Advances in Applied Clifford Algebras

Transcription

Please stand by for realtime captions. >> Morning and welcome back . Thank you first the city. A number of you e-mailed with, and questions welcome to. Number two of Telehealth and thank you so much to our sponsors that thank you to the IOM the other this workshop that I want to express my gratitude to the planning committee member. This morning I want. What we did yesterday and advance the an exciting day have discretion. The focus of this event is to put it to record where we think we need to the with Telehealth as it is integrated into mainstream healthcare. Yesterday we had a wonderful passionate presentation by Mary Wakefield sharing the various roles of HRSA Sherry. World of healthcare disparities that patient the faith Erlanger urban setting family had an inspirational talk five, Nesbitt to that challenge us to continue to provide the evidence and Telehealth and mainstream and Pamela towards the parishes are talking about. Moving forward, we had people speaking and presenting the contrary version of where we have not present value. We had greatest Goshen on the healthcare continuum and today please, to the equally as exciting and challenging. This morning we will open with our first panel and they will talk about the current evidence they and how to integrate that into advancing public policy. Good morning and welcome to Dave number two. Dave number one was exciting for those who are Europe yesterday we had interesting discussion on various barriers and the locators of Telehealth. We collectively came to the conclusion that we feel that Telehealth can help us achieve. We also suddenly need more evident than we will start off with something that is close to our heart. What is the evidence days of Telehealth, how do you now I what are the barriers and created this evidence days? Are there new ways of doing it?? Is the standard of randomized controlled trial post way to achieve that and if not, what are the more out there solution the The achieved for more cost and better efficiency and how we translate that into policy and to speak to these two topics I will invite our speakers today. Elizabeth Karpinski and Dr. Lee Schwalm. We will start off with Elizabeth and then we will follow with a case study of a stroke which has been a very successful initiative in translating what we know about evident that the policy. Thank you very much and good morning. I would like to thank the organizers for inviting me and thank you for being here so early. I want to reiterate to think from yesterday. There is a huge body of literature at evidence for telemedicine. There are two keys Journal, that Tele health medicine Journal and five others better formally dedicated completely online or in print to present change research and medicine and evident. It is better to subspecialty journal and you will find more articles there electrified the telemedicine Journal. After that has been out there for 15 years ago have to do is go look at it and find it and to reiterate, we do not need more satisfaction study but I would like to have the feasibility and receptiveness studies. I get two or three of these the month where people are going and doing very sophisticated social flight left of the focus group and looking at, the doctors ready, are the nurses ready, the dentist ready they're traveling the same themes over and over. How are they different? We are asking the nurses. Oh, these are nurses in Indiana, they're different. So we have done that as well and we know people are receptive. They are doing it. Again, we don't need any of those so what is it that we do need? We need to figure out how to advance the flight. I was asked to start out by taking a semester's worth of information and the staff and design course I could good thing it down with how we do research in general and what we are doing in telemedicine. This is a classic. But of the hierarchy of evidence that the kind of study one can conduct and clearly there is a hierarchy of important and relevant and hopefully we are not doing a lot of animal and in vitro studies property or to the veterinary reading they're doing a lot of telemedicine and it is fascinating and does not quite animal studies so I want to focus on are these and I consider the clinical studies of voter going to do to validate if something is useful in the medical arena. At the top are forward called thematic reviews and meta-analysis and then under that, evident guidelines and evidence summary to do things that appear as literature evolved from the body of of evolved than this is where we are and telemedicine we are saying systematic reviews and meta-analyses of the data that exist& Point to the maturity of the field. You cannot do the studies on Schiavo body of evidence and if you have scientifically sound studies you can conduct a meta-analysis on I would argue that telemedicine that the point where we can do the studies indicating we have that body of evidence that people are looking for. She met very briefly with fast reviewed the primary design that are out there has to category is experimental and observational and experimental studies are what people consider the gold standard, will hereafter and here you have the primary investigator assigned then choose the event that the intervention. Telemedicine versus not. There is all of that control or comparison group of the subject are allocated randomly you have randomized clinical trial, community child, lab trial and on the observational five, I'm not saying one is better than the other you have observational studies were the primary investigator of the people in the closures and sometimes very that control or comparison group and sometimes there is not that is like what they observational studies are less reliable and valid but I would argue that that is not the case. Whether that control or comparison group to have a analytic study or is control or cohort study and if you don't there more descriptive and correlational are you may have a case. Jury case report or a cross-sectional study. The strengths and weaknesses of the RCP and I cannot remember a time. This is the gold standard there was an argument I want and that we must be doing need to know the argument on the other hand that these are too complicated. There is a gold standard after randomization component. If your perspective rather than a retrospective. One of the main goals is to eliminate or minimize all of the different types of biases you could have a generally falsifying hypotheses rather than confirming, a philosophical point it also allows for meta-analysis because you have quantitative data. Some of the weaknesses, they're expensive, time-consuming, true randomization, sometimes it can be very practical and there may the ethical issues and thought it was funny that nobody wanted to be in the studies because they wanted to give of. That is sort of ethical issue had the telemedicine I have not figured out how to do a double-blind study and whether that is critical or not, that is a whole other story. RCP have positive and negative. Cohort studies. New York measuring the same characteristic into your group for that, or issue are disease and they disappeared they different one parameter only, telemedicine versus the traditional the eligibility and the outcome assessment are standardized. The weaknesses and to the, there observational and often not randomized. Patient are select it into which group they're going to go into based on characteristics, Internet connectivity. Everyone has COPD but if you have Internet connectivity will actually telemedicine are they have introduced a bias the people with a that is a weakness there. However, when you compare them by--side-by-side each one has positive and negative and I would argue in the long line of both of these are valid and have been used a lot of telemedicine studies. Again, each one has positive and negative so most of them are valid and you see a lot of these up-and-coming in the literature that exists in telemedicine we are seeing randomized controlled trials of about we don't have to wait 15 years to get the result, there are some conditions that we may have to take a day randomized controlled study. Good solid result and a couple of years ago the data out there published. Cross-sectional studies, they're generally considered--considered less rigorous they have any sense, telemedicine is being held today higher standard than traditional medicine. These types of studies are in the literature as medicine in general Alan telemedicine does one of these they're criticizing not seeing rigorous enough. Whether standard or with the help to? Why should the rest of medicine be able to do these and get data published in get funding and get approval for reimbursement when telemedicine is not. It seems to be a double standard these types of studies are just as good and when they're done they should not be held to a different standard other than anything else that is the done in medicine in general we are being forced into a perspective that is unreasonable. Cross-sectional studies. Have a representative sample or interview survey or study data the data collected in a single point in time and this can be difficult for telemedicine to give the impact is going to be something more in the long run more likely the short run there a lot of valuable to the information that the-I can be collected as well sometimes they rely on history and recall which introduces five and if you are doing it in a proper manner it should not be a problem and typically it establishes associations rather than causality. In my opinion, what is out there in medicine is Association and not causality. These are very useful for developing future research in the field, however. A little less rigorous but nonetheless, not valuable or informational case studies, these are typically detailed provisions of a single case and how something impacted somebody in a unique manner. These are typically with rare events than unusual that station and responses. These are incredibly useful. This is the type of stories you will take to the know over and over were you have a unique patient and a unique circumstance. We heard about one yesterday with the Dr. was driving home and he got a phone call any save the person's life and it went viral on YouTube that was a case study and a clue illustrated the needs of telemedicine. They look at impacted they usually don't have hypotheses, there is no statistical analysis they're not all of anecdotal because a case study that is written up with more scientifically rigorous the map of these are incredibly useful yet often for a different purpose than what one would think. The case. Is more powerful than a case study these are 10 to 30 subject and typically will not consider it statistically powerful that is not what they would consider scientifically valid but it provides a body of evidence there is usually a well described treatment or intervention that if the they are very detailed and occlusion in inclusion criteria, surprisingly. It could the prospective or retrospective that the downfall is there is no comparison group. You can typically do a limited statistical analysis the lease. --At least. Is of the type of studies we should be saying in telemedicine and the each serve different purposes. Although the RCP is the gold standard, there are a lot of other viable alternatives that are being used in traditional medicine and there is no reason why we should be able to use these have the same impact that the rest of medicine does as well. I would like to shift focus a little bit and obviously I can't go over the entire literature of the body of evidence that exists I would be here forever. It exists, it is out there without a to sit there and fight for it anymore. If you look at the journals that are out there, telemedicine, they have each gone to more issues each year. Injection rates have gone up the Keeter about that other one. It is a rigorous field and we have a lot of evidence that we would talk about two studies, meta-analysis, systematic review, to show where we are at with some of the downfalls are some suggestions we can make to Health and Human Services and funding agencies in general and the first video by to talk about was just published in 2012 and with a review of randomized controlled trials the highest standard out there, obviously didn't have enough to do the review of chronic disease management facilitated, they look at asthma, COPD, heart failure, hypertension. And they put strong explosion criteria in specific method and meta-analyses and this was a rigorous study and we had one or more convention than the control group. They could use on, telemonitoring, videoconferencing and they were not limited to a type of intervention and they did a literature review one from 1990 through 2011 and just on the five conditions, randomized control trial, there were 1300 publications. There's your body of evidence. You have five major diseases that impact community, Hama, here they are. 1300 randomized controlled telemedicine studies data extraction, it looked at the number of subjects patient types of severity, what type of telemedicine was it? How long did the studies go on? So are the primary outcomes? Everyone is talking about outcomes. We have a ton of literature and for the most part they are positive and elicit the results may overall value of the intervention and they scored the value, a five-point scale going from positive, no affect, negative on the other side. Primary outcome significantly better than the control negatively primary outcome no statistically worse no statistic different and they had 20 asthma trial with 10,000 patient, COPD trial with 1100, diabetes, 39 trial with 5000 patient heart failure, 61 with 16,000 patient hypertension, 17 trial with 4800. At those numbers just and you have a lot of patience and randomized control trial on telemedicine. They do exist effect estimate they found 73% of those studies favorable there were 65 positive and 43 is rated on a scale I should view of 46% were neutral or as good as traditional and 1% was unfavorable telemedicine there was one weekly -1 negative Betty so again this meta-analysis of the literature that exists on randomized control trials there out there, there are a lot of subjects being studied in on these key diseases 99% of the study were as good as or better than the traditional way of practicing telemedicine came out on top. Trial duration, most of the trial lasted a year. Most under a year this could be considered a week in which I will get into later but this shows how the duration did not affect the quality of the study or the outcomes. A couple of them did go out to year so it is possible to do that is, randomized controlled but the majority were a year or less so when you look at the various diseases, that they studied, and you look at the range of the scores given positive no effect there are two studies, overall, you could see the majority of the studies were rated as high in error is actually not a lot of variability there. Therapist is looking at the types of interventions, routine voice contact, phone, remote monitoring, teleconferencing, real-time session said no significant differences in a function of if you are rated at positive or negative in terms of the functionality, duality of the intervention phone, VPC, telemonitoring, equally effective. For the limitations that were observed? Is there a publication bias? You will find this and generate--medicine as well most favorable results are published. Maybe we did not see enough negative studies because they were published. I find that hard to believe. People will publish negative results. I published them myself I disagree with their conclusion that there is publication five. I believe people published the negative studies. No significant differences to the diseases for telemedicine effectiveness as they questioned if this is believable or not if it works, it works I don't think it matters in a majority of types of diseases and we found very few circumstances where it doesn't work. The media and duration was only six months can you truly affect observed impact? I would have to agree with this somewhat. Six months to observe a significant impact of questionable but possibly could happen and clearly the result of finding statistically significant differences to like this the studies that go on longer than six months, they second study, they looked at 1500 1600 studies that addressed assessment methods and they found 50 studies that qualified for their investigation and basically what they did was review the body of literature on the method that exist to make him a recommendation for larger trials as well they suggested larger more rigorous design studies and they suggested a better standardization of population interventions and outcome measures to reduce heterogeneity and combine quantitative and qualitative methods and do these studies and more naturalistic method of setting that I would have to agree with all of these looking at trying to do more multi-center trial three have standardized population and interventions everyone looks at the same outcome and measures could be incredibly useful in this was a review of the review and those recommendations I would completely agree with. What is the utility award of that impact public policy and are taking the body of evidence in attacking public policy? I would agree and I would say yes that clearly one of the things of the body of evidence leads to have allows us to do is to create evidence Lines of the civic clear indication of maturity and we have it. The APA is, the number of Lines and these are some of the ones that are out there and are being used and if you have a body of guidelines that are built on and derived from the evidence in the literature, that is assignment we have that evidence that clearly these the ones that have been established am these are the ones that are in the development and a lot of the critical one of the people were talking about yesterday and today, a number of other bodies and associations of love. American College of radiology American dermatology Association, SDA, they all of this, there is a ton of standards out there and you don't build standards out of thin air you pull them out of a body of evidence. The European code of practice for telecom, Canadian guidelines, Australia as well and others being developed. These are just people sitting around thinking this would be nice and this is a good thing to do, these are standards and guidelines coming out of the body of evidence that we have. In conclusion, what are my recommendations? We need to work with other funding agencies to develop RFP for telemedicine research with specific goals. Large rigorously defined studies assessing impact preferably multi-center study for you standardized population of interventions been out, combined method, naturalistic settings I would suggest to support meta-analysis project these are difficult to conduct their time-consuming you could put a graduate student on but you need a few of them to do it provides us with a more broader comprehensive perspective. Disease specific interventions specific and I would support guidelines development that resumes are difficult task and it is hard to do them for free but these the types of specific things that could be supported that would allow us to do the literature reviews, to the summarization, do meta-analysis of systematic reviews, bring evidence together and put it in the form of standards and guidelines and if we have standards and guidelines the research will get better because people do the research based on standards and guidelines and you will get payment. We know what we're doing here is the evidence and here is what will the approved and that is the key thing. Thank you. [Applause] Thank you very much. It is a pleasure to be here. Thank you for asking me to join you. I am talking to you about a program I sent the last 10 to 15 years working on which is an intervention in the field until help in the field of stroke I was asked to you dated change policies and create new standards of care and I'm going to talk to that tell of stroke and frame it is a disruptive policy have this intervention is changing how we take care of patients. I am a consultant to the department of Public health in Massachusetts and the Center for disease control my chariot heart of the fishing committee that focuses on improving quality of acute stroke care, hospital provide contracted total health services across New England and some of this work was supported by a grant from HRSA that we will discuss at the end. Value and acute stroke care is entering the question for the station, make the right diagnosis he can get the right treatment for me right now. That is what it acute stroke evaluation is about right now that have taken her out as an early--this gentleman is in the middle of having an acute the Stroke. Can you tell me what is unusual about him besides this Band-Aid which we know does not work for sleep apnea. Anyone see anything unusual? One side of his face is a well shaded the other one isn't. To neurologist, the sense of importance of information. His eyes gazed into the right and left faces unshaven he has a parietal stroke of this is a situation called left neglect this. A lot of information and it carries a tremendous amount than people ask me why go after told stroke and acute stroke and it seems like it is not the easiest place to go to the high-impact low frequency event that it is a clinical need the call for a solution. This is how the story goes. We know that a clot dissolving medication is beneficial in that requires expertise 24/7. You had to prove acute stroke evaluation could be done safely and effectively via tele-health you had to achieve consensus on the need to regionalize care having centers typically designated to care for these patients having ongoing patient and staff and that of the blueprint it is a we have achieved in Massachusetts the goal is to expand access to rural and smaller hospitals so many that are under neurologically served. He has to show that rates are improving after promote fusion innovation and push for reimbursement of services so that is what our journey has tried to be without we were new and exciting in 1925, here is the diagnosis of the physician online and using the tele-dactyl and I have to say, except for the drawing, this is close to what we do, it is amazing. Clay Christiansen a professor at the Harvard business cause the popularizing the idea of disruptive changes the world of business and this is a quote from one of his books about healthcare the challenge that we make is not unique to healthcare the transformational force that has brought affordability and accessibility is disruptive innovation. If the fine technology of business model innovation in a value network. . The snapshot, 15 years from concept initiation to a sustainable network with 30 hospitals in New England their prior virus six site and hubs across the country all working together to try to bring this model there and we added tele-neurology and it has been diffusion across the political spectrum the simplifying technology with the use of brain CT imaging which allowed us to look at the brain in vivo and the injectable clot dissolve or could be given anywhere, die, standard to enable image transfer. Video standards the first enable low cost, still expensive, lower cost technology that was reliable and innovation in the last five years that makes videoconferencing and everyday events. Everybody knows about Skype, it is a verb now have the Beatles provide technology for stroke care? I do not think any of you would know the answer in 19 Q2, they signed with electric and music industry, EMI and they were working of electronics manufacture and music with a sideline of they were so successful that they had to reinvest cash somewhere and then take the engineer named Godfrey--Godfrey counsel and you can think of you know the retirees slide into the CAT scan and this is a CT scanned showing a tumor in the brain indicated by the yellow arrow Pershing seen in 1971 and the rest is history. This is a bottle of TPA this cartoon shows how a thrombus can form an be dissolved and restore blood flow: a work such a dramatically increases the likelihood patients will improve and return train near-normal life but if you get treatment the first 90 min. you have an 18 fold chance of being helped rather than harmed and we have to get people in right away so we have treatment available. Early treatment reduces mortality. Symptomatic hemorrhage, dreaded complication decreases when the treatment is given rapidly so lots of reasons to get the drug rapidly and I dedicate this fortune cookie, don't just spend time, invested and if we're trying to get treatment fast it doesn't make sense to the transporting patients at a hospital with their untradable for focusing on rapid treatment is the right thing to do for patient and guideline support the concept of bypassing hospitals who don't have resources to treat stroke and certifying stroke centers with external bodies so we created a blueprint for getting patient to the right place of this possible. We still have to the question, where is the right place to stop? Do you stop at a primary stroke center, comprehensive very TPA capable hospital if they won't keep the patient? If you're having a stroke, you want to go to the nearest place that is going to get you TPA. If it is given properly. You don't care what the emergency room look like, you care that the right people out there. External forces" provider decision-making I think legal action was one of the things that changed physician receptiveness and started to drive use because of fear of lawsuits for not providing TPA. Pretend you are the MTA you drive at the scene and this is what you see. I have no audio. .. A very heavy--we had a-- I would argue, you can Google that if you want to see it again, Google reporter aphasia. You had better be taking that woman to an emergency room. Turns out she had a complex migraine but there is no way for you to know that. That is aphasia that is a warning sign that the public needs to be aware of and several people started calling 911 one that Eric thing that woman was having a stroke of they were right to do that. What is the business model innovation enabler? Everybody can do it and you can do it in a way that is transportable from site to site. Hospitals need to purchase expertise to stay open for stroke business if you don't have it in their centers developing you need to figure out how to provide that service which is a basic service she should have been providing in the first place they are in the short supply and they're hard to attract the easy access via tele-health at a distance and lower cost and access to a higher-quality and those are high-volume providers and there is plenty literature to show that providers in this area do a better job. Expertise is a commodity that hospitals can purchase. This is the fourth leading cause of death of the leading cause of disability we have one practicing neurologist for every 20,000 Americans and that means 14,000 to 15,000 neurologist and 40 to 50 strokes per neurologist per year that is manageable. Many do dementia and back pain but they don't do stroke. That is intimidating. More importantly it is a resource distribution problem. This is the line for gas in Egypt last year if you're having a stroke you want to be in the back of the line waiting to get in. We want to figure out we allocate expertise and make it available probably a that is what will help those. Some people are not supposed to do that but no one told us. So this is actually my younger brother, just kidding, this is me in 1999 the first prototype acute stroke consult using a quick cam. 15 frames per second, 16 shades of gray and it wasn't pretty but it was enough to prove the concept that could evaluate the patient, do the scan, make the decision and we knew we had something to offer calcite hospital and what it looks like, there is a patient with a physician provider at the bedside, there is digital imaging, they get encoded, sent to look distant location, they have hospital and the physician can be remotely located, and the hospital, nurses can screen, they become essentially case teaching events. You can zoom in and look at the face, these are shots from the late 90s when we were using dedicated boxes and now everything is PC-based. And we showed in a similar paper that the quality and reliability of doing that NIH stroke scale structured neurologic exam at the bedside was equivalent to an observer remotely and an observer at the bedside these are subsequent studies that have shown a confirmed that the rates of agreement can increase higher if you create more clearly defined protocol to score these tests and this was the bedrock of thing we can do what needs to be done remotely. This is the first patient treated back alley 2000 he was 88 years old, collapsed on the beach and here he is unable to lift his right arm and his head is turned to the left and he had a CT scan and got intravenous TPA as a persistent occlusion at his not benefit from treatment for many patients do not benefit but if family was grateful he was treated with comprehensive level stroke care at a tiny community Hospital on an island off the coast of Massachusetts. Part of the reason why you need acute stroke expertise that is hard to read a CT scan and here they settle subdermal hematoma, bleeding on the brain and had you treated that patient with TPA, you would have killed them because they would have had life-threatening bleeding in the brain. We publish analysis of the first two years of the pilot demonstrated not only that the therapy increased public with of treatment and a statistically significant manner it did not add to the time of treatment and demonstrated that neurologist, not radiologists, no offense, carried a CAT scan without the need of an additional radiologists. Illuminating another person for the next further enable the technology to move forward. Why telemedicine for stroke? I haven't talked about standardizing care across the network or state. Developing stroke centers in the community focusing on providing care at the community level and evaluating and treating more patients with TPA more reports than remove reviews showed it dramatically reduces TPA when dramatically resources are lacking. This is a brief comparison to show you the symptom onset was what drove-drive the benefit. Until stroke programs make rural hospitals behave like comprehensive teaching hospital because his to the conventional approach and this data was her front door admission and in Ontario that transfer everyone before treating them treatment time for close to 180 min. and this translate to a substantial decrease the longer you have to wait for treatment. We also shouldering the supervision of TPA by telephone or telemedicine before transfer is feasible and safe we could hear the outcome of the patient treated in the network versus the front door and they're no different. We did not have enough of a sample size to distinguish between telephone the telemedicine but I think there are some significant analysis that can be done there. There is scientific statement from the reviews of level I recommendation to include the stroke scale of equivalent should be used when a person is not available at the bedside. Stroke specialist radiology system appropriate for identifying exclusion therapy and is highly recommended they provide medical opinions about TPA youth. Mimicking the recommendations that are in place for bedside use. We have a tiered system that can support aggregation of appropriate patient that the high-volume comprehensive centers and there are additional techniques, catheters can engage a clot to pull it out directly and you can see a poor and after picture showing a blocked artery and full restoration of blood flow after a brief time, 40 or 50 min. these devices are revolutionizing the field of acute stroke care apply to the need for a tiered system of care that can be supported by tele-health it is very important and Arnold want you to start improving your stroke. If you don't you will be getting less reimbursement or less patient with public reporting about, to the started two years with meaningful use of the inclusion of stroke in core measures hospital for other website will show performance in stroke if you don't have the expertise you are going to be bypassed if you have the expertise you're not doing a good job people will vote with their feet. It is very important that hospitals have an incentive and it is part of the disruptive value network and they get highly experienced expert survey brandishes a comprehensive center at a reasonable cost. They retained her growth strabismus and there is an additional value enhanced patient provider satisfaction local emergency room and improvements in overall stroke care anticipation defend the relationship and open the door to access additional services. Clinical trials, it starts to build deeper relationships with the community to drive demand for the delivery models. In Massachusetts our network is 25% of TPA we have 70 hospital we're making a big dent and we are showing the rates of TPA youth have increased substantially but it is not just the big hospital we have a stroke center designation hospital in Massachusetts and many were on board to be certified because they had these programs in place it is not a discriminator of big versus small, level the playing field the hospital get to extend expertise into the community they grow stroke business and attract patients for innovative treatment and clinical trial permit this patient defense relationships and allow them to deliver traditional services and not just innovative services at the hub level a cam increase provider compensation and satisfaction and I'm getting that care to a broader audience of patient and her opportunities to academic growth and this is a cartoon you can see they have across the United States and within Massachusetts and Maine and New Hampshire you can see how widely distributed our site are we are penetrating into rural areas within the meaning of subpart of New Hampshire and Western Massachusetts. This is a network that looks like ours but it is in Germany and is run by a colleague of mine who demonstrated very nicely that care delivered at the major centers of equivalent to that delivered to the campus community Hospital compared to a control group of hospital that was not participating with the care with significantly less than what they have shown nicely creating stroke unit allows the patient to remain at the community Hospital for the duration of their care they have used this model to encourage the German government to fund the model across other centers in Germany and if you look at other experience, the orange bars are the patients we treat at our front door with TPA. We're in the middle of the big city with other hospitals but if you look at the total stroke volume that continues to increase and we give over 140 cases of TPA making us one of the largest volume centers in the country and our physicians our expert every time they enter a new case they come through the tremendous amount of experience, more than what we would have gone without this. We have traded for the 1000 patient at our hospital and you can see for total stroke cases we treat 37% of all consult which is remarkable. If we get called to the phone or bedside it is 10%. It is an effective filter. If you build it, they will, bring their friends than half of what we get called about turned out to be acute stroke many are subacute, hemorrhages, TIA, seizures, and you have to. For that. Total stroke, thumb interesting work in Arizona looking at cost-effectiveness demonstrated that basically there is a breakeven at 90 days and for a lifetime horizon there is a line separating instantly and it is very cost effective and lifetime of disability is--for the fifth. What is happening in the field, if you Google public telemedicine stroke you will see 37 publications in total and 33 the last year and the activity is starting to heat up when I ran the search of May 2011 I got 24,000 per tele-stroke on Google and 88,000 in February this year 500,000. Things are happening. I said this last night at dinner, what is happening, disparity, so much is driven towards digital access disparities in access to broadband are going to translate to disparities in healthcare not at the home at the level of the facilities themselves and the national broadband plan the president released a year and a half ago one of the boxes was about tele-stroke and described a patient in late 40s early 50s that a stroke and was taken to a community Hospital South of Boston who was affiliated and received treatment have recovered as an example of how broadband access can mitigate some of these disparities and if you can play this clip, I want to show you what this means for patients, not just for us in this room. Beverly was 51 years old when she experienced a stroke like symptoms and went to her local hospital 50 miles away from Boston using the tele-stroke program they determine she was a candidate for TPA. Here she is being examined. They were trying to get the exact time because that was crucial. We got a 10 point is though they knew that I fell into the times the. I was fortunate enough-- all right. Basically, she had a stroke just like her father did when he was her age and into the paralyzed the rest of his life. She went to her local hospital which was 50 miles away from Boston. I am not going to belabor that but she recovered fully and was spared 30 years of living with major disability and she knows what that of life because her family member went through that and to be able to translate that to the level of what it means to patient this extraordinary. So, to to federal funding we cannot afford picture had back on. These programs can't rely on federal grant to sustain themselves. Federal dollars are helpful to getting infrastructure in place the real changes need to be around sustainability not initial funding. We just had approved this last week, health reform payment which includes reimbursement for telemedicine services. We don't know what this will apply because the regulations have been written that the legislation is landmark for us. So I will finish by sharing with you the results of a survey that we did, environmental scanning programs and total stroke services these are the location of a fight responded to the survey's and we found that have the support folks that are only 20% of the time with of the formal organization I work for the vast majority support hospital that are not of corporate networks formal agreements and contracts in almost all network of almost all of that 80% to 90% are small hospital and three years from now, greater than 90% of respondents thought they would be expanding the code scope and size that provide services for 95% high-quality two-way video and 70% reviewing brain imaging is a part of the consult process and many Incorporated telephone only and these are cartoons of the different ways in which people are receiving services. A model like I described and profit companies are further separating spokesman not by eliminating the house and having physicians provide these as a one-off consultative model