Please stand by for realtime captions.>> Morning and welcome back . Thank you first the city. A number of you e-mailed with, andquestions welcome to. Number two of Telehealth and thank you so much to our sponsors thatthank you to the IOM the other this workshop that I want to express my gratitude to theplanning committee member. This morning I want. What we did yesterday and advance thean exciting day have discretion. The focus of this event is to put it to record wherewe 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 rolesof HRSA Sherry.World of healthcare disparities that patient the faith Erlanger urban settingfamily had an inspirational talk five, Nesbitt to that challenge us to continue to providethe evidence and Telehealth and mainstream and Pamela towards the parishes are talkingabout. Moving forward, we had people speaking and presenting the contrary version of wherewe have not present value. We had greatest Goshen on the healthcare continuum and todayplease, to the equally as exciting and challenging.This morning we will open with our first paneland they will talk about the current evidence they and how to integrate that into advancingpublic policy. Good morning and welcome to Dave number two.Dave number one was exciting for those who are Europe yesterday we had interesting discussionon various barriers and the locators of Telehealth. We collectively came to the conclusion thatwe feel that Telehealth can help us achieve. We also suddenly need more evident than wewill start off with something that is close to our heart. What is the evidence days ofTelehealth, how do you now I what are the barriers and created this evidence days? Arethere new ways of doing it?? Is the standard of randomized controlled trial post way toachieve that and if not, what are the more out there solution the The achieved for morecost and better efficiency and how we translate that into policy and to speak to these twotopics I will invite our speakers today.Elizabeth Karpinski and Dr. Lee Schwalm. We will startoff with Elizabeth and then we will follow with a case study of a stroke which has beena very successful initiative in translating what we know about evident that the policy. Thank you very much and good morning. I wouldlike 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 evidencefor telemedicine. There are two keys Journal, that Tele health medicine Journal and fiveothers better formally dedicated completely online or in print to present change researchand medicine and evident. It is better to subspecialty journal and you will find morearticles there electrified the telemedicine Journal. After that has been out there for15 years ago have to do is go look at it and find it and to reiterate, we do not need moresatisfaction 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 sophisticatedsocial flight left of the focus group and looking at, the doctors ready, are the nursesready, the dentist ready they’re traveling the same themes over and over.How are theydifferent? 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, wedon’t need any of those so what is it that we do need? We need to figure out how to advancethe flight. I was asked to start out by taking a semester’s worth of information and thestaff and design course I could good thing it down with how we do research in generaland what we are doing in telemedicine. This is a classic. But of the hierarchy of evidencethat the kind of study one can conduct and clearly there is a hierarchy of importantand relevant and hopefully we are not doing a lot of animal and in vitro studies propertyor to the veterinary reading they’re doing a lot of telemedicine and it is fascinatingand does not quite animal studies so I want to focus on are these and I consider the clinicalstudies 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, evidentguidelines and evidence summary to do things that appear as literature evolved from thebody of of evolved than this is where we are and telemedicine we are saying systematicreviews 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 scientificallysound studies you can conduct a meta-analysis on I would argue that telemedicine that thepoint where we can do the studies indicating we have that body of evidence that peopleare looking for.She met very briefly with fast reviewed the primary design that areout there has to category is experimental and observational and experimental studiesare what people consider the gold standard, will hereafter and here you have the primaryinvestigator assigned then choose the event that the intervention. Telemedicine versusnot. There is all of that control or comparison group of the subject are allocated randomlyyou have randomized clinical trial, community child, lab trial and on the observationalfive, I’m not saying one is better than the other you have observational studies werethe primary investigator of the people in the closures and sometimes very that controlor comparison group and sometimes there is not that is like what they observational studiesare less reliable and valid but I would argue that that is not the case. Whether that controlor comparison group to have a analytic study or is control or cohort study and if you don’tthere more descriptive and correlational are you may have a case.Jury case report or across-sectional study. The strengths and weaknesses of the RCP and I cannot remember a time. Thisis the gold standard there was an argument I want and that we must be doing need to knowthe argument on the other hand that these are too complicated. There is a gold standardafter randomization component. If your perspective rather than a retrospective. One of the maingoals is to eliminate or minimize all of the different types of biases you could have agenerally falsifying hypotheses rather than confirming, a philosophical point it alsoallows 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 theremay the ethical issues and thought it was funny that nobody wanted to be in the studiesbecause they wanted to give of. That is sort of ethical issue had the telemedicine I havenot figured out how to do a double-blind study and whether that is critical or not, thatis a whole other story.RCP have positive and negative. Cohort studies. New York measuringthe same characteristic into your group for that, or issue are disease and they disappearedthey different one parameter only, telemedicine versus the traditional the eligibility andthe outcome assessment are standardized. The weaknesses and to the, there observationaland often not randomized. Patient are select it into which group they’re going to go intobased on characteristics, Internet connectivity. Everyone has COPD but if you have Internetconnectivity will actually telemedicine are they have introduced a bias the people witha that is a weakness there.However, when you compare them by–side-by-side each onehas positive and negative and I would argue in the long line of both of these are validand have been used a lot of telemedicine studies. Again, each one has positive and negativeso most of them are valid and you see a lot of these up-and-coming in the literature thatexists in telemedicine we are seeing randomized controlled trials of about we don’t have towait 15 years to get the result, there are some conditions that we may have to take aday randomized controlled study.Good solid result and a couple of years ago the dataout there published. Cross-sectional studies, they’re generally considered–considered lessrigorous they have any sense, telemedicine is being held today higher standard than traditionalmedicine. These types of studies are in the literature as medicine in general Alan telemedicinedoes one of these they’re criticizing not seeing rigorous enough. Whether standard orwith the help to? Why should the rest of medicine be able to do these and get data publishedin get funding and get approval for reimbursement when telemedicine is not. It seems to be adouble standard these types of studies are just as good and when they’re done they shouldnot be held to a different standard other than anything else that is the done in medicinein 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 ina single point in time and this can be difficult for telemedicine to give the impact is goingto be something more in the long run more likely the short run there a lot of valuableto the information that the-I can be collected as well sometimes they rely on history andrecall which introduces five and if you are doing it in a proper manner it should notbe a problem and typically it establishes associations rather than causality. In my opinion, what is out there in medicineis Association and not causality. These are very useful for developing future researchin the field, however. A little less rigorous but nonetheless, not valuable or informationalcase studies, these are typically detailed provisions of a single case and how somethingimpacted somebody in a unique manner. These are typically with rare events than unusualthat station and responses.These are incredibly useful. This is the type of stories you willtake 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 anysave the person’s life and it went viral on YouTube that was a case study and a clue illustratedthe needs of telemedicine. They look at impacted they usually don’t have hypotheses, thereis no statistical analysis they’re not all of anecdotal because a case study that iswritten up with more scientifically rigorous the map of these are incredibly useful yetoften for a different purpose than what one would think. The case. Is more powerful thana case study these are 10 to 30 subject and typically will not consider it statisticallypowerful that is not what they would consider scientifically valid but it provides a bodyof evidence there is usually a well described treatment or intervention that if the theyare very detailed and occlusion in inclusion criteria, surprisingly.It could the prospectiveor retrospective that the downfall is there is no comparison group. You can typicallydo a limited statistical analysis the lease. –At least. Is of the type of studies we should be sayingin 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 medicineand there is no reason why we should be able to use these have the same impact that therest of medicine does as well. I would like to shift focus a little bit and obviouslyI can’t go over the entire literature of the body of evidence that exists I would be hereforever. It exists, it is out there without a to sit there and fight for it anymore. Ifyou look at the journals that are out there, telemedicine, they have each gone to moreissues each year. Injection rates have gone up the Keeter about that other one. It isa 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 suggestionswe can make to Health and Human Services and funding agencies in general and the firstvideo by to talk about was just published in 2012 and with a review of randomized controlledtrials the highest standard out there, obviously didn’t have enough to do the review of chronicdisease management facilitated, they look at asthma, COPD, heart failure, hypertension.And they put strong explosion criteria in specific method and meta-analyses and thiswas a rigorous study and we had one or more convention than the control group.They coulduse on, telemonitoring, videoconferencing and they were not limited to a type of interventionand 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 controlledtelemedicine studies data extraction, it looked at the number of subjects patient types ofseverity, what type of telemedicine was it? How long did the studies go on? So are theprimary outcomes? Everyone is talking about outcomes. We have a ton of literature andfor the most part they are positive and elicit the results may overall value of the interventionand they scored the value, a five-point scale going from positive, no affect, negative onthe other side. Primary outcome significantly better than the control negatively primaryoutcome no statistically worse no statistic different and they had 20 asthma trial with10,000 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 havea lot of patience and randomized control trial on telemedicine. They do exist effect estimatethey found 73% of those studies favorable there were 65 positive and 43 is rated ona scale I should view of 46% were neutral or as good as traditional and 1% was unfavorabletelemedicine there was one weekly -1 negative Betty so again this meta-analysis of the literaturethat exists on randomized control trials there out there, there are a lot of subjects beingstudied in on these key diseases 99% of the study were as good as or better than the traditionalway of practicing telemedicine came out on top. Trial duration, most of the trial lasteda year. Most under a year this could be considered a week in which I will get into later butthis 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 controlledbut the majority were a year or less so when you look at the various diseases, that theystudied, and you look at the range of the scores given positive no effect there aretwo studies, overall, you could see the majority of the studies were rated as high in erroris 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 nosignificant differences in a function of if you are rated at positive or negative in termsof 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 thisand generate–medicine as well most favorable results are published. Maybe we did not seeenough negative studies because they were published. I find that hard to believe. Peoplewill publish negative results. I published them myself I disagree with their conclusionthat there is publication five. I believe people published the negative studies. Nosignificant differences to the diseases for telemedicine effectiveness as they questionedif this is believable or not if it works, it works I don’t think it matters in a majorityof types of diseases and we found very few circumstances where it doesn’t work. The mediaand duration was only six months can you truly affect observed impact? I would have to agreewith this somewhat.Six months to observe a significant impact of questionable but possiblycould happen and clearly the result of finding statistically significant differences to likethis the studies that go on longer than six months, they second study, they looked at1500 1600 studies that addressed assessment methods and they found 50 studies that qualifiedfor their investigation and basically what they did was review the body of literatureon the method that exist to make him a recommendation for larger trials as well they suggested largermore rigorous design studies and they suggested a better standardization of population interventionsand outcome measures to reduce heterogeneity and combine quantitative and qualitative methodsand do these studies and more naturalistic method of setting that I would have to agreewith all of these looking at trying to do more multi-center trial three have standardizedpopulation and interventions everyone looks at the same outcome and measures could beincredibly useful in this was a review of the review and those recommendations I wouldcompletely agree with.What is the utility award of that impact public policy and aretaking the body of evidence in attacking public policy? I would agree and I would say yesthat clearly one of the things of the body of evidence leads to have allows us to dois to create evidence Lines of the civic clear indication of maturity and we have it. TheAPA is, the number of Lines and these are some of the ones that are out there and arebeing used and if you have a body of guidelines that are built on and derived from the evidencein the literature, that is assignment we have that evidence that clearly these the onesthat have been established am these are the ones that are in the development and a lotof the critical one of the people were talking about yesterday and today, a number of otherbodies and associations of love.American College of radiology American dermatologyAssociation, SDA, they all of this, there is a ton of standards out there and you don’tbuild standards out of thin air you pull them out of a body of evidence. The European codeof 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 thingto do, these are standards and guidelines coming out of the body of evidence that wehave.In conclusion, what are my recommendations? We need to work with other funding agenciesto develop RFP for telemedicine research with specific goals. Large rigorously defined studiesassessing impact preferably multi-center study for you standardized population of interventionsbeen out, combined method, naturalistic settings I would suggest to support meta-analysis projectthese are difficult to conduct their time-consuming you could put a graduate student on but youneed 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 thatresumes are difficult task and it is hard to do them for free but these the types ofspecific 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 togetherand put it in the form of standards and guidelines and if we have standards and guidelines theresearch will get better because people do the research based on standards and guidelinesand you will get payment.We know what we’re doing here is the evidence and here is whatwill the approved and that is the key thing. Thank you. [Applause] Thank you very much. It is a pleasure to behere. Thank you for asking me to join you. I am talking to you about a program I sentthe last 10 to 15 years working on which is an intervention in the field until help inthe field of stroke I was asked to you dated change policies and create new standards ofcare and I’m going to talk to that tell of stroke and frame it is a disruptive policyhave this intervention is changing how we take care of patients.I am a consultant tothe department of Public health in Massachusetts and the Center for disease control my chariotheart 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 wassupported by a grant from HRSA that we will discuss at the end. Value and acute strokecare is entering the question for the station, make the right diagnosis he can get the righttreatment for me right now.That is what it acute stroke evaluation is about right nowthat have taken her out as an early–this gentleman is in the middle of having an acutethe Stroke. Can you tell me what is unusual abouthim besides this Band-Aid which we know does not work for sleep apnea. Anyone see anythingunusual? One side of his face is a well shaded the other one isn’t. To neurologist, the senseof importance of information. His eyes gazed into the right and left faces unshaven hehas a parietal stroke of this is a situation called left neglect this. A lot of informationand it carries a tremendous amount than people ask me why go after told stroke and acutestroke and it seems like it is not the easiest place to go to the high-impact low frequencyevent 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-healthyou had to achieve consensus on the need to regionalize care having centers typicallydesignated to care for these patients having ongoing patient and staff and that of theblueprint it is a we have achieved in Massachusetts the goal is to expand access to rural andsmaller hospitals so many that are under neurologically served.He has to show that rates are improvingafter promote fusion innovation and push for reimbursement of services so that is whatour journey has tried to be without we were new and exciting in 1925, here is the diagnosisof 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 Harvardbusiness cause the popularizing the idea of disruptive changes the world of business andthis is a quote from one of his books about healthcare the challenge that we make is notunique to healthcare the transformational force that has brought affordability and accessibilityis disruptive innovation.If the fine technology of business model innovation in a value network. . The snapshot, 15 years from concept initiationto a sustainable network with 30 hospitals in New England their prior virus six siteand hubs across the country all working together to try to bring this model there and we addedtele-neurology and it has been diffusion across the political spectrum the simplifying technologywith the use of brain CT imaging which allowed us to look at the brain in vivo and the injectableclot dissolve or could be given anywhere, die, standard to enable image transfer.Videostandards the first enable low cost, still expensive, lower cost technology that wasreliable and innovation in the last five years that makes videoconferencing and everydayevents. Everybody knows about Skype, it is a verb now have the Beatles provide technologyfor stroke care? I do not think any of you would know the answer in 19 Q2, they signedwith electric and music industry, EMI and they were working of electronics manufactureand music with a sideline of they were so successful that they had to reinvest cashsomewhere and then take the engineer named Godfrey–Godfrey counsel and you can thinkof you know the retirees slide into the CAT scan and this is a CT scanned showing a tumorin 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 andrestore blood flow: a work such a dramatically increases the likelihood patients will improveand return train near-normal life but if you get treatment the first 90 min.You have an18 fold chance of being helped rather than harmed and we have to get people in rightaway 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 getthe drug rapidly and I dedicate this fortune cookie, don’t just spend time, invested andif we’re trying to get treatment fast it doesn’t make sense to the transporting patients ata hospital with their untradable for focusing on rapid treatment is the right thing to dofor patient and guideline support the concept of bypassing hospitals who don’t have resourcesto treat stroke and certifying stroke centers with external bodies so we created a blueprintfor 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, comprehensivevery TPA capable hospital if they won’t keep the patient? If you’re having a stroke, youwant to go to the nearest place that is going to get you TPA. If it is given properly. Youdon’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 thingsthat changed physician receptiveness and started to drive use because of fear of lawsuits fornot providing TPA. Pretend you are the MTA you drive at the scene and this is what yousee. I have no audio. .. A very heavy–we had a– I would argue, you can Google that if youwant to see it again, Google reporter aphasia. You had better be taking that woman to anemergency room. Turns out she had a complex migraine but there is no way for you to knowthat.That is aphasia that is a warning sign that the public needs to be aware of and severalpeople started calling 911 one that Eric thing that woman was having a stroke of they wereright to do that. What is the business model innovation enabler? Everybody can do it andyou can do it in a way that is transportable from site to site. Hospitals need to purchaseexpertise to stay open for stroke business if you don’t have it in their centers developingyou need to figure out how to provide that service which is a basic service she shouldhave been providing in the first place they are in the short supply and they’re hard toattract the easy access via tele-health at a distance and lower cost and access to ahigher-quality and those are high-volume providers and there is plenty literature to show thatproviders 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 haveone practicing neurologist for every 20,000 Americans and that means 14,000 to 15,000neurologist and 40 to 50 strokes per neurologist per year that is manageable. Many do dementiaand back pain but they don’t do stroke. That is intimidating. More importantly it is aresource distribution problem. This is the line for gas in Egypt last year if you’rehaving a stroke you want to be in the back of the line waiting to get in. We want tofigure out we allocate expertise and make it available probably a that is what willhelp those. Some people are not supposed to do that but no one told us. So this is actuallymy younger brother, just kidding, this is me in 1999 the first prototype acute strokeconsult using a quick cam.15 frames per second, 16 shades of gray and it wasn’t pretty butit was enough to prove the concept that could evaluate the patient, do the scan, make thedecision and we knew we had something to offer calcite hospital and what it looks like, thereis a patient with a physician provider at the bedside, there is digital imaging, theyget encoded, sent to look distant location, they have hospital and the physician can beremotely located, and the hospital, nurses can screen, they become essentially case teachingevents. You can zoom in and look at the face, these are shots from the late 90s when wewere using dedicated boxes and now everything is PC-based. And we showed in a similar paperthat the quality and reliability of doing that NIH stroke scale structured neurologicexam at the bedside was equivalent to an observer remotely and an observer at the bedside theseare subsequent studies that have shown a confirmed that the rates of agreement can increase higherif you create more clearly defined protocol to score these tests and this was the bedrockof thing we can do what needs to be done remotely.This is the first patient treated back alley2000 he was 88 years old, collapsed on the beach and here he is unable to lift his rightarm and his head is turned to the left and he had a CT scan and got intravenous TPA asa persistent occlusion at his not benefit from treatment for many patients do not benefitbut if family was grateful he was treated with comprehensive level stroke care at atiny community Hospital on an island off the coast of Massachusetts. Part of the reasonwhy you need acute stroke expertise that is hard to read a CT scan and here they settlesubdermal 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 thebrain.We publish analysis of the first two years of the pilot demonstrated not only thatthe therapy increased public with of treatment and a statistically significant manner itdid 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 anotherperson 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 strokecenters in the community focusing on providing care at the community level and evaluatingand treating more patients with TPA more reports than remove reviews showed it dramaticallyreduces TPA when dramatically resources are lacking. This is a brief comparison to showyou the symptom onset was what drove-drive the benefit. Until stroke programs make ruralhospitals behave like comprehensive teaching hospital because his to the conventional approachand this data was her front door admission and in Ontario that transfer everyone beforetreating them treatment time for close to 180 min. and this translate to a substantialdecrease the longer you have to wait for treatment. We also shouldering the supervision of TPAby telephone or telemedicine before transfer is feasible and safe we could hear the outcomeof the patient treated in the network versus the front door and they’re no different. Wedid not have enough of a sample size to distinguish between telephone the telemedicine but I thinkthere are some significant analysis that can be done there.There is scientific statementfrom the reviews of level I recommendation to include the stroke scale of equivalentshould be used when a person is not available at the bedside. Stroke specialist radiologysystem appropriate for identifying exclusion therapy and is highly recommended they providemedical opinions about TPA youth. Mimicking the recommendations that are in place forbedside use. We have a tiered system that can support aggregation of appropriate patientthat the high-volume comprehensive centers and there are additional techniques, catheterscan engage a clot to pull it out directly and you can see a poor and after picture showinga blocked artery and full restoration of blood flow after a brief time, 40 or 50 min. thesedevices are revolutionizing the field of acute stroke care apply to the need for a tieredsystem of care that can be supported by tele-health it is very important and Arnold want you tostart improving your stroke.If you don’t you will be getting less reimbursement orless patient with public reporting about, to the started two years with meaningful useof the inclusion of stroke in core measures hospital for other website will show performancein stroke if you don’t have the expertise you are going to be bypassed if you have theexpertise you’re not doing a good job people will vote with their feet. It is very importantthat hospitals have an incentive and it is part of the disruptive value network and theyget 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 providersatisfaction local emergency room and improvements in overall stroke care anticipation defendthe relationship and open the door to access additional services.Clinical trials, it startsto build deeper relationships with the community to drive demand for the delivery models. InMassachusetts our network is 25% of TPA we have 70 hospital we’re making a big dent andwe are showing the rates of TPA youth have increased substantially but it is not justthe big hospital we have a stroke center designation hospital in Massachusetts and many were onboard to be certified because they had these programs in place it is not a discriminatorof big versus small, level the playing field the hospital get to extend expertise intothe community they grow stroke business and attract patients for innovative treatmentand clinical trial permit this patient defense relationships and allow them to deliver traditionalservices and not just innovative services at the hub level a cam increase provider compensationand satisfaction and I’m getting that care to a broader audience of patient and her opportunitiesto academic growth and this is a cartoon you can see they have across the United Statesand within Massachusetts and Maine and New Hampshire you can see how widely distributedour site are we are penetrating into rural areas within the meaning of subpart of NewHampshire and Western Massachusetts.This is a network that looks like ours but it isin Germany and is run by a colleague of mine who demonstrated very nicely that care deliveredat the major centers of equivalent to that delivered to the campus community Hospitalcompared to a control group of hospital that was not participating with the care with significantlyless than what they have shown nicely creating stroke unit allows the patient to remain atthe community Hospital for the duration of their care they have used this model to encouragethe German government to fund the model across other centers in Germany and if you look atother 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 strokevolume that continues to increase and we give over 140 cases of TPA making us one of thelargest volume centers in the country and our physicians our expert every time theyenter a new case they come through the tremendous amount of experience, more than what we wouldhave gone without this.We have traded for the 1000 patient at our hospital and you cansee for total stroke cases we treat 37% of all consult which is remarkable. If we getcalled 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 beacute stroke many are subacute, hemorrhages, TIA, seizures, and you have to. For that.Total stroke, thumb interesting work in Arizona looking at cost-effectiveness demonstratedthat basically there is a breakeven at 90 days and for a lifetime horizon there is aline separating instantly and it is very cost effective and lifetime of disability is–forthe fifth.What is happening in the field, if you Google public telemedicine stroke youwill see 37 publications in total and 33 the last year and the activity is starting toheat up when I ran the search of May 2011 I got 24,000 per tele-stroke on Google and88,000 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 accessto broadband are going to translate to disparities in healthcare not at the home at the levelof the facilities themselves and the national broadband plan the president released a yearand a half ago one of the boxes was about tele-stroke and described a patient in late40s early 50s that a stroke and was taken to a community Hospital South of Boston whowas affiliated and received treatment have recovered as an example of how broadband accesscan mitigate some of these disparities and if you can play this clip, I want to showyou what this means for patients, not just for us in this room.Beverly was 51 years old when she experienceda stroke like symptoms and went to her local hospital 50 miles away from Boston using thetele-stroke program they determine she was a candidate for TPA. Here she is being examined. They were tryingto get the exact time because that was crucial. We got a 10 point is though they knew thatI fell into the times the. I was fortunate enough– all right. Basically, she had a strokejust 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 50miles away from Boston. I am not going to belabor that but she recoveredfully and was spared 30 years of living with major disability and she knows what that oflife because her family member went through that and to be able to translate that to thelevel of what it means to patient this extraordinary. So, to to federal funding we cannot affordpicture 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 aroundsustainability not initial funding.We just had approved this last week, health reformpayment which includes reimbursement for telemedicine services. We don’t know what this will applybecause the regulations have been written that the legislation is landmark for us. SoI will finish by sharing with you the results of a survey that we did, environmental scanningprograms and total stroke services these are the location of a fight responded to the survey’sand we found that have the support folks that are only 20% of the time with of the formalorganization I work for the vast majority support hospital that are not of corporatenetworks 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 