[Senate Hearing 111-603]
[From the U.S. Government Publishing Office]
S. Hrg. 111-603
HEARING ON AGING IN PLACE:
THE NATIONAL BROADBAND PLAN AND BRINGING HEALTHCARE TECHNOLOGY HOME
=======================================================================
HEARING
before the
SPECIAL COMMITTEE ON AGING
UNITED STATES SENATE
ONE HUNDRED ELEVENTH CONGRESS
SECOND SESSION
__________
WASHINGTON, DC
__________
APRIL 22, 2010
__________
Serial No. 111-17
Printed for the use of the Special Committee on Aging
Available via the World Wide Web: http://www.gpoaccess.gov/congress/
index.html
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SPECIAL COMMITTEE ON AGING
HERB KOHL, Wisconsin, Chairman
RON WYDEN, Oregon BOB CORKER, Tennessee
BLANCHE L. LINCOLN, Arkansas RICHARD SHELBY, Alabama
EVAN BAYH, Indiana SUSAN COLLINS, Maine
BILL NELSON, Florida GEORGE LeMIEUX, FLORIDA
ROBERT P. CASEY, Jr., Pennsylvania ORRIN HATCH, Utah
CLAIRE McCASKILL, Missouri SAM BROWNBACK, Kansas
SHELDON WHITEHOUSE, Rhode Island LINDSEY GRAHAM, South Carolina
MARK UDALL, Colorado SAXBY CHAMBLISS, Georgia
KIRSTEN GILLIBRAND, New York
MICHAEL BENNET, Colorado
ARLEN SPECTER, Pennsylvania
AL FRANKEN, Minnesota
Debra Whitman, Majority Staff Director
Michael Bassett, Ranking Member Staff Director
(ii)
C O N T E N T S
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Page
Opening Statement of Senator Herb Kohl........................... 1
Opening Statement of Senator Bob Corker.......................... 2
Opening Statement of Senator Ron Wyden........................... 3
Opening Statement of Senator Susan Collins....................... 5
Panel I
Statement of Mohit Kaushal, Digital Healthcare Director, Federal
Communications Commission, Washington, DC...................... 7
Statement of Farzad Mostashari, Senior Advisor to the National,
Coordinator for Health Information Technology, U.S. Department
of Health and Human Services, Washington, DC................... 17
Panel II
Statement of Eric Dishman, Intel Fellow, Intel Corporation,
Global Director of Health Innovation and Policy Digital Health
Group, Senior Policy Advisor, Continua Health Alliance, Senior
Fellow, Center for Aging Services Technologies, Washington, DC. 40
Statement of Robin Felder, Professor of Pathology, Associate
Director, Clinical Chemistry, The University of Virginia School
of Medicine, Charlottesville, VA............................... 61
Statement of Richard Kuebler, Telehealth Department Head,
University of Tennessee Health Science Center, Memphis, TN..... 68
APPENDIX
Mr. Dishman's Responses to Senator Kohl's Questions.............. 81
Dr. Felder Response to Senator Kohl's Question................... 83
Statement from Americans Telemedicine Association................ 84
Comments Submitted by Mark Reisinger, Geisinger Health System.... 87
(iii)
HEARING ON AGING IN PLACE: THE NATIONAL BROADBAND PLAN AND BRINGING
HEALTHCARE TECHNOLOGY HOME
---------- --
THURSDAY, APRIL 22, 2010
U.S. Senate,
Special Committee on Aging,
Washington, DC.
The Committee met, pursuant to notice, at 2:03 p.m. in room
SD-562, Dirksen Senate Office Building, Hon. Herb Kohl
(chairman of the committee) presiding.
Present: Senators Kohl, Wyden, Corker, and Collins.
OPENING STATEMENT OF SENATOR HERB KOHL, CHAIRMAN
The Chairman. Good afternoon. We thank you all for being
here.
We'd like to thank today's witnesses for joining us,
whether in person or thanks to the wonders of technology.
We are fortunate to have Senator Ron Wyden chair today's
hearing on the National Broadband Plan and the impact it may
have on telehealth for seniors.
Senator Wyden has always been a very active member and an
outstanding member of the Aging Committee. He brings to the
table his experience working with the Gray Panthers, in his
home State of Oregon. He's known for his passion and leadership
on the issue of healthcare. We are very pleased to have him
chair this hearing today.
As we will hear, communications and medical technology has
the ability to keep more seniors healthier, at a lower cost,
particularly those who live in remote rural areas. There are a
number of health systems and organizations in my State of
Wisconsin that are putting telehealth technologies to work,
such as ThedaCare, Wheaton Franciscan Healthcare, Marshfield
Clinic, as well as Aurora Visiting Nurse Association.
Thanks to funding made available in last year's stimulus
bill, the Federal Government is making efforts to expand our
national broadband network so that more doctors and patients
can take advantage of these technologies.
Through the Judiciary Committee, we are working to ensure
that this is done in a way that fosters competition amongst
broadband providers. Unfortunately, despite the spread of
broadband, several stumbling blocks stand in the way of
widespread adoption of telehealth technologies in the home.
Senator Wyden and the witnesses he has invited today will shed
light on this timely issue, and hopefully suggest some
potential solutions.
I'm sorry that I'll not be able to stay very long at this
hearing, as I have other obligations and prior commitments.
But, I have full confidence in Senator Wyden, and I thank him
very much for his contributions to this committee.
We turn, at this moment to the committee's ranking member,
Senator Bob Corker.
[The prepared statement of Senator Herb Kohl follows:]
Prepared Statement of Senator Herb Kohl
Good afternoon. First, I'd like to thank all of today's
witnesses for joining us, whether in person or thanks to the
wonders of technology. We are fortunate to have Senator Ron
Wyden chair today's hearing on the national broadband plan and
the impact it may have on telehealth for seniors. Senator Wyden
has always been a very active member of the Aging Committee,
bringing to the table his experience working with the Gray
Panthers in his home state of Oregon. He is known for his
passion and leadership on the issue of health care, and we are
so pleased to have him hold today's hearing.
As we will hear today, communications and medical
technology has the ability to keep more seniors healthier at a
lower cost, particularly those who live in remote rural areas.
There are a number of health systems and organizations in
Wisconsin that are putting telehealth technologies to work,
such as ThedaCare, Wheaton Franciscan Healthcare, Marshfield
Clinic, and the Aurora Visiting Nurse Association.
Thanks to funding made available in last year's stimulus
bill, the federal government is making efforts to expand our
national broadband network so that more doctors and patients
can take advantage of these technologies. Through the Judiciary
Committee, we are working to ensure that this is done in a way
that fosters competition amongst broadband providers.
Unfortunately, despite the spread of broadband, several
stumbling blocks stand in the way of widespread adoption of
telehealth technologies in the home. Senator Wyden and the
witnesses he has invited today will shed light on this timely
issue, and hopefully suggest some potential solutions.
I'm sorry that I cannot stay very long, as I have other
obligations and prior commitments. But I have full confidence
in Senator Wyden, and I thank him once again for his
contributions to the Aging Committee. I'll now turn over the
gavel.
OPENING STATEMENT OF SENATOR BOB CORKER
Senator Corker. Mr. Chairman, I want to thank you for
having this hearing.
Certainly, Senator Wyden always has lots to talk about when
it comes to innovation.
So, I think all of us, especially after the debate we've
had over the last 14 months, know that one of the things we
still haven't addressed is cost. That hopefully the kind of
things we're talking about today, and we'll learn from and then
expand on--hopefully, these are the kind of things that help us
move ahead into the future so that people throughout our
country have access to quality healthcare, and yet it's being
done at a much lower cost. So, I'm glad we're able to review
the impediments to some of the breakthroughs today.
I want to thank you both for calling this hearing.
Certainly the wonderful witnesses that we have, not only
here, but through, again, great technology, from other places.
So, thank you very much.
The Chairman. Thank you, Senator Corker, well said.
Senator Wyden.
OPENING STATEMENT OF SENATOR RON WYDEN
Senator Wyden. Thank you very much, Mr. Chairman, and for
all of your leadership and, particularly, putting the field of
aging on the side of innovation. All through the health reform
debate, when we talked about the future of healthcare reform,
you constantly kept coming back to the question of how we look,
not just over the next few years, but into decades ahead. This
gives us a chance to do that. I thank you very much for your
leadership, and it's a pleasure to be able to serve with you.
To my friend Senator Corker, we talk often about
healthcare, and I think one of the other two aspects of this
hearing that you two illustrate is how important it is that the
big issues, like healthcare, be dealt with in a bipartisan way.
We didn't get enough of that in the healthcare reform, but
there are a lot of us who believe, in the years ahead, there
are going to be a lot of opportunities to prosecute this
question of the future of American healthcare in a bipartisan
way.
You, Mr. Chairman and Senator Corker, set a very good
example for it. I thank you both for always making sure, in the
Aging Committee, we don't get lost in some sort of petty
partisan kind of discussion. I thank you both.
Today's hearing is about how new healthcare technologies
that use a high-speed Internet connection can better meet the
health needs of America's seniors. These new technologies can
save the older people a trip to the doctor or, in tragic
instances, to the emergency room. I'm of the view that a number
of these technologies will save Medicare money in the years
ahead.
So, for the purpose of this hearing, I'm going to call
these new technologies ``e-care.'' It is also a subject that
the Federal Communications Commission is focused on. I want to
take a minute to just talk a little bit about the possibilities
for e-care. I'm going to use a couple of devices to highlight
it. I'm old enough to report that I always call them
``gadgets.''
But, what we're talking about, folks, for example, using is
a device like this. It isn't on the market just yet. But, what
this is, is, in effect, a high-tech Bandaid. It attaches to a
patient's skin, and it's loaded with drugs that are
administered in the exact way the physician prescribes; that's
wirelessly. That means that a doctor can vary the dose, based
on the information the doctor receives. The patient doesn't
have to go into the doctor or the pharmacy to change his or her
prescription.
So, then we go to the next device. We call this, I guess,
some version of a Health Pal. This device connects to other
devices that would measure a patient's blood pressure and
glucose levels, obviously areas that any physician treating a
diabetic patient wants to know about. It then wirelessly
uploads the data to an electronic medical health record that is
monitored by a healthcare professional.
So, then we go to one of my favorites, a third device. In
effect, this is a product that's available on the commercial
market now. So, what you do here is, you, in effect, put your
finger in it, something along the lines of what I'm doing. This
particular product measures the pulse and the level of oxygen
in a patient's blood. So, right here in this small device is
critical information for those patients who have cardiovascular
disease. Then, this device transmits the data to what the
physicians call their ``SmartPhone'' in an electronic medical
record. So, then you get a readout that, in effect, confirms to
your spouse that you have been eating properly and exercising.
So, the last device that I would bring before the committee
politely, if I could characterize it, attaches to a patient's
chest to monitor the heart. This will, in effect, produce data
that uploads to a physician, enabling that physician to call
the patient if there is a problem. So, this small device can
help prevent a heart attack among America's seniors.
Now, many of these devices are targeting the population
that have chronic conditions. These are the folks who might
make up perhaps 10 percent of those on Medicare, but whose care
each year accounts for up to 85 percent of all Medicare
spending. I'm of the view that e-care could be a huge step
forward in improving the care for older people and lowering
costs to Medicare as a government program.
At the same time--this is a matter that Senator Corker and
I, I think, talked about during our times of negotiating how we
might pursue cost containment. I want to make clear that I'm
not of the view that everybody ought to be able to run up with
a gadget and say, ``OK, let's now make this eligible for
Medicare reimbursement.'' This is going to have to involve a
program to really scrutinize the cost-effectiveness of the
various products, and what they will do for the patient.
We know that Don Berwick has been nominated to head an
important office in this area, the Federal Medicare Program. I
think that he ought to examine e-care as one of his top
priorities.
