[Senate Hearing 106-990]
[From the U.S. Government Publishing Office]
S. Hrg. 106-990
TELEMEDICINE TECHNOLOGIES
=======================================================================
HEARING
before the
SUBCOMMITTEE ON SCIENCE, TECHNOLOGY, AND SPACE
OF THE
COMMITTEE ON COMMERCE,
SCIENCE, AND TRANSPORTATION
UNITED STATES SENATE
ONE HUNDRED SIXTH CONGRESS
FIRST SESSION
__________
SEPTEMBER 15, 1999
__________
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SENATE COMMITTEE ON COMMERCE, SCIENCE, AND TRANSPORTATION
ONE HUNDRED SIXTH CONGRESS
FIRST SESSION
JOHN McCAIN, Arizona, Chairman
TED STEVENS, Alaska ERNEST F. HOLLINGS, South Carolina
CONRAD BURNS, Montana DANIEL K. INOUYE, Hawaii
SLADE GORTON, Washington JOHN D. ROCKEFELLER IV, West
TRENT LOTT, Mississippi Virginia
KAY BAILEY HUTCHISON, Texas JOHN F. KERRY, Massachusetts
OLYMPIA J. SNOWE, Maine JOHN B. BREAUX, Louisiana
JOHN ASHCROFT, Missouri RICHARD H. BRYAN, Nevada
BILL FRIST, Tennessee BYRON L. DORGAN, North Dakota
SPENCER ABRAHAM, Michigan RON WYDEN, Oregon
SAM BROWNBACK, Kansas MAX CLELAND, Georgia
Mark Buse, Staff Director
Martha P. Allbright, General Counsel
Ivan A. Schlager, Democratic Chief Counsel and Staff Director
Kevin D. Kayes, Democratic General Counsel
------
Subcommittee on Science, Technology, and Space
BILL FRIST, Tennessee, Chairman
CONRAD BURNS, Montana JOHN B. BREAUX, Louisiana
KAY BAILEY HUTCHISON, Texas JOHN D. ROCKEFELLER IV, West
TED STEVENS, Alaska Virginia
SPENCER ABRAHAM, Michigan JOHN F. KERRY, Massachusetts
BYRON L. DORGAN, North Dakota
C O N T E N T S
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Page
Hearing held September 15, 1999.................................. 1
Statement of Senator Burns....................................... 23
Prepared statement........................................... 23
Statement of Senator Frist....................................... 1
Statement of Senator Wyden....................................... 3
Witnesses
Brick, James Dr., Chairman, Department of Medicine, West Virginia
University..................................................... 4
Prepared statement........................................... 7
Burgiss, Sam Dr., Manager, Department of Telemedicine, University
of Tennessee Medical Center.................................... 8
Prepared statement........................................... 10
Ferrans, Richard, M.D., Chief of Medical Informatics and
Telemedicine, Louisiana State University....................... 12
Poropatich, Ronald K., M.D., LTC, USA, Member, Board of
Directors, American Telemedicine Association................... 14
Prepared statement and attachments........................... 17
Waitz, Aaron S., Chief Technical Officer and Vice President,
Health Imaging Division, Eastman Kodak Company................. 24
Prepared statement........................................... 27
Appendix
Nicogossian, Arnauld E., Dr., Associate Administrator, Office of
Life and Microgravity Sciences and Applications, Chief Medical
Officer, National Aeronautics and Space Administration,
prepared statement............................................. 46
Response to written questions submitted by Hon. Bill Frist to:
Dr. James Brick.............................................. 39
Dr. Sam Burgiss.............................................. 40
Dr. Ronald K. Poropatich..................................... 42
Aaron S. Waitz............................................... 44
TELEMEDICINE TECHNOLOGIES
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WEDNESDAY, SEPTEMBER 15, 1999
U.S. Senate,
Subcommittee on Science, Technology, and Space,
Committee on Commerce, Science, and Transportation,
Washington, DC.
The Subcommittee met, pursuant to notice, at 2:30 p.m. in
room SR-253, Russell Senate Office Building, Hon. Bill Frist,
Chairman of the Subcommittee, presiding.
Staff members assigned to this hearing: Floyd DesChamps and
Elizabeth Prostic, Republican professional staff; and Jean Toal
Eisen, Democratic professional staff.
OPENING STATEMENT OF HON. BILL FRIST,
U.S. SENATOR FROM TENNESSEE
Senator Frist. The Subcommittee on Science, Technology, and
Space, hearing on telemedicine technologies, will come to
order. I want to thank all of our witnesses today, who will be
both presenters and discussants of a field that is really
fascinating, and one that I think has as much potential as we
find here today, some realized applicability in practice today,
but also tremendous potential in terms of more efficient use of
resources, more effective use of resources, that we have in
medicine today. So right at the outset I want to thank all of
you for coming and spending time with us.
I mentioned just prior to the hearing, to my colleagues
that had just left a lunch who basically said, these are the
sorts of questions that I really want to know the answers to,
and some of these questions I will be able to ask today, and
some we will submit for the record as well, but I wanted to
share with you their enthusiasm about a field that you are
recognized experts on but which, as I look back to my career
before coming to the Senate, being a physician leads me to be
very enthusiastic in my support for all that you are doing.
Today's hearing on telemedicine technologies really is at
the heart of my own personal interests, both curiosity and
profession. It really is the cross-section of medicine, of
emerging technology, of the delivery in a very direct way,
improved patient care, reaching out to people, many of whom
could not be reached otherwise.
Our purpose today is straightforward, and it is to explore
the technological barriers to telemedicine, as well as to
educate ourselves about the core principles that surround this
multidisciplinary field.
The multidisciplinary aspect reflects the great potential,
but also introduces, as we will hear today, many of the
challenges to technological development. The technology has
grown tremendously, even over the last 6 years, since I
actively practiced medicine in the field of thoracic surgery,
challenges to not just the evolution of technologies, but then
the application of those technologies at the dissemination of
that manner, that system of delivery of technologies as well as
issues that are becoming increasingly important as we share
information over distances, and that brings up the issue of
privacy.
Throughout the course of the hearing today, we will hear
about a number of the activities that are ongoing. We will hear
a little bit about the whole spectrum, from creation to the
application itself. We will hear from scientists and
administrators who are out there pushing forward this
technology in all sorts of areas, from the urban areas, which
we will hear about today, and--which an area to me is very
exciting, the rural areas, areas of health shortage.
As I traveled around the State during our August recess, I
had the opportunity to talk to a number of people in the rural
communities around Tennessee and learn a little bit about what
they are doing. As the way medicine is practiced changes, the
opportunity is very apparent as to the great potential for
telemedicine.
I think it really does have the opportunity to lower cost,
and numbers that have been presented are an estimated $36
million in savings, by patient monitoring or consultations, but
it can also revolutionize our entire health care delivery
system in that we find a better way to deliver existing
resources that are there by operating more effectively through
telemedicine, using them so that we get more value for those
existing resources.
Again, we have barriers to address. They are technical,
they are administrative, all of which will come out today.
There are numerous challenges, and I look at it parallel to
when we just started using fiber optics to do laparoscopic type
surgery, or thoracoscopic type surgery, that initially there
was some resistance to it.
I remember the first presentation at a grand rounds--I
happened to be in Tennessee--of the first laparoscopic
cholecystectomy, removal of the gall bladder, the huge
resistance to a new technology, the fiber optic core, opened up
a whole new world that people were resistant to. General
surgeons such as myself, and thoracic surgeons, very resistant
to that change that new technology opened up, and we have seen
a huge revolution in the past 10 years in this thoracoscopic
fiber optic minimally invasive surgery.
Government does have a role, a role that again we need your
suggestions as we go forward in terms of the privacy issues, in
terms of the licensing issues, in terms of the issues of
working across the States, which we will hear about today.
Our goal today, and I do not want to keep belaboring it, is
to learn more about it and learn more about the challenges we
are going to encounter. I will shortly introduce our panel. I
want to turn to Senator Wyden, who has worked very closely with
me, I met with him on a number of issues in the past, somebody
who has been a real advocate in health care issues and in rural
health issues, Senator Wyden.
STATEMENT OF HON. RON WYDEN,
U.S. SENATOR FROM OREGON
Senator Wyden. Thank you, Mr. Chairman. I think you have
made an excellent statement, and I will be very brief.
I will tell you that from this vantage point this looks
like another opportunity for an EDFLEX style coalition. You
know, we teamed up, as you know, on getting the only major
education bill through so far this session, and certainly you
have given an excellent statement, and I will just highlight a
couple of points.
I think one of the additional challenges, Mr. Chairman, is
to try to address exactly what the role of the Federal
Government ought to be and what the role of the States ought to
be, because it is clear that there are so many impressive
activities taking place, and as we try to integrate this into a
coherent kind of policy it seems to me we have to try to
identify some of the elements where the Federal Government
takes the lead and areas where the States are in a better
position to lead.
For example, I think we have all heard from providers at
home that reimbursement is very limited in many areas of
telemedicine. It seems to me that is an appropriate area under
Medicare and Medicaid where the Federal Government has an
appropriate role and clearly could be a leader in.
With respect to States, it seems to me the system of
licensure at the State level is an appropriate process. That is
the way it has historically been done. I think we ought to
leave it that way, but perhaps there is a way to share, for
example, information among the States with respect to
licensure.
My home State of Oregon is very proud of how they have
handled the licensure issue. What we have stipulated at home in
Oregon is a physician outside Oregon is seeing patients who are
residents of Oregon through telemedicine. The physician need
only register with the State Licensure Board.
That way we sort of have a midstream kind of approach where
we do have adequate oversight and accountability, but we are
not seeing some of the jockeying between the States that has
contributed to some tensions, and I just offer that up as the
kind of issue that I think we have to deal with as we look to a
telemedicine kind of policy, is to try to figure out exactly
what the Federal Government has an appropriate role and what
the States have an appropriate role in.
The other area, Mr. Chairman, I would mention, and perhaps
our witnesses can touch on as well, is what, if any, policy
ought to be articulated with respect to Web sites and health
Web sites, and it seems to me what we are hearing from
providers in this area is essentially two concerns.
One, I think there is a concern among some providers that
individuals may be practicing medicine without a license
through some of these Web sites, and this is an area that may
involve even the Federal Trade Commission. If people are, in
effect, misrepresenting their services and their products
perhaps the FTC, the FDA, HHS ought to be involved.
But I will tell you, I have a growing concern about that.
The other concern I have is whether or not on health Web sites
there ought to be some disclosure of commercial interests. It
seems that there is a growing concern that the public is having
difficulty sorting out Web sites that are in effect offered and
operated by individuals that are essentially of a nonprofit
nature, and distinguishing those from Web sites where in effect
there is an effort to make profit, and so be it.
The question is, should there be some disclosure, for
example, so that people who in effect visit those Web sites
know exactly what kind of site they are talking about, but just
as you say, there are many challenges, and this is such an
exciting field with such promise, and I thought your opening
statement was excellent, and I would very much like to work
with you on this in the days ahead.
Senator Frist. Thank you. I am going to introduce our panel
of speakers just very briefly, and feel free to enumerate or
elaborate upon your credentials or positions, because it is a
fascinating group.
I am going to introduce you in alphabetical order, and why
don't we proceed in alphabetical order. Try to keep your
statements to about 5 minutes, which I know will be very
frustrating. It is more frustrating for us, especially when you
have such excellent testimony, which I have had the opportunity
to review.
The witness' entire written testimony will be made a part
of the official record.
Dr. James Brick, who is chairman of West Virginia
University's Department of Medicine, a rheumatologist, will
open; followed by Dr. Sam Burgiss, Manager of Telemedicine at
the University of Tennessee Medical Center; Dr. Richard
Ferrans, Chief of Medical Informatics and Telemedicine at the
Louisiana State University School of Medicine; Dr. Ron
Poropatch, a Board Member of the American Telemedicine
Association, and practicing physician, pulmonologist and
critical care medical specialist; and Mr. Aaron Waitz, Vice
President and Chief Technical Officer of the Health Imaging
Division at the Eastman Kodak Company.
Senator Breaux, who had planned to be here but had to
return to take care of a very urgent matter, is not going to be
with us today and asked me to extend a warm welcome to Dr.
Ferrans' mother, who happens to be here as well today, so I
wanted to recognize her as well. I will not make you stand up.
Put a hand up in the air, Dr. Ferrans' mom. It is good to have
you here.
I also want to recognize Dr. Brick, who has testified
before this Subcommittee during our last hearing, which I guess
was 2 years ago, and we appreciate your being back with us.
With that, let us go ahead in alphabetical order out of
convenience, and we will begin with Dr. Brick.
STATEMENT OF DR. JAMES BRICK, CHAIRMAN, DEPARTMENT OF MEDICINE,
WEST VIRGINIA UNIVERSITY
Dr. Brick. Thank you, Senator Frist and members of the
Subcommittee. I want to thank you all for inviting me again to
come and speak to you about our telemedicine experience in West
Virginia with Mountaineer Doctor Television.
As of today, 19 MD telemedicine sites are present in West
Virginia, and these include service centers that we call hubs
for specialty care in Charleston, West Virginia, at the
Charleston Medical Center, and also at WVU, where I come from,
at the Robert C. Byrd Health Sciences Center. Five more sites
are planned to be added by the end of this year.
When MDTV first went into operation in 1992, and at the
time that I was before the subcommittee the last time, with the
help of Federal funding, the cost of both the equipment and
telecommunications were very high. We had equipment in each
site that was about $100,000, and the cost of our T1 phone
lines that we were using at that time were anywhere between
$1,200 and $3,000 a month, and these things have improved
significantly since then.
Today, the same equipment, depending upon the need and the
number of medical peripherals--say, for example, electronic
stethoscope, things like that--can cost between $10,000 and
$60,000, so that is a lot better than it was before.
Telecommunications costs have also improved significantly
for us. We are very fortunate to have enlightened lawmakers in
West Virginia who have been able to negotiate very reasonable
and fair telecommunications rates for us, and they have come
down significantly as well. We would like to see them lower,
though, I will say that.
Who benefits from MDTV, and who has really been the
benefactor of this program in the last 7 years since we began
it? Patients, rural physicians, the rural hospitals, and the
University in Morgantown and Charleston Area Medical Center our
really important partner, have all benefited from this.
Patients have almost uniformly, and we have surveyed them
about this, been pleased with this service and really
appreciate the savings to them in time and money. It gives them
access to things in their rural communities that they just
cannot get at home. Doctors like it for the specialty backup
that is so often lacking in small communities.
Medicine now is practiced as a team, and is very different
than it was 50 years ago. We train people in areas where they
have a lot of specialty expertise, a lot of backup and help,
and then we send them to small communities and they do not have
that. But by using telemedicine we can avail them of those
services, and they have backup, and that really means a lot to
people.
The continuing medical education that we give our doctors
and nurses and other health care providers over the network is
also very important, and in almost every State now this is
needed to maintain licensure and it can involve travel over
long distances to keep up with that, and our people in West
Virginia can get this. Almost every day through the network we
have some educational programs.
Rural hospitals also benefit from MDTV, because they can
keep the patients in the communities who might otherwise need
to be transferred out to larger hospitals.
We really believe that we need to have a strong network of
small rural hospitals and clinics in West Virginia and all over
the country, but in order for that to happen as much care as
possible has to be kept in local communities. We think that for
many of these locations the ability to use telemedicine has
also become a powerful recruitment tool for gaining medical
staff.
One of the hospital administrators in West Virginia, one of
the smaller rural hospitals who has been one of our co-partners
in this enterprise for many years told me sometime ago that he
had been able to recruit an internist to come to his small
hospital because he had this kind of a hookup. He thought that
was one of the things that allowed him to get this fellow to
come in there.
WVU, the School of Medicine, also uses MDTV to allow us to
send our medical students out to rotate in rural clinics and
hospitals, hopefully to encourage them to think about
considering a rural practice, and it is also important for us
to allow them to stay connected with the academic medical
center. This is very important, because the accrediting
agencies that we have to deal with in medical education require
that we have close contact with the students.
As with any new technology there are still issues that need
to be resolved, and for us most of the issues are related to
reimbursement, and I would like to highlight those just very
briefly.
The network sites that are not located in HPSA's, health
professional shortage areas, do not qualify for Medicare
reimbursement. That is a problem. These networks are set up in
complicated ways, and it would be good if we could get better
spread of the reimbursement.
The new 75/25 fee-sharing policy between referring and
consulting specialists requires that on the consulting end
there be a physician, a PA, a nurse practitioner, nurse
midwife, clinical nurse specialist, clinical psychologist, or
clinical social worker involved. Most of our telemedicine
encounters in West Virginia do not involve on the referring end
that high a level of sophistication.
We use a lot of registered nurses on the sending end, and
we use LPN's, and for me as a rheumatologist that is just fine
for me. I can get a lot of information from having a nurse
there, and I do not need necessarily a PA or a nurse
practitioner, and that would be a big help if we could get that
changed.
The CPT codes for telemedicine reimbursement we think are
also too limited. For example, telepsychiatry is not covered,
and in some areas of the country telepsychiatry has been a very
important use of this. I do not know where we are now with
this, but I know in the past, for example, in Montana, there
was a really big use of this, and my understanding is that
telepsychiatry is not covered in the current CPD codes. That
would be a real help.
The level of reimbursement we have for these services is
very low and we think deters physicians from using the
technology, and we really need some reimbursement for the
technical aspects of this service. We still do not have that.
This is not a cheap thing to do, and people are putting
together pieces of ``this and that'' to pay for the technology.
We need some reimbursement for that.
Universal reimbursement for telemedicine is also needed,
and I believe it should be mandatory for all third party
carriers to reimburse for telemedicine encounters.
West Virginia University's goal continues to be providing
increased access and better care to the people of West
Virginia. We believe that we have to make every effort that we
can to capitalize on telemedicine's potential in this area.
Even though we are very encouraged about the future of
telemedicine in West Virginia, you must recognize there are
still barriers, and most of the barriers we believe are related
to reimbursement and paying for this.
I am going to stop now. You have a detailed statement from
me, and at the end of the panel, if I can answer any questions
I will be glad to. Thank you for letting me come up.