respondentsthought they would be expanding the code scope and size that provide services for 95% high-qualitytwo-way video and 70% reviewing brain imaging is a part of the consult process and manyIncorporated telephone only and these are cartoons of the different ways in which peopleare receiving services.A model like I described and profit companies are further separatingspokesman not by eliminating the house and having physicians provide these as a one-offconsultative 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 emergencydepartment consultation triaging patients with high on the list and not much else metthat level of recognition of the event inpatient consultation community benefit was an importantfactor as well improving clinical outcomes reducing cost was at the bottom of hospitalthey’re not looking at this as a cost-saving approach is improving quality reaching outto provide care. Only 50% had a dedicated software package they were using for the sitevisit 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, manyrated lack of infrastructure funds of the highest and lack of physician Diane at thespoke with the second most important and a lack of reimbursement and lack of evidencethat the bottom of the list, that is not the issue but if you ask them what the singlemost important barrier to get rid of, they say inability to get gain licensure as thebiggest barrier and lack of infrastructure funds a lack of physician buy-in is low theyare worried about how I can get this up and running.So I would argue it is not aboutthe technology, video support the trust relationship that is needed so it is not about more andbetter technology is about eradicating conventional barriers. I went with my two slides of recommendationsto promote the continued growth with federal grant is a cost-effective means and I am framingthese in the form of tele-stroke these apply widely to a broad category of diseases andassured access to care and any where patients are neurologically underserved many communitieshave barriers where there is no access to specialist relation to stroke and simplifyingthe administrative processes that are frequently different in each state to present a barrierto accepting stroke expertise require federal third-party reimbursement at rate equivalentand using critical care billing codes: there is a problem but they require physical proximityto the patient if you’re face-to-face for two hours, it doesn’t Some of the codes thatare most appropriate and encourage the use within a few days stroke system of care modelrather than transactional model because that is what addresses access to care buildingdeeper relationships to hospital the require the five provide stroke care to participatethey have to measure and report outcomes of that is the stick the comes with the carrotyou get support but you have to report.And I think we need funding to determine the mosteffective model, we don’t know which is better we have hypotheses they should be tested andif they could be applied effectively to the condition that they have access to broadbanddecision something I alluded to but should be study provide funding to measure the actualcost of tele-stroke versus conventional delivery have right now are using estimates from studiesabout the impact elite clinical effectiveness research to see what the true cost savingsare and I would argue that we could convene a committee to gather together the evidenceof the current barriers to make recommendations and create a clearinghouse of informationfor states patient the provider so benefits of work like this become readily accessiblethe parties that are interested rather than having to call the restaurant rent and searchand multiply on a variety of sources and not get the best information.For that, I willthank 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 workand research method into a 20 min. session. And thank you for sharing a very interestingway of approaching tele-health in general and tele-stroke specifically telling us howyou can translate that into policy, it was interesting. We have 25 that for questionsand we have to microphone account of the microphone and will alternate.Good morning I am from the West Virginia school’ssick medicine. –. The technology very or. 12 years I was chief technology officer. Iused to this kind of failure. Okay. West Virginia school’s sick medicinein the West Virginia tele-health alliance I want to complement both of you, excellentpresentation and I am struck by the kind of contrast in perspective and I want to questionyou about that and why the Fed cost, reducing costs with low, four points higher, with increasingrevenue. They’re still looking at the money. It is interesting because total stroke isobviously beneficial and you have this string of recommendations to increase the adaptationor 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 nothingto do with the evidence so you are looking at his political spectrum of what people thinkthey want and don’t want and why and with regard to the whole larger studies you’retalking about an evidence-based, there are ways to aggregate that so we can pull thatout.To our legislators want to suggest another area that needs to that carefully with regardto the patient center medical home on the movement I contend that rural communitiescannot provide patient centered medical home they don’t have resources or facilities, itadds to the cost we need to be looking at how the entire spectrum, including telephonesand fax machines, how they contribute to prevention and to coordination of care. So that we canimprove the quality of life without having to bring people into the main medical center’sand 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 terriblethere is nothing you can look at the tells you anything.I would put the same challengefor tele-health and medicine, can we look at how these resources can help fulfill thepromise of the patient center home, the AAA them, and provide the kind of evidence willbe accepted because we know it is not about evidence, it may fit preconceived notion forpeople 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 literatureand making smart homes of putting in sensors and cameras and other things around the homethat is incredibly cost and efficient, it is impractical but the problem is, but technologyhas changed so much that you can literally go on the web and find these devices for verylow cost.I could put them in to my parents home, call at the call center and say, I havethe equipment, can you do the monitoring and so on that has moved so rapidly and changeso rapidly it is almost impossible to do an effective study and get the results out andpublished within the year because the technology has changed so much. Technology is going tobe off-the-shelf people are going to be buying it, it is going to go to commercial centersand we’re going to see development and software algorithm and sensor monitors and want tofigure out those algorithms and get those false positive rate can the true positivesare going to be up there and once we figure out those algorithms and the mechanism bywhich 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 difficultand in rural areas, the cost is dramatically dropping.The feasibility studies are thereand everybody is going to be using it the question is, can we get to sit still longenough to get the get data on it? I would agree with that and I will try torespond to the first part, the reason why total stroke of the perfect storm. It is anacute low frequency event that requires access to a high level of expertise without havingto touch the patient so it was right for application in hospital were willing to pay money outof their own capital and operating budgets to purchase this service because policy wasmoving ahead of the business model to say this is a healthcare right issue, disparityin access is not acceptable the fast change in hospital had an incentive financially toparticipate I don’t see that president in the fee-for-service environment the good newsis that health reform movement that is moving across the country and the most recent healthreform bill is moving us towards–rapidly within a couple of years, more than 50% ofour patients will be under so kind of global payment and that of the movement to liberateresources to allow hospitals to the and medical homes, better approaches to maintaining secondaryprevention, maintaining continuity doing a better job but have never been able to billfor and have resources for this allow the to achieve the goal for which are being paidand reducing events and reducing costs and I think that tele-stroke is expanding andwill become a fixture of how we take care of patients.It is almost guaranteed thatit is here to stay. The adoption has been so widespread that I don’t think it will gofurther than that, to start to rethink how they payment models are structured so we canhave hospitals know they can invest in the infrastructure and access to people there’lldid some downstream return on that investment to defray the cost. That the investment isgoing down dramatically that barrier in the past with the hospital saying they neededfederal funding to get the there already-I federal radiation involved and their workstationscost $50,000. The–have approved the application on your I had and with proper lighting conditionsthey can read these images often than I’ve had. That is dramatically reducing the costand hospital has to invest. Buy yours now for 10 or $99. It is an FDA approved device for reading CTand MRI images. We started we have boxes the size of the stableand now I could do it off of my iPhone. I don’t because it is not the proper environmentbut I could if I wanted to and we’re just going to see this ever-increasing generationof innovation and innovation–evolution.It is like the ATM I am old enough that I rememberwhen you could not go to the ATM. Many of you remember Deutsche Bank to get cash inwith 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 thebank than other brick-and-mortar buildings and then in the mall, and kiosk. People areready for videoconferencing because of Skype and saying their grandchildren and 30 collegekid, it is part of what you do on an everyday basis and it is not frightening and societyis getting more ready for tele-health with the adoption of these. I studied emergency and I have a, then a questionin the comment is about the need or lack of need for studies for receptivity and readinessfor change that I thought yesterday and today were they say and I believe there is a rolefor these studies negative studies cited as negative in theacute care setting, service understanding for understanding why they may not want touse this technology in my question is about the state of the literature I did not seecited as a limitation of the systematic review the idea of the control group were what theright control groups are for telemedicine evaluation so one theme of the conferenceof them the telemedicine should be considered regular clinical care provided in a differentway and not paying telemedicine is a tool for quality improvement and my sense is thatshould be compared to less expensive quality improvement tools traditional education andoutreach about making the control group nothing regaining the literature of it to make itappear that it is better that I might be compared to a less expensive alternative that I’m interestedin your perspective and if you think the existing literature adequately reflect the right controlgroup.I am a firm believer that we need controla comparison group and you cannot study something in a vacuum but I think there is a whole varietyof ways and depending on the intervention and the treatment some respect that is goingto define the control group. With the TPA, that would clearly define current have thatwere obvious what you should compare it to. Someone coming into the door and a strokecenter versus, coming into the door in a non-stroke center, the problem, that is why one of therecommendation implied and that was the natural control group was to do this and more naturalsetting studies that we have been doing are very contrived that are specifically takingthe group and you’re going to be the controller and it is quite obvious that is not what theywould normally get it is a short-term study and is probably not the way that treatmentis going to take place in the future once the that he hasn’t done that was the recommendationwas to this in natural settings and circumstances where the patient will go about their normalbusiness myelopathy define what the control group is.What I would say, is to make itas natural as possible so whether it is asked treatment and the circumstances we are sayingstudies that are mixing interventions and you don’t have that thing happen traditionalversus telemedicine you have different degrees of telemedicine intervention for example itis just telemedicine telephone versus telephone with the video added profound degree of traditionalnurses visiting the house so what we are doing is evolving toward something that is morenatural and back to the point about we donate to any more receptivity studies, a lot ofthis can be done at the local level and more in terms of education, we know what the barriersare and I would disagree with you. Those types of studies can be done on a local level tounderstand your own organization but you don’t have to publish that. Because somebody elsehas done it. It may not be your exact situation and when you do in your exact situation you’llfind the same result and it is incredibly useful for setting up and getting the by andthat she wanted a local institution, but is it worth publishing, is my point.I agree with everything you said I will takea different response to your client the first 20 were making was more about implementationresearch just because we know the barriers, what we don’t know, is one of the best solutionfor the problem with LOL it is an intersection between technology and human behavioral aretrying to change the behavior of a multiple number of providers across multiple institutionsto achieve a certain result and that is what I think is an important role for evolvingsocial scientist and personally, a cluster randomized designs of the right way to gobecause the problem with saying on Monday we will do that tele-health and Tuesday, non-tele-healthand you contaminate the providers at the remote site once you start changing behavior in aprofound way by providing education and interaction your provided way more than the tele-healthapproach for creating a structured environment for your increasing the level of care andthat naturally contaminate the non-tele-health encounter and that is because part of whatis doing is not just bringing that for the whole systematic approach to the disease andprotocols the better patient identification and connection with the peer institution hisopinion is valued there is a lot going on in the most effective ones have been identifiedhospitals 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-monthare one year and crossover so everybody gets intervention.That is the wayside so the willingto participate. Is Elizabeth pointed out, the way this technologyget used, I don’t know any site that does IOM full interactive videoconferencing thatrequires videoconferencing every single time. You start with a phone call. The decisionis made, the escalated video? The idea you would force everyone into a paradigm has thepotential to introduce bias in ways, second favorite intervention are the control. Theseare important and challenging statistical methodology questions and to a certain extentthey are shaped by the actual intervention with some of these could be addressed at thelevel of a consensus committee or a paper around study design that the other organizationscould do.So there are a lot of methodologies that exists to study these sociotechnicalperspective and you have to work outside traditional literature to find it. They’re using telemedicineat case studies and case examples and that is where you’re going to find the types ofthings you’re talking about the impact on the social technical system and batted thisand you have to find it. Good morning, I with the Center for connectedhealth care policy in Sacramento California I want to echo the comments this is an excellentpanel it is critical we are able to demonstrate the evidence and two points I would like tomake. The first has to do with how we talked about Telehealth and heavily demonstrate theevidence and the benefits of Telehealth. Technology enabled healthcare is a very broad encompassingfield and it is important when we use language it is important to talk about synchronousTelehealth our home health monitoring we heard yesterday very few states reimbursed for–letalone remote patient monitoring.We need to develop the evidence specifically to demonstratethe quality and effectiveness and quality of those interventions and the second hasto do with the national quality strategy in the moving towards AAA man the center wasforming a policy in California to pass landmark legislation and it was fascinating processbecause we were able to make the case clearly in terms of quality and improvement of servicesand what the legislators wanted to hear was cost-effectiveness and tell me it is not goingto cost more money, tell me that you can save money and the body of evidence has been movingtoward demonstrating quality, which is important, he referenced the MILF study you can showcost-effectiveness and the contact as a field, if we’re going to influence policy at thestate and federal levels any to begin to understand that they talk in different ways we talkedabout evidence and cost savings is a language that our government are interested in thewe can make those cases.Thank you. In my own organization, I spent a lot of timethinking about ways in which you could make it more cost-effective and we have lookedat options and we have looked at bundled payments around diseases like stroke and I agree withyou about the size and our language, thought what Telehealth means you have to be preciseabout 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 becausesome of these may save the patient money that is not currently accounted for and healthcaredollars.If the patient has to drive three hours and their daughter has to take off fromwork, drive down, part, have lunch, Phoebe for 30 min., get back of the car and repeatthe exercise, there is a lot of money is being spent by that family that nobody is currentlyinterested in saving and so they want to know how to make the bill lower.And what Elizabethwas alluding to about the idea of software algorithms and ways to process informationthat doesn’t require human labor. It is critical because my time is my time and access to mytime cost the same if I am doing it in person or over video and we’re going to see the potentialthat Telehealth start to the road the value of physician time and nurse time and providertime because the remove barriers to the makes access more feasible why can we cram moreaccess into the same day and so I don’t think it should be thought of in terms of increasingproductivity the challenges to say, how can we reduce utilization, how can we use systemto obviate the need for a person to look at it when the machine can look at it that wehave a nurse practitioner providing care with support from the physician that we have thephysician providing care and support from a senior position–physician and to get everyoneoperating at peak capacity and using telemedicine tools for connectedness through to be limitedby geographic proximity so that is where we will be able to show cost-effectiveness sohave to be precise about true cost of where we are saving them.Definition of terms that cost analysis oflaw which is what I talked about before, a standardization every circumstance is goingto be different but it is very difficult to compare cost analysis studies because theytake it from one to the next and this one will take into account the amateur divisionof equipment cost and this one won’t. So there is no standardization so this study is goingto looking at your program and somebody will come in and look at it this way and use thesame data and they will come up with a this is nowhere near cost efficient and lookingat the program in the same like, how can you come up with to radically different conclusions? Doing studies in tracking cost which is anoverhead because it is expensive and you have to track actual cost over time if you wantto get the real cost.You cannot divorce quality from cost and thatis a lot of think we are attempting and in radiology, there is incredible valuable circumstanceswhere MRI is incredibly useful and they’re using somebody cut this is not allowed, youcannot do the MRI because it is too expensive and the quality has been demonstrated andeveryone will acknowledge it expenses that we are saving life. You have to acknowledgethat you cannot divorce quality either. Michael Porter has written nicely about thisand you can find some of his work online and the value equation is quality over cost andif you frame it in that way, physicians and other providers will engage around that equationthere is a nice editorial talking about efforts related to this and how to implement thisequation actual payment care.Thank you very much. Thank you to the panel my name is Carol atthe 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 comparedto the 2010 back is a very important motivator and I am wondering if you should look moreabout what can be related and what would have a promising effect. And the hub and spokemodel and it relates the public by and–at Harvard talking about the consumerizationof 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 pieceand getting the public outcry. After all, serving the public and why are we lookingmore at that and leveraging it. Let me respond to the first thing, we arein 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 arebut we have a fairly–we are fairly advanced and we have a single modified record in partbecause of the contingencies cost inefficiencies associated with the active it is clear wecannot do it without an integrated platform nowhere is the integration a key priorityto selecting a vendor, then at the front of the table it is an afterthought and I wouldargue as organizations in the next two years we will start to embrace and make these decisionsI need to put the vendors to make it clear the links will be there to incorporate Telehealth 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 becomea process in a message those connections have to be to everything that we do so that isvery important in terms of the public outcry getting the public engaged, it is very engageand 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 connectednessin a way that we have not been ready to grant so we have to the working with public activistis not the right word but interest groups, disease-based organization that advocatesfor patient, organizations like that figure out how we can create metal layers that providepatients with trusted sources of information trusted relationship that require ubiquitous24/7 access to me as their provider but to my network as a place that is what cares forthem.Both activities are taking place there a lotof patient advocacy group a lot in DC, the American telemedicine assist patient is workingclosely with them and we talked about going to the Hill, these groups are going to thehelp talking to their senators, representatives and so on and abdicating and you don’t hearabout it as much as you do and you don’t publish the results the boy are they powerful wasthe don’t think that they are not, they are out there and their abdicating.I think that is all we have time for. I amsorry. 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 PatientsLike Me Mohit Kaushal West Wireless >> We will startright 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 somethingrecently and someone said that over the next five years the most important person in acare team is probably going to be a mobile app developer. It probably is not that outthere, but it could be possible. Today’s panel is going to take you a little bit furtheraway into the future. We are going to talk about how mobile health and mobile phonesand 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 importantand how we should be prepared. Keeping with that, I am going to quickly introduce ourpanelists for today. We have David Muntz come of Bonnie Britton and Dave Clifford and thenwe will talk about the future of wireless health. With that further ado, we will start off withDavid. >> Thank you — you can tell that I am not fromaround here. I appreciate what the doctor referenced here — the Field of dreams — Iam a movie buff and I am it is one of my favorites — if you build it they will come — thisis very popular and I really believe the reference there is appropriate. I wanted to use it earlierthis morning.I appreciate you doing that. The truth is, when you talk about — if youbuild it they will come, they were talking about the players, not the people who weregoing to be there in the audience to see it. What I would like to spend my time is talkingabout how to get the audience to come and right now we have not seen a lot of progressin that area. We see right spots and I will try to quote some of the figures that showthe challenges that we have and what I would like to do is get everybody here to feel somepersonal responsibility for hoping ring everybody into the Field of dreams. We have unbounded expectations. The fact isthat I carry devices on my hip. I expect them to do things. Everybody does. It affects theway that I did work when I was a chief information officer.In fact, there are different planninghorizons that we used to have. We used to have short-term which was whatever you definedand there was midterm and long-term. Well, I think what as happened with the presenceof the mobile devices is that we have a new planning horizon. That is the media to — immediateterm. The expectations are now that when you seesomething — it will happen quickly. I hear people talking about the studies. We willhave to figure out how to do things more rapidly to get the technology into the hands of thepeople. The other thing is that people will have the technology and we are going to haveto figure out how to deploy it quickly within our own areas. In terms of the roles thatwe see changing, I think that the question is who is going to be the primary coordinatorof care and the secondary? Will it be the physicians or the patient’s? Or will it bethe patient support groups? These conversations are important.I do appreciate and want tothank you to everybody at the meeting. I won’t 12 to much on this because I appreciate everybodyelse’s opinion. I would rather talk about the meaningful conversations that occur asa result of meaningful use. What we really need to do as we deploy these technologiesis get into meaningful conversations where we discuss what the roles will be for therespective 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 outthere. 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 custodianof the data. I had the privilege of speaking to the American health information managementAssociation and now in most states and virtually all — the medical records person or the healthinformation is considered the custodian of data. When I went to speak to them, I saidI think we will see a shift — I was expecting a negative reaction, especially in the nationalgroup where these people are doing the things that they do every day and I said what I expectto see is a complete shift and the logger will be health information management peoplebe 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. Westill 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. Thiswill mean health information exchanges and 70 will have to be the primary coordinatorof care. You think about — I am from Texas — there are 30% underinsured or uninsuredpatients that digital divide is pretty large that we do need to figure out at the sametime are taking care of the people who have crossed the divide how we are going to takeyour 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, beingan outsider — only being there seven months — the first thing I noticed was that thingswere not? Organized as I would expect. I had an opportunity to talk about how we shouldchange the focus a little bit.We talked about consumers, but we did not have a place togo to represent the consumers. Now, with inside the office of national coordinator, thereis a consumer eHealth group that focuses entirely on that. The work had been going on and ithad been going on in diffuse ways. What I will show are examples of how this is occurredand talk about what some of the things we will do our. We do have 3 A. — how to get it patient tothe data — access, action — how did it patient to take action on the data, and how to changethe attitudes about care? When you talk about the market for mobile health — I appreciateyour comment — I have a quote here — by the way, these quotes are all within the lastweek am a so it is incredible how relevant all of the activities are that we are engagedin, but it says that the market for mobile health applications is continuing to growand 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 aboutthe patient because the role they have is so critical. In terms of what the personal health ecosystemis like, continue — they provided a slide — continue I — this is a group of 220 organizationsthat 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 examplesof products that are currently available in the market to do such things as chemistrythrough 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 makesure that people get trained for it? We will talk about that in a minute. In terms of this — this is important. Bythe way, the definition of elderly keeps changing — the older I get, the higher it goes. Mymother is older than I am so I will at least say that I do worry about her exercising enoughto avoid a fall.The question is, what is available? This is a slide from 2009. Thetechnology has been around for a while. The fact is, you can watch what the activitiesof daily living are inside a household. The question is, can you afford it? What is thereimbursement model that was supported? Interesting possibilities already are in existence. Then, the smart car. This is probably a littlebit 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. Thequestion is, how will we use the technology and what are we going to do to gather theinformation and he able to take actions associated with it. Look at some of the challenges — how to engagethe patient. There are some cultural things that go on. There are some discussions — meaningfuldiscussions that have to take place. What do you do to make sure that an adolescentrecord — it is always the mom that should do that? The rules in Texas are specific abouta minor. If we are trying to deal with sexually transmitted diseases, how will you be affectedif you don’t let the individual to you the results? How will you inform people aboutwhat needs to be done? It is huge. Literacy — we talked about the digital divide.Peopledon’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 thepeople using it for a long time or not? It has something to do with that. There is anage thing. So, domestic demographics and politics — these will be affected by that. It willbe impacted by this. Security and confidentiality — all of a sudden said this before — butthere are things that you will tell your position that you will not tell another soul in theworld. Whether it is your priest, rabbi, best friend, etc. Again, getting the patient involvedis huge. It affects the relationship with the provider. Who hasn’t gone into a physicianand said I looked online in here is information and the question is, is the physician goingto be able to keep up with that? We saw a slide yesterday the talked about the increasingavailability of information.Affirmation is doubling every two and have to four yearsin the medical space. How are the physicians going to keep up? Will there be some competitiondeveloping once the patients have access to the same kind of information the providersdo? The rhyolite edibility — the liability of information — people question whetherthe reliability of the patient it is good. One thing that pushes us to when they areassessing a patient is understanding if the patient is a real source of truth. It is thereason that body language is so important during an interview. Well, the other questionis, what about the positions data? How reliable is it? Some of the patients have discoveredthat some of the information in their medical record is not accurate. The question is, howdo you deal with those issues? Again, having everybody look at the data in sure set thevalue 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 orpersonal health record, you will probably not use it if you are consumer. We know whatthe situation is for physicians. If you want to train them, you need to do at the elbowtraining. This comes from years of classroom training that is not affected. Why not givepeople software that is been designed better? We did establish a new office within the agencythat is called the chief medical officer. One of the responsibilities that he has isusability. It has huge implications for safety. So, if the advice — if the device is intoit is and easy to use, — intuitive and easy to use — this will help. The question is — the life work balance — whenyou talk about consumers, instead of talking about workflow, I think we ought to talk aboutlife 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 reallyis 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 instantsleep safety.I happen to be a grandfather now. I can tell you that this is a huge issuefor my daughter. She is very concerned. The study notes that 28.4% of the online searchresults provided a relevant data which is not really harmful, but — 28.1% providedan accurate data. So, if we want people to use data and to come to the technology, andto the information stewards, we need to figure out a way to improve the integrity of thedata. Here is what I think is one of the most ofher Markle evidences of how important it is to get the patient involved. AARP did a studythat showed these results. It is incredible when you have a more interested and engagedpatient 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 anotherto put up new payment models, you have to have a different behavior in the patient.Here is the concern — because there is agap between reality and the title and this is remarkable. 