[House Hearing, 116 Congress] [From the U.S. Government Publishing Office] UPSKILLING THE MEDICAL WORKFORCE: OPPORTUNITIES IN HEALTH INNOVATION ======================================================================= HEARING BEFORE THE COMMITTEE ON SMALL BUSINESS UNITED STATES HOUSE OF REPRESENTATIVES ONE HUNDRED SIXTEENTH CONGRESS SECOND SESSION __________ HEARING HELD NOVEMBER 13, 2019 __________ [GRAPHIC NOT AVAILABLE IN TIFF FORMAT] Small Business Committee Document Number 116-058 Available via the GPO Website: www.govinfo.gov __________ U.S. GOVERNMENT PUBLISHING OFFICE 38-248 WASHINGTON : 2020 -------------------------------------------------------------------------------------- HOUSE COMMITTEE ON SMALL BUSINESS NYDIA VELAZQUEZ, New York, Chairwoman ABBY FINKENAUER, Iowa JARED GOLDEN, Maine ANDY KIM, New Jersey JASON CROW, Colorado SHARICE DAVIDS, Kansas JUDY CHU, California MARC VEASEY, Texas DWIGHT EVANS, Pennsylvania BRAD SCHNEIDER, Illinois ADRIANO ESPAILLAT, New York ANTONIO DELGADO, New York CHRISSY HOULAHAN, Pennsylvania ANGIE CRAIG, Minnesota STEVE CHABOT, Ohio, Ranking Member AUMUA AMATA COLEMAN RADEWAGEN, American Samoa, Vice Ranking Member TROY BALDERSON, Ohio KEVIN HERN, Oklahoma JIM HAGEDORN, Minnesota PETE STAUBER, Minnesota TIM BURCHETT, Tennessee ROSS SPANO, Florida JOHN JOYCE, Pennsylvania DAN BISHOP, North Carolina Melissa Jung, Majority Staff Director Justin Pelletier, Majority Deputy Staff Director and Chief Counsel Kevin Fitzpatrick, Staff Director C O N T E N T S OPENING STATEMENTS Page Hon. Nydia Velazquez............................................. 1 Hon. Steve Chabot................................................ 2 WITNESSES Dr. Matthew Conti, Orthopaedic Surgery Resident, Hospital for Special Surgery (HSS), New York, NY, testifying on behalf of the American Academy of Orthopaedic Surgeons (AAOS)............ 4 Dr. Ingrid Zimmer-Galler, Associate Professor of Ophthalmology, Founding Clinical Director of the Office of Telemedicine, Johns Hopkins University School of Medicine, Baltimore, MD, testifying on behalf of the American Academy of Ophthalmology.. 6 Dr. Nancy Fahrenwald, PhD, RN, PHNA-BC, FAAN, Dean and Professor, Texas A&M University, College of Nursing, Bryan, TX, testifying on behalf of the American Association of Colleges of Nursing... 8 Mr. Michael Hopkins, RN, CEO & Founder, True Concepts Medical, Centerville, OH................................................ 9 APPENDIX Prepared Statements: Dr. Matthew Conti, Orthopaedic Surgery Resident, Hospital for Special Surgery (HSS), New York, NY, testifying on behalf of the American Academy of Orthopaedic Surgeons (AAOS)..... 25 Dr. Ingrid Zimmer-Galler, Associate Professor of Ophthalmology, Founding Clinical Director of the Office of Telemedicine, Johns Hopkins University School of Medicine, Baltimore, MD, testifying on behalf of the American Academy of Ophthalmology........................................... 34 Dr. Nancy Fahrenwald, PhD, RN, PHNA-BC, FAAN, Dean and Professor, Texas A&M University, College of Nursing, Bryan, TX, testifying on behalf of the American Association of Colleges of Nursing........................................ 40 Mr. Michael Hopkins, RN, CEO & Founder, True Concepts Medical, Centerville, OH................................... 46 Questions for the Record: Questions from Hon. Troy Balderson to Dr. Matthew Conti and Responses from Dr. Matthew Conti........................... 59 Questions from Hon. Troy Balderson to Dr. Nancy Fahrenwald and Responses from Dr. Nancy Fahrenwald.................... 64 Additional Material for the Record: Letter from the Healthcare Leadership Council................ 68 UPSKILLING THE MEDICAL WORKFORCE: OPPORTUNITIES IN HEALTH INNOVATION ---------- WEDNESDAY, NOVEMBER 13, 2019 House of Representatives, Committee on Small Business, Washington, DC. The committee met, pursuant to call, at 11:32 a.m., in Room 2360, Rayburn House Office Building. Hon. Nydia Velazquez [chairwoman of the Committee] presiding. Present: Representatives Velazquez, Finkenauer, Kim, Chu, Evans, Delgado, Craig, Chabot, Balderson, Hern, Hagedorn, Stauber, Burchett, Joyce, and Bishop. Chairwoman VELAZQUEZ. The Committee will come to order. I thank everyone for joining us this morning, and I want to especially thank the witnesses who have traveled from across the country to be with us here today. On this Committee we are focused on ensuring that cities and towns across the country have a vibrant and growing main street. Small firms, with their innovations and character, create jobs that lead to healthy and sustainable local economies. As we all know, an essential part of any community are the doctors and nurses who are relied upon in every corner of our country to keep us healthy. However, many people forget that these health care professionals are themselves small businesses. They are relied upon to care for our families, while also taking on the challenge of operating a business. Not only do they face capital challenges, they also face the increasing costs of interacting with insurance companies, larger student loan burdens, and a growing patient population. Challenges such as these have led to a declining physician workforce which has disastrous effects for many Americans in underserved and rural communities. In fact, by 2030, the Association of American Medical Colleges expects the workforce shortage to expand to over 100,000 doctors nationwide. The greatest need will be for primary care physicians who face the test of caring for every kind of patient and illness. They have become the first, and in many cases, only source of care for millions of Americans. Luckily, advancements in technology are changing the face of medicine. Like every other industry, health care is undergoing a rapid transformation, and these emerging technologies are changing the way we think about health care in this country. Telemedicine is allowing providers to take appointments over video chat and perform virtual visits with patients many miles away. It is not only making it easier for patients to access care, it leads to better health outcomes by giving doctors the ability to remotely monitor their patients. In fact, telemedicine services are already being offered at 46 percent of rural community health centers and we should be expanding their funding to ensure access to care for our rural communities. Other technologies, like robots, are improving minimally invasive surgeries, allowing for more precision, safety, and a quicker recovery time. Health information technology, such as electronic health records, is helping providers sort and transfer important health information to specialists that can advise them on treatment. Technology like this helps doctors and nurses become more efficient, cut costs, and improve quality for their patients. For these technologies to be fully realized, we will need highly skilled physicians, nurses, and even administrators to make our healthcare system more efficient while still delivering quality care. Unfortunately, formal curricula in virtual care and telehealth has not been widely incorporated into medical and nursing schools. Despite the availability of simulators and virtual reality to provide the opportunity to train surgeons for procedures without using patients, there are few training programs in this area. Medical technology advancements provide a great opportunity to expand access to health care and save lives, but the complexity of these technologies requires investments in training programs to upskill medical professionals. If we poorly train, or neglect to train, our health care providers to adapt to new developments in medical devices and practices, we risk negating the potential benefits of this technology and put patients at risk. This is why we are here today. It is clear that this technology has the potential to dramatically alter the industry. What we need to realize is, if it is done correctly, it can incentivize doctors to open practices in rural areas. It can help nurse practitioners provide care where physicians are unable and consult with specialists when needed. It can empower those in the home health care space, many of whom are small businesses. Emerging technologies in health care can be the great equalizer allowing smaller, independent practices to treat more people and cut the cost of doing business. To do this we need to ensure proper training. Whether through new and innovative ways of training physicians during school or upskilling nurses as they progress in their careers, providers need this training to avoid confusion and uncertainty in the face of change. I look forward to hearing from our expert witnesses who have direct experience in training to use these technologies and developing curriculum for that training. I would now like to yield to the Ranking Member, Mr. Chabot for an opening statement. Mr. CHABOT. Thank you, Madam Chair. Health care is a critical and constantly changing field with new technologies emerging every day. The advanced technologies of artificial intelligence, AI, robotics, and telehealth or telemedicine, are trending now. Each of these areas presents new solutions to old problems but do not come without cost. It is important to weigh the positives and negatives with each advancement. That is why we are here today, to discuss the effects of these innovative forces on the healthcare industry. Larger companies seem to dominate the emerging technologies of AI and telehealth. We need to understand how small businesses fit into