we don't know much about the efficacy because it has not been studied. In terms of what their functions are, the goal of starting the program, 100% that emergency department consultation triaging patients with high on the list and not much else met that level of recognition of the event inpatient consultation community benefit was an important factor as well improving clinical outcomes reducing cost was at the bottom of hospital they're not looking at this as a cost-saving approach is improving quality reaching out to provide care. Only 50% had a dedicated software package they were using for the site visit he and many were using their own EMR, not documenting, dictating, using paper only, it is a wasteland in terms of medical record-keeping and the barriers to preventing stroke, many rated lack of infrastructure funds of the highest and lack of physician Diane at the spoke with the second most important and a lack of reimbursement and lack of evidence that the bottom of the list, that is not the issue but if you ask them what the single most important barrier to get rid of, they say inability to get gain licensure as the biggest barrier and lack of infrastructure funds a lack of physician buy-in is low they are worried about how I can get this up and running. So I would argue it is not about the technology, video support the trust relationship that is needed so it is not about more and better technology is about eradicating conventional barriers. I went with my two slides of recommendations to promote the continued growth with federal grant is a cost-effective means and I am framing these in the form of tele-stroke these apply widely to a broad category of diseases and assured access to care and any where patients are neurologically underserved many communities have barriers where there is no access to specialist relation to stroke and simplifying the administrative processes that are frequently different in each state to present a barrier to accepting stroke expertise require federal third-party reimbursement at rate equivalent and using critical care billing codes: there is a problem but they require physical proximity to the patient if you're face-to-face for two hours, it doesn't Some of the codes that are most appropriate and encourage the use within a few days stroke system of care model rather than transactional model because that is what addresses access to care building deeper relationships to hospital the require the five provide stroke care to participate they have to measure and report outcomes of that is the stick the comes with the carrot you get support but you have to report. And I think we need funding to determine the most effective model, we don't know which is better we have hypotheses they should be tested and if they could be applied effectively to the condition that they have access to broadband decision something I alluded to but should be study provide funding to measure the actual cost of tele-stroke versus conventional delivery have right now are using estimates from studies about the impact elite clinical effectiveness research to see what the true cost savings are and I would argue that we could convene a committee to gather together the evidence of the current barriers to make recommendations and create a clearinghouse of information for states patient the provider so benefits of work like this become readily accessible the parties that are interested rather than having to call the restaurant rent and search and multiply on a variety of sources and not get the best information. For that, I will thank you for your attention. [Applause] Thank you so much it was very informative. Thank you for reviewing existing literature and compressing an entire semester of work and research method into a 20 min. session. And thank you for sharing a very interesting way of approaching tele-health in general and tele-stroke specifically telling us how you can translate that into policy, it was interesting. We have 25 that for questions and we have to microphone account of the microphone and will alternate. Good morning I am from the West Virginia school's sick medicine. --. The technology very or. 12 years I was chief technology officer. I used to this kind of failure. Okay. West Virginia school's sick medicine in the West Virginia tele-health alliance I want to complement both of you, excellent presentation and I am struck by the kind of contrast in perspective and I want to question you about that and why the Fed cost, reducing costs with low, four points higher, with increasing revenue. They're still looking at the money. It is interesting because total stroke is obviously beneficial and you have this string of recommendations to increase the adaptation or adoption by funding agencies and get back to a fundamental question about evidence. We have tons of evidence but they don't result in anything for reasons that have nothing to do with the evidence so you are looking at his political spectrum of what people think they want and don't want and why and with regard to the whole larger studies you're talking about an evidence-based, there are ways to aggregate that so we can pull that out. To our legislators want to suggest another area that needs to that carefully with regard to the patient center medical home on the movement I contend that rural communities cannot provide patient centered medical home they don't have resources or facilities, it adds to the cost we need to be looking at how the entire spectrum, including telephones and fax machines, how they contribute to prevention and to coordination of care. So that we can improve the quality of life without having to bring people into the main medical center's and without having to increase the workforce and rural communities that is not sustainable. The evidence on patient centered medical home the recent report says evidence this terrible there is nothing you can look at the tells you anything. I would put the same challenge for tele-health and medicine, can we look at how these resources can help fulfill the promise of the patient center home, the AAA them, and provide the kind of evidence will be accepted because we know it is not about evidence, it may fit preconceived notion for people handling funding. How do you react to that? In terms of evidence for the medical home, there is rapid notice of which technology is changing and if you look at the literature, you're talking about sophisticated systems, and a lot of the system the Japanese literature and making smart homes of putting in sensors and cameras and other things around the home that is incredibly cost and efficient, it is impractical but the problem is, but technology has changed so much that you can literally go on the web and find these devices for very low cost. I could put them in to my parents home, call at the call center and say, I have the equipment, can you do the monitoring and so on that has moved so rapidly and change so rapidly it is almost impossible to do an effective study and get the results out and published within the year because the technology has changed so much. Technology is going to be off-the-shelf people are going to be buying it, it is going to go to commercial centers and we're going to see development and software algorithm and sensor monitors and want to figure out those algorithms and get those false positive rate can the true positives are going to be up there and once we figure out those algorithms and the mechanism by which those alarms are going to be responded to, that is what is going to be critical. Your complaint is justified but it is a fast-moving field and that is what is making it difficult and in rural areas, the cost is dramatically dropping. The feasibility studies are there and everybody is going to be using it the question is, can we get to sit still long enough to get the get data on it? I would agree with that and I will try to respond to the first part, the reason why total stroke of the perfect storm. It is an acute low frequency event that requires access to a high level of expertise without having to touch the patient so it was right for application in hospital were willing to pay money out of their own capital and operating budgets to purchase this service because policy was moving ahead of the business model to say this is a healthcare right issue, disparity in access is not acceptable the fast change in hospital had an incentive financially to participate I don't see that president in the fee-for-service environment the good news is that health reform movement that is moving across the country and the most recent health reform bill is moving us towards--rapidly within a couple of years, more than 50% of our patients will be under so kind of global payment and that of the movement to liberate resources to allow hospitals to the and medical homes, better approaches to maintaining secondary prevention, maintaining continuity doing a better job but have never been able to bill for and have resources for this allow the to achieve the goal for which are being paid and reducing events and reducing costs and I think that tele-stroke is expanding and will become a fixture of how we take care of patients. It is almost guaranteed that it is here to stay. The adoption has been so widespread that I don't think it will go further than that, to start to rethink how they payment models are structured so we can have hospitals know they can invest in the infrastructure and access to people there'll did some downstream return on that investment to defray the cost. That the investment is going down dramatically that barrier in the past with the hospital saying they needed federal funding to get the there already-I federal radiation involved and their workstations cost $50,000. The--have approved the application on your I had and with proper lighting conditions they can read these images often than I've had. That is dramatically reducing the cost and hospital has to invest. Buy yours now for 10 or $99. It is an FDA approved device for reading CT and MRI images. We started we have boxes the size of the stable and now I could do it off of my iPhone. I don't because it is not the proper environment but I could if I wanted to and we're just going to see this ever-increasing generation of innovation and innovation--evolution. It is like the ATM I am old enough that I remember when you could not go to the ATM. Many of you remember Deutsche Bank to get cash in with people started introducing a can they do not introduce them to the supermarket, they were the bank of the Teller show you how to use it and then the outside of the bank than other brick-and-mortar buildings and then in the mall, and kiosk. People are ready for videoconferencing because of Skype and saying their grandchildren and 30 college kid, it is part of what you do on an everyday basis and it is not frightening and society is getting more ready for tele-health with the adoption of these. I studied emergency and I have a, then a question in the comment is about the need or lack of need for studies for receptivity and readiness for change that I thought yesterday and today were they say and I believe there is a role for these studies negative studies cited as negative in the acute care setting, service understanding for understanding why they may not want to use this technology in my question is about the state of the literature I did not see cited as a limitation of the systematic review the idea of the control group were what the right control groups are for telemedicine evaluation so one theme of the conference of them the telemedicine should be considered regular clinical care provided in a different way and not paying telemedicine is a tool for quality improvement and my sense is that should be compared to less expensive quality improvement tools traditional education and outreach about making the control group nothing regaining the literature of it to make it appear that it is better that I might be compared to a less expensive alternative that I'm interested in your perspective and if you think the existing literature adequately reflect the right control group. I am a firm believer that we need control a comparison group and you cannot study something in a vacuum but I think there is a whole variety of ways and depending on the intervention and the treatment some respect that is going to define the control group. With the TPA, that would clearly define current have that were obvious what you should compare it to. Someone coming into the door and a stroke center versus, coming into the door in a non-stroke center, the problem, that is why one of the recommendation implied and that was the natural control group was to do this and more natural setting studies that we have been doing are very contrived that are specifically taking the group and you're going to be the controller and it is quite obvious that is not what they would normally get it is a short-term study and is probably not the way that treatment is going to take place in the future once the that he hasn't done that was the recommendation was to this in natural settings and circumstances where the patient will go about their normal business myelopathy define what the control group is. What I would say, is to make it as natural as possible so whether it is asked treatment and the circumstances we are saying studies that are mixing interventions and you don't have that thing happen traditional versus telemedicine you have different degrees of telemedicine intervention for example it is just telemedicine telephone versus telephone with the video added profound degree of traditional nurses visiting the house so what we are doing is evolving toward something that is more natural and back to the point about we donate to any more receptivity studies, a lot of this can be done at the local level and more in terms of education, we know what the barriers are and I would disagree with you. Those types of studies can be done on a local level to understand your own organization but you don't have to publish that. Because somebody else has done it. It may not be your exact situation and when you do in your exact situation you'll find the same result and it is incredibly useful for setting up and getting the by and that she wanted a local institution, but is it worth publishing, is my point. I agree with everything you said I will take a different response to your client the first 20 were making was more about implementation research just because we know the barriers, what we don't know, is one of the best solution for the problem with LOL it is an intersection between technology and human behavioral are trying to change the behavior of a multiple number of providers across multiple institutions to achieve a certain result and that is what I think is an important role for evolving social scientist and personally, a cluster randomized designs of the right way to go because the problem with saying on Monday we will do that tele-health and Tuesday, non-tele-health and you contaminate the providers at the remote site once you start changing behavior in a profound way by providing education and interaction your provided way more than the tele-health approach for creating a structured environment for your increasing the level of care and that naturally contaminate the non-tele-health encounter and that is because part of what is doing is not just bringing that for the whole systematic approach to the disease and protocols the better patient identification and connection with the peer institution his opinion is valued there is a lot going on in the most effective ones have been identified hospitals to participate at randomly allocate treatment and control and cluster randomized, hospital acus intervention and feet is not a compare outcomes of the of the six-month are one year and crossover so everybody gets intervention. That is the wayside so the willing to participate. Is Elizabeth pointed out, the way this technology get used, I don't know any site that does IOM full interactive videoconferencing that requires videoconferencing every single time. You start with a phone call. The decision is made, the escalated video? The idea you would force everyone into a paradigm has the potential to introduce bias in ways, second favorite intervention are the control. These are important and challenging statistical methodology questions and to a certain extent they are shaped by the actual intervention with some of these could be addressed at the level of a consensus committee or a paper around study design that the other organizations could do. So there are a lot of methodologies that exists to study these sociotechnical perspective and you have to work outside traditional literature to find it. They're using telemedicine at case studies and case examples and that is where you're going to find the types of things you're talking about the impact on the social technical system and batted this and you have to find it. Good morning, I with the Center for connected health care policy in Sacramento California I want to echo the comments this is an excellent panel it is critical we are able to demonstrate the evidence and two points I would like to make. The first has to do with how we talked about Telehealth and heavily demonstrate the evidence and the benefits of Telehealth. Technology enabled healthcare is a very broad encompassing field and it is important when we use language it is important to talk about synchronous Telehealth our home health monitoring we heard yesterday very few states reimbursed for--let alone remote patient monitoring. We need to develop the evidence specifically to demonstrate the quality and effectiveness and quality of those interventions and the second has to do with the national quality strategy in the moving towards AAA man the center was forming a policy in California to pass landmark legislation and it was fascinating process because we were able to make the case clearly in terms of quality and improvement of services and what the legislators wanted to hear was cost-effectiveness and tell me it is not going to cost more money, tell me that you can save money and the body of evidence has been moving toward demonstrating quality, which is important, he referenced the MILF study you can show cost-effectiveness and the contact as a field, if we're going to influence policy at the state and federal levels any to begin to understand that they talk in different ways we talked about evidence and cost savings is a language that our government are interested in the we can make those cases. Thank you. In my own organization, I spent a lot of time thinking about ways in which you could make it more cost-effective and we have looked at options and we have looked at bundled payments around diseases like stroke and I agree with you about the size and our language, thought what Telehealth means you have to be precise about what affordability means because right now there are costs incurred by patients, third party payers and we have to make sure we know who you are saving money for because some of these may save the patient money that is not currently accounted for and healthcare dollars. If the patient has to drive three hours and their daughter has to take off from work, drive down, part, have lunch, Phoebe for 30 min., get back of the car and repeat the exercise, there is a lot of money is being spent by that family that nobody is currently interested in saving and so they want to know how to make the bill lower. And what Elizabeth was alluding to about the idea of software algorithms and ways to process information that doesn't require human labor. It is critical because my time is my time and access to my time cost the same if I am doing it in person or over video and we're going to see the potential that Telehealth start to the road the value of physician time and nurse time and provider time because the remove barriers to the makes access more feasible why can we cram more access into the same day and so I don't think it should be thought of in terms of increasing productivity the challenges to say, how can we reduce utilization, how can we use system to obviate the need for a person to look at it when the machine can look at it that we have a nurse practitioner providing care with support from the physician that we have the physician providing care and support from a senior position--physician and to get everyone operating at peak capacity and using telemedicine tools for connectedness through to be limited by geographic proximity so that is where we will be able to show cost-effectiveness so have to be precise about true cost of where we are saving them. Definition of terms that cost analysis of law which is what I talked about before, a standardization every circumstance is going to be different but it is very difficult to compare cost analysis studies because they take it from one to the next and this one will take into account the amateur division of equipment cost and this one won't. So there is no standardization so this study is going to looking at your program and somebody will come in and look at it this way and use the same data and they will come up with a this is nowhere near cost efficient and looking at the program in the same like, how can you come up with to radically different conclusions? Doing studies in tracking cost which is an overhead because it is expensive and you have to track actual cost over time if you want to get the real cost. You cannot divorce quality from cost and that is a lot of think we are attempting and in radiology, there is incredible valuable circumstances where MRI is incredibly useful and they're using somebody cut this is not allowed, you cannot do the MRI because it is too expensive and the quality has been demonstrated and everyone will acknowledge it expenses that we are saving life. You have to acknowledge that you cannot divorce quality either. Michael Porter has written nicely about this and you can find some of his work online and the value equation is quality over cost and if you frame it in that way, physicians and other providers will engage around that equation there is a nice editorial talking about efforts related to this and how to implement this equation actual payment care. Thank you very much. Thank you to the panel my name is Carol at the Stevens Institute of technology I'm looking at this from a healthcare IT perspective. I was appreciating hearing about the meaningful use connection and coming down the road looking at a high-tech implementation going on and comparing the 2009 high-tech act compared to the 2010 back is a very important motivator and I am wondering if you should look more about what can be related and what would have a promising effect. And the hub and spoke model and it relates the public by and--at Harvard talking about the consumerization of healthcare. So I think we are missing the fact that there could be a huge public push, not just coming from the other side and how we might leverage the IT consumerization piece and getting the public outcry. After all, serving the public and why are we looking more at that and leveraging it. Let me respond to the first thing, we are in the midst of the electronic record which is basis six hospital network we include acute-care, postacute care, they're all rolled into one common line, and they function like they are but we have a fairly--we are fairly advanced and we have a single modified record in part because of the contingencies cost inefficiencies associated with the active it is clear we cannot do it without an integrated platform nowhere is the integration a key priority to selecting a vendor, then at the front of the table it is an afterthought and I would argue as organizations in the next two years we will start to embrace and make these decisions I need to put the vendors to make it clear the links will be there to incorporate Tele health and all modalities and it will be a domain of the medical record a billing type, a note type and need to be integrated horizontally across activities because it is going to become a process in a message those connections have to be to everything that we do so that is very important in terms of the public outcry getting the public engaged, it is very engage and access the healthcare permission and they are frustrated about was access to their provider. They want access to the providers on smart phones, websites, they want connectedness in a way that we have not been ready to grant so we have to the working with public activist is not the right word but interest groups, disease-based organization that advocates for patient, organizations like that figure out how we can create metal layers that provide patients with trusted sources of information trusted relationship that require ubiquitous 24/7 access to me as their provider but to my network as a place that is what cares for them. Both activities are taking place there a lot of patient advocacy group a lot in DC, the American telemedicine assist patient is working closely with them and we talked about going to the Hill, these groups are going to the help talking to their senators, representatives and so on and abdicating and you don't hear about it as much as you do and you don't publish the results the boy are they powerful was the don't think that they are not, they are out there and their abdicating. I think that is all we have time for. I am sorry. It is 10 o'clock the next panel by want to quickly think our panel and our presentation. So thank you very much. [Captioners transitioning] Test >> David Muntz Bonnie Britton Vidant Dave Clifford Patients Like Me Mohit Kaushal West Wireless >> We will start right away. We have spent a lot of time discussing areas of facilitators and evidence or no evidence. We want to move into something that is lighter but more important and exciting. I heard something recently and someone said that over the next five years the most important person in a care team is probably going to be a mobile app developer. It probably is not that out there, but it could be possible. Today's panel is going to take you a little bit further away into the future. We are going to talk about how mobile health and mobile phones and smart phones and social media and remote monitoring and verbal devices and center devices -- exciting technologies -- are going to make their way into healthcare. How they are important and how we should be prepared. Keeping with that, I am going to quickly introduce our panelists for today. We have David Muntz come of Bonnie Britton and Dave Clifford and then we will talk about the future of wireless health. With that further ado, we will start off with David. >> Thank you -- you can tell that I am not from around here. I appreciate what the doctor referenced here -- the Field of dreams -- I am a movie buff and I am it is one of my favorites -- if you build it they will come -- this is very popular and I really believe the reference there is appropriate. I wanted to use it earlier this morning. I appreciate you doing that. The truth is, when you talk about -- if you build it they will come, they were talking about the players, not the people who were going to be there in the audience to see it. What I would like to spend my time is talking about how to get the audience to come and right now we have not seen a lot of progress in that area. We see right spots and I will try to quote some of the figures that show the challenges that we have and what I would like to do is get everybody here to feel some personal responsibility for hoping ring everybody into the Field of dreams. We have unbounded expectations. The fact is that I carry devices on my hip. I expect them to do things. Everybody does. It affects the way that I did work when I was a chief information officer. In fact, there are different planning horizons that we used to have. We used to have short-term which was whatever you defined and there was midterm and long-term. Well, I think what as happened with the presence of the mobile devices is that we have a new planning horizon. That is the media to -- immediate term. The expectations are now that when you see something -- it will happen quickly. I hear people talking about the studies. We will have to figure out how to do things more rapidly to get the technology into the hands of the people. The other thing is that people will have the technology and we are going to have to figure out how to deploy it quickly within our own areas. In terms of the roles that we see changing, I think that the question is who is going to be the primary coordinator of care and the secondary? Will it be the physicians or the patient's? Or will it be the patient support groups? These conversations are important. I do appreciate and want to thank you to everybody at the meeting. I won't 12 to much on this because I appreciate everybody else's opinion. I would rather talk about the meaningful conversations that occur as a result of meaningful use. What we really need to do as we deploy these technologies is get into meaningful conversations where we discuss what the roles will be for the respective parties because it is not about the technology, as everyone is pointed out. It is all about the people and processes. In terms of community, there are plenty out there. They are helping each other, but the question is -- how to get them connected? The other thing that is interesting is the potential change in who will be the custodian of the data. I had the privilege of speaking to the American health information management Association and now in most states and virtually all -- the medical records person or the health information is considered the custodian of data. When I went to speak to them, I said I think we will see a shift -- I was expecting a negative reaction, especially in the national group where these people are doing the things that they do every day and I said what I expect to see is a complete shift and the logger will be health information management people be responsible as custodians of data, but the patient will become the Estonian of data. The truth is that this tells solve significant problems -- privacy, confidentiality, etc. All of these problems go away. This is a good notion if you have an educated populace. We still have a significant digital divide. For the people who can take vantage into this, we want to promote this. For the people who can, we will have to figure this out. This will mean health information exchanges and 70 will have to be the primary coordinator of care. You think about -- I am from Texas -- there are 30% underinsured or uninsured patients that digital divide is pretty large that we do need to figure out at the same time are taking care of the people who have crossed the divide how we are going to take your the people who would not. A couple of things -- I will not 12 on these. Always see -- this ONC -- this was started with 28 people and now we have 128. Strangely enough, being an outsider -- only being there seven months -- the first thing I noticed was that things were not? Organized as I would expect. I had an opportunity to talk about how we should change the focus a little bit. We talked about consumers, but we did not have a place to go to represent the consumers. Now, with inside the office of national coordinator, there is a consumer eHealth group that focuses entirely on that. The work had been going on and it had been going on in diffuse ways. What I will show are examples of how this is occurred and talk about what some of the things we will do our. We do have 3 A. -- how to get it patient to the data -- access, action -- how did it patient to take action on the data, and how to change the attitudes about care? When you talk about the market for mobile health -- I appreciate your comment -- I have a quote here -- by the way, these quotes are all within the last week am a so it is incredible how relevant all of the activities are that we are engaged in, but it says that the market for mobile health applications is continuing to grow and expected to reach $11.8 billion. In 2018, according to global data. This is pretty remarkable. What we need to do -- we talked a lot about the providers that we also need to talk about the patient because the role they have is so critical. In terms of what the personal health ecosystem is like, continue -- they provided a slide -- continue I -- this is a group of 220 organizations that includes providers and vendors and other interested parties and when you see this, it is daunting. The question is, does this exist? It does exist. Here are some examples of products that are currently available in the market to do such things as chemistry through smart Band-Aids and then the ability to communicate this. It makes Telehealth accessible. The question is how to package it and make sure that you get reimbursed for it and make sure that people get trained for it? We will talk about that in a minute. In terms of this -- this is important. By the way, the definition of elderly keeps changing -- the older I get, the higher it goes. My mother is older than I am so I will at least say that I do worry about her exercising enough to avoid a fall. The question is, what is available? This is a slide from 2009. The technology has been around for a while. The fact is, you can watch what the activities of daily living are inside a household. The question is, can you afford it? What is the reimbursement model that was supported? Interesting possibilities already are in existence. Then, the smart car. This is probably a little bit invasive and I actually got into one of these that when I got in, it said please, only one driver anytime. I was a little insulted. [laughter] Even -- you got that -- good. Even the automobiles are smart. The fact is, my car has more technology than any prior move landing device. It is remarkable. The question is, how will we use the technology and what are we going to do to gather the information and he able to take actions associated with it. Look at some of the challenges -- how to engage the patient. There are some cultural things that go on. There are some discussions -- meaningful discussions that have to take place. What do you do to make sure that an adolescent record -- it is always the mom that should do that? The rules in Texas are specific about a minor. If we are trying to deal with sexually transmitted diseases, how will you be affected if you don't let the individual to you the results? How will you inform people about what needs to be done? It is huge. Literacy -- we talked about the digital divide. People don't know how to use computers. If you want to learn something, give a device to a teenager. They are the best training manual you could get. Yet, why are they so used to it and the people using it for a long time or not? It has something to do with that. There is an age thing. So, domestic demographics and politics -- these will be affected by that. It will be impacted by this. Security and confidentiality -- all of a sudden said this before -- but there are things that you will tell your position that you will not tell another soul in the world. Whether it is your priest, rabbi, best friend, etc. Again, getting the patient involved is huge. It affects the relationship with the provider. Who hasn't gone into a physician and said I looked online in here is information and the question is, is the physician going to be able to keep up with that? We saw a slide yesterday the talked about the increasing availability of information. Affirmation is doubling every two and have to four years in the medical space. How are the physicians going to keep up? Will there be some competition developing once the patients have access to the same kind of information the providers do? The rhyolite edibility -- the liability of information -- people question whether the reliability of the patient it is good. One thing that pushes us to when they are assessing a patient is understanding if the patient is a real source of truth. It is the reason that body language is so important during an interview. Well, the other question is, what about the positions data? How reliable is it? Some of the patients have discovered that some of the information in their medical record is not accurate. The question is, how do you deal with those issues? Again, having everybody look at the data in sure set the value of the data goes up and the integrity of its days as high as possible. Into a collection of data -- I think that -- into it if collection of data. If you have to train on an electronic how the record or personal health record, you will probably not use it if you are consumer. We know what the situation is for physicians. If you want to train them, you need to do at the elbow training. This comes from years of classroom training that is not affected. Why not give people software that is been designed better? We did establish a new office within the agency that is called the chief medical officer. One of the responsibilities that he has is usability. It has huge implications for safety. So, if the advice -- if the device is into it is and easy to use, -- intuitive and easy to use -- this will help. The question is -- the life work balance -- when you talk about consumers, instead of talking about workflow, I think we ought to talk about life flow. How are you going to incorporate the technology into the lives of the consumer's? It has to be unobtrusive that always available. If you were going to train chronic conditions -- 70% of all diseases chronic -- you will have to figure out a way to make this happen. I hope again that we will be having discussion about the meaningful use of the technology, not meaningful use as defined by the ONC. Although I certainly like their definition. Consumers are looking for trusted sources. It used to be that I laughed at this, but a report just came out two days ago that really is a disturbing -- the Journal of pediatrics -- have you seen the article? It is remarkable. It says that a new study examines Google search results for various phrases related to instant sleep safety. I happen to be a grandfather now. I can tell you that this is a huge issue for my daughter. She is very concerned. The study notes that 28.4% of the online search results provided a relevant data which is not really harmful, but -- 28.1% provided an accurate data. So, if we want people to use data and to come to the technology, and to the information stewards, we need to figure out a way to improve the integrity of the data. Here is what I think is one of the most of her Markle evidences of how important it is to get the patient involved. AARP did a study that showed these results. It is incredible when you have a more interested and engaged patient what the outcome is for their health. As we talk about trying to to help reform, you have to have the patient at the center of the discussions. It is not just another to put up new payment models, you have to have a different behavior in the patient. Here is the concern -- because there is a gap between reality and the title and this is remarkable. 