15% were new to the prescriptiononline. How many in this audience have renewed a prescription online? This is a much better audience. At least twiceas good as the general public. Please continue to do this. Here is another thing — again, I find thisdisturbing. It is not that it discourages me, it encourages me to be more enthusiasticabout what we are doing. I hope you will do this as well. Data from the third annual EHRsurvey conducted for xerox showed that only 26% of Americans wanted to adopt digital healthrecords. It also found that only 40% of respondents said that digital records would boost healthcaredelivery. 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 rightand look for them.It is difficult to do what is right for somebody else. We are tryingto do and we have been successful at this — I would encourage everybody in here whois 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 nicefortune of the populace. Both data holders and non-data holders.You can see a lot oflarge 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 healthinformation technology to do real things. There is nothing more impressive than anecdotalevidence. Here is a cancer survivor that was able to dance at his daughter’s wedding becauseof some things that were done and enabled by health information technology. The millionhearts campaign — get out there and get the individuals committed.This is a remarkablesuccess, but we need to do more. We have tried to gauge the developers — engage the developersand 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 clevername. We now have something that you can do now. This ends on August 20. There is moneyavailable. $7200 in prizes and we are not beyond paying this. You can see that thisis an opportunity to tell your story about how you have used technology. I would encourageyou and your friends to get engaged.I think you probably know about the blue button andhow many people have downloaded records. This is available from the VA and DOD. We havebeen in conversations to move some of the activities over to ONC and what we are tryingto do is figure out how to do this not just in data blobs — now, the data that comesis in text format. So, what we want to do is take it to the next level and provide datato the patient in discrete format so you can incorporate this automatically into your personalhealth record and the other thing that is required by the current deployment is thatyou have to click on the blue button.Would like to create a set and forget it kind ofenvironment so that the data gets downloaded to you automatically. I think this will be something that you willsee is working on in the next year. So, I will end with 3 seconds left. — I am overby 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 tosum it up is that you are helping an individual and helping the population. I would encourageyou to go out there. We yesterday released a small cartoon for the public to help themexplain — help explain to them ways that may be more accessible what an electronichealth record and two. This is the link for that. I would encourage anyone who has ideasthat cover today to oh ahead and contact me at the e-mail address on the screen. Thankyou. [applause] >> Good morning, how is everyone?Bonnie Britton My name is and I am excited to be here to talk you about a remote monitoringprogram that is new and unique.Some of our outcomes that we have had. I work for Vidant help. It is located in NorthCarolina — we are the largest healthcare system in North Carolina. We have a littleover — right at 1500 bed. We provide services to patients in 29 counties and we cover 1.4million lines. We are also affiliated with ECUs skill — school of medicine. Here’s amap of Eastern North Carolina. We are very rural. Seven of our counties out of 29 arethe top chronic disease counties in the state. We have a tertiary care center and medicalcenter. All of the hospitals that you see around — there are 10 of them total and ourhealth 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 about150. I want to talk to you about some of the successfulprograms we have had in eastern North Carolina. Being in a rural state and a state and anarea where there is a lot of poverty, a lot of illiteracy, and number one in the statefor chronic disease in several of these counties, I worked previously in another place wherewe implemented a patient provider telehealth model looking at how primary care providerscould identify their patients. Then, refer them to remote monitoring where we would monitorthe patient’s blood pressure and pulse and weight and oxygen saturation as well as theirblood sugar levels. We had so much — so many good impact with the patients that we wereable to expand the program and at one time we were doing all of the centralized monitoringfrom one location in the world eastern Carolina up to 12 community health centers across thestate.Currently, there are three community health centers. These are monitoring patientsas well as [indiscernible]. This is for of total. The average length of saying — length ofstay was six months. The outcomes we had — we contracted with wake Forrest University. Wedemonstrated significant reductions in bed days and hospitalization as well as overallhealthcare. 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 writea business plan and to diplomat a remote monitoring program for patients with heart about thelegacies as well as pulmonary disease.This is for all 10 of the hospitals. What we havedone is — the hospital pay for the program — it is self funded. The reason they aredoing 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 numbersof readmissions for heart failures and acute MI and community acquired pneumonia are goingto be quite significant. What we wanted to do is to try to develop a program that wouldidentify patients while they were in the hospital and then refer them to a telehealth programwhere we would monitor the patient’s blood pressures and walls and weight and oxygensaturation on a daily basis.One of the things that we incorporated which I think has beentremendously important and valued is that we have implemented a patient tool that wasdeveloped out of the University of Washington said. It is a 13 question tool that the nursesin the hospital ask the patient. They get the tool to the patient. Once the patienthas answered their perception of their level of engagement, it gives a score between zeroand 100. It places the patient at a level of activation from 1 to 4. The level I patientsare the ones that are distrustful of healthcare and they fear helped out. They have had anegative experience. They believe it is the doctors and nurses responsibility for theirhealth 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 — 30day hospital agents are much higher. We determined that we would implement the patient activationmeasurement tool. We have it in our all electronic health record. We only focus on patients thatare activation level of 1 or 2. We are focusing on the most unengaged group of patients.Westarted our program in February. I just got an update from my team. We have now enrolled496 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, weenrolled 200 patients into the program and then we obtained 180 additional sets of equipmentand 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 medicalgroup which is the primary care provider. With that approach, we are looking at howweekend proactively identify patients to monitor before they get into the hospital. I wanted to talk about lessons learned.Alot of people are doing on telehealth or remote monitoring in the patient’s homes. I was disappointedyesterday to hear from CMS that they don’t see the value yet in this. One of the bigthings 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 lookedat where we are on the linear graph of value-based purchasing to make our determination of thefocus of patients. We had to shift from hospital care to carethe home. The patient will always be the center. In our program, everything that we do andeverything we say and how we act is to the patient’s eyes. If it is not, the behavioris called on quickly. This is all about the patient. There are a lot of research out thereon care coordination and transitions in care.These are great programs; however, the modelsfor the programs — ratio of nurses patient is 1:18 and 1:30. When you have ratios atthat level, it is hard to scale a program and it is not affordable. Our ratio of justTurner’s to monitoring patients is one nurse to between 85 and 100 patients. This is aprogram that you can scale. It also requires that you change the way that hospital casemanagement 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 havefour of these groups that are going for certification as patient medical homes. They have incorporatedtelehealth 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 largemajority are doing a job 18 and 60. A set their engagement and teach and coach basedon the activation. I want to give you an example. One of the first patients that we had — thegoals for the patients — it has to be the patient goals, not the nursing or positionedgoals.We drove to the patient’s own and it was a 54-year-old patient with heart failureand COPD. That’s bad enough — I said — the number one goal is — what is that? We gotto the home and there were signs on the door — no smoking — oxygen in use. She opensthe door with a lit cigarette and walks in. I looked at the team and said — what is goalnumber one now? Then, we go into the home and there are medications everywhere.I saidwhat is goal number two? Get these meds together. For the majority of these patients, it istiny steps that you are having to take with these patients to get them engaged. I believe in inclusive patient selection andcriteria versus exclusivity or he a to our only exclusion criteria is that the patientdoes 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 referraland enrollment. You need to have a provider plan of care. We have it in the military healthrecord. We have a physician referral in our inpatient electronic health record. We useLPN’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 installthe equipment.I will move forward now. It has to be data driven, as we heard overand over. These are some of the data points that we are collecting. Financial data isabsolutely important. We first started this program, Y. orders were to only monitor thesepatients for 30 days to prevent the 30 day readmissions because that is where we arefinancially hurting. I met with the vice president of finance last Wednesday I was concernedbecause the pre-world hospitals in which we have this program, the last four months theyhave had zero hospital admissions for heart failure. I was concerned that we had overaccomplish, but when I met with him he said move forward and move on because every Medicarepatient and help a patient — we lose money. We have given the responsibility for the financialanalysis to the vice president of finance for our company because there is no way thatI could provide them what they want to hear.EHR integration is critical. We are goingto go live with phase 2 integration between the telehealth enter and at that. This ison September 4 of this year. Before we could get the entire integration, it was a painfulprocess. 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 paidfor meaningful use and they have to come to the plate. They have started initially — theywere going to charge $20,000 for the integration. This is ridiculous. We got them down to 5million. We have built in Black’s and standing orders and — flags and standing orders. Probe lacks — capital for a program likethis. Lack of reimbursement. That is not a barrier for us because we are not lookingfor reimbursement for the program, we are looking at this as a cost avoidance and costsavings for the organization.54% — so far, out of 496 patients, we havehad 65 patients who I’ve been monitored. The average stay is 60 days. I went over the 30that I was ordered to do. They just gave me approval last week to extend that to 90 daysbecause 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 priorto telehealth — then during telehealth and then three months post-telehealth. We have65 patients that have completed — the majority are female. If you look at this, yes the majorityare over the age of 70, but look — 12% of these patients are between 18 and 49 yearsold. We have a 24-year-old heart failure patient. We have a 19-year-old patient with morbidhypertension. This is just settling for me because in my past I have focused on patientsabove 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 fortaking care of Medicaid patients. Our outcomes for the 65 patients — they experienced100 hospitalizations. Three months prior to terror help — telehealth. During telehealththere were 19 hospitalizations in the three months post-discharge there have been eight. This is the percentage off reduction. I have10 seconds left. Hospital bed days — there were 489 bed days during terror 12 and thisdecreased 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 surgicalpatients and other paying patients. Also, this allows for us to be able to transferback to the community hospitals and get the patients back in the community where theyneed 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 tojoining the company. I used to be with the defense advanced research agency. I did alot of work in telehealth Intel medicine. One of the main reasons I came to patientslike me is because they work uniquely positioned at the time as a generator of data. We talkabout 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 getat some of the patient outcomes. Unfortunately, these skills are less than I would like.Wewill talk about that. Patients lIke Me was founded by this guy — Stephenis pretty far along during a progression with ALS — Lou Gehrig’s disease. One of the thingsthey found when the family was going through this — it is a family of engineers. The volunteerdata about people with ALS in the literature is limited to small coworker 12. There isnot — go work trials. There is not a lot of information about what day-to-day lifeis like. You can pick up the book by Stephen Hawkins or you can look at the experienceof 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 tohave that disease or many other chronic diseases with a data-driven perspective. There wasa 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 thefounders was trying to populate a trial or ALS.He could go on OK Cupid and find a womanin his age range and had similar interests and pick out their color and proximity, buthe could not do that for a clinical trial. What is it today? It is a network of over150,000 patients — people who of signed up for this. They connect with others like themfor personalized learning and support. They enter information over time and it grabs theinformation. They have an immediate visual perspective on what their disease course hasbeen 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 amountof time. Or maybe just shared common symptoms with a completely different disease. Theytalk about binary diseases and coworker to these. A lot of this helps to activate thepatients 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 showup.A small percentage of people have small but well. Most people have private profilesmajor they can be access by other patients. Most people use pseudonyms. We know thereis a lot addresses for adverse event reporting. We don’t all their real names. We know theirlocation when they share that with us. A lot of people do not use a picture. People are surprisingly open about a lot ofsevere pathology. They score quality of life — correlated to the SF 36. This is a personwith MS. They have an MS RS score. This is a questionnaire administered to them. Theytake 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 theParkinson’s a score in Parkinson’s disease.In many of the communities, we have not developedscores for literature. The majority of the patients using our site have severe neurologicaldiseases. ALS, fibromyalgia, Parkinson’s, epilepsy — not some of the big drivers ofcare 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 isvisually 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. Thisgives you a sense — of double up. — Epilepsy. I am concerned about headaches. You can lookat this and get a sense for this. You can look at the medications most used in the evaluation’sof the negations and the side effects and how severe they are.Then, you can go intothe discussion on the right-hand side epilepsy where people talk about what it is like tohave in more of a narrative you. — Narrative view. This is the place to come to get togetherand talk about stuff — is there a benefit? In the context of rural health, one of thelargest benefit that we can see is that one third of the people in our community had noone 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 cannotI do support group. This provides a 24/7 access to a support group at two in the morning ifyou are in a small town in North Carolina. If you have a like comparing condition. For a majority of the people with Apple let’ssee, it gives them a better understanding of their seizures. We provide a descriptionof the different kinds of seizures.They go from calling things by the was the two tonicclonic — 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 becausethey do not know about the side effects — it makes them feel weird or strange. In epilepsyin particular, adherence is the difference between continuing to have seizures or not.There is a large percentage of people with uncontrolled epilepsy. This is uncontrolledbecause they do not take the medication. 20% — they are using this to get better permissionand they insist on seeing a specialist.This is positive across the board for many of thesepeople. What are we do? From a broader view, we area novel patient registry. We are a competent resource of data to the remote role in thiscare world. We are more closely integrating with the other data streams as the other datastreams are becoming available. We talk about patient centricity and patient being ownersof their data.Very few care systems have adopted good places for patients to be meaningfulcustodial to the data. So, for example, the Kaiser health system has spent a tremendousamount of effort holding a good patient portal. It is frequently used by their patients andit were present enormous time and enormous resources. On the other hand, something likeGoogle health — they said we are going to create a home for people to upload their medicalrecords independent of their care teams. Independent of other health related environments. Thatwas a catastrophic failure. It is been discontinued. It doesn’t exist anymore. What people aretrying to manage their health online, they are trying to do it in the context of otherinformation. They don’t want to do it in a sealed vacuum. If I can put my prose personalhealth 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 anotherpart 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 thepersonal health information management as a good thing on its own. For providers and care teams, we provide aclinically robust understanding of the patients and real-world outcomes. We aggregate thedata and supply to people interested in the patient information. We divide by directional lines to patientvoice. One of the things that we found is that MS patients, for example, would reallytake their biologic medications at night rather than during the day. This is not somethingthat 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 havethe flu. I’ve patients know that you feel like you have the flu when you take thesemedications so you should take them at night.The drug manufacturers and clinicians aren’tas aware of that information. As we talked, there is an information explosion — thisis 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 dangerof the pediatrician for fighting that information — the person interest in doing a search onpediatrics retrieving that information or low quality information. Part of this is becausein many of these places, they information does not have a doublecheck or another personsaying — 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. Thepeople who populate this are people who feel like they are experts or they have a lot oftime to waste. On the other hand, people with Patients lIkeMe are people seeking health information and have some personal experience to reflect onwhen they are sharing this information with others. The presence of data as an underlyingthing to these narrative threads allows someone to say — I am thinking about undergoing liberationthere at the — it is a drastic therapy that is not well received in the peer reviewedliterature. It involves categorizing a pain in your neck to alleviate MS symptoms. Thereare people who have gone through that.They continued tracking their data. When someonecomes and says I am thinking about doing this — the community can say — we would suggestthat you look at these 30 people’s profiles or these 40 people’s profiles — a set ofpeople who of undergone this therapy — see what happened to them afterward. For the majorityof these people, it provided them no long-term benefit. It allows there to be a databaseddoublecheck for some of his health information that otherwise exist in the wild. This isgood. These are good things. The goal — the substantial goal — buildinga world where every patients is affected by other patients experiences. This is a complimentor a role that patients can bring to Telehealth and telemedicine. Especially in the contextof things I’d remote patient monitoring we are getting data from sensors and we are notsure if it is coming off of the sensor and it is apparent because there is a medicalevent 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’slife that day. This is in order to make these things more robust and useful. There is theTelehealth and medicine part and is the patient beneficiary part, but overall we are tryingto integrate with as many data streams as possible to make the system go. Thank you. [applause] Good morning, everyone. Mohit Kaushal My nameis. Thank you for having me. I am going to spend the next 10 or 15 minutes talking aboutsome of the future technologies we are seeing within the wireless help space and the thingsthat have to come together which I think have been touched on today including policy, clinicalprocess, etc. The key take away is that it has to be bundled in with other pieces ofthe 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 andpolicy Institute and DC. A couple of topics that I hope to cover — a brief overview aroundthe transition in healthcare right now.Again, the world owes her will be different willbe different which creates a huge amount of opportunity or these real disparaging — disparatetechnologies and bringing them together. Secondly, a little bit about the overview of wirelesshelp and the state of the industry today. At a macro level, the forces around macroeconomics are not positive, but they create a real opportunity. I know I am preachingto the converted, but three drivers that we see — cost, epidemiological transition, anda shortage of doctors and nurses and nurse practitioners. While we are spending now isabout 18% of GDP on healthcare. This is growing an estimated to be around 20%. This doesn’tgive us the real value that other countries have. Second, and I will summarize this — we haveor elderly people coming into the population.As we know, they have chronic disease andunfortunately 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, therein lies the opportunity. I believe that technology — especially mobility — can solve some ofthese issues. In the backdrop — I know that many of you know what is going on — we arehaving a shift away from patient transactions and volume of care to outcomes. I will notdebate whether and ACO will work and not — whether it is an ACO or bundle or 30 day or whatevercomes around him a sum will work and some will not. They are all trying to do the samething. As a ratio, and hospital were get paid more for what goes on outside its four wallsmore than what goes on inside.From a clinical perspective, if we can prevent costly butmissions and prevent exacerbations, one would like to think that these will be rewardedwith 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 fromexpensive centralized? And mortar hospitals managed by expense of physicians and nursesto 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 compareand 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. Verylocation 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 righttime whatever the patient has. And again I think we all firmly believe that if you canprevent exacerbations of COPD and ammonia and IIM Hubbell see HF — all of the costlyconditions, 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 wecan pick up these patients earlier, and manage them in cheaper places rather than a centralizedhospital, we are talking from a nursing home of $80,000 moving down to independent livingof $1600. Even if we shift a small proportion of the elderly population into independentliving, the cost savings are huge. Post reform, here are some of the interestingpoints that we are seeing. I have touched upon payment reform. Again, I would adviseno one to to get deep into the debate of which one is going to work. If we do the right thingclinically, the that is that it will be reported in the new world and I’m a firm believer ofthis.The other piece I will go into — mobilityis one piece of technology and it is not a solution. There are other things they needto 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 intothe healthcare system and mobility — it is just a piece of that. The third practical effect of reform — weare seeing a lot of of physicians become salaried employees. Hospital systems are producingphysician offices and positions preferred to be salary. Anyway from the transactionsystem is where we are going. Let me go now deeper into why this — thetax on any — you have wireless help and Telehealth. It is hard to navigate. Here is somethingthat we use. When metadata, let’s go through the different components. There is the datainput side — a mechanism to capture these things.Then, think about how to move aroundthe data via wired and wireless networks. The third piece is how the data will be storedand what are the analytics we are going to push onto raw data to turn it into meaningfulinformation? Physicians and nurses do not want to see raw data. The want to know whatto do. Finally, we get this information, how do we push it in the right user interfaceto the final user? Mobility and powers both extremes. It allows capture of data anytimeanyplace and running out of information anytime and anyplace. But, my hypothesis is that thisis not enough. The wireless health industry has moved away from just mobility and analyticsand healthcare IT and it is becoming it lamenting into medical devices.The final point thatis 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 pieceis how to create whole new clinical processes and how are they these technologies to lookafter patients for a fraction of the cost with that are outcome? Now going into some of the technologies thatwe are seeing — around the data input side, centers are becoming cheaper they are moreubiquitous. For me there is a hierarchy of data. It is a commodity to be able to captureblood pressure and pulse and weight.The more exciting thing are the higher levels of thedata 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 becomessymptomatic, that is a game changer. That is what we are going to see as sensor technologybecomes more dance. >>, This whole space has been getting a lot of press — the economistor science — we are seeing a lot of movement from four years ago when I started, a movementaway from the convergence of devices to the convergence of healthcare IT and service deliveryand user interface and design.Again, I think it will be an about the Mission of all ofthese disciplines that creates a positive final outcome. Again, it is not about makinga device wirelessly enabled, it is around how this better managers patience for a fractionof the cost. To do this, it will be multiple technologies and disciplines to get us there. There are reasons for optimism. From a technologyperspective and then from the data coming out — some of the intellection points abouttechnology — ubiquitous networks whether they are wired or wireless.This can transfermore information. I’ll will touch upon the work we did in the FCC — unfortunately, thereare huge parts of the company lacking behind in the connectivity piece. This these to besolved. Consumer scale production of smart phones and ubiquitous devices. Again, theamount of apps proliferating on the smart phone for the consumers and providers andother caregivers will only grow. Slowly we are seeing the ones that are creating a lotof the value. Again, the decision support is the most important piece. There’s a realgeneration 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 theEMR and social factors — how do we capture all of that and turn it into something meaningfulto 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. Theimpossible cannot occur. Either data changes will occur which I hope not where we actuallyredesign healthcare system. Reasons for optimism — I know the call? From the VA will presentthis afternoon — Adam [last name indiscernible] is one of the architects of this.. They havesome 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 coverthis, but it is not just about the technology, it is the right payment model and the rightculture and standardization of processes and using care coordinators in the right technologyto help augment an accelerated that. Unfortunately, there are still significantbarriers. This is something that we outlined at the FCC national broadband plan a coupleof 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 quiddityof data. Right now, data is silos and it is in non-interoperable systems. Within the wirelesshealth the concern is that if these up front and devices cannot talk to the warehousesor EMR’s, we need to solve this. We need to prevent the same problem from occurring withthe device aspect. The next level is integration — how do thesedifferent 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 entrepreneursplugging into that. That is what we need to do here. The best by this need to be intermingledwith the best pieces of analytics and there can be innovation all the time. How do weget to it plug and play technology landscape? Finally, the clinical evidence needs to bearound the final value proposition of all of this. Again, the key point is that technologyby itself has to be able that in the right your processes to that outcome.There aremany cases where there is cool technology with a great proposition, but it is not gottenthere. Again, back to this point — the industryhas 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 comprisingof acid technologist, but also people understanding healthcare policy very well and people withclinical expertise understanding the care proxies and people from the payer and providerworld coming in. This combination of teams we are now seeing and more startups will disruptthe landscape versus just a technology piece with a policy piece. In summary, it is a multitude of technologiesthat need to work together. It needs to be a woman in the right care process I have saidthis about five different times. I believe it has to be done in the right way. Thankyou very much. [applause] Thank you. That was excellent. I want to summarizewhat we just heard.All of these presentations came together really well. I loved David’spart — 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 — technologyis a tool and an enabler, but we really need to get everything else to center around thisand come together. I think that we heard a lot about who should be the custodial thedata. 