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House | June 24, 2015 | Committee Room | Health

Full MP3 Audio File

I'd like to call our health committee meeting to order, and if you'd please take a seat. There're many activities going on around the general assembly this morning, and sure there'll be members who will be in and out during the presentations. Our sergeant arms this morning, John Bay, Bill Morris, Jim Moran and David Liken. We have few pages, we have few pages this morning, and they're all lined up against the back row, if you all just raise your hand when I call your name, Burkling Bridlow, Rathford Mike Hader, sponsor, Davis Jones, Davis welcome. Gilford, Jon Hardister, Chris Norris, Roanne, Harry Warden, Andrew Adkins, Gilford again John Hotstar, Gabi Banks, Gabi welcome, Frankline Bobby Richardson and ILer Catlin wait county traces [xx]. Welcome to LA and I know it's not only a hot week, but a busy week, so we hope you'll enjoy the time you have here, lets see, we have a former staff member to this committee that's back, watching our proceedings this morning, Amy Joe? Where is she? Way back there, does it feel better being way back there than up here? I don't know. And we miss you. Fortunately we've not had too much activity since you left, but we had some. We have had a lot interest in what's going on in health care and telemedicine and telehealth and we thought it would be an interesting presentation if you had an opportunity to just actually hear and see from some of our physicians how we're using telemedicine across the state. I'm actually one of those who believes that we've only tapped the surface on telemedicine, that this is an expanding program and as we reform Medicaid, we will have opportunities to see health telemedicine and tele health programs actually can drive the cost of health care in North Carolina down, how we actually going to improve access particularly in our own communities and we've invited two positions who have been involved in this for sometimes, we'll first going to call on Dr. Allan Stiles, his Vice President for Network Development and Strategic Affiliations for the UNC health care system Dr. Stiles and I've had the opportunity to meet and talk a few times and the work that he's involved in on behalf of UNC is very impressive and will ask him if he would like to come up and address the committee, and feel free to ask questions as we go through and we'll also allow time at the end for questions as well. Thats sounds welcome and thank you for being here. Now I'll turn back to you. What I'm about to do this morning first of all is to thank you for the opportunity to be here, I very much appreciate the chance to talk to you about something that I think is very important as a clinical tool, to a clinical medicine and something that unfortunately we're not by using as broadly in North Carolina as hoped as we can. To start with, I'd like to just touch on a little bit of the reason for trying to say that. You can see a picture off in the corner of Dr. Josh Alexander, he's a colleague of mine. He's a pediatric which means a rehab doctor, Dr. Alexander for about 20 years now, has been doing a tele-medicine program largely supported by grants to connect with patients he cares for and have severe disabilities, and the community at home or in a clinic setting near their homes to care for them. If you think about it patients like him has extremely difficult to move from one place to another, and in this case he set this up so that he can have the therapists himself to do an exam by video conference and the family members are there, so there's a lot of education, a lot of support that goes in. This has been so well received for several reasons. One is patients don't have to load into a van and travel several hours to get to Chapel Hill, they don't miss work, they don't miss school and from a cross perspective it reduces their families indirect and direct cost and be able to do this per tele-medicine. The second program I want to mention to you is run by

Dr. Bruce Karen he's there in the centre using his hands which is the way he always talks to folks and Bruce is the director of our JC Burn Center at UNC next we will be starting a program at our hospitals that UNC has affiliations with across the state and emergency rooms to have real time connections between the burn specialist and the JC Burn Center and the emergency room doctors 24/7. If you are aware, if you're not aware the state if North Carolina is in the Burn Bill meaning that we have an awful a lot of patients who show up with burns in many other community hospitals, who don't see them very often and that will not necessarily mean they don't get care, but they may have to laze in getting what will be consider appropriate care and so the intention with this is to actually put these emergency room doctors and the patients in direct contact using a robot, called an intouch robot to do a visit video visit directly at the time patient to the emergency room, and so what that does for the patient is that it allows them to get an immediate appropriate plan for care. It may surprise you to know that this will very likely keep more patients in the community hospital, rather than having to send them to a center that has limited beds for burn care were they may actually not need to go. We can also do followup on those burn patients later on which is very important part of this also without having the patients travel great distances to get there. From a personal perspective my brother who actually lives in Western North Carolina, where I grew up, had a burn a few years ago, this sort of thing was not available, and it took a couple of days for him to get moved from hospital he was in to higher level of care and he ended up being there for three weeks. So this is the kind of thing that there's even a personal connection for me with, but we are very excited about this because this technology will not be limited to just doing burns, it's immediately available to do other sorts of consultation with specialist and that would open the door to being able to have specialist in the areas where they would not be available, meaning more access for those patients. You can do education through this modernity, you can even do surgical consultation. So we believe that this robotic system, which is the same one that is used for telestroke and many other things, is one of those cutting edge opportunities that allows us to deliver much better care to patients. So I apologize for the size of this information, but I I'm cramming a lot of information and I have given you handouts with this information on it, into just very few slides on purpose. So what I would like to do is give you just a few minutes of background on what telehealth or telemedicine is. My definition working a definition for this is the use of technology to interact with patients, or facilitate patients care at a distance. Very simple what you may not have thought about is how many ways you can actually deliver medical care using telemedicine. I have listed seven things  out here as ways you can actually do telemedicine. The first is the traditional one that you usually think about, which is a video conference interaction between a patient who is at a distance and a physician who is at some site, where they would be working from usually a specialist or some sort. That video conference interaction can also include many elements of physical exam, because a lot of equipment can be attached to this telemedicine instruments now, and if you have what we call an operator or an assistant, locally they can actually go through an exam at the direction of the physician and give you what problems and purposes as a fairly extensive physical exam to be able to assess and decide what the patient needs. The second is something that's no surprise to you and that would be called [xx] forward this has been known for any years where images like radiology, X-ray studies or echo-cardiograms are sent from a site locally to a distance site for someone to do an interpretation of those films to the last 30 years we've been doing this UNC with pediatric cardiology in a dozen smaller hospitals around the state to diagnose newborns who have complex heart disease and allow them to

