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For information on downloading documents using File Transfer Protocol(FTP) see the file how2ftp in the following directory path: /pub/Bureaus/Miscellaneous/Public_Notices/ ***************************************************************** FEDERAL COMMUNICATIONS COMMISSION TELECOMMUNICATIONS AND HEALTH CARE ADVISORY COMMITTEE MEETING Pages: 1 through 189 Place: Washington, D. C. Date: July 11, 1996 FEDERAL COMMUNICATIONS COMMISSION TELECOMMUNICATIONS AND HEALTH CARE ADVISORY COMMITTEE MEETING July 11, 1996 FCC BUILDING ROOM 110 2000 M STREET, N.W. WASHINGTON, D.C. 20554 IN ATTENDANCE: GREG LAWLER, ESQ. Floria & Perrucci Presiding ELLIOT MAXWELL Federal Communications Commission LYGEIA RICCIARDI Federal Communications Commission JAMES BRICK West Virginia University JAY H. SANDERS ATA BILL BAILEY Southeastern Bell Tel. JAMES MCCONNAUGHY NTIA/DOC IN ATTENDANCE: (Continued) RON COLEMAN Med. Tel. International RICK PFARR Med. Tel. International LOUISE NOVOTNY CWA WILLIAM ENGLAND HCFA JOAN KING AARP HELEN CONNORS University of Kansas Medical Center School of Nursing PAUL ZIMNIK Department of Defense CINDY TRUTANIC OVP - Tipper Gore MIKE KIENZLE University of Iowa National Lab. MARY JO MACLAUGHLIN Eastern Maine Healthcare NANCY SHARP American College of Nurse Practitioners EUGENE V. SULLIVAN University of Virginia ART LIFSON CIGNA TOM SPACEK Bellcore AL SONNENSTRAHL Consumer Action Network IN ATTENDANCE: (Continued) THOMAS LORAN High Plains Rural Health ROGER GUARD University of Cincinnati NetWellness JAMES H. "RED" DUKE University of Texas Houston Medical School STEVE COTTON Texas Tech. University Health Science Center CANDY CASTLE AT&T Wireless Services/CTIA DENA PUSKIN Chair, Joint Working Group on Telemedicine Deputy Director, Office of Rural Health Policy MARY JO DEERING USDHHS Office of Disease Prevention and Health Promotion REED TUCKSON Drew University BILL M. WELCH Nev. Rural Hospital Project ERIC R. MENN Partners HealthCare System, NC GEORGE KAMP American College of Radiology JEANINE POLTRONIERI Federal Trade Commission/AAD KIM KIRBY MCI JIM POTTER ACR IN ATTENDANCE: (Continued) BOB WATERS Arent Fox/Center for Telemedicine Law SUSAN STEVENS MILLER Maryland Public Service Commission HARRY L. ROESCH Appalachian Regional Commission THAYER NELSON Managed Care Options ALLISON BAKER American Telemedicine Association JENNIFER RAPP National Rural Health Association KURT SLOOP NTIA STEVE TOLKEN Communications Daily KEVIN ROTH IBM PAT HUNNICUTT IBM LOUISE ARNHEIM Consultant SUZY TICHENOR Council On Competitiveness ROBERT HAGA NECA MIKE BUAS Federal Communications Commission/OCF RICHARD RETTIG Rand RAM BHAT Rand IN ATTENDANCE: (Continued) CHARLES DOUGHERTY Creighton University LYNN START Telecom Reports SID HOUSEIN Bellcore GOU SANCHEZ Neuro Surgical Associates Sioux Falls Sioux Valley Hospital ERIC G. TANGALOS Mayo LUIS GUILLERMO KUN, Ph.D. Center for Information Technology P R O C E E D I N G S 10:05 a.m. MR. LAWLER: Why don't we try to get started. We've improved over last time. We have coffee this time. Welcome, everyone. I know we've got some people who weren't here last time and some replacements or stand-ins temporarily. But welcome to our second meeting. What I'd like to do both for -- just very briefly, a couple of ground rules. We have a court reporter again, so we need to identify ourselves before we speak. And I think we ought to quickly go around the room just -- and say who we are and where we're from to reaquaint ourselves from the last meeting. I'm Greg Lawler and the Chair for the Advisory Committee. And Elliot, why don't you -- MR. MAXWELL: I'm Elliot Maxwell of the FCC's Office of Plans and Policies and we welcome you all and thank you all for coming. And in order not to call upon the services of any of the doctors here, maybe you -- if anyone wants to take off their coats, feel free to do so. MS. MACLAUGHLIN: I'm Mary Jo MacLaughlin from Eastern Main Healthcare, Bangor, Maine. MR. BAILEY: I'm Bill Bailey from Southwestern Bell in St. Louis. MR. KIENZLE: I'm Mike Kienzle. I'm the Associate Dean for Clinical Affairs at the University of Iowa College of Medicine and the Director of the National Laboratory for the Study of Telemedicine. And NLM funded a hospital R & D network for telemedicine. DR. SANDERS: I'm Jay Sanders, President of the American Telemedicine Association. MS. TRUTANIC: I'm Cindy Trutanic. I'm an attorney and I'm with the Office of Tipper Gore. MS. CONNORS: I'm Helen Connors and I'm with the University of Kansas Medical Center School of Nursing. MS. KING: I'm Joan King with AARP National Legislative Council. MR. ENGLAND: I'm Bill England with the Office of Research and Demonstrations of HCFA and I'm the project director for their telemedicine demonstration. MS. NOVOTNY: I'm Louise Novotny with the Communications Workers of America. MR. PFARR: Rick Pfarr with Med. Tel. International, McLean, Virginia. MR. COLEMAN: I'm Ron Coleman. I'm also with Med. Tel. -- I'm Chairman of Med. Tel. International Corporation. MR. MCCONNAUGHY: I'm Jim McConnaughy, NTIA, the Commerce Department filling in for Kathy Brown who got pulled at the last moment. MR. MENN: I'm Eric Menn from Partners HealthCare System in Boston, part of Massachusetts General Hospital. MR. WELCH: Bill Welch with the Nevada Rural Hospital Project in Reno, Nevada. MR. TUCKSON: Reed Tuckson, President of Charles Drew University of Medicine and Science in Los Angeles. MS. DEERING: Mary Jo Deering with the Office of Disease Prevention and Health Promotion where I'm the Director of Health Communication and Telehealth. MS. PUSKIN: I'm Dena Puskin. I'm Deputy Director of the Office of Rural Health Policy where we administer over 20 networks in telemedicine and telehealth and administer evaluations. And I'm also Chair of the General Interagency Joint Working Group on Telemedicine which cuts across all cabinet agencies developing (inaudible). MS. CASTLE: I'm Candy Castle. I'm with AT&T Wireless Services representing Cellular Telephone Industry Association. MR. COTTON: Steve Cotton, Director of Marketing and Program Development for an organization called TelNet (phonetic) which is a telemedicine and a satellite-based distance learning project in Texas, out in west Texas at Texas Tech. University. DR. DUKE: My name is James, people call me "Red", Duke, D-U-K-E of the University of Texas Medical School in Houston. I'm professor of surgery and a trauma surgeon. And you'll understand later why I'm here. DR. BRICK: I'm Jim Brick. I'm a rheumatologist for West Virginia University School of Medicine. And I'm Medical Director of our telemedicine project which is Mountaineer Doctor Television (phonetic). MR. GUARD: I'm Roger Guard, NetWellness and University of Cincinnati Medical Center. MR. LORAN: I'm Thomas Loran, Executive Director of High Plains Rural Health, Fort Morgan (phonetic), Colorado. MR. SONNENSTRAHL: I'm Al Sonnenstrahl from Consumer Action Network of Deaf People. I'm here representing people with hearing impairments, hearing disabilities. MR. SPACEK: I'm Tom Spacek. I'm the Executive Director for National Information Infrastructure Initiatives at Bellcore in Morristown, New Jersey. MR. SULLIVAN: Gene Sullivan from the University of Virginia, Charlottesville. MS. RICCIARDI: Lygeia Ricciardi from the FCC's Office of Plans and Policy. MR. LAWLER: And Thayer Nelson is back there who many of you have talked to on the phone. Thayer is sitting actually directly straight back there. There is an agenda that I don't whether we passed it around, but it's back there. Lygeia, why don't you just hand them out? It doesn't tell us -- it just lays out what we're going to do with the hour. What we want to try to do today is spend -- each of the subgroups, I know, has been talking either electronically or otherwise about where to go. And what we're going to do today is spend an hour with each subgroup, the first 20 minutes to a half an hour with each subgroup head and members of the subgroup describing just what they've done so far, what they've identified as issues, how they're approaching those issues, where they think this ought to go, and then follow that with a general discussion so that there is interaction with everyone with that subgroup. If there's a complete uniform view on that, if that's a great thing to do or a terrible thing to do or whatever, we will have a discussion about it. What we want to try to do just to lay out -- well, everybody wasn't here last time. But we have another meeting sometime in September which we'll talk about later, early in September. And we are then going to submit a report to the FCC by the end of September. There may actually be a date. I think it's the end of September. That does not give us very much time for a very large subject. So what we want to try to do today is get all the issues on the table so that everybody is comfortable that we are discussing issues that are significant and frankly try to organize them in a way so that we can get our hands around this in -- by September and actually provide some focused sensible advice to the FCC in the short time that we have. I think the one thing that everybody -- well, I won't speak for everyone. Certainly, the thing that I've concluded which I think we all knew coming into this is, you know, this is an enormous subject. And if we can focus our efforts, focus our thoughts, pick out the things that we think are most important and to try to provide some sensible advice on those things, we will have made a great contribution. We are not going to be able to do everything. Telemedicine is going to evolve in a way that, you know -- we could have a pool and we could guess about it, but we do need to try to focus our thoughts and -- and that's really what the purpose of today's meeting is. What I'd like to do is also just if people have plans, if the subgroup heads are available after the meeting, I think we're going until 3:00 or 3:30, just for a short time so we can talk about how to organize ourselves going forward between now and September, that would be useful if you have the time. What we thought we'd do is start with Jim Brick who is our rural subgroup head. Do we have any other things we need to say before we get started? MS. RICCIARDI: That's about it for now. When we take a break, I'm going to say something about a number of handouts that I've prepared, just copied, the reports and other items that I think may be useful to you. And I'll just give you a quick run-through of that when we convene after the lunch break. I think it's easier that way. MR. LAWLER: And I just saw walk in -- I don't know if anyone else has walked in. Maybe if we could go around the room and identify those people. MR. LIFSON: Art Lifson with CIGNA. MR. LAWLER: Also, when you -- I'm sorry. MR. ZIMNIK: Paul Zimnik, the Department of Defense. MR. LAWLER: And another? DR. KAMP: George Kamp, American College of Radiology. MR. LAWLER: Also, we have a court reporter, so -- oh, I'm sorry. Did I miss someone? MR. ROESCH: Harry Roesch from the Appalachian Regional Commission. MR. LAWLER: I'm sorry. Before you speak, please identify yourself so that the court reporter will know who you are. We're going to pass around an attendance sheet so she will be able to see who you are and correctly identify you. So let's try to help her out, as well. It will help people looking at this. What we thought we'd do is start with Jim Brick and the rural subgroup and spend an hour talking about that and then move forward. So Jim, it's all yours. RURAL SUBGROUP REPORT DR. BRICK: Okay. Thanks, Greg. I'm Jim Brick for the record. Thanks a lot for this opportunity. The rural subgroup is comprised of a number of folks. I'd like to put their names in the record: Narcisso Cano (phonetic), Helen Connors, Charles Holland, Mary Jo McLaughlin, Paul Pilar (phonetic), Dena Puskin, Eugene Sullivan and Bill Welch. Most of these folks, nearly all of them really have contributed to the things that I'm going to tell you today. As we discussed at the last meeting, there is a lot of overlap between all of the groups that we outlined last time. And I think that that's good because that way we get a lot more input into what we're going to decide. Dena Puskin and I after the last meeting, we did talk about this though and decided that we needed to start somewhere. It's kind of a guldian (phonetic) knot that we're trying to unravel here. And we decided we would send out four questions to people and let them respond to these. And then we would start with those. And my job was to sort of collate everything and put it together into a summary that we could present to you folks and also to cajole them into responding while they were on vacation and stuff like that. There are four questions -- and I hope you have the handout that was in the back -- that we asked. The questions -- MR. LAWLER: Does everybody have -- do we have copies of it -- DR. BRICK: I put lots of copies back there. You can -- I have these overheads if -- I wasn't going to use them. But in case people don't have the handouts, we could put those up. Anyway, there are four questions. And the four questions are: 1) What is the definition of rural? 2) Who should be the providers that we include in this? 3) What is the minimum functionality that we thought that should be covered under the universal service provisions and should it be the same for all providers? 4) And what are the current variations in pricing in rural communities for various levels of functionality and what are the implications for the subsidy of establishing various minimums? We had lots of responses to all the questions. There are a lot of differences in opinion about how we need to do this. I think some of the differences are engendered by the fact that people are -- bring something to this committee, their own experiences of where they are; what's available in their particular part of the country; the problems they have; what they're doing there. And I think that that accounts for a lot of the differences. But there are also a lot of similarities. With regard to the first question -- what's the definition of rural -- the act requires that access be given to services comparable to those available in urban areas and at comparable rates. And this requires a practical and a sensitive definition of rural. And a definition of rural is hard to come by. We had a lot of comments. People thought it needed to be as inclusive as possible. But they also didn't want to cost to be extraordinarily prohibitive. There's a lot of concern that if travel time is used as a benchmark by some people, that -- that -- or distance is used as the only benchmark, that it will be prohibitively expensive in some rural states in the west because of the long distances to get from anywhere to anywhere else. Another suggestion that after reading the responses that everybody sent in, I think one of the ideas was Dena's idea that was in a handout that she gave us from some testimony that she gave which was a combination of office management and budget, metro and nonmetro county rankings which is a way to divide counties as to rural and nonrural. And then there's a U.S. Department of Agriculture Economic Research Service, urban influence codes which can be dovetailed with that, and a modification of that which comes out at Dena's office. I think, again, an attempt to be as inclusive as possible with this definition of rural because there isn't any one definition of rural that fits everything. And also, one of the points that Dena made in her comments to the board I think which was very appropriate is there also needs to be some special consideration for these parts of the country where you just have a few people living per square mile. I mean, just really, really frontier areas of the country and really none of the rules really fit those kind of folks. We don't want to leave them off the information super highway. From the meeting that we had the last time when the senators got up and made speeches, it sounds like they don't want anybody left off the information super highway. So I think we need to consider those folks, as well. What providers should be included on the list of eligible providers? For example, should physicians' offices be included on the list? This is the second question. Again, here we had lots of viewpoints. The real issue here I think is is whether to include the private practitioners' office, not usually thought of as being a not-for-profit venture though at the last meeting, some WAGs (phonetic) suggested maybe that they were not-for-profit ventures. I think they don't meet anybody's definition of being not-for- profit. And -- but there was a lot of concern that we needed to find some way to be able to do that. There were - - there were several comments maybe that this could be addressed as part of a network or cooperative type arrangement between smaller places, the doctor's office, very small clinics, et cetera, and maybe a bigger place; that this would allow them to share use and decrease cost. But there was also a lot of concern as to whether that would be allowed by the act. I think the act has some specific language about selling services. And I'm not sure how that we can address that. But that was a concern that people had because -- because a lot of the care that's given in rural communities is given not even in the small rural hospitals. It's given in individual practitioners' offices. And we put those people out there. We want them to do a job for us. And then we cut them off the network. That -- you know, that doesn't seem to make very much sense. People thought it ought to be very inclusive. There was a lot of comment that it ought to be public and not for profit. Again, include doctors, nurse practitioners, PAs, you know, any kind of health care provider that needs it. Some people thought that -- that it would be okay to just include anybody that's now reimbursable for services; that is, anybody that can be paid now to be included. And one person suggested that we ought to ask Congress for some clarification on this and see exactly what they mean by that. The third question is is what is the minimum functionality or band width covered under the universal services provisions and should that minimum be the same for all health care providers. The main issue here seems to be the less-than-hospital-size application. I think everybody that responded -- and everybody did respond to this question -- felt that -- that we need to have a fairly robust service that goes to small rural hospitals. And most people talked in terms of something equivalent to a T1 line. Some people talked about, you know, fancy switching with ISDN lines and using those to -- to mount up a T1 line and some other things. I read all these responses. But I've got to be honest with you. I don't understand all this stuff. But I -- but I know there are ways to assimilate broader band width using smaller pieces. And I think people were very interested in being able to get that kind of a service, approximate the T1 lines in the hospitals. There was also a lot of talk about the Internet and the Internet being available in all of these communities as a local call, not as a long distance call. The Internet, of course, allows access to the National Library of Medicine, world wide web, all these services that we all take for granted now. But I can tell you now that my friends and classmates that work in rural West Virginia don't have those things. And they would love to be able to have those things and they want them. And in some places in West Virginia, you can't get them at any price. And I think that's a very appropriate thing to be able to do that. On the other hand, in the last three weeks, I personally found out as a result of collating all this stuff that it's -- the Internet is not going to be available to do brain surgery. Okay? It -- things happen on the Internet. You don't get messages. And it's hard to find out what messages you get and you didn't get. It crashes. You know, you go down on vacation and you have your laptop with you and on Tuesday, it dies. And you call the computer guy at your place and he says oh, that; no, I can't fix that from up here; you've got to bring it back. Okay? So -- and -- so, you know, I think there is a limit to how much you can do with the Internet. But the Internet can do a lot of things with telemedicine and certainly, the education things should be available to everybody. As far as providers, there was some talk, a great deal of talk about more robust service for them. For example, in qualified clinics, it would be ISDN lines that - - that that would allow more robust service in those areas. And one of the comments that I thought was particular appropriate was that whatever we -- we set -- we decide on, that there needs to be an appeals process so that if I think that I've got a problem that needs to be addressed with more robust service than the act -- than our reading and putting into effect provides for, that there's an appeals process that they can come and provide information that allows them to get a more robust service. The final question is regarding current variation in pricing in rural communities for various levels of functionality and what are the implications for the subsidy of establishing various minimums. I think there's a lot of agreement here in the issue of shared use. I think people understand that by having education, the libraries involved in this, that there's at least the potential here for the line cost to come way down. People believe -- a number of people believe that lower cost will increase use and make it economically feasible. And that reminds me of "Red" Duke beside me. And years ago in Texas when Lyndon Johnson was in the House or the Senate, he was trying to get a dam built in Texas to generate power. And we was told repeatedly that the people in east Texas, in the hill country of Texas, that they would never be able to use the power and they couldn't pay for it and, you know, there wasn't enough people there and, you know, all these kinds of arguments that we all hear all the time. But they built the dam. Sam Rayburn saw to it that they built the dam. And they sold the power. And in fact, they made the dam even higher after they started building it. So, you know, there is precedent for that idea; that lowered costs will increase use and make it economically feasible. There was also some comments which, again, I think I mentioned before that rates can't be distance sensitive or that that shouldn't be the only thing that goes into the calculation of the rates because charges get out of hand very quickly in some of the rural areas in the west where there are large distances that people have to go with the phone lines. And another comment was that if we would just tell the phone companies or the other carriers what it is that we want and go to them and ask for their help in finding a balance between what can be done and what can't be done, and putting together these cooperative ventures with the education and the libraries and the other people in the community that might be interested in participating. Obviously, we need to narrow these opinions down. And I would propose that we do this with some subgroups to give a more focused answer to all of these questions. But I wanted to tell you where we are. We obviously don't have all the answers yet. But I think we've made a good start. I'd welcome input now from any of the folks on the committee and thank you all for your attention. MS. PUSKIN: Could I just ask for clarification on something? DR. BRICK: Sure, Dena. Yes. MS. PUSKIN: I'm Dena Puskin for the record. Okay. On the issue of the definition of rural, in the testimony that I gave in front of the board, what I suggested was that there were several alternatives that one could use that are in place. You have to be feasible and practical and use things that are not -- the best can be the enemy of the good. And one of them is using OMB's metro/nonmetro definition, but doing what we call the Goldsmith variation which is something we developed for our own grantees because what's happening is metropolitan areas have grown very large as a result of various consolidations in the 1990 census. And you have really pockets of real rural areas within what's considered a metropolitan area. So we hired a demographer to look at those areas to basically define what are really rural in character, rural in economy, rural in characteristic within metro areas. And we have actually a list that we use in our grant programs that any GS-5 or 4 clerk can go down. And if you give them -- you know, a grantee can fill it in. And you can figure out very quickly what is metro -- what is urban and rural by that definition. And you'll need that kind of simplicity for administrative purposes. That's one option. The other is the Economic Research Service of the U.S. Department of Agriculture has come up with what they call they Urban Influence Codes. And they have some alternative definitions. And I suggested in my testimony that we look at both of those and decide essentially which might be better. But both are relative feasible to implement. And again, I always use the test is if I gave it to one of my clerks, could they implement it with accuracy; and if some hospital filled it out and gave it to a clerk to fill in, could they understand it well enough to apply. And that's I think very important in the definition of rural. In terms of the issue of frontier, I think it's very, very important to recognize that we have frontier areas. And we need to examine whether we need to impose some other definitions regarding them. But there's some trade-offs there. Clearly, frontier would fit the rural issues. There are some complicating factors in defining comparable services for frontier that go with the way the act reads. So I think our group needs to spend some time on that in order to give I think the FCC some good definitions for areas that can be viewed for some comparability for the purposes of what the act calls for. That's all. DR. SANDERS: Okay. Jay Sanders, American Telemedicine Association. There's -- one of the issues that Jim reported on that I would sort of like to underline and that I think is a very basic seminal issue -- and I'm not a member of the group so I wasn't part of the discussions that they had -- but to me a very critical issue relates to the basic construct of the Telecommunications Act in defining or allowing this to be provided -- the telecommunications infrastructure to be provided only to the nonprofit entity, and that basically being the hospital or health care facility. The reality in rural America -- and I've been involved with this for many years on a hands-on basis -- the reality is the majority of health care practice does not occur in the hospital. It occurs in the physician's office. It is, in fact, the -- the untoward event that has occurred in the physician's office that allows a patient to get into the hospital. To me we have got to indicate that the act in some way has got to either be amended or edited to include the primary care physician's office or the primary provider's office. That's where medicine occurs. If you're going to provide functionality to a facility where only ten percent of the health care is being practiced, it makes no sense to me. Ninety percent of the health care practice occurs in the primary care physician's office. I would hope that we would come out with a strong message to indicate that. MR. LAWLER: Can I just -- two reactions to that. One -- and really looking at this in two ways. One, if that is the advice that we think we ought to offer to the Congress meaning, you know, if you could make this better by including primary care physicians or however we want to describe it we ought to do that. But I also think we ought to be realistic about it and think, you know, in the context of what we have, what can we do to suggest that there is a mechanism here. Public and nonprofit may mean something more than just a hospital. And I do think maybe that's some specific task we could assign to people or people would volunteer for just to sit down and think about, you know, how do we take these words, what they mean, and suggest to the FCC, to the joint board that, you know, here's how medicine is practiced. There are parts of this which, you know, they may not appear to be IRS definitions but are public nonprofit nonetheless. And this is something you ought to think about when you interpret what these words mean because, I mean, we all know that Congress with the best of intentions doesn't move as quickly as -- Let me just -- Paul, I think you had your hand up first. MR. ZIMNIK: Yes. Paul Zimnik with the Department of Defense. Just to elaborate on Jay's comments, I further believe that if we are going to make recommendations along those lines, we take it even further. We see a growing decentralization in health care delivery. So it's not only from the hospital to the doctors' offices, but even one step removed from that, into the home. So I think that in the future, we are going to see much of the health care access and the services interaction from the home itself. So if we're talking about an act that will impact the next 50 to 100 years in this country, we need to keep that strongly in mind. MR. KIENZLE: Mike Kienzle, University of Iowa. I don't disagree with either of those comments. But I think that you're not factoring in some very strong market forces that have been in place and in play for over the last ten years or so. That is the integration and consolidation of physicians and other providers into integrated health care delivery systems including the hospital, including the physicians' offices, including the home health care sites of care. And frankly, I think just even left alone, the integration and consolidation of physicians within -- either in information consortiums or actual integrated delivery systems will, in fact, functionally take care