking over today and tomorrow.

this meeting is really about something different.it is really a heating that focuses on more about what is happening next. i have givenyou a lot of the context, but what we would like to engage the rest of this meeting iswhere we need to go next. not we have been and where we are right now, but i am askingyou and i know i am challenging you to figure out where we need to go next. any meaningfulway. we are well past the point that we need to prove the applications of some of thistechnology and prove they technology and that works. the focus now needs to be again fromwhere i sit on how we can do a better job of harnessing the technology to improve careand to do that as effectively and as efficiently as possible to make sure that this is a -- telehealthtechnology is embedded in the fabric of healthcare

for rural populations. that focus raises somequestions for you to think about. questions might include, for example, what is or whatcan be the role of telehealth in a healthcare system that is predicated on value? that iswhere we are moving. predicated on improving patient outcomes. another question -- howcould we or how should we use this technology in efforts that are designed to improve carecoordination? think about what i said a few minutes ago -- the focus of the affordablehealth care act -- teammates care. what is the role of this technology in that contextand how it can it decrease healthcare fragmentation? what can telehealth do to help clinicianswork more effectively together and harness data and use it in real time in the care ofpatients and, rightly, in the care of communities,

not just in terms of what goes on in an examroom and the pages that come through them, but how can telehealth technology be harvestedmore robustly to influence the care and health status of communities -- people outside ofthe exam rooms? we hope that today's meeting will help chart some of these answers to questionslike these and other questions that some of you have and that the reports will informour future actions going forward. we have a lot of challenges, that is certain, butthe good news is that we have a lot of opportunities. we are in a new light in terms of this technologyand the types of technology available to us. i think we need it renewed thinking aboutwhat we need to get to barriers out of the way and opportunities put directly in frontof us that we can capitalize on.

i would also ask you to keep a night on notjust the vertical applications of telehealth, but also telehealth technologies utilizationin terms of training. and pushing out even more robustly the availability of continuingeducation, new training opportunities, distance-based health professions training, oversight inthe use of these technologies. it is important for us on the training side, two, two maximizethe availability of resources. really, this can play a role in supporting the healthcareworkforce just as they can help us to be more efficient, particularly in underserved areas. mike thanks to each of you. and your willingnessto help us with this agenda. we are hoping that this summary will set the stage for somesteps we could take immediately. i am not

looking for something we can do six monthsfrom now or five years from now although that is important -- we may well come away witha study and look at this. i am also a asking you to think about what we can move forwardon and capturing ideas immediately on what we can do not today but six months or a yearfrom now or three years from now and so on if we start to put the right pieces in place.a lot of the building, i think, is not just from the federal government, but what we canbe doing in tandem with state governments and private sector partners and so on. forall of those reasons, i think the timing for this discussion could not be better. i wantto thank each of you -- those in the room anticipating virtually -- thank you for yourwillingness to engage with us on this topic.

it is quite near and dear to my heart andit's value and opportunity to be used that i have seen as recently as my last trip actto go to go to when i saw a family member who with her right technology in place wouldnot have had to think about traveling 110 miles to have something checked, but thiscould have been done if we had the infrastructure in place. this is very real for me in termsof the opportunities to i miss the technology -- harness the technology. it is also a goodreminder to get back to see these front-line challenges and to see the opportunities thatwe have to make a print in terms of access and care quality and efficiency and cost,too. this is one vehicle for doing that. thanks a lot for your time and the opportunity tospend a few minutes with you this morning.

[applause] >> thank you, dr. wakefield. sheis energetic, passionate, and the right person to be leading this agency. we are truly gratefulfor your participation and the work you do every day. it is starting to know that we have dr. wakefieldand maryland chapter -- into the jewels committee to advance in the feel and that they communicate.the bad tell message is an important one that we are working together to advance our mission. it also gives me great pleasure to introducethe next speaker, dr. thomas nesbitt, the professor of medicine at the university ofcalifornia at davis. he is the associate vice chancellor for the strategic technologiesand he has been the lead in the telehealth

program at uc davis. i'm a temp years ago-- i met him many years ago and he has ruled as a mentor for me in many ways. he has anamazing program and i am here -- i am excited that he is here to talk to us about wherewe have been and where we are going. where we are going is our focus. please welcome him. [applause] good morning. i am going to cover a lot ofmaterial in a short period of time first, i want to say i have no conflicts. i am noton any boards. i don't own stock. i am going to try and get through a lot of material veryquickly. i can only touch on some of these

things very briefly. if you have a particularpaper or project that doesn't get covered, i apologize. i want to cover definitions.i want to talk about the rationale. i want to talk about telehealth in the setting ofthe home, clinics, and hospital. i'd put in radiology, pathology, and pharmacy betweenthe clinic in the hospital because they relate to go. then, a quick summary. in terms of definitions -- into it is medicinedefined telemedicine is the use of electronic information and communication technology toprovide and support health care when distant separations -- as does the provides participants.there has been some interchanging of the terms of telehealth and telemedicine. both of thesedescribe the use of these technologies to

improve patients help status. telemedicinehas typically been used more to describe direct clinical services where telehealth has beenused to define a broader scope of services including things like patient education andother related services that improve health. what is the rationale for this? probably oneof the landmark publications in the last double of decades has been crossing the quality chasm.in that, the committee said that permission technology must play a central role in theredesign of the healthcare system if we want to substantially improve quality. i thinkit could be argued that nowhere is this more true than in rural areas and in rural communities. keep in mind that at the same time we aretalking about this, there continues to be

an increase in medical knowledge. the nihand national academy -- there is new knowledge being developed all the time in science. somepeople have access to the new knowledge and expertise and other people do not. then, thedisparity grows in a relative way. the theme here is that advances in telecommunicationand information technology can help overcome some of these disparities by redistributingthe knowledge and expertise to where and when it is needed. let's jump right into talking about care athome and in the community. there has been a long history of talking aboutproviding care into the home. there is an article in the lancet in 1879 that talkedabout the telephone to reduce unnecessarily

-- unnecessary physician visits. monitoring-- home monitoring -- this has a longer history -- it certainly was developed in the mergerwe program when they began doing physiologic monitoring over a distance. they expandedthat with this they technology applied to rural healthcare. -- the project where theyfurther develop this technology in a pilot with the indians. back in 1925, this was an article publishedin science innovation magazine where they envisioned video to the home and they evenenvisioned a device that would allow you to examine a patient over distance. they werethinking that this would occur in the next 50 years. we are not that far off.

we certainly have a need. the biggest need,in the home and community relates to chronic disease which, as mary said, affects ruralareas possibly more than anywhere else. there are 100 million americans with chronic diseasesaccount for about 75% of our health care expenditures. traditionally, we have used an episodic office-basedmodel for managing chronic disease whether than a care management model that uses frequentpatient contact and regular physiologic measurement. the ba -- va -- over a decade ago, they realizedthis was not the best way to manage chronic disease so they developed a program with educationmonitoring and feedback and personalized remote care management from a disease managementsupport team. the data goes back even further than the as,but in the study published in 2005 they showed

reductions in hospitalizations and reductionin bed days. they also showed some improvement in physiologic measures and they also showedthat are inherent for medication. >> in a later report of 17,000 people, they confirmedthese reductions in bed days and reductions in emissions and they had very high satisfactionas well as relatively low per annum cost. this report came out in may of this year fromnehi. they confirmed reductions in emergency department visits and hospitalizations andhospital we emissions and hospital length of stay and overall cost. i will talk on -- touch on a couple of areas.i have thousands of articles i can share with you, but i will touch on a couple of specificareas. in the area of hypertension, this is

a study of listing 2010 that showed the additionof monitoring at home that improved the management of hypertension. this is an analysis doneon chronic congestive heart failure of 21 studies negating that home monitoring reducedmortality compared to usual care. in diabetes, another meta-analysis showedthat home telemedicine had a positive effect on hemoglobin a-1 c. and they also showedthat home telehealth helps to reduce the number of patients hospitalized. in both of thesemeta- analyses, they'd knowledge the fact that we do need more high-quality studiesin these areas. where are we going in this area? i think thatthe devices that were being used in the va study -- we will see more of these. they arebeing produced by a number of different companies.

some are going to tablet-based and some aregoing to wrap top-based systems. they have peripherals connected. the other thing -- iam trying to avoid brand names -- i am using this from the berkeley school of engineering.we are going to see smaller devices for physiological margery -- monitoring. this combines a stethoscopeand my other be in other functions. it has bluetooth to a cell phone or pc and it hasa fair amount of storage with it. because we are able to use these and make these devicessmaller, we can put them into different form factors. different factors like a watch ora ring that measures blood pressure and heart rate or an earring that does pulse oximetry.that kind of thing. i think we are going to see these kinds of devices put out.

what are our challenges and opportunitiesfor the future in the area of home health? i think that one of the issues is patientpreferences and acceptability of telehealth. a lot of studies -- many of them have beendone. a lot of pilots show attrition of the chill -- people using these technologies.there is a lot of attrition from these and why is that? have we figured out the kindsof devices that people want to use? how much intrusion in people's lives are they willingto accept? there is a device that goes on your chest and will measure whether you swallowyour pill or not. do people really want that? how do we better involve patients and theirfamilies safely in care and what is their role?

how do we use off the shelf devices like mobilephones and gaming systems and other things that we need to figure out how to use? whatis the quality that we have to use of a mobile phone if we are going to do this? probablythe last two may be the most important. how do we manage and transform all the data thatis flowing in from these devices and turn that data into information that is actionableby a clinician? a lot of positions out there don't have disease management teams that theycan use to manage the data. so, how does the small doctor's office in nebraska or articleto use the data? this flow of data is somewhat threatening. what policy changes and supportsare needed to allow world populations to be able to use these models of care? again, althoughbig systems can have disease management, how

does the average clinician use that? let's switch to office-based care. the inventorof the ecg published a paper in 2006 talking about the tele cardiac graham. from clinicson ships two sure, they have been using the radio. this has been used in other placesfor many decades. probably one of the most famous uses of television is the 1968 useof it between massachusetts general hospital and logan airport. going further in time, there is the use ofother kinds of telemedicine. in alaska they have been a model for the development of telemedicine.i show this picture for a couple of reasons. this is a community health aide that is doinga test and they added audiometry. in this

population, they have a high rate of middleyour disease. the information can be sent to anchorage or fairbanks were specialistscan make a determination whether a patient needs to travel down there for more definitivetreatment. again, this has been done for decades in alaska. today, we think of telemedicine as these flatscreen high-definition units. there are a lot of them out there. all of these do nottalk to each other. some use proprietary communication standards. if we want this to be as it ubiquitousas the telephone, we need to think about things like communication standards. they have peripheral devices that can aidin the physical examination of the patient.

something that is been a great advance isthe use of more store and forward or asynchronous technologies. term ecology has been a successfuluse of this. in terms of ophthalmology and optometry, the use of these cameras to screendiabetics -- this has increased the screening rates of diabetics who need to have retinalscreening and these are non--- cameras that do not have to dilate the eye. teledata street -- -- tele dentistry. thishas been used where you can use this in combination with x-rays and these examination tools whereyou can examine patients and to a good agile exam -- a good dental exam and this can reallyimprove access to dental services. i want to touch on a couple of office pasteareas. -- office-based areas. i am going to

focus on dermatology and psychiatry, two ofthe biggest. there have been studies going back to the 90s showing very good agreementbetween in person care and tele dermatology. justin june of this year there was a studypublished on patient satisfaction. there have been a lot of these studies, but this is anew one showing that patients have a high satisfaction rate. the third study is importantbecause some people worry that if you see a patient via tele term ecology and you diagnosea condition that needs surgery or something, the patient will get delayed. in this population,this did not have it. the last one is from april armstrong. lookat why some dermatologist don't do this. if it is so wonderful, why is everyone doingthis? there were a number of reasons. issues

about malpractice and training. a lot hadto do with reimbursement. not knowing about this or the level of reimbursement. you willhear about some of this in the reimbursement panel about some of the barriers. i will giveyou a tease with that. in mental health, there have been studiesdone -- in 2000 and in 2019 98 and again in 2007. this shows good agreement between inperson diagnosis and treatment plans. when they are done in person versus telemedicine.again, there are high satisfaction rates. even among parents of kids with psychiatricillness. i wanted to show this study to give you someidea of the peripheral benefits. this is a study we did in separate rural communities.we looked at the opinion of healthcare in

that community prior to telemedicine beingintroduced and 19 months later looking at it after telemedicine was introduced in thecommunity. it showed that rural communities had -- a higher opinion of healthcare oncea new about telemedicine in the community. people with a higher opinion were less likelyto leave the community. where we going? i think the equipment willchange. this is an otoscope connected to an iphone. you can get a good picture. you canshow the patient and send it to do otolaryngologists. you can ask if the tube is in the right place.i think we are going to see more integration of telemedicine with electronic health records.a lot of the big companies are already doing this. you will see integration of telemedicineand decision support and the ehr.

in office-based care, what are the challengesand opportunities? how do we use nontraditional providers such as in alaska or a dental hygienist?rather than the traditional providers? this gets into scope of practice issues and thatis a touchy subject. again, we need to think about this. how do we use new models that build communityclinical expertise using these technologies? you will hear about some of these when wetalk about the project? oh. -- e. can we improve the interface? how about lesscostly equipment like handheld devices as i showed you with the otoscope? we need tocontinue to develop evidence a standards for

care, but how can these reimbursement modelssupport telemedicine to rural and remote communities? again, in the dermatology study there wasa lot of challenges for specialist even getting the patients in to see them in person. whyshould they then add providing care over distance? we need to think about how the reimbursementmodels work. i am good to talk about radiology and pathologyand pharmacology quickly. radiology has been around for a long time. i found an articlefrom 1948 from philadelphia to chester county hospital. teleradiology is the most commonform of telemedicine. we used to do it with camera on a stick or digitized films. nowwe use iraq digital capture in most of radiology systems. this has allowed for the developmentof nighthawk services. if you get an image

tonight in a hospital in this area, the personreading that image might be in australia. again, it is used quite commonly in a waythat radiology is done. one thing really all it is have done is promoteda standard that they use for transmitting and storing data. they have promoted the dicomstandard. they have been good about this. these are some images using this standard. going back to the late 90s, there were studiesthat showed that using teleradiology reduces transports for head injuries at a rural areas.also, a study done in 1998 show that went radiology was available to rural emergencyroom, it changed the diagnosis 30% of the time and the treatment plant about one quarterof the time.

pathology -- a report from 1989 showing itused it northern norway. it is less common than radiology, but digitized in pathologyslides has become much more common. these are very large files because you have to havecolor and you must have to be able to do it right of occasions. people were concernedabout moving these fires across -- these files across firewalls. there are models developedfor the image sits in the cloud and you only have to do it. it is sitting on a server somewhereelse and you can view it over a distance without having to move the files across firewalls. these are examples of some digitizers forslides. certainly, these are used for a second opinion on critical lesions which is whatthis study was about. this is a study that

demonstrated that a specialist pathologistdoing it via telemedicine is better than a staff pathologist there on site. in 74% ofthe cases, the diagnosis was more precise and in 18% it had a major positive impact.these were just in time pathology cases. these were two studies -- one in breast cancerand one in neuropathology. this shows that the histopathology can be done accuratelyusing tele pathology. pharmacy -- this has been done over distancefor a long time it. any healthcare professionals and the audience will know how often you callthe pharmacist -- the first day of your internship -- you call and say -- i'm supposed to givethis guy a medication -- he has real failure -- how much should i reduce the dose? thereare some well-known the projects in north

dakota as well as in eastern washington. now,tele pharmacy is facilitated by cpoe and remote review. even remote dispensing. you can dispensemedication using machines and other things from a distance. if you combine this withvideo and being able to review medications and having a video consultation with the patient,this will allow the whole thing -- the whole pharmacy visit to be done over distance. this is a paper published this year demonstratingthat on 47 cancer patients, they were able to save 27,000 miles of travel because oftele pharmacy. as many of you know, pharmacy is a critical part of the care of cancer patientsfor fixing and administering chemotherapy. this is an interesting study from north dakota.this showed that -- it was interesting because

they showed the error rate in tele pharmacyand in person pharmacy. both of these rates were far below the national rate. tele pharmacywas slightly higher. again, it may be the difference between no pharmacist and a telepharmacist. i had to put this in because we just publishedit. this was hospital-based pharmacy. this was a study we did with six rural californiahospitals. they have difficulty affording 24-hour armistice. when medications are orderedand delivered to patients in the hospital, at night there may not be a pharmacy review.we used tele pharmacy and found that about 90% of the patients there was one or moremedication error that was picked up by the remote pharmacist.

i'm in the home stretch. hospital based telemedicine.one of the most famous uses of hospital-based telemedicine -- this started developing inthe late 50s and early 60s -- a closed circuit television link 20 the nebraska psychiatricinstitute and norfolk state hospital where they did a psychiatric consultation. i wastrying to find something on skilled nursing facilities and i found this study from bostoncity hospital with a low-tech system that showed some positive results. hospital-based telemedicine in the hospitalversus nursing facility -- this is really growing in two areas. the areas are strokeand icu care. i've to talk about stroke first. the first report was a study published inthe lancet by brent meyer. the second was

the one that significantly change things.that was the american stroke association publication that said that stroke exams can be done overdistance and a quality way as long as you have good imaging, but also, they recommendthe use of tele stroke in hospitals that accepted these patients that to do not have strokeneurologists available. again, this is very important. in the inpatient setting and the skilled nursingfacility setting, there are a number of devices you can have -- there are robots or you canhave a nurse but the unit in the room and see patients this is low hanging fruit. thereare a number of studies that show a number of avoidable this it's to emergency departmentsfor skilled nursing patients. i think particularly

in rural areas -- some skilled nursing facilitiesexisting communities without positions. getting physicians they are urgently can be a challenge.nehi did a recent look at this. it published in may of this year. it showed strong evidenceof clinical benefit and staving suite includes use of telehealth the nursing homes. this is a paper published in 2010 again atpsychiatric your bird via tele-psychiatry. this showed that nursing home personnel werepositive about the use of this. again, it provided care that was very acceptable topatients and families in nursing home personnel. i want to talk about critical care for a minute.you are going to get a talk on this, so i will just freeze to a couple of things quicklybecause we are going to talk about this later.

this is probably bordering on 10% of batsnow. they are covered by tele icu. the components differ, but the most robust model of teleicu includes intensive this from a command center with nurses and other personnel monitoringsystems that track patient status -- smart alarms with full audio video and protocolsthat are wrapped around those that help manage patients. the literature in this has been mixed andeven since i put this talk together, there is another article that is come out showingthat it is mixed. this is an article by thomas. you will hear about this in a minute. thisdid not show overall improvement, but it did show some benefit for the sickest patientsin terms of survival.

this is a study that was done and publishedlast year in jama where they showed improvement in mortality and produced hospital lengthof stay as well as change and best practices. this is a study -- meta-analysis that concludedthat there probably is lower mortality and reduction in icu hospital length of stay,but they did it knowledge that they are not really sure what configuration and what elementsmake up the difference. >> this is a paper that jim marson did. it is a consultationonly model for pediatric vertical care. what jim showed in this paper was that it significantlyreduced transport costs from rural areas, but there were cost savings because of thatand there were also financial benefit as any of the adult icu studies have shown. thereis financial benefit because they keep the

patient and the revenue in these hospitalsrather than sending it to a larger tertiary center. where are we going? i try to come up withsomething space-age for the end of this. tell us surgery. -- tele surgery. the lindberghoperation that was done in 2001 -- september 7, 2001, from new york to france. they didthis surgery and it was a holy suspect to me. they did it over distance -- it was holysuspect to me. -- cholecystectomy. there are pilots being done -- operating fromone room to another -- you can do this over hundreds of miles. certainly, you can getgreat display and you can operate very well.

i have said to people -- i don't want to bethe first one. but, it can work extremely well and project expertise forward, particularlytechnical expertise. finally, what are the challenges and opportunitiesfor the future? i think in -- one thing we have to figure out -- what are the elementsof tele icu they can make a difference and can be tailored to smaller hospitals? it isdifficult for hospitals with two or three icu beds to bring this in and i think thatpeople are beginning to work on models that will incorporate that. as for the development, a lot of the expansionhas been for -- in for-profit companies coming into stroke care and icu care, etc. thosemodels, not unexpectedly, are with hospitals

that can afford it. so, how we can we buildincentives into expanding those two rural communities so that either private or publicinstitutions can't afford to do this in rural communities? telemedicine and skilled nursingfacilities -- are there enough incentives? i think they are as we do not pay for re-emissions.i think we will see the increase in telerobotic surgery as we try to project technical skills. in summary, i think advanced tele the communicationhas a role to play in transforming the health care system. i think that evidence-based modelsfacilitated by these technologies can improve access and quality across the geographic andcanonic spectrum. to date, though, we have been attempting tolayer these technologies onto a healthcare

system that don't have as a serious sentence.i was going to say a broken healthcare system -- you can be the judge -- we are attemptingto layer the technology onto something that is not working that well in the first place.i think would be aca, this can facilitate the transformation. i think that more researchis required to develop appropriate quality standards and all of the series of care. thank you. [applause] >> we have a minute for a questionor two. >> if not, great. >> while the panelists assembled,good morning. spero manson i am and in the spirit of his remarks, i have no conflictof interest and the only financial disclosure

that i have to make is that i do own stock-- ar of the four-legged type. they are on my ranch in colorado. for those of you who have been with us onthe webinar as well as in the audience, since the beginning this morning, you found thatwe opened with dr. rubin's remarks with respect to the format and purpose and content forthe next today's offerings. we then shifted to dr. wakefield and her enthusiastic overviewof how this particular set of issues relates to her agencies mission and the countriesobjectives overall with respect to healthcare. she painted a wonderful view of personallyand professionally of the landscape and charged us with looking ahead. let's behind and thepresent and forward into the future of where

we might go. dr. nesbitt's very powerful visitation regardingwhere we have been and where we are now -- with respect to a variety of technologies and theirapplications as well of historical forces that have been at work. this sets the stagefor each of the panelists to come. this first panel this morning begins to move more narrowlyinto the issues dissipated by doctors wakefield and nesbitt. it begins by alerting us to the scope andapplications process and structure and capacity issues that we face. there are four paneliststhis morning. the first is mr. jonathan linkous, the ceo of the telemedicine association. hewill focus on the -- using the platform provided

moving us into these issues. he will be followed by mr. kerry -- gary capistrantfrom the telematic and -- telemedicine association. he's the director of public policy. he will address issues of licensure. he will be followed by dr. dale alverson fromthe university of new mexico where he is a professor and director of their center ontelemedicine and cyber medicine research. addressing issues of federal communicationand the omission of rule healthcare support programs. followed by mr. steve hirsch from hrsa, specificallytheir world health policy program. he will

address matters of morality and the misalignmentor mel alignment of the definitions of the program and how it is organized financiallywithin the healthcare system. just a brief comment -- you saw flashing lights.each presenter with the exception of mr. linkous will have a little bit longer than the otherpanelists. he will have approximately 20 minutes and the others 15. they will share their remarks.we ask that you hold your questions until the conclusion of all four presentations.for those of you who are curious -- i heard you whispering when you saw the lights flash-- yellow in this case is with a one minute warning and the red flash means that the timehas concluded and we will be asserted about this. i was teasing about this -- i am americanindian by birth and cultural orientation.