this picture and what we can do to support the small firms already in these fields. It is not just the trending technologies that can have great impact on our healthcare workforce. Some solutions may seem smaller but can have an equally great impact. These changes tend to be led by small businesses or one entrepreneur with a big idea. Such technologies can reduce costs, streamline workflow, improve delivery of care, enhance patient experience, and most importantly save lives. The time and effort saved can then be spent on patient care and additional training for healthcare workforce and a whole range of other things. We must find ways to reduce waste and increase positive outcomes for patients and providers. This can only be done when innovators are able to create and develop products, technologies, and procedures that are properly and efficiently tested and proven to be effective. Small businesses can play a key role in all of these areas. We are very fortunate to have a very strong and esteemed panel here today. I think we all look forward to hearing their testimony. And Madam Chair, thank you for calling this hearing, and I yield back. Chairwoman VELAZQUEZ. Thank you, Mr. Chabot. The gentleman yields back. If Committee Members have an opening statement prepared, we will ask that they be submitted for the record. I would like to take a moment to explain the timing rules. Each witness gets 5 minutes to testify and each Member gets 5 minutes for questioning. There is a lighting system to assist you. The green light will be on when you begin, and the yellow light will come on when you have 1 minute remaining. The red light will come on when you are out of time, and we ask that you stay within the timeframe to the best of your ability. I would now like to introduce our witnesses. Our first witness is Dr. Matthew Conti, who currently serves as a PGY-4 at the Hospital for Special Surgery in New York City. He received a B.A. in economics and premedical studies from the University of Notre Dame and spent a year studying at Oxford before going to medical school at Cornell University. He is the founder of Our Hearts to Your Souls, a nonprofit organization that has provided free shoes and foot care to more than 40,000 homeless men and women across the U.S. for the last 15 years. Thank you, Dr. Conti, for being here today. I welcome you. Our second witness is Dr. Ingrid Zimmer-Galler. Dr. Zimmer- Galler is an associate professor of ophthalmology at the Johns Hopkins Wilmer Eye Institute and is the medical director of its Frederick location. She is also the executive clinical director of the Johns Hopkins Office of Telemedicine. Thank you for being here today. Our third witness today is Dr. Nancy Fahrenwald. Dr. Fahrenwald is the dean and professor at the Texas A&M University College of Nursing. Throughout her career she has been recognized as one of the 30 most influential deans of nursing in the United States. She earned her master's in nursing from the University of Portland, and her Ph.D. in nursing from the University of Nebraska. Thank you for being here. I would now like to yield to our Ranking Member, Mr. Chabot, to introduce our final witness. Mr. CHABOT. Thank you, Madam Chair. A graduate of the University of Cincinnati, UC, with a Bachelor of Science in Nursing, Michael ``Mick'' Hopkins is the CEO and founder of True Concepts Medical Technologies (TCMT) in Centerville, Ohio. Mr. Hopkins developed the ideas for TCMT's products with the support of Dr. Arash Babaoff, a coworker from the Cincinnati Children's Hospital, one of the greatest children's hospitals in the country. They developed new syringe technologies after witnessing waste in multiple areas of health care. Mr. Hopkins holds four U.S. patents for technologies developed and has multiple internationals pending. His business has been named 2019's Most Promising Startup by the Quality and Safety Education for Nurses International Forum, and we welcome him here today and look forward to the testimony of all four of the witnesses. Thank you. Chairwoman VELAZQUEZ. Dr. Conti, you are now recognized for 5 minutes. STATEMENTS OF MATTHEW CONTI, M.D., ORTHOPAEDIC SURGERY RESIDENT, HOSPITAL FOR SPECIAL SURGERY; INGRID ZIMMER-GALLER, MD, ASSOCIATE PROFESSOR OF OPHTHALMOLOGY, FOUNDING CLINICAL DIRECTOR OF THE OFFICE OF TELEMEDICINE, JOHNS HOPKINS UNIVERSITY SCHOOL OF MEDICINE; NANCY FAHRENWALD, MD, PHD, RN, PHNA-BC, FAAN, DEAN AND PROFESSOR, TEXAS A&M UNIVERSITY, COLLEGE OF NURSING; MICHAEL HOPKINS, RN, CEO AND FOUNDER, TRUE CONCEPTS MEDICAL STATEMENT OF MATTHEW CONTI Dr. CONTI. Chairwoman Velazquez, Ranking Member Chabot, and members of the Committee, thank you for the opportunity to testify before the House Committee on Small Business. I offer this testimony on behalf of the American Association of Orthopaedic Surgeons, which represents 18,000 orthopaedic surgeons and 5,000 orthopaedic residents nationwide, as well as our musculoskeletal patients. I am honored to share my perspective on the role innovation plays in the field of medical education as well as my current experience as an orthopaedic resident at one of the top surgical hospitals in the country. I would also like to than the Chairwoman, Ranking Member, and members of the Committee for your continued focus on issues important to physicians this Congress. Past hearings on prior authorization, student loan debt, and challenges to private practices have drawn great attention to some of the issues negatively impacting patient care, especially in areas where patient choice and access is decreased. These truly are small business issues, and we are grateful that this Committee is continuing to examine them with your specialized expertise. I am currently serving as an orthopaedic surgery resident with 1-1/2 years left in training at the Hospital for Special Surgery (HSS) in New York City. As a resident at HSS, I have been able to further my surgical training, as well as to pursue opportunities in research that I hope will advance the field of orthopedics. HSS is a special place for residency training. As a top nationally ranked hospital for orthopaedic surgery, residents at HSS have access to a range of new technology, innovative techniques, and experiences that those at smaller or more rural institutions may not have as part of their graduate medical education curriculum. I am fortunate to be able to train in such a unique environment. In addition, this year I was selected as one of two AAOS resident advocacy scholars which has allowed me to gain a broad overview of national issues affecting health care. As we discuss technology and innovation, surgical simulation quickly rises to the top of the list in terms of its importance and ability to effectively teach residents the skills needed to become successful surgeons. Whether it be through high-tech simulation tools or through cadaveric specimens, the surgical simulation work where I can practice techniques multiple times before treating patients has been one of the most valuable learning experiences I have had during my residency. Virtual reality technology is another tool being used with increasing frequency and success for surgical simulation in graduate medical education. New advances in this technology allow for both visual and haptic or touch feedback recreating the feel of an actual surgery. However, significant improvements in haptic feedback are necessary in order to make virtual reality more closely mirror true operating room experiences. When discussing innovation in technology, I also want to call attention to the issue of rural access. Patient access to specialty care is becoming an increasing challenge for patients across the country, but particularly so for those in rural areas. While telehealth has opened doors in many specialties, allowing patients in rural areas with limited medical professions to access needed medical care, there is still much to be done in the field of orthopedics. AAOS supports efforts to ensure rural providers have the resources and tools necessary to provide quality care via groundbreaking technologies and methods. Finally, the U.S. Federal Government invests significant funding into graduate medical education at hospitals who choose to sponsor residency programs. The health and welfare of patients is linked to the knowledge and skills physicians develop during their medical and surgical residencies. I cannot emphasize how important this is to produce qualified and competent healthcare providers to care for me, you, and our families and friends. Funding for graduate medical education spots has been capped to control costs since 1997, forcing hospitals in states to find creative ways to fund their residency programs and the technical investment that advances their students' opportunities. AAOS supports at a minimum maintaining current funding levels for graduate medical education, which are necessary to ensure future stability and access to a strong, diverse healthcare workforce. I would be remiss in my testimony if I did not mention the incredible burden that medical student loan debt places on medical students and their families today. As the number of specialists in rural areas declines and the physician work shortage continues to pose challenges to patient access, the crushing pressure that this debt puts on physicians very much influences their choice in where they obtain a residency and ultimately practice afterwards. AAOS supports common sense reforms like H.R. 5734, the Resident Deferred Student