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 shouldthe only data we generate, but they are generating their own data and they are validating theirown data and finding this data useful. They are sharing the data and they are findingsupport and they are looking at — doing things that we used to in the past.Then, the issues that we need to work on likeprivacy and security. The other thing — the industry is about reliability. The need tostart to think about how to make this reliable and how to make these sensors work Berkeleyand how to get there. Then, into a data collection. A couple of speakers spoke about this. Weneed to integrate the data collection into the flow and maybe wireless and mobile isthe perfect answer because smartphones are with you all the time and they are part ofyour daily routine and part of your daily workflow.And your life flow. It feels like all of these things give usa message that is the same. We are now open to taking questions. I can start off witha few questions — we have about 20 minutes. There are questions already. I will stop talkingand turn it over to the audience. I wonder if I can make a quick comment aboutwireless 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 mobiletechnology being the technology of the future and how being a big disrupt or an eight gamechanger. Year-over-year, the number of apps that you can download for help has gone updramatically on the app store. When people are surveyed, about uses of these apps, mostpeople 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 outfor help.This could be for a lot of reasons. One is that they don’t integrate into anykind 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? Peopleare we really very big cheerleaders of mobile help adoption, but the mobile app developmentcommunity is not going to invent the solution without the other players at the table. Theywill not do this on their own. So, earlier key said if you build it they will come. Sixyears into this enterprise, that is absolutely 100% not the case. If you build it and theylook for it and they know were to look and their clinicians are guiding them there andthey 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 technologycan only solve the problems of healthcare in so far as it is integrated intelligentlyinto a workflow and life flow and vertical flow. I would say that the problem is notthe intelligent technologists and binging solutions, I would say that the problem isthe clinical workflows that are not paid to adopt any of those solutions.That’s my twocents on this issue. Absolutely. This ties into my point. Theyactually facilitate what we did want to do we care and not build something that no onewill use. Thank you for your comment. I am Nina [last name indiscernible]. I wantto echo your comments on mobile help. I do some speaking on this. One of the examplesthat I use is smoking cessation. There is a smoking cessation out that is the most widelydownloaded. It is used for two weeks by most people and then they never use it again.Oneof the things that is consistently used is the cigarette calculate a. You can put inhow many times you smoke a cigarette. Then, you can work on decreasing the number of cigarettesyou smoke. It also calculates how much it is costing you. Most people — 95% — we usesto figure out how much to budget for cigarettes. [laughter] This is not a health value. I think health apps need to be written byclinicians. That is the only way we are way to reduce the statistics on the errors andmobile applications. I think it is interesting — there is an travel app for — you can putin — I need a taxi and it — it locates where you aren’t called a taxi to you. I stood onthe corner yesterday waiting for a taxi and then I think I saw Bonnie and Karen waitingon another corner. Why aren’t we using this app? My main point — part of this workshop — asa part of the planning committee — to engage people into something after this.I am thenit action and science kind of person. I need to make sure that something happens afterwe get all the data together. As the chair of a national work group supported by theproposed — from oh data management — Bonnie is already a member. I would like to inviteyou to join and be either some of the authors of the national standards for remote datamanagement which is, again, everything we’ve talked about in your session today, or atleast help us to be a reviewer for that. I will find each one of you after your sessionis over. Thank you. Going ahead. I am Dr. Schwalm from Boston. Wanted to askDavid and some of the other panelists — the things I’ve noticed is that patients are startingto aggravate themselves and identify researchers interested in studying their conditions. Thisis very interesting. There was a recent negative trial published that was aggravated to patientsstudying the effects of lithium on ALS.I am sure you are where this. What I want toask — two things — number one — what do your members, if you have a way of askingthem, what do they talk about in terms of how they would like to connect with providersusing technology? Are they looking for a face-to-face interactions that are geographically and physicallyeasier for them to a call Bush because of their conditions? Are they looking to supplementtheir traditional interactions with easier access to answer a question weekly? Or aska question is easy? Maybe you can tell us about what they are looking for and numbertwo, to you think that there is a role or there will be an evolution toward patientsreally essentially taking over a portion of this space and being the one to decide, forexample, that we won a question answered — issuing the RFP for the research question or the otherway around? There is a guy named Stephen Brand — friend.It is a multimillion dollar nonprofit located in Seattle.One of the things he is tryingto do is filled a new health comments. This includes portable legal consent — the abilityfor any person to consent to a global IRB and allow their data — the data they cana simple about themselves from the EHR and other sources to get aggregated into an opendatabase that is been used by researchers around the globe, really, for the purposesof research. That’s now? You can consent to this now and enter informationinto 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 togetherand say here is the research question we are interested in — here is the data.This isavailable on this website and we will give a $10,000 prize to whichever researcher cancome up with a model for than the one we have today. That’s happening? I don’t know what the timeline is becauseit is very much counter to traditional research. I don’t think anything that was started thatway we get through. You and I don’t think anything started that way would end up witha small molecule through a phase 1 clinical trial because I don’t think there is a goodway to aggregate enough dollars. 80 it could be used for the preliminary results in SBIR. Second question — regarding what motivatesthe patients. Our patients are not normal. 99% on the site do not get any questions wrongwhen you ask them health literacy questions. They score perfectly on that test. The onesthat get the questions wrong get one question wrong. These are people who are very engagedin their health and very engaged in health data. I wouldn’t look to them as being a sourcefor what patients want.These are people who use the Internet as part of a normal routineto seek care and seek health information. That being said, 20% of people with epilepsythat we surveyed fired their doctor. This is not uncommon. It is a year or Deb throughoutthe addition — described patient communities. Patients want doctors to talk to them as thoughthey are intelligent human beings. That is the biggest thing. Patients want doctors whoallow the patient to be able to be a project been in their care. For the most part, I don’tthink 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 differentsort of chronic impairment. What they want is to not be treated as though they are isinvolved or this intermediate it from their care processes. They want the best qualityinformation they can get. They want to have a dialogue with their providers. I don’t thinkthey 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 exchangeneeds to take into account the fact that somebody is enrolled in a clinical trial. The factthat someone is admitted to a particular venue for a treatment can significantly impact thecourse of the clinical trial and can either advance or retard clinical research. If itis not handled properly. So, one of the things that we need to be aware of is the clinicalconnectivity in that continuum we should be able to talk about clinical trials.The place I came from — we had 900 clinicaltrials going on. Very few of the physicians in the organization where where of all ofthem. There is an awareness issue. But, we had to write parochial interfaces, if youwill, so that every time a patient came in and varied the database of all the peopleenrolled in the clinical trial and would send an alert — to the clinicians — it had anincredible impact. To do that across boundaries is where we need to go.So, I am happy thatwe are talking about incremental success, but we also need to plan for some of the loftiergoals 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 differentturtles about the good and bad about technology. My question really is regarding the adoptionof technology — this data scope and x-ray — not a lot of peer-reviewed science provedor disapproved a lot of these tools — telemedicine seems to go through this constant — we needthe data. Show us the data. How does this relate from a technological perspective todevelop a federal policy? As I am now able to buy a smart phone that can do all of thesethings — whether they are except for people use them or not, and they change every sixmonths or so, how does federal policy change and what are some of the challenges that yousee from a technological perspective with the adoption of this in healthcare? I think technology innovation will outpaceor 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 keyfor service world. For me, we need to mail the payment models. It is based — basic economicswill 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 withindifferent 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. Ifthis is done and also some you look toward clarity around how innovators can get someof these solutions to the FDA process, I think these are the key levers. The rest of thestuff has to be figured out by innovative people on the ground. If you — in 1933, telecommunications — thisdid not change until 1997.From 1997 until 2012 — you know what kind of technology wehave had — beepers to smart phones to wireless telecommunications. So, today things changeso 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 thesechanges more rapidly because technology is changing. Can I comment? Coming from ONC, I need tosay that I’ve seen the impact. I was on the other side of the table as a CIO when thechanges came in and I can tell you that I started work in a hospital that was builtin 1969 without a medical records department because the founder was told that he couldput a computer in a data center and have an electronic health record. So, the notion hasbeen around for 50 years. This is an easy thing to see. The question is — what didit take to get us to the point where we are going to do something? The truth is, the marketswere not efficient and a lot of people were developing software that would not talk toother software.So, the government is the last resort when a market does not do thingsus officially is a good. So, I think that putting it stimulates money out did exactlywhat 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 thatwe want this to happen first, it is that we wanted to happen when other forces will letit happen.What I think you will see is that we will get to a critical mass more quicklyand we are seeing this already. I think the other thing that needs to happen — this isnot what government should play a role in — private industry should play a role — diversitiesas 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 connectand elaborate? I think that is where government did have a significant impact. Part of thereason I was drawn to the office of the national coordinator is because of the work that wasdone 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 createsmore of a commodity like use of the data and the data is the powerful driver here.Radicalmass 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 westart to exchange data freely and we truly get liquid information, I think you will seethe changes occur. My concern from a regulatory standpoint iscalled lament Rita this. — Couple married. When I use the data from the ecosystem tomake 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 someonewho 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 vascularsurgeon I have a gamut of patients to bring to me names from the Internet and say whycan’t I have my graphed? Versus ones that just want to be told what to do.Positionas advisor versus physician as parent — it goes through this. How do we come up witha payment system to enable us to do exactly what you have done? Owing to the patient’shome and get their medications that and go to get them to their up appointments? I havea high no-show rate because they can’t even get to the appointment. That, of course, willincrease the cost in the long run. In the long run, it will decrease cost, but the patientthat you are talking about that don’t take responsibility for their own health are justmore expensive to take care of, usually, then the ones that are on the website — My comment from a policy perspective, youhave to act local. For us, our number one objective is to convince Medicaid of NorthCarolina 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 controltrials.The primary reason we have not done that and are doing that now is because ofthe 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’tcare about a randomized controlled trial. They are concerned about how to change theway that they deliver care so that they can exist. I think that is the biggest thing andit is going to be — it is a great thing to get the hospitals to move and act to takecare 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 havethose trials. That leads into my second question. This isabout research. This is also near and dear to my heart. Programs like yours could bethe pilot data and preliminary data in the world of grants to that lead to exactly whatyou are talking about and can we somehow look — hook up with NIH and clinical translationalscience programs across the country in linking some of this research exactly to that? I lovethe idea of a national research database.CTA — across institution in your own CTSa — come up with combined IR these you do not have to spend all your time processingconsent issues whether than actually doing the work? Then, there is a push with the CTSApushing for a national network that gets a lot of university research. Can we partnerwith that? Another government agency getting another one to talk to each other to actuallyforward the agenda. That is a great idea. Something I was notaware 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 stateor 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 andhave a repository of data within that state or within that region so that we would havethe ability to do one IRB and bring all of the data together to have greater numbersand be able to take this to Medicare and the federal government.Great idea. I was just going to spout some heresy fora few minutes. The randomized control trial in medicine is outlined pretty well in a documentthat 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 anythingabout 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 aguy and I can get correct truth centered data what is going on in this person’s physiologyfrom the second I start an intervention until the observational.Is concluded. The datathat I am sure she is collecting on the hundreds of people she is putting numerous sensorson out strips most of the data — outstrips the density of data in this study. I wouldguarantee that. Yet, we look at these large studies of interview-based data of clinicalfollow-up based data when we have actual data from physical sensors that tell us somethingabout the real world and we say that the actual data from the sensor that we have tells ussomething about the real world is less valuable than about a group of people who work carefullycollected from criteria and most like engaged in a clinical trial because they were locatedin a proximal geographic area to the site with the clinical trial was located so theyare okay to their a hospital that was getting a lot of money to do a clinical trial.Assomeone who is not a clinician and not a medical person and whose background is in social sciencesand physics primarily, this is disgusting to me. We have good, rich centered data thatwe can do good math on. We don’t have algebra anymore — we have calculus. We need to livein a world where calculus exists and where supercomputing exist and stop holding theRTC to this gold standard. It is 1000 years old. I love your is the. [laughter] The randomized control trial hasa place. This goes all the way from T. 1 to T. capital for research — all the way todissemination science and how to get positions to do at it based medicine — why are theyresistance and where the patients resistant? The randomized controlled trial is here tostay but it is only one part of the research. As technology grows and as we become smallerand smaller in the world, that is exactly what we need to do. New research techniquesthat will be need to do. We have time for one more question. This will be a short one with a quick answerI will direct this to [indiscernible] — I don’t know if people know that you are oneof the major architects in the national broad and plan.We had a discussion yesterday aboutbroadband in the FCC — what do you think we need to do to make this ubiquitous? Forevery American in their home and facility? [captioners transitioning] Our areas of market failure and other areaswhere there is no market failure and at the cost of implementation and cost of buildingnetwork and managing decreases more and more will get that but what you’re asking aroundme 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 thankour panel, this is an interesting discussion and thank you for your lively discussion andbeing a part of this.[Applause] And thank you to the audience on the webcast. So I just want to mention before we lose peopleonline, people have been asking, the entire webcast will be archived on the project websiteforever as well as individual presentations so you’ll be able to look back on the richdata that is there. We will start at 12:15 PM. Our afternoon is packed and we will doour best to stay on time. For those in person yesterday, if you are the speaker are partof the committee, we have lunch for you on the left and everyone else, the cafeteriacloses that 1:45 PM today so if you want to get something to snack on, however you cannoteat 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 lunchbreak 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 wellthis afternoon we have an exciting agenda and I am thrilled to be here right now onthe stage with some rock stars and state policy. We have a lot about how to advance the tele-healthagenda at the federal level and we heard a reference in many presentations about whatdate can do because so much fall under the state. They play a role with state statuteregulation health reform initiative licensure, reimbursement, Medicaid, credentialing privilegingin some cases and I am thrilled and honored to be here this afternoon with colleaguesfrom the mid-Atlantic region and I want to introduce Arab Pamela, Cindy Johnson to isthe director of the medical system services for the Commonwealth of Virginia and on thesecretary of Bill Hazel she chairs our initial–health reform initiative that Dr.Laura Herrera chiefmedical officer for the Maryland Department of Health and mental hygiene and she justpassed a have-they just passed a bill as well hopefully becoming more sweeping and we haveDelaware’s secretary of Health and Human Services, Rita, who is a champion and previously workedfor AARP. The president of AARP Delora she has played a huge role it is damping servicesfor the underserved and last but not least,–from the minority media and telecom Council therea policy group that advocates for underserved and disenfranchised and has done a lot ofwork in the telecom space and works closely with the national organization of Black legislativewoman who have become devout visa tele-health and she will talk to us about how to advocateand engage Arab states in terms of advancing our mission. I would like to welcome Cindyjumped the podium. Good afternoon. I am privately from the Commonwealthof Virginia we call–in Virginia, the Mother Teresa of total health she has been very committedto moving us in the commercial arena as well as in Medicaid of not tele-health as an afterthoughtbetter integrated very important aspect of everything we do in terms of delivering healthcareyou and I have the privilege of wearing you have to the state of Virginia the before Iwent to my presentation and wanted.Apparently are implementing tele-health over the yearsin Medicaid, I would tell you from a governors perspective, when he came into office, herealized that healthcare reform, there are lots of things to do that are beyond whatwas in the federal affordable care act he created an advisory group of healthcare leadersand business leaders to talk about what we could do better in Virginia and six strategicareas, payment and delivery reform, capacity access other relates to the doctors, technologyMedicaid insurance and how you get players of all and moving the ball forward for value-basedpurchasing and as you can tell from the topic, tele-health was intertwined we talked aboutthe payment and delivery system, fee-for-service, global payment the different models area itis a tool that people use to deliver healthcare and in terms of capacity, everyone realizeswe don’t have enough doctors and healthcare professionals now so what can we do to makesure, not just in rural areas that have access to competent care and healthcare professionaldoesn’t have to be physically in the room so we talked a lot about tele-health and howthat combined with team composition of doctors and can help us have more capacity for peoplethat we serve in Virginia but the new people seeking insurance under the affordable careact and when you talk about technology, tele-health is a tool that keeps changing as time goeson.Technology in itself is wonderful and I am a generation that grew up with one TVin the house that was black and white and the remote control was a and think how farwe have, now, just on television. Basically, we have been trying to do whateverwe can Virginia to break down barriers for total health and I know that you have hadseveral conversations about what works and what are some of the barriers and I am surethat Karen will work with us and tell us what we can do in our control the state level becauseeveryone, the governor and secretary are pro-will help in terms of making sure we have the bestcost effective delivery system in Virginia and as far as Medicaid is concerned we havealways been interested in tele-health and that coincide with all the work that Karenhas been doing because she has been in Virginia and I will fast-forward through a lot of thethings because it is background but as you look at our Medicaid program, we started in1995 which: five when she was in Virginia and that is what we call her the Mother Teresaof tele-health.We serve almost 1,000,000 people in the Medicaid program in Virginiaat a budget of 8 billion. We started embracing rather than in 1995 when Al Gore inventedthe Internet at the same time just think how much we have grown since then it was a smallpile 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, wehave been talking about a fee-for-service were you have to put another modifier to makesure you’re doing tele-health as we have moved to managed care in Virginia, it is under theglobal 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 forwardand then we added providers that we recognized in Virginia and other states may not haveembraced 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 costmore but it is a method of delivering services and that is how it has been embraced and convincethe general assembly this is not a new service you have to price out this is another mechanismto make sure we provide access to our client.Obviously, in October 2009, we expanded withthe originating site and again you can see it is an evolution, you need to allow it inyour pace program, of all-inclusive care for the elderly and that make sense for thoseof you who are familiar this is where you combined Medicare and Medicaid and provideservices that an elderly person needs centered around adult day health care. Under fee-for-servicewe have billing procedures for fee-for-service we have moved further away from fee-for-servicewe are now 70% managed care and SMS sent to different payment systems, the code is notas important. Obviously, if it has specific providers weexpect them to fully comply with service documentation and billing requirement and when we do auditthe extent that the future going to audit those types of things but the good thing thatwe were able to do, is not to follow the definition of Medicare coverage and tie it to rural areadefinitions even though it tends to be used in rural areas, a lot of us realize in urbanareas this is a very useful method of getting services.Recently we have added some newservices and these are things that were brought up in the larger arena, commercial as wellas Medicaid and when we talk about healthcare reform and having a dividing line, commercialprovide certain thing and Medicaid might not provide that, doesn’t make sense for us wedo a lot of comparisons of what we are going to do based on what is out there in the commercialareas so we added –I am not going to try to list all of these that you get to thatwe keep adding things with eyesight, dermatology, speech therapy, all the things that you knowis important and valuable with tele-health.And this slide doesn’t say much except thatfee-for-service program, we haven’t got much of utilization if you just look at claim butif 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. Youget paid, it is not just broken out. We have six managed care plans that we have had fiveyears and we survey each of the five managed care plan because we say, we will providetelemedicine think that we cover in the fee-for-service program at the very least you have to do thatand they also use the fact that they have a calculated payment to go further than thatin the next couple of slide is just an example of how they have used to manage care and especiallyfor adolescent psychiatric services they have used–and you can see another managed carehas over 51 telemedicine presentation side you can see that one third of starting tomove better in that direction by working with Karen at the University of Virginia and afourth one has talked about encounters are focused on aged, blind, and disabled.Andanother one, make sure that telemedicine is available to all and doesn’t require preauthorizationand what we just did in Virginia, the far southwestern Virginia hasn’t had managed careand we just went there July 1 and obviously, if you look at the map, and something lookslike it takes 10 min. and if you drive it it takes 45 min. to an hour around the mountainthat telemedicine has been very important as we move from that area. We are still talkingabout several things we think will move the ball forward such as adding home health servicesto telemedicine, looking at how it will help someone who has just gotten out of surgeryhigh risk pregnancy and infection and we are looking at the store and forward coverageand as I mentioned, that is particularly important for ophthalmology. Also, we just met lastweek. On something that Karen has asked us to look at because I have different peoplebut give me their wish list on a regular basis and Karen is one of those only are happy toaccommodate her but we’re working on a Medicaid, that will deal with the out-of-state positionand how they can receive reimbursement on Virginia Medicaid and unfortunately we can’tjust the memo there are some systems issues so that will probably not occur until theend of this year and my staff put in that cartoon.You might understand it. I didn’tbut I could not delete it while I was driving. So thank you. [Applause] I’m going to give a tele-health perspectivefrom the state of Maryland and we are very similar and the number of people that we servein a budget but on my Virginia we are late to the party and we started looking at thisin 2010 as part of the quality help cost counsel which is chaired by the Lt. Gov. in the secretaryof health on this is one of the initiative they took on to look at not only access toquality of care and cost implications of the committee was tasked with identifying challengesand solutions and they came up with a report that will was advanced to the next level byputting forward a task force to look deeper into the what the initial report that it wasled by the Maryland healthcare commission and the Maryland Institute for emergency medicalservices and three advisory groups were established to develop formal recommendation and theseare the three groups financial business model advisory technology solutions and standardsin clinical advisory group.The finance business model group recommended the state regulatedreimbursement for services to the same extent of healthcare services providing face-to-face.Technology solutions and standards wanted a network built on existing standards integratedin the statewide information exchange which has 46 hospitals reporting regularly, dischargedata, radiology data, they wanted this integrated into the statewide information exchange ata minimum there should be required to related to technology connectivity. In the clinicaladvisory group, which centered around licensure credentialing and privileging of providers.Cannot from the finance and business model advisory group can legislation was introducedthis session, there is a house built and a Senate bill that says Jay regulated privatepayers needed cover delivered healthcare services delivered through tele-health as they wouldin person private payers were not permitted to require preauthorization for tele-healthservices and were not required and could not limit it to rural areas.So the argument supportedthe bill supported it with amendment, specifically they would allow Medicaid to conduct a reviewand unlike other health department in the state of Maryland, six are recommended inthe Department of Health the Medicare hygiene and so, local care services only supportedthe bill to understand what the implications were the system and basically wrote and respondedthat we supported that we needed to see if it would cost neutral and that was, we wouldcover it and this is a typo, and the year 2013 they were not cost neutral mood withthe 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 Pastoresigned into law the amendment that Medicaid was available to do further analysis on theimpact of the system. Pursuant to cost neutral language we decided to conduct the evidenceon tele-health and we did a comprehensive analysis with information of publicly availableas well as using the network available to Medicaid directors to understand what wasbeing 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 monitoringand only to state covered telephone and the moment we started raining out what we wouldcover and in addition to what we found, we also looked to the private payers in the stateof Maryland, both commercial and managed care and we started researching modalities andservices not only by Medicaid but private payers as well as, studies were there anymodalities that stood out and we were doing this in keeping in mind Maryland efforts aroundimplementation of the affordable care act.We have lots of things happening in the stateand accountable care organizations and trying to keep that in mind Maryland just got funded44 ACO’s and they were practicing in rural areas. And working with hilltop developinga function-based, portable care act and pleaded cover tele-mental health services and originatingsite could come from an outpatient mental health service Hospital and it could be limitedto 12 counties in addition to what we are doing now, we are something tele-mental healthutilization looking to expand that further. I can tell you based on the analysis we’reincluding everything in the assumptions from real-time interface to store-and-forward technologyand home health monitoring as we think about our long-term care rebalancing effort happeningin the state, we think that is going to be key.We have to report back to the Gen. assemblythat 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 tobe with you today and before I start talking about the little state of Delaware, unlikethe bigger states of Maryland and Virginia, does everyone know where Delaware is? We arenot a County of Pennsylvania, we are actually a date. We have less than 1 million our populationthe governor likes to collect a state of neighbors because we now everyone in the state of Delawarebut before I go into more details I would like to applaud the effort of Dr.Reuben Delawarestarted to advance tele-health effort Dr. Reuben came to visit our state and gave apresentation that I happened to be present at and it really excelled the interest andthe energy around, how come my gratitude goes to her for being such an ambassador and passionateabout what they can do to advance better health outcomes for our population. Now, I want totalk about that moment some after Dr. Reuben met with us and Delaware we created a tele-healthcoalition was formed. It now has advantage over 15 members including our hospital. Forlarger state that doesn’t sound like much but for the state of Delaware we have threecounties in our state, New Castle County cosmopolitan County Dover and Sussex. Have any of you visitedSussex County? It is resort area.However, it is still fun agriculture open space, peopleare spread across the county and we are concerned about those counties largely because of thechallenges from the medical infrastructure and it is the county many retirees are migratingto Sussex County, Washington DC and relevant to medical and the structure it is not keepingup with the pay of that demographic have only think of telemedicine and tele-health thatpresents itself a marvelous opportunity for us to advance our medical infrastructure forthat technology.The Department of Health and social services is not the Medicaid programand Delaware Medicaid began reimbursing for telemedicine which we started July 1, 2012of the sheer that is the start of our fiscal year we did this so that policy did not goto the Gen. assembly, we evaluated this concert was the tele-health coalition and we wereable to advance that as a policy driven. Largely Delaware is supported through managed careorganizations to have contracts with numerous providers and they are all able to offer telemedicine.