be transferred to a appropriate places for more care provider to provider interactions are very important, that being doctor to doctor there's a lot of this that goes on by telephone some can go on by Email, some goes on by video conference and sharing can be done in that setting, one example this is tumor boards that we have with the university research cancer fund, and Oncologists or cancer doctors all across the state are involved with this particular program and they can present their patients, have a discussion about what their patients has, look at the slides from pathology and make good decisions about what the care should be for those patients without the patient ever having to drive and be at the center to get that sort of second opinion and instead implementation of care can be done locally. The other piece of this that I think that support a whole lot provider to group interactions and that's probably haven't thought much about it but diabetes education is commonly done this way, the behavioral health or Telepsychiatry is frequently done by and Tele Madison and it's extremely important as a tool to allow large groups of patients at a distance to get opportunities for access to appropriate care takers. We have hybrids of these systems that exist out there and those hybrids would be doing a study like Fetal echo study, and then a face to face by video conference interaction between an obstetrician and a patient to discuss the findings from that particular study. And then the last two things I want to mention are home health, which is something that I suspect you are generally aware of, but probably haven't thought much about, but today they're many things out there that a patient can have in their home, a scale, a glucose monitor to measure their blood sugars with, blood pressure cuffs, all of which can connect through the internet back to their provider and monitoring of their state of health can be done. This is something that we've done in a pilot fashion with some elderly patients and it's been incredibly well accepted by the patients, which may be a little surprise, to the point that they won't turn loose of the devices even though they've reached the point where they probably no longer need them. but the most crucial bit of information to tell you is that we were measuring 30 day readmissions, which is the part that CMS wants to know about with readmissions because they penalize hospitals for that. We're now measuring 90 day readmissions because it's been so effective that we have few 30 day readmissions that really this other point and time is more important. The last thing I'll mention to you is something called M-health noble health or E-health, electronic health. Those are things which may have in your pocket right now if you have a Iphone 6 you have this fitness monitor on your Iphone, you may not use it but it's sitting there collecting information about the the steps you take during the day whether you are up and down the stairs and all these other staff we have safe gear that another thing that work like this but it can also be used to push information out to patient so that for example a patient who is pregnant may get some information push to them everyday by text or email they tell him something about their foetus or tells them some hint about a good health tool that they might implement in their care and this are things that consumers really want, actually they'll  pay for this and buy them to put them on their devices to use around fitness and other things the last thing I'll comment about in this, is that patient severely accepting entire health, I'm going to give a statistic that you might hard to believe and behavioral health that tell a psychiatrist many study have been done and in seven minute the patient is no longer where that they are doing a video conference with their provider that's a remarkable thing, think about it they are that quick to accept this supportive care, so the things that are important to remember with this the number one that this is a tool which is proven as a way to deliver healthcare, secondly it increases it access to healthcare dramatically thirdly there are clear cost reductions that goes with doing it this way, some are direct and some are indirect meaning that the family doesn't have money to travel and that sort of thing or missing work or school and then finally it's clearly way

to improve compliance by patients because that that connection can go on more frequent basis, nurse to patient, doctor to patient, will make difference on how well they do things so my question to you would be is the environment ripe now to do telemedicine telehealth in North Carolina and I've a whole series of things we don't have to touch on all though, but there's no question we have a state that would be classified as a rural state, having grown up in western North Carolina pretty line between two places except maybe I'm 40 and my grandparents are here concerned that that's why we started having bad weather in the mountains but that rule of nature of this really is a health care impediment for people to actually get to a point that they can receive the care that they need, we are aware words state thanks to lots of work by you and other leadership of the state over many years to get internet out there. It was done for education, but now it's connected to most of the health facilities and when I was driving over I heard the announcement about the gigabyte level fiber that's out there another great thing that's going to make a big difference and particularly be useful to tele-medicine. We've health care systems that are under Pressure right now to do more and more. With the population health issues and they're doing it with less and less particularly around specialists and tele-medicine is a way to multiply the opportunities for specialists to touch patients at a distance without requiring travel, work, all the hustles that come with parking with parking at a place at UNC. And, we're also seeing medical insurers now recognize this as a legitimate way to deliver health care and so, reimbursements is beginning to be done across the country for this the last thing I would say this is there is a growing tele among the providers, but also among the patients they have the convenience of telemedicine available. So, what is happening in North North Carolina over the last three years am going to just talk about three things with this, one is that we have seen a very rapid growth of what would be termed different programs in telemedicine and I'm only going to mention