FEDERAL COMMUNICATIONS COMMISSION TELEMEDICAL ADVISORY COMMITTEE Pages: 1 through 113 Place: Washington, D. C. Date: June 12, 1996 FEDERAL COMMUNICATIONS COMMISSION TELEMEDICAL ADVISORY COMMITTEE June 12, 1996 RUSSELL SENATE OFFICE BUILDING ROOM 385 WASHINGTON, D.C. APPEARANCES: GREG LAWLER, ESQUIRE Chairman (301) 654-9737 (301) 907-8212 (fax) BILL BAILEY Director, Regulatory and External Administration Southwestern Bell Telephone (314) 247-2565 (314) 247-1280 (fax) RON BOTTS Grants Specialist, Policy Office Brown Medical Institute JAMES BRICK Founder, Mountaineer Doctor Television (304) 293-2084 (304) 293-8824 (fax) CATHY BROWN Associate Administrator for the Office of Policy Analysis and Development NTIA Department of Commerce (202) 432-1880 (202) 432-6173 (fax) APPEARANCES: (Continued) NARCISO CANO President and Owner, Distributed Communications Corporation (210) 731-6601 (210) 731-6606 (fax) CANDY CASTLES Director of External Affairs, AT&T Wireless Services, Inc. (202) 828-8407 HELEN R. CONNERS, RN, FAAN Associate Dean of Academic Affairs and Associate Professor, PhD University of Kansas School of Nursing (913) 588-1614 (913) 588-1660 (fax) STEVE COTTON Director of Programming and Marketing Development Texas Tech. University (806) 743-1500 (806) 743-2233 (fax) MARY JO DEERING, PHD Director, Health Communication, Office of Disease Prevention and Health Promotion HHS (202) 401-6295 (202) 401-6295 or (202) 205-9478 (fax) JUDY DEMERS, RN Associate Dean of Student Affairs and Admissions University of North Dakota School of Medicine Honorable State Senator of North Dakota (701) 777-4221 (701) 777-4942 (fax) CHARLES DOUGHERTY, PHD VP for Academic Affairs Creighton University, Nebraska (402) 280-2772 (402) 280-5762 (fax) APPEARANCES: (Continued) WILLIAM ENGLAND Office of Research Demonstration HCFA (410) 786-0542 (410) 786-5534 (fax) ROGER GUARD Director, University of Cincinnati Medical Center Libraries (513) 558-5656 (513) 558-2682 (fax) FRANK LYMAN EthiconEndo CHARLE F. HOLUM Doherty, Rumble & Butler (303) 572-6200 (303) 572-6203 (fax) MICHAEL G. KIENZLE, MD Van Buren County Hospital, Iowa (319) 353-5637 (319) 335-8318 (fax) JOAN KING National Legislative Council of AARP JOSEPH C. KVEDAR, MD Professor, Harvard Medical School (617) 726-4477 (617) 726-4453 (fax) ART LIFSON VP for Health Policy, CIGNA (202) 296-7174 (202) 296-2521 (fax) MARY JO MACLAUGHLAN Director of Regional Information Bangor Hospital (207) 973-7046 (207) 973-8995 (fax) APPEARANCES: (Continued) ELLIOT MAXWELL Deputy Chief, Office of Plans and Policy FCC BOB PILLAR Director of Public Utility Law Project, NY 39 Columbia Street Albany, NY 12207 (518) 449-3375, ext. 19 (518) 449-1769 (fax) JAMES POTTER American College of Radiology DENA PUSKIN Chair, Federal Joint Working Group on Telemedicine HHS Office of Rural Health Policy (301) 443-0835 (301) 443-7320 (fax) LYGEIA RICCIARDI Office of Plans and Policy FCC GONZALO SANCHEZ, MD President, Neurology Associates Chief of Neurology and Neurosurgery Sioux Valley Hospital (605) 335-8470 (605) 335-1489 (fax) JAY SANDERS, MD President, American Telemedicine Association Professor of Medicine & Surgery Medical College of Georgia (706) 721-6616 (706) 721-7270 (fax) AL SONNESTRAHL President, Consumer Action Network Telecommunications Deaf Inc. 1-800-735-2258 then dial (301) 552-2110 (301) 552-552-1337 (fax) APPEARANCES: (Continued) THOMAS R. SPACEK Executive Director, National Information Infrastructure Initiative Bellcore (201) 829-3990 (201) 829-4325 (fax) spacek@bellcore.com (e-mail) EUGENE SULLIVAN Professor of Neurosurgery, University of Virginia (804) 243-0303 (804) 243-0332 (fax) ERIC G. TANGELOS, MD Mayo Clinic Institute of Medicine's Committee to Evaluate Telemedicine Applications (507) 284-5126 (507) 284-7811 (pager) DOUG TINDALL UT-Houston REED TUCKSON, MD President, Charles Drew University of Medicine and Science (213) 563-4987 (213) 563-5987 (fax) CYNTHIA TRUTANIC, ESQUIRE Consultant, Health Care and Telecommunications Health Information Applications Working Group of Committee on Applications and Technology of the Information Infrastructure Task Force (202) 456-6640 (202) 456-6298 (fax) ROBERT WATERS, ESQUIRE Arent Fox Creator, World Wide Web legal reference site on Telecommunications and Health Care (202) 857-6000 (202) 857-6395 (fax) APPEARANCES: (Continued) WILLIAM WELCH President, Nevada Rural Hospital Project (702) 827-4770 (702) 827-0190 (fax) BRIG. GENERAL ZAJTCHUK Commander, US Army Medical Research Development Acquisitions and Logistics Command, DOD Russ, MD (301) 619-7613 (301) 619-2982 (fax) PAUL ZIMNIK Medical Records & Materiel Command (301) 619-7928 P R O C E E D I N G S MR. LAWLER: Hello, and welcome. My name is Greg Lawler, and I am the chair of the Advisory Committee. I welcome you all here to the Advisory Committee for what I think is a very interesting and exciting opportunity to participate in a public policy discussion about where telemedicine is going and to assist the Federal Communications Commission in that effort. What I'd like to do just to start -- we have a lot of people here, some I've met, some I've not met -- is just go around the room, introduce yourself, say where you're from, say anything you want about yourself, professional or perhaps personal, if you'd care, so we begin to put names with faces. One rule to start -- and we'll talk about more rules later -- but one rule to start, we do have interpreters here; so whenever anyone speaks throughout the day, if you would first identify yourself so they can identify you. I think that will help the court reporter also who isn't familiar with all of us, and we don't have name tags in front of us. I will start. I am Greg Lawler. I am a lawyer in private practice here in Washington; have been in private practice for about a year, year and a half; have worked on healthcare, first in the White House for two years; before that worked for the Governor of New Jersey in New Jersey; and then worked for many years on the House Commerce Committee. I'm looking forward to our opportunity for the intersection of telecommunications and healthcare and what advice we can provide to the FCC. Elliot, why don't we start next with you. MR. MAXWELL: I'm Elliot Maxwell. I'm Deputy Chief of the Office of Plans and Policy at the FCC. And I'm working with Greg and with the Advisory Committee and the other parts of the FCC to try to make the act requirements about telemedicine come to life and to try to help the FCC understand where this burgeoning area is going. I am just delighted to see all of you here and to welcome you. MR. HOLUM: I'm Chuck Holum. I'm a lawyer from Denver, Colorado, where I work on a number of different rural issues and rural groups, including some rural health groups, many of whom are very curious what will happen in this room. MR. SULLIVAN: Good morning. Gene Sullivan. I'm at the University of Virginia. I am the Director of the Office of Telemedicine at the Medical Center. MR. DOUGHERTY: I'm Charlie Dougherty, Academic Vice President of Creighton University in Omaha; former Director of Creighton's Center for Health Policy and Ethics; and my academic field is medical evidence. MR. TANGELOS: I'm Eric Tangelos, a physician at Mayo Clinic; and over the years, I have been involved with most of the aspects of our telemedicine programs. MS. DEMERS: I'm Judy DeMers. I'm from the University North Dakota. I'm Associate Dean for the School of Medicine there. I'm also a State Senator in North Dakota serving my 14th year. MR. SANDERS: I'm Jay Sanders. I am a physician. I was formally the Director of the Telemedicine Center at the Medical College of Georgia. I will be with the Medical College of Georgia for another two weeks, at which point I'm moving to Washington D.C. I'm also President of the American Telemedicine Association. MR. KVEDAR: Joseph Kvedar from Partners HealthCare Systems, Inc., the company that is the merger of the Massachusetts General Hospital and the Bingham Women's Hospital in Boston. My role there is Director of the Telemedicine and Remote Education. MR. SANCHEZ: I'm Gonzalo Sanchez. I'm a neurosurgeon in Sioux Falls, South Dakota. I'm involved in the telemedicine and education aspects. MR. BARR: Rick Barr, Executive Vice President MEDCO International, McLean, Virginia. We operate remote diagnostic centers for rural communities. MS. MACLAUGHLAN: I'm Mary Jo MacLaughlan, Eastern Main Healthcare, in Bangor, Maine. I'm the Director of Telemedicine for the Northern New England Telemedicine System. MR. CANO: Narciso Cano, San Antonio, Texas. Owner of Distributed Communications Corporation, which is an Internet service provider and provider of digital circuits. MS. KING: I'm Joan King. I'm representing AARP. I'm a member of the National Legislative Council of AARP's, which is an advisory board. I'm a policymaker, and I Chair the Consumer Committee. My background is in hospital medical social work. MR. LEWIS: Michael Lewis. And I'm with MCI. I work in public policy with MCI. MR. KEMPLER: I work in FCC Affairs. MS. KARY: Margaret Kary, physician from Denver, Colorado. I'm currently representing a six-state area and happen to be outside the Beltway for a couple of issues: One is telemedicine and telehealth; and the other one is American Indian issues for the Department of Health and Human Services. MR. ENGLAND: I'm Bill England with the Health Care Finance Administration, Office of Research. I'm an electrical engineer and a lawyer. And I run HCFA's telemedicine demonstration, which will be starting this fall. MR. WELCH: Bill Welch, President of the Nevada Rural Hospital Project, a 12 hospital-consortium. We have a teleradiology program. We also have telemedicine and a nursing for program. MS. MADISON: I'm Cathy Madison. I'm with AT&T Wireless Services. I'm the Vice President for External Affairs. I'm sitting in today for Candy Castles who is our Director of External Affairs. MR. BRICK: I'm Jim Brick from West Virginia University. I'm our Medical Director for our Telemedicine Program, and I'm also a physician. MR. BAILEY: I'm Bill Bailey. I'm with Southwestern Bell Telephone Company, St. Louis. MR. SONNESTRAHL: Hello. My name is Al Sonnestrahl. I'm another person who has a hearing problem other than the court reporter. Before I was Director of Telecommunications for the Deaf, we developed Title IV in the Americans With Disabilities Act, and that led to implementing relay services all over the country. We also developed a language in Title II in the Americans With Disabilities Act that required all emergency service centers to have access to TTY telecommunications in systems for deaf people who use text telephones. I'm now Chair of Consumer Action Network for deaf and hard of hearing people. And I'm here to make sure that everything is accessible to people with hearing impairments and hearing people with disabilities as well. MR. MARINE: I'm Steve Marine from the University of Cincinnati Medical Center. I'm here for Roger Guard. He couldn't make it today but sends his regards. I'm involved in a number of clinical telemedicine programs and distance learning programs. MR. TINDALL: Hello. I'm Doug Tindall. I am trying to act as much as I can without the accent as Red Duke would if he were here. We have a multi-facted research proposal and project underway that had a demonstration last year with a pilot project -- hopefully it will kick off in 1997 -- that takes a look at what can we do within a medical center to help support EMS units in far, rural areas and in suburban rural areas. And that's the focus of what we are working on. Dr. Duke does sends his regrets. He very much wants to be here and is definitely honored and excited to be working on this committee. MR. SPACEK: I'm Tom Spacek from Bellcore in New Jersey. I'm responsible for the business/market/policy/technology issues associated with making the national and global information infrastructure a reality. I'm personally interested in those situations where market forces will not create the incentives for private sector investment in particular applications and interconnections and networks. MR. PILLAR: I'm Bob Pillar. I'm the Executive Director of the Public Utility Law Project in New York State. We're an intervener group that represents the interests of low-income consumers in utility and energy issues. We're here on behalf of the National Association of State Utility Consumer Advocates. In addition to that, I serve as the Vice Chair of the Diffusion Fund in New York State which is a group that's come together as a byproduct of a piece of the settlement of the last NYNEX rate case in New York State where a fund was created to allocate $50 million over a five-year program for advanced telecommunications projects in economically disadvantaged areas. A number of those proposals include rural, health-related advanced telecommunications projects. MS. TRUTANIC: My name is Cynthia Trutanic. I'm a lawyer with a background in telecommunications and in mental health. I have been working in this area for -- doing special projects in telemedicine and mental health for Tipper Gore. And I also was in the telecommunications business as an entrepreneur in the early '80s during the first deregulations. MR. ZIMNIK: My name is Paul Zimnik. I'm here representing General Russ Zajtchuk and the Department of Defense Telemedicine Test Bed. I'm a physician and manage several of the ongoing telemedicine projects in the Department of Defense. MS. DEERING: I'm Mary Jo Deering in the Department of Health and Human Services. I'm the Director of Health Communications and Telehealth in the Office of Disease Prevention and Health Promotion. We are very concerned with the non-healthcare services aspects of the telecommunications in health, which includes direct-to-consumers, into the home, and work sites and other settings, and also those applications which would be relevant for broader public health, what we call population-based health. MR. LIFSON: I'm Art Lifson. I'm with CIGNA. I represent them with regards to health policy and telemedicine. Telemedicine, obviously, is one of the great potentials of the future. MS. RICCIARDI: I'm Lygeia Ricciardi. I'm with the Federal Communications Commission in the Office of Plans and Policy. I've been working on implementing the universal service, parts of the Telecom Act of 1996. I've spoken with most of you on the phone, and I'm very glad to see you in person. Thanks For coming. MS. CHEW: I'm Patricia Chew. I'm with the FCC's Office of Public Affairs. I am your liaison person with that office, so I need to make sure I have everybody's fax numbers and phone numbers. And if you need anything, just call us. We are glad to serve you. MR. LAWLER: Did we get everybody over -- no. We have more. MR. WATERS: My name is Bob Waters. I'm an attorney and a partner in the health group of Arent Fox. We serve as counsel to the Center Telemedicine Law. We are particularly interested in areas where there are barriers to access for health access -- MR. POTTER: My name is Jim Potter. I'm with the American College of Radiology. I'm here representing Dr. George Kamp who regrets that, because of his schedule, he couldn't make this meeting. The American College of Radiology, with the National (inaudible) Manufacturers Association, over 12 years ago, developed an ACR NIMA standard for electronic transmission of data that has now been transformed to what is called the DIMCOM standard, the Digital Imaging Medical Communications Standards, which is about, yea thick (indicating), and represents the body of standards that are very flexible and that help implement current standards among the manufacturers to date. In fact, one example I have is where I guess a number of systems for the Bosnian theater for medical imaging were developed in less than four months due to the DIMCOM standard. Without that standard, it was estimated it would have taken two to three years to develop that medical imaging. The American College of Radiology also has a practice standard on teleradiology for its member practitioners. Thank you. MS. BROWN: Good morning. I'm Cathy Brown. I am with NTIA, which is the National Telecommunications and Information Administration, in the Department of Commerce. We advise the President, Vice President, and Secretary of Commerce on telecommunications matters. The administration has been very involved in the universal service issues with respect to this bill. And I am very pleased that we are here at the table with you. MR. SHORT: I'm Brad Short with the American College of Radiology. I'm an observer today. MS. SHIVER: Nancy Shiver with the American College of Nurse Practitioners. Also an observer today. MS. TICHNER: I'm Susie Tichner with the Council on Competitive Investment. Observer. MR. PLISKO: I'm Harry Plisko with the Ball