In the matter of: ) ) ADVISORY COMMITTEE ON ) TELECOMMUNICATIONS AND ) HEALTH CARE ) Volume: 1 Pages: 1 through 238 Place: Washington, D.C. Date: September 17, 1996 Before the FEDERAL COMMUNICATIONS COMMISSION Washington, D.C. 20554 In the matter of: ) ) ADVISORY COMMITTEE ON ) TELECOMMUNICATIONS AND ) HEALTH CARE ) Suite 856 FCC Building 2000 L Street, N.W. Washington, D.C. Tuesday, September 17, 1996 The parties met, pursuant to the notice, at 10:10 a.m. ATTENDEES: STAFF MEMBERS: GREG LAWLER, Chairman THAYER NELSON ELLIOT MAXWELL LYGEIA RICCIARDI MEMBERS: WILLIAM C. BAILEY, Southwest Bell Telephone JAMES E. BRICK, West Virginia University CANDY CASTLES, AT&T Wireless Services, Inc. JOHN CLARK, RONALD D. COLEMAN, Med-Tel International HELEN R. CONNORS, School of Nursing, University of Kansas Medical Center STEVE COTTON, University Health Science Center - HealthNet MARY JO DEERING, Department of Health and Human Services JUDY L. DEMERS, University of North Dakota School of Medicine MEMBERS: CHARLES DOUGHERTY, Creighton University JAMES H. DUKE, Herman Hospital WILLIAM L. ENGLAND, HCFA DIONNE GREEN, ROGER GUARD, University of Cincinnati Medical Center WILLIAM HAWKINS, Ethicon Endo-Surgery CHARLES F. HOLUM, Attorney, Doherty, Rumble & Butler GEORGE H. KAMP, American College of Radiology MICHAEL G. KIENZLE, University of Iowa College of Medicine JOAN KING, AARP JOSEPH C. KVEDAR, Partners HealthCare Systems, Inc. GREG LITCHFIELD, ART LIFSON, CIGNA TOM LORAN, MARY JO MACLAUGHLIN, Eastern Main Healthcare JIM MCCONNAUGHEY, MTIA DAVID METLZER, LOUISE NOVOTNY, Communications Workers of America ROBERT B. PILLAR, Public Utility Law Project of New York, Inc. DENA S. PUSKIN, Department of Health and Human Services GONZALO M. SANCHEZ, Sioux Valley Hospital JAY H. SANDERS, The Global Telemedicine Group AL SONNENSTRAHL, Consumer Action Network of Deaf and Hard of Hearing Americans THOMAS R. SPACEK, National Information Infrastructure Initiatives Belcore EUGENE V. SULLIVAN, University of Virginia ERIC G. TANGALOS, Mayo Clinic CYNTHIA TRUTANIC, Office of Tipper Gore REED TUCKSON, Charles Drew University of Medicine and Science ROBERT WATERS, Arent Fox and Center for Telemedicine LaW BILL WELCH, Nevada Rural Hospital Project BRIG. GENERAL ZAJTCHUK, U.S. Army Medical Research Development and Logistics Command, Department of Defense I N D E X VOIR WITNESSES: DIRECT CROSS REDIRECT RECROSS DIRE None. E X H I B I T S IDENTIFIED RECEIVED REJECTED None. Hearing Began: 10:10 a.m. Hearing Ended: 4:05 p.m. Recess Began: 12:20 p.m. Recess Ended: 1:17 p.m. P R O C E E D I N G S MR. LAWLER: First, I want to welcome everyone and thank people for their hard work. I am not going to single anybody out. There has been a lot of work that's gone on over the past, well, really since our last meeting. Normally more of it happens at the end than at the beginning, or at least the visible signs of it. So a lot people have been working very hard. I know some didn't get their, either due to the U.S. Mail in some cases, or errant faxes, some did not get the things that were sent out. If you don't have them, anyone that doesn't -- let me just run through these things. There is a -- Lygeia, would you just hold that up? There is a memo with findings and recommendations that was faxed out to people. If you don't have it we have got them here. There is one that does not have it. If you would just pass it around. And another. Let's just pass them around. MR. SANDERS: Did you say errant fax or a red box? (Laughter.) MR. LAWLER: There was also, and this was sent out by mail, I don't know, at the beginning, like Tuesday of last week, which is a compilation of all the subgroup reports. And, Judy, I know you did not get one. I don't know if you got one subsequently. MS. DEMERS: No, I got one. It came about three hours before I left. MR. LAWLER: They are coming around, a couple more. There is also -- where is Tom? There he is. There is also a redraft of the infrastructure subgroup report which I don't think anybody has. So why don't we pass that around. It's obviously going to be too long to read immediately, but it's some, not -- well, I will characterize it my way. Tom can disagree. They are not major changes, but they are minor changes after discussion, and it is now consistent with the recommendations, findings a recommendations we've sent out. MR. SPACEK: Please throw away the infrastructure report that's in the combined package. MR. LAWLER: Is the other one going around? It is. And if we don't have enough of those, which we may not, we will make more. MS. PUSKIN: Is it possible to get some kind of printed -- some of it's not very readable. MS. RICCIARDI: Yes. I want you to know we tried to do it from disks, but do to a series of computer errors, I made some fax copies. We can try that again. MS. PUSKIN: Well, does anyone have a clearer copy. MR. SPACEK: I have a clearer copy, if somebody -- it's back to back. MS. RICCIARDI: Okay. MR. LAWLER: We will make clean copies, and whenever they are ready they will be ready. All those are being reproduced. Hopefully, we will have them soon. When Lygeia returns there are a couple of things that are going to happen during the day. I guess the staff of the joint board is a round Elliot, and they are going to join is at some point for a discussion, a couple of events like that, but I will wait for Lygeia to get back because she knows who and when. What I thought we ought to try to do today is really going through the findings and recommendation attached to this document. My memo is a cover sheet to what's nine pages long. And called FCC Telecommunications Health Care Advisory Committee, Summary of Findings and Recommendations of Subgroup reports, and use this as an outline as we go through of where the difference subgroups arrived, what the actual findings and recommendations that we would be making are, and use that to provoke discussion, although before we get stared, Lygeia, if you could just run through or schedule for today, in terms of who is -- other than our discussion, who is coming and when. MS. RICCIARDI: Yes. For those of you who missed the Intel SAT presentation, which Cindy Trutanic arranged for us yesterday, David Meltzer will be returning at noon and again at four o'clock to talk to us formally or informally and bring us up to speed on a program that they are beginning. Also, later in the day we're going to have the opportunity to meet members of the state staff of the Joint Board. These are the people who staff the state commissioners who make up the Joint Board, and they will be in here about three o'clock, at which time we will give them an update of what we have been talking about, and just get to talk with them. MR. MAXWELL: Let me just piggyback onto that. They are a very important group because with respect to the Joint Board they will be advising the state commissioners who sit on that board as to the recommendations, and there are obviously a very strong connection between what you have all been doing and the work of the Joint Board. We plan to take the recommendations and to put them into the public record so there would be comment on it. But these are the folks who will be making a preliminary analysis of what other people say and what you say, and how it relates to the recommendations as to what will constitute universal service and what the particular provisions regard to telemedicine are. So I would encourage you to, if you have got concerns and ideas, to make them know to these folks. MR. LAWLER: Let me just describe before we get into the findings and recommendations what has gone on that I am aware of anyway. The subgroup reports came in, I forgot what the date was, but either right before or right after Labor Day. I think there was some interchange among the subgroup heads of those reports. There was a lot of discussion that went on. We tried to pull out from those the findings and recommendations like you see here. There were several long phone conversations between subgroup heads about where there were inconsistencies or things that needed to be meshed. And this document, I think, I hope reflects those discussions. It is for the most part consistent, although as Tom's report, subgroup report changes indicate, there are some changes, but it is mostly consistent with the different subgroup reports. So what I would suggest is we go through this, have a discussion, I'm sure, on some of these things will be some disagreement, and that's what we are here for, to have that discussion, and see if we can arrive at a consensus by the end of the day or maybe by 10:30, if we're, you know, all in agreement. So why don't we start at the beginning. The first finding is a general one. I actually have even seen a comment about this -- I forgot where I saw it -- about this should be a -- we could add to this the fact that it will help reduce cost, which I think is a good point, but hopefully this is not going to be one we're going to spend a lot of time on. Anybody have comments on the first finding there? MS. PUSKIN: I would be -- as much as I think it has a potential for reducing costs, I think that the jury is out on that. So I think one might want to talk about potentials as well as more than realities if one ever adds that comment to it. MR. LAWLER: I'm sorry. On cost? MS. PUSKIN: On cost. MR. LAWLER: Say potential on cost. MS. PUSKIN: Right. Because I think there is -- the history in the health care field of new technology as it's been -- MR. LAWLER: Always add costs. MS. PUSKIN: -- an add-on and not a substitute, and while there is this potential in some instances, certainly from the average, if we prove access from a system-wide point of view, we may in fact be adding costs that are well worth the investment, don't misunderstand me, from many peoples' perspectives, but I think we should not be glib about that. MR. LAWLER: The whole thing is couched in terms of potential. MS. PUSKIN: Right, right. MR. LAWLER: So obviously it's consistent. Anybody else? MR. SANDERS: Of course, they are between per patient cost and -- MS. PUSKIN: Right, exactly. MR. LAWLER: Right. MS. PUSKIN: Exactly. But since this is a terse finding, I mean one. MR. LAWLER: Finding number two here, they are not numbered, but the rural telemedicine one is just really what's underway out there shows that some of these things do work in terms of improving access. Any disagreement there? MR. GUARD: I would add consumer health and patient education information. MR. LAWLER: Consumer health? MR. GUARD: And patient education information. MR. LAWLER: Education information. No disagreement there. Any other? MR. SANDERS: There is another critical component of the education. One of the primary impacts is to provide a colleague to the primary care practitioner -- MR. LAWLER: Right. MR. SANDERS: -- out there and improving the educational level of the primary care practitioner. MR. LAWLER: How would you say that, Jay? Just that improving? -- MS. PUSKIN: Health professional education which can go in a number of way, both didactic and preceptorship-- MR. SANDERS: Right. MS. PUSKIN: -- things which we want to skirt that one a little carefully because some practitioners while it does do that, some of them would argue that they are also educating the urban practitioners at that rural practice. MR. SANDERS: I would be the first to say that. MS. PUSKIN: I know you would. That's why I said it. MR. LAWLER: Is everyone comfortable with education of health care professionals? The third finding is infrastructure and costs, both obstacles to successful rural telemedicine efforts. Okay, the first recommendation is the definition of rural -- Dena, I know you had, or I didn't hear it directly, but I overheard you saying there was something. MS. PUSKIN: I have no problem with deferring to our office. I have problems. My staff has been working with the staff of the FCC, and I know there is some discussions about using some of the Telco definitions. And we are having some problems with that. So I don't -- Elliot, you and I and Lygeia need to talk off-line about what this is. I just got this message cryptically from one of my staff who is working with the staff. And so we need to just explore what that is and make sure we have -- MR. LAWLER: Dena -- well, go ahead. But I think for these purposes, the advisory committee -- MS. PUSKIN: Right. MR. LAWLER: This is appropriate. MS. PUSKIN: This is fine. Right. MR. LAWLER: Okay. MS. PUSKIN: And the reality is, the off-line reality is what happens with FCC staff later. MR. LAWLER: Right. Could I actually -- Lygeia reminds we, we have a court reporter. So, unfortunately, we all need to identify ourselves before we speak just so the court reporter can get it. Dena, can I ask this? This is a very cryptic sentence and this is not a simple subject. It might be worth spending a minute describing what the approach is that the Office of Rural Health Policy believes is the right one. And then I think it's important that we have that in as -- you know. MS. PUSKIN: We have given a little bit of background material, but we certainly can write up even more if it's needed. MR. LAWLER: Yes. I think maybe if we -- I don't know what the right