The reason I feel so strongly about this is that the
Medicare reimbursement system is fundamentally flawed. We saw,
in the course of the Medicare Reform debate, that, in many
respects, it rewards inefficiency and it generally only pays
the older people when they go, in person, to the physician's
office. So, in effect you have a system that literally rewards
volume, rewards people who come in, whether or not that might
be the appropriate approach. You will have, in my view, if that
persists, greater expense for Medicare and the taxpayers than
you would have if you looked to the kinds of technologies that
I've offered the committee here today, that could allow people
to be cared for, I think, in a more constructive way at home;
produce better quality and more timely care at a cheaper price
to taxpayers.
So, among other things, I hope today's hearing will help
spark rethinking the way Medicare pays doctors. At this point,
Medicare barely acknowledges the existence of e-care. Medicare
spends over $400 billion a year; about 2 million is spent on
these kinds of technologies. In particular, I think these e-
care technologies could reduce hospital readmissions, which
could, in turn, save the Medicare program from substantial
costs, in the years ahead.
Now, what all these devices and technologies require is
access to a high-speed Internet connection, what is commonly
referred to across the country as ``broadband.'' So, that's why
today's hearing is also going to consider the national
broadband plan that was developed by the Federal Communications
Commission and delivered to the Congress last month. That was a
plan that was mandated by the Congress, and it demonstrates
that high-speed Internet is the backbone of e-care. The
broadband plan is the blueprint for how to make a high-speed
Internet connection as ubiquitous as a phone line or an
AMFURTHERMORE signal.
Now, in the 20th century, infrastructure that enabled the
movement of goods, people, and protons is what separated
developed countries from the developing ones. In the 21st
century, broadband infrastructure will be a central component
of the competitiveness of any country and its producers.
According to the broadband plan, one in three Americans do not
have broadband at home. The United States lags far behind other
countries in the adoption of broadband and e-care that would
improve healthcare and save hundreds of billions of dollars in
health costs.
So, there are big, big traffic jams and unpaved roads on
the information superhighway that is called the Internet. That
is holding back improvements in healthcare for those in rural
and tribal areas. Seventy percent of small physician offices
which aren't located in metropolitan areas don't have access to
an affordable broadband service that is available in the
metropolitan areas. Many of these providers have to pay three
or four times the price for the same broadband service that an
urban provider pays.
I'm of the view that Congress and the Federal
Communications Commission ought to deploy significant public
resources to deliver broadband to areas where the private
market has not yet been able to deliver the service. Moreover I
believe that rural healthcare providers ought to receive
assistance in purchasing broadband services if they are not
affordable in their area. Only when the country has a reliable
broadband infrastructure and policies in place to encourage the
development and deployment of innovations in healthcare will it
be possible to transform the healthcare system that is today
all about ``sick-care'' into one that finally focuses on
healthcare and keeping our folks well. Achieving that will
allow America's older people the ability to more comfortably
age in place.
Let us turn now to colleagues who have a longstanding
interest in this. I know Senator Collins and I talk often about
healthcare, and continue to have an interest in a number of
bipartisan healthcare reforms.
Senator Corker, would you like to say anything else, to
begin?
Senator Corker. That's the longest opening statement I've
ever given so----
Senator Wyden. Well, I---- [Laughter.]
I tell you, you're a role model for us, and we thank you
for it.
Senator Collins, any remarks.
OPENING STATEMENT OF SENATOR SUSAN COLLINS
Senator Collins. Thank you. Thank you, Mr. Chairman, for
calling this important hearing to examine the ways that we can
unlock the value of broadband to bring telehealth and other
patient monitoring technologies into the home.
According to the National Broadband Plan that the FCC
submitted to Congress last month, the development of the
broadband network and health information technologies has the
potential to truly transform healthcare, simultaneously
enabling better outcomes and lowering costs. The FCC found that
increased use of electronic health records and remote patient
monitoring, alone, could reduce healthcare costs by more than
$700 billion dollars over the next 15 to 25 years. Moreover, in
addition to the significant cost savings, these technologies
have the potential to improve the quality of life for our
seniors dramatically by allowing them, as you've pointed out,
``to age in place'' in the comfort and security of their own
homes and their own communities.
A recent study of remote patient monitoring programs at the
Veterans Administration found that it resulted in a 19-percent
reduction in hospital admissions, a 25-percent reduction in bed
days of care, and an 86-percent patient satisfaction rate.
Moreover, the average cost per patient was $1600 per year, as
compared to more than $77,000 a year for nursing-home care.
Mr. Chairman, the benefits of these technologies, both in
terms of cost savings and quality of life, are clear. They
assume particular significance in rural States, like mine, the
State of Maine, which have serious shortages of primary care
and specialty physicians, and where patients often have to
travel long distances to receive healthcare services. Yet, the
United States continues to lag far behind other industrialized
nations in the adoption of these critically important
technologies.
This afternoon's hearing will give us the opportunity to
examine whether implementation of the National Broadband Plan
will provide for more widespread adoption of these
technologies. It'll also give us the opportunity to identify
barriers to using telehealth and remote patient monitoring
devices that rely on a broadband connection. Finally, it will
help us to determine what more the Federal Government can do to
increase access to these new and rapidly developing
technologies.
Again, thank you, Mr. Chairman, for calling this
afternoon's hearing.
Senator Wyden. Thank you very much, Senator Collins.
I think--all three of us represent States with substantial
rural areas, and I think this is particularly important, to
highlight your point, that this can compensate for the distance
from a lot of major health facilities.
Senator Collins. Absolutely.
Senator Wyden. I appreciate the points.
Let us go now to our first witness, who, due to the
challenges of the airlines, is going to speak to us from
London. I note that he comes today to talk about technology,
through the use of modern technology. We welcome Dr. Mohit
Kaushal. He is the Digital Healthcare Director at the Federal
Communications Commission. He led the healthcare team that
contributed to health sections of the broadband plan delivered
to the Congress. This was mandated by the Recovery Act. He's
also an ER physician by background.
Why don't we begin with you, Doctor?
STATEMENT OF MOHIT KAUSHAL, DIGITAL HEALTHCARE DIRECTOR,
FEDERAL COMMUNICATIONS COMMISSION, WASHINGTON, DC
Dr. Kaushal. Senator Wyden and others on the Senate Special
Committee on Aging.
I hope you can hear me.----
Senator Wyden. We missed a little bit of your first few
words, but we're hearing you now.
Dr. Kaushal. Great. So, thank you for the introduction. As
you said, I head up the healthcare team for the National
Broadband Plan at the FCC. As you know, Congress mandated that
the FCC prepare a National Broadband Plan. The plan also
recommends how broadband can be harnessed to tackle important
national purposes, including healthcare.
Improving America's health and America's healthcare system
is one of the most important tasks for the Nation. Healthcare
already accounts for 17 percent of U.S. GDP; and By 2020, it
will top 20 percent. This is due to many factors, but one of
the most important is that America is aging. There is a direct
correlation between the elderly and chronic disease----
Senator Wyden. Doctor, we just lost you. Can you hear me?
Dr. Kaushal. I can hear you perfectly.
Senator Wyden. OK. If you can back up one sentence. We just
lost you, about a sentence ago.
Dr. Kaushal. Got it.
So, healthcare already accounts for 17 percent of U.S. GDP;
and by 2020, it will top 20 percent. This is due to many
factors, but one of the most important is that America is
aging. There is a direct correlation between the elderly and
chronic disease, which already accounts for 75 percent of the
Nation's healthcare costs. By 2040, there will be twice as many
Americans over 65 as there are today.
But, there's a set of broadband-enabled health information
technologies, both now and emerging, that can mitigate many of
these issues and reduce the cost of care while improving
clinical outcomes--to the study that claims that remote
monitoring could generate net savings of approximately $200
billion over 25 years, from just four chronic conditions.
Although economic studies like these are open to criticism due
to the difficulty in quantifying savings, the Veterans Hospital
System has implemented its Care Coordination Home Telehealth
Program, which has resulted in improved clinical outcomes and
significant cost savings.
Even though these technologies hold great promise, the U.S.
lags behind other developed countries in health IT adoption,
with one study ranking it in the bottom half on every metric
used to measure adoption. The plan identifies some of these
barriers that prevent the use broadband-enabled health
solutions, and provides specific recommendations that
government should undertake to remove them.
So, with respect to the e-care technologies that enable
``aging in place,'' these barriers and subsequent proposed
solutions fall into three main categories. Firstly, the
connectivity gap; broadband is either missing or too expensive
in some cases. Second, misaligned economic incentives; the
prevailing fee-for-service reimbursement system pays for
volumes rather than outcomes, and hence prevents many of these
technologies from being paid for. Third, outdated regulations,
created back when our only interactions with physicians were in
their offices, not via remote monitoring and videoconferencing.
So, let me now discuss each one of these briefly.
The first issue is connectivity, including both broadband
at home, as well as connectivity to health providers. With
respect to the home, the plan estimates that 14 to 24 million
Americans do not have access to broadband where they live, even
if they want it. It's hard to identify what proportion of this
is over 65, but what we do know is that the over-65s are poor
adopters of broadband, estimated to be 35 percent, as compared
to the national average of 65 percent.
My focus and my team's focus has been primarily on the
connectivity issues for healthcare providers. It is imperative
that hospitals and physician offices have adequate
connectivity, as any care that will be delivered to an
individual's home will likely originate in a healthcare
facility of some description.
Our analysis highlighted that some providers are not served
by existing mass-market broadband infrastructure, and others
are facing large disparities in the price of broadband. The
plan addresses this issue by proposing a revamp of the FCC's
Rural Healthcare Program, which, capped at $400 million per
year, is the largest sustainable fund for healthcare
connectivity within the government.
Second, although the connectivity supply problem is an
issue, the greater barrier is on the demand side of the
equation. Within a fee-for-service reimbursement system,
providers bear the costs of health IT implementation and
changes to their workflow, but don't fully capture the economic
gains they create through improved clinical outcomes. The plan
recommends that well-understood use cases of e-care
technologies should be incented with outcomes-based
reimbursement. In addition, novel technologies should be tested
for their clinical efficacy, as well as within novel payment
models, in order to ascertain their economic value.
Senator Wyden. Doctor. If you wouldn't mind, I--I've just
been summoned, because the Budget Committee is trying to wrap
up, and apparently they can't do it unless I arrive.
Could I impose on my colleagues, Senator Corker and Senator
Collins, who I know will very ably handle this is my absence?
Senator Corker. Absolutely.
Senator Wyden. Very good. We'll see you shortly.
Doctor, my apologies. I'll get back as soon as possible, to
all our witnesses.
Thanks.
Dr. Kaushal. Thank you very much. So, let me continue then.
Given that it will take many years to implement an
outcomes-based payment model, reimbursement should be expanded
for e-care technologies that will prove systemwide expenditure
reductions under CMS's fee-for-service model.
Third, there are a range of regulations that prevent e-care
solutions from being adopted. State licensing, credentialing,
and privileging rules prevent physicians from providing remote
broadband-enabled care. Patient safety must be addressed by
ensuring that physicians are suitably skilled, but regulations
must not hinder the innovation and gains promised by health IT,
and should, therefore, be reevaluated.
In addition, there is a great deal of regulatory
uncertainty regarding the convergence of telecommunication and
medical devices, which is preventing private-sector investment
and innovation. Further regulatory transparency within the area
must be provided to industry. The FCC and FDA both recognize
this need, and we're working together to address it.
So, in conclusion, there are multiple barriers that must be
resolved in order to develop the ecosystem of broadband-enabled
health IT. Technology alone will not solve our healthcare
challenges. It must be coupled with payment reform, innovation
in service delivery, and improved regulatory transparency
before we will recognize the benefits of all these
technologies. Thus, any government approach to solve these
issues must be coordinated, not only across the government, but
with the private sector and the entire healthcare community.