only one of those as an example on that's telestroke. You will have some difficulties finding even small hospitals now that are not connected in their emergency rooms together some evaluations are patients who present with a stroke because it is very important that they get certain medication in a termly way, if we are going to have a better outcome from the stroke. So, there is a program [xx]. For good or bad most of these are now being done by contract to the hospital so its not done on the basis of the position designing to do this We stay back contract that the hospital pays to have that employees. The second is the board of medicine has really looked hard at tele-medicine over time, there's always been a concern that tele-medicine will turn into something that, you might have heard before too as a pill meal or just a way that you could get prescriptions, not really deliver medical care. And they've done a very careful job at assessing and looking at it and came out with a new statement which is attached in your handout, to give you an idea of what their view is about where we were tele-medicine and it remove many of the barriers to being able to do tele-medicine effectively. So, people a very positive that they are looking to this carefully and thinking through how to safely do tele-medicine to stay. And then finally something I dare, you're all aware of, is that there has been an ad hoc group of organization and individuals who've been meeting for now four years occurring to look at ways that we can accelerate the adoption and utilization of tele-medicine in North Carolina this group includes NCNC which is responsible fro a lot of the internet cabling NCHRCA the NCHRE group has been in the table, A-Hec has been in the table all the academic centers has representatives there from the RT or the [xx] groups and then other stake holders have interest in tele- medicine we moving forward so this discussions have been very well asked have been civil state wide meetings has been held open this up to other stake holders by this group and what they if I arise the outcomes I'd say four thing s are really important came out of the things that the work of these committee is done over the last few years. First they've really encouraged the expansion of high speed

internet and I've had the opportunity to talk a coiple of times about this [**] or ginger belt level things related to health with group across the state. They have been trying to develop a consensus among providers in Medical System about how a detailed medicine, so it  become into operable but not closed so that you you can only see it, if you're within the system you're in, so that the need is for this to work across the state globally not be limited to just one system in the way it works. There's been an evolving interest in having something available to provider which is I going to term, as my time as state level resource center that sits in a neutral spot to help people understand what good equipment it is, what good software it is, how you become inter-operable in this situation and basically to give advise. Not control, not put anything out there but a clearing house so people can get together and collaborate. And then finally the group is worked on two advocacy here. One has to do with reimbursement for doing telemedicine and the second was to work with the board of medicine, the board of pharmacy around this changes that have been with that so the group although informal has been pretty active in areas that they've chosen to go after when I look at the challenges that we face as a state in getting Telemedicine to move more quickly and in to an expanded state, I would identify four things for you that you need to think about. At the bottom in that dark box, I want you to understand that most Telemedicines stay except those things done by contract are coming up based on grantsr or state funding has been provided to do the work. The problem is that is as soon as the grant money or the state funding goes away, this program could just close and patients lose access too but there's no way to sustain so there needs to be some thought given to how we get to a sustainable state. We've provider issues and it's very important to understand that physicians don't like to change things. We have a tendency to sit really still and be very comfortable with what we're doing people are really busy. So there're cultural issues that you have to do, a lot of physicians are very afraid of technology and that's understandable, because the group some [xx] are little older, and we don't necessary feel comfortable about what we will do with technology and we're trying to move tha forward. And then there some really unfounded issues at this point with compliance and with risk that is there around it, and those two things have been addressed pretty carefully even at a national level, and I think truthfully those are minor issues for physicians as far as there acceptance. Secondly technology, today is much easier to do the technology aspect of telemedicine. It's possible to do things in a very cost effective manner and there is lot of option out there. There many vendors the cost of doing telemedicine has dropped like a stone over the last five years. We've gone from a cost of around 50, 000 dollars to set up a single in the room did you tell him [xx]? Now to that $2500 so that's a dramatic change in the cost of actually putting the necessary technology out here and can't even work. The last issue is reimbursement for care and this is a very tricky area because steps on loss issues but has important things to consider, but reimbursement fertility health is really the key to sustain there has to be a way for the people who provide it to keep the doors open while they are doing this and unfortunately for reasons that I think you would understand for better than I, this is the end of being state by state issue and so what's occurred is that telehealth parity as a terminal, talk about that again in just a minute, has become something that is out there going state by state to be opened up and directed to go around the payers and how they're going to deal with telemedicine. So, I would say these three areas I think consider catalyse moving tailor medicine forward. First would be that we would have to have sustainability in the program so to provide us and the physicians will actually do it. Secondly technology and interlocal ability and critically important and we really can't afford to have hundreds programs that don't talk to each other and have no way to work together that we're going to end up with

