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For information on downloading documents using File Transfer Protocol(FTP) see the file how2ftp in the following directory path: /pub/Bureaus/Miscellaneous/Public_Notices/ ***************************************************************** FEDERAL COMMUNICATIONS COMMISSION TELECOMMUNICATIONS AND HEALTH CARE ADVISORY COMMITTEE MEETING Pages: 1 through 189 Place: Washington, D. C. Date: July 11, 1996 FEDERAL COMMUNICATIONS COMMISSION TELECOMMUNICATIONS AND HEALTH CARE ADVISORY COMMITTEE MEETING July 11, 1996 FCC BUILDING ROOM 110 2000 M STREET, N.W. WASHINGTON, D.C. 20554 IN ATTENDANCE: GREG LAWLER, ESQ. Floria & Perrucci Presiding ELLIOT MAXWELL Federal Communications Commission LYGEIA RICCIARDI Federal Communications Commission JAMES BRICK West Virginia University JAY H. SANDERS ATA BILL BAILEY Southeastern Bell Tel. JAMES MCCONNAUGHY NTIA/DOC IN ATTENDANCE: (Continued) RON COLEMAN Med. Tel. International RICK PFARR Med. Tel. International LOUISE NOVOTNY CWA WILLIAM ENGLAND HCFA JOAN KING AARP HELEN CONNORS University of Kansas Medical Center School of Nursing PAUL ZIMNIK Department of Defense CINDY TRUTANIC OVP - Tipper Gore MIKE KIENZLE University of Iowa National Lab. MARY JO MACLAUGHLIN Eastern Maine Healthcare NANCY SHARP American College of Nurse Practitioners EUGENE V. SULLIVAN University of Virginia ART LIFSON CIGNA TOM SPACEK Bellcore AL SONNENSTRAHL Consumer Action Network IN ATTENDANCE: (Continued) THOMAS LORAN High Plains Rural Health ROGER GUARD University of Cincinnati NetWellness JAMES H. "RED" DUKE University of Texas Houston Medical School STEVE COTTON Texas Tech. University Health Science Center CANDY CASTLE AT&T Wireless Services/CTIA DENA PUSKIN Chair, Joint Working Group on Telemedicine Deputy Director, Office of Rural Health Policy MARY JO DEERING USDHHS Office of Disease Prevention and Health Promotion REED TUCKSON Drew University BILL M. WELCH Nev. Rural Hospital Project ERIC R. MENN Partners HealthCare System, NC GEORGE KAMP American College of Radiology JEANINE POLTRONIERI Federal Trade Commission/AAD KIM KIRBY MCI JIM POTTER ACR IN ATTENDANCE: (Continued) BOB WATERS Arent Fox/Center for Telemedicine Law SUSAN STEVENS MILLER Maryland Public Service Commission HARRY L. ROESCH Appalachian Regional Commission THAYER NELSON Managed Care Options ALLISON BAKER American Telemedicine Association JENNIFER RAPP National Rural Health Association KURT SLOOP NTIA STEVE TOLKEN Communications Daily KEVIN ROTH IBM PAT HUNNICUTT IBM LOUISE ARNHEIM Consultant SUZY TICHENOR Council On Competitiveness ROBERT HAGA NECA MIKE BUAS Federal Communications Commission/OCF RICHARD RETTIG Rand RAM BHAT Rand IN ATTENDANCE: (Continued) CHARLES DOUGHERTY Creighton University LYNN START Telecom Reports SID HOUSEIN Bellcore GOU SANCHEZ Neuro Surgical Associates Sioux Falls Sioux Valley Hospital ERIC G. TANGALOS Mayo LUIS GUILLERMO KUN, Ph.D. Center for Information Technology P R O C E E D I N G S 10:05 a.m. MR. LAWLER: Why don't we try to get started. We've improved over last time. We have coffee this time. Welcome, everyone. I know we've got some people who weren't here last time and some replacements or stand-ins temporarily. But welcome to our second meeting. What I'd like to do both for -- just very briefly, a couple of ground rules. We have a court reporter again, so we need to identify ourselves before we speak. And I think we ought to quickly go around the room just -- and say who we are and where we're from to reaquaint ourselves from the last meeting. I'm Greg Lawler and the Chair for the Advisory Committee. And Elliot, why don't you -- MR. MAXWELL: I'm Elliot Maxwell of the FCC's Office of Plans and Policies and we welcome you all and thank you all for coming. And in order not to call upon the services of any of the doctors here, maybe you -- if anyone wants to take off their coats, feel free to do so. MS. MACLAUGHLIN: I'm Mary Jo MacLaughlin from Eastern Main Healthcare, Bangor, Maine. MR. BAILEY: I'm Bill Bailey from Southwestern Bell in St. Louis. MR. KIENZLE: I'm Mike Kienzle. I'm the Associate Dean for Clinical Affairs at the University of Iowa College of Medicine and the Director of the National Laboratory for the Study of Telemedicine. And NLM funded a hospital R & D network for telemedicine. DR. SANDERS: I'm Jay Sanders, President of the American Telemedicine Association. MS. TRUTANIC: I'm Cindy Trutanic. I'm an attorney and I'm with the Office of Tipper Gore. MS. CONNORS: I'm Helen Connors and I'm with the University of Kansas Medical Center School of Nursing. MS. KING: I'm Joan King with AARP National Legislative Council. MR. ENGLAND: I'm Bill England with the Office of Research and Demonstrations of HCFA and I'm the project director for their telemedicine demonstration. MS. NOVOTNY: I'm Louise Novotny with the Communications Workers of America. MR. PFARR: Rick Pfarr with Med. Tel. International, McLean, Virginia. MR. COLEMAN: I'm Ron Coleman. I'm also with Med. Tel. -- I'm Chairman of Med. Tel. International Corporation. MR. MCCONNAUGHY: I'm Jim McConnaughy, NTIA, the Commerce Department filling in for Kathy Brown who got pulled at the last moment. MR. MENN: I'm Eric Menn from Partners HealthCare System in Boston, part of Massachusetts General Hospital. MR. WELCH: Bill Welch with the Nevada Rural Hospital Project in Reno, Nevada. MR. TUCKSON: Reed Tuckson, President of Charles Drew University of Medicine and Science in Los Angeles. MS. DEERING: Mary Jo Deering with the Office of Disease Prevention and Health Promotion where I'm the Director of Health Communication and Telehealth. MS. PUSKIN: I'm Dena Puskin. I'm Deputy Director of the Office of Rural Health Policy where we administer over 20 networks in telemedicine and telehealth and administer evaluations. And I'm also Chair of the General Interagency Joint Working Group on Telemedicine which cuts across all cabinet agencies developing (inaudible). MS. CASTLE: I'm Candy Castle. I'm with AT&T Wireless Services representing Cellular Telephone Industry Association. MR. COTTON: Steve Cotton, Director of Marketing and Program Development for an organization called TelNet (phonetic) which is a telemedicine and a satellite-based distance learning project in Texas, out in west Texas at Texas Tech. University. DR. DUKE: My name is James, people call me "Red", Duke, D-U-K-E of the University of Texas Medical School in Houston. I'm professor of surgery and a trauma surgeon. And you'll understand later why I'm here. DR. BRICK: I'm Jim Brick. I'm a rheumatologist for West Virginia University School of Medicine. And I'm Medical Director of our telemedicine project which is Mountaineer Doctor Television (phonetic). MR. GUARD: I'm Roger Guard, NetWellness and University of Cincinnati Medical Center. MR. LORAN: I'm Thomas Loran, Executive Director of High Plains Rural Health, Fort Morgan (phonetic), Colorado. MR. SONNENSTRAHL: I'm Al Sonnenstrahl from Consumer Action Network of Deaf People. I'm here representing people with hearing impairments, hearing disabilities. MR. SPACEK: I'm Tom Spacek. I'm the Executive Director for National Information Infrastructure Initiatives at Bellcore in Morristown, New Jersey. MR. SULLIVAN: Gene Sullivan from the University of Virginia, Charlottesville. MS. RICCIARDI: Lygeia Ricciardi from the FCC's Office of Plans and Policy. MR. LAWLER: And Thayer Nelson is back there who many of you have talked to on the phone. Thayer is sitting actually directly straight back there. There is an agenda that I don't whether we passed it around, but it's back there. Lygeia, why don't you just hand them out? It doesn't tell us -- it just lays out what we're going to do with the hour. What we want to try to do today is spend -- each of the subgroups, I know, has been talking either electronically or otherwise about where to go. And what we're going to do today is spend an hour with each subgroup, the first 20 minutes to a half an hour with each subgroup head and members of the subgroup describing just what they've done so far, what they've identified as issues, how they're approaching those issues, where they think this ought to go, and then follow that with a general discussion so that there is interaction with everyone with that subgroup. If there's a complete uniform view on that, if that's a great thing to do or a terrible thing to do or whatever, we will have a discussion about it. What we want to try to do just to lay out -- well, everybody wasn't here last time. But we have another meeting sometime in September which we'll talk about later, early in September. And we are then going to submit a report to the FCC by the end of September. There may actually be a date. I think it's the end of September. That does not give us very much time for a very large subject. So what we want to try to do today is get all the issues on the table so that everybody is comfortable that we are discussing issues that are significant and frankly try to organize them in a way so that we can get our hands around this in -- by September and actually provide some focused sensible advice to the FCC in the short time that we have. I think the one thing that everybody -- well, I won't speak for everyone. Certainly, the thing that I've concluded which I think we all knew coming into this is, you know, this is an enormous subject. And if we can focus our efforts, focus our thoughts, pick out the things that we think are most important and to try to provide some sensible advice on those things, we will have made a great contribution. We are not going to be able to do everything. Telemedicine is going to evolve in a way that, you know -- we could have a pool and we could guess about it, but we do need to try to focus our thoughts and -- and that's really what the purpose of today's meeting is. What I'd like to do is also just if people have plans, if the subgroup heads are available after the meeting, I think we're going until 3:00 or 3:30, just for a short time so we can talk about how to organize ourselves going forward between now and September, that would be useful if you have the time. What we thought we'd do is start with Jim Brick who is our rural subgroup head. Do we have any other things we need to say before we get started? MS. RICCIARDI: That's about it for now. When we take a break, I'm going to say something about a number of handouts that I've prepared, just copied, the reports and other items that I think may be useful to you. And I'll just give you a quick run-through of that when we convene after the lunch break. I think it's easier that way. MR. LAWLER: And I just saw walk in -- I don't know if anyone else has walked in. Maybe if we could go around the room and identify those people. MR. LIFSON: Art Lifson with CIGNA. MR. LAWLER: Also, when you -- I'm sorry. MR. ZIMNIK: Paul Zimnik, the Department of Defense. MR. LAWLER: And another? DR. KAMP: George Kamp, American College of Radiology. MR. LAWLER: Also, we have a court reporter, so -- oh, I'm sorry. Did I miss someone? MR. ROESCH: Harry Roesch from the Appalachian Regional Commission. MR. LAWLER: I'm sorry. Before you speak, please identify yourself so that the court reporter will know who you are. We're going to pass around an attendance sheet so she will be able to see who you are and correctly identify you. So let's try to help her out, as well. It will help people looking at this. What we thought we'd do is start with Jim Brick and the rural subgroup and spend an hour talking about that and then move forward. So Jim, it's all yours. RURAL SUBGROUP REPORT DR. BRICK: Okay. Thanks, Greg. I'm Jim Brick for the record. Thanks a lot for this opportunity. The rural subgroup is comprised of a number of folks. I'd like to put their names in the record: Narcisso Cano (phonetic), Helen Connors, Charles Holland, Mary Jo McLaughlin, Paul Pilar (phonetic), Dena Puskin, Eugene Sullivan and Bill Welch. Most of these folks, nearly all of them really have contributed to the things that I'm going to tell you today. As we discussed at the last meeting, there is a lot of overlap between all of the groups that we outlined last time. And I think that that's good because that way we get a lot more input into what we're going to decide. Dena Puskin and I after the last meeting, we did talk about this though and decided that we needed to start somewhere. It's kind of a guldian (phonetic) knot that we're trying to unravel here. And we decided we would send out four questions to people and let them respond to these. And then we would start with those. And my job was to sort of collate everything and put it together into a summary that we could present to you folks and also to cajole them into responding while they were on vacation and stuff like that. There are four questions -- and I hope you have the handout that was in the back -- that we asked. The questions -- MR. LAWLER: Does everybody have -- do we have copies of it -- DR. BRICK: I put lots of copies back there. You can -- I have these overheads if -- I wasn't going to use them. But in case people don't have the handouts, we could put those up. Anyway, there are four questions. And the four questions are: 1) What is the definition of rural? 2) Who should be the providers that we include in this? 3) What is the minimum functionality that we thought that should be covered under the universal service provisions and should it be the same for all providers? 