15% were new to the prescription online. How many in this audience have renewed a prescription online? This is a much better audience. At least twice as good as the general public. Please continue to do this. Here is another thing -- again, I find this disturbing. It is not that it discourages me, it encourages me to be more enthusiastic about what we are doing. I hope you will do this as well. Data from the third annual EHR survey conducted for xerox showed that only 26% of Americans wanted to adopt digital health records. It also found that only 40% of respondents said that digital records would boost healthcare delivery. That is a decrease from last year of 2%. Things are not going in the right direction. It will take people like you and me out there trying to encourage people to do what is right and look for them. It is difficult to do what is right for somebody else. We are trying to do and we have been successful at this -- I would encourage everybody in here who is not already a member -- to join the pledge program put up by the consumer health group. We have 350 organizations that were present over 100 million Americans. This is a nice fortune of the populace. Both data holders and non-data holders. You can see a lot of large companies that are well represented. I am glad to see that Pepsi-Cola is up there. They are helping to produce the snacks I eat. This makes it a little more challenging. The idea is to figure out how to put the I. in health IT. The stories on health IT.gov are stories about people who have used health information technology to do real things. There is nothing more impressive than anecdotal evidence. Here is a cancer survivor that was able to dance at his daughter's wedding because of some things that were done and enabled by health information technology. The million hearts campaign -- get out there and get the individuals committed. This is a remarkable success, but we need to do more. We have tried to gauge the developers -- engage the developers and get real people out there to do testimonies. This was a prior challenge that we put out. We offered money to get people engaged. This was a beat down blood pressure -- a clever name. We now have something that you can do now. This ends on August 20. There is money available. $7200 in prizes and we are not beyond paying this. You can see that this is an opportunity to tell your story about how you have used technology. I would encourage you and your friends to get engaged. I think you probably know about the blue button and how many people have downloaded records. This is available from the VA and DOD. We have been in conversations to move some of the activities over to ONC and what we are trying to do is figure out how to do this not just in data blobs -- now, the data that comes is in text format. So, what we want to do is take it to the next level and provide data to the patient in discrete format so you can incorporate this automatically into your personal health record and the other thing that is required by the current deployment is that you have to click on the blue button. Would like to create a set and forget it kind of environment so that the data gets downloaded to you automatically. I think this will be something that you will see is working on in the next year. So, I will end with 3 seconds left. -- I am over by 5 seconds. I would like to end by asking you all to connect, Munich eight, and collaborate. Patients and consumers deserve everyone's help. If you think about this, easy way to sum it up is that you are helping an individual and helping the population. I would encourage you to go out there. We yesterday released a small cartoon for the public to help them explain -- help explain to them ways that may be more accessible what an electronic health record and two. This is the link for that. I would encourage anyone who has ideas that cover today to oh ahead and contact me at the e-mail address on the screen. Thank you. [applause] >> Good morning, how is everyone? Bonnie Britton My name is and I am excited to be here to talk you about a remote monitoring program that is new and unique. Some of our outcomes that we have had. I work for Vidant help. It is located in North Carolina -- we are the largest healthcare system in North Carolina. We have a little over -- right at 1500 bed. We provide services to patients in 29 counties and we cover 1.4 million lines. We are also affiliated with ECUs skill -- school of medicine. Here's a map of Eastern North Carolina. We are very rural. Seven of our counties out of 29 are the top chronic disease counties in the state. We have a tertiary care center and medical center. All of the hospitals that you see around -- there are 10 of them total and our health system hurried as well as home health, hospice, and we also have Vidant medical group. This is a primary provider. We have 50 practices right now and it is being expanded to about 150. I want to talk to you about some of the successful programs we have had in eastern North Carolina. Being in a rural state and a state and an area where there is a lot of poverty, a lot of illiteracy, and number one in the state for chronic disease in several of these counties, I worked previously in another place where we implemented a patient provider telehealth model looking at how primary care providers could identify their patients. Then, refer them to remote monitoring where we would monitor the patient's blood pressure and pulse and weight and oxygen saturation as well as their blood sugar levels. We had so much -- so many good impact with the patients that we were able to expand the program and at one time we were doing all of the centralized monitoring from one location in the world eastern Carolina up to 12 community health centers across the state. Currently, there are three community health centers. These are monitoring patients as well as [indiscernible]. This is for of total. The average length of saying -- length of stay was six months. The outcomes we had -- we contracted with wake Forrest University. We demonstrated significant reductions in bed days and hospitalization as well as overall healthcare. As a result of these outcomes and the program that was developed that was -- I was recruited to come and work with Vidant. It's almost been a year. I was tasked to write a business plan and to diplomat a remote monitoring program for patients with heart about the legacies as well as pulmonary disease. This is for all 10 of the hospitals. What we have done is -- the hospital pay for the program -- it is self funded. The reason they are doing this -- we have talked about these things -- value-based purchasing, core measures, public refer thing of outcomes, and the other area is to decrease the 30 day rehab missions. As every hospital knows, the penalties coming starting in October for having high numbers of readmissions for heart failures and acute MI and community acquired pneumonia are going to be quite significant. What we wanted to do is to try to develop a program that would identify patients while they were in the hospital and then refer them to a telehealth program where we would monitor the patient's blood pressures and walls and weight and oxygen saturation on a daily basis. One of the things that we incorporated which I think has been tremendously important and valued is that we have implemented a patient tool that was developed out of the University of Washington said. It is a 13 question tool that the nurses in the hospital ask the patient. They get the tool to the patient. Once the patient has answered their perception of their level of engagement, it gives a score between zero and 100. It places the patient at a level of activation from 1 to 4. The level I patients are the ones that are distrustful of healthcare and they fear helped out. They have had a negative experience. They believe it is the doctors and nurses responsibility for their health versus owning their own responsibility. The majority of these patients are not compliant. At the last presentation, you saw the slide for patients who are engaged. They are -- 30 day hospital agents are much higher. We determined that we would implement the patient activation measurement tool. We have it in our all electronic health record. We only focus on patients that are activation level of 1 or 2. We are focusing on the most unengaged group of patients. We started our program in February. I just got an update from my team. We have now enrolled 496 patients into the program. We started in February with 200 sets of monitoring equipment. We started at four of the hospitals -- three world and the medical center in Greenville, North Carolina. We also partnered with ECUs geriatric division and we are monitoring patients. They are homebound with chronic disease. So, our focus is trickling on chronic disease. Patients who are frequent readmissions and patients who have low activation levels. Between February 1 and the end of March, we enrolled 200 patients into the program and then we obtained 180 additional sets of equipment and we are now rolling those out to other hospitals. By the end of September, this year, we will have 500 sets of equipment world out to all 10 hospitals as well as the medical group which is the primary care provider. With that approach, we are looking at how weekend proactively identify patients to monitor before they get into the hospital. I wanted to talk about lessons learned. A lot of people are doing on telehealth or remote monitoring in the patient's homes. I was disappointed yesterday to hear from CMS that they don't see the value yet in this. One of the big things on lessons learned is to develop your program based on the new payment structure. We looked at who the core measures -- what we are going to publicly report. We looked at where we are on the linear graph of value-based purchasing to make our determination of the focus of patients. We had to shift from hospital care to care the home. The patient will always be the center. In our program, everything that we do and everything we say and how we act is to the patient's eyes. If it is not, the behavior is called on quickly. This is all about the patient. There are a lot of research out there on care coordination and transitions in care. These are great programs; however, the models for the programs -- ratio of nurses patient is 1:18 and 1:30. When you have ratios at that level, it is hard to scale a program and it is not affordable. Our ratio of just Turner's to monitoring patients is one nurse to between 85 and 100 patients. This is a program that you can scale. It also requires that you change the way that hospital case management is run. Most of the manager programs were started in the last model in the 90s. We need to move forward. Then, patients in a medical home. We have four of these groups that are going for certification as patient medical homes. They have incorporated telehealth into the programs as well. You need to focus on the top 5% of your users -- high-risk patients that have aged -- when you see the data -- it is sad that a large majority are doing a job 18 and 60. A set their engagement and teach and coach based on the activation. I want to give you an example. One of the first patients that we had -- the goals for the patients -- it has to be the patient goals, not the nursing or positioned goals. We drove to the patient's own and it was a 54-year-old patient with heart failure and COPD. That's bad enough -- I said -- the number one goal is -- what is that? We got to the home and there were signs on the door -- no smoking -- oxygen in use. She opens the door with a lit cigarette and walks in. I looked at the team and said -- what is goal number one now? Then, we go into the home and there are medications everywhere. I said what is goal number two? Get these meds together. For the majority of these patients, it is tiny steps that you are having to take with these patients to get them engaged. I believe in inclusive patient selection and criteria versus exclusivity or he a to our only exclusion criteria is that the patient does not have an electricity. At the 496 patients -- we had 10 patients that did not have electricity. You need to have standardization as far as patient identification screening and referral and enrollment. You need to have a provider plan of care. We have it in the military health record. We have a physician referral in our inpatient electronic health record. We use LPN's to the equipment installation and the training of the equipment and competency validation. They also do medication reconciliation a discharge and the day after discharge when they install the equipment. I will move forward now. It has to be data driven, as we heard over and over. These are some of the data points that we are collecting. Financial data is absolutely important. We first started this program, Y. orders were to only monitor these patients for 30 days to prevent the 30 day readmissions because that is where we are financially hurting. I met with the vice president of finance last Wednesday I was concerned because the pre-world hospitals in which we have this program, the last four months they have had zero hospital admissions for heart failure. I was concerned that we had over accomplish, but when I met with him he said move forward and move on because every Medicare patient and help a patient -- we lose money. We have given the responsibility for the financial analysis to the vice president of finance for our company because there is no way that I could provide them what they want to hear. EHR integration is critical. We are going to go live with phase 2 integration between the telehealth enter and at that. This is on September 4 of this year. Before we could get the entire integration, it was a painful process. The telehealth vendors are willing and ready and able to do this integration. It is the EHR vendors that we need to push. They have to do this. They are being paid for meaningful use and they have to come to the plate. They have started initially -- they were going to charge $20,000 for the integration. This is ridiculous. We got them down to 5 million. We have built in Black's and standing orders and -- flags and standing orders. Probe lacks -- capital for a program like this. Lack of reimbursement. That is not a barrier for us because we are not looking for reimbursement for the program, we are looking at this as a cost avoidance and cost savings for the organization. 54% -- so far, out of 496 patients, we have had 65 patients who I've been monitored. The average stay is 60 days. I went over the 30 that I was ordered to do. They just gave me approval last week to extend that to 90 days because we are focusing on the most unengaged nations -- it takes longer. I've those patients, we have had 65 who have completed their monitoring and have been off the program for three months. So, how we analyze the data is that we have pulled all of the data -- three months prior to telehealth -- then during telehealth and then three months post-telehealth. We have 65 patients that have completed -- the majority are female. If you look at this, yes the majority are over the age of 70, but look -- 12% of these patients are between 18 and 49 years old. We have a 24-year-old heart failure patient. We have a 19-year-old patient with morbid hypertension. This is just settling for me because in my past I have focused on patients above the age of 70, but with this, our age between 18 and 60 is growing rapidly. The majority of the patients are African-American. The average length of stay in six months. Binary diagnosis is heart failure and diabetes. Hypertension stalls behind that. Primary insurance is Medicare. We are not focusing on Medicaid. Every once in a while we will have a Medicaid patient, but we have a statewide program for taking care of Medicaid patients. Our outcomes for the 65 patients -- they experienced 100 hospitalizations. Three months prior to terror help -- telehealth. During telehealth there were 19 hospitalizations in the three months post-discharge there have been eight. This is the percentage off reduction. I have 10 seconds left. Hospital bed days -- there were 489 bed days during terror 12 and this decreased to 76 and for the three months following it has decreased and 24. Is this good or bad? It is good. Because if you can decrease that a bad, you can backfill those ads with surgical patients and other paying patients. Also, this allows for us to be able to transfer back to the community hospitals and get the patients back in the community where they need to be. That's it. Thank you. [applause] I am Dave Clifford from Patients Like Me. We are a social network platform for patients with chronic illness. My background is as a technologist prior to joining the company. I used to be with the defense advanced research agency. I did a lot of work in telehealth Intel medicine. One of the main reasons I came to patients like me is because they work uniquely positioned at the time as a generator of data. We talk about remote monitoring and we talk about what data we can gather from outpatient life, in the patients in a centered medical home -- this was a sensor list cheaper way to get at some of the patient outcomes. Unfortunately, these skills are less than I would like. We will talk about that. Patients lIke Me was founded by this guy -- Stephen is pretty far along during a progression with ALS -- Lou Gehrig's disease. One of the things they found when the family was going through this -- it is a family of engineers. The volunteer data about people with ALS in the literature is limited to small coworker 12. There is not -- go work trials. There is not a lot of information about what day-to-day life is like. You can pick up the book by Stephen Hawkins or you can look at the experience of someone like Lou Gehrig's, but as an average person in the late 20th or early 21st century, what is it like, there is no place for someone to come and talk about what it is like to have that disease or many other chronic diseases with a data-driven perspective. There was a place to blog about it and there was a place to write about it and have narrative content, but they wanted to supplement this with data content. Part of this came about because one of the founders was trying to populate a trial or ALS. He could go on OK Cupid and find a woman in his age range and had similar interests and pick out their color and proximity, but he could not do that for a clinical trial. What is it today? It is a network of over 150,000 patients -- people who of signed up for this. They connect with others like them for personalized learning and support. They enter information over time and it grabs the information. They have an immediate visual perspective on what their disease course has been like. They can use this information to dive into the richer community experience. People on the same medications, etc. People that have the same disease for the same amount of time. Or maybe just shared common symptoms with a completely different disease. They talk about binary diseases and coworker to these. A lot of this helps to activate the patients to move them to the levels higher up along the patient activation chain. What is the profile look like? Here is one. This person has a public profile. That means that if you Google the list -- it will show up. A small percentage of people have small but well. Most people have private profiles major they can be access by other patients. Most people use pseudonyms. We know there is a lot addresses for adverse event reporting. We don't all their real names. We know their location when they share that with us. A lot of people do not use a picture. People are surprisingly open about a lot of severe pathology. They score quality of life -- correlated to the SF 36. This is a person with MS. They have an MS RS score. This is a questionnaire administered to them. They take a questionnaire as often as they like. They can have things taken weekly or monthly. It will break it down into the different domains. In ALS we use the ALS at RS and we use the Parkinson's a score in Parkinson's disease. In many of the communities, we have not developed scores for literature. The majority of the patients using our site have severe neurological diseases. ALS, fibromyalgia, Parkinson's, epilepsy -- not some of the big drivers of care in the remainder of the population -- things like COPD, MI, etc. They tracked medication doses and strength. If they switch medication dosages, the bars would be bigger over time. It is -- it is visually intuitive. This is a person with MS. You can see that they also have OCD symptoms. We are looking at their coworker 80s. -- comorbidities. This looks at a community -- Biloxi. This gives you a sense -- of double up. -- Epilepsy. I am concerned about headaches. You can look at this and get a sense for this. You can look at the medications most used in the evaluation's of the negations and the side effects and how severe they are. Then, you can go into the discussion on the right-hand side epilepsy where people talk about what it is like to have in more of a narrative you. -- Narrative view. This is the place to come to get together and talk about stuff -- is there a benefit? In the context of rural health, one of the largest benefit that we can see is that one third of the people in our community had no one in the real world to discuss their epilepsy with. In the cases of stigmatized diseases, in urban populations, you can find a support group, but in rural populations you cannot I do support group. This provides a 24/7 access to a support group at two in the morning if you are in a small town in North Carolina. If you have a like comparing condition. For a majority of the people with Apple let's see, it gives them a better understanding of their seizures. We provide a description of the different kinds of seizures. They go from calling things by the was the two tonic clonic -- but now this is less accurate. We help them to understand their side effects. This drives them to be more inherent to medication. People will frequently discontinue it because they do not know about the side effects -- it makes them feel weird or strange. In epilepsy in particular, adherence is the difference between continuing to have seizures or not. There is a large percentage of people with uncontrolled epilepsy. This is uncontrolled because they do not take the medication. 20% -- they are using this to get better permission and they insist on seeing a specialist. This is positive across the board for many of these people. What are we do? From a broader view, we are a novel patient registry. We are a competent resource of data to the remote role in this care world. We are more closely integrating with the other data streams as the other data streams are becoming available. We talk about patient centricity and patient being owners of their data. Very few care systems have adopted good places for patients to be meaningful custodial to the data. So, for example, the Kaiser health system has spent a tremendous amount of effort holding a good patient portal. It is frequently used by their patients and it were present enormous time and enormous resources. On the other hand, something like Google health -- they said we are going to create a home for people to upload their medical records independent of their care teams. Independent of other health related environments. That was a catastrophic failure. It is been discontinued. It doesn't exist anymore. What people are trying to manage their health online, they are trying to do it in the context of other information. They don't want to do it in a sealed vacuum. If I can put my prose personal health information somewhere in share with someone, that is my clinician or my peer group -- that is better than if I can put it somewhere and then bring it to someone else in another part of the system. Both of these things are exceptionally social tasks and necessary, but it seems that for the broad majority of people, there is less of an interest in the personal health information management as a good thing on its own. For providers and care teams, we provide a clinically robust understanding of the patients and real-world outcomes. We aggregate the data and supply to people interested in the patient information. We divide by directional lines to patient voice. One of the things that we found is that MS patients, for example, would really take their biologic medications at night rather than during the day. This is not something that clinicians tell them to do. This is not something that AGP would tell someone to do. Other patients told them to do this. The side effects are severe. You feel like you have the flu. I've patients know that you feel like you have the flu when you take these medications so you should take them at night. The drug manufacturers and clinicians aren't as aware of that information. As we talked, there is an information explosion -- this is proliferating at a much higher rate than someone can put their heads around. Additionally, we have this breadth and adaptability of social networking. Earlier we talked about the danger of the pediatrician for fighting that information -- the person interest in doing a search on pediatrics retrieving that information or low quality information. Part of this is because in many of these places, they information does not have a doublecheck or another person saying -- yes or no. If you go to DOS who answers -- Yahoo answers -- don't do this. Don't do this if you want an answer on anything. There is no validation of information. The people who populate this are people who feel like they are experts or they have a lot of time to waste. On the other hand, people with Patients lIke Me are people seeking health information and have some personal experience to reflect on when they are sharing this information with others. The presence of data as an underlying thing to these narrative threads allows someone to say -- I am thinking about undergoing liberation there at the -- it is a drastic therapy that is not well received in the peer reviewed literature. It involves categorizing a pain in your neck to alleviate MS symptoms. There are people who have gone through that. They continued tracking their data. When someone comes and says I am thinking about doing this -- the community can say -- we would suggest that you look at these 30 people's profiles or these 40 people's profiles -- a set of people who of undergone this therapy -- see what happened to them afterward. For the majority of these people, it provided them no long-term benefit. It allows there to be a databased doublecheck for some of his health information that otherwise exist in the wild. This is good. These are good things. The goal -- the substantial goal -- building a world where every patients is affected by other patients experiences. This is a compliment or a role that patients can bring to Telehealth and telemedicine. Especially in the context of things I'd remote patient monitoring we are getting data from sensors and we are not sure if it is coming off of the sensor and it is apparent because there is a medical event or cause there was a live event. In order to zero the sensors that we are having, we need to have some of this problem and we data about what was going on in the patient's life that day. This is in order to make these things more robust and useful. There is the Telehealth and medicine part and is the patient beneficiary part, but overall we are trying to integrate with as many data streams as possible to make the system go. Thank you. [applause] Good morning, everyone. Mohit Kaushal My name is. Thank you for having me. I am going to spend the next 10 or 15 minutes talking about some of the future technologies we are seeing within the wireless help space and the things that have to come together which I think have been touched on today including policy, clinical process, etc. The key take away is that it has to be bundled in with other pieces of the story to perpetuate this whole space. Briefly a round the West Wireless Institute -- our mission is to reduce the cost of healthcare. We do this by innovation and investment and policy Institute and DC. A couple of topics that I hope to cover -- a brief overview around the transition in healthcare right now. Again, the world owes her will be different will be different which creates a huge amount of opportunity or these real disparaging -- disparate technologies and bringing them together. Secondly, a little bit about the overview of wireless help and the state of the industry today. At a macro level, the forces around macro economics are not positive, but they create a real opportunity. I know I am preaching to the converted, but three drivers that we see -- cost, epidemiological transition, and a shortage of doctors and nurses and nurse practitioners. While we are spending now is about 18% of GDP on healthcare. This is growing an estimated to be around 20%. This doesn't give us the real value that other countries have. Second, and I will summarize this -- we have or elderly people coming into the population. As we know, they have chronic disease and unfortunately this rides or cause. This is going to get worse. To compound all of this, there will not be enough impression those to look after all of these people. So, there in lies the opportunity. I believe that technology -- especially mobility -- can solve some of these issues. In the backdrop -- I know that many of you know what is going on -- we are having a shift away from patient transactions and volume of care to outcomes. I will not debate whether and ACO will work and not -- whether it is an ACO or bundle or 30 day or whatever comes around him a sum will work and some will not. They are all trying to do the same thing. As a ratio, and hospital were get paid more for what goes on outside its four walls more than what goes on inside. From a clinical perspective, if we can prevent costly but missions and prevent exacerbations, one would like to think that these will be rewarded with whatever payment model ensues. I am a for a believer of this -- the health Institute -- one of my colleagues -- essentially what we need to do is shift the site of care from expensive centralized? And mortar hospitals managed by expense of physicians and nurses to outside the hospital. We need to be skill healthcare. If you look at other industries, it is improved over the last decade. In healthcare, it lags behind like many other things. Into structure independence -- let's compare and contrast. The current model is very reactive. Low frequency this is driven by an appointment -- when a physician can see you, the patient, not when you need to see the position. Very location centric and high cost. Again, I see mobility . What we need to do -- this is happening -- we need to move to a proactive high-tech system providing the right drug at the right time whatever the patient has. And again I think we all firmly believe that if you can prevent exacerbations of COPD and ammonia and IIM Hubbell see HF -- all of the costly conditions, we can lower the cost and a macro level for these patients. Then, on the scare -- it is cost-effective. There is a lot of data out there. The post acute space is an increasing in cost. If we can pick up these patients earlier, and manage them in cheaper places rather than a centralized hospital, we are talking from a nursing home of $80,000 moving down to independent living of $1600. Even if we shift a small proportion of the elderly population into independent living, the cost savings are huge. Post reform, here are some of the interesting points that we are seeing. I have touched upon payment reform. Again, I would advise no one to to get deep into the debate of which one is going to work. If we do the right thing clinically, the that is that it will be reported in the new world and I'm a firm believer of this. The other piece I will go into -- mobility is one piece of technology and it is not a solution. There are other things they need to go on. We are undertaking this digitization of healthcare -- if we look at other industries, data in additional form and analytics has toes transformed productivity and outcome. This is what we need to do in healthcare. Meaningful use is bringing more data into the healthcare system and mobility -- it is just a piece of that. The third practical effect of reform -- we are seeing a lot of of physicians become salaried employees. Hospital systems are producing physician offices and positions preferred to be salary. Anyway from the transaction system is where we are going. Let me go now deeper into why this -- the tax on any -- you have wireless help and Telehealth. It is hard to navigate. Here is something that we use. When metadata, let's go through the different components. There is the data input side -- a mechanism to capture these things. Then, think about how to move around the data via wired and wireless networks. The third piece is how the data will be stored and what are the analytics we are going to push onto raw data to turn it into meaningful information? Physicians and nurses do not want to see raw data. The want to know what to do. Finally, we get this information, how do we push it in the right user interface to the final user? Mobility and powers both extremes. It allows capture of data anytime anyplace and running out of information anytime and anyplace. But, my hypothesis is that this is not enough. The wireless health industry has moved away from just mobility and analytics and healthcare IT and it is becoming it lamenting into medical devices. The final point that is touch upon today -- all of this has to be implemented within the right clinical process. Either the existing clinical process is to make a better, but the more exciting piece is how to create whole new clinical processes and how are they these technologies to look after patients for a fraction of the cost with that are outcome? Now going into some of the technologies that we are seeing -- around the data input side, centers are becoming cheaper they are more ubiquitous. For me there is a hierarchy of data. It is a commodity to be able to capture blood pressure and pulse and weight. The more exciting thing are the higher levels of the data hierarchy. How can centers be used to capture noninvasively really hard parameters? Thing about CHF. It is their device to pick up decomposition but for the patient becomes symptomatic, that is a game changer. That is what we are going to see as sensor technology becomes more dance. >>, This whole space has been getting a lot of press -- the economist or science -- we are seeing a lot of movement from four years ago when I started, a movement away from the convergence of devices to the convergence of healthcare IT and service delivery and user interface and design. Again, I think it will be an about the Mission of all of these disciplines that creates a positive final outcome. Again, it is not about making a device wirelessly enabled, it is around how this better managers patience for a fraction of the cost. To do this, it will be multiple technologies and disciplines to get us there. There are reasons for optimism. From a technology perspective and then from the data coming out -- some of the intellection points about technology -- ubiquitous networks whether they are wired or wireless. This can transfer more information. I'll will touch upon the work we did in the FCC -- unfortunately, there are huge parts of the company lacking behind in the connectivity piece. This these to be solved. Consumer scale production of smart phones and ubiquitous devices. Again, the amount of apps proliferating on the smart phone for the consumers and providers and other caregivers will only grow. Slowly we are seeing the ones that are creating a lot of the value. Again, the decision support is the most important piece. There's a real generation gap now and analytics. And healthcare versus other industry. We are catching up. How do we turn this multisource data for mobile centers and medication compliance and the EMR and social factors -- how do we capture all of that and turn it into something meaningful to figure out letters we never knew before? I always put the cost pressure side out there. Because 18% of GDP going to 25% -- it can't continue. The country will go bankrupt. The impossible cannot occur. Either data changes will occur which I hope not where we actually redesign healthcare system. Reasons for optimism -- I know the call? From the VA will present this afternoon -- Adam [last name indiscernible] is one of the architects of this.. They have some compelling figures. They have a 90% reduction in emissions were people within their program. Patients who are admitted -- 25% reduction in bed days. I am sure that it will cover this, but it is not just about the technology, it is the right payment model and the right culture and standardization of processes and using care coordinators in the right technology to help augment an accelerated that. Unfortunately, there are still significant barriers. This is something that we outlined at the FCC national broadband plan a couple of years ago. He going to be taxonomy. We think about. -- The base layer is connectivity. We need to connectivity to empower everything. The next level is the durability and the quiddity of data. Right now, data is silos and it is in non-interoperable systems. Within the wireless health the concern is that if these up front and devices cannot talk to the warehouses or EMR's, we need to solve this. We need to prevent the same problem from occurring with the device aspect. The next level is integration -- how do these different technologies integrate together? In an ideal world, think about the Internet. You have basic data the quiddity and apps or programs developed by the best entrepreneurs plugging into that. That is what we need to do here. The best by this need to be intermingled with the best pieces of analytics and there can be innovation all the time. How do we get to it plug and play technology landscape? Finally, the clinical evidence needs to be around the final value proposition of all of this. Again, the key point is that technology by itself has to be able that in the right your processes to that outcome. There are many cases where there is cool technology with a great proposition, but it is not gotten there. Again, back to this point -- the industry has moved away from an and four years ago that and it was pushing a lot of technology. I am seeing a lot more solutions out there now. I am seeing management teams comprising of acid technologist, but also people understanding healthcare policy very well and people with clinical expertise understanding the care proxies and people from the payer and provider world coming in. This combination of teams we are now seeing and more startups will disrupt the landscape versus just a technology piece with a policy piece. In summary, it is a multitude of technologies that need to work together. It needs to be a woman in the right care process I have said this about five different times. I believe it has to be done in the right way. Thank you very much. [applause] Thank you. That was excellent. I want to summarize what we just heard. All of these presentations came together really well. I loved David's part -- point about it is not about the technology -- about the people and the processes. Then, every other speaker repeated that. That resonates with me and with the people here -- technology is a tool and an enabler, but we really need to get everything else to center around this and come together. I think that we heard a lot about who should be the custodial the data. I think that they made a good point about the patient being the custodian. Then, we