Institute. And I'm an observer. MS. BRENNER: I'm Irene Brenner. I'm an attorney at the FCC. And I too am working on the Universal Service Provision of the telecom act. MR. LYMAN: Good morning. I'm Frank Lyman, Vice President of Professional Education at Ethicon Endosurgery, a Johnson & Johnson company. I'm sitting in today for Bill Hawkins, our President. He sends his regrets that he could not make it. Ethicon Endosurgery is a medical device company. We've primarily been using this technology for educational purposes at Johnson & Johnson. We are very excited about the future of this technology. MR. BOTTS: And I'm lost. I'm Ron Botts. I'm a grants specialist at Brown Medical Institute working in our policy office. MS. NELSON: I'm Thayer Nelson. I'm a healthcare consultant working with the Managed Care Options in Bethesda. And I work with Greg Lawler. If you need anything, I'm a lot easier to get in touch with than Greg. MS. JANES: I'm Laurie Janes with GCI in Alaska. I'm an observer today. MR. LAWLER: Let me just start by describing what we're going to do today so everybody can get a sense of what our schedule is. We are here in the Senate Office Building because there is a meeting today of the Congressional Ad Hoc Steering Committee on Telemedicine and Health Care Informatics. And they have a demonstration that starts at 2 o'clock, as I think you have probably all seen in the information that was sent to you. So we are going to meet from now until we break up, with time for lunch, and then go to the demonstration. At 3 o'clock, there is a press conference with -- I believe, there are several Senators coming, including Senators Snowe and Rockefeller and Chairman Hunt. MS. RICCIARDI: Senators, also, Exon, Pressler, and Conrad. MR. LAWLER: And I think Commissioners Ness and Chong also will be there. What I'd like to try to do first is just describe, to the extent that I can, why we're here, what I think our mission is, and the short time frame, frankly, that we have to accomplish it, because we do have a very short time frame. Everybody knows that telemedicine is a great subject that people are interested in because it is, in a sense, an unknown. It's something out there that looks like we can make a tremendous amount of progress, both in healthcare and in the telecommunications industry as a way to deliver better healthcare, reduce costs, and make money from it in some cases. Senators Snowe and Rockefeller, as you know, have a provision in the telecom bill that talks about rural healthcare and requires the FCC to implement it in a -- I forget what the final date is -- but in a fairly short time frame. Elliot and Lygeia can describe what the FCC specifically is doing on that. I know there is a joint board. They have another meeting sometime in July. They are specifically looking at this issue. Our role, as I see it -- and I really would like this to be a discussion. If there are things that we are leaving out or that are over-inclusive, people can feel free to speak their mind. We want to make this a real meeting and have a discussion about it. We have been arbitrary in some senses because of the time frame and tried to arrange things, tried to group things, simply to get going on this because of the short time frame. We have planned a meeting in July. We have planned another meeting in September. And then we have a report to the FCC which is due before the end of the month in September, which frankly, given the summer schedules that people generally have, is not a heck of a lot of time to produce. We have tried to look at telemedicine in a specific way and also in a general way. We want to provide whatever advice we can to the joint board to the FCC on the telecom bill, on the rural health provision that is in the telecom bill. But we don't want to restrict it only to that. What we want to do is look at where telemedicine is, where it's going, look at this from the communications perspective. A lot of people here have backgrounds in healthcare as well as in telemedicine. There are a lot of discussions going on, if I can call them that, on the healthcare side about reimbursement, about licensing, about all kinds of things. That's what we're not -- we're not here to discuss those things. We're here to the look at the telecommunications part of this. I mean, put yourselves in the shoes of the FCC. They're making enormously important decisions about the shape of our telecommunications system literally for the next several decades. And those decisions are going to be made in the next months and year. This is our opportunity, as I view it, to say: Look, there's another perspective on this that you just have to keep in your mind if you do this. There is a telemedicine aspect of this. We're not going to be able to predict precisely where it's going, but we know it's going somewhere. I think it's going somewhere very important. You know, we could create an office pool here to -- everybody put in a buck to say where it's going to be in 10 years, and we probably would all be wrong. But I think, at least from the number of people that I've talked to, that everybody believes, in the next decade, that it's going to be a very, very significant part of our healthcare system; it's going to be a very significant part of our telecommunications system; and that means it's going to be part of our insurance reimbursement system for healthcare; medicare is already in the middle of it. You know, there's just so many aspects of this that it's almost difficult to get your mind around it at one time. What we have done -- and I'll talk it about it more, but you may just want to -- if you haven't gone through the packet, we actually have two things in there that we can talk about. It's this sheet that looks like this, which is a breakdown of subgroups, which we can discuss. And then there is an arbitrary dictatorial breakout of people in the subgroups with a Chair for each one. We haven't had a lot of time to talk to the chairs. I think and hope everybody is willing to do it; but we may have somebody who says, you know, I've got a big business deal coming up or I've got a big report due, and I can't do it. So that really is a discussion we need to have. At this point, why don't I turn it over to Elliot Maxwell from the FCC who can talk about this from the FCC's perspective, and then Lygeia can say a few words. Elliot. MR. MAXWELL: For someone who comes from the telecom side and who's worked in this area for most of my professional life, it really is a privilege to look around the table and see an extraordinary group of people working in an area which looks to be on the point of taking off and a group of people who can really provide us with the expertise and the insight so that at least on the telecom side, from the regulatory side, we don't do anything that inhibits the development of this area and, in fact, we do things that provide a foundation for it, to grow and to kind of take its rightful place in healthcare. We look to you for expertise and advise. I mean, that's what we're all here for. And we really look to you for work because we don't know this area. And the processes that we have, that are common in the regulatory world, really are processes that generally involve the providers of telecommunications. What we wanted to do is to kind of make sure that we could bring around the table people from the provider side but more importantly people who have a vision of where this area is going; what it needs to succeed; where we may be standing in the way; or where we, through the universal service provisions of the telecom act, can help provide the monetary incentives, as much is necessary, to ensure access to these services throughout the country and which would not be available if markets simply went as they currently exits. I'm going to turn it over to Lygeia who can give you background about what the provisions of the Telecommunications Act of 1996 say and what we're trying to accomplish. But, once again, let me thank you all for participating. It's both short notice, heavy lifting; but the possibility, I think, exists for our doing something that, in 30 years, you can look back and say, I was there, and I helped make this thing work. And our children and our children's children will benefit from it. MS. RICCIARDI: You people are here for a couple of different reasons. One is, as Elliot mentioned, you're all experts in your field, be it healthcare or telecommunications or some combination of the two. And we need to benefit from your expertise. Another important reason that you're here is that on February 8th, President Clinton signed the Telecommunications Act of 1996. This really is a revolution piece of legislation because it totally changed communications policy for the first time in about 62 years. Regulation of the communications field used to be based on the monopoly model. And now all regulation is going to move toward engendering competition. So that's a new direction we're taking in policy. While we are growing this competition, the act also keeps in it very important provisions that help to assure that public benefits from that competition can be realized. Among the most important of those public benefits is the idea that all Americans should have access to communication services. There's a part of the act which we have been talking about, the Universal Service Provision, that helps assure that access to everyone. And the Universal Service Provision has several broad principles that its based on. One of those is that advanced services should be made available to all schools, libraries, and healthcare providers. That's Section 254. And that part of the telecommunications act is in your folders, as is Section 706 which talks about the advanced deployment of telecommunications services. Now, this is a very complicated process of implementation at the FCC. Because this is more intricate than a lot of the other proceedings that we work on, the act commanded us to put together a federal-state joint board which is going to help us specifically on our Universal Service Proceeding. The joint board members are: Chairman Hunt, Commissioner Ness, Commissioner Chong from the FCC. You'll be meeting those three later on today. The state Commissioners Ken McClure from Missouri, Sharon Nelson from Washington, Julia Johnson from Florida, and Laska Schoenfelder from South Dakota. There's also a state utility consumer advocate, Martha Hogerty who's from the State of Missouri. Now, also we have a joint board staff which is made up of both FCC staff and state staff. Irene is a member of that staff, and she's helping us to do some of the heavy lifting in terms of reading and analyzing public comments that went out. We issued something called a "Notice of Proposed Rule-making," which broke down pieces of the act that apply to universal service and asked questions about them. We then received comments and reply comments on those issues. That Notice of Proposed Rule-making is also in your folder. The reason that we're here on such short notice is that we have a very short time frame in which to work on these issues. We need to produce our report -- which will help the joint board and the FCC -- by September because, by November 8th, the joint board needs to make a recommendation on universal service to the FCC. And the FCC must then write some rules by next March 8th. So that's why everything is happening so quickly here. And we appreciate you're being able to jump in and help us out at such short notice and under such pressure. MR. LAWLER: Thank you both. MR. MAXWELL: It may be because it's very easy for us to fall into sort of "teleco" speak or "regulatory" speak, and sometimes, even in legislation it's not so wonderfully clear, but let me just sort of ask you to kind of open up -- or if you want not open and have me read -- to this piece which is headed "Communications Act of '94," which is in the folders. And if you look in there, you will see a provision that says: "Telecommunication services for certain providers," Section 254. And just to make clear what we're focused on, it says: "Telecommunications carriers shall, upon receiving a bona fide request, provide telecommunications service which are necessary for the provision of healthcare services in a state, including instruction relating to such services, to any public or non-profit healthcare provider that serves person who reside in rural areas in that state at rates that are reasonably comparable to rate structures of similar services in urban areas." And it's a remarkable provision in the sense that the society is saying that we will provide a mechanism to allow for users as a whole to ensure that people have access to those services at reasonably comparable rates and to direct it at healthcare in ways that has not taken place in the past. And so we're trying to understand and to work with you not only in the question of what this provision means but in the larger set of questions, how can we encourage an environment in which people have access to services not necessarily subsidized but through the operation of the marketplace? So this is a very big job and a very big task that the Congress has set for us. And because there will be funding mechanisms, we have an opportunity to intervene, because of a social decision, but we also have a chance to set a framework so that the market can drive these activities as well. So I just wanted to point you to what our charter is and to let you know how important this is, because it's going to affect the flow of millions and probably billions of dollars and, of course, that benefits a part of society that might not otherwise have access to these things. And we really do need your help. MR. SONNESTRAHL: Excuse me. I only have one pair of eyes. It's hard for me to read and watch the speaker sometimes. Do you mind giving me or telling us which part of this section you're talking about? 254? Or where are you quoting from exactly? MR. MAXWELL: I'm quoting from 254(h)(1). It's page 96 in this handout which is set horizontally, and the page number is found in the upper right-hand corner. MR. SONNESTRAHL: I've got it. Thanks. Thank you. MR. LAWLER: If any -- Eric? MR. TANGELOS: Yeah, I do have a question. We are appointed by FCC, at least that's how the announcements went. The joint boards seem to have a lot of responsibility to the FCC, and it really seems to be where our report is going to end up. There's also been a lot of proposed rule-making that's out there. There's a lot of information that you've already seen. A lot of deadlines have already ended. So where do we fit in between now and September? Who do we report to? Why us now, with proposed rule-making in place? Just so we get an idea of what our role is as we complete our tasks. MR. MAXWELL: We had to kick off, because of the time requirements in the act, the universal service proceeding like any other FCC proceeding governed by the Administrative Procedure Act. There have been comments upon the questions that we asked -- and the questions are included in your folders -- and reply comments. What we have gotten so far takes us some way in our understanding of this field. But I think it would be fair to say that, without further comment and further information, it would be very hard for us to meet the requirements of the act and to really specify the kinds of services or functionality, the kinds of price supports that are necessary. And the way we anticipate this occurring is this is a body that will advise the FCC. The report that it makes will go into the file of comments for the universal service proceeding. They will be opening it to comments by others, by the public in general to say: That's a good idea. That's a bad idea. No, what about this? What about that? The joint board, then, will take the report and the other comments that are made before and after that, consider them, and then make a report to the FCC saying what the joint board, the state and federal regulatory members, say should happen. Then, next spring, the FCC will adopt its findings on universal service based on the joint board recommendations and any subsequent information. So that's one role for this committee. The second role -- and I don't want to minimize this -- is that, as a regulator, I am sure, as God made little green apples, that there are things that we do or don't do that get in the way of the development of this field. And what I would like the committee to feel comfortable in is to say: Well, we understand this universal service requirement and we will bend our backs to get what you need to make good judgments about this for the country; but we will also look at what you do or don't do in equipment authorization, in how companies offer services or price services, how you do the