[House Hearing, 116 Congress]
[From the U.S. Government Publishing Office]
UPSKILLING THE MEDICAL WORKFORCE: OPPORTUNITIES IN HEALTH INNOVATION
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HEARING
BEFORE THE
COMMITTEE ON SMALL BUSINESS
UNITED STATES
HOUSE OF REPRESENTATIVES
ONE HUNDRED SIXTEENTH CONGRESS
SECOND SESSION
__________
HEARING HELD
NOVEMBER 13, 2019
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[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Small Business Committee Document Number 116-058
Available via the GPO Website: www.govinfo.gov
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U.S. GOVERNMENT PUBLISHING OFFICE
38-248 WASHINGTON : 2020
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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
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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.]
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