[Applause] Thank you, I am coming down here more oftenand in conjunction with that he Delaware hospital and the Department of Health and social servicesare utilizing total psychology for crisis evaluation and again, that is an Sussex Countyarea where indicated infrastructure is very stretched so we were able to offer that tele-psychiatryhave a more robust system for psychiatric services and we did not want to transportpeople even though we are a small state we can travel within 20 half hours in each directionand was still not serve the population nor us from a cost-benefit perspective to putpeople in cars and travel to New Castle County to access the service so we do that that throughtele-psychiatry.A hospital and Sussex County partners with the hospital in new CaswellCounty, our largest medical provider for tele-consulting services on trauma cases and otherwise thosepatients traumatized by accident or injury would have to take the helicopter to New CastleCounty for a trauma evaluation it is very safe to keep them in the hospital and SussexCounty and in partnership with they were more robust–of care they are able to connect thedots of wealth of through tele-health, regardless of what Kathy you may reside in, looking withfederally qualified health care centers.Read healthcare Center is an Sussex County andthey received an outreach grant to provide tele-psychiatry and they’re interested inadvancing 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 historyhas been an advocacy. The one that try to influence government from the outside findsherself trying to influence it from the inside and really, it is the ground that makes thedifference of the pressure point from the ground government is not that quick to advancemultiple issues that impact the government and you look to that quick you will on theoutside and then came from Washington DC, a retiree that landed in Delaware his wifethat he was diagnosed with Parkinson’s disease 10 years ago and in 2008 they retired fromCollege 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 individualswith Parkinson’s because he found many retirees are faced with a devastating disease and werelooking for care and as I said, Sussex County does not have a robust clinical support systemso many support group members were saying specialist in Washington and Baltimore andPhiladelphia and it was a difficult round-trip to see the doctors if you are suffering fromParkinson’s disease so Dennis met with me early on I was appointed in 2009 and cameto me and introduced me to Dr.Dorsey who is at John Hopkins, a neurologist and he wassupporting many individuals from Suffolk County he would have to take travel to Baltimoreto see specialist. And what we are doing now, we are working with federally qualified healthcare system Center and Dr. Dorsey to bring that telephone to Suffolk County with a specificinterest in supporting individuals who are suffering from Parkinson’s disease so theyno longer have to do that round-trip and travel which actually, for many of them, would takethem two days to recover from that travel, not a good way to promote good health carefor those individuals and I credit Dennis but also Dr. Dorsey who has been phenomenalwith trying to support this in our state. And then I effectively put yourself in ourshoes 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 bestour you suffer from any type of disease , Delaware seems to be aging at a faster rate and weare ninth in states and a lot of that has to do, I would tell you a lot of that hasto do with the duty of our state, but it also has to do with our tax base and people aremigrating and along with that we know the people who were aging present some healthissues the body tends to wear down easily take good care of it so we know that we willbe impacted and again the lowermost County so it only makes sense for us to really starttrying to get ahead of that paradigm shift and the most cost efficient and effectiveway how we can connect people to healthcare regardless if it is the best professionalthat we have within the state or we can expand beyond our state and connect people so wecan 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 thatthe coalition continues to dedicate effort to address distant site providers must belicensed in Delaware.I must tell you to get a license and Delaware is not the easiestthing to go through. So in a sister department,, the Secretary of State, what I do with a chiefmedical position, a secretary within my department, and they are working hand-in-hand with thesecretary of state to streamline that process because we have a series of workforce developmentissue. The last people to the licensing problem and we don’t want that to happen. It is notin the best interest so I dedicated the position to work closely with the sister organizationlook at how we streamline that process and technology has not been widely adopted. Iam sorry to say, if they bring Dr. Reuben back into state because she is very effectiveat doing that. Some people are very skeptical. Any–with Medicare reimbursement we can showevidence of a good outcome that the cost is not prohibitive and that we can advance thisthrough the whole system and many patients aren’t comfortable saying it provided thisway I must tell you that they have to drive three hours to see them they’re going to getpretty comfortable pretty quick and many individuals are in the rural areas of Delaware becausestart talking about transportation which is also extremely challenged several people whohad nothing, visit the a tremendous gift for them and hospital that practitioners.As arevenue stream however that is reimbursable they won’t see it as a threat they will seeit as advancement of ability to serve a population. They’re bringing hospital for primary caredoctors 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 cooperationand we will be working together and hospitals are coming on board and application includingat home uses for Delaware’s aging population and the state underserved rural areas andwe can use the data evidence they practices that we will be able to dance some cosmopolitanarea we are creating a website for the coalition and people can get access to the website withadditional information I believe it also brings additional advancement and what we want todo at stateside is to begin utilizing tele-health of the means to manage chronic care conditionsas supported by the affordable care act so it thank you very much for spending time withme today and come and visit us the Delaware.[Applause] Thank you everyone. I am the chief operatingofficer of minority media and telecommunications Council and I am pleased to be here todayrepresenting the national organization black elected legislative women also known as thenoble women, and MPC as I can talk about our organization first we have been around for25 years we are a leader in media telecommunications policy and advocacy for a minority and underservedcommunities and we started advocating for minority ownership and diversity and thatwe have expanded into broadband adoption advocacy and telecommunications policy that are designedto deal with issues with the people who don’t necessarily have iPad, I thought, three AirForce not–smart phones like some of our colleagues.We have worked with the Nobel women. On anumber of preceding such as the open Internet preceding universal service reform, lifelineservice, any kind of issues doing with low income family we have an interactive of thenational broadband plan and adoption him minority media ownership policies. Our chair, JuliaJohnson, I am sitting in for today is an advisor to Nobel women on telecommunication policyissues and the Nobel president served on our advisory board so it is not exactly interlockingdirectorate, that is a good collaboration with the Nobel women and only publish whitepapers if you look on our website you will see white papers on broadband adoption, minoritiesin high tech area, we tweak each other, we comment on stuff and we collaborate to tryto get information out that is directed toward underserved communities. They have partneredon a number of registry –regulatory policies that marathon a lot of discussion about thebroadband 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 businessopportunities and work with spectrum, exhaust, Nobel, wireless smartphone adoption of theway 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 adifference between the underserved communities in rural and urban, a lot of the disparitiescome from a lack of access or representation of whatever it may be from grocery storesto food side to healthcare practitioners.This is a lot of things in common and justto tell you things in detail about the Nobel women there am I the group of 255 membersof state legislators current and former and 39 states and they were to communicate thelegal social political economic and health needs of children women and families and wework with them and advocate on behalf of issues and telecommunications at the local stateand federal level than at the White House Federal Communications Commission FederalTrade Commission, House and Senate. What we want to talk about today, Nobel model telemedicinelegislation which is launched last year but a formal launch occurred last month in Washingtonand if I can give them a shout out, she has been an advisor to Nobel and indirectly aswe’re learning telecommunications telemedicine along with Nobel women and it is an opportunitythere is an opportunity for a widespread advocacy in telemedicine, much of what we have donein broadband adoption and on the model legislation, primarily the same as American telemedicineAssociation legislation that is focused on trying to require private mandates to be thesame for in person and telemedicine coverage but what the Nobel women do is also focusedon extending Medicaid coverage and medicine legislation.The highlights of the Nobel womenmodel legislation is to require a coverage of telemedicine, expand the definition andin some cases define it to include A/V another telecommunications Tech knowledge he had asite 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 plancan deny coverage if they would cover in person consultation and it would require statewidemedical assistance benefits of the health home for individuals with chronic conditionsand that is something that Novell has taken not because of their interest in serving womenand family, there are a lot of conditions, chronic conditions within minority communitiesthat were over indexing and heart disease and diabetes 20% of African-Americans over30 are being diagnosed with diabetes and there is a whole host of problems in the minorityunderserved communities that can be addressed, we think through telemedicine.One of the other big thing that Nobel is interestedin is trying to do a the 56 million Americans who are racial athletic role Americans toour without a primary care physician and I can’t imagine that because I feel for theyears that I have been in Washington my primary care physician and I are on a first name basisand I can remember calling her when I was on vacation for an emergency and it is hardfor some of us to imagine this but a lot of people don’t have access to a primary carephysician.I live in an area of Washington that doesn’t have any that I have seen, doctorsoffices and primarily it is composed of the urgent care and it is great to have urgentcare providers but there are a lot of urgent care providers and nighttime pediatrics providersis an issue that is important that often by work of the policy areas we don’t really recognizebecause they now live in areas where there are food and medical care. This is somethingthat Nobel is very much interested in trying to deal with those kinds of disparities andtrying to bridge some of the healthcare gap. We believe that telemedicine is in game changerand critical and the care Are caused by financial issues transportation and we are talking aboutpersonal transportation and public transportation barriers along with the insufficient primarycare resources and this is something that exists in the rural areas most states providecoverage of medicine but this varies widely at one of the things that Novell wants todo is work on establishing equal–Novell want to establish an equal playing field and lastmonth the big launch with the help of Karen in a number of other advisors Novell decidedthat we are going to expand telemedicine legislation to every state where there is Nobel womencurrently 39 states it is growing every day as we are being elected and getting more involvedin solving the issues in their communities not an extension action plan for each stateone of the things we have noticed, in many cases, telemedicine is covered and it is somethingthat is a matter of pulling am bringing in legislation to the attention of the statesecretary of health and how things work on the ground to get the state secretary of healthto clarify that this medicine is covered with physician services.Novell is going to drivethe model was placement, state-by-state basis hosting roundtables, being on panels, increasingawareness, identifying key stakeholder organizations and groups for partnering and collaboratingof 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 pregnanciesstroke diagnosis and rehabilitation patient monitoring for chronic care mental healthcounseling stool-based health services speech and hearing, Medicare level coverage for underservedareas 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 forimproving Medicare coverage for urban beneficiaries,-based services, store and forward kinds of tele-healthin urban and rule areas and payment and services nationwide portability for healthcare professionallicenses which brings us to the issue of an issue related to this but they have gotteninvolved in, licensure of practitioners resolution tele-health licensure resolution was passedon June 22 at the legislative, and Baltimore have basically this is what you have beenhearing about for the past couple of days a need for a framework so doctors and medicalproviders don’t have to get Mr.Graham –and we celebrate with victory in Maryland, twoof 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 Marylandlegislation signed on May 22 and I guess I don’t need to go into that because we havea real-life representative here but we’re looking forward to taking the package, themodel legislation and representation and almost all 50 states the taking that show on theroad getting involved with those of you in the room, those involved in coalitions andother 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 aloneis something we will have to do a collaboration with those of us in the relevant those ofus not in the room food and you to go from state to state and down the street on thehell and we will be involved in federal advocacy with the Federal Communications Commissionwith the Federal Communications Commission-the commissioners and on the state advocacy withcommunity advocates and policymakers and on the media side with press releases, mediaplacement, politics 365 of the media place values on a regular basis and also broadbandof social justice Huffington Post, and a number of other areas where we plan to have four2013 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 havebeen an advocate at the state level and great things are coming in Maryland and you madeDelaware the little engine that could and the Nobel women-fantastic and we are verycross fertilized in terms of advancing our mission together. I would love to open thefor questions of our panelists about how we can advance further at the state level. Stuart? I want to congratulate you, you are a powerfulforce, the great what you’re doing at the state level and what you are doing, you guysare heroes, on behalf of–and Telehealth, saying what you have done a spectacular workwith the American telemedicine Association working with NOBEL women and that is a greateffort has so many states under the spotlight right now that is a great effort.I have twoquestions and they’re directed at Marilyn and Laura and you’re talking about doing acost neutrality study and I think you’re going to have that work done by December so my firstquestion is, I would be very interested in learning what you learn about that processand will that report we available at the detailed level? Yes, with the public. Available once it isreleased to the general assembly and will be detailed not only having looked at all50 states that what they’re doing but what the literature, the VA, health services, weare looking at everyone. Connect fantastic and my second question, you had one sentencethree talked about being required to integrate with the health information exchange and Iwas curious if you could explain what the intent and desired functionality of that wouldbe. Connect to the point about record-keeping of the encounter and having incorporated intothe patient record the way we are trying to include all of the other wreck or the rightnow we are getting information from hospitals that we are ultimately looking to expand thataround the for accountable care organizations and I need tele-health encounters that wouldhappen under those umbrellas for lack of a better description, we want that data includedin the health information exchange.Thank you very much, congratulations, youguys are amazing. We talked about the value proposition in eachstate is different in terms of looking at the value proposition. I know Virginia Medicaidthat millions and millions of dollars on transportation, are they going to be looking at the cost savingsas part of the value proposition as well? Were definitely looking for cross saving themback to the affordable care act there are initiative around utilization and admissionand presenting the access point for healthcare system will be built into the list of assumptionsand at the hilltop, we will be doing the modeling and we are looking for everything not justlimiting ourselves to real-time interface, we are looking at store and forward and balancingthe efforts of going to be key to how that plays out.Thanks. I am the director of Telehealth businessat the clinic and was confident and I really need to reiterate Stuart,. You ladies areamazing. Justin your vision and in your actual presence and I feel like I can go and changethe world and people ask me to change the world because I am usually described thatway so thank you for being mentor stuff. I have two questions and I think it is the secretaryLinda Graff, one of the flies you have without barriers and yesterday we had a lot of assumptionsof public policy is built upon and that drives us crazy because we know different, thoseof us doing the work, I was wondering, because those barriers, I don’t see them in my programor in many programs I work with to get it started so I am wondering, not that I’m questioningit, but what evidence was there that led to be on your list of barriers and my other questionis how can we get involved with NOBEL women and help you do what you are doing even ifit is not–we have good reimbursement because the state came to me and said, can you writea reimbursement policy? Of course I did that is probably as I could but I would love tothe engaged somehow with your organization and helping you get the work done that needto 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 thatthey were identifying command the secretary, we are trying to advance and some significantbarriers and licensure issue for the doctors was one that came up as the highlighted lineand 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 arevery stretchy from a workforce development perspective and some people are threatenedby this use of technology, some people in the medical field are threatened by this technologyand we had to get to the point, the usage of nurse practitioners because you have primarycare physicians to trying to advance that people were threatened by it and some of itis a mind that not necessarily policy driven and we have a body called the healthcare commissionand the state of Delaware.I have the Commissioner but it is made up of public sector and privatesector and reopen that the public is very engaged and we offer you that the will toeducate the public on these issues because most of it is a mess and somehow they becomefactual the how do you dispel the myth? You have to concentrate and educate and for whateverreason the use of tell help people think it is dumbing down medicine and a is then, justbefore it additional access to some of the best medicine out there so that is where thosebarriers are but we are committed to engaging broader stakeholder network to come acrossthose barriers and I did say something that they were able to do but I also believe stronglythat we need to codify this as a legislative issue, as a state law because this administrationcame in and said it was something we wanted to advance put under policy anybody can comein and take that away so I really want to leap.And then of healthcare reform and theaffordable care act, this HP modified. On behalf of the Bolan, thank you for askingthat question because first of all, if anyone is interested, you can look at these, Novell.woman.orgthe–we have representative and we have a whole strategy that we can put together inyour state and Karen was very active in the strategy in Maryland which I understood. Itwent nominally well with Sen. Pugh and representative Lee and working through the legislature andwe are interesting in partnering with anyone in this area because the NOBEL women are interestedin these issues and women in the position of head of household, you can look us up onthe website and I can give you my personal information to connect to.Thank you. My name is Amy from UNC Chapel Hill. NorthCarolina 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 soinformative 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, chronicdisease populations, we are looking at other populations such as the Department of Correctionsand I went to know if that is something you have also ruled that in addition to the populationyou are speaking about. If you have cost recovery models and cost saving model that would beable to be shared. In the Commonwealth of–Virginia, there isa very important element of healthcare delivery to Virginia prisoners and it is managed bya different secretary, that is where it is managed and it is done and there are correctionalprograms around the country and certainly patients deserve high quality care as welland has been a very successful tool at the University of–, a lot of University, Texasthere is a large one there a lot of food be happy to share.And of course, they wouldpay for transportation and security and patient for traveling. I look forward to the Medicaid data and myfinal question, to out onto his, do you foresee developing plans to engage with providersto develop more interest to get the usage and the providing of telemedicine servicesof, you mentioned the numbers are pretty low. There are John Hopkins and University of Marylanddoing a fair amount of Telehealth and they have their own Telehealth departments andthey are engaged in all these different advisory committees and providing subject matter expertisefrom equipment to standards of care and I think they have been working with ATA on standardsas well so this was not just done by the department, there were lots of people engaged in thisprocess to get us where we are now that is the same people in the original task forceand they continue to move the initiative forward.Education and training will be part of thateither Medicaid says we will go forward educating our providers and that is certainly builtinto the strategic plan to move Telehealth forward. Thank you. [Captioners transitioning] One of our colleagues was a physician fromAustralia who led the medical expeditions to Antarctica for decades. His emphasis ashe looked at telemedicine is that it has been around ever since. Ever since medicine isbeen 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 failuresOregon affiliate to embrace or lack of training, etc. I wonder — are you dealing with these embracementissues or technology — bringing the right technology and in a stepwise fashioned — bysaying do you have a phone? Can you utilize the telephone? Certainly, all of us are accustomedto 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 isnot the latest and most sophisticated technology? >> I think one of the things that we do iswe get carried away with technology and we don’t step back and realize that there aresome significant areas of the state that can’t get the Internet.What we did — the secretaryof technology did a comprehensive survey of all of the healthcare providers in Virginiato find out what their disabilities were, not just for telehealth but for electronichealth 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 getpeople 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 ArcticCircle using telehealth equipment more than 14 years ago. So, I thought it was incrediblein action. Now to be in a state where we hardly have any telehealth, it is hard to at peopleengaged. To the point about even something as basic as a phone, I think that reimbursementwill be the issue. I think it was said earlier in the last panel — providers want to doall they can to deliver and be accessible and deliver holiday care, but if they arenot reimbursed for it, with all of the competing priorities of the clinicians time, it is justnot going to happen.So, I think we are certainly looking to these other technologies. If thereis a way to reimbursed for using something other than the three big groups of that wetypically 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 willnot be able to access within their home in a given time, but then, can we work with theretail market. Some of the pharmacies want to be able to provide this service or getthe level of access, so I think that the more that there is a coalition and the more engagementbetween the private and public sector, I think the reality of this is quite feasible. Therewas 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 thatprimary care physicians did home visits. That is coming back again. It can come back byperson to person or it can come back through telehealth. That is — your question gets directly onthe advocacy work that Nobel women have been involved in the past several years. We havegone out really big on broadband adoption because what we learned is that a lot of — approximately35% 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 thesestudies were done that dealt with the issue of pay. The FCC has worked on this in termsof the universal service fund in making it available for high-speed Internet and notjust for land line telephone. We have worked on the issue of providing packages so thatpeople can have low-cost computers. We found out this was another barrier. People do nothave I speed Internet at home because at first of all they have to buy it in a cannot payfor it. Then, you have to buy a computer. One of the things that surfaced was that anequal barrier or maybe higher barrier is the lack of informed use. People don’t understandtechnology.It is over their heads and they don’t know how to use it. Your point is welltaken. I think that is sort of a prerequisite to rolling out telemedicine the way we mightreally want to do that. My grandmother is on Skype now. [laughter]. By the time sheis 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 impressedwith the presentation. You have advanced things in telemedicine.I think that the secretarytalked 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 dimensionwhich 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 — whatare your expectations? The experience has not been that robust yet.But, I think from the chronic care disease management site, I actually have an opportunityto meet monthly with my managed care organizations. They are a significant partner with us underthe Medicaid program. While we have noticed is the traditional tonic care disease managementis not actually producing the outcomes that we want.So, we are looking at in concertwith the NCOs — what we can bring to the table and really look at who are my high costdrivers and looking at that data and looking at some methodologies that we can put intoplay that — evaluate that in real time as we are doing it to see if we are at and gettinga 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 costpeople that have chronic care disease within my Medicaid a population and doing pilotsto focus on this that I can tweak as I go to develop access to that through the useof telehealth.In Virginia, like many states, the 30% outsideof managed care are our most costly. The people receiving long-term care services is as wellas behavioral health. We are one state that is working with CMS to try to do a dual eligibleproject. When we talk about telehealth and how it plays into care coordination, fourhour populations, in the RFP or the contract, we always describe that we expect to telehealthto 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 needto have a little bit of both. We don’t want to tie people’s hands. As soon as you sayyou have to do it a certain way, six months later it changes.We want to make sure thatwhatever care coordination umbrella we have — this allows telehealth to grow naturallyand 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 youagain this afternoon. Our panel this afternoon focuses on the recent cutting edge work ofseveral of our major federal healthcare organizations and agencies, specifically the Veterans Administrationand Indian health service. In that regard we are fortunate to have Dr. Adam Darkinswho leave the telehealth initiative for the VA. Bringing to that effortt a breath of experienceboth intellectually as well as programmatically. This is from his work internationally. Were also joined this afternoon by Mark CarrollDr. who recently left her — left after a full decade of work with IHS to join the Flagstaffmedical Center. He is there to direct their program in population innovation.Among his roles in the IHS, Dr. Carol ledthe planning and conceptualization of the telehealth initiatives nationwide for theIndian health services. Last but not least, we are joined by Dr. JayShore, an associate professor at the University of Colorado in Denver. Centers for AmericanIndian and Alaskan native health. He is also employed by the DOT telemedicine and advancedresearch Center. He is also working for the be a — VA in the native domain of rural healthresource Center. This is a unique opportunity to have the perspectiveof two federal agencies which work independently of one another for the most part, but haveformal agreements.This dictates the ways and encourages the manner in which they shouldwork cooperatively to serve the veterans of mutual interest. Dr. Shores work is at the interface of thosetwo things in the application of such efforts in attempting to bridge on an operationalbasis such a memorandum of agreement. So, today’s panel is intended to provide us withgreater insight into these organizations and their approach and current thinking and futurechallenges with respect to the role of telehealth in their specific enterprises and also tobegin to highlight for us some of the challenges and opportunities emerging with respect tocollaboration across federal agencies and in-service a particular segment of our population.We will begin with Dr. darkens — Dr. DarkinsDr. Good afternoon. I am glad to be here. Forone second, I will start with a couple of personal notes. I first got involved withtelehealth back in the mid-1990s. I worked for a startup help your organization. Thereason 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 thethings that became clear to me at the time — the future of this area of telehealth wasgoing to solve problems — developing large networks. By the definition of telehealth, institutionof medicine definition — we have had a network that is been around for over a century — thetelephone network. I want to do that if you look at the experience with that, all thatis currently being talked about is going to happen. It is not a pass question of whetherit will happen, the way of technology is that it will be ubiquitous and people will useit.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 workof many individuals over years. It is building on things to take us there. First, just to describe quickly what I meanby 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, andmobile health are all elements of this. Slides are available if you want to go into moredetail. What I will talk today is about three elements of this — the clinical video telehealthand store and forward and hold telehealth. One of the things from my point of view isthat this has to be based on a demonstrable need.For my decision, it makes sense to dothis and focus on the battery delivering care and looking forward into the future of servicethat will be done, but very much around the results. The organization has introduced telehealthnot because of an interest in this, but primarily an interest in providing care to a populationof veterans. First, home Telehealth. Many in the audienceare familiar with this. From the point of view of the VA, the value in delivering homeTelehealth is, as you have heard, dealing with people with chronic conditions. Thereis no evidence that dealing with long-term chronic conditions, the traditional clinicis the most effective way to do this. We have introduced non-institutional care in keepingpeople out of nursing homes and chronic here management for expensive patients and acutecare management, health promotion, and disease prevention. We use off-the-shelf technologies and havea 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 over74,000 people as you sit here and I am standing. The growth, I can show you from fiscal year2008. This is at any point in time — it is the amount of patience being managed. We builtup from originally in 2003 — we started off at around 800 patients. We plan to be at around92,000 by the end of next year. Second program I will talk to you about isstore and forward Telehealth. This again — the main areas that we do this for our or imagingfor 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 — preventavoidable blindness. There’s a large population for this. The many organizations in ruralareas have difficulty finding dermatology services. So, Tele or mythology makes sensewith this structure in place.We are exploring how to move forward into wound care. To give you a sense of how this is grown from2005 we started off at around 1500 patients. We grew 227,000 by fiscal year 2008. Thisyear, 171,000 last year and at the end of this year we plan to be at 256,000 patientsbeing 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 withouttravel. We have done this for mental health which I will cover in a moment. We have alarge 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 byIP video. We are also extending this to IP video intothe home and spread out — this is an example of how these areas are converging. I am talkingabout three of them separately, but they are actively converging as we go forward.Fiscal year 2008 — 93,000 patients receivedcare 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 roughlydoubling 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 problemsto deal with as you are all aware. Tell a cardiology and neurology and women’s telehealthand primary care and spinal cord imaging and audiology and pathology and moving forwardas in the last year with Tele ICU.Home Telehealth — the care of manage thatup chronic conditions and also moving forward to do disease prevention particularly in weightproduction. Store-and-forward — retinal imaging and Tele dermatology and Tele would care. The VA is recognized as a national leaderin this. We provided care for more than 150 VA medical centers and outpatient clinicsto 380,000 patients. The reasons for doing telehealth art to producecost and increasing quality and improving access. 