geographical relationship between states, and the federal jurisdictions for services. All of these things may have an impact, and we would like to identify those things to get regulatory underbrush cleared away to make this field flourish. So I think there are two parts. The universal service is the most obvious, nearest term, with the largest dollar amount attached to it and one which I think all of us, not only as practitioners but as citizens, have a real stake in. The other is: Can we do things as a commission, as a regulatory agency, that make more sense for the field? MR. LAWLER: Just to add on to that, it is clear we have a role with respect to this specific provision in the telecom law. And it's my view of this that you can't really act responsibly as a commission on that unless you have some concept of where the whole field is going. So it is part and parcel of the same overall -- MR. TANGELOS: But if the proposed rule-making comments had been incredibly rich and full, there would probably be no reason for us to be here? MR. MAXWELL: No. Reason two -- I mean, the second piece of that would have existed regardless of the rule-making. We need to look for expertise beyond our own field because you are users, you are takers of an input; you are people who understand that it will make some difference whether you have this facility available or whether there's something in the rules that discourage people from doing that. MR. LAWLER: Mary Jo? MS. DEERING: As you've said, we really are working here on something that will be in place for decades yet to come. And I'm wondering if there's been any thought to helping us start off, from a common foundation, of a vision of what healthcare is likely to be at that time. We need only read the newspapers to know how rapidly it's reinventing itself right now. And I think of an excellent presentation by Admiral Bill Rowley who heads the Defense Department's "Health Systems 2020" project and who would tell us all here today that it is certainly evolving, as we already know, away from hospitals to clinics and away from clinics to homebound care. And so if we make decisions here based on the structure that we have known, we will be in grave error because the likelihood is that an increasing amount of care will not be delivered in clinics or what we consider healthcare facilities now, and a lot will be delivered in homes. MR. LAWLER: Right. From my healthcare background, I certainly agree with that. I think predicting where we are going to be on any of these things 10, 20 years from now is extremely difficult because of the great unknown of the new thing that's out there that will change how we do both healthcare and telecommunications. But I absolutely agree with your statement. MS. DEERING: The Defense Department is investing quite a bit in understanding that structure, and I just thought it might be helpful if we had the benefit of understanding some of those trends as they are perceived by people who are putting a lot of energy into them. MR. LAWLER: Well, certainly I'll take that as a suggestion for our next something. Maybe that's something that -- I don't know, Admiral Rowley? Is that his name? -- but maybe that's something we could arrange for the next meeting. MR. ZIMNIK: I'm Paul Zimnik with the Department of Defense, and I'm on the steering committee for H.S. 2020 for Admiral Rowley. I would certainly endorse that comment. We in the Department of Defense -- as all of you know, because we have worked in partnership with many of you -- have been looking at this field seriously for a long time because we recognize the importance of what we're talking about today to what medicine will be like in the future. And as a foundational step in that effort, what this committee is, this meeting is, H.S. 2020 that we're talking about, gathering a representative group of healthcare, involved people, providers and customers of the healthcare system, from many different aspects of military healthcare systems, and actually our partners who are non-military, and come together to try to define what medicine will be like in the year 2020. Now you can imagine, that is a very involved process. We are about half way through the effort and are trying to formulate our ideas that cover a large range of issues. And I know that we would be thrilled to contribute some of those thoughts to this advisory panel. And I'm sure that Admiral Rowley himself would be very interested in pursuing a collaborative effort, again, to share some of the thoughts and resources that we have brought together on this topic with this commission. MR. LAWLER: Well, let's see if that isn't something we could do for July. I'm sorry. I don't know your name yet. MR. TINDALL: That's okay. I'm Doug Tindall from UT Houston. I'm representing Dr. Duke today. Dr. Duke is partnered with numerous other groups as well, including DoD up in Fort Dietrich, have been looking, as I said before, at telemedicine out in the field. We have three doctors there, along with some people in the School of Public Health and with telemedicine programs at the Medical Center UT that are really already spending a lot of cerebral time thinking about this as well. We are going to be working with the Defense Department at Fort Dietrich, and I know that Dr. Duke would very much like to present some of our thoughts as well in conjunction possibly with Fort Dietrich's presentation. MR. LAWLER: Sure. MR. MAXWELL: You may want to introduce Dena. MR. LAWLER: Oh. Hi. MS. PUSKIN: Hi. I'm sorry I'm late. I just got in from rural America, Durango. Let me tell you, it's hard to get from there to here. Let me just say that I would share much of the comments here about the evolving healthcare system. And I think it's very important that we have a perspective on that, or at least we speak off of the same sheet. I would be very, very concerned that we also have a good picture of where we are now and what some of the issues are and barriers. I just came off of the Navajo Reservation at Shiprock -- and let me tell you, it looks a lot different in Shiprock than it does here -- and what is happening currently, so that when we look at the vision, we have a sense of how to get from here to there, because part of what your charge is, as I understand it, is not to make the final, this is the be-all, end-all, but that this is an evolving process in defining universal service. So I think a very key component of our deliberations is not only where we want to be but how we get there over time with a recognition that there are those with that perspective. So I would also urge that in this process we all have some sense of where we are right now; and I think we probably have different perspectives. MR. LAWLER: Sure. MR. MAXWELL: Dena, you want to introduce yourself? MS. PUSKIN: I'm Dena Puskin. I'm the Chair for the joint working group on telemedicine that is the federal interagency working group on telemedicine that cuts across all federal agencies. And in another hat, I'm Deputy Director of the Office of Rural Health Policy. MS. DeMERS: I'm Judy DeMers from North Dakota. I just want to make sure if we're going to concentrate on where medicine is going to be that we look at rural medicine because I see that as the true charge of this bill; and I think that's very different than what you see in the major medical centers. A lot of us are from rural parts of the country, and we see this as a real opportunity to have access to the same kinds of specialists and quality of services that people in large cities and large medical centers do. I guess I'm a little worried that the DoD study might not be looking at that kind of delivery system. So I guess I'm supporting what you said: I think it's very, very important that we do that and that we not just focus on the theoretical of where medicine is going in general. MR. LAWLER: Chuck? MR. HOLUM: Chuck Holum from Denver. I want to second that comment. We have three meetings, including one that's probably half over now. We're not going to understand the healthcare system in any context in three meetings. That's just a general observation. I guess, getting back to the FCC process, there have already been 200-some comments on the rule-making process. I don't want to repeat all that work either. And I wonder if there's some way that we could get some summary of the comments that have already been made so that we can use that as a starting point? MR. MAXWELL: Absolutely. And we will do that. What I want to caution you is that few of those 200 addressed the rural healthcare issues; and even fewer of those, I think, helped move the ball along some considerable way. So you will it, but it's not something that I think -- MR. HOLUM: Won't take that long to read then. MR. MAXWELL: And it will take less time to understand. When we talked about sort of the these three meetings, I think our expectation is that people will need-be doing homework between those meetings if we are to make the kind of progress that we need. MR. HOLUM: That's why I think some of the written materials would be helpful. MR. LAWLER: Did somebody have their hand up back here? MARGARET CAREY: I want to just go back to something Mary Jo said. Last week, I was talking with another person about putting up a web page that would be accessible to everyone, and we are in the process of doing that. So if that happens, I will let you know. MR. SULLIVAN: Gene Sullivan from the University of Virginia. I think you just beat me to the punch. Paul, you've got a really good web page up at the DoD telemedicine. I think maybe if the Admiral's presentation could be posted there, those that haven't seen it will see that there is quite a bit of correlation to military telemedicine and rural medicine or rural telemedicine, if you will. Don't think of just big installations. Think of small ships with limited duty corpsmen, with maybe a primary care physician on board; and that can very closely replicate rural environments throughout many parts of the United States. MR. LAWLER: Al, did you have a comment? MR. SONNESTRAHL: Thank you. Al Sonnestrahl from Consumer Action Network. When you're speaking about rural medicine, I was wondering what's the definition of "rural." Are you speaking geographically? Or what about minority communities? Low, incidental populations? For example, what about those people who live in a larger community, for example, just that sector of a metropolitan area, who rely heavily on interpreters, sign language interpreters, for communication purposes with their physicians? As a deaf person, are you considering deaf people -- I'm considering myself as rural communities here, because they are isolated in larger metropolitan communities. So if you could just think about the definition that you're using with rural in these proceedings. MR. LAWLER: Cindy? MS. TRUTANIC: I'd just like to sort of underscore the point that's being made here, that there are some regulatory barriers to the implementation of telemedicine in general, whether it be rural or underserved populations in urban areas. And then if we focus on the specific types of telemedicine that we may be limiting ourselves in the process trying to understand what the barriers are and how the new rule-making seems to be enhancing the direction of telemedicine for the next decade or two. MR. LAWLER: Paul? MR. ZIMNIK: Paul Zimnik of the Department of Defense. I would like to address two issues real quick. Number one, we do, in fact, have a large body of information from H.S. 2020 and a variety of our other telemedicine projects that are all available on the Internet at various worldwide web locations. To address your comments, sir, perhaps maybe to help educate what we're doing, between our meetings, I noticed that there is a sign-up sheet, if at some point I could get the e-mail addresses of everyone here, I could certainly have an e-mail sent to you that would give you the addresses of all of these. If there happens to be any areas that right now, for whatever reason, aren't generally available to the public, I'll make them available to you. And I could communicate that by e-mail. And then to address the topic of the rural issues and non-rural access, difficult access areas, we in the DoD are acutely attuned to that. And in fact of late, over the last one or two years, we have been very aggressive in forming partnerships and collaborations with non-DoD groups and have addressed the topic of rural access issues in Alaska, where we're being very aggressive; in the Southwest with some of the Indian Health Service programs that are out there; and we also recognize that there are significant access issues in inter-city-type environments. So access that's difficult for people is not only in rural communities, and we're looking at systems and technologies that can improve that. So that kind of information will also be available. And in the short time frame that we have, I would further promote the concept that we need to be somewhat virtual in our proceedings here. So, again, if I could have -- whoever is collecting the e-mail addresses, I will make sure that people get that information. MS. RICCIARDI: Yeah. Actually, in your folders, you will find a sheet that asks for your name and your title. And please make any corrections on information that we already have on you. And do include your e-mail address and give it, before the end of the day, either to myself or to Thayer Nelson. And we'll be sure that we circulate that information. MR. LIFSON: I have -- this is probably a very naive question. MR. LAWLER: Best kind. MR. LIFSON: Our charge in this is universal access to the transmission of data, or it's not -- I just want to be careful. Are we talking about universal access to the delivery of the healthcare services? Or facilitating, through new methods of transmitting data and creating a more competitive marketplace for the transmission of those data that the delivery of the services will be facilitated whether it's in rural areas or inter-city areas or wherever? But we're not necessarily talking about those services but rather making it possible for those services to be delivered? MR. LAWLER: If I hear what you're saying, we are talking about the telecommunications part of this, not the healthcare part of this. If I catch your drift, we're not talking about the delivery of the healthcare services. That's not the charge of the FCC in any respect. Let me just make a point, and then we have more hands here. In one sense, we have two very different charges here. One is to respond in a fairly detailed way to the rural provision in the telecom bill. And that's something that, you know, we can have opinions on what they mean; we can make recommendations to the FCC about what it should mean. But it's a very specific thing. There's another charge which I think was equally important which is, as Elliot said, regulatory barriers or affirmative things that the FCC can do to encourage telemedicine generally. And it is a much broader charge. In many cases, we have not advanced to a level where we can even identify precisely what that is. There is no one over there pounding on the Commission's door saying: You've set the wrong standard for X; therefore, my system doesn't work. But to me, those are all going to be issues in the not very distant future, and they are things we ought to be thinking about. And we are not going to solve them for ever. Hopefully we can give policy direction advice so that the FCC is thinking about them so Elliot and Lygeia and the Office of Policy are saying: Gee, here's an issue. We need to be thinking about this. In a year, we ought to be doing X. Or we ought to be doing a report to the Congress saying we have incompatible equipment out here and that's silly. We ought to come up with a way to get compatible equipment, whether it's an industry panel or whatever it is to come up with it. So they're very different charges. I happen to think they end up being very -- you know, you end up talking about precisely the same things. But we do have words to respond to in the telecom law which make it a different kind of issue than the others. I think you had your hand up. MR. DOUGHERTY: Charlie Dougherty, Creighton University. I'm trying to put together some of the remarks about rural with minority populations, underserved areas, et cetera. It seems to me the one take on this is that if we're moving in a market-based direction, we all understand the market, on its own, is not going to reach everybody, because that's not the way the market works. And so universal service principles says we have to tweak the market somehow and have to pay attention to all the areas in which the market is not likely to serve the interests of Americans. So if that's a fair global understanding of this, then it