it is a great irony of being the timekeeper. we will move in that sequence. i encourageyou to look at your biographical background provided at registration to little bit moreabout each of today's panelists. mr. linkous mr. >>thank you. by saying i have a longer time, i see there is already resentment started. [laughter] it didn't help when i told themi was good to take 45 minutes. i want to talk about the challenges of telemedicine.i was going to talk about the world of telemedicine and i think todd did a great job of this.he gave us that. briefly, the world of telemedicine from our perspective was largely telemedicinethat worked was based out of tertiary care

or academic medical centers. today, it isquite a different picture. i think this leads to one of the challenges, but we estimatethat there are about 10 million patients in the united states that are getting the servicesby telemedicine each year. this is broken down by a number of areas and we will be publishingsome data on this shortly. about 5 million patients get that out of radiology and almost1,000,000 patients are on a dirt -- cardiac monitoring. there are devices for a tonighthundred thousand patients that are monitored by tele urologic monitoring. they are operatedon -- spinal or brain surgery by a neurologist at it as is. in most cases, they do not knowthis is done. we think this is a sign of success. it is also a sign of how telemedicine hasbeen absorb into a lot of the healthcare.

let me talk about what i call the seven deadlybarriers. money, regulations, hype, adoption, technology, as it is, and success. we see all of those right now as really thinkswe need to address and overcome. some of these are shared with where healthcare is generallyand some are traditional barriers that we talked about. and some are new barriers thatwe are seeing today that have transformation in telemedicine. which initially, the first is money. -- traditionally.you will hear a lot about reimbursement. medicare does not we ever sent off -- reimbursementof. it is still limited largely to nonpublic areas, but within non-metropolitan areas,it is limited to the type of institutions

that you can provide and limited by the cptcodes. there are a lot of limitations. this is largely growing from a fear that the correctionalbut it did office of the federal regulators have that telemedicine will either be -- allowfighters to abuse the healthcare system or it will be over utilize would drive up costs. this is a real fear not only by federal butalso by private pairs as well. there is an overwhelming concern of money.but, within the money there is also a whole area of telemedicine -- healthcare, rather,that we largely ignore in telemedicine. this is about the payments. the managed care populations.there are about 90 million people who are receiving services in managed care and thatwill probably be the fastest growing group

of patients in the next couple of years withthe changes in the healthcare system. except for the veterans administration, there wasa lot of -- not a lot of evidence out there of managed care using telemedicine to controlcosts. that is a right area. it is low hanging fruit. it is an area where we have got tostart look at an address how within the managed care system we use telemedicine as an integralpart of use of telemedicine. we have yet to do that. the other part of the money is the attractivenessof telemedicine. we have little honey in some areas and get telemedicine -- healthcare isa 20 have billion-dollar market. $2.5 trillion market. a lot of companies and a lot of peopleare getting involved in telemedicine and we

have a lot of solutions in telemedicine bypeople who do not know what is going on in healthcare. they do not will know what ishappening, but they see a huge market and we are seeing huge groups coming in to workwith that. is a challenge and store us and healthcare and telemedicine because we seea lot of solutions being used by people who are attracted to the potential market of telemedicine-- healthcare -- without knowing how to use these devices and get involved in the actualpractice of care. the next areas regulation. they will talkabout licensing. this is a big area. this is an area of interest when a ta was formed,but it was not a huge area because most of these systems work listed within a state.now that we have multistate systems going

on and we have multistate practices, now thatmost of the major healthcare providers are moving into a national system, i think thatlicensure is a big problem. we need to address that. along with that, our practice regulationswhich i think are more of a problem than licensure. i would've said that a few weeks ago, buthaving talked to a lot of medical state regulators -- talking to them -- they are cranking downon how you can use telemedicine to practice care through the regulations requiring inpatientand live physician consultation before you provide any telemedicine services. that -- weare going backwards on that. i think the regulations are getting worse. not only have we had severalstates crack down on this lately, but we have

had national legislation proposed -- theyproposed a resolution recently. this is been reported, but this is a sign that there willbe more of this type of approach to looking at the way that we provide healthcare. itis a big problem. then we had the traditional regulatory agencies-- fda, the mutations commission, all of the regulatory areas that are moving forward.we're going to talk about that today. i am sure over the next couple of days we willtalk about all of these issues. finally, under the regulatory area we havewhat i call stupid regulations. one of those is the fact that even though we have accountablecare organizations that are supposed to really move out on telemedicine, even though we havegreat issues talking about using telemedicine

as we move forward with the healthcare thefuture, we still have 1830 4 am which is a section of the social security act which willhave its much of the telemedicine work and this applies to account will care of innovations.if you are and aco populate a large area, you cannot use telemedicine even though congresssaid when they packed the affordable care act that this would be a great use of telemedicine.even though cms said when they talked about regulations that this is great for telemedicineon the impact they have not waived that section of the act. i don't care how much accountablecare organizations -- you're not going to use telemedicine. the stupid laws often waivedfor that regulation. moving on.

that is how it feel about that. we are victims of our own hype. i am as guiltyas anyone, by the way. we tend to talk about studies and we tend to talk about all thewonderful things that telemedicine can do -- the studies that we quote are the studiesthat show the wonderful parts of telemedicine, but there are a lot of studies that show thatsome things in telemedicine don't work. some studies have shown that telemedicinehas caused a lot. there are areas in telemedicine the cost too much. there are applicationsthat may not work right. if we are going to get serious -- we will take the telemedicineand move it from tillman and it 10,000,000 to 100,000,000 -- we have to get serious aboutthis and face these issues. the hype is wonderful

-- we are expected to be hype we also haveto be realistic because what happens is you have an atmosphere that is poisoned. whenwe come to an organization -- a major payer or a -- we talk about telemedicine, i cansee their eyes glaze. they say here is another one trying to sell me something. where isthe money they are going to try to make? [captioners transitioning]if you are looking at the adoption, we need to look at our own medications. there aresome providers. we talk about licensing, and they are saying i don't want you to fix thealizingproblem. i have a telemedicine that works well. i don't want another telemedicine comingin here and competing with me. it is a real issue. what is goingoon get worse when wehave the large systems moving around to nationwide

networks. we had partners healthcare thatjust signed with cnh services, which is implant and in office healthcare assistance. theyare providing a national contract to provide remote medical services to their nursing stationsand healthcare offices in plants and offices all over the country. we see the mayo clinicthat has three sites now and looking on a 50 state basis as to where they can put theirfootprint and their referral partners. we have nation systems moving into this and lookingat real, i think, some real resistance to this innovation, even by some of the traditionaltelemedicine networks. because telemedicine opens up competition. technology, technologyis the focus of telemedicine for a long time. we have got to get over the point, , it isnot the technology. it is not the technology

if we focus on the technology we will notbe successful in telemedicine. it is the services. technology is ubiquitous in areas. the costof the technology has to come down, it is coming down, we have to get onto the pointwhere we are talking about the serviceswork it can be provided and how the changes people'slives and not the neat new piece of technology that we have coming up. the other thing thathappens with the technology, of course, and tom alluded to this, as we implement telemedicineand all of this technology, it will create huge data flows. if you are look at my vitalsigns, 24/7, temperature, blood pressure and on a 24/7 basis. i don't know who wants tolook at it, i don't, my interest doesn't, my doctor doesn't, nobody wants to, it mightgo into a sims where it triggers an alarm

if invitals go, but we don't have a systemof maintaining that and looking at a huge data flow that we're going to gets a technologycoming out there and everybody is hooking up their cell phones to their bodies. evidence,we need to look at evidence there. are areas that show great progress in telemedicine andareas in telemedicine that needs to be looked at by large studies that have not been doneyet. the large payers in the country are ready to do telemedicine. united healthcare, thelast two days we had a board of directors meeting. he is a strong advocate, but it iscost, there is cost, there is no more money in healthcare. zero. if you're thinking abouttelemedicine is going to open up new waves of money. forget it, it is not going to happen.if you can go to a payer and show if you're

going to use telemedicine in this way, you'regoing to save money in certain areas you can get them open. we can talk about quality andaccess. that is wonderful. it is really important that people pay attention to that. i'm sorry,if you're not reducing costs you're not going to have the door open. it is the number oneissue. we have to face it. we have the show evidence of it and be very upfront about that.finally success. this is an interesting one. because as we move forward, the thing thati've seen that's really changed is telemedicine has moved into the cease week. i had conversationsover the last several months preparing this database and report on where telemedicineis, i'm talking to ceos of major hospital change and telemedicine is a fun thing whereit is down there. we have funded the grants.

they supported it. it is great and wonderfulpeople. now, they are saying wait a minute this is part of our new corporate plan andbeing a land grab. it is a land grab in healthcare. hospitals are making up referring and linkingin networks. the ceo is saying this is where we got to go. ceos are saying this is a priorityfor us, because it is in their business plan. what happens to the rural networks and ruralpopulations. what happens when the priority for telemedicine, the networks is focusedon urban areas and i the population is. it's like the bank robber because they rob bankswhere the money is. the telemedicine is moving into the urban the urban the urban the urbanthe urban the urban the urban the urban the urban the urban the urban the urban the urbanthe urban the urban the urban the urban the

urban the urban areas, that's where the peopleare. understandable and a good things in the many ways, but the issue is what happens tothe rural populations that are being served under traditional networks. are they movingforward. we have networks now that are looking at icus and we're looking at neuro networksfor stroke care. many are independent, they are not tied into the traditional networks.are they competing or part of it? [ no audio ] so there is a whole bunch of challengesbefore us, some is the traditional challenge that we have worked on, but we have no challengespart of our own success moving telemedicine forward. thank you. [ applause ] good morning. i want to talk to you aboutthe licenser piece of this as a challenge,

but instead of thinking of it as a challenge,i would like to start what is possible. we heard a lot about the morning what is possiblewith the medical science. what is possible in, in the -- healthcare delivery system.if we were to devise a licenser system for healthcare professionals and i'm start bysaying that is obviously very important. say, i do have an occupational license in the districtof columbia. so, i know some of the issues of that, but if you were to devise a systemfor healthcare license, it wouldn't look like what we have today, but let'ses start withsome of those issues that we have. we have an incredibly mobile population. i live inthe state of maryland. i don't have my medical records in the district of columbia. i don'tdeal with the district of columbia physician.

yet that would be a barrier if i had emergencymedical need right now. we have people that are always traveling. think of pilots. thinkof -- athletes. they, they -- we, we also have doctors that are traveling. number ofdoctors that are in this room today who are not licensed in the district of columbia,but you could not deal with your patients back home because you're here. the telemedicinehas been great for dissolving the barriers of distance and, and certainly, it can playa role in -- dealing with the, the issues of distance and geography when it comes tolicensing. so, we, we've got a very mobile population. one of the things is patient choice.i think patients should have the choice of going to -- whatever practitioner they wantto go to. we have -- systems that are multistate

and the, the, in those health care systemsyou should be able to chose where you want to go. if you want to use a physician in newyork city, you should be able to do that. if you want to use it wherever, that you shouldhave that choice. patient safety and quality. one of the things is to be able to go to aperson who you trust, who you think is higher quality than somebody else. that choice shouldbe yours. one of the things is access to specialist. we talked a lot about physician -- maldistributionof physicians. usually that includes an overwhelming number of physicians who are primary caredoctors. that's think about for a minute access to specialist, not subspecialist, but specialist.these 12 states have less than 2,000 specialists. if you told somebody in those states theyhad to be limited to the physician pool in

that state, they wouldn't like that, but that'swhat we end up doing. so, in, in, you think of in terms of raw number of specialist, oneway to look at it, but also we can think in terms of perpopulation. what that is. now,three of the states are on both of these lists. montana, idaho and wyoming. if you look ona map it is a nice almost square in the northwest. so, this is a problem for people who havespecial needs. in particular, let's think about rare diseases. the national organizationof rare diseases looks at those diseases that have less than 200,000 americans that havethose conditions. what kind of access does somebody that has one of those rare conditionsand there are 6800 of them, have in north dakota. in wyoming, in montana, in rural areasall over the country, even in the district

of columbia. with three medical schools righthere in 69-square-miles. so, access is a huge issue. think in terms of languages. doctor,pediatric cardiologist, think if you needed a pediatric cardiologist that spoke spanish,did sign language, where would you go? we have a system that doesn't allow you to choosethose resources. one of the other issues is provider productivity. the current systemdoes not encourage provider productivity. we can't do too much in the short-term aboutphysician supply. nurse supply. supply of physical therapists, but we can do somethingabout the productivity of their precious time and resources. that there are ways to dealwith that. we do have, as i mentioned and john mentioned, you know, we increasinglyhave multistate plans for dividing -- for

delivering healthcare. whether it's managedcare plan, an accountable care organization or our employer is multistate and they wantto do a better job of taking care of their population. we have the issue of border communities.one of, i'm fascinated by what you can find on the internet nowadays, do a quick googlesearch you can find about anything. i was curious how many miles of borders there arein the united states, not including coastline, but borders. where there is a state on oneside and a state on the other. there's that answer on the internet. there are 22,000 milesof borders. so, we have a lot of people who live close to that border where they're closestdoctor is across the river, is across the bridge, is, is just down the road, but that'sa different state. now, we do have people

that have multiple state licenses. the othernight i was having dinner with an ophthalmologist, who have 15 state licenses. there is a hugeprice to that. we conservatively figure, just physicians, it is about $300 million thatis involved. now, we think that sometimes that, oh, license is not an issue that affectsme. it is kind of like your car insurance. you have that protection every day. you don'tjust have that protection when you have a car accident. in the same way, you, you're-- being harmed by not having that access to all of what america medicine offers onan on demand basis. that there are also, then the costs, that gets added to the healthcaresystem of multistate licenses. again, just think 3 ran million$ conservatively for multiplephysician licenses. we have one company as

a mer. radiology company, 380 radiologists.they have 8500 state licenses. they have learned to be very smart about how to go about dealingwith each of the state jurisdictions, but that is something that may have been acceptablein the past, but is no longer acceptable. we don't, we don't, are not willing to havethose kind of restrictions of being limited to the supply of physicians in a state fordelivery, for delivering health care systems. there are other issues that go with licenser.john mentioned a couple. some of the practice acts, that what is a sufficient doctor' patientrelationship. which is a medical exam involved. what can you do with prescribing that arebecoming greater barriers then they were 10 to 20 years ago. we're going backward, we'renot going forward, but there is a lot of potential

to go forward. we have a system of licenserthat is unhealthy and doing more harm to patients than good. there are some solutions. certainlythere are lots of things that people have looked at. reciprocity. great, do it. we,we can't even get some states to allow for a physician to talk to another physician withoutbeing licensed in that other state. that, that is just bizarre. not even involving thepatient, but a doctor talking to a doctor that you have to be licensed in that state.we are some states that have gone to a telehealth license. which seems like a nice short-termsolution. it is a little bit cheaper and faster to get, but i would suggest that's not a verygood long-term solution. telemedicine should not be separate it is not a specialty of medicine.it should just be healthcare. so, that's useful

in some cases, but not completely. i do alot of reading about history and american presidents, i was recently reading the autobiographyof teddy roosevelt and he had a quote or a statement in there that surprised me as aparticularly a good republican that he was, he says, the constitution was formed verylargely because it became imperative to give some central authority to the power to regulateand control interstate commerce. this was republican saying that the constitution and,and, you know, you think back to some of those issues that interstate commerce was a bigreason for the constitution coming into being. states couldn't agree on weights and measures.states couldn't agree on a whole lot of other measures. so, the constitution was formed.we're in the district of columbia. we're no

longer in what was the state of maryland.because the federal government did not want to be hindered by state law. they ran intosome problems when they were up in philadelphia with the pennsylvania militia. they decidedthen that they were not going to be hindered by state law. they wanted to create a place,a district, that they would would would would would would would would would would wouldwould would would would would would would would would be in ultimate control of. federalgovernment healthcare programs at not be hindered by state law. the same way, the federal governmenthas, has incredible authority to deal with interstate commerce. we hear a lot about theconstitution. well, the first article of the constitution that the states had agreed toin developing it, gave to the congress the

power to regulate interstate commerce. thenlater on, in the constitution, in an amendment, gave the states the authority to essentiallydeal with intrastate commerce. i think that is a pretty good arrangement. some peoplehave used this to deal with -- exceptions for federal agencies to multiple state licenser.dod, va had some exceptions. in december, congress on a bipartisan basis, in fact, unanimouslyapproved an expansion for the defense department. if you have a license in one state, just asyour driver's license in one state, that's good in all of the other states. you onlyneed one license. you only need one license to drive. that, that legislation is -- hr1832,that was essentially in acted in a bigger package. that has, that model is being usedin another proposal for the veteran's administration.

the vets act that congressman rangel recentlyintroduced hr1067, that molecule be used for other federal agencies, federal health programslike midcare and medicaid, the federal government is a major payer in and federal funded sites,like community health centers and community health centers. so, i could suggest that thehave lots of ways that we can go at licenser, it would be useful for the committee and theinstitute of medicine to think what is possible. not starting with where we are, but somewhatpossible to have a healthy, good regulatory system for professional licenser. what isa good way to -- to be patient centered in our licenser and -- to, to move forward andto deal with some of these other issues, not just the mere license, but some of the discrepanciesand practice issue that vary from state to

state. [ applause ] well, good morning, everyone. what an honorto be here at the national academies of science and the institute of medicine. we know howimportant and powerful the reports that come from the institute of medicine can be. so,we're all very, very fortunate to be here. i wanted to thank first of all, our moderator,doctor mason, thank you for bringing us today and -- thank the workshop planning committeeand the doctor for organizing twist inviting many of us in the telemedicine commune tocome together to talk about where we go from here and where we are at now. my talk really,i want to point out we're addressing challenges. i'll talk about the challenges of broadbandand getting connected. but it reminds me of

what many of you may know of the serenityprayer. would often get discouraged it says give me the serenity to know those thingsi cannot change, but also give me the power to change those things that i can and thewisdom to know the difference. ladies and gentlemen, i believe that all of these challengeswe're talking about we can change. we can change in a very positive meaningful way.so we'll talk about the federal communications commission, rural healthcare support programs.but i'd like to talk about the lenses learned and opportunities for improvement. first iall i have no financial or afiggationwise the presentation and i do not represent thefederal communications commission. i may be in a better position to speak to this experience.in doing so in the presentation, i would like

to briefly describe the need for broadbandconnect tev tafor healthcare. in the end, we should improve our healthcare system andserve every citizen of the country. always describe the fcc healthcare program and therural healthcare program and rule making. describe the challenges and finish with possiblesolutions and next steps. so, what's the need? well there is no question if we're going todo any of these things with healthcare and telemedicine, this country needs you bickiaitous,adequate, affordable broadband to support telemedicine and exchange so we can achieveincreased access to appropriate care for all individuals at the right place is the rightstep when it is needed. this can improv access to care, better health and cost reduction,but yet there are significant gaps in access

to affordable broadband in this country. particularlyamong the rural countries. for the underserved. inadequate affordable broadband can be blendedwith other community needs in education, training, economic development and government. we, weclearly have gaps in broadband connectivity. you can look at new mexico and we have gapsin access to healthcare services in rural new mexico. you hear about some of those withsome of the other speakers that effect not just our state, but our entire country. hepatitisc. behavior health, a huge issue in our country. diabetes, asthma, cancer, oral health, whichoften we don't talk about, but so critical. cardiac and stroke care, hirisk pregnancy,pediatric care. walsh, we have to look at now we saw with dr. nesbitt's presentation,even back here in 1924, many of you may have

seen this from radio news about the radiodoctor. how do we get into the home environment. when we talk about connectivity as you andi as providers how do we bring this care to the patient wherever they are, that includesthe home environment. we know that handheld devices m health, part of the broader umbrellaof telemedicine and tell health, i would venture to say that probably everyone out there inthe audience and every one out there in cyberspace, has a smart phone. now we're seeing the tabletsplaying a huge role. this is from the "chicago sun times" showing an er physician, pullingup an ankle e x-ray to this young man, showing him the fracture and to follow-through withhis care. there are mote monitoring. the so-called the smart bandaids. in the u.k. the plasters.we can monitor vitals that can be sent your

cell phone and the clouds to help you as thepatient and the healthcare provider management your care better. that's about about the federalcommunication issues. touch on the fcc rural healthcare programs. and then the fact thatthe united states general accounting office, the gao came out with a tough report aboutwhat is happening with the fcc programs and the fact that we really don't have good dataon the impact and we're interesting millions or billions of dollars in broadband, we needto demonstrate the value it brought to our country. i see people out in the audiencethat worked on the fcc's national broadband plan that was issued in 2010. i -- referenceyou to chapter 10 that talks about recommendations. then finally the implications of the noticeof proposed rule making of 2010. yes. it is

has been over two years and now, a recentrequest again from the fcc with the release date of july and for more comments about howwe might reform the broadband programs. many of you probably already know this, as a quickreview. the fcc using the universal services administration. company, called usac for theprimary urban rate discount program. in a urban area you only pay as much as the largestcity in your area. so, if it is a thousand dollars for you to have broadband connectty,but it is only $100 in a larger city. you only pay $100 and the fcc pays the difference.there is the internet subsidy that precedes 25% of the cost of internet. then, the ruralhealthcare pilot program. in which we were provided coaches in addition, to usac supportin managing these programs. i just want to

mention briefly again to look at the nationalbroadband plan, and particularly chapter 10. there were five sections and you can see herefrom the slide, i won't go through it, that reviews the potential value that we're talkingabout right now and an overview of the current health i.t. and provides recommendations,which includes a lot of things that have already been mentioned. the need for better reimbursement.modern regulation that was brought up. increased data capture utilization with sufficient connectivity.i'll bring you back to the notice of proposed rule making. how many of you out there providedcomments. many of you probably did. it was released july 15th, 2010 and suggested changesin the rural healthcare programs and asked for comments by august 14th, 2010, and thenreply to the comments as a standard procedure.