of the notion of access for all of the various providers of health care. MR. SULLIVAN: Gene Sullivan, University of Virginia. You know, the act does not prohibit or exclude the doctors' offices from activity. What I think -- when the phone company puts in and meets our requirements, if a private practice office wants to be included, they can be included. It's just we were talking about the subsidies and the rate differences. Why are we looking at subsidizing someone that's in a private practice? If, for instance, the T1 line goes down the street to the rural hospital and along that street is the private practice office, why can't the private practice office jump onto the competitive carrier and use that service paying the appropriate rate? MR. LAWLER: Al. MR. SONNENSTRAHL: Al Sonnenstrahl speaking of Consumer Action Network, speaking through a sign language interpreter. I have several questions. I appreciate the comments brought up today. But first, we do have a clear definition of the word, "rural". Does -- does the definition of the word, "rural", include people with disabilities who are isolated -- insulated -- as insulated as people living outside in the boonies. We have to research that. How accessible also are these services? Are we over-depending on audio -- the audio part? Can we become co-dependent between audio and visual use? I watch TV pretty often and I notice that often when they use distance interviews, the audio part gets lost. So we have to be careful and make sure that we're not overly dependant on the audio only and make sure that everything is captioned so that we won't be depending on sound alone. And you mentioned about appeals. I think that's wonderful. How accessible are they? How can a deaf person file a complaint if there's no way for a person to call in or for a person to get information visually? And you mentioned that this should not be distance sensitive. And I agree with that. How about multi-line sensitivity because sometimes a doctor needs an interpreter to communicate with a patient, especially in a rural area or in a metro area. They will need to include an interpreter. And you'll have to get another line to communicate with a patient through the interpreter. And that would mean an additional line. And that should not be included in the cost or it should not be an additional charge to the cost. And when I speak about deaf people or disables people, I'm not speaking about them as patients. I'm speaking as if they are involved -- involved in the health care system itself. I've met some deaf doctors who have expressed some frustration over not being able to get information as much as you guys do. Thank you. MR. LAWLER: Somebody else had their -- MR. WELCH: Bill Welch from Nevada Rural Hospital Project. I don't disagree with any of the previous comments that have been made. I would like to support a couple. As we move forward with this, I agree that there's nothing in the act that prohibits the private practioner from having access to whatever is developed. I would want to make sure that we don't dilute this so much that the resources available are not going to be able to be effective in developing an effective system. Whoever is subsidized and supported through this act I believe should have the same responsibility to provide all the patients services. And I find from my experience that many of our private practioners would not collaborate, cooperate, they are not always available and they do not agree to see all patients. Hospital centers, at least in the west, are beginning to have to subsidize many physician practices and would be the core focus of an integrated delivery system, as least that's our experience in Nevada. And so while I support having primary care physicians having this functionality, I think that the biggest cost factor is getting the line functions to the rural community. And I think the competitive market is going to make the equipment affordable to the private practitioners or the private industry to buy into it. DR. BRICK: Could I just ask -- I've read the language of the act, you know, as regards this. And I have not real -- you know, I'm not used to reading acts. Okay? But -- MR. LAWLER: Thank God. That makes you qualified. DR. BRICK: Yes, right. But one of the things which several of the folks here have commented on and wrote in on the e-mail about this was is there some way that this can be done to get these folks tied into a hospital or a bigger clinic through the idea of a network or co-ops or something. You know, I don't know what the right word is, but some way of doing this that they're sort of brought into the fold and at the same time not violate the spirit of the act that I think kind of prohibits subsidy of private business. I mean, that's my understanding of it. Is there some -- you guys read these things. Is there a way to do that, you know, or -- MR. LAWLER: We put a big cloud over it and say some magic words and -- DR. BRICK: Yes, okay. MR. LAWLER: I mean, there really isn't and -- Bill had a comment which we'll get to. But I mean, the answer is none of this is clear. I mean, you're talking about a lot of money moving around. You have a provision that, you know, is literally that long. And the FCC's got to interpret. They're, you know, I'm sure sitting there saying, you know, who is going to sue us about what. DR. BRICK: Yes, right. MR. LAWLER: You know, it -- and I think we have to think about what our job is. And our job is, you know, we're not writing a regulation. We didn't write the law and we're not writing the regulation. Our job is to provide advice about what we think the right outcome is. And we can say, for example, with the word we think that you ought to interpret them to cover things which we think are important; and by the way, you ought to do something more because, you know -- I'm not saying there's agreement on this -- but if everybody says it ought to go to every primary care physician in -- you know, in a rural area, you know, we ought to tell the FCC and the Congress they ought to do that. I'm not suggesting we do that, but that -- you know, we can certainly give that advice. I think you will find some people saying isn't that going to cost a lot of money and, you know, not out of my pocket. But -- MR. BAILEY: Well, and -- Bill Bailey. To build on that and what I think you said earlier, the fact that -- we're looking at telemedicine. And I think the act requires some sort of subsidy to flow. And the question is whether or not subsidy is needed in every circumstance. Obviously, you can have a primary care physician on a network operating using telemedicine in a nonsubsidized environment. So I mean, they're not going to be precluded from that. And somebody earlier mentioned the idea of home health care. And I think there had to be some point where things start making sense and stop making sense. I mean, are you going to subsidize an ISDN line into everyone's home so that they can health care? No. I -- there's -- you're going to back up from that at some point. And I think what's important is what level of subsidy do we want to have happen. And then, is there a way for primary care physicians either to take advantage of that subsidy under the act or not? MR. LAWLER: Jim, can I ask a question. DR. BRICK: Sure. MR. LAWLER: And I think Tommy's going to raise this later. But I -- we did talk about it to some extent last time. It also seems to me that we need to be talking about a common set of things. What is it about health care that we're talking about? You know, we're obviously not talking about everything from, you know, the day you're born until the day you die in terms of health care. We are talking about, you know, how do we identify what the -- what the medical technology that we want to cover for a rural area. And then you have -- I'm not going to steal Tom's thunder because I know he wants to talk about this. But you're also talking about what can the telecommunications technology do to help that. You know, there are some things that it can do and there are some things that it can't do. But it seems to me that's another thing that, you know, we need to focus on from a rural perspective. You know, you have a national perspective, you have a rural perspective. Is there some level of health care service that is, you know, the minimum that we can identify or isn't there? And if there isn't, we ought to say that. But I do think that those are kind of -- you know, that ought to be included in our discussion of, you know, what is critical for a rural area. And you know, the bigger it is, the more costly it is and the more people you put into it, you know, the more objections you're going to get to it. But I do think that we need to be thinking about that. Let me -- I'm going to start with people who haven't talked. I'm sorry, I don't know your name. MS. CONNORS: Helen Connors. I'm with the University of Kansas School of Nursing. And I just wanted to states that I think we need to be cautious about using the word, "primary care physicians", in rural areas because much of the care in rural areas is provided by nurse practitioners and physicians assistants. So I think we need to be careful of that. MR. LAWLER: Let's go down the row. Yes? MS. KING: One of the things that Dr. Brick said that I was impressed by was that lower costs will increase use. I think an important point is that you have to get the price of these services correct when you're putting them in in the first place. We're in a situation where there's more investment in urban areas than in rural areas. And it's the discretion of the telephone company to make those calls where they're going to put the investment. And it would seem that there should be an incentive to bring some of that investment back into the rural areas. And they don't have to invest depreciation and profit mining in rural areas if they don't want to. So rather than just say well, we'll subsidize, why not give incentives to improve the infrastructure across the country. But along that line, that the service is actually priced at cost for many of the users in rural areas whether they be physicians or nurse clinics or teaching institutions. So getting the price right and to bring the investment to the area is a crucial issue that should be brought to the forefront. MR. LAWLER: Down on the end. MS. POLTRONIERI: Hi. I'm Jeanine Poltronieri. I'm in the FCC Accounting and Audits Division. And I'm working on the Universal Service Fund of this. First of all, I'd like to thank everyone for being here. I think the advisory committee is doing great work and I really appreciate it. I know everyone in our division appreciates it and everyone on the joint board appreciates it. I'd like to make a comment on the definition of health care practitioner. And I think it has some broader applicability. I think the joint board has a very specific task before implementing Section 254 of the act. And if you look at the act and look at the definitions of certain terms and see what's there, I think you're going to be given a lot of guidance about how you would define health care practitioner. What I'm hearing is people are concerned that that -- the definition in the law isn't broad enough or that there should be other incentives to allow people to get hooked into this network although not necessarily be subsidized. So maybe in looking at this issue and other issues, a proper way to approach it would be first to think of what is the act telling us; what direction is the act suggesting; what would be helpful for the joint board to hear from us when they're implementing these various specific issues. And then I saw that the second question, what other provisions of the Telecommunications Act of 1996 can we look at that might -- might have a broader approach? What might we suggest as the next step for Congress? What might we suggest as the next step for the Commission? But I think it might be easier if we sort of -- if you're doing your work, is to separate it out; what the joint board should do; what did Congress need for them to do; what does the language of the act say and what do we think is the best way to reach that goal. And then secondly, what else is there; what was left out; what didn't they get right and how we can move towards those goals. But I don't mean to limit anybody's efforts. MR. LAWLER: The gentleman in the back. MR. WATERS: My name is Bob Waters. I'm with the law firm of Arent Fox and the Center Telemedicine Law. When I listen to the discussion on this, I would think that in order to allow us to move forward, I think we first need to really focus on those services that are available via the telecommunications, you know, technologies that are available in urban areas, define what those are and define which of those we feel -- or define how to make those applicable, what kinds of subsidies would be necessary to make them applicable to rural areas. I am not as hung up on the issue of public and nonprofit language in front of the provider section of the statute because I think that -- I think Dave's point is well taken. I think that a lot of services can be delivered by private practice provisions in rural areas. But there may be creative things we can do in terms of structuring the maintenance and work your way around that. I think that is really the system with an intent of the authors of the statute and I think we need to take a look at it. I think we need to do that without having to go to the process of reopening such issues. But I think the first issue is how do you get comparable services in the rural areas. And once you've done that, then you know what you need to do. MR. LORAN: Yes. Tom Loran of High Plains Rural Health, Fort Morgan (phonetic), Colorado. I'd like to echo that concern. Our big challenge right now isn't so much subsidies. It's the lack of services. We simply don't have digital services available in 95 percent of our area. And what we have to do is back haul hundreds of miles at a cost of $2,000.00 to $5,000.00 a line. So really, subsidy is my second concern. My first concern is building an infrastructure to support what we need. MR. LAWLER: Dena. MS. PUSKIN: Yes, I'd like to go back and -- I agree that the strategy should be for us to concentrate and make sure we do what's in the act and make sure we help the FCC get through what is being asked in the act. And if you look at the act very carefully, it says really there are two areas. There is one area which says what really do we need to ensure comparable services in rural areas for everyone, not -- you know, not just health providers. But what's a basic minimum level of universal service in a rural area? Now, if you look at that component and you start thinking about that, you might say, well, look it, if we could get Internet access a reasonable rate, let's say 28.8 baud or some other to basically everyone in a rural area, how would that not only help everyone in the area and build the services, but also build those services out to private practitioners and others who might not necessarily be eligible for the subsidy, but certainly will have an affordable service. Because that is really the key. Without the basic level of infrastructure there, no one out there gets an affordable service. And that's what High Plains has felt. That's what I know has been felt in west Texas. And a number of the projects that you probably have around the table, we've funded. So I know what their problems are. So it would say to me that part of is -- is in thinking about the health side, to say well, look it, if we have a basic infrastructure out there and we define that for everyone, that would get your home health care services out there. That would be affordable and it also would probably also be acceptable. The other thing to recognize is it's a moving target. What is the services now that we think are critical medically is not going to be the case three years from now. So we're talking about a medical -- and I am not -- and I now we're going to get into this -- I'm not sanguine about developing guidelines by service. What I am -- I am not sanguine about that at all. And I will -- I will argue against it later, so I'll set you up for that right now. I think we do need to define functionality by some very broad characteristics. And I believe we should define in a way by at least what we want for the clinics, what we want for the hospitals out there and what we want as a basic service for everyone which may indeed evolve and make it much easier for systems to reach out to hospitals. And just one second. I think we have some very basic problems even within the act with definitions. And I know this is the technician in me. But what do you mean by a community health center? Do you mean a federally qualified community health center or do you mean anyone who puts a shingle out and says they're a community health center and they happen to be nonprofit? The reason I ask that is because I think we probably will want to seek the broader definition. But it makes -- it may make a big difference for the subsidy level. And so we've got two issues I think. We've got the basic issue of what do we want out there that helps to stimulate, incentivize that basic infrastructure and what do we want particularly to get subsidies in the health care field. And that is essentially, initially at least defined by the act, and how do we refine these definitions. Given that, then I think we can make comments again along what we think needs to be done in the future. But we've got to get the work done with the act. And we don't have it done. And we've got a short time frame. DR. KAMP: George Kamp, American College of Radiology. Earlier, Dena's comments, I was wondering if there was discussion in the subgroup in terms of the definition of rural and its implications as far as differences in HCFA reimbursement, for example. Did the subgroup discuss that? DR. BRICK: No. MS. PUSKIN: No. I mean, there are -- HCFA has some very specific definitions which are -- they vary by program. If -- if you're talking about payments for hospitals, it's metro/nonmetro. If you're talking about special payments for rural health clinics, it's another definition by the Center called nonurbanized areas. And so there are some differences. And I think what we thought would be very critical was just to have a rational definition for rural that could be implemented that basically irrespective of this -- which would relate to a subsidy for infrastructure development. DR. KAMP: I understand. I was simply asking was there anything useful in those previously established terms as far as this effort? MS. PUSKIN: Well, metro/nonmetro is the first cut. And then the Goldsmith variation is a cut on that. It takes the metro and breaks it down further into areas that are really rural in character but are within metropolitan statistical areas. So we did start with that. DR. KAMP: If we are sharing about unfamiliarity with acts, I'm unfamiliar with variations on the Goldsmith. MS. PUSKIN: Okay. Well, we have a paper that actually relates to the last iteration. We've just updated it. But it's something that we use. Why should you know? MR. LAWLER: Bill. MR. BAILEY: Bill Bailey. I didn't disagree with what you said, Dena. I just want to clarify one thing. I heard you say sort of a minimum standard of 28.8. MS. PUSKIN: Oh, that was just thrown out. MR. BAILEY: Well, understand rarely does any 28 modem run at 28.8. The telephone network isn't designed to handle that. Even in metro areas, they don't run at 28.8. MS. PUSKIN: I threw that out as just an example of what -- that it's very important to define what would be acceptable. In my testimony, I must admit that I said the Internet -- access to the Internet at this level. And I didn't define at what rate. And that was an oversight that in some part was intentional because I don't -- I couldn't - - among the people, we had not really given enough thought to what would be reasonable. But I think that's the kind of thing that really needs to come out of a group like this. MR. LAWLER: Jay. DR. SANDERS: Just one side comment, a for your interest -- for your information type of response. That Paul Zimnik generated a comment about home health care. There's no question in my mind that the primary site for health care in this country in the next five to ten years will migrate to the homes, so I'm in total agreement. But I wouldn't be as concerned about the need for functionality because the reality is the functionality and the band width and the communication infrastructure to the home even in the rural area is already there. Most health care whether it's vis-a-vis the patient themself accessing it or whether it is the provider themselves accessing it will occur over the Internet. And with web technology as it presently is, you're going to be able to do video conferencing over web technology. The TV set and cable communication will afford that functionality right now. If you look at what is happening right now with respect to cable modem, if you look at the improved band width that's going to be provided through direct access TV, a lot of the necessary health care needs in the home will occur through the TV set which, in effect, will become the telemedicine modality. MS. DEERING: I want to add to that something that happened fortuitously to be in the Washington Post this morning in the business section. And it's short so I'll read it. "U.S. Healthcare invested 25 million in a newly created company that would deliver health information directly to consumers over the Internet as well as through pagers, radio and traditional mail. Teaming with Johns Hopkins, a university and medical system, it will manage the content", et cetera. "U.S. Healthcare will own most of the new venture called Intelehealth." I think what -- if we are concerned, especially in this hour of our discussion, about a definition of rural and behind that is a concept of equity, then we also have to realize that the big integrated delivery systems are going to do this. But they're probably going to do this to their beneficiaries who may be in more concentrated areas. I don't know. And so if there's a concept of equity behind what we're doing and you want to ensure equitable services in rural areas, then you need to make sure that you're matching that level of service into the rural area. MS. PUSKIN: And let me just say that that means that you need that infrastructure there to deliver it over the Internet. And I would suggest to you that right now that's not there. And despite the fact that we may have -- that we may see it evolve there. And that would mean that there would be need over time for less subsidy. But the issue is really defining what that basic level is for everyone. Then you deal with all of these issues, at least at a basic level. And I think that's what we're saying. MR. LAWLER: Gene. MR. SULLIVAN: Gene Sullivan, University of Virginia. If you still have the business section of the Washington Post there, there was another article on GTE forming a partnership with U-Net (phonetic) to provide Internet access services to the 18 million GTE customers. And I believe that if you do look three years out into the future, you're going to see that this is available. Many, many phone companies are partnering with ISPs (phonetic) to give you the local dial service to the Internet. So maybe in that particular case, we're setting our sights a little bit low. And maybe we ought to start looking a little bit higher as to what the requirements would be just as Dr. Sanders said. The phone companies aren't the only ones out there. If your standards are high, quite possibly there will be others that are very interested in providing this service such as the cable companies, such as the oil companies with their dark fibers (phonetic) in the ground. So let's not think today what we need to do to provide medicine either to the rural clinics or to the home. Let's think just a little bit down the road. MR. LAWLER: All right. Let's do a couple more and then we'll let everybody get a cup of coffee and move on to the next one because we're just about running at an hour. MR. ZIMNIK: Paul Zimnik with the Department of Defense. A couple of comments. I agree completely with you that if we bear in mind what we are trying to do here, we need to remember that this is not an island. We're not looking at -- particularly today and in the next five or ten years, health care delivery, telemedicine, is not an island unto itself. We are talking about information aided technologies. And there are market driven forces. You know, we've seen what Paul Forder (phonetic) has said even about the third wave. This is overtaking everything we do in society. So as we sit here trying to define what kinds of applications, what kinds of infrastructure will be required for health care delivery, we need to be very careful not to fall into the trap of defining an infrastructure for a particular application or, in fact, I believe even for a particular industry like health care. We need to keep in mind what is going on in the world, what is going on in the cable industry. Web TV is another thing that just came out yesterday. I believe if we move into the next hour talking about infrastructure development and such, that we'll find out even that health care type applications in the near future will require a minimum of six megabits a second type capacities. And that kind of access into the home will be enables by processes that again are being caught up in this revolutionary change that we're seeing that's effecting every individual in society. So we just at a philosophical level need to bear that in mind as we talk about making recommendations for implementations that we hope will sustain the needs of our country for the next ten to 20 years hopefully. MR. LORAN: My comment to -- Tom Loran, High Plains Rural Health. I just think it's important for everyone to realize that there's a lot of people out there that still are on party line phones. And they don't have cable service. And all these things are really nice. You can read about it in the paper. And they dream from that. So I just, once again, say lets not get so far out in the future that we forget the people that are still on party line phones and that there's a basic infrastructure in the rural areas that just doesn't exist and needs to be built. MR. LAWLER: Down on the end, and then we're going to take a break and move on. MR. MCCONNAUGHY: Just one comment on the last comment. Party lines used to be a huge problem. Fortunately, it's becoming less of a problem. It still exists, I mean, no question about it. But it's not -- thanks to REA loans and public policy, it's -- well, it's something to be reckoned with. But it's not the overwhelming problem that it used to be. But the point I wanted to make, looking at Question 4 that the subcommittee addressed, I keep seeing the terms, "schools", "libraries", and "shared use", which I think is a terrific idea, not only in terms of the cost savings, but in terms of getting the total community involved, just a community access center as it were for new information. I would suggest the subgroup look more closely at a specific part of the act which may or may not throw a monkey wrench into that. Perhaps a creative interpretation would help here. But I would say to look at Section 254 HB3. DR. BRICK: H what? MR. MCCONNAUGHY: HB as in boy 3. It talks about terms and conditions of public institutional users receive discounts -- some rock dollar type discounts. The way it's termed, it specifies in the language that it cannot be sold, resold or otherwise transferred by such user in consideration for money or any other thing of value. Now, resale and shared use has a long history before the FCC. I was just looking to that for some guidance now leading through these waters. But I think in a nutshell that the idea of shared use is a fantastic idea, but we may need to carefully navigate through the act to make sure that's a reality. MS. POLTRONIERI: If I might add to that recipes concerning the schools and libraries. You who are working on that, that's very significant to talk about here. MR. LAWLER: All right. MR. MAXWELL: I think that we can commit that we will be spending a fair amount of time within the FCC to explore what that means and what the restrictions on that are for precisely the reasons that you are suggesting. MR. LAWLER: Last comment and then we'll move on. MR. KIENZLE: Mike Kienzle, University of Iowa. Just one pragmatic comment. That I'm sure some of my colleagues from West Virginia, Georgia, Kansas and elsewhere would agree that the fall off in expertise or technology, as you move into a rural community, it's extreme. And I can tell you as an R & D director, I've had to send people 90 miles just to replace a toner cartridge. And so for us to be talking about future -- future digital services in a very, very rural setting, talking is one thing and doing is quite another. And the implications for the actual implementation of this kind of technology in a rural setting is immense and cannot be discounted. And I so I agree with trying to look ahead far enough to try to anticipate the needs. But at the same time, we still have people on party lines and we still have to send people out to replace toner cartridges. So, you know, I would just urge a little bit of prioritism. MR. LAWLER: Well, if people want to get up and get a cup of coffee for one minute. But let's quickly return and get back to the next one. (Whereupon, a brief recess was taken.) MR. LAWLER: Tom, it's all yours. INFRASTRUCTURE SUBGROUP REPORT MR. SPACEK: Okay. First of all, I would like to thank all the subcommittee members for their inputs. We sort of requested that, and I'll discuss that, similar to the set of questions. And I was just amazed that everybody came back with, you know, three or four pages of very insightful comments within the time frame. I never ask people who work for me to do things and expect that to happen. You know, it was really