Interest Act, or REDI Act, which would allow interest-free deferment on student loans for borrowers serving in a medical or dental internship or residency program. I would like to thank Chairwoman Velazquez and others on the Committee who have already expressed their support for this important legislation through their co-sponsorship. We greatly appreciate the Committee's interest in this and other healthcare topics and hope to continue to serve as a resource going forward. Thank you so much for the opportunity to speak with you today. Chairwoman VELAZQUEZ. Thank you. Dr. Zimmer-Galler, you are now recognized for 5 minutes. STATEMENT OF INGRID ZIMMER-GALLER Dr. ZIMMER-GALLER. Chairwoman Velazquez, Ranking Member Chabot, and members of the Committee, I am honored to be testifying before you today on behalf of the American Academy of Ophthalmology. I am an associate professor of ophthalmology at the Johns Hopkins Wilmer Eye Institute. I also served as the founding clinical director of the Office of Telemedicine at Hopkins for the past 3 years. I serve on the American Academy of Ophthalmology's Telemedicine Task Force, and recently, I was invited to join the World Health Organization's Digital Health Roster of Experts. I am excited to share and discuss with you today the promise of telemedicine, both in ophthalmology and more broadly, and to highlight the culture shift that is already occurring among patients and providers as telemedicine is being recognized as a new tool to deliver health care. In July of 2016, the Johns Hopkins Office of Telemedicine was launched, and since then we have performed over 18,000 telemedicine encounters with 63 different programs. Our telemedicine programs include both image and data-sharing consults between providers or between a provider and a patient and live interactive video visits. Additionally, we have remote patient monitoring programs for patients with chronic disease that promote lower healthcare costs by allowing early intervention for patients who are declining, and thereby reducing the costs for hospital readmission and emergency department visits. Telemedicine can benefit institutions, healthcare systems, patients and providers by expanding access to care, lowering the total cost of care, and improving the quality of care in rural and urban areas. The challenges and burdens on patients from rural areas to access care can be significantly alleviated with virtual care. Imagine the challenges for someone at work who receives a call from their elderly parent who is not feeling well and their specialist is at an academic institution several hours away. Imagine the convenience that exists today, the reality that exists today of using a video visit to loop in the family caregiver, the patient, and the patient's specialist to allow the patient to stay at place at home and allow the family caregiver to continue staying at work. Millennials who are very comfortable with digital technology not only want to receive their care virtually and use technology to receive their care but they want to have providers that will provide care to them at the right time, the right place, and the right care. Similarly, telemedicine can be extremely helpful for patients with limited mobility, including the wheelchair bound. For example, neurologists at Hopkins offer follow-up video visits at home to patients with ALS or Lou Gehrig's disease. These are patients who may not be able to walk and sometimes are on a respirator. And again, imagine how much easier it so for caregivers to have that patient have a video visit from home rather than transporting them with all of their medical equipment. Numerous examples of successful telemedicine programs exist in my specialty in ophthalmology with the earliest being in the realm of diabetic retinopathy screening. Early detection of diabetic eye disease is key to allow intervention before permanent damage and vision loss occur. The effectiveness and success of these diabetic retinopathy screening programs with telemedicine can be measured by the many programs that are in place across the U.S. and internationally. Both the veterans' healthcare system and the Indian Health Service have large national telemedicine diabetic retinopathy programs which have significantly improved access to care across the U.S. Digital health and virtual care are rapidly changing and evolving and evolving, and the workforce will need to keep up with advances to bring this technology to patients and providers. A typical telemedicine workforce will involve staff of various education and skill level. Staffing, as well as their additional training or upscaling for telehealth roles is critical as these individuals are the ones that will likely determine the success of the program. There are multiple recommended staffing roles for successful telemedicine programs which are detailed in my written summary of my testimony. In spite of the promise of telemedicine, policy barriers on both the state and the Federal level continue to contribute to its limited use. A major barrier to telehealth adoption is the lack of consistent reimbursement for virtual care. Medicare and Medicaid dictate their own policies on coverage of services, types of services allowed, and the setting where they may occur. With individual state policies added to this, we have a patchwork quilt of telehealth laws and regulations across the United States making it difficult for programs and providers to keep abreast of what they can and cannot do. An additional major policy barrier inhibiting adoption and widespread use of telemedicine is licensing of providers. Current regulations require that providers are licensed in the state where the patient is located. Applying for licenses in multiple states is time-consuming and costly. The American Academy of Ophthalmology has supported action to facilitate multi-state physician licensure for those looking to provide telemedicine services outside of their home state. And the Interstate Medical Licensure Compact currently offers qualified physicians an expedited pathway to licensure. On behalf of the American Academy of Ophthalmology and the ophthalmic community, I thank you for your time in allowing me to discuss my work in this field and the benefits of telemedicine. Chairwoman VELAZQUEZ. Thank you. Dr. Fahrenwald? STATEMENT OF NANCY FAHRENWALD Ms. FAHRENWALD. Thank you, Chairwoman Velazquez, Ranking Member Chabot, and members of the Committee, for the opportunity to provide testimony on how we, in academic nursing, are re-envisioning the education of the next generation of nurses and nurse leaders to thrive in an ever- changing healthcare system. I am Nancy Fahrenwald, dean and professor at Texas A&M University College of Nursing. I also serve as the Chair of the Government Affairs Committee of the American Association of Colleges of Nursing (AACN). AACN represents 825 schools of nursing, 543,000 baccalaureate and graduate students, and more than 45,000 faculty members. With over 20 years of experience in nursing education, I have witnessed firsthand how innovation impacts healthcare delivery. I have also seen how technology and innovation have supplemented and enhanced education so that students can become effective and proficient practitioners. I have experienced how academic nursing, and nurses in general, have been early adopters of these advances, not only in practice, but also in the way that we educate our students. As we continue in this era where there are rapid changes in technology, health professions schools, like Texas A&M, are including clinical simulation, virtual reality, telehealth, and other technology-based education platforms within the curriculum to prepare tomorrow's practitioners. Today, as the dean of the College of Nursing at Texas A&M, I collaborate with other A&M health profession schools to educate our students in the largest and most geographically diverse clinical simulation laboratories in the state, the Clinical Learning Resource Center. At the center, students have hands-on experience making decisions about patient care as if it were real, while also allowing faculty to remediate, debrief, and educate students on best practices. Nursing students are able to prepare for skills, such as learning to administer a medication independently or to take care of something as complex as a cardiac arrest or a post-partum hemorrhage. In fact, our center has high-fidelity, full-bodied computer program mannequins that can simulate a range of responses. They can bleed, have dynamic heartrates, and even birth babies. Other emerging technologies, such as augmented and virtual reality may be used to enhance the educational experience, for example, by putting on 3D goggles, the student can see through a mannequin or they are able to practice procedures such as insertion of a feeding tube or conducting a physical exam. Other mixed technologies allow students to virtually enlarge, turn, or rotate organs with their hands. These types of high- tech innovations once dreamed up in science novels are now cutting-edge tools that provide students an immersive, comprehensive, and live-action learning experience without the fear of harming a live patient. In other nursing programs we are also seeing an emergence of entrepreneurship laboratories or innovation classes. So often, our students and faculty have an idea but they may need a software expert or an engineer to translate that idea into tangible healthcare solutions. Adopting and integrating health and