some of the main points, it would allow theapply to the primary program and the primary urban rate rural discount, each individualsite had to apply. that was a big burden if not a barrier. so, allows clinics to applywould be a positive thing. and increase internet subsidy from 25% to 50% and many of said more.let's continue the construction program at 85% subsidy. doing so allow administrativecosts. now as of july of 2012. we are all actiously awaiting the fcc to come out withits new order. as of july 19th. they asked for more comments on the comments by august23rd. if you're not already aware, look at this and make some more comments. most ofthat announcements are questions, which we should be answering as part of the telemedicinecommunity. those comments are due this month,

august 23rd. i encourage you to look at thatannouncement and respond. what about the rural healthcare pilot program, which many of havebeen involved. i can certainly been in the trenches in this project and made commentsto fcc in that regard. the goal is to facilitate the creation of a nationwide broadband networkdedicated to healthcare. provide funding for 85% of an applicants direct cost. that meanseach applicant would have to provide 15% in cash. it was established by the fcc to hebpublic and nonprofit healthcare provider degrees ploy a state or regional dedicated broadbandnetwork, that was the purpose. the paperwork had to be completed by june 30th, 2012 thisyear for any funds. there were initially 69 funded projects announced in november of 2007.almost five years ago at a total of 7 $17

million to be distributed over three years.it was a two year program, and then at the announcements a three year program. to makethis program work it is required two one year extensions. why i point that out is that ifyou have to take a program that has so much potential value and keep extending it to allowpeople to take advantage of it, there is probably an issue with the process. out of the 69,50 remain. we had an attrition. they were able the smit $369 million, 88%, that leftabout $50 million. out of that $50 million, they provided another temporary program, wecall bridging funs for those programs that others with had completed what they neededto do for construction. but needed to wait for the new programs to come in place, forcome we are angivistly awaiting the announcement.

this is our program in new mexico. one ofthe larger ones really connecting networks of networks and even trying to determine wheredoes internet 2 and national rail fit into that. i will briefly mention those. we wereawarded 15-point $5 million, to cover 85% of our build out and operations for our networkof networks. in doing so, as we went through the process, i have presented this beforeto the fcc, we did a s.w.a.t. analysis, the strength, weakness, opportunities and threats.well, the strength is obvious, what a great idea for the fcc to build up broadband acrossthis country. it was a great idea to design, construction and operate broadband to supporthealthcare and metcon exchange. provide more access to healthcare for all americans. theweakness then, the process did not just work

well. it is cumbersome, i mentioned it requirestwo one year extensions and several projects dropped out. that tells you something andhopefully, a lesson learned. there has been these programs in place using universal servicesfunds, but we have little data to dempen straight the benefit had it has bought to this countryand we have poor coordination with other federal programs. i will mention those briefly. theopportunity that we have now is to improve and streamline the process. make it more userfriendly. more timely achievement of the goal provide adequate and affordable broadband.the threats are we will have incomplete product implantation because of the difficulties inthe process and gaps will remain across this country, unless we change the way that weapproach it. we must then, if we don't demonstrate

the benefits, that's a threat and funds mayhave been wasted if we are not using them appropriately and the threat is a lack ofsustainability, if we put the programs in place. i will close with the challenges. thereis a need for coordination, cooperation and collaboration across programs and initiatives.we have the fcc programs that i've mentioned. the department of commerce and b top,usda,rus, the bip program. we have internet 2, we have the process that combines it. we havenational land rail. we have gig u, university communication next generation project. now,u.s. ignite out of the white house with nsf. then nationalism if that is not confusingenough for you, there are proponents are saying it creates more reliable and high qualityservices compared to the commodity internet.

now you look at i-2, that's its own systemand national lambda rail, and they superimpose, why are they not coordinated. with internet2, they are reaching out internationally, that ads value and someone said to combinethe two, you have the u.s. you fined community anchor network. it is a project of $62.5 millionto bring the two organizations together. then you have there national coalition of healthintegration, which is going use national lambda rail. so, you should be part of that one.that's what this looks like. don't the networks start to look familiar, right? then we havegig u, to accelerate the deployment of my networks. should you be part of gig u, ifyou are a university based program and now we have u.s. ignite. i'm not saying the programsare not well meaning. it is hard for those

of us in the trenches to look at how thesethings are coordinated. so, what are the solutions? i'll close with this, my red light is blinking.did you did you say i would drop through the floor? or just jerked up. one is i would recommendthat we form an advisory board. this should not be the only time we talk about this. itis great we have the federal agencies finally talking to each other. those of down in thetrenches ought to be part of that. we need to streamline the processes and develop anetwork and design for modeling of the state, regional and national initiatives. we needto look at the gaps and fill them with affordable appropriate broadband. develop and implementevaluation metrics. because in the end, this is the last slide, this is what it is reallyall about. how do we serve this mother and

that child and that family anywhere in thiscountry, anywhere in the world and to do that appropriately, you must have affordable, appropriate,adequate broadband. thank you, very, very much. [ applause ] hello. i'm steve hearse, i'm from the officeof rural health policy. i'm here to talk about what is rural. this is not my fairly well-knownpresentation, which is anything that you want to know about rural. this is a much shorterpresentation. i'll try to get through it in 15 minutes. excuse me. who defines rural?i'm going to talk about some of the major federal players, in defining what rural is.the census bureau, of course, as you would expect talks about rural. the office of managementand budget. the usda economic and research

service. the office of rural health policy,has a definition of what rural means. but to start, i have to really talk about urbanizedareas. the census bureau has two different types of urbanized areas. urban areas thathas a core population of at least 50,000 people. then you have urban clusters which have acore population of 2500 to 50,000 people. before 1950, the census actually defined urbanas any population in a, in, in a core, incorporated place that had at least 2500 people. thatdoesn't sound like many people anymore. an incorporated place with only 2500 people,most of us would consider fairly small, but back about a century ago the census bureautook that as the minimum amount of people they would start calling something urban.around 1950, they realized we were beginning

to see suburbs growing up around cities. theydecided to expand their definition of what urban meant and include suburbs by ignoringthe borders of the incorporated places and start look at what was spreading out. so,they went away from simply defining, using the incorporated placed borders and beganto look beyond that. you'll notice they are not defining what rural is. in fact, theynever define what rural is. they define what is urban and anything that is not urban isrural. generally the urbanized places they have to have a population density of at least500 people were-square-mile. so, as they start going out, they look at areas and stop definingthe urbanized area when they reach that edge. 500 people per square mile might sound likea lot of people, but one-square-mile has over

600 acres in it. so, you're looking at fewerthan one person per-square-mile if you're looking at 500 people per-square-mile. now,the census recently back at the end of march released their latest figures on what theurbgen rural population is. i put it up here to compare between the 2000 census and the2010 census and see how things have changed. obviously, the population of the whole u.s.went up quite a bit. the population of the urban united states went up quite a bit. that'swhere most of the population growth was. you can see that over all, urban went up over25, 27 million, actually, right around 27 million. it went up over to be 80% of thepopulation of the united states. urban clusters actually lost a little bit of population.the rural areas actually grew a little bit

in population to 59 1/2 million, but for thefirst time fell under 20% of the population of the u.s., down to 19.3%. this, to me, thiswas really interesting. i had to include it. the population of the u.s. is really concentratednow. it's not spread out all over the u.s. it is not at all uniform. the u.s. populationhas a whole, the density of the entire u.s. is about 87 people perp square mile. new jerseyis the most densely populated state, 1100 people per-square-mile. alaska is the leastdensely populated state. one person per-square-mile, but the population as a whole. the densityis 87 people perp-square-mile. the urban population of the u.s. is very concentrated. 250millionpeople living in 1 mile of square land. most people think of the neverlands of being asmall country, they have a population density

that is 1/2 that. it is, the u.s. is becomingthe majority of the population is living in a very small amount of the total land areaof the united states. here's what i mean by that. this is the census bureau's map of urbanizedareas. all of the little pink spots you see are the urbanized areas. everything else isrural in the united states. most of the population, obviously, just over 80% of the populationlives in those little pink splotches on the map. the ads up, i usually round it up andstay it is 5% of the land area of the united states. it is actually under 5% of the landarea of the united states. so, like i said, 250 million people are living in about 3%,100,000 square miles of the united states. what has this men over the years? going backto the 1900 census when they started using

2500 people at the minimum amount for an urbanized population. the majority of the people of the united states were rural. before thatfar more of the population was rural. obviously the drops throughout the century, by 1920,it falls under 50% of the population is rural. we end up now just under 20% of the population,in the 2010 census now considered rural. somewhat surprisingly you can see that actually thepopulation is higher, the rural population is higher than was back in 1900, when it wasabout 45 million people and over the last four censuses from 1980 on, it settled inaround 60 million people in the united states are considered rural. so it has been reallystable. 60million people is larger than any state in the united states. it is far biggerthan the population of california, which is

the most populated state. so, a good dealof the population is still rural, even though the portion of the population keeps falling.i don't know how many people here are from the washington area, but if you are leavingwashington and you want to get to baltimore, you pass through montgomery county and cometo howard county, the yellow highlighted county here and reach baltimore. if you look at themap you notice that howard county, the pink area again is the urbanized area. everythingelse, at least half of howard county is considered rural by the census bureau definition. whenthe office of rural health policy and look at maps like this, we go, this is not reallyvery rural land. this is what we're, what we mean here when -- the title of this talkhas to do with malalignment. the census bureau,

by -- using this 500 people per-square-milecutoff, is -- including in rural areas lots of land that is really suburban. so, you'regetting out into suburban washington and baltimore here. these people in suburban -- in ruralhoward county, have easy access to all of the healthcare resources that exist in baltimoreand washington, d.c. so, they can get in their car and within less than an hour or less than40 minutes or so, get to gw or georgetown medicine center or johns hotchsons in baltimore.so, we think that the census bureau is over counting rural. now, the office of managementand budget has a different definition. they start with a core area, a core urban areaof 50,000 people. so, they are using the census bureau's urban areas and then classifyingwhole counties as being parts of metro areas.

they do this micro paulten areas, but theystart with an urbanized core of 10,000, but fewer than 50,000 people. 10,000 feels likea better cutoff than 2500 people. but together these are known as the core based statisticalareas, you will see that referenced cbsas. now, the, the one of the advantages to thisit does use whole counties. so it is very easy to tell if you are in a metropolitanor a micro paulten county. you will noting again, they are not defining a rural or anon metro county. they just define metro and micro. everything else is non-core based.this is what the u.s. looked like after the last census with the omb took the census andthe metropolitan county and micro paulten counties are the lighter shades and finallythe non-core based counties are everything

else that are not shaded in. before the lastsentences, we had 870 metro counties, they had not defined micro at that time. everythingelse was nonmetro. after the 2000 census when they went back and analyzed the data, theydefined 1100 counties being metropolitan. then the micro and the non-core based countiesare now 241. or 66% of the counties in the united states. as far as the office of ruralhealth policy is concerned and cms is concerned, micro paulten counties have nonmetro counties.so, we add them altogether and come up with the nonmetro counties. this sounds like itworks pretty well. metro micro. the population based on 2010 census, but the 2000 metropolitandefinition, we come out with 260,000 people living in the metro counties. non metro, 50.4million people. that will change when omb

redoes the designations to the counties inthe next year or so. this is baltimore county now, every county in the area is a metro county.those are shaded. the unshaded counties, the non metro counties, you have to cross thebay. you have to go across the bay to get to a nonmetro county or across the pennsylvanialine. those are the metro counties or head out west until you get to west virginia orto western maryland to find non metro counties. that seems to make sense. howard county ispart of the baltimore washington, d.c. metro area. well, this is audience population part.so, anybody been to this place it system for healthcare it is a pretty well-known touristdestination. it is the grand canyon in arizona. it is in one of the dark shaded counties here.it is a metropolitan area. the grand canyon

is a metropolitan area. the reason is thatmost of the population living in the southern, very, very southern part of the county thatgo to flagstaff and phoenix. they are pulling the whole county into the metropolitan area.that's what omb is looking at, but because it is a really huge county and includes thegrand canyon, it doesn't make sense really. this is a malalignment we're looking at areasif census is including a lot of suburben area that should not be considered as rural. ombis including a lot of area that should be rural but inside of the boundaries of themetropolitan county. omb says it is a metropolitan area.it doesn't look like a metro area, at least they would fall into this classification ofmetro code 3 here. then there are a bunch

of nonmetro codes as well. i'm having to hurrya little bit, i'm running out of time, but there is another -- also, way of dividingcounties up. metro areas of a million or more and small metro areas with less than a millionand dividing up the surrounding non metro counties. depending if they are next to amicro area with less than 50,000 and more than 10,000 or nonadjacent, they are furtheraway from a metro or micro area. finally, orhp and ers worked together to make ruralurban community area codes. they are based on subcounty units. we can look at the largecanyon, like in arizona and say, is there metro, is there rural area inside of metropolitancounties. so there are a bunch of codes get assigned to every census tract in the unitedstates. 1-3 are the metro cores and then micro

and small towns and finally 10s that are wayout in the middle of nowhere. frequently. this map of arizona shows you that the northernrim of the grand canyon is a 10. it is an isolated census track that is out there. itis not easy to get to flagstaff. so, it's not considered really part of the flagstaffmetro area anymore. now there are problems with, even with the codes. if you notice onthe left hand corner there is a big yellow census tract. it is a 3, considered part ofthe yuma metro area. that census tract is over 2,000 square miles. so the people ifthere is anybody out on the eastern edge of it. they are way far away tromp yuma. theyare not close to a metro area. so, we put that in rural. we can crosswalk to this, tozip codes. again if you're doing research

and looking at population data and have zipcodes you can find out what their code is and consider they are considered rural ormicro or metro. our definition covers all non metro counties in the united states. theyare considered rural. we just take them. then we look for ruca tracks inside of the metrocount. with certain, they have problems and they have very few few people in them. weend up with 60 million people being rural. close to the census bureau number. we alsoend up with 91% of the u.s., less than the 97% really that is rural by the census bureau'sdefinition and more than the nonmetro counties in the united states. so -- i'm going to skipon. we have a new frontier definition, but i have run out of time. so, i'll just, thisalso has several different categories you

can use, if you want to identify really sparselypopulated, isolated areas in the united states. this is a possibility to use it. this is websitesyou can use to find out more information about census. omb or the orhp's definition and theusda. that will wrap me up without going too much over time i hope. so, thank you. [ applause] thank you to all of our panelist. i'm remindedby your remarks, steve, there is a career in demography, for those interested in telemedicine.so, i'm going to alter my career guidance counseling to a number of my gradiate studentsto include that, but i will tell you, it's fascinating to me about, we're clearly interestedin it from a policy point of view in many, many different census. but one can't helpbut wonder if there is not another dimension

that rurality has been sort of offered simboughticly to stand for, that is one of isolation. i work in the area of bebeattys and obesityprevention. where am struck by food deserts and seeing them in our centers, not that differentfrom healthcare deserts and seeing many of our rural areas not equally afflicted by thisnotion of food deserters. so, i'm wondering a little bit about the dimensions that wehave assumed that rural and urban capture. that perhaps that indeed in light of yourpresentation, steve, argues that we ought to reexamine that. dale, another point, thankyou for your very thoughtful comments with the fcc. two weeks ago my 16-year-old sonwe were cleaning out a large abandoned storage in my home. came across vhs systems. he said,what are these, i said you can play a videotape.

none of them were compatible with any of theothers. dale as you began to talk about the different kinds of networks that merged national,regionally and international, i was reminded of the discontinuity and the challenges ofbringing them together. gary when you held up your driver's license, i wanted to makesure it was not your room key, that only gets you into your room, 30 a state there. areinteresting precedences for rethinking the notion of licensure. both that state leveland at the federal level, but as anticipated by john's initial remarks, those notions aboutpractice standards and scope of practice and other regulatory issue of the day that arebecoming increasingly polarized in today's climate. they provide yet another layer tothis issue of licensure as a subset of, of

matters, of, facing us with respect to regulation.we want to continue this as a conversation. so, there are microphones that are throughoutthe audience. we have -- just under a half-hour, which we went to fully dedicate to this conversation.so, we encourage you to pose your questions to an individual panel member or to the panellargely. i will intervene if we get a little bit too announcement oriented from the flooror panelist. so, let's make it interactive. so, please start here and move back and forth. hello. i'm from west virginia. this is a greatpanel. [ low audio ] thank you, panelists? let me start out, thanks for your comments.clearly all the things that we do whether

we call it telemedicine, telehealth, e health,getting connected has to be needed driven. so, for instance, in our state we have anoffice for community health. that office is, is there really to really to really to reallyto really to really to really to really to really to really to really to really to reallyto really to really to really to really to really to really to really to work with withthe communities collaboratively, addressing what the community sees as their health need,which would also involve the provider. it is not just physicians, it is pa, advancepractice nurses. it's -- the community health workers. so, in our state, we feel that'scritical. we can't, from the health science center say in new mexico. this is what wethink you need and here it is. addressing

needs and doing it community by communityi think becomes very important. in fact there is a program called heroes in new mexico,which is health extension rural offices, which are patterns after the agricultural ruralofficials that help farmers understand best practices. that we're realistically deployedin their communities. we're trying to look at the same thing with healthcare. so, itis critical for a connection collaboratively with rural healthcare providers. i will commentbriefly on special systems. i believe these will be really important tools for us to domapping of a variety of public health issues, both dynamically, a spread of flu or understandingwhere our patients with diabetes reside and the population with the greatest need are,are, within a region. so, that we can better

direct our resources in a meaningful way.so yes. we have to involve our rural healthcare providers and the communitys. yes. i thinkthere is new technologies emerging like geo spatial information systems to make a difference.they are all going the needed aicate connectivity. so, we got to find a way to facilitate thatprocess and getting people affordable broadband. thank you, dale. any other comments from panelists. let me make a comment. i don't know if thisis on. i guess it is on. i think the economics are such that the days of the independentrural healthcare provider are fairly limited. not to say there will not be any, but fewerand fewer as we consolidate systems and develop networks that are broader, the use of technology,telemedicine and otherwise will be critical

to link in health providers in rural areasto other parts of the network that they belong or are partners with. we see providers linkingin technology. we're going to see a lot more branding into rural areas that you have anindependent provide that may say dr. jones and underneath it an affiliated of the clevelandclinic or whatever is in that state, for example and telemedicine will play a very importantrole in providing that empowerment to the local provider to link back to larger systemsand larger resources. thank you, john. our next audience member?[ low audio ] i'll jump in and say that, i think whetheryou're urban, rural, frontier, inner city, it should be irrelevant when you talk abouthealthcare. it should just be what everyone

gets and the artificial distinctiontions inmedicare, in many of the state laws on medicaid, that limit it to rural need to be -- doneaway with. those kind of artificial disstimulations. california has done a great job on that andbe a beacon for the rest of the states. but one of the -- one of the challenges, sensethis is a challenges panel is to get the government out of the way. with medicare, medicaid, statelicensure, some of these things that throw-in artificial geographic distinctions when youhave to look on the map to figure out whether you're in or out, i just, no longer applyin, in a world that is very connected, 4g. you know, lambda, what ever, you know, thatit just should not matter. every american should have access to one healthcare system.we should have tell -- coverage across the

country. not state by state or county by county.or plan by plan. it's inexecutable that we don't have a national network. so, i understandthat, some of the needs in rural areas are different than urban areas, but we have transportationdifficulties in metro areas. we have people that can't get out of their house or theirapartment. they may be able to see the specialist office, but they can't get there. so, i, ithink -- while we're hearing a lot of rural and it is important to deal with rural, thatit is important that it -- we remove those distinctions. it is also important to, fortelemedicine, you have to have a population base to work from. if medicaid doesn't coverin a state, state of florida, for example, highly urban. so, when you don't have themedicare beneficiaries in florida covered,

it's hard to create a helnetwork that willbe sustained. so, it is important for rural areas to get the urban population coveredas well. so that there can be a robust network that benefits everybody. steve, and wondered if you had any additionalthoughts since this truly cross cut with your area and presentation. well, to me and i'm -- not part of the officefor the advancement of telemedicine. so, they are located with us, when i bring up how denselypopulated the urban u.s. is, to me i go, this should be a no-brainer that we have broadbandcoverage in this area. now the problem is the rest of the 97% of the u.s. and the 60million people who live there, mow do we get

broadband to them. so, that's, that's -- wherei think we need to -- concentrate more. though, i understand even in the urban areas we'renot getting the kind of broadband coverage we ideally see, really the problem is outthere where there are 60 million people who deserve had same kind, the same high qualityservice that anyone else should be able to get. steve, let me put you on the spot. all right. how viable do you believe this continued distinctionbetween rural and urban is? in the context of the issues under discussion here. is theresomething that your privy to.

i'm pretty happy with the definition thatwe use in the office. it is not perfect. there are no perfect definitions, but i like thefact that we use subcounty units. the census tracts and the metropolitan areas. the newfrontier definition that i mentioned i think is also going to be useful for really beingable to identify areas that are truly isolated that really need greater help in being ableto connect to -- urban cores and to the kind of health services there. i'm hopeful thatwe're, we're going in the right direction. thank you. the next member from our audience,please? [ low audio ] thank you. it is more than a point of information.one thing in the workshop. we are been asked to address the current state and the futureopportunities in the field in the context

of the aca. so, john or gary, i wonder ifyou can speak to this issue as you understand it in the context of ac a and licensure. sure. we're aware of that provision. it isa good one. there have lots of different ways this issue can be dealt with. it could bedealt with the existing state boards through their national federations. there have lotsof things that could happen. i would say that the problem is getting worse not better. wealso have, have the issue of declining productivity of, of physicians and other practitionersthat we need to do everything that we can to have people operating at the high end oftheir license to, to, to -- you know, come up with, with ways and, and, i know telemedicinesometimes adds to the burden of physicians,

john was talking about the tsunami of data,but to come up with ways to use technology to improve provider productivity to deal withsome of the shortage issues. so, there's lots of opportunities. the nurses have, their nursecompact that started off great, but kind of stalls out in terms of implementation. we'reat, in a position where there have a lot of big alternatives. i appreciate mike cash beingsupportive of telemedicine, i would be happy to talk to him about a long list of thingsthat his department could do to advance healthcare improvement for all americans. please do. thank you. if, if i could just add a couple quick comments.jonathan will probably -- grimace when i says

this, but i talk about we're in a perfectstorm right now. i mean, you have the affordable care act, but still very controversial andvery partisan. we have an economic downtown, the healthcare is not sustainable. more demandfor care. an aging population. baby boomers are in the medicare error and we have a crisisin the number of providers in at all levels. i believe this is where telemedicine, telehealth,health information technologies will play an important role of navigating this perfectstorm. i think groups, i think ata is trying to work with the federation state medicalboards. they a process called the uniformed application, the federal vudenchallying verificationservices. trying to steam line the process of licensure. it takes too long and lastlyintegrated health, too often we have taken

physical health and carved out behavior healthfrom the. i believe they have to be integrated. we have to look at health holistically. i'mhopeful however we use telemedicine in the technologies will allow us to integrate healthin a much more meaningful manner. thank you, john. you look like you're aboutto add something. i was going to jump in, since you did mentionperfect storm. i wanted to add a comment not on the subject. i don't think this meetingwould be right without mentioning another challenge that is unmentioned, the elephantin the room. some physicians love telemedicine, they can see 20 patients in an hour, wherethere used to be 15 or 10 patients, but they want to be paid the same amount. silence inthe room. i think that a huge issue. we have

to come to terms with it. because i thinkif you're more efficient in telemedicine, we have to come to terms that maybe we don'tpay the same amount for that service, if it is done over telemedicine. that actually isa model that is being used in other places. it is being used in neuro physiological monitoringand other places. it is a very sensitive third rail. the third rail of telemedicine is notstate licensure, but payment, that has to be addressed at some point. some of you were worried this panel will beboring. i hope that is set aside by the comments so far, this morning. back over to the audience,please. would you take a moment to remind the audiencehow they can find that report? [ low audio