good and we appreciate that. And I'd also like to thank Sid Housein here from Bellcore for standing in while I was away. I was away for the several weeks for the last two meetings. And he helped out quite a bit. Okay. These are the topics that I know were covered. Let me start with what we solicited from the key members. We sort of came to the same conclusion as Jim. Let's get some input from the subcommittee members. And we asked them four types of things. First was the kinds of telecommunications services that were essential for providing healthcare in rural areas to be included in the Universal Service Fund , inclined particularly to the word, "react". Next we asked well what are the infrastructures that's available today to meet those needs and what are the shortcomings, where aren't those needs met. What are future needs for the next three or four years, and this is where we applied (inaudible) and where people brought up this home health care issue and so forth and expanded in that direction and several other issues. And then we asked what were the barriers or providers to put the equipment in the infrastructure in reaching the rural and (inaudible) area and what might policy be to reduce those barriers although this was very preliminary in a sense that we believe that's one of the major outputs at the end of the flow. Okay. In doing that, we do have draft report here. I didn't have it on the back table before. I'll pass it out in a little while. Sid pulled the draft report together. And the attempt of this was to summarize the input as best as we could from the various members. Now, I believe it was going to be summed in (inaudible), especially the ones that were found in this morning, but will not be included in this report but we'll work in as a working document. But most of them we worked in as best we could, but we probably missed some. So in our ongoing work of the subcommittee, we will not just use our summary report as source report for input, but use the original documents that you all heard (phonetic). I'll also ask that the subcommittee members, and you can tell from the subcommittee, re-read this document because its significantly different from the one that we had two or three days ago based on inputs that you all provided. And clearly, I'd like for the rest of you folks to read it, too. What I'm not going to do today is summarize all those inputs. Okay. I've handed it out and you can read it. It's only four or five pages. You can read it on the plane or whatever. What I'm going to do is highlight some of the key issues that were uncovered and that need to be addressed, and suggest an approach to what we've been told. That's what we're going on. With respect to the key issues, we solicited input as one of the essential services that were required. We had some commonality in responses, pretty much commonality. We had quite a bit of variety, just as Jim suggested. And I think that mostly -- and there's a lot of reasons for that. I think it mostly had to do with the way we asked the questions. We basically asked for -- you know, what are the telcom services that should be provided. What does that mean? What does that have to do if you receive this input? You have to make some implicit assumptions about the telemedicine applications that are required and the potential (inaudible) and the future (inaudible), and convert that or translate that somehow in your head into telcom service. Well, that's not an easy thing to do. It really takes a little bit of pressure to do that. So I think that's one reason, that we didn't ask the question very well. I think what we should have asked, and several people commented on this, is that we should have asked for what are the fundamental telecommunication needs that are required and to get an understanding of that, and I'll talk about that a little bit with this chart. So what we really need is a framework for getting (inaudible). And that's what I'll be talking actually talking mostly about, the particular framework. And several of the members suggested that we do that. The next issue was the boundary between essential and advanced applications. And this has to do with what we were talking a little bit about before in some of the comments about what are the things we can do now and where are we headed in the future. In 254 H1A, it talks about in a sense, services that are essential for health care. And we need to define them. The FCC needs guidance as to what we recommend. And then 254 H2A talks about advanced services that aren't necessarily in the initial universal service set, but that the FCC would like to know about because they want to set up some rule for competitive -- some competitively neutral rules for access to such services in the future and make sure you can evolve to that. So we had the issue of how do you separate those. And I'll discuss that in the next chart, too, because we have either a solution or a cop-out depending on how you want to interpret the chart. Okay. Next, the idea was we wanted to assure that whatever we recommend, that there is flexibility for evolution. There were comments earlier that telemedicine application and considerations will change over time so we don't want to get locked in. So how do we address that issue? We have some thoughts on that. Related to that is there were some comments on the issue of the definition of the telecommunication service, and it should be broader than pipes and the switches and the band switching and band width and so forth. And it really needs to include the various protocols and data standards and software standards to some degree. And I'll touch on the benefits of that later, too. Also brought up this morning, the performance level of Internet access. It was fairly -- fairly unanimous -- it may have been unanimous; I don't recall -- that Internet access was clearly something very critical for telelmedicine application, especially cooperative and information access in more places. But there is a tremendous difference in T1 access and POTS access (phonetic) and what should be available where. Clearly, lack of uniform coverage and reliability of the current infrastructure. And that's kind of what this whole idea is about, is how do you solve that problem and get infrastructure into the rural areas at a comparable cost. And then a whole series of economic elements, we've got a few of them here on economics and cost issues. The last mile issue and the cost of the day (phonetic); incentive parastructures (phonetic), some people mentioned that today. It's really what the difference in urban/rural cost differential and how to get a handle on that. And in some sense, it's not a matter of what costs are. It's a matter of it's going to cost something to get service, to get the infrastructure to the rural areas. The providers -- the beneficiaries of this line in the act need to get it for a comparable price. The Universal Service Fund which we are not designing although we may give some input about what we think it's about -- I don't think we're designing an intelligence committee -- has to -- makes up the gap. So we need to put our objectives I think out there with recommendations. And the designers of the Universal Service Fund can hopefully meet some of our objectives which will introduce cost issues because I don't think this committee can solve all of those pricing issues. We have to get to what our financial objectives are anyway. But there's lots of issues here. Some folks brought up the issue of the economic realities of what can really get out there and be identified versus, you know, kind of we want it all even though the we want everything we can get now scenario may mean you may mean you may never get it because it costs too much. So it's a reality out there. And then there are issues of stimulating the private sector investment to compliment Government funding. And that gets to the issue of how much Government intervention is really needed or not needed. So this is sort of a series of issues that are to be addressed, that kind of came up. Some of them have been partially addressed by the inputs and some were just raised who were suggesting an approach to move forward here. The first thing is basically to try to understand what we're doing. We're making a bunch of implicit assumptions about what telemedicine's for and so forth. And everybody at this meeting can probably make a good statement to that. But I think we need to articulate it in a way that, you know, that the committee kind of agrees to; you know, (inaudible) patient to provider and so forth, just kind of obvious things about the -- you know, just moving distance and specialties that are not available and certain areas and so forth. But I think there may be some different views of that. But what are we trying to accomplish? And I think that's put together relatively quickly. And also in the goals, I think we might want to address this issue of flexibility, extendability over time. The idea then is to - - what we need to do to meet those goals. And the first thing that we think we need to do is try to understand what the applications are to be enabled by the Universal Service Act. What are you going to do in telling us? The kinds of applications I'm talking about -- I've given some examples here. These are -- you know, physicians and physicians consultants. That may be with or without, you know, images and other -- other records along with it. Remote diagnosis, and of course, there are several types of that; something as critical as in the triage center. So these kinds of -- this is what we mean by applications. And those applications are influences by several things. One is the needs of different specialties differ and there are different applications for different specialties. This can give some overlap, too. They also differ by time delays. And I'll mention that a little bit later. What's an acceptable time to receive something because as we'll see, there is a tremendous cost difference in something -- getting something in a minute versus getting something in an hour. Well, in some cases, an hour or two days is sufficient and in others it's not. So we need to get a handle on that. And as also mentioned this morning, the particular health care provider sight makes a big difference. In other words, a hospital might have different needs and requirements for services than for a clinic or individual operator. So these are the kind of parameters that need to influence these applications to some degree. When we're talking about, you know, this distinction between potential and advanced applications which is the name of the bill (phonetic), the comments that we received are that the boundary is not going to be very clear. We have a list of these various applications. It's not going to be very clear where is the boundary that we're going to recommend these and say these are the future ones. There's going to be a bunch of fuzzy stuff in the mill. So we thought -- and the cost difference, too. Clearly, some of the things that are more extensive will be on the list and some of them may actually be high priority and some may not. So we thought that the best thing to do from the comments was to try to come up with instead of a boundary, a prioritized list. And a prioritized list may not be exactly what we need. It could be the first five things and the next five and something of that sort of these applications. And why is that important? Well, you give the joint board and the FCC some flexibility that way to try to include as many applications down the list as possible to be supported by the telcom services. When they consider the shared costs, we may get inputs not just for us, but inputs from the education people and the library people and so forth. So the whole idea is looking at that in the context of the national information infrastructure where you do have (inaudible) which in that infrastructure solves a variety of societal needs and as well as commercial needs. So that was the idea of trying to get around this distinction to some degree. The next thing you need to do is now once we understand these applications and the time frame and so forth, you've got to translate those into telecommunications services. And what I mean by telecommunications services might be a little different in terms of vocabulary. In fact, let me give an example. In telecommunications services, I'm talking about things like store and forward file transfer as a need to meet a particular application; teleconference; fast type quality English transfer (phonetic); Internet access and so forth. So what are those services (inaudible). And then when we understand that, we can translate that into one of our primary outputs which was the recommended infrastructure functionality. And here is where we're talking about the things like band width requirements, switching and routing requirements, whether or not there should be an open architecture -- and I'll say a word about that -- and standards and so forth. However, this is a process to get to these -- these infrastructural obligations. The intent is to provide the recommendation in the aggregate form. For example, potentially aggregated by facility like hospitals of a certain type need this or by the kind of hospital it is or something. It might be aggregated by -- you know, it might be a different set for clinics than the things we're struggling with this morning. So the intent is not that the FCC is given information like this and we put the burden on them. I don't think we even want to think about asking them to come up with what are band width requirements for a particular medical service or feature. That's not what we're intending. The intent to give them recommendations in the aggregate form. But in order to do that in a meaningful way with some logic and back-up as to why we're recommending this, we believe that we've got to understand what these applications and then what the telcom services are to meet those applications. That's the basic approach that we're suggesting. And beyond that in addition recommending what infrastructure needs might be, we also intend to make policy recommendations. That's part of what we're being asked to do. And the are policy recommendations that will remove barriers in order to get this infrastructure out there in the rural areas and at a comparable price as urban areas and not to mentioned underserved in urban areas and so forth -- that's an issue that has to be dealt with -- and to assure that this is extensible over time; that we don't get locked in. So what are the policy recommendations to all of them. And finally what's below the line here that we really don't think are in the purview of the advisory committee, and this is to specifically specify what particular technology should be use and what the technology alternatives are. I mean, some of these needs will require cable and some might require cable. Some might require wire line, wireless satellite, who knows. But here we're specifying the functionality that's needed to meet these needs. Until it gets put out there, we don't believe it's in our purview to specify. So that's kind of the approach of getting there. A lot -- some of these steps have been at least started. Okay. And then just an example of what we're talking about to understand these applications. This top part was pulled from one of the inputs using teleradiology as an example. And there was one particular application for physician consulting. And within that application, the idea was there may be several different key components even within one application. And then we looked at a piece of market research that came out this year where a question was asked about -- of the physicians, how long do you consider a significant delay in getting a pre-existing xray or pre-existing study in each of the following situations. And these are the results of the survey. And clearly if it was a critical or very critical situation, it wouldn't be a number of that sort. So I don't know the exact definition of what that emergency setting was. But the point is here is not to analyze -- I mean, to, you know, question what the resulting surveys were. The point is to realize that there are multiple applications within a specialty that will have different needs. There are multiple time constraints and those will have different needs. And we've really got to get a handle on that to move forward. And this is just a picture of a teleradiology application. And I'm not going to go through the details, but I just want to make one or two points. We're talking about, you know, here's remote site here; accessing medical center that has a local area (inaudible) particular images stores and so forth. Okay. What we're trying to get at is in this circle here, in the network and the interface of the network and so forth, what are the requirements that are needed to meet this application need. And there are a lot of questions you want to ask. For example, a new network. Do we want to push or make a recommendation that there should be an open architecture, for example. We may not be able to do that. What might the benefits be of that? Well, it facilitates alternative technologies perhaps. It facilitates alternative providers to be competitive with each other and things of that sort. So that's the thing we need to consider. Within the interfaces of the network, issues like data standards and interface standards so that it will allow interoperability among various vendors' equipment that you might want to buy. So these are the kinds of things as well as the band width requirements and those sort of things that we're talking about. And this is just based some work that's still being done. But I'm not going to go through these details. But there are some -- it's interesting -- points here that discuss the issue of cost. Again, we're using teleradiology for an example. And within this application, there are many different modalities, MRI, CT, ultrasound and so forth. And within each modality in some cases as are listed here, there are different evolutions with the respect to the quality of the image and so forth. And those are relatively easy to translate into file sizes. And then once you've got file sizes, you can look at various ways of transmitting -- there are many more ways than are listed here -- of transmitting some of these. And take a case here where you're talking about five hours transmitted over POT (phonetic). And I think the point is well made, 28 kilobits modem (phonetic), but specifically out running at about 21.6. Anyway, you're talking five hours. And on T1 over here, it takes five minutes. That's a 60 fold speed based on what rate you're talking about, different prices in different parts of the country. That might be a 40 fold -- only a 40 fold increase in price for 60 fold speed. The point is do you need it and the answer might be yes or it might be no. And if you deploy something very broadly that costs 40 times more than something else, you know, is that -- does that make sense or not. I'm not answering the question. I'm saying we need to raise those issues in order to make our recommendations. We need to know what's required, under what time constraints and examine the cost trade-offs in order to make our recommendation. And then similarly, you can just extend that to that same kind of example. And we've done a lot of this already. So I'd rather it be somebody who will do the testimony -- extending some of this stuff to other specialties and applications, cardiology technology, health care, mental health and so forth. So just summarizing, in addition to asking you to read the report which summarizes all the inputs, I think what we need to do is articulate what these goals and objectives are overall. And I think that requires inputs from all the committees. And potentially if the chairpeople are meeting later, we can discuss that. We need to develop this priority list of essential advanced services that are enabled by the universal service set. And I think that's something that our infrastructure can do jointly with the rural committee. We'll have the initial crack at it and go through the same problems. But I think we can work together to get a handle on that. And then translating those applications into telcom service needs. The infrastructure subcommittee can take a crack at that. With respect to the data standards and system hardware compatibility, I think that might fit more into the purview of the architecture subcommittee. So we may get inputs there. Then translating telcom services into the infrastructure and concluding the extensibility issue. We can take a crack at that. And then based on all this stuff, and all of us have to work together and say what our policy recommendations in addition to telcom (inaudible). That's basically what I have to say and here is the report. And again, there were one or two comments that were phoned in this morning that didn't quite make it in, but most of them are there. MR. LAWLER: Yes. Jay, do you want to start? Are you done with this, Tom? I'll turn it off here. MR. SPACEK: Yes. DR. SANDERS: Hopefully -- this will be an off- handed comment -- but I hope that in the final report, we don't include that example of teleradiology, that in the emergency setting we can allow 2.6. My radiology colleague -- that was probably a survey amongst radiology, not amongst trauma surgeons. DR. KAMP: Semi-retired. Just to get our attention. This is a slightly more serious comment, actually, two. One is simply to point out what a moving target we're dealing with on the example of teleradiology in terms of cost and time of transmission trade-off. I would simply point out that the FDA just a few months ago gave pre-market approval for compression technology of wavelength pipe (phonetic) will upgrade 30 to 1 ratio which again just to emphasize how a chart of this type, however meaningful, when you're talking about the fastest thing is 6 to 1, it really changes the way we look at things. Secondly, and just informational, the American Medical Association in its annual meeting two weeks ago adopted a ten page report on telemedicine which was really fairly informative. It dealt with issues of standard reimbursement and licensure. I realize some of these are not within the purview of this committee, but would be happy to get copies of that document for the committee if they would like. MR. LAWLER: Yes. MR. POTTER: Yes, thank you. MR. TUCKSON: Reed Tuckson from Drew University. I appreciated the sensitivity and the underscoring of the -- of the underserved urban areas. I think that is very important. I'm struggling to -- I missed the first meeting and so I don't know whether I'm behind on the curve here -- of our definition of health care. These services such as cardiology, pathology and so forth are very important. But what also is important, particularly in urban environments and inner city environments is the notion of using this technology for promotion of health and prevention of disease. Just as we've gotten the FCC act deals importantly with how to get lines into libraries and other such areas that are -- that, you know, are at schools where we don't have this capacity -- and to exclude, particularly in urban environments, comes the notion of how we are going to be able to get communities involved and community-based institutions involved in having an opportunity for dialogue and innovativeness in terms of promoting health, defending against disease and earlier diagnosing disease in the people that live there. So I hope at some point we'll add those things to this list of telemedicine issues and that we'll look at the health promotion and the prevention issues as actively as we're looking at some of the radiology, pathology, dermatology services. And maybe we can come back and talk about that. MR. LAWLER: Cindy. MS. TRUTANIC: My name's Cindy Trutanic. I'd just like to underscore that point from the perspective of the users of telemedicine for telepsychiatry and mental health - - mental health purposes. There is a lot of talk about prevention in the mental health context and -- and having points of presence in a -- a school or a community center to really address, you know, adolescent and children's needs in the urban context. And they certainly are under-served in many respects. And I think that we should identify that as a need. MR. KIENZLE: Mike Kienzle, University of Iowa. Just to again underscore the very broad definition of telemedicine, we define telemedicine to include a direct consumer source of information. And our virtual hospital gets about a half a million hits a week, 40 percent of which come directly from the public. It's interesting that many of the public come in on the virtual hospital for the -- in the information section devoted to patients and family members. And most of them then migrate and read the information that is on the same illness that was intended for the -- for the physicians and other health care providers. So clearly, there's a huge need and a huge desire on the part of the public to have information. I think the Internet may turn out to be the platform that serves the broadest public good and certainly needs to be carefully crafted so that maximum access to the Internet on the part of the general public, particularly K-12 schools will serve as well. MR. LAWLER: Jay. DR. SANDERS: Jay Sanders. I guess it doesn't need any more underscoring in terms of what Drew said and the subsequent comments. But I probably can talk for Paul here vis-a-vis his comment about the -- in effect, the electronic house call. Our total intent as a major reason for having access in the home is predominantly for disease prevention and health promotion. And in fact, one of the initiatives that we've taken in Georgia is to integrate the health care telemedicine initiative into all the disconcerning sites in the states. So along with the Spanish teacher and the advanced algebra teacher, we have our -- our pediatrician in the disease prevention mode discuss with the children preventative health, proper nutrition, anti-smoking, et cetera. MR. MENN: Eric Menn, Partners HealthCare of Mass. General. Just as an extension of what Dr. Sanders was saying, in an integrated delivery system, it is very much in a capitated environment in our interest to keep people out of the hospital. So it is economically reasonable for us to install telemedicine infrastructure as a vehicle by which you will keep people at home or with their primary care provider. And that further (inaudible). MR. TUCKSON: The issue here, again, that's so important -- we come down to this discussion as we get into rural subsidization, who bears the cost. And again, it's a matter of what -- the profits, not-for-profits, who pays those fees. And there are a lot of us who are really concerned about the highway bypassing inner city America and how do you try to give a little bit of equity to that. And if it's just the folks who have -- who feel that there is an economic incentive to enroll patient population base, get access, that's one thing. That's great. And it's logical and it makes sense. But those who are not enrolled in that population base with that particular managed care firm not still get left out. And so I think you really hit the real issue. And it really starts to get down to now this notion, as Mike said in terms of fairness of equity of access and the portion of subsidization and how do you make that happen. MR. LAWLER: Can I ask an ignorant question which -- in the rural -- and I'm sure that there's nothing but a generalization answer to this -- is the extent of capitation in rural areas getting anywhere near where it is in the rest of the country? VARIOUS SPEAKERS: No. MR. LAWLER: Is it a totally different environment.? VARIOUS SPEAKERS: Yes. DR. SANDERS: The basic problem that you're having and one of the things that telemedicine can help to alleviate is the reality -- is just the actuarial reality. Managed health care can't go into a rural community. Even if you have a 1,000 member rural community and all of them sign up for that managed health care entity, all you need is one catastrophic illness to totally wipe them out. From an actuarial standpoint, it's a disaster. However, what telemedicine can in effect do is to electronically consolidate ten 1,000 member rural communities into a single provider base so that you now have 10,000 electronic members made -- in ten different communities. And telemedicine will, in fact, facilitate the ability of managed health care to begin to market into rural areas. MR. LAWLER: Mike. MR. KIENZLE: You're not suggesting, are you, that the -- they're going to shear risk -- insurance risk electronically? I don't think -- DR. SANDERS: Not electronically. MR. KIENZLE: But even within a rural setting, the consolidation and integration that goes on, it goes on independent of whether managed care is in that state or not. People are finding a lot of reasons to integrate within health care systems. And so we're really talking about systems of care and I don't think we can assume that just -- that this applies only in a capitated environment. DR. SANDERS: I agree with that. I just wonder if -- MR. LAWLER: Is the percent of those with insurance -- I think I do know the answer to this -- different than in the rest of the population? MS. PUSKIN: There's -- I think there are a number of issues. The University of Minnesota has done a lot of studies for us on the extent to which, a) there is vertically integrated systems being developed out there and the extent to which they are undertaking risk. And in the first instance, let me say that the extent of vertically integrated system is -- has not proceeded at the rate that they proceeded in -- in urban areas, but they are increasing. But it is a much different picture. And there are a whole host of reasons why. The extent to which risk is being undertaken out there by rural systems is -- is quite minimal. However, that is misleading because, in fact, you