[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

                               __________

    Printed for the use of the Committee on Commerce, Science, and 
                             Transportation


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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

                              ----------                              
                                                                   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

                              ----------                              


                     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/ 

                                
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