47% of the patients who were servedby these programs are in rural areas or 3% are in highly rural areas. This is one ofthe reasons to do this. One of the things I heard yesterday was a discussion aroundwhether urban versus rural — being a simpleminded soul and talking about networks, your resourcesto provide care in rural areas come from urban areas.To my mind, it is not a question ofone versus the other. If you are developing a large network, you can serve the rural networkfrom urban resources. This is about a large network. As we move forward this year, we plan to have480,000 veterans turn this year which is 9% of the veteran population who have been servedin some way by these three programs. Next year, in fiscal year 2013, that number willrise to 820,000 which is 15%. There are benefits of the organization — wehave talked about this. Access in rural areas. We have routine outcome data which we collecton these pages being provided. For the home Telehealth programs, we are seeing a reductionin 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’sand also for chronic care management. The clinical video Telehealth — we have datafor mental health cares that shows we are reducing bed days of care in the order of25%. 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 forwardTelehealth — we have a 92% score for satisfaction and we are just instituting the program intothe 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 savingsfor home Telehealth per year and next year in — this was in 2010 — these were savingsabove all of the costs of the program factored in. Just to drill down in mental health — lastyear, 55,000 Tele mental health video patients and 140,000 Tele mental health visits wereprovided for 146 hospitals to 531 community-based outpatient clinics.442 patients receivedcare by video into the home and home tele-mental health patients for PTSD, depression, — 6764. Outcomes related to this — the study lookingat 2006 through 2010 of the video based services — a 25% reduction in the location for thepatients who had been managed in that time. Home Telehealth — looking at the 1041 mentalhealth patients reviewed before and after enrollment in the program in 2011, we sawthat we were getting a 70% reduction. 3262 bed days of care saved I using this program. Some unique challenges which are not uniqueto us but you need to Telehealth — training is not offered in medical school or includedin the health pressure will curriculum. Know outside resources to train VA and providerson the kind of skill we are talking about. There are more than 60 requirements to establisha 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 donefor an average program to be put out.Joint commission does not survey telehealthspecifically, but during the trace methodology, we are now doing such volumes that it is comingacross Telehealth all the time, so it is important to end up thinking about joint commissioninspections. We have three Telehealth training centersthat were developed to provide standardized training. The quality measure team does reviewsus each one of these things — the VISN.We have national databases so that routinedata is provided locally to substantiate board these local centers and the benefits to thesesites to have these services. We have national contracts and contract supportfor Telehealth technology including service and warranty and to ensure equipment qualityand safety. We collaborate with national clinical expertsto provide standards for care to Telehealth and guidance. Lastly, as in the program willtell you a big piece is how one deals with the permission technology and biomedical engineeringto be able to make sure that this copy of the recovers the services. Our training — good training at the rightplace at the right time it goes with the care.In terms of a large network, this is importantthat people are trained in a systematic way and we have a high turnover, not because peoplecome into the program and they want to leave, but one of the rewarding things about allof these programs is that quite a number of people come to the into their programs atthe end of their career in the VA. To have them say this is the best job they have everhad in that is why they came into healthcare, is one of the many gratifying things abouthaving this program. The emphasis is on virtual training and strategicpartnerships with the employee education system and all annual strategic plan for the areaswe are talking about.I won’t go through this in detail other thanto say that we successfully plan to deploy managed health programs and we organize clinicaltechnical and business infrastructures. We assess programs to identify clinical needsthat Telehealth can address. We improve and expand the delivery of care by Telehealthto ensure that it is has quality and it is sustainable. Some data — through this fiscalyear, FY 12 — in the third quarter, we had 150 training courses or forms available fromprecise. The clinical video Telehealth has done 2500 unique staff training for 800 trainingevent. Store and forward national training center — 3200 unique staff trained by 250training event. And, home Telehealth 2500 staff saw 800 trainingevent. 90% is done virtually. There is no point inhaving to pull something from Montana down to Denver or fly them to a national centerto train so we have three centers in the collaborate and they have slightly distinct areas, butthey are converging in terms of what they are doing much as the technology is. Some of the training innovations — littlepractice forms, integrated Telehealth receptor programs, interactive meeting rooms, new andimproved methods of training, test out options for super users, video used to capture thehuman Elliman, scenario-based instruction, and rapid response training.I will finish on this note — when I was amedical student I went to southern island I was taught by a professor of surgery andhe came back at the end of being a broad and we did round and at the end he said to medid you notice I touched every patient? He washed his hands — no patient should evermade to feel that he is untouchable. One of the lessons I got is that is importantto 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 theremission — 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 thoseof the agencies. Difficult crossing — the infusion of Telehealth innovation. This isfrom the 19th century and this captures some of the difficulty for me. We could spend sometime looking at who the actors are here and metaphorically relating that to the currentsituation, but I will not dwell on that because I am interested on what’s on the other sidefor 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 thisquestion — where we tried to go? I believe that we would all agree that the widespreadadoption of Telehealth is an important and major goal and we have tried this in differentways. 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 beento where we want to go. An issue comes up, obviously — why is thiscrossing so difficult? Are requesting the way we should? Well, there are many answersto this we have seen over the past 15 years. The current answer — the no-brainer — itis about reimbursement. Telehealth payment should be equivalent to in person care. Wehave heard this multiple times. I would remind myself and many of you would agree that thewidespread adoption of Telehealth isn’t really our goal — these ideas — quality is ourgoal.This is casual asides — conceptualized by the AAA. It is not about the Kazakh — thecare and the cost, but about population health. The question I like to ask — how can Telehealthinnovation 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 withgrace and ease. Or it could be like other types of crossings where a lot of money andgood 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 allof 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 of600+ facilities and some hospitals a lot of outpatient facilities. Some full-time andpart-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 thiscountry is under tribal self-governance. So, partnerships and collaborations are goingto call and tribal governance is an important part of that. The other thing is that thisis 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 differentiatingpoint — for all those of facilities, over half of the app running budget of most bothfacilities, from third-party billing. So, business models matter. This as noted yesterday — Telehealth is notnew for Indian health. This is a picture of the band from the project from the 70s whichwas an interesting collaboration. This applied some of the same basic precepts of care thatwe 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 willnot go through these listed here, but the service model is key and there are not reallynew service models except for radiology which I will remove. There are a virgin servicemodels. This is the challenge I would like to discuss. One model does not fit all. Itis 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 Southwestat 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 onnew partnerships — partnership that we may not be accustomed to. Yesterday we heard aboutthe county where I am from in northern Arizona — the second-largest county in the US — andcounty larger than nine stays with one regional referral center. It sits adjacent to the Navajonation and Hopi nation. New service models require new partnerships and we are workingon 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 isdone in store and forward consultation across the state of Alaska. I don’t have time togo 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 intothe care systems. This depicts the care approach and the culturally appropriate cycle in theunit on the Navajo reservation. New types of innovation do not work in this type ofmodel and addiction are not easily integrated. Many models require new commitments. We haverun tele-nutrition services from northern Arizona for Indian health sites in multiplestates. That commit was there for four years and we did thousands of interactions. Thiscommitment recently went away.The ability to continue with that model did with it. Most models don’t happen without a lot ofeffort. The IHS has its own apology program for right now though the — what knowledgehe screen. — Written knowledge he screen. The actual care and screening is better whenin person. You can look at the slope of the uptake — over12 years, while we have made significant inroads, it has taken a while and we are only finallyperhaps reaching the inflection point. Unfortunately, screening of eyes across theIndian 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 notbe new — we know that many care models using Telehealth innovation do not diffuse the sameway. Yet, we still talk about Telehealth innovation in these buckets of tools and how we can considertheir use real-time store and forward and remote monitoring. I would ask that we considerespecially looking at diffusion of new stratification. We can consider innovation that status fivein two — integrate better into the vaginal models of care that is a require fundamentalprocess and payment change.Radiology perhaps as an example of that. There is innovation requiring important buttonon fundamental change within certain systems in the US. Some specialty care in organizationssuch as Kaiser or VA is representative of this. There iss Telehealth innovation and a lotof what we have been discussing the last two days — this requires fundamental change especiallyfor open systems — systems that are collaborative in nature and not a particular organizations.Chronic care organization — after hospital discharge — I believe this falls into thiscategory. I would like to wander in front of you carefullywith the next thought — Telehealth enabled care is not necessarily the same as in personcare. It shouldn’t be. Because it is different andthe innovations are different with different care model, we should not expect that it wouldbe reimbursed in the same way.I don’t think we have done our job in workingwith new models of reimbursement. As I have noted, in some care models, thereis no in person option. I think that reimbursing the same way across video makes sense. Forsome 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 asgood as conventional care and there is growing literature on this. Importantly, sometimesit is actually better. I don’t think we should try to push this bigrock up telehealth up the hill as if it is a single rock.Some of the risks it are thatwe could confuse ourselves and the folks we are trying to speak with that this is applesto 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 from2010 — entitled Telehealth — tele-monitoring in patients with heart failure published inthe New England Journal in December 2010. The conclusion was that among patients recentlyhospitalized for heart alien, tele-monitoring did not improve the outcomes. The general conclusion — perhaps from otherswho may not read the full article — tele-monitoring for heart failure and care ordination modelsdon’t work. When you dig inside the discussion of thearticle, there are two very important points. The first is that this trial which was multi-sidenote of a single side trial where they found a 44% reduction in the rate of re-additionwhich 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 automatedmonitoring system.So you can step back and say — is there analternative conclusion that we could reach from that study? I believe there is. The nonrelationshipbased model didn’t work about the relationships based model that this was built from thatwasn’t published in the New England Journal dead. We are running a project right now tryingto learn from that lesson. It is called care beyond walls and wires — it is a projectbetween private industry and Indian health and the Flagstaff medical Center. It is builtaround patience. This is a patient who is a part of the project right now.He livesin 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 othercare coordinators after discharge into the community. Some basic approach to care coordinationwe are familiar with. We emphasize what we talk about this — thetools. This is about the relationship between Mr. [last name indiscernible] and Kelly. Iwill remove the tools and is about the relationship and the communication they have on a regularbasis that is made the difference. So much so that on an NPR story he noted that it’sjust feeling that backbone there to have support. You know it does touch emotionally becausewho else is watching out for you? I would ask us and in a research locationwe think about research, what is the value of relationship and connectedness in someof these care models? >> We have put together a mockup model.This is not new. It is beenin social science literature. We think of innovation in healthcare we are trying totrigger certain intermediate behaviors and activities of such as activating self-efficacyand self-management and compliance to achieve the triple aim. Social supports on behavioralhealth 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 shouldstatus by Telehealth differently and identify and learn and disseminate diffusion modelsaccordingly from that. We need to support more collaborations inopen health systems that work toward achieving triple aim for the population such as thatI described in northern Arizona. We can do — open system is one between different healthorganizations that have different business drivers and motivators. We could then studythe role of connectedness in reader partnerships to improve transitional care for patientswith heart failure, especially during the critical 30 days after hospitalization. Finally, I believe that we can support caremodel change at a larger scale by focusing on key locations like India and health facilitiesand community health centers and I believe that a national project is an ideal way tostudy the effects on triple aim of systematic use of Telehealth innovation in this can leadto policy and a display of change.To close, changing care models is a dauntingtask. Change can challenge and does challenge our care teams and policymakers. As my colleaguepointed out — standing to next to the sculpture of Albert Einstein — we stand on the shouldersand next to giant. As my mom and sister remind me, generationalchange does not always have to be difficult. It is different and we are different fromour 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 Instituteof 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 whohave provided leadership in pushing Telehealth on a national basis in a public manner forour veterans and our native patients.I am a psychiatrist based out of Universityof Colorado. I am going to talk about relationships. I will echo some of the comments that Markmade. I do where several hats as mentioned, butthis is my get out of jail free card — I am solely responsible for the content I willdiscuss. To give you a brief overview, I have spentthe 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-veteranpopulations doing program at it and clinical and administrative work. My comments are comingfocused out of those experiences with life interactive videoconferencing predominantly. I think as we have heard several times overthe last day or two, it is really not about the technology, but the technology is theconduit and bridge to that relationship with the patient to provide care.A lot of ways — even in non-mental healthfield, some of the most important treatment we give is the relationship and the healingrelationship between a patient and a provider. That, really, is the core of Telehealth servicesthat I have been involved in. But, this doesn’t happen without a series of relationships thatneed to occur to allow a provider to see a native patient in a rural community.It isvery complicated and in fact if the relationship is going medical — it is not the most importantrelationship occurring for the successful clinic. The most important relationship thatI’ve seen is the relationship between the service and the provider and community weare working in. If that relationship doesn’t exist — youdon’t have a clinic or service. In that it within that is the important organizationto organization relationships and particularly for native patient you are talking about eligibilityacross will double systems and there is a lot of data and research showing that nativepatients in particular used various systems — native veterans that I work with my getthere primary care from IHS and choose to get specialty mental health care from theVA, for example. Finally, in specific programs you also have relationships both internaland external that need to occur for successful clinical interaction.Jumping back a little bit, there has beensome discussion about mental health, but I did want to make a few comments, particularlyabout tele-Nettle health. In the field of mental health, I would argue that we havea unique fit for Telehealth in that most of what we do clinically can be accomplishedin some form over videoconferencing. This has been shown in the growing literature overthe past gave across age groups and populations and across treatment. Certainly, we need togrow and nurture that literature.Particularly, in the last five years within the emergingtechnologies of direct and home video conferencing and mental health and web-based care whichis how we interact with our patients. Obviously, we have heard the particular relevance ofTelehealth and tele-mental health for special populations and in particularly native communitieswith geographic barriers to access as well as cultural and institutional barriers theymay prevent them from accessing care.I would argue, also, that although — there has beensome talk about randomize to control trials — there is certainly a place and we needto do more of this in the field of Telehealth and tele-mental health to demonstrate ourtreatments are as rigorous as any other treatment which I believe to be true. But, we also needto begin taking nuanced approaches which I will talk about in a minute. Trying to understandthis tool of technology and how it interacts in the relationships. Rather than just askingif 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’tthink we understand in a systematic way how to make these pairings and how to addressthat.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 thattells the story of rural tele-mental health clinics for veterans with PTSD in some ofthe words of native veterans in the Northern Plains. There is also a recent article inthe Journal of telemedicine on a review of some of the data I will present. People havetalked about some of the basic guidelines available for tele-mental health and thereare a number of general public training sites. This one — was developed by our program inconjunction with fans to help introduce patients and administrators to the use of videoconferencing. Let me shift gears back to the diagram andstart with patient provider relationship and talk about — what we know both clinicallyand from the research they do about the strengths and weaknesses. As Mark pointed out, theyare — there is good data that there are some situations where Telehealth they be more effectivethan face to face visits.For example, I do work with the tribal council and I treat patientsin Alaska from Denver. When I am working with female natives who have a history of the mysticviolence or post traumatic stress disorder, they tell me it’s a lot easier to begin ourwork together over video because of the feelings of safety and it isn’t that they have beenworking 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 havebeen 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 theliterature, in the 5 to 10 randomized control trials in tele-mental health, you see equaloutcomes, there are some hints that there is an impact on the doctor patient relationshipin 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 workingin tele-mental health will take a bit it is true — it is different than seeing someoneface to face. The good clinicians understand this and the good systems understand thisand make adaptations. There are a lot of different adaptations tobridge 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 providersare often from urban areas. The amazing thing about the environment that we work in is thatyou can be getting lunch in downtown Denver and I can drive to my office and I am workingwith patients from Alaska — a different environment than where I am sitting. You feel more disconnecteddoing this over video. So, and less you make an effort is a provider in a system to understandthe environment and the issues impacting the patient, even on a weekly basis in terms ofthe 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 tribaloutreach worker. That is a native veteran Elizabeth community that does the schedulingand purchase the report and gaps and helps us to bring patients in to the system thattraditionally may have been reluctant to get care from rural healthcare systems. I knowthis both from data and experience from patients. We have had a Korean and Vietnam veteran whopreviously sought no care for mental health issues who came in not because a strangercame over the video from Denver but because of the community — community member involvedin the clinic and balding getting them in.That is one adaptation that the patient andprovider level. Additional adaptations include collaborationwith traditional healing which helps acknowledge the local context of the patient’s treatmentwhich is so critical. One of the other things that I observed — someof the biggest cultural issues that I often see — I am involved in a training clinicthat teaches residents to work with rural veterans. This is not the coach Earl issuesbetween native and non-native, but the urban and rural difference. There can be a realdivide. 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 sothey can communicate with their patients.This is critical. That are some of the salient issues that thepatient provider level — would we not — Telehealth requires program to program interaction. Insome ways, for mental health, which is traditionally been silo, it is a good thing. When I am workingwhen in the VA, to develop a clinic, I work with IT. I am having to coordinate with thelocal 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 clinicalcare. 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 consistencyin the care and leads to more holistic approaches.We need to systematically understand and beginto look at what the 21st century health care team is. Traditionally, 20 years ago, it wasoften just a mental health provider. If you are working in tele-mental health, the teamnow is likely a mental health provider, and in the VA system that will be the IT serviceand the local Telehealth coordinator for the facility you’re working with and at the clinicat 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 technologyand 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 putthis together. Multiple systems of care are possible and highly desirable at times. Theybring together resources where one institution doesn’t have all the resources as you bringthe 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 multiplesystems you also have maybe additional resources and funding.On the challenges — bringing the right partnersto the table is often critical and having the wrong configuration of organizationalpartners can sabotage any developing service. Trying to hit technology to talk between systemscan be a critical issue as you can’t will multiple organizations together and deal withmultiple compliance and regulatory issues across systems. This can also be challengingand on the flipside, identifying who is going to be the primary funder when you have localsystems involved and who is reimbursing for which parts of which programs and servicescan also be an issue of discussion.As I said, some of the fundamental lessonslearned is that multiple system collaborations can be highly desirable hurried you need toknow the local ecology. It is important to put together the right communication and collaborationprocess. And holding environment to be able to do this work. Alternately, finding a wayto take the organizational elaborations which often start off based on individual relationshipswhich can be critical in native communities and all healthcare and actions and systematizingthem.So, when you’re champions move on and people move on, you don’t miss what you abill. So, I will conclude where I started. Gettingback to this model. We need to do a better job of investigatingand exploring and confine these models that are successful at these different organizationallevels — codifying them. Understanding the importance of the impact of the relationshipsand how things are successful or how they do not work. As well as understanding, particularlyon the patient provider level, how the technology affects the process. Either positively ornegatively in the appropriate adaptations to make sure that as we develop these serviceswe are keeping our eye on enhancing the quality of care and enhancing the access and fulfillingthe 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 discussionstoday. 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 providerand 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 theencounter as well as the service long-term. Questions from the audience? Deal — Dale. [participant comment – no microphone] >> [captionerhas 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 informationbecomes 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 happentomorrow — and I have the capacity to do it, I would. But, there are other challengesin the meantime. However, putting these programs together — it takes 68 separate rings forus to develop a program — it is — the devil is in the detail.You have the pieces togetherfrom imperfect things at the moment and if it were — it would fall together and havea — we could do this a lot more easily and we could not have this discussion we are havingnow. I know that the audience would love to chatabout 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 back30 years. And from which the graphical user was built. It is interesting when you talkabout the occupational health — in my new role in the region in northern Arizona — wecan think about outreach and collaborations in the region of which we are doing and thinkingto models of care, but not only — 30% of the admissions at the medical center are NativeAmericans 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, maybeat like stab medical center — they should think about — like stab medical center — — FlagstaffMedical Center — this is what we should do.Other aspects that have been anticipated butnot closely examined — this has to do with how have you thought about in your respectivesystems — bringing into play local, regional, and national leadership, not just within theagency, but those that can champion an advocate the context and opportunities for you to pursuethe networking you are talking about, Adam, across the multiple entities? Encouragingand 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 sharingthis for fear of this application.Adam, it seems like the VA has done a great job infiguring out — with a nor a notice amount of effort — the kind of information is neededand applying it regularly to the improvement of quality of care as well as the accountabilityof effort. So, I would be interested in how you have thought about educating and traininginto the sense of community — not just providers or administrators, but also key decision-makersfrom Al Qaeda operations is.This seems radical to the success that you’ve had. I will start here. I would say, in particularlyin the work we do in the VA, both the VA system leadership and the tribal leadership has beencritical. In each community that we set up, Tele mental health services, we go and havediscussions with the tribal Council and engage the leadership. We then engage the local VAleadership as well. That has been a part of theprocess and it is hard to move forward if you don’t have the local, regional leadershipbuy-in. On the national level it is through venues like this where you can discuss andpromote your model and get access to decision-makers and look at — also identified — others thatmay have an interest in taking that model and expanding it. For instance, in the Telemental health clinics, we run for northern plains of veterans, this started in the northernplains — the VA region 19 — in the coming year, we are going to help 2 sites nationallyoutside adapt this.This has come about because we the word about this through the leadershipdecision 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 creditwhere credit is due — major capital risk taking on the part of the VA — with respectto Adam — having seen the opportunities and deciding to invest in seeing what possibilitiesmight be realized. Thus, generating a series of small but early effect of models that canserve to inform other advocacy efforts. I think that you are referencing the firstclinic — this was on the Rosebud Sioux reservation.It was Dr. darkens off this that providedthe funding — it was a national office. This was going through the process, really, withDr. 