have a lot of people who are part of so-called managed care that are out there with their urban-based systems, but they really are a preferred provider organization. But they're not really systems of care. And so it gets very complicated. What do you mean by managed care? And your original question was real capitation. And real capitation where people take responsibility for the full health care of the population is -- is much less, much less out there. And what Jay was suggesting is that the -- the evolution to that will be enhanced by the availability of telemedicine for linking people. I think it's by the availability of telecommunications technology which allows record transfers and allows sharing of information. I think that is true, but I think it remains to be seen how fast that evolves. And, see, it's very, very important to not assume that managed care is generically termed. It's the same as really having really capitated systems. And it's really only when you get systems in which you take responsibility for the population that you see really the full evolution of this technology or the full use of it occurring. MS. POLTRONIERI: Just to go to the point of the availability of telecommunications services, generally, Section 254 B3 of the act which is not the rural health care provision, but it is the broader provision -- broader principles for how the action works, Section 254 of the act. And it includes support for rural high cost, low income consumers in insular areas. And that is separate from the subsidy that we're talking about, particularly for rural health care providers. But it's another part that's a piece that might fit in. And if that part is done right, that should help facilitate getting the infrastructure out that you're interested in. On a second point related to the definition of telemedicine and what was to be included in getting that definition to be broad enough, I just wanted to point out that 254 H1A allows for subsidy including instruction rendered to such services, telecommunications services. And this is a very -- this is very particular to the rural health care part of the act. It's different from -- there's no allowance for instruction in the school or libraries part of the act. And that's something that we essentially want to keep in mind as you look at key definitions of telemedicine. MR. LAWLER: Art. MR. LIFSON: Well, just -- Art Lifson of CIGNA. Two things. One is I don't think if we just look at this as integrated delivery systems that are solely focused on rural areas that are developed in rural areas and somehow confine themselves to a rural area however that's defined, that that is, in fact, the total universe. In many states, it's in fact integrated delivery systems that are in -- may have started in urban areas and move out into rural areas. And this comes back from both a provider perspective. You may have an academic medical center or a tertiary care hospital that for its own business reasons has decided to try to get control over its inputs and establishes relationships with rural hospitals, physician networks, et cetera, or it could be an integrated delivery system sponsored by somebody other than a hospital that for the same reason is going out into rural areas. That's point number one. Point number two, managed care is different in different places and -- because there are different demands made and there are different needs. And in many cases, it - - at least in our experience, it requires the adding of resources in a rural area in order to make this work rather than your moving into an environment in which there is excess supply. Clearly in most rural areas, there is not an excess of supply. And that, in fact, makes it a big difference. If I can make just one last point, somebody earlier in the conversation made the point about private activity and the incentives that exist for private activity to fill many of these gaps. And I think that is real and I think it is happening for lots of different reasons within our health care economy. And one of the things we have to be concerned about is in trying to meet the needs of this act, that we don't create disincentives for certain types of entities to enter a particular market. For example, if you create such a huge price difference in the subsidies -- and I don't know, we've talked about subsidies here but I'm not sure whether we're talking about two percent of 25 percent of 50 percent and I don't know what the total cost -- what proportion the total delivery of that service that subsidy represents. But assuming that it's significant and that it's large enough to move people, then you might -- may be preventing part of the capital from moving into an area where it might otherwise move. And I think we have to be cognizant of that and concerned that we might be cutting off certain avenues to capital that would otherwise be there. MR. LAWLER: Elliot. MR. MAXWELL: Yes, I -- this is more an appeal for information and data. Around the table, there are a numerous number of people who have done a rich of variety of things in the area of telemedicine or telecommunications- based health related activities. We're not hearing I think as much as is known from your own work -- and I think it's sort of becoming increasingly available -- about the things that you are finding critical in doing it. And we sort of have the greatest pay-off at least in the experience to date. And I'm very appreciative of the work that Tom has done in sort of analytically saying we can do all these different things. But there really is this rich variety of experience that we need to sort of get into this mix. I know that the vector work that Dena's work has been connected to has been trying to do some evaluation of that; what the HCFA work has been doing to evaluate this are all things that we'll make concrete what some of these services are that have the most immediate pay-off. And I -- because of this very short period of time, I really want to encourage people to get that into the discussion because the discussion about how theoretically these telecommunications could provide these services is interesting and useful and helpful. But we've got real data. And where we have real experience if we're not tapping into that, I think we make -- we make a kind of very short term mistake. This other part is very valuable for the long term, but I don't want to neglect that. And because some of the people around the table are not necessarily sort of part of all these information gathering activities, what you can do to make real for us and to make sure we're getting the things with the most potential benefit as quickly as we can would be very helpful. MS. PUSKIN: Can I ask help with that though? I think it's very important to articulate what the questions are so that then we can -- there is a lot of work going on, but it is not necessarily always targeted or relevant or maybe presented in such a way that would be relevant. So if we could really -- and I think this is what Tom was really getting at -- the questions are then those of us who are actively involved with different hats might be able to bring our experience more efficiently to bear. MR. MAXWELL: That's perfect and it's more than an appeal on my part. And I think that we are getting at those when we get at those questions and how to formulate them. But because of this window we've got, I really hope that people will sort of jump in and say, you know, here's what we've done and here's what's had the most impact and here's the problem we've had. We know there are problems about cost, but we also have these two kinds of interesting polar positions. And they're not -- they're not mutually exclusive. But they tend to drive you -- potentially drive disbursed results. I think traditionally, it use to have been that the availability of information about prevention and health care education sort of has taken people in one direction. Now clearly, that's increasingly available. There are 2,000 web sites about health care information. People are -- and people -- sort of with the exception probably of money, it's the place that people are going most on the web to look for information. Now, that's a very healthy, sort of in quotes, activity. On the other hand, at the high end of this, we talked about surgery and we talked about radiology and we've talked about cardiovascular work. That's a very different kind of activity. We need to be able to sort of an integrated way as a group make recommendations about what kinds of things are the things that will have the most punch to help in this area and are deserving of these kinds of support for the underlying telecommunications services. So as best we can, if we can try to keep our minds on how to use our own experience in finding the most powerful of these tools, it would be great. MR. SPACEK: I'd just like to sort of second that with Elliot and Dena's comments. I mean, the structure that I was talking about, the hard part of that structure is the part up front, in identifying what those applications are that will have the most punch that are the ones that we should be recommending to be included and so forth. And there are going to be trade-offs, you know, and different points of view. But that's the hard part. And that's only going to come from your experiences with these things, what works, what doesn't, what the barriers are and so forth. The stuff we're proposing to do after that to make those translations are relatively straight forward. It's not easy, but it's easier than -- than getting those applications understood and understood well and getting your -- those needs understood. So I think we need a major focus on that up-front piece. DR. DUKE: I'm "Red" Duke. I'm from Houston. And pretty quick I'm going to expose to you how little I understand about what most of you all are doing or talking about it. I'm a trauma surgeon and I've spent a lot of time trying to take care of folks in one way or another, both in rural and urban settings because we run a huge helicopter service over the whole southeast part of Texas. So what we're talking about here applies to both groups. I don't -- most people in this country haven't got the foggiest notion how big injury -- how big the problem of injury is. It's the number one cause of death under the age of 44; number one cause of death of all premature injuries - - I mean it's the number one cause of all premature deaths. We lose, you know, more people -- more per day -- more potential years of life each year from injury than we do from cancer, heart disease and infection put together. But nobody thinks they're going to get hurt. The trouble is they do. And I'm sure everybody has heard of the 60 -- the golden hour. But the problem is that's not 60 minutes. That hour is as long -- it's directly proportional to the cross-sectional diameter of the blood vessel that's cut or how long you can get by with breathing with the airway you've got left. We started working several years ago trying to figure out how we could get better information back to a medical center because if you're hurt and you've got a first responder that shows up at the scene, that may be a highly skilled inner city paramedic or it may be a volunteer basic life support person. And until you get back to some center, your survival is dependent upon that individual's interpretation of what they see and what they can feel and maybe read off of data generated from some kind of monitor. Well, what we've done is take some off-the-shelf materials like ProPak -- some of you might know what a ProPak is -- and modified it so that you can transmit, you know, like blood pressure, pulse, respirations and oxygen concentration. And we've been able to do that from an ambulance. And we tried to use compression techniques to transmit live video because this idea of a helmet which is going to occur within the next few years -- we've got, you know, a helmet like on the military -- the medics have got this where you can have an actual on-line realtime picture of what's going on at the scene is going to make a difference. Every year -- last year I saw three people come in dead as hammers. They had tension pneumothoraxes. And I'm sure most of you don't know what a tension pneumothorax is. But the way the paramedics are taught to treat that is with a needle in the chest. The only trouble is the needles get stopped up and the people still die. If you can -- Jim and I were talking about it awhile ago, if you cut an artery -- there's no excuse for people dying of a major artery cut in an extremity. But they do it all the time because the paramedics don't know what to do with it. They cover it up and then after it gets red, they take a bandage off and put another one on it. Well, you can just do that so many times before you run out of red. It's real simple to treat that if you just use some head, you know; you know, use your kidneys up here. But they don't get it. And so the whole idea is we're trying to get good information back to a medical center where somebody can do it and actually guide them through some procedure like a crycothyroidotomy. If you can't get an airway in, help them go through it because they don't do that every day. But that can be life-saving. What -- the reason that I'm am here is to suggest that in the division of this resource, that there be a commitment on a national basis to an EMS band. And I don't have the foggiest notion how wide that thing is, you know. I mean, like I told Jim, I feel like I'm the only tree in a pack full of dogs around here. I don't have the foggiest notion what ya'll are talking about and all that sort of thing. But I can sure tell you when a guy's going to die or not. That's all I've got to say right now, but I'll answer any questions. MR. COTTON: Greg, this is Steve Cotton from HealthNet, Texas Tech. One of the things I have not heard talked about here this morning from either task forces we've heard from yet is are we going to provide information to the FCC and the joint board about how to define discounts so that all these wonderful things we're talking about can, in fact, happen? As I look at the subcommittees, I'm wondering if that's more of a rural telemedicine -- you know, Jim Brick's group or perhaps it's an infrastructure. You know, how do you incentivize the creation of this infrastructure? But I think we can talk all day about what kinds of services need to be out there; who needs to have the services for what kinds of functions; how fast the compression rates and all of that. But I think if we don't address the issue of what is a discounted rate; what is an affordable rate for rural or for urban underserved inner city; if we don't provide some kind of input in that direction, I think we're going to be missing the boat and missing an opportunity to really help the FCC understand what affordability really means. I know in Texas in the last session of our legislature two years ago, a year and a half ago, they struggled quite a bit with this question of affordability. And some of the phone companies would go to legislature and they'd say we're going to give you affordable rates; we're going to only charge $1,500.00 a month per T1 in your rural hospitals; we're going to do you a favor. And the rural hospitals said, you know, we can't afford $300.00 a month. So I think this group has an opportunity to address the issue of affordable rates and discounts. The FCC in their request for comment clearly indicated that it wanted some guidance in this area. And I'm just wondering - - and I'm directing this to Greg or to Jim or to Tom -- is this an issue that you think can be, should be addressed in your subgroups or in the group as a whole? MR. LAWLER: The answer -- again, in two parts, the answer is yes, the law does provide some guidance. If I remember it correctly, it's the -- and Jim, you correct me if this is wrong -- what it says is -- and you can call it a subsidy or a discount, whatever you want -- an urban area gets the same rate as a -- I'm sorry, a rural area gets the same rate as an urban area in that state. So they -- MS. POLTRONIERI: For the health care providers in rural areas. MR. LAWLER: Right. MS. POLTRONIERI: Right. That's what's (inaudible). MR. LAWLER: So now, you know, that could mean a thousand different things. MR. COTTON: Sure. MR. LAWLER: But there is some -- you know, the law does say something that, you know, from the perspective of the law, we need to tell you what we think it means. In general -- and I'll just use Tom's sort of structure -- let's say we get through the, you know -- Tom's matrix and we come to a conclusion about precisely what we thing ought to be included and, you know, there is a question of affordability. I forget where it is in your chart. But it's in there somewhere. You know, we can make a recommendation that may not be included in the law that, you know, everybody ought to have a T1 and here's what it costs and it ought to go to, you know, this number of people. But I do think we have to be mindful that that is what the law says. Let me -- way in the back there. DR. KUN: I'm Luis Kun and I represent the Agency for Health Care policy and Research. Some of the things that we do involve cost and medical effectiveness. And I just wanted to point out a couple of items. One is that it's essential in order to do those studies to have information concerning all citizens and not just urban or just rural. And therefore, it ought to be structured not only to be beneficial for telemedicine, but also to start creating -- going with the model of the computer-based patient records that could be going to that infrastructure and do the studies more effectively. Secondly, the incorporation of this data, it may perhaps improve the lifestyles of the people in the city. Perhaps these studies can do comparisons between living in stress-free environments. And there's a lot to be learned from those environments in other areas. This (inaudible) prevention and fewer disease by focusing on wellness. MR. LAWLER: Cindy. MS. TRUTANIC: I just -- back to the other point about the charges for the access. From the networks that I've talked with that are in, you know, rural areas, it's not necessarily the access or the inter connection that's killing them. It's the transport element of the charge. And you know, so you could have in one state, you know -- say within Billings, Montana which is the Billings site that Dena has funded, they pay $300.00 a month within the Billings network. And to their farthest site from Billings out to eastern Montana, it costs them $1,500.00 a month. And so that that -- that cost structure is what's really making a difference. If they can cost-out their equipment, they can lease purchase it. It's the monthly charges that are really getting to them. And somehow the subsidies that we talk about, we really need to get specific about what part of those subsidies end up getting -- how they're structured. And also the other point I made because they've asked me to make it is that the -- they feel that technical assistance is really an important element of designing a network and keeping a network updated and the efficiencies that you can provide with the technology that's emerging. They don't always have the time to take out from saving lives to -- or whatever if it's a trauma care situation to really figuring out how to efficiently use the network that they're provided and that is an important element in keeping down the cost of actually practicing the teleconference services. MR. LAWLER: Right. Tom. MR. SPACEK: I think with -- I mean, I think it's important that we try to understand, especially with people who have, you know, under -- underserved and inner city issues and rural issues and so forth that we make recommendations that address and talk about some of these issues about -- you know, about cost and expense and, you know, we want to make this affordable to the degree that, you know, you have opinions in those areas to get this to move forward. But I -- I think what the idea here is is that a line over a -- a high density line, high capacity line over a long distance may, indeed, cost more. Okay. So the point is it's not up to us to say how do you make from the beginning of the point of view, not from what you pay. So we're not going to change that. But -- but I think what we're going to -- what the FCC and the joint board is trying to do is differentiate saying as a regulate cost that perhaps is in a urban area, there's a regulated -- there's another cost that's in a rural area and there's going to be a subsidization to make up that difference. Okay. I don't know how helpful it will be for us to try to structure -- to come up with rate structures and tell them how to do that job. There's some guidance. I think we can give them principles that we would like; objectives that you would like to have with respect to affordability and things of that. So I don't know if I'm clear or not, but I read that as what -- my understanding of what this Universal Service Fund is all about. MR. LAWLER: Right. Bill. MR. BAILEY: Bill Bailey. I -- I agree with you, Tom, but I don't think it -- we're talking a lot about the types of services that are available and so forth. And I don't think we can -- it's hard to say what they are today, more or less what they're going to be a year from now or five years from now. And I think -- I think the point's valid. Probably whatever we recommend should be flexible enough so that you say here's what -- here's the kind of things that should be subsidized -- and I guess that's the rural issue and the underserved urban areas whether that's a consideration -- and let the joint board figure out how they're actually going to -- who they're going to get the money from and -- but -- but in terms of who would receive the subsidy or how, I think it's important that we not limit it to any particular type of service; to rather say, you know, whatever's needed. And again, the issue is one of making sure that rural areas don't pay more than urban areas. Now -- and several people have mentioned it -- a significant component of that is the distance sensitivity of many of the telephone rates that exist out there today. And that's something that I think we and/or the joint board is going to have to address. MR. LAWLER: May I just -- it even seems simple to me. But something that I haven't thought about before that I heard people say this morning which is part of the rural problem, for example, is that the infrastructure isn't there. SPEAKERS: Right. MR. LAWLER: It's not, you know, we don't want a subsidy, we want the infrastructure. SPEAKERS: Right. MR. LAWLER: You know, and how do you make those things work together which, clearly, you know, the law doesn't even think about. You know, and maybe there's some way we can think about that to say, you know, here's a way to do that; you know, here's how you spool those two things together. Obviously everyone -- I assume everyone here would say, you know, we ought to get the infrastructure there. Okay, fine. How can we do it? What can we recommend to get you from here to there? Steve. I'm sorry, Jeanine. MS. PUSKIN: I know I made this point before. But I just want to emphasize that the law does allow and does direct the joint board to look at rural insular, high cost and low income areas and going to individuals and provide support. It's one of the principles of the 254 implementation. So while this scope is more on the rural health care provider part, there is -- there is a mechanism that I commented on previously. There's a number of different models that are being proposed and different ways to do that. And if people are interested in doing that, they can. I don't know how broadly you want to set your sights. But it's in the law. It's there. MR. LAWLER: Bill. MR. BAILEY: There's a problem though in that portion of the law, at least the way I understood it, is addressing the provision of basic telephone service to those areas. And what we're talking about here is beyond basic telephone service. And the availability of the network is a significant problem that won't be addressed by the other section because virtually every place in the country you can get telephone service. But that doesn't mean you can transmit video. MS. POLTRONIERI: That issue is up for grabs. The definition of what services are going to be included in basic telecommunication services is something that the FCC specifically asked for comment on. It's something that people are working on. Now, in the past in the traditional old Universal Service Fund, you're right. It was the basic service. But, you know, this is a brave new world. So people are presenting comment on that. And I also want to note that the part about affordable and low income, that's pretty much the first time that that's been introduced into the law and caudified. There's been a lot of interest in that. Congress is specifically addressing what are the agencies that are doing that and we're grappling with that. That's a new set of issues for us. MR. TUCKSON: I want to make sure that I'm clear on these two points here. Let's say that we recognize in our model of health care delivery that there's a significant accordance for prevention. And we understand that -- that the use of cable in people's home will be, for example, a major opportunity for Americans to be able to access lifesaving health information, health and welfare information, earlier diagnostic stuff. If you live in a public housing development, you don't get cable. Now, you're therefore out of business when it comes to what a large number of Americans will be able to do. So low income people living in public housing would be out of that. Without -- I'm trying to genericize an example and I don't want to get too far out on it specifically. But in that case, would we not -- if our concept was that it was extremely important for -- given that where the world is going, is that cable lines and so forth through -- you know, had an opportunity to be helpful to -- in promoting health and preventing disease, that you were able to address some of those issues because they are low income people. They are poor. And they are disenfranchised. Now, how do you deal with that issue? Or it could be -- the same example would be something where if now it's important -- and we recognize through this law that schools have the opportunity to have access to more than one telephone line for a school. Now, I've heard Reed Hunt (phonetic) talk about this a lot. You know, it makes no sense for schools to have all these computers connected to nothing because you've got one telephone line and the principal's on that. Now, you can subsidize phone service for Vale, Colorado ski chalets. But you don't subsidize in this country extra phone lines for schools to be able to connect to the Internet. So this addresses that. We need to do that conceptually for community-based institutions that are the focus in place by which health information can be disseminated. So how do we subsidize or help or at least create an environment for them to have access to the lines and to the information networks? Are those things under your understanding of the law within our purview of opportunity to comment on? MS. POLTRONIERI: It's a little bit different. The law is bifurcated. There's one part -- and if you look at the antherium (phonetic), there's one part that specifically talks about definitions of universal service, quality and rates, access in rural and high cost areas including low income consumers. And that's a general how are we going to get access to people in these areas. And there will be a report like this to provide that. MR. TUCKSON: Right. MS. POLTRONIERI: Then there's a second part that is the rural health care provider's part which is what people have been focusing on in this group more. And that has to do with low income, high cost. But that specifically is the rural help. MR. TUCKSON: So I mean at least in terms of the rule book, how do we decide to do it -- but it sounds like the field is a little open and that we have the opportunity to address this in the ways we feel appropriate. MS. POLTRONIERI: There's been a lot of comment already from you to the agency on all these issues. And I think you should try to take these opportunities to figure out what the priority is and where you think they could be most helpful and what people are most interested in. MR. LAWLER: A couple of more comments and then we're going to -- Jim. DR. BRICK: I just -- I wanted to make one comment about -- you asked for sort of testimony or personal experience. Okay. One of the problems that we have -- and I don't think that this is unique to West Virginia; I think it's unique to -- or it applies to most places around the country -- and that is that we buy expensive equipment to do this stuff. Okay. And we also buy expensive computer equipment for data transfer. You know, most major medical centers and middle size hospitals in the country now are moving in bits and pieces towards this ethereal thing that people talk about, computerized patient record. But we buy all these things. And the boxes don't talk to each other. This is a tremendous problem. Okay. And when you go and talk to the vendors, they'll say oh, we can fix that. Okay. And they have some consultant come in and he says he can fix it. Well, you know what? I haven't seen it. Okay. And I would like for one of the committees -- I don't know if it's this one or I guess the architecture committee which is coming up this afternoon will talk about that. Okay. We need some serious stuff. If we leave it up to the vendors, it's going to be forever or it maybe never happens that these things are not applied in a way that there are standards that you can make things talk to each other. We really need this. This is a medical issue. And it applies to patients every day. We can't afford to leave this to the whim of people when they decide that they're going to start sharing their code with each other. This