4) And what are the current variations in pricing in rural communities for various levels of functionality and what are the implications for the subsidy of establishing various minimums? We had lots of responses to all the questions. There are a lot of differences in opinion about how we need to do this. I think some of the differences are engendered by the fact that people are -- bring something to this committee, their own experiences of where they are; what's available in their particular part of the country; the problems they have; what they're doing there. And I think that that accounts for a lot of the differences. But there are also a lot of similarities. With regard to the first question -- what's the definition of rural -- the act requires that access be given to services comparable to those available in urban areas and at comparable rates. And this requires a practical and a sensitive definition of rural. And a definition of rural is hard to come by. We had a lot of comments. People thought it needed to be as inclusive as possible. But they also didn't want to cost to be extraordinarily prohibitive. There's a lot of concern that if travel time is used as a benchmark by some people, that -- that -- or distance is used as the only benchmark, that it will be prohibitively expensive in some rural states in the west because of the long distances to get from anywhere to anywhere else. Another suggestion that after reading the responses that everybody sent in, I think one of the ideas was Dena's idea that was in a handout that she gave us from some testimony that she gave which was a combination of office management and budget, metro and nonmetro county rankings which is a way to divide counties as to rural and nonrural. And then there's a U.S. Department of Agriculture Economic Research Service, urban influence codes which can be dovetailed with that, and a modification of that which comes out at Dena's office. I think, again, an attempt to be as inclusive as possible with this definition of rural because there isn't any one definition of rural that fits everything. And also, one of the points that Dena made in her comments to the board I think which was very appropriate is there also needs to be some special consideration for these parts of the country where you just have a few people living per square mile. I mean, just really, really frontier areas of the country and really none of the rules really fit those kind of folks. We don't want to leave them off the information super highway. From the meeting that we had the last time when the senators got up and made speeches, it sounds like they don't want anybody left off the information super highway. So I think we need to consider those folks, as well. What providers should be included on the list of eligible providers? For example, should physicians' offices be included on the list? This is the second question. Again, here we had lots of viewpoints. The real issue here I think is is whether to include the private practitioners' office, not usually thought of as being a not-for-profit venture though at the last meeting, some WAGs (phonetic) suggested maybe that they were not-for-profit ventures. I think they don't meet anybody's definition of being not-for- profit. And -- but there was a lot of concern that we needed to find some way to be able to do that. There were - - there were several comments maybe that this could be addressed as part of a network or cooperative type arrangement between smaller places, the doctor's office, very small clinics, et cetera, and maybe a bigger place; that this would allow them to share use and decrease cost. But there was also a lot of concern as to whether that would be allowed by the act. I think the act has some specific language about selling services. And I'm not sure how that we can address that. But that was a concern that people had because -- because a lot of the care that's given in rural communities is given not even in the small rural hospitals. It's given in individual practitioners' offices. And we put those people out there. We want them to do a job for us. And then we cut them off the network. That -- you know, that doesn't seem to make very much sense. People thought it ought to be very inclusive. There was a lot of comment that it ought to be public and not for profit. Again, include doctors, nurse practitioners, PAs, you know, any kind of health care provider that needs it. Some people thought that -- that it would be okay to just include anybody that's now reimbursable for services; that is, anybody that can be paid now to be included. And one person suggested that we ought to ask Congress for some clarification on this and see exactly what they mean by that. The third question is is what is the minimum functionality or band width covered under the universal services provisions and should that minimum be the same for all health care providers. The main issue here seems to be the less-than-hospital-size application. I think everybody that responded -- and everybody did respond to this question -- felt that -- that we need to have a fairly robust service that goes to small rural hospitals. And most people talked in terms of something equivalent to a T1 line. Some people talked about, you know, fancy switching with ISDN lines and using those to -- to mount up a T1 line and some other things. I read all these responses. But I've got to be honest with you. I don't understand all this stuff. But I -- but I know there are ways to assimilate broader band width using smaller pieces. And I think people were very interested in being able to get that kind of a service, approximate the T1 lines in the hospitals. There was also a lot of talk about the Internet and the Internet being available in all of these communities as a local call, not as a long distance call. The Internet, of course, allows access to the National Library of Medicine, world wide web, all these services that we all take for granted now. But I can tell you now that my friends and classmates that work in rural West Virginia don't have those things. And they would love to be able to have those things and they want them. And in some places in West Virginia, you can't get them at any price. And I think that's a very appropriate thing to be able to do that. On the other hand, in the last three weeks, I personally found out as a result of collating all this stuff that it's -- the Internet is not going to be available to do brain surgery. Okay? It -- things happen on the Internet. You don't get messages. And it's hard to find out what messages you get and you didn't get. It crashes. You know, you go down on vacation and you have your laptop with you and on Tuesday, it dies. And you call the computer guy at your place and he says oh, that; no, I can't fix that from up here; you've got to bring it back. Okay? So -- and -- so, you know, I think there is a limit to how much you can do with the Internet. But the Internet can do a lot of things with telemedicine and certainly, the education things should be available to everybody. As far as providers, there was some talk, a great deal of talk about more robust service for them. For example, in qualified clinics, it would be ISDN lines that - - that that would allow more robust service in those areas. And one of the comments that I thought was particular appropriate was that whatever we -- we set -- we decide on, that there needs to be an appeals process so that if I think that I've got a problem that needs to be addressed with more robust service than the act -- than our reading and putting into effect provides for, that there's an appeals process that they can come and provide information that allows them to get a more robust service. The final question is regarding current variation in pricing in rural communities for various levels of functionality and what are the implications for the subsidy of establishing various minimums. I think there's a lot of agreement here in the issue of shared use. I think people understand that by having education, the libraries involved in this, that there's at least the potential here for the line cost to come way down. People believe -- a number of people believe that lower cost will increase use and make it economically feasible. And that reminds me of "Red" Duke beside me. And years ago in Texas when Lyndon Johnson was in the House or the Senate, he was trying to get a dam built in Texas to generate power. And we was told repeatedly that the people in east Texas, in the hill country of Texas, that they would never be able to use the power and they couldn't pay for it and, you know, there wasn't enough people there and, you know, all these kinds of arguments that we all hear all the time. But they built the dam. Sam Rayburn saw to it that they built the dam. And they sold the power. And in fact, they made the dam even higher after they started building it. So, you know, there is precedent for that idea; that lowered costs will increase use and make it economically feasible. There was also some comments which, again, I think I mentioned before that rates can't be distance sensitive or that that shouldn't be the only thing that goes into the calculation of the rates because charges get out of hand very quickly in some of the rural areas in the west where there are large distances that people have to go with the phone lines. And another comment was that if we would just tell the phone companies or the other carriers what it is that we want and go to them and ask for their help in finding a balance between what can be done and what can't be done, and putting together these cooperative ventures with the education and the libraries and the other people in the community that might be interested in participating. Obviously, we need to narrow these opinions down. And I would propose that we do this with some subgroups to give a more focused answer to all of these questions. But I wanted to tell you where we are. We obviously don't have all the answers yet. But I think we've made a good start. I'd welcome input now from any of the folks on the committee and thank you all for your attention. MS. PUSKIN: Could I just ask for clarification on something? DR. BRICK: Sure, Dena. Yes. MS. PUSKIN: I'm Dena Puskin for the record. Okay. On the issue of the definition of rural, in the testimony that I gave in front of the board, what I suggested was that there were several alternatives that one could use that are in place. You have to be feasible and practical and use things that are not -- the best can be the enemy of the good. And one of them is using OMB's metro/nonmetro definition, but doing what we call the Goldsmith variation which is something we developed for our own grantees because what's happening is metropolitan areas have grown very large as a result of various consolidations in the 1990 census. And you have really pockets of real rural areas within what's considered a metropolitan area. So we hired a demographer to look at those areas to basically define what are really rural in character, rural in economy, rural in characteristic within metro areas. And we have actually a list that we use in our grant programs that any GS-5 or 4 clerk can go down. And if you give them -- you know, a grantee can fill it in. And you can figure out very quickly what is metro -- what is urban and rural by that definition. And you'll need that kind of simplicity for administrative purposes. That's one option. The other is the Economic Research Service of the U.S. Department of Agriculture has come up with what they call they Urban Influence Codes. And they have some alternative definitions. And I suggested in my testimony that we look at both of those and decide essentially which might be better. But both are relative feasible to implement. And again, I always use the test is if I gave it to one of my clerks, could they implement it with accuracy; and if some hospital filled it out and gave it to a clerk to fill in, could they understand it well enough to apply. And that's I think very important in the definition of rural. In terms of the issue of frontier, I think it's very, very important to recognize that we have frontier areas. And we need to examine whether we need to impose some other definitions regarding them. But there's some trade-offs there. Clearly, frontier would fit the rural issues. There are some complicating factors in defining comparable services for frontier that go with the way the act reads. So I think our group needs to spend some time on that in order to give I think the FCC some good definitions for areas that can be viewed for some comparability for the purposes of what the act calls for. That's all. DR. SANDERS: Okay. Jay Sanders, American Telemedicine Association. There's -- one of the issues that Jim reported on that I would sort of like to underline and that I think is a very basic seminal issue -- and I'm not a member of the group so I wasn't part of the discussions that they had -- but to me a very critical issue relates to the basic construct of the Telecommunications Act in defining or allowing this to be provided -- the telecommunications infrastructure to be provided only to the nonprofit entity, and that basically being the hospital or health care facility. The reality in rural America -- and I've been involved with this for many years on a hands-on basis -- the reality is the majority of health care practice does not occur in the hospital. It occurs in the physician's office. It is, in fact, the -- the untoward event that has occurred in the physician's office that allows a patient to get into the hospital. To me we have got to indicate that the act in some way has got to either be