heard about patient generating their own data. They are not only -- not only should the only data we generate, but they are generating their own data and they are validating their own data and finding this data useful. They are sharing the data and they are finding support and they are looking at -- doing things that we used to in the past. Then, the issues that we need to work on like privacy and security. The other thing -- the industry is about reliability. The need to start to think about how to make this reliable and how to make these sensors work Berkeley and how to get there. Then, into a data collection. A couple of speakers spoke about this. We need to integrate the data collection into the flow and maybe wireless and mobile is the perfect answer because smartphones are with you all the time and they are part of your daily routine and part of your daily workflow. And your life flow. It feels like all of these things give us a message that is the same. We are now open to taking questions. I can start off with a few questions -- we have about 20 minutes. There are questions already. I will stop talking and turn it over to the audience. I wonder if I can make a quick comment about wireless health and health in general. Do you mind if I supplement what I was saying? I go to a lot of these meetings as many of us do. And frequently people talk about mobile technology being the technology of the future and how being a big disrupt or an eight game changer. Year-over-year, the number of apps that you can download for help has gone up dramatically on the app store. When people are surveyed, about uses of these apps, most people open these apps after they download them -- about 20% of them open them once. I'll that, after 30 days about 4% of their them are continuing to use a continuing out for help. This could be for a lot of reasons. One is that they don't integrate into any kind of life flow currently. Don't forget that this includes things like run keep a, it is apps, etc. Apps for health -- it is not am I managing my COPD or diabetes? People are we really very big cheerleaders of mobile help adoption, but the mobile app development community is not going to invent the solution without the other players at the table. They will not do this on their own. So, earlier key said if you build it they will come. Six years into this enterprise, that is absolutely 100% not the case. If you build it and they look for it and they know were to look and their clinicians are guiding them there and they are finding some utility from it, some of them will calm. People talk about technology -- solving the problem of healthcare. What this panel pointed out was that technology can only solve the problems of healthcare in so far as it is integrated intelligently into a workflow and life flow and vertical flow. I would say that the problem is not the intelligent technologists and binging solutions, I would say that the problem is the clinical workflows that are not paid to adopt any of those solutions. That's my two cents on this issue. Absolutely. This ties into my point. They actually facilitate what we did want to do we care and not build something that no one will use. Thank you for your comment. I am Nina [last name indiscernible]. I want to echo your comments on mobile help. I do some speaking on this. One of the examples that I use is smoking cessation. There is a smoking cessation out that is the most widely downloaded. It is used for two weeks by most people and then they never use it again. One of the things that is consistently used is the cigarette calculate a. You can put in how many times you smoke a cigarette. Then, you can work on decreasing the number of cigarettes you smoke. It also calculates how much it is costing you. Most people -- 95% -- we uses to figure out how much to budget for cigarettes. [laughter] This is not a health value. I think health apps need to be written by clinicians. That is the only way we are way to reduce the statistics on the errors and mobile applications. I think it is interesting -- there is an travel app for -- you can put in -- I need a taxi and it -- it locates where you aren't called a taxi to you. I stood on the corner yesterday waiting for a taxi and then I think I saw Bonnie and Karen waiting on another corner. Why aren't we using this app? My main point -- part of this workshop -- as a part of the planning committee -- to engage people into something after this. I am then it action and science kind of person. I need to make sure that something happens after we get all the data together. As the chair of a national work group supported by the proposed -- from oh data management -- Bonnie is already a member. I would like to invite you to join and be either some of the authors of the national standards for remote data management which is, again, everything we've talked about in your session today, or at least help us to be a reviewer for that. I will find each one of you after your session is over. Thank you. Going ahead. I am Dr. Schwalm from Boston. Wanted to ask David and some of the other panelists -- the things I've noticed is that patients are starting to aggravate themselves and identify researchers interested in studying their conditions. This is very interesting. There was a recent negative trial published that was aggravated to patients studying the effects of lithium on ALS. I am sure you are where this. What I want to ask -- two things -- number one -- what do your members, if you have a way of asking them, what do they talk about in terms of how they would like to connect with providers using technology? Are they looking for a face-to-face interactions that are geographically and physically easier for them to a call Bush because of their conditions? Are they looking to supplement their traditional interactions with easier access to answer a question weekly? Or ask a question is easy? Maybe you can tell us about what they are looking for and number two, to you think that there is a role or there will be an evolution toward patients really essentially taking over a portion of this space and being the one to decide, for example, that we won a question answered -- issuing the RFP for the research question or the other way around? There is a guy named Stephen Brand -- friend. It is a multimillion dollar nonprofit located in Seattle. One of the things he is trying to do is filled a new health comments. This includes portable legal consent -- the ability for any person to consent to a global IRB and allow their data -- the data they can a simple about themselves from the EHR and other sources to get aggregated into an open database that is been used by researchers around the globe, really, for the purposes of research. That's now? You can consent to this now and enter information into the database. Another thing is a project called Bridge. This is seeking to be a kick starter for medical research. About two people can get together and say here is the research question we are interested in -- here is the data. This is available on this website and we will give a $10,000 prize to whichever researcher can come up with a model for than the one we have today. That's happening? I don't know what the timeline is because it is very much counter to traditional research. I don't think anything that was started that way we get through. You and I don't think anything started that way would end up with a small molecule through a phase 1 clinical trial because I don't think there is a good way to aggregate enough dollars. 80 it could be used for the preliminary results in SBIR. Second question -- regarding what motivates the patients. Our patients are not normal. 99% on the site do not get any questions wrong when you ask them health literacy questions. They score perfectly on that test. The ones that get the questions wrong get one question wrong. These are people who are very engaged in their health and very engaged in health data. I wouldn't look to them as being a source for what patients want. These are people who use the Internet as part of a normal routine to seek care and seek health information. That being said, 20% of people with epilepsy that we surveyed fired their doctor. This is not uncommon. It is a year or Deb throughout the addition -- described patient communities. Patients want doctors to talk to them as though they are intelligent human beings. That is the biggest thing. Patients want doctors who allow the patient to be able to be a project been in their care. For the most part, I don't think they care if it is over the phone or over the Internet or over Skype or face-to-face. It is published. What this population once -- people with severe neurological impairments -- it is a separate set of people than the people with COPD or diabetes -- a different sort of chronic impairment. What they want is to not be treated as though they are is involved or this intermediate it from their care processes. They want the best quality information they can get. They want to have a dialogue with their providers. I don't think they care about the implementation. Can I make one comment about clinical trials? This should be interesting in this building to talk about this. Health information exchange needs to take into account the fact that somebody is enrolled in a clinical trial. The fact that someone is admitted to a particular venue for a treatment can significantly impact the course of the clinical trial and can either advance or retard clinical research. If it is not handled properly. So, one of the things that we need to be aware of is the clinical connectivity in that continuum we should be able to talk about clinical trials. The place I came from -- we had 900 clinical trials going on. Very few of the physicians in the organization where where of all of them. There is an awareness issue. But, we had to write parochial interfaces, if you will, so that every time a patient came in and varied the database of all the people enrolled in the clinical trial and would send an alert -- to the clinicians -- it had an incredible impact. To do that across boundaries is where we need to go. So, I am happy that we are talking about incremental success, but we also need to plan for some of the loftier goals that we should have as well to promote clinical research. I had to say that since I am in this building. My name is Chuck [last name indiscernible] from NASA.. This morning we heard about evidence and we now we heard about technology. Obviously, there is a lot of data out there and a lot of publications and a variety of different turtles about the good and bad about technology. My question really is regarding the adoption of technology -- this data scope and x-ray -- not a lot of peer-reviewed science proved or disapproved a lot of these tools -- telemedicine seems to go through this constant -- we need the data. Show us the data. How does this relate from a technological perspective to develop a federal policy? As I am now able to buy a smart phone that can do all of these things -- whether they are except for people use them or not, and they change every six months or so, how does federal policy change and what are some of the challenges that you see from a technological perspective with the adoption of this in healthcare? I think technology innovation will outpace or in most cases outpaced regulatory or policy innovation. There is a time. To your point, many of the technologies within Telehealth have less of a value proposition in a key for service world. For me, we need to mail the payment models. It is based -- basic economics will cause adoption. I am less worried about clinical process innovation and culture change. I think that once the right incentives are set, decentralization and empowerment within different providers systems we will figure that out. They need to get paid for this. I think from a policy of this but, this is the most important thing to figure out. If this is done and also some you look toward clarity around how innovators can get some of these solutions to the FDA process, I think these are the key levers. The rest of the stuff has to be figured out by innovative people on the ground. If you -- in 1933, telecommunications -- this did not change until 1997. From 1997 until 2012 -- you know what kind of technology we have had -- beepers to smart phones to wireless telecommunications. So, today things change so rapidly I am concerned that the government can't or is either unwilling or the process -- we haven't thought outside the box. We need to think about how we can make these changes more rapidly because technology is changing. Can I comment? Coming from ONC, I need to say that I've seen the impact. I was on the other side of the table as a CIO when the changes came in and I can tell you that I started work in a hospital that was built in 1969 without a medical records department because the founder was told that he could put a computer in a data center and have an electronic health record. So, the notion has been around for 50 years. This is an easy thing to see. The question is -- what did it take to get us to the point where we are going to do something? The truth is, the markets were not efficient and a lot of people were developing software that would not talk to other software. So, the government is the last resort when a market does not do things us officially is a good. So, I think that putting it stimulates money out did exactly what both of the prior presidents wanted to do -- to computerize the records for all Americans. In a way that it could not have done without government intervention. So, it is not that we want this to happen first, it is that we wanted to happen when other forces will let it happen. What I think you will see is that we will get to a critical mass more quickly and we are seeing this already. I think the other thing that needs to happen -- this is not what government should play a role in -- private industry should play a role -- diversities as well. That is publishing the value propositions associated with all these technologies. But, what is going to be divorcing factor that causes people to finally start to connect and elaborate? I think that is where government did have a significant impact. Part of the reason I was drawn to the office of the national coordinator is because of the work that was done that I started four years ago we started to write for electronic health records. So, I think the regulations available now are forcing interactions in a way that creates more of a commodity like use of the data and the data is the powerful driver here. Radical mass is not such a large number. It is usually defined as a square root -- the question is -- when we we have enough critical mass to -- critical mass to move forward? When we start to exchange data freely and we truly get liquid information, I think you will see the changes occur. My concern from a regulatory standpoint is called lament Rita this. -- Couple married. When I use the data from the ecosystem to make a clinical decision, the FDA has indicated that this is something they want to regulate. The standards for that regulating that sort of algorithm or application -- to me as someone who cares about mathematics it doesn't make much sense. Thank you. Paula [last name indiscernible] -- UT mentioned, San Antonio. Funny, I was especially delighted to hear what you were talking about as a vascular surgeon I have a gamut of patients to bring to me names from the Internet and say why can't I have my graphed? Versus ones that just want to be told what to do. Position as advisor versus physician as parent -- it goes through this. How do we come up with a payment system to enable us to do exactly what you have done? Owing to the patient's home and get their medications that and go to get them to their up appointments? I have a high no-show rate because they can't even get to the appointment. That, of course, will increase the cost in the long run. In the long run, it will decrease cost, but the patient that you are talking about that don't take responsibility for their own health are just more expensive to take care of, usually, then the ones that are on the website -- My comment from a policy perspective, you have to act local. For us, our number one objective is to convince Medicaid of North Carolina that a program like this would be beneficial and worth the value of reimbursing. We are close to doing that. I think from a policy perspective from the federal government, our biggest -- one of the biggest issues is that we have not done the randomized control trials. The primary reason we have not done that and are doing that now is because of the need being so urgent. From the hospital perspective, as well as from the patient perspective, I have always believed in randomized controlled trials, but in this case the hospital doesn't care about a randomized controlled trial. They are concerned about how to change the way that they deliver care so that they can exist. I think that is the biggest thing and it is going to be -- it is a great thing to get the hospitals to move and act to take care of these patients and WAP services around patients that are the most fun mobile; however, from a policy perspective, it will be difficult to have policy change because we don't have those trials. That leads into my second question. This is about research. This is also near and dear to my heart. Programs like yours could be the pilot data and preliminary data in the world of grants to that lead to exactly what you are talking about and can we somehow look -- hook up with NIH and clinical translational science programs across the country in linking some of this research exactly to that? I love the idea of a national research database. CTA -- across institution in your own CTS a -- come up with combined IR these you do not have to spend all your time processing consent issues whether than actually doing the work? Then, there is a push with the CTSA pushing for a national network that gets a lot of university research. Can we partner with that? Another government agency getting another one to talk to each other to actually forward the agenda. That is a great idea. Something I was not aware of. One of the things we were having a discussion in the state of North Carolina -- we are having a Telehealth summit on September 12. My thought is -- why can't we as a state or a region of the country start a tonic disease Consortium? -- Chronic disease Consortium? You can have the most monitoring to keep the costs down and standardization in place and have a repository of data within that state or within that region so that we would have the ability to do one IRB and bring all of the data together to have greater numbers and be able to take this to Medicare and the federal government. Great idea. I was just going to spout some heresy for a few minutes. The randomized control trial in medicine is outlined pretty well in a document that is been written. He wrote the annals of medicine in the 11th century. This is pre-calculus. We need to tell what effect a drug Mike having a population because we don't know anything about biology. We know that sometimes we give people plants and sometimes they get better. Sometimes they don't. This is experimental, fundamental things. I can put an EKG on a guy and I can get correct truth centered data what is going on in this person's physiology from the second I start an intervention until the observational. Is concluded. The data that I am sure she is collecting on the hundreds of people she is putting numerous sensors on out strips most of the data -- outstrips the density of data in this study. I would guarantee that. Yet, we look at these large studies of interview-based data of clinical follow-up based data when we have actual data from physical sensors that tell us something about the real world and we say that the actual data from the sensor that we have tells us something about the real world is less valuable than about a group of people who work carefully collected from criteria and most like engaged in a clinical trial because they were located in a proximal geographic area to the site with the clinical trial was located so they are okay to their a hospital that was getting a lot of money to do a clinical trial. As someone who is not a clinician and not a medical person and whose background is in social sciences and physics primarily, this is disgusting to me. We have good, rich centered data that we can do good math on. We don't have algebra anymore -- we have calculus. We need to live in a world where calculus exists and where supercomputing exist and stop holding the RTC to this gold standard. It is 1000 years old. I love your is the. [laughter] The randomized control trial has a place. This goes all the way from T. 1 to T. capital for research -- all the way to dissemination science and how to get positions to do at it based medicine -- why are they resistance and where the patients resistant? The randomized controlled trial is here to stay but it is only one part of the research. As technology grows and as we become smaller and smaller in the world, that is exactly what we need to do. New research techniques that will be need to do. We have time for one more question. This will be a short one with a quick answer I will direct this to [indiscernible] -- I don't know if people know that you are one of the major architects in the national broad and plan. We had a discussion yesterday about broadband in the FCC -- what do you think we need to do to make this ubiquitous? For every American in their home and facility? [captioners transitioning] Our areas of market failure and other areas where there is no market failure and at the cost of implementation and cost of building network and managing decreases more and more will get that but what you're asking around me world care healthcare program and I could not update you on what they are thinking through, but we can have a chat later maybe. All right. On time. Perfect. I want to thank our panel, this is an interesting discussion and thank you for your lively discussion and being a part of this. [Applause] And thank you to the audience on the webcast. So I just want to mention before we lose people online, people have been asking, the entire webcast will be archived on the project website forever as well as individual presentations so you'll be able to look back on the rich data that is there. We will start at 12:15 PM. Our afternoon is packed and we will do our best to stay on time. For those in person yesterday, if you are the speaker are part of the committee, we have lunch for you on the left and everyone else, the cafeteria closes that 1:45 PM today so if you want to get something to snack on, however you cannot eat it in here that you can be a the atrium to enjoy that. So thank you. Thank you very much. [IOM Telehealth Workshop is taking a lunch break and will reconvene at 12:15 p.m. EST. Captioner is standing by.] >> Good afternoon, it is 12:20 PM thank you for congregating again thank you to our web viewers as well this afternoon we have an exciting agenda and I am thrilled to be here right now on the stage with some rock stars and state policy. We have a lot about how to advance the tele-health agenda at the federal level and we heard a reference in many presentations about what date can do because so much fall under the state. They play a role with state statute regulation health reform initiative licensure, reimbursement, Medicaid, credentialing privileging in some cases and I am thrilled and honored to be here this afternoon with colleagues from the mid-Atlantic region and I want to introduce Arab Pamela, Cindy Johnson to is the director of the medical system services for the Commonwealth of Virginia and on the secretary of Bill Hazel she chairs our initial--health reform initiative that Dr. Laura Herrera chief medical officer for the Maryland Department of Health and mental hygiene and she just passed a have-they just passed a bill as well hopefully becoming more sweeping and we have Delaware's secretary of Health and Human Services, Rita, who is a champion and previously worked for AARP. The president of AARP Delora she has played a huge role it is damping services for the underserved and last but not least,--from the minority media and telecom Council there a policy group that advocates for underserved and disenfranchised and has done a lot of work in the telecom space and works closely with the national organization of Black legislative woman who have become devout visa tele-health and she will talk to us about how to advocate and engage Arab states in terms of advancing our mission. I would like to welcome Cindy jumped the podium. Good afternoon. I am privately from the Commonwealth of Virginia we call--in Virginia, the Mother Teresa of total health she has been very committed to moving us in the commercial arena as well as in Medicaid of not tele-health as an afterthought better integrated very important aspect of everything we do in terms of delivering healthcare you and I have the privilege of wearing you have to the state of Virginia the before I went to my presentation and wanted. Apparently are implementing tele-health over the years in Medicaid, I would tell you from a governors perspective, when he came into office, he realized that healthcare reform, there are lots of things to do that are beyond what was in the federal affordable care act he created an advisory group of healthcare leaders and business leaders to talk about what we could do better in Virginia and six strategic areas, payment and delivery reform, capacity access other relates to the doctors, technology Medicaid insurance and how you get players of all and moving the ball forward for value-based purchasing and as you can tell from the topic, tele-health was intertwined we talked about the payment and delivery system, fee-for-service, global payment the different models area it is a tool that people use to deliver healthcare and in terms of capacity, everyone realizes we don't have enough doctors and healthcare professionals now so what can we do to make sure, not just in rural areas that have access to competent care and healthcare professional doesn't have to be physically in the room so we talked a lot about tele-health and how that combined with team composition of doctors and can help us have more capacity for people that we serve in Virginia but the new people seeking insurance under the affordable care act and when you talk about technology, tele-health is a tool that keeps changing as time goes on. Technology in itself is wonderful and I am a generation that grew up with one TV in the house that was black and white and the remote control was a and think how far we have, now, just on television. Basically, we have been trying to do whatever we can Virginia to break down barriers for total health and I know that you have had several conversations about what works and what are some of the barriers and I am sure that Karen will work with us and tell us what we can do in our control the state level because everyone, the governor and secretary are pro-will help in terms of making sure we have the best cost effective delivery system in Virginia and as far as Medicaid is concerned we have always been interested in tele-health and that coincide with all the work that Karen has been doing because she has been in Virginia and I will fast-forward through a lot of the things because it is background but as you look at our Medicaid program, we started in 1995 which: five when she was in Virginia and that is what we call her the Mother Teresa of tele-health. We serve almost 1,000,000 people in the Medicaid program in Virginia at a budget of 8 billion. We started embracing rather than in 1995 when Al Gore invented the Internet at the same time just think how much we have grown since then it was a small pile of services and it wasn't until 2003 that we started branching out. Basically, as it has evolved, now we need to consider that and I think we will see over time, we have been talking about a fee-for-service were you have to put another modifier to make sure you're doing tele-health as we have moved to managed care in Virginia, it is under the global payment we expect people to do what they need to do to take care of the client. So in 2003 we added a list of services that you see and that was a major movement forward and then we added providers that we recognized in Virginia and other states may not have embraced telemedicine at, generally, and the Medicaid arena, want something new comes up, we have to price out how much this is going to cost them people say, it is going to cost more but it is a method of delivering services and that is how it has been embraced and convince the general assembly this is not a new service you have to price out this is another mechanism to make sure we provide access to our client. Obviously, in October 2009, we expanded with the originating site and again you can see it is an evolution, you need to allow it in your pace program, of all-inclusive care for the elderly and that make sense for those of you who are familiar this is where you combined Medicare and Medicaid and provide services that an elderly person needs centered around adult day health care. Under fee-for-service we have billing procedures for fee-for-service we have moved further away from fee-for-service we are now 70% managed care and SMS sent to different payment systems, the code is not as important. Obviously, if it has specific providers we expect them to fully comply with service documentation and billing requirement and when we do audit the extent that the future going to audit those types of things but the good thing that we were able to do, is not to follow the definition of Medicare coverage and tie it to rural area definitions even though it tends to be used in rural areas, a lot of us realize in urban areas this is a very useful method of getting services. Recently we have added some new services and these are things that were brought up in the larger arena, commercial as well as Medicaid and when we talk about healthcare reform and having a dividing line, commercial provide certain thing and Medicaid might not provide that, doesn't make sense for us we do a lot of comparisons of what we are going to do based on what is out there in the commercial areas so we added --I am not going to try to list all of these that you get to that we keep adding things with eyesight, dermatology, speech therapy, all the things that you know is important and valuable with tele-health. And this slide doesn't say much except that fee-for-service program, we haven't got much of utilization if you just look at claim but if you look at the next slide, it says some providers are not using billing modifiers , part of a larger bundle of services a lot of hospital and clinic don't record out. You get paid, it is not just broken out. We have six managed care plans that we have had five years and we survey each of the five managed care plan because we say, we will provide telemedicine think that we cover in the fee-for-service program at the very least you have to do that and they also use the fact that they have a calculated payment to go further than that in the next couple of slide is just an example of how they have used to manage care and especially for adolescent psychiatric services they have used--and you can see another managed care has over 51 telemedicine presentation side you can see that one third of starting to move better in that direction by working with Karen at the University of Virginia and a fourth one has talked about encounters are focused on aged, blind, and disabled. And another one, make sure that telemedicine is available to all and doesn't require preauthorization and what we just did in Virginia, the far southwestern Virginia hasn't had managed care and we just went there July 1 and obviously, if you look at the map, and something looks like it takes 10 min. and if you drive it it takes 45 min. to an hour around the mountain that telemedicine has been very important as we move from that area. We are still talking about several things we think will move the ball forward such as adding home health services to telemedicine, looking at how it will help someone who has just gotten out of surgery high risk pregnancy and infection and we are looking at the store and forward coverage and as I mentioned, that is particularly important for ophthalmology. Also, we just met last week. On something that Karen has asked us to look at because I have different people but give me their wish list on a regular basis and Karen is one of those only are happy to accommodate her but we're working on a Medicaid, that will deal with the out-of-state position and how they can receive reimbursement on Virginia Medicaid and unfortunately we can't just the memo there are some systems issues so that will probably not occur until the end of this year and my staff put in that cartoon. You might understand it. I didn't but I could not delete it while I was driving. So thank you. [Applause] I'm going to give a tele-health perspective from the state of Maryland and we are very similar and the number of people that we serve in a budget but on my Virginia we are late to the party and we started looking at this in 2010 as part of the quality help cost counsel which is chaired by the Lt. Gov. in the secretary of health on this is one of the initiative they took on to look at not only access to quality of care and cost implications of the committee was tasked with identifying challenges and solutions and they came up with a report that will was advanced to the next level by putting forward a task force to look deeper into the what the initial report that it was led by the Maryland healthcare commission and the Maryland Institute for emergency medical services and three advisory groups were established to develop formal recommendation and these are the three groups financial business model advisory technology solutions and standards in clinical advisory group. The finance business model group recommended the state regulated reimbursement for services to the same extent of healthcare services providing face-to-face. Technology solutions and standards wanted a network built on existing standards integrated in the statewide information exchange which has 46 hospitals reporting regularly, discharge data, radiology data, they wanted this integrated into the statewide information exchange at a minimum there should be required to related to technology connectivity. In the clinical advisory group, which centered around licensure credentialing and privileging of providers. Cannot from the finance and business model advisory group can legislation was introduced this session, there is a house built and a Senate bill that says Jay regulated private payers needed cover delivered healthcare services delivered through tele-health as they would in person private payers were not permitted to require preauthorization for tele-health services and were not required and could not limit it to rural areas. So the argument supported the bill supported it with amendment, specifically they would allow Medicaid to conduct a review and unlike other health department in the state of Maryland, six are recommended in the Department of Health the Medicare hygiene and so, local care services only supported the bill to understand what the implications were the system and basically wrote and responded that we supported that we needed to see if it would cost neutral and that was, we would cover it and this is a typo, and the year 2013 they were not cost neutral mood with the coverage in 2014 and work with the budget and the Gen. assembly to get it covered. So, we want to allow private payers to allow preauthorization for tele-out there this and until Pastore signed into law the amendment that Medicaid was available to do further analysis on the impact of the system. Pursuant to cost neutral language we decided to conduct the evidence on tele-health and we did a comprehensive analysis with information of publicly available as well as using the network available to Medicaid directors to understand what was being covered and what we found 37 states are covering hub and spoke teleconferencing, 16 states were covering store-and-forward and 15 state covered home health monitoring and only to state covered telephone and the moment we started raining out what we would cover and in addition to what we found, we also looked to the private payers in the state of Maryland, both commercial and managed care and we started researching modalities and services not only by Medicaid but private payers as well as, studies were there any modalities that stood out and we were doing this in keeping in mind Maryland efforts around implementation of the affordable care act. We have lots of things happening in the state and accountable care organizations and trying to keep that in mind Maryland just got funded 44 ACO's and they were practicing in rural areas. And working with hilltop developing a function-based, portable care act and pleaded cover tele-mental health services and originating site could come from an outpatient mental health service Hospital and it could be limited to 12 counties in addition to what we are doing now, we are something tele-mental health utilization looking to expand that further. I can tell you based on the analysis we're including everything in the assumptions from real-time interface to store-and-forward technology and home health monitoring as we think about our long-term care rebalancing effort happening in the state, we think that is going to be key. We have to report back to the Gen. assembly that we think most of the analysis will be done in the next couple of months. Thank you. [Applause] Good afternoon everyone it is a pleasure to be with you today and before I start talking about the little state of Delaware, unlike the bigger states of Maryland and Virginia, does everyone know where Delaware is? We are not a County of Pennsylvania, we are actually a date. We have less than 1 million our population the governor likes to collect a state of neighbors because we now everyone in the state of Delaware but before I go into more details I would like to applaud the effort of Dr. Reuben Delaware started to advance tele-health effort Dr. Reuben came to visit our state and gave a presentation that I happened to be present at and it really excelled the interest and the energy around, how come my gratitude goes to her for being such an ambassador and passionate about what they can do to advance better health outcomes for our population. Now, I want to talk about that moment some after Dr. Reuben met with us and Delaware we created a tele-health coalition was formed. It now has advantage over 15 members including our hospital. For larger state that doesn't sound like much but for the state of Delaware we have three counties in our state, New Castle County cosmopolitan County Dover and Sussex. Have any of you visited Sussex County? It is resort area. However, it is still fun agriculture open space, people are spread across the county and we are concerned about those counties largely because of the challenges from the medical infrastructure and it is the county many retirees are migrating to Sussex County, Washington DC and relevant to medical and the structure it is not keeping up with the pay of that demographic have only think of telemedicine