[The prepared statement of Dr. Brick follows:]
Prepared Statement of Dr. James Brick, Chairman, Department of
Medicine, West Virginia University
Mr. Chairman, members of the Subcommittee, I thank you for inviting
me to talk with you today about telemedicine technologies and our
experiences at West Virginia University's Mountaineer Doctor Television
program. Chairman McCain and subcommittee chairman Frist, I
congratulate you for your interest in bringing the advantages of modem
telecommunications to address the special challenges of rural health
care.
MDTV, Mountaineer Doctor Television, is a two-way interactive audio
and video system that uses ISDN PRI and BRI digital telephone lines for
transmission It allows a physician specialist at the West Virginia
University Health Science Center in Morgantown to see and talk with a
patient at a distant site. The patient and the community physician also
see and hear the university physician, just as though they were in an
exam room together.
As of today, nineteen MDTV telemedicine sites dot the state of West
Virginia, including service centers with specialty care located in
Charleston (CAMC) and in Morgantown (RCBHSC). Five more are planned by
the end of 1999. When MDTV first went into operation in 1992, the cost
of both the equipment and tele-communications were high: $100,000 per
location covered the cost of equipment, and anywhere between $1,200 to
$3,000 dollars per month was spent for T-1 digital telephone lines.
Today, the same equipment, depending on the need and number of medical
peripherals (like an electronic stethoscope), can cost between $10,000
to $60,000 dollars. Telecommunications cost have also improved. We are
fortunate to have enlightened lawmakers in the state of West Virginia
who have negotiated reasonable and fair rates for telecommunications. A
digital ISDN, PRI line costs $416 dollars a month with a per minute
usage rate. The rate for telemedicine at 512 kbps is $30.00 per hour.
The rate at 384 kbps, (a rate used for educational and administrative
events), is only $22.50 per hour. Our utilization of the system is a
history of steady growth. Medical education has consistently been our
networks number one user. In 1998, over 1036 hours of medical education
and 209 hours of administrative teleconferencing topped the use of the
network over 146 hours of clinical care. However, that 146 hours of
clinical care translates into over 680 patients seen. Over all, 1,929
individuals have taken advantage of the specialty doctors via MDTV.
This year we anticipate to see 850 patients over MI/TV.
There are many kinds Of health problems for which a visual
presentation of the patient is invaluable for a sound diagnosis. In my
own field of Rheumatology, MDTV enables me to assess a patient with
arthritis in a way that a verbal description over the phone would never
do. In many fields, ranging from dermatology to emergency medicine,
actually seeing the patient is often indispensable. Who has benefited
from MDTV over the past seven years? Patients, rural physicians, rural
hospitals, and the University have.
Patients get the advantage of seeing a specialist without having to
travel for hours to a major medical center. A patient in pain might
find such travel too demanding. Patients may not be able to take a day
off work, and some patients don't have transportation and depend on
family or community transportation. For patients in need of immediate
attention, the delay involved in travel might put their lives in
jeopardy.
Rural doctors benefit form MDTV because it gives them the same
level of professional support that doctors in urban or academic centers
take for granted. These rural doctors see every kind of problem, but
they simply can't be an expert in everything. Working with our
specialist gives them the security of knowing the they are doing the
absolute best for their patients. MI/TV also provides Continuing
Medical Education which is needed for physicians to maintain their
medical licenses.
Rural hospitals benefit from MDTV because they can keep patients in
the community who might otherwise have to be transferred to larger
hospitals, are to have a strong network of rural hospitals and clinics,
we must keep as much of the care in the local community. For many of
these locations, the ability to use telemedicine becomes a powerful
recruitment tool for gaining medical staff. WVU also uses MI/TV to
allow medical students to rotate in rural clinics and hospitals,
hopefully to encourage them to consider a rural primary care practice
as-well-as staying connected with the academic medical center.
As with any new technology, there are issues to be resolved. Equal
access to health care may never be realized in West Virginia or the
nation as a whole without changes to the currant Medicare roles
regarding telemedicine reimbursement. Network sites not located in
rural Health Professional Shortage Areas (HPSA) do not qualify for
Medicare reimbursement The new 75/25 fee sharing policy between
referring and consulting specialist requires the Consulting specialist
to bill for the telemedicine encounter, but this is only possible if
the Physician, PA, NP, Nurse midwife, Clinical Nurse Specialist,
Clinical Psychologist or Clinical Social Worker is involved. Most of
our telemedicine encounters involve a health care provider (RN, LPN)
and therefore do not qualify for reimbursement.
The CPT codes for telemedicine reimbursement are too limited. For
example: Telepsychiarty is not covered.
The level of reimbursement is extremely low and deters physicians
from using the technology. Universal reimbursement for telemedicine is
needed.
It should be mandatory for all insurance companies to reimburse for
telemedicine encounters.
West Virginia's goals continues to be directed toward providing
increase access and better care to the people of rural West Virginia.
We must make every effort to capitalize on telemedicine's potential.
Utilization numbers are growing steadily and telemedicine services are
becoming an ``expected'' part of the health care services in rural
communities. Even though we feel much encouraged about the future of
telemedicine in West Virginia, we must recognize that barriers still
exist. These barriers are for the most part, universal, and address
issues like licensure, confidentiality, the need to have on line
patient records. These issues continue to be important, but until we
address the reimbursement issues and reducing the disparity of line
charges in health care, nothing else will matter. We need government
and business working together toward this outcome. We strongly suggest
the split fee from the Federal Health Care regulations to be removed
and that we find ways to reimburse the overhead costs of the
telemedicine systems (mainly in the rural area, but also with the
consulting doctor or organization as well) just as we do with
physicians offices. The process needs to be simple and support the use
of telemedicine as any other ``tool'' used to deliver health care.
Thank you Mr. Chairman and members of the Subcommittee for your
time and understanding.
Senator Frist. Thank you, Dr. Brick. We will be using the
lights, and then if there are points we did not have time to
get in the question and answer we will have time to make those
as well.
We will go in alphabetical order. Dr. Burgiss, again,
welcome.
STATEMENT OF DR. SAM BURGISS, MANAGER, DEPARTMENT OF
TELEMEDICINE, UNIVERSITY OF TENNESSEE MEDICAL CENTER
Dr. Burgiss. Thank you, Senator Frist. Thank you for the
opportunity to be here and testify at this hearing. You and the
other members of the Subcommittee have been provided a folder
with photographs that relate to this discussion. The University
of Tennessee Telemedicine Network at Knoxville provides care to
the people of East Tennessee. Patients can receive medical care
in their community hospitals and clinics, and in their homes.
The beautiful mountain ridges in East Tennessee and rivers
between these ridges create barriers to medical access. Low
income and a fear of driving in the city increase the medical
access problem.
In 1995, the University of Tennessee Medical Center at
Knoxville established the UT Telemedicine Network. Since that
time, the network has increased in patient encounters by an
average of 178 percent per year. Services offered include
clinical consultations, homecare, and family visits. Clinical
consultations provide specialty care in communities where it is
not otherwise available.
To begin a telemedicine program in a community, we first
ask the medical leaders in that community to identify the needs
of their patients. Next, we consider the patient's medical
needs and how these would be addressed in a telemedicine
clinic, and the needs of a care provider during consultations
with the patients. Finally, we address the technology.
Medical need of the patients drives the process, not
technology. We do not practice telemedicine, we practice
medicine. When a telemedicine clinic is scheduled a physician
or other care provider is at the UT telemedicine exam room in
Knoxville and patients are in the telemedicine exam rooms in
their community hospitals and clinics.
The first patient is seen by connecting the UT exam room to
his or her community exam room using audio and
videoconferencing equipment. The UT Telemedicine Network does
everything possible to make the patient and the care provider
feel that they are in the same room, and to provide them with
the privacy of a traditional exam room.
The Electronic medical instruments are provided to assist
the provider in evaluating the patient. A nurse is in the
community exam room with the patient to present him or her to
the provider. The provider is given the patient's medical
records, diagnostic test data, and standard office forms that
are used in the provider's practice. The physician's written
prescriptions are faxed from the UT exam room to the community
exam room, and are handed to the patient as if the patient and
provider were in the same room.
After the first patient is examined in the clinic, the
provider electronically exits from the patient exam room and
prepares notes on the evaluation. These notes are sent to the
community physician who referred the patient so that the two
providers can coordinate care.
While the provider has been busy completing the notes for
the first patient and reading the record of the second patient,
a nurse or a medical assistant with the provider has switched
the network to the community exam room for the second patient.
The provider electronically enters the second room when the
patient and the presenting nurse are ready.
As can be seen, telemedicine clinics are operated as a
virtual office. The provider at the UT telemedicine exam room
is switched from one community exam room to another as if he is
going from one exam room to another in a traditional office.
Patients benefit because they do not have to leave their
community to obtain the needed medical care when it is suitable
to provide this care by telemedicine. Community physicians and
health care facilities benefit because the patient is kept in
their town where they can participate in this care, including
tests and procedures.
The patient's community benefits because the patient is
purchasing more medical services in the town and not spending
money in the city during trips to get medical care. In
addition, the community does not lose the productivity of the
patient from his or her employment.
The UT Telemedicine Network has offered clinics in
dermatology, anesthesiology, psychiatry, surgery, physiatry,
cardiology, neurology, and gastroenterology. In each of these
clinics, the providers only offer services that are appropriate
by telemedicine.
Evaluation of care by patients showed that 68 percent rate
``seeing the doctor'' by telemedicine as better than a
traditional office visit due to the focused attention of the
care provider. In addition to clinical telemedicine, homecare
is an important part of the UT Telemedicine Network.
We have provided over 500 homecare visits in our
telemedicine Home Touch program since April 1998. These are
similar to clinical evaluations, except the patient is in the
home and the nurse is the typical care provider. Patients
benefit because the care can be obtained quicker and
independent of weather. Evaluations of care by home patients
have shown that 100 percent are comfortable with talking to the
nurse, and are willing to use telemedicine again.
After having telemedicine for 9 months, one patient said,
``I'd probably done been in the hospital for 9 or 10 days
without telemedicine.'' His statement was based upon his
previous experience prior to telemedicine.
Another patient's family said, ``When we need medical help,
we need it right now, not an hour later.''
The cost savings per visit has averaged $49 by removing the
nurse travel time and transportation expense. Typical equipment
costs in the home is equivalent to the costs saved in 35
visits. Using homecare telemedicine for only 10 percent of the
visits in the United States has the potential to save over $1
billion a year. Telemedicine can decrease the cost and improve
the delivery of homecare, with benefits for patients and
providers.
When a patient is sent to see a specialist too early in the
disease process, the cost of care increases. In research done
by our program, the cost of care for skin diseases in a
community without a dermatologist was twice that of care with a
dermatologist provided by telemedicine. The correct level of
medical care at the correct time results in the least cost.
As Dr. Frist mentioned, we need the efficiency improvement
in medical care here in the United States. A portion of the
medical cost that could be saved by telemedicine providing the
correct level of care in clinics and homes should be applied to
the facility cost of providing this care.
Thank you, Mr. Chairman.
[The prepared statement of Dr. Burgiss follows:]
Prepared Statement of Dr. Sam Burgiss, Manager, Department of
Telemedicine, University of Tennessee Medical Center
The University of Tennessee Telemedicine Network at
Knoxville provides care to the people of East Tennessee.
Patients can receive medical care in their community hospitals
and clinics, and in their homes. The beautiful mountain ridges
in East Tennessee and rivers between the ridges create barriers
to medical access. Low income and a fear of driving in the city
increase the medical access problem.
In 1995, the University of Tennessee Medical Center at
Knoxville established the UT Telemedicine Network. Since that
time, the network has increased in patient encounters by an
average of 178% per year. Services offered include clinical
consultations, homecare, and family visits.
Clinical consultations provide specialty care in
communities where it is not otherwise available. To begin a
telemedicine program in a community, we first ask the medical
leaders in that community to identify the needs of their
patients. Next we consider the patients' medical needs and how
these would be addressed in a telemedicine clinic, and the
needs of the care provider during consultations with the
patients. Finally, we address the technology. Medical need of
the patients drives the process, not technology. We do not
practice telemedicine. We practice medicine.
When a telemedicine clinic is scheduled, a physician or
other care provider is in the UT Telemedicine Exam Room in
Knoxville and patients are in Telemedicine Exam Rooms in their
community hospitals and clinics. The first patient is seen by
connecting the UT Exam Room to his or her Community Exam Room
using audio and video conferencing equipment. The UT
Telemedicine Network does everything possible to make the
patient and the care provider feel like they are in the same
room and to provide them with the privacy of a traditional exam
room. Electronic medical instruments are provided to assist in
evaluating the patient. A nurse is in the Community Exam Room
with the patient to present him or her to the provider. The
provider is given the patient's medical records, diagnostic
test data, and standard office forms used in the provider's
practice. The physician's written prescriptions are faxed from
the UT Exam Room to the Community Exam Room, and are handed to
the patient as if the patient and provider were in the same
room.
After the first patient is examined in the clinic, the
provider electronically exits from the patient exam room and
prepares notes on the evaluation. These notes are sent to the
community physician who referred the patient so that the two
providers can coordinate care. While the provider has been busy
completing notes for the first patient and reading the record
of the second patient, a nurse or medical assistant with the
provider has switched the network to the Community Exam Room
for the second patient. The provider electronically enters the
second room when the patient and the presenting nurse are
ready.
As can be seen, telemedicine clinics are operated as a
``virtual office.'' The provider in the UT Telemedicine Exam
Room and is switched from one Community Exam Room to another
like a provider going from exam room to exam room in a
traditional medical office. Patients benefit because they do
not have to leave their community to obtain the needed medical
care when it is suitable to provide this care by telemedicine.
Community physicians and health care facilities benefit because
the patient is kept in their town where they can participate in
the care including tests and procedures. The patient's
community benefits because the patient is purchasing more
medical services in the town and is not spending money in the
city during trips for medical care. In addition, the community
does not lose the productivity of the patient from his or her
employment.
The UT Telemedicine Network has offered clinics in
dermatology, anesthesiology, psychiatry, surgery, physiatry,
cardiology, neurology, and gastroenterology. In each of these
clinics, the providers only offer services that are appropriate
by telemedicine. Evaluations of care by patients show that 68%
rate ``seeing the doctor'' by telemedicine as better than a
traditional office visit due to the focused attention of the
care provider.
In addition to clinical telemedicine, homecare is an
important part of the UT Telemedicine Network. We have provided
over 500 homecare visits in our telemedicine Home Touch TM
program since April 1998. These are similar to clinical
evaluations except that the patient is in the home and a nurse
is the typical care provider. Patients benefit because care can
be obtained quicker and independent of weather. Evaluations of
care by home patients have shown that 100% are comfortable with
talking to the nurse and are willing to use telemedicine again.
After having telemedicine for nine months, one patient said,
``I'd probably done been in the hospital for 9-10 days''
without telemedicine. Another patient's family said, ``When we
need medical help, we need it right now, not an hour later.''
The cost saving per visit has averaged $49 by removing the
nurse travel time and transportation expense. Typical equipment
cost in the home is equivalent to the cost saved in 35 visits.
Using homecare telemedicine for only 10% of the visits in the
United States has the potential to save over a billion dollars.
(National Association of Home Care, www.nahc.org) Telemedicine
can decrease the cost and improve the delivery of homecare with
benefits to patients and providers.
When a patient is sent to see a specialist too early in the
disease process, the cost of care increases. In research done
by our program, the cost of care for skin diseases in a
community without a dermatologist was twice that of care with a
dermatologist provided by telemedicine (Burgiss, et.al.
Telemedicine for dermatology care in rural patients.
Telemedicine Journal, 1997;3:227-233.) The correct level of
medical care at the correct time results in the least cost. A
portion of the medical cost that could be saved by telemedicine
providing the correct level of care in clinics and homes should
be applied to the facility cost of providing this care.
Thank you, Dr. Burgiss.
Dr. Ferrans.
STATEMENT OF RICHARD FERRANS, M.D., CHIEF OF MEDICAL
INFORMATICS AND TELEMEDICINE, LOUISIANA STATE UNIVERSITY
Dr. Ferrans. Thank you, Senator Frist. I want to thank you
and also Senator Breaux for inviting me to testify. Thank you
for recognizing my mom. I also want to thank Senator Breaux and
his fine staff for their support of the LSU Health Sciences
Center.
Today I want to address the utilization of telemedicine in
rural Louisiana to improve health care, some of the barriers to
progress that we face, and the specific policy recommendations
that will lower barriers. I would also like to note for the
record that I am also a member of the Southern Governors
Association Task Force for Medical Technology, which is
responsible for developing a unified policy for telemedicine
for the South. Two days ago, we just met in Memphis and
finished this report, which I've submitted into the record.
I am also a member of the Computer-Based Public Health Work
Group for the National Committee for Vital and Health
Statistics that is charged with implementing HPA. So Senator
Wyden's comments, I was very interested in those and hope to be
able to address those, although my views do not necessarily
reflect those of the NCVHS.
I think we have defined telemedicine as the use of
telecommunications technology and information systems to
deliver clinical care at a distance. I think most of us know
what a typical telemedicine encounter is like, a specialist in
an urban medical center seeing a patient in a rural facility in
realtime, and all of the things that technology today allows us
to do, with really, in large part, off-the-shelf hardware and
software. That technology exists today. We do not have to go
out and invent it.
So how are we using that to improve care in rural
Louisiana? Well, we have really embraced technology as a
critical tool to transform our health care system in Louisiana
that provides services to all, irrespective of their ability to
pay. As a safety net system of care for almost 2 million
patients, LSU is committed to network our nine hospitals and
clinics with rural facilities using telemedicine. We have
recently begun to design a more integrated system, under the
auspices of a grant from the Robert Wood Johnson Foundation.
The pilot program is in the rural parishes surrounding
Lafayette, Louisiana. All totaled, we will probably see about
2,000 patients via telemedicine next year.
Two years ago, Vice President Gore and I took a medical
history online, and reviewed the echo cardiogram of a patient
in Church Point, Louisiana, using telemedicine. That patient
did not have to travel 3 hours, with congestive heart failure,
each way to get medical care.
Today, the LSU Health Sciences Center is committed to
bringing emergency services online. Soon, we will be launching
the Teletrauma Network of Louisiana, an emergency telemedicine
system that will bring the expertise of our world-class trauma
team in New Orleans to rural hospitals in Southern Louisiana.
So this will enable an accident victim at a rural hospital,
like Riverside Medical Center of Saint James Parish Hospital,
to be seen via telemedicine by a board-certified trauma surgeon
at Charity Hospital in New Orleans--one of only two level 1
trauma centers in our State.