amended or edited to include the primary care physician's office or the primary provider's office. That's where medicine occurs. If you're going to provide functionality to a facility where only ten percent of the health care is being practiced, it makes no sense to me. Ninety percent of the health care practice occurs in the primary care physician's office. I would hope that we would come out with a strong message to indicate that. MR. LAWLER: Can I just -- two reactions to that. One -- and really looking at this in two ways. One, if that is the advice that we think we ought to offer to the Congress meaning, you know, if you could make this better by including primary care physicians or however we want to describe it we ought to do that. But I also think we ought to be realistic about it and think, you know, in the context of what we have, what can we do to suggest that there is a mechanism here. Public and nonprofit may mean something more than just a hospital. And I do think maybe that's some specific task we could assign to people or people would volunteer for just to sit down and think about, you know, how do we take these words, what they mean, and suggest to the FCC, to the joint board that, you know, here's how medicine is practiced. There are parts of this which, you know, they may not appear to be IRS definitions but are public nonprofit nonetheless. And this is something you ought to think about when you interpret what these words mean because, I mean, we all know that Congress with the best of intentions doesn't move as quickly as -- Let me just -- Paul, I think you had your hand up first. MR. ZIMNIK: Yes. Paul Zimnik with the Department of Defense. Just to elaborate on Jay's comments, I further believe that if we are going to make recommendations along those lines, we take it even further. We see a growing decentralization in health care delivery. So it's not only from the hospital to the doctors' offices, but even one step removed from that, into the home. So I think that in the future, we are going to see much of the health care access and the services interaction from the home itself. So if we're talking about an act that will impact the next 50 to 100 years in this country, we need to keep that strongly in mind. MR. KIENZLE: Mike Kienzle, University of Iowa. I don't disagree with either of those comments. But I think that you're not factoring in some very strong market forces that have been in place and in play for over the last ten years or so. That is the integration and consolidation of physicians and other providers into integrated health care delivery systems including the hospital, including the physicians' offices, including the home health care sites of care. And frankly, I think just even left alone, the integration and consolidation of physicians within -- either in information consortiums or actual integrated delivery systems will, in fact, functionally take care of the notion of access for all of the various providers of health care. MR. SULLIVAN: Gene Sullivan, University of Virginia. You know, the act does not prohibit or exclude the doctors' offices from activity. What I think -- when the phone company puts in and meets our requirements, if a private practice office wants to be included, they can be included. It's just we were talking about the subsidies and the rate differences. Why are we looking at subsidizing someone that's in a private practice? If, for instance, the T1 line goes down the street to the rural hospital and along that street is the private practice office, why can't the private practice office jump onto the competitive carrier and use that service paying the appropriate rate? MR. LAWLER: Al. MR. SONNENSTRAHL: Al Sonnenstrahl speaking of Consumer Action Network, speaking through a sign language interpreter. I have several questions. I appreciate the comments brought up today. But first, we do have a clear definition of the word, "rural". Does -- does the definition of the word, "rural", include people with disabilities who are isolated -- insulated -- as insulated as people living outside in the boonies. We have to research that. How accessible also are these services? Are we over-depending on audio -- the audio part? Can we become co-dependent between audio and visual use? I watch TV pretty often and I notice that often when they use distance interviews, the audio part gets lost. So we have to be careful and make sure that we're not overly dependant on the audio only and make sure that everything is captioned so that we won't be depending on sound alone. And you mentioned about appeals. I think that's wonderful. How accessible are they? How can a deaf person file a complaint if there's no way for a person to call in or for a person to get information visually? And you mentioned that this should not be distance sensitive. And I agree with that. How about multi-line sensitivity because sometimes a doctor needs an interpreter to communicate with a patient, especially in a rural area or in a metro area. They will need to include an interpreter. And you'll have to get another line to communicate with a patient through the interpreter. And that would mean an additional line. And that should not be included in the cost or it should not be an additional charge to the cost. And when I speak about deaf people or disables people, I'm not speaking about them as patients. I'm speaking as if they are involved -- involved in the health care system itself. I've met some deaf doctors who have expressed some frustration over not being able to get information as much as you guys do. Thank you. MR. LAWLER: Somebody else had their -- MR. WELCH: Bill Welch from Nevada Rural Hospital Project. I don't disagree with any of the previous comments that have been made. I would like to support a couple. As we move forward with this, I agree that there's nothing in the act that prohibits the private practioner from having access to whatever is developed. I would want to make sure that we don't dilute this so much that the resources available are not going to be able to be effective in developing an effective system. Whoever is subsidized and supported through this act I believe should have the same responsibility to provide all the patients services. And I find from my experience that many of our private practioners would not collaborate, cooperate, they are not always available and they do not agree to see all patients. Hospital centers, at least in the west, are beginning to have to subsidize many physician practices and would be the core focus of an integrated delivery system, as least that's our experience in Nevada. And so while I support having primary care physicians having this functionality, I think that the biggest cost factor is getting the line functions to the rural community. And I think the competitive market is going to make the equipment affordable to the private practitioners or the private industry to buy into it. DR. BRICK: Could I just ask -- I've read the language of the act, you know, as regards this. And I have not real -- you know, I'm not used to reading acts. Okay? But -- MR. LAWLER: Thank God. That makes you qualified. DR. BRICK: Yes, right. But one of the things which several of the folks here have commented on and wrote in on the e-mail about this was is there some way that this can be done to get these folks tied into a hospital or a bigger clinic through the idea of a network or co-ops or something. You know, I don't know what the right word is, but some way of doing this that they're sort of brought into the fold and at the same time not violate the spirit of the act that I think kind of prohibits subsidy of private business. I mean, that's my understanding of it. Is there some -- you guys read these things. Is there a way to do that, you know, or -- MR. LAWLER: We put a big cloud over it and say some magic words and -- DR. BRICK: Yes, okay. MR. LAWLER: I mean, there really isn't and -- Bill had a comment which we'll get to. But I mean, the answer is none of this is clear. I mean, you're talking about a lot of money moving around. You have a provision that, you know, is literally that long. And the FCC's got to interpret. They're, you know, I'm sure sitting there saying, you know, who is going to sue us about what. DR. BRICK: Yes, right. MR. LAWLER: You know, it -- and I think we have to think about what our job is. And our job is, you know, we're not writing a regulation. We didn't write the law and we're not writing the regulation. Our job is to provide advice about what we think the right outcome is. And we can say, for example, with the word we think that you ought to interpret them to cover things which we think are important; and by the way, you ought to do something more because, you know -- I'm not saying there's agreement on this -- but if everybody says it ought to go to every primary care physician in -- you know, in a rural area, you know, we ought to tell the FCC and the Congress they ought to do that. I'm not suggesting we do that, but that -- you know, we can certainly give that advice. I think you will find some people saying isn't that going to cost a lot of money and, you know, not out of my pocket. But -- MR. BAILEY: Well, and -- Bill Bailey. To build on that and what I think you said earlier, the fact that -- we're looking at telemedicine. And I think the act requires some sort of subsidy to flow. And the question is whether or not subsidy is needed in every circumstance. Obviously, you can have a primary care physician on a network operating using telemedicine in a nonsubsidized environment. So I mean, they're not going to be precluded from that. And somebody earlier mentioned the idea of home health care. And I think there had to be some point where things start making sense and stop making sense. I mean, are you going to subsidize an ISDN line into everyone's home so that they can health care? No. I -- there's -- you're going to back up from that at some point. And I think what's important is what level of subsidy do we want to have happen. And then, is there a way for primary care physicians either to take advantage of that subsidy under the act or not? MR. LAWLER: Jim, can I ask a question. DR. BRICK: Sure. MR. LAWLER: And I think Tommy's going to raise this later. But I -- we did talk about it to some extent last time. It also seems to me that we need to be talking about a common set of things. What is it about health care that we're talking about? You know, we're obviously not talking about everything from, you know, the day you're born until the day you die in terms of health care. We are talking about, you know, how do we identify what the -- what the medical technology that we want to cover for a rural area. And then you have -- I'm not going to steal Tom's thunder because I know he wants to talk about this. But you're also talking about what can the telecommunications technology do to help that. You know, there are some things that it can do and there are some things that it can't do. But it seems to me that's another thing that, you know, we need to focus on from a rural perspective. You know, you have a national perspective, you have a rural perspective. Is there some level of health care service that is, you know, the minimum that we can identify or isn't there? And if there isn't, we ought to say that. But I do think that those are kind of -- you know, that ought to be included in our discussion of, you know, what is critical for a rural area. And you know, the bigger it is, the more costly it is and the more people you put into it, you know, the more objections you're going to get to it. But I do think that we need to be thinking about that. Let me -- I'm going to start with people who haven't talked. I'm sorry, I don't know your name. MS. CONNORS: Helen Connors. I'm with the University of Kansas School of Nursing. And I just wanted to states that I think we need to be cautious about using the word, "primary care physicians", in rural areas because much of the care in rural areas is provided by nurse practitioners and physicians assistants. So I think we need to be careful of that. MR. LAWLER: Let's go down the row. Yes? MS. KING: One of the things that Dr. Brick said that I was impressed by was that lower costs will increase use. I think an important point is that you have to get the price of these services correct when you're putting them in in the first place. We're in a situation where there's more investment in urban areas than in rural areas. And it's the discretion of the telephone company to make those calls where they're going to put the investment. And it would seem that there should be an incentive to bring some of that investment back into the rural areas. And they don't have to invest depreciation and profit mining in rural areas if they don't want to. So rather than just say well, we'll subsidize, why not give incentives to improve the infrastructure across the country. But along that line, that the service is actually priced at cost for many of the users in rural areas whether they be physicians or nurse clinics or teaching institutions. So getting the price right and to bring the investment to the area is a crucial issue that should be brought to the forefront. MR. LAWLER: Down on the end. MS. POLTRONIERI: Hi. I'm Jeanine Poltronieri. I'm in the FCC Accounting and Audits Division. And I'm working on the Universal Service Fund of this. First of all, I'd like to thank everyone for being here. I think the advisory committee is doing great work and I really appreciate it. I know everyone