length is, but if we had a page describing succinctly precisely what it is, you know. MS. PUSKIN: Let me just say for the group, just to give -- we have struggled with this because we have had to implement programs where the ultimate person filling out whatever is being filled out is often a clerk. And you have to have definitions that are administratively reasonable for definitions. And really there are two questions here in defining rural: which areas should be designated rural, and among rural areas, because of the issues of comparability, and there are wide variations in population density size, you might want to distinguish among types of rural. And I think the most extreme is the frontier areas versus the townships of New England. Both are rural but they have very different characteristics and very different needs. So we, for the purpose of administering public programs, which we have to do all the time, we recommend that the in the first area that we designate non- metropolitan statistical areas as defined by OMB as the first cut on defining what is rural. Now, the problem is we have within those, and those are county-based definitions, so they are easy to implement. The problem is we have some very large counties in this country. Counties are not uniformly defined. So you have Pima County in Arizona, which is huge, or San Bernardino County which goes from the Pacific Coast to basically almost, almost the Pacific Coast to the border of Nevada. How do you define within that where you have, you know, large cities the rural area where there are more road runners than there are people? Well, we have developed something called a Goldsmith variation, which is basically after Hal Goldsmith, who is our demographer, and he basically has looked at that and come up with some definition for these very large counties to subdivide them in a way that is administratively simple, and we provide that based on census data. Then you have gotten now the metropolitan counties that are large, and you have gotten their rural areas out of them in an administratively simple way. Now you have got to distinguish among this great variety of rural areas. And we are recommending the use of Urban Influence Code, which have been developed by the Economic Research Service at the Department of Agriculture. There are lots of reasons why we think these are superior to anything else that's right out there, and also it's administratively simple. It's again based on counties. The data are easy to get at. You can put out a list and say here, you know, code yourself. And so we are looking for ways of defining -- of getting both as sensitive a measure of rural, because these are going to require some sensitivity for purposes of administration, as well as administratively simple. And so this is what we are recommending. We can write up a one pager on pros and cons. It is what we recommend for a whole host of reasons. MR. LAWLER: Jim, did you have any comment? MR. BRICK: Dena did send this information, and I sent it to you guys after we had sent this in, and I am sorry it didn't make its way into the report here, but she did send me that -- MR. BRICK: -- describing this. MS. PUSKIN: But it may be that I -- I sent you something really sort of designed as background for the committee. MR. BRICK: Right. MS. PUSKIN: And for staff. But maybe what they need is a little more lay type of write up. MR. LAWLER: Right. Right. MS. MACLAUGHLIN: Mary Jo MacLaughlin, Eastern Maine HealthCare I just wanted to reinforce the fact that we -- that Dena really put out a good explanation of rural at our first meeting, and we, who have very, very large counties in our state, were very pleased with that. And I think that if we just make sure that it gets into the recommendation to specifically talk about how we are going to break that out. That would be very helpful to states that reflect large counties. MR. LAWLER: anyone else? All right. UNIDENTIFIED SPEAKER: Greg, should we go ahead and change the wording to say that then we use that definition instead of follow the lead? MR. LAWLER: Yes. You're right. UNIDENTIFIED SPEAKER: I mean, just make it a recommendation. MR. LAWLER: Right. MORE. MAXWELL: And that there be some brief description of what that recommendation is. MR. LAWLER: Absolutely. Yes. MS. PUSKIN: Yes. MR. LAWLER: We need, as I think Dena used, a lay description of what it is, but enough so that someone reading it knows what it is, and if they need more detail precisely where to look. MS. PUSKIN: And if you want, we could actually list, you can list the counties that fall under each. It gets pretty complicated. MR. LAWLER: All the counties in the United States that qualify? MS. PUSKIN: Yes, but in fact what you end up doing in the end is -- administratively that's what you give a clerk, and you give a clerk with a -- UNIDENTIFIED SPEAKER: We can just attach that as part of a record -- MR. LAWLER: Sure. UNIDENTIFIED SPEAKER: -- for this, so that if there is any question, it will be in the record. But for the purposes of the committee it can just be the recommendation is that the Goldsmith variation as played by Van Gould -- MS. PUSKIN: And the Urban Influence Code. UNIDENTIFIED SPEAKER: You can tell that Elliot and I have been working together. It's now an attachment rather than a footnote. MR. LAWLER: Okay. The next recommendation, and this is really a series of them. Why don't I do this, Tom, if you are willing, this is from your paper, do you just want to go through and give us a brief description sort of bullet by bullet. MR. SPACEK: Sure. MR. LAWLER: And how you arrived there, and start the discussion that way. MR. SPACEK: Okay. For the minimal package basically the approach that was taken that was sort of joint between two of the subcommittees was actually -- we actually ended up defining a marketbasket of services, and we did that not by an approach that you will in the further recommendation about what to do in the future, which is actually to take a survey, but using members here as a proxy for that survey. So in the report, and I think this is probably pretty much the same in both the old one and the revised one, there are seven different telemedicine items listed that seem to me to be the most important items that you needed to do. And so given that marketbasket, what we then attempted to do is say what is the band width that would be needed to accomplish that at reasonable speeds. And there are footnotes in the report where how long x-rays would take and how long other things would take. And what we had come up with is that 384 kilobits per second was sufficient to do these kinds of things, but that's clearly open for discussion. And I guess in addition to that we had some footnotes that if, for example, someone had a higher speed line, or even 384, depending on what you were doing, you could use those same lines for other things. For example you could use a T-1 or a quarter T-1, which is 384, for your telephone service. So, okay, somehow it would have to distinguish that if you use something for things that are not covered by the act, that they should not be given discounted rates. In any case, 384 is what we had come up with, although I know there are some people in the room here who would prefer T-1, and we can have that discussion and you buys can decide, okay. Secondly, there was internet access, including electronic mail, information access, cooperative applications and so forth. We didn't cover the pricing of that in this recommendation cause pricing is really a separable issue and comes up later. And I think when you see the pricing differential recommendations later, I am not aware of any urban area in the U.S. at the moment where you can't get flat rate internet access via a local call. That could change over time, of course, but at the moment that will get covered later. But internet access as a service is also in the recommendation. And on that same issue, internet access could also be done using your T-1 or 384 line also. In fact, some of the larger areas -- well, people who want to use more, do more video or imaging on the internet might chose that as a preference, and that would be another valid use of that line that would be covered. That's actually about it on this particular recommendation. The -- there is two things that, in sort of working on this and thinking about this over the weekend, there is actually two things that should change compared to what is written here, and I think it doesn't change the proposal. But basically in this particular recommendation it says what the 384 is used for. It should not say that. Rather, we should have a footnote and have the marketbasket listed, you know, that we have in the report, because, you know, these are the things. And then another item is that something that we say at the bottom of the fourth bullet is that although we have this marketbasket there is no intent that your use of telemedicine would be limited to that marketbasket. In other words, you are getting this telecommunication services at a discount rate. Any telecommunication application is okay to use. Okay? So that sentence should probably get moved up to this recommendation. So basically we are saying there is a marketbasket which has these seven or eight things in it. You are not limited to that 384 kilobits, internet access. That's the minimal package to meet the marketbasket in the recommendation. MR. LAWLER: Tom, also, why don't we get to all of these bullets at once, and then I will ask Jim and Eric, who also participated in various parts of this if they have comments. But the emergency services, you have a recommendation. What else? Home health care. MR. SPACEK: Yes. Why don't we just cover those now. MR. SPACEK: Okay. MR. LAWLER: And have a full discussion on this. MR. SPACEK: Okay. On emergency services, and especially for mobile units like helicopters and ambulances and so forth, the recommendation here is to have a minimum of 9.6 kilobit data transmission to enable reports to emergency departments, urban trauma centers and so forth on vital signs and things of that sort. Relatively low speed. Cost-wise, it probably, you know, urban and rural, probably not much difference in that except when we get later into infrastructure development there probably will be a difference in getting the infrastructure further out into the rural areas to do that. This is the -- this is what's recommended in the minimal package. And as you will see when we get to advanced services later, we are recommending that in these biennial reviews of what the minimum package is over time as you move advanced services and you consider that the Joint Board and the FCC consider many additional types of services as costs get reduced and infrastructure gets built and so forth, such as you can potentially video or, you know, imaging and video from ambulances and helicopters. Okay, so the recommendation though here is 9.6 for mostly vital sign information, available to any rural area that requests it. Yes? MR. SANDERS: Just one thing, Tom. In this bullet, just from a semantics standpoint, the first sentence says, "Based upon experience," et cetera, et cetera, "80 percent of the casualties are occurring in rural areas. To reduce this imbalance," well, we're not reducing the imbalance in terms of the casualties. MR. SPACEK: Casualties, yes. MR. SANDERS: Really what we are reducing is we need a sentence in between there which, and this is the data, that there is a four to one greater morbidity and mortality to rural casualties in Texas. This was a study done by the University of Texas about six years ago. MR. SPACEK: Could you mail or provide the details on that? MR. DUKE: Hey, Tom, it's also in other places too. I mean, the same -- the disparity and distance from where it is in the country -- I am Duke. But they -- it's the far out, that's why -- the travel faster, and they are harder to find, and when we find them, you still got that period between the time they find them and the time they get them back where you can do something effective, and that's where I'll be -- and time goes get to be important, you know, when that -- you know, when you are watching that blood run out on the highway, it does -- time becomes imperative. MR. MAXWELL: Is the four to one, or approximately that, pretty consistent? MR. DUKE: Those are just number of guesses. Those studies have been done all over everywhere, and it's kind of following a gillion different states. I just happen to be in Texas. But the first one ever done was in California, and then just different people looked at the same thing, and it's just kind of a principle. I wouldn't live by that exact ratio, but you may die by it. MR. LAWLER: Jay is correct on the grammar though. He is also right about the merits, but there does need to be a different -- MS. PUSKIN: In order to improve this something about -- that's what you're looking at, right? MR. LAWLER: Right. MR. DUKE: That's the whole point. If you can get, if you can get someone out there -- if you have some person or responder out there who is communicating with a knowledgeable person at a center. MS. PUSKIN: That's right. MR. DUKE: You've therefore