and tele-health that presents itself a marvelous opportunity for us to advance our medical infrastructure for that technology. The Department of Health and social services is not the Medicaid program and Delaware Medicaid began reimbursing for telemedicine which we started July 1, 2012 of the sheer that is the start of our fiscal year we did this so that policy did not go to the Gen. assembly, we evaluated this concert was the tele-health coalition and we were able to advance that as a policy driven. Largely Delaware is supported through managed care organizations to have contracts with numerous providers and they are all able to offer telemedicine. [Applause] Thank you, I am coming down here more often and in conjunction with that he Delaware hospital and the Department of Health and social services are utilizing total psychology for crisis evaluation and again, that is an Sussex County area where indicated infrastructure is very stretched so we were able to offer that tele-psychiatry have a more robust system for psychiatric services and we did not want to transport people even though we are a small state we can travel within 20 half hours in each direction and was still not serve the population nor us from a cost-benefit perspective to put people in cars and travel to New Castle County to access the service so we do that that through tele-psychiatry. A hospital and Sussex County partners with the hospital in new Caswell County, our largest medical provider for tele-consulting services on trauma cases and otherwise those patients traumatized by accident or injury would have to take the helicopter to New Castle County for a trauma evaluation it is very safe to keep them in the hospital and Sussex County and in partnership with they were more robust--of care they are able to connect the dots of wealth of through tele-health, regardless of what Kathy you may reside in, looking with federally qualified health care centers. Read healthcare Center is an Sussex County and they received an outreach grant to provide tele-psychiatry and they're interested in advancing beyond the psychiatric support. I must tell you in addition to Dr. Reuben, we had a tremendous advocate the state I coming from an organization like AARP, the history has been an advocacy. The one that try to influence government from the outside finds herself trying to influence it from the inside and really, it is the ground that makes the difference of the pressure point from the ground government is not that quick to advance multiple issues that impact the government and you look to that quick you will on the outside and then came from Washington DC, a retiree that landed in Delaware his wife that he was diagnosed with Parkinson's disease 10 years ago and in 2008 they retired from College Park Maryland and have a second home and now they call Lewis their home. In 2009. Advocacy efforts he founded a support group of hundred 50 individuals to support individuals with Parkinson's because he found many retirees are faced with a devastating disease and were looking for care and as I said, Sussex County does not have a robust clinical support system so many support group members were saying specialist in Washington and Baltimore and Philadelphia and it was a difficult round-trip to see the doctors if you are suffering from Parkinson's disease so Dennis met with me early on I was appointed in 2009 and came to me and introduced me to Dr. Dorsey who is at John Hopkins, a neurologist and he was supporting many individuals from Suffolk County he would have to take travel to Baltimore to see specialist. And what we are doing now, we are working with federally qualified health care system Center and Dr. Dorsey to bring that telephone to Suffolk County with a specific interest in supporting individuals who are suffering from Parkinson's disease so they no longer have to do that round-trip and travel which actually, for many of them, would take them two days to recover from that travel, not a good way to promote good health care for those individuals and I credit Dennis but also Dr. Dorsey who has been phenomenal with trying to support this in our state. And then I effectively put yourself in our shoes it is a three-hour drive up there, getting part, half an hour, waiting half an hour, you get an hour appointment and it is a 10 hour to 12 hour day and that is not the best our you suffer from any type of disease , Delaware seems to be aging at a faster rate and we are ninth in states and a lot of that has to do, I would tell you a lot of that has to do with the duty of our state, but it also has to do with our tax base and people are migrating and along with that we know the people who were aging present some health issues the body tends to wear down easily take good care of it so we know that we will be impacted and again the lowermost County so it only makes sense for us to really start trying to get ahead of that paradigm shift and the most cost efficient and effective way how we can connect people to healthcare regardless if it is the best professional that we have within the state or we can expand beyond our state and connect people so we can promote the best health outcomes possible regardless of age or if you have disability. Now that doesn't, not barriers and here are some barriers that we find ourselves that the coalition continues to dedicate effort to address distant site providers must be licensed in Delaware. I must tell you to get a license and Delaware is not the easiest thing to go through. So in a sister department,, the Secretary of State, what I do with a chief medical position, a secretary within my department, and they are working hand-in-hand with the secretary of state to streamline that process because we have a series of workforce development issue. The last people to the licensing problem and we don't want that to happen. It is not in the best interest so I dedicated the position to work closely with the sister organization look at how we streamline that process and technology has not been widely adopted. I am sorry to say, if they bring Dr. Reuben back into state because she is very effective at doing that. Some people are very skeptical. Any--with Medicare reimbursement we can show evidence of a good outcome that the cost is not prohibitive and that we can advance this through the whole system and many patients aren't comfortable saying it provided this way I must tell you that they have to drive three hours to see them they're going to get pretty comfortable pretty quick and many individuals are in the rural areas of Delaware because start talking about transportation which is also extremely challenged several people who had nothing, visit the a tremendous gift for them and hospital that practitioners. As a revenue stream however that is reimbursable they won't see it as a threat they will see it as advancement of ability to serve a population. They're bringing hospital for primary care doctors and to the coalition and it was strictly a lot of the grass-roots advocates, state, we have to branch out for a private sector. And with collaboration brings cooperation and we will be working together and hospitals are coming on board and application including at home uses for Delaware's aging population and the state underserved rural areas and we can use the data evidence they practices that we will be able to dance some cosmopolitan area we are creating a website for the coalition and people can get access to the website with additional information I believe it also brings additional advancement and what we want to do at stateside is to begin utilizing tele-health of the means to manage chronic care conditions as supported by the affordable care act so it thank you very much for spending time with me today and come and visit us the Delaware. [Applause] Thank you everyone. I am the chief operating officer of minority media and telecommunications Council and I am pleased to be here today representing the national organization black elected legislative women also known as the noble women, and MPC as I can talk about our organization first we have been around for 25 years we are a leader in media telecommunications policy and advocacy for a minority and underserved communities and we started advocating for minority ownership and diversity and that we have expanded into broadband adoption advocacy and telecommunications policy that are designed to deal with issues with the people who don't necessarily have iPad, I thought, three Air Force not--smart phones like some of our colleagues. We have worked with the Nobel women. On a number of preceding such as the open Internet preceding universal service reform, lifeline service, any kind of issues doing with low income family we have an interactive of the national broadband plan and adoption him minority media ownership policies. Our chair, Julia Johnson, I am sitting in for today is an advisor to Nobel women on telecommunication policy issues and the Nobel president served on our advisory board so it is not exactly interlocking directorate, that is a good collaboration with the Nobel women and only publish white papers if you look on our website you will see white papers on broadband adoption, minorities in high tech area, we tweak each other, we comment on stuff and we collaborate to try to get information out that is directed toward underserved communities. They have partnered on a number of registry --regulatory policies that marathon a lot of discussion about the broadband plan and yesterday and today, we have worked on that to try to achieve 98% broadband adoption by 2015 is our president wants us to do and to create jobs and business opportunities and work with spectrum, exhaust, Nobel, wireless smartphone adoption of the way we look at telemedicine, we view it as actually an overuse of the word, game changer, this is an urban areas and rural areas and the underserved area is not that big of a difference between the underserved communities in rural and urban, a lot of the disparities come from a lack of access or representation of whatever it may be from grocery stores to food side to healthcare practitioners. This is a lot of things in common and just to tell you things in detail about the Nobel women there am I the group of 255 members of state legislators current and former and 39 states and they were to communicate the legal social political economic and health needs of children women and families and we work with them and advocate on behalf of issues and telecommunications at the local state and federal level than at the White House Federal Communications Commission Federal Trade Commission, House and Senate. What we want to talk about today, Nobel model telemedicine legislation which is launched last year but a formal launch occurred last month in Washington and if I can give them a shout out, she has been an advisor to Nobel and indirectly as we're learning telecommunications telemedicine along with Nobel women and it is an opportunity there is an opportunity for a widespread advocacy in telemedicine, much of what we have done in broadband adoption and on the model legislation, primarily the same as American telemedicine Association legislation that is focused on trying to require private mandates to be the same for in person and telemedicine coverage but what the Nobel women do is also focused on extending Medicaid coverage and medicine legislation. The highlights of the Nobel women model legislation is to require a coverage of telemedicine, expand the definition and in some cases define it to include A/V another telecommunications Tech knowledge he had a site other than where the patient is located and videoconferencing, patient monitoring, to require any denial of coverage is the subject to review procedures. And the Medicaid plan can deny coverage if they would cover in person consultation and it would require statewide medical assistance benefits of the health home for individuals with chronic conditions and that is something that Novell has taken not because of their interest in serving women and family, there are a lot of conditions, chronic conditions within minority communities that were over indexing and heart disease and diabetes 20% of African-Americans over 30 are being diagnosed with diabetes and there is a whole host of problems in the minority underserved communities that can be addressed, we think through telemedicine. One of the other big thing that Nobel is interested in is trying to do a the 56 million Americans who are racial athletic role Americans to our without a primary care physician and I can't imagine that because I feel for the years that I have been in Washington my primary care physician and I are on a first name basis and I can remember calling her when I was on vacation for an emergency and it is hard for some of us to imagine this but a lot of people don't have access to a primary care physician. I live in an area of Washington that doesn't have any that I have seen, doctors offices and primarily it is composed of the urgent care and it is great to have urgent care providers but there are a lot of urgent care providers and nighttime pediatrics providers is an issue that is important that often by work of the policy areas we don't really recognize because they now live in areas where there are food and medical care. This is something that Nobel is very much interested in trying to deal with those kinds of disparities and trying to bridge some of the healthcare gap. We believe that telemedicine is in game changer and critical and the care Are caused by financial issues transportation and we are talking about personal transportation and public transportation barriers along with the insufficient primary care resources and this is something that exists in the rural areas most states provide coverage of medicine but this varies widely at one of the things that Novell wants to do is work on establishing equal--Novell want to establish an equal playing field and last month the big launch with the help of Karen in a number of other advisors Novell decided that we are going to expand telemedicine legislation to every state where there is Nobel women currently 39 states it is growing every day as we are being elected and getting more involved in solving the issues in their communities not an extension action plan for each state one of the things we have noticed, in many cases, telemedicine is covered and it is something that is a matter of pulling am bringing in legislation to the attention of the state secretary of health and how things work on the ground to get the state secretary of health to clarify that this medicine is covered with physician services. Novell is going to drive the model was placement, state-by-state basis hosting roundtables, being on panels, increasing awareness, identifying key stakeholder organizations and groups for partnering and collaborating of this will be done on both a federal and they state basis and the overall strategy, stateside is going to look at things like health home for chronic care high-risk pregnancies stroke diagnosis and rehabilitation patient monitoring for chronic care mental health counseling stool-based health services speech and hearing, Medicare level coverage for underserved areas safety net could lack the facilities and also looking into coverage for state employees. Then the strategy on the federal level will be advocating for federal legislation for improving Medicare coverage for urban beneficiaries,-based services, store and forward kinds of tele-health in urban and rule areas and payment and services nationwide portability for healthcare professional licenses which brings us to the issue of an issue related to this but they have gotten involved in, licensure of practitioners resolution tele-health licensure resolution was passed on June 22 at the legislative, and Baltimore have basically this is what you have been hearing about for the past couple of days a need for a framework so doctors and medical providers don't have to get Mr. Graham --and we celebrate with victory in Maryland, two of the NOBEL women were actively involved in passage of the registration and Sen. Katherine. I delegate to the money, women of color, were very actively and vaulting getting the Maryland legislation signed on May 22 and I guess I don't need to go into that because we have a real-life representative here but we're looking forward to taking the package, the model legislation and representation and almost all 50 states the taking that show on the road getting involved with those of you in the room, those involved in coalitions and other state and basically looking at it, you don't have to reinvent the wheel, we are prepared, we have representatives in the legislature but it is something that women can do alone is something we will have to do a collaboration with those of us in the relevant those of us not in the room food and you to go from state to state and down the street on the hell and we will be involved in federal advocacy with the Federal Communications Commission with the Federal Communications Commission-the commissioners and on the state advocacy with community advocates and policymakers and on the media side with press releases, media placement, politics 365 of the media place values on a regular basis and also broadband of social justice Huffington Post, and a number of other areas where we plan to have four 2013 a full-scale national campaign for telemedicine and we want to have everyone in this room, Web involved with us. Thank you. [Applause] Thanks to each of our panelists, you have been an advocate at the state level and great things are coming in Maryland and you made Delaware the little engine that could and the Nobel women-fantastic and we are very cross fertilized in terms of advancing our mission together. I would love to open the for questions of our panelists about how we can advance further at the state level. Stuart? I want to congratulate you, you are a powerful force, the great what you're doing at the state level and what you are doing, you guys are heroes, on behalf of--and Telehealth, saying what you have done a spectacular work with the American telemedicine Association working with NOBEL women and that is a great effort has so many states under the spotlight right now that is a great effort. I have two questions and they're directed at Marilyn and Laura and you're talking about doing a cost neutrality study and I think you're going to have that work done by December so my first question is, I would be very interested in learning what you learn about that process and will that report we available at the detailed level? Yes, with the public. Available once it is released to the general assembly and will be detailed not only having looked at all 50 states that what they're doing but what the literature, the VA, health services, we are looking at everyone. Connect fantastic and my second question, you had one sentence three talked about being required to integrate with the health information exchange and I was curious if you could explain what the intent and desired functionality of that would be. Connect to the point about record-keeping of the encounter and having incorporated into the patient record the way we are trying to include all of the other wreck or the right now we are getting information from hospitals that we are ultimately looking to expand that around the for accountable care organizations and I need tele-health encounters that would happen under those umbrellas for lack of a better description, we want that data included in the health information exchange. Thank you very much, congratulations, you guys are amazing. We talked about the value proposition in each state is different in terms of looking at the value proposition. I know Virginia Medicaid that millions and millions of dollars on transportation, are they going to be looking at the cost savings as part of the value proposition as well? Were definitely looking for cross saving them back to the affordable care act there are initiative around utilization and admission and presenting the access point for healthcare system will be built into the list of assumptions and at the hilltop, we will be doing the modeling and we are looking for everything not just limiting ourselves to real-time interface, we are looking at store and forward and balancing the efforts of going to be key to how that plays out. Thanks. I am the director of Telehealth business at the clinic and was confident and I really need to reiterate Stuart,. You ladies are amazing. Justin your vision and in your actual presence and I feel like I can go and change the world and people ask me to change the world because I am usually described that way so thank you for being mentor stuff. I have two questions and I think it is the secretary Linda Graff, one of the flies you have without barriers and yesterday we had a lot of assumptions of public policy is built upon and that drives us crazy because we know different, those of us doing the work, I was wondering, because those barriers, I don't see them in my program or in many programs I work with to get it started so I am wondering, not that I'm questioning it, but what evidence was there that led to be on your list of barriers and my other question is how can we get involved with NOBEL women and help you do what you are doing even if it is not--we have good reimbursement because the state came to me and said, can you write a reimbursement policy? Of course I did that is probably as I could but I would love to the engaged somehow with your organization and helping you get the work done that need to be done. Thank you. Thank you for your question, relative to barriers, that came out as part of the work of the coalition so it came out through the grassroots that they were identifying command the secretary, we are trying to advance and some significant barriers and licensure issue for the doctors was one that came up as the highlighted line and that is the one that we are focused on how we can advance that and the other one, it is interesting because the technology is the access when I think of Delaware, we are very stretchy from a workforce development perspective and some people are threatened by this use of technology, some people in the medical field are threatened by this technology and we had to get to the point, the usage of nurse practitioners because you have primary care physicians to trying to advance that people were threatened by it and some of it is a mind that not necessarily policy driven and we have a body called the healthcare commission and the state of Delaware. I have the Commissioner but it is made up of public sector and private sector and reopen that the public is very engaged and we offer you that the will to educate the public on these issues because most of it is a mess and somehow they become factual the how do you dispel the myth? You have to concentrate and educate and for whatever reason the use of tell help people think it is dumbing down medicine and a is then, just before it additional access to some of the best medicine out there so that is where those barriers are but we are committed to engaging broader stakeholder network to come across those barriers and I did say something that they were able to do but I also believe strongly that we need to codify this as a legislative issue, as a state law because this administration came in and said it was something we wanted to advance put under policy anybody can come in and take that away so I really want to leap. And then of healthcare reform and the affordable care act, this HP modified. On behalf of the Bolan, thank you for asking that question because first of all, if anyone is interested, you can look at these, Novell.woman.org the--we have representative and we have a whole strategy that we can put together in your state and Karen was very active in the strategy in Maryland which I understood. It went nominally well with Sen. Pugh and representative Lee and working through the legislature and we are interesting in partnering with anyone in this area because the NOBEL women are interested in these issues and women in the position of head of household, you can look us up on the website and I can give you my personal information to connect to. Thank you. My name is Amy from UNC Chapel Hill. North Carolina is just beginning to move forward in a collaborative fashion to advance Telehealth. Not just on our local level but on the state level and I really appreciate you being so informative because now I know where to get information that we need. The might question, Wally are trying to serve, rural communities, minority communities, aging communities, chronic disease populations, we are looking at other populations such as the Department of Corrections and I went to know if that is something you have also ruled that in addition to the population you are speaking about. If you have cost recovery models and cost saving model that would be able to be shared. In the Commonwealth of--Virginia, there is a very important element of healthcare delivery to Virginia prisoners and it is managed by a different secretary, that is where it is managed and it is done and there are correctional programs around the country and certainly patients deserve high quality care as well and has been a very successful tool at the University of--, a lot of University, Texas there is a large one there a lot of food be happy to share. And of course, they would pay for transportation and security and patient for traveling. I look forward to the Medicaid data and my final question, to out onto his, do you foresee developing plans to engage with providers to develop more interest to get the usage and the providing of telemedicine services of, you mentioned the numbers are pretty low. There are John Hopkins and University of Maryland doing a fair amount of Telehealth and they have their own Telehealth departments and they are engaged in all these different advisory committees and providing subject matter expertise from equipment to standards of care and I think they have been working with ATA on standards as well so this was not just done by the department, there were lots of people engaged in this process to get us where we are now that is the same people in the original task force and they continue to move the initiative forward. Education and training will be part of that either Medicaid says we will go forward educating our providers and that is certainly built into the strategic plan to move Telehealth forward. Thank you. [Captioners transitioning] One of our colleagues was a physician from Australia who led the medical expeditions to Antarctica for decades. His emphasis as he looked at telemedicine is that it has been around ever since. Ever since medicine is been around, essentially, it is the way to go about doing it. He saw in many cases, again, both wanted to bring in technologies to austere environments and having technology failures Oregon affiliate to embrace or lack of training, etc. I wonder -- are you dealing with these embracement issues or technology -- bringing the right technology and in a stepwise fashioned -- by saying do you have a phone? Can you utilize the telephone? Certainly, all of us are accustomed to this and not terribly fearful of telephones -- dumb phones -- smartphones may be intimidating. If there is a fashion to bring people into the environment stepwise even though it is not the latest and most sophisticated technology? >> I think one of the things that we do is we get carried away with technology and we don't step back and realize that there are some significant areas of the state that can't get the Internet. What we did -- the secretary of technology did a comprehensive survey of all of the healthcare providers in Virginia to find out what their disabilities were, not just for telehealth but for electronic health records. We found some significant black holes and now there is a push to provide -- close the black holes as far as the Internet is concerned and to provide funding to get people up to where they need to be in order to communicate a laconically. -- Electronically. On a personal level, I was saying this earlier -- I volunteered with Indian health services years ago. I was in Alaska North of the Arctic Circle using telehealth equipment more than 14 years ago. So, I thought it was incredible in action. Now to be in a state where we hardly have any telehealth, it is hard to at people engaged. To the point about even something as basic as a phone, I think that reimbursement will be the issue. I think it was said earlier in the last panel -- providers want to do all they can to deliver and be accessible and deliver holiday care, but if they are not reimbursed for it, with all of the competing priorities of the clinicians time, it is just not going to happen. So, I think we are certainly looking to these other technologies. If there is a way to reimbursed for using something other than the three big groups of that we typically think of. She brings up a great point about the reimbursement. If you think about the sustainability, you are going to need the reimbursement component. I think we also have to think creatively relative to the barriers for it may be people will not be able to access within their home in a given time, but then, can we work with the retail market. Some of the pharmacies want to be able to provide this service or get the level of access, so I think that the more that there is a coalition and the more engagement between the private and public sector, I think the reality of this is quite feasible. There was one time -- history repeats itself -- maybe it gets more sophisticated along the way. Now we are talking about patients that are in medical homes. It used to be the norm that primary care physicians did home visits. That is coming back again. It can come back by person to person or it can come back through telehealth. That is -- your question gets directly on the advocacy work that Nobel women have been involved in the past several years. We have gone out really big on broadband adoption because what we learned is that a lot of -- approximately 35% of women are non-high-speed Internet users. They don't have it on. The same with minorities -- there is a lot of overlapping in terms of income, gender, ethnicity, and all of these studies were done that dealt with the issue of pay. The FCC has worked on this in terms of the universal service fund in making it available for high-speed Internet and not just for land line telephone. We have worked on the issue of providing packages so that people can have low-cost computers. We found out this was another barrier. People do not have I speed Internet at home because at first of all they have to buy it in a cannot pay for it. Then, you have to buy a computer. One of the things that surfaced was that an equal barrier or maybe higher barrier is the lack of informed use. People don't understand technology. It is over their heads and they don't know how to use it. Your point is well taken. I think that is sort of a prerequisite to rolling out telemedicine the way we might really want to do that. My grandmother is on Skype now. [laughter]. By the time she is ready for something, she will be ready to see her doctor on TV or on her cell phone. Thank you. One last question. Bill? My name is Bill Applegate. I was impressed with the presentation. You have advanced things in telemedicine. I think that the secretary talked about taking home care -- maybe this is for you and for Cindy who still has 30% that are before service. When you take this telehealth to a new dimension which is really managing chronic diseases and things like that, what are your expectations? What kinds of plans do you have for deploying something? You have had to experience -- what are your expectations? The experience has not been that robust yet. But, I think from the chronic care disease management site, I actually have an opportunity to meet monthly with my managed care organizations. They are a significant partner with us under the Medicaid program. While we have noticed is the traditional tonic care disease management is not actually producing the outcomes that we want. So, we are looking at in concert with the NCOs -- what we can bring to the table and really look at who are my high cost drivers and looking at that data and looking at some methodologies that we can put into play that -- evaluate that in real time as we are doing it to see if we are at and getting a benefit. That is where I see telehealth as playing a significant role in that. So, maybe not rolling it out to the whole population initially, but looking at my most high cost people that have chronic care disease within my Medicaid a population and doing pilots to focus on this that I can tweak as I go to develop access to that through the use of telehealth. In Virginia, like many states, the 30% outside of managed care are our most costly. The people receiving long-term care services is as well as behavioral health. We are one state that is working with CMS to try to do a dual eligible project. When we talk about telehealth and how it plays into care coordination, four hour populations, in the RFP or the contract, we always describe that we expect to telehealth to be used. What we need to do is step back and say -- how directive are we going to be? To believe that to be -- leave that to the companies with experience? We probably need to have a little bit of both. We don't want to tie people's hands. As soon as you say you have to do it a certain way, six months later it changes. We want to make sure that whatever care coordination umbrella we have -- this allows telehealth to grow naturally and how it should. Let's a car panelists for their vision. That was a great session. [applause] >> Ready for the next session? >> Good afternoon. It is nice to be with you again this afternoon. Our panel this afternoon focuses on the recent cutting edge work of several of our major federal healthcare organizations and agencies, specifically the Veterans Administration and Indian health service. In that regard we are fortunate to have Dr. Adam Darkins who leave the telehealth initiative for the VA. Bringing to that effortt a breath of experience both intellectually as well as programmatically. This is from his work internationally. Were also joined this afternoon by Mark Carroll Dr. who recently left her -- left after a full decade of work with IHS to join the Flagstaff medical Center. He is there to direct their program in population innovation. Among his roles in the IHS, Dr. Carol led the planning and conceptualization of the telehealth initiatives nationwide for the Indian health services. Last but not least, we are joined by Dr. Jay Shore, an associate professor at the University of Colorado in Denver. Centers for American Indian and Alaskan native health. He is also employed by the DOT telemedicine and advanced research Center. He is also working for the be a -- VA in the native domain of rural health resource Center. This is a unique opportunity to have the perspective of two federal agencies which work independently of one another for the most part, but have formal agreements. This dictates the ways and encourages the manner in which they should work cooperatively to serve the veterans of mutual interest. Dr. Shores work is at the interface of those two things in the application of such efforts in attempting to bridge on an operational basis such a memorandum of agreement. So, today's panel is intended to provide us with greater insight into these organizations and their approach and current thinking and future challenges with respect to the role of telehealth in their specific enterprises and also to begin to highlight for us some of the challenges and opportunities emerging with respect to collaboration across federal agencies and in-service a particular segment of our population. We will begin with Dr. darkens -- Dr. Darkins Dr. Good afternoon. I am glad to be here. For one second, I will start with a couple of personal notes. I first got involved with telehealth back in the mid-1990s. I worked for a startup help your organization. The reason was that it was a way to solve problems. So, I will talk to you with that perspective. I also was involved with a startup technology company around the same time and one of the things that became clear to me at the time -- the future of this area of telehealth was going to solve problems -- developing large networks. By the definition of telehealth, institution of medicine definition -- we have had a network that is been around for over a century -- the telephone network. I want to do that if you look at the experience with that, all that is currently being talked about is going to happen. It is not a pass question of whether it will happen, the way of technology is that it will be ubiquitous and people will use it. Is not whether it will happen it is how it will happen. So, I feel privileged, indeed, to work for the organization -- the department of Veterans Affairs. I will describe the work of many individuals over years. It is building on things to take us there. First, just to describe quickly what I mean by telehealth in terms of what we talk about today. I won't go into detail, but home telephone, video telehealth, store and forward, tell it over and yelled he secure messaging, and mobile health are all elements of this. Slides are available if you want to go into more detail. What I will talk today is about three elements of this -- the clinical video telehealth and store and forward and hold telehealth. One of the things from my point of view is that this has to be based on a demonstrable need. For my decision, it makes sense to do this and focus on the battery delivering care and looking forward into the future of service that will be done, but very much around the results. The organization has introduced telehealth not because of an interest in this, but primarily an interest in providing care to a population of veterans. First, home Telehealth. Many in the audience are familiar with this. From the point of view of the VA, the value in delivering home Telehealth is, as you have heard, dealing with people with chronic conditions. There is no evidence that dealing with long-term chronic conditions, the traditional clinic is the most effective way to do this. We have introduced non-institutional care in keeping people out of nursing homes and chronic here management for expensive patients and acute care management, health promotion, and disease prevention. We use off-the-shelf technologies and have a dedicated national telehealth training center. I will talk about the staff. Standardized this is processes -- essentially, what I talk about developing large networks am a a need to have standards and interoperability. We currently are providing care to just over 74,000 people as you sit here and I am standing. The growth, I can show you from fiscal year 2008. This is at any point in time -- it is the amount of patience being managed. We built up from originally in 2003 -- we started off at around 800 patients. We plan to be at around 92,000 by the end of next year. Second program I will talk to you about is store and forward Telehealth. This again -- the main areas that we do this for our or imaging for diabetic retinopathy and four tell it or mythology. -- Tele dermatology. In this population, the 5.6 million veterans -- around 20% have diabetes. Screening for diabetic retinopathy is a way to avoid -- prevent avoidable blindness. There's a large population for this. The many organizations in rural areas have difficulty finding dermatology services. So, Tele or mythology makes sense with this structure in place. We are exploring how to move forward into wound care. To give you a sense of how this is grown from 2005 we started off at around 1500 patients. We grew 227,000 by fiscal year 2008. This year, 171,000 last year and at the end of this year we plan to be at 256,000 patients being managed. The third area is clinical video telehealth. Replicating a face-to-face visit. This face-to-face visit enables them to see some of without travel. We have done this for mental health which I will cover in a moment. We have a large dedicated national hell network at which is been built over the last several years. There are now 4000 video endpoints in the VA and each is connected with each other by IP video. We are also extending this to IP video into the home and spread out -- this is an example of how these areas are converging. I am talking about three of them separately, but they are actively converging as we go forward. Fiscal year 2008 -- 93,000 patients received care in this manner. This year it will be 200,000. This year it will be at 308,000. At this moment in time, the programs are roughly doubling every 12 months. Let me drill down more of what these are. The clinical video telehealth services -- this is a large population with mental health problems to deal with as you are all aware. Tell a cardiology and neurology and women's telehealth and primary care and spinal cord imaging and audiology and pathology and moving forward as in the last year with Tele ICU. Home Telehealth -- the care of manage that up chronic conditions and also moving forward to do disease prevention particularly in weight production. Store-and-forward -- retinal imaging and Tele dermatology and Tele would care. The VA is recognized as a national leader in this. We provided care for more than 150 VA medical centers and outpatient clinics to 380,000 patients. The reasons for doing telehealth art to produce cost and increasing quality and improving access. 