Testimony to Senate Aging Committee: National e-Care Plan Needed Now

Eric Dishman

This week, almost 6 years to the day of giving similar testimony to the same Senate Special Subcommittee on Aging, I had the opportunity on behalf of theContinua Health Alliance (www.continuaalliance.org) to reflect on the persistent barriers that prevent the widespread implementation of telehealth, aging-in-place, and what Continua calls “e-care” (for “electronic care”) technologies. In this hearing chaired by Senator Wyden from Oregon, we also had participation from Senator Kohl from Wisconsin, Senator Corker from Tennessee, and Senator Collins from Maine. The online video for the hearing can be found here. Below is my intended opening testimony, but this is not a verbatim transcript by any means. I decided to just talk from notes at the last minute. I think this still captures the gist of what I said, though I was nervous about having enough time and barely remember any of it (and refuse to watch myself on video!).

Mr. Chairman and Members of the Aging committee, I thank you for this hearing on aging-in-place innovation. Senator Wyden, I want to thank you in particular for your leadership on independent living and healthcare innovation and for creating this opportunity today to cover such an important topic of bringing healthcare home through new broadband-connected technologies–a topic that has had too little focus in our national dialogue about healthcare reform.

I would like to introduce two technologies before I introduce myself, since getting to know these kinds of e-care systems is more important today than getting to know me.

Preventing Falls

Many of us in this room have had the painful experience of a family member–often an aging parent–falling at home and breaking a hip. This often begins a cascade effect of hospitalizations, institutional care, and even death for many seniors. In fact, 1 in 3 people over age 65 fall each year, and the CDC estimates that falls will cost the U.S. economy $44 billion each year by the end of this decade.

What if we could prevent the majority of falls from ever happening–I hope even as much as 70% or more eventually–by deploying simple e-care technologies in the home? I am wearing a small sensor platform called Shimmer (www.shimmer-research.com) that our Intel team helped to develop with a company called Realtime Technologies in Ireland (www.realtime.ie). We have been using this tiny wireless computer to help capture the detailed, daily movements of seniors in our research program at the TRIL Center in Dublin, Ireland (www.trilcentre.org) with hundreds of seniors to begin to understand–using real data from their movements–what is happening with their bodies over time that makes them more at risk for falls.

We’ve done similar early fall detection research in the homes of seniors using simple motion sensors mounted on their hallway walls, with our colleagues at ORCATECH (www.orcatech.org), the Oregon Center for Aging and Technology in my home town of Portland, Oregon. This kind of home-generated information can be fed back to the seniors themselves to help them track progress towards 10,000 steps or to alert them to instabilities in their walking patterns. Or it can go to authorized family members to alert them to decreases in Mom’s exercise or Dad’s increases in fall risk. And it can be sent securely to physicians to potentially help diagnose and/or differentiate movement disorders or other conditions that might need early medical intervention well before the dreaded hip fracture becomes a reality.

Let me give you one other quick example.

Personalizing Parkinson’s Treatment

If you have had experience with someone dealing with Parkinson’s disease, you might know that the disease can be very difficult to diagnose and even more difficult to treat given how variable symptoms can be week by week–even day by day–and how painful some of the drug side effects can be. About 1.5 million Americans have Parkinson’s today with 50,000 new cases diagnosed each year, and total cost estimates to the U.S. are about $27 billion annually, with medications being a huge chunk of those costs.

I’ve brought with me today a laptop-sized prototype for research we’ve done with Andy Grove, one of the legendary founders of Intel, who is now dealing with Parkinson’s himself and is using some of his Foundation’s resources to help come up with better ways to track and treat the progression of the disease. In our studies of Parkinson’s patients, we have seen them travel to the clinic for their annual or bi-annual exam with a neurologist and exhibit symptoms for that brief visit that aren’t at all indicative of how they are really doing. It’s almost unethical today that we are using crude clinical tools and quick office visits to treat a disease that is so variable–a once-every-six-month visit just doesn’t give an accurate enough picture of what is going on.

This prototype goes home with a patient and allows them to capture more accurate trend data about their tremor, motor skills, and voice changes that might that might someday help us better understand the disease progression. And this e-care research offers the hope of eventually personalizing treatment for a patient–not based on a once a year shot in the dark where they perform tests well for a doctor in a 15 minute exam–but based on behavioral markers and objective measures taken more regularly, longitudinally, and naturally at home.