I thank you all for giving me the opportunity to speak
today.
[The prepared statement of Dr. Kaushal follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Senator Corker. Thank you very much for that outstanding
testimony, and especially in different time zones and different
places.
Our second witness is Dr. Farzad Mostashari, if I
pronounced it correctly. Dr. Mostashari serves as Senior
Advisor with the Office of National Coordinator of Health
Information Technology at the U.S. Department of Health and
Human Services. His latest work has been on the implementation
of health IT provisions and the American Recovery and
Reinvestment Act. He holds both a medical degree and a master's
in public health. Congratulations.
We welcome you here and thank you for your testimony.
STATEMENT OF FARZAD MOSTASHARI, SENIOR ADVISOR TO THE NATIONAL
COORDINATOR FOR HEALTH INFORMATION TECHNOLOGY, U.S. DEPARTMENT
OF HEALTH AND HUMAN SERVICES, WASHINGTON, DC
Dr. Mostashari. Thank you, Ranking Member Corker, Senator
Collins.
I'm Dr. Farzad Mostashari, as you said, Senior Advisor to
the Office of the National Coordinator for Health Information
Technology. Thank you for the opportunity to testify before you
on HHS's efforts to harness telehealth, to transform healthcare
and improve health, and support aging in place by America's
seniors.
The American Recovery and Reinvestment Act of 2009 made a
historic investment in health information technology, providing
up to tens of billions of dollars in incentive payments for
certain Medicare and Medicaid providers who adopt, and are
meaningful users of, certified electronic health record
technology.
These are unprecedented, outcomes-oriented investments. The
goal is not just for providers to purchase and install health
information technology, but to make improvements in health and
healthcare through use of health IT. This means our goals are
to increase healthcare quality and safety, reduce disparities,
engage patients, improve efficiency of care, and enhance care
coordination. It's abundantly clear that telehealth can make
substantial contributions in all of these areas and help
elderly patients remain in their homes and avoid costly and
unnecessary hospital admissions.
As Senator Collins pointed out, the Department of Veterans
Affairs has dramatically decreased unnecessary hospitalization
through a wide-ranging effort to help veterans manage chronic
conditions at home. Hospital use decreased 25 percent overall,
and 50 percent for patients in highly rural areas, by linking
32,000 chronically ill veterans with healthcare providers and
care managers through video phones, digital cameras, messaging,
telemonitoring.
There are also many private-sector examples of these
innovations. Using home-based monitoring and Web-based care to
improve medication management, an effort at Group Health in
Washington State almost doubled the number of hypertensive
patients with controlled blood pressure and made care more
convenient and responsive to patient needs. Kaiser Permanente
has reported on increased use of e-visits, increasing primary
care capacity.
Technologies for telehealth and e-care, and the payment and
delivery structures to support them, are evolving rapidly in
the marketplace. New offerings combine telehealth technologies
with innovative service delivery platforms that have the
potential to transform care for the elderly, making it more
responsive and available to support aging in place.
I'll give one example. A company named American Well
partners with health plans to deliver just-in-time video-
supported e-Care to patients with an Internet connection. The
model leverages a large network of patients and providers, who
can connect securely on the Internet, along with existing plan
licensing arrangements, provides malpractice coverage, and
takes advantage of distributed excess physician capacity.
A wide range of initiatives and programs across HHS aim to
support innovation in telehealth in three areas: video
consultation services, remote patient monitoring, and secure
sharing and reading of patient information, like radiographic
images.
Secure sharing and remote reading of patient information,
professional interpretations of tests or specimens that require
practitioner reviews, need not be done at the same place that
the care is delivered. Radiographic images on high-speed
channels can improve care coordination and reduce the risk of
medical errors. This already occurs widely under Medicare, and
is treated no differently than services provided onsite at the
medical facility where the patient is located. Many
radiological and pathological services, including reading X-
rays, interpreting EKGs, examining tissues specimens, are
routinely provided in this manner.
Video consultation services that require face-to-face
contact can occur across sites of care, or in patient homes,
addressing geographic and other barriers to care, including low
mobility. Medicare pays for telehealth services for
beneficiaries seeking care in certain rural and non-urban
provider sites, including critical-access hospitals, rural
health clinic, and federally qualified health centers. This
includes telehealth services provided by physicians and
nonphysician practitioners; for initial and followup inpatient
consultations; office or other outpatient visits; and
pharmacologic management, among other clinical services.
In addition, States are encouraged to use the flexibility
inherent in the Medicaid program to create innovative payment
methodologies for services that incorporate telehealth
technology.
Home monitoring can place daily metrics of patient's
health, weight, blood pressure, other vital measures in
patients' and providers' hands, improving chronic-care
management and patient engagement; avoiding unneeded
hospitalizations for patients with heart failure and other
chronic conditions. CMS already pays for some examples of this
with home-event cardiac monitoring and Holter monitoring.
The Health Services and Resources Administration funds six
telehealth networks focused on improving outcomes and access
for seniors through telehealth care and telehome monitoring.
Initial evidence of the impact of HRSA's telehealth programs is
encouraging. From 2006 to 2007, the number of patients
achieving glycemic control, a key indicator of successful
diabetes management, rose from 34 to 42 percent.
Since 2004, AHRQ has awarded over $260 million in grant
funding for health IT, including 23 telehealth projects in 16
States. For example, supported by funding from AHRQ, patients
at Saint Vincent Hospital, in Billings, MT, share realtime
information about weight, blood pressure, and blood sugar with
physicians across phone lines with the simple touch of a
button. I heard, this morning, from Cleveland Clinic about
their dramatic shift away from episodic to continuous care
using these methodologies.
While there is evidence that certain telehealth
applications can improve care and reduce certain unnecessary
costs, more information and experience is needed about which
strategies are most effective, and under what circumstances;
how to integrate telehealth with traditional healthcare
delivery, and reduce barriers to adoption; and how to assure
privacy and security of health information shared through these
technologies. Patient safety issues will be carefully
considered by the Food and Drug Administration to address the
challenges and safety risks of using medical devices that were
not designed for use in this setting, or by lay users in the
home.
Over the upcoming months and years, there will be
considerable investment in innovative care-delivery models and
payment approaches that can foster telehealth. New models for
deploying and integrating telehealth technologies will be
developed and tested through the HITECH Beacon Community Grant
Program. This initiative will support at least 15 vanguard
communities, many of them predominantly rural, with high levels
of electronic health record adoption to lead the way in
demonstrating concrete and measurable improvements in areas
such as patient experience, health disparities, and national
high-priority health conditions, such as blood pressure and
diabetes control, and reducing unnecessary hospitalizations.
Many applicants propose to integrally involve telehealth in
these efforts.
But, most significantly, looking forward, the Affordable
Care Act allows providers to utilize a series of new and
innovative delivery system and payment reforms, such as
accountable-care organizations, bundled payments, and value-
based purchasing, which incentivize high-value healthcare that
focuses practitioners on the quality, not quantity, of care. As
providers do so, we expect that the use of innovative
telecommunications technology in medical care will be fostered.
The new Center for Medicare and Medicaid Innovation has
given explicit authority to test innovative payment and service
delivery models, which may include care coordination for
chronically ill individuals at risk of hospitalization through
telehealth, remote patient monitoring, care management, and
patient registries.
These new payment approaches mean a move away from fee-for-
service payment toward a more outcome-oriented approach, as
Senator Wyden suggests. This allows for adoption and use of
technologies and care delivery approaches that improve care,
engage patients, and reduce unnecessary spending.
We don't yet have all the answers. They will come from
continued market-based technology innovation, paired with more
results-oriented payment and thoughtful study to capturing the
lessons and evidence from ongoing efforts.
Thank you for the opportunity to testify today.
[The prepared statement of Dr. Mostashari follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Senator Corker. Thank you very much for your testimony.
A matter of fact, since we typically start here with the
other side of the aisle, I'm going to start with you. Even
though----
Senator Collins. Uh-oh.
Senator Corker [continuing]. We're on the same side of the
aisle.
Senator Collins. Does that mean you consider me to be a
Democrat?
Senator Corker. Not at all.
Senator Collins. I hope not. [Laughter.]
Senator Corker. You're a great partner.
Senator Collins. Thank you, Mr. Chairman. How's that sound?
Senator Corker. Very good.
Senator Collins. I thought it might.
I'd like to discuss, with our witnesses, a couple of
challenges to telehealth and monitoring, using broadband
technologies. One of the problems is, this technology holds the
greatest promise for rural areas and senior citizens. Yet, if
you look at rural areas and senior citizens, those are the two
categories where broadband and digital literacy is the lowest.
Rural areas tend to have been left behind. I know we're trying
to fix that. Seniors tend--not all of them, but as a group--
tend to have a lesser degree of digital literacy than younger
Americans.
The cost issues perhaps can be solved through subsidies,
but those cultural issues and infrastructure issues are more
complicated. So, I'd like both of you to comment on the
challenges faced by the lower rate of digital literacy among
seniors, and the lower availability of broadband in our rural
areas.
As I said, it's ironic, because that's where telemedicine
could be most helpful.
Director, why don't we start with you.
Dr. Kaushal. Great. I only picked up a part of that
question, I'm afraid--you're talking about--and the elderly,
and then some of the complex issues that they face, correct?
Senator Collins. I was talking about the fact that the
senior population is less likely to have access to broadband
technologies in their homes.
Dr. Kaushal. Right. Let me just talk about some of the
statistics that some of my colleagues at the National Broadband
team came up with after a lot of analysis. So--you're very
correct--so, the national average for adoption of broadband is
65 percent. The over-65s, on average, are only 5 percent, in
terms of adoption of broadband. This is due to multiple
reasons, but digital literacy leads the way, at 29 percent. The
relevance of digital content is second, at 26 percent. Cost is
third, at 22 percent.
This is very different than the national averages of other
age groups. So, they have very specific reasons why they're not
adopting these technologies. We spent a lot of time thinking
through that.
Then the other issue is just, in rural areas, there's
just--penetration of broadband.
So, the plan, in its totality, has come up with a number of
proposed recommendations to solve these--both supply and
demand-side issues.
So, if we talk about the infrastructure side first--as you
know, one of the goals is to promote -00 percent penetration of
4 megabits per second down, and 1 megabit per second up. It
will do that in a number of ways. First of all, making it just
easier to access poles and rights-of-ways for the private
sector. Also, lower the cost of deployment trenching is very
expensive, so proposals to allow--if the ground is opened up,
for whatever reason, that fiber should be laid there.
Then, on the adoption side, which we all think is a much
more complicated issue, although the adoption is lower than
average in the over-65s, there's a huge disparity within that
group, as well. So, what really is required is a lot of
research. A number of centers are doing this, and we've worked
with a couple of them. How do we provide innovative solutions?
Healthcare is one of them. By providing applications to let the
elderly manage their conditions better, to stay in contact with
their loved ones, we really feel that adoption will be
increased.
Then, go back to the question of reimbursement. Physicians
and providers really have to be incented to trial and test as
many of these technologies as possible within this elderly
population. Unfortunately, by just doing one, won't solve the
problem at all. We have to really push forward on all these
different avenues. The issue is complex, as you outlined.
Senator Collins. Thank you.
Doctor.
Dr. Mostashari. I think the supply issues will, we trust,
be dealt with. I agree with you, that the demand side is a key
issue. As Dr. Kaushal pointed out, people have to have a reason
for getting online. I applaud the broadband plan's strategy,
focusing on rural health providers. For every primary care
physician with an electronic health record who adopts
technology, there are thousands of patients--elderly patients,
patients with chronic conditions--who will have a reason to go
online.