a hard project in the state that really is not good for our patients citizens, and thirdly we have to think about this place of reimbursement and how we would do this with all the care so medicaids take care of planned commercial insurers. Seeing as for medicaid does pay for medicine but it is highly restricted and there was an article yesterday discussing and it is a very serias problem at the medical level but forget about that we can do anything about their much in the state level and the federal groups that I am I touch with very much [xx] for changes in there. So if you look at the map of the country as it stands now they this are actually green but they are blue on the real slide are states that have whats called the parity bill which we means that for appropriate care done by telemedicine you pay the same if you do a face to face with the patient or you do it by telemedicine as you can see there are a number of states that are blue in this thing in fact 27 states in the District Colombia have now parity bill now sold to another there are few states North Carolina included that have looked at parity questions at one level or another and have not yet adopted those and then the rate status of those that have no parity and some are desperately in need of telemedicine I would say Alaska would fit that criteria quite well that in my view a wider use entailing health will aid in delivery of care, it will clearly increase accessed care from specialist and others, the efficiency in cost of care would be reduced by using it and we see compliance of patients improve their care plans and those are all important aspects that going to improve the health of North Carolinians. Styles thank you very much let's see if there's a few questions we're going to let the next presenter come in an start setting up, we'll take a few questions. Rep. Bryson. Thank you Mr. Chair, I've got files of, just question on telehealth and telemedicine in rural areas, and I do never understand rural ares and health care. What we've basically done for all the years particularly in the emergency rooms is stabilize transfer of patients simply because most rural hospitals are contracting doctors to come in with emergency services in 12 hour shifts. So how do we get these people to fit in particularly when the doctors are coming in. My area in the east of North Carolina, a lot of them come from the bases and give them extra dollars and extra training but how do we get this folks involved and how do we get the people to know that this available or the locals are participating in it and get the trust of the public where we could get not only providers but the patients more involved knowing that the care can be close at home than has been in so many years. So I think that is an excellent question and one that we struggle with a lot part in general trying to think through how we get manpower into particular areas around the state. Certainly the use of Telemedicine will be something that if it's in bedded in the emergency room, the one thing that doesn't change is the staff generally there and that's a very good thing that if we have the staff in place they're going to remind this attenuate doctors you have that they have this access point to use for that if it's available all the time as I described with this burn council opportunity or tele-stroke, then it's going to get used and because you have a face to face with family and patient as well as what you're doing with the provider, you can usually help them feel more comfortable about the care they are going to have locally as opposed to having to go to other place. So it's a challenge in that Telemedicine is not going to solve it entirely but it will give you a resource that you might not have otherwise. Representative Lucas. Thank you Mr. Chair as we continue to delve into this experience, I certainly encourage us to do that until I have to care because it's going to really

improve the excess it's going to reduce cost and it had several other assets, you probably haven't had an opportunity to delve in it to the extent of my concern right now, but I just want to share, ask rather if there is any particular concern among the caregivers the physicians if you would, about the increased numbers and the potentiable risk or malpractice issues, because it's going to be impersonal more and more impersonal. I think that's another excellent question and I did mention this risk question that some physicians have concern with, I can tell you that from one of the things I do is oversee our risk management program for our system and I can tell you that over the last, I've been doing this almost twenty years, over that period of time we've not had a single tele-medicine claim now we don't do tonnes of it, but we do some and there hasn't been anything. Nationally that is also the same trend, there are very few malpractice that come up, but to convince physicians if that's true, is another discussion area and something that's hard to do. So, I think you're right, the cultural issues that we're dealing with are going to be very important and we do have to train positions beginning with the medical students to help them understand, but this is a clinical tool not something that is exotic or esoteric and you don't have t be an evangelist to get out there and use it. If I can do it I can tell you, you can be gentle. I tell you what, we have a number of individuals who'd like to ask questions, we're going to come back to the questions, but since we're started up now to do actually love, we moved presentation we are going to call him doctor [xx] who is orthopedic surgeon and also has some information to share. We have some technical problems with General Assembly side is very secures he 's worked very hard behind the scenes trying figure out how to get hooked up there, we thank you for working so diligently to do that. Some [xx] in question? So thank you for all being here and thanks for members of the committee as well as for the chairpersons and as I was introduced there I'm leaving in the judgement and in also North Carolina can everyone hear me? Okay? What you going to  see in the purpose this, is to show you that we are doing live work with the robot or rounding on patients that I've operated on, we have just a month ago that's is in personal issue where possible issues will related to non having access on issue of North Carolina well what I'm doing is operating on patients from the Wilson area at North Carolina Speciality Hospital what is indoor arm. One of the reasons that I started going over there, Is I do robotic surgery, and that's where the robot was available to introduce surgery and we have this practical issues developed At such time where I'm operating on them but I'm going back to Wilson and continue working to in patients, I was unable to see my patients on daily basis. So that role can be filled with possibly a PA or a nurse practitioner but you run into many times the same to personal idea. So what this has done for us, is allowed us to utilize the robot where I can at least  see and interact with my patients. Can you hear me there? So, many of the patients find it quite interesting, actually you kind of turn into a celebrity a little bit and everybody actually comes with you, people giving you high fives and all that. I don't have arms with robot, the robot's are about five foot tall, it's called Irvin. So I'm actually driving around North Carolina specially hospital right now via GPS. So we're going to head to a room, we have a fictitious patient in the room. One of the nurses was kind enough to work with us. I don't know if the audio will project on what they are saying. but this is how I round on a regular basis over at North Carolina Specialty. So the robot has, fortunately, automatic controls and it'll find its way. Hey there, say Hi, to the General Assembly. So as you can see sometimes we have some internet issues as well, you're going to have a high bandwidth and a T-connection to make this work. Okay, so I'm coming off auto drive and I'm going to drive into the room. So I'm driving [xx] and the Speaker issue may become a problem here in a second because I haven't heard anything out of the speakers. Audria, can you hear me? I can.