] thank you very much. i want to make a quick comment on that. wheni was young, i thought never bite the hand that feeds you. so, in the s.w.a.t. analysis.i think it is a great idea. what we have to do is work together with realistic solutions.i've stated that to fcc as well over and over again. we all want the same thing. i thinkif we work together collaboratively, you can play a huge role or fcc play as huge rolein getting this country connected. so, i really do appreciate your efforts. i think part ofmy other message, we had a lot of other federal programs that i don't think, from my standpointwere well coordinated. we dealt with that

is in new mexico, we had a hospital sayingthat we were approached by a b top project and there is no cost and no cash match. so,why would we go with you. everyone is trying to do the right thing. they are well intendedprograms. hopefully, we can continue this dialogue, because i believe that this countryis falling behind the rest of the world in adequate broadband connectivity for all kindof things, not just healthcare. i appreciate what you are doing. hopefully we can continuethis. we have three audience members left. let'smake it through in the next three minutes. please. [ low audio ] in something less than15 to 17 years, should we continue to require the level of r cts or the level of evidenceneeded for these studies to be published in

reputable peer reviewed journals? if thereis a reason why we might go to a different standard, how should we go about doing that? we are about 30 seconds left. [ laughter ] so-- panelists, please. yes. thank you. tom? [ laughter ] yeah. [ no audio ] let me very quickly. let's not spend timeon patient acceptance, patients love telemedicine. i have never seen a patient acceptable studywhere they didn't love telemedicine. let's focus on costs, that is the issue. qualitypeople talk about, but it is cost. there is

a lot of telemedicine that is proven thatit is cost-effective and fine. let's go with those. there are other areas that need somestudy. part of that is because the studies are not there. part of that is the congressionalbudget office and others are looking at a very narrow definition of cost savings. that'sthe other definition that we have. the cost savings for stroke care it is in rebilitation.so, they think it costs money, so they are not going to approve it. that's the realityof what we're facing it right now. part of it is the studies and part is how you treatit. high apologizes to the other two audiencemembers we ran out of time, but thank you for thoughtful comments and to the questionsof the pannests and the panelists for their

insightful comments on today's remarks. thankyou. [ applause ] now, further directions with logistics over the lunch hour. i was going to say next slide, please. thanks, i get to talk to you about food. soif those of you who are -- there's a lot of people here. we have a very small cafeteria,for those who are speakers or part of our planning committee, we ask that you go straightout into the large atrium and samantha will point you in the right direction. the otherparticipants take a right. in terms of going out of the building there is nothing in theimmediate area, you will have to walk if you chose to do that. i want to remind you thatthe cafeteria actually closes after that lunch

hour. so, any food that you want to get, getit now, but you can't bring it in the room here. so, we will have coffee available duringthe afternoon that you can have outside. we're going to start sharply at 1:00. so, thankyou. [ music ] [ music ] [ music ] [meeting is on lunch break at this time and will resumeat 1:00 p.m. e.t.] [ music ] [ background music] [ music ] [switching captioners atthis time. thank you, >> start to take your seats. we want to getstarted. if you can hear this in the hallway, come on in. we are going to start in 1.5 minutes.>> we are going to get started. i hope everyone found food. the talk after lunch is goingto be exciting and stimulating and everyone will be awake for it. a couple of housekeepingthings -- i violated this -- when you talk,

make sure the you have a microphone. wheni answered a question, i was sitting in my chair. the webcast doesn't pick it up. evenif you have a comment that is just burning, you have to jump up and go to a microphone. this is telehealth and payment. we often talkabout the elements necessary for a technology enabled healthcare system. we talk about ubiquitousbroadband and equipment and a trained workforce and we talk about removal of regulatory barriers.we also talk about reimbursement and payment. most people think of that as first among equals-- payment. if there is no payment, it is amazing how people are not as motivated. thisis an important subject for us to cover. something that karen gave me this morning is somethingthat came out from medicare reimbursement.

i would play a game of guessing how much medicarereimbursed for telehealth services in 2011, but you would be wrong. according to thischart, it is less than $6 million. that is barely a decimal. even when there is payment,people are not taking advantage of this. the bill are not addressing this. the biographiesof the speakers are available to you. we will go in the order on your program. we will startwith jeff stensland from that back. -- medpac. karyn edison will follow. she is from theuniversity of missouri. then, manish oza and linda magno. >>i am an analyst with the medicare advisory commission. the commission is a congressionalagency that works as the research arm for congress. the reason i'm here today is becausecongress mandated that we do a study of rural

health care. as a part of this study, we lookedat some of the data on medicare and telehealth. we try to get an idea of how far it is expandingand why it is expanding and what is promising and what has been disappointing. that is whati will go through today. i think i will try to frame my points in terms of what i wouldcall the two triple aims. one that you hear a lot about -- if we have an insurer withus today -- the government perspective -- often we want better access for patients. we allwant better quality of care and we all want to see cost growth constrained. that is oneof the aims. the other aim is for the providers -- they want to improve access that theirpatients we see. they really do all want to improve the quality that their patients receiveand they want to make money. you have two

of these things. if you do not meet both ofthese aims, there are problems. you will not see the expansion of telemedicine. this is a basic slide. there has been a long-standinggoal to improve access to care for isolated beneficiaries and about 7% of medicare beneficiariestravel an hour or more for -- 7% of rural beneficiaries -- travel one hour or more toreceive care. this could improve access to care. medicare pays only for interactive videoconferencingbetween the beneficiary and a certified rural site. that is what medicare is supposed topay for. here is a big shift that is happen. between1999 and 2001, the initial payment policy essentially said we are going to give youone payment, but you have to have 2 providers.

one has to be the originated site and wantedthe consulting side. that clearly fails the aaa and for the provider because there isno way a provider can't be losing money on that prospect relative to what they couldmake on a face-to-face visit. we saw very little telemedicine at that time. i workedat the university of minnesota telemedicine center. this was grant funded and there weremission driven people not doing this to make money even though they were losing money.under that type of scenario, you do not get a lot of people joining the bandwagon. wedid not get a lot. starting in 2001, you see the shift of nowhaving 2 patients -- payments and one practitioner. from the revenue standpoint, they are madewhole. it is equal to what they would make

in a face-to-face visit. the cost i be higher,but at least the revenue is equal. i think that from the taxpayer standpoint it is importantto note that down the payments are higher. i think that any discussion of expanding telemedicinewidely will have to take into consideration how much more those visits will cost the taxpayernot only on an individual basis, but the number of visits. here is what we found when we look at thedata. i think you heard the number of $6 million which is not a lot of money that medicarereimbursed. i don't know what year that was -- probably 2011. we looked at the data, welooking at 2009. we were also surprised that there was not a lot of use. there were 14,000beneficiaries of one or telehealth this is.

we found 369 practitioners who provided 10or more he telehealth services to the beneficiaries. most of these were mental health services.we try to ask ourselves why there is a low level of adoption and certainly there is thenurture i am sure you are familiar with and some people have told us that in some casesthere is extra time for the visit. if i am a direct knowledges, if it takes extra timefor the visit, or if i am a direct knowledges to -- from ecologist -- dermatologist -- therecould also be some issues with cardiology. maybe they are making more money from theancillary is that if they see someone face-to-face -- they get to have the ancillary income ona telemedicine visit. maybe they don't. there are also administrative better start-- barriers. this could be another hindrance.

in general, the bill and we got from talkingto people in the literature and you all have your own opinions that are at least equallyvalid is that this is a fragile process. often, telemedicine except for the mental healthproviders is that may be part of their business. if you put enough to call in their way, theymay just say no, i will not provided. that may be why we only saw 369 providers providinga significant amount of telehealth care. for these providers? who are these providers?the first row is not surprising -- most are psychologists. psychiatrist and clinical socialworkers. the second one would eat surprising -- 19%of them were ba's and clinical nerve specialist. these are not the subspecialists positions.they are nonphysicians. it would be interesting

to learn more about what they are doing. thisis not the traditional model you here -- we had to bring expertise into the world areasand highly trained individuals. you also see a fair amount of family practitioner. an internalmedicine. what you get out of the other categories -- neurology and cardiology and a dermatology-- there were only eight are one of them that were billing more than 10 business. thereare more now, but still it is not a huge number. i should also say that we looked at the numberof a visits in 2009 there were about 40,000 visits. you will see this in any data youlook at on telemedicine. there are usually two different types of data -- how many visits-- how many bills medicare received from the provider, and this was more like 40,000 in2009. it is public closer to 70,000 or 80,000

now. and how many bills from the originatingsite? the originating site has a substantially fewer bills, less than 30,000 from the originatingsite. you think that these would come in pairs. we looked at the data and said -- who arethese people that are not -- where are these claims that don't have an associated originatingsite build? we called them to see what they were doing. these were 2 individuals that were responsiblefor 4% of all the claims. they were providing a telemedicine claims to individuals in theirhomes in urban areas and rural areas. this is not allowed under the rules. it is importantthat when you look at the data to take it with a grain of salt. when you see the medicareclaims numbers, do not assume that these are

according to the rules, because of probablya large share are not. >> i also want to talk about some promising new telehealth uses.this is the stuff that is exciting we talked to people about telemedicine. one is tella pharmacy -- we heard about that. mary wakefield talked about north dakota. i was excited aboutthis because it really that a couple of the aims. tell a pharmacy, -- tell a pharmacy-- the critical access pharmacy without a pharmacist on staff could improve quality.also, telepharmacy is used in towns with less than 10,000 people. this improves access.especially with the freestanding pharmacies in the small towns -- you can meet a tripleaims. you might get better quality and you are getting more access and it doesn't lostthe insurer any extra money. when we talked

to the people running those programs, theysaid that none of the pharmacies are receiving any other grant ones other than what theyinitially started with. they are all self funded in making all of the money from theadditional prescriptions that they sell to cover the cost of the pharmacy tech in a townof 800 people and the additional cost of the pharmacist looking at everything over telemedicine.that was promising. it is a triple a winner. -- triple aims winter. tell emergency care -- this is a broad spectrum.i was struck by the article talking about tele icu care in the new yorker a couple ofdays ago. this was about high-tech medicine. detailed specialists talking to another physicianwho is attending to a patient in the room.

then i think about when i go out on some ofthese rural site visits to these small hospitals -- some of you don't know this, but the criticalaccess hospitals often does not have a position on site. they don't have to have an rn on-site.the highest trained person when you come in my he and lpn. -- might be an lpn. this isnerve-racking for the nurse as well as the patient. it might make a differences the nursecould hit a button it would go to the icu somewhere where the physician could help thelpn stabilize that patient. it is important to think about the spectrumof what is happening, especially those tiny hospitals. the nurses that we talked to were fabulouspeople doing great work with their limited

training, but it is very scary for them whenthey are the highest trained person in the hospital in a heart attack comes in the door. remaining questions -- these are good forthe academics. first, when we went through this, i think there are a couple of motivators-- back in the 90s when i looked at this, a lot of people were talking about the motivators-- producing -- producing patient travel time. -- reducing it. i am excited about improvingquality as a potential motivated. we see this in pharmacy and telemedicine. i think thetroubled times -- another thing i would like to see more of in the literature that we don'tsee is looking at the trade-offs between the physician time and the patient time. one ofthe difficulties that we may not have seemed

so much expansion of telemedicine is thatif you look for some of the providers, if you talk to a ecologist or cardiologist -- theymade be able to bill hundred dollars in 10 minutes -- if you take an extra 10 minutesdue to the computer not putting up or them having to go to another room or administrativehassles with paperwork to deal with, if you make them take an extra 10 minutes, that is$100 down the tubes. you ask -- how much patient travel time could we pay for with $100? thereare a lot of patients that might be willing to have a four hour trip from there into theurban area and that for that $100. it is hard to make the economics work. i would like tosee the literature get more sick merger -- serious about the differential in the race for thepositions get aid versus the patient time

and the patience employers. it is a difficult issue. people may thinkit is a crash issue -- but you need to think about this when you ask yourself why telemedicinehasn't taken off. back to my top point, we talk about quality,that is not such a big deal because when you talk about the tele emergency care, transportationis not an option. this is about the quality of the patient and improving the care theyget. i think it is a more compelling case. finally, the research that we looked at -- wedid a literature review of telemedicine were doing our studies -- i think there are twothings would like to see -- more studies by people more involved in actually providingthe care. there are a lot of studies by people

saying this is what we did in this all works.more independent studies and i heard about the difficulty this morning -- more independentstudies. i also think some studies of people who ofstopped doing telemedicine. this would be a fascinating study. one of the things thatwe mention we talk to these people billing for care in urban areas or in people's homes-- they said we don't do it anymore because we found out that it didn't work. we are tryingto manage our chf patients and manage our diabetes patients better with home on enteringand we thought it didn't work, so we stopped. 90% of the time the workcenter presented doesn't.but i would like to see more studies of the physicians who stopped doing telemedicine.we have 12 years of medicare claims -- somebody

can take these claims and download all theproviders numbers of the physicians were provided this telemedicine and take the data and lookat how many of them are not doing it or how they stop doing it. my guess is that you willhave hundreds of fighters who stopped doing telemedicine and it would be great to heartheir stories. did they think it didn't work? administrative barriers? cut into the profitability?we have a lot of success stories, but i would love to hear some failures because it wouldhelp us to move to more success stories. [applause] >> i will tell you a story. mymother is a nurse practitioner. she does diabetes care. she told me she was not going to doany more telemedicine because she sent a couple of people for telemedicine in rural areasand they had been told at the door that it

was going to cost the patient if you dollarsto come in to get a telemedicine service. i said that's not right. we are going to fixthat. she said i can't do this. sometimes it is the little things. not things you mightthink. i am going to talk about challenges to telehealthwith traditional payment. i threw in a little bit of regulation. when i started to put thesecomments together, i started to feel guilty. many of you know that i was here in the congresswhen we were expanding payment for telemedicine. we put all of these constraints around becausewe were trying to get the congressional i did office to give us a reasonable score.this is so it could get past. that is what we did things we didn't want to do. that iswhy we put the codes in the law and why we

made the list of providers and the list ofsites -- all of those constraints. that is why we only sent store and forward in alaskaand hawaii. now, we are fighting against of the constraints.i think it is time to get rid of these. i'm going to talk about traditional payment andsome of the challenges there and a little bit about new models. most of you know thatreimbursement in that care is for live interactive telehealth if the patient is in a nonmetropolitanstatistical area. most of you know that store and forward is paid for in alaska and why.you probably know that medicaid reimburses in most states 45 states. store and forwardservices of one type or another are reimbursed in 16 states including california with thebig medi-cal program. this number has gone

up gradually over time. private payers in many places. 15 states havemandated that private payers pay for telehealth. in my state, there is not such a law. mostof all the private papers paper telehealth. just because 15 states have a lot -- thatdoes not mean these are the only 15 states in which private payers pay. private industry -- this is starting to contractwith us directly for services. i didn't know how much you would get ahead of time of thatthe payment you have gotten -- you know all this -- the providers and the site and theservices. you know that the facility fee is over $24.it is low -- the sites where patients are

seen -- they think it is low, but that iswhat it is. as a provider, i have to be privileged andcredentialed to provide this service and i have to be licensed in that state. i willtalk more about this issue that is been a barrier for us this year. the licensing issueis a big one. i live in missouri. i am at the university of missouri in the middle ofthe chat -- the state. our population centers on the coasts, if you will. kansas city andst. louis is where most of the population lives. both of those cities are truly by statecities. this licensure issue is an issue. eight different states such our state. wehave a lot of cross state issues to think about.

dedicated missouri is every much like themedicare reimbursement scheme and that is true for many states. -- medicaid. the patternof reimbursement after medicare. >> in our state, the facility be in the medicaid programis only $14.60. it turns out that is not really enough given the new meaningful use requirements.i don't know how many clinicians are in the audience, but at how many ears as -- but,that occasion reconciliation where when the patient comes in you have to go over all theirmedicines and verify them and put them in the electronic health record -- that is atime-consuming process. it is a key function and marker of meaningful use. meaningful useis providing pressures on telehealth. also, at the end of the visit, the patient has tohave a depart summary -- a clinical summary

printed out as a part of meaningful use. now,we are mailing or faxing our depart summaries to various sites. meaningful use is puttingpressure on telehealth. we have a group meeting to try to solve these problems that come upwith some best practices and policy around meaningful use and telehealth. barriers -- what are they? some are perceivedand some are real. liability -- the medical malpractice situation, as you know -- theaffordable care act did not do much. we still have a lot of the fears out there. particularlyin the community health centers and critical access hospitals. we hear back from them thatthey are afraid to let us see a patient that lives in their community in their center ifthey are not there patient. if you are a community

health center and the patient is not one ofyour health center patients, they won't let the patient come in and be seen via telehealthbecause we are -- where the care is delivered as far as medicare is concerned is where thepatient is. not where the care providers. so, they are worried that if something happens,they will be liable. that has turned out to be quite a barrier. reimbursement. you haveheard from many of the speakers so far in this covers that have talked about the rural-- mellow politician -- metropolitan issue. this is been a big issue for us. about a thirdof our sites, when a change the designations, we lost a minute for the medicare patientswe were seeing because of that. we don't just build -- we actually figureout whether it is appropriate and approved

to build. regulation privileging credentialing -- wewill talk about that. here is the map showing the metropolitan and nonmetropolitan countiesin missouri. the oranges that enter politics. i don't know if many of you up into the donaldcounty in the southwest part of our state, but i would not call that a enter politicscounty. i wouldn't call have of these metropolitan counties. they are called this because ofwhere people drive from in the counties to go to bigger cities to work. right, steve?but, it is the able bodied people that do that. we're talking about medicare reimbursement.the elderly people are not driving to counties over there to get their healthcare. we needto get a handle on this urban metropolitan

restriction on telehealth reimbursement inthe medicare program. credentialing -- i know that cms tried hardto do this in a way that would not do damage telehealth. as you know, i was here as a policyfellow in the 106th congress for two years on the health education and pensions committee.i learned the lesson well. when it seems like it makes good sense in washington, this canplay out differently when you get into the real world. this one is playing out differently in mystate. basically, the ruling was that hospitals can't accept the decisions of the distantsite hospital; however, the hospital has to change their bylaws to allow for that. toallow for credentialing by proxy. this has

turned out to be a big area for some of thehospitals. over the last six months, i have gotten stacks of papers to fill out and billsfor $400 each to join medical staffs. i might go to 60 different places. we are workingon that and trying to work through that, but that is been quite an issue for us. this is where we are -- we have 200 210 inpoints in 67 counties. this is all over missouri. we are in the middle -- right there -- thatis where the diversity of missouri is in colombia. we are in hospitals and community health centersand state facilities and nursing homes. a lot of different places. although use of telehealthhas not gone up dramatically, it is gone up steadily in our center as well as other peoples.this is just our center. we saw 6000 people

last year in over 20 specialties, but thebulk of it was until health, dermatology, child health, autism, and a relative. manydifferent specialties have uses. i do not give a talk without giving in a patient case.this patient as the two uses case to remind us all why we are here what we are talkingabout. this is a father of four -- a 44-year-old farmer from the story -- three hours awayfrom columbia in the middle of harvest season. he would not have given to get his will evaluateit. for the clinicians in the audience, this was a 1.1 mm superficial spreading melanoma.we got it diagnosed and got a mini got it off and it saved his life. it saved who knowswhat for those poor kids for the rest of their lives not to mention his wife. so, telemedicinematters and access to expertise and care matter.

back in 2001 we expanded reimbursement, wegot this score. the cbo said it was $150 million over five years. five years later -- from2001 to 2006, that kerry spent $3 million. i just heard that these tenured numbers havegone up some, but they are very modest. what we need to do? we set up a system wherewe are tinkering around the edges. here are the codes we want covered. here are the providerswe want covered in the places we can be. here are the counties. we need to stop and throwoff the bondage and the shackles. let's stop and free the telehealth providers in thiscup three -- in this country to do telemedicine. we need to treat it the same as in personcare. if you drive to see a doctor, no matter wherethey are, they care is delivered with a doctor

is. just because technology takes you thereshould not be any different. if we agree that the location of the service provided is thatthe location of the service provider, we will have a lot of problems. these issues would be helped immensely. theselicensure issues would be helped immensely. the liability of your issue would go away.the patient location issues would evaporate. what is to fear from doing that? there is nothing to fear. early on what westarted to talk about expanding reimbursement for telehealth, there was a lot of fear. iwent to a lot of meetings where i heard a lot of to change -- fears about fraud andabuse. well, it hasn't happened and it is

not going to happen. telehealth is harderto do than in person care. most of us have more to do than we can possibly do anyway,so there is nothing to fear. healthcare for most americans to matter what you hear -- thebreathless announcements in the media about all of these different things -- most americansget their health care in a local regional fashion. referral medicine is based on relationships.people who refer patients to me know me. they know they can call me and i can call them.that is how medicine works. no, not all of medicine is going to be bought into the practices.that is something that i here in washington. -- i hear this in washington. we do get outinto real america, that is not the case. we

will continue to have independent providersin rural missouri and we need them. having knowledge about health care ever structureabout the patient side is critical. you can't be a good doctor if you don't know what theresources are for the patient where they are. do they have access to pharmaceuticals? isthere someone who could do a procedure if they needed? there are a lot of other constraintsthat could train -- constrained telehealth. the major barrier to the mind -- widespreaduse -- in the old model -- the major barrier is a lack of an incentive to do it. why wouldyou do it? >> long wait times in most practices -- i am taking a day to be here and my nextavailable is -- november or december. long wait times in most practices and higher reimbursementsfor procedural codes as referred to is you

earlier. i am a german ecologist and i stillmake a lot more money with what i do with my hands and what i do with my brain and myeyes. hopefully, we will see this change because we need to. why now, i lose money every timei do a telemedicine clinic. this is because i make much more money with what i do withmy hands and i don't do those things and telemedicine. i and the chair of our department so i haveto look at the bottom line -- i do to have taste and -- half days. -- 2 have taste. i have certain responsibilities. it is patientbase and we are a land grant university and once you start to do this, you realize thatpower to deliver patients -- the liver care to patients who were not going to get thecare otherwise.