healthcare technologies beginning in the educational setting is imperative as nurses are at the forefront of care. The need for highly educated nurses is only expected to grow. The U.S. Department of Labor estimates that by 2028, the demand for registered nurses, or RNs, is expected to increase 12 percent nationally, and the demand for most advanced practice registered nurses (APRNs) sometimes serving as the only care practitioner in rural and undeserved areas is expected to grow by 26 percent. Whether nurses are providing care in hospitals via telehealth, through managed care clinics, schools, federally qualified health centers, or even establishing their own small businesses, pairing the products of health and healthcare innovation with foundational nursing principles is imperative for upscaling the future healthcare workforce. I am grateful for the opportunity to be here today to discuss ways that we are doing just that in academic nursing. Chairwoman VELAZQUEZ. Thank you very much. Mr. Hopkins? STATEMENT OF MICHAEL HOPKINS Mr. HOPKINS. Thank you, Chairwoman Velazquez, Ranking Member Congressman Chabot, and to all the members of the Committee for this opportunity to testify before you today. It is an honor to be here. My name is Michael Hopkins. I am the CEO and founder of True Concepts Medical Technologies located in Dayton, Ohio. I am here today to share with you how innovations from the bedside can have a global impact. For the past 24 years, I have worked as a critical care nurse focused on emergency medicine and trauma. This, coupled with 25 years of design experience, has led me to develop a series of next generation dual-syringe technologies which have the capability to save the U.S. healthcare system billions of dollars while improving patient outcomes. We have developed three separate standalone dual-syringe technologies, each a business unto itself. The patented safe syringe for better delivery of life-saving cardiac medications to the heart, Recon pen, a dual-syringe technology for the reconstitution of dry powder medications, and the patented dual-syringe technology, Diversion, for the best practice collection of blood cultures. Due to time constraints, I will only be highlighting Diversion today. True Concepts Medical Technologies is a medical device innovation engine that delivers novel, manufacturable solutions based in clinical experience. Our devices are designed by clinicians for clinicians with a focus on areas that have significant morbidity and mortality such as sepsis and sudden cardiac arrest. Our goal is to save lives and reduce healthcare costs with intelligently designed solutions that eliminate the opportunity for human error. To better understand the solution, we must first appreciate the scope of the clinical problem. Sepsis is the body's overwhelming and life threatening response to infection that can lead to tissue damage, organ failure, and ultimately death. Each year, nearly 1.7 million individuals in America develop sepsis and 270,000 die as a result. One in three patients who dies in a hospital dies of sepsis, making it the leading cause of death in U.S. hospitals. Sepsis kills more Americans than breast cancer, lung cancer, and opioid overdoses combined. At $27 billion annually, it is the leading cost of hospitalization. However, 80 percent of sepsis deaths may be averted with rapid diagnosis and appropriate treatment. Rapid diagnosis starts with the proper collection of blood cultures which have long been the gold standard in confirming infectious etiology and guiding anti-microbial therapy. However, current blood culture collection techniques are highly flawed leading to delayed or misdiagnoses. Nearly 40 percent of all positive blood cultures are considered false positives, making an accurate and timely diagnosis of sepsis very difficult. Annually, the U.S. healthcare system spends billions of dollars treating 1.5 million false positive blood cultures as a result of contamination that occurs during the collection and processing of the blood cultures. With just over 40 percent of the U.S. population receiving some type of government assisted health care, the financial impact to the U.S. Government is $3 billion annually and accounts for upward of a million unnecessary inpatient hospital days. The three main sources of contamination include skin preparation, subsurface bacteria, and human factors. Of particular significance, subsurface bacteria colonize beneath the skin in the sebaceous glands and the subsurface portions of the hair follicles where antiseptics are not effective. Recent research has demonstrated by isolating the initial 2 mLs of blood, 2 milliliters of blood during a peripheral collection of blood cultures you can reduce contamination by 92 percent, dramatically reducing false positive blood cultures. Our solution is the patented dual-syringe technology Diversion as seen on page three of our written testimony before you. Diversion isolates the initial 3 milliliters of blood from the rest of the sample within a single syringe ensuring contaminate free blood culture collection. A novel plunger design with an integrated transfer device allows the user to transfer collected blood from the syringe to the blood culture bottles via closed system minimizing the opportunity for contamination and all but eliminating false positive blood cultures. We received our first utility patent for Diversion within a year of filing, as well as receiving clean reviews on our international application. Recognizing the impact that this technology can have globally, we have filed patents in the European Union, Canada, Mexico, India, Israel, Japan, and Hong Kong. With minimal training and without change to existing workflows, Diversion will significantly improve timely, accurate diagnosis of sepsis, saving lives and reducing the financial burden on the U.S. healthcare system. Chairwoman VELAZQUEZ. Thank you very much. We appreciate all you have shared with us this morning. I will begin by recognizing myself for 5 minutes. Dr. Zimmer-Galler, a large problem for our rural doctors and population is that often there is no full physician network. There may be a general practitioner in the area but perhaps not a full network of specialists. Can you explain how clinician-to-clinician telemedicine, especially in something like ophthalmology can benefit patients who may not have full access to health care? Dr. ZIMMER-GALLER. Yes. So the beauty of telemedicine is that you really can bring specialty care to any area, whether it is a rural area of any geographic location. Typically, in rural communities this works best by having a network where the clinicians or a small community hospital where they work together with a larger tertiary care center and it is very simple to then find the appropriate specialist provider and consults can be done between providers using video technology. But these consults can also be very simply done with data sharing, transferring the medical record and then having the specialist return their recommendations to the local provider. Chairwoman VELAZQUEZ. Thank you. Dr. Fahrenwald, the AMC projects that by 2030, we could have a physician shortage of upwards of 100,000. The main shortage will be in primary care and the hardest hit will be our rural and under resourced urban communities. Can you tell me how nurse practitioners can help fill that gap? Ms. FAHRENWALD. Thank you for your question. Nurse practitioners are educated to provide varying levels of care depending upon their specialty. The family nurse practitioner is the role that is most often assigned or appropriate for rural and underserved areas. They can see patients across the lifespan. Preparation of family nurse practitioners at schools and colleges of nursing across the country is at the graduate level with a minimum number of clinical practice hours required with patients across the lifespan in order to sit for a national certification exam. These practitioners are often the providers in the rural areas that provide that critical access. They are also small businesses. Keeping people in these rural areas to access care so they are able to maintain their businesses in town or their farms in local communities, these providers, educated at the graduate level, either the masters or the doctor of nursing practice level in nursing, are safe, qualified health professionals whose outcomes are excellent in terms of quality, cost-effective primary care. Chairwoman VELAZQUEZ. Is this how telehealth can help nurse practitioners open their own practices in collaboration and coordination with physicians and specialists using telehealth? Ms. FAHRENWALD. Thank you for that question. All health care is delivered as team work. Regardless of the setting, we work in teams for the best patient outcomes. That includes when we practice in rural and undeserved areas where our nurse practitioners might be the only healthcare provider present. Access to other providers who can provide consultation that keeps patients from having to be seen in other settings and to travel for that care, but also to provide the confidence in the assessment of that provider is critical. Those consults can be with another nurse practitioner. They can be with a specialist. Certainly, the access to telehealth care has provided phenomenal support for these providers in the rural area and ultimately for the patients. Chairwoman VELAZQUEZ. Thank you. Dr. Conti, much of the equipment you use for training costs hundreds of thousands of