in our division appreciates it and everyone on the joint board appreciates it. I'd like to make a comment on the definition of health care practitioner. And I think it has some broader applicability. I think the joint board has a very specific task before implementing Section 254 of the act. And if you look at the act and look at the definitions of certain terms and see what's there, I think you're going to be given a lot of guidance about how you would define health care practitioner. What I'm hearing is people are concerned that that -- the definition in the law isn't broad enough or that there should be other incentives to allow people to get hooked into this network although not necessarily be subsidized. So maybe in looking at this issue and other issues, a proper way to approach it would be first to think of what is the act telling us; what direction is the act suggesting; what would be helpful for the joint board to hear from us when they're implementing these various specific issues. And then I saw that the second question, what other provisions of the Telecommunications Act of 1996 can we look at that might -- might have a broader approach? What might we suggest as the next step for Congress? What might we suggest as the next step for the Commission? But I think it might be easier if we sort of -- if you're doing your work, is to separate it out; what the joint board should do; what did Congress need for them to do; what does the language of the act say and what do we think is the best way to reach that goal. And then secondly, what else is there; what was left out; what didn't they get right and how we can move towards those goals. But I don't mean to limit anybody's efforts. MR. LAWLER: The gentleman in the back. MR. WATERS: My name is Bob Waters. I'm with the law firm of Arent Fox and the Center Telemedicine Law. When I listen to the discussion on this, I would think that in order to allow us to move forward, I think we first need to really focus on those services that are available via the telecommunications, you know, technologies that are available in urban areas, define what those are and define which of those we feel -- or define how to make those applicable, what kinds of subsidies would be necessary to make them applicable to rural areas. I am not as hung up on the issue of public and nonprofit language in front of the provider section of the statute because I think that -- I think Dave's point is well taken. I think that a lot of services can be delivered by private practice provisions in rural areas. But there may be creative things we can do in terms of structuring the maintenance and work your way around that. I think that is really the system with an intent of the authors of the statute and I think we need to take a look at it. I think we need to do that without having to go to the process of reopening such issues. But I think the first issue is how do you get comparable services in the rural areas. And once you've done that, then you know what you need to do. MR. LORAN: Yes. Tom Loran of High Plains Rural Health, Fort Morgan (phonetic), Colorado. I'd like to echo that concern. Our big challenge right now isn't so much subsidies. It's the lack of services. We simply don't have digital services available in 95 percent of our area. And what we have to do is back haul hundreds of miles at a cost of $2,000.00 to $5,000.00 a line. So really, subsidy is my second concern. My first concern is building an infrastructure to support what we need. MR. LAWLER: Dena. MS. PUSKIN: Yes, I'd like to go back and -- I agree that the strategy should be for us to concentrate and make sure we do what's in the act and make sure we help the FCC get through what is being asked in the act. And if you look at the act very carefully, it says really there are two areas. There is one area which says what really do we need to ensure comparable services in rural areas for everyone, not -- you know, not just health providers. But what's a basic minimum level of universal service in a rural area? Now, if you look at that component and you start thinking about that, you might say, well, look it, if we could get Internet access a reasonable rate, let's say 28.8 baud or some other to basically everyone in a rural area, how would that not only help everyone in the area and build the services, but also build those services out to private practitioners and others who might not necessarily be eligible for the subsidy, but certainly will have an affordable service. Because that is really the key. Without the basic level of infrastructure there, no one out there gets an affordable service. And that's what High Plains has felt. That's what I know has been felt in west Texas. And a number of the projects that you probably have around the table, we've funded. So I know what their problems are. So it would say to me that part of is -- is in thinking about the health side, to say well, look it, if we have a basic infrastructure out there and we define that for everyone, that would get your home health care services out there. That would be affordable and it also would probably also be acceptable. The other thing to recognize is it's a moving target. What is the services now that we think are critical medically is not going to be the case three years from now. So we're talking about a medical -- and I am not -- and I now we're going to get into this -- I'm not sanguine about developing guidelines by service. What I am -- I am not sanguine about that at all. And I will -- I will argue against it later, so I'll set you up for that right now. I think we do need to define functionality by some very broad characteristics. And I believe we should define in a way by at least what we want for the clinics, what we want for the hospitals out there and what we want as a basic service for everyone which may indeed evolve and make it much easier for systems to reach out to hospitals. And just one second. I think we have some very basic problems even within the act with definitions. And I know this is the technician in me. But what do you mean by a community health center? Do you mean a federally qualified community health center or do you mean anyone who puts a shingle out and says they're a community health center and they happen to be nonprofit? The reason I ask that is because I think we probably will want to seek the broader definition. But it makes -- it may make a big difference for the subsidy level. And so we've got two issues I think. We've got the basic issue of what do we want out there that helps to stimulate, incentivize that basic infrastructure and what do we want particularly to get subsidies in the health care field. And that is essentially, initially at least defined by the act, and how do we refine these definitions. Given that, then I think we can make comments again along what we think needs to be done in the future. But we've got to get the work done with the act. And we don't have it done. And we've got a short time frame. DR. KAMP: George Kamp, American College of Radiology. Earlier, Dena's comments, I was wondering if there was discussion in the subgroup in terms of the definition of rural and its implications as far as differences in HCFA reimbursement, for example. Did the subgroup discuss that? DR. BRICK: No. MS. PUSKIN: No. I mean, there are -- HCFA has some very specific definitions which are -- they vary by program. If -- if you're talking about payments for hospitals, it's metro/nonmetro. If you're talking about special payments for rural health clinics, it's another definition by the Center called nonurbanized areas. And so there are some differences. And I think what we thought would be very critical was just to have a rational definition for rural that could be implemented that basically irrespective of this -- which would relate to a subsidy for infrastructure development. DR. KAMP: I understand. I was simply asking was there anything useful in those previously established terms as far as this effort? MS. PUSKIN: Well, metro/nonmetro is the first cut. And then the Goldsmith variation is a cut on that. It takes the metro and breaks it down further into areas that are really rural in character but are within metropolitan statistical areas. So we did start with that. DR. KAMP: If we are sharing about unfamiliarity with acts, I'm unfamiliar with variations on the Goldsmith. MS. PUSKIN: Okay. Well, we have a paper that actually relates to the last iteration. We've just updated it. But it's something that we use. Why should you know? MR. LAWLER: Bill. MR. BAILEY: Bill Bailey. I didn't disagree with what you said, Dena. I just want to clarify one thing. I heard you say sort of a minimum standard of 28.8. MS. PUSKIN: Oh, that was just thrown out. MR. BAILEY: Well, understand rarely does any 28 modem run at 28.8. The telephone network isn't designed to handle that. Even in metro areas, they don't run at 28.8. MS. PUSKIN: I threw that out as just an example of what -- that it's very important to define what would be acceptable. In my testimony, I must admit that I said the Internet -- access to the Internet at this level. And I didn't define at what rate. And that was an oversight that in some part was intentional because I don't -- I couldn't - - among the people, we had not really given enough thought to what would be reasonable. But I think that's the kind of thing that really needs to come out of a group like this. MR. LAWLER: Jay. DR. SANDERS: Just one side comment, a for your interest -- for your information type of response. That Paul Zimnik generated a comment about home health care. There's no question in my mind that the primary site for health care in this country in the next five to ten years will migrate to the homes, so I'm in total agreement. But I wouldn't be as concerned about the need for functionality because the reality is the functionality and the band width and the communication infrastructure to the home even in the rural area is already there. Most health care whether it's vis-a-vis the patient themself accessing it or whether it is the provider themselves accessing it will occur over the Internet. And with web technology as it presently is, you're going to be able to do video conferencing over web technology. The TV set and cable communication will afford that functionality right now. If you look at what is happening right now with respect to cable modem, if you look at the improved band width that's going to be provided through direct access TV, a lot of the necessary health care needs in the home will occur through the TV set which, in effect, will become the telemedicine modality. MS. DEERING: I want to add to that something that happened fortuitously to be in the Washington Post this morning in the business section. And it's short so I'll read it. "U.S. Healthcare invested 25 million in a newly created company that would deliver health information directly to consumers over the Internet as well as through pagers, radio and traditional mail. Teaming with Johns Hopkins, a university and medical system, it will manage the content", et cetera. "U.S. Healthcare will own most of the new venture called Intelehealth." I think what -- if we are concerned, especially in this hour of our discussion, about a definition of rural and behind that is a concept of equity, then we also have to realize that the big integrated delivery systems are going to do this. But they're probably going to do this to their beneficiaries who may be in more concentrated areas. I don't know. And so if there's a concept of equity behind what we're doing and you want to ensure equitable services in rural areas, then you need to make sure that you're matching that level of service into the rural area. MS. PUSKIN: And let me just say that that means that you need that infrastructure there to deliver it over the Internet. And I would suggest to you that right now that's not there. And despite the fact that we may have -- that we may see it evolve there. And that would mean that there would be need over time for less subsidy. But the issue is really defining what that basic level is for everyone. Then you deal with all of these issues, at least at a basic level. And I think that's what we're saying. MR. LAWLER: Gene. MR. SULLIVAN: Gene Sullivan, University of Virginia. If you still have the business section of the Washington Post there, there was another article on GTE forming a partnership with U-Net (phonetic) to provide Internet access services to the 18 million GTE customers. And I believe that if you do look three years out into the future, you're going to see that this is available. Many, many phone companies are partnering with ISPs (phonetic) to give you the local dial service to the Internet. So maybe in that particular case, we're setting our sights a little bit low. And maybe we ought to start looking a little bit higher as to what the requirements would be just as Dr. Sanders said. The phone companies aren't the only ones out there. If your standards are high, quite possibly there will be others that are very interested in providing this service such as the cable companies, such as the oil companies with their dark fibers (phonetic) in the ground. So let's not think today what we need to do to provide medicine either to the rural clinics or to the home. Let's think just a little bit down the road. MR. LAWLER: All right. Let's do a couple more and then we'll let everybody get a cup of coffee and move on to the next one because we're just about running at an hour. MR. ZIMNIK: Paul Zimnik with the