My parents use the Internet faithfully to be in touch with
their providers, to look at their lab results, to ask for a
refill, to ask a question. It is those--enabling those health
providers to use electronic health records, to have patient
portals that will create the demand on the side of the elderly,
those with chronic conditions.
So, I think that the approach that the broadband plan
takes, in terms of focusing on the health sector, is
appropriate.
Senator Collins. Thank you.
Mr. Chairman, do you want me to continue, or do you want to
switch off?
Senator Corker. Well, let's just go back and forth.
Senator Collins. Sure.
Senator Corker. I was very interested in what you were
saying about being able to share capacity, if you will, in the
medical system by using this type of technology. If somebody
doesn't have that much of a load, they could deal with a
patient. But, I also understand that what you do is very
complex, that it's really not just science, but also art,
knowing the patient, sort of following through with a patient.
How much of that, if any, is diminished where you actually--
especially in this case of not just using this technology, but
sharing physicians that may not have familiarity with the
patient, themselves?
Dr. Mostashari. I think that is--it's a very perceptive
point. Clearly, having a patient-centered medical home is an
important aspect to provide continuity of care and the
knowledge of the patient. The home doesn't necessarily need to
be provided by one provider, though. One of the, I think,
important innovations that is happening is, through the use of
information technology, making sure that everybody who touches
the patient has access to all the information. Not necessarily
all the medical information, at least; not necessarily the
years of relationships that have built up between the patient
and provider, which is critically important, but at least all
the medical facts are available to everybody who touches the
patient. That is one of the really important advantages of
electronic health records, compared to paper--their
availability, wherever and whenever the provider needs them.
Senator Collins. Let me follow up on an issue that many
hospitals in my State have brought to my attention. As part of
last year's Recovery Act, Congress made a major investment of
some $19 billion to increase the meaningful use of electronic
health records on the part of both hospitals and physicians.
Hospitals can collect an initial bonus, and an extra payment
each time a Medicare patient is discharged.
But, a number of the smaller financially strapped hospitals
in my State are struggling to find the funds necessary to build
the infrastructure that they would need to meet the meaningful
use or criteria. These are the ``tweener'' hospitals, we think
of them as. They're too big to be critical access hospitals, or
they don't qualify as critical access hospitals for other
reasons. But, they're not large enough to enjoy any economies
of scale or to have the resources to do the investments that
are needed.
If these smaller hospitals fail to meet the meaningful user
criteria, then they not only are ineligible for any of the
bonus payments, but they'll actually, eventually, be subject to
penalties. Are you aware of any assistance, any grant programs
or sources of Federal funding, that could help these hospitals
cover their initial startup costs? I will tell you, when they
first started coming to me, I said, ``Oh, we put all sorts of
money in the stimulus bill for this purpose, $19 billion.'' I
thought surely that would be a source of funding, but it's
proving not to be.
Dr. Mostashari. We are carefully looking at all sectors in
the marketplace, and quite concerned that digital divides not
develop in any of the critical sectors, whether it's safety
nets, critical-access hospital, rural health hospitals, small
practices, primary care practices. There are many, many, many
segments within our healthcare--diverse and heterogeneous
healthcare environment that could face significant challenges,
whether it's because of the lack of capital and access to
capital markets, or human resources, technologic know-how.
We have put in place many programs to support different
slices of those communities. We are expecting the marketplace
to step in, for example, on the credit side with the hospitals,
who are--as a group tend, to be more financially capable than,
for example, small practices.
I take your point about the tweeners, that there may be
hospitals that are bigger than the critical-access hospitals,
and smaller and less financially robust than the larger
centers.
Recently, the House and Senate passed the extension of the
meaningful-use payments to hospital-based outpatient providers
who could--and those are additional dollars that the hospital--
could be directed toward the hospital, on the outpatient side,
building out their information systems and EHRs.
So, we do have, through the Regional Extension Center
Program, which is our single largest investment from ONC's
onetime ARRA expenditures--we have established network of
Regional Extension Centers to help provide project management,
technical assistance know-how, education to primary care
providers and smaller practices, community health centers, and
we recently added a supplement for critical access and rural
hospitals with fewer than 50 beds. So, we will continue to
monitor. If it emerges--we're doing--working with the American
Hospital Association on surveys to monitor the rates of
adoption and meaningful use among hospitals, and if something
emerges--a gap there emerges, we will be constantly looking for
ways to improve that.
Senator Collins. Thank you.
Senator Corker. Director Kaushal? Are you tuned in?
Dr. Kaushal. I am.
Senator Corker. Good. I didn't know if you were operating
your BlackBerry or listening to us. I just thought----
[Laughter.]
I'd check.
You mentioned something that all of us talked about a great
deal over the last year, and that was paying for outcomes.
Obviously, you know, in our fee-for-service program right now,
there's really not a real way to deal with this type of
technology in that sphere. Yet, all of us, I'm sure, have been
down on the Senate floor, at one time or another, talking about
the fact that our payment system needs to be based on outcomes.
But, could you describe a little bit how that might work?
Just--you know, not 8 pages, but a paragraph or two about how
that might work in this sphere. Candidly, even in the
traditional sphere of physician services. [No response.]
OK. So, you might want to start again, or maybe not--take
the mute button off, possibly, if----
Dr. Kaushal. Can you hear me now?
Senator Corker. You're at----
Senator Collins. Yes.
Senator Corker. Yes, sir.
Dr. Kaushal. Hello?
Senator Corker. Yes, sir.
Senator Collins. We've got you back.
Dr. Kaushal. Great. So, as I was saying--on this, because--
the recommendation that--.
I think Farzad was spot-on, in terms of--we need to really
trial and experiment with many of these technologies to
understand the economic impact,--accountability--organization.
These are a range in different payment model pilots which are
being undertaken. What we suggested is that these technologies
explicitly be trialed in those pilots to understand whether
they do result in improved economic outcomes. We don't want to
carte blanche reimburse for every single technology, because
that would bankrupt the system. We have to really understand
what works or not. Then the next step is, if things work, there
has to be a mechanism to implement them, which is what some
observers see out there as some of the disconnect over the last
couple of years.
Then the second way--my second point to answer the
questions that there are already great news cases out there.
We've already talked about the VA and the great data that they
received. News cases from systems like that should be analyzed
to understand what worked, what didn't work, and is there a
method to translate them into outcomes-based reimbursement,
perhaps by the extension of meaningful use? The important
caveat there is, of course, that the VA is an integrated
healthcare system and has a very different incentive mechanism.
Senator Corker. So, if I might ask you the same question,
just following up it seems to me that, at present--I think all
of us would love to see a system that, instead of paying for
volume, paid for outcomes, but it's hard to find that, right
now, isn't it?
Dr. Kaushal. Sorry, I. [Laughter.]
Dr. Mostashari. You know, there's the famous story about
the drunk looking under the street lamp for his keys, and, you
know, they asked him, ``Where--did you lose them here?'' He
said, ``No. But, it's--the light's good over here.'' That's
been a limitation in our ability to measure quality--for so
long has been the information that we had access to in order to
measure quality.
I believe that the healthcare ecosystem will be a
dramatically different one if we succeed--and I believe that we
will succeed, in the next 5 to 10 years--of creating a health
IT infrastructure that can collect information--structured
information electronically about the things that matter, that
really affect health and patient satisfaction and care
coordination, and that we will be able to use that health IT
infrastructure to produce meaningful quality measures that can
form the basis for payment innovations.
So, I think this--the environment is changing. In many
ways, HITECH was the first and important cornerstone for that
to develop.
Senator Collins. Just one final question. We've seen, in
the past few years, an increase in cybercrime. We've seen
breaches of Internet security that have caused people to be
subject to identity theft and lose personal financial
information. While the development of broadband networks and
health technologies clearly has the potential to transform
healthcare in a very positive way, doesn't it also raise some
new concerns about the privacy and security of some of the most
sensitive personal information that anyone has--that is, their
medical records? How do we address those concerns? Whoever I
can hear. [Laughter.]
Dr. Kaushal. I'll take--computing as applied to other
industries. There've been huge gains, both in terms of
productivity and the--. But, you're very correct, healthcare
has a very specific security and privacy issue. Having said
that, so does finance. The reason some of the real unknown
questions, when we think about, What does constitute a medical
grade network?--and this is one of the regulatory uncertainties
when we do think about this convergence--so, this is one of the
major topics the FDA and we are working on. We're right in the
early stages, but we hope to really define the privacy and
security issue in a much more tangible way.
Senator Collins. Thank you.
Doctor.
Dr. Mostashari. It is No. 1, two, and three, in terms of
concerns that we have to be attentive to, and leave no stone
unturned in doing so. There are policy, clearly, issues that
need to be determined. We're working with the Health IT Policy
Committee that was created under the HITECH legislation and has
been tremendously helpful in setting a framework for us, not
only in meaningful use, but also now we're moving into the
privacy and security realm. We have to work with practices.
Ultimately, it's not just about the--whether you have the
right policies, it's not about whether you have the right laws,
it's not about whether you have the right technology, it's
about whether they're implemented. So, the best technology in
the world, or the best policies in the world do you no good if,
in the provider's office, they don't use the technology
appropriately. That's one of the things that, in addition to
technology innovation--we just awarded a research award to 20
investigators from 12 topflight universities around--on our
security research. We're working diligently. We have, now, a
chief privacy officer for the Department of Health and Human
Services, and the Office of National Coordinator.
So, we're really tackling it from a policy side, from a
research side, from a technology side, from a standards
perspective, around encryption, around identify assurance, and
so forth. We're merging these activities with the--over all the
administration activities around cybersecurity. But, we're also
looking at on-the-ground--boots-on-the-ground in the doctor's
offices and using the Regional Extension Centers as a key point
of education to make sure that the practices do a risk--a
security risk assessment and take steps--practical steps to
reduce the risk of the network.
Senator Collins. Thank you.
Thank you, Chairman. I yield.
Senator Corker. We thank you both for your testimony, and I
appreciate your input. We look forward to our staffs following
up with you in the future. Again, thank you for doing what
you're doing to advance something that I think we all think is
very promising. So, thank you.
I'll say goodbye to our friend in London. I hope you have
an enjoyable evening.
With that, we'll bring the second panel up.
But, thank you, Doctor. Thank you, Director. [Pause.]
So, I want to welcome each of you.
I apologize for the way this hearing is. This is kind of
the way things are in the Senate, especially when votes ended 3
hours ago, and a lot of people ran to airports and to do other
things. But, you're testimony is all part of a public record.
When we advance legislation here, we have to have hearings that
take place. Our staffs follow up. So, this is all for good. Let
me introduce each of you.
Our first witness on the panel is Eric Dishman. Mr. Dishman
represents the Continua Health Alliance, a consortium of
industry leaders in the field of telehealth and e-care
technologies. Mr. Dishman is a longtime, well-known advocate
for personal healthcare and innovation. We thank you.
Our second witness is Dr. Robin Felder. Dr. Felder is a
Professor of Pathology and Associate Director of clinical
chemistry at the University of Virginia School of Medicine. He
served as a founding Director of the Medical Automation
Research Center, MARC, from 2002 to 2008. He holds a Ph.D. in
biochemistry. Thank you.
As you can imagine, I'm especially proud to introduce our
third witness, Richard Kuebler. Mr. Kuebler is telehealth
department head at the University of Tennessee Health Science
Center. We thank you for the advancements you all are making
there in this field. He has worked in telehealth for over a
decade, and can share the experience of providers using this
technology.
So, we welcome all three of you. Thank you for your
testimony.