has to be addressed now. And I think that that should be something that this committee should -- or we should make some recommendations about. MR. LAWLER: Gene. MR. SULLIVAN: Gene Sullivan, University of Virginia. Just a question to our representatives from the FCC. There was a statement made that the infrastructure is not available in many places throughout the United States. Did I correctly read in the act that if a provider built the infrastructure, that that would be credited toward their payments of the universal service? MR. MAXWELL: That's one of the things that's being -- that is being considered. MS. POLTRONIERI: Yes. MR. SULLIVAN: So the incentive would be rather than providing dollars to the Universal Service Fund, that a small phone company could go ahead and put in the infrastructure, the backbone and that would become part of the credit? MS. POLTRONIERI: One of the issues to be considered is whether carriers should get the reimbursement pertaining to rural, high cost, low income. That's -- I think that's how that's posited. MR. SULLIVAN: I would opt, and I suspect many of my rural colleagues would opt, that that's probably a good way to go to push an issue like that. You get to give them the incentive to get in there rather than make them pay to put it in and then, oh, by the way, you've got to pay more money into the Universal Fund to help support it. There's got to be a trade off. DR. KAMP: If I might speak out of turn, I want to be responsive to Dr. Brick's question. There are more radiologists doing telemedicine than any other specialty. We have been deeply concerned with the boxes not talking with each other phenomenon. MR. BRICK: Right. DR. KAMP: Dr. Steven Horii of the University of Pennsylvania has sort of led our charge on that. We made a presentation to the General Accounting Office about it. And we will share his work with the appropriate subcommittee. MR. BRICK: These fellows have worked really hard on that trying to get the standards. MR. MAXWELL: The critical piece I think is not where the standards are, but what you think made it possible for you to get standards that work together because it's -- this is a kind of process issue and what we might be able to do in the process issue as opposed to -- DR. KAMP: I don't want to belabor the point. We have worked on that process considerably. And in the specific boxes part, we've worked cooperatively with the National Electrical Manufacturers Association (phonetic) on that very point. But we will be happy to share that. MR. LAWLER: Two more and then we'll wrap it up. Paul. MR. ZIMNIK: Yes. Real quick. In the Department of Defense -- because we spent a lot of money addressing the issue that you're exactly talking about -- and again, it gets back to my previous comment, that we in our committee, even the health care industry is not large enough to drive standards. Dicom (phonetic) is a great standard in the field of radiology or in the field of any image transmission type standard. But we have -- as Jay said just a couple of seconds ago, if you look at the driving and the substantiation of standards, we need to look at the world around us right now. And in fact, the reason why the Internet is such an important vehicle for us is its ubiquity, yes. But it's also the standards. It gives us the standards. So, in fact, from the DoD, everything that we are doing in the field of telemedicine, medical informatics exchange, database access will all be based on the standards that the rest of the world is telling us to use. So everything we do in medicine now whether it's video teleconferencing, store and forward type technology and such, they are all "standards" that are being developed and utilized over the biggest standard that there is right now. And those are Internet-based. MR. LORAN: Paul, it's important that we develop the Internet -- oh, I'm sorry. MR. SONNENSTRAHL: I'm curious. Are you speaking of international teleconferencing? What happens if there's a language barrier? Do you get a translator involved? MR. ZIMNIK: Exactly. And in answering that question, the fact that the Internet is growing the way it is, that right now the language of the Internet is English. But more important than that, the world is accepting the fact that items like translation of languages and then also data structures are critically important and -- but again, for our uses, those tools and techniques of communicating around the world, of security paradigms, of video teleconferencing standards, those are being provided and worked out in the very large industry that is utilizing the Internet. So I think we in the field of health care will be forced to -- whatever we say, whatever we decide as a committee, whatever the FCC decides, we in the health care arena will adopt those standards that are being utilized in -- by the Internet because those are market driven effects, those are well factors, those are philosophical and psychologically effects. That's what the world of information is coming to. So it -- my position and I believe that the position of a lot of people in the DoD is that we don't even have to think about this anymore. We are -- we've accepted it to modify our health care informatics exchanges into modalities and protocols that are Internet based. MR. LAWLER: Who -- all right. We've got one point in the back here, and then we're going to go eat lunch. MR. ROESCH: I'm Harry Roesch of the Appalachian mission. We funded a lot of projects. But most of projects and our networks are basically multiple service sector based, education, telemedicine, business, whatever. But the issue that Dr. Brick brought up, we supported that particular project that he started a number of years ago. And what we have found in the past few years is that as networks are starting to be developed in our 13 state area (phonetic), we're requiring that they come up with at least -- they have to have a fiscal plan in place to be able to set their plan in motion. But when they do it in a piece meal basis, phase 1, phase 2, phase 3, we are concerned that different entities starting up don't get equipment that will not be interoperable. And what we're now seeing is we're seeing systems that are operable functioning extremely well. And what we see now which is unusual, we see an entire package come to us. And it's a replica of something we've already funded because they know it works. And this is because the vendors that Dr. Brick is talking about really are not servicing the industry. They're creating oh, yes, we can do it. And then they get in there. And we've seen systems that we had to go back into in several years and replace equipment. And that's tragic. MR. LAWLER: Why don't we -- Lygeia has a housekeeping matter. And then why don't we come back at -- it's 12:30. Why don't we try to be back at 1:30 -- 1:15, 1:15. Lygeia. MS. RICCIARDI: Yes. A couple of items. Before you go, I'd like to distribute to you some letters which we need to distribute for legal reasons. They have your names individually as advisory committee members and they just explain your status as such and say that you are not, for instance, actual Commission employees. They're in alphabetical order. If we could just pass them around and you could just pick out your names, I think that's probably one of the easiest ways to get them spread around. Second, by way of dissemination of information, in the next room over there which is Room 111, I've got copies of the testimony on health care which was given before the joint board in April and June, as well as some comments on the universal service proceeding that I thought might be useful and some reports on telemedicine. And what I would suggest is rather than having everyone sort of charge in there, I know a lot of people picked up some materials when they were in the back there. If I could just have one representative from each subgroup go in there and make sure that you have a copy of everything in there. And then when those four people have gone in, if then everyone could head in, that would be great. And please do just keep it to one copy if you could. Does someone want to volunteer from each group just so it's clear? Preferably somebody who picked up a lot of this stuff. Do we have a rural volunteer? Excellent, thank you. Infrastructure? Just picking up papers. Thank you. Architecture. Great. And international. Thanks a lot. One more thing, if -- Paul, if you're ready to just give us a moment here. MR. ZIMNIK: Oh, sure. Yes. MS. RICCIARDI: Paul has been kind enough to help us in setting up with the help of the Department of Defense a web site that we can all use to communicate more easily. And I have the address here. I'm just going to pass that out as he's giving us a real quick run-down of what the site is and what it can do for us. MR. ZIMNIK: Yes. This is in reference to what we were addressing before, that we have a very short time frame to do a lot of things. There's a lot of information on the Internet, a lot of information each one of us has accumulated in these various areas. And to help facilitate the process of this advisory group, we've set up a web site for better distribution of information. And what you have down there -- and this will be a relatively dynamic process as we move forward over the next month or two. Right now, I'm in the process of getting a domain name assigned to it. So you'll see that. Right now, you'll see I've given you just the IP number. As we move forward with this, you'll have -- and you'll see on the site the actual domain name once it becomes available. And it will be automatically forwarded. There won't be any problems with that. For now, if you have information that you would like included, a number of -- and that could include either your sites or sites that you know of that would be valuable resources for folks because, again, in the spirit of the Internet, we don't need to reproduce all the information there. Just give me the URLs to it or actual reports like the various subcommittee reports and any other information you'd like included on the site. You can e-mail it to me or, as I said, if you have a site where you have this information, just let me know and we'll make sure that there's a pointer on it on this site. If -- furthermore in addition to this, if there's an interest, we can make available a mailing list, a list server on this topic for people to better dialogue back and forth. And if you do not have an e-mail account yet you do have Internet access, I'd be happy to provide you with an Internet-based e-mail account for you to participate in e- mail which I believe is the most important tool we could talk about here. And then, again, my focus here is on information distribution. So please don't look to this site for a nice multi-media or a graphically rich type beautiful pages. I'm not going to focus our efforts on that. I want this to be a site that is accessible from people everywhere from a 14.4 modem up to a T1 band width. So I have a fairly robust infrastructure to take care of the demand here. If you do have any comments or requests or Paul, that's a dumb way of doing that, please let me know and I'll incorporate those recommendations or changes into the site. So thank you. MR. MAXWELL: I'd like to express our appreciation for your work in doing that. It's a great help. MR. LAWLER: We'll be back at 1:15. Thank you. (Whereupon, at 12:30 p.m., the hearing recessed to reconvene at 1:15 p.m., this same day.) A F T E R N O O N S E S S I O N 1:26 p.m. MR. LAWLER: We're ready to started. ARCHITECTURE SUBGROUP REPORT MR. TANGALOS: We're going to take the hour or less to discuss some of the information we've gathered through the architecture group. And according to the Chairman's instructions, the first half hour -- the first half of the presentation, we're going to go through the handout that you have right now with comments based on the proponents that submitted those pieces to us. And in the last half hour, it will be open discussion based on what we've got. Our goal -- MR. LAWLER: Does everybody have a handout? MR. TANGALOS: Your getting it now. MR. LAWLER: All right. MR. TANGALOS: The first part should be 33 pages long. The second part should be four pages long. And the four page part says, "Mayo Comments". My own team was late. But we had -- the way this worked is we had a conference call on the 24th of June. And I promised the group that whatever information they got to me by the 3rd of July would be back in their hands. And so on the 3rd of July, we sent Lygeia the 33 pages. And because I was out of town most of the time that we were on conference call, the Mayo team did not meet until after that and, thus, the four additional pages right now. Our request to the individual members of this group were to provide as much written information as they felt comfortable on the topic of architecture. Our goal was to provide today's session a smorgasbord of information that could be at a later time whittled down, more forcefully put forward and then drafted and crafted into a more precise document. You'll notice that there are comments that range all the way from Australia to Sandias. And except for Max Alexander's comments from Australia, I do think I have a representative here that can speak each of the issues. So let us begin with the comments from Steve Cotton. Steve is a member of our group. These were questions that he sent to us and questions that we discussed through the conference call. And I would say, Steve -- are you here now? -- that out of this arose an 18 point questionnaire that we sent around the country. Steve, take a few minutes and walk through your concern and walk through your questionnaire. MR. COTTON: Thank you, Eric. Getting our arms around the architecture issue is obviously difficult. It's a pretty broad area just like the infrastructure area is a broad area and there are some overlaps. But some of the things we tried to do on the information was focus in on some specific areas where we though maybe the FCC needed our guidance or wanted our guidance. And this was really just a starting point for our discussions. There were -- we started initially with these six questions: 1) What are the problems in this telemedicine infrastructure area and architecture area? Basically, what's broken; what's not working. 2) What is the trend in the market forces concerning architecture issues? Are there forces out there moving us in positive directions to solve some of the problems so that we ultimately don't need to address them or the FCC doesn't need to address them or are there some market forces that are going in the opposite direction moving us toward interoperability and user friendly architecture? 3) What is the status of current internation negotiations on the development of technological standards? We needed a benchmark. We needed to see where is the technology standards -- where are the standards today? Where are they going to be tomorrow? Where are they for teleradiology and all the other tools? And there, again, we wanted to see that there were some trends that were moving us forward in operability or maybe there might be some way that the FCC could help incentivize the completion of these standards. 4) Should there be some focus on the need for planned interoperability? A lot of us in the field that are actually doing the consultations with remote sites and talking to vendors and integrating equipment are very acutely aware of the problems of the lack of interoperability. And for new potential sites that are wanting to start telemedicine, a lot of people are very unaware, unskilled in what the technological situation is. They have a couple of vendors they talk to. The vendors pose solutions. And the people in their ignorance which is understandable pretty much buy-off on the vendors' solutions not realizing that the vendor architectures that they have today won't talk with something that they may want to buy tomorrow to work another problem. So we wanted to focus a little bit on that. 5) Is there a role for the FCC to play in encouraging interoperability? And this is a key question because the FCC as a regulatory body has some broad latitude, but it also has some obvious restrictions. I don't believe it can tell a -- I don't believe it can tell the industry what kind of architecture specifically to design necessarily. It may be -- the question we're looking at is is the FCC a (audible) or a (inaudible) regulator, or is the (inaudible) somewhere in between. And in our role as a recommending body, we've got to be careful we don't tell the FCC to go work a problem that they can't work, that they don't have the authority to work or that's really out of their domain. And finally, how do we reconcile individual company's need for some proprietary architecture with the obvious need to benefit from interoperability and especially user friendliness. As we have experimented in integrating different telemedicine equipment in Texas in our correctional health care program, for example, we worked a long time on what kind of architecture do you really need for that prison doctor. And hand-held cameras versus cameras on the headset versus stationary cameras. And we found that the initial architecture we designed at first was actually used in the field. The doctors or the nurse practitioners were saying that doesn't work; it's too jittery; it's too shaky; we cannot go with that approach; we need this approach. So user friendliness is an issue also that we are going to try to address. From that list of six questions, I put together a questionnaire of my own really of about I guess 18 questions that I sent out to people around the country. And responses are just now starting to come in. But we're really looking at a lot of different issues and hope to get some more information. MR. TANGALOS: And Elliot, just for you we have -- the cover letters that Steve put together was -- we are working on behalf of the FCC. These are specific questions we'd like you to address. And so hopefully, we'll have more of that basic information, you know, the hard and fast numbers. And with that, let me introduce Bill England because Bill's on this committee, as well, and has sent out information to the HCFA telemedicine sites to provide information, as well. Bill, do you want to update us on where that is? MR. ENGLAND: Yes. Unfortunately, I was not able to participate in the conference area with the group. And I sent this just a few days after our last meeting and really have not been able to get back to it other than to talk to a few of our sites. The main thing I was wanting to get at was the level of sophistication of what they're doing, what kind of band width they're using, what sort of equipment, et cetera. I knew that -- and I think that Dena is not -- I think that Dena had to leave. The Office of Rural Health Policy actually have a very interesting table that they have put together -- it's in the other room -- that talks about what their sites are doing and what they're costing, et cetera. I was attempting to replicate that for our sites. And I have not yet gotten that together. MR. TANGALOS: And I hope we'll be able to use some of that. MR. ENGLAND: Yes. And, again, I wanted to get it in a format similar to what she has. When I was making reference to the vector research project and the joint working group on telemedicine, I think we will have this soon for all federally funded sites that will have probably a hundred at least different sites, what kind of equipment they have, et cetera. We'll get that to you as soon as it's available. MR. MAXWELL: Thank you very much. MR. TANGALOS: Our group was pretty good as far as making the conference call. There was one person who missed it. Sonny Sonnenstrahl missed our conference call. He walks in late and he misses our conference call. MR. ENGLAND: Where was he? MR. TANGALOS: He was out rafting and that was a good excuse because I think he was on the water at the time of the call. And it brings to mind though that we would have done a TDY conference call if he were available. And that would have been a new endeavor for us. Sonny's been very good in dealing with us with e-mail. And the communication lines have been very, very open. MR. SONNENSTRAHL: There's no water proof. MR. TANGALOS: Bill Bailey was also traveling at the time of the conference call but was able to join us for that conference call and has provided the next three pages of document. Would you like to comment, Bill? MR. BAILEY: Sure. I really discussed two areas in those three pages. One area we talked a great deal about this morning. I think it probably dealt more with telecommunications infrastructure than it did architecture. But the point I was trying to make there and I think I made earlier today is that there -- competition is going to cause existing circumstances or existing differences between rural and urban area groups to get worse and it's going to result in a greater problem later on and I thought the FCC should be aware of that. The next problem I talked about was one of interoperability. And I have to admit that I came into this thinking gosh, this would be a great opportunity for the FCC to put down and solve the problem. But some people I work with changed my mind on this and I decided that a certain level of interoperability is going to exist because to do otherwise would mean that you'd have to settle for the lowest common denominator. And, obviously, the joint board is going to be faced with an option of trying to provide some incentives in some form or another to help the interoperability problem through the development of standards and the adherence of standards through whatever mechanism it establishes for subsidy. But there's a trade-off there that they have to recognize, is they put their foot down and say the only thing we're going to have is standards, eventually it will not be as robust as it would be otherwise. So it's just something they need to consider. And that's basically a summary of what I said. MR. TANGALOS: The next set of comments come from the National Library of Medicine and Betsy Humphrey is the executive deputy director, I think. That's what her title is. They've had a particular interest in controlled vocabularies. In the world of medical education that Jay's been involved with (inaudible) the National Library feels very strongly having funded a number of telemedicine projects, as well -- feels very strongly with this project on uniform medical language. And you can see from her remarks, that they believe that telemedicine inventions need to be recorded as patient data, and that the transmission of patient data over distance facilitating that usage is a form of telemedicine. So all kinds -- they are broadening the definition. And I think the next paragraph with regard to the controlled vocabulary incorporated in the UMLS medithaurus (phonetic) is a good idea because then you can start to search your own patient databases for diagnoses and look for patterns of care that develop. So they have a very strong vested interest in telemedicine in general and with response to standards, a very strong interest in the uniform language that they are promoting. I'm was a little bit desperate in going on to the next bit in getting enough information together. And so I sent out not a broadcast e-mail, but I sent out e-mail to various places. And one of my friends is Max Alexander in Australia who really actually took this quite to heart. And if somebody has an Australian accent and wants to pretend he's Max Alexander, we can do that today. But I won't go through all of his notes. But his -- his responses to this were very pointed, very direct making a nice comparison to where the Australian system is and where it's tending to go which is closer to the U.S. system and where the U.S. system is and tending to go which may be closer to the Australian system. And again, Elliot and Lygeia, I think we have some specific examples here that we will be able to carry forward. And I see no reason not to include international examples. And that will come up again as we come up to the final Mayo comments in terms of where we have difficulty in the international marketplace, as well. MR. MAXWELL: I actually just came back from a universal service conference where one of the issues has been the broadening of universal service obligations beyond simply single voice-grade (phonetic) circuits. The Canadians are worried a good deal about education and some about health care, the Australians, the New Zealand folks, the Brits. So there's a -- there is experience to draw from beyond our own. I encourage people in this way. MR. TANGALOS: Dr. Duke, there are international emergency programs going on right now. The G-7 has a Subproject 4 which is a 24 hour surveyance for emergency medical services. And there will be a U.S. counterpart to that, as well. So there really are interests are around us that we need to pay particular attention to. Now, Dr. Kamp left our group. He chose to go to a different subgroup. DR. KAMP: The pay was better over there. MR. TANGALOS: But you get your chance anyway. And Jim Potter's been very good about providing us information. And, indeed, what Dr. Kamp was talking about, Dr. Horii's work, we've incorporated here. Would you like to comment further? DR. KAMP: Eric, I'll just be very brief. I think the material in the handout is self-explanatory. I'll just emphasize that DICOM was really focused with an emphasis on medical imaging, but we realize it may have some transfer value elsewhere. If the logistics work and the staff is interested, we could have a -- a brief demonstration set up perhaps prior to our next meeting. I think this is pretty well self-explanatory unless Mr. Potter who is our associate director governing installations (phonetic) has some further comment. Jim? MR. POTTER: Briefly. What you have there is an issue of where it's common. DICOM is now a 13 year old project. It's very well known in radiology because (inaudible). And so they play with them all the time. The word is really moving out. Part of the information we got is now doing what's called an ISIS project. And that's infiltrating all of the other fields of medicine using similar standards. DICOM is based on a standard of information object definitions. And they way it's set up is it's a very robust and expandful system where you can stack on new components, let's say, of a new specialty as a broad kind of layman's definition of how it works. But we've also been working with all the international groups. There's a text base image (phonetic) called HL7 that has now been incorporated into -- to DICOM. The European CEN group that puts together the European standards, they have had negotiations for the last year and a half of DICOM. And there to, now the European standard is essential DICOM. The Asian standard, JIRA is now -- they've had negotiations ongoing for the last year, too. So what you're finding is DICOM has become an international based standard for medical information and communication use. It doesn't mean it's an approved project because it is a dynamic one. It is always constantly moving. And I think the core here among most of the participants is to create open architecture systems that work for everyone. The problem is while the expanse of this has been quite -- quite profound, we have most of the major subspecialties -- MR. TANGALOS: Could you speak up just a little bit louder? MR. POTTER: Okay. Sure. We have most of the major subspecialties participating. And I'll get you a little bit of information. We also have NIMA participating which has over 25 of the major medical electronic manufacturers who have adopted these standards. The problem is you have a lot of intermediate vendors who don't want to or are not knowledgeable or a lot of medical institutions who are not knowledgeable of these standards. And so they have an incentive of their own to develop computer closed architecture or architecture systems that benefit them staying around for longer. So while this is not perfect -- the perfect model is plug and play where you have something and bam, it all works together. And that's not going to be there and it's never going to be there. But the idea is to have some kind of dynamic role for the user as robust and with accountability. The accountability now is in ANSI because DICOM is part of the -- ANSI's health informatic standards board. They're a founding member of it and as now, they have delegated the responsibility for health informatics to DICOM or the ACRP (inaudible). All right. Just to end it up there, this is really a subject that you can go on for days about. I hesitated in bringing it. But this is just the cover of the standard on paper. It stands about yay thick. I have it in my car but I didn't want to bring it in here because it hurts my arm. It hurts just lugging it around. So there is work that's been done. The problem is just really getting that out to a much wider audience. (Inaudible) medical subspecialty right now. And it's beginning. But we really need to get that information down to the individual health providers. MR. TANGALOS: In my request to the American College of Radiology, I asked for a version that was DICOM for Dummies. So this is what we received. Just so you know, we do most of our work by e-mail. And this was the hardest document to receive. It came as a cut and paste. And were it not for "replace all function" within Word, I would have "end of line markers" everywhere. But we did accept anything that came in. I edited it somewhat to dig out the superfluous comments. You'll still see that we covered a large area. There's lots of gaps. But it's up to the subcommittee and anybody else that's interest to provide us with a substrate as we go on. Elliot, did you have a comment? MR. MAXWELL: Yes, I was just curious as to whether it might be possible through the American College of Radiology to -- to ask ANSI and the health informatic standards board for any comments it might have about the issues that we're addressing