I think, in the future, our surgical experts can use Next
Generation Internet technology to instantly evaluate a sugar
farmer from Houma, injured in a combine accident during
grinding season, or an injured driver, traveling from LaFourche
Parish to Baton Rouge. We can aggressively stabilize that
patient during the golden hour, which, Senator Frist, of course
you know is the first hour after major trauma, when care
decisions literally mean the difference between life and death.
In the future, we hope to continue to expand those services
to other emergencies that are time dependent, like stroke and
myocardial infarction. Again, our mission, as we see it, is to
move beyond our walls and take care of our rural citizens. If
there is one point that I want to stress, it is, at a
fundamental level, we believe that our rural citizens deserve
the same quality of care as our urban counterparts. So we are
determined to bring the doctor to the patient using
telemedicine. In the next year, we will extend our services to
more long-term care facilities for the severely disabled. We
will increase our correctional telemedicine program. We are
even linking up with rural hospitals to provide more
psychiatric care, as someone else had mentioned.
With respect to education, we train 90 percent of the
primary care physicians in our State. They are the rural
doctors of tomorrow. They can spend more time in rural
hospitals, our resident physicians, because today they can get
their required resident lectures online from LSU Medical Center
in Shreveport.
So, why have we been successful? I think there are four
reasons. They illustrate the barriers that currently exist for
telemedicine. First of all, because of some unique arrangements
we have with Bell South, we have unusually low
telecommunications rates for rural health care. This makes
everything possible. The cost of telecommunications is a major
barrier.
Now, the Congress attempted to assist rural hospitals by
establishing lower rates through the Telecommunications Act. I
will tell you that not a penny of that money has been received
by rural hospitals. So my first recommendation to you is to
urge the FCC to fulfill the intent of the Telecommunications
Act. Our 18 Southern Governors wholeheartedly agree with me on
this position.
The second issue deals with reimbursement. It is intuitive
that no business can flourish if it cannot charge for its
services. We have coverage for Medicaid for telemedicine, and
it has not overrun the Medicaid budget. We have coverage for
private insurance also. Medicare, after resisting telemedicine
coverage for years, HCFA finally relented and began providing
coverage, but placed the fee splitting provisions on it.
I will tell you what a rural doctor told me. He said fee
splitting is illegal if I send a sick patient 100 miles to see
a specialist, but I am required to do it if that patient is
seen in my office by the same specialist via telemedicine. So I
would recommend that you all direct HCFA to treat a
telemedicine encounter like any other clinical encounter.
A third reason deals with infrastructure. The details are
in my report. But I think the bottom line is that the Federal
Government shares, with the State governments, the funding for
highways. We can share the funding for information
superhighways, too, by establishing block grants for States
that coordinate their telemedicine and their telecommunications
planning. I believe that this can be done through existing
programs through the Department of Commerce, specifically TIOP,
and also through the National Library of Medicine.
Finally, I think that we are succeeding because of the
vision of our leadership. And we are trying to invest in the
long term. So I would ask you to please assist us in lowering
telecommunication rates, simplifying Medicare rules, and
establishing block grants to States for health care
superhighways on the Next Generation Internet.
As a final recommendation, I would just urge you to visit
your telemedicine programs in your home States. The publicity
from your participation in these hearings will help us join in
this vision. This forum certainly propels us forward to a
better future for our rural citizens.
Thank you very much.
Senator Frist. Thank you.
Dr. Poropatich.
STATEMENT OF RONALD K. POROPATICH, M.D., LTC, USA, MEMBER,
BOARD OF DIRECTORS, AMERICAN TELEMEDICINE ASSOCIATION
Dr. Poropatich. Thank you, Mr. Chairman. Good afternoon,
science and distinguished guests. My name is Dr. Ronald K.
Poropatich. I am an elected member of the Board of Directors of
the American Telemedicine Association, and provide these
remarks today on behalf of the Association.
I am a practicing physician in pulmonary and critical care
medicine, with over 7 years of direct experience using
telemedicine. I am also a Lieutenant Colonel in the United
States Army and Director of the Telemedicine Program at Walter
Reed Army Medical Center in Washington, as well as on the staff
of the Telemedicine and Advanced Research Center up at the U.S.
Army Medical Research Command at Fort Detrick, Maryland.
However, I am here today strictly on behalf of the American
Telemedicine Association, and my remarks do not necessarily
reflect the operations of the U.S. Department of Defense.
The American Telemedicine Association represents
physicians, other health care professionals, technologists, and
companies involved in developing telemedical systems, and
providing health care services via telecommunications. We are a
nonprofit membership-based organization, established in 1993,
which serves to promote telemedicine and resolve barriers to
its deployment.
In my remarks today, I would like to briefly point out a
few of the critical national issues we believe inhibits the
growth of telemedicine. These serve as a barrier to realizing
the potential benefits of telemedicine to expand access by all
Americans to quality medical services and reduce the cost of
providing health care services.
Many of the obstacles facing the use and deployment
telemedicine today require changes in existing laws and
regulations. I will highlight several specific areas that
should be addressed by the Federal and State governments in the
United States.
First is the lack of payment for services. As previously
commented on, despite many years of successful telemedicine
demonstrations and the rapidly expanding deployment of
telemedical services in the private sector and in other
countries, the U.S. lags behind in recognizing and paying for
medical services provided via telemedicine. Medicare currently
reimburses for several different types of remote services,
including teleradiology, remote patient monitoring and live
video consultations with patients residing in remote health
professional shortage areas.
However, broad reimbursement for telemedicine services is
still unavailable. This failure to provide coverage of
telemedical services has put a brake on the growth of
telemedicine, restricted access to health services by many
Americans, and hampered the ability of the United States health
care industry to use telemedicine in reducing costs and
increasing the quality of care.
Knowing the crisis facing the cost of providing health care
and the cost associated with increasing access to health
services, the ATA has three specific priorities for providing
Medicare coverage of telemedicine services. Each of these
priorities costs little or nothing in additional Federal
outlays, and will help expand access to needed medical services
by the American consumer.
First is the Health Care Financing Administration, or HCFA,
should clarify that it can fully reimburse for telepathology,
since this is a service similar to teleradiology, which can
easily be conducted remotely and does not require a direct
physician/patient consultation. This can be simply accomplished
by HCFA today, and does not require any additional legislation.
We are hopeful that HCFA will clarify this issue before the end
of the year.
Second, we urge Congress to eliminate existing flaws in the
current Medicare program supporting telemedicine services to
residents of rural health professional shortage areas. For
example, the program does not reimburse for medical
consultations provided using store forward technology. This is
a very efficient and appropriate way of delivering patient
information to a medical specialist, and is being practiced
today in the military, in other countries and in demonstrations
projects across this country. ATA fully supports legislation
introduced by both Senator Kent Conrad and Senator Max Baucus
to amend this program.
Finally, when HCFA introduces a prospective payment system
for home health care services next year, the provision of
telemedical services to the home should be an allowable service
that can be used by home health care agencies in providing
services to the homebound patient. Studies have shown that the
use of telehome care can improve patient care and reduce the
utilization of acute care services. The use of telehome care
under the prospective payment system will cost no additional
Federal dollars. It can help improve services to the patient.
And it can help homecare agencies to continue providing
services at lower costs. We strongly urge Congress to include
language this year, under the Balanced Budget Act Amendments
Bill, that directs HCFA to allow these telehome care services.
Second, improved access to telecommunications networks. The
deployment of telemedical links to rural and suburban medical
centers requires communication networks that are reliable and
capable of handling large amounts of data in a short time.
Homecare applications that require interactive video, as well
as clinical applications involving large patient data files,
will greatly benefit from the availability of broadband
networks. Congress established a program under the
Telecommunications Reform Act of 1996 to provide improved
access to high-speed data lines by rural health centers.
Although well-intentioned, the program has fallen far short
of its potential. The application process as it exists today is
burdensome, complicated, causes substantial hardship on
applicants, and creates a barrier on getting the program
benefits out to the intended beneficiaries. In addition,
eligible services and program beneficiaries are unduly limited.
In a letter to the FCC in March 1999, the American
Telemedicine Association called for specific changes in the
program by both the Federal Communications Commission and
Congress. I have included this letter in my written testimony.
ATA is a member of the Advanced Coalition, a group
promoting improved broadband deployment of the Internet. The
Internet is becoming the preferred platform for the delivery of
telemedical services and can be an important vehicle for
providing health services to the individual at home. It is
therefore important that Congress help ensure that high-speed
access to the Internet is available throughout the country,
including to rural communities and individual homes.
State medical licensure is a third issue, sir. Currently,
each State requires separate medical licenses for physicians
practicing inside State boundaries. Telemedicine challenges
this by allowing for the practice of medicine across State
lines. Some States have enacted restrictive laws to keep out
health professionals licensed in other States. This has been
viewed by some as efforts to protect the economic markets of
the professionals residing within the State.
Earlier this year, the ATA Board of Directors adopted a
position on State licensure that preserves the right of States
to continue to license medical professionals, while allowing
access by patients and primary care physicians within the
States to services of qualified health professionals located in
other States. I have included a copy of this statement in my
written testimony, as well, sir.
There are other issues and concerns that may require
Federal policies. These include protection of health care and
telecommunications entities from undue liability arising out of
the use of telemedicine and ensuring patient privacy and
confidentiality in the transmission of medical information and
electronic storage of personal medical information. Within the
military, we have addressed the privacy issues by establishing
a strict policy of requiring a separate secure server to be
used for all medical transaction, with encryption of all
medical-related files.
In my responsibilities within the military, I have
witnessed a tremendous growth in the use of telemedicine in the
delivery of health care. The results of research and services
performed at the Telemedicine and Advanced Technology Research
Center at the U.S. Army Medical Research and Materiel Command
have enabled us to provide cost-effective and expanded access
to medical specialty cases where none was available before.
At Walter Reed Army Medical Center, we are now providing
well over 3,000 medical consults per year to armed forces
personnel and their families worldwide. In some ways, the
efforts achieved by the military have provided a model that
might be adopted by civilian medical organizations. However, in
the military, we have not been faced with many of the barriers
I have discussed here.
It is the hope of the American Telemedicine Association
that Congress will help eliminate many of these barriers so
that all people throughout the United States can benefit from
the potential of telemedicine.
Sir, in closing, in August 1999, the ATA issued a public
statement on the role of the Internet in health care. In
regards to Senator Wyden's comments, I would be happy to
include this ATA position statement on the Internet as part of
my testimony.
Thank you.
[The prepared statement and attachments of Dr. Poropatich
follow:]
Prepared Statement of Ronald K. Poropatich, M.D., LTC, USA, Member,
Board of Directors, American Telemedicine Association
Thank you Mr. Chairman.
My name is Doctor Ronald K. Poropatich. I am an elected member of
the Board of Directors of the American Telemedicine Association and
provide these remarks today on behalf of the Association. I am a
practicing physician in pulmonary and critical care medicine with over
7 years of direct experience using telemedicine. I am also a Lieutenant
Colonel in the United States Army and the Director of the Telemedicine
Directorate at Walter Reed Army Medical Center in Washington, DC and
also serve on the staff of the Telemedicine and Advanced Technology
Research Center at the U.S. Army Medical Research and Material Command
at Ft. Detrick, Maryland. However, I am here today strictly on behalf
of the ATA and my remarks do not necessarily reflect the position of
the U.S. Department of Defense.
The American Telemedicine Association represents physicians, other
healthcare professionals, technologists and companies involved in
developing telemedical systems and providing healthcare services via
telecommunications. We are a non-profit membership-based organization,
established in 1993, which serves to promote telemedicine and resolve
barriers to its deployment.
In my remarks today I would like to briefly point out a few of the
critical national issues we believe inhibits the growth of
telemedicine. These serve as a barrier to realizing the potential
benefits of telemedicine to expand access by all Americans to quality
medical services and reduce the cost of providing healthcare services.
Many of the obstacles facing the use and deployment of telemedicine
today require changes in existing laws and regulations. I will
highlight several specific areas that should be addressed by the
federal and state governments in the United States.
1. Lack of Payment for Services: Despite many years of successful
telemedicine demonstrations and the rapidly expanding deployment of
telemedical services in the private sector and in other countries, the
U.S. lags behind in recognizing and paying for medical services
provided via telemedicine. Medicare currently reimburses for several
different types of remote services including teleradiology, remote
patient monitoring and live video consultations with patients residing
in remote Health Professional Shortage Areas. However, broad
reimbursement for telemedicine services is still unavailable. This
failure to provide coverage of telemedical services has put a brake on
the growth of telemedicine, restricted access to health services by
many Americans and hampered the ability of the U.S. healthcare industry
to use telemedicine in reducing costs and increasing the quality of
care.
Knowing the crisis facing the cost of providing healthcare and the
cost associated with increasing access to health services, ATA has
three specific priorities for providing Medicare coverage of
telemedicine services. Each of these priorities costs little or nothing
in additional federal outlays and will help expand access to needed
medical services by the American consumer.
(a) First, the Health Care Financing Administration (HCFA) should
clarify that it can fully reimburse for telepathology since this is a
service, similar to teleradiology, which can easily be conducted
remotely and does not require a direct physician-patient consultation.
This can be simply accomplished by HCFA today and does not require any
additional legislation. We are hopeful that HCFA will clarify this
issue before the end of this year.
(b) Second, we urge Congress to eliminate existing flaws in the
current Medicare program supporting telemedicine services to residents
of rural Health Professional Shortage Areas. For example, the program
does not reimburse for medical consultations provided using store-
forward technology. This is a very efficient and appropriate way of
delivering patient information to a medical specialist and is being
practiced today in the military, in other countries and in
demonstration projects across this country. ATA fully supports
legislation introduced by both Senator Kent Conrad (D-ND) and Senator
Max Baucus (D-MT) to amend this program.
(c) Finally, when HCFA introduces a Prospective Payment System
(PPS) for home healthcare services next year the provision of
telemedical services to the home should be an allowable service that
can be used by home healthcare agencies in providing services to the
homebound patient. Studies have shown that the use of telehomecare can
improve patient care and reduce the utilization of acute care services.
The use of telehomecare under PPS will cost NO additional federal
dollars, it can help improve services to the patient and it can help
homecare agencies to continue providing services at lower costs. We
strongly urge Congress to include language this year under the Balanced
Budget Act Amendments Bill that directs HCFA to allow these
telehomecare services.
2. Improved Access to Telecommunications Networks: The deployment
of telemedical links to rural and suburban medical centers require
communications networks that are reliable and capable of handling large
amounts of data in a short time. Homecare applications that require
interactive video as well as clinical applications involving large
patient data files will benefit greatly from the availability of
broadband networks. Congress established a program under the
Telecommunications Reform Act of 1996 to provide improved access to
high-speed data lines by rural health centers. Although well
intentioned, this program has fallen far short of its potential. The
application process as it exists today is burdensome, complicated,
causes substantial hardship on applicants, and creates a barrier on
getting the program benefits out to the intended beneficiaries. In
addition, eligible services and program beneficiaries are unduly
limited. In a letter to the FCC in March 1999 ATA called for specific
changes in the program by both the Federal Communications Commission
and Congress. I have included this letter in my written testimony.
ATA is also a member of the Advance Coalition, a group promoting
improved broadband deployment of the Internet. The Internet is becoming
the preferred platform for the delivery of telemedical services and can
be an important vehicle for providing health services to the individual
at home. It is therefore important that Congress help ensure that high-
speed access to the Internet is available throughout the country
including to rural communities and individual homes.
3. State Medical Licensure: Currently each state requires separate
medical licenses for physicians practicing inside state boundaries.
Telemedicine challenges this by allowing for the practice of medicine
across state lines. Some states have enacted restrictive laws to keep
out health professionals licensed in other states. This has been viewed
by some as efforts to protect the economic markets of the professionals
residing within the state. Earlier this year the ATA Board of Directors
adopted a position on state licensure that preserves the right of
states to continue to license medical professionals while allowing
access by patients and primary care physicians within the states to
services of qualified health professionals located in other locations.
I have included a copy of this statement in my written testimony.
4. Other key policy issues: There are several other important
issues and concerns that may require federal policies. These include
protection of healthcare and telecommunications entities from undue
liability arising out of the use of telemedicine and ensuring patient
privacy and confidentiality in the transmission of medical information
and electronic storage of personal medical information. Within the
military we have addressed the privacy issues by establishing a strict
policy of requiring a separate secure server to be used for all medical
transactions with encryption of all medical related files.
In my responsibilities within the military I have witnessed a
tremendous growth in the use of telemedicine in the delivery of
healthcare. The results of research and service efforts at the
Telemedicine and Advanced Technology Research Center at the U.S. Army
Medical Research and Material Command have enabled us to provide cost
effective and expanded access to medical specialty care where none was
available before. At Walter Reed Army Medical Center we are now
providing well over 3,000 medical consults per year to armed forces
personnel and their families worldwide. In some ways the efforts
achieved by the military has provided a model that might be adopted by
civilian medical organizations. However, in the military we have not
been faced with many of the barriers I have described here. It is the
hope of the American Telemedicine Association that Congress will help
eliminate many of these barriers so that all people throughout the
United States can benefit from the potential of telemedicine.
Thank you.
______
AMERICAN TELEMEDICINE ASSOCIATION
ATA POLICY REGARDING STATE MEDICAL LICENSURE\1\
Although telemedicine utilization is increasing, it accounts for
only a small fraction of all medical ``encounters'' in the United
States (including teleradiology). Despite that fact, during the last
four years at least 14 states have passed legislation severely
restricting the practice of telemedicine across state lines.
---------------------------------------------------------------------------
\1\ Adopted by the ATA Board of Directors, May 21, 1999.
---------------------------------------------------------------------------
Most often this restriction takes the form of requiring full and
unrestricted state licensure for any external physician providing
services via telemedicine to residents of the State. Other states have
similar statutes in various stages of the legislative process. Unless
meaningful alternatives are developed, it is expected that many more
states will follow the trend of restrictive legislation.
BACKGROUND
The powers that are not granted to the federal government under the
Constitution are reserved to the states as provided for by the Tenth
Amendment of the United States Constitution. These activities are
traditionally local in nature and most often pertain to health, safety,
and welfare of a state's citizenry. Under this authority physicians and
other healthcare practitioners are required to obtain state licenses,
comply with various state medical practice acts and are otherwise
regulated by state medical boards whose members are usually appointed
by state governors.