47% of the patients who were served by these programs are in rural areas or 3% are in highly rural areas. This is one of the reasons to do this. One of the things I heard yesterday was a discussion around whether urban versus rural -- being a simpleminded soul and talking about networks, your resources to provide care in rural areas come from urban areas. To my mind, it is not a question of one versus the other. If you are developing a large network, you can serve the rural network from urban resources. This is about a large network. As we move forward this year, we plan to have 480,000 veterans turn this year which is 9% of the veteran population who have been served in some way by these three programs. Next year, in fiscal year 2013, that number will rise to 820,000 which is 15%. There are benefits of the organization -- we have talked about this. Access in rural areas. We have routine outcome data which we collect on these pages being provided. For the home Telehealth programs, we are seeing a reduction in bed days of care of 53%. These are assessed -- these are not just patients who get technology, they are assessed in terms of need for an honest digital care by their ADLs and IDL's and also for chronic care management. The clinical video Telehealth -- we have data for mental health cares that shows we are reducing bed days of care in the order of 25%. Home Telehealth -- we get 80% -- 86% in satisfaction. It varies from year to year, but we are in the mid-80s to low 90s. Store and forward Telehealth -- we have a 92% score for satisfaction and we are just instituting the program into the video Telehealth. We are finding that we get 34.45 that we get $34.45 of savings for consultation and 38 or video Telehealth and also for store-and-forward. We have seen in previous years $1238 in savings for home Telehealth per year and next year in -- this was in 2010 -- these were savings above all of the costs of the program factored in. Just to drill down in mental health -- last year, 55,000 Tele mental health video patients and 140,000 Tele mental health visits were provided for 146 hospitals to 531 community-based outpatient clinics. 442 patients received care by video into the home and home tele-mental health patients for PTSD, depression, -- 6764. Outcomes related to this -- the study looking at 2006 through 2010 of the video based services -- a 25% reduction in the location for the patients who had been managed in that time. Home Telehealth -- looking at the 1041 mental health patients reviewed before and after enrollment in the program in 2011, we saw that we were getting a 70% reduction. 3262 bed days of care saved I using this program. Some unique challenges which are not unique to us but you need to Telehealth -- training is not offered in medical school or included in the health pressure will curriculum. Know outside resources to train VA and providers on the kind of skill we are talking about. There are more than 60 requirements to establish a Telehealth program. So, the devil is in the detail. The vision of this is called located, but relatively easy and devil is how to make it happen. 60 requirements need to be done for an average program to be put out. Joint commission does not survey telehealth specifically, but during the trace methodology, we are now doing such volumes that it is coming across Telehealth all the time, so it is important to end up thinking about joint commission inspections. We have three Telehealth training centers that were developed to provide standardized training. The quality measure team does reviews us each one of these things -- the VISN. We have national databases so that routine data is provided locally to substantiate board these local centers and the benefits to these sites to have these services. We have national contracts and contract support for Telehealth technology including service and warranty and to ensure equipment quality and safety. We collaborate with national clinical experts to provide standards for care to Telehealth and guidance. Lastly, as in the program will tell you a big piece is how one deals with the permission technology and biomedical engineering to be able to make sure that this copy of the recovers the services. Our training -- good training at the right place at the right time it goes with the care. In terms of a large network, this is important that people are trained in a systematic way and we have a high turnover, not because people come into the program and they want to leave, but one of the rewarding things about all of these programs is that quite a number of people come to the into their programs at the end of their career in the VA. To have them say this is the best job they have ever had in that is why they came into healthcare, is one of the many gratifying things about having this program. The emphasis is on virtual training and strategic partnerships with the employee education system and all annual strategic plan for the areas we are talking about. I won't go through this in detail other than to say that we successfully plan to deploy managed health programs and we organize clinical technical and business infrastructures. We assess programs to identify clinical needs that Telehealth can address. We improve and expand the delivery of care by Telehealth to ensure that it is has quality and it is sustainable. Some data -- through this fiscal year, FY 12 -- in the third quarter, we had 150 training courses or forms available from precise. The clinical video Telehealth has done 2500 unique staff training for 800 training event. Store and forward national training center -- 3200 unique staff trained by 250 training event. And, home Telehealth 2500 staff saw 800 training event. 90% is done virtually. There is no point in having to pull something from Montana down to Denver or fly them to a national center to train so we have three centers in the collaborate and they have slightly distinct areas, but they are converging in terms of what they are doing much as the technology is. Some of the training innovations -- little practice forms, integrated Telehealth receptor programs, interactive meeting rooms, new and improved methods of training, test out options for super users, video used to capture the human Elliman, scenario-based instruction, and rapid response training. I will finish on this note -- when I was a medical student I went to southern island I was taught by a professor of surgery and he came back at the end of being a broad and we did round and at the end he said to me did you notice I touched every patient? He washed his hands -- no patient should ever made to feel that he is untouchable. One of the lessons I got is that is important to touch patients. I started with the telephone -- this is going to happen one way or another. It's be his usual of how it will happen both in terms of the technology and otherwise. I would also -- the great challenges how it will talk to the patients to make it work. I feel privileged to do what I do because I work with people for whom this is there mission -- making a big make it a difference to the veterans. Thank you for listening. [applause] Thank you for the opportunity to be here. While I work for the IHS service for 20 years, my comments do not miss early labor for those of the agencies. Difficult crossing -- the infusion of Telehealth innovation. This is from the 19th century and this captures some of the difficulty for me. We could spend some time looking at who the actors are here and metaphorically relating that to the current situation, but I will not dwell on that because I am interested on what's on the other side for where those folks were trying to go? When I think about the workshop we are having, entitled the role of Telehealth in the evolving healthcare in private -- I would have this question -- where we tried to go? I believe that we would all agree that the widespread adoption of Telehealth is an important and major goal and we have tried this in different ways. We tried it the noble stealth nighttime way with reimbursement across the country -- a.k.a. Washington on Christmas night of 1776. We have also been trying it this way -- the follow, hold, and try to edge ourselves across the bar moving from where we have been to where we want to go. An issue comes up, obviously -- why is this crossing so difficult? Are requesting the way we should? Well, there are many answers to this we have seen over the past 15 years. The current answer -- the no-brainer -- it is about reimbursement. Telehealth payment should be equivalent to in person care. We have heard this multiple times. I would remind myself and many of you would agree that the widespread adoption of Telehealth isn't really our goal -- these ideas -- quality is our goal. This is casual asides -- conceptualized by the AAA. It is not about the Kazakh -- the care and the cost, but about population health. The question I like to ask -- how can Telehealth innovation help achieve the AAA in? -- AAA and? In nature we talk about leapfrogging -- but in nature they have sticky things and they can move from one thing to another with grace and ease. Or it could be like other types of crossings where a lot of money and good planning and very careful engineering gets us from one side to the other. It is more like this. It is more confusing. It is more difficult for us to know what it is we are trying to cross. The IHS in this country does not help all of these highways, but it has its own confusing conundrums that are similar in terms of crossings. These are applied whether they are in environment in Alaska or warmer environments in Arizona. By the way, in all of those photos, those were patient homes that were there. The Indian healthcare system is a system of 600+ facilities and some hospitals a lot of outpatient facilities. Some full-time and part-time across the country. I would call your attention to two key parts on this slide. The arrow points to the travel components -- over half of Indian health system in this country is under tribal self-governance. So, partnerships and collaborations are going to call and tribal governance is an important part of that. The other thing is that this is not about rural -- it is mainly rural, but Indian healthcare occurs in urban environments. There are some urban facilities both that are fully funded as well as some of the hospitals. Really importantly and this is the differentiating point -- for all those of facilities, over half of the app running budget of most both facilities, from third-party billing. So, business models matter. This as noted yesterday -- Telehealth is not new for Indian health. This is a picture of the band from the project from the 70s which was an interesting collaboration. This applied some of the same basic precepts of care that we are talking about today. Since that time and really in recent decades, we have embraced a lot of new tools. On the way to having new service models, -- I will not go through these listed here, but the service model is key and there are not really new service models except for radiology which I will remove. There are a virgin service models. This is the challenge I would like to discuss. One model does not fit all. It is not do this for many organizations were for us. Some of the models are driven by necessity. Dr. Andy [last name indiscernible] who works at the NIH -- he was working in the Southwest at IHS and he worked for the Sunni healthcare system. They did not have a nephrologist. And he was willing to embrace this. Many of the models for these new services rely on new partnerships -- partnership that we may not be accustomed to. Yesterday we heard about the county where I am from in northern Arizona -- the second-largest county in the US -- and county larger than nine stays with one regional referral center. It sits adjacent to the Navajo nation and Hopi nation. New service models require new partnerships and we are working on those right now in shared models with people in the region for sky a tree and other services. Some models at every robust efficiencies. This is a great slide from Stuart Ferguson looking at the speed of her plight work is done in store and forward consultation across the state of Alaska. I don't have time to go into this, but it shows dramatic improvements in efficiencies. >> In some parts of our system, however, those efficiencies cannot be reached because the models are not integrated into the care systems. This depicts the care approach and the culturally appropriate cycle in the unit on the Navajo reservation. New types of innovation do not work in this type of model and addiction are not easily integrated. Many models require new commitments. We have run tele-nutrition services from northern Arizona for Indian health sites in multiple states. That commit was there for four years and we did thousands of interactions. This commitment recently went away. The ability to continue with that model did with it. Most models don't happen without a lot of effort. The IHS has its own apology program for right now though the -- what knowledge he screen. -- Written knowledge he screen. The actual care and screening is better when in person. You can look at the slope of the uptake -- over 12 years, while we have made significant inroads, it has taken a while and we are only finally perhaps reaching the inflection point. Unfortunately, screening of eyes across the Indian health has improved, but they still have a lot of room for improvement. I read a book called Diffusion of Innovation. There are still lot of lessons for us. These are things that are not new. They may not be new -- we know that many care models using Telehealth innovation do not diffuse the same way. Yet, we still talk about Telehealth innovation in these buckets of tools and how we can consider their use real-time store and forward and remote monitoring. I would ask that we consider especially looking at diffusion of new stratification. We can consider innovation that status five in two -- integrate better into the vaginal models of care that is a require fundamental process and payment change. Radiology perhaps as an example of that. There is innovation requiring important button on fundamental change within certain systems in the US. Some specialty care in organizations such as Kaiser or VA is representative of this. There iss Telehealth innovation and a lot of what we have been discussing the last two days -- this requires fundamental change especially for open systems -- systems that are collaborative in nature and not a particular organizations. Chronic care organization -- after hospital discharge -- I believe this falls into this category. I would like to wander in front of you carefully with the next thought -- Telehealth enabled care is not necessarily the same as in person care. It shouldn't be. Because it is different and the innovations are different with different care model, we should not expect that it would be reimbursed in the same way. I don't think we have done our job in working with new models of reimbursement. As I have noted, in some care models, there is no in person option. I think that reimbursing the same way across video makes sense. For some care models, Telehealth innovation does not add value. If the care model doesn't change, enter a new tool will not bring value and there are a lot of examples of that. For certain care models it may be just as good as conventional care and there is growing literature on this. Importantly, sometimes it is actually better. I don't think we should try to push this big rock up telehealth up the hill as if it is a single rock. Some of the risks it are that we could confuse ourselves and the folks we are trying to speak with that this is apples to apples when they may think it is apples to oranges or even though they are both healthy, apples to tofu. This creates difficulty in bridging the gap of understanding. I would call attention to this article from 2010 -- entitled Telehealth -- tele-monitoring in patients with heart failure published in the New England Journal in December 2010. The conclusion was that among patients recently hospitalized for heart alien, tele-monitoring did not improve the outcomes. The general conclusion -- perhaps from others who may not read the full article -- tele-monitoring for heart failure and care ordination models don't work. When you dig inside the discussion of the article, there are two very important points. The first is that this trial which was multi-side note of a single side trial where they found a 44% reduction in the rate of re-addition which was associated with significant cost savings, these people were looking for scale. They did not try to scale based on single skilled nurse case manager, but via an automated monitoring system. So you can step back and say -- is there an alternative conclusion that we could reach from that study? I believe there is. The nonrelationship based model didn't work about the relationships based model that this was built from that wasn't published in the New England Journal dead. We are running a project right now trying to learn from that lesson. It is called care beyond walls and wires -- it is a project between private industry and Indian health and the Flagstaff medical Center. It is built around patience. This is a patient who is a part of the project right now. He lives in a remote part of the Navajo nation. Via smart phones and wireless tools and 3G signal, this reaches near to his own. He can stay in communication with Kelly DeGraff, and other care coordinators after discharge into the community. Some basic approach to care coordination we are familiar with. We emphasize what we talk about this -- the tools. This is about the relationship between Mr. [last name indiscernible] and Kelly. I will remove the tools and is about the relationship and the communication they have on a regular basis that is made the difference. So much so that on an NPR story he noted that it's just feeling that backbone there to have support. You know it does touch emotionally because who else is watching out for you? I would ask us and in a research location we think about research, what is the value of relationship and connectedness in some of these care models? >> We have put together a mockup model. This is not new. It is been in social science literature. We think of innovation in healthcare we are trying to trigger certain intermediate behaviors and activities of such as activating self-efficacy and self-management and compliance to achieve the triple aim. Social supports on behavioral health screening and health coaching -- this is critical to opening this ticket, we think. There are research agendas but I would like to see us focus on. I know considerations -- I think we should status by Telehealth differently and identify and learn and disseminate diffusion models accordingly from that. We need to support more collaborations in open health systems that work toward achieving triple aim for the population such as that I described in northern Arizona. We can do -- open system is one between different health organizations that have different business drivers and motivators. We could then study the role of connectedness in reader partnerships to improve transitional care for patients with heart failure, especially during the critical 30 days after hospitalization. Finally, I believe that we can support care model change at a larger scale by focusing on key locations like India and health facilities and community health centers and I believe that a national project is an ideal way to study the effects on triple aim of systematic use of Telehealth innovation in this can lead to policy and a display of change. To close, changing care models is a daunting task. Change can challenge and does challenge our care teams and policymakers. As my colleague pointed out -- standing to next to the sculpture of Albert Einstein -- we stand on the shoulders and next to giant. As my mom and sister remind me, generational change does not always have to be difficult. It is different and we are different from our parents generation. In fact, we can have loving and continuing relationships with them. I will close now. Thank you. [applause] Good afternoon. I want to thank the Institute of medicine and the National Academy of Sciences for this timely and much needed discussion. I want to also acknowledge that it is an honor to sit on this panel with these doctors who have provided leadership in pushing Telehealth on a national basis in a public manner for our veterans and our native patients. I am a psychiatrist based out of University of Colorado. I am going to talk about relationships. I will echo some of the comments that Mark made. I do where several hats as mentioned, but this is my get out of jail free card -- I am solely responsible for the content I will discuss. To give you a brief overview, I have spent the last decade focused on work in clinical video teleconferencing and tele-mental health. Working with native and non-native populations in rural areas. Including better in an non-veteran populations doing program at it and clinical and administrative work. My comments are coming focused out of those experiences with life interactive videoconferencing predominantly. I think as we have heard several times over the last day or two, it is really not about the technology, but the technology is the conduit and bridge to that relationship with the patient to provide care. A lot of ways -- even in non-mental health field, some of the most important treatment we give is the relationship and the healing relationship between a patient and a provider. That, really, is the core of Telehealth services that I have been involved in. But, this doesn't happen without a series of relationships that need to occur to allow a provider to see a native patient in a rural community. It is very complicated and in fact if the relationship is going medical -- it is not the most important relationship occurring for the successful clinic. The most important relationship that I've seen is the relationship between the service and the provider and community we are working in. If that relationship doesn't exist -- you don't have a clinic or service. In that it within that is the important organization to organization relationships and particularly for native patient you are talking about eligibility across will double systems and there is a lot of data and research showing that native patients in particular used various systems -- native veterans that I work with my get there primary care from IHS and choose to get specialty mental health care from the VA, for example. Finally, in specific programs you also have relationships both internal and external that need to occur for successful clinical interaction. Jumping back a little bit, there has been some discussion about mental health, but I did want to make a few comments, particularly about tele-Nettle health. In the field of mental health, I would argue that we have a unique fit for Telehealth in that most of what we do clinically can be accomplished in some form over videoconferencing. This has been shown in the growing literature over the past gave across age groups and populations and across treatment. Certainly, we need to grow and nurture that literature. Particularly, in the last five years within the emerging technologies of direct and home video conferencing and mental health and web-based care which is how we interact with our patients. Obviously, we have heard the particular relevance of Telehealth and tele-mental health for special populations and in particularly native communities with geographic barriers to access as well as cultural and institutional barriers they may prevent them from accessing care. I would argue, also, that although -- there has been some talk about randomize to control trials -- there is certainly a place and we need to do more of this in the field of Telehealth and tele-mental health to demonstrate our treatments are as rigorous as any other treatment which I believe to be true. But, we also need to begin taking nuanced approaches which I will talk about in a minute. Trying to understand this tool of technology and how it interacts in the relationships. Rather than just asking if it is as good as -- what are the differences? Each of these tools have strengths and weaknesses. There is appropriate pairings of technology with diseases and populations and I don't think we understand in a systematic way how to make these pairings and how to address that. What I will talk about for the next 10 minutes -- if it eats your interest -- if you go to rural health.VA.gov -- there is a video that tells the story of rural tele-mental health clinics for veterans with PTSD in some of the words of native veterans in the Northern Plains. There is also a recent article in the Journal of telemedicine on a review of some of the data I will present. People have talked about some of the basic guidelines available for tele-mental health and there are a number of general public training sites. This one -- was developed by our program in conjunction with fans to help introduce patients and administrators to the use of videoconferencing. Let me shift gears back to the diagram and start with patient provider relationship and talk about -- what we know both clinically and from the research they do about the strengths and weaknesses. As Mark pointed out, they are -- there is good data that there are some situations where Telehealth they be more effective than face to face visits. For example, I do work with the tribal council and I treat patients in Alaska from Denver. When I am working with female natives who have a history of the mystic violence or post traumatic stress disorder, they tell me it's a lot easier to begin our work together over video because of the feelings of safety and it isn't that they have been working with e-mail provider. As they get to know me and we develop a relationship, then that Mississippi, especially in the first few visits -- feelings of safety -- I have been able to develop a trusting relationship. Obviously there are counterpoint to this. The biggest one is the loss of the perception of emotional distance. If you look at the literature, in the 5 to 10 randomized control trials in tele-mental health, you see equal outcomes, there are some hints that there is an impact on the doctor patient relationship in the clinical process and we do not know how that translates into the -- how it impacts, ultimately, the clinical outcomes. This is important to understand. Clinicians working in tele-mental health will take a bit it is true -- it is different than seeing someone face to face. The good clinicians understand this and the good systems understand this and make adaptations. There are a lot of different adaptations to bridge those types of That come out. In our programs and working with native communities, we do a lot of contextual training. One of the things that happens is that the providers are often from urban areas. The amazing thing about the environment that we work in is that you can be getting lunch in downtown Denver and I can drive to my office and I am working with patients from Alaska -- a different environment than where I am sitting. You feel more disconnected doing this over video. So, and less you make an effort is a provider in a system to understand the environment and the issues impacting the patient, even on a weekly basis in terms of the events occurring in the community, you may lose touch with what is going on contextually. We have also used cultural and clinical facilitators. For instance, in a series of clinics we work with the regional VA and we have a tribal outreach worker. That is a native veteran Elizabeth community that does the scheduling and purchase the report and gaps and helps us to bring patients in to the system that traditionally may have been reluctant to get care from rural healthcare systems. I know this both from data and experience from patients. We have had a Korean and Vietnam veteran who previously sought no care for mental health issues who came in not because a stranger came over the video from Denver but because of the community -- community member involved in the clinic and balding getting them in. That is one adaptation that the patient and provider level. Additional adaptations include collaboration with traditional healing which helps acknowledge the local context of the patient's treatment which is so critical. One of the other things that I observed -- some of the biggest cultural issues that I often see -- I am involved in a training clinic that teaches residents to work with rural veterans. This is not the coach Earl issues between native and non-native, but the urban and rural difference. There can be a real divide. A lot of the urban providers have not spent time in rural communities. Again, using some of these tools and training to allow them to learn the rural language so they can communicate with their patients. This is critical. That are some of the salient issues that the patient provider level -- would we not -- Telehealth requires program to program interaction. In some ways, for mental health, which is traditionally been silo, it is a good thing. When I am working when in the VA, to develop a clinic, I work with IT. I am having to coordinate with the local primary care services. You are looking at both internal and external probe ran it -- programmatic collaborations which may not traditionally happen in the course of clinical care. In some ways, it is a real benefit in terms of having to work together programmatically. What it does is almost worse than increased level of coordination and continuity and consistency in the care and leads to more holistic approaches. We need to systematically understand and begin to look at what the 21st century health care team is. Traditionally, 20 years ago, it was often just a mental health provider. If you are working in tele-mental health, the team now is likely a mental health provider, and in the VA system that will be the IT service and the local Telehealth coordinator for the facility you're working with and at the clinic at may involve primary care, a desk clerk, an outreach worker working with tribal communities, and so our conceptualization of health care teams has not kept pace with the technology and the model betters delivering these technologies. Finally, concluding the organizational issues -- as our programs have learned to be successful in implementing new services in native communities, it has forced us to do multiple organizational collaborations. One of the clinic said fifth -- six different partners. To at the VA and at the clinic and a travel services to put this together. Multiple systems of care are possible and highly desirable at times. They bring together resources where one institution doesn't have all the resources as you bring the different players together and you can have a full menu of resources for your patient. As I said of the program level, it increases care coordination and also when you have multiple systems you also have maybe additional resources and funding. On the challenges -- bringing the right partners to the table is often critical and having the wrong configuration of organizational partners can sabotage any developing service. Trying to hit technology to talk between systems can be a critical issue as you can't will multiple organizations together and deal with multiple compliance and regulatory issues across systems. This can also be challenging and on the flipside, identifying who is going to be the primary funder when you have local systems involved and who is reimbursing for which parts of which programs and services can also be an issue of discussion. As I said, some of the fundamental lessons learned is that multiple system collaborations can be highly desirable hurried you need to know the local ecology. It is important to put together the right communication and collaboration process. And holding environment to be able to do this work. Alternately, finding a way to take the organizational elaborations which often start off based on individual relationships which can be critical in native communities and all healthcare and actions and systematizing them. So, when you're champions move on and people move on, you don't miss what you a bill. So, I will conclude where I started. Getting back to this model. We need to do a better job of investigating and exploring and confine these models that are successful at these different organizational levels -- codifying them. Understanding the importance of the impact of the relationships and how things are successful or how they do not work. As well as understanding, particularly on the patient provider level, how the technology affects the process. Either positively or negatively in the appropriate adaptations to make sure that as we develop these services we are keeping our eye on enhancing the quality of care and enhancing the access and fulfilling the comments of Telehealth in those areas. [applause] A heartfelt thanks to all three presenters. I think that many of the things that they shared our XO from -- e from our discussions today. Pointedly underscored in a number of ways that perhaps we have not acknowledged? Was a late. I think that this emphasis on relational building -- not just at the provider and patient level, but throughout the hierarchy of relationships that underpin and actually, I believe, and eloquently stated by the panelists relate directly to the the success of the encounter as well as the service long-term. Questions from the audience? Deal -- Dale. [participant comment - no microphone] >> [captioner has no audio - still connected to event] >> [Captioner has no video or audio after refreshing twice. Standing by] >> -- How one gets that kind of linkage. The answer is -- when health information becomes more commoditized and you have a to tremendous mercy of systems at the moment. Will this happen? I believe so. If it were in my sphere of influence, to make it happen tomorrow -- and I have the capacity to do it, I would. But, there are other challenges in the meantime. However, putting these programs together -- it takes 68 separate rings for us to develop a program -- it is -- the devil is in the detail. You have the pieces together from imperfect things at the moment and if it were -- it would fall together and have a -- we could do this a lot more easily and we could not have this discussion we are having now. I know that the audience would love to chat about the ability to exchange bidirectionally and continuously in terms of systems development. This is been a history would be be a forum information system development that goes back 30 years. And from which the graphical user was built. It is interesting when you talk about the occupational health -- in my new role in the region in northern Arizona -- we can think about outreach and collaborations in the region of which we are doing and thinking to models of care, but not only -- 30% of the admissions at the medical center are Native Americans and making it the largest -- largest Indian health facility in any IHS run a facility -- so many employees are Native Americans. If you step back and think about this, maybe at like stab medical center -- they should think about -- like stab medical center -- -- Flagstaff Medical Center -- this is what we should do. Other aspects that have been anticipated but not closely examined -- this has to do with how have you thought about in your respective systems -- bringing into play local, regional, and national leadership, not just within the agency, but those that can champion an advocate the context and opportunities for you to pursue the networking you are talking about, Adam, across the multiple entities? Encouraging and seeing the value of certain things -- for example, information, and knowledge is power. In many native communities, for example, there is a great deal of reticence about sharing this for fear of this application. Adam, it seems like the VA has done a great job in figuring out -- with a nor a notice amount of effort -- the kind of information is needed and applying it regularly to the improvement of quality of care as well as the accountability of effort. So, I would be interested in how you have thought about educating and training into the sense of community -- not just providers or administrators, but also key decision-makers from Al Qaeda operations is. This seems radical to the success that you've had. I will start here. I would say, in particularly in the work we do in the VA, both the VA system leadership and the tribal leadership has been critical. In each community that we set up, Tele mental health services, we go and have discussions with the tribal Council and engage the leadership. We then engage the local VA leadership as well. That has been a part of the process and it is hard to move forward if you don't have the local, regional leadership buy-in. On the national level it is through venues like this where you can discuss and promote your model and get access to decision-makers and look at -- also identified -- others that may have an interest in taking that model and expanding it. For instance, in the Tele mental