seems to me it's not only rural but any place where we think market incentives are not going to bring these services. MR. MAXWELL: I want to be a little bit careful about how we talk about this issue. At one level, I think you're absolutely right, we need to be looking at this in the broadest possible way to see where there are underserved populations. And we would welcome suggestions about how FCC actions affect that and, in particular, how one provides incentives for competition to serve those areas when they might not otherwise do that. At a more narrowly focused way, the act says, with respect to universal service, there will be a funding mechanism to ensure that rural healthcare provision receives funds to provide services that would not otherwise be available. So there is a specific instruction to the Commission that telecommunications providers will provide these and will be reimbursed for these through a fund which we will set up. But that involves definitions of what's rural, what services, what costs are, and what the subsidy mechanism will be. On this larger question, I think we do need to look at that. But there is not a mechanism that says: These customers will, in fact, provide some subsidy to other customers. And if we try to extend that to solve all of the possible problems of underserved communities, A, we would be going beyond our charge; and, B, we might find that the best is the enemy of the good. We would be forever in the possibility of trying to tweak every market to accomplish every purpose. So I think we have to look at this in the two ways you suggest but recognize what we can do in one and what the limits are in the other. MR. LAWLER: Tom, did you have a question? MR. SPACEK: Tom Spacek from Bellcore. With respect to some of the comments about background material and in particular doing homework between meetings, I think one of the best things to read -- at least that I have come across so far, and I've only read part of it -- is a report that the Council on Competitiveness has written on healthcare which talks about current situations and potential markets in the future, especially the chapter on remote healthcare. And Susie Tichner is here from the Council. I don't know if you want to say a little bit about the report or not. MS. TICHNER: Well, we just released this report about six weeks ago. It was a year in preparation, and the tasking that we had was to look at the impact on the national information infrastructure on the healthcare market in the U.S. So we pulled four different areas. One was remote care. One was the use of the infrastructure for delivering personal health information. We looked at what are some of the systems integration challenges. And we also looked at how these tools are being used to foster and encourage collaborative medical research and education. And each section looked at: What's the market today? What does the market potential look like? What are the barriers to achieving that market potential? Whether they be technical, regulatory, policy, cultural, financial. And then a series of recommendations that our advisory committee put together for both the public and the private sector to address some of those barriers. MR. LAWLER: Eric? MR. TANGELOS: More in the way of ground rules again, when I read the act and the pieces that I can understand in the act -- and there's the difference between law and medicine: There's more footnotes in the article when it's done by a lawyer than there is text -- the bail out seems to go back to the states over and over again. When you look where the rights are reserved, it goes to states. And, you know, there's a dichotomy here. We talk about universal access, the universality, and yet we come back to the states. Before, again, we embark on too much, what are the ground rules? What's your read on rights reserved by states? MR. MAXWELL: Let me give you sort of the 30-second history of universal service. What happened over time -- and this is a gross distortion. This is not the FCC's view of this. This is an idiosyncratic, probably wrong, view of the last 35 years in telecommunications in 10 seconds. MR. SANDERS: This is a footnote, right?. MR. MAXWELL: As a lawyer, when doctors criticize legal writings, we won't even talk about handwriting. Over the last several decades, the cost of long-distance telecommunications has gone down because of technical change. The cost of local service has stayed reasonably similar. What's happened is that people have tried to do pricing of services in a way that kept local service down. And so what they did is kind of shovel cost over into the long-distance piece. So what you had is probably prices for long-distance higher than they ought to be, maybe prices for the local service lower than they ought to be; but it was a social determination that that sort of made sense. What happened with universal service was basically that people charged long-distance carriers a cost to subsidize the lower costs of local service. And so the funding for universal service was largely paid by large users of long distance service. So, basically, for the purposes of universal service, the federal jurisdiction has had most of the control. And so if you looked at all the mechanisms that tend to support the difference between the cost of provision of service and the actual price of provision, it's come from a long-distance thing. So, net, net it has left to the FCC a charge: How do I do this? Rather than the states saying: How do I do this? Now, let me do the one further caveat, which is the states may have a decision to make whether they want prices to be even lower than might otherwise be the case. And they have had mechanisms to support lower prices on their own. But, basically, for universal service purposes, the mechanism we have in the joint board and the federal jurisdiction will deal with the basic fund of money that will accomplish the purposes of the act. And we don't need to worry so much about what's going do happen at the state level because the action is going to be at the federal level involving the states through this joint board process. MR. LAWLER: Dena? MS. PUSKIN: One of the critical things, I think, the charge we have, as a result of the act, is to define what we mean by "universal service." In the past, it was assumed that, at the very least, we would describe it as plain old telephone service available. And the question now comes down to: What do we mean by what is the level of service that we think is essential to form that base line? And I think that's a very critical question that we have to ask. And we will certainly make -- depending on how we answer it -- make a huge difference in what is available in those -- whether they're inter-city or rural underserved areas. And it's a very delicate question because, as Elliot has indicated, there are cross-subsidies here. And so, you know, at what point is the best the enemy of the good? And I know in our office, we have struggled with it in the joint working group. But I think as part of why we're here, is bringing our expertise and our expertise about various communities that we're dealing together with the communications people saying: What is the basic service that we think is essential to move the field forward recognizing that that definition is evolving? MR. LAWLER: Yes? MR. POTTER: Jim Potter representing Dr. George Kamp from the American College of Radiology. I would like to echo a few of Dena's comments and thrust. I think telemedicine is a moving dynamic. I think the one thing we can say about the future is that medicine will be dramatically impacted and will change from what we know it is now because of telemedicine. Beyond that, I think there are two things that relate to the two charges that I would like to request. One, I think we really need to know what's existing now. And I would request that we make a presentation on the present DIMCOM standards. We can make it a brief one, but we would like to do that at the next meeting, if possible. Secondly, regarding the other charge on the regulatory barriers, I think it's important that we ask the very hard questions up front: Are we doing a disservice to the American public down the line? I think there's a number of legal, public protection issues, state rights issues, sociological issues. Right now about three-quarters of our members practice telemedicine; and some of the anecdotal information that we are getting reactions from primary care providers and patients is probably less than what you would think, not as glorifying as you might expect, as well as the socioeconomic barriers and obstacles here. I think if we ask the hard questions now, it will help to steer what the future will look like more appropriately. MR. LAWLER: Tom? MR. SPACEK: Tom Spacek from Bellcore. On your comment on definition of universal service with respect to healthcare, is that part of what one of the subgroups is supposed to address? It's not clear, at least in reading a few words, what or which or all of the subgroups is supposed to say, at least in the initial phase. We're not going to be able to say what the evolution will be, I'm sure, right now because -- you know, we can speculate on that. But at least in the initial set, I think we will need to determine what services should be available to everyone. MR. LAWLER: Yeah. I think on the specific language of the law and what it means, that's certainly part of the question that the FCC has to answer. MR. MAXWELL: And I think in the sort of first cut in time to organize that, the first group that was mentioned, the Telecommunications in Rural Areas, would be focusing on a set of questions. One of the questions would be, in fact: What services or functionality is required there? I think there is very strong links between that activity and the infrastructure and architecture pieces. But there are, I think, some very clear questions that need to be resolved and to get your best thinking about. And they are: When the act talks about services or functionality, what do people contemplate? Do you need to define specifically services that you, as experts, think need to be there to have the universality that's implied? Or is it a functionality without specifying a particular service? There are questions, obviously, about what is rural for these purposes. Because there are a whole batch of definitions that are available and which commentators have suggested. There is a question, as I said earlier, about rates and its comparability, because it could be an administrative nightmare to try to go through all of the comparability from urban to rural and from state to state. And there are questions about eligibility and definition of bona fide requests. All of which lawyers parse, you know, for remarkable amounts of money and remarkable amounts of time, but which are going to be important for us to set rules about at least initially so that we can make this work. So those have to be answered. They obviously are related to what exists now in terms of infrastructure, what's likely to exist in a more competitive environment, how does one get a more competitive environment in these places? And also the questions of architecture: What is it going to evolve to? Because we don't want to set a definition that, obviously, is only about today and can't gracefully evolve. So this is a big job. It's a big job. MR. SPACEK: I was just getting additional clarity for the subgroups as far as, you know, you leave here and do something and you can miss a very important aspect of the job. MR. LAWLER: Can I make a suggestion? We don't have coffee or anything -- did you have a question? Go ahead. MR. TINDALL: Okay. No. I just wanted to get an idea out on the table that I think could be talked about and discussed between the physicians here at a later time. As an engineer listening to this discussion of whether or not they should be specifically -- you know, we should specify or we should define functionalities, I think if an ideal is sufficiently important to society, then -- for example, like giving an exemption to -- this is a very poor example, but it's the only one I can think of -- giving an exemption from some of the laws that baseball has been able to do so they don't get taken into court for misrepresenting themselves and also creating a monopoly -- if it's socially vital enough, can some of these things like, here is the state line I'm going to cross, but this guy over here is going to die in 15 minutes, why can't some of that stuff just disappear and we go back to what doctors were meant to do in the first place, back to the hippocratic oath? That's a tough question that needs to be discussed, too. And I know I'm throwing a can of worms on the table; but I think this is the right body to debate it. MR. LAWLER: Well, this certainly is not as important as baseball. I guess I'm just going to be mindful of the fact that if we don't set some limits on what we try to accomplish, we are never going to get anywhere. Because every issue of telecommunications and every issue of healthcare and every issue of medicine is involved in this. And, I mean, for better or worse, even if we are capable, we are not capable in this period of time in grappling with all of them. MS. PUSKIN: It might be helpful to know what else is going on. Because these issues are all, in fact, of concern and certainly of concern to the Congress. In January, there's going to be a report to Congress produced out of the Department of Commerce but reporting on the activities of the joint working group on telemedicine in which the range of issues affecting the diffusion and efficient deployment of telemedicine will be discussed with options for addressing them. One of them will be, indeed, the issues of cross-state licensure, which I think is what you're getting at. There will be a range of other issues, including the infrastructure. That's why we are very actively participating. And, in fact, what the Congress has asked is essentially that options be laid at their feet as to how to address some of these issues. So I think there will be other venues for looking at these issues. The process of the joint working group is to make this a very public process. The draft report will be circulated in the fall. Certainly parts of it will appear in the Federal Register for comments. So I think there will be ample public process. I do also want to take a minute to say that there have been a number of documents written that have come out coincident or prior to the excellent document produced by the Council on Competitiveness that addresses some different aspects of, essentially, the national information infrastructure and telemedicine and other applications of health. Those documents can be made available to this group. I think we would like to work with the staff to determine what would be appropriate and not give you information overload. But certainly there are reports that go back to 1993 that, very specifically, focus on rural -- I mean, there are just a whole host. And the question really comes down to, I think -- and they cover somewhat different aspects -- what is really going to be critical for your deliberations once you narrow down, I think, some of the questions? Because I think the issue right now is focus. MR. LAWLER: Right. I agree with that. Can I make a suggestion? We don't have coffee here, for which I apologize. We were trying, and for some reason we couldn't do it. There is a cafeteria downstairs. People can go to the restroom, got get a cup of coffee, and come back in 15 minutes, and we'll continue on. What I would like to do next is try to figure out -- if you would look at two things: This one-page, four subgroups. And this is really the same thing, just with people's names in a table there -- and just talk about whether those are the right four subgroups. We want to discuss them, at least have some common understanding on what they mean, if we agree on them. If we're going to change them, what that means. And then we'll talk specifically about what we want to try to accomplish at a meeting in July, knowing what our time frame is. So why don't we come back at 11:40. MR. MAXWELL: You can leave your things here because the hardy federal employees will stay and guard them. (Whereupon, a brief recess was taken.) MR. LAWLER: Okay. Let's get started. It looks like we lost a few. Maybe they're wandering around the bowels of the Russell Building. MR. MAXWELL: But we know they are in constant touch telephonically. MR. LAWLER: What I'd like to try to talk about is, this was our cut on how to divide ourselves -- that's this page with the four subgroups on it -- into the areas that we felt that we ought to be looking at. And let me just spend two seconds on it. The first one, the focus of