Department of Defense. A couple of comments. I agree completely with you that if we bear in mind what we are trying to do here, we need to remember that this is not an island. We're not looking at -- particularly today and in the next five or ten years, health care delivery, telemedicine, is not an island unto itself. We are talking about information aided technologies. And there are market driven forces. You know, we've seen what Paul Forder (phonetic) has said even about the third wave. This is overtaking everything we do in society. So as we sit here trying to define what kinds of applications, what kinds of infrastructure will be required for health care delivery, we need to be very careful not to fall into the trap of defining an infrastructure for a particular application or, in fact, I believe even for a particular industry like health care. We need to keep in mind what is going on in the world, what is going on in the cable industry. Web TV is another thing that just came out yesterday. I believe if we move into the next hour talking about infrastructure development and such, that we'll find out even that health care type applications in the near future will require a minimum of six megabits a second type capacities. And that kind of access into the home will be enables by processes that again are being caught up in this revolutionary change that we're seeing that's effecting every individual in society. So we just at a philosophical level need to bear that in mind as we talk about making recommendations for implementations that we hope will sustain the needs of our country for the next ten to 20 years hopefully. MR. LORAN: My comment to -- Tom Loran, High Plains Rural Health. I just think it's important for everyone to realize that there's a lot of people out there that still are on party line phones. And they don't have cable service. And all these things are really nice. You can read about it in the paper. And they dream from that. So I just, once again, say lets not get so far out in the future that we forget the people that are still on party line phones and that there's a basic infrastructure in the rural areas that just doesn't exist and needs to be built. MR. LAWLER: Down on the end, and then we're going to take a break and move on. MR. MCCONNAUGHY: Just one comment on the last comment. Party lines used to be a huge problem. Fortunately, it's becoming less of a problem. It still exists, I mean, no question about it. But it's not -- thanks to REA loans and public policy, it's -- well, it's something to be reckoned with. But it's not the overwhelming problem that it used to be. But the point I wanted to make, looking at Question 4 that the subcommittee addressed, I keep seeing the terms, "schools", "libraries", and "shared use", which I think is a terrific idea, not only in terms of the cost savings, but in terms of getting the total community involved, just a community access center as it were for new information. I would suggest the subgroup look more closely at a specific part of the act which may or may not throw a monkey wrench into that. Perhaps a creative interpretation would help here. But I would say to look at Section 254 HB3. DR. BRICK: H what? MR. MCCONNAUGHY: HB as in boy 3. It talks about terms and conditions of public institutional users receive discounts -- some rock dollar type discounts. The way it's termed, it specifies in the language that it cannot be sold, resold or otherwise transferred by such user in consideration for money or any other thing of value. Now, resale and shared use has a long history before the FCC. I was just looking to that for some guidance now leading through these waters. But I think in a nutshell that the idea of shared use is a fantastic idea, but we may need to carefully navigate through the act to make sure that's a reality. MS. POLTRONIERI: If I might add to that recipes concerning the schools and libraries. You who are working on that, that's very significant to talk about here. MR. LAWLER: All right. MR. MAXWELL: I think that we can commit that we will be spending a fair amount of time within the FCC to explore what that means and what the restrictions on that are for precisely the reasons that you are suggesting. MR. LAWLER: Last comment and then we'll move on. MR. KIENZLE: Mike Kienzle, University of Iowa. Just one pragmatic comment. That I'm sure some of my colleagues from West Virginia, Georgia, Kansas and elsewhere would agree that the fall off in expertise or technology, as you move into a rural community, it's extreme. And I can tell you as an R & D director, I've had to send people 90 miles just to replace a toner cartridge. And so for us to be talking about future -- future digital services in a very, very rural setting, talking is one thing and doing is quite another. And the implications for the actual implementation of this kind of technology in a rural setting is immense and cannot be discounted. And I so I agree with trying to look ahead far enough to try to anticipate the needs. But at the same time, we still have people on party lines and we still have to send people out to replace toner cartridges. So, you know, I would just urge a little bit of prioritism. MR. LAWLER: Well, if people want to get up and get a cup of coffee for one minute. But let's quickly return and get back to the next one. (Whereupon, a brief recess was taken.) MR. LAWLER: Tom, it's all yours. INFRASTRUCTURE SUBGROUP REPORT MR. SPACEK: Okay. First of all, I would like to thank all the subcommittee members for their inputs. We sort of requested that, and I'll discuss that, similar to the set of questions. And I was just amazed that everybody came back with, you know, three or four pages of very insightful comments within the time frame. I never ask people who work for me to do things and expect that to happen. You know, it was really good and we appreciate that. And I'd also like to thank Sid Housein here from Bellcore for standing in while I was away. I was away for the several weeks for the last two meetings. And he helped out quite a bit. Okay. These are the topics that I know were covered. Let me start with what we solicited from the key members. We sort of came to the same conclusion as Jim. Let's get some input from the subcommittee members. And we asked them four types of things. First was the kinds of telecommunications services that were essential for providing healthcare in rural areas to be included in the Universal Service Fund , inclined particularly to the word, "react". Next we asked well what are the infrastructures that's available today to meet those needs and what are the shortcomings, where aren't those needs met. What are future needs for the next three or four years, and this is where we applied (inaudible) and where people brought up this home health care issue and so forth and expanded in that direction and several other issues. And then we asked what were the barriers or providers to put the equipment in the infrastructure in reaching the rural and (inaudible) area and what might policy be to reduce those barriers although this was very preliminary in a sense that we believe that's one of the major outputs at the end of the flow. Okay. In doing that, we do have draft report here. I didn't have it on the back table before. I'll pass it out in a little while. Sid pulled the draft report together. And the attempt of this was to summarize the input as best as we could from the various members. Now, I believe it was going to be summed in (inaudible), especially the ones that were found in this morning, but will not be included in this report but we'll work in as a working document. But most of them we worked in as best we could, but we probably missed some. So in our ongoing work of the subcommittee, we will not just use our summary report as source report for input, but use the original documents that you all heard (phonetic). I'll also ask that the subcommittee members, and you can tell from the subcommittee, re-read this document because its significantly different from the one that we had two or three days ago based on inputs that you all provided. And clearly, I'd like for the rest of you folks to read it, too. What I'm not going to do today is summarize all those inputs. Okay. I've handed it out and you can read it. It's only four or five pages. You can read it on the plane or whatever. What I'm going to do is highlight some of the key issues that were uncovered and that need to be addressed, and suggest an approach to what we've been told. That's what we're going on. With respect to the key issues, we solicited input as one of the essential services that were required. We had some commonality in responses, pretty much commonality. We had quite a bit of variety, just as Jim suggested. And I think that mostly -- and there's a lot of reasons for that. I think it mostly had to do with the way we asked the questions. We basically asked for -- you know, what are the telcom services that should be provided. What does that mean? What does that have to do if you receive this input? You have to make some implicit assumptions about the telemedicine applications that are required and the potential (inaudible) and the future (inaudible), and convert that or translate that somehow in your head into telcom service. Well, that's not an easy thing to do. It really takes a little bit of pressure to do that. So I think that's one reason, that we didn't ask the question very well. I think what we should have asked, and several people commented on this, is that we should have asked for what are the fundamental telecommunication needs that are required and to get an understanding of that, and I'll talk about that a little bit with this chart. So what we really need is a framework for getting (inaudible). And that's what I'll be talking actually talking mostly about, the particular framework. And several of the members suggested that we do that. The next issue was the boundary between essential and advanced applications. And this has to do with what we were talking a little bit about before in some of the comments about what are the things we can do now and where are we headed in the future. In 254 H1A, it talks about in a sense, services that are essential for health care. And we need to define them. The FCC needs guidance as to what we recommend. And then 254 H2A talks about advanced services that aren't necessarily in the initial universal service set, but that the FCC would like to know about because they want to set up some rule for competitive -- some competitively neutral rules for access to such services in the future and make sure you can evolve to that. So we had the issue of how do you separate those. And I'll discuss that in the next chart, too, because we have either a solution or a cop-out depending on how you want to interpret the chart. Okay. Next, the idea was we wanted to assure that whatever we recommend, that there is flexibility for evolution. There were comments earlier that telemedicine application and considerations will change over time so we don't want to get locked in. So how do we address that issue? We have some thoughts on that. Related to that is there were some comments on the issue of the definition of the telecommunication service, and it should be broader than pipes and the switches and the band switching and band width and so forth. And it really needs to include the various protocols and data standards and software standards to some degree. And I'll touch on the benefits of that later, too. Also brought up this morning, the performance level of Internet access. It was fairly -- fairly unanimous -- it may have been unanimous; I don't recall -- that Internet access was clearly something very critical for telelmedicine application, especially cooperative and information access in more places. But there is a tremendous difference in T1 access and POTS access (phonetic) and what should be available where. Clearly, lack of uniform coverage and reliability of the current infrastructure. And that's kind of what this whole idea is about, is how do you solve that problem and get infrastructure into the rural areas at a comparable cost. And then a whole series of economic elements, we've got a few of them here on economics and cost issues. The last mile issue and the cost of the day (phonetic); incentive parastructures (phonetic), some people mentioned that today. It's really what the difference in urban/rural cost differential and how to get a handle on that. And in some sense, it's not a matter of what costs are. It's a matter of it's going to cost something to get service, to get the infrastructure to the rural areas. The providers -- the beneficiaries of this line in the act need to get it for a comparable price. The Universal Service Fund which we are not designing although we may give some input about what we think it's about -- I don't think we're designing an intelligence committee -- has to -- makes up the gap. So we need to put our objectives I think out there with recommendations. And the designers of the Universal Service Fund can hopefully meet some of our objectives which will introduce cost issues because I don't think this committee can solve all of those pricing issues. We have to get to what our financial objectives are anyway. But there's lots of issues here. Some folks brought up the issue of the economic realities of what can really get out there and be identified versus, you know, kind of we want it all even though the we want everything we can get now scenario may mean you may mean you