Although administrative practices might vary from state to state,
in the past 30 years there has been a remarkable convergence in
licensing requirements stipulated by states to license physicians. All
states require the United States Medical Licensing Examination (USMLE).
All recognize appropriate credentials from nationally accredited
medical schools and residency programs regardless of location. All
specialty board certification is conferred by national organizations
and are based on national standards.
Today, state licensure requirements have substantially more
similarities than differences. In fact, they only vary in terms of
procedural and tangential issues, such as the number of times an
applicant can take the USMLE (the range is from three to unlimited
attempts) and the number of required postgraduate training years (the
range is from zero to three years). In fact there is little, if any
data to support the claim that physicians of one state are more or less
qualified than those of any other state.
The debate surrounding telemedicine and state medical licensure has
focused on three approaches: Full and Unrestricted Licensure;\2\
Limited Licensure,\3\ and National Licensure.\4\
---------------------------------------------------------------------------
\2\ Full licensure has unfortunately been the most ``successful''
approach to telemedicine licensure in recent years. It is rapidly
becoming the de facto licensing approach for telemedicine today.
\3\ In 1996 the Federation of State Medical Boards (FSMB) produced
a ``A Model Act to Regulate Practice of Telemedicine or Medicine by
Other Means Across State Lines'' containing legislative language to
create a secondary or limited license for telemedicine purposes. Only
three states (Alabama, Tennessee, and Texas) have enacted legislation
in any way consistent with FSMB's philosophy. The American Medical
Association (AMA) opposed the act and called for a resolution requiring
``full and unrestricted license'' in each state for those ``who....wish
to regularly practice telemedicine in that state.''
\4\ There are least three potential forms of creating a more
uniform national licensure system: Federal Certification or Licensure;
Federal Preemption of certain restrictive state laws; and Mutual
Recognition between states. Federal Certification would actually grant
licensure at the federal level. An example is aviation. All civilian
pilots (including airline transport pilots) are licensed at the federal
level. The Federal Aviation Administration (FAA) manages pilot
certification in the US. Preemption grants functional licensure in
certain circumstances by superceding state statutes. The Wyden
Amendment (a 1995 attempt to preempt state law in cases in which a
physician conducts a consultation using telecommunications) is an
example of an attempt to restrain overreaching state laws through
limited federal action. Mutual Recognition of licensure between states
is based on the concept of reciprocity. The drivers license is an
example of automatic reciprocity in which the holder of a license in
one state can legally drive in any other state. The Nursing Licensure
Interstate Compact, currently being finalized by the nursing community,
grants nursing licensure privileges in all participating states
provided the nurse already has a valid license in at least one state.
---------------------------------------------------------------------------
FINDINGS
1. The requirement for full and unrestricted licensure in each
state can have a chilling effect on telemedicine practice. Moreover, it
places excessive economic, administrative, and political burdens on
current and future telemedicine providers.
2. Full and unrestricted state-based licensure requirements limit
patient rights by denying easy access to remote medical expertise.
3. While reciprocity or other mechanisms of mutual recognition
could solve interstate medical licensing issues, recent actions and
positions taken at the state level and by a few medical organizations
bring into question the political viability of these approaches. Recent
attempts to change state laws have resulted in an increase rather than
a decrease in licensure barriers.
4. A more flexible and permissive licensure environment is
inexorably tied to reimbursement.
5. A new approach is required that provides a basis for legal
challenge of the status quo. For any real movement to occur, state
authority in this matter may have to be subordinated a legal instrument
of an external authority.
6. The only external authorities are the US Congress or the
Judicial system.
Interstate Commerce: Although the states rightfully hold the
authority to regulate activities of legitimate local concern, this
power is not absolute. The Commerce Clause of the US Constitution
(Article 1) prohibits states from erecting barriers against activities
that are inherently national in scope. In addition, barriers that
transcend the traditional scope of state regulatory authority by
protecting local economic interests, which restrict interstate
commerce, have been treated as violations of the Commerce Clause.
Although the practice of medicine has traditionally been local in
nature, telemedicine introduces a distance independent variable that
is, by definition, neither local nor traditional.
In a legal challenge, courts would balance the objective and
purpose of state law against the burden on interstate coniirierce. If
benefits of state law outweigh the burden of interstate commerce, state
regulation will generally be upheld. If regulation imposes a
substantial burden on interstate commerce, it will likely be held
unconstitutional. Industries with legal and/or legislative precedents
for transitioning from local to national regulation includes trucking,
food, telecommunication, banking, railroad, and automotive. The
hallmark of industries making the transition is financial viability.
Sustained economic growth for telemedicine may be essential prior to a
successful legal challenge.
If the nature of activity being regulated requires uniform national
regulation, then no state regulation is permissible. This is why pilots
are certified at the national rather than state level.
Traditionally, the courts have had little tolerance of interference
in interstate commerce, especially interference that protect local
economic interests, even when state's rights issues are in the
forefront. In the majority of cases, state regulations are struck down
if it can be shown state laws are designed to protect local interests
at the expense of out of state competitors.
ATA POSITION:
The ATA state licensure policy position offers a compromise between
full national licensure and state-imposed unreasonable barriers that
meets the following guidelines:
Preserves the right of each state to regulate
medicine in traditional face-to-face (FTF) physical setting
Preserves licensure authority at the state level
Avoids unnecessary restraints on interstate commerce
Ensures that all patients have access to health care
expertise necessary to protect and promote their health
regardless of the location of the provider
Advances telemedicine as a valuable service delivery
strategy that can play a critical role in overcoming time and
distance barriers that often limit access to quality health
care
1. The medical event should be defined as occurring where the
physician is located. No medical event can occur in the absence of a
either patient or physician (or other medical provider). Both are
essential.
2. A physical face-to-face (FTF) encounter between physician (or
other medical provider) and patient within state borders remains the
purview of the state.
3. If the encounter is virtual (i.e. non-physical FTF) and a
physician is located in another state, the encounter is neither
traditional nor local and is therefore outside the purview or
jurisdiction of the state.
4. States should not restrict physical travel by patients to seek
medical advice outside the state and should not be permitted to
restrict ``virtual'' travel as well.
5. States should not restrict a duly licensed physician or other
medical provider from seeking consulting medical expertise from a
physician or other medical provider licensed in another state.
6. The ATA should support and define the Interstate Telemedicine
Encounter (ITE) within the following specific guidelines:
Telemedicine request originates from a provider who
is fully licensed in the patient's state
The patient and requesting physician must have a real
physician-patient relationship
The patient and requesting physician must have a real
(i.e. physical) FTF encounter
The out-of-state consulting physician using
telemedicine must be fully licensed in the state in which the
physician is located
[Optional] The out-of-state physician must register
his/her intent to provide telemedicine services to patients
residing in that state. This is for information purposes only.
No action by the state is required except confirmation of
receipt of the letter of intent
The responsibility of medical care for the patient
must remain with the requesting physician. Care never transfers
to the out-of-state physician in this telemedicine model. The
requesting physician is the attending physician.
7. The ATA recognizes that these jurisdictional and licensure
issues also effect a wide variety of individuals within, as well as
outside, the health care community. The ATA should utilize the state
licensure issues to expand the constituency of telemedicine by formal
and informal outreach to the ``digital community'' (hardware, software,
and telecom vendors; electronic commerce industry), managed care, and
patient advocacy groups.
8. Strategies for creating a more favorable licensure environment
and for securing expanded reimbursement should be synergistic. They
must be implemented in parallel over time with long term commitment.
Implementation: ATA will assume a proactive position on state
licensure and ATA will make every effort to provide input reflecting
these policy statements to legislative and/or regulatory organizations.
__________
March 5, 1999
Mr. William Kennard
Chairman
Federal Communications Commission
445 12th Street, SW
Washington, DC 20554
Ms. Cheryl Parrino, CEO
Universal Services Administrative
583 D'Onofrio Drive
Suite 201
Madison, WI 53719
Dear Chairman Kennard and Ms. Parrino:
The groups indicated below provide these comments regarding the
Rural Health Care program that is being administrated by the Universal
Services Administrative Corporation (USAC). These groups represent a
wide variety of individuals and institutions from across the United
States who are involved in the provision of health care,
telecommunications services, telehealth and telemedicine. We have a
strong interest in the implementation of the Rural Health Care program
that maximizes the benefits for patient care in rural America. These
comments reflect a level of frustration with the limitations of the
program that have become apparent over the first year of
implementation.
Our comments are divided into two areas. First, we include proposed
actions that can be made by the FCC, which are critical in order to
improve the current program operations. These are:
1. The Commission should take steps to notify all approved
applications and start the discounts immediately. Current applications
now before USAC have been pending for many months. Approvals for these
applications have been held up for months for reasons that are not
clear. This delay has caused undue hardships on the rural health
providers, who are operating on very narrow financial margins already.
Continued delay is unconscionable.
2. The application process as it exists today is burdensome,
complicated, causes substantial hardship on applicants, and creates a
barrier on getting the program benefits out to the intended
beneficiaries. The process should be streamlined in two ways.
a. The Commission should reconsider the requirement that all
applications are required to enter into a 28-day posting period, at
least for areas where there is no existing competition for local
service. To date, there have been no competing bids proposed for any
application, nor are any competing bids anticipated. The applications
are typically for services to very remote locations where no
alternative service providers are available. We understand and
sympathize with the desire of the Commission to promote competition.
However, this has led to additional delays and costs placed on the
backs of rural health care providers and delayed the provision of
health services for rural Americans.
b. The Commission should streamline the application process. We
suggest that the Commission eliminate the complicated process of
requiring the local exchange carrier to make calculations of specific
charges to be discounted. Instead a simplified process should be put
into effect whereby the approved rural health care provider simply
submits their paid phone bill for eligible broad band (T1) services
with distance line charges spelled out to USAC. USAC would reimburse
the carrier for the discounted distance line charges on the bill. The
carrier would pass on the money in the form of a discount on the next
bill. The discounts should be based on an average cost for
communications services to rural areas versus urban areas in existence
for each state.
3. The Commission should consider reimbursement for other costs
associated with providing telecommunications services for rural health
care that have higher costs for rural areas. Such costs include
connection fees for ISDN and switched services, and toll charges for
connections to urban areas.
4. The rural health program is supposed to serve public health
agencies, which provide essential services to rural communities.
However, very few of these agencies currently have applications
pending. The Commission should assess the reasons for this non-
participation, identify specific program elements needed to increase
participation and set targets for improving participation.
Second, we include a set of recommendations that may require
statutory amendments to the governing legislation. These are based on
the experience gained in the program over the past year where obvious
deficiencies have become apparent. Given the current under utilization
of estimated funding of the rural health program, the approval of these
changes would have minimal impact on the size of the rural health
program as originally envisioned. These are:
1. The program should include discounts for all forms of
communications services when used in the delivery of health care to
rural health care providers. As currently designed, services eligible
for the rural health care program are effectively limited to a T1 line,
largely because of the use of distance costs associated with this
service. However, advancements over the past few years in technology
and communications have enabled health care providers to transmit and
receive information at speeds lower than that required of T1 lines.
Although lower in cost, this still remains an impediment to many health
providers due to the few resources available in support of rural health
care.
2. The existing regulatory framework requiring additional
agreements between multiple local and long distance carriers should be
resolved. Establishing links between many applicants and urban centers
require crossing LATA boundaries, due to the large distances. The ETC
requirement has either precluded support for rural health care
providers or led to unnecessary complications between local and long
distance carriers in the development of applications by eligible health
providers. Coordination between multiple telecommunication companies
requires the rural provider to rely on employees of the companies to
help complete forms and develop adjusted rate schedules. This adds time
and complexity to the application process.
3. The rural health care program, unlike the school and library
program, does not cover associated costs with the establishment of
high-speed communications connections. The health care program should
be changed to mirror those services that are currently eligible in the
school and library program.
4. The rural health care program should be changed to foster
collaboration among all eligible institutions where appropriate and
allow the rural health provider to collaborate with public health
agencies in the implementation of the program. In many rural
communities the health care institution and the local school and
library are located in very close proximity. However, the programs
operated by USAC do not allow a combined effort by health, school, and
library facilities. In many areas this leads to unnecessary duplication
of communication services. In addition, local public health agencies
can be an important partner with the rural health care providers.
5. The program should consider all rural health institutions under
the program without regard to tax status as eligible for receiving
discounted services. In many areas, particularly the many different
Health Professional Shortage Areas, the only health provider serving
rural residents does not happen to be a non-profit institution.
6. The legislation ignores three other important health care
institutions serving rural America: long-term care facilities, home
health agencies and skilled nursing facilities. These facilities should
be made eligible for support under the program.
Jonathan D. Linkous
Executive Director
American Telemedicine Association
Organizations endorsing this letter:
American Academy of Physician Assistants
American College of Nurse Practitioners
American Hospital Association
American Telemedicine Association
Association of Telemedicine Service Providers
National Association of Community Health Centers
National Organization for State Offices of Rural Health
National Rural Health Association
Senator Frist. Thank you very much.
I am going to turn to Senator Burns for a statement.
STATEMENT OF HON. CONRAD BURNS,
U.S. SENATOR FROM MONTANA
Senator Burns. I thank the chairman. I just want to submit
my written statement.
I want to thank Dr. Brick for recognizing the advances that
we have made in Montana. We started doing this a long time ago.
This is nothing new for the State of Montana, as you well know.
And so we are pretty familiar with this.
I am going to read your statements, and I have listened to
your statements with a great deal of interest. I thank you for
coming today and offering these statements. Because especially
in the mental health area, we are starting mental evaluations
by telemedicine. That has been very successful in Montana. And
we are even doing it in youth justice, a lot of those things.
Because we are a big State. You guys think you come from
big States. Tennessee is awful long, but you ain't very deep.
[Laughter.]
Senator Burns. We are long and deep.
Senator Frist. Now, this deepness. We will debate about how
deep we are.
Senator Burns. You ain't very deep. I have been there.
Dr. Burgiss, I have got a spy down there spying on you
anyway.
Thank you very much. I appreciate that.
[The prepared statement of Senator Burns follows:]
Prepared Statement of Conrad Burns, U.S. Senator from Montana
I'd like to start by thanking Senator Frist for holding this
hearing today. I'm especially proud knowing that Montana is home to the
11th largest telemedicine network, the Eastern Montana Telemedicine
Network. This is especially amazing considering that the EMTN was only
created in 1993. It's grown from the small network of 5 hospitals to an
extensive association of 11 sites. These sites have connected to other
networks throughout the country and even internationally.
So, what impact does telemedicine have on rural health care? In
Montana, it has made a huge difference. A rancher injured up in
Glasgow, Montana now has the same access to specialists that a resident
of Billings would have. Glendive Medical Center Personnel can now
attend classes and learn about the latest medical techniques through
their videoconference connection. Colstrip Medical Center
administrators can coordinate their operating plans with the other 10
administrators on the network, allowing greater efficiency in health
care. All of these opportunities are critical to providing the best
possible health care to all of Montana's rural communities.
The volume of traffic over the network is a good indicator of how
doctors view the effectiveness of this capability. In the last three
years alone, traffic has increased 65% on the EMTN. Again, in 1996, it
was rated as the 11th most active telemedicine network nationwide. The
number of participants has increased from 525 people in 1995 to almost
17,000 participants annually by 1997. People believe in the benefit
from this system, and I expect that usage will continue to grow in the
coming years.
But before I go too far in boasting about how wonderful this system
is for Montana, I want to quickly touch base on what I believe is
holding it back from its maximum benefit. The single greatest cost of
running this system is in the data network cost. We were lucky in
getting a Rural Electrification Administration grant in 1993 to get
this thing started, and the Office of Rural Health Policy helped expand
the network in the last few years, but the monthly telephone bill with
US West runs into the thousands each month. That's even after taking a
network discount into effect. To really keep this thing going, we need
to make sure that the high data rate connections are cost effective.
That's what holds telemedicine back nationwide; easy, cheap, local
access to a broadband backbone. We were lucky to get some assistance in
developing ours. Other regions haven't been as fortunate. I think this
committee owes it to our rural citizens to find ways to bring enabling
technologies like broadband access to local communities. This, in turn,
will help stimulate development of capabilities like the telemedicine
networks. It's a great example of leveraging technology to directly
improve the health care of people who would otherwise be overlooked by
the big heath care affiliates.
So again, has telemedicine made a difference in rural life? I'm
sure you can tell by now that I believe it has. I'm personally
committed to try to keep expanding telemedicine networks nationwide by
whatever means possible. I've included broadband access in my digital
agenda to try to expand inexpensive access to everybody who wants it.
Eastern Montana has certainly benefitted by having the EMTN through
their local hospitals. Others deserve the same chance.
Thank you, Mr. Chairman. I look forward to hearing from the
panelists.
Senator Frist. Thank you very much, Conrad.
The spy is his daughter, who is a physician in the great
State of Tennessee.
Mr. Waitz, thank you.
STATEMENT OF AARON S. WAITZ, CHIEF TECHNICAL OFFICER AND VICE
PRESIDENT, HEALTH IMAGING DIVISION, EASTMAN KODAK COMPANY
Mr. Waitz. Good afternoon, Chairman Frist and Subcommittee
members. I am Aaron Waitz, Chief Technical Officer and Vice
President of the Eastman Kodak Company's Health Imaging
Division. I am pleased to be here today to share our views on
telemedicine and telehealth, a phenomenon that will transform
the way health care is delivered.
Mr. Chairman, telemedicine and telehealth have the
potential to transform the world of health care, just as the
Internet transformed the world of commerce. Today, individuals
are comfortable going on the Internet to seek out all sorts of
information, including medical information. Tomorrow,
individuals will turn on the telehealth product in their home
to link with a health care provider, obtain medical images and
information, and manage their wellness program.
As background, the Eastman Kodak Company, headquartered in
Rochester, New York, employs approximately 84,000 people
worldwide, with over 44,000 in the United States. The business
of the Health Imaging Division is medical pictures. Integrated
solutions to capture, process, present, distribute, and print
health-related images, using a broad range of sophisticated
technology. For over 100 years, Kodak's health imaging business
has served the needs of providers and recipients of health
care. Kodak is the leading manufacturer of x-ray film, and we
are leading the development of electronic medical imaging
products.