Okay, can you all hear that? I don't know, this is the room right in the hospital right here in Daram, and This is Sandy, our pleasant fictitious patient, who just had a robotic partial knee replace for which they typically stay overnight. Sandy can you hear me? Yes Sir. I can hear. How are you feeling this morning? I'm feeling great. Alright, is the knee doing okay, did the therapist get you up this morning? Yes that hurt. Can I see your leg? Sure. So I can sort of zoom in and search, a little too much, sorry. So we can zoom in, zoom out, we've a stethoscope that actually works quite frankly on computers is better than real stuff stethoscope. I was really surprised, you know the definition of double blind study, right? It's a two orthopedics looking at an EKG, so I don't listen to the hardware much, but so this is what we're able to do. Cindy, do you've any other question or any problem or OK, well thank both of you very much. So one thing that I do want to point out is what happens when I have the robot is what happens along time ago. Before I was in school, I heard stories of nurses in white hats when the nurse and the doctor came on the floor, the nurses would actually get up and go around with the physician, and what that does in my opinion is continuity of care, ease of communication. Quite frankly names shall remain vacant from the conversation at the moment, but when a recent large community hospital in Riley that I work at started an electronic medical records system, when I came to the floor, or when I came to an area in preop[sp?], there was not one person looking at the patient, they were all looking looking at a computer screen. So what I think is unique about this is I'm looking at a computer screen looking at a patient, and I think that's where we lose our focus with electronic medical records and some of the electronics have come into play. What happens is the nurses come with me because I don't have arms. So whether they like me or not, which is a problem sometimes, they have basic he knows my wife left, I need a little help to do this, and that help that is fostered by the fact that I don't have arms allows the nurses to feel free to come with me and it's sort of fun, I think the novelty will wear off at certain point, but the point is we're interacting over the patient together at the same time at the same point in time and I can say what needs to be done and that's another check on the system when you write orders, we're getting away from hand-writing orders and all that  because nobody can read our writing, we understand that and it's better, maybe it's safer but what I'm seeing the electronic medical records now having worked in the [xx] hospital, in a hospital in Greenville, [xx], Durham and Wilson, on the last five years and having also spend sometime with with a pretty well known guy and friends for while for a while and also doing some work in the choreography, I can take you from a third world to first world but I's still about interaction with the patient and the rapport and being able to communicate with them. And this toll in m opinion, is what is going to facilitate that and if you look from efficiency stand point, physicians are consumers of healthcare as well. So, with that experience in mind of these different hospitals, I can go to hospital X right now and do three total joints and be done noon, round on my patients electronically at a distance and it's actually care. I go to a hospital Y and it will take me until 5 PM to do the same three cases. There was a study done outside at one of the hospitals I work at a few years ago that showed my average operative time is 48 minutes, my average wait time is 55. So, if we are talking about efficiency, we are talking about cost savings, in my opinion, this at the appropriate institutions centers of excellence have been mentioned by medicare as potential work for cross savings. I know for a fact that this particular hospital we're talking about here has the lowest implant cost in the state. So, we can get a total need for 2800 bucks. Well in my lifetime, at my small community hospital, cause we didn't have large purchasing power, we were paying as much as $ 9, 000 for the same implant. Same pair, okay. It's medicare so the point is we have access, it's easy to use, the patients like it, the nurses like it, and I think it's a great way to improve continuity of care as well as safety, cause I get to see my patients. I'm operating at a facility that is high quality low cost. And so I think this technology needs to be brought into the fore front and I think that one thing mentioned about malpractices we do have to have some help here, to be able to talk to people this way and understand that it is not in person and we do need some safeguards I would prefer that the market takes care of it but when

we don't find that then we turn to government. So, I would hope that people do listen try to bring us into the fore front and also get a low maybe a little bit assistance on the malpractice front. So that's really all I have to present so thank you very much for your time. Thank you Dr. Martin, excellent. [xx] do you want to come back up, we got some time to take questions still. I'll go back to my list Rep. Farmer-Butterfield Thank you Mr. Chair I wanted to, of the initial presenter and that Senator efficiency and cost, you did an excellent job by the way. The presentation was very thorough and straight to the point and I appreciated it. In terms of cost to the patient based, on what you saying I know there's going to be a reduction in calls, and over years I can see a dramatic reduction in calls. Do you also envision that, there will also be reduction in the patients calls factual treatment? I think that in general costs for medical care and now let me talk about this because, other part of my job, is population health and trying to move to value based care for assistance and I work with that. I think what we're going to see happen is reduction in general with all these things that we're doing to bring the cost of care down so that it levels out about where we are with public payers right now and the reason being that, that's what we can sustain over time. If we don't work on that and do it through efficiencies as we just described in ways that save you time and energy when you see more patients via still be a way to do this so you could see more patients at less cost per patient and still have the same amount of dollars. Now that's a business sort of way to talk about medicine but truthfully keeping the doors open requires that also. So volume is a key of what could go on until telemedicine is absolutely a way to continue to do