extended the physician care to the same, which beats the thunder out of variously trained, wonderful, but variously trained first respondent. MR. LAWLER: Right. MS. PUSKIN: Now, let me just say that w have done a study in North Carolina which supports this, a very detailed study in looking at the problems of rural emergency rooms as well. And what you are trying to do is beef up the emergency response system both at the first responder level and the emergency room. MR. DUKE: I couldn't agree more. MS. PUSKIN: And I want to talk a little later about why there is some inadequacies here in some -- MR. DUKE: You are absolutely correct. MS. PUSKIN: But, in fact, we have problems in both, of which this technology can be a major difference. MR. LAWLER: Just anybody who can get us references to the studies or the studies themselves it will help, again, you know, bolster the report in terms of this is something that the -- MR. DUKE: You want a bunch of references? MR. LAWLER: -- yes, the Joint Board and the FCC can actually look at and say, you know, there is data here, we're not making this up. I'm going to first go here. MR. KIENZLE: Mike Kienzle. You know, the magnitude of the rural/urban disconnect, I think, is the basis for the emergency medical services statewide kinds of things that are happening in many states. I mean, the fact that there is a rural/urban discordance has given rise to the kinds of state-generated legislatively mandated emergency medical services acts, and those are in place in many, many states. So I think that's been recognized for some time. MS. PUSKIN: Unfortunately, that -- it's nothing compared to what was in place in the seventies in the Emergency Act. We have real problems and holes. MR. SULLIVAN: Eugene Sullivan with a question. Does 9.6 then meet the needs of the emergency services? I wonder if we are setting our target maybe a little bit too low there. Obviously, the ER is going to want a lot more information, and we can't give them everything, we may not be able to give them everything, but I think we need to look higher than 9.6, and maybe your studies show that. MS. PUSKIN: Right. Well, that's what I was getting at. It's one thing to talk about 9.6 for the first responder at the scene, and the other issue is what do you need at the emergency room once you get someone there or once they are there in terms of relationship to follow up with in fact a tertiary center in terms of follow-up care and what you need. And I'm not sure about the 9.6 for the first responder, but I can tell you on the emergency room level or the rural emergency access community hospitals which people are talking about, which is a whole different model that we're talking about here, I am not -- I am convinced 9.6 won't work, and I certainly am very skeptical about 384. MR. LAWLER: We have another comment here, Tom. MS. CONNORS: Helen Connors. I would just say that since I am hearing people say that there are studies that have been done out there, that we change that first part of that sentence instead of saying, "Based upon experiences in Houston," because it sounds like it's too local, and it sounds like there is other broader studies done. MR. DUKE: That it goes down to local. MR. LAWLER: Tom, did you have a -- yeah, I agree with that comment. You are absolutely right. We should get the other studies references, and it should be broader than Houston. MR. SPACEK: Yes, and on your comment, there are two separable issues. The 9.6.6 is the -- you know, the first arrivals and so forth. And once you are in the emergency, you know, in an emergency area, clinic or something of that sort, then the telemedicine services available would fall under the other items, which would be the 384. MS. PUSKIN: And I think we need to talk about that separately. MR. SULLIVAN: But I think Dena and I said the same thing. Does the first responder need more than 9.6? MR. SPACEK: Oh. she didn't -- MR. SULLIVAN: And I think if there hasn't been a study done, maybe a study needs to be done cause 9.6 would probably give them about the same capabilities as they have now, which is the voice saying blood pressure, et cetera. Why not look to more tools to aid them out in the field? Pick a number, 14.4, 28.8, something up there that maybe they can take a picture and send a high quality image even though it takes a little bit of time? MR. SANDERS: But Picasso does that now. MR. SULLIVAN: Right. At what speeds? MR. SANDERS: I don't know. And the question I was going to ask is what modality are we talking about? Are we talking about cellular capability? MS. PUSKIN: We are talking about that. MR. SANDERS: Now, I know there will be a quarter of the T-1 within the next 12 months on cellular, but it doesn't exist now. What can we get from cellular? That's what we're talking about. MS. PUSKIN: But 20., we can get now, and that does give you a lot more capability. I mean, I would agree, I mean, I didn't want -- since this is -- the area, first responder, is not my specialty area, and I think we do have someone here who it is. I think we should really defer. But I would say base on our experience with our outreach grants, which we have funded some of them, we go to a higher band with those. We use 28.8 modem capabilities and that's questionable too. MR. DUKE: Duke again. I can 'tell you about the cellular. We had a lot of tough experience with that. We tried it, we tried compression. Now understand, I don't understand what I'm saying. If you talk about 9.6, you can tell me anything and I'd believe you, you know. (Laughter.) But I am talking about trying to make it work out in the field, and we used -- we tried cellular transmission by using phone lines, and somebody from Oklahoma had a technique or some technology to compress it, and they were using it, selling it to new stations to show people tornadoes. Well, the hooker is if you go -- if you have a new authority, particularly tension pneumothorax, and for you that don't know what that is, you've got too much air pressure in one lung, you've blowing along and you've got more pressure in there than you've got blood coming back to the heart, you're going to die if somebody doesn't fix that. And it doesn't work. If you move and you go from one cell to the next, and it goes dead, and you can't find it again, you know, or it -- also, it's too slow. It doesn't give you -- you either get a slide show, you know, or you're so far behind the guy is already dead anyway. It's interesting you said you would do a study on this thing about whether -- what impact it has. The only study that I can tell you, and I don't how else you would get it, but Dr. General Zajtchuk, who is a member of this task force, told me not long ago that out of the 8,000 odd autopsies done, complete autopsies done among the Vietnamese men in the Vietnam War, 80 some odd of those men died of tension pneumothorathine because they had -- MR. SANDERS: Head and thorax, the closed head wound and closed chest wounds are the one major casualties. MR. DUKE: So that is one of them. MS. PUSKIN: So what would be needed? I mean, it's just that -- what would be needed? MR. DUKE: Don't ask me the number, but ideally we perfected the -- I say "perfected," I haven't done anything. We have worked with people that are a lot smarter than I am, and they got this little bitty cameras, you know, and doing this stuff trying to transmit this stuff back if you can get some band width to do it on. You know, I don't know how many bits, bytes or anything else it takes to do that. You know, but if you can see it -- I mean, I can tell a paramedic out there better put a chest tube in, put it down one rib place lower, and so forth. MR. LAWLER: Jay. MR. SANDERS: Well, I feel somewhat credible in discussing this. I helped start an EMS system in Dade County, Florida. The reality is that in the example that you give, tension pneumothorax, the real need is for the EMS personnel to be able to, you know, identify tension pneumothorax, and that's listening to the lungs and feeling -- MR. DUKE: Well, they do this all the time, and I defy you -- I mean, I know what the books say, and I know what everybody teaches, but in the emergency room you can listen to one of those buggers and he will have plenty good breath sound, and be all dead as a hammer. MR. SANDERS: I know, so what then is -- MR. DUKE: You can tell by the way -- it's the look you can get on their face and the way they are breathing, and also if they start getting a lot of subcutaneous emphysema and they're not breathing right, that sort of thing. You can pick them up. And the thing, you know, that we teach them now, you know, to stick needles in there. This last year I had three people come in dead with needles in place because the needles stop up. MR. SANDERS: I actually think, and it's probably for another time, if you actually look at the trauma cases that you are dealing with, it's not going to be the picture that is going to give you the information. It's going to be the training of the EMS personnel and their audio capability and their hand capability that is critical. But with that said, my feeling is we ought to provide as much band width as possible to EMS in rural areas. By the way, the sentence that I would stick between the first and the present second sentence in that second bullet would be, "However, the trauma expertise that exists," I would say, "There is a great disparity between the trauma expertise in rural areas versus urban areas," something to that effect. Then I would say "to reduce that imbalance." MR. MAXWELL: Just a question. There is a difference between getting as much band width as you are able to get and going back to at least the injunction from the law, which is to say establish a kind of comparability, listings that are essential. And so I have no expertise in this, but to the extent that we are talking about it, we're talking about this is to what is deemed essential in urban areas, not sort of what we are capable of getting. So with respect to whatever recommendation the committee makes, it should be thinking about what is available in urban areas as a basis for determining what's essential for health care, and therefore the services need to be available at comparable rates. MR. KIENZLE: Mike Kienzle. I think the committee has to be a little bit careful about defining applications and band width that might be in some circumstances essential. I mean, from the perspective of someone who is very familiar with the problems of rural hospitals, who are often somewhat vulnerable to vendors of certain types of hardware and software, that there is a problem in holding out in a public forum a certain application that may be helpful, but it may not be helpful. But one thing is certainly true, it is expensive. And so I would just hope that we can be reasonable about what we're defining as being essential, and try to recommend those things that are clearly been shown to be helpful and valid. MR. LAWLER: Cindy, did you have a comment? MS. TRUTANIC: I'll wait. MR. LAWLER: Okay. Eric, hold up. Tom, why don't we finish running through this set of bullets, and then we will have this entire discussion, and Eric and Jim, if you have comments we will -- when Tom is Done. MR. SPACEK: Okay. The next item is a recommendation with respect to nursing homes that several people thought was very important that not-for-profit nursing homes be considered to be covered by the act. It turns out that, in reading Section 254(c)(1), where it defines -- I'm sorry, I have the wrong page. But anyway -- let me find the right -- MR. LAWLER: Here you go, Tom. MR. SPACEK: I have it. Okay, it's 5(b), as health care provider, it defines health care provider in 5(b). And no matter how you try to stretch your imagination you can't -- I mean, it's hard to say that nursing homes are covered there, okay. So they are not. I mean, we were hoping that there would be some category that say, ah, it falls under that. So what the recommendation basically is, is that the FCC consider either a mending the act or new legislation or something, however one would change something, to get nursing homes included. That's that recommendation. The next one has to do with this marketbasket of essential services, and that is, even though this group sort of as a proxy came up with the seven items that make up the marketbasket, in addition to the fact that you can do anything else within -- within the telecommunication service that is discounted as long as it is telemedicine, that that should be reviewed every two years, cause applications change. They may have greater requirements, or in some case, less requirements if there is better technologies and compression techniques or something of that sort. But in any case, it should be reviewed with a group that has the characteristics of this group, in the sense people who do rural telemedicine, people who know telecommunications, and other health care -- government, health care providers and so forth. And the idea is to continue, you know, equalizing telemedicine services in rural and underserved urban areas. And we also recommend, based on some of the members of the committee,that the revised marketbasket