we have a lack of training and mentoring intelehealth in this company. we are working with the rrc and we need to get out thereand train people and mentor people in its use. you heard a lot about the workforce shortages.i will not delay for this, but it is across the board. not just primary care, everybody.not just doctors, but nurses and their business and everybody. we can't take of the parishes-- we can't take care the patients we have now and with 30 million new people we willnot be able to do this. let's make the location of the service where the provider is. what'sgoing to support it? eliminate the restriction. reimburse store and forward services especiallydermatology. when it medicare did away with

the console coats, this resulted in peoplehaving no dermatologist that would go to the major hospitals. we can do that via a storeand forward telehealth and we need to. provider supported care will support this.meaningful use will support this. to dale's,, mature electronic health information exchangeenvironment will support this. these are things that are coming that will support telehealth.i will stop there. [applause] my name is manish oza, the medicaldirector for wellpoint. karen has touched on a lot of the things that i am going tospeak to, also. conceptually, we know today that healthcare is complicating and findinga provider is challenging. there is limited transparency when you go out on the web tofind a primary care doctor or an orthopedist

or an and chronologies. we know there is along wait time in the emergency room trying to find a primary care doctor, a specialistcan be extremely challenging as karen mentioned. an accessible -- we have heard a lot aboutrural areas and the challenges that distance can be in terms of a barrier to access. onlinecare -- we know it is a simple. it can be simple. it potentially can be fast. videochat is enticing. it is user-friendly. it is accessible. being able to log on anytimefrom anywhere is something that consumers want and have been asking for. trusted -- atthe blue cross blue shield, we are handpicking providers which is been painful -- they areready to embrace mobile health. this is not easy. you have heard this over and over again-- there are a lot of obstacles in our way

to try to find providers that are willingto embrace mobile health and get reimbursement at the right spot so that the carrots arethere for them to do this. and that they are not actually losing money. from our vantage point, this is what we want.we want car all to have a choice of a trusted provider with one click that he can choosefrom and we want to provider to be able to a prescribed and be able to order lab testsand radiological test is necessary so that are all does it have to go to the office -- karldoesn't have to go to the office but all the testing can be done and then, if necessary,he comes to the provider for a face-to-face visit.

this slide has the spectrum. it is probablynot all the potential things you could do from a mobile health standpoint. from my managepoint, when you start to say -- what could mobile health impacted -- you start off here-- then, when you say which one of these will have an r. capital i., you go to hear. thenyou say which ones will improve quality or will be the same quality if you want to theoffice space to face, you go to hear. then, you start to go to now trying to find providersin our environment and the incentives that are there financially that karen spoke to-- that is why we are now here. maybe smaller. these are the challenges we are facing atand them. i am passionate and i speak to where i think this will play a big role is in thepatient centered vertical homes. i dream of

the day when they could just of our killerpatient is discharged from the hospital -- a congestive heart failure patient -- theirphysician from their office can talk to the patient via the web about salt intake andexile their medications and talk about why it is important for them to weigh themselveson a daily basis. and the science of chf exacerbation. we know from managed care our ability to engagemembers and case management and disease management -- it is not that great. this is one exampleof where i feel you could plug in mobile health. most of you know that with the patient centeredmedical home model -- most of the models start with before service or enhanced fee-for-servicein the end with a shared savings. this is where you would align the incentives. nowthis doctor has an incentive to make sure

that congestive heart failure patient is notreadmitted or the patience on their panel are not going to the emergency room for a-- affordable erp is as in the first reductions are pcp before going to the emergency room. from the employer perspective, i service nationalaccounts. i am responsible for the east region. some of our clients are ibm, verizon, goldmansachs, etc. from their vantage point, they think this is great. that is music to theirears. they think it is convenient. they think it is going to be a timesaver. they thinkit will increase access. cost effective -- we have to proceed withcaution. definitely there is an opportunity. yes, but there is also potential for abuseand some people don't want to hear that, but

it is a reality. i could give you a separatelecture on abuse of what we face on a regular basis. hr directors -- they are excited about increasedproductivity -- a banker not having to leave his desk or his phone to go to the er or toa primary care doctor in manhattan, that being able to get on the web and see a doctor forwhat ever it is that he needs to be. -- but he needs to do. you to demand -- who doesn't want this? 74%of our consumers are saying that they would be likely to use online services. from myvantage point, i worry about whether we are prepared for the first encounter when youopen a program like this up and when the member

goals on the web and the first time we needto make sure that the right doctors are they are online 30 to receive the members of thatthey have a good experience. we all know what happens. we you have a good experience, you'rehappy. when you have a bad experience, you will tell seven or 12 other people about whythis is bad and how does it work and it was a waste of time. we are trying to be as diligentin as we can 2.our eyes across our teas and develop a network and try to find the providersready to embrace this. the challenge from our vantage point is -- will we have enoughproviders available in a 12 hour day time from 7 to 7 to staff the influx? especiallywhen you first open this up -- this is a big concern of ours at anthem.

bottom line -- these are the have the easythings. do we think members will be happier? yes. can they be healthier with greater accessibilityor? for sure. more productive? yes, if you are getting healthcareto people that potentially would not access healthcare or the egg example that karen gaveyou about the malignant ellen oma -- melanoma -- it probably would not have been treatedif they did not access telehealth. for medical cost -- i say proceed with caution.there are opportunities. it has to be done right. it has to be well thought out. theproper incentives have to be in place for clinicians to embrace this. today they arenot there. i think this is clear. why wouldn't

someone that can generate $100 or $200 anhour want to be compensated with 20 or $30? it doesn't make sense. we will spin our wheelsunless we align these things properly. healthcare in your hand -- we have had a pilotat anthem which leveraged case management via the web. the initial feedback was positive.engagement rates were higher than normal. the bean counters are still trying to do this-- figure out if there is really an roi. some interesting facts that i learned from thisstudy was that members told us they actually i to see the nurse, but they don't want thenurse to see them. this was eye-opening. the other challenge that we found -- if theywant to see the nurse -- a lot of the nurses

work from home. now you are starting to talkabout a nurse -- does she have to wear a uniform? does she need to be in a white outfit? mostpeople think of the white coat and a stethoscope. they think of the white uniform. does thereneed to be a backdrop behind the nurse? can you see into her kitchen what she is cookingfor lunch or dinner? barriers -- things we didn't think about. this is multi-factorial. the goal, ultimately, we all agree -- we wantour members to be healthier when and where they want and the way they want. from a payersperspective, we have multiple challenges. we have the integration of the data. you haveall these wireless devices that are monitoring glucose and weight. where is the data going?is it being integrated into an electronic

health record? can we or cms mine this datawe are trying to find out information in terms of the tricks and quality? additional costs-- that is a reality. i am a practicing appellee r. dr. when they came to me with the roi -- theylisted over 300 diagnoses -- one was ballot structure. i said are you kidding me? -- ballotstructure -- bowel obstruction. unless someone can pop in an iv tube and give them medications,let's be realistic about what you can treat over the rebbe -- over the web. let's be realisticon what it is. i would be lying if i didn't say that we are concerned about multiple visits.does the member go to mobile health and get a web visit and then say no, i don't thinkthey were right -- i don't know that dr. i don't agree. or as an er doctor, i have patientscoming in that are hell-bent on wanting their

antibiotics. i'd can talk to them until iam blue in the face -- you don't need antibiotics. this is viral. antibodies can be bad. thereare other side effects. i can tell them they are not going to get it and then they cantalk to my chairman about one of that dr. im, or i can write the prescription. if thereis a clinician here that tells you they didn't write a prescription when they knew they didn'tneed to, they are lying. we have done it. i've done it. i worry that it will happeneven more or some patients may shop until they get the antibiotic they want. so, let'sbe realistic about what we can treat with this. karen did a nice job talking about the laws.we are in shackles right now. we have states

where you can do mobile health, but then youcan't prescribe you want to prescribe unless you physically see the patient. well, doesn'tthat defeat the purpose? there are a lot of barriers there. i will close with the emphasis on let's lookat which ones are going to save money because i think we are all tasked with trying to findvehicles that will save money? increase college -- that is important. again, the 800th on-- 800 pound grill in the room -- you have to find the providers willing to embrace this.this number becomes a sickly small, unfortunately, today. linda magno good afternoon, i am and i appreciatebeing invited to speak this afternoon. i am

excited to talk about what cms is doing -- centersfor medicare and medicaid services -- in the way of interesting new projects in the areaof telemedicine and tele-health. i will talk about these as i go forward. i will not spendtoo much time on some of these slides. you know some of the issues we have with someof the existing delivery system -- it is fragmented, care is a coordinated and system is not supportiveand we have hit you hit the nail on the have with a lot of this discussion this afternoon.it is not supportive of physicians and patients and it is not sustainable. we think we have or we like to think we havethe best care in the world does he will come from around the world to be treated here.in some instances, you can find the best care

in the world, but across the system on a systematicongoing sustainable basis, that is not what we have today. that is what we are try to look for. i amfrom the center for medicaid and medicare innovation -- the charges to move the agendatoward a future delivery system that is more affordable, accessible, it provides seamlessand warning data care of high-quality, it is person and family centered, and it is supportiveof clinicians in serving the patient's needs. we want to transform the delivery system.we think we can innovate this to a reliable and sustainable and high-quality health caresystem that produces the goals of better care the point of delivery through identificationand dissemination of best practices. we hear

frequently that it takes 17 years for knowledgefor new science to make its way from lab bench to bedside. that is true with many of thethings we are talking about today -- using our heads instead of our hands deliveringcare. things that require using our hands seem to make their way a lot sooner. we arelooking for ways to disseminate best practices in other areas of care. but, across the spectrum. will looking for better outcomes of care throughthings like measurement and public reporting. and to changing the incentives and ultimatelywere looking for lower total per capita cost of care through restructuring the incentivesthat all of us face and deal with in order to be able to reward value over volume. theseare easy things to say, but they are challenging

to produce. we heard about telehealth. i'm talking aboutencounter-based telemedicine -- that is much the focus of this discussion today. we'lltime encounters between patients and physicians in a different location, but there is alsoa range of telehealth around remote patient monitoring. basically, the transportation-- transmission of information about and from patients on an ongoing basis to the positionto permit ongoing monitoring and adjustment of care around one or more conditions. in addition, there is an explosion as we gothrough -- day-to-day there is an explosion of new technologies, devices that offer remotemonitoring of a lot more things than we used

to be able to do and getting lab values andmedication adherence. sensors will detect false or movement of elderly patients wholive alone in their homes. keeping track of whether they are getting in and out of bedfrequently during the night with a ball or flush toilets or return to bat and trip orwhether they move from the bedroom to the kitchen and whether they are eating. thereis an explosion of apps for smartphones and mobile devices. i think increasingly as thedevices become more common and the users age, we will seek much more demand for interestin mobile health outpatient -- reminders and healthcare management kinds of things. there are a lot of people out there developingall of these technologies and i have experienced

it in my almost 10 years doing demonstrationsin the medicare program -- they basically would like to come in as vendors or manufacturersof these technologies and applications and essentially get ready care coverage and consequentlymedicare payment for what they are providing, but it is important, i think, for that communityand for all of us to recognize that we need to think about who the consumer is of theinformation that many of these technologies provide. the consumers are sometimes physicians,sometimes care delivery organizations other than physicians, sometimes patients, caregivers,remote caregivers -- some of the center devices are very popular with family members beingable to know what is going on with a family member living alone. knowing when to callsomeone your the patient. -- mute patient.

sometimes, payers has interest in this information.when we think about reimbursement as we are today, think about who the consumer of theinformation is because i think that this helps frame the discussion around reimbursement.as we look at the medicare program historically, we don't generally pay providers for the toolsthat they use in delivering care. we pay them for the care that they are delivering. sometimes,be in equity in the way in which this care is paid for creates incentives that may discouragethe use of better, cheaper, more friendly and accessible technologies such as telehealthand telemedicine. i am reminded of the clinton campaign sloganfrom 1992 -- it is the economy, stupid. don't forget healthcare. in the era of telemedicineand the information that telehealth technologies

offer us, i think it is important to rememberthat it is the delivery system. much of what we are looking for as we look at innovationstoday is to look at where innovations fit into the delivery system and is the deliverysystem demanding the information and prepared to organize itself to use the informationand doesn't provide value? in some of the work we have done in the past, some of themodels that we tested and some of the disease management models, workable, which would'veremote monitoring with devices and some just person-to-person contact by telephone, havenot been very well received by position because it was more information than they wanted orneeded about their patients. it was not useful. there were too many different individualstrying to provide information to a physician

for different patients with different insurerspaying different organizations to provide disease management services. so, it is importantto think about the delivery system using the information. and the challenge for us, then,is to mind some of the delivery and payment models that work together to create an environmentin which telehealth services are both valued and can be paid for because of the way inwhich the entire set of instructions -- incentives is being structured. this is in order to achieve-- achieve the results we are looking for. i am happy to report that some of what weare going to do over the next few years is to support a number of models. this is my slide that is not going to be readable.we have a number of awards that were recently

made as a part of the healthcare innovationawards. nearly $1 billion and cooperative agreements that were made to 100 and 107 differentprojects around innovation and care delivery. and payment models. seven of them specifically identify and arefocused around telehealth and telemedicine. to summarize the models, they offer day-to-daymonitoring of patients with stroke and heart disease. they minimize the amount of travelthat the patients have from rural or underserved areas will need to do in order to be treatedby specialist for specialty care. i know that you will hear later in the next session fromdr. [last name indiscernible] -- project echo. we will also look at extend the reach of intenseit is to allow them to work as a supervisor's

of -- by remote contact with teams providingicu care in rural and underserved areas. we are excited to be beginning to work on theseprojects and these awards were just an outstanding in july. just announced in the month of mayin july. the challenge, again, for us is to be able to work with these organizations tofigure out what it takes to make these projects work and make these technologies work operationallyand what the kinks are. this is so we can learn from them and scale them up and beginto use these and other types of models to shape national policy as we move forward.with the authorities -- the centers for medicare and medicaid -- through the innovations wehave the authority to be able to take models that work and to produce better care and betteroutcomes and higher-quality and lower-cost

and expand those in scope and over time toit or national policy without getting specific legislation. so, we are looking forward toworking with these and another of -- a number of other projects, many of which will alsoinclude some of the kinds of things we are talking about today and encouraging thesetimes of technologies -- these and others as we move forward. >> i think one of thethings that struck me as i was looking at the descriptions of the projects we have justawarded these organizations is that they have opportunity to help us achieve what the iomidentified to make care safe, timely, effective, efficient, equitable, and patient centered.i think the things we will see what these organizations and these models and othersof the types we talked about today really

have a promise to allow us to do this. i will stop there so we can allow the restof the time for discussion. thank you. while you make your way to the microphones,what we have heard is -- jeff talked about the realities of where we are today and thekinds of studies that are probably needed. one of the points that karen made, i think,is good. it is not only about creating reimbursement, but also about removing barriers for doctorsand other clinicians to take manage of the reimbursement. you can reimburse, but if youhave their ears, it is not going to work -- barriers -- it will not work. from a private payerspoint of view, sometimes the payers are getting ahead because they know what their memberswant. but, i think you raised some interesting

questions -- if you just open up everything,there are still challenges. even when you are paying your providers to do it. you stillneed to find doctors are willing to do this. these new models are really very interestingand i think this gives us hope at the end of this conversation that there really aresome great opportunities here. we will start over there. jeff, in the medpac report of june 2012 -- inchapter 2 -- you talk about the fragmentation of care that exists for medicare beneficiaries,particularly those with chronic conditions, which is the will to pull majority. -- themajority. we have not heard a lot about care coordination -- whether it is in the be forservers portion or as we move toward the client

centered patient centered approach to carewith a team approach. i think it would be important to hear more about how telehealthas a tool, not just for diagnoses, but for getting at the issue of quality and improvingthe care coordination for the care patients in this case because it is recommended inthe medpac report and as we move forward with implementation of the aca -- how it increasesif efficiency and will improve the quality of care. >> i don't have the scope of expertiseto talk about all of this, but i will say that any different to liberate system shouldbe patient centered, whether it is before service medicine or a managed care plan. ithink that i would be somewhat agnostic in terms of what we know works. a fully, we allwant to do what is best for the patient there

are two different avenues going on. one isthe more ornate it systems -- the ma plants, and the aco, and the fee for service system-- a lot of the demonstrations that you talked about and in my mind, whichever ones of theseare successful, they are the ones that should win out at the end. in terms of the paymentrecommendations we have made in the past, to be a -- neutral with respect to the plan.if the ma blank into a better than medicare, go for it. if before service without, thenthey should be the winners. the patient should be able to pick whichever one they think deliversbetter care. i am from [indiscernible] clinic. thank youto the panelists for your talks to be a. it is nice to see people from cms engaging withus. i want to share -- our program -- we have

45 different clinical services. we have about25% of our total clinicians around 1000 who use telehealth in their practice on a regularbasis. we do about 5000 interactive consoles a year -- about 40,000 telephone the see.-- telepharmacy. we analyze our reimbursement and we do not build medicare or medicaid ifit is not allowable. i want to share numbers with you -- in 2011, we build -- we sent abill -- we build everybody. in 2011, we sent a bill for a total of 160,000 $7000. thatis about $100 per console. this is what we sent the bill for. now we got paid. medicaid -- $200,000. at is about $50 perconsole. the total that we build was -- we discounted 100 and we discounted $168,000-- about 40% -- most of this is attributed

to medicare and medicaid discounts. this endedup with about $206,491 that the patient had to pay out of pocket -- 11% of that totaldiscounted rate. we lost about $13,000 which we can't send a bill to anyone for. this isnot include all the services we didn't bill for. this whole telehealth reimbursement issueis not so much about telehealth, it is about reimbursement in general. even if we did getpaid, we still have significant losses just trying to provide care to piece it -- to peopleon an everyday basis. it goes back to equity. there are regulations that they medicare beneficiariesand medicaid beneficiaries to have equity, but as dr. edison said, if you are on thatside of the road in one facility, you can't get care so we have to pay $694 for a skillednursing facility resume to travel to get wound

therapy what if we did it over telehealthit would cost the system $56. we have done a lot of this analysis and it goes back to-- treat it as normal healthcare delivery and we are still struggling with a dollara location , but it leaves we have made it equitable for people. i think the remote monitoringpeace -- we need payment because we are delivering care. this will leave the cost to the technologyin a care delivery system. we really do need to that aim for evaluating the data that comesin and then acting on it in a clinical decision-making process. my question -- the other issue -- the alliedproviders -- they are providing specialty care. it is not really the positions. we needto look at what they are doing. they are providing

diabetes management -- some are doing sleepdisorder assessments and follow-ups. they are doing endocrinology. they are doing psychiatriccare. they are providing specialty care. it may not be a physician, but they are doingit incident to a supervised by physicians. my question is -- we save medicare millionsof dollars in five years. we didn't really see any of that transform into you paymentstrategies. what is your thought on -- we could give you a ton of data -- we could fillup the room -- but, what is the likelihood that this will actually transform into newpayment strategies for us? the act that the physician group demonstrationserved as the platform, essentially, on which the entire medicaid savings program is built.i am hard pressed to say it has not already

begun to change payment policy or create newpayment models. i think we continue to be challenged and i think part of what i am hearingtoday or what is part of what that what are my mind as i listened to the other speakers,is that we are all trapped by before service because part of what we are talking aboutis paying for individual services delivered by telemedicine that are not currently paidfor today -- paying different providers and so on. you are talking about whether the paymentamounts are adequate. i will not even go near that. congress deals with that once or twicea year. i will not touch that. i think the real issue is the challenge for timing thetypes of delivery systems are willing to operate as a system and create the infrastructureto be able to support the most efficient set

of tools for delivering care whether theyare telemedicine tools or whether they are other types of things that are not necessarilycovered and paid for explicitly today, but would be a part of the care that an organizationthat is focused on providing the outcomes we are interested in supporting -- higher-quality,better outcomes, and lower provide the -- lower per capita costs -- if they are producingthose by using some of these technologies, then the shared savings model or other typesof models really are supporting those. we get out of that issue of what is the rightamount to pay for a telemedicine visit versus and e-mail consult versus telephone consultversus in person visit. all the details of administrative pricing that were under a fee-for-servicesystem -- you the organization are taking

responsibility for the health of this population.we will pay you on the basis of the outcomes and results you deliver. there are a lot ofmeasurement issues, but that is the goal that we are moving toward. that is the way in whichreimbursement will change more likely than by trying to identify each of these individualshortcomings in the existing set of arrangements and what is covered and what is not and whatcodes are used for web services. your point is validate it -- validated bythe va system -- they have adopted telehealth. their job is to figure out how to deliverthe best care with the amount of money they have. it is interesting that in californiaand the kaiser system is rapidly advancing the amount of telehealth but they are doing.