health clinics, we run for northern plains of veterans, this started in the northern plains -- the VA region 19 -- in the coming year, we are going to help 2 sites nationally outside adapt this. This has come about because we the word about this through the leadership decision discussions and have been convinced that at least for their regions and areas, this model may make sense for some further adaptation. And an example that you cite -- to give credit where credit is due -- major capital risk taking on the part of the VA -- with respect to Adam -- having seen the opportunities and deciding to invest in seeing what possibilities might be realized. Thus, generating a series of small but early effect of models that can serve to inform other advocacy efforts. I think that you are referencing the first clinic -- this was on the Rosebud Sioux reservation. It was Dr. darkens off this that provided the funding -- it was a national office. This was going through the process, really, with Dr. Darkin's leadership and working with the tribal community as well working with Dr. Manson's collaboration with this tribe. We had those relationships with the leadership. I think the example that is the example you are referring to. Onto this question -- a relation to that, the reason why it was -- a privilege to support that program was having been down to New Mexico and being on some of the pueblos and seeing the help me. Coming back to the driver for this -- the driver is really a public-health needs that is understanding and delivering care. It is something that was not a funding of one project -- this is something that I feel passionate about personally that we develop. Being slightly humble -- I am not exact sure how to do it if I could do it. I was certainly doing much more of it. I enjoyed very much listening to the panel on what is happening in the states. I think that part of this is that it needs a large vibrant immunity thinking the same thing. To see large state programs that are active is going to be helpful to form how these things come together. Decisions that lie outside one agency -- if this is about population health at a state level, there is a way in which there are multiple resources and other ways in which these resources can be pulled and used in different ways. If there would be networks were Telehealth -- at the state level and some in the VA in some another health services. There are complex questions to get there, but I think that the discussions have to be around those groups. I don't exactly have the answer. What I do have -- having built over time -- a community within the VA which has built a community from nowhere where it is regional -- we certainly have a regional capacity to two Telehealth and help it grow. People's primary mission -- they are hard pressed to deal with the veterans, but one of the missions is that it has that mission -- first to work with other organizations and the private sector. I would put this on the table -- we have ways in which we do have regional representation in ways that I would be happy to see -- ways to broker relationships and establish what you are talking about. Suggestions would be welcome. Thank you. I submit that that has not been a part of what we have systematically investigated with respect to the diffusion going back to your earlier observations, Mark, I've the technology as a means for improving healthcare. Nina and the other gentleman -- I saw you at the microphone. I wanted to ask this question in another way, if I could. Adam, I have known your work for years and marks and days -- -- Jay's. How can we get CMS to accept your work in this area and not ask them to reinvent the wheel over and over again? All the way back to the meeting 10 years ago, Mark you percent of this. You have a gold mine of data that we don't have to prove over and over again. There are valid statistically and sound studies with amazing results. Help us to understand the reason that we don't get CMS to accept this. I don't think it is a silo issue, but I understand that it is maybe more of a capture population in that the veterans access most of their care through VA facilities and the natives and tribal groups access most of their care through IHS. The Medicare population goes over the place. There has got to be a way that we can capture the value of what you have done and convince HHS agencies to accept that somehow. Thank you for that question. The IHS has actively been dialoguing with different offices in CMS about that. National coverage determination for Indian health side -- the coverage in Alaska which included store and forward and the fantastic data that we have both in terms of outcomes and process and cost. We didn't show that data, but there is a phenomenal data for that. There have been some bills that have been proposed by US Senators. There was a particular bill, in fact, that would authorize four community health centers in India and help help sites to -- Indian health sides -- for reimbursement for Telehealth within that model of care. I think it is a great idea. A TA supports that. They have that language. I am happy to partner with anyone in this room who can help Al Qaeda move this forward. I believe this is an ideal arena for us to move forward and to move forward in a partnership, say, with CMS and others to evaluate names that make sense to them going forward. We are interested in that, and they are are active dialogs right now, but it is uncertain where it may lead. I would say CMS has been actively involved in Telehealth since its inception and still lives and is interested in what happens. I put it back and say -- what exactly are you asking here? In the sense that it seems to me that part of making this work is that one has to take responsibility to make it happen. If you are asking do I personally -- obviously, the department I work in has no position on this. My personal views on this are as follows: there is no systematic way that Telehealth is being done. So, we do it systematically and it is hard work to do it. We have seen where things have not been systematic with home telecom -- LL -- Telehealth. What would you describe? Secondly, I think the other thing we have to of knowledge is that this is not the standard way of practicing. I believe that if something suddenly said there was a way in which this could be done tomorrow, there is a tremendous clinical change management piece that has to be dealt with this as well. So, I think -- I am not sure the solution you are suggesting. Of suddenly being adopted. Lastly, again, five found in Telehealth -- I said from the beginning -- it is been about solving problems. I have never thought about where the money will come from in terms of -- elsewhere other than saying -- this is really about how you change clinical process and how you to make it value in work. So, lastly you have to say that CMS has to be driven I everything else as by evidence. More widespread than just our organization -- we search on Telehealth. This is been going on for 15 or 20 years. We are still answering the same questions. I would say that one of the things -- a personal observation -- this is about networks and it needs to be done with networks of a larger size to be able to look at this before one can talk about models which are transferable. Thank you. Last question. This is Mr. Terrace from the center of health policy. I want to echo what she is saying. For example, the health Buddy program from the VA has been demonstrated to be incredibly successful in working with clients at home. How that information and data and success can influence Medicare policy, for example -- they are both federal agencies that can learn from each other. I think it would've been so we are talking about -- the triple aim. The issue I would like to propose -- another aspect of the benefits of Telehealth that are being surface. That is the relationship between the client and the provider. Having worked with health programs in California -- mental health and behavioral health is one of those critical areas of cultural competency. Traditional values go into mental health. I am wondering if you could speak to that point. Have you seen in your work, either one of you how Telehealth can incorporate the cultural values and to use traditional healers in this practice? In the clinic that we run in the northern Plains, we have, depending on the facility both formal and informal relationships with traditional peoples. We have had ceremonies and blessings. I was actually blessed as a clinician to work in a video conference. The healer felt that that could be done. In one of our clinics, we have a referral system. Again, not all clients want to follow traditional medicine, but we have or furl system where we refer patients that are interested in healers for sweat lodges to help with PTSD and occasionally they healers will come in and communicate and discuss with the patient permission they going on and the treatment. We have done that, but we systematically tried in each of the communities to establish either a formal or informal network and then establish a process around doing that so that we can do it in a regular systematize way. I think that this demonstrates to the individual veteran that we are taking into account their perspective on health care and treatment, but more portly it gets to what I said, particularly in small communities -- native and non-native -- it is an indication to the community that that individual provider and data service and that healthcare realization is taking into account the community needs. You get a lot of credibility. Again, that think that is important with Telehealth because often your representation as an organization and a system may be a room or a small clinic. It is a VA clinic but you are presenting a big organization. Things you can do to demonstrate that elaboration and partnership at the community level in the treatment of provision of care is critical, but certainly I think there is a lot that you can do there. That brings our time to close this afternoon. We now have a 15 minute break from three o'clock until 3:15. We will reconvene on the next panel followed by a panel of the landing committee to provide brief thoughts with respect to next steps. Any logistics, Tracy? Please find your way back within the next 15 minutes. That would be appreciated. Thank you. [applause] [IOM Telehealth workshop is taking a 15 min. break and will reconvene at 3:15 EST. Captioner standing by.] >> We are going to get started again. Everyone outside -- thank you for hanging in until the very end. It is interesting -- when Tracy called me to ask if I would be a part of the planning committee, she said that this workshop would try to determine and understand the evidence-based fact is a Telehealth. Do we know anything about outcomes? Where is the best place for Telehealth in the affordable care act? What are the research questions that the IOM can help answer? Just what we have seen over the last two days, we have, a long way from that original goal. People have disclosed things and I guess I have nothing to disclose -- I wish I did because I wish there is money associated with that somehow. Then I realized in speaking with David at lunch today that I guess I am a proponent of disclosure. When I were bottled an old farmhouse, I put all clear glass doors on the bathrooms because I lived by myself and I think it would let a light in and the air. Until I had my first house cat -- how's guest -- they couldn't close the door. When we put this session together, we talked about taking a look at if we could bring a variety of stakeholders together to discuss actions that HHS could undertake to further the use of Telehealth to improve healthcare outcomes while controlling costs in the current healthcare environment. I think one of the things that maybe for the next one of these that we would do -- hint Tracy -- we probably made it -- made in air in not having consumers except for us. We could probably use a consumer panel. We got the next test name -- the panel today represents the majority of the rule stakeholders that access their care through what I call Telehealth technologies into the virtual space. I will introduced the panelists -- Dr. Georges Benjamin is the executive director of the American public health Association cash the largest organization since 2002. Prior to that, he was the secretary for the Maryland Department of Health and mental hygiene. I imagine a lot of your preliminary work ended up with some of the things that we saw today from Maryland. Stuart Ferguson -- you have heard a lot of questions from him. He is the CIO for the native health Consortium in Alaska and he has the primary responsibility for all IT operations through the Alaskan it of medical center which is the largest native hospital and medical center in the United States. Alan Morgan -- Which is reconnecting after not seeing each other for years. He is the CEO for the national rural health Association and he has more than 20 years of experience and health policy development at the state and federal level. Ellen, your first? -- Alan -- You are purse. Good afternoon. On the behalf of the national rural health Association it is my honor to be here today. We are going to talk about the role of Telehealth and the evolving healthcare environment. I will follow up on me this suggestion and I will disclose something as well. We were asked within a 10 minute period of time to talk about the great challenges facing Telehealth and provide the all possible solutions during that 10 minute time as well, too. Don't laugh -- I think an can accomplish this. Let me start by highlighting what we do which is to take innovative approaches to move healthcare for. As such, for everyone currently here today in the audience, I would encourage you to pull out your smart own and open up your browser and Google were will help. -- Rural health. If you are online, open up a separate browser. The first thing that comes up is the NRHA website. On that website under the tap listed as log, you can pull up our 11 page. The mode he including the state of Telehealth in rural America and all possible solutions from a policy standpoint as well, too. This is a wonderful tool in a document for the IOM and committee and staff as you go forward to try to develop your recommendations. This document was developed by leaders in telemedicine and tele-health in rural America from across the country, many of which are the audience today. I would encourage the committee and staff to simply cut and paste as liberally as you deem appropriate as you pull up together your comments. We are here to help. See -- that was in two minutes. The remainder of my eight minutes, I will highlight some of the key policy recommendations that we would like to put forward. Unfortunately, these are not new or novel recommendations. They are going to be the same recommendations that you all have heard frequently and forcefully recommended over the last two days of during this session. This is a good thing. It clearly demonstrates that there is coalescence among the Telehealth community on what needs to be done to further expand telemedicine and tele-health. We have put these recommendations together into 4 policy buckets -- reimbursement, credentialing, broadband infrastructure, and research. I don't know how that matches the buckets in your head today, but that is how we have put them together. In the area of reimbursement, NRHA recommends as many of you have done at this meeting that first we lived the geographic patient requirements of receiving care through telemedicine and Telehealth. It is very important as we proceed with this to not lose sight of the rural designations in ensuring that rural is served. These providers are reimbursed less than their urban counterparts. The financial equation for the Irvine-based originating site does not work as we have heard so mentioned in the last two days, telemedicine will remain as a branch of service. Eliminate separate billing procedures for Telehealth services. Telemedicine is a tool for the clinician. A separate CPT code does not do any sense. Third, reimburse care provided by physical therapists, respiratory care this, speech there this, and social workers. These are services provided and in high demand in rural areas but it often not available to rural communities. Finally, provide reimbursement for store and forward applications. Nina mentioned that I have been involved for 22 years -- 21 years ago I was a healthcare staff on Capitol Hill and the CEO of Kansas came into talk about a novel payment methodology the reach each program. This was the precursor for the critical assess product hospital program. He said Ellen, let me be honest -- five years from now we will not be talking about these hospital reimbursement issues because telemedicine is going to address all of our workforce concerns and quality and access concerns. 21 years ago. I am optimistic and I firmly believe that 21 years from now we will not alluding to the comments that I had now. That is because obviously we are in the perfect storm of healthcare right now where if we were going to proceed with it lamenting the affordable care act and the expansion of care, if we are going to address current workforce shortages in rural America and address quality and health disparities, we have no option forward other than to -- utilize to let health as a tool for the clinician. That is my optimistic page -- I will not be mentioned this 21 years from now. The second bucket -- credentialing. We have discussed this over the last two days. The IOM should study the cost effective -- cost of filling it with credentialing and privileging as it is very burdensome to rule -- rural providers. This is a bullish barrier. A Telehealth provider can administer services to patients anywhere in the country. The NRHA recommends that CMS that does the polities to allow Telehealth providers to receive status and to allow facilities receiving Telehealth services to perform credentialing by proxy. Again, this is not a new recommendation. You have heard this repeated by many of the speakers of the last two days. On the topic of broadband infrastructure, this is an easy recommendation going forward because in best minute brought and will require a combined will and collaboration of both the private industry and government regulators. The IOM should make this is a priority for combination. This goes back to the FCC comments we had during yesterday morning. Finally, on the issue of data and outcomes research, number one is that you have heard many times there is much research already available. I am going to differ a little bit from some of the earlier comments of yesterday morning and on behalf of the national rural health Association, call for additional quality measures and Telehealth three minutes to improve the services in rural America. Let me be careful on this. As IOM considers this, I hope that you won't fall into the trap of assuming that just because healthcare is delivered in rural America, it must be of lower quality. That is not the case. That is not the case highlighted by the IOM report quality through collaboration and also looking at CMS 's own hospital data comparing small critical assess hospitals that have reported through hospital compare to -- versus urban counterparts. These two sources clearly indicate that rural healthcare when delivered as they do in rural America compared with urban communities is operable and in fact sometimes better quality. We are talking about is directly to what Dr. [last name indiscernible] talked about during his presentation. For some specialized care, it might make sense to take a look at that more in-depth to see whether the quality has actually improved. I think this is a great research potential going ahead and will help make the case for the need of the expansion into rural communities. HRSA -- NRHA also calls for research to aid regional extension centers to improve the services they provide. Importantly -- NRHA does not think that these two entities are not doing their job. They are. But, without the research and the outcomes research of how they are providing successfully to rural communities, they cannot amend or correct and move forward in providing that technical expertise to rule providers and will communities. I will close my comments by something that Dr. Wakefield said in her opening remarks. NRHA would call for the study and look at the effect of Telehealth on recruiting clinicians and training clinicians. Telehealth not only addresses the direct clinical application, but also as Dr. Wakefield indicated can't help address these workforce challenges that we often face. I see my light is on. Let me go ahead and conclude. This is a realization that we all know -- to can set you free and the truth has been indicated and articulated over the last two days here that it is time to set telemedicine three. The barrier is no longer the technology as it was 20 years ago. The barrier now remains in the rules and regulations and guidelines that we have opposed -- imposed upon it. On the have of the NRHA, I want to thank you for this opportunity to provide testimony to the IOM it is a look at this topic and again mind you all to go online and type in the words moral health. Thank you very much. -- World health. Thank you very much. [captioners transitioning] Great the. Thank you for the chance to talk, I am Stuart Ferguson and it is my privilege and honor to the president of the telemedicine Association I'm going to type about the Association have word fits into the jigsaw puzzle of Telehealth. And as long as itt strives locally, regional and national efforts I thought I like them I talked that way and there are 50,000 cases the share and we spoke to the state legislature when it landed in general to different individuals told me you'd better be prepared because health of social services of state Medicaid director testified they're counting on telemedicine to save as much as $30 million in travel costs to decrease the cost of care and are Commissioner and state Medicaid director looked at partner to have to come up with of that this plan and different methodologies for payment by hospital administrator meet with me they have tell health activities and patient monitoring are-little advocate the and tribal partners mandating the use of Telehealth next Friday to meet with 60 drive and talk to them about what we are doing to meet demand for specialty accesss they're trying to scale the system went to the challenges go away I would like to say this is where the ATA has a role, with a 17 member board and staff look ahead and prepare to meet the demand that is going to be there in 12 to 24 months of this is the division of the American Medical Association and that is a division we have in Alaska the division the many of you have your own tell health systems --you're on Telehealth systems and they can provide the services I cannot achieve on my own down the official journal of the ATA and one of the editors in chief and starts with online resources and they continue webinars and webcasts of their involvement social media and you can connect. Facebook and other methodologies and they have member participation like all good the creation you have a large meeting of that kind devoted to tell how the telemedicine and it is a convenient meeting of the five tried to bring those together and have a good session that happened in April and May and their other meeting the they do as well and very convener of people involved in telemedicine and something else they do is extremely important to this field of the move forward and that is the active participation of bumper down they involve members through other mechanisms than one of of of member groups and within they have special interest groups such as business and what have you participate in many more of these and these are the subject matter expert interest groups and that you webinars and meetings and they get involved in evidence-based guidelines and practices and they have chapters with discussion groups and because we are interesting organization where we involve the industry we have a of the street counselor have the voice the Association and we have healthcare and institutional Kyoko --total health forward practice guidelines use of advocacy, evolved of your review the ATA is heavily involved in helping evidence-based practices guidelines and standards of this is important. And we want to follow best practices we don't want to reinvent with want to try to discover the fire also the source of that information is the only source that is out there right now to go to the ATA of what standards and guidelines have been developed with the involvement of academics and industry practitioners providers and so forth have a series of guidelines that have been completed and number of progress I highlighted a few vanilla because they have images throughout the top, specifically heading up the remote health monitoring and data management she expanded her group by inviting other speakers to that group and we don't have a formal guidelines of how to do this one of the best practice and give a blend of academics and providers and service have is a fairly nice group to work with and the reason that we need guidelines and the reason that we need standards is not do arrived but because Telehealth of the solution of skill . I can tell you it makes no sense to do it for five tab 15 or 20 patient when you start getting into the 100 and as soon as you start to get into scale, if you have a department that went from 40 to 404,000 consult the year was only eight physician the problems changed the challenges change and I think if we look at year or two ahead we realize we are online adoption curve are going to be facing a different set of challenges and they're going to be challenges of scale these are the challenges we face people talk about doing a chronic care and patient monitoring and those of a the conversations Pamala to play a role of conversations in which is came from a two-day board we and the strategic plan for the coming year and to give you a idea of the key areas we will continue to work a public policy and comprehensive educational subsystem and consumers and so it exists further mates. And that is good because Telehealth and healthcare working aggressively to make sure the lessons learned are shared and the other less of their shared back here that is the goal to bring people together and to move the field forward. Thank you very much. Good afternoon I'm going to take a different approach, those of us in public health and like the healthcare system many drivers and a population healthcare system change and I just want to point out a couple and there is a lot of data floating around public health liver the data enhanced capacity analyzing large data set speed at which technology is changing we think enormous potential have been lost with early prevention and the benefit of and of course, the fact that a lot of the system changing it going to be driven and as baby boomers were trying to catch up with our kids that it included a goal for health information technology wave West are patient with knowledge and wisdom and bilateral conversation and try to help them we need to recognize that as they go forward and secondly the fact that we went to deliver actionable information and there is lots of information on the web and in cyberspace and a lot of it is actually inaccurate that one of the challenges of public health is to try to work with it and other objective the IDF trying to connect to populations that are culturally diverse, also remains a big challenge and really trying to build programs and interventions that result in behaviors and we think it is one of the big challenges and there is no question that brings enormous value in the keyword is enormous managing population interventions than I watch talk about each of those very specifically and the financial services public health and reminding people that public health is doing assessments to take what we learned from that policy development. For variety of venues sure that those things get done the we think are important and do that have the essential server I have I want to remind everyone that as we move to an environment where everyone has an insurance card, some still think why do we need a public health service and one is clinical in nature and it is split between not of providing that care for people that still do that but the key word is linking people to system the fact public health those more linking in most public health system but in terms of providing care. With that in mind, clearly Telehealth is going to be helpful as we look at tracking activities and these trends with things such as immunization the cancer registries as we investigate new disease outbreaks we have an enormous number of mechanisms to do disease surveillance where we are collecting data not just from the health system but looking at what is being sold in pharmacies and grocery stores and putting that data together with school absenteeism to do some early pickups on new disease processes based on clinical syndromes and communities. A variety of ways to communicate effectively with the stakeholders including the network for example the Center for disease control and a variety of public health emergencies. The idea of mobilizing community partnerships I'm going to come back and talk about social media in just a moment the primarily through linking people and engaging them through the web another mechanism could help mobilize community partnerships the move communities to taking Parliament action toward their own health. Linking and coordinating care we can continue to talk about the 25% of people spending 75% of the dollars, with interesting part of this session is when you start overlaying the patient bar with the challenge communities and associated problems that we have and many of the communities the same people that were challenge of the same places with high levels of lead in the environment and we have crime or violence and street--they are not walkable or by couple and booster call them noncompliant believe just the mother noncompliant and we find out there many things, fundamentally outside the functional control because of socioeconomic status and prefix of from a community perspective medical community medical care community and public health community would look at those folks of data points on the map and put in place strong community programs and interventions that make it easier for them to improve their health and try to reduce the number of noncompliant so we have. Whole range of activities around workforce training. Webinars like today, videoconferencing, interactive Journal, and there are videos the blog. Conversational tool would go forward that information to try to prove build on ongoing basis of fundamental research that happened for health systems research public health systems research Gauger the community and we are recruiting people to be part of it and does the flu season develop leaders advocate the reported systems and if it does you can send out targeted authoritative information to the listserv about what the terms of enhancing social distancing handwashing getting a vaccine whatever the intervention may be as you go forward and that the range of social media tool that are going to be affected as we look at this and go forward. Of course like everything else the challenge that we have obtained for health information technology before 9/11 the public health. Was operating off of Rotary phone we have gotten rid of those we are still operating on both the wonderful new technology got right after 9/11 as part of emergency preparedness in the equipment has been replaced and those of you that have kids in college know that colleges say two or three computers. For most parents. That is not the case for public health department. They need the technology but don't have it in investment in prevention and the need to have a much better investment in the second. So I leave with three recommendations. We clearly need to make strategic investments in population-based aand data systems that we should require appropriate linkages of the public health care data and provide prompt the perspective the public health of the fence, that data can go into the public health. And of course patient confidentiality and appropriate protections in place and finally, we need to demand accountability for population-based outcomes for everyone I remain impressed of the public health advocate that the number of states that are linking systems remain at the bottom and they had been at the bottom for some time and those requirements logistics public health outcomes at the bottom of the tent 20 years and that is something to be activism around trying to address that obviously Telehealth will of that but only document those little clout, etc. but targeting solutions we can make a difference. Thank you. Thank you very much all of our speakers I am impressed again and each one of these panel, very interesting, nobody talk to each other beforehand to say what are you talking about so we don't duplicate but we never duplicate, it is amazing and the consistent message that we have heard that we still have a need to document the health care in general and not so much, I am moving very quickly away from the full Telehealth used but the document return on investment strategies use of healthcare and to look at large data sets to enhance the use of public policy through the efforts that we are trying to achieve public health, private help, Telehealth, whatever it is so I will put it up to questions from the audience. I have a question for Dr. Ferguson. I have heard it futile the last couple of days a good statement about the focus The on technology. There is technology involved than I guess I find myself wondering why there is a more focused on interoperability standards I have heard that from one other panel those are issues it looks to me like that is one of the major challenges that we have and secondary piece to that, and this is a what if, I find myself wondering, it appears everyone that is doing this is building their own support network is there an opportunity to fill that a shared services support network for multiple providers?. Those are great questions. Interoperability has been a struggle and the does get addressed at that level and we don't have the productivity focused on that with of the ADA that device interactions a lot of that discussion has moved to the industry panel at the ATA is -- Can interrupt for a second? That is good to hear, image the industry counseling approved, my university the crest very hard, marketed to very hard by local cable company and national cellular provider who have, really interesting home systems their proprietary. They will work with anything else that wonder at this point, that even an issue of discussion? You're talking about patient monitoring devices? I will say as privately as I can on a public audience, the time is long overdue to use things such as direct messaging and of the technologies that is Vista standard to move that data on a standard slave slave devices to talk to her. Terry servers and can give you a HL seven the real-time into the BHR and perhaps of the models I have seen from companies that will do direct messaging and because you some options to do real-time feed so I don't know, we don't have a position on that but I think it is a good question and I know of one very large total health system and I think those business model are driven at this point and have seen it happen with--is going to happen with another field. It is interesting to see a variety of issues there is a picture of a 6 foot to yesterday of the ticket picture of the dental hygienist and at a school in Sacramento, for low income children, California, 25% of children have never had dental care and we have a huge level of health disparities that are experienced in the general healthcare system and that level. Lots of opportunities to be able to reach people who are not taking advantage of traditional oral health care system to get dental healthcare through tele-health technologies of the California to the effort and the telemedicine Association and the more inclusive the could find a way to characterize the topic of my abstract that would to put in -- We screened head start children, three and four-year-old, and five-year-old the cheerily basically find 75 to 80% of them have active dental caries and 20% have open pit that if you don't know if that is, it is scary. I cannot name one other tele-dentistry program, except maybe yours, that does tele-dentistry and what we found, six years ago, we started putting up dental clinics of the result of the tornado and it lasted only dental clinic and we supported that dentist to get the practice of again and realize there is a great partnership and collaboration that need to occur between our dental providers on her medical providers because oral health of the direct impact on the quality of life and the quality of the visual path and we have actually taken the model of Telehealth, one of the dentist came and said what can we do this for dentistry? And it is something to think aboutt global retinal screening, so many different disciplines that are using Telehealth now it is not so much about medical practice of surgical practice the dentistry in mental health we thought earlier.. I was going to say two things, the fovea test simply Canaveral health to the drop-down list--oral health to the drop-down list. Alaska is the place with challenges with dentistry, lack of dentist a lot of dental challenges. We have a program called the dental health aide training program and that is typically people in villages to come in and get trained in go back to Mary dental therapist and we do Telehealth training in the training program and now they take images and communicate with them unsupervised outside the state inland you go to the village we use Telehealth all the time it is a natural fit , we agreed. If people to find out more about how my work, the California dental physician Journal there is a free download the July issue is dedicated to the program we are running about five articles and the methodology of the flesh get more information about how to do the project which has demonstration plant across the state of California. Thank you so much. Other questions? I have a question for the panel. As you are large organizations, three stakeholder organizations, can you talk about how you are working together to advance public policy quality cost return on investment whatever your thoughts on how we might all work together in the future with our organizations? Let me start of they just of collaboration is important as a go forward is support for the national organization to go ahead as well and I was just talking earlier, we partnered on a numerous issues that we have not on the area of Telehealth I look forward to doing that going forward, the ATA, I want to say your staff and if we are not talking every week, every other we, obviously but the nature of the healthcare delivery process that has to be a strong partnership and I think it is going to be incumbent on all of us to bring and other organizations into this discussion as we move forward. I will concur with that and I think the health educators with a good partner with us