perhaps come up with taking a survey of sort of well served areas. Okay, I guess that's really it. The last sentence there, you know, I already suggested moving that up to the band width recommendation. So that's the marketbasket approach, and this method also -- this is put here also, this review, so that we really review the applications and what you need to do in telemedicine; that the idea is not to review band width. Once you review that and decide what is essential, and if the -- you know, the bar moves up for what is essential over time and what is affordable over time, that you -- then you figure out what that is, and then translate that somehow into telecommunications and with requirements. So we are just recommending a similar approach in the future that was used by this committee except for the serving. Okay, there is a lot said here about home health care, and how to expanding and becoming more and more important and why it's becoming more important. It's covered in the next recommendation. And the idea here is that we are recommending that services for home health care be identified and potentially be included in the first biennial review, and we look at that to see the status of technology at the time, the costs and so forth, to see whether not-for-profit home health care providers would be included in the next round of marketbasket. MR. LAWLER: I just wanted Jim Brick and Eric Tangalos, they -- sort of a joint effort in this one. MR. BRICK: I guess the only comments I have about this is I am concerned, as Dena is, about the 384. The folks that responded to me in my group in the multiple surveys that we did, I don't think that there was a single person that said that -- that used a number that was as low as 384 for the service in the rural hospitals. I think that the practice around the country that is going on as people moving when it's available and when they can afford it, and those are two important issues to the higher band width services in those small rural hospitals, and I am very concerned that we will set a standard here that will become not a minimum, but a maximum, and that because of that, if folks have the money, and they have the wherewithal and they have the need, that they are willing to make the investment in a higher band with service, that they are going to have difficulty obtaining services. That's my major concern about this. The issue about the other end of the spectrum, about the emergency services and the ambulances and with the first responders, I don't think we have enough information to -- we have even less information on that end of the spectrum, about what is needed and what's necessary and what people are using across the country. But I think on that end we also need to set a standard and we need to -- and then in the biennial reviews that this can be evaluated, not just leave it open-ended. And from what I am hearing from Jay and from other people that have some familiarity with what's the capabilities at that end of the band width, I'm not even sure that 9.6 is enough to do anything other than tell the doctor in the emergency room what the patient's blood pressure and pulse and that kind of thing is. And that's not, I don't think, what they are talking about. I think they are looking to have a little more information than that. How much is necessary, I'm not sure. That's an end of the spectrum where we haven't done very much work. But if we're going to -- if we want that end of the spectrum to expand, I think we should give them enough band width to be able to use it for something, and get something out of it. And maybe we can learn something that in these biennial reviews can be used to change standards. MR. LAWLER: All right. Eric. MR. TANGALOS: I think the chair struggled with two issues that needed to be resolved here, nd it was interesting to see everybody lock on 9.6. But that's one of the issues. We need a discussion of 384. The question is, is that a minimum, is that a maximum, where do you want to go with those things. And that relates to the other issue here, which is the marketbasket. And Chuck Dougherty in our group, I mean, in our report, eloquently described the difficulties in a marketbasket, and that's again what we have already started to discuss; that as you define elements, you are putting things in and leaving things out, and the closer you define what those services are, the less likely you are to allow other services later on to be in there, and the more you are really defining the max rather than the minimum. And so I think that a discussion -- we need guidance and direction as to, one, what the minimums are going to be; and then how closely or clearly do you define a marketbasket. How much do you want to say this is what's in that versus saying these are the services that we think, you know, are kind of out there that that help gauge what the proposes are? So that's the two issues that have to be resolved before we go forward. MR. LAWLER: Let me just add, and this keeps hitting me, and if people think this is irrelevant, so be it. But, and it really appears later on, actually it's the next section, the backbone infrastructure. I think it's important to keep in mind exactly what we're talking about here. We are talking about two things that the law says will happen. The first is that you get a comparable rate to an urban area. So, you know, a hospital in West Virginia, you set up a telemedicine network, I don't know what the urban rate will be in West Virginia, but whatever it is in that state you get the comparable urban rate. But we are also talking about something more than that, which is sort of what I call the build out of the rural infrastructure. It also means that if that infrastructure is not there in the parts of West Virginia that your telemedicine network is covering, whatever the term in the act is, the eligible telecommunications carrier, whoever is either going to volunteer or be drafted to build that infrastructure, they are going to have to build it to whatever we -- whatever the Joint Board and the FCC decide is the -- you know, the minimum that they are going to have to build it to. So it's not only an issue of, well, are we going to give them a cheaper rate, it is you've got to go build the infrastructure. And I just think it's important to keep that in mind when we're talking about all this, because, you know, somebody is going to go spend a lot of money doing this, and the Universal Service Fund is going to put out a lot of money to support it. And obviously, you know, if you go -- I don't know what the most sophisticated thing you could build in the world is, but if you say ever rural area has got to have it because we might want to use telemedicine, we would quickly run out of money. So we need to keep that in mind. Tom, did you have a -- and I will be right over here. MR. SPACEK: Yes, I have two comments. One, Eric, with respect to the marketbasket, I think that's -- you know, it's an excellent point. You don't want to try to define what's in it and say you can only do those things. And I don't think that's what was done this year, nor are we recommending in two years. I think what we are doing is saying defining a marketbasket as a guide, and that's how it was used. In other words, these are the things that people are claiming are the most important things that need to get done, essential things. And then as a guide use that to determine, or to estimate what some band width requirement would be, because that's the thing you are getting the discounted service for. You have to specify what the service is that is going to be cheap, okay. And then specify that you cannot -- that that marketbasket was just a guide, and any valid telecommunications application can be used on that service, okay. And that's a little different approach, and I think that makes it a fairly amount more flexible. Just one comment on your -- MR. LAWLER: Sure. MR. SPACEK: In building out the infrastructure, that's sort of, you know, technically -- you know, it is costly and all that stuff. But in some sense it's a little bit less of an issue than the 384 is or the 9.6 is in the sense that this is the -- the 384 and 9.6 is what you get to use at your site. The infrastructure development most likely will have facilities -- you know, when people are burying cables and all this stuff, it's much less expensive to put in more than you need, okay. And that typically is done and all that. MR. LAWLER: I agree with that. MR. SPACEK: So that would be less of a problem. MR. LAWLER: Yes, I agree with that completely. Let's go over here. Judy? MS. DEMERS: I am Judy DeMers from the University of North Dakota, and I served on the infrastructure subcommittee and I was the one hold out who opposed the recommendation of 384 and supported the T-1 as the minimum. And I did want to comment on that in terms of, first of all, I am not infrastructure expert, but for that reason I developed a group of about 12 to 15 people that I talked to consistently as this information came across, and to a person, they feel that the T-1 is the minimum that we need to use for a number of reasons. First, if you look at what's available in urban areas, the infrastructure committee report says very clearly that T-3 is available in most of those areas, and yet we are wiling to say for rural areas we will go with a quarter T or a 12 volt difference. I guess I don't think that's particularly appropriate. Second, if you're going to build a system, you don't underbuild a system, you overbuild a system to begin with because the technology is going to catch up very rapidly. Thirdly, you can't buy 384 in my state. So we can provide subsidizes rates for 384, but the fact is if a rural hospital is going to use that system they are going to have to go out and buy T-1 and pay full rates for three-quarters of that T-1. Folks, that doesn't make sense. I think that's extremely discouraging, if not prohibited, to many rural hospitals that we are trying to reach. I also called my U.S. senator. I have been working with his staff as well as we have received these reports. And they talked to the VA for me. And the chief information officer at the VA, Dr. Robert Collander, said that the VA Hospital also selected T-1 as their minimum for all of their hospitals basically because of significant clinical implications; the ability to split, the ability to use four quarter T-1s for different purposes and different kinds of transmissions. For that reason I think that, even though I have great respect for what my subcommittee has done, I am still in disagreement with the 384 and would urge us to consider the T-1 as the minimum. MS. MACLAUGHLIN: Mary Jo MacLaughlin. One comment about the home health care bullet that's been inserted. As a matter of fact, I spoke with Jim Brick several weeks ago about including the point about home health care. It talks about during the first biennial review to consider home health care for possible inclusion in the minimum package. I wonder if this is a wise thing to do, to wait two years to address this issue. Because as we know, more and more people are being forced to go home earlier or stay home longer. And therefore if we can't even address this issue for two years, I am afraid that the marketplace is going to push people into the homes, and even to a greater extent than they are now, and those folks attending to them won't have the opportunity to have some of the advance technology that even EMS has, or some of the small rural providers. MR. LAWLER: If I, and this is really just a comment on what the law says. If you read the seven categories of people who are eligible under the law, I don't know how you get home health care in there, but somebody smarter than I, cleverer than I may be able to figure out a way. So I think the only other recommendation we could make would be that the Joint Board and the FCC ought to consider recommending a change in the law. If we are going to do that, I think we ought to have some evidence to suggest that there is a -- here is the reason you ought to do it, and, you know, we may have that. I have not seen it. We may have that. And, frankly, I wouldn't suspect that this is going to be changed immediately no matter what we suggest. So, you know, I think we ought to think carefully about, you know, do we have the evidence at any point in time to suggest this, and have it taken seriously. I think at least we ought to pay the attention due it to see whether or not this might not be a recommendation made to them, to include home health care, because to exclude them, I believe you are leaving out a huge chunk of the world population, and will cause greater expense because that rural population will then have to seek services at the hospital. MR. LAWLER: Right. Chuck? MR. HOLUM: Yes, I have a question related to that and also to the nursing home question. Is there talk already of some kind of a fix bill for the Telecom Act. I mean, is there going to be some legislation? MR. LAWLER: How long did this one take, Elliot? Twenty years. So. MR. HOLUM: But that doesn't mean you wait two years to start the process. If you start now, it will take four years or 20 