STATEMENT OF ERIC DISHMAN, INTEL FELLOW, INTEL CORPORATION,
GLOBAL DIRECTOR OF HEALTH INNOVATION AND POLICY, INTEL DIGITAL
HEALTH GROUP, SENIOR POLICY ADVISOR, CONTINUA HEALTH ALLIANCE,
SENIOR FELLOW, CENTER FOR AGING SERVICES TECHNOLOGIES,
WASHINGTON, DC
Mr. Dishman. Great. Well, thank you, Mr. Chairman. It's
great to be here.
I have been working on aging-in-place technologies for the
last 20 years of my life. I'm really thrilled to have this
testimony today.
It's ironic. Almost 6 years ago to this day, I spoke to
this very same committee, to a different Congress, and said a
lot of the same things I'm going to say today. I'm going to
repeat them today, with a bit more urgency, given that we're
moving quickly toward 2017 and the demographic crisis that we
face.
Senator Corker. I wasn't here then. I thank you for
repeating things.
Mr. Dishman. I have---- [Laughter.]
I will come back 6 years from now, but I hope we've made
progress by then, and I believe we will have.
Before I introduce myself, I want to introduce two
technologies to you, because in--frankly, they're more
important than I am. The first is this small device here. We
probably--if I look around this room and took a survey, a large
number of us would have an experience with a loved one--a
parent, a grandparent--who have had a fall in their home.
Falls, in the United States, cost about $44 billion, annually.
One out of three people over the age of 65 fall each year. It's
a classic problem that leads people to institutionalization, if
not death.
I believe, I don't know, but through our research, we're
trying to discover, that 70 to 80 percent of falls could be
prevented in the first place through some simple technologies
like this. I've had this in my pocket. It's been tracking not
only my number of steps per day, but also micro movements that
are looking at, ``Am I becoming more unbalanced and more
unstable, or changing the rate of speed in my walking norms
around the kitchen, or around the home, or around the hallways
of Congress?'' This kind of data's never been collected in the
real world before.
We're collecting this kind of data with hundreds of
households in Oregon, where I live, and hundreds of households
in a lab in Ireland. The hope is that by collecting real-world
data, not bringing patients into a clinic encounter and saying,
``Are you feeling more unstable on your feet?'' and, ``How have
you been doing with falls in the last few weeks?'' when they
can't remember that. That real-world data will help us
understand and prevent the vast majority of those falls from
ever happening in the first place.
I want to give you a second example. This is a laptop-sized
device. If you know much about Parkinson's disease, about 1.5
million people in United States with Parkinson's, costs us
about $27 billion annually. The disease is incredibly variable.
The fact that we are sending Parkinson's patients to a once-
every-6-month visit to a doctor, who may or may not capture
them, in that exam room for that 15 minutes, with an accurate
assessment of how their tremor is really doing and how the
disease is progressing, and then we will proceed to give them
very expensive medications, that have terrible side effects, is
almost unethical, especially when we can use simple
technologies at home, where patients could do a series of
activities, moving pegs back and forth and speaking into this
device, to look at changes that are going on in their voice,
and get a much more accurate trend about the disease
progression. That's a game-changing, simple technology that
could change how we treat Parkinson's today, and prevent a lot
of overmedication, and a lot of expense and side effects and
hospitalizations. This is work that we did with Andy Grove, the
cofounder of Intel, who has Parkinson's, and his foundation.
Very promising research.
Those three words, ``very promising research,'' are what I
would describe for the field right now. Not a lot of products,
but lots of very promising research. I've spent 20 years doing
social science research of aging-in-place technologies and e-
care technologies. At Intel, where I have my day job, we have
tested over two dozen in-home pilots, with seniors, of
different technologies, like these two that you've seen today.
We have lived with and observed 1,000 elderly households in
20 countries, understanding their needs and trying to figure
out how e-care technologies could be used in ways that no one's
imagining right now. We have funded well over 100 university
grants in this area, out of Intel. We have helped to start
several not-for-profits, including Continua, that I represent
today, which is a not-for-profit advocacy group and standards
organization, to make sure that these home-based technologies
for e-care are interoperable, and are built on standards and
advocate for these. The Continua is now 227 companies strong.
That's the good news. The bad news is--I mean, my career is
great. My research career is wonderful, and I'm very happy on
that regard. Personally, I cannot use these technologies to
help take care of my own aging parents, who live far across the
country from me in North Carolina, because there are neither
the incentives nor the infrastructure to allow their doctors to
get this data and interact with them or with me in any
compelling way. I can't use the own products and research that
my own company is creating to help take care of my own parents.
That's why I'm here today.
Four big barriers, many of them I'm going to reiterate from
things you've heard from other people today. The first is
imagination. As I make Hill visits, most policymakers do not
understand there's an imagination gap about what is available
today already, and what is possible. If they have an
imagination for e-care or telehealth or telemedicine, they
mostly think about physician-to-physician video consultation,
which is certainly part of it, but that's not--that's very
different than a Parkinson's device that's helping to track
your disease, or a simple wearable technology that may prevent
the vast majority of falls. So, we need to do something to help
policymakers and your colleagues understand what's possible and
what's real today.
There's also no agency--and 6 years later, this is the main
thing I asked for 6 years ago--no one in Federal Government
owns driving the e-care/telehealth agenda. No one owns putting
together a national telehealth and e-care strategy. I've worked
with the European Union, 10 years ago, and I've worked with
nine European countries, who each have their own national
strategy for e-care and telehealth to the home, for chronic
disease management and independent living. But, we need a
national coordinator for e-care, here in the United States, to
get our act together and catch up with a lot of what the rest
of the world is doing.
I often call this the Y2K Plus 20 Commission, because by
2020 we've got a lot of baby boomers retiring, and we need the
kind of energy and attention that the Y2K Commission brought,
where we brought the private sector, government leaders, and
not-for-profits- at an executive level- to own this agenda and
move it forward quickly as a national infrastructure.
So, imagination is the first.
Second--we've talked about it already a little bit--are
incentives. We pay for reactive medicine today. With few
exceptions, we pay for sickness and injury care, not health; we
pay for face-to-face visits. When I show these devices to
clinicians and they work on our teams, they're, at first,
skeptical of the technology, then they see what it can do, and
they say, ``Oh my gosh. I can't treat patients without this
data, because I'm flying blind in a once-a-year visit with
them. I just hope that I actually have their paper chart or
their electronic record in front of me.'' The kind of data that
you have doesn't exist in a face-to-face encounter, because
you're pulling real-world trend data. Then they have that
moment where they say, ``But- I can't use any of this. There's
all these reasons why I can't. The most fundamental is- I only
get paid, and the whole system only works if you come into my
office.'' So, incentives are certainly key to that, and we've
heard a lot of that today.
The third is investment. Our medical research dollars today
in the United States are spent primarily on great drug therapy
and diagnostics. We will spend--if you come back to my example
with falls--we will spend tens of billions of dollars on the
next great piece of hospital equipment, to look at even higher
resolution of the bone break that you got from falling in your
home, or of creating a new drug that may be incrementally
better for painkillers once you've already broken your hip, but
we will not spend tens of millions of dollars on interventions
that may prevent 70 to 80 percent of falls from ever happening
in the first place. That's completely backwards.
There is no major funding bucket. My recommendation here
is, the United States needs to match what the European Union
invested, of 1 billion euros that they invested 3 years ago,
into this area of e-care and independent living technologies
for seniors. There's no major program at the National
Institutes that own this. There are a few grants here and
there. But, it's happening by accident, not by intentional
strategy.
The fourth is infrastructure. You've heard some about
broadband today, and there are two kinds of infrastructure I
want to close with. Technology infrastructure and broadband
being key to that, but workforce infrastructure is the other
key.
Our infrastructure today is preparing professionals and
professional places, clinicians and hospitals. It is not
preparing consumers and home to be part of the care force that
we need to do in the 21st century.
So, one is, we need this next-generation broadband network.
We need to make sure that the FCC's broadband plan, which we
have to admit is one chapter of a large broadband plan, and is
likely to dissipate if somebody does not watchdog this, many of
the people who created this broadband plan are not going to be
at the FCC in 4 months. So, I keep asking myself, how is this
going to be implemented and carried through? Because the very
brilliant people who created it will no longer be around. We've
got to make sure we follow through and don't let this just be a
chapter in the broadband plan, but there's an implementation
plan to move this technology all the way to the home.
The second is, we have to train--and this is what Europe is
well ahead of us in doing--volunteers, family members, and e-
care virtual workers, both professionally and clinically
trained and nonclinically trained, to use these technologies
and integrate it into workflow. It's not the technology alone;
it's the technology plus the workforce.
So, in conclusion, I'd say, global aging leaves us no
choice but to invent these new care models. There is no
scenario in which we're going to suddenly create enough doctors
and nurses and bedspace to catch up with the age wave, or even
to add the uninsured to the current system. We need to do for
global aging and what I would call ``gray technologies'' here
what we have done for global warming and green technologies.
Invest in it. Catalyze it. Make sure that U.S.-based companies
are going to catch up and compete with Europe in what's likely
to be a large market opportunity. This will help us take care
of our own demographic in aging population, as well as help
give us an advantage to sell those capabilities to the rest of
the world.
Thank you.
[The prepared statement of Mr. Dishman follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Senator Corker. Great testimony.
Mr. Felder.
STATEMENT OF ROBIN FELDER, PROFESSOR OF PATHOLOGY, ASSOCIATE
DIRECTOR, CLINICAL CHEMISTRY, THE UNIVERSITY OF VIRGINIA SCHOOL
OF MEDICINE, CHARLOTTESVILLE, VA
Dr. Felder. Senator Corker and your colleagues in absentia,
I thank you for the invitation for being invited to present
here today. Today's testimony and the accompanying written
statement will address how an expanded broadband infrastructure
can result in dramatic cost savings, yet higher quality health
and wellness in elders, and hopefully add to the well-published
VA-system studies we heard about today.
Broadband-based telemedicine has the potential to reduce
the cost of medicine by well over 50 percent, stimulate
economic growth in the medical technology sector, and raise the
quality of life for seniors and all Americans to unprecedented
levels. Since our elders will generate a high percentage of the
estimated 4.2 trillion total annual economic burden of chronic
disease by 2023, how is the United States going to deal with
this enormous challenge?
Advances in telemedicine, sensors communication,
information technologies will enable distance-based healthcare
that rivals hospital-based care; essentially, the hospital,
without walls.
In-home monitoring has the added benefits of measuring
individualized health, as well as psychosocial status, and
continuously reporting it to the individual, primary care
providers, and caregivers alike. I don't think we've heard a
lot about psychosocial support today. The benefits will include
quicker and understandable wellness information and targeted
preventative interventions. In-home monitoring may be the key
solution that addresses efficient and effective means of care
delivery to elders, while allowing them to age in their place
of choice, particularly in rural health, which we've heard
about earlier this morning.
Health-monitoring home environments have been accomplished
by wearable sensors and passive sensors embedded in the home
environment. I'd like to emphasize that compliance is one of
the major challenges with monitoring the elderly today such as
getting them to strap on that wristwatch, place that device in
their pocket.
But, there is a new wave of passive sensing that, simply by
existing in your home, you will be monitored for health
conditions. For example, sensors embedded in a mattress pad can
provide high-quality sleep assessments that rival sleep-lab
assessments in hospitals. Continuous monitoring of vibrations
in the floor can detect falls and classify them according to
the best choice of first responders, either a 911, if it's a
concussive fall, or a visit by a care provider that could help
deal with falling issues such as stumbling followed by
continuing ambulation. Tiny sensors worn in body orifices
engineered, so these can be placed and remain for 6 months, can
report glucose continuously to cell phones or to the home
phone. In other words the elder does not have to be compliant,
since there are no buttons to push and no instruction manuals
to read.
Deploying sensor-based telemedicine does not have to be
costly. We conducted, in our group, a case-controlled study
comparing monitored versus nonmonitored elders, passively, in a
senior living facility in the Midwest over a 3-month period.