it is obvious, it's the provision in the law: What are we going to say about it? What is our advice to the FCC. The second is -- and actually the second, third, and fourth are more point two of our advice to the FCC. They are things that we have either had experience with or contemplate a need. I think they are, frankly, directly related, with the exception of the International one, to the first one, because you start to answer questions about rural telemedicine and you've got to start the answer -- the general infrastructure question, and you've got to start to answer the architecture question. You know, we are not going to answer this, especially on the rural side, one time, forever, for all. But I do think when you set out a policy, when the FCC makes the decision on what they are going to do on the law, you know, you have set something in place that, for better or worse, when the Federal Government does something, it often takes a long time to undo it. Sometimes that's good; sometimes it's not so good. But that's generally at least my experience of how it works. The infrastructure issue is simply: What are we going to need out there? And I am not the world's expert at telecommunications, but I have talked to enough people to know that there is discussion about where is telemedicine ultimately going? Is it wireless? Is it over lines? Is it satellite? Is it cellular? The FCC is doing a fabulous job of selling the spectrum left and right. You know, is it an issue that there may be, some day, something left for telemedicine or something else? That's, you know, a question I do not have an opinion on. But it seems to me things like that are very legitimate issues for us, if we have an opinion on, to offer that opinion. The architecture one is very simple. Somebody -- I forget actually who it was -- told me a story where they had, in the last two days -- where they had purchased some lines -- Eric, actually this might have been you -- you know purchased some lines that were incompatible with equipment. I assume that's a problem you can solve, but it will be a headache to solve. MR. TANGELOS: Well, the equipment is looking for 1/4 T-1 at 384, and the lines were delivering 350; and it you doesn't work. MR. LAWLER: And, you know, whether that's something for the FCC to be saying, we ought to be convening an industry panel so we get some sort of standard method for this, I guess not. Unlike what the radiologists have done for -- I forget who you said you did this with a couple of years -- but the -- MR. POTTER: It's not only for radiology. It's also for pathology, determatology, cardiology, et cetera. MR. LAWLER: Right. And those are, in one sense, very elementary issues. But, by the same token, if you do it wrong you've, at the very least, wasted a couple of years and a lot of money doing it wrong. The fourth one is simply the international part of this. And this is probably the most future-oriented of all of these in the sense that it is going to take more development. There are people in the business currently, and I know DoD is doing some things on this. And, frankly, it is simply a -- you know, we have the best telecommunications system in the world. We've got the best healthcare services in the world. It is insane of us not to take advantage of that to help people around the world and to help those two industries in this country. And this may be less scientific than it is, how do we get a process in place so that we are talking to the rest of the world about what we can offer them, and what can the FCC do? I know that there are international meetings -- I'm sure Elliot doesn't miss a one -- in fabulous places. At $75 a day in Paris, he goes crazy. But it is an export opportunity, an opportunity to do good in the world that we really ought not to ignore. So it's just something we thought we ought to cover. What I'd like to do is try to talk about these and see whether people have suggestions, whether we need different ones, more or less, whether they need more definition, whether we should leave it to the subgroups to define them, just how people think we ought to try to proceed. Let me give you two seconds -- again, this is just to start a discussion. I think what we need -- we are aiming for a meeting some time in the middle of July. Is that right, Lygeia? MS. RICCIARDI: Right. MR. LAWLER: We will get a date around to people as soon as we can. We need to have something come back from the subgroups, whatever they are, at that point. And that's going to mean, whoever is on them, however we structure them, I assume that's mostly going to be done through electronic communications of some sort. And it seems to me what we really need at that meeting is, you know, not a finished product but a product in progress which is: Here are the things this subgroup is trying to grapple with. We have five pages of the issues we are trying to define. An options paper would be great in the sense that, you know, we have looked at this; we think there are four choices here; this is what we're talking about; this is what the issues are. And then we can use that meeting really for the subgroups to present it to the entire advisory group. And if everybody says: Great, that's the way we ought to do it, you know, terrific. If you hear a roar of disapproval, you will know that there are other opinions. And then people can go back with more direction that this is something that we can try to reach consensus on or we ought to explore two options or three options, can go back to work, come back to a meeting in September with a lot more detail, have a similar kind of discussion, hopefully a more detailed discussion, reach some kind of consensus, to the best extent we can, and then be a position to have a written report by the end of the month. So with that sort of background -- and we can do it a different way, but unless we want to have a lot more meetings or -- you know, we cannot change the time frame; so that's really what we're looking at. Why don't we try to talk about these four issues and see what your reaction is. Tom? MR. SPACEK: If I -- MR. LAWLER: Tom, why don't you identify yourself and what you do. MR. SPACEK: Tom Spacek from Bellcore. If I look at the act and what it appears that the FCC needs -- I'm going to talk about this a little bit out of context of the four groups but it could very easily map in -- it seems like a critical thing we need is some definition of the minimal set of services and advanced services -- and let me just loosely throw out the word "services" -- that would be in a universal service set having to do with healthcare. And the reason I said minimal set is because, what I mean by that is there's going to be loads of advances in different places and universities that, at least initially, the idea is that they would not necessarily have to be available to meet whatever critical healthcare needs there are. So what is that minimal set of simple and perhaps advanced services that is needed? Okay. The universal service set that we agree and we think that the whole country should have availability of? And the reason that needs to be done is because the -- and the bill basically says, if those are available in urban areas, then you're going to have to figure out some way of reaching rural areas and other areas with technology and so forth at an affordable price. So that set needs to be defined. It's not clear whether to define that set in terms of technological capabilities or applications. I think we need to start with applications and then do a mapping into what technological capabilities are needed to provide those applications. It's going to evolve over time. What's the set now that we want to recommend? And how to pay for all that later, that's separate from our task because there's some fund that the other people are working on. Once that set is known and agreed to, at least it's our recommendation, then you have to define or try to define what is the infrastructure capabilities -- perhaps not in terms of specific technology but maybe in terms of technology properties of those technologies -- that's required and what you would need to reach all these rural areas? And as part of that, you also need to define: What does it mean to reach rural areas in the sense that, do these services -- and these may vary from application to application -- they have to be available to every hospitality, clinic, community center, doctor's office, home; or if it's sufficient for some subset of them that we define, to be available just to hospitals or just in community centers in rural areas, is that what it means? And my guess is, for some services, that will be the answer because it will be too costly otherwise. For others, maybe it has to go to every doctor's office. And, in fact, those two things need to be defined first before you can really start specifying what the infrastructure might be that's needed. So that's what I think we need to do. I'm not sure how it maps into these. And the only problem I see in timing is that, although the infrastructure and technology activities can kind of muddle a long a little bit and think about this, you really need to know what that set is before you're going to say what the infrastructure capabilities would be. MR. LAWLER: I agree with that analysis. But I also -- and I don't want to play lawyer, and I don't want us to be the lawyer for this provision precisely. I mean, for example, the telecom bill says specifically public or non-profit. You know, what does that mean for doctors' offices sitting in Montana making a living? MR. SANDERS: He's not-for-profit. MR. LAWLER: If you can get the IRS to buy that -- You know, but I do think that that is the way we ought to be thinking about this. I also think this has to be dynamic in the sense of what is the set today most likely is going to be very different in a very short period of time. And that has to be built into the model, the equation, however we describe it. MS. KING: Joan King with AARP. I just wanted to bring in a consumer perspective, which is complementing what he said, that my understanding is the subsidy would only go to telemedicine; but the infrastructure would serve multiple purposes. So ultimately, there's going to be a cost that has to be picked up by other kinds of consumers of the telephone network. So I think we have to take into consideration the balancing act when we're asking for an infrastructure, where is the cost allocations going to be? How much of it will be paid back to the physicians? Or how much of telemedicine is going to be subsidized? So ultimately this is a consumer issue. Each of the committees should be looking at the costs. MR. PILLAR: I'm Bob Pillar with the Public Utility Law Project in New York. I want to continue on this theme. And I want to suggest that I think this advisory board needs a little bit of guidance as to how far our mandate goes. Because if you pick up the theme that you had started with, there is a case to be made out that, for every analog central office in the country in the rural area, that in order to provide almost any of these services it has to be upgraded, becoming a digital office and have to minimally have ISDN capabilities put into the switch and the line cards that are associated with it. This is short of even the question of extending fiber plant. There are applications here that require fiber plant. Once you put in that huge investment, that investment will then be marketed for private purposes and for other purposes that would never have otherwise been brought about. So there is a case to make out why we should do it. But the cost implications of that are so profound and so dramatic, especially as you get into -- further down the line into fiber or even the switch over from analog to digital offices in any quick time frame, that we need some guidance as to whether or not we're supposed to, at this point, even take costs into account. Or do we just come back and say: This is the vision that if you were going to make this widely available, here's what it takes. MR. LAWLER: Elliot, you may want to respond, but let me just say this: I don't know whether it is a part of our mission to be the cost accountants for this or not. We would be insane if we came back with a grand system that cost 400 zillion dollars and was absurd. MR. PILLAR: But if you focus on functionality and you do take the approach of what does it take to make all rural areas comparable to the urban areas where a lot of companies, out of their own business plans, will invest? MR. MAXWELL: That's not what the act says. I think this is a very important discussion, absolutely fundamental discussion. And when we were talking about the composition of the advisory committee, we could have done it a number of ways. One of the reasons why there are people who are either identified as consumer advocates or represent a consumer group is because, in fact, this is, in some ways, a kind of forum in which one says: Let's understand what's going on now, both in terms of the access to services in rural areas, what we think would be important as a society for universality of access; what does it mean for consumers across the country, because, in fact, consumers will be paying for this indirectly insofar as there are services that are subsidized, because someone's going to be paying for them. So I think the discussion of cost is a very important piece, though, in forming this. And when we start to think about the definition, if we start and said, what would everybody like, that's a very different discussion than the discussion that says, what are those services that one could expect were contemplated by the people who wrote this that were essential for a healthcare provision in these areas? MR. PILLAR: That's helpful. Is there an answer to this question: What time frame, in responding to the questions you have asked us, should we be thinking in terms of? Should we be thinking in terms of the next three to five years? The next decade? Because I think you come up with different answers about what kind of technologies you might need. MR. MAXWELL: This, again, is a personal view as opposed to any institutional view. But this is, again, an act which I think was, in a lot of ways, a very, very creative act. It said: Look at what's going on now and what you think is essential now, but you should remember that you're going to have to come back to this because this will evolve. So my reaction is, I think we look at a three- to five-year horizon and then assume that, in fact, the Commission is going to come back and do it again. So what we're, I think, trying to create is a foundation from which one can build and a foundation that can evolve gracefully as things change. And let me give one other sort of characteristic of this foundation. The foundation has to accommodate the fact that, while in many cases there are either not the facilities available and where provided are provided on a monopoly basis, the foundation has to accommodate the provision of competition and, to the extent that we can, incentives for competition to provide facilities and provide services in these areas which may not be served now. So I hope that's helpful. MR. PILLAR: That is. MR. LAWLER: Cindy? MS. TRUTANIC: I just have a technical question. The independent telephones companies and those companies that are in areas that were subsidized by REA, are they encompassed in this whole consideration? And are there going to be kind of different rules for them versus the other common carriers? I ask it because, as you know, there's been sort of different paths for each of them. MR. MAXWELL: I think, in general, what the act said is whatever mechanisms exist have to be competitively neutral and leaves to the joint board and to the FCC a fairly substantial flexibility on how the mechanisms will provide subsidy. There was a question raised earlier whether it's going to be defined in terms of the existing carriers or whether other people would be able to come in and get the subsidy. That's clearly one of the questions that the FCC is looking at very closely. There have been different treatment of small telecos versus larger telecos. I expect that there will still be elements of differences in the treatment. But for our purposes, I don't think we need to focus on them. MS. TRUTANIC: But the impact would be, for example, in a rural community where the independent telephone company is not necessarily subject to the same rules and regulations as larger common carriers and they maybe take acts against other carriers trying to come in that may be anti-competitive, which has been -- you know, where they were not on a level playing field in the old days, today it's a different story. And it would maybe impact some of the services and