years. MR. LAWLER: Right. MR. HOLUM: And maybe you want to start putting these ideas into the report. MR. LAWLER: Sure. MR. HOLUM: The nursing home language is similar and troubles me just because the more I learn about these different reasons the more I am troubled by saying nursing home because that probably includes things and excludes a lot of other long-term care facilities. And I would recommend saying, for instance, nursing homes and other long-care facilities in rural and underserved areas so that you don't exclude some whole category of facilities. MR. LAWLER: Just while those words are on the table, anybody have any objection to that, other long-term care facilities? Cindy? MS. TRUTANIC: Cindy Trutanic. First, I would just like to express my gratitude as a member of the infrastructure subcommittee for Tom and Sid Hussain who really put in a lot of work trying to really pull together a lot of various and different thoughts from subcommittee members, and I think they did a very good job. The marketbasket of services language has been a difficult one for us to manage because while I think the services is important to identify services that are used to serve as an illustration for the types of -- the kinds of band width that we are recommending, it is a slipper slope because they you, as Eric said, you get stuck in an application-centered approach which is limiting and may not keep up with the technology. One of the things I think that we can do, which is it's mentioned as a guide indirectly in our infrastructure report but not in the list of recommendations, and I think if we just specifically state that this is by no means an inclusive list, but a guide for the infrastructure recommendations that we have made. The one thing I disagree with, though, is that to compare the applications -- to use the service applications in an urban context to compare them to service applications in the rural context to achieve some sort of parity, I'm not sure that's the way to go because the applications in an urban community may be very different than the health applications required in a rural community. And the Act really talks about the parity of the rates and of the skeletal structure or the potential to get the infrastructure there. And I think you get into trouble trying to compare urban and rural services, you know, service by service. I don't know if anybody has any other thoughts about that, but it seems to me kind of difficult. MR. LAWLER: Jim? MR. BRICK: I just wanted to make one more comment about the home health care issue. I had a lot of conversations with Mary Jo back and forth about that during the last month, and she is very eloquent in her -- in her pleading for us to do something about that. And I think there is an issue there that maybe we could say is more strongly in here. I'm not sure how to say it, a recommendation, that this needs to be looked at and it needs to be looked at soon if it can't be covered under the bill. And the reason why it is is because there are other people believe that this is a valid thing. The industry is interested in this. At my place we have had several folks come in there looking for people to partner with as a way to use telemedicine, to be able to deliver home health care. I know that -- I think that Hewlett Packard has a project with the Mayo Clinic, and also the folks at Duke looking at that specific issue. And, you know, I think this is an area that is going to expand, and I think if we can put -- make some more stronger language in here that we recommend that this be pursued, maybe it can't be done under the provisions of the law now, but I think that is an area that is going to expand, and that we should go on record as saying that we are aware of that, and that we think it should be pursued. MR. TUCKSON: There is a related point on all of these that I don't want to introduce a third issue in terms of the diad that we are dealing with. Maybe we can come back to it. But what we have is we continue to talk about underserved as well. There is this language in both the second and third bullet that talk about underserved communities being distinct from rural, and being distinct from purely urban environment. So there is a whole another set of issues. And what we haven't done in the record as I read it is to describe what that means, what is an innercity or urban underserved area and the special challenges therein both for nursing homes and home health care, as well as the marketbasket issues. And this is probably a little different discussion than the one we have been having on these two points, and so I just urge us to put a footnote to that and come back -- MR. LAWLER: Okay. MR. TUCKSON: -- to what does that mean. MR. LAWLER: Sure. MR. MCCONNAUGHEY: Jim McConnaughey, MTIA. A couple of points on the third bulleted paragraph. Maybe I have been inside the Beltway too long, but I think we may want to clarify the language, the third sentence talking about the objective of equalizing telemedicine services. I think the act points more towards similar services on a reasonably comparable basis. It's a bit of a nitpick, but it's -- we may want to show that this group is in sync with the act, not blazing a different trail. The second point is I would share the concerns that a number of folks have said about this marketbasket process. As an economist, sort of my instant knee-jerk reaction is how about if a rural health care provider needs a service, they get it, and then they get a discount in the sense of the reasonable comparability with the urban provision of it. That could be fraught with difficulties too. I mean, in terms of the size of the fund, well, and just trying to keep track of that sort of thing would be a nightmare as well. But it seems to me there should be sort of a cost benefit type of look at this sort of thing; that it is probably the right way to go though. There are some concerns but perhaps it should be mention in the report that we realize that a marketbasket is not a panacea that, I guess guide was the word that was used along the way here, I think that would serve us well. On the subject of the biennial review, I was just curious about why two years was chosen, and why -- not why, but what group would be constituted to do this sort of thing, and would it be under the auspices of the Joint Board which would, I guess, have to be reconvened, or would it be under the umbrella of the FCC? MR. LAWLER: Well, I think I -- I don't know where two years came from, but I suspect it was, you know, carefully considered. One or three, how about two. MR. MCCONNAUGHEY; I don't have a glib answer. MR. LAWLER: But I do think -- I mean, there was in fact a recommendation, I think, Tom, it was in yours, that the advisory committee continue. Actually, I will take responsibility for suggesting that that might look somewhat self-serving to say that we ought to continue our existence, you know, forever so we can provide you advice. (Laughter.) MR. TANGALOS: We did not have the hubris to do that. (Laughter.) MR. LAWLER: And the thought was, you know, it didn't have to be this group, but there ought to be a group out there of, you know, representing similar interests with similar expertise that was available to say, yeah, we have moved, you know, the technology has moved, the rural medicine has moved, something has moved, you know, so you ought to look at it this way as opposed to that way. And my recollection is, Elliot, and you correct me, I think that, you know, this would ultimately be something that the FCC would continue. The Joint Board is got at some fairly quick point. So I think, you know, it would be up to the FCC in the future to update any of this that needed updating, and I think a lot of it probably would. MR. MAXWELL: Elliot Maxwell. I expect that also the Joint Board would make a recommendation about how this should be reviewed in the future as well. MR. LAWLER: Right. Let me start here and then we will go. MS. DEERING: I want to get back to the marketbasket question as well. And without trying to come to closure on exactly what we put in, I think it's clear that everyone agrees that it will be illustrative. We had also talked earlier on that as a matter of process it was at least the effort to address what constituted this marketbasket that would then indicate what types of services that were needed. I wonder if we couldn't get around some of our difficulty by putting the marketbasket in a preamble or an introductory, moving it up front with the clear statement that it is illustrative. After all, the state/federal board will not know exactly what it is we are talking about, and I think that it might be helpful and important for them to see the array of specific functions that can be carried by these services to illustrate the importance of it, and that gets around the issue of recommending a specific marketbasket. MR. LAWLER: Just so I understand what you are saying, you are suggesting that wherever, earlier on than this there actually be a description of the different services that would be available under whatever the -- MS. DEERING: What is it that it does. MR. LAWLER: Right. MS. DEERING: Who does what with it. MR. TANGALOS: Having looked at Chuck's comments again, it doesn't get into what the pieces are, but it's a very nice discussion that he carried out earlier on, on that concept, and you might want to use some of the language that we've got. MR. MAXWELL: Just a comment. I think that one of the interesting things about any advisory committee like this and the people who are getting the advice is that sometimes you get so far down into what you are doing that you forget the audience knows far, far, far, and I can -- dot, dot, dot, less than you do, and will have less ability to understand why you came to that conclusion. So I think any comments about the process, sort of what you were assuming and what the process was for getting to this conclusion will be helpful so that when they have to make a decision about, you know, do I have to say this or that, you've taken them through it in a way that they can say, oh, I'm comfortable with the notion that they have looked at it, they have looked at the act, they have seen what the charge is, they have made a right decision, and I can do that. And so I think those are good suggestions to improve sort of the understanding that your readers will have. And we can work on that as we short of reach consensus about the recommendations, about how to present it in a way that makes it accessible to the audience. MR. SULLIVAN: Gene Sullivan. For Greg and Elliot both if I may, I think -- I applaud the idea of an extension or a continuation or a reforming of the advisory board. There is a lot of issues that we're not going to finalize today. Just as a quick example, Jim and I, Dr. Brick and I were talking about the act and who is considered a health care provider, and who is then afforded this act's protection, if you will. What if a not-for-profit hospital has a nursing home affiliated with it that's also not for profit, does that nursing home gather the same benefits as the hospital? And then what about the not-for-profit nursing home that's across the street that's not affiliated? And then we go into the home health care. So that could be a whole session or two for a group like this -- MR. LAWLER: Right. MR. SULLIVAN: -- to further discuss. MR. LAWLER: I agree with that completely, and I think the fact that there is a list in here and it is a limited list, this is going to be -- some are going to get an advantage out of it. But frankly I don't know what we do about it other than say you ought to look at, you know, changing it for these other things because -- MR. SULLIVAN: But we may need to do that because of the -- again, the market forces, if you will, from those that aren't benefiting starting to ask for changes to the Telecom Act, and it's not going to take 20 years this time to make some of those changes. MR. LAWLER: Right. There is a recommendation later on, I forget precisely where it is, about, and we talked about this in the last meeting, that, you know, this is not available to physicians in their offices in rural areas, whatever percent people said, health care delivery in individual offices. So if it's not there, you know, people are not going to get it. And my recollection is we recommended that that is something that the FCC should look at to change, but it does open -- you know, it becomes very complicated. You have a, you know, successful practice in a rural area. They are making plenty of money. Do they need a subsidy? So they -- but I agree with you, that just shows the need for continuing review of this. Let me go over to this side. MR. ENGLAND: Bill England. I just want to make sort of a technical comment first on the 9.6. As an engineer, my guess is that that the band width for -- we're talking wireless on that issue -- is pretty well defined. I mean, the Motorola engineers that are designing transceivers, the cell phone people, have already defined the band width. My guess is it's substantially, it's a round 28 probably. So if we go out with anything less than what's currently standardly available, it