Our studies demonstrated a 36-percent reduction in billable
medical procedures, a 78-percent reduction in hospital days,
and a 68-percent reduction in the cost of care. In addition to
the reduced cost of care, the efficiency of the caregivers
actually went up by 50 percent. So, not only did costs come
down, but efficiencies went up for the caregivers. Thus,
monitoring technologies can significantly reduced billable
interventions, hospital days, and cost of care to payers, and
has a positive impact on professional caregivers' efficiency.
Medication compliance is also a significant challenge in
the eldercare environment. In the near future, small pill-
dispensing kiosks will dispense a wide range of medications at
home that will facilitate finding the optimal doses that
minimize side effects. These broadband-connected medication
dispensers will allow the electronic medical record to be
automatically updated with regard to medication compliance and
efficacy.
Nutritional support is often an overlooked factor in
managing health and well-being in elders. Lack of proper
nutrition can be a significant factor in hospital readmissions.
Broadband-based in-home monitoring can determine if meals were
delivered, if the elder consumed the meal, and if there are
steady improvements in health as a result. Thus, automated
nutrition support is one of the easiest challenges to solve and
one of the most costly to ignore in the United States.
In conclusion, broadband access with passive technologies
will enable even those with little interest in their health to
be encouraged to adopt healthy lifestyles. Delaying or
arresting chronic disease, providing nutritional support, and
assuring psychosocial well-being are some of the most proven
benefits of home-based passive monitoring technologies.
Finally, since home-based wellness results in costs that
are 50 percent less than traditional care, it provides a basis
for using broadband to revolutionize this Nation's healthcare
system.
Again, thank you for the invitation to address the
committee.
[The prepared statement of Dr. Felder follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Senator Corker. Well, Chairman--Senator Wyden, we have our
last witness. I want you to know he is from the great State of
Tennessee, and I've already introduced him, so I just wanted
you to know I was handing back off to you.
Senator Wyden [presiding]. I thank my colleague, and thank
him very much for ably stepping in.
I apologize to all the guests. In the Budget Committee,
you're technically sort of there, and you can't be liberated
until it ends. [Laughter.]
So, I apologize to all our guests.
I gather that we have a very thoughtful leader in the field
from Tennessee, Mr. Kuebler. Please proceed.
STATEMENT OF RICHARD KUEBLER, TELEHEALTH DEPARTMENT HEAD,
UNIVERSITY OF TENNESSEE HEALTH SCIENCE CENTER, MEMPHIS, TN
Mr. Kuebler. Good afternoon, Ranking Member Corker and
Senator Wyden. Thank you for having me here today. I'm grateful
for the opportunity to testify regarding aging in place and the
associated healthcare technology which has such a significant
impact on the quality and dignity with which our citizens
receive healthcare.
My name is Richard Kuebler, and I am responsible for the
telehealth program at the University of Tennessee Health
Science Center in Memphis. Our program is nearly 12 years old.
It's one of the oldest programs in the country. I, personally,
have worked within the telehealth environment for the last 10
years.
We see telehealth, telemedicine or e-care work across a
myriad of specialties. We use telehealth as a clinical delivery
mechanism over distance. Telehealth can be as simple as remote
glucometer monitoring or as complex as realtime diabetic
retinopathy diagnosis. However, the results are the same.
Telehealth as a delivery mechanism for healthcare works. We
see a diverse scope of patients. Since Tennessee borders more
States than any other State, our providers are able to see
patients from any of the eight States bordering Tennessee.
Patients see no discernible difference between the levels of
care. One provider was actually stunned when, at the conclusion
of a consult, the patient stood up to shake his hand, despite
being 200 miles away.
We've seen telehealth save lives, increase the quality of
life, and treat chronic diseases across our State and our
region. Telehealth specifically delivered remotely into the
home has had a significant impact on health outcomes and cost
savings. We, at UT, have the research outcomes that show home-
based telehealth used on an at-risk population for congestive
heart failure decreased hospital admissions by 80 percent.
Hospital readmission rates were reduced by 85 percent, and, as
a result, the cost per patient dropped from $10,000 to $2,500.
Nationally, there are 5 million hospital stays per year for
congestive heart failure, costing approximately $8 billion. The
national implications of utilizing telehealth in this single
specialty could reduce healthcare costs by $3.8 billion.
At the University of Tennessee Health Science Center in
Memphis, we've developed the only realtime diabetic retinopathy
technology program in the world. Diabetes is an epidemic that
affects 21 million of our citizens and 20 percent of
Tennessee's population. An additional 7 and a half million
people across the country have prediabetes. Diabetic
retinopathy is the leading cause of blindness among adults in
the industrialized world, and currently in the United States,
400,000 patients are screened for diabetic retinopathy each
month.
Traditionally, the screening is done as a store-and-
forward, and the results are returned, taking as long as
several days to a week. The patient then has to be rescheduled,
and then the diagnosis delivered. Utilizing digital imaging and
highly advanced computer algorithms, developed with Oak Ridge
National Labs, we've been able to deliver those results within
90 seconds, drastically saving costs and increasing the
efficiency of patient care.
Now, there are associated costs with telehealth, not the
least of which is connectivity. The FCC, as they mentioned
earlier, has several programs which subsidize connectivity into
rural and underserved areas, offsetting the cost of rural-based
broadband by up to 85 percent. While existing home-monitoring
technologies may not be bandwidth-intensive, the access of
broadband at home can establish a platform for ancillary
medical services, such as clinical videoconferencing,
education, and medication management technologies. The
expansion of wireless 4G technology or traditional land-based
fiber optics will have significant impact on the level of care
delivered to the home or the ``last mile.''
Successful business models for telehealth is direct
contracting between the service providers, such as UT, the
Health Science Center, and Managed Care Organizations. In the
case of maternal fetal medicine and pediatric cardiology,
providing blanket service for a regional population can provide
cost capitation for the MCO while also covering the cost of
delivering telehealth services into outlying or even
metropolitan areas.
However, the most significant barrier to adoption is
reimbursement. In the previous real-world examples I gave you
telehealth applications with both chronic heart failure and
diabetic retinopathy, there is no reimbursement for providing
these services.
When left to altruism alone, there is little hope of a
sustainable business model for telehealth or e-care. In most
cases where telemedicine practices are reimbursed, it's done on
a lower scale than a traditional brick-and-mortar patient
encounter.
So, if a provider is reimbursed two to three times as much
for a traditional clinical encounter versus a telehealth
encounter, which type of healthcare is incentivized? Telehealth
is actually disincentivized for both providers and facilities
in the current fee-for-service model. While reimbursement
varies from State to State, the successes of telehealth
implementation, from a billing standpoint, have been the
inclusion of telehealth as a traditional method of care.
Whether delivery of healthcare into the home or the extension
of specialists into rural and underserved areas, there must be
an equitable billing mechanism for telehealth to be
sustainable.
Currently, telehealth is reimbursed as an exception or a
``less than'' method of care delivery. States such as
California and Missouri, they've incentivized the practice of
telehealth by State Medicaid provisions, which reimburse
equally for telehealth services which meet certain technical
criteria.
Telehealth should be viewed as an accepted level of care,
versus an exception to the rule, from a reimbursement
standpoint, whether delivering care into the home or treating a
patient in a rural or metropolitan clinic.
At UTHSC, in Memphis, we've seen the opportunity and
radical improvement to healthcare that telehealth can afford.
The implications can go far beyond the quality of life for our
aging population, preventing hospital stays and nursing-home
enrollments. The significant cost of healthcare for our aging
population is undeniable, and we have demonstrated that the
cost savings exist. Ultimately, a model must be created to
ensure that telehealth-care providers are equitably reimbursed;
otherwise, there's no incentive to change traditional delivery
of care.
Telehealth is not a panacea. Like any other form of
healthcare practice, there is potential for abuse. However, the
potential of healthcare possibilities is almost limitless in
the ability to provide quality medical care over distance.
Ranking Member Corker, Senator Wyden, thank you for the
opportunity to speak with you about the incredible opportunity
that faces us regarding advancing the level of healthcare in
our State and our country. I am happy to answer any followup
questions you may have.
[The prepared statement of Mr. Kuebler follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Senator Wyden. Thank you very much.
Senator Corker's been so wonderfully patient all afternoon.
I think it's just appropriate he start the questions.
Senator Corker. Well, I will, then. Thank you.
I thank each of you for your testimony and your passion for
this particular topic. I hope you don't have to come back in 6
years----
Mr. Dishman. I'm happy to----
Senator Corker [continuing]. For the same----
Mr. Dishman [continuing]. Come back----
Senator Corker [continuing]. Testimony, but----
Mr. Dishman [continuing]. Every 6 weeks, if that's what it
takes. [Laughter.]
Senator Corker. Mr. Kuebler, the last panel was asked, by
Senator Collins, just about the whole issue of privacy. I
thought I'd ask you the same. Are there concerns that exist,
from your standpoint, as it relates to patient privacy, using
this type of technology?
Mr. Kuebler. Well, I think the ONC did a great job of
addressing the different opportunities for improvement that
there are. From a patient adoption perspective, it's been
interesting, the fact that the technology becomes relatively
transparent after initial adoption. Privacy is the largest
obstacle from a patient's standpoint.
Senator Corker. Privacy is what?
Mr. Kuebler. Is probably the most significant obstacle,
from a patient standpoint. But, our patient data shows that in
the high 90's--97, 98 percent of patients are equally as
satisfied with a tele-encounter versus a face-to-face
encounter.
Senator Corker. As a person who, obviously, has been highly
involved--we look at what happens with supply, and all the
various avenues that people have access to something does
create greater demand, right? We want everybody in our country
to have healthcare and access to good quality care. I know that
we talk a little bit about the fact that this is much less
expensive, obviously, on a per-visit type of situation. Some of
the technologies can prevent other issues down the road that
are more expensive. But, is there also a component of this--and
I'm not trying to be negative--but, with tremendously expanding
access to healthcare, through this type of technology, even
though it's at a lesser cost and it sounds like data maybe
presents better outcomes--is there also a situation that
creates much, much, much larger demand down the road, as
broadband becomes more available and as people become more
accustomed--our culture becomes more accustomed to using this
type of technology? What are some of the issues that come with
that?
Mr. Kuebler. Well, let me try and tackle that from a couple
different directions. From the provider perspective, obviously
the goal is to reduce the cost--but from the payer perspective
the goal to reduce payments out, or costs. From the provider
perspective, there's still an associated cost of doing business
in order to be able support the additional medical services
that are being provided. So, the goal would be some sort of
blending of the two, with agreements that would be directly
between the payers and the providers, to make sure that the
cost of carrying the additional clinical load is also offset by
the ultimate payments out that the payers are putting into the
system.
Senator Corker. Any other comments in that regard?
Mr. Dishman. I mean, I'd say, in our experience--and we've
tested this with thousands of seniors, in particular--often
frail, who have never used PCs or technologies in themselves--
in their lives. If you think back to email, when we used to do
surveys, at Intel, of people, about, ``Do you want email?''
People said, ``No.'' Because it was before everybody had email,
they didn't quite understand what it was. When email started,
everyone thought, ``Well, it'll replace the telephone. We'll
never use the telephone again.'' What we now know is that email
is a different way of interacting with each other. It didn't
replace the telephone. We use telephone for certain things, and
video conferencing for certain things, and email for certain
things.
These e-care visits are not just a replacement for a face-
to-face visit. They're a different kind of visit. I can give
you an example from, just last week, a study that we're doing
with veterans. Veteran, 90-some years old, woke up and had a
rash on his chin, on the side of his face, lives in a rural
part of the country, out in eastern Oregon. Today, our system
says, to get that checked out, the veteran even has--either
just does nothing and sits on it until it gets worse or makes a
pilgrimage to a clinic or a hospital, some distance away, and
has to schedule a full exam with doctor to get it looked at.