Today's telemedicine products can bridge the distances
separating practitioners in rural, underserved communities with
health care providers in more concentrated medical service
areas. The ability to provide patient monitoring results in
decisions at earlier disease states, and earlier interventions
results in fewer hospitalizations. The results are lower costs
throughout the entire health care system.
Kodak Health Imaging has been active in the field of
telemedicine for several years, through our partnership with
public and private sector health care organizations. In
Tennessee, our partnership with Midsouth Imaging covers
radiology services for six Baptist Hospital facilities in
Memphis, enabling the sharing of subspecialty expertise and
data.
In Louisiana, Kodak and Schumpert Medical Center in
Shreveport have in place an on-call teleradiology system to
facilitate remote diagnosis by on-call radiologists in their
homes.
In Texas, the Baylor Grapevine, in San Antonio, uses
Kodak's PACS systems to connect 30 mobile vans, offering remote
radiology services to a central reading site.
In the future, telehealth technologies will link health
care providers directly with their patients, improving
opportunities for contact between the two, and making
telehealth care a means through which patients are more
directly involved with maintaining their state of well-being.
Kodak is looking ahead to these types of products that will
enhance and expand the scope of that patient/provider contact
and that patient-directed care.
Telehealth applications in home health care could involve
the measurement of a patient's vital sign data via a device
directly linked to a remote health care provider, which
provides the quality images and data that providers demand to
achieve better outcomes.
The future of telehealth in physical therapy could involve
remote rehabilitation of extremities. Rather than a patient
traveling to a central facility, potentially requiring time off
from work, the patient could take a telehealth product and
receive remote therapy in the convenience of their home. The
incentives for this device would be timely access, higher
quality care and reduced costs.
Technology exists today to allow continuous monitoring of
patients via wearable and ingestible biosensors. In the future,
test orders will no longer require the patient to travel to a
diagnostic laboratory as is the case today. Instead, data could
be continuously recorded and uploaded via the Internet to a
health care provider for analysis.
Just as telemedicine products move the delivery point of
care from the hospital to freestanding community facilities, to
the home, future telehealth products will move the field away
from monitoring a patient after an episode of illness to self-
monitoring that ensures maintenance of health.
This Subcommittee, and the entire Congress, play an
important role in ensuring that the current and future
generation of telehealth products reach patients in health care
provider shortage areas and throughout the country. We are
seeing in practice throughout the country that telemedicine and
telehealth broadens access to care, reduces health care costs
and provides a better quality of care for patients. The
challenge is to strike the appropriate balance so that
government policies do not restrict the integration and growth
of telehealth technology in health care.
There are several areas that Kodak believes are important.
First, the regulatory and statutory barriers that impede the
acceptance of remote consultation across geographic boundaries.
Examining a patient in another State or recommending treatment
may be tantamount to practicing without a license.
Second, appropriate reimbursement for providers using
telehealth. Current law does not reflect the technological
advances and the resulting dramatic cost reductions that allow
new paradigms of interaction.
Third, a national high-speed Internet. The increase in
bandwidth throughout the national infrastructure enables cost-
effective transmission of high-quality diagnostic images.
Fourth, achieving the correct balance between the desire to
secure a patient's medical information and the inability of
remote providers and patients to interact. The use of
telemedicine health care networks to facilitate disease
management and health promotion will depend upon the ability to
gather and exchange medical information freely.
And, fifth, standardization of electronic medical records
and the communication protocols. The development of uniform
Federal standards will accelerate interoperability among the
vast numbers of medical image and information systems.
Mr. Chairman and subcommittee members, we want to partner
with you to address potential issue areas in a way that
ultimately benefits users and practitioners of health care. If
the system that delivers health care lags behind technical
capability of the next generation of telemedicine and
telehealth products, then patients and the entire health care
system will be the losers.
In conclusion, Eastman Kodak believes the future of
telemedicine and telehealth is brimming with possibilities. We
believe the next generation of products will have broad
applications that will profoundly change the current health
care paradigm. Kodak is excited at the prospect of taking
medical imaging to a place where barriers of distance and time
are removed.
We have a long history of breaking new ground in health
care, from our 1896 development of the first product designed
to capture x-ray images. Telehealth products represent the next
phase in the process of designing products that help providers
detect, diagnose and treat their patients more efficiently. We
applaud the leadership of this committee in discussing the
challenges and the potential of this technology, and we stand
ready to work with you.
Thank you.
[The prepared statement of Mr. Waitz follows:]
Prepared Statement of Aaron S. Waitz, Chief Technical Officer and Vice
President, Health Imaging Division, Eastman Kodak Company
Good Afternoon Chairman Frist and Subcommittee members. I am Aaron
Waitz, Chief Technical Officer and Vice President of the Eastman Kodak
Company Health Imaging Division. I am pleased to be here today to share
our views on telemedicine and telehealth, a phenomenon that will
transform the way healthcare is delivered.
Mr. Chairman, telemedicine and telehealth have the potential to
transform the world of healthcare just as the Internet transformed the
world of commerce. Within this decade, all of us witnessed the
expansion of the Internet, from narrow applications to broad consumer
acceptance and use. Once the capacity of the telecommunication system
was matched with the convenience of access, the Internet exploded. The
result is that, today, individuals are comfortable going on the
Internet to seek out all sorts of information, including medical
information. Tomorrow, individuals will turn on the telehealth product
in their home to link with a healthcare provider, obtain medical images
and information and manage their wellness program.
As background, Eastman Kodak Company is headquartered in Rochester,
New York. We employ approximately 84,000 employees worldwide with over
44,000 of them in the United States. Moreover, as a purchaser of health
care in the United States, we provide coverage for nearly 200,000
lives, of which approximately 70,000 are retirees and their families.
The business of the Health Imaging Division of Kodak is medical
pictures-integrated solutions that capture, process, present and print
health-related images using a broad range of sophisticated technology.
For over 100 years, Kodak's Health Imaging business, as served the
needs of providers and recipients of healthcare. Kodak is a leading
manufacturer of x-ray film and we are leading the development of
electronic medical imaging products, including PACS (picture archiving
and communication system), teleradiology and computed radiography. As a
purchaser of health insurance and provider of health care products,
Eastman Kodak understands the imperative of broad access to affordable
quality health care that is not inhibited by distance or time.
Today's telemedicine products can bridge the distance separating
practitioners in rural, underserved communities with health care
providers in more concentrated medical service areas. Now it is
possible to link health care professionals, regardless of location, and
the result is improved access to high quality health care for some
people. Closer patient monitoring results in decisions at earlier
disease-states and earlier interventions result in fewer
hospitalizations. Effective use of telemedicine and telehealth care
results in lower costs throughout the entire health care system.
Kodak Health Imaging has been active in the field of telemedicine
for several years, through our partnerships with public and private
sector healthcare organizations. In Tennessee, our partnership with
Mid-South Imaging covers radiology services for six Baptist Hospital
facilities in Memphis, enabling the sharing of sub-specialty expertise
and data. In Louisiana, Kodak and Schumpe Medical Center in Shreveport
have in place an in-hospital primary reading system and an on-call
teleradiology system, to facilitate remote diagnosis by on-call
radiologists in their homes. In Texas, the Baylor Grapevine in San
Antonio uses Kodak PACS to connect 30 mobile vans offering remote
radiology services to a central reading site.
In Colorado, Active Medical Inc. is using Kodak's computed
radiography (CR) units to offer x-rays in nursing facilities, instead
of moving nursing home patients to hospitals. The images are captured
on a storage phosphor screen and converted to viewable images. The
image can be transmitted to remote ``soft-copy'' viewing locations or
to laser printers for hard-copies. Not only does the x-ray technologist
come to the patient for this procedure, but the image is transmitted to
a nearby hospital where the radiologist reads the image and verbally
reports back to the nursing home within 35 minutes. The nursing home
patient does not have to worry about making a trip to the hospital, the
productivity of the radiologists is increased, all while providing
quality care.
In the future, telehealth technologies will link healthcare
providers directly with their patients, improving opportunities for
contact between the two and making telehealthcare a means through which
patients are more directly involved in the maintaining their state of
well-being. Kodak is looking ahead to the types of products that will
enhance and expand the scope of that provider-patient contact and that
patient-directed care. Telehealth applications in home health care
could involve measurement of a patient's vital sign data and ethoscopic
sounds by a device linked with a remote healthcare provider. Unlike the
blood pressure device that we currently see in grocery or drug stores,
this application of telemedicine would permit interaction between
patient and provider. Our scientists and engineers are examining
methods of linking the two, just as we now have the capacity to link
two providers remotely, with devices that are user friendly for
patients, provide the quality images and data that providers demand and
offer valuable information that can achieve better outcomes.
The future of telehealth in physical therapy could involve remote
rehabilitation of extremities, such as the hand or ankle. Rather than a
patient traveling to a central facility, potentially requiring time off
from work, the patient could take a telehealth product and receive
remote therapy in the convenience of their home. Rehabilitation
exercise could be performed on the home device and monitored remotely
by a physical therapist. During the manipulation of the extremity, the
telehealth product could measure strength or range of motion while
proceeding through a series of rehabilitation exercises. In this
example, a therapist linked remotely to the patient would monitor the
movements made and the progress between sessions. The incentives for
applications of this rehabilitation device would be present in remote
areas or more urban, larger facilities with many patients, through
timely access, higher quality care and reduced costs.
Technology exists today to allow continuous monitoring of patients
via wearable or injestible biosensors. In the future, tests ordered
will no longer require the patient to travel to a diagnostic
laboratory, as is the case today. Instead, data could be continuously
recorded and uploaded via the Internet to the healthcare provider for
analysis.
Just as telemedicine products move the delivery point of care from
the hospital to a freestanding community facility, to the home, future
telehealth products will move the field away from monitoring a patient
after an episode of illness to self-monitoring that ensures maintenance
of health, while continuing to offer care in locations of the patient's
and provider's choosing. If these advances are combined with others in
medical imaging, such as miniaturization or improvements in computer
aided diagnosis, the result is a dramatic improvement in the quality of
care available in telemedicine and telehealth. Add expansions in web-
based technology and the result is an explosion of possible
applications for telemedicine and telehealth products.
This Subcommittee and the entire Congress play an important role in
ensuring that the current and future generation of telehealth products
reach patients in healthcare provider shortage areas and throughout the
country. We are seeing in practice throughout the country that
telemedicine and telehealth broadens access to care, reduces health
care costs and provides a better quality of care for patients. The
challenge is to strike the appropriate balance so that government
policies do not restrict the integration and growth of telehealth
technology in healthcare. There are several areas that Kodak believes
are important:
The regulatory and statutory barriers that impede
acceptance of remote consultation across geographic boundaries.
Examining a patient in another state or recommending treatment
may be tantamount to practicing without a license.
Appropriate reimbursement for providers using
telehealth. Existing legislation was developed at a time when
telemedicine was synonymous with teleconferencing, restricting
reimbursment to provider-to-provider transactions. It does not
reflect the technological advances and resulting dramatic cost
reductions that allow new paradigms of interaction. For
example, direct patient-provider interaction.
A national high-speed Internet. The increase in
bandwidth throughout our national infrastructure, coupled with
advances in image compression technology, enables cost-
effective transmission of large high quality diagnostic images.
Telehealth consultations then become the beneficiaries of this
increased bandwidth.
Achieving the correct balance between the desire to
secure a patient's medical information and the inability of
remote providers or patients and providers to interact. A
balance must be reached between protecting sensitive
information and facilitating the coordination of information in
high quality healthcare networks. The use of telemedicine in
these networks to facilitate disease management and health
promotion will depend upon the ability of the healthcare
networks to gather and exchange medical information.
Standardization of electronic medical records and
communication protocols. The development of uniform Federal
standards will accelerate interoperability among the vast
number of medical image and information systems.
Current healthcare systems with experience with telemedicine and
telehealth, whether private insurers or national healthcare systems
like the Veterans Administration or Medicare, can offer data that
address concerns about efficacy and cost and remove the potential
barriers to product integration. As a partner with providers of health
care, Kodak has information on the success story of telehealth. We want
to partner with you to address potential issue areas in a way that
ultimately benefits users and practitioners of healthcare. If the
system that delivers healthcare lags behind the technical capability of
the next generation of telemedicine and telehealth products, then
patients and the entire healthcare system will be the losers.
In conclusion Mr. Chairman and Subcommittee members, Eastman Kodak
believes the future of telemedicine and telehealth is brimming with
possibilities. We believe the next generation of products will have
broad applications that will profoundly change the current healthcare
paradigm. The new millennium will be one in which quality healthcare
will be accessible to millions of people in settings more numerous than
those available today. Kodak is excited at the prospect of taking
medical imaging to a place where the barriers of distance and time are
removed. We have a long history of breaking new ground in healthcare,
from our 1896 development of the first product designed to capture x-
ray images. Telehealth products represent the next phase in the process
of designing products that help providers detect, diagnose and treat
their patients. We applaud the leadership of this Committee in
discussing the challenges and potentiaI of this technology and we stand
ready to work with you. Thank you.
Senator Frist. Thank you, Mr. Waitz.
Several of you commented in the oral testimony, then also
in your written testimony, on the privacy issues and security
issue, from fingerprinting to setting up separate servers. I
would like to give each of you an opportunity to expand or, if
you did not mention it in your oral testimony, to mention, in
terms of privacy and security, current state-of-the-art
technologies, pitfalls today, and then as we look out over the
next 5 years, what should be done, or what do you recommend
should be done to in some way--and maybe a policy that we put
forward--to assure both security and privacy, which are the
issues that come forward any time you communicate via the
Internet and Next Generation Internet or through the air.
Let me just open it up, and then any of you can comment.
And keep your comments fairly brief, because I would like to
hear from all of you.
Dr. Brick.
Dr. Brick. I will speak from our experience in West
Virginia. We were very concerned about this at the beginning
because of an unfamiliarity with the technology. We were just
sort of afraid we were spreading these electrons all over the
world with pictures of patients and things like that. But as we
have become more familiar with it, our concerns about privacy
have become less.
The network that we have used has always been secure. We do
not use the Internet. At the beginning we had a network that
was completely dedicated T1 lines. Now we have switched to
ISDN. But for us, that is not something that has concerned us
really.
I come from the days with paper charts. And everything was
written down on little pieces of paper. And you know that those
things fall into people's hands, too. And I think,
realistically speaking from our standpoint, this is more secure
than paper charts.
Now, we do not have a computerized medical record that goes
along with this. But from the standpoint of seeing patients and
patient confidentiality issues with that, I am more secure with
this than I am with the charts. And I do this every week. I see
lots and lots of patients on TV. And the patients are happy
with it, too.
Senator Frist. So with the dedicated line, the T1 or ISDN?
Dr. Brick. Yes, the dedicated network, that is right.
Senator Frist. Other comments? Dr. Ferrans?
Dr. Ferrans. Thank you. We also use a dedicated network. So
we can certainly put robust security around it. I think as far
as having a non-secure health care transaction over the
Internet, I would be very concerned about that.
With regard to information security and privacy and
confidentiality, it is very, very important that we protect
that information. That goes for everything from electronic
security to not talking in the elevators about patients.
I think one of the things that is of concern is that if HHS
does issue the regulations on privacy and confidentiality, that
will only cover electronic medical record information and not
all medical record information. This may have the effect of
serving as a financial deterrent for people to develop more
sophisticated information systems that really deliver benefits
to the patient.
I did want to mention one thing about our security. We are
determined to make sure that we know exactly who is accessing
the record. So we are going to be using desktop fingerprint
security. Now, we have gotten a grant from our State government
to do that. I can just show you--this is a biometric reader. It
just plugs into a computer. I put my fingerprint on it and it
instantly logs me in. It costs about $100.
So, again, the technology is there. We can safeguard
information.
Senator Frist. But you would argue for comprehensive
medical record privacy rather than just a focusing, which
probably would not happen unless the U.S. Congress acts, in
terms of regulation of just the electronic side?
Dr. Ferrans. I think we need comprehensive legislation,
covering patient confidentiality. It touches every area, from
informed consent--I am actually less worried about this than I
am worried about what happens to the information that goes
through third parties. And I have heard testimony about drug
companies buying transcription houses and all sorts of other
things that cause me great concern. There is no electronic
privacy out there today in general. And health care information
is not a secure----
Senator Frist. We have a patchwork that is really
inadequate today.
Dr. Poropatich.
Dr. Poropatich. Senator Frist, the current state of patient
security, as you know, is highly variable. First, I can walk
into most hospitals in this country and take a patient's record
if it is not paperless, and disclose important information
about patient confidentiality. It is a big issue. Clearly we
have not tackled it in the last 50 to 100 years that we have
been keeping written records.
However, we have an experience in both Internet and video
teleconferencing. Video teleconferencing is a very clean way to
provide consultations. It is more expensive, but it is fairly
secure. However, we are migrating very aggressively to the
Internet. Because we within the DOD, for example, because of
the limitations of bandwidth, for example, ships at sea, if you
turn the ship, you lose your connection with the signal that
you are trying to transmit, et cetera.
There is clearly electronic commerce security issues that
have already been reached. Electronic commerce, as you know, is
a growing business in this country. A lot of the security
features that we need for medicine have already been achieved
in electronic commerce. However, within the DOD, for example,
we have established a standard for using the Internet for
patient consulting. Those standards include the information
must reside on a dedicated server, used for nothing other than
clinical consultation. That the individuals that use it have to
have password protection into the system. That the information
that is sent across the Internet is encrypted.
It begs the question: How much encryption do you need, 40-
bit, 56-bit? We are establishing a threshold at 56-bit des.
However, that level of encryption was recently violated at the
Pentagon just within the last year. So 56-bit des does not buy
you full security if some hacker out there truly wants to get
into your medical record.
However, I think you need to also address the issues of
when you send information over the Internet, how do you know
that it is not being parted en route and changed, and when it
eventually reaches your site, things were changed? Or, if it is
residing in an archive in your hospital, that it is not being
changed while it is being archived?
Those are other issues that we need to address in addition
to the ones I have already alluded to. So it is a very thorny
issue. I think electronic commerce is going to help a great
deal. Many Americans are willing to give up their credit card
numbers over the Internet, even their social security numbers.
This week's issue of Newsweek is dedicated to the Internet. It
tackles a lot of these issues from a sociological as well as
practical electronic commerce frame.