would be just wasting the rest of the band width. So I am not sure what that is, but my guess is it's more than 9.6, and I don't think we should pick something less than what's out there. Secondly, on the home health issue, This is to be a subsidy to nonprofit providers. And for the same reason that Medicare has a problem dealing with home care, not that it's not needed, and all our demonstrations show that it is wonderful, but as soon as we make the service available it can easily get out of control. And we are now talking about not 8,000 hospitals and maybe a limited number of nursing home that can well be defined. But as soon as we talk home health we have got every potential rural home in the country possibly involved. And I think if we -- if we put that in here, we are loading this potential subsidy with something that could just completely drag the whole thing under, and I would be a little scared about putting that out there. Now, if it's not needed, I just don't think this is the way to address that. They have already got 288 available just by virtue of the phone lines in the house, and I think that for now is quite adequate. MR. LAWLER: Dena. MS. PUSKIN: Well, I would sort of like to respond on a number of levels here. It's Dena Puskin. First of all, very quickly in response to the home health, the real issue we have out there in getting services to the home for a lot of different things, and I would argue this is also true to private doctor's office, is dial up access to the internet. For many of the things we need to do, we need local dial up access to the internet. And we can do an awful lot with that kind of capability into the home. And I point to what's going on in Hayes, Kansas, and a number of examples where we already have demonstrations at home health. If we get the first part of this defined as to what is a reasonable universal service in rural areas period in terms of the kind of band width, I think we go a long way to addressing it, and then raise the question as home health as something that needs to be very carefully looked at over the coming year with a specific time frame on it. I think we get around, because Bill has raised a lot of very good points, but other points have been raised. This is a growing area of immense importance in the health care system, and especially in rural areas. But that would be my recommendation, which is, again, to make sure that we get the equivalent of local dial up access for all rural people, and I think we go a long way to solve it. The other issue that I have is, and it goes back to this definition of nursing homes, and who should be a provider here. The law is very vague. As I said in my testimony, I don't know what a community mental health center is. There is no definition of that that we use any longer in the federal government. A community health center with a small "c", small "h," small "c" again, is that one that gets federal money? What do we mean? We need a recommendation or we need to begin to deal with defining who are the providers, even as specified in the current statute. And I think we need clarification, and I think the FCC ought to go for it because no matter what decision you make you're going to get some congressman mad as hell at you if you don't get clarification, and this is a very important issue. We could make recommendations here. This group has -- I mean, I can talk to you about FQHEs. I can tell you who I would include. But I am not sure that makes sense politically. I think you need to get clarification from Congress as part of a dialogue, and I think that should be part of a recommendation that I don't see anywhere here, and I was hoping that I would see it. MR. LAWLER: But, Dena, do you agree that that list of seven does not include home health care no matter how you read it. MS. PUSKIN: I agree -- MR. LAWLER: And it doesn't include nursing homes. MS. PUSKIN: And I agree, and I think we need to have -- there are two issues here. What it doesn't include that we need to have it include, and I think nursing homes, we have had now a number of grantees in which the ability of this technology to improve the care of patients in nursing homes and long-term care centers is enormous. I don't necessarily think, you know, I am not going to argue what band width you need, I don't -- it's not the same as you need in a rural hospital. Let me leave it at that and we can discuss that a little later. But we have experience with it, and it is enormous, and the law is remiss in not including it, okay. So I think we have what's not in there, and then what is in there not being well defined and very problematic. And I think we need, and I think those are two issues here. In terms of underserved which was raise earlier, which indeed the statute addresses, I think the question is what do we mean by underserved. Do we mean underserved in terms of the telecommunications infrastructure, or in terms of the providers in the community, because there is a difference? I can have an area that is underserved, I don't have primary care docs out there, I don't have psychiatry, but in fact they may have an infrastructure out there that's pretty decent. I think that it is very important that we define that and deal with that very carefully. I think the staff is dealing with underserved in terms of actually the infrastructure and not in terms of the providers, but I think that's what the intent is. MR. LAWLER: Right. MR. KIENZLE: I'm Mike Kienzle. Would some of the problem -- would some of the problem that's been expressed of what is intended to be a floor becomes a ceiling, would it be actually improved by inserting the words "or higher" after each of the band width specifications to explicitly indicate that that's -- that there is a range above that that's also at least potentially eligible for subsidy. MR. LAWLER: And this, I guess, is how the reader reads it, but my own opinion is anytime you put a number in there, then that's the number even if you put a bunch of, you know, words around it, that becomes the floor and the ceiling. Others may differ. MR. SPACEK: In this discussion, when we get back to it of 384(d)(1), you may very well want to consider that because you really have to specify something that some service that you get the discount for, and you've got to -- it has to be essential, so, you know, you can't make it too high, but you need it because you can't just say "and higher" because that's anything that's available for discount. And I think that that, you know, the guidance that -- my understanding of the guidance that's needed is what is available for discount. And it gets reviewed, you know, over time. MR. WATERS: This is Bob Waters, The Center for Telemedicine Law. I do think on the issue of whether, you know, nursing homes or home health agencies are covered, Jim raised a pretty legitimate point, which is that even under the existing definition it may be possible for those entities if they are owned by a covered institution to also get coverage, particularly in those components where I think we could easily see applications like a nursing home. I think we need to make a recommendation that that be addressed so that there is sort of a level playing field out there because that can cause, I think, some real distortions in some areas. To that end, I think it would be helpful in terms of the way we present this to sort of group together those areas where we believe there ought to be an expansion statutorily of the covered services, whether it's nursing home, home health, or underserved urban areas, but just organizationally I think that would make the report a little clearer to folks because we have sort of skipped around a little bit on that. But I think our intent is to have certain categories of things that ought to be added, and then other categories where we are making recommendations within the statute. MR. LAWLER: Right . Let me just, and I think there is going to be -- you know, assuming that the subsidies, if I can call them that, are significant to people, who gets covered I think is an issue that is going to be incredibly important as we go forward. Frankly, I don't know how to address it. I mean, does a rural hospital that -- pardon my phrase, but owns the doctors, you know, they have an HMO or whatever, but the doctors also have independent offices, you know, they are paid a salary for a not-for-profit that clearly qualified, do they get the advantage of this? You know, probably. You know, the competing doctor across the street who, you know, for whatever reason is on his own practices at the hospital but on his own, does he get it? No. But other than describing that and saying this is something that you've got to look at on an ongoing basis, and that's the easy example, there are probably of them that are more complicated, I, frankly, don't know how we address it other than to say this is something you've got to look at it. MR. SPACEK: Later, again the organization of this is -- you know, this may not be the best, but we are getting into a lot of issues that also will come up later because there is the resell recommendation later which touches on this issue; at least gives guidance. You know, it won't resolve all the individual situations one can come up with, but it least it will give the FCC and the Joint Board guidance as to the intent. MR. LAWLER: Right. Cindy? MS. TRUTANIC: Just one last comment on the health care issue. Cindy Trutanic. I do think that there is a growing trend towards taking care of elderly, chronically ill and home bound mentally ill individuals in their home. And I think that we just need to recognize for the record that there are other ways of providing home health care services that are less costly than, you know, laying new fiber out to every home in the country, and that the second generation of cable modems that are being explored may be an inexpensive way of doing it, and there are other pass-throughs into homes. So I think by not acknowledging that this may not be a great tax on the subsidy fund, you know, the Universal Fund, that we have to just acknowledge that there are other ways to skin this cat, and that it may be worth pursuing in the future. MR. LAWLER: Let me try -- let me find the one on physicians. Actually, it's not on physicians. It's on health care professionals, which is on page 6, and maybe there is a way to try to deal with all of these in one recommendation, which I may fail in this attempt, but let me try. This is a general statement. It says, you know, most people get their health care in an individual's office in a rural area. You know, they are wonderful people. To the extent that the patients don't have access to this telemedicine through them, you know, it does not benefit the patient. And then the last sentence is, you know, what our suggestion is or our recommendation, which is that the FCC look at this. Let me just try to throw out as a -- you know, as a possibility to this. We have got what I will call a competitive equality issue, which is, you know, is this fair and whether it's the nursing homes example or the physician example, you know, across the street from each other. One gets availability of it, one doesn't. We have got nursing homes. We have got home health care. Is it worth putting all of those in one and making a -- Dena, actually this corresponds with the point that you made, and really making a suggestion that who is eligible for this is something that needs to be addressed, and can't be addressed simply by -- my own belief is it can't be addressed simply by the FCC. As wonderful as you are and as clever and as much as you can interpret regulations, Elliot, I'm not sure you can make this one work, to address these issues. And that way we get the opportunity to say, you know, you have got to look at this. Obviously, you go forward with what you've got, but you've got to look at this. You have got a competitive issue. You've got an access issue. You've got all these things covered. And try to cover them all in the -- you know, in one sort of category, and, you know, tell the Congress this is -- we want this to work, it's a good thing, but you've got to pay careful attention to who gets it and who doesn't, and then they will shoot us for dropping this, you know, for raising this issue with them. MR. SPACEK: I think that was the same thing that I kind of thought I heard over there, the recommendation, which is really a matter of, you know, how the report is organized. I mean, in making our decisions today about which category or what we want to make things is to look at in two years, or to change it, for example, to say we recommend that this, you know, be looked at for potential change, that's just -- I think we can take those one by one. But when you organize the report, you probably want to put all things of that ilk, you know, together in one spot in the report, and all others in -- I think that's what you are recommending. MS. PUSKIN: But I think there are some things that they have to address now or very soon. You need guidance now as to -- on some things. MR. LAWLER: but, Dena, that's what we need to try to figure out right now though. Some of these