more volume without having to do it, the indirect cost to the patient in my view is that today's best value for the patient. They don't have to travel, they don't have to miss work, they don't have to miss school, they can actually get something done and in a way from an indirect cost is dramatic and that piece is probably very valuable to them and the convenience of having access either after hours or during the day in different ways which some groups are doing will make a difference in their perspective of about cost. Follow up? Yes. Go ahead I noticed that you attached in the PowerPoint that you did a bill that was done in what, Arkansas? and I thought that was really helpful. I haven't had a chance to thoroughly review it, but it looks as though this is focused on physical health, the medical piece Is there anything in terms of legislation that also involves telepsychiatry? The reason I attached this bill has nothing to do with Arkansas or the fact this bill. It is what is called a parity bill. It is the last of these bills to come out from a timeline perspective, and I thought it would be interesting for you to at least see what one of these looks like telepsychiatry and behavioral health to do whole patient care are crucially important. Of all the specialty areas we have, the inability to get behavioral health delivered to patients and sometimes do it contigiously with what we're doing with primary care physical health I think is one of the most important innovations we've to drive ourselves to work. So, I agree with you, this probably doesn't, I don't remember all the contents of this bill but the idea with was just to get to a place where any sort of care was going to be reimbursed to the patient, for patient care. Representative Pendleton. Thank you Well, I want to thank both the presenters, I've learnt a lot. Nice to meet all I have, on this presentation with the cord marked United State it can propose Parity bill and Mr. Chairman do we have anything like that pending I don't have power to recalling We have talked about what representative Insco is working on as a state committee when we followed out of section the focus is in top held tele-medicine issues the thought being we would bring a

neighboring legislation in the next opportunity we have because this is a way to the future and this will increase access and reduce cost and we do need to get in front of it and I've heard discussions about this fund positions, about things they're doing, and they're very anxious to help us move in that direction. Follow up. Yes sir go ahead.  I do corporate health points and the number of them what we use co-federal commercial in charge captain Whitemire cross had handled it that but the term the third part administrator in Charlotte that does health plans and they actually buy reinsurance so that people don't have to worry about big shot claims but they've been doing tele-medicine. They're regulated by the funds were insurance companies are regulated by the state, so they're already doing it. And either phenomenal they've got 24 nurse practitioners, and this has been going on for three years, and that might be somebody if you want me to when you get the same goals.  It would be. Thank you for that. Representative Insko. Thank you Mr. Chairman, I would like to thank both Dr. Styles and Dr. Martin for coming helping educate us. I'm interested especially in following up with and Representative Brisson's comments about care in the rural parts of the state and one concern is whether or not we actually Dr. Styles that we have internet connectivity. Do we need additional of sites connected in the real parts of the state especially we hear that we don't have dependable connectivity, and maybe not fast enough, so that was one of my question is the internet actually broad enough, is your broadcasting actually broad enough and the other part is will this help us keep our real hospitals open will it be enough business that we could look to having some support for our real hospitals financially through this process and then Dr. Martin if you have any comments about the connectivity for what you're doing or where you're doing it how broadly it can be around the states the bill happen. That's tell you, stop. So as usual representative Vansco you ask interesting and hard questions I'm not an expert on cabling and connectivity I will tell you that from a hospital perspective in general most hospitals are willing connected at this point to be able to do tele-medicine reasonably well issues aside for what we have here but that probably is firewall and security issues and I'm not a technical computer person so I'm not going to get into any of that I do you think that faster and faster internet will be something that people seek you want to download movies and watch those it takes a whole lot less to do Telemedicine than to download a movie just to put that into context I want to make sure you have that this is not skype this older thing that you see people use when they are just trying to talk to their kids in Europe, it's really something a little more sophisticated and much more secure which is the critical part because it is patient information. will it help our hospital stay open my personal belief is that it probably will have an impact on being able to keep patients in the community instead of forcing them to be moved out immediately when something is found in the emergency room, the response shouldn't be move the patient, the response should be how do we get the patient to live with care and that could be in the community especially if you have a little body to suite of ability that can you move around and see patients as Dr. Martin describes in hospital itself for follow up by special so in my personal abilities, yes you'll have an impact. Well, it have an immediate rapid impact depends on how quickly we get this up and working. Okay, go ahead Dr. Martin. The issue today as I understand is related to firewall is he mention it's more of security issue here, I can use the standard hot spot with 3G or 4G connection and do what you just saw there and so it's really not that much of an issue. I would interject one thing may be answer your question now passed to me with permission but in terms of hospitals being open, I think there been a lot of change in many industries I have come through three different electronic medical records in the last six years one of which we are still paying for even though it moved on to. So, the is point the things are changing and so that rural hospital staying open to my opinion which I'm sort of one of them in Wilson, I think we need to change the paradigm on which