linda, i wanted to thank you -- i agreed withthe shared savings. our challenge now is that the only option is the physician fee schedule.a lot of people struggle with that. thank you. >> i am larry conrad -- university ofnorth carolina at chapel hill. i am working with a set of people trying to find ways toencourage greater adoption and deployment of telehealth in a sustainable manner in northcarolina. i am wondering for the panel what sort of things can be done at the state level-- state policy? what ideas do you have that we might want to take a look at? this is tohelp specifically with a workable payment model. i would say whatever you do, don't do it onyour own. this room is full of experts. experts

on state policy around reimbursement. anynumber of us would the war than happy to help with that. is that fair to say? there are a lot of people in this room thatcan help with that. it has been done in most if not any other states. -- if not many other states. one issue at the state level is that differentparts of the state have different missions. just on the licensure issue, one of the issuesaround licensure is that our licensure people are -- they are basically and consumer protection.the medical board said -- we don't care who is delivering the care. if you are deliveringit on a california resident when they are

sitting in california, it is our job to protectthem. that person will have a california license they come into our state. that is becausetheir view isn't a global view. part of it is getting a number of people at the tablewhich we have been able to do in california in a number of settings. we did test passsome enabling legislation for telehealth by bringing a lot of it together to him up withwhat would be the best solution and let every agency have it say in how we can address theirconcern. this is fail [last name indiscernible] fromthe university of new mexico. also, it medical director for health information exchange.these comments have been great from the panel. you have done a tremendous job getting a greatoverview. i want to reinforce one of the things

that someone just said. one of the thingsis that we have to make a fundamental change in how we pay for healthcare. some peoplesay we are a sick system. we pay more for procedures and for you to be in the hospitaland we don't a well for preventive care. any, do you have on that would be welcome. howdo you think we can move forward? linda, you were just beginning to address that. so didjeff. i think one of the areas late into this -- going forward -- i feel a retinal scanshould be included in that -- defending blind isn't detecting a problem. i pointed thisover and over in new mexico -- they will not reimburse for store and forward in new mexico,but if we miss retinopathy with the site being threatened, they will pay for that, but theywill pay for her rehabilitation. something

is backward with the system. i would liketo hear from medicare cms -- what is the issue here? why are we paying for that? lastly,i want to reinforce what dr. edison said. i don't know why this decision was made -- forsome reason, we look at care being provided only where the patient is at the originatingsite and we get rid of a host of problems with us and sure, credentialing, maybe evenreimbursement issues. just say -- just like when i drive to see karen in missouri fora problem, i relied on her credentialing privileges and her qualifications in missouri and notin new mexico. if she did it to helen house -- why does she have to the credentialed andprivilege where i am living. this doesn't make sense to me. i would like to see somefundamental change made in that we look at

where the care is provided just as we wouldwith in person face-to-face. your comments on that -- i know karen made them, but i wouldlike to hear from others on the panel how they look at that. to me, that would takecare of a host of problems that we face. one -- store-and-forward. the other is -- whereis the carefully being provided? -- where is the care really being provided? i will not say too much about existing policy-- most of it is governed by statute and has the constraints basically that are in thestatute. beyond that, i am on the things outside of the organization. we are looking at alternatives.as i described and put their -- we will continue to work on innovations that we hope will shapechanges in policy. as to the historical practice

of not paying for store and forward technology,i cannot speak to that. >> i am not familiar with the store and for debate. it sounds likeit was a budgetary issue. it was a budgetary issue 12 years ago. wewere worried about what would happen if we said mary kate -- medicaid would pay for store-and-forward.alaska and hawaii have experience with this. we have 10 states with varying years of experience.in general, we haven't seen that explosion and fraud and abuse that people were worriedabout. there has been a variety of other things that happen. i mentioned -- doing away withthe consult close means that people lose money when they see a hospital console. it is hardto get people to do that. i am not proud of that. i am the chair of the workforce taskforce and it is a concern of mine because

we need to be serving those patients. in myown academic health center, one of my residents seize patient and i am in the clinic -- theywill send me the photos and we will talk about it and make a recommendation and then i goby and see the patient within 24 hours if i am going to build for this. but, i neverchanged my mind. the technology is so good -- i can't make a split-second decision andmake the estimate recommendations in real-time. i go by to meet the letter of the law. thisis so i can bill for that consultation if no date they don't pay for consult close.i think store and forward tell us their mythology -- these no-brainers. when california expanded their medi-cal program-- these are the two things they carved out

-- tele dermatologist and retinal screening.he did this for good reason. also, in the patient centered medical homeswe are seeing, we are partnering with our family and immunity medicine department andour internal medicine department and their patient centered home environments becausein dermatology you can do three, direct care, and consulted care. if they see a patientin a no-no what it is -- they can send me a photo -- they do this all the time. we aretrying to formalize this. patience send photos all the times. the vips of your organizationsend you photos -- we are trying to make it secure and private and formalize it. if theysee a patient in a patient centered healthcare home, they can take a photo and send it tome and i can say -- we have to see that patient

today. or, that can wait for a couple of weeksor one that you try this. if this doesn't work it -- let me know. you can do a lot withthe technology that is better quality and better access and lower-cost. when you accessme that way, you are going to send less people to me. that is going to be fine with me becausemy waiting room is too full already. diversity of pittsburgh -- thank you for agreat session. my question is about financial incentives for telemedicine with the forestservice -- i believe that these models are a great idea, but there will be a role forthe four services in a large health system across state boundaries. i was struck by whatkaren and jeff indirectly said -- questioning the role of telemedicine to increase efficiency.there are not enough special is that we are

to have too many patients. if we would justrather see a patient person that through telemedicine. the obvious fee for services solution wouldbe to reimburse more for a telemedicine consult and that would provide us with financial incentivesto see a patient be a telemedicine. obviously, this one out there. we've heard someone fromthe ata suggest that we should be happy with less reimbursement. i want to press you tocome up with other innovative payment models within the forest service that might incentivizea specialist to use telemedicine and i will throw out to potential ideas that you canshoot down. one will be to potentially build it into the value-based purchasing systemso that maybe we get bonus points. you get the same reimbursement or maybe even less,but bonus points via value-based purchasing

for participating in a telemedicine couple. then, this is more of a question -- are therealready financial incentives for a specialist provider to provide rural healthcare in person?and those incentives be translated like loan repayment in those kinds of things? those are my questions. thank you. there are not incentives to go in person toprovide rural care. for specialist. there are four pcps and general surgeons in somecircumstances. i would say that some of us have proposedthe idea. the loan repayment programs that are now used for physicians to go and locatein a rural community -- in a huge number of

those people leave after they met their commitment.this is to break that up and say to graduating specialists that it you provide 10% or 20%or some time -- you will get that percent of your time toward your loan repayment. thisis in order to incentivize them to start the model of practice. what we found is that oncepeople start to telemedicine, as long as they are department chair will let them, therewas one right there -- they like doing it. they want to continue doing it. one of thethings to do is to introduce early on in their practice. if you get new graduates and say-- i can't do one day per week in telemedicine in a rural area and i will get a percent ofmy loan payback. that is a potential proposal. i know there isn't not enough money in theloan repayment program in general, but that

is an idea. any other ideas? [indiscernible] this is nota formal position -- but i would toss this out -- i am concerned about the cost of telemedicineon the go. if everybody has their personal device and they call someone up and say -- oh,my prescription has run out and i need a refill and you call up on your device and it usedto be a phone call and now is a consult any new cost for the insurer. i think it wouldbe to get around that -- this is a hypothesis -- if the telemedicine consults were a partof a medical home damon. you are getting it for member per month payment in over orderto courtney cared have access available. part of that could be telemedicine. this gets aroundthe trying to hit more units of service, but

it also requires that you provide this accessfor the patient. i don't know if you think that is feasible? we are definitely looking -- that is why istress -- we have to understand the stresses we are putting on these doctors and now weare asking them to do management. whereas in them to expand access and they have a panelfull patience and they are seeing 20 or 30 or 40 a day. now we are asking them -- canyou hire position extenders and we will have you with that too over the disease managementcase management and now telemedicine? we are already trying to ask them to do more thingsand they are filled to capacity. there are many hours in a day -- they tell you thatthey work 10 or 11 or 12 hours a day.

ipo personally that the pm pm reimbursementis the way to go, but the primary care doctors -- many of them are worried. by fully so.will i make more less money? everybody in society was to make more money, especiallythe more that they were. alternately, if we have the incentives aligned and it makes financialsense for the primary care doctor to keep the patient to the emergency room to see themvia telemedicine for a uti or a perception resell in stead of saying come into the office,we will have a potential for this to work. we are still skeptical. we want to be reassuredthat they will not make less or that drastically less -- that is their worst nightmare. interms of fee-for-service -- i don't know if this helps -- i will give you an example andmaybe this will answer your question. a long

time ago, when we were trying to decide aboutreimbursement for end up to be and: after be -- we said use got a certain amount ofmoney. but, if you do them the same day, one anesthesia and the 2 procedures together shouldbe less time so you will get less. the majority of the patients -- it is rare to get to seeand end o the end: after be on the same day. -- endoscopy and col;onoscopy. were not seeingthat -- we are seeing them come back to separate times for two separate procedures becauseeveryone makes more money on the provider side. i would just say -- i mentioned it brieflyand -- one of the things we are seeing -- health systems and industry. contract on it be ofservice rate. for the consult. for the employees.

or the members. that is a fee-for-service -- not a traditionalbeef or service. it is a contract for services. so, we negotiate the contract weight and theypay us per no matter what it is. [captioners transitioning] retinal new th non pat thee retinopathy retinopathy[ indiscernible ] telemedicine end scope pee end scope endoscopepee colonoscope pee colon pee i agree that the site fee at $24 is not equitable.i was sensing a lack ofness tuesday a for increasing it. people ask us when we advocatewhat should it be in a rural facility. if

it is not $24, what would be equitable? i think that is a tough question exactly whatit should be. on the one hand, you want patients to have access to care. on the other hand,if i was, say, 45 minutes away from sue falls and i could drive there in 45 minutes andsee my dermatology gist or i could stay in my local community and see the local dermatologygist, i save 35 minutes each way, over an hour. you could say what is that worth toyou? they might say 20 bucks. should we set up a 50-dollar extra payment for the hospitalto service the point of care for that person and basically say, mr. rural south dakota,we will take $50 of your tax dollars to cover the hospital to what you think is worth $20.that is the downside. we want the access there

and maybe we need more payment to have accessthere. i want to keep it balanced. we don't always want to spend more money on a servicethat is not worth that much money to the patient. it is not a popular thing to say but i thinkit is the reality. i may be somewhat biased because back in the 90s when we worked forthe telemedicine center, we asked the patients what would you do if it wasn't there? howmuch is it worth to you? would you drive? it is a difficult question because we wantto have as much equal access as we can but we also don't want to be spending more onsomething than it is worth to the patient. doctor edison? i was hoping to duck that one. we actuallypicked -- when we did this, we were trying

to keep the cost down and i literally pickedup the phone and called around the country, people i knew and asked people and said howmuch does it cost to put a patient in a room and sort of averaged it and it was 20 bucksat the time. that was 20 years ago. as i was trying to point out with the meaningful userequirements, it ratchets up what it means to put a patient in a room, a lot, particularlyif they have a lot of medications and a lot of chronic diseases. will maybe that is notthe right price point on that right now. i think we have to really think about this ashealthcare evolves and the mature electronic health exchange information involves, whatimpact that should or should not have on our paint systems.

stew wart ferguson of alaska. i have to apologize-- we have benefitted from karen's efforts back in the ' 90s i think it was. i guessthis is the issue that i see is ten years ago, maybe 15 years ago, the issue was forreimbursement in general for telehealth, the strategy was to work with cms. so go privatepairs and their parties and medicare, right? what we have learned over the last few yearscms hasn't moved the dial and forward. most of your private payers have fee for servicesor private contracts. there is millions of telehealth cases happening with groups whodo it with store and forward. two questions i guess really. one of them is how relevantis a strategy today to work with cms? is that key to what we are trying to do right nowgiven the changes that have happened. it is

a question. the second question is -- again,with karen's talk was very focused. she is looking for one change that will move us forward.what is the strategy to make that happen? is it a cms strategy or is it something else?if you haven't had enough coffee, we can talk about this off line. to me, these are thequestions. life has changed and we are not talking about how the strategies have to adjustwith time. [ laughter ] i will not tell you whether cms is the rightstrategy for you to pursue. cms deals with medicare and medicaid can move ahead and insome cases has. we are clearly open to testing new models of payment and delivery. i wouldnote -- the thing that struck me in the previous discussion about what this is worth to patientsis that while our patients are sicker and

maybe less likely to drive over time, by thetime they are likely to drive, they are often more complex that telemedicine may not bethe appropriate model for them. without getting into an neck dotes, i think there are a lotof elderly people who value face to face time they have with physicians and if telemedicinebrings the care to them in their homes, that might be a model that would be attractiveand appealing and clearly worth considering but when we talk about saving time in a populationthat is largely retired and has lots of time, saving time by not driving 35 minutes or anhour each way or 45 minutes, whatever, is not as critical as it is clearly for youngerpopulation where i think the convenience of telemedicine is something that will drive-- is driving private insurers as well as

some of the other issues. as i look at thepopulation, i look at the population needs, the costs are and the complexity. i see itas a case if there is something that makes the care easier and more convenient for patientsand that's the form they want it in, i think that may be a strategy. in general, thereare a lot of other things besides medicare that are playing into telemedicine -- whoit is valuable for and how and why. stew wart, i agree with your comments abouthow the landscape has changed but i still think it is a valuable strategy to partnerwith cms in both of the issues you mentioned. i think it is a valuable strategy and i thinkwe should continue to partner with cms on these issues. i think not doing so would bea mistake.

i think it is good to partner with cms andhope people will work with the private issuers and people outside the fee for service systemlike a kaiser or something. in my mind -- when we do our research, we are looking for whatis the private sector doing. we know what the financial centers are. if we think theycan provide better care for less model, we get excited. if you can't convince cms andit works for someone else, that's great. if kaiser gets bigger and bigger market shareand cap at a timed systems get more and more market share because they can do more forthe patients, great. if it kicks linda and i out of a job, that's fine with me. hopefullyit goes in both directions and we can let all good ideas come to the floor.

i wasn't saying not to partner with cms. forthe kinds of things that medicare can do to make telecare valuable to the patient. i don'tthink cms should be the cornerstone to make all the rest of the market to move. medicareoften sets the direction, not exclusively and i think it is important to look acrossthe board at other payers as well. that is what i was getting at. join me in thanking our panel for a greatdiscussion. [ applause ] we will be starting back at 3:00 so we have20 minutes. [ break ]

we will start in one minute . our next panel is the healthcare continuewomen. we have three speakers today. the first speaker is bill apple gate. executive directorof the iowa consortium . i think you heard earlier, project echo isone of the award winners for the cmmi project. who will start first? bill will start first.thank you. good afternoon. you see the title. i ask forworld peace but they give me this one. i guess it was a negotiation. i think i just clickthis . i will say some things with health systems over a period of time. i worked withthem and was the ceo of multiple healthcare systems for years. i may be on the outsidenow but i do have experience with those systems.

i say what i say with a view of what is goingon there and for the last ten years, i worked in a health sciences university at medicalschool while finding the consume um. we work in about 28 states so we have a number ofprojects going on. i wanted to show you this slide. it is my favorite slide in the wholewide world. we all play in this in different areas and the better we can play in it, thebetter off our health of our nation will be. i like to talk about individual parts of it.we have quizes among our staff that says pick out one block of this and tell us somethingimportant that you want to share about this block. we enjoy this a great deal. i wantto make some personal disclosures. i have no money and it hasn't been doing very wellso i don't know where it is. i can't tell

you whether i have it in the right or wrongplace. i thought there would be other personal disclosures that would be good for me to sharewith you. i'm deeply, deeply devoted by making health happen by making shocking strategiesthat touch the lives of people. i want you to know that it is really making better healthand lower costs which is better healthcare. so we are kind of involved with the tripleaim but we are really focused on achieving better health and lower cost. sol route generalparticulars. it is the opposite of path general in this cases. it is the building and establishmentof health . then i had a curious pathogenic industry that we are all involved in and knowof in all different ways and seems to busy itself with a lot of costly approaches tofixing the health and healing the sick and

diagnosing -- but does little for mitigatingthe most costly component of healthcare expenditures and the last thing, you will learn a littlebit about this the iowa consortium. i will talk about that in a little bit. here is whati will do today. i will talk about some truth about managing chronic conditions. the realwill he ever has to do with chronic conditions. i like a lot of things that are going on buta lot -- the willie sutton comment, why do you rob banks? because that's where the moneyis. a lot of healthcare can be better off. i want to share some field proven experiences.just about everything we do is telehome care and health based. we don't believe you haveto come to the office or hospital to do an awful lot of things to get really powerfulresults and then i want to explore clinical

health coaching and how i believe it is relatedto lightening in the bottle. i did a presentation a couple weeks ago at a meeting and i askedeverybody how many of you in the audience are now directly or indirectly interestedin management of chronic diseases? do you identify those with chronic conditions andproactively? do you identify and manage those fairly well or do you wait in affect untilpeople present themselves with their chronic conditions and you deal with them at thatpoint? these are the kind of questions that are really important. you have to reflecton that with your own organizations. i hope what i share will help move you to a betterplace on this screen than where you are at the present time. why are we in those conditions?sometimes we are unclear about what our desired

results are. and how we are going to do it.if that's not a problem enough, reimbursement, we heard about it in the last segment, itis inhibiting getting us going where we want to go. frankly there is not a lot of confidencein what we need to do. i review a lot of propose sals and like a lot of you do and for organizationswe know of and i'm interested in how we have set ups, lots of data stuff being developednow. it is really impressive and we have outcomes over here but i'm lost in space in this magicin between about something that is going to happen in the lives of people to get the outcomes.in fact, i just don't see them very often. we will expand access, prompt healthcare reform.implementing new strategies of payment reform through cmmi and others and reduce overallcosts of healthcare. i think we are doing

some specific things in number 1 and 2 andsome in number 3 and the last couple of them are what i call faith based strategies andpromises of healthcare reform. i believe in them a lot but i think we need to work towardsthose. i want to talk about the big thing. some of you say it is not a secret. this isundeveloped and often unspoken saves costs for individuals and health plans and hospitalsand governments. it saves costs all over the place and improve healthcare and does a lotof other things and we can do it. it is within our ability to do it. what it is is keepingindividuals with chronic diseases out of the er. that is it. well, i know that is big butwhat does that mean. i want to draw a little picture for you. 50% of the people on medicareright now cost $550 a year or less. this is

a lot of people. what does that mean? thatmeans that a bunch of them are costing more. we go back to some data. in 2007 the averagemedicare beneficiary with -- if you flip back and say 50% are costing 550 and less. thepercentage of cost associated with hospital aces and er visits and around chronic diseaseis 83%. this is where the money is. we can do intervention that will reduce that substantially.we have a sick care system which a lot of us have talked about that needs to be moreof a well care system. we need to move from path general cysts to absolute general cysts.we have a difficult time doing it because of the structures and systems we have . themiss aproposition of education as an end game is a real problem. healthcare professionals,i'm the patient and i'm the individual. you

tell me what to do and we have operated fora long time under the assumption that after you have told me, you have done your job.it hasn't changed my behavior or performance and lastly, we have an over artificial -- artificialover alliance of coming to the healthcare provider to get chronic disease managed. i'mso sad. it is too bad. i want to talk to you about projects. they are about what you cando. these are telehealth projects. the office of management of telehealth has funded someof these because they have faith in us. we like to work with medicaid populations. bythe way, we work with other populations. we work with heart failure program for their265 cardiologists. we did that. we are doing things all over. we like to cut our teethon medicaid. if you can do things on medicaid,

you can do things anyplace. 266 members ofmedicaid with heart failure. they cost 24,000 when we did this. we did home monitoring devices.it is heavily technology leveraged and we avoided hospital visits, the entire get dressedup for a party expenditure of $330,000. we saved over $3 million. this is no scienceproject, how do i want to say it, bad evaluation. we did match control groups. these are prettypowerful designs to show this. this gives you some idea. here are the expenditures inour match cohort and our project. this is under way at the present time. this is a 2010and 2012 project on diabetes. our inpatient visits are 54% under for those in the controlgroup. office visits down 6. a lot of our projects we have office visits go up. 1 to100. an office visit costs 1% of what a hospitalization

costs. i don't care if we double, quadrupleour office visits, we are well on our way to prevent a hospitalization. the total costreduction is about 20%. the return on investment is pretty shocking on this. i just got offthe phone with cdc. we want to do behavior change in health and wellness, medicare people58 to 63 and we took farmers because they are an easy group to change behaviors in andwe gave them health risk assessments and gave them education and we gave them diet and exerciseand prevention incentives and then we gave them coaching. we got reduced risk, improvedhealth status and improved trending. as we grow older -- we believe in population stuff-- you are all better than this -- as populations our health risks go up when we grow olderand our health status goes down. what our

job is to hit that group and say how can wezero trend those. that's what we have done and we will report that out in a couple ofmonths and i will be very, very happy about what we have done and it is exclusively doneover the telephone. even the hras and the fasting blood sugars are all done by homekits so nobody has to go to any doctor to do this. doctors are involved in this if theywant to be. something else we have done. if i don't goto the hospital or you don't go to the hospital, who saves money. it isn't just you or me orour health planning. 50% of the hospitals in this country -- happy to name some names-- are losing money on medicare heart failure admissions. they don't know it but they are.some of them believe it helps build their

baseline costs so it is okay. now, here wego, maybe, our telehome care learning 89% of the healthcare takes place in the bedroomsand bathrooms and kitchens of our own homes. if we can't get to those places with people,we will not get healthcare changed. their health is priority number 1. we can get apreponderance of these type of interventions that can take place telephone ton cal lee.how do we get the results we get? we give $35 per month for pmp coordination. 50 doorsfor technologies and registries and $5 for the network. you get pattern groups of peopledoing this and you can do all kinds of things. if you believe in medical homes or acos, weare working with a lot of people on both of those and it is scaleable to all payer applications.

health coaching. we are getting to the 80to 90% of the healthcare that takes place in the bedroom, bathrooms and kitchens inhomes. we developed health coaching. all of our projects have pretty active health coachingin it. it is not like a football coach. it is not like a teacher telling people whatto do. health coaching is its own style and it is important. why do we want to get tobehaviors. if you take a look at factors contributing to health and behavior things, what you willsee a lot of them are, in fact, malable. if you can get to those, you can get big differences.self care, harq said 95% of the dye beat tease care. we weren't getting topeople like we want to. what we have done is create something called evidence basedhealed had health coach. transform the information.

that's what takes place between the providerand the individual. we don't call them patients very often. we call them individuals and thetruth of the matter is that's where we are trying to get . i want to make sure some recommendationshere. i call them the loving suggestions for themselves. we need to support telehealthwith robust evaluations and that means research quality. we can't get to clinical trials.i get that fully. i know we can't get to clinical trials. the reason we need to have prettygood designs is if there is a lot of bad evaluations. i think we need to take a look at projectsthat leverage work at costly -- another thing we need to do is we need to i think providesome design and evaluation technical assistance to projects, need to work closely with cmsand have seen good demonstrations of that.

i think lastly we need to take a look andvalue at some of the clinical health coaching. remembering the idea that so much of the carethat takes place in the country happens as a function of self management or self care.if we don't get to that, we have to have better strategies and that won't revolve around changingthe healthcare system as we know it now. done. thank you. [ applause ]? good afternoon. i'm joe, vice president of-- i will go as fast as i can because i don't want to see the red light. i will take about15 minutes and tell you about some of the programs we are doing in acute setting and-- thank you to the planning committee, especially karen and tom for inviting me to speak. whereis allen town, pennsylvania, hum the billy

joel song. just to give you an idea of whatwe are. we are a big place. about 981 beds, three facilities. we employ about 1200 plusdoctors and 300 plus nurses and we have about 11,000 employees. i will jump in and talkabout critical care right now and talk about some of the challenges that we have. i willnot paint exactly a nice picture at the moment. we have an aging population, somewhere between8000 and 12,000 people are turning 65 each day. i know i'm getting younger but i haveto keep an eye on the rest of you. there is an increased demand for the service and providersand the lovely increased costs. it is about 90,000icu beds in the country representingabout 15% of all hospital beds and actually there is a decline in the number of hospitalswith icu beds. however, there has been an

increase in the number of beds total. so wehave fewer hospitals with those beds but we have more beds overall. approximately 540,000people die in icus each year. and mortality rates average 10 to 20% in most hospitals.only 10 to 20% of hospitals have critical care staffing that is dedicated and only 1%have it at night. the bad news is there will be a 35% shortage of intensiveses going forward.we need to find a way to spread this expertise out beyond the large centers that are fortunateenough to have large icus and a large number of intensiveses. we developed the icu at leehigh valley network. we called it the advanced icu because we wanted to improve patient safety.we purchased the hospital and wondered how will we keep the level of icu equal to thelarger facility and we were already leap frog

compliant but we wanted to go beyond whatthey require in terms of their model and frankly it was the right thing to do. let me introduceyou to mat mick cambridge. he is chief of critical care. he is silting in one of fouridentical pods and i will describe them to you in detail. mat has every information toolhe would have at the bedside and he has it in a remote location. i don't think it isall about an audio video system. i think it is about a combination of all sorts of healthtechnology information and we are referring to as our hit bundle. he has access to thepack system. he has real time audio and video into each room. he can zoom the cameras inand do a pipe pill reaction. we have electronic administration record. we have physician orderentry. all orders are done through that system.