and whether there may be useful things that the FCC could do in this area. MR. POTTER: I think that's something that we could re-lay on top of the various subcommittee structure. MR. MAXWELL: Okay. Very good. MR. TANGALOS: This document as well is double spaced. And it was double spaced intentionally. I would love to get your handwritten comments back. So it was intended to be this long as a work-in-progress for those who don't want to send an e-mail or have an electronic bit of information that you can include. You can work off of this if that's stimulus enough. The subcommittee also experienced its own troubles with standards on e-mail. We were unable about half the time to open documents that came to us. There was another comment though that I didn't want to interrupt. MS. KING: Oh, I just want to follow up on what you said. One of the questions that I would have is what changes would be needed for consumer promises equipment (phonetic) if any of this kind of material was brought closer to home. It would seem that there is another issue there. I think this was mainly the specialists talking within a limited network. And that may be something that isn't translatable into a rural area and I'm not sure about that. MR. TANGALOS: John Linkus to go on was kind enough as executive director of the Telemedicine Association to provide me a daring testimony that was reported in PRM. And Jay as president of the association, would you care to say anything at this point? DR. SANDERS: I think this is a fairly good summary of the issues that I thought were important. The document, in fact, was generated by all members of the board of directors of the ATA, many of which are actively involved in telemedicine on a day to day basis. We were very concerned in particular that at the very least, that we make sure that standards of architecture and standards of telecommunication of infrastructure be based upon what the end user's needs really were. The end users here they define not only as the primary care practitioners out there, but also the patients. And we felt as a bare minimum, we needed Internet access in terms of the educational process, in terms of the store/forward process. And we also felt as a bare minimum, apropo of "Red" Duke's comments earlier in the trauma situation, that at a very minimum, we need 112 kilobit or 128 kilobit capability because when I have a deceleration injury of the aorta or if I have a tension pneumothorax, I need to look at that chest xray very quickly and get an answer -- get an answer back. So we started from the perspective of yes, we would like to base it on the widest type of channel and the most functional capability. But the reality is we need to deal with what the end users are doing right now and ensure that we have a basic bare minimum in terms of band width capabilities. MR. TANGALOS: Thank you, Jay. I consider Suzy Tichenor from the Council on Competitiveness. And she quickly responded with a wealth of information from a project that she was involved with through SANDIA. You sent me a lot of information. I chose to use this particular subgroup. Would you care to comment? MS. TICHENOR: I'll just tell you a little bit about what SANDIA is doing and you can read the documents. SANDIA National Lab. out in Albuquerque, maybe you're familiar with these labs, has developed an gaming process, a very complex economic model that simulates contracts business and economic situations much like war games. And they have been developing some of these to test out business and policy and legal and economic situations that are national level problems in many cases. And they just inducted one focusing on the biomedical industry and biomedical technology. And their objective is to try as a result of going through this gaming process to develop a biomedical technology roadmap. And the information that Eric has included in here is one piece of the output that is being developed for that. This happens to be looking at a number of systems and architectural issues given that the experts of this game filed the heterogenous components in any kind of health infrastructure that would have to work together. And given that, what are the -- what are the challenges that have to be worked out; what are the legal implications of those; and what are the policy implications. Jay Sanders is chairing another one of the committees that is looking very specifically at telemedicine. And there are about six or seven different subgroups. And if you have a broad interest in this, I would urge you to contact SANDIA and get that. And then at least as a start, review information that Eric's included in here. MR. TANGALOS: And they've been most helpful and are quite comfortable that anything that we've used can be taken and pulled right out of their documents. They're delighted to -- they've been very helpful. MS. TICHENOR: It's extremely complimentary to what this group is doing. And I think you'll find some information that's there that you can lift and use to support some of your work. MR. TANGALOS: The last bit then is the Mayo concerns. And we have it divided up into comments and commentary. And the troops were able to (inaudible) to put this together. And you can see some of the costs that we incurred in terms of pricing for T1 lines, it's in here twice. Pricing may indeed be tied to distance that it travels; so very, very highly dependent on the last model serviced by our local carrier whoever that may be. One of the regional practices that we have purchased is in Decorah, Iowa. We use U.S. West as our local carrier. We use the MEANS Network which is a state- based network which is also very, very cheap. And then once we get to the local exchange across the state line to Cedar Falls, it becomes a very expensive undertaking for us to get there. You can see that the costs of going to Decorah, Iowa are more expensive than our T1 lease rates to go to Jacksonville, Florida. DR. SANDERS: Eric, can I interrupt just for one second because I think your work with MEANS needs to be underlined as an example of something that perhaps the FCC ought to push. MEANS stands for Minnesota Equal Access Network System. And it really is a consortium of 50 local telephone companies that got together and decided to put fiber in the ground in Minnesota and some of the peripheral states. They did it in a very cooperative way and in that spirit, they also came up with very competitive types of rates. MR. TANGALOS: It's actually our way into the isolated world. But we use it all of the time when we want a T1 access to the rest of the world. It's kind of strange to say that we got our access anyway, but that's how we use it. And it's very cost effective. We go on and -- these were kind of the way we do business. The Mayo standard for all of our connections to all of the regional practices that we've purchased are T1 lines. A quarter of that line is dedicated to video; one quarter is dedicated to data invoice. Far more often when we're dealing with a non-Mayo entity, we resort to the lowest common denominator which is one-twelfth and we're lucky. For our video conferencing if we get a 384. One observation is -- and I think this is kind of key -- is that local carriers are still on the voice analog mindset where 56 kilobits is just fine. But technically, the digital framework is in DSO at 65 kilobits. And these routines are incompatible. So it's an analog mindset versus a digital mindset. And standards are different. Mark Mitchell would like to be king for a day. And you have the FCC ordered to switch multi-band megabit data service for everyone. And it would compile ITU (phonetic) standards. We talked about ATM not being tariff (phonetic). High data long haul capability is still very spotty. ATM supplies us with service, but it's not in many instances. And this is an area that we thought certainly the FCC could get involved with. Then we got to international compatibility and it's almost nonexistent. Even ISDN is very difficult to get except on contract services. Our Harvard people are here and maybe they'll want to comment on how they nailed down ISDN lines to carry out services in the Middle East. We'll open that up in just a few minutes. U.S. standard of T1 is 1.544. The international standard is only 2 megabits (phonetic). And again, here common activity resorts to the lowest common denominator which is not necessarily 1.544. And then again, we were looking at some of the business aspects. You pay for what you've ordered. If your connection line is a T1 but you're only able to connect at a quarter T1, you're still going to be paying for the whole T1. And according to Mark Mitchell, there are no bit counters and he wishes there were. We feel that store and forward telemedicine is generally okay. One way or another, the information is going to get there. It's going to get there sooner or later. It's the realtime stuff that needs a lot of help. In addition to equipment incompatibilities, there are lots of problems with lease lines outside of our home network. It's very spooky stuff to go outside of our own network to get lease lines. And, you know, if -- and not to brag, but if Mayo is having trouble with the vast resources we have available to us and the amount of time and effort we put in with a dedicated team to get the job done, just think about the rural provider. Again, we talk about going out of the system being a real crap shoot. And then the last mile and the local exchange whatever that may be seems to be the most expensive and the most difficult piece we have. The commentary really is the same information in paragraph format with a couple of very good examples, as well, that we think are valuable to the FCC. And we've attached the dollar amounts exactly to what our line costs are. And then we've gone ahead and discussed the -- in very technical terms, the technology capability on page 3. So that's what we've been able to accomplish so far. Again, by no means complete. Hopefully, this will stimulate others to send in more information. And Greg, at this point in time, I'd like to turn it back over to you to give this working group further direction in the next half hour. MR. LAWLER: Do people have questions? I have one if somebody -- actually, I'll start. And this is directed at you, Bill, I think just at the -- what I think is a generally agreed upon or I've seen it not only from you, but from elsewhere. But the new competitive system is going to mean that there are rural -- costs of rural are going to go up compared to the costs of urban. There's more money to be made in urban. There's going to be more investment in the urban areas. What is that -- I mean -- what I'm trying to imagine is a concrete what does that mean for West Virginia, for example. Does that mean it's actually going to get worse in terms of the cost differential? MR. BAILEY: Well, and we're talking about -- for the most part what we're talking about is data transmission. And today for my company, data transmission at the T1 level, for example, you pay for the last mile and you pay mileage charges between those locations. But those rates are the same throughout all of our territory in the state. They don't -- I mean, anyone in the state would be subject to the same rates. The cost of providing any telephone service is largely a function of distance and density. So as you move away from urban areas, you've got longer distances. You've got less dense population. Costs go up. And that fact means that the margins are greater for urban areas. So there's going to be greater competition. Prices are going to be driven closer to cost in urban areas. That means that if they're driven closer to cost in urban areas, there's at least a possibility that cost in rural areas for data services like that will not go down. Okay. I doubt that they'd go up, but they probably would not go down. Even though -- I say today we have a disparity because of this distance sensitivity. Tomorrow you may have a disparity because you've got competition in a very metro area or even on this block of this city you'd have competition because carriers have the right to price on what we call an individual case basis or a large customer, they'll offer a price to cover their cost because they want the customer. It may be very much below what some other customer might have to pay for the like amount of capacity. So that's going to happen. That's the dynamic. MR. LAWLER: And if, for example -- I forget uses a T1. Jim, I think you said you do in West Virginia and you do in Texas. What you're saying is that to the extent those costs are going down, costs to them of a T1 line are going down in an urban area. They're not going down for them. MR. BAILEY: Well -- DR. SANDERS: And I'm -- this is in general. MR. BAILEY: No, in general for my company at least, we serve large portions of the states we operate in. And our costs are statewide average costs. We come up with rates for everybody. As you become more and more competitive in certain areas and you drive the rates down for that group of customers, you may find that while you have great -- well in excess of the cost before, when you drive them down through your more populous areas, your rates don't really cover the costs in the rural areas. MR. LAWLER: But if we had an urban versus rural cost now for the state of Colorado and we saw the disparity, what we're going to see is a greater -- in all likelihood, what we're going to see is a greater disparity in the future. MR. BAILEY: The cost will probably be the same. MR. LAWLER: I don't mean your cost, I mean the cost to the health care provider. MR. BAILEY: Right. One of the points that I wrote there was that there may be differences today that exist because of -- because of the distance sensitivity of the rates. But I think that competition is going to make that circumstance even worse. MR. TANGALOS: If we have someone from Rural Utilities, I'd rather they speak at this time. If not, I think the analogy is that once upon a time, we had REA, Rural Electric. Now we have RUS. And I think it exists for very similar purposes of what we're discussing right now. Back in the '20s and '30s, no one wanted to string electricity out to that last barn and light that last lightbulb because it was very costly for the electric companies to do that. And indeed, we've gone from REA to RUS I think with the same philosophy in mind. Someone has to be out there thinking of that last telephone, that last ISDN line, that last whatever it is, that last provider down the line that needs that same service. And it was very interesting to watch REA almost disappear and then watch the rural consortium say no, the job is not done. MR. LAWLER: Let me just ask then what we heard this morning is we have big problems in Colorado. We have party lines. Don't talk to us about fancy future. We've got party lines. How are we going to deal with that? What -- connect that with your comment about the cost going -- the cost not going down as they will in the urban areas. MR. BAILEY: And circumstances vary broadly across the country. MR. LAWLER: Sure. MR. BAILEY: In -- in Missouri for my company, we have fiber optics to connect every office in the state. We have no party lines in the state. MR. LAWLER: Right. MR. BAILEY: But -- and we offer -- we offer basic rate or ISDN throughout all of our (inaudible) with some minor adjustments. But when you get into areas that are non-Southwestern Bell which are significant -- geographically significant areas around the state -- there is not other country offering ISDN at this point in our city. There continue to be -- although it's a goal of our public service commission to eliminate all party lines in the state, they continue and I don't think will be eliminated throughout the state until after the year 2003. And Missouri is probably in good shape when you compare that to Montana or some places a good deal more rural. So I suspect the problems are even worse in other areas. MR. LAWLER: Is it -- does the new competitive environment mean it's -- there's less incentive to make it better quicker from an economic perspective? MR. BAILEY: Well, I think the new competitive environment -- let's say, companies like mine, companies like new entrants will likely spend their money where they can make money. And that won't be -- at least early on, won't be in rural areas. I think early in the process, much of the competition is going to be in urban areas. MR. LAWLER: Steve. MR. COTTON: Let me just dovetail on Bill's remarks by telling you what we did in Texas and what has happened because it's quite dynamic and it's quite promising I think. The legislature a couple of years ago passed a House bill 2128 which Bill has heard of and is probably familiar with it. But in exchange for deregulation, what the legislature said to the telecommunications community was we'll deregulate you or we'll deregulate part of our services, especially your future very high margin type services, if you will help build infrastructure in Texas. And we want are distance insensitive rates and we want guaranteed access and affordable costs for advanced services. And oh I guess six or eight months ago, I came across this brochure from Southwestern Bell, discounted rates for telecommunications services for schools, libraries and hospitals under House bill 2128. And Bill's company which has been a real pioneer in terms of trying to help make things really happen in this arena, not an obstructionist approach, but a cooperative approach -- Southwestern Bell is offering a price for T1 of $130.00 a month per channel termination, connection point, regardless of the distance between two locations that are in one lada (phonetic). And that's $130.00 for a T1. That tells me this can be done. This can be done. This mission here is doable. And the private sector will respond if given the right guidance I think by the FCC and with the right cooperative spirit. And I commend Bill's company for being in the forefront of this. It doesn't mean all the problems have been worked out. But this tells me the private sector will respond if they'll just get the right guidance. And one of the things we did in Texas when we talked about what is a discounted rate, what they ultimately agreed was cost plus five percent which is the cost to that rural hospital. MR. LAWLER: Did you come to sell us -- MR. BAILEY: No. And I should point out that I'm not quite that good in Missouri. I just filed a -- last week filed a tariff for distance learning T1 at a rate of $600.00 a month. So it's available to any school in the state. But we're also offering ATM technology for business learning at $1,380.00 a month. So we're doing some things. MR. COTTON: And see, if you're a small hospital, you can't afford $1,300.00 a month. You're lucky to afford $250.00 or $300.00 a month. Some rural hospitals and clinics can't afford that. But where there's the right kind of rate of the (inaudible) structure and incentives and political influence, it's happening. MR. BRICK: I just think that's -- this is Jim Brick. I just think that's incredible. Okay. That's a whole order of magnitude difference than if you look at these numbers on Dena's sheet. That's a whole order of magnitude difference, you know. I just -- that's incredible. MR. SULLIVAN: That was -- and jumping across the border only about 40 miles from Jim there, the same question. You know, $130.00 for a full T1 service? That's -- MR. COTTON: That's if you're in the same lada (phonetic). MR. SULLIVAN: Yes, I understand. But even that is -- MR. BAILEY: $3,000.00 if you go over. And I would be remiss not to point that probably the result of what he's talking about there, my company got something very valuable for being willing to do that. Okay. One of the problems with legislation is that a number of those incentives have gone away because we got in Texas a good deal of freedom that we wanted through the legislature. And one of the things I -- probably we agreed to do some of those things to help grease the skids you might say. But the problem is that some of those incentives won't be there tomorrow. So companies would be less likely to be given incentives to do those sorts of things in the future than they are today. MR. COTTON: You need to follow that up. MR. BRICK: What did you get for this? I mean, obviously, you made some kind of deal with the Texas legislature. Didn't the Texas legislature only meet every other year? The last laws are better, right? But what did you get for this? MR. BAILEY: Well, that's not the only part. The Texas legislation, I mean, it does an awful lot. But basically what it does is it deregulates the telephone company in the state. I mean, that's basically what it does. MR. BRICK: Tell us what that means. What do you mean -- MR. LAWLER: The federal laws also change the -- the telecom laws have changed. MR. MAXWELL: Here's the ECON 101, a take on this. If you have essentially a monopoly provider who has relative freedom to price within some -- within some constraints and can take profits from one pocket, sort of much lower cost areas to serve because they're more dense and the runs are shorter, and take the earnings that they get from that above cost and say okay, I'm going to give something away at low cost, potentially at cost or below it, that's an easier thing to do in a monopoly environment. Now, if I'm now saying there's going to be competition, then the question is where are the competitors going to come. Are they going to come and say excuse me, I would love to give you $130.00 T1 or are they going to say now, I expect maybe in Dallas or Houston or Corpus Christi or Fort Worth that you were taking some money out of that market and giving away these T1s. Or maybe I'm going to go into that market and price slightly above my cost, but it sure ain't going to be at necessarily the rates that you were charging in those markets as a monopoly provider. And so what -- a competitive environment is potentially at war with this notion of subsidy. The difference is that this legislation with respect to health care providers in rural areas said we think it's real important to be able to have services that are essential for health care providers in these areas. And we think it's so important that we're going to essentially tell the companies you ignore the cost differences because we'll make it up to you. You don't have to worry that you're going to have to give it away or that you're going to make yourself vulnerable to competition. We're going to say that if you price it correctly in an urban area, we will subsidize the difference in cost that you might incur because of these longer runs and this - - and we're going to find a competitively neutral way of providing -- of making you whole. So it's trying to say there is Economics 101. It does work. And that's why we keep kind of getting back to saying what are the services that you -- that you really think are important for the rural areas; then, what kinds of telecom pieces do you need for that; then what's the urban prices for that. And we can -- and the society will make this work, see, because the people will be taxed for that. It won't be the monopolist who's got to go around with these funny prices and say -- you know, because the guy -- the guy in -- in Corpus Christi probably wasn't getting it for $130.00 for a T1 a month either. This was a deal. MS. KING: I would just like to say something about could this committee recommend that there be actual cost studies. I think people would have more confidence if they understood what the real costs of these kinds of elements were. And then that would -- I mean, I think that's missing from the Telecommunications Act, that -- I don't know if the states have authority on that any longer or not. MR. BAILEY: Sure. The states do and -- I can't speak for every company, but in virtually every one of my -- at least my competitive services, I have cost studies I've done. What you have to recognize is that there -- for every person in this room, there's probably a different method on how you would do cost studies. And everywhere -- every method would end up with a different cost. I have cost studies for virtually every service I've produced based upon the way I'd like to do them. And there are those out here who would say my methods are wrong. But there are cost studies. They're not -- they typically aren't made public though because they -- those are competitive services. And I don't want to tell my competitor what my costs are because that gives my competitor an advantage. MS. KING: That's the irony of the thing. If we want to recommend subsidies, where are we subsidizing? I think that's one of the -- MR. MAXWELL: I think, again, sort of the theory is going to be that you've set the conditions so that there can be competition. And competition is going to be more likely to get services to reflect their costs than an environment in which you have a monopoly who is pricing out for some -- for whatever the profit maximizing strategy would be, and that it's more likely that that competition is going to come in areas that are a lower cost to serve. And therefore, those prices will more likely reflect -- I'm not going to make any claim whatsoever that they will be at cost. But they're more likely to be related to cost than an implicit subsidy which is what we've had in monopoly environments where the pricing subsidies are disguised where nobody can kind of know because there's no one who is going to come in and say well, I can do it cheaper. If you don't have that possibility, it's very hard to make sensible pricing decisions. And you will have sort of not only one for everybody here, but one for any potential competitor is going to say how to do the cost and what I will do for you if I'm given the following things. So the idea is to try to encourage competition, encourage multiple providers, both in urban and rural areas because one of the things we talked about last time was if there are things that we can do to induce people to come into rural areas, we'd be delighted to do it because we think over the long term, that will drive down cost of services in rural areas, as well. So we would love to have competition there. And that's one of the aims. MS. DEERING: Mary Jo Deering, HHS. I would like to take us -- I would like to ask you to take us to ECON 101B. My understanding is that in the new environment, it will also be harder for the FCC to project what the subsidy pool is -- is actually going to be. Maybe that's not correct. I think I heard that somewhere. And I'm wondering if you could talk us through what the -- the foundations of that subsidy pool are and, secondly, whether -- again, this is my ignorance -- whether there is a provision in the bill for given the undoubted fluctuations in revenues and subsidies especially as everything shakes out, whether there is any provision for recommending uses of surplus funds however the period -- the accounting cycle happens because I have some suggestions. I've been asked to recommend some suggestions of there are moneys other than for straight subsidies. MR. MAXWELL: Would you like to answer this? MS. POLTRONIERI: Sure. I think -- let me tell you what happens now. We made the projection as to the size of the fund. And then a factor objective, and that's (inaudible) to come up with the money for the next year. Right now we're looking at ways to restructure the way the fund is collected. But it will be -- the funds will be collected through telecommunications carriers. There's different ways of doing that even through net revenues and gross revenues or (inaudible), a number of very complicated systems. But in terms of an extra fund, I don't really postulate that. It's sort of -- we're thinking about (inaudible) and project how much that's going to cost. And if there's too much money, we can go back and fiddle with the books a little bit. MR. MAXWELL: It's a term of art in the Government. That's being recorded. MS. POLTRONIERI: If there were -- if we collected too much. MR. MAXWELL: People are not getting anonymously (inaudible). MS. DEERING: The only reason I asked, and I'll mention it here -- this wouldn't have necessarily been the appropriate place for it -- but HHS is supporting something that is called a science panel on interactive communication technology and health which is to begin to take a critical look at interactive communication technology, not the technology itself, but the applications that are delivered and to come up with a frame work for evaluating them, standards of quality, et cetera. And they're very interested in this -- in this activity. And they wanted to suggest unofficially since they -- they really can't -- they're not in a position to make this official -- that evaluation be built into this on a couple of levels. The first is is there any provision for the FCC to collect and publish how much access is actually occurring to these various things. I mean, what kind of data will you in fact be collecting about the conductivity and to what unit of provider will you be collecting? I'm sure you have that kind of data collection, but to know -- to let us know in as much detail as possible what that is because for those of us who are concerned with access to the home and to the school, et cetera, we'd like to be able to factor that in to our assessments. The second one is -- and I realize that this is beyond the purview of the -- of our committee and of the law -- is to what extent do we try to educate people about the importance of the content that goes over these pipelines. We're looking at what specific services we want to recommend with the assumption that all of these services have value. Again, I'm recognizing that it's not within the purview of this committee to try to evaluate whether the content that's delivered is actually doing what the sponsors of the bill, you know, thought it would do. But I raise that as a point of interest by this committee in saying if in any way this revolutionary initiative which is being unleashed could help