So I think medicine is going to be able to solve this
problem due to the fact that we are going to be using the
Internet more and more. I think it is a very important way to
do telemedicine, because you can distribute it, you are not
tied up with expensive bandwidth, you can do the consults from
your home, on the road, with wireless. We think that in the
military, for example, within the next 5 years, every soldier
will have their own personal communication device, a
wristwatch, that will allow them to move information. I think
the security issue is important to start planning now for
legislation to ensure a minimum standard.
I will leave my comments at that.
Senator Frist. Thank you.
Dr. Burgiss.
Dr. Burgiss. Thank you, Dr. Frist.
What we have done in Tennessee is primarily interactive
consulting, as you could tell. We have tried to apply some
Tennessee ingenuity using what we have. We do not have the
infrastructure that the military might have concerning
encryption, et cetera. But some of the things that we have
done, such as point to point, as was mentioned in West
Virginia, provides for security. Other things we are doing for
security in clinics include using three ISDN lines instead of
one. This makes it more difficult to put this data back
together, by spreading it among lines.
Also, security is in our home telemedicine. You may have a
question in mind of how secure is the home situation? When we
are doing a home consultation, both the audio and the video are
digitally encoded. It is even more secure than the patient
talking by phone to the nurse without the telemedicine.
If you have been in a home where you have a computer using
a modem, which is like what we are doing, and if somebody picks
up another phone on the line, they certainly do not hear
anything, they do not see anything, and it all crashes. We are
using technologies and some inherent considerations.
Another example is to transmit the patient's name and the
data by separate paths. That has been a creative way for
improved security that we have used.
These things have worked for us. But they will not work on
the Internet. That is a different situation. I do believe and
endorse that the Internet will need a different level of
security, innovative security. Creation and work within the
military and other branches will be very supportive of this
technology that will be required.
Senator Frist. Thank you.
Mr. Waitz.
Mr. Waitz. I think the current state-of-the-art in terms of
access to medical information really falls in two areas right
now--devices that health care providers actually carry with
them, things like smart cards, radio tagging devices--versus
things that actually positively identify you based on
biophysical parameters, biometric devices like fingerprinting,
face recognition or retinal scanning. I think all of these
devices, that are devices that you do not have to carry
something with you, avoid the pitfall of when you want to
access medical information for example not having that
particular device there.
I think the biggest issue, at least in clinical
environments that I have been in, is quick access to
information and not providing the barrier in order to get
access within the institution. As my colleagues on this panel
have said, walk into any hospital in America today and that
information is freely available inside the hospital.
I think the recommendation going forward is really secure
transmission capability. I know there are technologies that the
NSA is using that does not use encryption, it uses an optical
technology to provide secure data transmission. I think, in
essence, the work that is being done in electronic commerce
will be leveraged for telemedicine applications. It is the same
kind of problems, really, regardless of the application that is
going across the Internet. All these applications have the same
security and privacy issues.
Senator Frist. Good. Thank you. Thank you all. The privacy
issue and the security issue is obviously one that is very
frightening to individuals, to patients, in that very, very
privileged engagement of provider and patient. It is something
that I think we must address, must stay ahead of the curve,
without throwing new barriers up.
Senator Wyden.
Senator Wyden. Thank you, Mr. Chairman. It has been an
excellent program. I just have a couple of questions at this
point.
First, maybe for the folks at the Telemedicine Association.
I know you all indicated, and I had to be out of the room for
just a couple of minutes, that you are going to send us a
policy paper on Web sites. Could you, though, just for purposes
of this afternoon, take a few minutes and highlight what the
Association's position would be in the two areas that I am
getting the most questions about.
First, the question of practicing medicine without a
license. Second, the question of commercial disclosure, when a
Web site is involved in an area of health care where they are
making money, what is the appropriate role?
As you know, there have been several celebrated cases--one
of which was discussed in the New York Times just last
weekend--that have raised this issue. If you could just
highlight your position in those two areas, and then we will
dig into the policy paper when it arrives.
Dr. Poropatich. Yes, sir. I think the key uses right now
for the Internet, as we are aware, includes general health
information. Then the second issue would be clinical
consultation; a patient wishes to get an opinion from a
physician or a provider. Then the issue is raised, well, how do
I know that the individual who is giving the information is
qualified?
There needs to be, I think, within the medical community--
within the associations perhaps is where I would target it--
that they need to validate that the people on the other end
answering these questions have the approval of their certifying
medical agency, whether that is the Medical College of Chest
Physicians, the AMA, whatever, a professional organization
could endorse them in a way that does not necessarily imply
further financial remuneration.
As you know, the most celebrated case recently, the
gentleman who has developed a very high-profile Web site, a
very prominent physician in this country, had to essentially
eliminate his financial gain from this particular Web site.
That kind of disclosure of financial interest I think needs to
be addressed head-on. It is unclear to me at this point whether
we took a specific stand at the ATA in our policy paper on
that, sir. I would ask that I could come back and address that
issue with you in my additional testimony.
Senator Wyden. Can I just interrupt you at that point. I
appreciate your candor. I hope that you all at the Telemedicine
Association will come out very strongly for disclosure of
commercial interest in this area. Because I think it could do
great damage to this extraordinarily exciting field. It is a
field that Dr. Frist and I are so excited about.
I think it could do great damage if what happens now is a
lot of people are misled through health Web site, go to these
Web sites believing that they are being run by nonprofit
organizations, organizations without a pecuniary interest, and
then all of a sudden, 6 months later, they find that they have
in effect been steered to yet another deep pocket.
I do not happen to think we need legislation on this. I do
not think we need to rush and write a whole crate full of laws
at this point. But what will happen if we cannot get
thoughtful, concerned folks like you all at your Association,
with aggressive disclosure policies, we will see abuses. Then
it does come to the doors of Dr. Frist and myself.
I want to hear you on the other point, but I am encouraged
that you all are concerned about it. I hope that you will
tackle this head-on. Because if there are a couple of cases
where people are flagrantly misled, this will do a lot of
damage.
Dr. Poropatich. Yes, sir. I think the medical societies
need to take action on that. It could involve perhaps some
validation of that individual giving the advice, an endorsement
from that medical society.
The other issue that has been getting a lot of negative
press with the Internet is in regards to prescription drugs
being prescribed without a health care provider even seeing the
patient. Viagra, antidepressants, a whole list of drugs are
being made available to consumers illegally and unethically.
That is another issue that is being raised I know within the
pharmaceutical industry as well.
So we raise these issues in that ATA statement, sir, and
caution consumers primarily to be very wary of who is the one
providing the information and what kinds of professional
endorsements that individual has from such medical societies or
from other nonprofit agencies that can validate the statements
that are being made.
Senator Wyden. Are you saying that fairly soon, say within
a matter of months, we will start seeing medical societies
requiring disclosure policies in these areas? Is that
essentially what you are hoping for?
Dr. Poropatich. I think it is a hope more than a reality. I
think the medical societies--you know, telemedicine has been in
effect for almost 30-40 years now; 1959 was the first time in
this country. We are in our third wave now. I think the medical
societies are just now starting to embrace the notion of
telemedicine. It is not a four-letter word as some people may
perceive it. I think it is gaining a great deal of credibility
within the medical community.
The medical societies, especially the American College of
Chest Physicians, the Society of Critical Care Medicine, have
now developed subcommittees, the American Dermatology
Association, the American Dental Association. There are a lot
of societies out there, sir, that have already started to have
subcommittees to look at medical informatics in general, of
which telehealth, telemedicine is one piece.
I think that is where we make the push to police these
kinds of illegal actions.
Senator Wyden. Well, that is certainly sensible. To some
extent, the two areas can often intersect. Because practicing
medicine without a license very often involves someone trying
to engage in a practice for purposes of profit. At the same
time when someone visits a Web site, they ought to be able to
know about commercial interests. Hopefully you all can lay out
a very clear policy of what you hope will happen around this
country, and then publicize it aggressively. Because I can tell
you, I would like to pick up on that.
I think that the role of the Congress in this area is not
to rush and legislate and to write some new laws, but to give
you all a decent berth to sort of prosecute this position. I
would like to see it.
The only other area I wanted to ask about is each of you in
your statements raised the question of adequacy of
reimbursement. Again, I had to be out of the room for a few
minutes. But except for one of you who mentioned I think fee-
splitting, I do not think I got the sense of what your priority
would be if you could wave your wand and the U.S. Congress
would make one change in Federal reimbursement policy that
would be helpful to telemedicine.
So, if we could, for my remaining time, why do not we just
start with Mr. Waitz and just go right down and let us just say
you are in our shoes and you can make one change in terms of
Federal reimbursement policy that would be helpful to
telemedicine. Starting with you, Mr. Waitz, what would that be?
Mr. Waitz. I think current laws today regarding
reimbursement were built in a time when telemedicine was
equated with video conferencing. As a result, a physician was
available on both ends. Because of the high cost of the
equipment, it was not foreseen that you potentially could have
these kinds of interactions with low-cost technology between
provider and patient directly without a physician at both ends.
Currently that kind of situation is not reimbursed. That would
be an area, we think, where there is tremendous growth and
tremendous good for both the patient and the whole health care
system.
Senator Wyden. Dr. Burgiss.
Dr. Burgiss. Yes, I agree in concept that the problem that
needs to be fixed is the way the Medicare reimbursement is
being done by the law and rulings that went into effect January
1st. That law should be revised to treat telemedicine as any
other care of medicine, as near as possible like an office
visit, for reimbursement.
We certainly provide telemedicine care like an office
visit. We know that the model of having a physician come with
the patient for a consultation is not the model that is used in
conventional care. Rural physicians certainly do not have that
kind of time and they do not have high-level nurses either.
They would do well to have a licensed practical nurse.
I would think that No. 1 is Medicare reimbursement and I
think with a Medicare revision, it will help Medicaid and other
reimbursements to follow suit. Thank you.
Dr. Poropatich. Sir, if I had just one wish, it would be to
eliminate the Medicare limits placed on reimbursement for store
and forward teleconsultation. This would open up telepathology,
for example, where we are still waiting, which is very
analogous to teleradiology which is being reimbursed. We fax
EKG's back and forth across States. Store and forward, in my
mind, is a very viable means of doing telemedicine and
providing quality patient care.
We do provide, as you know, for video teleconference, when
you have talking heads and providers on both ends. However, the
store forward is, in my mind, the way we are going to be
practicing medicine in the future. That would be my wish. Which
would then incorporate other forms of other applications, such
as home health care, which could also then be reimbursed.
So I think one wish would be to open up the Medicare laws
and reimburse for store forward.
Dr. Ferrans. The Task Force for Medical Technology for the
Southern Governors Association issued nine specific
recommendations regarding Medicare. They have been submitted
into the record. I would just highlight, in addition to the
fee-splitting, this idea about the health professional shortage
areas should be changed to what we call MSA's, or non-
metropolitan statistical areas.
I agree with the other comments about store and forward.
This idea about having to have a physician present to present
the patient--I mean, as an internist, if Dr. Frist was seeing
one of my patients, I do not understand why, for him to be
reimbursed, I have to be in the room with the patient to
present him to him. It does not make clinical sense from that
standpoint.
So I think the regulations just need to be simplified to
provide coverage like any other encounter.
Senator Wyden. Thank you.
Dr. Brick. I would confirm what the other fellows said.
They have already asked for most of my wishes. But I would add
then, if I got another wish, that we get some reimbursement for
the technical costs of this. Most of the programs that I know
of in this country are being run out of State university
medical schools and other large not-for-profits like that. We
are now paying the technical costs, buying the equipment,
paying the phone lines. These things are a lot cheaper than
they used to be, but they still cost.
For this to become real medicine, and it really is real
medicine--it is not telemedicine, it is real medicine--we have
got to get a way to pay for the technology. So I would add that
to the wish list.
Senator Wyden. Thank you, Mr. Chairman.
Mr. Waitz. Can I add something? I think it is really
important in talking about telemedicine to say that it is
really enabling technology. Telemedicine is not an end onto
itself. I think the reimbursement really needs to be thought of
in those terms. So the reimbursement should be technology
neutral.
Senator Frist. Thank you.
Several of you mentioned in your written testimony the
Universal Service Fund, the provision in the Telecommunications
Act of 1996, the provision dealing with establishing
telecommunications discounts to rural hospitals through the
Universal Service Fund, with recommendations of urging the FCC
to fulfill the intent of the Telecommunications Act. Anything
to add to that?
Dr. Ferrans, you very specifically went into it. Has it
been a total sort of nonstarter to date? Is there any history,
any positive direction? Your letter, will hopefully have an
impact. I will take a careful look at that, to see how we can
facilitate the process.
Any other comments that I should know about in terms of the
lack of action on that, Dr. Ferrans?
Dr. Ferrans. I think it is a nonstarter. Like someone else
said, the single greatest barrier is the forms that people have
to fill out.
Senator Frist. It is the complexity of the forms at a rural
hospital if they are sitting there?
Dr. Ferrans. Impenetrable barriers, No. 1. The other thing
is that they have limited eligibility of services to T1 lines.
I think all of us have been talking about trying to get
broadband services. So larger bandwidth should also be
discounted. We believe that long distance carriers should also
be able to participate. They are laying fiber everywhere.
Whoever can come in cheapest for the rural hospitals, I think
the competition should be there. I think that that is obviously
in a broader perspective that the committee has jurisdiction
over. But certainly the FCC has limited it to only local phone
companies who can provide that. That situation is not open
today, as we all know.
Senator Frist. Other comments? Yes, sir, Dr. Poropatich?
Dr. Poropatich. Yes, sir, Senator Frist. There are several
problems that I would just like to reiterate. It is in the
letter that we sent out in March. There is a 28-day posting
period, which seems unduly necessary. Eliminate the calculated
charges for discounted services. It does not seem that that is
a worthy thing.
Getting to Dr. Brick's comment, reimburse for other costs
such as ISDN connection fees, toll charges for connections to
urban areas from the health professional shortage area, calling
into the city. That seems unnecessary. Solicit more public
health agencies to participate. There are a few public health
agencies in these areas that have actually submitted proposals
because of the burden of going through this process.
Discount all forms of communications, not just T1 lines.
This specifically addresses T1, and that has been mentioned
already. Avoid local and long distance phone company charges
which are built in there. The Rural Health Program should
include schools and libraries regarding this high-speed
communications. The Rural Health Program should be coordinated
with the schools and libraries, which it currently is not. Then
consider all rural health programs, not just the nonprofits in
this particular application. Also include in this program, sir,
long-term facilities, home health and skilled nursing.
I will leave my comments at that.
Senator Frist. Thank you.
Other thoughts or comments?
Dr. Brick. I was on a public committee. I was asked to be
on it by Senator Rockefeller to develop the rules for this,
after it was written. I was the chairman of the rural
subcommittee. All the things that these fellows have talked
about here are all things that we brought up in that committee.
We thought that we were done with it, that we had it fixed.
I went back to West Virginia and I thought, boy, we are
going to get our phone lines cheap and we can pay for this, and
this thing is just going to explode. It did not happen. We did
not get what we expected--little twists here, little twists
there. They made it more and more difficult. Pretty soon we
were not able to get the breaks on the phone lines that we
needed. I would agree that it has not come across the way we
thought it was going to.
Senator Frist. We will keep the record open for 7 days for
other questions from my colleagues as we go forward. There is a
bill,
S. 980, that has been referred to that I am a cosponsor on,
that Senator Baucus and others have participated in it as well.
I would be very interested in each of you looking at that--it
is a rural health bill--that apply to telemedicine and make
specific recommendations on how that might be improved. It is a
very important bill that covers a lot of areas.
But as we look at telemedicine and we look at the Next
Generation Internet, which is mentioned in much of your
testimony, which is a bill that I was the author of that came
out of this particular committee, you look at broadband, the
potential of lowering costs once we take advantage of the
tremendous technology that is, over the next 12 months, going
to be coming online, I would be very interested in focusing on
telemedicine, based on your comments today, looking at S. 980,
pulling out where we might improve that particular bill.
Again, there are a number of issues. I think that we will
bring the hearing to a close. Let me just give any of you an
opportunity to touch upon something that we may not have
touched upon yet. Again, your written statements are superb and
bring to my attention a number of issues that I have not
thought about, that are very important, that we are all
thinking about. Any other points that you would like to make
before we close?
[No response.]
Senator Frist. Let me then just basically close by saying
that your participation really does help in painting this
picture, to give us meaningful insight as we go ahead. The
technological advances are rapid. We have this long history
with telemedicine. The credentialing issues, the across State
line issues, the technology barriers are all issues that we
will continue to explore.
The privacy issue is one that has to be addressed, and I
think addressed pretty soon. Because although you give me some
reassurance that today we are using the existing technology in
lots of different ways and there have not been big problems,
there is a huge difference between me going across town, going
in a hospital, and because I am a doctor, having access and
taking a record out and misusing it versus hitting the key on a
computer and pulling it out and sending it to 50 million people
around the country. It does introduce new concepts that we as
policymakers will continue to need your help to address.
This, again, is a dialog that is ongoing. I want to express
my appreciation for all of your supporting this, and for taking
time to help educate us.
Thank you very much. With that, we stand adjourned.
[Whereupon, at 3:55 p.m., the hearing was adjourned.]
A P P E N D I X
Response to Written Questions Submitted by Hon. Bill Frist to
Dr. James Brick
Question 1. What will telemedicine look like in 5 years? In 20
years?
Answer. We believe that in West Virginia, telemedicine will still
be a viable option for our citizens to obtain their specialty health
care. Will it change five years from now? Yes. Chances are that both
the low-end picture phones will be of better quality and will be used
more frequently as well as the high-end video over the Internet. The
World Wide Web will be more reliable and the problems of streaming of
video and lack of bandwidth will be answered. In twenty years, we
believe that telemedicine will be an invisible part of all health care
in our country, just as telephones are today. Telemedicine will save
many rural practices, clinics and hospitals by keeping the patients in
the community for their care. There will be universal licensure for all
practices of medicine that will allow physicians in one area of the US
to treat patients in other parts of the country via telemedicine.
Question 2. Can private industry accelerate the growth of
telemedicine? Or is this a question of policy?
Answer. Private industry can aid in the growth of telemedicine via
technology advances and by the private insurance carriers reimbursing
for clinical telemedicine encounters. The private insurance industry
needs to consider reimbursement to providers for operations of their
equipment. Policy certainly has influence over the private sector.
