[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

                               __________

[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                     
          
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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

                              ----------                              


                      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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