A Professional Mission

For almost 20 years now, I have been doing social science research and testing dozens of prototypes like these with patients and seniors in their homes. For the past 11 years, I have led Intel’s health research and innovation group, who has studied 1000 elderly households in 20 countries, funded almost 100 university grants in this domain, built two cohorts of seniors households–the ORCATECH and TRIL efforts I mentioned earlier, and helped start several non-profits to try to accelerate R&D and commercialization of e-care and aging-in-place technologies. I am here today, in fact, representing one of those non-profits, the Continua Health Alliance, an international collaboration amongst 227 healthcare, medical device, and technology companies whose mission is to make sure that e-care technologies for the home and consumer are interoperable.

A Personal Mission

We’re making small but important progress on e-care solutions, and I have one of the world’s best jobs in being able to work on so many industry and non-profit efforts for this aging-in-place mission. Professionally, things are going great. But personally, I am frustrated and struggling. While I know from my own research experience and advocacy work that these technologies enable better, cheaper, and safer care at home than many kinds of in-clinic care, I don’t see our country inventing and investing enough in this area. In fact, I can’t even use the products and prototypes my own Intel team has helped to create to care for my aging parents across the country in North Carolina. There is just too little infrastructure or incentive to support e-care. Our antiquated healthcare policies, technologies, and business models are locking us into a 19^th century medical mentality that won’t work for us in a 21^st century economy so challenged by Global Aging.

Over and over again, I see four big barriers–the four Is–to the widespread deployment and benefit of e-care technologies:

1. IMAGINATION

Our policies and infrastructure reflect our imagination of how healthcare should be done, and we have done little to update our thinking about this since the 1850s as hospital-centric care was invented. We imagine healthcare to be reactive to a crisis, injury, or illness. And we imagine care has to be delivered in an institution like a hospital or clinic. We also have an imagination gap–from Congress to clinicians to consumers–about what kinds of e-care technologies for remote patient monitoring, independent living, chronic disease management, and social support are available today and possible tomorrow. Furthermore, just as I lamented six years ago to your Senate Aging colleagues back then, there is no government agency that has taken on reimagining care and shifting it to the home and to the patient through e-care technologies. There is still no executive leader at the federal level to drive this agenda and to work across the agencies to help make the e-care models and marketplace happen.

I have three recommendations for this imagination problem.

1. Appoint a national leader who reports to the President or Secretary of Health and Human Services to own and coordinate e-care innovation and implementation across all agencies.

2. Much as European nations have done, drive a national plan for e-care through a government, not-for-profit, and corporate partnership to accelerate the research, evaluation, and deployment of these technologies (I often call this the “Y2K + 20 Commission”).

3. Bring a demo day of the nation’s current e-care products and future e-care prototypes to a Congressional forum where you and your colleagues can learn first-hand about the promise of these technologies to help with our quality, cost, and access challenges.

2. INVESTMENT

Our nation spends its research dollars–in part because, again, our imagination for healthcare is rooted in reactive medicine delivered by highly-trained professionals–primarily on pharmaceutical and high-end diagnostics. We are so caught up in finding the next great blockbuster drug (even though many critics of the pharmaceutical industry see this as a dying business model) that we don’t stop to ask ourselves where the best results for our research dollars may come from. We will readily spend tens of tens of billions of dollars on creating the next new scanning machine for a hospital technician to look at a broken hip in even higher resolution…or to develop a slightly-improved painkiller…once a senior has already fallen. But we won’t spend $100 million on technologies that might prevent the majority of those falls from happening in the first place. As our National Institutes focus so much on reactive, professional medicine, there is no major grant program on e-care technologies. Yes, there are some small, scattered investments in telehealth and independent living technologies, but there is no coherent and comprehensive national research roadmap or program for tackling e-care in a methodical and scalable way.

Again, I have three recommendations for our investment challenge.

1. At least match the 1 billion euros Europe has invested in what they call “Ambient Assisted Living” technologies in an e-care research program at the National Institutes to jumpstart American researchers in this area.

2. Create a national cohort of elder and chronic patient households with next generation broadband as a resource for companies, non-profits, and universities to test out e-care technologies in larger and more longitudinal studies.