foster some more critical sense of what the content of the health services or health information is that's being transmitted, that it would be valuable. So thank you. MR. MAXWELL: Let me just take ten -- you know, 15 seconds to respond. Those are exactly the kinds of questions that seem to me that would be important for the committee as a committee expert about health in large measure as opposed to necessarily about telecommunications to be saying should be thought about by the FCC in its administration because it's not necessarily the way we would come at the issue. We know something about communications and something about tariffing and something about practices within the industry where you can come in and say this is the kind of service, this is the kind of, you know, evaluation that might be very helpful; is there a way that we can make sure that we, in fact, are working together on this as opposed to bifurcating to both -- the detriment of both. MR. LAWLER: Jay. DR. SANDERS: Jay Sanders, ATA. Two things. Number one -- and Steve and Bill, please correct me if I'm wrong -- one of the other very interesting aspects of Senate bill 2128 is the fact that it levies a tax on all the communication providers in the state of Texas to the tune of 150 million dollars a year times ten years. The fascinating thing to me of that 1.5 billion largess that the state of Texas has to create an infrastructure for telemedicine is that the people lobbying for it was the industry that was going to be taxed for it. And I cannot conceive that they did not lobby for it without doing a heck of a lot of homework like a business plan to figure out, well, let's see, if we're taxed X millions of dollars per year and we lay the infrastructure, is it possible that if we build it they will come. And I would suspect that the answer to that was yes. So there's some very interesting aspects of this -- of this Texas bill. The second thing is a question. When we began to build our infrastructure in the state of Georgia and, obviously, looking at the most inexpensive way to do it and to determine what existing resources were there, we were very surprised and the federal -- the state communication board was very surprised when we gave them an overlay map of all the fiber that was laid by Georgia Power throughout the state which the Public Service Commission in no way regulated and, in fact, in no way knew about it. We had a very cooperative relationship with Georgia Power. In fact, they funded a part of our original telemedicine initiative. And they are very -- they were very, very willing to lease all the excess band width that they had for the communication infrastructure. Taking that, when we went into other states to look at what existed in other states, we found in just about every state we went to the same situation existed. There was a huge amount of fiber underground laid by the power and light companies that nobody was using except the power and light companies, and a huge excess band width available. What role if any do we have in trying to in effect hold hands with the power and light companies to help us in terms of the laying of the infrastructure? MR. SULLIVAN: Do you want to answer that, Bill? If he doesn't want it, they can have it. MR. BAILEY: No. From my understanding and I'm not -- I've dealt with some people at a particular operation in Missouri, the -- Springfield where the -- there the power company is owned by the city of Springfield and has a very elaborate fiber network circling the city. And they've done that for the sole purpose of controlling their power network. And that's the cheapest way they could do that. And in the process, they created a great deal of excess band width that has virtually no marginal costs. I mean, they can provide that to other people for very little additional cost. And I will say that companies like Southwestern Bell view power companies as a very real threat down the road. And I don't understand why they're not more actively involved today than they are. I suspect that they are also regulated utilities and recognize that whatever money they make in their telecommunications provision would somehow get rolled into their electric provision and they'd probably not benefit a whole lot out of it. So there's all sorts of motivations going on here. And so maybe what you need to do is deregulate power and all of a sudden we'll have a lot of telecommunications. MR. MAXWELL: Just as an observation, the new act changes the rules that previously governed public utility holding companies which was a substantial impediment to utilities entering the power and light, utilities entering the telecommunications business. And a number of those companies have come to the FCC under an expedited provision that exists to get into that business. In a number of states -- California which I know reasonably well, the power and light companies have leased those facilities to long distance providers and other providers to offer service. But it is -- one of the questions that has come up in the universal service proceedings in general and that clearly applies here is if there is to be a subsidy, who is eligible to receive it. Is it simply that the local -- the incumbent local exchange company; is it any wireline provider; is it a wireless provider; is it any provider? So in fact, one of the questions would be would these people be able to offer these services and be eligible for subsidies in -- whether it's in the general universal service proceeding or in this particular proceeding or the educational one and, therefore, make it more likely that they will provide their facilities, make use of their facilities. MR. LAWLER: Just a couple more, then we're going to -- MR. MENN: Well, I was just going to comment on -- Eric Menn from Mass. General -- on what Bill Bailey said about electrical companies being players down the line. In Massachusetts, the Massachusetts Turnpike Authority has created a fiber optic ATM link the length of Massachusetts. And one of the founding partners of that was the Boston Edison Company because they want to be a major player down the line. And I'm sure that's true elsewhere. MR. LAWLER: Down at the end. MR. MCCONNAUGHY: Well, another bite at the rural infrastructure development process besides discounting rates is NTI currently has an infrastructure grants program called T-Op (phonetic) which I think over the course of two years has been 60 million dollars in grants and I imagine fund basis which I think it key. We need an incentive-based plan to -- to really make these things work. So I think the grants are in 47 states. Somebody did a calculation where I think over a third of the grants have been given to rural areas and within those rural areas, of course, rural health care providers have benefitted. So there's lots of ways to get - - part of the whole mosaic to get the rural infrastructure development whether it's (inaudible) loans, grants from various sources or (inaudible) discounts. I think everything moving ahead on a (inaudible) I think will get a lot done in terms of getting the available infrastructure that's needed. MR. LAWLER: Cindy, go ahead. MS. TRUTANIC: I just have a very basic technical question. Assuming that there's all this interoperability and the infrastructure is all there. In terms of the applications, it appears that there may not be -- I mean, I know that the spectrum is finite and that the demands in the spectrum are going to be increasing exponentially and with all kinds of medical, educational and other applications. At what point -- does it ask anything about prioritizing a spectrum allocation for health, education and whatever uses? I mean, assuming we get 20 years down the road and we've got the same problem that we do with cellular service in that there's not enough band width to accommodate the demand, what happens? Are we interested in that? MR. MAXWELL: That's something the group can address. I think this is a curious situation with respect to rural areas at this moment. And that is the FCC over the last several years has put an enormous amount of band width out into the market. MS. TRUTANIC: Right. MR. MAXWELL: There are essentially now for most every area, I think probably every area in the United States, as many as seven different providers with spectrum available. Now, in most rural areas, there is either one or two rural providers of wireless service putting aside the educational spectrum that was available and others, but of things like cellular service. The awards through auctions have taken that number up to seven. And there's not the congestion that you now have in urban areas. So one of the things that we think is probably likely to happen in areas where there's great distance sensitivity, that someone will say I've got spectrum, it's easier for me to offer this in something akin to wireline- like services because I don't have the other demands on it. And that -- that over the next several years, we might be seeing much more entry by wireless providers into rural areas because of simple costs of wiring these areas, even for new developments is such that they may be competitive economically. So I think, in fact, what we will see -- and one of the reason why the notices were phrased as they were -- that wireless providers may well be eligible for subsidy and wireless may have favorable economics for this. And so we should be thinking not only traditionally the wireline providers, but what wireless can do in this area and how we might make use of that. MR. ENGLAND: Bill England, HCFA. In terms of the way the subsidy works, one of the things that worries me a little is that if we -- the subsidy is sort of a monthly subsidy for a T1 line or whatever. I mean, you can multiplex, you can do something that -- whatever you've got out in the rural area, twisted pair (phonetic) or whatever, you can get the T1 to a hospital or two hospitals. But at some point, it's going to be cost effective to put fiber out to some small rural area. And then you've got -- we talked about it before - - this huge unused band width that could be used at almost no cost for other things. So depending on how this subsidy is structured, it needs to be structured in a way that encourages the people that lay the cable to make that capital investment up front instead of just sort of doling it out monthly in a small amount. You're not going to get the infrastructure being built. And I don't know if that's something we ought to address. But if you knew that guaranteed for the next ten years you've got a subsidy of however many thousand dollars to reach this community, and essentially the health community is going to buy band width even if it's not used through this subsidy and that could all be lumped to lay a cable out there, then you -- it's a better way of doing that. MR. MAXWELL: I think that's perfectly appropriate to comment about. What you would like to have happen -- clearly, the Commission would be happier than a pig in slop to get facilities out there. The notion is not we like the idea of running these huge tax systems. That's not the idea. The idea is to try to make sure a) that we meet the mandate of the law and b) introduce competition where it's economically sensible. And facilities out there is very important to be able to do that. MR. LAWLER: Just one last -- you've had your hand up. MR. BUAS: I just wanted to raise the obvious point that probably occurred to everybody; that if I send e- mail from my office upstairs to my colleague next door, the price is the same as if I send it to Australia. That's just the pricing model of the Internet which is sort of bizarre, but it's magical and it's made an incredible phenomenon possible. Now, whether it will be sustainable is another question. But that's a cost mile that's not price sensitive. You go from the middle of Montana over 200 miles - - I'm just sort of saying that it's ironic that this T1 pricing is distance sensitive right now whereas you can go across the world and you're not distance sensitive. So I realize telepany has a long history; the cost model has been in place a long time. But perhaps this other cost model will also come in, change the way people look at things, and have impact on this role play. MR. LAWLER: We now have our international subgroup. And Ron is -- do you want to come down here or stay there or whatever? MR. COLEMAN: No, I think everybody ought to stretch. MR. LAWLER: I'm sorry. Let's stretch. (Whereupon, a brief recess was taken.) MR. LAWLER: All right. Two housekeeping things before we start. I see here some people are thinking about running out to catch airplanes and other things. So let me just say we're looking at dates in September. Not the first week -- not the week of Labor Day because that's always a bad week for everyone. But either the following week or early the next week. So if there are events in those, that second or third week in September that will keep a lot of people from attending, why don't you let us know quickly and we'll make sure that we avoid those dates. And the best thing is to contact Lygeia. MS. RICCIARDI: Yes. If you want to give me an e- mail or a call or something like that. MR. LAWLER: And Jay, you had one comment, and then we'll go to Ron. DR. SANDERS: Yes, one comment because Cynthia and I were talking about this during the very short stretch. But in keeping with -- Paul's not here -- he probably should be if he heard my comment -- but in keeping with the idea of looking at where infrastructure already exists so that we don't recreate the wheel, in keeping with the idea of looking at the power and light companies, one thing you should know is that in the state of Georgia at the request of DoD, we piggy-backed a military health care system onto the civilian backbone that we had developed. What about the reverse? There is a huge amount of band width out there that the military has in continental United States that they're not using. And they're spending a lot of money for that band width that's not being used. Do we have any -- is there any role, can we make and suggestion that we begin a dialogue with the military with respect to the available infrastructure that they have that could be made -- or leased to the civilian sector? MR. COTTON: Jay -- MR. LAWLER: I can't say anything with that comment. So Steve, go at it. MR. COTTON: -- is this fiber in the ground? Is this satellite capacity? What kind of -- DR. SANDERS: All of the above. All of the above. And there's a lot less need for dark fiber (phonetic). MR. MENN: I would just make the comment, Jay, that there is historic reasons why this would be reasonable because a long time ago the interstate highway was justified as a military necessity. And we piggy-backed on that very nicely. And there's no reason why the same argument couldn't be made in this setting. DR. SANDERS: Should we take a vote while Paul is out? MR. MCCONNAUGHY: At least on the spectrum part of the question, there is a shear thunder way that the Government spectrum band width there of currently being shifted on a phased in basis over to the private sector and the FCC overseeing it. So that doesn't address directly your question. I mean, that's just sort of a -- sort of a macro look at what's going on. The Government spectrum is shrinking and it will be for the next several years. MR. KIENZLE: The Iowa National Guard has a subnetwork of the Iowa Communications Network. And they have made all of the hours during the day when they're not using their network for military purposes -- which is really every day except weekends and, you know, every other weekend and two weeks in the summer -- for the public use of their video classroom. So I mean, I think there are precedents for that kind of multi-user approach, even to -- even to military networks. MR. LAWLER: Ron, do you want to speak international? INTERNATIONAL SUBGROUP REPORT MR. COLEMAN: Yes, thank you. I'm going to remain seated. I've got a bad leg. I've been out of the country for about the last three or four weeks so it's nice to meet those of you who I have. When I returned I spoke to I think all but one of the subgroup members. So we put together a list of the international telemedicine issues, problems, that sort of thing. I mentioned to Greg that we were doing this. That most of the issues are not too complicated and they're really not in the purview of this group. But we're going to talk about them anyway so I hope you're interested. Those telcom issues -- and we're sending the outline around -- those issues that are telcom related, I will go through them briefly because we've spent the day already discussing it. But the problems become exacerbated when your talking about international agreement. Obviously, the first one is the availability of the appropriate telecommunications infrastructure in the various countries, not only in the United States, but in the various countries to support the provision of telemedicine services. So that means not only domestically, but an international component and the domestic component (inaudible). The second point is access to that international telecommunications infrastructure at reasonable and affordable rates. And there we don't have groups such as the Texas legislature. There will be the telecommunications ministry of Saudi with respect to those reasonable affordable rates. We've also already talked about point number 3 which is the adoption of internationally agreed standards and protocols with the necessary medical and telcom equipment services, an issue that again is -- is much more of an issue, much more exacerbated when you get to the international arena than it is in the domestic arena. The fourth issue that's telcom related is the possible use of Internet-based services to support primary care providers in the developing nations; patient education and consumer programs worldwide; and continuing education programs for health professionals worldwide. And of course, the major problem is all of this hangs on the availability of those various nations of the necessary hardware and software access and services that the providers in the United States provide. Okay. Those are the principal telcom issues and by and large they have been discussed. The areas that are beyond the purview of this group where I think organizations such as the FCC together with the Department of State, the Department of Commerce and perhaps the Office of the Trade Rep. (phonetic) would be helpful is that when you get involved in international telemedicine, one of the first things that comes to mind is the existence of medical licensure requirements in the overseas vocation for U.S. physicians performing diagnoses or other medical services in the United States via the telephone line, already a problem in the United States and I see a recent article in the paper that the AMA proposal for uniform licensing in the United States has already been struck down. So you can imagine what a problem we have on a global basis. Another issue is the existence of foreign government restrictions, licenses, permits, et cetera, for the simple construction of telemedicine facilities in overseas locations. These approvals can be a major barrier ironically, and especially in the countries that probably need the telemedicine services the most which would be in the lesser developed countries. Another issue is the existence of important duties on medical and telcom equipment in the various foreign locations. Getting the equipment there and into the country necessitates coordination between ministries of health as well as ministries of finance collecting the sort of import and duties. Obviously, another major barrier to the proliferation of international telemedicine is the availability of local personnel, medical and technical, in the various foreign locations, and the overwhelming need to train such personnel. So this will vary from country to country obviously. Another significant point is the existence of appropriate payment mechanisms. I know many of you in this room come from the nonprofit world. My company is supposed to be a for-profit. So the existence of appropriate payment mechanisms, insurance or otherwise, in the various foreign locations are very important as are restrictions on currency conversion and repeat provision (phonetic). The availability of malpractice insurance coverage for U.S. physicians practicing telemedicine internationally is a problem. It's a problem both with respect to the carrier in the United States and the possibility of coverage on the other end. And I guess last but not least, in this whole area where the FCC can probably use held is there's obviously a role for the international treaty organizations such as the ITU and the World Health Organization, Government agencies in the private sector. I know there is a study group at the ITU in Geneva on telemedicine. (Inaudible) more study groups studying, trying to determine what telemedicine is. So I don't look for anything to happen quickly out of the ITU. Perhaps it can be a vehicle to face some of these other issues in the various foreign country. I'd like to -- I told you I'd be mercifully brief. I'm going to turn to each of the committee members for comment. Let's start first with Mary Jo Deering. MS. DEERING: Thank you. Actually, I was realizing an oversight that I alone have to be responsible probably for here, which is we've left out something that we can all relate to which is not health care delivery, but public health and epidemiology and the emergence of infectious disease and the whole information infrastructure for that. And I apologize for not inserting that earlier. In fact, it occurs to me that we've left it out of all of our discussions today. And I would be certainly be happy to help that. And I appreciated the opportunity to add that emphasis on primary care and patient education worldwide because I think that clearly -- that those are -- that that's a spectrum of health care services that are not only appreciated in the developing countries, but increasingly due to cost containment also in the developed world. So thank you. MR. COLEMAN: Okay. Roger. MR. GUARD: I think Mary Jo just covered my key point. Apparently, great minds think in the same direction. And the consumer health patient education focus is what we added to -- MR. COLEMAN: Eric Menn. And I also want to point out that we have distributed a paper that Eric was kind enough to provide which was -- cites the experience of Mass. General and Cleveland Clinic Foundation in their 18 months of operational experience providing teleradiology services to Saudi and Jordan and Lebanon. Eric. MR. MENN: And actually, the list is very, very good from my thinking. From again an urban perspective from a teaching hospital, part of our mission on the international side we have told been by the administration of the hospital is to make a contribution to, as it were, the rural and underserved of the world because we are a teaching hospital. We regard it as part of our mission to find ways to subsidize that with hopefully a created revenue source. MR. COLEMAN: Next, Dr. Sanchez. DR. SANCHEZ: Covering all these aspects, it's -- all of it is that every effort has been made in international plans that were mostly successful in application, the Canadian project and others. And that really meets with very little problem or opposition. The implementation of disaster plans perhaps would be another area which has been addressed in different countries, Europe and the United States. And the problems are almost unsurmountable when you get into a -- the so-called third world countries because of the problems of communication. But also the infrastructure that everybody has attempted to build apparently sooner or later finds the way into private pockets. And so if we are looking at helping building up a market for medicine in the United States or plain assistance, some of those issues which may include some degree of funding, at least the conservation, might be almost a loss. It might be better to favor incentives and reduce tariffs, et cetera. I'm not sure the economics support that directly because of the -- unfortunately, the corruption that exists in most of those countries. MR. COLEMAN: Reed. MR. TUCKSON: This is very good I think, as well. I think the -- the notion of incentives is particularly important. And the degree to which these initiatives can be coupled with other international business enterprises which I think is also an important opportunity, (inaudible) particularly for Vice President Gore has a number of international trade missions with other nations bringing in private sector in collaboration with Government energies. South Africa is a good example of one that seems to be working fairly well. And in this regard, in fact, we see a number of AID grants to try to have cooperative ventures with the United States health organizations to improve the infrastructure for the delivery of health care within South Africa. This is a wonderful prototype and model I think for a public/private partnership across international boundaries that might need to be looked at in this context. MR. COLEMAN: Okay. Bob. MR. WATERS: Yes. I would just offer two additional comments. One, I think the discussion earlier today about the sort of standardization of architecture and the efforts of folks like the American College of Reality and the DICOM Group is particularly important in terms of from an international perspective to the extent that as you get more developed countries and technology proliferating further down, that's going to be an important focus I think for us to make sure that we have as wide a standardization as possible. Secondly, it strikes me that health care is one of our greatest potential export opportunities. And that to the extent that we can utilize some of the capacity we have within telemedicine where there are sites that are engaged in telemedicine but perhaps they are not fully utilized using their equipment, resources, knowledge, that is something that other countries want, probably more than the product that we produce in this country. It's got real value added. It's where we're still in a very dominant position. I think we need to be thinking about that in terms of as another way to make the deliver of these products not only more widely available, but also in the end, perhaps more inexpensive for people in this country. And there's a lot of applications that go with that. And one need not look far. But I think the Internet is a good situation -- a good example where there's a greater national demand to obtain health information and knowledge. And I'm fully aware of some personal situations where friends of mine encountered health care situations. And in less-than-developed countries, they would have been eager to have consulted with any of the physicians that are in this room or any leading health care institutions about their problems because they just didn't have the expertise locally. And we ought to be thinking about how to do that and build that into whatever models we create. MR. COLEMAN: Okay. I'm just wondering to what extent do you think the liability issue that we discussed earlier for the physician in the United States practicing international telemedicine -- do you see that -- DR. SANDERS: There is none. There is virtually none. First of all, by the decree of the Federation of State Medical Boards that has chosen in its infinite wisdom to suggest that over an interactive medium, in fact the physician is being transported to the patient. In effect, a physician in the United States who is reading a fax of a medical record from Saudi Arabia would be defined by the Federation as practicing in Saudi Arabia. And since the Federation of the United States has absolutely no jurisdiction in Saudi Arabia, the point is we -- second of all, the overall liability or litigiousness of the rest of the world is a logarithmic order of magnitude less than what exists in the United States. Third, I think this committee would be amazed -- I mean, it would be very difficult for us to over-estimate, as Bob pointed out, the degree of interest, the degree of aberrance that exists in the rest of the world for our medical expertise. And in fact, from a commercial standpoint, it represents a multi-billion dollar resource that has gone largely untapped in this country. One of the reasons you see the major medical centers in the U.S. like MGH, like Johns Hopkins, like Duke, like Stanford, like Cleveland Clinic, like Mayo -- is Eric still behind me? MR. TANGALOS: Yes. DR. SANDERS: Thanks. Going into the international market is, number one, the legal and regulatory infrastructure that is so confining in the U.S., is very minimal in these other countries. Number two, there's a huge potential revenue strength that exists there. So that's why a lot of telemedicine practice in the United States is being practiced internationally. You also need to understand the offsets or the by- products when partners or what -- what ATI was initially; it's now WellCare and soon to become WorldCare -- started with was wavelength compression, teleradiology over a standard Pots line (phonetic), analog line from Saudi Arabia because Saudi Arabia had not developed their digital infrastructure yet. And they also started the actually started the United Arab Emirate also. They started with teleradiology. What happened was and what is soon to probably take over already -- it probably has taken over in terms of the largess of the revenue stream was the fact that really they're just faxing medical records for a second opinion from these countries to the U.S. And even if someone like Roman Bisankus (phonetic) in cardiology at the MGH charges $500.00 for the consultation that he's read in a half an hour and gives a second opinion, it is a huge cost savings to that Saudi Arabian government rather than having to send that patient over. Let me give you an example. Three years ago, I met with the Minister of Health of the United Arab Emirate in Awidadi. And