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 Mexicoand being on some of the pueblos and seeing the help me. Coming back to the driver forthis — the driver is really a public-health needs that is understanding and deliveringcare. It is something that was not a funding of one project — this is something that Ifeel passionate about personally that we develop. Being slightly humble — I am not exact surehow to do it if I could do it.I was certainly doing much more of it. I enjoyed very muchlistening to the panel on what is happening in the states. I think that part of this isthat it needs a large vibrant immunity thinking the same thing. To see large state programsthat are active is going to be helpful to form how these things come together. Decisionsthat 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 resourcescan 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 complexquestions 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 communitywithin the VA which has built a community from nowhere where it is regional — we certainlyhave 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 thatit 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 representationin ways that I would be happy to see — ways to broker relationships and establish whatyou are talking about. Suggestions would be welcome. Thank you. I submit that that has not been a part ofwhat we have systematically investigated with respect to the diffusion going back to yourearlier observations, Mark, I’ve the technology as a means for improving healthcare. Ninaand 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. Howcan we get CMS to accept your work in this area and not ask them to reinvent the wheelover and over again? All the way back to the meeting 10 years ago, Mark you percent ofthis. You have a gold mine of data that we don’t have to prove over and over again. Thereare valid statistically and sound studies with amazing results. Help us to understandthe reason that we don’t get CMS to accept this. I don’t think it is a silo issue, butI understand that it is maybe more of a capture population in that the veterans access mostof their care through VA facilities and the natives and tribal groups access most of theircare through IHS. The Medicare population goes over the place. There has got to be away that we can capture the value of what you have done and convince HHS agencies toaccept that somehow.Thank you for that question. The IHS has activelybeen dialoguing with different offices in CMS about that. National coverage determinationfor Indian health side — the coverage in Alaska which included store and forward andthe fantastic data that we have both in terms of outcomes and process and cost. We didn’tshow that data, but there is a phenomenal data for that. There have been some bills that have beenproposed by US Senators. There was a particular bill, in fact, that would authorize four communityhealth centers in India and help help sites to — Indian health sides — for reimbursementfor Telehealth within that model of care. I think it is a great idea. A TA supportsthat. They have that language. I am happy to partner with anyone in this room who canhelp Al Qaeda move this forward. I believe this is an ideal arena for us to move forwardand to move forward in a partnership, say, with CMS and others to evaluate names thatmake sense to them going forward. We are interested in that, and they are are active dialogs rightnow, but it is uncertain where it may lead.I would say CMS has been actively involvedin Telehealth since its inception and still lives and is interested in what happens. Iput it back and say — what exactly are you asking here? In the sense that it seems tome 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 onthis. My personal views on this are as follows: there is no systematic way that Telehealthis being done. So, we do it systematically and it is hard work to do it. We have seenwhere things have not been systematic with home telecom — LL — Telehealth.What wouldyou describe? Secondly, I think the other thing we have to of knowledge is that thisis not the standard way of practicing. I believe that if something suddenly said there wasa way in which this could be done tomorrow, there is a tremendous clinical change managementpiece that has to be dealt with this as well. So, I think — I am not sure the solutionyou are suggesting. Of suddenly being adopted. Lastly, again, five found in Telehealth — Isaid from the beginning — it is been about solving problems. I have never thought aboutwhere the money will come from in terms of — elsewhere other than saying — this isreally about how you change clinical process and how you to make it value in work.So, lastly you have to say that CMS has tobe 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 answeringthe same questions. I would say that one of the things — a personal observation — thisis about networks and it needs to be done with networks of a larger size to be ableto look at this before one can talk about models which are transferable.Thank you. Last question. This is Mr. Terrace from the center of healthpolicy. I want to echo what she is saying. For example, the health Buddy program fromthe 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’vebeen so we are talking about — the triple aim. The issue I would like to propose — anotheraspect of the benefits of Telehealth that are being surface. That is the relationshipbetween 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 thatpoint. Have you seen in your work, either one of you how Telehealth can incorporatethe cultural values and to use traditional healers in this practice? In the clinic that we run in the northernPlains, we have, depending on the facility both formal and informal relationships withtraditional peoples. We have had ceremonies and blessings. I was actually blessed as aclinician to work in a video conference. The healer felt that that could be done. In oneof our clinics, we have a referral system.Again, not all clients want to follow traditionalmedicine, but we have or furl system where we refer patients that are interested in healersfor sweat lodges to help with PTSD and occasionally they healers will come in and communicateand 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 orinformal network and then establish a process around doing that so that we can do it ina regular systematize way. I think that this demonstrates to the individual veteran thatwe are taking into account their perspective on health care and treatment, but more portlyit gets to what I said, particularly in small communities — native and non-native — itis an indication to the community that that individual provider and data service and thathealthcare 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 organizationand a system may be a room or a small clinic. It is a VA clinic but you are presenting abig organization. Things you can do to demonstrate that elaboration and partnership at the communitylevel in the treatment of provision of care is critical, but certainly I think there isa 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 nextpanel followed by a panel of the landing committee to provide brief thoughts with respect tonext steps. Any logistics, Tracy? Please find your way back within the next15 minutes. That would be appreciated. Thank you. [applause] [IOM Telehealth workshop is takinga 15 min. break and will reconvene at 3:15 EST. Captioner standing by.] >> We are goingto get started again. Everyone outside — thank you for hanging in until the very end. Itis 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 isa Telehealth.Do we know anything about outcomes? Where is the best place for Telehealth inthe affordable care act? What are the research questions that the IOM can help answer? Justwhat 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 becauseI wish there is money associated with that somehow. Then I realized in speaking withDavid at lunch today that I guess I am a proponent of disclosure. When I were bottled an oldfarmhouse, I put all clear glass doors on the bathrooms because I lived by myself andI 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 talkedabout taking a look at if we could bring a variety of stakeholders together to discussactions that HHS could undertake to further the use of Telehealth to improve healthcareoutcomes while controlling costs in the current healthcare environment. I think one of thethings that maybe for the next one of these that we would do — hint Tracy — we probablymade it — made in air in not having consumers except for us. We could probably use a consumerpanel. We got the next test name — the panel today represents the majority of the rulestakeholders that access their care through what I call Telehealth technologies into thevirtual space. I will introduced the panelists — Dr. GeorgesBenjamin is the executive director of the American public health Association cash thelargest organization since 2002.Prior to that, he was the secretary for the MarylandDepartment of Health and mental hygiene. I imagine a lot of your preliminary work endedup with some of the things that we saw today from Maryland. Stuart Ferguson — you have heard a lot ofquestions from him. He is the CIO for the native health Consortium in Alaska and hehas the primary responsibility for all IT operations through the Alaskan it of medicalcenter which is the largest native hospital and medical center in the United States. Alan Morgan — Which is reconnecting afternot seeing each other for years. He is the CEO for the national rural health Associationand he has more than 20 years of experience and health policy development at the stateand federal level. Ellen, your first? — Alan — You are purse. Good afternoon. On the behalf of the nationalrural health Association it is my honor to be here today. We are going to talk aboutthe role of Telehealth and the evolving healthcare environment. I will follow up on me this suggestionand I will disclose something as well.We were asked within a 10 minute period of timeto talk about the great challenges facing Telehealth and provide the all possible solutionsduring that 10 minute time as well, too. Don’t laugh — I think an can accomplish this. Let me start by highlighting what we do whichis to take innovative approaches to move healthcare for. As such, for everyone currently heretoday in the audience, I would encourage you to pull out your smart own and open up yourbrowser and Google were will help. — Rural health. If you are online, open up a separatebrowser. The first thing that comes up is the NRHA website. On that website under thetap listed as log, you can pull up our 11 page. The mode he including the state of Telehealthin rural America and all possible solutions from a policy standpoint as well, too. Thisis a wonderful tool in a document for the IOM and committee and staff as you go forwardto try to develop your recommendations. This document was developed by leaders in telemedicineand tele-health in rural America from across the country, many of which are the audiencetoday.I would encourage the committee and staff to simply cut and paste as liberallyas you deem appropriate as you pull up together your comments. We are here to help. See — thatwas in two minutes. The remainder of my eight minutes, I will highlight some of the keypolicy recommendations that we would like to put forward. Unfortunately, these are notnew or novel recommendations. They are going to be the same recommendations that you allhave 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 Telehealthcommunity on what needs to be done to further expand telemedicine and tele-health.We have put these recommendations togetherinto 4 policy buckets — reimbursement, credentialing, broadband infrastructure, and research. Idon’t know how that matches the buckets in your head today, but that is how we have putthem together. In the area of reimbursement, NRHA recommendsas many of you have done at this meeting that first we lived the geographic patient requirementsof receiving care through telemedicine and Telehealth. It is very important as we proceedwith this to not lose sight of the rural designations in ensuring that rural is served. These providersare reimbursed less than their urban counterparts. The financial equation for the Irvine-basedoriginating site does not work as we have heard so mentioned in the last two days, telemedicinewill remain as a branch of service. Eliminate separate billing procedures forTelehealth services.Telemedicine is a tool for the clinician. A separate CPT code doesnot do any sense. Third, reimburse care provided by physicaltherapists, respiratory care this, speech there this, and social workers. These areservices provided and in high demand in rural areas but it often not available to ruralcommunities. Finally, provide reimbursement for store andforward applications. Nina mentioned that I have been involved for22 years — 21 years ago I was a healthcare staff on Capitol Hill and the CEO of Kansascame into talk about a novel payment methodology the reach each program. This was the precursorfor the critical assess product hospital program. He said Ellen, let me be honest — five yearsfrom now we will not be talking about these hospital reimbursement issues because telemedicineis going to address all of our workforce concerns and quality and access concerns. 21 years ago. I am optimistic and I firmlybelieve that 21 years from now we will not alluding to the comments that I had now.Thatis because obviously we are in the perfect storm of healthcare right now where if wewere 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 qualityand health disparities, we have no option forward other than to — utilize to let healthas a tool for the clinician. That is my optimistic page — I will not bementioned this 21 years from now.The second bucket — credentialing. We havediscussed this over the last two days. The IOM should study the cost effective — costof filling it with credentialing and privileging as it is very burdensome to rule — ruralproviders. This is a bullish barrier. A Telehealth provider can administer services to patientsanywhere in the country. The NRHA recommends that CMS that does the polities to allow Telehealthproviders to receive status and to allow facilities receiving Telehealth services to perform credentialingby proxy. Again, this is not a new recommendation. You have heard this repeated by many of thespeakers 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 requirea 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 hadduring yesterday morning. Finally, on the issue of data and outcomes research, numberone is that you have heard many times there is much research already available. I am goingto differ a little bit from some of the earlier comments of yesterday morning and on behalfof the national rural health Association, call for additional quality measures and Telehealththree minutes to improve the services in rural America. Let me be careful on this. As IOM considersthis, I hope that you won’t fall into the trap of assuming that just because healthcareis delivered in rural America, it must be of lower quality.That is not the case. Thatis not the case highlighted by the IOM report quality through collaboration and also lookingat CMS ‘s own hospital data comparing small critical assess hospitals that have reportedthrough hospital compare to — versus urban counterparts. These two sources clearly indicatethat rural healthcare when delivered as they do in rural America compared with urban communitiesis 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 hasactually improved.I think this is a great research potential going ahead and will helpmake the case for the need of the expansion into rural communities. HRSA — NRHA also calls for research to aidregional extension centers to improve the services they provide. Importantly — NRHAdoes not think that these two entities are not doing their job. They are. But, withoutthe research and the outcomes research of how they are providing successfully to ruralcommunities, they cannot amend or correct and move forward in providing that technicalexpertise to rule providers and will communities. I will close my comments by something thatDr. Wakefield said in her opening remarks. NRHA would call for the study and look atthe effect of Telehealth on recruiting clinicians and training clinicians. Telehealth not onlyaddresses the direct clinical application, but also as Dr. Wakefield indicated can’thelp address these workforce challenges that we often face.I see my light is on. Let mego ahead and conclude. This is a realization that we all know — to can set you free andthe truth has been indicated and articulated over the last two days here that it is timeto set telemedicine three. The barrier is no longer the technology as it was 20 yearsago. The barrier now remains in the rules and regulations and guidelines that we haveopposed — imposed upon it. On the have of the NRHA, I want to thank you for this opportunityto provide testimony to the IOM it is a look at this topic and again mind you all to goonline 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 telemedicineAssociation 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 themI talked that way and there are 50,000 cases the share and we spoke to the state legislaturewhen it landed in general to different individuals told me you’d better be prepared because healthof social services of state Medicaid director testified they’re counting on telemedicineto save as much as $30 million in travel costs to decrease the cost of care and are Commissionerand state Medicaid director looked at partner to have to come up with of that this planand different methodologies for payment by hospital administrator meet with me they havetell health activities and patient monitoring are-little advocate the and tribal partnersmandating the use of Telehealth next Friday to meet with 60 drive and talk to them aboutwhat we are doing to meet demand for specialty accesss they’re trying to scale the systemwent to the challenges go away I would like to say this is where the ATA has a role, witha 17 member board and staff look ahead and prepare to meet the demand that is going tobe there in 12 to 24 months of this is the division of the American Medical Associationand that is a division we have in Alaska the division the many of you have your own tellhealth systems –you’re on Telehealth systems and they can provide the services I cannotachieve on my own down the official journal of the ATA and oneof the editors in chief and starts with online resources and they continue webinars and webcastsof their involvement social media and you can connect.Facebook and other methodologiesand they have member participation like all good the creation you have a large meetingof that kind devoted to tell how the telemedicine and it is a convenient meeting of the fivetried to bring those together and have a good session that happened in April and May andtheir other meeting the they do as well and very convener of people involved in telemedicineand something else they do is extremely important to this field of the move forward and thatis the active participation of bumper down they involve members through other mechanismsthan one of of of member groups and within they have special interest groups such asbusiness and what have you participate in many more of these and these are the subjectmatter expert interest groups and that you webinars and meetings and they get involvedin evidence-based guidelines and practices and they have chapters with discussion groupsand because we are interesting organization where we involve the industry we have a ofthe 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 theATA is heavily involved in helping evidence-based practices guidelines and standards of thisis important.And we want to follow best practices we don’t want to reinvent with want to tryto discover the fire also the source of that information is the only source that is outthere right now to go to the ATA of what standards and guidelines have been developed with theinvolvement of academics and industry practitioners providers and so forth have a series of guidelinesthat have been completed and number of progress I highlighted a few vanilla because they haveimages throughout the top, specifically heading up the remote health monitoring and data managementshe expanded her group by inviting other speakers to that group and we don’t have a formal guidelinesof how to do this one of the best practice and give a blend of academics and providersand service have is a fairly nice group to work with and the reason that we need guidelinesand the reason that we need standards is not do arrived but because Telehealth of the solutionof skill .I can tell you it makes no sense to do it for five tab 15 or 20 patient whenyou start getting into the 100 and as soon as you start to get into scale, if you havea department that went from 40 to 404,000 consult the year was only eight physicianthe problems changed the challenges change and I think if we look at year or two aheadwe realize we are online adoption curve are going to be facing a different set of challengesand they’re going to be challenges of scale these are the challenges we face people talkabout doing a chronic care and patient monitoring and those of a the conversations Pamala toplay a role of conversations in which is came from a two-day board we and the strategicplan for the coming year and to give you a idea of the key areas we will continue towork a public policy and comprehensive educational subsystem and consumers and so it exists furthermates.And that is good because Telehealth and healthcare working aggressively to makesure the lessons learned are shared and the other less of their shared back here thatis the goal to bring people together and to move the field forward. Thank you very much. Good afternoon I’m going to take a differentapproach, those of us in public health and like the healthcare system many drivers anda population healthcare system change and I just want to point out a couple and thereis a lot of data floating around public health liver the data enhanced capacity analyzinglarge data set speed at which technology is changing we think enormous potential havebeen lost with early prevention and the benefit of and of course, the fact that a lot of thesystem changing it going to be driven and as baby boomers were trying to catch up withour kids that it included a goal for health information technologywave West are patient with knowledge and wisdom and bilateral conversation and try to helpthem we need to recognize that as they go forward and secondly the fact that we wentto deliver actionable information and there is lots of information on the web and in cyberspaceand a lot of it is actually inaccurate that one of the challenges of public health isto try to work with it and other objective the IDF trying to connect to populations thatare culturally diverse, also remains a big challenge and really trying to build programsand interventions that result in behaviors and we think it is one of the big challengesand there is no question that brings enormous value in the keyword is enormous managingpopulation interventions than I watch talk about each of those very specifically andthe financial services public health and reminding people that public health is doing assessmentsto take what we learned from that policy development.For variety of venues sure that those thingsget done the we think are important and do that have the essential server I have I wantto remind everyone that as we move to an environment where everyone has an insurance card, somestill think why do we need a public health service and one is clinical in nature andit is split between not of providing that care for people that still do that but thekey word is linking people to system the fact public health those more linking in most publichealth system but in terms of providing care.With that in mind, clearly Telehealth is goingto be helpful as we look at tracking activities and these trends with things such as immunizationthe cancer registries as we investigate new disease outbreaks we have an enormous numberof mechanisms to do disease surveillance where we are collecting data not just from the healthsystem but looking at what is being sold in pharmacies and grocery stores and puttingthat data together with school absenteeism to do some early pickups on new disease processesbased on clinical syndromes and communities. A variety of ways to communicate effectivelywith the stakeholders including the network for example the Center for disease controland a variety of public health emergencies. The idea of mobilizing community partnershipsI’m going to come back and talk about social media in just a moment the primarily throughlinking people and engaging them through the web another mechanism could help mobilizecommunity partnerships the move communities to taking Parliament action toward their ownhealth.Linking and coordinating care we can continue to talk about the 25% of people spending75% of the dollars, with interesting part of this session is when you start overlayingthe patient bar with the challenge communities and associated problems that we have and manyof the communities the same people that were challenge of the same places with high levelsof lead in the environment and we have crime or violence and street–they are not walkableor by couple and booster call them noncompliant believe just the mother noncompliant and wefind out there many things, fundamentally outside the functional control because ofsocioeconomic status and prefix of from a community perspective medical community medicalcare community and public health community would look at those folks of data points onthe map and put in place strong community programs and interventions that make it easierfor 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 forwardthat information to try to prove build on ongoing basis of fundamental research thathappened for health systems research public health systems research Gauger the communityand we are recruiting people to be part of it and does the flu season develop leadersadvocate the reported systems and if it does you can send out targeted authoritative informationto the listserv about what the terms of enhancing social distancing handwashing getting a vaccinewhatever the intervention may be as you go forward and that the range of social mediatool that are going to be affected as we look at this and go forward. Of course like everythingelse the challenge that we have obtained for health information technology before 9/11the public health. Was operating off of Rotary phone we have gotten rid of those we are stilloperating on both the wonderful new technology got right after 9/11 as part of emergencypreparedness in the equipment has been replaced and those of you that have kids in collegeknow that colleges say two or three computers.For most parents. That is not the case forpublic health department. They need the technology but don’t have it in investment in preventionand 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 thatwe should require appropriate linkages of the public health care data and provide promptthe perspective the public health of the fence, that data can go into the public health. Andof course patient confidentiality and appropriate protections in place and finally, we needto demand accountability for population-based outcomes for everyone I remain impressed ofthe public health advocate that the number of states that are linking systems remainat the bottom and they had been at the bottom for some time and those requirements logisticspublic health outcomes at the bottom of the tent 20 years and that is something to beactivism around trying to address that obviously Telehealth will of that but only documentthose little clout, etc.But targeting solutions we can make a difference. Thank you. Thank you very much all of our speakers Iam impressed again and each one of these panel, very interesting, nobody talk to each otherbeforehand 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 todocument the health care in general and not so much, I am moving very quickly away fromthe full Telehealth used but the document return on investment strategies use of healthcareand to look at large data sets to enhance the use of public policy through the effortsthat we are trying to achieve public health, private help, Telehealth, whatever it is soI will put it up to questions from the audience. I have a question for Dr. Ferguson. I haveheard 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 morefocused on interoperability standards I have heard that from one other panel those areissues it looks to me like that is one of the major challenges that we have and secondarypiece to that, and this is a what if, I find myself wondering, it appears everyone thatis doing this is building their own support network is there an opportunity to fill thata shared services support network for multiple providers?.Those are great questions. Interoperabilityhas been a struggle and the does get addressed at that level and we don’t have the productivityfocused on that with of the ADA that device interactions a lot of that discussion hasmoved to the industry panel at the ATA is — Can interrupt for a second? That is good tohear, image the industry counseling approved, my university the crest very hard, marketedto very hard by local cable company and national cellular provider who have, really interestinghome systems their proprietary. They will work with anything else that wonder at thispoint, 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 usethings such as direct messaging and of the technologies that is Vista standard to movethat data on a standard slave slave devices to talk to her.Terry servers and can giveyou a HL seven the real-time into the BHR and perhaps of the models I have seen fromcompanies that will do direct messaging and because you some options to do real-time feedso I don’t know, we don’t have a position on that but I think it is a good questionand I know of one very large total health system and I think those business model aredriven 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 yesterdayof the ticket picture of the dental hygienist and at a school in Sacramento, for low incomechildren, California, 25% of children have never had dental care and we have a huge levelof health disparities that are experienced in the general healthcare system and thatlevel.Lots of opportunities to be able to reach people who are not taking advantageof traditional oral health care system to get dental healthcare through tele-healthtechnologies of the California to the effort and the telemedicine Association and the moreinclusive the could find a way to characterize the topic of my abstract that would to putin — We screened head start children, three andfour-year-old, and five-year-old the cheerily basically find 75 to 80% of them have activedental caries and 20% have open pit that if you don’t know if that is, it is scary. Icannot name one other tele-dentistry program, except maybe yours, that does tele-dentistryand what we found, six years ago, we started putting up dental clinics of the result ofthe tornado and it lasted only dental clinic and we supported that dentist to get the practiceof again and realize there is a great partnership and collaboration that need to occur betweenour dental providers on her medical providers because oral health of the direct impact onthe quality of life and the quality of the visual path and we have actually taken themodel 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 disciplinesthat are using Telehealth now it is not so much about medical practice of surgical practicethe dentistry in mental health we thought earlier..I was going to say two things, the fovea testsimply Canaveral health to the drop-down list–oral health to the drop-down list. Alaska is theplace with challenges with dentistry, lack of dentist a lot of dental challenges. Wehave a program called the dental health aide training program and that is typically peoplein villages to come in and get trained in go back to Mary dental therapist and we doTelehealth training in the training program and now they take images and communicate withthem unsupervised outside the state inland you go to the village we use Telehealth allthe 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 dedicatedto the program we are running about five articles and the methodology of the flesh get moreinformation about how to do the project which has demonstration plant across the state ofCalifornia.Thank you so much. Other questions? I havea 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 returnon investment whatever your thoughts on how we might all work together in the future withour organizations? Let me start of they just of collaborationis important as a go forward is support for the national organization to go ahead as welland I was just talking earlier, we partnered on a numerous issues that we have not on thearea of Telehealth I look forward to doing that going forward, the ATA, I want to sayyour staff and if we are not talking every week, every other we, obviously but the natureof the healthcare delivery process that has to be a strong partnership and I think itis going to be incumbent on all of us to bring and other organizations into this discussionas we move forward.I will concur with that and I think the healtheducators with a good partner with us as well. The biggest challenge I think we’re goingto have the amount of misinformation flowing through all of these electronic systems. Wehave enough problems with their same the same thing and people here different things. Butwhen you had the amount of misinformation we are going to need a lot of work to becomea trusted advisors to the American people on this issue that is going to be from theclinical five to the American people on this issue that is going to be from the clinical54 population-based side and getting make sure that information is accurate and thereis a rapid response and we’re doing that with back pain and there is a large anti-vaccinemovement would spend a lot of time responding to that information about back pain.Specific to the ATA, board of seven yearsand every time we meet with this facet of the small staff and I know they have to workand collaboration in association with other organizations and we worked with–and theywork with NOBEL women and a lot of different programs including Parkinson’s group for theirpatient population that could benefit from Telehealth. I know that is happening. Any other questions or comments? I am Janice of the American speech languagehearing Association and a cochair of the subcommittee on the American medicine we have group andthe subcommittee is on life Dr. portability and I bring this up because of the last ofthe couple of days the number one issue that keeps coming up is the problem around licensureand as a state policy person, that is a big deal and when you mentioned coalition, thisis a perfect opportunity in our little subcommittee we invited the PT OT and speech and hearinglicensure boards to join in with us in our conversations around portability of of ofthe things they keep saying, why are we being asked my happen to know by research nationalGovernors Association everything using a problem that we have Fortran want to be able to progressthe cross strait line they are not necessarily being involved and we know it is a big obstacleand we need to have them involved and I just want to put that out there is something toconsider and bring them in and help start talking with them and that is what it saidon a national basis but nobody is doing and nobody is actually doing it.I think theywant to be invited and there are some possibilities thereof the other part of this