may never get it because it costs too much. So it's a reality out there. And then there are issues of stimulating the private sector investment to compliment Government funding. And that gets to the issue of how much Government intervention is really needed or not needed. So this is sort of a series of issues that are to be addressed, that kind of came up. Some of them have been partially addressed by the inputs and some were just raised who were suggesting an approach to move forward here. The first thing is basically to try to understand what we're doing. We're making a bunch of implicit assumptions about what telemedicine's for and so forth. And everybody at this meeting can probably make a good statement to that. But I think we need to articulate it in a way that, you know, that the committee kind of agrees to; you know, (inaudible) patient to provider and so forth, just kind of obvious things about the -- you know, just moving distance and specialties that are not available and certain areas and so forth. But I think there may be some different views of that. But what are we trying to accomplish? And I think that's put together relatively quickly. And also in the goals, I think we might want to address this issue of flexibility, extendability over time. The idea then is to - - what we need to do to meet those goals. And the first thing that we think we need to do is try to understand what the applications are to be enabled by the Universal Service Act. What are you going to do in telling us? The kinds of applications I'm talking about -- I've given some examples here. These are -- you know, physicians and physicians consultants. That may be with or without, you know, images and other -- other records along with it. Remote diagnosis, and of course, there are several types of that; something as critical as in the triage center. So these kinds of -- this is what we mean by applications. And those applications are influences by several things. One is the needs of different specialties differ and there are different applications for different specialties. This can give some overlap, too. They also differ by time delays. And I'll mention that a little bit later. What's an acceptable time to receive something because as we'll see, there is a tremendous cost difference in something -- getting something in a minute versus getting something in an hour. Well, in some cases, an hour or two days is sufficient and in others it's not. So we need to get a handle on that. And as also mentioned this morning, the particular health care provider sight makes a big difference. In other words, a hospital might have different needs and requirements for services than for a clinic or individual operator. So these are the kind of parameters that need to influence these applications to some degree. When we're talking about, you know, this distinction between potential and advanced applications which is the name of the bill (phonetic), the comments that we received are that the boundary is not going to be very clear. We have a list of these various applications. It's not going to be very clear where is the boundary that we're going to recommend these and say these are the future ones. There's going to be a bunch of fuzzy stuff in the mill. So we thought -- and the cost difference, too. Clearly, some of the things that are more extensive will be on the list and some of them may actually be high priority and some may not. So we thought that the best thing to do from the comments was to try to come up with instead of a boundary, a prioritized list. And a prioritized list may not be exactly what we need. It could be the first five things and the next five and something of that sort of these applications. And why is that important? Well, you give the joint board and the FCC some flexibility that way to try to include as many applications down the list as possible to be supported by the telcom services. When they consider the shared costs, we may get inputs not just for us, but inputs from the education people and the library people and so forth. So the whole idea is looking at that in the context of the national information infrastructure where you do have (inaudible) which in that infrastructure solves a variety of societal needs and as well as commercial needs. So that was the idea of trying to get around this distinction to some degree. The next thing you need to do is now once we understand these applications and the time frame and so forth, you've got to translate those into telecommunications services. And what I mean by telecommunications services might be a little different in terms of vocabulary. In fact, let me give an example. In telecommunications services, I'm talking about things like store and forward file transfer as a need to meet a particular application; teleconference; fast type quality English transfer (phonetic); Internet access and so forth. So what are those services (inaudible). And then when we understand that, we can translate that into one of our primary outputs which was the recommended infrastructure functionality. And here is where we're talking about the things like band width requirements, switching and routing requirements, whether or not there should be an open architecture -- and I'll say a word about that -- and standards and so forth. However, this is a process to get to these -- these infrastructural obligations. The intent is to provide the recommendation in the aggregate form. For example, potentially aggregated by facility like hospitals of a certain type need this or by the kind of hospital it is or something. It might be aggregated by -- you know, it might be a different set for clinics than the things we're struggling with this morning. So the intent is not that the FCC is given information like this and we put the burden on them. I don't think we even want to think about asking them to come up with what are band width requirements for a particular medical service or feature. That's not what we're intending. The intent to give them recommendations in the aggregate form. But in order to do that in a meaningful way with some logic and back-up as to why we're recommending this, we believe that we've got to understand what these applications and then what the telcom services are to meet those applications. That's the basic approach that we're suggesting. And beyond that in addition recommending what infrastructure needs might be, we also intend to make policy recommendations. That's part of what we're being asked to do. And the are policy recommendations that will remove barriers in order to get this infrastructure out there in the rural areas and at a comparable price as urban areas and not to mentioned underserved in urban areas and so forth -- that's an issue that has to be dealt with -- and to assure that this is extensible over time; that we don't get locked in. So what are the policy recommendations to all of them. And finally what's below the line here that we really don't think are in the purview of the advisory committee, and this is to specifically specify what particular technology should be use and what the technology alternatives are. I mean, some of these needs will require cable and some might require cable. Some might require wire line, wireless satellite, who knows. But here we're specifying the functionality that's needed to meet these needs. Until it gets put out there, we don't believe it's in our purview to specify. So that's kind of the approach of getting there. A lot -- some of these steps have been at least started. Okay. And then just an example of what we're talking about to understand these applications. This top part was pulled from one of the inputs using teleradiology as an example. And there was one particular application for physician consulting. And within that application, the idea was there may be several different key components even within one application. And then we looked at a piece of market research that came out this year where a question was asked about -- of the physicians, how long do you consider a significant delay in getting a pre-existing xray or pre-existing study in each of the following situations. And these are the results of the survey. And clearly if it was a critical or very critical situation, it wouldn't be a number of that sort. So I don't know the exact definition of what that emergency setting was. But the point is here is not to analyze -- I mean, to, you know, question what the resulting surveys were. The point is to realize that there are multiple applications within a specialty that will have different needs. There are multiple time constraints and those will have different needs. And we've really got to get a handle on that to move forward. And this is just a picture of a teleradiology application. And I'm not going to go through the details, but I just want to make one or two points. We're talking about, you know, here's remote site here; accessing medical center that has a local area (inaudible) particular images stores and so forth. Okay. What we're trying to get at is in this circle here, in the network and the interface of the network and so forth, what are the requirements that are needed to meet this application need. And there are a lot of questions you want to ask. For example, a new network. Do we want to push or make a recommendation that there should be an open architecture, for example. We may not be able to do that. What might the benefits be of that? Well, it facilitates alternative technologies perhaps. It facilitates alternative providers to be competitive with each other and things of that sort. So that's the thing we need to consider. Within the interfaces of the network, issues like data standards and interface standards so that it will allow interoperability among various vendors' equipment that you might want to buy. So these are the kinds of things as well as the band width requirements and those sort of things that we're talking about. And this is just based some work that's still being done. But I'm not going to go through these details. But there are some -- it's interesting -- points here that discuss the issue of cost. Again, we're using teleradiology for an example. And within this application, there are many different modalities, MRI, CT, ultrasound and so forth. And within each modality in some cases as are listed here, there are different evolutions with the respect to the quality of the image and so forth. And those are relatively easy to translate into file sizes. And then once you've got file sizes, you can look at various ways of transmitting -- there are many more ways than are listed here -- of transmitting some of these. And take a case here where you're talking about five hours transmitted over POT (phonetic). And I think the point is well made, 28 kilobits modem (phonetic), but specifically out running at about 21.6. Anyway, you're talking five hours. And on T1 over here, it takes five minutes. That's a 60 fold speed based on what rate you're talking about, different prices in different parts of the country. That might be a 40 fold -- only a 40 fold increase in price for 60 fold speed. The point is do you need it and the answer might be yes or it might be no. And if you deploy something very broadly that costs 40 times more than something else, you know, is that -- does that make sense or not. I'm not answering the question. I'm saying we need to raise those issues in order to make our recommendations. We need to know what's required, under what time constraints and examine the cost trade-offs in order to make our recommendation. And then similarly, you can just extend that to that same kind of example. And we've done a lot of this already. So I'd rather it be somebody who will do the testimony -- extending some of this stuff to other specialties and applications, cardiology technology, health care, mental health and so forth. So just summarizing, in addition to asking you to read the report which summarizes all the inputs, I think what we need to do is articulate what these goals and objectives are overall. And I think that requires inputs from all the committees. And potentially if the chairpeople are meeting later, we can discuss that. We need to develop this priority list of essential advanced services that are enabled by the universal service set. And I think that's something that our infrastructure can do jointly with the rural committee. We'll have the initial crack at it and go through the same problems. But I think we can work together to get a handle on that. And then translating those applications into telcom service needs. The infrastructure subcommittee can take a crack at that. With respect to the data standards and system hardware compatibility, I think that might fit more into the purview of the architecture subcommittee. So we may get inputs there. Then translating telcom services into the infrastructure and concluding the extensibility issue. We can take a crack at that. And then based on all this stuff, and all of us have to work together and say what our policy recommendations in addition to telcom (inaudible). That's basically what I have to say and here is the report. And again, there were one or two comments that were phoned in this morning that didn't quite make it in, but most of them are there. MR. LAWLER: Yes. Jay, do you want to start? Are you done with this, Tom? I'll turn it off here. MR. SPACEK: Yes. DR. SANDERS: Hopefully -- this will be an off- handed comment -- but I hope that in the final report, we don't include that example of