things I am suggesting that you can't deal with them; that Congress has got to deal with them if they are going to deal with them at all. MS. PUSKIN: But Congress needs to know that they need to deal with some of them now. MR. LAWLER: Fine, and we -- yes, and we can say that as clearly as we can write it down. MS. PUSKIN: Right. And some things may require some study, and I think you need to distinguish between those very clearly. I mean, the ambiguity in some of the current designations I know cause Elliot's staff calls me and we have been working on it, and there are no easy answers for them. MR. LAWLER: But that's not -- well, this is the question. I don't believe that's in the category of something that Congress has to address. You can take whatever it is, a community health center which does not refer to anything in another statute, and the Joint Board and the FCC can interpret that, you know, to include some things and not include some things. If we have an opinion, we can recommend it. I'm not sure we do. MS. PUSKIN: Right. Well, I do. (Laugher.) MR. LAWLER: Jay? MR. SANDERS: I think, in listening to all the comments, that we have three issues that really can come to closure on right now. MR. LAWLER: Right. MR. SANDERS: Number one, I would just echo the comments that Bob made and that you made, and that is that we have got to at the very least identify critical constituencies within the bill, within the law that have really been excluded that we consider to be very, very critical, and we have named them. And I think at the very least we have got to state that we recognize the fact that this is an inadequacy as we see it at the present time with the present legislation. Number two, one of the things I think that we are all having angst with is reviewing this in many respects as the last meeting. And one reality or one recommendation we need to really very strongly underline is that this is a dynamic living process, and there has got to be this review. Whether it's a year or biennial or every three years, it's got to be reviewed. And whether it's this body and these individuals or whatever other mechanism, it's got to a dynamic, living re-review process. And I think, third, I have heard a lot of comments about the issue of 384 versus T-1, but I really haven't heard a lot about -- I haven't heard a lot of people standing up and saying, well, it's got to be a quarter of T- 1. So I would like to recommend that we take the minority view and that we recommended full T-1 access. MR. LAWLER: Can I -- I want to try to close one issue at a time here. MR. SPACEK: Do you want to close one in order, and I think that was the first one? MR. LAWLER: Do we have agreement on the recommendation for the three groups, nursing homes, home health care, health care professionals, that that's something that we recommend that Congress has to look at? Do we also have agreement that the competitive issue is something that we have to look at covering not-for- profits the way health care is changing. When you say "not- for-profit," there are a lot of -- I don't know what the right word is, people earning a profit under not-for-profits who are competing with people who are for profit, that that's something that needs to be looked at, and we can't address with the language that is here? Is there any disagreement with that? Done. Now, for the noncontroversial part of it. 384 versus T-1, let's continue the discussed because I think there is a little more? Bill? MR. ENGLAND: In terms -- Bill England. In terms of the law, I thought the standard was going to be urban areas, and I guess I am wondering do we have to define it, but simply to say that the subsidy makes available at a reasonable cost similar to the urban area, however you want to define it. So if you want a T-1, it's what a T-1 would cost in an urban site, not at your rural site. And you can -- or T-3 would also get a subsidy. We don't have to specify a specific band width for the subsidy. MR. LAWLER: Well, let me again, again, not to rely entirely on the word of the act, but what it literally says is a telecommunications carrier provide whatever is necessary for the provision of health care services for people, for an institution which is providing service to people who reside in a rural area. So it doesn't say you get whatever you get in an urban area. It says whatever is necessary for health care in the rural area. And I think that's why everyone is saying, okay, you know, what the hell does that mean. MR. TANGALOS: Bill, part of the issue on the low side was that Mayo has hooked up with providers that were at 12, and that's a disaster to try to communicate at that level. And so we don't want to it below a certain minimum because you can't -- you can't work with it. So we were looking at it not from the high side. Indeed, if somebody wants to provide -- if somebody wants to buy T-1 at the urban rate, that's what they are going to do, but we know that with each increment you are paying more and more. And we heard from plenty of rural providers that with each jump it's going to cost us more, and there are only a certain amount of dollars that we're going to allocate to this anyway. So there is a lot of reasons on the low side and on the high side why we compromise to 384. MR. SPACEK: Yes, this is not the 384/T-1 issue, but it's the issue of saying another reason, I think, why we have to specify, in addition to like what Greg said, is that Section 102 of the act also requires the eligible telecommunications provider to give you whatever service is recommended in the minimum basket. So, you know, if somebody in some island somewhere wants, you know, off the coast in a rural area wants some, you know, an OC-12, and we don't specify that T-1 is it for now, you know, they get it, and that would be sort of an unrealistic thing to do. MR. KAMP: George Kamp, College of Radiology. Related to this discussion, I also am surprised that it hasn't been mentioned the changes in data compression technology. In my own practice, we work with everything from the 112. I absolutely agree with you, Eric, it's awkward, it's difficult. We work all the way up to T-1 lines. But data compression technology is changing so rapidly with the wave length compression of up to 30 to one, I think, now has FDA approval. But this emphasizes the point Jay makes. This is a rapidly moving target, and whatever we say has got to be looked at again and soon. MR. SPACEK: Do you want to try to reach closure on T-1 versus 384, whatever represses you would like picked? MR. MCCONNAUGHEY: Not to beat a dead horse here, but given the statement he just made about how dynamic the industry is, could there be two or three years and then perhaps, or a petition from interested group? I mean, if there is some incredible breakthrough maybe two years isn't soon enough to reconvene the group and do a new batch of surveys. MR. LAWLER: Well, I mean, the easy part of this, and I -- you know, I think two years was the number and they picked it, and it wasn't immediate and it wasn't too far away, I mean, we could certainly recommend, for example, without, you know, saying you have to keep us around forever, that this being an ongoing -- this being an ongoing process of consultation, whatever the right words are, advice from, you know, people with the same expertise as the people in this room. I don't have any problem with that at all. And, you know, when there is a -- it doesn't have to, you know, we don't even have to recommend that they, you know, who they are or when they meet. But if there is, you know, a breakthrough or for some reason the experience says get together and tell the FCC they ought to change something, they don't have to wait, you know, for two years. They could do it in two weeks. MR. SPACEK: Yes, you may want to say that there should be a formal review at least every two years, and by petition or by some organization or whatever in the interim that, you know, could be called for another review based on a breakthrough or whatever else. MR. LAWLER: I guess I'm -- it just seems to me we have got to look at this in terms of what we think is realistic in terms of cost. You know, I happen to believe, and Tom and I have had this conversation, that we ought to recommend T-1. People are using it, it's out there. But I also think that -- I don't know whether people remembered this, at one point, I think it was in your last paper, Tom, there was a distinction between the different providers. Rural hospitals were going to get 384, and I forget what others were going to get, something less than that, which I don't -- you know, just in terms of the law I am not sure it works. And then distinguishing between the seven categories of providers, you know, we will have everybody gone made within a short period of time. But I do think we have got to look at what the, you know, there is a cost to this. And even though, yes, people overbuild -- you know, you put home health care in, and you say -- we say T-1, and anybody who want home health care, you know, you put in T-1 to every home in a rural area where someone is getting home health care. I mean, I have no idea what that number is, but I suspect that we can't afford it. So I do think there has got to be some context. Jay, you are shaking your head in disagreement over there. MR. SANDERS: Yes, because I think one of the things that we, and I have fallen into this trap many times, I get so hooked into the idea of health care as the use of the telecommunication infrastructure that I forget about the fact that the telecommunication infrastructure you put in, once it's in place can be used for all sorts of things. MR. LAWLER: Right. MR. SANDERS: So when we talk about cost, what happens when we get interactive entertainment and shopping and banking and commerce coming into the home on that same telecommunication infrastructure. Our costing for that is going to be a lot less. MR. LAWLER: Well, Jay, I agree with that completely, but I don't -- you know, we can call Time Warner or somebody else and ask them, I don't think they are putting that in rural Colorado right away. MR. SANDERS: No, they are even having trouble in Orlando, Florida. MR. LAWLER: Right. So I do -- to the extent that we put in, you have an instant mechanism and an immediate mechanism in place to say that you get this, you know, eventually it's going to get there cause it's going to get everywhere, but I do think we're saying do it here sooner, and, you know, there is a cost to that. MS. DEMERS: Judy DeMers from the University of North Dakota. I just want to remind us all that we also in this report endorse the sharing concept between public schools and libraries and health care facilities. And I guess in my state, and I would guess in many more states, you know, that's what is going to happen. We are going to see that joint kind of approach. And that's why I think the T-1 is minimal at this point in time when you talk about the ability to split and use and who has priority and all the other kinds of issues that you are going to see out there. I can't imagine that the school system and the public library and the hospital are not going to work together because this is something they all -- MR. LAWLER: Right. MS. DEMERS: -- very badly need. MR. LAWLER: Let me, in the interest of trying to split this baby, and, Tom, listen to this, what would people feel about recommending T-1 with the condition that it is found to be affordable under the Universal Service Fund? MR. SPACEK: I would go for it. If I were going to put it, I would just go for T-1 or 384, and not say that because part of the determination of the size of the Universal Service Fund in some sense will be what we recommend. MR. LAWLER: Okay. MR. SPACEK: So, you know, I would go for, you know -- UNIDENTIFIED SPEAKER: Do it or not do it. MR. SPACEK: Yes, go for one or the other. The only caveat I would have is if you were going to say T-1, or that you would say something about that the intent of that is for telemedicine services, and if you are lumping your voice and other things onto that, that, you know, the discount is appropriately allocated. MR. LAWLER: Jim? MR. BRICK: May I am misunderstanding, but is what we are saying here is up to T-1 or are we saying that's all the subsidy is for is for T-1? MR. LAWLER: Well, that was a question I raised, which Tom said he's not enthusiastic about, which he says prick a number, T-1. If you want T-1, you get a subsidy for the urban rate for T-1, and you get it built to your facility. MR. BRICK: But I think that's -- correct me if I'm wrong, Tom, that's not quite what I heard. I heard him say that we need to pick a number, okay, but I didn't hear him say that it wasn't okay to say up to a level, because it may be that's all you're requiring. MR. SPACEK: Up to T-1, up to 1.54 or whatever. MR. BRICK: I misunderstood. I'm sorry. MR. SPACEK: I don't know if I said it, but that's what the intent was. MR. MAXWELL: Let me see if I am understanding that and maybe make one clarification. It seems to me that for the purposes of what the advisory committee is saying, you've already dealt with the question of sort of who gets it, and what