Policy makers need to support efforts for open architecture of
telemedicine systems and standards for all telemedicine equipment and
procedures. A combination of both policy and private sector initiatives
is what is needed for continued growth.
Question 3. How can universities accelerate the growth of
telemedicine in rural communities? Are there targeted training programs
for medical students and residents? If so, are there special incentive
programs for those who participate?
Answer. Yes, universities can accelerate the growth of telemedicine
in the rural community. Often, it has been the university academic
medical centers that have made the in-roads into the rural communities.
These rural communities have needs that work well with the missions of
these centers of learning and often present opportunities for the
medical students to further their experiences in medicine. At the
Robert C. Byrd Health Science Center in Morgantown, our students rotate
into the communities during their training. Telemedicine allows for
them to stay ``connected'' to Morgantown, so that they may receive the
same academic opportunities while they are on rotation.
No, there are no incentives other then experiencing medicine in a
new environment and learning how to use the medical tools of the future
via telemedicine.
Question 4. You mentioned in your testimony that medical education
has consistently been the number one user of your network. Can you
describe some of these applications?
Answer. We have nursing and pharmacy courses, for credit, taught
over the network statewide. We have continuing medical education (CME)
credit given for various lectures for multiple medical disciplines.
Additionally, we give access to our residents on rotation to lectures
and grand rounds. We also provide communities throughout our state
network, health information that is useful and timely.
Question 5. What do you believe is the major contributor to the
increase in the use of telemedicine: equipment cost reduction or
improved care to the patients?
Answer. We believe that both have merit. With the lowering cost of
the tools of telemedicine, more locations can entertain the idea and
make it a reality. Needless to say, it is the improved access to
specialty care and the convenience to the patient that makes the
decision of using telemedicine so appealing. Additionally, it cannot be
overlooked that here in West Virginia, the state via contracts with
telecommunications carriers, have made the access and cost of digital
communication affordable. If on the national level, telecommunication
costs could truly be reduced for small rural health care centers, this
would indeed make for an increase in the use of telemedicine.
Question 6. Does MDTV collaborate with other states?
Answer. As of today, no collaborative arrangements have been made.
We do however, communicate with the telemedicine community concerning
issues of importance. We additionally host future telemedicine groups
if they require demonstrations of the technology and need assistance
with start-up questions.
______
Response to Written Questions Submitted by Hon Bill Frist
to Dr. Sam Burgiss
Question 1. What will telemedicine look like in 5 years? In 20
years?
Answer. During the next five years, we expect to see telemedicine
to homes grow significantly. The traditional homecare patient will
receive care using telemedicine when suitable to his or her medical
condition. This care will include videoconferences with a provider or
vital signs monitoring, or both based on the need of the patient. In
five years, homecare should utilize advanced non-invasive monitoring
sensors worn by the patient, including blood glucose and cardiac
function sensors as well as others available today. The patient monitor
will have a wireless connection to a receiving unit in the home,
allowing the patient mobility. This receiving unit will evaluate the
data to determine if alarm values have been exceeded and will notify a
central monitoring station attended by a nurse or other provider who
can help the patient with his or her condition.
Urban homes will have access to standard telephone lines, high-
speed telephone lines, cable television lines, and wireless
communication for telemedicine. In the rural environment, standard
telephone lines will be used until a cost-effective wireless technology
exists for each home, since it is not likely that additional wired
infrastructure would be established in rural areas due to cost.
Patients will either use dedicated electronics or their computers for
telemedicine. The Internet will provide the major backbone for
communication, which will require enhanced privacy and security for the
patient. In five years, it is not likely that all patients will become
literate in computer use and thus, will need units designed for
telemedicine to provide simple operation and reliability.
Telemedicine will spread in homes beyond the traditional homecare
patient to any patient with a chronic illness or who needs medical care
often. The use of present telemedicine clinics held in community
medical facilities will shift into home telemedicine for many patients.
The goal of this care will be to improve quality of life and to reduce
the cost of care by preventing the need for care at a more acute level.
In 20 years, telemedicine will provide care where the patient is
located, which could be at home, at work, or while traveling. The
patient will use a digital video wireless personal telephone (like
cellular) to connect with his or her physician or other care provider.
The patient and provider will have a videoconference about the
patient's condition. A camera on the unit will show skin and wound
conditions. If the patient needs to provide vital sign data, he or she
will have a small sensor that plugs into the data port of the telephone
to make the measurement and send the information to the provider. If
testing or treatment at a hospital is required, the patient will be
referred to a hospital near their location. Medical records will be
forwarded to the appropriate location, or patients will carry smart
cards containing their records. This concept raises the question,
``Will it be better in the future to have medical records distributed
to all locations where a patient might travel, or would it be better to
distribute care to all locations where a patient might travel?''
Question 2. Can private industry accelerate the growth of
telemedicine? Or is this a question of public policy?
Answer. Private industry and public policy makers should work
together to accelerate the growth of telemedicine. Public policy is
needed for telemedicine examinations to be treated without
discrimination as face-to-face consultations between patients and
providers. Policies must allow reimbursement for professional and
technical fees, promotion of telemedicine as accepted practice, removal
of licensure boundaries, and the opportunity to use telemedicine when
needed to provide the correct level of care. Our telemedicine program
has shown that providing the correct care at the correct time can
decrease medical cost (Burgiss, et.al. Telemedicine for dermatology
care in rural patients. Telemedicine Journal, 3,3,1997.). Funds saved
by providing the correct level of access should be used, in part, to
pay the technical expense of delivering care by telemedicine. This
includes the cost of equipment, communication lines, and personnel to
provide this service. The goal will be a net reduction in the cost of
care with improved health.
Private hospitals and other private healthcare businesses ideally
will provide the telemedicine service infrastructure. These private
industry groups would establish interconnected health care networks
using telemedicine to support a patient in their region just as if that
patient had access to a tertiary care medical center. One goal of
interconnected networks is to allow a patient to be seen by any needed
provider.
Question 3. How can universities accelerate the growth of
telemedicine in rural communities? Are there targeted training programs
for medical students and residents? If so, are there special incentive
programs for those who participate?
Universities have the capability to provide medical education
programs using telemedicine networks. These programs are needed by care
providers in rural communities and are required for credentialing.
Health care professionals in rural communities typically do not have
access to educational opportunities without traveling to a metropolitan
region, which requires a large amount of time away from caring for
patients in their community.
Several telemedicine programs are beginning training for medical
students and residents. Medical faculty members of the University of
Tennessee Graduate School of Medicine who provide consultations using
the UT Telemedicine Network have introduced medical students and
residents to telemedicine. Nursing students have also been to the
telemedicine department for orientation training. More formal training
in telemedicine is being discussed for these students.
Question 4. You mentioned in your testimony that the University of
Tennessee Telemedicine Network has increased by an average of 178
percent per year since its opening in 1995. Can you describe some of
the challenges and opportunities in accommodating this level of growth?
Do you expect this rate to continue?
The challenge has been to operate the telemedicine department as a
dedicated team willing to do what is needed to make telemedicine
successful for the medical facility. Team members must be flexible and
sufficiently dedicated to change from one task to another when
priorities change. Every opportunity to provide a patient service,
demonstrate telemedicine for providers, and expand the program must be
addressed as a new challenge in providing the best possible service to
our customers. The energy, enthusiasm, and willingness to address any
appropriate ``instant opportunity'' is similar to that of an emergency
department and different from some other areas of medical care.
Opportunities are exhibited by the service provided to the patient,
the growth of the program, and the program is increased in national
visibility. The primary opportunity is to be involved with the bridge
between technology and health care that can revolutionize the delivery
of that care.
The rate of growth in the first four years of the program was
affected by a slow beginning with a single clinical site and expanding
into homecare and patient services in the fourth year. Between January
1, 1998, and June 30, 1999, the patient encounters during each six
month period averaged a 50 percent increase above the previous period.
The program is presently in a rapid expansion at the present with
homecare sites increasing from eight to 69 in the next few months. In
future years the growth may decrease to a steadier rate of 10 to 20
percent per year. The actual increase will depend on the development of
new opportunities for the application of telemedicine.
Question 5. You stated in your testimony that 68 percent of the
patients rate ``seeing the doctor'' by telemedicine better than a
traditional office visit due to the focused attention of the care
provider. Can you explain why the care provider is more focused in a
telemedicine session than a traditional office visit?
Answer. During our telemedicine clinics, the provider sits at a
desk with the patient record, a camera, and a video monitors. Without
moving from the desk in our telemedicine exam room, the provider visits
the patient at the first site, completes notes for the first patient,
prepares for the second patient, visits with the second patient at
another site, and completes that patient's notes. The provider would
normally be walking between exam rooms in a typical office. In the
telemedicine exam room, there is no chance for the thoughts of the
provider to be interrupted by staff and patients, as there would be in
the hall of the typical office. In a recent telemedicine clinic, our
dermatologist examined 14 patients in two hours and every patient
response was very positive about the quality of the interaction. A
nurse or medical assistant supports the provider with patient records,
sending prescriptions and documents by telefax, obtaining medical
references, and operating the telemedicine system. Thus, the provider
is sitting at a desk concentrating on providing care without
interruptions and distractions. Recent data from the UT Telemedicine
Network further verifies the preference of the patient for ``seeing the
doctor'' by telemedicine as compared with a traditional office visit.
Our latest report (including 60 patient surveys from 112 visits from
January through August 1999) shows that 95 percent rated telemedicine
``more convenient'' than an office visit in Knoxville. This is an
expected response since many patients would have to drive for an hour
to see the physicians in Knoxville. The following question asks
``Compared to an office visit, how would you rate seeing the doctor by
telemedicine?'' the patient is asked to indicate ``better,'' ``same,''
or ``worse.'' On this report, 75 percent rated the telemedicine visit
``better'' and 25 percent rated it the ``same'' as an office visit.
None rated the telemedicine visit ``worse.'' Comparison with the
``convenience'' question shows that the patients are actually rating
``seeing the doctor'' rather than the convenience.
To the question, ``Based on your experience today, would you be
willing to be seen again by a doctor using telemedicine?'' 97 percent
responded ``yes.'' When asked ``Would you recommend seeing a doctor by
using telemedicine to your family and friends?'' 97 percent responded
``yes.''
Some of the comments provided by patients are shown below:
This is the most fascinating experience I have ever seen in the field
of medicine.
The nurse and doctor were very helpful and explained procedure to my
understanding; very cordial and made me comfortable during the exam.
It was quite an experience. I found that it was easier to talk to the
doctor on TV than it would have been if he were there in the room.
I was not asking my last question to someone walking out of the room.
The doctor impressed me very much. Thank God for new technology.
______
Response to Written Questions Submitted by Hon. Bill Frist
to Dr. Ronald K. Poropatich
Question 1. What will telemedicine look like in 5 years? In 20
years?
Answer. Five years--with FCC Telecommunications Act of 1996 and
development of new shared bandwidths across all communications
businesses I think home health care telemedicine will become a major
force in meeting the health care needs of Americans. Low cost and
readily available bandwidth will be available, to include rural
America. Legal issues with reimbursement, will be resolved as HCFA
completes its multiple pilot projects on Store-Forward TMED, showing
its utility in delivering quality low cost health care. I would expect
that the medical community will gradually increase its acceptance and
use of the use of telemedicine in health care as more computer savvy
physicians emerge from medical school into key medical leadership
roles.
Tele-pharmacy will evolve to a level whereby patients can walk up
to vending machines in most public places and acquire medications
similar to Banking ATM machines.
Patients will begin to carry their personal health care records on
them in an electronic format--similar to the credit card (Smart card)
or medical dog tag (Personal Information Carrier--PIC), currently being
evaluated by the Department of Defense.
Public health kiosks will begin to emerge whereby patients can
consult directly with medical experts on health questions or medical
diagnosis and treatment recommendations. All transactions will be
logged on the patients PIC or Smart card for documentation.
Health care centers will be three types--hospital based, out-
patient based, and virtual (i.e. WebMD). As more physicians choose
lifestyle issues over long hours away from home for various reasons
(woman on convalescence leave after having a baby), medical payors will
have a cadre of medical expertise that fall directly in these three
categories.
Twenty years--biosensor technology will have evolved along with
wireless services, such that all Americans will be able to wear health
care monitoring devices (perhaps on a wristwatch-type device) that feed
into a central medical database, rich in Knowledge Management. This
Artificial Intelligence monitoring station will directly notify
patients of times to take medications, track trends in patient vital
functions, and alert to possible medical problems developing. A
patient's health care provider will be included in reviewing this data
and making recommendations directly with patients. The Electronic
Patient Record will have already been developed, and a large archive of
medical data will be stored and reviewed (data-mining) enabling the
best treatment courses for all diseases. Bandwidth and memory storage
issues will not be problematic for health care workers engaged in
telemedicine (all health care providers!). As such, remote tele-surgery
will be widely utilized with surgical expertise located in Centers of
Excellence, and general surgeons or physician extenders (PA's / Nurse
Practitioners) actually located with the patient and performing the
surgery.
Home health care will have evolved to such an extent that most
testing--sleep studies, ultrasound of body parts, x-rays, etc will be
consolidated either in the home or in most public places close to home.
Holographic images of health care providers will be electronically
transmitted into the patients home such that physical exams could be
performed, appearing as if the provider is actually present.
Question 2. Can private industry accelerate the growth of
telemedicine? Or is this a question of public policy?
Answer. Accelerating the growth of telemedicine is both a public
policy issue and an important role for private industry. Private
industry, from developers and vendors of equipment and services to
health care facilities, will continue to be pivotal in the deployment
of telemedicine. However, issues such as licensure of health
professionals, reimbursement by government-run programs and
establishing liability boundaries remain barriers that require
government action. It is critical that governmental institutions from
Congress to state and local governments take positive actions to
support telemedicine.
Question 3. How can universities accelerate the growth of
telemedicine in rural communities? Are there targeted training programs
for medical students and residents? If so, are there special incentive
programs for those who participate?
Answer. There are several targeted training programs for
telemedicine that exist today. East Carolina University, The University
of Vermont, Oklahoma State University and the University of Texas
Medical Branch at Galveston all have telemedicine training programs.
The military is currently developing a five block, two hours per block
curriculum on telemedicine.
Universities need to develop curriculums and teach at early years
of training. Key will be the need to broadly expose all health care
fields to the concepts needed for utilizing telemedicine in their
respective fields.
Question 4. You mentioned in your prepared statement that the
military has addresed the privacy issue by requiring a separate secure
serve to be used for all medical transactions with encryption of all
medical related files.
(A) Are you aware of any similar type of transactions being
taken by the private industry to protect patient privacy and
confidentiality?
(B) What would you estimate the additional cost would be for an
independently operated secure server?
Answer A. There are many activities underway in the private sector
to maintain patient privacy. The move toward computer-based patient
records raises a number of substantive and process issues. We do not
keep records of individual policies and practices followed by
individual private institutions. However, there are privacy and
security efforts underway in practically every major hospital systems
regarding protecting patient privacy when dealing with either
computerized patient records or transmission of medical data and images
over networks. The National Library of Medicine is funding several
demonstrations on various uses of privacy and confidentiality in the
use of telemedicine. One of the concerns that ATA has made public is
the privacy of patient information when provided over the Internet to a
commercial health or medical Web site. The level of use of encryption
for such transactions is unknown.
B. The cost of an independent server can vary. However, the cost of
the equipment and appropriate software can be obtained for as little as
$2,000. Additional expenses would include the cost of connecting to the
communications network.
Question 5. How significant a problem is reliability of
communications network for telemedicine?
Answer. This is a difficult question to answer. There are broadband
issues with VTC, both in rural and metropolitan areas--both differ.
Rural communities are limited to availability of high speed
communications networks as well as reliability and cost, whereas
metropolitan areas are less effected. I think this a moving target as
more areas come on line with alternate bandwidth choices--wireless
(cellular, satellite) as well as terrestrial (cable, ADSL). I have had
problems in the past with various ISDN providers having different
``clock speeds'' for their proprietary ISDN systems, such that
connecting between facilities was impossible or fraught with
reliability concerns. This is less of a problem now as ISDN development
matures in this country. Reliability with the Internet has been less of
an issue with the DOD and is more dependent on whether a user has to
compete with a small finite ``pipe'' coming into their work area, vs.
slow computers that make downloading information tedious. Again, I
think it less of an issue as technology improves for both hardware as
well as bandwidth availability.
A related issue is providing reliable and affordable communications
network to the home. As I mentioned above telehomecare is one of the
most promising new applications of telemedicine. While much can be
accomplished over voice grade telephone lines some applications require
more than just plain old telephone service. Deployment of high speed
networks to the home via wireline, wireless or cable should be a
priority in the development of telecommunications related public
policy.
Question 6. Can you elaborate on any licensing reciprocity efforts
that the ATA has been involved with?
Question 7. Can you update the Committee on any activities ATA may
be involved with on flexible and permissive licensure initiatives?
Answer. As I mentioned in my earlier testimony, the ATA Board of
Directors recently adopted a statement regarding state medical
licensure. Although we have not been directly involved in any
reciprocity or related initiatives related to licensure, several of our
members have been involved in developing the recent statement issues by
the Southern Governors Association on this issue and we endorse efforts
by both the Southern Governors Association and the Western Governors
Association to address health and medical licensure issues as they
relate to telemedicine.
Question 8. You mentioned that homecare applications will benefit
greatly from the availability of broadband networks. In these
applications, what is the range of the estimated cost for the equipment
at home? Do the patients incur the cost of the equipment and associated
cost such as access cost?
I have met with various vendors setting up homecare with
telemedicine follows. In my opinion over the past few years the
equipment has been better designed for a less computer savvy patient.
Those applications that have been the most developed for remote patient
monitoring homecare include: Congestive Heart Failure (CHF), Diabetes,
and Chronic Obstructive Pulmonary Disease (COPD)--which includes
asthma, bronchitis, and emphysema. Most vendors will install the
equipment to operate over POTS. In many cases fees are assumed by the
patient's insurer and the medical clinic providing the consultative
service. The provider is charged an amount for having so many patients
on the system--i.e. $100/patient start up fee, and $10/month
maintenance fee (These numbers were from a vendor from February 1999).
The patient assumes the cost of the phone charge and a monthly fee for
equipment use (perhaps around $15 per month). VTC based telehomecare
consultations are not fully reimbursed at the moment but ATA has been
advocating for the Health Care Financing Administration to allow
homecare agencies to use telehomecare devices in the delivery of
homecare services under Medicare.