we have an icu electronic medical record thatties to the master medical record. we have an event system so if a patient's vital signshead in a very bad way, we know it in one minute. we have access to labs. we have allthese tools all night long. what did it take to develop it? a lot of money. it took twoyears to develop just on paper. we had to involve all the key stakeholders in doingit. of we did site visits and budgeting and business planning. so let me tell you a littlebit about the critical care during the day. they are rounding during the day 7:00am. to7:00pm. they are closed so the intensiveses can intervene and consult on every case inthe icus and just so you know our trauma icu and our burn icu have physicians in-houseall night long long. it is in a remote location

separate from all three of our facilities.just so you know, this is an added layer of care. this was an expense on the hospitalsystem because we replaced nobody at the bedside. so this is just an added layer of care, asecond set of eyes and ears to watch over the patients all night long. we have 12 boardcertified intensiveses that rotate through and four clerical team members rotate witha take home point nobody works full-time in the advanced icu. they all maintain theirfloor and unit duties so they can keep up their skills with patients on the floor . iwanted to tell you that to put that in context. one of the first studies was out of northernvirginia. big decreased in mortality. length of stay decrease which decreased their costs.allowed them to have more admissions through

the icu and it contributed to their bottomline and i will tell you ours probably does too as a result of the length of stay. weare able to have more through put into the system. we published a study in april of 2010in the archives of internal medicine. we went back and looked at 954 patients prior to theicu and 959 after . we did have a drop in length of stay of .29 days. while that wasnot significant from a statistic cal standpoint, it is always statistical from our standpoint.the patients that benefit from this. based on the reduction in mortality, we are estimatetag over 500 more patients are leaving our icus alive in any given year at this point.we had a positive study. there are also some studies that basically did not find the sameresults. this one was by eric thomas and con

that remote monitoring of intensive care patientswas not -- another study by janet more son, they did not find any reduction in mortality,length of stay or hospital costs attributeable to the introduction of the teleicu. why didour results differ from theirs? in the more son study, they were looking at a model whereonly 73% chose low level teleicu involvement. so they were not using this to its fullestcapability. the thomas study only 66% of admitting physicians chose minimal admission to theicu. every patient is treated the same way every time. there is no difference in thelevel of care they receive during the night. so i don't think it really has much to dowith the study, the methodology, the design. it has to do with the model of the telehealthprogram. i will be the first one to tell you

if you want me to develop a really bad telehealthprogram, i can do that fast. it takes time to create a good one. if you study a bad one,your study would be inn -- i would be remiss if i didn't do a shout out for my nurses.we looked at this early on. the effectiveness every nurse on each 12 hour shift got 90 minutesmore of direct patient care than they did prior to the implementation of the icu. theyare feeding the electronic -- they have reduced the amount of charting. we have a lot morebedside care time back. i will back up one slide. i will throw this out there for youto consider. if you put a network in place and you are not treating each patient thesame in an icu environment, have you created two levels of care? i will let you think aboutthat. i'm not the one to say whether that

is true or false. in some cases if you arejust not treating the patients the same, maybe you have. back to the nursing thing, not onlydo they have more time back in patient care, we don't have to wake up a sleepy intensivistat night and report on something that they may or may not need to talk about the intensivistabout. that has been a real positive for us as well? another project we are looking on is teleinfectiousdisease. there are provider shortages here as well. you have to deal with the burn outissue. it becomes how do we use this resource the best way. what we did was available programremote consultations during daytime hours. exam cameras, document cameras and the doctorshave access to labs. we are in three hospitals.

one is a rehab facility. two hospitals seekingan agreement. we do not assume care of the patient. that stays with the hospital group.we do a true consultation and provide documentation back. these hospitals have daytime hospitallists and they pay us for the service. why would they pay us for the service? this isbeyond my wildest dreams. 85% of the patients we are with now are staying in the remotehospital. you are reducing all the transport costs associated with an inpatient transfer,an inner facility transfer and we have to charge them because there are things calledthe antikickback statutes where you can't give things away. that is one thing i wouldlike to see stopped. is there anything else i wanted to say on that? we are using theservices at the smaller hospital, their labs

and x-ray and we are leaving beds open inthe bigger centers for people who need them. i have two minutes before the red light comeson. i'm going -- this is the part where if you go seconds, someone has already said whatyou wanted to say. my goal, keep patients close to home in a safe, lower cost environment.the two themes we have heard today has been reimbursement and license sure. your addressshould not dictate where you receive care in this day and age. if i lived in new jersey,i could cross the delaware river on the ben franklin bridge going to philadelphia, noquestions asked . this is good for the rural hospitals. keep them lives. how many of youknow that the office of inspector general issued an opinion from a requester last septemberand the requester asked "i have a telestroke

program and this telestroke program is intendedto keep patients in their remote hospital and i would like to give them the equipment.i don't want to charge them for the service. i will give them the protocols and i willgive them the education and for all of this i would like to do this in an exclusive formatwhere that hospital can only use my services for two years. this would be a clear violationof the antikickback statutes and it would but based on your argument that you hope andwill keep telestroke patients in the local communities, we will probably not prosecutorthis. you can make that argument for every single telehealth service you do to a ruralarea or any under served area. if they have gone that far to basically kind of push asidethe antikickback statutes that we should try

to go for a wider coverage of that so thatthey gave the antikickback statutes for many more telehealth programs. i think that issomething we need to do. there is my contact information. that's my story and i'm stickingto it and thank you for listening. [ applause ]? echo stance for extension for community outcomesand the mission of project echo is to expand for common and complex diseases in under servedareas and monitor outcomes. it is funded by the state, legislature, department of healthand medicaid department, harq and robert johnson foundation and most recently by central medicaidand medicare innovation. the story of he can so with hepatitis c. it is expected about20 million will die from this disease if the

current rates of this continue. in new mexicowhere we live 28,000 patients had this disease and less than 5% have you been evaluated -- havebeen evaluated for it and 2300 prisoners that have been diagnosed haven't been treated.this was occurring despite the fact that this is a curable disease, there are gene knowtype can be cured -- 75% of the time. despite the fact it was curable, the bad news is itinvolves weekly injections chemotherapy like injections. not a single primary care doctorin new mexico were treating hepatitis c. there was an 8 month wait to see me. sometimes peoplewould need to drive 200 miles each way to see me . only 20% of our doctors practicein rural areas. we developed a new model to take care of this problem with the goal ofexpanding the capacity to safely and effectively

and monitor outcomes and mon we wanted todevelop a model -- we knew if hepatitis c would work -- dave albert son is the headof telemedicina i'm just a clinician in the department of medicine there. i said look,i have no money and no grants but i want to do this and you know who your friends arebecause they are your friends when you are poor. he gave me his facility to use withoutany cost to me and help us set up the echo model in his facilities and thank you verymuch for that. we have -- the first step was we developed a partnership with the universityof new mexico, department of corrections, health department and indian health serviceand community clinicians who had an interest in hepatitis c. these are the four main pillars.first we use technology, multi point video

conferencing and the internet. second, weuse a disease management model. third, we set up 21 centers for excellence for treatinghepatitis c all over new mexico. we asked ourselves how will we make them experts. wewill make them experts by case based managing and by learning by doing. lastly we do usethe internet to track outcomes. this was published in 2007. we train them to use our web basedsoftware to track patients and conduct medicine clinics which we call knowledge networks.they join us simultaneously. one by one these primary care clinicians present patients withhepatitis c. i have a standardized format. i need all 20 pieces of information in a maximumof 3 to 4 minutes. our team gives them advice and we co- manage the patients and go to thenext place. in two hours we give them a didactic

presentation which lasts 10 or 15 minutesor so. this is what you just saw was a knowledge network. no patient ever comes onto this network.the way these doctors learn and become experts. they learn through our presentations. theylearn from each other and mostly they learn from doing. they collect data and no -- wewant to reduce professional isolation by improving professional interaction for rural doctors.we want to bring a mix of learning -- why is there such high turn over. they tell usthere is no blooming deals and here and no alibi questioner key academy here. when theywent to medical school and residency, it was ague had mix of learning. by giving them accessto multiple specialists and learning. we use very simple technologies which i will notgo over. the lectures can be seen. web cam

interfacing. they can use a web cam we havedone 500 such telehealth clinics. we have expanded to multiple diseases and overallprovided 27,000 hours of cme credits to rural physicians in new mexico and 19 differentconditions. we know a doctor is not going to be willing to treat hepatitis c. becausethere are lawyers out there. we asked our doctors what is your ability to identify suitablecandidates for hepatitis c. question 3 what is your ability to treat hepatitis c and treatside effects. can you now serve as a local consultant in my clinic question number 5,goes from 2.4 to 5.6. 2.6 to 5.1. overall competence goes from 2.8 to 5.5. this is publishedin hepatology in 2010. we asked them, primary care clinicians are not just free all thetime waiting for television shows to start.

they have very limited time. they are notgoing to come on a network unless they find it beneficial. we ask them is this kind ofnetwork beneficial to you. 97% said it was major to moderate. 94% feeling -- 98%. thiswas published in health affairs in june of 2011. we measured the professional isolationin 2005. project echo 4.3 out of 5 and 4.8 out of 5. benefit to my clinic 4.9. expandedaccess to my patients, 4.9. the purpose of the trial was to train primary care cliniciansand prisons to deliver care and to show that that care is as safe as university clinic.intervention sites were 16 community based clinics. the control was the university ofmexico, liver clinic. there was auto prospective -- participation was -- clinician was notfeasible. if you were living in silver city,

it would be difficult because you were 250miles away. the bigger problem is if you live in al but questioner key, it is harder torandomize you to the prison . once you are cured of hepatitis c even after we go 15 yearslater, there is no virus. if you have sir row cyst and you are young, it reverses. theseare the treatment outcomes that we published in the new england journal of medicine onjune 9 of 2011. 68% of the patients were minorities, 49% university, highly significant. cure ratefor general know type 150% in echo, 70 for gene know type 2 and 3. he as safe and effective-- we can improve careful minorities but a very, very interesting new finding unexpectedoccurred. the cure rates were much higher than any other community to put a trial inthe united states. gene know type cure rates

of 20%. there were community gastroenterologygists in very large trials. we asked ourselves why are the outcomes so much better, by teambased care -- where patients don't have to travel long distances where you use best practicesand where the patient has a relationship with the team that is actually providing the care,you can get better outcomes than even a specialist can do. after hepatitis c was successful wewere asked by primary care doctor toss start other disease categories. if you have effectivetreatments, you can use this model. here there are two principles. the 80/20 rule. you don'tneed echos for 500 diseases. there are about 20 diseases that account for most of the morbidityand mortality. if you do echos on that, you can have a high impact on healthcare. everybodyprovides different care in private practice,

universities. we want to cut horizontallyto provide the same care everywhere especially in rural areas. the key goal of project echo,is the force mute applier. redefined it in healthcare, ten times or greater improvementin the capacity to provide care for complex problems. how does this happen. like nursepractitioner they ares to provide the same level of care as specialists, you get forcedmute complication. we improved the capacity more than ten fold and my waits in the clinicshave gone to 3 weeks from 8 months. we have 400 sites all over new mexico for 19 differenthealthcare problems. in every area, let's take the bottom right, we have one doctorwith a special interest with rheumatology, one with hiv and one with asthma. people don'thave to travel 250 miles to see a specialist.

medical knowledge is increasing expo thenshallly. mine is going down steeply with time. there is an increasing gap with what a doctorneeds to know and what he can possibly learn with more care. we would like to transformprimary care with network. they choose -- i'm a general list with a special interest inhepatitis c and so on and so forth. echo doesn't train primary care doctors and nurse practitioners.we train medical assistants because chronic disease management is a team support. thepotential benefits to our health system are improved quality and safety. reducing radiationof care -- work force training by de mon non pleasing knowledge. supporting the medicalhome model. preventing costs of untreated disease had disease and integrated -- theva is having a national replication -- just

the albuquerque -- our current represent indicationsites are university of washington for those four diseases, university of chicago, utah,nevada, department of defense, we have a worldwide partnership for chronic pain and the othercountries shown here also replicating project echo. this is our team doing this work. iwant to share some of the awards they got in 2001. this team won the award for the mostdisruptive innovation in healthcare worldwide. they received the other grants in this slide.-- using multi practice -- could k managing patients with case based learning is a robustway to effectively -- and under served areas and outcomes and thank you for your attention. [ captioners transitioning. please stand by.]]

ou this integrated will enter the p aradigm.to get it example the virginia va all-caps putting patients effectively -- universityof washington for those for diseases university of chicago harvard that israel utah nevadasouth florida virginia virginia for 11 411 regions department of defense we have faithpartnership for chronic pain and in other countries shown here also replicating projectecho. this is a team that has done this work, i don't want any of you to think i had thatmuch to do with the. i went to share some of the awards they got into thousand one,this team one the award for the most disruptive innovation in healthcare worldwide. subsequentlythey received the other grants as stated on the s lide. in conclusion, using multipointvideoconferencing best practice protocols

comanaging patients with case best learningwhich is the echo model is a robust way to treat common complex diseases in underservedareas and monitor outcomes. thank you for your attention. everything that you were talking about youdid emphasize the technology but what people can do together with the technology. thatwas one of the things that came to mind. i really liked your saluted jet assisted setof basic care system. it was interesting about the idea of pushing the envelope on the antikickbackissue. i'm not recommending it, but something that you mentioned and the whole project echo,but this is the first time that i have seen it in this type of demonstration. it is obviouslyvery powerful. i want to thank you for that.

i went to turn it over because i know youhad something that your presentation. yes, i had taken so many notes this morningi fail to mention a couple of things of the presentation on reimbursement. first, buildingon what nina had talked about for reimbursement in general, this will sound a little sick,but my institution is now looking at things going, how can we use technology to lose lessmoney on the patients were already losing money on. those congestive heart failure patientsthat will be readmissions. how many readmissions does it take to do a whole lot of tele- health?this is a different concept than asking how we get reimbursed and how we was less. severalpeople asked about the side site of service never being d efined, especially as it relatesto reimbursement. how many people remember

the healthcare finance administration? isnow known as cms. back in the day when they came out with a balanced-budget act in 1997,they've had a proposed rule. in that ruled they basically said the side of the servicewill be defined where the provider is located. that is what we talked about today. all ofthe other problems tend to go away at that point. in the final rule, and their finalcomments, they said, nevermind. from that point forward the side of servicehas really never been defined. while the healthcare financing administrative service years agotry to do that, it did not make it through. i thought you would like a little bit of history.i don't think the side of service is cacciatore lead to find and can be changed.

thank you. i would now like to open it upfor questions. please come to the mike --mic. thank you. amazing information. bill, couldyou give us your thoughts on, you have been doing this long time, so have we and someother people also. what do you think the reasons are that we have not been able to transformpayment policy around some of the data that we've gotten out of population health managementrex is it really about shared savings these days? doctor aurora, i was contacted by oneof those programs on your list to work through reimbursement issues and they were convincedthat they could get paid for what they were doing under the echo model. i convinced themthat they could not built for what they were doing. what are your thoughts on actuallymoving to a model where your consultants who

are helping our very care would actually bepaid under a consultation model? thank you. that may make a quick couple of comments.one, is the question you ask is about how we are not getting a cajun reimbursements?a couple of things, one is that we have a reimbursement system and there are a lot ofthings to keep in place. it doesn't take too innovation really well. i don't think youyou're going to get reimbursement for the things we are doing with population groups.we have to move everything t ogether. i think it becomes very difficult. plus some of theresults we're getting are pretty good. i want you to know that some of the results on similarthings are not so good and they haven't been so great. let me give you an example and iwant to be clear about this. a big medicaid

project in this country hires a disease managementcompany and they promised to pay them $20 million if they would sort out the peoplewith chronic diseases in their group and then save them $15 million. that was the firstrun. after 1 year, they showed how they saved $15 million. i want you to know that we werecalled in to do an analysis of that and it was of course quite hocus-pocus. this is abig well-known company and they had done anything but picked people at the point of exacerbationand no one in medicaid understood the regression to the mean that occurs with people with chronicdisease. they prove that they had $50 million in savings. i could've done that same thingwith no intervention whatsoever. that is what we call a placebo intervention, i could'vegotten the same results just about the cause

of the regression to the mean. what happens is we have not had an acrossthe board compelling evidence that is needed to confirm the payment systems. the secondthing is, not all of this is really worked in population especially in big groups. alot of disease management companies have known the secret of how you show results withouthaving any very long time and they've been doing it. that is getting blown a little bitnow and that has not helped the reimbursement. thanks for the question. i think that thereare two fundamental kinds of health care system in the united states. one is the kaiser permanente's,the va, and accounts for a very substantial part part of healthcare in the united states.these are fully accountable organizations

where billing and collection is not an importantpart of their business at all. they adopt echo like a fish adopts water. it is not aproblem for them. nobody has to be paid for anything for anything, they can see the immediatetravel benefits, they can see the benefit of less hospitalization and other costs. theycan push any of their priorities through the knowledge networks. i know you're talkingabout the other part. in the other part, in the and the healthcare system, also thereare portions such as the medicaid, manage medicaid programs. these programs are payingfor total cost including transportation c osts. in new mexico, all of the manage medicaidplans currently have agreed to pay us for echo. every aspect of echo. the primary careside, to present the patients, the specialty

site, to provide the consultation, the infrastructureside, that is one particular the state medicaid also gives us direct grants for echo becausethey see the benefit of that. we would consider this one off, but nevadahas most recently gotten the grant from medicaid for the same purpose. i am currently in meetingsin seattle just yesterday where all of the managed care health plans and every singleone of them is agreeing to pay for it it. when every health plan comes responsible forthe total cost of the patient, you are going to find them as extraordinarily good partnersto pay you, because it will help their pocketbooks in a very immediate way. i think that is wherei would say, yes, in commercial plans to talk to them about spending $100 for a consultation,i never tried that, i am not interested in

that. we are talking about partnerships toimprove healthcare on a statewide basis with these health plans. one of our health plansgave gave me eight check for $300,000 when they first set i will give you $200 per consolei said i did not want to. you can keep it. it is paid for the entire infrastructure sowe can create a support system for all of their patients, less transportation, lesshospitalization and better access to care. there is clearly a lot of interest in thisand our cmm i grant innovation grant that we just received. every health plan in twostates signed it as a partner to pay for it. my name is dave clifford i work with patientslike me we are eight technology platform company for monitoring chronic health disease outcomes.my concern continues to be translation of

knowledge and practice and the route to sustainability.i think doctor aurora you just highlighted one way of when people take on more responsibilitythere is some inevitability in doing things like the common sense way, coming from a feelthat is not medicine, coming from a generic background. secondarily, there are the strugglesthat doctor applegate you are having with taking this very good 200 or 300% cohort andtranslating the technology packages that were pay for under a grant or a pilot study andevangelizing t his. you can point to number number of graphs and say this is the rightthing to do, it will save you m oney, you should do it, but for totally there is a challengein many institutions to take up those lessons of innovation. i am looking to hear some commentson the paddle -- panel around the sustainability

of what we have learned. health systems tendto be% it percentage with facts and quickly forget. i will make a quick comment. we do some workthat have been funded by grants and others funded by healthcare organizations and alsoby health plans. we have done some for different kinds of groups. we've also done for medicaidas well. i would say that we have a thing that we do in all of our projects, we havea lot going on that we don't run anymore, because we are a capacity building organization.one thing i would say is that we have a sustainability claws and our contract. if we get money fromgrants, we go to whoever the benefactor of that is a we are training and building capacityto this. if we get results out of that deal

then they have responsibility to continuethat with their own funding however they do that. that varies, but if we do a for yourproject they typically have a responsibility that shows value of that period of time thatthey running for another five years or three years after 1 year. we are getting everyonesigning those agreements. a lot of these are going on and being paid for by regular funds.what i would say is that, and i feel good about the sustainability feature, and thatis one of the things we have done with these. if we get these kinds of result, when thefunding goes away, you will continue them. we have had both health systems, health plans,and several medicaid programs that have done that. that is one thing that goes on. someof our projects are 300 and summer 700 and

sometimes they are limited by the fact ofthe amount of money we have from external resources to do it. we did one with the medicaidprogram that was with 400 people, now that program is being run under sustainabilitywith about 1600 people. i would like to echo what you said. we havevery low grant funding at lehigh valley health network. we do have a trust which funds andprograms, but that tell health function has been placed under the chief strategy officer.going forward it is part of the strategic plan of the network. i think. i think from our perspective the issue weare trying to solve his is cap we what you're trying to talk about. 17 years to take bestpractice to the less mileage healthcare and

less than 50% of people are getting best practicecare. the question is, is easy to say the primary care doctor is not really doing asgood job as he could. the point is he can't. if if i can to you today and said ready hundredmeter dash and 9.5 nine seconds like we just saw, it will be hard for you to do it. thesame is true with the knowledge explosion. the primary care doctor cannot do it. it isimpossible. we try to solve the problem where we have them narrow the scope of the practiceand give them the mentorship they need to provide the best practice in a particulararea of their choice. we have found with payment that we are actually, i am not approachinghealth plans for funding at this point. they are coming to me to fund us. i would submitthat one possible way, the reason that tell

health is having some difficulty is that wehaven't shown adequate value. i think the important thing here is that the healthcareleadership plan are extraordinarily sensitive to value. they can smell it out from a nywhere.they are in business to make money and to provide better care. if we were to providecompelling evidence for value, i think these reimbursement problems will solve themselvesautomatically. i think the challenge for us is the evidence for value has not been compellingenough from their perspective. it has been compelling enough from hours perspective,but we are preaching to the choir. it has not been compelling from their perspective.we need to do whatever we need to do to make that happen.