3. Drive “X-prize” or “grand challenge” grant programs to attract new scientists to tackle big aging-in-place and e-care problems like preventing falls, medication assistance, or help with activities of daily living.

3. INCENTIVES

Our healthcare system, as many have pointed out during the health reform debate, is incented to be a “sick care” system instead of a “health care” system. I still remember the phrase a skeptical doctor told me 20 years ago when I first showed him some telehealth technologies: “Face time pays the bills, Eric! I can’t use any of this stuff.” With few exceptions, we pay doctors and nurses for sickness/injury repair on a per-visit and/or per-test basis, not for health outcomes. And we pay for visits that have to be done face-to-face at a medical institution, even when traveling to the clinic or hospital may be more expensive, intrusive, or even dangerous (e.g., from hospital borne infections or catching H1N1 during an outbreak) for seniors and other patients.

My three recommendations for our incentive challenges are:

1. Incorporate e-care technologies as options in payment reform pilots, especially for Medical Homes, Accountable Care Organizations, Payment Bundling pilots, and Independence at Home pilots

2. Insure that the Electronic Health Record “meaningful use” criteria includes the use of e-care technologies as a legitimate option for credentialing & reimbursement.

3. Use Comparative Effectiveness Research dollars to test e-care technologies and disseminate best practices for e-care to the provider community.

4. INFRASTRUCTURE

Finally, our nation’s infrastructure–both our technological infrastructure and our teaching infrastructure–need to be readied for e-care. Because so much of health reform focuses on professional people and places to do care, we have not adequately thought about how we will build a 21^st century workforce and technology infrastructure that reaches into the home and reaches out to the consumer to be integrated into Care Coordination teams. In particular, the chapter on healthcare in the recently released National Broadband Plan is a great start to designing a broadband “pipe” that is ready for the kinds of e-care visits and data collection we need to support aging-in-place, but it is key that some of the expertise brought in to write that healthcare plan at the FCC be used in the implementation phase to make sure it actually happens. If we are not diligent, the focus on e-care and telehealth in our broadband build-out will be a passing fad and won’t end up being designed into other workforce and infrastructure programs.

My three recommendations are for our infrastructure challenges:

1. Insure that our National Broadband Plan implements a next generation network that accommodates the high bandwidth, reliability, privacy, and health prioritization of both consumer access and health data to make e-care everywhere in the U.S. a reality.

2. Develop workforce training (based upon CER studies of e-care mentioned above) for credentialing and licensing new kinds of professional e-care workers who integrate e-visits and telehealth technologies into their everyday practice.

3. Build a national “care corps” of trained volunteers and family caregivers who can effectively serve on care coordination teams using e-care technologies to help complement and offload scarce medical professionals when appropriate.

CONCLUDING THOUGHTS: CREATE NATIONAL E-CARE PLAN

In closing, we have to remember why we’re doing healthcare reform in the first place: because our current model is not economically sustainable or scalable to meet the needs of our demographic situation. We’re doing it because we need a next generation healthcare system for our next generation of seniors and patients who want, need, and deserve to be part of their own care teams…and who want, need, and deserve to receive care at home, on-the-go, at work, or in the community, whenever it makes good medical sense to do so. And at the end of the day, we’re putting ourselves through far more pain, suffering, and death than we need by failing to shift to a more proactive and preventive system that e-care can help us accomplish. These technologies are no magic pill for all of our economic ills, but they most certainly should be part of our 21^st century imagination, investments, incentives, and infrastructure for healthcare.

Global Aging leaves us no choice but to invent new care models for independent living, disease management, and health at home because there is no scenario in which we will magically create enough doctors, nurses, bed space, or dollars to maintain our clinic-centric model of care. As we have done for Global Warming industries and green technologies, we need to catalyze Global Aging industries and “gray” technologies… to help us with our own demographic challenges…and to generate new economic growth in America by leading the worldwide marketplace for new broadband-enabled e-care technologies that can bring healthcare home and to the consumer.

I am honored to have had this opportunity to share my experiences and recommendations with you today. Please let us know–at Continua or Intel–how we can work with you on the committee to make this happen. If you do only one thing as a result of this hearing today, I ask that you work to appoint a federal executive who will work with us to develop the national e-care plan. With that small step, I bet you’ll be amazed at what we can accomplish, if you invite me back in six more years for a progress report. Thank you.