teleradiology, that in the emergency setting we can allow 2.6. My radiology colleague -- that was probably a survey amongst radiology, not amongst trauma surgeons. DR. KAMP: Semi-retired. Just to get our attention. This is a slightly more serious comment, actually, two. One is simply to point out what a moving target we're dealing with on the example of teleradiology in terms of cost and time of transmission trade-off. I would simply point out that the FDA just a few months ago gave pre-market approval for compression technology of wavelength pipe (phonetic) will upgrade 30 to 1 ratio which again just to emphasize how a chart of this type, however meaningful, when you're talking about the fastest thing is 6 to 1, it really changes the way we look at things. Secondly, and just informational, the American Medical Association in its annual meeting two weeks ago adopted a ten page report on telemedicine which was really fairly informative. It dealt with issues of standard reimbursement and licensure. I realize some of these are not within the purview of this committee, but would be happy to get copies of that document for the committee if they would like. MR. LAWLER: Yes. MR. POTTER: Yes, thank you. MR. TUCKSON: Reed Tuckson from Drew University. I appreciated the sensitivity and the underscoring of the -- of the underserved urban areas. I think that is very important. I'm struggling to -- I missed the first meeting and so I don't know whether I'm behind on the curve here -- of our definition of health care. These services such as cardiology, pathology and so forth are very important. But what also is important, particularly in urban environments and inner city environments is the notion of using this technology for promotion of health and prevention of disease. Just as we've gotten the FCC act deals importantly with how to get lines into libraries and other such areas that are -- that, you know, are at schools where we don't have this capacity -- and to exclude, particularly in urban environments, comes the notion of how we are going to be able to get communities involved and community-based institutions involved in having an opportunity for dialogue and innovativeness in terms of promoting health, defending against disease and earlier diagnosing disease in the people that live there. So I hope at some point we'll add those things to this list of telemedicine issues and that we'll look at the health promotion and the prevention issues as actively as we're looking at some of the radiology, pathology, dermatology services. And maybe we can come back and talk about that. MR. LAWLER: Cindy. MS. TRUTANIC: My name's Cindy Trutanic. I'd just like to underscore that point from the perspective of the users of telemedicine for telepsychiatry and mental health - - mental health purposes. There is a lot of talk about prevention in the mental health context and -- and having points of presence in a -- a school or a community center to really address, you know, adolescent and children's needs in the urban context. And they certainly are under-served in many respects. And I think that we should identify that as a need. MR. KIENZLE: Mike Kienzle, University of Iowa. Just to again underscore the very broad definition of telemedicine, we define telemedicine to include a direct consumer source of information. And our virtual hospital gets about a half a million hits a week, 40 percent of which come directly from the public. It's interesting that many of the public come in on the virtual hospital for the -- in the information section devoted to patients and family members. And most of them then migrate and read the information that is on the same illness that was intended for the -- for the physicians and other health care providers. So clearly, there's a huge need and a huge desire on the part of the public to have information. I think the Internet may turn out to be the platform that serves the broadest public good and certainly needs to be carefully crafted so that maximum access to the Internet on the part of the general public, particularly K-12 schools will serve as well. MR. LAWLER: Jay. DR. SANDERS: Jay Sanders. I guess it doesn't need any more underscoring in terms of what Drew said and the subsequent comments. But I probably can talk for Paul here vis-a-vis his comment about the -- in effect, the electronic house call. Our total intent as a major reason for having access in the home is predominantly for disease prevention and health promotion. And in fact, one of the initiatives that we've taken in Georgia is to integrate the health care telemedicine initiative into all the disconcerning sites in the states. So along with the Spanish teacher and the advanced algebra teacher, we have our -- our pediatrician in the disease prevention mode discuss with the children preventative health, proper nutrition, anti-smoking, et cetera. MR. MENN: Eric Menn, Partners HealthCare of Mass. General. Just as an extension of what Dr. Sanders was saying, in an integrated delivery system, it is very much in a capitated environment in our interest to keep people out of the hospital. So it is economically reasonable for us to install telemedicine infrastructure as a vehicle by which you will keep people at home or with their primary care provider. And that further (inaudible). MR. TUCKSON: The issue here, again, that's so important -- we come down to this discussion as we get into rural subsidization, who bears the cost. And again, it's a matter of what -- the profits, not-for-profits, who pays those fees. And there are a lot of us who are really concerned about the highway bypassing inner city America and how do you try to give a little bit of equity to that. And if it's just the folks who have -- who feel that there is an economic incentive to enroll patient population base, get access, that's one thing. That's great. And it's logical and it makes sense. But those who are not enrolled in that population base with that particular managed care firm not still get left out. And so I think you really hit the real issue. And it really starts to get down to now this notion, as Mike said in terms of fairness of equity of access and the portion of subsidization and how do you make that happen. MR. LAWLER: Can I ask an ignorant question which -- in the rural -- and I'm sure that there's nothing but a generalization answer to this -- is the extent of capitation in rural areas getting anywhere near where it is in the rest of the country? VARIOUS SPEAKERS: No. MR. LAWLER: Is it a totally different environment.? VARIOUS SPEAKERS: Yes. DR. SANDERS: The basic problem that you're having and one of the things that telemedicine can help to alleviate is the reality -- is just the actuarial reality. Managed health care can't go into a rural community. Even if you have a 1,000 member rural community and all of them sign up for that managed health care entity, all you need is one catastrophic illness to totally wipe them out. From an actuarial standpoint, it's a disaster. However, what telemedicine can in effect do is to electronically consolidate ten 1,000 member rural communities into a single provider base so that you now have 10,000 electronic members made -- in ten different communities. And telemedicine will, in fact, facilitate the ability of managed health care to begin to market into rural areas. MR. LAWLER: Mike. MR. KIENZLE: You're not suggesting, are you, that the -- they're going to shear risk -- insurance risk electronically? I don't think -- DR. SANDERS: Not electronically. MR. KIENZLE: But even within a rural setting, the consolidation and integration that goes on, it goes on independent of whether managed care is in that state or not. People are finding a lot of reasons to integrate within health care systems. And so we're really talking about systems of care and I don't think we can assume that just -- that this applies only in a capitated environment. DR. SANDERS: I agree with that. I just wonder if -- MR. LAWLER: Is the percent of those with insurance -- I think I do know the answer to this -- different than in the rest of the population? MS. PUSKIN: There's -- I think there are a number of issues. The University of Minnesota has done a lot of studies for us on the extent to which, a) there is vertically integrated systems being developed out there and the extent to which they are undertaking risk. And in the first instance, let me say that the extent of vertically integrated system is -- has not proceeded at the rate that they proceeded in -- in urban areas, but they are increasing. But it is a much different picture. And there are a whole host of reasons why. The extent to which risk is being undertaken out there by rural systems is -- is quite minimal. However, that is misleading because, in fact, you have a lot of people who are part of so-called managed care that are out there with their urban-based systems, but they really are a preferred provider organization. But they're not really systems of care. And so it gets very complicated. What do you mean by managed care? And your original question was real capitation. And real capitation where people take responsibility for the full health care of the population is -- is much less, much less out there. And what Jay was suggesting is that the -- the evolution to that will be enhanced by the availability of telemedicine for linking people. I think it's by the availability of telecommunications technology which allows record transfers and allows sharing of information. I think that is true, but I think it remains to be seen how fast that evolves. And, see, it's very, very important to not assume that managed care is generically termed. It's the same as really having really capitated systems. And it's really only when you get systems in which you take responsibility for the population that you see really the full evolution of this technology or the full use of it occurring. MS. POLTRONIERI: Just to go to the point of the availability of telecommunications services, generally, Section 254 B3 of the act which is not the rural health care provision, but it is the broader provision -- broader principles for how the action works, Section 254 of the act. And it includes support for rural high cost, low income consumers in insular areas. And that is separate from the subsidy that we're talking about, particularly for rural health care providers. But it's another part that's a piece that might fit in. And if that part is done right, that should help facilitate getting the infrastructure out that you're interested in. On a second point related to the definition of telemedicine and what was to be included in getting that definition to be broad enough, I just wanted to point out that 254 H1A allows for subsidy including instruction rendered to such services, telecommunications services. And this is a very -- this is very particular to the rural health care part of the act. It's different from -- there's no allowance for instruction in the school or libraries part of the act. And that's something that we essentially want to keep in mind as you look at key definitions of telemedicine. MR. LAWLER: Art. MR. LIFSON: Well, just -- Art Lifson of CIGNA. Two things. One is I don't think if we just look at this as integrated delivery systems that are solely focused on rural areas that are developed in rural areas and somehow confine themselves to a rural area however that's defined, that that is, in fact, the total universe. In many states, it's in fact integrated delivery systems that are in -- may have started in urban areas and move out into rural areas. And this comes back from both a provider perspective. You may have an academic medical center or a tertiary care hospital that for its own business reasons has decided to try to get control over its inputs and establishes relationships with rural hospitals, physician networks, et cetera, or it could be an integrated delivery system sponsored by somebody other than a hospital that for the same reason is going out into rural areas. That's point number one. Point number two, managed care is different in different places and -- because there are different demands made and there are different needs. And in many cases, it - - at least in our experience, it requires the adding of resources in a rural area in order to make this work rather than your moving into an environment in which there is excess supply. Clearly in most rural areas, there is not an excess of supply. And that, in fact, makes it a big difference. If I can make just one last point, somebody earlier in the conversation made the point about private activity and the incentives that exist for private activity to fill many of these gaps. And I think that is real and I think it is happening for lots of different reasons within our health care economy. And one of the things we have to be concerned about is in trying to meet the needs of this act, that we don't create disincentives for certain types of entities to enter a particular market. For example, if you create such a huge price difference in the subsidies -- and I don't know, we've talked about subsidies here but I'm not sure whether we're talking about two percent of 25 percent of 50 percent and I don't know what the total cost -- what proportion the total delivery of that service that subsidy represents. But assuming that it's significant and that it's large enough to move people, then you might -- may be preventing part of the capital from moving into an area where it might otherwise move. And I think we have to be cognizant of that