we will take two more questions in the nextthree minutes. [ indiscernible - low volume ] to the speakersgave examples of tell health programs that have not achieve the same results becausethe protocols and designs with different. if we start to go mainstream and this grows,there is a way to do have tell health and achieve results and one that does not achieveresults. i posted to you with 30 seconds left, where do you see the role of best practicesand practice guidelines intel a health and what would the role of that be in growingthis field into a larger scale? it is key. i think that is part of the reasonthat the value proposition to the peers is not clear because they see this contradictingarticles and they say i don't know what to

do. i think that we have to define the valueproposition in the trials plus exact methodologies of how to do it correctly. otherwise, thereis going to be a constant challenge for us. i don't know any other way of doing it thenwriting a book of why programs work and others don't. it is all over the country, you cansee various programs that have great results and then you see the articles that come outand sometimes, unfortunately, the payers like to hang everything on the ones that don'twork. this is a way of them saying i do i'm not sure i want to pay for t his. other programshave great result. honestly, i don't know how we roll that out, but we need to. one of my comments and recommendations wasthat some of our projects that are funded

by different agencies need some good technicalassistance. i don't know exactly how to make that work, but i think that there are errorsthat are evident in really good proposals. there needs to be some good crap detectionor technical assistance. i don't know what the real word is. one more thing, there is a group that is called-- that funds regional tele-health health c enters. perhaps they can assemble informationon programs that work and others that don't. they are the ones that have access to thisinformation. there our a lot of different programs andours doesn't look like anybody else's. it just doesn't and i'm happy with that, butit is not the same as everybody else's.

dale alverson, university of new mexico. thisis great presentations and i have great respect for after sanjjeev arora and echo. one ofthe speakers and writers about this whole issue of healthcare reform and cost is -- alot of you'd touched on parts of that what i would like your comments about that. heis talked about the cost conundrum and looked at -- in texas and compared it to el pasowith no better outcomes. he is talked about the hotspots and give some compelling argumentsabout changes that have to occur in the system. ewald touched on that about unnecessary evaluationsin care and best practices. could you are have comment on his comments? i will start with the second spot first, thehot spotters. our cmmi is tickly focused on

developing outpatient teams to develop a newspecialty in medicine for the care of the 5% of medicaid patients that consume 57% ofthe resources supported by echo like knowledge networks. we are on that trail right now.the second part about reducing variation, that really wasn't ever the goal of echo.what we find is the second pillar on which echo stands the first technology in the secondis best practices. when we disseminate this practices, variation automatically reduces.for example, if i am a gastroenterology doctor and i like to do colonoscopy on a patientfrequently, when i am on the knowledge network i have to follow best practice. we are a communityof practice. a community of practice in which best practices are being discussed. automaticallythis reduces variation, despite your contact

just like we all behave better when we area part of our peers, the same way professionals gravitate toward the mean. there is much lessvariation when you have to discuss your decisions in a peer forum. it is an automatic systemproperty of the echo model to reduce variation. dale, my bad. i guess i missed the article.in terms of variation, since i have been in two different institution with tele-healthprograms, a lot comes down to politics. in the icu environment, sometimes they are openenvironments with multiple different providers covering the units. sometimes they don't wantothers consulting other cases. it is a culture and in our case, we decided to close the icuslong ago, before the advanced icu was even created so that the intensivists managed carein those units and if need be brought in a

specialist who may have put them in thereto begin with. i am really a student of the -- conundrumarticle. i would say one thing about that article and he has other lots of great ones,i am eight student of him. in terms of what we deliver and what we do with our populationhealth management and also with our tele-health home care. we have to make it worth whereever and the costs are an additional value. even though there are great regional variations,and he illuminated the two that he talked about, we have to make our things work whereverthey are. i don't think the margins are good enough to say cms has said, will work in miami?that is the favor question. it works here, will work in miami? i want you to know, iknow i have heard that three times. that is

a find question and it is so because whateverit is we are doing it should be the kind of project that will work in miami and it willwork in north folk and a lot of other places. i think we need to develop strategies thatbridge that cost conundrum issues. please join me in thanking the panel. [ applause] [ silence ] i would like to invite our planning committeemembers to the podium, please for a wrapup of the day. i want to thank everyone for theirendurance. this has been a talk full day of fabulous content and great presentations. age of us will be constrained to five minutesand then we will take some questions from

the audience. i will start with a summaryany recap. this was a fabulous day and i want to thank everyone for their participation.it is clear and we learned that tele-health absolutely and key coordination improves access,improves quality. in most cases it lowers costs when integrated in chronic and acutedisease management. tele-health reduces the burden and cost of travel with benefits accruingto patients for sure and also to many of the payers, including medicare for seniors whoare transported in skilled nursing facilities to emergency d epartments, two medicaid programsand two patients. in our va program we have documented documented travel avoided of 7.2million miles in our program. that is a lot of gas and a lot of time. it's also a lotof money. tele-health is a force multiplier,

i love that. thank you. it can mitigate workforceshortages and even creating new work force as we look at new models of care delivery.tele-health is perfect for integration into new payment delivery mechanisms such as patientcentered medical homes, accountable care organizations, bundle p ayments, as long as weight affectthe regulations to be facility where he. we still remain constrained by outdated paymentdelivery mechanisms, federal and state statutes and regulations that limit the expansion ofservices and interstate commerce in healthcare. the way forward, greater engagement of ourproviders, shared best practices, work with the specialty societies, advance innovativecare coordination m odels, evaluate our programs. the outcomes we saw demonstrated today ourfabulous. innovative payment models come a

fresh look at point of care and side of servicedefinitions to mitigate the barriers and maybe that is a simple solution that can be promotedby the institute of medicine's. share best practices regularly and i we need to movefor pathogenesis to saluted genesis. thank you. i have been in this business 15 years timeit seems like not that long, but it has been a long time and i am always struck when icome to meetings like this and listen to other speakers or i speak and get the questionsafter the audience how the industry and how healthcare changes. we think we know how itchanges, but i'm always surprised. from today, i don't have a lot of advice, but i will tellyou what i am thinking as a result of today.

certainly, we need to stop treating tele-healthis something different than in person care. it is in person care it is just that the twopeople are not in physically the same place. if we adopted that philosophy and culturewhether it is public p olicy, whether it is working with our attorneys, whether it iswhatever we are doing, it would really eliminate a lot of the discussion, the arguments, thepositioning, the barriers, whatever we are dealing with. i think the issue, and i'vetalked about this a lot myself over the last two years, the payment be can i get paid for15 minutes of care is going to go away and maybe our energy isn't really worth puttingin that area anymore in the shared savings models are probably the way to go. i lovesaluted genesis that is one of my new words.

i think doctor sanjjeev arora comments andthis also struck me is maybe we need to stop asking people to pay for consults underagefee-for-service model or shared savings. maybe we just need to say how about paying for theinfrastructure and in the infrastructure is included payment for the physicians and theallied providers to actually provide the consultations. i am going to be working myself on compellingevidence for value. i have been a value kind of gal for about 12 years here in tele-health.i think that, again, that is what i've heard today is we need a more compelling value argumentfor are business people. what irked me and and i could've strangled somebody was thecomments on what the assumptions were made that i heard today on what patients want.if anybody asks any of my retiree patients

how much time they had, they would say i ammore busy than i will was when i was working. they don't have time to travel two hours onbusy roads in wisconsin where there is dear, eyes, crazy teenagers, for a 15 minute ordealit you consult. i think problems intel health our problems in healthcare and we should stopdigging about them as separate. tele-health is one of the strategies, but it is also subjectto everything else that is going on in healthcare. the other thing that i was struck by is asthe day moved on we went from the whining about everything that is not right to amazing,innovative, and champions who are doing things out there. they don't don't care if they'regetting pay. they know they are making a difference. the world is a better place. people are healthier,payers are happier, and the government is

actually participating as a p artner. lookingat some of those models is a strategy we need to do more of as tele-health leaders. do we actually know who the providers of careare rex i heard to date people surprised in our government that nurse practitioners wereproviding tele-health but didn't consider them to be specialists. i find that interestingthat maybe we don't even know who the providers of care are in our country and who is actuallyout there doing the work. i learned a lot today and it will keep itbrief. i think the perspectives that were share today we were well articulated. i wastelling someone that is been one of the more useful conversations i've heard him the lastyear. what struck me hard and we have been

working with for a long time now is what ishappening now is that technology is allowing us to create a new model of delivery. we havebeen delivering healthcare a certain way and we are now onto place where we can changehow are delivering care and technology will allow that. it is going to help us keep caresimple and keep it patient c entered. this has been difficult to do so far, but technologycan provide us the opportunity. it can help us focus on -- and we are all going to repeatthat word but it spoke to us on overall health and not just illness is very important. ithink it is going to help us with that. it will help us make care more collaborativeinstead of prescriptive. i don't need to tell you any longer to lose weight in come backand six-month but i can give you tools that

will monitor you daily to help you lose weightand i can monitor you more frequently to make sure that you are losing weight. r-value demonstrationneeds to be more creative. we need to stop talking about only cost or only outcomes andbe more creative around how we demonstrate value of the and desmet -- investment. ourevidence creation needs more creativity we need to think of newer models of research.we need to fake of newer models of analyzing the data and collecting the data and provingvalue and proving our outcomes anyway that will move this forward without having to wait15 years again to create something like this evidence -based system. nina, i want to underscore the importanceof not isolating a discourse among those in

this particular section of the industry fromthe broader narrative around health care. i come to this discussion perhaps less centrallyembedded within the tele-health industry than most, but i am absolutely convinced that theissues that i for today are matters of degree and emphasis not substantially different thanwhat all others in healthcare interest street are facing. so, i think your point is extremelyimportant. in my walks of life we talk about the notions of eight pseudo- species likeargument is that we are so different from everybody else that we've removed ourselvesfrom the discourse and the table and i would encourage those most centrally involved inthe industry to be -- to ensure that this narrative takes place within the broader landscape.your point about the science, i'm sorry, rcts

are possible. the comments i heard earliertoday about the challenges of our doing rcts set of methods and procedures are the onesthat we face in all other aspects with respect to recruit and retention and minimizing avariety of the threats and the division -- diffusion of affects. we need to be as you pointed outmore creative. i think it is possible, i think there are great examples out there. i wouldstrongly encourage us to raise the bar in terms of alternating the level of the science.i am not persuaded that the quality of the science has been especially great in thisparticular area. i dig it has been in normal sleep important.it has been consistent with the evolution of the methodologies to date, but it can improveand improve more market oblate. it has to

go hand-in-hand with where things are headedtoday and i would encourage us to not shy away from seeking to meet those highest expectationsaround scientific merit. speaking of science, it is not just the scienceof cost as it relates to value or science with respect to outcomes as it relates toprevention or treatment, but it is also i think here is a wonderful opportunity to pursuethe science of dissemination. had a we think about in rigorous ways the diffusion and adoptionand operationalization of these effective models? for example, dell in your last commentsyou talked about taking a particular model and applying it to a variety of you for geographicsettings. i am not sure that it is necessarily feasible or desirable. i think that many ofthe programs that we've heard of today have

critical essential components to them. itis structure, content, format, and delivery that we have to carefully describe and understand.how those critical components become assembled or reassembled among the relationships thatobtained with in particular settings are geographies, which is an enormous source of variation,that is going to be quite resistant to uniformity. that is the critical piece and that is howwe think about it in terms of intervention resource. what are the critical componentsand how can they be assembled in the way that remain true or infidelity to the originalmodels that gave rise to them? those are my brief comments, thank you. well, i agree with most of what has been saidalready. one think that is very good and refreshing,

even though sometimes it is not easy, is tobe in a setting where it is not tele-health in louisiana's talking to other tele-healthenthusiast and same we have solved every problem. it is good for us to have this discourse withsome people not being necessarily tele-health enthusiast and challenging us. that is wherewe need to get. i think, also, some of us have complained about the fact that tele-healthget help to a higher standard. we don't know -- in some cases where we are trying to howwell tele-health works we don't know how well in person care works, but if it is tele-healthyou have a higher standard to prove. we need to move past that. i think there is good newsand there is good news and the bad news about her health care system.

the good news is we spend a lot of money onevery person in this country on average and we should be able to figure it out with thatamount of money, how to fix some things. one of the problems that i heard little hintsof is that people react when it becomes about the technology as an and in itself. we mayhave done, and i'm also guilty, two go out and give talks about tele-medicine ratherthan evidence -based models of care that are better facilitated with the use of technologyas part of that model of care. i think we need to begin to approach things in that way.i think that is what we are looking for. again, i heard throughout, people are looking forvalue. that means we just don't have -- people want to bend that cost curves and so we havebeen -- if we were doing this 20 years ago,

there would be tons of money flowing to tryevery thing we can try. there isn't today, so we fortunately or unfortunately need toreally focus on value. the last thing i will say and it's one thingthat we heard from mary this morning to think about. as we think about these models likeecho which is a very impressive system, what are the implications for medical student inresident training. we need to start thinking about, because i know you rsa is involvedin some primary care funding, what do we do differently in our medical student and ourresident training to prepare the rural practitioner for the next century rather than train thefor the last century. we do need to think about this and some of us in academic institutionsare beginning to plan that.

i think these are exciting t imes. it is atime of tremendous change and somewhat chaos. whenever there is a lot of change, there isa lot of opportunity. i really like the different models that we have seen and i know therearen't lots of other different models that utilize tele-health that are going on. peopleshould try things like we've seen today, there have been tremendous possesses and i alsoexpect that there will be failures. that is expected. someone this morning said, it wouldbe interesting to find out people that started to use tele-medicine and then they stopped?why? what they do? how come it didn't work? that is something that we need to continueto embrace. what worked, what didn't work, and then move forward. i am very happy withthe way today has turned out. it has been

a very exciting day for me. i could not sleeplast night. i'm going to get a good night sleep tonight in a better night sleep tomorrow.i appreciate you all being here. i mostly have a lot of q uestions, so i willlet you know what is going on in my mind as i ponder what we've talked about today andmore about what we're going to talk about tomorrow. are the days of the rule independentprovider over? will all providers become part of the larger system? not everybody wantsto work for somebody. will the rush to increase market share lead out small rural providersor people in urban areas that are underserved, poverty-stricken, already don't have providers?how will the move toward clinicians reaching their patient directly in their home impactcomprehensive care? will this information

get into their electronic medical records?who will be their primary care provider? what about the continuity of care? how will therapidly evolving technology continue to change how health care is delivered and how can wekeep up with the changes? i think of a hologram next, not just tele- dermatology, but threed telegraphic image. it could happen it could be. this is mundane, but is really important.what is the best way for my office to share best practices? posting on a website is notreally effective. face-to-face meetings, webinars, i don't know. i am really open to ideas. thoseare my thoughts for today. thanks to everyone. are there any questions?

i am talk door and from nasa and [ indiscernible- low volume ] i would advocate that there are 18 plus years of experience written inat least two journals and there are five specialty journals now in tele-medicine worldwide whichis amazing. plus there is also the specialty journals that you have quoted this morning.i remember, ron merrill, when we worked in richmond, we talked about medical doctorsin 1980 about a shortage in the future. there was a lot of push to build new medical schools.a lot of people asked who would pay for that. we did not build them and now we're payingwe are paying for it. the point is that, when we look at this from an economic perspectiveand there have been a number of articles written in the journal about business models and soforth, very effective worldwide not just in

the united states, is the concept of opportunitycost. one of the editorials we wrote in the lastcouple of months address some of this. it is like having the opportunity to spend moneyon this or spend money on that. i spend it on this, there is an effect on the other side.if we don't do tele-medicine or utilize these kinds of tools, you can be assured we aregoing to be spending a lot more money in healthcare the future. we see that today. it is not amatter of whether we're going to do it or not going to do it, it is when. it is likeif i look at the federal government inability or it doesn't seem to me that it is goingfast enough with keeping up with technology. if i look at being able to go to best buyand buy technology that can monitor my health

and the federal government saying is thata medical device or not, and then there is five more versions. i bought an android phoneand i went to get it fixed the other day and said we stopped making that 18 months agowe are on the first edition, now. government cannot keep -- you can't develop policy todayand think it's going to last for 20 years. it is going to change in the matter of time.there has to be a faster turnaround in that regard. the other concept is c onsumerism. we as consumersare going to start demanding these things. i will close with a quote from ron. as a assertedhe would come out and say, mrs. smith we did everything for your spouse. today, that spousesgoing to say did you get a tele-medicine consult

lex because you can then you can get expertise.we did a lot of telerobotic surgery work several years ago and if the answer is well no, wedid not, what is the answer going to be to the patient's family that you didn't do thebest you could because the technology is there, the ability is there, it is just a matterof doing it and getting off of this, well we don't know if there's enough data to showfor can be paid for. the europeans have done it. the australians have done done it. they'reeven doing in china. and we are still trying to figure out how are going to pay for. wehave to look at what the rest of the world is doing. i will close with that. thank you, there is no question, even in termsof case law, tele-medicine has change the

standard of care in rural and remote communitiesas well. in new mexico there were some cases and in virginia there were cases brought tocourt over not using tele-health or using its enough. it is an expectation that thisis standard of care in our healthcare delivery system. i wanted to make a, regarding doctor nesbitttalking about training residents and medical students. in echo we have some medical studentsrotating through the public health rotation than sometime we have residents coming in.we find when early medical student comes into echo and says, why would everybody not bedoing this. this make sense for people to be sharing information with each o ther. asthey go through the indoctrination of medicine

and they get into their residencies, theyimmediately say, this is not the way it is. they have been slowly indoctrinated into ourfee-for-service ways that basically we won't talk to anybody unless they pay sav. essentially,at the end of the day, we have a huge system problem in terms of how we pay and how wethink about healthcare. when an early medical student comes he is using technology and shareswith other people. he is telling people where years when he when he is entering everythingabout his life even when he goes to my restaurant. this transition occurs because we, the eldersand healthcare, indoctrinate different ways of doing business into them and how the feefor service the system works and how we build level fives when we write a three-page noteand web web rewrite a one-page know we can

only bill 11.2 and get paid $70. the residentis talking to us and the attending his thing you need to dictate more and this takes usaway from what doctor nesbitt was talking i will tell you a story and thank you, doctor.talking about diffusion, we have more and more examples of diffusion that we think.as i said, i have a doing this 15 years. about 12 or 13 years ago a group of us that, ifwe want to be here in 10 years, we better part tainting the world around us. at thattime, people could get physicians to use tele-health and we thought would be really wonderful somedaywhen we didn't have to convince people come us sell sell our forsworn force point fundsfor somebody to try tele-health. about eight years ago we saw schools starting to pickup and teach tele-health. family started to

get residents who had come out of a residencyprogram that use tele-health. in my business at marshfield c linic, i haven't had any troublegetting physicians to use tele-health or allied p ractitioners. i had the same thing, wouldn'tit be nice if we just had this is a normal practice. five years ago we started hiringresidents that had tele-health and were trained and they were wondering why they didn't havetele-health. two months ago, a new physician was hired, a plastic surgeon at marshfieldclinic and she had six years of private practice experience with tele-health and she was indignantthat she didn't have tele-health in her office when she arrived. i believe we're seeing itat the practice level, were just not so much seeing it at the policy level.

i am karen mcneely from south florida. i weartwo hats, i make goes provider that you talked that i may psychiatric nurse practitionersand have seen a lot of mental health patients over the last 25 years. i'm the executivedirector of my program but i am it doctoral student at the university of miami. tele-healthseem like the perfect project to merge the two i am in the process and that is why amhere to get this information. you have shared great information and i appreciate that. mychallenges to implement this program in florida. the majority of our recipients our medicaidrecipients and floored it doesn't pay for medicaid reimbursement. that is my talentsto sell that to my executive board. i know will work and save money and reduce recidivism.is getting them to jump on board with the.

i have gotten great feedback and i look forwardto tomorrow that may be able to help me get this program off the ground. i'm sorry, what was her name? my name is karen, mcneely. contact one of us because we would like towork with you and i think you can do that very easily. it was actually the house last year in floridajust ran out of time. maybe if it comes up this year will have some muscle behind it. also the national -- [ indiscernible - static] to advance at the state level and will have

someone representing them tomorrow to speakat the state panel. this is really and formative, thank you. dale alverson, one more comment and get yourresponse. someone mentioned consumerism, and i can tell you it is already happening. inthe matter what we think is providers or as federal agencies and so on, the consumer,particularly the younger generation is going to demand it and is already using it. forexample, my daughter who is a young adult had a rash and i get to calls from my children,one is i need money or dad i got this health issue what you think? should i go to the emergencyroom? she told me that she had a rash and she had been on a course of antibiotic andthe rash suddenly appeared and scared her.

should she go to the emergency r oom, seea dermatologist, urging care? i asked her a few questions as most of us would aboutthe rash and any of the problems. it is really hard for me to say we should do without seeingit. within 30 seconds i had a whole series of pictures of her rash on my smart phone.the point is, the younger generation consumer will use this technology. whatever we wantto collect, tele-medicine, e-letter health, connected care, virtual care. and we as asystem need to keep up because basically value and in the end we will make a reasonable decisionabout whether she needed to go to the emergency room and so on. i just wanted to make thatpoint that hopefully what comes out of this as well is we are going to have to keep upwith the consumers of care and our patients

who are really when they see the advantagesof this they will demand. yes, and that is a great story. i will tellyou to others that are similar. one is relatively well-known story that happened with one ofour infectious disease doctors, doctor siddiqui who was driving to home one night and hisphone rang and it was somebody at a smallbore hospital bed has a guy with the rash and itis cellulitis but he's allergic to these medications and he's diabetic. what drug would use? helooked at it through an iphone and he said get me another picture of that with a bluebackground behind it, because it is not very clear. since the time you took the first picturein the second picture this has advanced significantly. he's got necrotizing fasciitis and you needto get a surgeon in right away. it to come

along time to get the surgeon in and in andconvincing. a brand around the internet, iphone saves patients limb and pace of life. it wasinteresting just to see the response to that. there were a number of very negative, peopleshould be using iphones for this. this is malpractice etc. it's amazing to think aboutthat particular case. people are going to use it. they weren't tryingto do a tele-medicine consult. the other thing is that when i flew here i flew with rt periodmust surgery and she was talking to us about tele-medicine and other s tuff. it's a goodidea, tele- mentoring. my ex- residents use their iphones all the time and take picturesduring cases and send them to me and say, do you think this is something i should approachanteriorly or do i need to go post? i never

even thought of that. i think even in -- evenif we didn't say we were doing tele-medicine, doctors are going to start using this to takepictures of things and send to consultants rather than just talking on phone. you'reabsolutely right. this is going to happen whether we try and push it or not and we justhave to figure out how to channel it and move it in the right directions and best practices.is a good. any other comments or questions? i want tothank our planning committee and cheryl lynne in particular and your support of this programi wish you all he good evening. tomorrow morning we started a 30:00 a.m. if you don't mind,be here earlier and hopefully we will still have coffee in the morning. thank you, tracy.and thank you for everything you have done

to bring this program forward. [ applause] [ event concluded ]