dollars, if not millions. How can we make this equipment more accessible to surgeons that are not accepted to a residency program at such a forward-thinking institution? Dr. CONTI. Thank you, Chairwoman. At the Hospital for Special Surgery where I am, a lot of our simulations and our BioSkills Education Laboratory is funded through both government research grants, but also through private industry. So not all surgical simulation needs to be high cost. For example, the American Association of Orthopedic Surgeons provides orthopedic video lectures online that allows residents and surgeons who have not seen a procedure before be able to practice or at least view the procedure online. And that is a very low cost way for residents to get involved in simulation. Other ways are to have a lab that has saw bones or cadaveric specimens or to just work more closely with mentors. All of those things can be done in a more cost-effective way. And the AOS finally has courses that are put on for residents and the courses are sometimes free to residents. And as long as the resident can make travel arrangements and take time off for work, they can fly to these courses and learn the newest simulation techniques. So these are some of the ways that we can bring simulation to residents and attendings. Chairwoman VELAZQUEZ. I have other questions but my time has expired. Now we recognize the Ranking Member, Mr. Chabot. Mr. CHABOT. Thank you, Madam Chair. Mr. Hopkins, I will go with you first. You mentioned the difficulties that you had in securing capital in order to move forward on your products and those things. Could you review with us sort of the process that you went through to secure that funding, and did you ever consider trying to get some help from the SBA, or did that ever enter your mind? Mr. HOPKINS. Thank you for the question. We have relied solely on friends, family, and physicians. Dr. Babaoff has been instrumental in connecting us with individuals who have expressed an interest in investing in us. We have been able to come a very long way with very little to this point. We are in our second round of funding, and again, we are leaning on friends, family, and physicians for that round. In the state of Ohio, we have a unique way of trying to raise money because as being an early stage medical startup the risk is much higher. And so many investors do not want to take on that risk. So we have been fortunate enough to be paired with Tech Dayton, which is the entrepreneur center. It is an entrepreneur services program out of the state of Ohio, and they provided us with resources, business mentorship, build a website, did a market analysis for us for free through government grants. But it is more the connections that they have made that has led us here today actually to be in front of you all. Mr. CHABOT. Thank you very much. Dr. Fahrenwald, I will go to you next. How does healthcare innovation fit in to addressing the shortage of doctors and nurses, and how does small businesses fit into that as well? Ms. FAHRENWALD. Thank you for your question. Healthcare innovation provides a platform to offer care. People need care where people are. We prepare the healthcare providers to provide that care in the settings where people need it using the technology that is available. If that technology is not available we encourage and support entrepreneurial behavior on the part of our students or providers in order to improve access to care. It varies by state what nurse practitioners in particular as our primary care provides that we educate are able to do depending upon regulation of their practice by state boards of nursing. Certainly, in many of the rural states in this country, practice regulation has changed because of access to a nurse practitioner being the only provider or even a certified nurse midwife being the only provider in a very rural and remote area and wanting to retain them. Technology and innovation have allowed these providers to be able to have the support they need to be successful when they are presented with a myriad of surprising situations that they may have not been exposed to before. In our simulation laboratory right now we are training nurses from across the state of Texas in how to perform examinations of people who have experienced violence, either child abuse, elder abuse, or sexual assault. Preparing them in that simulation setting so that when they are out there in their rural practices and encounter those situations they can provide safe, competent trauma-informed care. Mr. CHABOT. Thank you very much. I appreciate it. Dr. Zimmer-Galler, telehealth obviously is marked as a suitable alternative to in-person care for those in all communities. My question would be relative to rural communities. How might the lack of access to high-speed internet affect this alternative, and what would you suggest that we on this Committee or Congress work on relative to that? Dr. ZIMMER-GALLER. So thank you. That is an excellent question. Absolutely---- Mr. CHABOT. All my questions are excellent, by the way. Just kidding. Dr. ZIMMER-GALLER. Absolutely. Access to broadband is something that for many types of telehealth services is required. But I would also venture to say that there are few geographies left in the world where there is not access to broadband. Perhaps one of the bigger challenges that comes is in communities in disparate communities where there is perhaps access to broadband but the patient does not necessarily have the means. They may have a cellphone but they do not have the means to have data coverage with that cellphone. So we do have to be careful that we do not introduce disparity by bringing telehealth in. But remember, a lot of telehealth can also be done with very low broadband requirements. When we are simply sharing data, that takes much less broadband, much less width than if you are trying to do a video visit. So it certainly does not always have to have a video visit. In terms of providing care, being able to actually see the patient and see how they look, interact with them, yes, a video visit adds a tremendous amount of information but it is not always necessary to get very good telehealth opportunities. Mr. CHABOT. Thank you very much. My time has expired, Madam Chair. Chairwoman VELAZQUEZ. His time has expired. Now we recognize the gentleman from Pennsylvania, Mr. Evans, Vice Chair of the Committee. Mr. EVANS. Thank you, Madam Chair. Dr. Zimmer-Galler, I still would like to follow up on what was just said. Would telehealth and telemedicine help address physician shortages and healthcare disparities among the disadvantaged populations? Dr. ZIMMER-GALLER. Absolutely. For example, one of the things that one of the programs that we have at Hopkins is to provide pediatric specialty care to the Eastern Shore of Maryland where there is very little access to any type of specialty care. And these are communities that have relatively few means and ability to even bring children to a tertiary center. Many of these families are single parent families, and for them to take time off of work to bring a child to Baltimore or to a large center where you have specialists, such as pediatric rheumatology or pediatric endocrinology, that obviously can be a huge burden. But working with county health departments, these children can come to a facility where they can actually then have a facilitated video visit with a specialist and then we can provide that care with really the family needing to have relatively few additional things other than to bring the child to the health department. Mr. EVANS. Unfortunately, Pennsylvania is one of only a handful of states that have been unable to pass legislation to require insurance companies to reimburse telemedicine services at the same rate as in-person services. There is currently a bill in the Pennsylvania Senate which seems to have large opposition of the industry. Can you, Doctor, again, in your testimony, you stated a major barrier to telehealth adoption is the lack of consistent reimbursement of virtual care. Can you describe the challenges healthcare professionals face when getting reimbursed from insurance companies for telehealth or telemedicine services? Dr. ZIMMER-GALLER. Yes. Thank you. So there are certainly many states that have not yet passed parity laws, parity regulation that requires that payers will cover for telehealth services. But it is not only the coverage, it is the amount that is reimbursed that is also an issue. So it is definitely one of the barriers. It is difficult for us to ask providers to do things if there is no reimbursement, obviously. And with telehealth, even with relatively simple telemedicine programs there is certainly some cost associated with that. And so it does become a huge challenge. You know, where there is no money, there is no mission. So unfortunately, reimbursement is a problem, not just from commercial payers but also from our Federal and state for Medicare and Medicaid. Mr. EVANS. Have any of the other panelists run into a similar problem? None have run into a similar problem as just described? Have you, Dr. Conti? Dr. CONTI. At the Hospital for Special Surgery, I work with many attendings, and so I have a chance to see the schedule of many different orthopaedic surgery attendings. And I would say that time and physician burnout is a very significant problem in medicine right now. And so to finish up your clinic day or your OR day and then to see patients at the end of that day for 15 or 20 minutes for each