we think of this hospitals and we need to go to more of tree argue base system And have specialist at the disposal of something like this, where you can make confident decisions about disposition and whether they should stay or go, how they can, and can be shipped. The ability for me to work on attarde and see the patient, with 15 years of experience, I can tell you eye ball in your patient giving the source of history, I can probably tell you what's going to happen about 80% of the time. So, I think it may help keep the hospitals open to a degree, but we need to change the idea that you need redundant systems, I mean this goes back to Nixon's idea in 1974 with the chief process, infrastructure of the country being based on hospitals, I think we need to change that paradigm and if we do, I think you'll be allowing your hospitals to stay open in maybe a confined way, smaller way, hopefully more efficient, hopefully cheaper, and hopefully more accurate diagnosis and more time to treatment by the appropriate specialist. Thank you Bartholew. Representative Avil. Thank you, Mr. Chairman. My question goes to little bit of Representative Bristin as well as Insko in terms of I'm looking at rule and thinking way out down the road just a quick clarifying question. Currently these Tele, medicine Telehealth psychiatry are all located in hospitals, I'm I correct? Okay, what I'm looking is way, way down the road and particularly in rural areas where there's a significance lack of accessibility. And not just accessibility, but just purely no physician available. Would it be feasible? And if you don't want to answer and commit yourself to this, that's perfectly fine because I'm asking as a sponsor of a Bill here that will modernize [xx] Practice Nurse's Act. Would this lend itself at some point in time to a point of contact for patients outside of a hospital which still is one of the highest cost delivers of care. With them being able to work independently but use the Telehealth as the oversight may need to go to a physician or a her low level of education and promise of dealing with a patient in medical ill specialty or GPA whatever, is that a feasibility it could that service in the inside of the some of our inability doctor give just routine health care, not necessarily the emergency room type game it's true. So let me start and Dr. Martin will have an opinion about this too I'm sure, I'm a big thing of the vence practise nurses and I said a program have to do that in meanwhile I will see you many many years ago, it's wonderful program, these are terrific care akers they know their limits, they are able to do what they should do and the primary care setting there are many things means you had advanced practise and also position assitance could do very effectively in that primary care sitting with the opportunity to connect to a position when they need that fortage that's today we don't to wait five years, or 10 years for them, what we don't get today is reimbursement for doing that from the position perspective, so it's a very difficult to set that model up and make it sustainable in our situation, but I agree with you that the search for funding away to deal with this and rural areas can't just be more and more primary care positions. We just can't do fast enough to make that happen, and despite the fact that we're very focused on that UMC from a primary care perspective, it is not going to be the case we're going to be able to turn out those numbers quickly enough to fill the state with those. So, I think the use of ultra new models is a wonderful opportunity. I agree and with a resounding yes, I think there are issues associated with the delivery of such, starting my career as an medical professional as a physical therapist. I think the scope of practice issues need to be curtailed. I think we need to quite frankly if a barber says he's an orthopedist who meets the of what the criteria and I'm fine with that, and I'm so lousy fair and puts some of the honest a little bit on the patient about education things but to speak to that specifically of course we need to do that, we must have some type of leeway from a medical legal stand point. We understand physical exam is accurate 70% of the time with appropriate history in a knowledgeable patient. X-Ray and other additional [xx] studies taking about 85-86% accuracy in an MRI, for an

anatomic physical diagnosis will take you to 90--96%, but there're still some error and so we can do a lot with educated people, able, enabled by government to take risks so that they don't lose their house if they make mistake. So yeah, but we've got to change some other things first. The other thing that throw the sand is remember ICD-10 hits in October, and delayed twice. We're going from 10, 000 codes to over 100, 000 codes the ability for government to instill change in the current environment in the next cycle of collections is not going to be there. I've been told the hold six months accounts receivable because I'm not going to get paid for six months, so we're getting ready here to roadblock in delivery of healthcare system, so it's great but doing it imminently I don't think it's going to happen in the marketplace we have two more that would like to ask questions, we're trying to get those in before we adjourn, Representative [xx]. Thank you Mr. Chairman and I would like like to thank Dr. Styles and Martin for coming today I came here and think I have a lot about Tele-Health and I learned a lot so basically I don't have a question or a comment as a nurse practitioner who works in copper base family practice and has major practices in [xx] but we are employees all over the country I'll tell you that Tele-Health works because we have employees who access, our specialism health and nutritionists, lactation consultants, and diabetes educators although they maybe in Kansas city or California the other thing going out using our health plant to pay for those services which we pay for they utilizes specialist in our building by using TeleHealth and get the information and the care that they need to either take the place that using those specialist in Carifornia working as a city or tools supplement that so I'm very excited about the potential for this and just to comment about the last question about the use of Absence practice nurses in rural areas or other areas that under serve because not all Right now we use consultant from the rich at the extent of our knowledge and that cause that provider to provider consultation not something that's reimbursed right now, it;s a privilege and the courtesy that one extends to the other something we just need to take in mind as we look at all these challenges