anomalies there exist in the act, or what ambiguities exist in the act, or what things you think you should not -- you restrict it the way it is in the act, and the second is what services are included to this group. And it is, it is for the purposes of this subsidy a ceiling that you can get up to -- MR. BRICK: Okay. MR. MAXWELL: -- this data rate for -- at a subsidized rate. That subsidy being the comparable rates with urban areas. That provides the flexibility to the taker of the service as to what they were asking. It doesn't necessarily mean that the fund is going to be required to provide this to every potential user, and the shift is to put the burden onto the user to determine what they believe is necessary, and the group has said that up to this data rate is necessary for health care and people will use it for those purposes. MS. PUSKIN: Can I -- MR. LAWLER: Wait a minute. Stop there. Did I hear you say the fund doesn't necessarily -- MR. MAXWELL: Well, I mean, in thinking about what the size of the potential subsidy is one could sort of say let's imagine having a T-1 facility to every rural health care provider as defined in the act. MR. LAWLER: Right. MR. MAXWELL: That's not necessarily what would happen. MR. LAWLER: Right. MR. MAXWELL: What was being described here is that the user would say this is what I would need to provide heath care, but the service provider would provide that facility, and we're then talking about the delta between -- MR. LAWLER: Right. MR. MAXWELL: -- the urban rate and the rate that's charged, and going further to something we will discuss a little bit more, the infrastructure that we are required to provide if it were not always available. MR. LAWLER: But the maximum exposure to the fund -- MR. MAXWELL: The maximum exposure would be defined as -- MR. LAWLER: -- is everyone of those seven categories would be able to say we want T-1, and here is where our network is, and we want the urban rate, and build us the infrastructure. MR. MAXWELL: And would have to pay the comparable rate for that service -- MR. LAWLER: Right. MR. MAXWELL: -- to the provider. MR. SANDERS: With that clarification, I don't see how we could -- we wouldn't go up to T-1. MR. HOLUM: I think the provider is still going to have to -- this is Chuck Holum. The provider is still going to have to demonstrate or show that they need the full T-1 as opposed to a quarter T-1. A full T-1 is going to cost more maybe. MR. LAWLER: They don't. They have to -- they have to say we want T-1, and they would be silly to, you know, they are not getting it free. They have to pay for it. All they get is the differential between the urban and the rural. MR. HOLUM: But if they don't need the whole -- MR. LAWLER: They would be silly to buy it. MR. HOLUM: They would be silly to pay the whole thing. I think there is a natural check on how much demand they are going put on -- MS. MACLAUGHLIN: Mary Jo MacLaughlin. I would have to say that that's absolutely true. From the point of view of rural health care, we are going to have to outlay money in order to have T-1, and therefore it's not like it's a free ride. We are still going to have to contribute, and therefore the market will control itself because if I can't afford even what an urban hospital pays for T-1, I am going to get along with 384, and therefore it's going to control itself, and therefore why wouldn't we say up to T-1, and let the hospitals and health care providers control what they can afford and what's necessary in their practice. MS. DEMERS: Judy DeMers. My argument has always been for up to T-1. When we started talking about this, we were talking about hospitals, rural clinics and others. And I have very strong feelings that hospitals ought to be able to have the T-1 line, the rural hospitals. I didn't have as strong a feeling about others because I think that there is a really varying kind of need out there. And so I think if we talk to subsidies up to T-1, and we don't put too many strangle holds, i.e., federal regulations on those hospitals for having to document the fact that they want to use T-1, then we are really right in the ballpark. MR. LAWLER: Keep moving down the line. MR. KAMP: George Kamp. I like that also for two reasons. One, it deals with my earlier point about changing technology and the interaction of the band width requirements and the data compression. And, two, the tremendous differences that I see in my own practice of the needs of the outlying facilities. We have got one outlying hospital who has a small bed capacity, and at the intersection of two very busy interstates, and their needs are very different than the more isolated community on the through roads. So I would be supportive of that also. MR. LAWLER: Cindy? MS. TRUTANIC: Cindy, just for the record, there exists an anomaly today in that networks that require maybe only a half T or a quarter T are being forced, because of a lack of a band width on demand system, to pay for a full T-1 capacity, which is what's killing them. You know, they can cost out their equipment over time, but the line access charges and the fact that they have to pay for more capacity than they are actually capable of having is a real problem. So whatever we do in that regard we have to be careful that that doesn't continue. MR. SPACEK: On that issue, I mean, one thing you can do, and a rural hospital is likely to have some number of telephone lines too. You can lump those telephone lines onto the T-1, reducing the cost of the other telephone lines. So you can handle that to some degree. With respect to, you know, T-1 versus 384, I mean, in some sense it's just -- I think, you know, I don't know whether -- you know, there are kind of arguments on both sides. It doesn't make much difference, you know, I don't care. I mean, I care in the sense that I want to get the right, you want to get the right stuff out there, we want to make the right recommendations. You know, it's really a matter of where our subcommittee came out with an exception that up to 384 was probably okay to meet these applications, and there is a lot of other people in other groups who think up to T-1 is necessary to meet those obligations. So, you know, it's really just a matter of, you know, are there more of one than the other, which is the right thing to do. We can argue it forever. MR. LAWLER: Let's keep going here for a minute. I have a feeling we are getting somewhere. MR. MCCONNAUGHEY: Jim McConnaughey, MTIA. It seems to me if we package all of these together, we might have a solution. You cap it out at T-1, which is Elliot's point. Then you mention in the report 384 seems to be the minimum level for adequate performance for telemedicine. I think it's mentioned in a footnote here someplace it will be a self-policing process. I mean, people are with budget constraints. They are not just going to go crazy in terms of how much band width they get. And it would have to be necessary for medical purposes pursuant to the act. I think the puzzle pieces, thanks to everybody around the table, are on the table. It's a matter of putting them together. MR. LAWLER: Right. Mary Jo. MS. MACLAUGHLIN: I am glad you spoke before me because it actually clarifies something that I wanted to say And my concern is about the remarks that have been made that it is the provider who is going to have to request this. Well, how is the provider going to know what they need? And certainly if we think to the thrust of the consumer movement overall, we have an obligation to help them understand what capacity will do what. And I am wondering, without throwing this in too much in advance, I don't know what function the clearinghouse was supposed to play or what function our report was supposed to play in helping identify specifically what capacity did what so that people have some guidelines. That gets me onto the other point that I am even more concerned about and yet nobody else seems to be, which is normally in this day and age people would hate like heck to ever specify very precisely exactly what technology and lock it in. We have made that comment numerous times, and therefore we are going to allude to the need for review. All I am wondering is whether we can accomplish the goal that we seem to be moving toward on a consensus basis by modulating the language somewhat that -- and perhaps we can't -- that specifies what we are trying to accomplish, and then saying that currently that capacity is illustrated between the band widths of 384 and T-1. In other words, I am just saying as a matter of avoiding unintended consequences I would be -- do we need any concerns about being so precise about the technology now? And is there anyway we can accomplish that without boxing ourselves in? MR. LAWLER: Well, isn't the -- and correct me, people if you hear different, but I think what everyone is saying that whatever number we pick we are saying it is up to the provider to make the choice. MS. MACLAUGHLIN: And they have to know how to make that choice. MR. LAWLER: Well, but that's for a different moment here. They do have to know how to make that choice, but we are saying under the act you get a subsidy, you get the discounted urban rate anything from nothing up to T-1 or 384, wherever it comes out, and you make the choice. You may not want to pay for it. You know, whatever technology you are going to in your wisdom or ignorance pick and pay for, and the service that goes with it, that's your choice. MR. SPACEK: Yes. And by the way, I don't think we do actually want to say T-1, even if you pick that. We want to say 1.5 megabits or equivalent, because we want to be technology independent. MR. LAWLER: Let's keep going here. MS. CONNORS: And I think the provider knowing what they want to do with it can give what band width they need. MS. PUSKIN: I just -- with studying that sort of floor that was suggested at 384, I have a problem with that because then you are going to have to say it's appropriate for what kinds of application, and there really is a great difference clinically in peoples' views about what 384 is adequate for versus what you need T-1 for in terms of the time it takes to transmit an image, whether store and forward is a capable application. And I would simply like to leave it at up to T-1 and not get the floor in there because, in fact, I think that it would lead people to say, well, what is one good for and what isn't it good for. And I believe that gets us into the specificity we don't want to be in. So I would say if you just say "up to," you in a sense let the market determine a lot of things. MS. KING: I just want to follow up on a comment that was in my earlier, which there should be really some sort of clearinghouse for information because however you are going to deliver up to 1.5 megahertz, it would be based on engineering studies. It might be done in a variety of ways, given, you know, your particular locality. And I don't know if the FCC is going to be doing this, to offer clearinghouse information to a particular rural site or some government agency, but it seems as though by pooling or aggregating demand in a particular area, then you can interact better with the telecommunications provider on how to engineer this particular service at the most cost- effective rate. And the other issue, of course, is what kind of cost studies are going to be done to determine the difference between a rural and urban rate. That will depend on what the Universal Fund will be, and that's another piece of the pie. But I would think that up to T-1 would be appropriate or 1.5 megahertz. MR. BAILEY: I just have a clarifying point I want to ask, and we have been talking about T-1 versus 384. Are we talking dedicated or are we taking switch? I assume we're talking dedicated because switch could be a real big problem. MS. KING: You mean it's a lot more expensive. MR. BAILEY: Yes. Well, it just doesn't exists everywhere, so it would be very expensive to make it exist everywhere. MR. SPACEK: We should probably put the term "dedicated" in there? MR. BAILEY: I think so, dictated, or point to point, or some phase like that. MR. SPACEK: Yes. MR. LAWLER: Cindy? MS. TRUTANIC: One thing that Mary Jo alluded to that wasn't responded to, and it's something that came up in our infrastructure discussions, about training the consumer or helping the consumer determine what technology is out there so that they could make their networks more efficient rather than less efficient in the future. And whether that comes under our discussion of peripheral or on-premises equipment, we never really resolved it, to my understanding. But I think it's an issue that's going to -- that the FCC should address because if you don't support that training or on-site training or network training, what you are doing is encouraging inefficiencies for people who don't understand the communications component of their network. MR. LAWLER: Mike. MR. KIENZLE: The one other, the one other perhaps unintended impact of defining a floor is that it would also discourage research and development in areas in which lower band width applications are being developed. And I don't think we would want to do that. I think we would want to,