patient via a telehealth medicine visit and then to not be reimbursed for that would be, I think, very difficult for many of the attendings who I have worked with. Mr. EVANS. I thank you, and I yield back the balance of my time, Madam Chair. Chairwoman VELAZQUEZ. The gentleman yields back. Now we recognize the Ranking Member of the Subcommittee on Economic Growth, Tax, and Capital Access from Oklahoma, Mr. Hern. Mr. HERN. Thank you, Madam Chairwoman, Ranking Member Chabot, and our witnesses for being here today to discuss this very important topic. As a member who represents a rural state, I appreciate the hearing on the anticipated shortage of doctors and to discuss on how to prepare to overcome this worrisome trend. However, I will tell you that I find it a little bit troubling that some of my colleagues claim to support innovation and also, you know, against this shortage, but also supporting Obamacare which according to the Nonprofit Tax Foundation, in 2013, took $35 million out of innovation. Between 2013 and 2015, took 22,000 out of innovative areas and the medicine field. And given that one of the pillars of Obamacare funding is the Medical Device Tax, which stifles innovation, is critical to support of Obamacare and to also claim that you support innovation. I find it interesting. We have a lot of those kind of things happen in Washington, D.C. I am hopeful that my colleagues across the aisle can realize this and take actions to start advocating for policies that will actually help spur innovation as you all describe how important that is to the future of health care. That said, the Trump administration recently released a report that shed some light on this topic titled ``Reforming America's Healthcare System through Choice and Competition.'' One major conclusion that came from the report was that reduced competition among clinicians leads to higher prices for health care and reduce choice. Specifically, the report states that ``scope of practice restrictions limit provider entry and ability to practice, and when this happens, these undue restrictions are likely to reduce healthcare competition and harm consumers.'' The report also points out that advanced practice registered nurses, physician assistants, pharmacists, optometrists, and other highly-trained professionals can safely and effectively provide some of the healthcare services as medical doctors. This is something I would like to ask each of you. I will start with Mr. Hopkins. Do each of you think that at least some of our doctor shortage problems, and it is going to continue to grow based on a meeting I just had this morning, might be effectively addressed by assuring that all of our licensed providers operate at the top of their education and training? Mr. HOPKINS. I see not only a shortage in physicians but also a shortage in the nursing practice. But to answer your question, I believe that a physician should be working up to their capabilities to meet the requirements. Mr. HERN. Dr. Fahrenwald? Ms. FAHRENWALD. Yes, thank you for your question. All healthcare professions should be practicing at their full scope of practice authority. In the best interest of Americans is that the providers of their care are able to perform the care, and much of that care can be reimbursed by the Federal Government and safe. For example, CMS regulations allow for billing for some wellness visits in older adults. Those visits can be handled by a registered nurse in a primary care setting. They do not have to be a physician. Our colleagues practicing at the full scope are able to manage the complex pyramid of care where the most complex patients need to be managed by our physician colleagues. The day-to-day primary care that most of us need can be managed by many of these other healthcare providers as you have mentioned, including advanced practice registered nurses. But certainly, the role of all healthcare providers working together as a team in addressing our healthcare needs in this country is important. Mr. HERN. Thank you. Dr. Zimmer-Galler? Dr. ZIMMER-GALLER. Thank you. When it comes to telemedicine, there are actually a number of restrictions in place on the state level and the Federal level in terms of which type of licensed providers can actually provide telemedicine services. So there are regulations that prohibit, if you will, some licensed providers from practicing at the top of their level if you pull telemedicine into the picture because the regulations actually do not allow certain providers to provide care by telemedicine. I would like to also add just a quick comment on the shortage of healthcare professionals, that we do need to start looking at how to tie technology into this, for example, with artificial intelligence. The FDA last year cleared the first autonomous AI device in the U.S. and it was actually for identification of diabetic retinopathy referable disease using AI. And so here we are taking a huge public health problem, screening patients with diabetes for diabetic retinopathy. If we were to actually screen every patient in person, we do not have the healthcare personnel to do that. If you tie AI into this, you can actually alleviate a lot of that public health problem with lack of providers. Mr. HERN. Thank you. Dr. Conti, I would love to have gotten your thoughts on this but Madam Chair, I yield back. Chairwoman VELAZQUEZ. The gentleman yields back. Now we recognize the gentleman from Minnesota, Mr. Hagedorn, for 5 minutes. Mr. HAGEDORN. Thank you, Madam Chair. I appreciate the opportunity. It is nice to see the witnesses here. Thank you for your testimony. I am just going to add a little bit to Congressman Hern, what he said about regulations. The doctors and technicians and others that I talk to, nurses, will say that increased costs in the medical field are maybe 35 percent higher because of needless regulations. AMA came out and said maybe 25 percent. So I think we should be focusing on some of the things that government does in these areas in order to drive up costs that just should not be borne at all. So I think we could eliminate a lot of the problems right there with some common sense. I would also like to talk about another aspect of this. If we are worried about doctor shortages and we are worried about providing health care in rural parts of the country, I represent Southern Minnesota, a very rural district. It includes the preeminent institution of medicine in all the world, the Mayo Clinic; right? A great spot. Also, some terrific rural hospitals. The New Ulm Medical Center was voted the number one rural critical access hospital in the whole country. So we have some good things. But if anyone thinks that we move toward more government reimbursement, Medicare for all, single payer, things of this nature and you think that these hospitals and the models are going to survive, they will not. The Mayo Clinic is going to be harmed, as are the rural hospitals. And almost everyone I talked to in the rural hospitals will say you are going to have massive consolidation. They are just going to disappear completely and you are going to have people in rural areas having to travel 50, 75 miles, maybe more in some cases, just to get care. So that is just going to exacerbate the problem because there is no way you can convert all this, have massive government reimbursement, and think the reimbursements are going to go up or stay the same. They are going down. And everybody knows that. I think we should just, you know, that is a bigger problem than some of the things that we are talking about today. Dr. Zimmer-Galler, I was touched by what you said about ALS patients. I happen to have a friend who went through that and I can attest that when you take someone to the doctor, and sometimes those things could be done at home, it is way better for someone, for instance, for ALS. As much as you try to care for someone, there are accidents. People fall. They end up going to the doctor and having to be dealt with with a broken arm or a deep bruise or something like that which is going to take a long, long time to heal, if ever. Whereas, if somebody could do the telemedicine or have even a home healthcare provider be out there to do tests, fit them for braces, things like that, that would be a much better deal. So obviously, the broadband is a big deal. Regulations in these areas. What specifically do you think the Federal Government should be doing today in order to move that alone? Dr. ZIMMER-GALLER. So with the ALS example, that program, actually, most of those patients are self-pay patients because Medicare, for example, does not reimburse, in most instances, for a few specific diseases they do, but in most instances Medicare does not reimburse for telehealth visits, video visits from home. So the restrictions on not just geographic areas but actually the site where the patient is located, the restrictions on where telehealth services are covered, those are areas where I think we really could work to alleviate some of the regulatory burden and allow more people to have access to new ways of having healthcare delivered that are much easier for many of these, especially the chronically ill patients. Mr. HAGEDORN. Thank you. And sometime I think people get a little backwards. They think as far as rural areas, the reimbursement should be lower because it costs less to live there and all those things. But actually, the reimbursement should be higher. It should be higher because a lot of people have to travel distances, especially