things that are provided in the rural community. MR. MAXWELL: I would, again, sort of give a personal view. And that is that insofar as the independent companies have to respond to this, they will be governed by the provisions of the act that says bona fide requests of a telecommunications provider have to do it; here's the subsidy mechanism. As to the questions of whether others can come in, there will be rules that will govern entry and anti-competitive behavior by the incumbent that I think will address the questions you raise. MR. LIFSON: Art Lifson with CIGNA. But we're looking at this at the margin for the most part. I mean the telemedicine piece of this, as I've listened to the discussion, is not the driver of the technology and the diver of whether a community is wired or not wired. But if it is, how can we take advantage of that technology and that community and provide support? Or is there a thought that telemedicine could become the driver of entry of new technology into a rural area? MR. SANDERS: Telemedicine is the driver. Jay Sanders from American Telemedicine Association. The reality is, we can't be looking at infrastructure and taking a look at the technology. We've got to be looking at what the needs are. We've got to be defining what the rural healthcare delivery problems are and what's the functional realities and what the functional solutions to those needs would be. That will totally dictate the infrastructure that we need to recommend and the architecture that we need to recommend. I would also like to say that, given the fact that what we have to do is indirectly proportional to the amount of time that we have to do it, I'd like to underline what someone earlier stated; and that is, there are a bunch of resources that exist for the committee here that I think would be very helpful background homework, particularly a lot of the testimony that was provided by a number of us to the joint board, which specifically addressed issues such as what is the basic minimum, for instance, architecture, basic minimum infrastructure, that we need? Those comments that we made and provided were not simply our own personal views but really the collective views of the people and the organizations that we represent. And I think, I think that would be very helpful to the group. MR. LAWLER: If you could get those to us or get somebody to get them to us, we'll get them out to -- MR. MAXWELL: We have them. MR. LAWLER: Oh, actually, yes, you have to have them. MR. TANGELOS: I think that's a very important piece. I mean, that's the freshest piece out there right now. And I definitely want to see that. MR. LAWLER: Sure. MR. TANGELOS: The other piece besides the Council on Competitiveness is the OTA work that was done, their last work, before Congress put them out of business; but that's a very nice document as well. MR. SANDERS: As well as the Augusta Conference and the Arias Conference which dealt with these issues. Very, very comprehensive. MS. DEERING: Mary Jo Deering from Health and Human Services. There are also documents coming through the administration's Information Infrastructure Task Force Subcommittee on Health Information and Applications that would also be valuable to you. And I think what we could undoubtedly -- even though they are in draft stage -- make those available. There's one on managed care. There is one on consumer health information. Your material, of course, is already in other forums, so that's available, too. MR. LAWLER: Can I ask this: Do I hear Tom Spacek and Jay Sanders saying the same thing? I mean, you're saying we need to know what the service are that people need, that will dictate where we're going. Tom, if I hear you, you said it from a different perspective, but your conclusion was precisely the same. Is that something they we have -- you know, is there general agreement on that? MR. TANGELOS: I think, again, in looking at the act, indeed, telemedicine was specified. I mean, that is the diver. MS. PUSKIN: Another thing I want to make available to the committee is a book chapter that's going to be out on multi-use systems. I want to remind people that the act also has libraries and schools in it. And part of what we need to do is recognize that if we're looking at the needs, we're looking at -- especially if we look in rural areas -- and I know Jim and I have worked together, and a number of you -- you can't look at healthcare in isolation of looking at some of those other things. Now, we're not necessarily going to look at libraries and schools per se. But how do you build this into the context of a multi-use system? Because when you do that, you also change the cost function, or you can change the cost function very dramatically. So what's the driver here? Well the driver is the needs of the community. How you meet them may be in the context of looking at a variety of resources in that community. You don't want to, if you can avoid it, build separate infrastructures for schools and libraries, especially in rural areas. You want to be able to get a synergy to create sufficient demand to get that competition in there. MR. LAWLER: Isn't that -- for us, though, that's a cost issue which we are not going -- I mean, we're going to assume that some other rationale being out there is going to do that. MR. PILLAR: Bob Pillar. But the problem is that -- let's just say hypothetically that an appropriate minimal technology standalone is ISDN with some multi-plexing. Well, you look at -- and you're going to run this in a rural area in a typical location for a couple of hours a day. Clearly appropriate. But when you add in the needs of the school district, if you add in the needs of the library system, maybe other resources within that community, if they can come together and then decide that it's far more efficient from a technology and from a cost perspective to have a T-1 line on a closed system, private network, that's the smartest choice and the appropriate choice then for telemedicine, too, and allows for more capabilities. So it's almost like you only ignore that at your peril. MR. LAWLER: I want to come back to what Jay and Tom said, which is, if we can agree on the way to approach this, which is, let us try to define what the services are that people need, if we agree on that, we then have a place to start from and we can address the issues. If we agree on that and then we all, in our wisdom, say, that's great, we know what the services are, but it's too expensive to say, this is something we're just going to do with a flat out cost subsidy, you know, then we can have a discussion about whether other schools, libraries, other users can deal with the economics of this. But that's not a decision we will ultimately even recommend, I hope. MS. BROWN: Cathy Brown with the Department of Commerce. I'm a little concerned about what you mean by "service." I think we need, then, to back up and talk about what the functionality of the need is in order to deliver that service. Then I think we have a plan. What I am worried about, though, is that we don't get technology specific. It may or may not be fiber. It may be wireless. There's functionality; there's speed; and there's kinds of things that they're going to need in the healthcare community that the schools are going to need and that the libraries want that will be built into any network that is out there. As Elliot says, when you start to look at that and look at what the needs of the community are, you then drive competition in that community. There is a caveat there that this is a subsidy not only for healthcare but for education. And then you actually start to have some reason for providers -- whether they be wire line providers, wireless providers, or cable providers -- coming in and serving a particular community. So I'm with you if what we're going to do, then, is then sort of see what the broader need is. And so I'm building on this idea. MR. LAWLER: Well, I agree with that. But I also want us to keep our focus here, which is -- MS. PUSKIN: -- healthcare. But let me just say to you that that's -- exactly. We have to focus on the needs of healthcare. But let me give you an example of how this relates. When you talk about physicians' offices or services to the home, you may not talk about in terms of advanced telecommunications services. What you may say is that every community, as a basis of its rural needs, needs dial-up access to the Internet. That's the base level of service. When you do that, the implications for healthcare you can get services cost effectively to the home. That's major implications. So what you're defining is you are going to define a level of sort of functional need within the context of health implications, but it also has implications for the other sectors. MR. LAWLER: You're absolutely right. MS. PUSKIN: And if you think about it in those terms -- and that's all I was saying -- if your focus is in health, but if you think about the implications and how to build that system, you create a case that is much more acceptable for looking at this. MR. MAXWELL: Just kind of remember that the work you will be writing and providing is for a joint board of state and federal regulators who are looking across these universal service requirements, who are looking at libraries and schools and healthcare and affordability of service in general. So you don't need to solve all the problems of how this will work. Let's get your expertise focused on the healthcare piece to the extent that we have wisdom about how demand can be aggregated to be able to bring competition in, to be able to make better, more effective use of the technology, that's great. And that's important. But there is a kind of integrated function which should take this contribution and add it to the contribution of others in these other areas to look at this systemically. MS. PUSKIN: Can I ask you a question about the act? Because it was raised in the context of physicians' offices and the fact that this act talks about advanced telecommunications for non-profit providers. And that's why we also -- Mary Jo's concern about the home and the evolution to residential care facilities and where this is going. If we can also, at least in the context of the rural discussion, talk about what a basic level of service, not just the health applications, to allow us to reach these other healthcare entity, is that within the scope as you see it? Because certainly it was in the scope of testimony we provided. MR. MAXWELL: Let me answer that in two ways. I think it would be a mistake for us to get into sort of a legal dialogue about what the precise meaning of the act would mean. You are advisors to a process where there will be lots of people who are going to parse the act. If there are feelings and insights in addition here about what should take place, that is perfectly appropriate to put in because, in fact, if someone said, well, it doesn't, you know -- we will interpret the law to be mean X, and that's the legal judgment. This group can say, that may be a perfectly appropriate legal judgment. We want you to think about this from a societal standpoint, and you should amend the act. And the act should be saying this because that's what it should mean for rural America. MR. SANDERS: Jay Sanders, American Telemedicine Association. I think that's very, very critical; and I really feel good about that comment because one of the critical concerns that we have -- and we addressed this in our testimony -- is related to the fact that it seemed to isolate the primary provider of healthcare, and that is the individual physician. Many of us around the area who are involved in this on a day-to-day basis will tell you, even though you think of rural as the rural providers being proximate to the rural healthcare delivery system in terms of hospital, the reality is if you put a telemedicine wing on a hospital and you have a doctor who's office is literally across the street from the hospital, it might as well be 10,000 miles away. The reality is, it's got to sit on that doctor's desktop and be as convenient as the phone, and it's got to go into the patient's home. And that's where all healthcare is going. It's not simply rural community. It's urban community. That's where it's happening. That's where it's got to be. So the fact that we can provide recommendations that address a very basic part of that law that basically says we're only talking about non-profit organizations, which, the way we interpreted it, that meant we could only put it in the hospital; and the actual provider of care, the individual doc in their office, is basically excluded, the fact that we can provide those recommendations is very helpful. MR. LAWLER: Perhaps a clever lawyer somewhere can interpret this to mean a doctor's office, but I'd be surprised. But there is certainly nothing that says that we can't say, this ought to be -- you know, in the future, when you figure out a way to get there, it ought to include a doctor's office and it ought to include -- you know, whatever. Home healthcare. Whatever we think it ought to include. MR. HOLUM: This is the subsidy we're talking about. I mean, the services, presumably, would be available in the community. Are we talking about -- MR. LAWLER: In theory they'd be in the community. But, yes, the subsidies would be available to a primary care physician, whether you're a mile away or 200 miles away. MR. HOLUM: But not under this act. MR. LAWLER: Not under the existing law. Chuck coming up with a great legal argument. MR. SONNESTRAHL: This is Al Sonnestrahl speaking, from CAN, Consumer Action Network. You are talking about systems and mechanisms with equipment and communities and people in general. And I was just wondering if you're talking about individuals as well? For example, what if one individual who is deaf and cannot hear and is trying to communicate with a physician, there would need to be a third-party line to include interpreter services with that. Would that be subsidized under the guise of universal service? That's one example for us to consider as well, is the individual needs as well as the community needs in these systems, the needs of the program, et cetera. MR. MAXWELL: It seems to me, that that's the kind of question that the advisory group should be addressing and the kind of recommendations that are perfectly appropriate for this committee. I think the worst thing that we would do is to set a very, very narrow boundary on the discussion because we're looking to you as experts, as people with knowledge, understanding, experience, and insight. And if there need to be changes in the future, then people should say that. If there are constraints that this is not thought through well, you should say that. We have a responsibility under the act; we need your guidance and don't want to say, sort of a priori, that this isn't a good comment or this is a bad idea or a forbidden notion. MR. LAWLER: Tom, you had your hand up first. MR. SPACEK: Tom Spacek from Bellcore. Tying together a few of these things, the comments from the woman from NTIA -- I don't remember your -- MS. BROWN: Cathy Brown. MR. SPACEK: Cathy. Putting her remarks together with some of Jay's comments and so forth, it seems like there's a few things that, you know, one is, defining this set of services. And when you define them, in addition, you would need to define what infrastructure might be needed, taking cost into account as best you can and not being technological specific because it may turn out that, you know, upgrading central offices in rural areas is not a possibility and maybe there are satellites solutions or something else; but at least the capabilities that are needed -- you know, would need to be definitely specified. One additional thought on top of that is, you know, we talked about the -- we're talking about this in the context of a national information infrastructure, which implies shared lease of resources, which are some of the comments we're talking about here, and that impacts cost. And the fact that the joint board is the one who will integrate these things, we have to worry a little bit less about that. It seems like, perhaps, in our definition of what this minimal set of services for the initial set of universal service is, in specifying those things, we should probably specify it in some sort of a priority order and even some beyond what we think should be in the minimal set. The reason being is that when the joint board gets together, perhaps through the synergies between education and libraries and so forth, they could do more or less than we initially recommended because the cost structure will take that into account. So we may want to add some things or prioritize some things. MS. DEERING: Mary Jo Deering from Health and