as well. The biggest challenge I think we're going to have the amount of misinformation flowing through all of these electronic systems. We have enough problems with their same the same thing and people here different things. But when you had the amount of misinformation we are going to need a lot of work to become a trusted advisors to the American people on this issue that is going to be from the clinical five to the American people on this issue that is going to be from the clinical 54 population-based side and getting make sure that information is accurate and there is a rapid response and we're doing that with back pain and there is a large anti-vaccine movement would spend a lot of time responding to that information about back pain. Specific to the ATA, board of seven years and every time we meet with this facet of the small staff and I know they have to work and collaboration in association with other organizations and we worked with--and they work with NOBEL women and a lot of different programs including Parkinson's group for their patient population that could benefit from Telehealth. I know that is happening. Any other questions or comments? I am Janice of the American speech language hearing Association and a cochair of the subcommittee on the American medicine we have group and the subcommittee is on life Dr. portability and I bring this up because of the last of the couple of days the number one issue that keeps coming up is the problem around licensure and as a state policy person, that is a big deal and when you mentioned coalition, this is a perfect opportunity in our little subcommittee we invited the PT OT and speech and hearing licensure boards to join in with us in our conversations around portability of of of the things they keep saying, why are we being asked my happen to know by research national Governors Association everything using a problem that we have Fortran want to be able to progress the cross strait line they are not necessarily being involved and we know it is a big obstacle and we need to have them involved and I just want to put that out there is something to consider and bring them in and help start talking with them and that is what it said on a national basis but nobody is doing and nobody is actually doing it. I think they want to be invited and there are some possibilities thereof the other part of this is, sometimes it is not always the boards that are driving this and I look around and I am wondering where the AMA is on the sign out there has been a major obstacle, not necessarily the medical board they start out as trying to make it different than creating special licenses and trying to do things going the can down the road on a policy level the AMA has not embraced this that makes it difficult for all of the other groups but if you want to put that out there and I welcome your thoughts on that. I will jump into that one. Thank you for serving on the group was ATA, I appreciate that. As you probably know that Alan is on our board and very actively involved than the ATA is aware of the issues and what position to take. Amen state medical board a lot that goes into the picture I have been some changes recently which is the ability of the federal side the console. Not have a license to see that they're providing care to a patient rapid changes and talk at the national level and Medicare having a similar requirement in there is talk about changes in what I can tell you, we are involved more and they took a position the sure they want ATA to be very actively involved and the push for change in the past it has been more passive than somebody invoked Winston Churchill, we have --we will in the air, we will win on the land, we will go after this pretty aggressively. Bigger business interest, integrated health systems and care organizations, across state lines, consolidation of industry it will drive a lot of the issues and, line concern, it is all about money and I think once you start bringing people in these larger systems I will watch and see what happens and in Boston the particular as they begin remodeling their systems because people are moving rapidly across. Supporters. --Various borders. With content on the licensure portability grant and I could tell you we have nine days seven of those represented all of the licensed clinicians and practitioners and that the state level I totally agree, we don't do a good job and that goes to 1998 and the more collaborative than one more question and we're going to close. I am Bill Applegate and I don't want to end on anything but a rabble rousing note, see you go. I am appreciative of all three of these organizations and a member of them and I want you to know that I have been involved in nominal ways over the last few years and something else, you respond to what your members want a great deal and I want to sympathize a little bit with Alan that I have any of these numbers are when I asked this question and is primary for Alan and maybe for--and I won't let Stewart off the hook entirely. Tell me why the world of healthcare is so focused because the money is there and chronic disease in managing chronic disease that the national world health Association American Public health Association isn't more aggressive demonstrative and leader like in addressing those particular issues and I don't want to be terribly critical but I do think, that is where the money is that is where the opportunity is and when I look at meeting schedules and events that you have things like that I am impressed and. I have terrific they are lots of attention as managing chronic disease in that country. Thank you for that softball questions to close the agenda with. I say the question begs a much larger question and I won't speak but the national health is officially asked 21,000 members for submissions for conferences to set educational content and added the 207 submissions we have a planning committee of 25 members the select that agenda and I have to be honest with you the submissions have not been there and that is not that is, the raises the larger issue of where you said from a membership perspective, where the focus is that and what the attention is put on for people involved in delivering and receiving oral healthcare. I think we decided the solution to this problem is through bundling primary prevention of that pre-primary prevention of looking at things like the--environment, food systems, trying to build transportation system and looking at how we reviewed with a fair amount of money time and effort in doing that and the affordable care act we are very much involved in all of the clinical preventive health services attrition and tobacco and the look of the leading causes of death and disability that goes back to tobacco and was you get back to that one the range of nutrition and activity and root causes and we have been very focused on trying to engage this and we are pushing a big rock up the hill and trying to get the public to embrace that change and the prevention fund is designed to engage communities and recognized until my grandmother and her uncle and her daughter would love to the legislature to tell them that we want change it is not going to change and they know exactly what I'm going to say and when we get that ever anticipated messenger coming up somebody from the utility company or the grocery store, the CEO coming up for time that we have to have fundamental change for a broader health perspective, if we are serious about getting cost down, the cheapest way to get Medicare costs down is not that sick people at the Medicare and the best way to not do that is to give people a healthier lifestyle from the beginning. And we have worked very hard to try to change the perspective than as you know, there has been an enormous assault on the public health prevention fund and we have had very focused and in that battle for infrastructure of public health in addition to additional dollars we have for the affordable care act that is were spending our time and effort that we are supporting chronic diseases on the international front and locally. I thought you were going to let me off the hook. I did want you to feel left out. From a market perspective, home Telehealth remote patient marketing is the largest segment ATA has a large industry component and standards and guidelines and I think the ADA recognizes the and is doing everything in their scope to be involved in the and that I returned to the comment you made about these organizations staying responsive to mom to numbers, I would let Paul the dentist know that oral health is now on the website. If you want to finish on a high note. That is good. Thank you very much I appreciate it. What they called the speakers on our panel. [Applause] Will the planning committee please come to the stage? Our next session is planning committee concluding remarks and discussion. This has been a full two days that we have learned a lot to think about and we are excited that the Institute of medicine has convened us and to HRSA for finding this initiative to bring us together my hope is that we actually talk about next steps and I know that Spiro have to catch a plane so we want to give him the first opportunity and we are grateful for the time they spend with us. I have several thoughts, thank you Karen and Tracy and Institute the other staff very well supported logistically smooth and I have been a member of this over a decade anticipated a number of workshops and this has been consistently high quality engaging appropriately provocative and among the best I have been privileged to participate in the thank you for that opportunity. The next steps are clearly --fairly clear in terms of short and intermediate term, short term, HRSA can actually begin to task a number of technical assistance and research resource centers with a number of the objectives that we are described in terms of further synthesis further assistance with respect to articulating the critical key essential components of best practices in this regard. And I think that is particularly important because at the second recommendation that I make is that the HRSA actually convene a study with the Institute, there is enough here and the timing of it is appropriate that it can provide enormous leverage with respect to operationalizing the number of the opportunity that are available to us in the short term work could inform that process the mentally and give Institute study group great foundation from which to work so the breadth of topics today were absolutely appropriate and that is to be careful consideration by HRSA to what specific priorities they would want a study to address and I think that is a critical charge to the Institute if it goes that way because the breast is there but for those that is to be effective it has to have their specificity in terms of anticipated gold. Thank you. And thank you all, I apologize for running out early. It is my delight. Thank you. [Applause] The first thing I want to say, thank you to the panel for having such a nice working relationship have a plan the whole meeting it was a lot of fun and I think the today's word. And thank you also to the speakers and I thought the presentations were wonderful and thank you, Tracy, forgetting the live webcast and it was nice that people who cannot physically make it could get in and some people e-mail the overnight and some of our questions could be raised through other people and I found this extremely enjoyable and I think we learned a lot. In terms of my,, some of the themes that came up over the last two days, emphasis on the relationship between the patient and the provider and the technology is not a barrier is something that facilitates a greater access for war patient to get interaction with provider and the focus on the patient versus focus on technology and that was a, Damon and people talked about the--as the facilitator should the focus: technology, that those great guys and trade by the whole idea of flipping the side of service space onto the provider is hesitation as I talked to Karen about that and she said that was a new idea that it was new to me and I had not thought about it now way before so thank you for bringing it back to my attention and I thought that with all the whole lot of problems analysis but it would be against that I can think of a lot of people that would not promote that but it is something to consider. Another thing I am thinking about, the more systematic way to implement Telehealth across the country as I was walking up to the stage these banners at the side of the stage, the thing that is holding up the banner says imagine I am wondering if we can imagine it Telehealth system that work across the country so that everybody could get caree the matter where they were, the appropriate specialist or whatever care they need, the matter where they were, what would that look like Catholic last few days people don't have all the pieces of the jigsaw puzzle and the people had their pieces together and Alaska known for their part would look like in the VA would know what their part look like a we have other people and I feel like we're all working on it together and it would be nice to take a step back, imagine what it would look like and how can each of us play our role in putting the pieces together and the goal that we want and there's a lot of information and the presentation the talked about the studies that exist and all of the evidence is there why do people keep that he like it not? Are people reading these studies? Maybe we need a more systematic way to get knowledge into practice, we can't wait 17 years, technology would be obsolete has to be a way to accelerate the process in two years and 717. And in addition to Medicare, and Medicaid is getting involved, how can we increase the participation of paying for Telehealth and how can we learn from what is going on in other countries? In some cases they are ahead of us and what can we learn from them that is something that we haven't considered that much in these two days but if we were able to do the full-blown study thereof the a component that we should add and the previous life there is a community-based model and these models were identified they were given a grant and they created strategy for application and community could download it from the Internet than they could contract with the model winner and they would God to that community and help them adopt or adapt their project and funding was provided by the government to that model winner to help implement that program and I am thinking, maybe that is something that my office can do that the most efficient way we could take this knowledge of the community and spread across the country so those are the things I am thinking about. Thank you. I agree with what you said, I thought about it a little bit differently but I like the puzzle analogy because I was thinking one of the things that we want to be able to have in our mind is what does it look like if we do it right and what is the model technology enabled it in the future and if we did all of this right, what services, how does chronic disease management, what does it look like when you go to your commission and what does that look like when you go to the emergency room with a stroke or you're in the ICU and to have the model community and I think we are beginning to assemble the pieces of that and what that looks like an the same thing I was thinking and to go through what we are thinking today, the evidence is strong and some of the areas that I think but we also heard, there is an opportunity to do studies using a variety of methodology and later have to be ashamed that we use one methodology for looking at Telehealth and its benefits and I agree with you, I think we need to have a better way to pull together consumptive of the evidence that we pulled them together in some way that is accessible to people because I think it is not only policymakers that the evidence is there, from what we heard today, some people are saying we are repeating studies because people don't know that the evidence is there some mechanism to do that. And we heard there is a explosion in technology that is rapidly changing and it is very hard to stay up with how rapidly the technology changes and get the evidence to finally get out there published the technology authority changed and that is one issue that the other issue, the consumers are going to push the directions that we might not expect. Consumers are going to come up with their own solutions and we are not proactive, there'll be solutions that may not be the best, websites where evidence recommendations are not write etc., we need to think about that and one of the most impressive thing of the level of activity at the state level and during this particular time in the politics of this country I think top-down approaches from the federal government around healthcare are not going to be popular and surgically removing barriers could be and I think that state initiated approaches are not using a waiver for their Medicaid programs and I think somehow supporting the state efforts is going to be critical because this state, of with solutions and we see them in terms of addressing Medicaid reimbursement across 30 or 40 states it will be easier to make federal policy changes and again I was very impressed with the enthusiasm of the states and I think we saw the VA, and the IHS, there are great model that their we have to remember that we are dressing the Telehealth issues in rural areas in the VA, and even in prison and we are beginning to address it and figure out how to get lessons learned applicable to the rest of the organization and have those lessons learned and available to those trying to implement that on a bigger area to the rest of the population and from the last panel the organizations are clearly in support of what we are doing with Telehealth they could the applicant and I would be reminded not to forget tell a public health and again, there are great applications for these technologies to help in the prevention of disease and we should remember about these and health promotion and disease prevention. Great. I want to start by saying thank you was a great panel, a great workshop that I think it was fun to do and fun to organize and most of that point has been settled and a couple of things that stood out to me, one being there is evidence and there are strong-that is out there and another thing, enough to prove to us this works but not enough to help adoption and as we take our next step forward ready to come up with some kind of standard with the--study that Tony is what kind of evidence we need and maybe we want cost-effectiveness data, something that will accelerate the adoption and the standards we should come out of the immediate next up and the application of data public health and how you can make healthcare efficient are going to use it at a population level for population management, reminded me of an article originally came out in the New York Times on how healthcare can be made as efficient as a cheesecake factory and he talked about the cheesecake factory works at a 2%--they don't waste more than 2% of groceries and raw material that is a very high standard and they do it by knowing exactly how many customers are going to come by benchmarking customer base for the last week of the last year they know the game is coming up, they will have lower people and they will by lower groceries and the cackling themselves to make sure they never run out of things but also not to waste more than 2% the keeping a tight control, lessons for healthcare, collecting so much data, patient generated data, monitoring data, given the spark that we have on our team we could come up with ways that would make ourselves efficient and it seems like we have lagging behind industry on other times we can do banking are found the financial data which is more valuable I have a cold or cough or acne, what can't to lower health care and we need to get that sooner or later. As I thought about some of the speakers today, the information that was shared, I started to think, Karen asked me to think about what I would recommend the next steps be worthy IOM or HRSA help us doing our community and the office of the national coordinator and David talk. The issue is the vision versus, the bureaucracy that. The barriers and where one pushes for the latest and one holds to the oldest standards, I am in the same agency in that seems odd to me and how you resolved that the economy within HHS and how do you transform what we heard today to the public policy and how can we help each other do that so one of the call to action, as I call them, for the Institute of medicine is HRSA is a lot like to see the vision transformed into forward thinking to other policy agencies in HHS affect the ability to people receive care and interact with the healthcare system in the virtual space from the direct patient provider consult to have overlap or whatever it is you're using and privileged the evaluation thesis today, my question is, are clearly making this to heart? And I said that people all the time,, help supplement Telehealth I listen to what they are doing, and I think, wow, you're making this way too hard name too that question for myself each time. In Wisconsin with the get the pharmacy board regulations, we did under the physician practice model which is totally legal and we were able to call adjuster our experience and bringing them and showing them you can see down to half of a tent that they cc on video, we have pharmacist at their essay, I have looked into the future. We have no evidence on anything but they change public policy have made it legal for pharmacist to dispense medication outside of the licensed pharmacy. We got dialysis care and in 2006 by because of the body of evidence that fake solution versus technology, I love that and 1998 I heard a representative, I hope he is retired at this point say, that Telehealth is a solution waiting for a problem and I heard that at a government-sponsored meeting and that for those of us that were there and I think that is how public policy the still developed, it is just this thing out there that have a problem it is solving, solution versus technology and I would challenge the institution of medicine, to establish a valid clinical trial design and validate the controlled study design is a cold standard and mashed controlled studies are easy to do, we have a control group if we do it and it is very easy to find the other group in our own organization so I would ask the Institute of medicine to really come out and find that is the gold standard and develop that is our clinical design for evaluating Telehealth. It is not about the technology it is about the people on the process of we heard today I would ask the Institute of medicine to force a model that doesn't allow public policy. Based on assumptions. We heard a lot of assumptions and I think we are mired in the culture that we know what patients want. We don't know what patients want. We have to go out there and asked, develop our public policy based on that. My next challenge is consumerism. We talked a little bit about that I would like to see the Institute of medicine and HRSA establish a methodology that HHS would develop mobile health of public policy consumers push off all the time and healthcare to do something different and we do it because that makes sense we have good outcomes that engages patient in the way that we don't engage with our other systems of care that should mean something in terms of public policy at my last charge, to the Institute of medicine I would like you to continue this work with an ongoing IOM HRSA committee for action focused on integrating technology support healthcare and evidence-based practice public policy and mainstream and I think that was the exceptional work. I have been sitting here as I hear my colleagues say the same things I have been thinking about my desire would be to see HRSA Monday. It because as the advisory, there is so much power that IOM has to accomplish and in my mind I it is now about--I can't open it up and in that regard, we have heard broadening reimbursement, federal and state, that is imperative for us to get our providers on board, both the current fee-for-service model and the payment model and this is that the say with my sponsor is coming from the office of rural health policy that it takes a massive provider to support Telehealth a lot of our specialty providers let them to support the world patient who wanted to support their own so open it up to all. And across the disciplines certainly. Reduce regulatory barriers different this day in and day out. Credentialing privileging of practice it is not spent a lot of time on that but as we talked about dentistry today and my colleague is here, Virginia had change for a pilot for hygienist used Telehealth to connect dentist because it was not in the scope of practice of the policy decisions state and federal that are important and I thinkk as Joe Tracy mentioned for a long time in Canada, look at a new paradigm terms of service and that may actually eliminate some of the regulatory barriers that have been major challenges for all of us. So expansion of broadband, studies on the value proposition and return on investment we have a lot of science and accountability to the payers and the taxpayers in particular so I think this is fantastic and it has been a wonderful couple of days I want to give a special thanks to Tracy and Samantha. [Applause] We have a few moments or questions? Anybody that wants to comment or provide other questions? [Indiscernible question from the audience] >> [Indiscernible question from the audience] It would not just in the plant community, would be able to see it on television is about the one thing that would be useful in getting that message out and one of the other thing we have talked with both Marianne and Vicki who are responsible for the publishing of the journal itself about fast-track articles so somebody comes to me and says they have an article on-is this a year ago, we got that out as quickly as possible for people to see that we have been doing our regular basis and even though it made the there for 6 to 9 months months it is not faster than I would be in the I have also endorsed this idea doing a full study I think it is important, use the Institute of medicine anathema had done a phenomenal job of providing some well-done report have been helpful for us developing medical policy for healthcare and so forth so I really endorsed doing that the last thing, last night, we had dinner in Georgetown were coming back Alexei gas station, $4.99. Gallon of gasoline that will be what drives changes in the consumer is going to drive this change we start seeing gas at five dollars or six dollars a gallon. Thank you. [Indiscernible question from the audience]Outstanding conference a kaleidoscope of Telehealth. We saw from every different angle in the area that I did not hear enough of that I think require some attention has to do with the changing nature of the healthcare workforce not only the retraining of the providers of the physicians and practitioners but the kinds of personnel that are going to be needed in rural communities to be able to support Telehealth I know we learn from our demonstration programs working in rural healthcare clinics, they don't have the staff and it is retraining people like a nurse case manager who is managing not just patients that data and being able to filter that data in the right area and the whole field of Telehealth coordinators and without that in a rural clinic, just of the work that I think we learn that from the work with the TRC and the notion of how scope of practice of the appropriateness of care and working with providers and other areas that need to be thinking about. More attention to the area the kind of workforce that is going to the in the future to support this. We all know about the IT guy, that person is going to be different to support Telehealth to be able to maintain the technology because of that unit goes out, that is going to set the quarter. So if we could include that as part of the scope the need to identify I think it would add to the full range of things that we are discussing. I want to make a quick, about that. And HRSA funded a workforce authority one of the grant project they will be funding is a certified technician program because we don't need necessarily lead doctors to understand what the technology can do that they don't need to be operating technology themselves the we have trained a workforce to manage the data, to manage technology keep it from being inside that closet or on the set--shop for not being used on a day-to-day basis. Another mechanism to support the funding that HRSA provide for training and primary care and other health fashion, a subtle changes the at to add bonus points or something when people put in proposals and they include some sort of training for the providers and if you didn't, were able to create a new program for that I think there may be defensive avoidance when you get your grant your family practice residency program included training in that you get extra points or something like that because exposure of the clinicians, the clinicians on the rural and remote and really need to embrace it in order for to work. There are several models that use the old precursor of distance education and I think is an Arizona there is that dental school without walls were they attend classes virtually there and that in a dental practice their experiences and Marsha followed clinic starting a dental school with the same philosophy the student will be the virtual space but there are the from the first days embedded in a dental practice for their online experiences and the early mentorship that a supervisory role with their instructors. We can train a lot of health professions in that same blanket them trained much quicker it is the old diploma nursing degree where you have 40 hours of nursing training and you are a slave to the hospital for 40 hours while you are learning. We generated some good nurses and three years and they have the practical skills they wanted so I think there are still a lot of that. We can certainly capitalize on top of. I would disagree with Karen, my colleague probably the first time ever, we train our clinicians to operate their own equipment we train them not to fix it, as well the presenters and the real issue there, if you make it does the practitioner within 5 min. late you have disrupted their day for an hour. So they get their the looking get an IT person to respond that we can responded 5 min. so as part of our training of Telehealth clinicians, we teach them how to fix it so they can move quickly through the patient load. To are model, we know the practitioners are so busy all day we wanted to have someone on their staff who could do it within the clinic facility, I don't need to be pulling out batteries and rebooting computers I have a line of patients to see so that is the point of what we were trying to advance. I want to follow-up on the, that Jennifer Lopez she has a foundation in a have to key focuses one of the focuses is on telemedicine and if we did get CNN to do a story on medicine he had Jennifer Lopez hosted, we like it were people to watch. Bill is kind enough to let me make a, Dan for IOM to consider, because I think this is the first step.. But I want to make a plea and became a a lot of the presentations of how we should be integrating a taxi and general health information technology and health information exchange this whole push by the office of the national coordinator for achieving meaningful use and health information exchange I think has to be blended and integrated with medicine because frankly, we see a patient in person face-to-face, their information, we document the event look at lab data look at images and so on. And we document that event and we do ordering and we have a wonderful opportunity to put in decision support they can decrease medical error have greater consistency, variation in care all of those things that are coming out and I just think we shouldn't take medicine along with upbringing that together because I think that is of real value is going to come we're just seeing that on health information exchange side the emergency room departments as long as they have a different, sharing information they secure a meaningful way is really improving our comprehensive continuity of care and decreasing unnecessary duplication of test and improving efficiency and waste of time so I just want to make sure that gets noted that the bank have to be integrated with telemedicine, however you want to look at it has to bring in health information and good health information exchange and eventually not only for this country with the The nationwide health information network and public health information network eventually this is not to become a global international effort because we are all traveling we are all interacting on a global level and so Telehealth have to become the international global issue that this health information exchange they want to make sure that gets noted and has the IOM and HRSA move forward, we need to be looking at were the things get integrated in huffily the office of the national coordinator will begin to recommend that telemedicine needs to be blended with all of these efforts as well. Thank you. [Indiscernible question from the audience] I have some things I want to share with you the most are complementary I want to say I think it was great to have Medicaid people here today. That was smart and I want to tell you, I want to pile on a little more than say how smart that was the why we need to pay attention to Medicaid. Two big reasons of Medicaid expansion we will see lots of state or 30% or more of covered by Medicaid so if you think it is big now, wait for the future and when we can do things with the Medicaid populations we can do a lot of things because the that the test population to deal with and the people are just tough and there are other challenges that they have in mind and there is another reason of the stuff it turns like mad and if you don't know I can give you lots of statistics but they turn rate is phenomenal and that is not the case with Medicare. Health plan would die if they had the Medicare turn rate so we talked about 2.2 years any health plan that is way too long for most Medicaid programs and I want to say that was big and the Family Dollar life take a look at what we are spending on Medicaid by state budgets over 50%, 60% of our states spend more money on Medicaid than they do on the state operating budget. And they have a contribution as a state they have a federal match and that there is the Medicare expenditure for Medicaid beneficiaries. And 50%, 60% of the state and this country more money than is spent on the entire state operating budget. I just want you to know that Medicaid is big and it is big in a lot of ways and we think about the other things that we do the truth of the matter is are spending a lot of matter more than the state operating budget, the state this country so paying attention is really a big thing I want to gradually on doing that. I want to say with respect to the idea of having matched cohort group designed, it is fabulous because without the more facile and being able to do this so I had a brief conversation and my mind has been working because I have a great imagination and I want you to know could be IOM, HRSA, the whole idea is, we have to have some training and really focus on how you do cohort groups of the research design and that can be done and webinars that could be done in a session like this and televised for the world to say but I think that is important because I think they need to be the gold standard and I realized that we need a standard pulley to do this to prove efficacy of things that we gave and it ought not to be a secret or mystical about not the magic and not up to be a non-how to do it has to recently do it pretty accurately. The other thing I wanted that want to talk about Telehealth and what you do with IOM on the idea, I love the comment about solutions and using Telehealth to do it and we need to think about how telemedicine Telehealth is advanced to the stayed there is proof that we need to think of how we use that to leverage solutions to what we do and I love the word leverage becausee it isn't what we are doing it is and how we are doing that is most important we are leveraging real solutions that we have to use leverage enter order to do healthcare in this country we have to leverage technology to get populations. And it is part of the way that we leverage solutions to larger populations we can scale the things that we need to do healthcare without leveraging technology and I just need to know that that is what we are doing and why we're doing it things like that because have to leverage knowledge. The same thing, we have to leverage Telehealth and telemedicine and the last thing I want to make a comment on how we deal with the but it is important and it is selfish but not terribly that this world of healthcare is not going to be changed by the wonderful things that we do, the people's behaviors and all in all he could think about how medicine healthcare professional workforce technology get to the behaviors of people I will go back to my comment the other day that-says it is 95% of diabetes care in healthcare is somehow we have to get that amount That workplace, I don't know how to do it. But if we can't get to that more effectively they're doing it another project going on I think they're starting to get the behaviors that we have to do that are off we are getting dressed up in ADP diving suit to fit in a bathtub filled with 3 inches of water. One quick comment about what you made about Medicaid, you are right, with the expansion this point the tremendous pressure on some of the managed care programs and some stayed, their son, access requirement. Lunch take population you sure you're going to be able to provide timely access to services and somehow would have to position Telehealth is a solution for the people because this challenge is going to be daunting for some of the statee of the Medicaid rolls increase in timely access in some states the there is poor reimbursement for their programs, it really has a role to play to allow them to have a bigger pool of providers to choose from to meet, access requirement. Last point I want to make, know there's going to be a formal report from the media my understanding is in the November timeframe which the my the outcome of the meeting and I would like to see an executive summary written which we could fast-track up there is interest in doing that I can help you get that written and try to help you get that in January so more people will be aware because not everyone is going to speak the report that the Journal is worldwide hundred 57 countries not that we care what other countries might think that I think it broadens the audience that would see that and we can get feedback at the state level. This is about all of healthcare and the tools for improving health of that is another article that will be disseminated. We will conclude on a wonderful two-day workshop and thank you for watching on the web. After look forward to the next step. [Applause] [Event concluded]