and concerned that we might be cutting off certain avenues to capital that would otherwise be there. MR. LAWLER: Elliot. MR. MAXWELL: Yes, I -- this is more an appeal for information and data. Around the table, there are a numerous number of people who have done a rich of variety of things in the area of telemedicine or telecommunications- based health related activities. We're not hearing I think as much as is known from your own work -- and I think it's sort of becoming increasingly available -- about the things that you are finding critical in doing it. And we sort of have the greatest pay-off at least in the experience to date. And I'm very appreciative of the work that Tom has done in sort of analytically saying we can do all these different things. But there really is this rich variety of experience that we need to sort of get into this mix. I know that the vector work that Dena's work has been connected to has been trying to do some evaluation of that; what the HCFA work has been doing to evaluate this are all things that we'll make concrete what some of these services are that have the most immediate pay-off. And I -- because of this very short period of time, I really want to encourage people to get that into the discussion because the discussion about how theoretically these telecommunications could provide these services is interesting and useful and helpful. But we've got real data. And where we have real experience if we're not tapping into that, I think we make -- we make a kind of very short term mistake. This other part is very valuable for the long term, but I don't want to neglect that. And because some of the people around the table are not necessarily sort of part of all these information gathering activities, what you can do to make real for us and to make sure we're getting the things with the most potential benefit as quickly as we can would be very helpful. MS. PUSKIN: Can I ask help with that though? I think it's very important to articulate what the questions are so that then we can -- there is a lot of work going on, but it is not necessarily always targeted or relevant or maybe presented in such a way that would be relevant. So if we could really -- and I think this is what Tom was really getting at -- the questions are then those of us who are actively involved with different hats might be able to bring our experience more efficiently to bear. MR. MAXWELL: That's perfect and it's more than an appeal on my part. And I think that we are getting at those when we get at those questions and how to formulate them. But because of this window we've got, I really hope that people will sort of jump in and say, you know, here's what we've done and here's what's had the most impact and here's the problem we've had. We know there are problems about cost, but we also have these two kinds of interesting polar positions. And they're not -- they're not mutually exclusive. But they tend to drive you -- potentially drive disbursed results. I think traditionally, it use to have been that the availability of information about prevention and health care education sort of has taken people in one direction. Now clearly, that's increasingly available. There are 2,000 web sites about health care information. People are -- and people -- sort of with the exception probably of money, it's the place that people are going most on the web to look for information. Now, that's a very healthy, sort of in quotes, activity. On the other hand, at the high end of this, we talked about surgery and we talked about radiology and we've talked about cardiovascular work. That's a very different kind of activity. We need to be able to sort of an integrated way as a group make recommendations about what kinds of things are the things that will have the most punch to help in this area and are deserving of these kinds of support for the underlying telecommunications services. So as best we can, if we can try to keep our minds on how to use our own experience in finding the most powerful of these tools, it would be great. MR. SPACEK: I'd just like to sort of second that with Elliot and Dena's comments. I mean, the structure that I was talking about, the hard part of that structure is the part up front, in identifying what those applications are that will have the most punch that are the ones that we should be recommending to be included and so forth. And there are going to be trade-offs, you know, and different points of view. But that's the hard part. And that's only going to come from your experiences with these things, what works, what doesn't, what the barriers are and so forth. The stuff we're proposing to do after that to make those translations are relatively straight forward. It's not easy, but it's easier than -- than getting those applications understood and understood well and getting your -- those needs understood. So I think we need a major focus on that up-front piece. DR. DUKE: I'm "Red" Duke. I'm from Houston. And pretty quick I'm going to expose to you how little I understand about what most of you all are doing or talking about it. I'm a trauma surgeon and I've spent a lot of time trying to take care of folks in one way or another, both in rural and urban settings because we run a huge helicopter service over the whole southeast part of Texas. So what we're talking about here applies to both groups. I don't -- most people in this country haven't got the foggiest notion how big injury -- how big the problem of injury is. It's the number one cause of death under the age of 44; number one cause of death of all premature injuries - - I mean it's the number one cause of all premature deaths. We lose, you know, more people -- more per day -- more potential years of life each year from injury than we do from cancer, heart disease and infection put together. But nobody thinks they're going to get hurt. The trouble is they do. And I'm sure everybody has heard of the 60 -- the golden hour. But the problem is that's not 60 minutes. That hour is as long -- it's directly proportional to the cross-sectional diameter of the blood vessel that's cut or how long you can get by with breathing with the airway you've got left. We started working several years ago trying to figure out how we could get better information back to a medical center because if you're hurt and you've got a first responder that shows up at the scene, that may be a highly skilled inner city paramedic or it may be a volunteer basic life support person. And until you get back to some center, your survival is dependent upon that individual's interpretation of what they see and what they can feel and maybe read off of data generated from some kind of monitor. Well, what we've done is take some off-the-shelf materials like ProPak -- some of you might know what a ProPak is -- and modified it so that you can transmit, you know, like blood pressure, pulse, respirations and oxygen concentration. And we've been able to do that from an ambulance. And we tried to use compression techniques to transmit live video because this idea of a helmet which is going to occur within the next few years -- we've got, you know, a helmet like on the military -- the medics have got this where you can have an actual on-line realtime picture of what's going on at the scene is going to make a difference. Every year -- last year I saw three people come in dead as hammers. They had tension pneumothoraxes. And I'm sure most of you don't know what a tension pneumothorax is. But the way the paramedics are taught to treat that is with a needle in the chest. The only trouble is the needles get stopped up and the people still die. If you can -- Jim and I were talking about it awhile ago, if you cut an artery -- there's no excuse for people dying of a major artery cut in an extremity. But they do it all the time because the paramedics don't know what to do with it. They cover it up and then after it gets red, they take a bandage off and put another one on it. Well, you can just do that so many times before you run out of red. It's real simple to treat that if you just use some head, you know; you know, use your kidneys up here. But they don't get it. And so the whole idea is we're trying to get good information back to a medical center where somebody can do it and actually guide them through some procedure like a crycothyroidotomy. If you can't get an airway in, help them go through it because they don't do that every day. But that can be life-saving. What -- the reason that I'm am here is to suggest that in the division of this resource, that there be a commitment on a national basis to an EMS band. And I don't have the foggiest notion how wide that thing is, you know. I mean, like I told Jim, I feel like I'm the only tree in a pack full of dogs around here. I don't have the foggiest notion what ya'll are talking about and all that sort of thing. But I can sure tell you when a guy's going to die or not. That's all I've got to say right now, but I'll answer any questions. MR. COTTON: Greg, this is Steve Cotton from HealthNet, Texas Tech. One of the things I have not heard talked about here this morning from either task forces we've heard from yet is are we going to provide information to the FCC and the joint board about how to define discounts so that all these wonderful things we're talking about can, in fact, happen? As I look at the subcommittees, I'm wondering if that's more of a rural telemedicine -- you know, Jim Brick's group or perhaps it's an infrastructure. You know, how do you incentivize the creation of this infrastructure? But I think we can talk all day about what kinds of services need to be out there; who needs to have the services for what kinds of functions; how fast the compression rates and all of that. But I think if we don't address the issue of what is a discounted rate; what is an affordable rate for rural or for urban underserved inner city; if we don't provide some kind of input in that direction, I think we're going to be missing the boat and missing an opportunity to really help the FCC understand what affordability really means. I know in Texas in the last session of our legislature two years ago, a year and a half ago, they struggled quite a bit with this question of affordability. And some of the phone companies would go to legislature and they'd say we're going to give you affordable rates; we're going to only charge $1,500.00 a month per T1 in your rural hospitals; we're going to do you a favor. And the rural hospitals said, you know, we can't afford $300.00 a month. So I think this group has an opportunity to address the issue of affordable rates and discounts. The FCC in their request for comment clearly indicated that it wanted some guidance in this area. And I'm just wondering - - and I'm directing this to Greg or to Jim or to Tom -- is this an issue that you think can be, should be addressed in your subgroups or in the group as a whole? MR. LAWLER: The answer -- again, in two parts, the answer is yes, the law does provide some guidance. If I remember it correctly, it's the -- and Jim, you correct me if this is wrong -- what it says is -- and you can call it a subsidy or a discount, whatever you want -- an urban area gets the same rate as a -- I'm sorry, a rural area gets the same rate as an urban area in that state. So they -- MS. POLTRONIERI: For the health care providers in rural areas. MR. LAWLER: Right. MS. POLTRONIERI: Right. That's what's (inaudible). MR. LAWLER: So now, you know, that could mean a thousand different things. MR. COTTON: Sure. MR. LAWLER: But there is some -- you know, the law does say something that, you know, from the perspective of the law, we need to tell you what we think it means. In general -- and I'll just use Tom's sort of structure -- let's say we get through the, you know -- Tom's matrix and we come to a conclusion about precisely what we thing ought to be included and, you know, there is a question of affordability. I forget where it is in your chart. But it's in there somewhere. You know, we can make a recommendation that may not be included in the law that, you know, everybody ought to have a T1 and here's what it costs and it ought to go to, you know, this number of people. But I do think we have to be mindful that that is what the law says. Let me -- way in the back there. DR. KUN: I'm Luis Kun and I represent the Agency for Health Care policy and Research. Some of the things that we do involve cost and medical effectiveness. And I just wanted to point out a couple of items. One is that it's essential in order to do those studies to have information concerning all citizens and not just urban or just rural. And therefore, it ought to be structured not only to be beneficial for telemedicine, but also to start creating -- going with the model of the computer-based patient records that could be going to that infrastructure and do the studies more effectively. Secondly, the incorporation of this data, it may perhaps improve the lifestyles of the people in the city. Perhaps these studies can do comparisons between living in stress-free environments. And there's a lot to be learned from those environments in other areas. This (inaudible) prevention and fewer disease by focusing on wellness. MR. LAWLER: Cindy. MS. TRUTANIC: I just -- back to the other point about the charges for the access. From the networks that I've talked with that are in, you know, rural areas, it's not necessarily the access or the inter connection that's killing them. It's the transport element of the charge. And you know, so you cou