Human Services. I have a technical question also that sort of builds on that, and it does have to do with our work product eventually. I'm sort of one of these task-oriented types that congregates and breeds in Washington I guess. I'm wondering whether what I'm hearing would shape our input to you in the following way: That on one hand we are to address the law as it is written and give useful guidance for doing something in the next three to five years based on the way the law is written. On the other hand, I hear a strong feeling that, number one, we need to educate them about the evolution of healthcare and make certain points about likely scenarios in the future. And then, thirdly, not so much on a temporal basis, but that there are other considerations that do not fall within the scope of the act itself that we feel they should take into account nevertheless that might result, either in the near term or the long-term, in amendments or other types of action. I mean, is that a useful framework? Are we limited to any other framework at all? MR. MAXWELL: Not that we have -- MS. DEERING: I mean, we do need to do that first piece, we need to tell them -- I mean, we must tell them the first piece sort of clean. That's really my technical question. MR. MAXWELL: There were very good comments that have been provided on the panels in front of the joint board. I think some of the comments have been very helpful in the proceedings itself. I was, frankly, a little surprised that we didn't get as much information as I had hoped. And, again, this is a personal view as opposed to a Commission view. Being a creature in Washington -- and perhaps some task orientation rubs off -- where there is money, there usually is comment, if not excessive comment, on how we should get that money. Here's a situation in which a societal decision that there should be this kind of service available as a society, and yet I don't think there has been a consensus yet reached about what those service are, sort of what merits subsidy, what merits, essentially, a tax from one party to another. And so we really need to focus very much on getting that answer and getting that right in the context of these other activities that are also determined to be recipients of subsidies: schools and libraries and underserved areas, high-cost and underserved areas. So if we do that alone, we would have accomplished a great deal. If we do this in a way that it can be built upon, it's better. If we do it in a way that recognizes where maybe people have not thought about how the evolution is proceeding or have missed areas that will be critical for this to be successful, all the better. And if we can do it in a way that suggests that, in the future, one should be looking at this and give people some insight about that, then it's a home run. MR. LAWLER: Doug? MR. TINDALL: Doug Tindall from UT Houston. And I hope Dr. Duke would permit me to say one more thing. Listening to this, I would like to relate a scenario that developed over the last 18 months in Houston. I'll keep it very short. We spent a very small sum of money, especially with respect to those sums of money we will probably be talking about allocating throughout this piece of legislation. And with this very, very small, insignificant amount of funds, we have learned many very valuable things that I'm not hearing in the discussion yet. First of all, yes, cost to a consumer is a very real concern; and it should be, especially for people like the AARP, for example. But I haven't heard anything about optimizing healthcare around telecommunications, because actually we'll have a net cost savings. I haven't heard that yet. As the devil's advocate, as well, I haven't -- for example, that little tiny research project that we did, we found many different areas within cardiology, trauma, and stroke that have been published from UT Houston and also School of Public Health documents that have been published from UT Houston that I think I can get for this board before the next meeting that address these costs, you know, public-service-versus-healthcare-dollars kind of thing. And I'm not hearing that in the discussion yet. Also about cost sharing, the whole idea about if you bundled education and maybe another agency together you can increase it from ISDN to T-1 but actually have a savings in installation, I submit that it's not only those. It's telecommunications companies, libraries, schools, other public safety agencies, emergency medical authorities, industry in general, the worldwide web industry, wireless telecommunications, and computers. And all of those really are -- it's just this huge maze. What we saw as a reaction of that tiny research project is that we are generating enough support within Texas that we probably will get something that we can put as far as a, quote, unquote, subsidy for rural care, at least in my opinion. This is hypothetical. And we think the state might be able to do a subsidy for rural care. We had a meeting also with some civic officials within the City of Houston, granted a much bigger pot, now you're talking urban and inter-city as well. And they are to the point that they are also justifying potential sharing and allocation of resources to us for a variety of benefits, both political and to the constituency as helping members in their healthcare needs. I think I've got the ball on the table. I could put more examples forth, but I think I got the ideas out. MR. LAWLER: Yes? MR. HOLUM: You know, I would love to begin this process and to proceed on the basis of satisfying the human needs because I think that's what healthcare is all about. But I want to express a caution at the outset. It seems to me that it's easy to say that, but it's very hard to develop a consensus on what people's needs are in the healthcare arena. I think the fact that we were unable to reform the healthcare system, in part, was a reflection of the lack of consensus on what people need as a basic minimum package of healthcare. It seems to me that there is another standard stated in the act. And that is that rural areas should have services that are reasonably comparable to what's in urban areas. So it might be a useful start to say: What do we think urban areas will have three to five years out? And then try to use that as the benchmark for what we need to get into the rural areas without spinning a lot of wheels about what would be nice and desirable and even, in some sense, practical from a human needs point of view. MR. BAILEY: Hi. Bill Bailey. I'm from Southwestern Bell. That's an important point. Someone said earlier that telemedicine is moving. It's moving within the context of telecommunications. Telecommunications, over the next several years, is going to move dramatically. Today, I think everyone agrees, that typically it costs less to provide telecommunications services in the metropolitan areas than it does in rural areas. That's just a function of the density and the distance which we have to provide service to. Competition is going to, at least in the near term, concentrate in the metropolitan areas where the margins are greater. And what's going to happen is that prices of services -- and many of the prices we're talking about for services which are being utilized for telemedicine already have built into them high prices to try to keep local telephone rates low. And what will happen in the future in the metropolitan areas, those rates will come down as a result of competition. But those same forces will cause rates in rural areas to likely go up, even more than what they are now, to meet their cost. So we can see that there are problems today in providing telemedicine; but the structure we're doing that it in is going to be even worse for rural areas. I mean, it's going to be much more difficult to provide services to rural areas at comparable prices tomorrow than it is today. MR. MAXWELL: I think there is a potential for a little confusion. Let me just go back again to the act for a second. Again, it's on page 96 of that handout. What we are thinking about in terms of healthcare services, it doesn't provide so much guidance, but the words are the words of the act. And it is that they are necessary for the provision of healthcare services in the state. So the underlining is a definition of what the society believes is necessary, not discretionary, not what one would like. And it then goes back to sort of the telecommunication services which are necessary for doing that. So it doesn't provide much sense, but we are trying to define a kind of set that we can all agree upon are required and then go to the telecommunication services which are necessary for that. And I'm only doing that because we could spend, you know, from here to the first part of September saying what the healthcare system should be like. And I think Tom was right, we have to make a stab at what is necessary in rural areas and then the services which are necessary for doing that and then look at the comparability issue for the costs involved. There is kind of logic about it which I think people were talking about, and it has to be sort of very much on our agenda. MR. DOUGHERTY: Elliot, could I just follow up? On the page before, the bottom of 94, this is where I was taking the language from, Number 3, "Access in Rural and High-Cost Areas: Consumers in all regions of the nation...should have access to telecommunications information services...that are reasonably comparable to those services provided in urban areas." That's the benchmark I was looking at. MR. MAXWELL: That has to do with, in general, telecommunications services. And there is a provision overall with respect to universal service that says the nation should look reasonable comparable, there should not be a distinction. When they talk about the healthcare piece, they're talking about sort of looking at a healthcare system in which rural areas should not be distinguished or deprived in a large measure, and then go back to the services necessary to make that happen, the telecom services. This is kind of a multi-layer view of universal service, one is universal service as a whole, and looking at the society as a whole. The other is just focused on the healthcare-related pieces in the rural areas. MR. LAWLER: Did somebody have a comment back there? I may have missed it. MR. ENGLAND: Bill England from HCFA. I was wondering about something that Jay said about heading down the path of who is the subsidy going to? And are private physician offices non-profit? And, of course, through our payment system, many of them probably are. But the IRS very clearly defines who is non-profit. I mean, Publication 17 tells us who public and non-profit entities are. You know, it's a list we can hold in our hands. It's fine. And I think if we try to discuss, are we going to subsidize nursing homes, are we going to include physicians' offices, et cetera, we are going to get way beyond anything that can reasonably be done. And I, first, would just like to suggest that for discussion, as it says, public and non-for-profit, that is defined and it's a fixed group of entities and we can limit what we're talking about to those entities only. And I agree, absolutely, that it's going to go to homes and it's going to go to doctors' offices. But Medicare is not, for example, planning on paying for that anytime in the near future. This is an issue -- MR. SANDERS: You don't want to get into that. MR. ENGLAND: Okay. That's one constraint. The second thing is, you know, we have this market system and it does efficiently price things in urban areas and rural areas. And it's how much are we willing to subsidize where? We are trying to set an objective -- maximizing an objective function, and we're not looking at, you know, how do you constrain, what are the constraints, what do you have to give up for subsidizing here and not here? And the market does that fairly well. If we just say, we want every hospital to have two T-1 lines, every rural hospital, well, that would be wonderful. I mean, there's no way we can mandate that to happen. So I think what we need to do is to set what it is -- is it 1/4 T-1 line from one of these entities, if they are requesting it, to say, okay, that's it, let the market price it, and then you provide the subsidy or figure out a way to provide the subsidy to pay for it. MR. LAWLER: Let's do a couple of more comments, and we're not going to get into Medicare reimbursement. I promise. Tom? MR. SPACEK: Tom Spacek from Bellcore. Just a comment on your comment, and maybe it's inappropriate because we are supposed to be moving forward and not debating at this point. I think what the issue is here and the purpose of this universal services subsidy issue is not that the market will set prices in these areas; but it is, perhaps, what Bill was talking about, that it's going to be very expensive in rural areas. So what is this minimal set of potential things that are needed now, and that will evolve over time? And then, what's the technological capabilities needed for that? Then it turns out, what will it cost? And by definition, if you agree, that said then, that this fund subsidizes those, you know, market forces don't create the prices for those, unfortunately; and that's the purpose of this whole deal, I guess. So it's a little different focus. MR. LAWLER: Yes, sir? MR. HOLUM: I'm very pleased with what I think is some narrowing of the focus of this discussion. I think the more focused and the narrower we can get, the more we're likely to add more value in this short amount of time that we all have to put in. Notwithstanding that, I think we would do ourselves a disservice if we so limited our discussion on this one point to simply the words of the statute with regards to the public and non-profit facilities. Because in that one component, I think we have to have a little broader vision in the sense of what the intent of this is. And it may be added as an addendum or an ancillary discussion with respect to what has to happen. If we don't constrain ourselves, we're going to be missing an enormous component of providing healthcare services and access to healthcare services in so many areas. MR. LAWLER: Let me try to declare, at the risk of getting tomatoes thrown at me, that we seem to have an evolving consensus on at least how we want to think about this, which is we do want to provide advise on the words of the statute. We can't change them. So we do want to provide advice. I happen to think that Tom's sort of formulation of this is a very constructive one, a good way to think about it. Beyond that, I do think we also have a consensus, that if we think there is something more that ought to happen, whether it's in rural areas or beyond rural areas, I think we ought to feel like we can say that. And, you know, that's what our job is, to give people advice. And we want our advice to be as narrowed and tailored as possible. But we should not -- you know, if we think that this particular provision is great but it's only 25 percent, we ought to say it's only 25 percent. And there's, you know, a lot more we need to think about. MR. HOLUM: At the same time, I would hope that our focus would be on access to the communications system and the cost and subsidies associated with access to the communications systems as opposed to -- you know, we could go a lot of different directions in terms of what kinds of healthcare services we think are necessary. You know, we could go a lot of different directions to get out of this focus on communications. MR. LAWLER: Right. MS. PUSKIN: I think actually we can do a lot, without getting too far away, within actually the current structure of the statute to apply what we think we see the communications needs are for the healthcare system in three to five years. For example, if you look at the Universal Service Provision, which is for all consumers, which is what you mentioned earlier, one might argue that in that context is where you might put physicians's office and some other evolving institutions if you say, really in rural communities, just as in urban communities, one would expect local dial-up access to the Internet. If that is a basic service that's available, that is a service that goes a long way to meeting the healthcare needs of physicians' offices, facilities, et cetera; and it's within the context of what it is your expecting in the universal service for everyone. Then you say: What's that basic service that you would expect to be out there and the implications for healthcare services? Then you go and say: What are the advanced services beyond that in the context of what we said earlier? And there may be some different levels. I think a lot can be done within the context of understanding the act. You may end up