is, sometimesit is not always the boards that are driving this and I look around and I am wonderingwhere the AMA is on the sign out there has been a major obstacle, not necessarily themedical board they start out as trying to make it different than creating special licensesand trying to do things going the can down the road on a policy level the AMA has notembraced this that makes it difficult for all of the other groups but if you want toput that out there and I welcome your thoughts on that. I will jump into that one. Thank you for servingon the group was ATA, I appreciate that. As you probably know that Alan is on our boardand 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 recentlywhich is the ability of the federal side the console.Not have a license to see that they’reproviding care to a patient rapid changes and talk at the national level and Medicarehaving a similar requirement in there is talk about changes in what I can tell you, we areinvolved more and they took a position the sure they want ATA to be very actively involvedand the push for change in the past it has been more passive than somebody invoked WinstonChurchill, we have –we will in the air, we will win on the land, we will go after thispretty aggressively. Bigger business interest, integrated healthsystems and care organizations, across state lines, consolidation of industry it will drivea lot of the issues and, line concern, it is all about money and I think once you startbringing people in these larger systems I will watch and see what happens and in Bostonthe particular as they begin remodeling their systems because people are moving rapidlyacross.Supporters. –Various borders. With content on the licensure portabilitygrant and I could tell you we have nine days seven of those represented all of the licensedclinicians and practitioners and that the state level I totally agree, we don’t do agood job and that goes to 1998 and the more collaborative than one more question and we’regoing to close. I am Bill Applegate and I don’t want to endon anything but a rabble rousing note, see you go. I am appreciative of all three ofthese organizations and a member of them and I want you to know that I have been involvedin nominal ways over the last few years and something else, you respond to what your memberswant a great deal and I want to sympathize a little bit with Alan that I have any ofthese numbers are when I asked this question and is primary for Alan and maybe for–andI won’t let Stewart off the hook entirely.Tell me why the world of healthcare is sofocused because the money is there and chronic disease in managing chronic disease that thenational world health Association American Public health Association isn’t more aggressivedemonstrative and leader like in addressing those particular issues and I don’t want tobe terribly critical but I do think, that is where the money is that is where the opportunityis and when I look at meeting schedules and events that you have things like that I amimpressed and. I have terrific they are lots of attention as managing chronic disease inthat country. Thank you for that softball questions to closethe agenda with. I say the question begs a much larger question and I won’t speak butthe national health is officially asked 21,000 members for submissions for conferences toset educational content and added the 207 submissions we have a planning committee of25 members the select that agenda and I have to be honest with you the submissions havenot been there and that is not that is, the raises the larger issue of where you saidfrom a membership perspective, where the focus is that and what the attention is put on forpeople involved in delivering and receiving oral healthcare.I think we decided the solution to this problemis through bundling primary prevention of that pre-primary prevention of looking atthings like the–environment, food systems, trying to build transportation system andlooking at how we reviewed with a fair amount of money time and effort in doing that andthe affordable care act we are very much involved in all of the clinical preventive health servicesattrition and tobacco and the look of the leading causes of death and disability thatgoes back to tobacco and was you get back to that one the range of nutrition and activityand root causes and we have been very focused on trying to engage this and we are pushinga big rock up the hill and trying to get the public to embrace that change and the preventionfund is designed to engage communities and recognized until my grandmother and her uncleand her daughter would love to the legislature to tell them that we want change it is notgoing to change and they know exactly what I’m going to say and when we get that everanticipated 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 healthperspective, if we are serious about getting cost down, the cheapest way to get Medicarecosts down is not that sick people at the Medicare and the best way to not do that isto give people a healthier lifestyle from the beginning.And we have worked very hardto try to change the perspective than as you know, there has been an enormous assault onthe public health prevention fund and we have had very focused and in that battle for infrastructureof public health in addition to additional dollars we have for the affordable care actthat is were spending our time and effort that we are supporting chronic diseases onthe international front and locally. I thought you were going to let me off thehook. I did want you to feel left out. From a market perspective, home Telehealthremote patient marketing is the largest segment ATA has a large industry component and standardsand guidelines and I think the ADA recognizes the and is doing everything in their scopeto be involved in the and that I returned to the comment you made about these organizationsstaying responsive to mom to numbers, I would let Paul the dentist know that oral healthis now on the website.If you want to finish on a high note. That is good. Thank you very much I appreciateit. What they called the speakers on our panel.[Applause] Will the planning committee please come tothe stage? Our next session is planning committee concluding remarks and discussion. This has been a full two days that we havelearned a lot to think about and we are excited that the Institute of medicine has convenedus and to HRSA for finding this initiative to bring us together my hope is that we actuallytalk about next steps and I know that Spiro have to catch a plane so we want to give himthe first opportunity and we are grateful for the time they spend with us. I have several thoughts, thank you Karen andTracy and Institute the other staff very well supported logistically smooth and I have beena member of this over a decade anticipated a number of workshops and this has been consistentlyhigh quality engaging appropriately provocative and among the best I have been privilegedto participate in the thank you for that opportunity.The next steps are clearly –fairly clearin terms of short and intermediate term, short term, HRSA can actually begin to task a numberof technical assistance and research resource centers with a number of the objectives thatwe are described in terms of further synthesis further assistance with respect to articulatingthe critical key essential components of best practices in this regard. And I think thatis particularly important because at the second recommendation that I make is that the HRSAactually convene a study with the Institute, there is enough here and the timing of itis appropriate that it can provide enormous leverage with respect to operationalizingthe number of the opportunity that are available to us in the short term work could informthat process the mentally and give Institute study group great foundation from which towork so the breadth of topics today were absolutely appropriate and that is to be careful considerationby HRSA to what specific priorities they would want a study to address and I think that isa critical charge to the Institute if it goes that way because the breast is there but forthose that is to be effective it has to have their specificity in terms of anticipatedgold.Thank you. And thank you all, I apologize for running out early. It is my delight. Thankyou. [Applause] The first thing I want to say, thank you tothe panel for having such a nice working relationship have a plan the whole meeting it was a lotof fun and I think the today’s word. And thank you also to the speakers and I thought thepresentations were wonderful and thank you, Tracy, forgetting the live webcast and itwas nice that people who cannot physically make it could get in and some people e-mailthe overnight and some of our questions could be raised through other people and I foundthis extremely enjoyable and I think we learned a lot. In terms of my,, some of the themesthat came up over the last two days, emphasis on the relationship between the patient andthe provider and the technology is not a barrier is something that facilitates a greater accessfor war patient to get interaction with provider and the focus on the patient versus focuson technology and that was a, Damon and people talked about the–as the facilitator shouldthe focus: technology, that those great guys and trade by the whole idea of flipping theside of service space onto the provider is hesitation as I talked to Karen about thatand she said that was a new idea that it was new to me and I had not thought about it nowway before so thank you for bringing it back to my attention and I thought that with allthe whole lot of problems analysis but it would be against that I can think of a lotof people that would not promote that but it is something to consider.Another thingI am thinking about, the more systematic way to implement Telehealth across the countryas I was walking up to the stage these banners at the side of the stage, the thing that isholding up the banner says imagine I am wondering if we can imagine it Telehealth system thatwork 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, whatwould that look like Catholic last few days people don’t have all the pieces of the jigsawpuzzle and the people had their pieces together and Alaska known for their part would looklike in the VA would know what their part look like a we have other people and I feellike we’re all working on it together and it would be nice to take a step back, imaginewhat it would look like and how can each of us play our role in putting the pieces togetherand the goal that we want and there’s a lot of information and the presentation the talkedabout the studies that exist and all of the evidence is there why do people keep thathe like it not? Are people reading these studies? Maybe we need a more systematic way to getknowledge into practice, we can’t wait 17 years, technology would be obsolete has tobe 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 forTelehealth and how can we learn from what is going on in other countries? In some casesthey are ahead of us and what can we learn from them that is something that we haven’tconsidered that much in these two days but if we were able to do the full-blown studythereof the a component that we should add and the previous life there is a community-basedmodel and these models were identified they were given a grant and they created strategyfor application and community could download it from the Internet than they could contractwith the model winner and they would God to that community and help them adopt or adapttheir project and funding was provided by the government to that model winner to helpimplement that program and I am thinking, maybe that is something that my office cando that the most efficient way we could take this knowledge of the community and spreadacross the country so those are the things I am thinking about.Thank you. I agree with what you said, I thought aboutit a little bit differently but I like the puzzle analogy because I was thinking oneof the things that we want to be able to have in our mind is what does it look like if wedo it right and what is the model technology enabled it in the future and if we did allof this right, what services, how does chronic disease management, what does it look likewhen you go to your commission and what does that look like when you go to the emergencyroom with a stroke or you’re in the ICU and to have the model community and I think weare beginning to assemble the pieces of that and what that looks like an the same thingI was thinking and to go through what we are thinking today, the evidence is strong andsome of the areas that I think but we also heard, there is an opportunity to do studiesusing a variety of methodology and later have to be ashamed that we use one methodologyfor looking at Telehealth and its benefits and I agree with you, I think we need to havea better way to pull together consumptive of the evidence that we pulled them togetherin some way that is accessible to people because I think it is not only policymakers that theevidence is there, from what we heard today, some people are saying we are repeating studiesbecause people don’t know that the evidence is there some mechanism to do that.And weheard there is a explosion in technology that is rapidly changing and it is very hard tostay up with how rapidly the technology changes and get the evidence to finally get out therepublished 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 goingto come up with their own solutions and we are not proactive, there’ll be solutions thatmay not be the best, websites where evidence recommendations are not write etc., we needto think about that and one of the most impressive thing of the level of activity at the statelevel and during this particular time in the politics of this country I think top-downapproaches from the federal government around healthcare are not going to be popular andsurgically removing barriers could be and I think that state initiated approaches arenot using a waiver for their Medicaid programs and I think somehow supporting the state effortsis going to be critical because this state, of with solutions and we see them in termsof addressing Medicaid reimbursement across 30 or 40 states it will be easier to makefederal policy changes and again I was very impressed with the enthusiasm of the statesand I think we saw the VA, and the IHS, there are great model that their we have to rememberthat we are dressing the Telehealth issues in rural areas in the VA, and even in prisonand we are beginning to address it and figure out how to get lessons learned applicableto the rest of the organization and have those lessons learned and available to those tryingto implement that on a bigger area to the rest of the population and from the last panelthe organizations are clearly in support of what we are doing with Telehealth they couldthe 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 weshould remember about these and health promotion and disease prevention.Great. I want to start by saying thank you was agreat panel, a great workshop that I think it was fun to do and fun to organize and mostof that point has been settled and a couple of things that stood out to me, one beingthere is evidence and there are strong-that is out there and another thing, enough toprove to us this works but not enough to help adoption and as we take our next step forwardready to come up with some kind of standard with the–study that Tony is what kind ofevidence we need and maybe we want cost-effectiveness data, something that will accelerate the adoptionand the standards we should come out of the immediate next up and the application of datapublic health and how you can make healthcare efficient are going to use it at a populationlevel for population management, reminded me of an article originally came out in theNew York Times on how healthcare can be made as efficient as a cheesecake factory and hetalked about the cheesecake factory works at a 2%–they don’t waste more than 2% ofgroceries and raw material that is a very high standard and they do it by knowing exactlyhow many customers are going to come by benchmarking customer base for the last week of the lastyear they know the game is coming up, they will have lower people and they will by lowergroceries and the cackling themselves to make sure they never run out of things but alsonot to waste more than 2% the keeping a tight control, lessons for healthcare, collectingso much data, patient generated data, monitoring data, given the spark that we have on ourteam we could come up with ways that would make ourselves efficient and it seems likewe have lagging behind industry on other times we can do banking are found the financialdata which is more valuable I have a cold or cough or acne, what can’t to lower healthcare 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 whatI would recommend the next steps be worthy IOM or HRSA help us doing our community andthe 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 tothe oldest standards, I am in the same agency in that seems odd to me and how you resolvedthat the economy within HHS and how do you transform what we heard today to the publicpolicy 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 intoforward thinking to other policy agencies in HHS affect the ability to people receivecare and interact with the healthcare system in the virtual space from the direct patientprovider consult to have overlap or whatever it is you’re using and privileged the evaluationthesis today, my question is, are clearly making this to heart? And I said that peopleall 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.InWisconsin with the get the pharmacy board regulations, we did under the physician practicemodel which is totally legal and we were able to call adjuster our experience and bringingthem and showing them you can see down to half of a tent that they cc on video, we havepharmacist at their essay, I have looked into the future. We have no evidence on anythingbut they change public policy have made it legal for pharmacist to dispense medicationoutside of the licensed pharmacy. We got dialysis care and in 2006 by because of the body ofevidence 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 problemand I heard that at a government-sponsored meeting and that for those of us that werethere and I think that is how public policy the still developed, it is just this thingout there that have a problem it is solving, solution versus technology and I would challengethe institution of medicine, to establish a valid clinical trial design and validatethe controlled study design is a cold standard and mashed controlled studies are easy todo, we have a control group if we do it and it is very easy to find the other group inour own organization so I would ask the Institute of medicine to really come out and find thatis 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 todayI 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 thatwe know what patients want. We don’t know what patients want. We have to go out thereand 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 andHRSA establish a methodology that HHS would develop mobile health of public policy consumerspush off all the time and healthcare to do something different and we do it because thatmakes sense we have good outcomes that engages patient in the way that we don’t engage withour other systems of care that should mean something in terms of public policy at mylast charge, to the Institute of medicine I would like you to continue this work withan ongoing IOM HRSA committee for action focused on integrating technologysupport healthcare and evidence-based practice public policy and mainstream and I think thatwas the exceptional work.I have been sitting here as I hear my colleaguessay the same things I have been thinking about my desire would be to see HRSA Monday. Itbecause as the advisory, there is so much power that IOM has to accomplish and in mymind I it is now about–I can’t open it up and in that regard, we have heard broadeningreimbursement, federal and state, that is imperative for us to get our providers onboard, both the current fee-for-service model and the payment model and this is that thesay with my sponsor is coming from the office of rural health policy that it takes a massiveprovider to support Telehealth a lot of our specialty providers let them to support theworld patient who wanted to support their own so open it up to all. And across the disciplinescertainly. Reduce regulatory barriers different this day in and day out. Credentialing privilegingof practice it is not spent a lot of time on that but as we talked about dentistry todayand my colleague is here, Virginia had change for a pilot for hygienist used Telehealthto connect dentist because it was not in the scope of practice of the policy decisionsstate and federal that are important and I thinkk as Joe Tracy mentioned for a long timein Canada, look at a new paradigm terms of service and that may actually eliminate someof the regulatory barriers that have been major challenges for all of us.So expansionof broadband, studies on the value proposition and return on investment we have a lot ofscience and accountability to the payers and the taxpayers in particular so I think thisis fantastic and it has been a wonderful couple of days I want to give a special thanks toTracy and Samantha. [Applause] We have a few moments or questions? Anybodythat 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 gettingthat message out and one of the other thing we have talked with both Marianne and Vickiwho are responsible for the publishing of the journal itself about fast-track articlesso somebody comes to me and says they have an article on-is this a year ago, we got thatout as quickly as possible for people to see that we have been doing our regular basisand even though it made the there for 6 to 9 months months it is not faster than I wouldbe in the I have also endorsed this idea doing a full study I think it is important, usethe Institute of medicine anathema had done a phenomenal job of providing some well-donereport have been helpful for us developing medical policy for healthcare and so forthso I really endorsed doing that the last thing, last night, we had dinner in Georgetown werecoming back Alexei gas station, $4.99.Gallon of gasoline that will be what drives changesin the consumer is going to drive this change we start seeing gas at five dollars or sixdollars a gallon. Thank you. [Indiscernible question from the audience]Outstandingconference a kaleidoscope of Telehealth. We saw from every different angle in the areathat I did not hear enough of that I think require some attention has to do with thechanging nature of the healthcare workforce not only the retraining of the providers ofthe physicians and practitioners but the kinds of personnel that are going to be needed inrural communities to be able to support Telehealth I know we learn from our demonstration programsworking in rural healthcare clinics, they don’t have the staff and it is retrainingpeople like a nurse case manager who is managing not just patients that data and being ableto filter that data in the right area and the whole field of Telehealth coordinatorsand without that in a rural clinic, just of the work that I think we learn that from thework with the TRC and the notion of how scope of practice of the appropriateness of careand working with providers and other areas that need to be thinking about.More attentionto 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 Telehealthto be able to maintain the technology because of that unit goes out, that is going to setthe quarter. So if we could include that as part of the scope the need to identify I thinkit would add to the full range of things that we are discussing. I want to make a quick, about that. And HRSAfunded a workforce authority one of the grant project they will be funding is a certifiedtechnician program because we don’t need necessarily lead doctors to understand what the technologycan do that they don’t need to be operating technology themselves the we have traineda workforce to manage the data, to manage technology keep it from being inside thatcloset or on the set–shop for not being used on a day-to-day basis.Another mechanism to support the funding thatHRSA provide for training and primary care and other health fashion, a subtle changesthe at to add bonus points or something when people put in proposals and they include somesort of training for the providers and if you didn’t, were able to create a new programfor that I think there may be defensive avoidance when you get your grant your family practiceresidency program included training in that you get extra points or something like thatbecause exposure of the clinicians, the clinicians on the rural and remote and really need toembrace it in order for to work. There are several models that use the oldprecursor of distance education and I think is an Arizona there is that dental schoolwithout walls were they attend classes virtually there and that in a dental practice theirexperiences and Marsha followed clinic starting a dental school with the same philosophy thestudent will be the virtual space but there are the from the first days embedded in adental practice for their online experiences and the early mentorship that a supervisoryrole with their instructors.We can train a lot of health professions in that same blanketthem trained much quicker it is the old diploma nursing degree where you have 40 hours ofnursing 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 wantedso I think there are still a lot of that. We can certainly capitalize on top of. I woulddisagree with Karen, my colleague probably the first time ever, we train our cliniciansto operate their own equipment we train them not to fix it, as well the presenters andthe real issue there, if you make it does the practitioner within 5 min.Late you havedisrupted their day for an hour. So they get their the looking get an IT person to respondthat we can responded 5 min. so as part of our training of Telehealth clinicians, weteach 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 staffwho could do it within the clinic facility, I don’t need to be pulling out batteries andrebooting computers I have a line of patients to see so that is the point of what we weretrying to advance. I want to follow-up on the, that JenniferLopez she has a foundation in a have to key focuses one of the focuses is on telemedicineand if we did get CNN to do a story on medicine he had Jennifer Lopez hosted, we like it werepeople to watch. Bill is kind enough to let me make a, Danfor IOM to consider, because I think this is the first step.. But I want to make a pleaand became a a lot of the presentations of how we should be integrating a taxi and generalhealth information technology and health information exchange this whole push by the office ofthe national coordinator for achieving meaningful use and health information exchange I thinkhas to be blended and integrated with medicine because frankly, we see a patient in personface-to-face, their information, we document the event look at lab data look at imagesand so on.And we document that event and we do ordering and we have a wonderful opportunityto put in decision support they can decrease medical error have greater consistency, variationin care all of those things that are coming out and I just think we shouldn’t take medicinealong with upbringing that together because I think that is of real value is going tocome we’re just seeing that on health information exchange side the emergency room departmentsas long as they have a different, sharing information they secure a meaningful way isreally improving our comprehensive continuity of care and decreasing unnecessary duplicationof test and improving efficiency and waste of time so I just want to make sure that getsnoted that the bank have to be integrated with telemedicine, however you want to lookat it has to bring in health information and good health information exchange and eventuallynot only for this country with the The nationwide health information network and public healthinformation network eventually this is not to become a global international effort becausewe are all traveling we are all interacting on a global level and so Telehealth have tobecome the international global issue that this health information exchange they wantto make sure that gets noted and has the IOM and HRSA move forward, we need to be lookingat were the things get integrated in huffily the office of the national coordinator willbegin to recommend that telemedicine needs to be blended with all of these efforts aswell.Thank you. [Indiscernible question from the audience] I have some things I want to share with youthe most are complementary I want to say I think it was great to have Medicaid peoplehere today. That was smart and I want to tell you, I want to pile on a little more thansay how smart that was the why we need to pay attention to Medicaid. Two big reasonsof Medicaid expansion we will see lots of state or 30% or more of covered by Medicaidso if you think it is big now, wait for the future and when we can do things with theMedicaid populations we can do a lot of things because the that the test population to dealwith and the people are just tough and there are other challenges that they have in mindand there is another reason of the stuff it turns like mad and if you don’t know I cangive you lots of statistics but they turn rate is phenomenal and that is not the casewith Medicare.Health plan would die if they had the Medicare turn rate so we talked about2.2 years any health plan that is way too long for most Medicaid programs and I wantto say that was big and the Family Dollar life take a look at what we are spending onMedicaid by state budgets over 50%, 60% of our states spend more money on Medicaid thanthey do on the state operating budget. And they have a contribution as a state they havea federal match and that there is the Medicare expenditure for Medicaid beneficiaries. And50%, 60% of the state and this country more money than is spent on the entire state operatingbudget. I just want you to know that Medicaid is big and it is big in a lot of ways andwe think about the other things that we do the truth of the matter is are spending alot of matter more than the state operating budget, the state this country so paying attentionis really a big thing I want to gradually on doing that.I want to say with respectto the idea of having matched cohort group designed, it is fabulous because without themore facile and being able to do this so I had a brief conversation and my mind has beenworking 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 groupsof the research design and that can be done and webinars that could be done in a sessionlike this and televised for the world to say but I think that is important because I thinkthey need to be the gold standard and I realized that we need a standard pulley to do thisto prove efficacy of things that we gave and it ought not to be a secret or mystical aboutnot 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 talkabout Telehealth and what you do with IOM on the idea, I love the comment about solutionsand using Telehealth to do it and we need to thinkabout how telemedicine Telehealth is advanced to the stayed there is proof that we needto think of how we use that to leverage solutions to what we do and I love the word leveragebecausee it isn’t what we are doing it is and how we are doing that is most importantwe are leveraging real solutions that we have to use leverage enter order to do healthcarein this country we have to leverage technology to get populations.And it is part of theway that we leverage solutions to larger populations we can scale the things that we need to dohealthcare without leveraging technology and I just need to know that that is what we aredoing and why we’re doing it things like that because have to leverage knowledge. The samething, we have to leverage Telehealth and telemedicine and the last thing I want tomake a comment on how we deal with the but it is important and it is selfish but notterribly that this world of healthcare is not going to be changed by the wonderful thingsthat we do, the people’s behaviors and all in all he could think about how medicine healthcareprofessional workforce technology get to the behaviors of people I will go back to my commentthe other day that-says it is 95% of diabetes care in healthcare is somehow we have to getthat amount That workplace, I don’t know how to do it.But if we can’t get to that moreeffectively they’re doing it another project going on I think they’re starting to get thebehaviors that we have to do that are off we are getting dressed up in ADP diving suitto fit in a bathtub filled with 3 inches of water. One quick comment about what you made aboutMedicaid, you are right, with the expansion this point the tremendous pressure on someof the managed care programs and some stayed, their son, access requirement. Lunch takepopulation you sure you’re going to be able to provide timely access to services and somehowwould have to position Telehealth is a solution for the people because this challenge is goingto be daunting for some of the statee of the Medicaid rolls increase in timely access insome states the there is poor reimbursement for their programs, it really has a role toplay 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 goingto be a formal report from the media my understanding is in the November timeframe which the mythe outcome of the meeting and I would like to see an executive summary written whichwe could fast-track up there is interest in doing that I can help you get that writtenand try to help you get that in January so more people will be aware because not everyoneis going to speak the report that the Journal is worldwide hundred 57 countries not thatwe care what other countries might think that I think it broadens the audience that wouldsee that and we can get feedback at the state level.This is about all of healthcare andthe 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. Afterlook forward to the next step. [Applause] [Event concluded].