______
Response to Written Questions Submitted by Hon. Bill Frist to
Mr. Aaron Waitz
Question 1. What will telemedicine look like:
In 5 years?
Answer. In the next five years we see a growing trend towards
patient centric devices used in telemedicine. This will allow
physicians and other health care providers to directly interact
utilizing the hi-speed digital communications infrastructure that will
be operational within this country. These provider/patient real-time
video interactions will also allow physiological monitoring to provide
a virtual presence for routine procedures. These kinds of interactions
will provide better access to health care providers, especially in
rural areas, and improve efficiency and productivity, thus reducing the
overall costs of patient management. Telemedicine consults will provide
better screening of patients, eliminating unnecessary visits to the
emergency room or clinic. Physiologic sensing devices will be in the
home or worn by the patient and provide continuous monitoring of
physiological functions. Some of this technology is now appearing on
the market, but five years from now the equipment will be more
sophisticated and even easier to use. It will not only provide the
monitoring function, but will provide real time computer aided analysis
of the data collected. This capability will be used to monitor specific
disease states as well as maintain the patient's state of well being.
We expect to see these devices operate in wireless environments.
However widespread perfusion of nomadic devices will probably be in the
five- to ten-year range driven mostly by consumer/commercial
deployment.
With the improved ability to transmit image data over the next
generation Internet we will see growing utilization of telehealthcare.
No longer will studies have to be repeated by the referring doctor due
to lack of timely access to diagnostic images and reports. These will
be available through a secure Internet connection. This should reduce
costs from the healthcare system by removing the necessity for
redundant diagnostic imaging procedures. Physicians will be able to
collaborate more easily to seek out opinions from their peers. No
longer will the bounds of their consults be limited to physical
geography.
In 20 years?
In 20 years, ``Mores Law'' predicts there will be a 10,000-fold
increase in computing power available. It is expected that similar
increases in communications bandwidth capacity will occur. This
development, coupled with ubiquitous wireless network access will drive
fundamental changes in the way healthcare is delivered. Remote
interactive sessions between providers and patients will be
commonplace. Access to this capability will be ubiquitous, convenient
and affordable. Access to an integrated patient's record will be widely
available regardless of number of physicians treating that patient and
regardless of their physical location. This patient record will be a
multimedia report rich with all the imaging content and diagnostic
interactive reports. The physician will be able to access vast secure
databases to correlate a patient's indication with other patients
suggesting the best course of action. This integrated record will also
contain information linking family history, lifestyle and dietary
information to allow diagnosis by looking at the patient's total
condition rather than today's limited access to the complete picture.
This kind of integrated record will allow focus on management of a
disease in a holistic approach rather than today's treatment of
independent events.
We expect to see common usage of implantable, self-monitoring and
self-regulating devices (smart devices) programmed by your doctor.
These devices will continuously monitor your health, provide
information into your medical record and alert the patient of pending
problems.
Even 20 years from now, we still see that some conditions will
require face-to-face interactions for diagnosis or therapy. However,
virtual sessions will replace the more common visits done today. These
sessions will allow the healthcare provider to be able to simulate the
four senses (hearing, sight, touch, and smell) currently used in a
diagnostic consultation providing true virtual presence. The physician
will have access to "super human" capabilities due to powerful computer
aided processing. We expect that tele-surgery will be done on a limited
basis for routine procedures. This will allow rural community hospitals
to provide the quality of care equivalent to the leading institutions.
Complex data analysis will be done by interactive computer systems and
provide expert consultation for the prescribed diagnosis or treatment.
This coupled with dramatic advancements in genetic science will
dramatically raise the level of quality of care while improving
productivity and cost. The costs associated with managing a patient
will take a broad long-term view rather than the short-term episodic
state we practice today. Data mining of these vast secure libraries of
patient history will allow use to more effectively determine the best
course of treatment that will improve patient outcomes in a significant
way while improving the patient's quality of life in a meaningful way,.
Question 2. Can private industry accelerate the growth of
telemedicine? Or is this a question of public policy?
Answer. Private industry will continue to innovate in the area of
telemedicine as long as the market materializes. However, private
industry alone cannot accelerate the growth of telemedicine. Public
policy can facilitate the process by addressing barriers to grow,
specifically provider licensure requirements and the reimbursement
policies of health systems, like Medicare and Medicaid.
For true acceleration, public policy should remove barriers or,
ideally, provide incentives for adoption of technologies that have the
potential to save money and improve care and outcomes. Reimbursement
should be formulated based on treatment of a patient's condition
regardless of how the treatment is physically delivered. We must insure
that legislation is technology neutral. We are living in a time where
the pace of technological change is constantly increasing. We cannot
afford to have barriers that hinder the acceptance of new medical
procedures or products that will fundamentally improve the entire
healthcare delivery system. If a technological neutral policy is
adopted, then market economics and improved patient outcomes will drive
the growth.
An important area where national funding is extremely important is
in facilitating the research and development of standards.
Standardization of communication protocols, communication
infrastructure and the integrated patient medical record are
fundamental requirements for full realization of all the benefits
touted for telemedicine. Government can play a role in accelerating
these activities by funding the R&D associated with the development of
these standards and providing test beds. One important area, which is a
major impediment to integration of today's medical information systems,
is the lack of a standard patient identifier. Without this,
heterogeneous information systems can not reconcile a patient's records
across multiple institutions. Of course with this patient identifier,
we need to insure that safeguards are in place to insure the security
and confidentiality of those records.
Question 3. How can universities accelerate the growth of
telemedicine in rural communities? Are there targeted training programs
for medical students and residents? If so, are there special incentive
programs for those who participate?
No comment
Question 4. Can you elaborate on the potential that telemedical
technologies have on increasing the productivity of workers in the
health care professions?
By removing distance as a factor in the delivery of medical
treatment, productivity can be improved. For example, the workload of a
single home health care nurse can be improved from five visits per day
to 15-25 visits per day by using a telemedicine technology.
By improving access via telemedicine, more effective triage can be
accomplished. Patients can be cared for by generalists able to handle
the case and higher skilled health professionals concentrate their
specialized attention on patients requiring that level of skill.
Also, are these savings from increased productivity on the same
level of savings due to improved patient monitoring?
More clinical research needs to be done in this area. Nevertheless,
we believe that savings from improved patient monitoring ultimately
will be significant, per patient and throughout the healthcare system.
Long term clinical outcome studies are necessary to provide the
conclusive data needed to support this claim.
Savings from increased productivity are easier to quantify and the
volume of encounters is large. For example, in home health care, large
savings can be demonstrated by increasing nurse productivity by two or
three times, assuming an equal outcome. For example, in telehomecare,
closer monitoring can result in fewer emergency room visits or hospital
readmissions, or can keep a patient's health status from deteriorating
as rapidly.
Question 5. Can you distinguish between the quality of care that
will be offered by direct linkages between health care providers and
their patients and those offered by current linkages?
Closer familiarity with the patient's condition,
response and support mechanisms increases the chances of the
"right" treatment.
Faster response and treatment by the provider improves
outcome. (Provide the ``right'' treatment faster).
Closer and more frequent monitoring increases patient
compliance with treatment plan and medications, which can
impact recovery times.
Increased patient satisfaction.
Direct access reduces anxiety, increases
feeling ``safe''--results in a more positive emotional
state.
Patients spend more time at home, with family
and not in institutions.
Behavior modification to wellness mode & self-
monitoring.
Provide access that cannot be easily obtained in rural
areas.
______
Prepared Statement of Dr. Arnauld E. Nicogossian, Assosiate
Administrator, Office of Life and Microgravity Sciences and
Applications, and Chief Medical Officer, National Aeronautics and Space
Administration
Mr. Chairman and Members of the Committee:
Mr. Chairman and distinguished members of the Committee, I am
delighted to have this opportunity to provide information on NASA's
telemedicine activities, specifically innovative technologies and how
these can be applied to rural health care.
NASA has fostered the development and application of telemedicine
as an inherent tool in our practice of medicine for human space flight,
which is conducted in a remote and hostile environment. NASA physicians
have faced a challenging dilemma in that our astronauts have not always
been within reach. During the early days of mission planning, we had to
develop the means to monitor the physiological status of our
astronauts, and provide medical care from a great distance. NASA
experience during the Apollo flights, the Apollo-Soyuz Test Project,
Skylab, and onboard Mir provides ample evidence of the utility of
telemedicine--bone and muscle loss, immune changes, and radiation
effects. We successfully diagnosed and treated. . . . The early
telemetry systems developed for telemedicine have become more
sophisticated through the years, going beyond monitoring to
teleconsultation and distance learning, aiming toward the development
of advanced sensors and the use of virtual environments for training,
and possibly treatment. As with much of NASA's technological
developments, the technology that enables our use of telemedicine,
telepresence, and virtual reality is now being used for the benefit of
non-astronauts as well; for all of us here on Earth.
Although NASA's main purpose for developing telemedicine is to
support space travelers, we utilize ground-based activities to
investigate and promulgate new technologies, protocols and procedures.
In 1997, NASA established an integrated strategic plan for
telemedicine, which formulates approaches that provide opportunities
for evaluation and adoption of technologies for space flight and
potentially for applications to terrestrial settings. This plan
involves activities in biomedical, medical, environmental monitoring,
clinical care, enhanced diagnosis and treatment, and medical education.
NASA defines telemedicine as the integration of telecommunications
information, human-machine interface, and medical care technologies for
the purpose of enhancing health care and maintenance in space flight.
Telemedicine in space flight and on the ground has been practiced
through the exchange of information, data, images, and video across
distances using telecommunications networks such as telephone lines,
satellites, microwave, and computer networks like the Internet. Today's
telecommunications technology, which is characterized by high-speed
links that connect the world, provides accessibility in real-time and
this can greatly enhance the delivery of medical care. The available
technologies can link remote locations to larger medical centers to
provide an opportunity for specialty consultations that might not
otherwise be possible. The application of telemedicine offers
advantages in terms of both cost-effectiveness and improved care to
remote areas, disaster sites, and under-served populations.
NASA has a rich history in telemedicine development. Much of the
recent work in telemedicine has been focused on applications on the
Internet. NASA was one of the very first to implement telemedicine on
the Internet, and recognize the important value of store-and-forward
telemedicine. NASA, under Administrator Daniel Goldin, has been pushing
the technology envelope in the area of information and intelligent
synthetic environments for the purpose of enhancing safety and further
reducing the cost of systems design. Under the NASA Administrator's
leadership, we are also developing biologically inspired technology,
biometrics, and nanotechnology which will further improve health and
safety during human and robotic missions in space. These technologies
will provide autonomy and reliability of operations. Technologies
developed for space applications will have direct benefit to
terrestrial applications as well. Combining the multimedia computer,
computer networks like the Internet, and the ability to digitize,
transmit and manipulate images, allows for high quality medical care,
at reduced cost, and with far more convenience for patients and health
care providers alike.
NASA Ames Research Center (ARC) has partnered with several other
agencies and departments of the Federal government to develop the Next
Generation Internet (NGI). One promising application is the use of the
NGI for telemedicine. In addition, the NASA ARC and several other NASA
Centers are connected to the NASA Research and Education Network (NREN)
for exchange of data and collaborative activities at very high speeds.
The Cleveland Clinic is working with NASA ARC, NASA Glenn Research
Center, and the NASA Johnson Space Center to explore the transmission
of 2-dimensional color Doppler echocardiographic images and how this
technology might be useful in biomedical research and for crew health
on the International Space Station (ISS). A new center for
biocomputation, linking ARC and Stanford, has been established to
improve not only training but also to benefit patients who require
complex reconstructive surgery.
Finally, we are developing new, portable, and compact technologies
that will allow in situ diagnosis of illness or injury during space
flight. These technologies will integrate information systems and
microsensors that will provide the capability for rapid, non-invasive
diagnoses of infectious disease and the use of virtual reality as a
treatment interface. Such capabilities are afforded by systems such as
the Telemedicine Instrumentation Pack (TIP), a compact and portable
doctor's office for medical evaluation and diagnosis, which will be a
useful tool in areas where medical capabilities are severely limited,
such as areas struck by natural disaster or isolated villages in
underserved parts of the world. The TIP was successfully evaluated on
the STS-89 Shuttle mission in January 1998. In addition, the TIP has
been demonstrated effectively in several areas, including rural Texas
and between the Crow Indian Reservation, Montana and Billings, Montana.
NASA's international test beds in telemedicine demonstrate the
usability and versatility of innovative technology for clinical
consultation and continuing medical education. NASA's telemedicine
technology allows for both video and audio communications between
multiple participants in live or ``store-and-forward'' sessions, and an
ever-enlarging database of medical imaging and diagnostic systems which
can transmit information across a network.
COMMERCIAL ENDEAVORS
To meet the challenges of our telemedicine strategic plan, NASA
sponsors a commercial space center (CSC) at the Medical College of
Virginia--Virginia Commonwealth University in medical informatics and
technology applications (MITA). This center has established a
consortium of industrial and academic partners. This consortium, known
as MITAC is focused on implementing the strategic plan through
partnerships to revolutionize the delivery of health care not only in
space but on the ground as well.
The MITAC at the MVC-VCU is focused on developing sensors,
transmitters, effectors, and process simulators for this purpose. MITAC
is a key partner in NASA's telemedicine activities. NASA and the MITAC
are working closely together with academia and industry to not only
meet the needs of the human space flight program but to enhance the
availability and quality of health care for all people regardless of
their location.
Recently, Yale University--a MITAC member--participated in the
Everest Extreme Expedition E\3\-99. Working with other academic and
industrial partners, a communication link was established at the Mount
Everest base camp to support telemedicine interactions. The effort used
videoconferencing between Mt. Everest and Yale University to offer
medical support to climbers and to collect physiological data on the
climbers for purposes of scientific research.
Among the advanced technologies used at the Mt. Everest
Telemedicine Clinic at Base Camp was the portable 3-D tele-ultrasound
system initially developed by Defense Advanced Research Project Agency
and now used by NASA for telemedicine in remote and extreme
environments. Numerous ultrasound images of internal organs and tissues
of the body were obtained during the expedition. Thus, in addition to
pushing the limits of advanced medical technologies, the new ultrasound
capability provided a valuable clinical tool that not only helped the
climbers, but also paves the way to advanced medical care for
astronauts, as well as people in rural areas.
During the past several years, NASA and MITAC have collaborated on
a unique experiment in telemedicine. Operation Rainforest is focused on
low bandwidth Internet solutions integrated with a remote and mobile
surgical van. Patients at an isolated hospital in Sucua (in the jungle
of Ecuador) require expert evaluation and guidance in the area of
laparoscopic surgery. Communication using a cellular phone and an
Internet Service Provider permit three teams of medical personnel--at a
hospital in Sucua, in Cuenca, Ecuador, and at Yale University--to
interact in real-time to effect decision-making and enhance the
clinical outcome.
These kinds of international test beds provide tremendous lessons-
learned and encourage the adaptation of the innovative technologies for
space missions, while enhancing life on earth.
FUTURE APPLICATIONS FOR SPACE FLIGHT
NASA is exploring ways to monitor critical health parameters that
are easy to use, lightweight, non-invasive, wireless, voice-activated,
and unobtrusive. Development of a telemedicine-based monitoring system
which will be used on the International Space Station (ISS) continues.
Integrating unobtrusive technology, such as the WARP (the Wireless
Augmented Reality Prototype), portends the future. It will allow an
untethered astronaut, wearing a lightweight pair of display glasses and
outfitted with a suite of miniature biosensors to communicate through a
sophisticated two-way wireless communications link to the ISS
communications infrastructure. On the heads-up display, the astronaut
responsible for crew health will be able to view biosensor data, such
as heart rate, and other information, such as how to conduct
Cardiopulmonary Resuscitation. This unique, wireless system involves
voice activation and control of the miniature camera and display. The
sensors on the body are also wireless, and the communications system
itself is worn on a belt.
Also in development are ``smart clothes'' with non-invasive sensors
woven into the fabric, which can monitor multiple internal parameters,
and be programmed to only alert the practitioner when unhealthy
parameters develop. This device tracks the position of various joints
and the pressure or load placed on the feet. The future of such
technology is limitless, and it is already delivering important near-
term benefits, such as aiding the retraining of patients whose injuries
have caused them to need to relearn how to walk.
POTENTIAL APPLICATIONS
NASA's efforts to monitor the health of its astronauts have helped
promote significant changes in the way medical care in terrestrial
medical transport (by ambulance) is conducted in the United States,
improving National efforts in telemedicine and creating potential
opportunities for ease of access to health care. Like those developing
countries previously mentioned, there are severely under-served areas,
with respect to medical attention, right here in the United States.
Access through telemedicine will greatly reduce this isolation.
Although many of our citizens in rural America live tens of miles away
from the nearest medical center, they have Internet access through
terrestrial systems or via satellite. This has tremendous implications
for poor and aging populations, homebound people, and even for infants.
This is also applicable to certain work sites, particularly in
hazardous fields, in remote areas such as on oil-drilling rigs or
aboard ocean-going vessels. There is also application for medical care
in secure areas such as prisons, where patient transport to a state-of-
the-art medical facility is inadvisable and expensive.
Further development of this technology can help us right here and
now, and maybe in the future will reduce the cost of health care.
Effective and secure use of electronic management and transmission of
patient information and teleeducation could save billions of dollars.
Integration of telecommunications, rapidly evolving computer
technologies and specialized sensors into health care delivery will
provide opportunities for increasing accessibility on a worldwide
scale, and improve health care for all. Experience gained from NASA's
efforts will help optimize the development of these applications of
telecommunications technology for health care.
SUMMARY
New challenges in space mean new solutions on Earth. As we continue
to develop new systems for the hostile environment of space, we will
find application to problems that we live with every day. While most of
the general population will never be aboard the ISS, in orbit more than
200 miles above the Earth, we can all benefit from the Earth-bound
applications of this tremendous, cutting-edge technology called
telemedicine.
Today we are researching technologies which can provide autonomy in
operation, decision making processes, and health maintenance for future
space explorers who might one day venture beyond low Earth orbit into
interplanetary space.
We thank you again for the opportunity to convey to you some of the
exciting progress in NASA's telemedicine program.
For additional information please visit the following Web site:
http://www.hq.nasa.gov/office/olmsa/aeromed/telemed/