With e-care technologies, the notion of a quick, ``Hey, doc.
Can you look at this?''--the answer is yes. The doc can do a
quick look at this and say, ``Yup, you need to come in, or
nope, I can treat you at home.''
So, what we're talking about is not replacing visits with
e-visits. We're talking about adding e-visits as one of the
tools that doctors can use, when medically appropriate, to mix
up care. Because sometimes they need to go into the actual home
of the patient, sometimes they need to bring them in, and more
often than not they can do it virtually, especially if they
have the data. That's been our experience in every study that
we've ever done.
Senator Corker. You mentioned the other experience you had
had with other countries, and how nobody here owns getting this
done. Obviously, it's not going to make much progress; you will
be back every 6 years if that continues.
Mr. Dishman. That's very true.
Senator Corker. Can you tell us who you think should own--
which department of which Cabinet? I mean, what's the most
logical place, here in the U.S. Government, for the central
effort to take place.
Second, you mentioned the other European countries that
have done it very differently. Well, how do they compare, as
far as adoption of this type of technology, to us?
Mr. Dishman. The first question I have been thinking about
this, and asking questions as I've been in D.C. this week. I
think that--personally, what makes more sense to me is, the
ONC, the Office of the National Coordinator, is trying to
coordinate health IT across all of these groups. I think we
need to add an administrator or an executive leader of the
Office of National E-Care Coordination, and drive that e-care
telehealth strategy. That would make--perfect sense. I mean the
challenge that we have is, it's not just the technology. You've
got to work on workforce issues, and broadband, and payment
reform. So, we need a place to stand where you can coordinate
across all these agencies, to tackle that. That would be my
best guess, personally.
To your second question, the EU, as a collective, and then
European countries, in particular, have been focusing on three
things. One is their broadband buildout, making sure that their
specification for broadband is driven by e-care-use cases. My
concern today, is that we are going to drive broadband to the
rest of the Nation, but I'm not sure we're designing a pipe
that's ready for where we're going, as a country, for e-care,
where you can do the kind of ``always on'' secure data
collection from the home; have your specialty-care doctor on a
high-resolution video--this is happening in South Korea now--
where you've got the senior, the family member, the specialty-
care doctor, and the primary-care doctor all on rich video at
the same time. That's one of the broadband network in South
Korea now, and doable. I'm not sure we're building a pipe
that's ready for that. So, before we go dig up rural America
and lay fiber, let's make sure that our specification's are
going to enable that fundamental infrastructure.
The second thing that Europe is working on is workforce.
Knowing that they have to train family caregivers to be an
active part of the care coordination team, and they've got to
train nurses and clinicians on how to integrate e-care
technologies into their workflow. They're ahead of us, because
they've already developed curriculums for virtual telecare
workers and saying, you know, ``What's the right mix of virtual
visits for a doctor to do in a day, and in-clinic visits?'' and
really starting to understand those kinds of things.
The third is really funding the fundamental research. This
is the billion euros that they put into what are called
``ambient assisted living.'' Our research, that we fund at
Intel, the universities--the hundred university grants that
were done, by and large those American researchers are now
trying to collaborate and partner with overseas researchers,
because there's no program here for them to go up and do
larger-scale studies. That's what really worries me, as a
citizen and as somebody in an American-based company. I don't
want all that intellectual property and that energy and that
know-how to, sort of, go overseas.
Senator Corker. Well, thank all of you for your testimony.
I look forward to pursuing this further.
Senator Wyden, thank you. I'm--like you, I've got a 3:30
situation I've got to step to. But----
Senator Wyden. Thank----
Senator Corker [continuing]. We've had some great
testimony. I want to thank you for your leadership on this
issue.
Senator Wyden. Thank you, again, for your patience. I know
we're going to work together on it. This is one of those
opportunities to get more value for the healthcare dollar. We
have talked often about it.
Let me pick up on this question that Senator Corker just
started into with, really, all three of you, because I think
you've got the alphabet soup of agencies. You've got the Center
for Medicare and Medicaid Services, that's, you know, CMS.
You've got FDA, the Food and Drug Administration. Clearly, the
Federal Communications Commission works in communications. I
just imagine trying, around here in the U.S. Senate, to watch
this get spread far and wide through all of these various and
sundry, you know, committees. I sit on the Finance Committee
and the Budget Committee, which has a key role in Medicare,
which has jurisdiction over the Department, you know, of Health
so you can get into some of these issues. But, then you have to
send all of this off to the Federal Communications Commission,
because this has, clearly, a communications role.
I think, for purposes of this afternoon and the lateness of
the hour, one of the questions I'd like to ask all three of you
is,--it seems to me that right at the heart of what needs to be
done is to change this embedded, outdated reimbursement policy
for these technologies. Do all three of you agree with that?
Mr. Dishman, yes?
Mr. Dishman. Absolutely.
Senator Wyden. Felder, yes? Mr. Kuebler, yes? All right.
The reason I believe its outdated is, it seems to me, by
its very nature you've got to have video and audio. It's got to
be at remote locations. I mean, it essentially precludes the
very benefits that we'd like most to secure for older people,
which is the opportunity to age at home. Is that right?
Mr. Dishman. Absolutely.
Senator Wyden. So, by way of starting this--and I said, on
the Finance Committee, where at least we've got jurisdiction
over the Department of Health and Human Services--strikes me,
that's where you ought to start the revolution, to really
start, you know, bold fashion, to get these products out on the
playing field. Do the three of you agree with that?
[All witnesses nodded in the affirmative.]
Senator Wyden. OK. That, leaves the other question of, How
do you take the array of alphabet soup agencies and in some way
consolidate them so you can get these devices out there in
something resembling a timely fashion? Because I see, for
example, once we get over reforming this outdated standard, for
purposes of Medicare reimbursement, you still have to run the
gauntlet, particularly, say, at the Federal Communications
Commission; we've got two health agencies involved, you know,
under the auspices of the Department of Health and Human
Services; and then, you've still got to go off and get into the
communications area.
So, do any of you have any thoughts about how you'd pull
these three agencies together in something that would allow
these products to be evaluated in a timely way?
Mr. Dishman?
Mr. Dishman. Well, I'd--in part say, go where the momentum
already is. I mean, I've read the entire health reform bill,
actually three times. It was hard, but I did it.
Senator Wyden. I read it once. [Laughter.]
Mr. Dishman. I've read it three times, because it took that
long for me to be able to understand it. But, what I would say
is, there wasn't a national strategy on e-care in the bill.
But, I would say there are lots of places where there's
momentum that we can build on top of. Those are, for me,
medical home, accountable-care organizations; Independence at
Home, your legislation. Those places create openings, because
you're talking about paying for outcomes and putting
coordinated-care teams together. We just want to make sure that
those teams then have the option of experimenting with the
different mixes of in-home, in-clinic, and virtual or e-care
visits.
I'd say, go where that momentum is. I don't think there's
anything precluding us from doing that in those domains. I
would say the comparative effectiveness money, we need to make
sure we spend some of it comparing e-care to in-clinic care,
and not to let all of that money go to just comparing
traditional medical devices or pharmaceuticals. So, that would
be the last piece--I'll reiterate what I said earlier--we need
an executive owner whether it's at ONC or wherever the person
is. If we don't have an executive owner who's driving this e-
care and telehealth strategy, I don't think we will be
continuing these hearings, 6 years from now, and 6 years after
that.
Senator Wyden. Mr. Felder?
Dr. Felder. I'm a----
Senator Wyden. Mr. Kuebler?
Dr. Felder [continuing]. Great believer in free enterprise,
as evidenced by the explosion of iPhone apps that are medically
related. I think what we need to do is just make sure we don't
have FDA and others impeding consumer-demand, government
expenditures aren't necessary. There is going to be tremendous
consumer pull in this area. So, I think the two are going to
meet in the middle, but I would venture that the private
enterprise approach is going to quickly overtake and swamp out
any government initiative in this area.
Senator Wyden. Well, I share that view. One of the reasons
I want something along the lines of a one-stop process for
evaluating these devices and getting them out on the playing
field is that I think the genius of the free enterprise system
could be impeded because you've got all of the agencies strewn
all over Washington with a hand in all this. What Mr. Dishman
said is, he'd like to have the health agencies, in effect, take
the lead, because that's where the expertise is, and that's
certainly going to be part of the debate. But, to realize the
genius that Mr. Felder has talked about is--I think you've got
to have a one-stop process for getting these products
evaluated, balancing the various interests, be it, safety and
cost-effectiveness and hard data, on quality, the various
interests that we've been talking about all afternoon.
Mr. Kuebler, did you want to add anything?
Mr. Kuebler. I'd just like to concur with Mr. Felder and
Mr. Dishman.
Senator Wyden. All right.
Let's talk about something else that I think is going to be
somewhat of a challenge in this area, and that is that we've
all come to love our iPhone applications. We have these--
staggering array of, iPhone applications. But, sometimes I
wonder about the implications of somebody reading a restaurant
review on Yelp that somebody's e-care data, in effect, then is
lost in an Internet traffic jam. I think that we continue to
have real challenges with respect to access of essential
services.
Is it appropriate for the Congress or the Federal
Communications Commission to start thinking about priority
access in this area of e-care? I mean, in effect, an HOV lane
for e-care data for wireless broadband.
I come to this having thought a fair amount about it, and I
haven't really reached any judgments about how you'd want to do
it, but, at some point, Americans are going to ask some
questions about whether everybody ought to be reading movie
reviews, when somebody who needs, for example, emergency
services gets caught in a Internet traffic jam.
Any thoughts on this? Talk about trying to balance issues
relating to the role of the private sector and the public
interest. I think this is right at that intersection.
Mr. Felder? I would just go right down the row. Mr.
Kuebler?
Mr. Kuebler. I think we saw earlier, with some of the burps
and hiccups with the video conferencing, some of the issues
that can be plagued by going over commodity Internet. So,
this--whether you call it a HOV lane or a ``quality of
service'' lane, would certainly scale. That is one of the
issues, especially in live consults----
Senator Wyden. You'd be for it.
Mr. Kuebler. I think it's----
Senator Wyden. You'd be----
Mr. Kuebler [continuing]. Definitely----
Senator Wyden [continuing]. For the----
Mr. Kuebler [continuing]. Something that's worth exploring.
Senator Wyden. Yeah.
Mr. Felder.
Dr. Felder. I'm not sure of the exact infrastructure, but a
stable and secure Internet is something we certainly don't have
right now, particularly stability. It goes in and out, as we've
just seen.
Mr. Dishman. I agree, in two ways. There's a practical
near-term and a long-term. The near-term is, we need to explore
the possibility of accelerating access to people for broadband
in today's marketplace for health purposes. If you're coming
out of a hospital discharge situation, and you need a
broadband-connected telehealth solution to help you recover for
that first 30 days, so you don't get a hospital admission, but
it takes 45 days for you to stand in line to get the broadband
provider to come out and hook it up to your house, then we've
got a problem.
Longer term, Senator Wyden, I think you're right onto
something. We need to be exploring use cases for the
technology--lets say, you know, heart rate data for a critical
patient needs to be extra sure it gets there well ahead of
something like a recipe being exchanged. I'm not an engineering
expert, but we need the experts to think through those problems
and solve them.
Senator Wyden. Mr. Dishman, as you know, I authored the
provision in the health reform law, promoting Independence at
Home, in effect, launching a variety of programs to address the
needs of the highest-cost folks on Medicare, the folks with
multiple chronic conditions. You would use a house call team
approach. Those that participate in this, the Independence at
Home providers, are required to achieve minimum savings of 5
percent, and to show that they can achieve these savings.