in home healthcare and things like that. It should be higher because it is sometimes tougher to attract talent to live in rural communities when they have opportunities to be paid even more money in the urban areas. Does anybody have a thought about that? It is just the opposite of what people think. We should actually be having much higher reimbursements in rural areas than we do in the urban areas. Anyone? All right. We will leave it---- Dr. ZIMMER-GALLER. I will speak. Congressman, I will answer that question. I cannot speak to higher but I can say that rural health clinics, nurse practitioner-owned rural health clinics are reimbursed at parity and that is a good thing. I recently visited a rural health clinic in Texas. A nurse-managed clinic in a very small rural town where patients are driving to these visits on their lawnmowers or on their horse. Mr. HAGEDORN. Interesting. Dr. ZIMMER-GALLER. The care that is offered there is lifesaving care that provides access for the people in that area where they have not had access for 100 years. Mr. HAGEDORN. How about that? Thank you. I appreciate that. I yield back. Chairwoman VELAZQUEZ. The gentleman yields back. Now we recognize the gentleman from Minnesota, Mr. Stauber, Ranking Member of the Subcommittee on Contracting and Infrastructure for 5 minutes. Mr. STAUBER. Thank you, Madam Chair. And I appreciate this opportunity to have a conversation. Thanks to the witnesses. It is difficult from my angle to see the names, but I will just say, Mr. Hopkins, you identified yourself as a nurse. Can you tell me, in your profession, approximately what percentage of the time are you filling out paperwork that has been put before you due to regulations? Mr. HOPKINS. At the hospital I currently work at and formerly worked at we had EPIC, which was a computer, electronic computer charting system. It does take a fair amount of time. Mr. STAUBER. Can you just give me a percentage when you say a fair amount of time? Mr. HOPKINS. Working in the emergency department I would probably say 20 percent of the time. Mr. STAUBER. Do you think that the rules and regulations that are put upon our entire health care can be part of the problem? Mr. HOPKINS. Yes. We do have a lot of kind of checks and balances that we need to do when we are checking the patients in. Certain questions that really do not have to do with what is going on with the patient. Mr. STAUBER. Yes. So you as a healthcare professional could probably put the pertinent questions that need to be put forth to the patient; would that be correct? Mr. HOPKINS. Correct. Mr. STAUBER. Thank you. I do want to talk about, so I represent Minnesota's 8th Congressional District. It is a rural district. It goes all the way up to the border of Canada. And my colleague, Mr. Hagedorn talked about the rural component of health care. We need to stay competitive and we need our healthcare clinics and hospitals to stay open. One of the things that we have talked about is telemedicine and telehealth. And one of you mentioned that broadband is pretty much across the country. In my mind that cannot be further from the truth. There are at least 26 million Americans that do not have that. So I think the ability to take that technology and make us competitive, deploy rural broadband that is dependable and high speed is critically important for rural America. And I will give you an example. If you are in Grand Marais, Minnesota, which is from close to the Canadian border, if you have one sheriff deputy in that whole country and there is a mental health crisis, an individual is going to harm himself or others or a danger to himself or others, they have to drive 160-some miles to Duluth, Minnesota, to get care when they leave their county without any law enforcement protection. So the ability to have that telemedicine, that telehealth, that rural broadband so the doctor in Duluth, Minnesota can see that patient in Grand Marais rather than taking all that time, there is a whole slew of things that can be helped with telemedicine and rural broadband. And I think it would probably be safe to say that that doctor would probably want to physically see on the screen the patient to see how he or she is acting and responsive to the questions. So that is just one example that we are getting that happens every day in rural America. And through your profession, you can help guide that and give us that technology into rural America. And I think there are rural members on this Committee, Small Business Committee that understand that we need to make sure that our rural hospitals are competitive. We need good quality healthcare professionals in rural America. And this is one of the ways that we can do it. And we can talk about billing with Medicare and Medicaid, and I think it is important. That is a good discussion to have because as the young doctor said, they should be reimbursed after a long day if they are going to do some telemedicine or some telehealth. I think for me I just appreciate the conversation about the technologies out there. Let's use it. Let's have the opportunity to move the health care forward in an affordable way and make that health care personable. In rural Minnesota, we have elderly people that have to come out in the cold to go see their doctor and they could just as well do it via telehealth and telemedicine. It would be easier on the patient and the family members that have to take time off or relatives to drive them. So Madam Chair, I was opining on some of my opinions, and I appreciate that I used my 5 minutes up. I appreciate your professionalism and your coming here and giving us your testimony from your worldly experience. And to the young doctor, I wish you nothing but the best. Thank you, Madam Chair. Chairwoman VELAZQUEZ. The gentleman yields back. Now we recognize the Chairwoman of the Subcommittee on Rural Development, Agriculture, Trade, and Entrepreneurship from Iowa, Ms. Finkenauer. Ms. FINKENAUER. Thank you, Madam Chair. And thank you so much to all the folks who came here to testify today and bring your expertise. I know it takes a lot to get here. So I represent Northeast Iowa. I have 20 counties in my congressional district. Seventeen of my 20 counties are very rural. And so one thing that we have been hearing a lot about is are facilities struggling to recruit enough providers. This is obviously especially challenging in Iowa, not just because of the location issues for some folks but also because we have some of the lowest Medicare reimbursement rates in the country which is something that we have been working on a lot to address and fix. And actually, just a couple weeks ago I found out that a clinic in Waukon, Iowa, up in the Great North I like to call it in my district, will be closing its doors next month. Their main issue, they cannot find the doctors. They have one doctor right now and cannot find enough providers to staff the clinic. And back in September, also not that long ago, just a few months ago, we heard a hospital in Marshall County has closed their OB/GYN unit making it actually the 34th hospital in Iowa to stop delivering babies and offering comprehensive care to new moms since the year 2000. The shortage of healthcare providers has long been a factor in these closures, and at the Federal level, I know we need to take a multi-pronged approach to address these workforce shortages. We need to recruit more doctors, obviously, in our rural areas, and in the meantime, we need to make sure that the medical practices in rural areas can keep serving patients with the number of providers they already have. I am especially concerned right now about the access to health care for our new moms, especially, again, given the stat I just gave you all. Women in general need weekly appointments towards the end of their pregnancy, and this can be hard on women who live in rural areas and may be forced to drive an hour each way to their appointments. When it comes to maternal health care, I know that telehealth is one way to improve access. I helped introduce, actually, the bipartisan Rural MOMS Act which would put great funding toward telehealth projects that will expand access to maternal healthcare services. And then, you know, this was one of the things that I started talking about when I have been out there around the district, and recently, just a few weeks ago, I was visiting a hospital in Grinnell and started talking to the nurses in the OB/GYN unit and asking them what they thought. And you know, if they had any ideas about what we should be looking at. And actually, one of the nurses just flat out said a dream that she would have is that there would be some mobile unit that could go out there and actually either stop at a worksite where there is moms who had just recently given birth who are back at work quite frankly too soon, or moms who are getting ready to have birth as well, making sure that they are getting the care that they need, or just getting out there, again, to folks who just cannot make it in because they do not have the transportation. You name is. There is a number of issues here. So that was one idea that she had. And I thought it was actually quite a good idea. And I know Dr. Zimmer-Galler, you work a lot on these issues, especially with the new technologies and with telehealth. Do you have any ideas and ways to expand services to our rural healthcare facilities, especially some of these smaller practices? And then do you have any ideas, too, any of the panel, about what