he told me they send 5,000 to 6,000 patients per year at an average cost of $35,000.00 per patient abroad for such specialty consultations. They're sent to Munich, Geneva, London, the United States. And the interesting thing was to look at a selective sample, a random sample of the charts, of the types of consultative needs they were requesting. They needed dermatologists. They needed ear, nose and throat doctors. Eighty to ninety percent of what the patients were going abroad for could have been handled by in-country capability brought to them electronically. They just don't have the medical expertise there for simple types of consultative needs. So they send them abroad. MR. COLEMAN: But was that simply for medical services or did that include shopping? DR. SANDERS: Very -- very, very important point. Very important point. And it's funny and yet it's very real. The reason that a -- that a company called HealthCare International went into receivership after raising $600,000,000.00 and putting a $400,000,000.00 coronary care center on the banks of a river in Glasgow was the fact that the people from the Middle East whom they were marketing to who could afford to go anyplace they wanted to didn't want to shop in Glasgow. That is one of the factors that led to their demise. And having to be two friends to -- both of whom emanated originally in the house of their training (phonetic) from the Mass. General Hospital. MR. TANGALOS: If I may -- DR. SANDERS: You'll get equal time for this. MR. TANGALOS: No, no, no. Let's just embellish this. But indeed, when we think about western medicine and a second opinion, that implies the United States. I think part of the Glasgow business was that it wasn't west enough. And in terms of some other store and forward activities, there's a project called MedJet right now. And it's an L1011. And it's equipped with four emergency suites, a complete ICU with extra seating available so that families from the Middle East can accompany their sick one to the United States and also have a cheap way of getting to the U.S., as well. So that's a twice a week flight that's going to start up this fall. DR. SANDERS: I think we also need to be aware of the -- not only the interest and the amount of the incredible activity that exists internationally from Central and South America, Chile, in Argentina to -- and Mexico, two huge projects in Norway -- they have much more telemedicine consultations in Norway than we have in the U.S. -- to Finland to beginning in the circumpolar health group to Australia. I was mentioning prior to this meeting that the state of Victoria has set aside over two million dollars in Australia, selectively set aside for telemedicine initiatives. Interestingly enough, in the states of Australia, they have the same legal and regulatory problems that we do relative to interstate licensure. And I would also suggest that there is a model in which that has been resolved. And in the same way that the European Union nations do everything else in a unionized fashion so to speak, so do they do that with respect to medical licensure. So if I am a medical graduate of a medical school in Belgium, when I graduate from medical school, I can practice medicine in France, in England, in any one of the European Union nations. The fascinating part about that as described to me by the president of the Royal Society of Pathology recently in Oxford is that -- he said Jay, it's ironic. He said in your country, you have a common standard that everybody's expected to be responsible for. And yet in each state, you have to get a license. He said here in our different nations, we unfortunately do have different standards and yet everybody has the same license. So on the one hand, there is a precedent for the internationalization of licensing and that's on a positive basis. But I think before we go out as we recently did at the ISAT (phonetic) conference in South Africa, the 41 ministers of developing countries, to plead to them for the development of a communication infrastructure and to develop the legal and regulatory framework that would facilitate private dollars, private corporate dollars coming in to these nations from outside to develop these infrastructures, we had better do a little bit of developing yourselves because the legal and regulatory infrastructures we were asking them to create, we ourselves don't have. MR. TANGALOS: I apologize for that, but it's very upsetting to see some of the problems that we have in this country. MR. LAWLER: Anyone else? MR. SONNENSTRAHL: I'd like to back up to Number 3. Can I talk about a different issue here that related to Number 3? MR. LAWLER: Sure. MR. SONNENSTRAHL: Can I do that? Okay. I'm happy to see that you've brought up establishing standards and formal protocols for the necessary medical and telecommunication equipment. But why did you use the word, "necessary", instead of all? MR. COLEMAN: It was just a term of art for whatever equipment is necessary to provide a service. MR. SONNENSTRAHL: The reason why I'm asking this question is because we may have a hard time defining which equipment is appropriate and necessary if you don't use the word, "all". We have seven different telecommunications systems for deaf people in this country in the world. In other words, I can't call France using my TTY here because we have different systems. So if we're involved in something medical, then we have -- you know, we have problems. So we're saying that TTY is not or -- no, is -- is TTY a medical telecommunications device or not? So if you use the word, "all", that would cut down all kinds of unnecessary red tape and make it clear. MR. COLEMAN: That sounds good. MR. SONNENSTRAHL: Thank you. MR. LAWLER: Any other international comments? MR. MENN: I guess the only other comment I would make, and I think it's been addressed around and about, is that most the things that we've found practicing internationally are that a lot of the protocols that we are being forced to develop, particularly we're starting to work on dermatologic imaging, will be applicable in the United States without having to go to the IRB clinical trial process, but that we will be able to simply lay them over existing practice standards. And I think that will go a long way toward bringing primary care physicians to the telemedicine table. MR. LAWLER: Just one general comment and people can agree or disagree with this. But I would view the international area of this as our role of advisor to the FCC we ought to interpret expansively because it's -- it's advice that the FCC can take. And they don't have the direct ability to make it happen tomorrow. They've got to go lobby others. So I think in all these things, we ought to -- and I agree with all the things that have been said about the opportunity that it provides to us to -- you know, as an export to improve health care and all the rest. So I think we ought to interpret our mission on the international side expansively unless Elliot jumps on my back and beats me here. MR. MAXWELL: No, to the contrary. There is an effort going on right now within the administration to try to identify impediments to the development of advanced telecommunications services internationally. And this is in part because of our belief that we are at the leading edge globally. And therefore, these provide great commercial opportunities to us over time. This is clearly one -- one of those areas related to that. And so we have been working with other -- other elements of the Executive Branch to try to see where there were obstacles to the development of telecommunications-based services. And so this is a very fertile area for those people who are, in fact, involved in telemedicine internationally or in other uses of telecommunications internationally to come in and let us know what would be the best -- sort of the most important things to be doing. We don't have much to say about licensure, but we do have a fair amount to say about market access and the ability of people to be able to get these lines and to be able to get capacity at reasonable cost. So please do feel free to put this within the realm. DR. SANDERS: Jay Sanders and I apologize but I can't resist. Once again, we as an administration and a country are seeking to utilize telemedicine to provide health care internationally. And we also anticipate and fully expect that that health care consultation will be reimbursed. Yet our own major administration -- Bill's not here. I wish Bill -- no, Bill's gone. I didn't plan for Bill to be gone when I said this. But the reality is the health care financing administration in this country has chosen to decide that telemedicine should not be reimbursed because it's not occurring in a face-to-face fashion. And they've chosen to define face-to-face as meaning physically in the same room. And here all we've been talking about is the necessity of electronically transporting information. MS. DEERING: In defense as a HCFA representative who -- from whom HCFA was a black box until quite recently, under Bruce Vladek, HCFA has become extremely wired or wired-oriented. And I think that given the unfortunate plaque that the administrations change periodically, one can't guarantee his continued tenure. But I wonder whether with sufficient time the types of attitudes and attitudal changes that he's -- I mean, that's -- that's quite a cultural change that's got to go in HCFA. And it is under way. In my own area, I have been absolutely flabbergasted to see the speed with which this change is occurring. And certainly, it will take much longer in that area. But I would like to hold that out as a light at the end of the tunnel. DR. SANDERS: I hope that within my lifetime -- I don't plan on leaving that soon. MS. DEERING: I'll keep the floor if I could though on one issue. And it has to do with our look at international opportunities for telemedicine as a business opportunity for American medicine. And I think we need to at least raise a couple of -- or one caveat here and maybe two. One caveat would be that -- that this be undertaken with a spirit of cultural sensitivity because medical practices, medical attitudes vary around the world. And I think that for us to export our medical practices and value into lease would be as imperialistic as the export of certain other products that are not welcome there. And the second is really much more pragmatic from a public health point. And it has to do with not displacing or weakening in any way or failing to help develop the local capacity. For a public health point of view, we do not want to undermine that capacity. We want to build it. So there should be nothing that we do that supplants it or our competition moves in. DR. SANDERS: Just to go along with that, you know, it's amazing to me because while we're -- while we're trying to export telemedicine, I think we need to recognize that the major cause of death in the developing countries is starvation and infectious diarrhea because of the absence of food and proper sanitation. They need food and sanitation before they need a neurosurgeon. That's a very, very critical issue and we -- we shouldn't forget that. The other thing we shouldn't forget is our advice may not only be viewed as imperialistic. It will also be viewed as wrong. And let me just give you a very quick vignette because when I -- about a year and a half ago when I was making rounds in Turkey in Ankara (phonetic) at the medical school, we were near the end of rounds. And I hope I didn't mention this the last time -- last committee meeting. And the professor there who was my host said, Jay, let's go off to the renal dialysis area. And I'm thinking to myself what in the world is of educational interest in the renal dialysis area. I know they all have renal failure. And he said, by the way, before we go inside and see these patients, what do you think the most common cause of renal failure is in Turkey? So as a turkey, I responded in the usual United States fashion. And I said oh, diabetes. He said no. I said hypertension. He said no. And I knew I was in trouble. So the most common cause of renal failure in Turkey happens to be a condition called amyloidosis. Now, amyloidosis as a cause of chronic renal failure in the United States is incredibly rare. And what is even rarer in the United States is what caused the amyloidosis in the patients in Turkey, a disease called familial mediterranean fever. So before we take our U.S. expertise abroad, we better be very knowledgeable about what the epidemiology of disease is in different parts of the country. MR. LAWLER: Anyone else? Let's -- we are running -- well, we're not that far behind, but we're far enough behind I know people are trying to get out. Let me just describe what -- where I think we need to go and arrive at. We're going to try to get the subgroup heads together. Somebody said they had to catch a plane. I forget who it was. But -- so we may accomplish that or we may not. We have covered a lot of ground today and, obviously, the thing we need is to try to focus our efforts. We have a -- as I said, we're going to try to meet in that second week of September. We really need to have something at that point that we can meld together into a report. It will require some editing and that kind of thing; probably a substantial amount just to make it work together. But the effort really has to be at our next meeting we have to -- we must have something that people have read and commented on and gotten their comments back to their -- however, you want to do it -- to your subgroup heads. And it's all focused heading in the same direction, and that's not going to be an easy task given the fact that we're, you know, not all together meeting once a week. What I would like to suggest and actually, maybe we'll just skip our subgroup meeting and just try to lay this out for everybody and see what -- see what the reaction is -- is maybe we should -- the subgroup heads and Elliot, Lygeia, myself, if we can do a call sometime early next week or whenever and try to get really an outline of work for the different subgroups to do so we have a -- you know, a clear description of -- you know, the rural subgroup is going to do X, Y and Z and the architecture subgroup will do A, B and C, and try to lay it out as carefully as we can. There will be overlaps and that's really up to the subgroup heads to communicate and try to minimize it, although we're never going to get rid of it entirely. But I really -- let's assume we can do that and accomplish that in the next week or so, week or ten days. Then we've really got to figure out -- and this is any subgroup -- how we focus on the things that we really talked about today and try to get to the things that we think are important. You know, I -- and this is said knowing that there are different people in the room based on the conversation today who think different things are important and, you know, there's nothing wrong with that. But I do think at the same time, we have to establish a focus or we're going to have a report that's all over the lot and not really that useful to anybody. So -- and I'm happy to have a discussion about this. But I think the effort ought to be in the next ten days to come up with a real outline of what we need to cover in terms of each subgroup. And then each subgroup has to organize themselves with the thought that they are going to have a -- a document ready for September that people will have read, criticized, edited, whatever the right words are, gotten back, had another draft of it go out however many times you think it needs to go and be -- be commented upon, and then get it out to everybody so we can come here and have a meeting about something that people have read and have opinions about; you know, I hate the fourth sentence or I love the fourth paragraph or whatever it is. It seems to me if we don't undertake something like that, we will come here in September and we'll have another nice discussion and we'll not get very far. MR. ZIMNIK: Again, I want to impress upon the group the value of doing this electronically as well with mailing lists and the web. And again, whatever tools you think you need, I'm not at all implying that I'm the only -- we're the only resource, but we're making that available. So let's make sure we utilize that to its fullest potential. MR. LAWLER: Right. Everyone has been enormously -- I mean, I've heard that from everybody -- that everyone has been enormously responsive in terms of, you know, a request for something goes out and there's very quick thoughtful response. And we need to keep that up. And I know vacation time and all the rest of it is approaching. But in spite of that, I think if we really want to have an impact with the comments we make, the more focused we can be between now and the beginning of September, the more in fact we'll have. Mary Jo. MS. DEERING: A question and a comment. The question gets back to something that Elliot said today and that he said back at the first meeting which is that in his mind, the -- our work product was first to define the services that we want and then the telecommunications that will address those services or avail those services. And really none of the sections specifically focuses on the bundle of services in reports that's come across in all of our discussions. And I wondered if you could give us some clarity whether we should all nominate our own list or whether you'll -- or whether you yourself see that there's one of those groups that should specifically articulate that, because, really, it has been sort of cross-cutting. And on that note, I would like to volunteer something on behalf of Reed and I and I can't remember who else in the group. But one of the other cross-cutting themes that we've heard today is the concern with prevention, wellness, consumer health. And we would volunteer to collect anyone who is interested in contributing to text on that -- on those issues as a set of materials to undertake to prepare that. And I don't know how you would want it to fit in. But again, it seems to be cross-cutting. MR. LAWLER: Yes. Well, the answer to the second part of that is easy which is please do that and anyone who wants to join in should. I think you're volunteering yourself to be the -- MS. DEERING: Well, we are. And I'm just saying I'd appreciate it if you'd actually post it on the web site. MR. LAWLER: Sure. MS. DEERING: And you can give my e-mail. MR. LAWLER: We will do that. The answer to the - - the answer to the first part of your question is I really do think we need to have a discussion about precisely how we want to do that with the subgroup heads because, frankly, I don't know the answer. I think -- you know, there are a bunch of different ways we can go and I have an opinion. But I think we ought to have a discussion before we just say what it's going to be. Steve. MR. COTTON: I'd like for us to have more guidance from Elliot, from the FCC standpoint. And on that line, these four subgroups, you've asked us to comment on some very general things. But I'm -- I think specifically it would be helpful to know what do you guys really want guidance on specifically. Where are the big grey or the dark areas that you're going to have trouble with unless you get some guidance from us? I mean, I'm not asking for an answer now. But there ought to be one, two, three, four in each of these subgroups that at least would serve as a starting point for us. MS. POLTRONIERI: Elliot, I'd like to comment on that. Is that okay? MR. MAXWELL: Sure. MS. POLTRONIERI: I think if you look at the Reg. 30 (phonetic), some of the questions we've discussed today (inaudible) about defining rural. We would be interested in your recommendations on that. But I think they'd be -- that's not going to be something that (inaudible). There was a lot of interest in the record on what services and whether we should define services and functionality, what options -- specify what services we want or you could sort of leave it to the health care provider to pick each possibility and the definition. There's a lot on the record on that, but we'd probably interested in hearing from you on that. The issue of the discount methodology and how the subsidy will work, again, very interesting comments. But I think that might be a difficult issue for this group to really tackle. The definition of health care provider is something that has -- is sort of up in the air. We've gotten comment on it and, you know, it runs the range. But that -- I think that will be a difficult question. Instruction related to provision of telecommunications services, very important point there's very little in the record on it. That's it. MR. MAXWELL: Let me sort of reinforce a couple of those and maybe add a little bit. For many of you, your expertise is in the provision of this kind of activity and you're doers of it. And to the extent that you help us understand what's working and what's not working, where the pay-offs are, that I think is very important and can be enormously helpful to us. That goes not only in terms of the kinds of services, but the kinds of difficulties you face with respect to obtaining telecom services; differentials in cost, questions of interoperability and standards all are issues which I think can be helpful to us. As Jeanine said, the training issues and the related issues to that are under-explored in the record for our purposes. And we have an opportunity because of the way the law is written to think more creatively about that than we have in the past. I think the -- what -- what we need to try to do is to get -- get a foundation -- well, a starting point so we get the starting point right. And we can then talk about how this evolves gracefully. And to the extent that you have thoughts about that, what you would do today without believing that sort of the world is going to be sort of an Internet-ready sort of convergent, multi-media world of five years. What are we talking about now for use? And then what we think about how this evolves and where we would like it to evolve and, therefore, what we might do to help an evolution that you think is positive or things that you think would be helpful because not -- we haven't talked very much about either of these kind of two poles; the kind of what happens when you've got a party line situation and you can't do things, as well as what you would like to have out of the -- out of the process in five years. Because as we've said before, this is going to be an evolving process, not one that's fixed in time. MS. CONNORS: I guess I just wanted to -- because you brought that up again about what works and what doesn't work. And I wanted to make this point this morning and didn't have an opportunity. But about a year ago, we went to Garden City, Kansas which is the southwestern part of Kansas to take Internet, our graduate full courses on the Internet for nurse practitioner students in that area. In order to do that, there was no Internet provider in Garden City. So we ended up being -- the University of Kansas Medical Center ended up being the Internet provider. We had to first go to the state and ask them to extend lines to Garden City because there was no point of presence in that area. So we had to set up that. We went to the hospital out there and talked with them about what -- what they had and how we could work with them. And we bought a router and put it in the hospital in Garden City. Garden City had bought a CODEX. They had money to buy a CODEX because that was part -- we were going to use the Internet and we're going to need a CODEX, also. They paid for the T1 line. And I think we -- we maybe bought the multiplexer for them. But they paid for the T1 line to the medical center. They put in the 800 number so that our students in that area could dial in through the hospital to the 800 number. And they provided technical support. Now, it was a win-win for everybody although we still had problems with it. It was a win for us because we were able to take our courses there to students. It's a win for the hospital because now they had a CODEX system (phonetic). They could connect with the medical center. They could connect with smaller hospitals around the medical center. They are putting in computers now that our students will be able to go to the hospital and have access on those computers. And they also will be able to connect to the medical center to our backbone and get Internet access through us. So it ended up being a community project, but not without its problems because there's a real learning curve there. The people there did not -- the students as well as some of the staff at the hospital did not understand. They don't even understand computers. One student had never turned a computer on. And we bought notebook computers and loaned them to all configured just like ours so it would be very simple. But we needed to supply the technical support there at the hospital, too. So their hospital staff and network specialist, when something happens with the computers, and it does frequently -- we're again starting the third semester anyway -- the students have to bring them in there and get them -- get him to work on them more or they have to ship them back. But I think that the technology is only going to get better. And I think in the long run, this has brought something to that community that wasn't there before. And I don't know if that's a kind of case scenario of what you're looking for. MR. MAXWELL: Again, sort of, as we aggregate the experience of people around here, other people can sort of comment on the record about the work that's being done on the federal level to try to get all of the federally funded projects to do an evaluation and that -- we start to build up something which is still in kind of an infinite stage as to where there's most important point of intervention. And that's what we're trying to make sure, that we don't -- that we don't stumble in this and that we really can provide. It may be baby steps at the first. But if we get the -- if we get the sort of directionally correct and if we do it in a way that can evolve, then I think we've made an enormous contribution. And you need to help us in that because we're -- we're -- you know, we could tell you what the bit rates are. You could tell us whoever -- what the doctor/patient, doctor/doctor relationship needs to be like and how it's facilitated because that's stuff that we don't know. MR. LAWLER: Any other comments? MR. SONNENSTRAHL: Al Sonnenstrahl. One more. I don't know if this is the right group to define this, the word, "rural". If so, who will be doing that? MR. LAWLER: Well, the -- I can answer what we've done so far. And this at least seems logical to me. But the -- the rural -- that was I think, Jim, your first -- your first question of the rural subgroup, what is rural. And I'm not the expert on that subject. But you had three or four different options which you laid out. And I think - - well, I won't say you expressed a preference, but you suggested there was one that was fairly well-developed. MR. BRICK: Right. MR. SONNENSTRAHL: So that group would be the one who is developing the definition of rural? MR. LAWLER: I think it's fair to say that's probably a logical prediction. MR. BRICK: Yes, that's fair to say. MR. TANGALOS: Let's get that -- and my apologies for coming late, but I couldn't get out of Rochester last night. I had other responsibilities. Are you going to redefine rural or use one of the defined definitions that's already out there? MR. BRICK: I think we will probably use one that's already there and not reinvent a wheel. MR. MAXWELL: There are, as Jeanine said, a number of contributions in the record already to try to define what rural is. And I think one of the useful contributions that have been made this morning is that we are thinking about this whole universal service issue as a kind of multi- layered activity with one part of it under the act being designed for rural, high cost, low income insular support which is one piece of the act. This piece of the act that we're worried about collectively here is for rural health providers. So there's going to be an overlap in this activity. And we will try to make sure that we recognize how these two things interact and the differences and similarities that exist. MR. SONNENSTRAHL: I hope you are sure to include people with disabilities as part of the insular -- as part of rural -- part of the rural program. MR. LAWLER: The -- okay, well we are done. We will have a -- the subgroup leaders will try to put that outline together and off we'll go. And thank you for your work in advance. See you in September. (Whereupon, at 3:35 p.m on Thursday, July 11, 1996, the hearing adjourned.) // // // // // // // // // // // // // // // // // // // // REPORTER'S CERTIFICATE FCC DOCKET NO.: CASE TITLE: TELECOMMUNICATIONS AND HEALTH CARE ADVISORY COMMITTEE MEETING HEARING DATE: July 11, 1996 LOCATION: Washington, D. C. I hereby certify that the proceedings and evidence are contained fully and accurately on the tapes and notes reported by me at the hearing in the above case before the Federal Communications Commission. Date: 07/11/96 _____________________________ Official Reporter Heritage Reporting Corporation 1220 "L" Street, N.W. Washington, D.C. 20005 Bonnie Niemann TRANSCRIBER'S CERTIFICATE I hereby certify that the proceedings and evidence were fully and accurately transcribed from the tapes and notes provided by the above named reporter in the above case before the Federal Communications Commission. Date: 07/15/96 ______________________________ Official Transcriber Heritage Reporting Corporation Bonnie Niemann PROOFREADER'S CERTIFICATE I hereby certify that the transcript of the proceedings and evidence in the above referenced case that was held before the Federal Communications Commission was proofread on the date specified below. Date: 07/19/96 ______________________________ Official Proofreader Heritage Reporting Corporation Barbara Blossom