advising some special things. But I think you also need to look and say, there are a lot of things out there where, in three to five years, actually the things we'll be doing in healthcare that won't require any greater functionality, in some way, in terms of the telecommunications industry, than we would expect that would be going into people homes and urban areas and, therefore, would expect in rural areas. I think you have to keep that construct so we're not -- and that may help you to address some of the issues in this act. MS. DEERING: My only observation on this -- and this is moving this forward, because I have a 1 o'clock conference call to make -- is, based on this emerging consensus, whether the structure of your subgroups really feeds into the final product that you want. It seems to me that they are horizontal slices, not vertical slices. And I just throw it out on the table as to whether or not there is any drafting process that might actually get us -- we've got an awful long way to go. And if we do it that way, will we have an awful lot of re-synthesis and re-packaging to do afterwards? MR. LAWLER: Right. Let me do one more comment, and then let's talk about how we go forward. Did somebody have their hand up back there? Yes. MR. BARR: It's a basic comment. Rick Barr. (inaudible) International, an end-user for two years of ISDN. A very basic request, as far as being a healthcare provider, is the issue of connectivity in rural areas. The band width is one issue. But more importantly is reliability of the service. And we fought for six months between the Arbachs and three different long-distance carriers to give us daily connectivity, which was a very, very rough start up just within a 200 mile radius of where we sit today. And I think the other issue that a consumer would also need assistance along with the telecom piece is the issue of slamming. We had many instances of being switched from one long-distance carrier to the next, not being aware that it happened at the local switches; but yet we lost connectivity for three, four, and five hours. And in the practice of telemedicine, which is really a deterrent to any local clinician is that, if you don't have the connectivity, you don't have service, you can't provide what would be the rationale for why you're even in telemedicine today. I think that's a very basic premise going back to some of Jay's comments about what do the people need. MR. LAWLER: We want to try to give people a chance to eat lunch before we go up to this demonstration, so let's try to move forward from here. Mary Jo suggested that, perhaps, there's a different way to slice this. If there is, let's see if we can do that. MR. TANGELOS: Well my brain has already been thinking along the lines of what we've got here. So 2-1/2 hours, 2-3/4 hours into it, with 15 minutes to go, that's a little tough. But for the pieces that we have got lined up, I think that, just speaking from the architecture point of view, I've already got a general design that we can come back at the next meeting in July, quite nicely within that framework to give the group plenty of information. It may, indeed, be horizontal. It may, indeed, be a box. But that's kind of easy to do within the time frame that we have remaining. MR. LAWLER: Tom, any contrary ideas? Or -- MR. SPACEK: Well -- MR. LAWLER: Or non-contrary? MS. DEERING: The one drafting piece which is missing here, unless it's in your first box, which it may well be, is the definition of "need of services." And to me that's a little bit cross cutting. MR. LAWLER: I agree with that. MS. DEERING: I think you may need a separate -- MR. TANGELOS: You know, you can leave that to the group as a whole, though. Again, the building blocks may be these four pieces here, and we as a committee of a whole finish the job. MR. SANDERS: And Jim Brick's committee could really address the "need" issue. MR. LAWLER: Yeah? MS. TRUTANIC: I guess what Mary Jo is saying, though, is that there may be, from each of these four sections, interaction and input that everybody can do. For example, DoD is heavily doing some international telemedicine right now and in addition to infrastructure, they can give some very vital insights into the problems of providing telemedicine services. MR. LAWLER: There is no question that there is almost total overlap, perhaps with the exception of the International subgroup. MR. TANGELOS: But I'm convinced that there are pieces already in testimony that I will be getting, that there are pieces in the Council's report that I will cut and paste right into the work that we want to submit in July. MR. LAWLER: Right. Tom? MR. SPACEK: I see the International one as being able to proceed, you know, soon. Even the one that's called "Architecture," because if I read it and also hear what a few of you just said, there's a lot of equipment out there, that's your viewpoint on what's out there, the compatibility that might be needed between the equipment, among equipment and so forth. So that potentially can be some useful stuff, too. It just seems like the definition of the essential set of services now and perhaps in the future, when there is a longer list of those put in priority order, really has to occur, in some sense, before you can do something useful with respect to what telecommunications capabilities are required to meet that. MR. LAWLER: Well, let me try something here; and I'll dump this on the three Chairs here of all but the International one. Is that something that the three subgroup Chairs can talk about and try to get a common language about and see if there can be a joint understanding that they can proceed on? And maybe, Jim, you can take the lead in doing that. MR. BRICK: I'd be happy to. MR. LAWLER: But, you know, you will be communicating with the other subgroups so there is some development of that jointly rather than -- MR. TANGELOS: Yeah, I'm really not uncomfortable. Let me just -- we are winding down, and let me give you an idea, if I may -- MR. LAWLER: Sure. MR. TANGELOS: -- what I would like from our group. I think a two- or three-page document from every member of my subgroup, providing with me basic information that they think is important and can be worked into a document that will end up being submitted by me at this next meeting that may be 15 to 20 pages long. I think it would also be easy, with the architecture question, listing many of the conflicts that exist, many of the anecdotes that are out there. And there's nothing wrong with listing them, getting the individual perspectives from ACR, from AARP, NTIA, and going forward from that. Then I think it's the responsibility to have that information here so that we can now work up, and Lygeia can work up, and get it to the next step. So I'm more concerned with getting something forward in the next six weeks than a finished product that's interrelated and goes together and looks beautiful. That's not what I want to get to in the next six weeks. There are more practical things that I hope each member of this group will at least give me two, two-and-a-half pages. MR. SPACEK: But that suggestion -- and maybe it's what you were saying before, I'm not sure -- but if the first one, which is called "Telemedicine in Rural Areas" -- which in some sense is telemedicine in urban areas, too -- if the idea is to define this minimal set, if that group is responsible for defining the set, perhaps the Chairpeople of the other groups can view themselves as members of that first group, so we will all focus -- you know, let the Chairperson of that first group be responsible for defining that set, the other Chairpeople having input to him. With respect to the "Telemedicine Infrastructure," which I would be Chairing, what we would do in addition to inputting into that, between now and July perhaps, is looking at the -- you're also asking for sort of the future vision here, too. So maybe between now and the next meeting we could focus more on that future vision. At the next meeting, once this set is sort of defined and we can agree to it, then between July and September, we could focus on the shorter term issues of what would be the telecommunications requirements to meet the agreed upon set. So we sort of do the future before the present, but that's okay. MR. LAWLER: That's fine. I also, if it's possible -- and that set will need to begin to be designed prior to our -- you know, everybody hearing about it in July. Maybe you can begin the second part of that even before that meeting. And that's really, you know, if you three can communicate on that. MR. MAXWELL: It may be useful, on the infrastructure side, to be also looking at sort of what exists today in terms of the rural infrastructure so one can say: What would need to be changed to be able to do some set which I think there will at least be input on from the statements that were made at the en banc hearings in front of the joint board, which we will gather up and make sure it's available to everybody here. Let me make one other comment, perhaps a process comment. MR. LAWLER: Sure. MR. MAXWELL: I think if we don't do as much of this as we can electronically, we are nuts. People are dispersed. The subgroup, in part, because it represents the rural areas and non-urban areas as well as urban areas, people beyond the Beltway, if you -- when you hand in those contacts sheets -- there are two things. Not only phone number and fax number, but if you have e-mail, please give the address. If you have a web page, please give it because we'll make sure that these are linked up. And, to the extent that we can, I think as much of the inputs that can be shared across the groups so that people can participate as they are able to, will allow it to make much more progress. And to the extent that we can deliver things electronically, your humble staff would, I think -- such as it is -- would be much appreciated. MR. LAWLER: Let me just say, on this list, we were totally arbitrary and ignorant when we did this. You know, we looked at what we knew about people, and we put them in various subgroups. I think the best way to try to deal with this, if I can impose on our Chairs here, is if somebody has a great deal of expertise in another subgroup and none in the one they're in -- although, that's almost impossible -- let's try to work out a way where -- each of them needs to be covered. But what I don't want to do is get everybody saying, you know: I don't want A. I want C. And we will start all over again, and we'll end up being equally arbitrary the second time around. So if you have a particular need, let's see if we can accommodate it. I will admit to just doing it arbitrarily because we couldn't figure out any other way to do it in the sort time frame we had. MR. BRICK: If I might, please, just don't put all the lawyers in one group. MR. LAWLER: All the lawyers are in your subgroup. MR. BRICK: We need everybody together so that, you know, we hear all the stories from everybody. MR. LAWLER: I think what we tried -- there was some method to our madness. I do think we tried to spread people out, you know, in terms of expertise. You know, we tried to put as many of the rural people on the rural. You know, it was not total madness, only partial madness. MS. DEERING: Can I just ask who is here representing Ronald Coleman as Chair? MR. BOTTS: I am. MR. LAWLER: I talked with Ron. He's, unfortunately, out of town but is eager to participate and will be here. Joan? MS. KING: Joan King from AARP. If we're on a committee, say the "Infrastructure," and we have -- and AARP has a policy on rural healthcare, we would like to be able to make comments to that committee. MR. LEWIS: Absolutely. MS. KING: The other thing is my name appears in here with neither a phone number or a fax. How do we handle that? MR. LAWLER: In your packet, there's a blank information sheet for you to fill out which is -- and we probably have people's wrong phone numbers and wrong addresses and all that. So please, please, please fill them out MR. MAXWELL: And no one gets out of this room without turning one in. MR. LAWLER: That's right. MS. RICCIARDI: Give it to me or Thayer. MS. DeMers: Could I plead for more at least more notice than we had? I ended up paying what it would cost me for two trips out here for this trip. MR. LAWLER: Yes. Lygeia, how soon will we have another meeting? MS. RICCIARDI: Well, the reason that we haven't given you a date for the July meeting is that we want to structure it around a joint board meeting which has not yet been set, and that's what we're waiting on. If they take too long, we will set it -- what? Within -- we realize that you folks need more time to prepare for this. Shall we just say within say a week we'll have an answer? MR. MAXWELL: You will have a date within a week. MS. DeMERS: Right. As long as we get three week's notice, that's fine. MR. MAXWELL: Right. What we wanted to do -- the joint board had tentatively scheduled a meeting about the third week or so in July. What we wanted to do was to be able to have a meeting before that because that meeting's going to be in Los Angeles. Lots of people would not be able to get out there. So we would at least have the potential of some people able to join the joint board there so that we can keep input going in and not sort of have to run up at the end and do that. So we will commit to having a date in -- MS. PUSKIN: Can I make a plea that you not set it for the same time as the COMNET meeting, which is in Washington, which is around the 17th -- MS. DEERING: The week of the 17th. MR. MAXWELL: If there are dates anywhere, let's say, between the 7th and 17th or so of July that don't work for you, could you feed them to -- MS. PUSKIN: That week of the 15th of July is bad. It's a pretty bad week. MR. LAWLER: That is the time frame we're looking at, between that really -- after that 4th of July week through the 20th of July or thereabouts. MS. PUSKIN: That particular week is a very, very bad week. MR. LAWLER: In September, we're talking soon after Labor Day. Isn't that right, Lygeia? MS. RICCIARDI: Yeah. We thought the third. But we can change that if that's a problem for us as a group. But that's what we're aiming for now. MR. TANGELOS: The Labor Day holiday is Monday the 2nd of September. MR. LAWLER: Yeah. We may want to -- we'll give a little time in between. MS. RICCIARDI: Oh, okay. MR. MAXWELL: Toward the end of that weekend is what we were thinking about. We do apologize about the time frames. MS. DeMERS: I think it was understandable for this time. I'm just making a plea for future hearings. MR. LAWLER: Yeah, you're absolutely right. Any more housekeeping things that we have not covered, Lygeia or Thayer? MS. RICCIARDI: Yeah. Just a couple of logistical things. You have in your folders a schedule for today, and it tells you that at 2 o'clock we're going to be reconvening in the Dirksen Building, which is the building connected to this, in Room 106, to look at the demos which have been organized by the Congressional Ad Hoc Steering Committee on Telemedicine and Healthcare Informatics. And if they ask you, just identify yourself as either a member of or a participant in our meeting here. And then, as you will also see on your schedule, at 3 o'clock, in the same building, different room, on the ground floor, Dirksen Room 50, we're going to have a press conference at which Chairman Hunt will be speaking as will Commissioners Ness and Chong from the FCC and several Members of Congress. They will be Senators Snowe, Rockefeller, Exon, Conrad, and Pressler. So we'll look forward to seeing you at both of those events. MR. LAWLER: And after the press conference -- and, Lygeia, correct me if this is wrong -- but after the press conference, if we can hang around for a couple of minutes, the three commissioners are just going to say a few minutes worth of, you know, thanks for doing this, here's how we look at it, in the same room, right after. And the press conference shouldn't take very long. We won't keep everybody hanging around too long. (Whereupon, at 1:00 p.m., the hearing was concluded.) // // // // // // // // // // // // // REPORTER'S CERTIFICATE FCC DOCKET NO.: CASE TITLE: TELEMEDICAL ADVISORY COMMITTEE HEARING DATE: Washington, D. C. LOCATION: June 12, 1996 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: _06/12/96__ _____________________________ Official Reporter Heritage Reporting Corporation 1220 "L" Street, N.W. Washington, D.C. 20005 Greg J. Poss 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: 06/14/96__ ______________________________ Official Transcriber Heritage Reporting Corporation Greg J. Poss 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: 06/20/96__ ______________________________ Official Proofreader Heritage Reporting Corporation Barbara Blossom