new technologies could do and things that we should be looking at to really, you know, make sure we are doing everything we can here and actually, listening to the people on the ground who are living it every day? Dr. ZIMMER-GALLER. So one aspect that we have not really talked about with telemedicine that can be very helpful for rural areas to attract and to retain providers that are there is using telemedicine to alleviate some of the feeling of isolation that providers have. When you are the only person there and you are taking care of pretty much everything that walks in the door, obviously, that can be something that is a daunting task. If you know that there is always someone that you can reach out to if you have a network in place, that you can reach out to a specialist or to another provider and you are able to call on them, not only does that help you take care of that patient but it also helps to allow for education that maybe the next time that provider will better be able to deal with that same problem. And again, it takes away a lot of that very scary sense of isolation if you are the only provider for hours' drive around. So I think that is an area where we really need to think of telehealth as well to support physicians or providers from that standpoint. Ms. FINKENAUER. Does anybody else have any---- Mr. HOPKINS. Yes. I think when it comes to creating medical devices, with nursing shortages, physician shortages, you need to create devices that are going to allow clinicians to work smarter with less opportunity for error. So just as I spoke about the Diversion syringe that we have, the technology, being able to eliminate one and a half million false positive blood cultures and saving the U.S. healthcare system $3 billion, just the government side of it, having those funds to reallocate and put into other innovations that are coming from the bedside would be very helpful. Ms. FINKENAUER. Well, thank you all again for being here. I really appreciate it. And with that, my time has expired. Chairwoman VELAZQUEZ. Her time has expired. Now we recognize Dr. Joyce from Pennsylvania, Ranking Member of the Subcommittee on Rural Development, Agriculture, Trade, and Entrepreneurship for 5 minutes. Mr. JOYCE. Thank you, Madam Chair. And thank you to our expert witnesses from leaving your practices, your training, and coming here. I represent south central Pennsylvania, Pennsylvania 13, which is a 10-county region that starts in the east in Adams County where Gettysburg is, you can identify it by that, and travels to the west to where Flight 93 went down. Until December of last year I was a practicing physician. I trained at Johns Hopkins Hospital. I did internal medicine followed by a specialty program in dermatology where I completed as chief resident. I listened with great interest of the issues that you bring because those are issues that allowed me to step up and run for the United States Congress. The number one issue in south central Pennsylvania that I ran on was health care. And that continues to be an issue today. In the first days of being a member of the United States House of Representatives, I started the Homegrown Healthcare Initiative, addressing issues that you and I both realize are incredibly concerning. In Pennsylvania, we have 11 medical schools, and yet, in south central Pennsylvania there are none. And there is a paucity of medical students in the medical facilities. So with one of the medical schools we have partnered and have started a Homegrown Healthcare Initiative where students who are from these communities can rotate in their third and fourth years, in their clinical years, and be part of the communities where often they were born, where their parents or siblings work, where they can return to the roots and establish medical connections. And we know, Dr. Conti, as you pointed out, that in your training you often stay in those areas. Your number was within a 100-mile radius of where you do your residency you see those residents stay. We need to allow those students to return to south central Pennsylvania and reconnect with the communities where they grow. And there are ways that the Homegrown Healthcare Initiative can be enhanced by the telemedicine Dr. Zimmer-Galler that you talk about. I think it is so important that those lines of education are not only opened but expanded, where individuals who are training in rural settings as medical students and as physicians and fellows can connect with the experts at places like Johns Hopkins or at HSS, at these top learning institutions which quite honestly I had the privilege to train at. And unless we encourage this to occur, we are going to see a continued decreased number of physicians in the rural areas that Representative Finkenauer just mentioned, that we all face in our areas. So my first question is for you, Dr. Zimmer-Galler, to address, please, how the innovations of telemedicine, and I as a board certified dermatologist and a board certified internist realize how important that is. But in ophthalmology, you talked about the ability to diagnose diabetic retinopathy which is certainly a big issue leading to blindness in the patients with diabetes. Talk to me, please, how we can open those dialogues of training in telemedicine with people in rural areas who are training to take care of the underserved? Dr. ZIMMER-GALLER. Thank you. So yes, that is certainly a huge challenge. And again, you know, everything kind of comes back full circle. The barriers are still, I think everybody recognizes the potential, what we can do, the good we can do with using telehealth. The problem in getting it to have more widespread adoption really, the root of that is the regulatory burden. The reimbursement issue, the licensure issues. Those are actually really the hardest, the biggest problems. The medical students, the residents that are in training today, they are very much into all of the technology, obviously, and I think we are starting to see more training that comes through medical schools and residencies where our physicians in training are exposed to telemedicine and how it can be used. But we need to do a much better job of actually then taking that and bringing that back to the rural communities. Mr. JOYCE. Thank you very much. Dr. Conti, you are closest to having been in medical school most recently. Was telemedicine part of your medical education as a medical student? Dr. CONTI. Where I went to medical school we did not do any telemedicine training. I went to medical school in New York City, at Cornell, so it is a large metropolitan area. There are not very many rural communities where I went to medical school. Mr. JOYCE. Were there patients who did not have access to be at Cornell that might have benefited from telemedicine? Dr. CONTI. I think so. I think that we on the Upper East Side, there are a large number of older patients who even going just a few blocks back and forth from the hospital can be a real burden to those patients. Mr. JOYCE. And if I might interrupt---- Dr. CONTI. Sure. Mr. JOYCE.--because I want to continue this line. During your residency training--you are PGY-4; correct? Dr. CONTI. Yes. Mr. JOYCE. And is there an opportunity to see and evaluate patients via telemedicine for you as a resident? Dr. CONTI. We do not see and evaluate patients via telemedicine with any of the subspecialties that we rotate through. And I think part of that is because we have patients from all over. And because of the regulatory burden, people have decided not to, because a lot of our patients are from Connecticut and New Jersey, people have decided not to engage in telemedicine. Mr. JOYCE. Thank you for those concise answers. I think this is an important part of our journey in the Small Business Committee to realize that this is an avenue that clearly needs to be expanded, and we should be working together, bipartisan as we do here, working for our patients and working with the physicians. Thank you again to our expert witnesses. Chairwoman VELAZQUEZ. Thank you, Dr. Joyce. Thank you all for being here today. I know that you might think telehealth is to cover for your work that you need to do while you are absent from your practices. Thank you so much for being here and for the wealth of information that you have provided. It is apparent that the pace of change in medicine is rapid and that those changes have the potential to increase access to health care while reducing costs. Whether it be the concentration of health services, lack of access for rural America, or the impeding doctor shortage, technology can solve many of the issues within our health care system. For that to happen, training programs are needed in telehealth and a curriculum must be incorporated to train the next generation of health providers. I look forward to working with my colleagues on both sides of the aisle to address these workforce challenges in the health care industry, and we are going to be looking into reimbursement, and regulations. Mr. JOYCE. Licensure. Chairwoman VELAZQUEZ. Regulations. I would ask unanimous consent that Members have 5 legislative days to submit statements and supporting materials for the record. Without objection, so ordered. This hearing stands adjourned. Thank you. [Whereupon, at 12:52 p.m., the committee was adjourned.] [Dr. Ingrid Zimmer-Galler and Mr. Michael Hopkins did not submit their responses to questions from Hon. Troy Balderson in a timely manner.] A P P E N D I X [GRAPHICS NOT AVAILABLE IN TIFF FORMAT] [all]