back from the regulatory from as well as from a reimbursement front thank you very much. Thank you for the comment. Representative Cotham. Thank you Mr. Chairman and for our presenters today just a quick question on definition and I want make sure I'm using the right words, if we have a E-visit that's what I've called it with our doctor that's not where we can see him but it's more a chatting back and forth over something simple like a sinus infection let's say, is that considered Telehealth it's considered Telehealth but it's not typically reimbursable in a standard fashion infact most we're on ethic I'm sure everybody in this room is part of ethic as one of the EMRs, ethic has embedded in the option easier and you can actually set those up and you can do them in real time and you go back and forth with someone by email like a chat almost or considered up to be delayed to get an answer back by email or whatever all done in a secure environment, a lot of places are using these in setting adapt so that you basically pay separately to have that convenience as opposed to what you'd get with the visit so it is technically in the general ball pack of what I would view as telemedicine or telehealth but it's not one of those things that people traditionally think about as a reimbursable tool to use it with. Thank you yes it did and it's been quite helpful service as a legislature I can tell you that, the next question I think you briefly mentioned I was just thinking with such an epidemic we're seeing with the onset of type 2 diabetes across North Carolina and it seem we have a lot of people not in compliance and not understanding what this disease and how it impacts their life, are there options for a group classes and care especially like on the evenings and weekends to kind of eliminate some of those barriers so people don't have to take time off from work but they can have a session with a dietitian or someone to help them understand this disease The answer to that is yes, and you can do it either in groups or individually. Going back to something that represents the ad card. mention this idea that people that are expert scenarios like nutritionists or social workers who do soccer therapy work outs, that sort of thing.

Those are individuals that don't necessarily practice [xx] at the top of their licence to actually be able to deliver that care it is unquestionably something that would be very helpful done either in groups or individual in many places are doing that because it's a right thing to do not because their is a way to get paid for that, I think broader use for those individuals with these levels of expertise or things that in the world population health we actually have to do it And just one more quick question, Go ahead. I have been tweeting this today and took some picture and put it out so I had a doctor out of state me a question through Twitter and so he wanted to know about licencing regulation and how that work. I can say you are all government on that I don't know, their doesn't seem to be any restrictions if you can talk to me in a cocktail party I think I can talk to you on the internet when it's worth to do later on with later on if their is a malpractice issue house have document and that's what I have seen we've diagnosed someone tat's gotten in trouble with texting a patient and such so that's something as I heard you could get off a head as well, and I would say to your first comment briefly, what I have learnt is that reality requires an audience so physical therapist love getting my patients together in a room, and like just a month ago I had 69 year old lady had a partial knee and a 47 year old guy who had a partial knee replacement and he is in his bed the morning after so I get her to walk into his room and say hey and walk out, and you should have seen the guy, so the point is collectively this group idea via internet sure it's going to improve compliance and it's going to help educate people that their though process in what they are doing is probably we are out side the group norm which makes people want to conform a little. Last question, Dr. Styles go ahead, I apologize. In our state if you are going to practice and provide medical care you must be licensed in North Carolina so, to do telemedicine and if you were sitting in Kansas you need a North Carolina licence to do that, so technically what was just said happens all the time, but if we're going to formally do Telemedicine our board expects you to be licensed. Last question Representative Adcock. Thank you Mr. Chairman and thank you Dr. Styles. I was going to say to Representative Connie's point it's actually a regulatory issue when it come to practice across state lines and these are issues that are being grappled with not just by each states. Regulatory boards like nursing and pharmacy, and medicine and the dietary, but also across the country about National Council State for nursing, National Federation of Medical Boards, but it's something that needs to be at rest rather than put our heads in the sand they always have to be they always it's always been since 1950. So, I think our regulatory boards are known in this state for being very proactive and cutting edge and I know that they're looking at these issues, and I look forward to their continued [xx]. Thank you. Thank you committee members for all the questions. These two are very busy physicians, and for them to come today to give us part of their time for the day we very much I appreciate both your efforts. And as I said we're looking at the possibility of a Study Committee if you're interested and feel this is an area you'll like to learn more, you'll like to contribute, let Representative Insko, or me know as we formulate the ideas behind the Study Committee because their are many,, many issues, but this is the way for the future. I want to reserve the last comment for Representative Martin to just say how they did. And it depends on what kind of lunch you get today probably it's what you Thank you Mr. Chair, I appreciate thank you for coming to my husband and thank you for the presentation very helpful and I think this is very exciting and I worked on tele-psychiatry which is great, and it's very helpful for access to patients that for my husband knew that he can get up in the morning sit at the couch, and  just check on our patients and know if they are okay or if there, they're occasion we do to get out to dinner or something comes up and he can say I need to go check and he had immediate access to that just make it available for the patient, it doesn't replace the hands on care at all so, thanks all for coming. Yes, thank you. And meeting is adjourned.