It seems to me that e-care is a very good way to prove
this. I think it's also a good way to get at this issue, that
Senator Collins apparently talked about in my absence, that
older people are going to say, ``I don't know so much about
these products. I'd like to know more about them.'' It would
seem to me that the Independence at Home providers would be a
natural way to get older people, who chose to do it,
comfortable with the products and devices, and be in a position
to use them.
So, I think this is kind of a twofer. It gets you launched
with Independence at Home, and it also gets at something of an
educational effort that's going to have to be part of any e-
care program.
What are your thoughts? Let me thank you. I consider you
sort of one of the godfathers of the Independence at Home
effort, since you and many you work with have educated me and
our staff on it. I think it's almost an appropriate way to wrap
up, because, you know, Independence at Home, in my view, is
going to be a significant part of Medicare's future. I mean, if
you look at the fact that a substantial number of Medicare
patients on any, you know, given day are going to require these
kinds of services--and here's an opportunity to really target
savings, because we know that there is great opportunities to
move away from the model where they have to come to the
office--this is the future.
So, close, if you would, with an assessment of what
Independence at Home can achieve, using e-care.
Mr. Dishman. I think an e-care-enabled Independence at Home
strategy is the essence of what our health reform is supposed
to be doing. My only complaint about Independence at Home is
that the Secretary has the option of waiting until 2012 to
implement it. I believe there are 60 or 70 organizations across
the United States today who are ready and can go do
Independence at Home now. Their big challenge is, they can't
scale, because they were not going to have enough staff, and
they're going to have to use e-care to help them do,
themselves. Intel and Continua have been supporters of
Independence at Home since day one. A technologized capability
brought to that is key.
I say we can actually look to the VA here, as well. If you
think about the home-based primary-care program that the VA
uses to care for seniors with many chronic diseases, who would
otherwise be in a nursing home or in a hospital, but in their
own home, and you think about the work that's a separate
program at the VA, on telehealth, the merger of those two is
what we're talking about with Independence at Home. I'm eager
to start working to make that a reality, and not wait til 2012
to do that.
Senator Wyden. Well, don't completely despair. One of my
favorite aspects of the legal consequences of legislation is
that no current Congress can bind future Congresses. Let's go
out there and show that we can get Independence at Home more
accessible and more quickly than people, this year, thought.
This isn't going to be the only provision that is going to be
sped up. I look forward to working with you on it.
Mr. Felder and Mr. Kuebler, anything else you'd like to
add? Further thoughts?
[The two witnesses shook their heads in the negative.]
Senator Wyden. Thank all of you for your patience, again.
My apologies. We're going to be working very closely with you.
This is an exciting topic. Obviously, you all are on the
cutting edge, with so many of these devices, and innovative
thinking for innovative products, and we look forward to
working with you.
With that, the Committee on Aging is adjourned.
[Whereupon, at 3:48 p.m., the hearing was adjourned.]
A P P E N D I X
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Mr. Dishman's Responses to Senator Kohl's Questions
Question. I have heard you speak about the many benefits of
using health care technology in the home. Are there any
disadvantages to using this type of technology for patients and
their family members?
Answer. Although remote patient monitoring consistently
shows improvements in health outcomes, reduction in hospital
admissions and length of stay, issues of implementation can
occur around four primary categories:
1. Device or instrument calibration,
2. Untrained use of the devices
3. Unauthorized users
4. Lack of personal contact
Calibration
Although the calibration activity is typically managed as a
factor for FDA 510(k) clearance, the devices can and should go
through a routine calibration schedule recommended by the
manufacturer. (Some may require more stringent settings and
some are designed specifically for rugged consumer use and may
never need recalibration.) The schedule and need for
calibration, or other maintenance, is determined by the
manufacturer. This can be a challenge for the patients using
the vital sign capture technologies to follow all the
manufacturers' guidelines for calibration of their home use
devices. The risk of a system not properly transmitting data to
clinicians may create not only misinformation that the
clinician may use in diagnosis and treatment, but also create a
false sense of security by the patients.
Training
Untrained user issues are also typically handled by the FDA
510(k) clearance process for user design and actual use
parameters. Once again, the devices are designed for this
purpose in field use and must also be designed with an
appropriate user interface for the intended user, taking into
account the environment where it will be used, a user's
physical limitations and the user's familiarity with
technology. For example the blood pressure measurement, asking
a patient to push one button to turn on a device and again to
do the measurement creates unnecessary complexity for what is
essentially a simple measurement. Where it becomes very complex
or difficult for the patient is with multi-use instruments with
several buttons to push and sometimes several cables to connect
or disconnect from the telehealth device. Designing and
delivering the correct UI design is essential and required by
the FDA.
The system may demand that caregivers, already
overburdened, also provide technical support. Patients living
alone without caregivers might not be able to use a
sophisticated system on their own. Thus, the people who need it
the most may not be able to benefit or may underutilize the
features. They may, for example, not know how to activate a
system to report questions at times outside of scheduled health
sessions on the system.
It is possible that in the course of reporting a symptom on
a survey, patients won't be able to provide related symptoms or
contextual factors that could come up in conversation with a
clinician. This could potentially lead a clinician to overlook
a more unique health condition.
Unauthorized users
In the home setting, one cannot always control who uses the
system, particularly when curious family members would like to
use the vital sign devices to check their own measurements.
Allowing access to devices by children or others can be
disruptive to the patients or to the clinician who may be
receiving data that is not from the patient. Additionally,
using a community device where more than one person inputs data
has the potential to be confusing if the data somehow is not
clearly tagged to an individual reporter. Several devices
already have the capability to manage more than one user which
requires effective training to ensure proper use. We are also
designing security standards into the guidelines to ensure we
have the right person identified, which becomes critical when
devices are intended to be shared in multiple locations: work
cafeteria, remote clinics, shared facilities, etc. This
escalates the importance for secure identification.
Lack of personal contact
The lack of physical contact with the patient was raised as
a disadvantage in one study (Sandberg et al. 2009), and may
also be an issue for patients.
Sandberg J, Trief PM, Izquierdo R, Goland R, Morin PC,
Palmas W, Larson CD, Strait JG, Shea S, and Weinstock RS. A
qualitative study of the experiences and satisfaction of direct
telemedicine providers in diabetes case management. Telemed J E
Health 2009; 15(8): 742-50.
Question. What types of training currently exists to teach
family caregivers how to deliver complex care using health IT?
How successful are these training programs?
Answer. The Veterans Administration (VA), which has the
largest deployment of remote patient monitoring devices,
attributes much of the program's success to the extensive
training programs enacted for clinicians, patients and
caregivers.
Three training centers have been established with discreet
responsibility for the major division within the VA for
Telehealth:
The Rocky Mountain Telehealth Training Center provides
training and support to staff involved in the delivery of
general-telehealth services, enabling real time telehealth
through a telecommunications link. This link allows for
instantaneous interaction via video conferencing between the
patient and the provider or even between two providers
regarding a single patient. Care Coordination Home telehealth
training is provided by the Sunshine Telehealth Training Center
to provide best practices for communicating health status, and
capture and transmittal of biometric data. Care Coordination
Store and Forward (S&F) Telehealth training is conducted in the
Boston S&F Telehealth Training Center for video, audio and
clinical data transmitted to a medical facility.
``Training center curricula are standardized and we
emphasize virtual training whenever practical and possible. The
three VA telehealth training centers have enabled over 6,000
staff to be trained and have helped sustain a rapid pace of
telehealth expansion that makes the VA a recognized national
leader in the field of telehealth. The VA has also implemented
an internal system to assess the quality and consistency of its
telehealth programs at a VISN level that is conducted in each
VISN biannually.''
Adam Darkins, MD, Chef Consultant, Care Coordination,
Office of Patient Care Services, Veterans Health
Administration, Senate Committee on Veterans' Affairs, February
26, 2009
Each mode of telehealth has its own training center, though
most staff training takes place over the network. ``The VA has
an employee education system,'' Darkins explains. This system
provides content and dedicated training to 18,000 computer
desktops throughout VHA institutions. There are satellite
broadcasts across this network every two months and an annual
virtual conference, as well as specialised training for
services like telehealth as needed. Last year, the VA trained
1,600 staff for home telehealth, 96% of whom received their
training remotely over the agency's vast electronic
infrastructure. More than 1,000 employees have been trained on
the clinical videoconferencing equipment, 90% of them remotely.
Adam Darkins, eHealth Europe, October 12, 2009
Caregiver training through telecommunications and web-based
education
Training the caregiver through technology is illustrated by
the work of Dr. Carol E .Smith, RN, PhD. Her program of
research emphasizes practical, cost-effective methods designed
to reach family caregivers of diverse ages, education, income,
and geographic residence. Her research has demonstrated that
relatively low cost technologies can be used effectively to
reach and support informal caregivers across all social
economic status and age groups from rural and inner city
locations. Additionally, one of Smith's family caregiving
interactive websites was selected for the International Nursing
Scholar's Society Pinnacle Award for excellence in computer-
based public health education. The current clinical trial
website tests ``virtual nurse caring'' to determine what
aspects of nursing can be safely conducted through the
internet. http://reporting.journalism.ku.edu/fall06/fred-
musser/2006/10/real--time--with--virtual--nurses.html
A second example is reported in Telecommunications
Technology as an Aid to Family Caregivers of Persons With
Dementia by Sara J. Czaja, PhD and Mark P. Rubert, PhD,
Department of Psychiatry and Behavioral Sciences, University of
Miami School of Medicine, Miami, Florida. (Psychosomatic
Medicine 2002; 64:469-476). The results of this study
demonstrate how current information and communication
technologies can be used to help caregivers meet the challenges
of caregiving and improve the quality of life for caregivers.
The data reported are based on responses to the usability
questionnaire at 6 months from a sample of 44 caregivers.
Overall the results indicate that the system is easy to use and
the caregivers find it valuable. The most common reason that
the caregivers use the system is to communicate with other
caregivers, especially those who are not nearby. The
caregivers, especially the Cuban Americans, reported that the
system facilitated their ability to communicate with family
members and their therapist. The caregivers also indicated that
they found participation in the ``online discussion'' groups to
be very valuable and also found the ``online resource guide''
useful.
A third example is found in the work of from a study
reported in The Journal of Applied Gerontology 2010,
doi:10.1177/0733464810366564), April 7, 2010 in which a small
control group 169 patients, evaluated the acceptability and
feasibility of telehealth videoconferencing for pre-clinic
assessment and follow-up in an interprofessional memory clinic
for rural and remote seniors. Patients and caregivers are seen
via telehealth prior to the in-person clinic and followed up at
6 weeks, 12 weeks, 6 months, 1 year, and yearly. On average,
telehealth appointments reduce participants' travel by 426 km
per round trip. Findings show that telehealth coordinators
rated 85% of patients and 92% of caregivers as comfortable or
very comfortable during telehealth. Satisfaction scales
completed by patient-caregiver dyads show high satisfaction
with telehealth. Follow-up questionnaires reveal similar
satisfaction with telehealth and in-person appointments, but
telehealth is rated as significantly more convenient.
Predictors of discontinuing follow-up are greater distance to
telehealth, old-age patient, lower telehealth satisfaction, and
lower caregiver burden.
------
Dr. Robin A. Felder Response to Senator Kohl's Question
Question. Can you give us an idea of how much some of the
in-home health monitoring devices you mentioned cost for
families?
Answer. Costs are currently varying widely for eldercare
monitoring technologies. For example equipment installation
costs are between $200 and $2,000. Monthly monitoring fees vary
between $50 and $100. Some of this variance is related to the
extent of the issues that are monitored and the degree of
interventions that are provided. Market pressures will
undoubtedly bring these costs down closer to $250 for basic
monitoring equipment and under $100 a month for monitoring
services.
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