U.S. GOVERNMENT PUBLISHING OFFICE

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S. HRG. 114–868

AGING IN PLACE:

CAN ADVANCES IN TECHNOLOGY HELP

SENIORS LIVE INDEPENDENTLY?

HEARING 

BEFORE THE

SPECIAL COMMITTEE ON AGING

UNITED STATES SENATE

ONE HUNDRED FOURTEENTH CONGRESS

FIRST SESSION

WASHINGTON, DC

MAY 6, 2015

Serial No. 114–05

Printed for the use of the Special Committee on Aging

( 

Available via the World Wide Web: http://www.govinfo.gov
(II) 

SPECIAL COMMITTEE ON AGING

SUSAN M. COLLINS, Maine, Chairman

ORRIN G. HATCH, Utah

MARK KIRK, Illinois

JEFF FLAKE, Arizona

TIM SCOTT, South Carolina

BOB CORKER, Tennessee

DEAN HELLER, Nevada

TOM COTTON, Arkansas

DAVID PERDUE, Georgia

THOM TILLIS, North Carolina

BEN SASSE, Nebraska

CLAIRE MCCASKILL, Missouri

BILL NELSON, Florida

ROBERT P. CASEY, JR., Pennsylvania

SHELDON WHITEHOUSE, Rhode Island

KIRSTEN E. GILLIBRAND, New York

RICHARD BLUMENTHAL, Connecticut

JOE DONNELLY, Indiana

ELIZABETH WARREN, Massachusetts

TIM KAINE, Virginia

PRISCILLA HANLEY, Majority Staff Director

DERRON PARKS, Minority Staff Director
(III) 

C O N T E N T S 

Page 

Opening Statement of Senator Susan M. Collins, Chairman .............................. 1 

Opening Statement of Senator Claire McCaskill, Ranking Member ................... 3 

PANEL OF WITNESSES

Laurie M. Orlov, Founder, Aging in Place Technology Watch ............................. 5 

Carol Kim, Ph.D., Vice President for Research, University of Maine ................. 7 

Maureen McCarthy, M.D., Deputy Chief Patient Care Services Officer, Veterans Health Administration, and Acting Chief Consultant for Telehealth

Services, U.S. Department of Veterans Affairs ................................................. 8 

Marjorie Skubic, Ph.D., Professor of Electrical and Computer Engineering,

and Director, Center for Eldercare and Rehabilitation Technology, University of Missouri ..................................................................................................... 10 

Charles S. Strickler, Caregiver ............................................................................... 12 

APPENDIX 

PREPARED WITNESS STATEMENTS

Laurie M. Orlov, Founder, Aging in Place Technology Watch ............................. 31 

Carol Kim, Ph.D., Vice President for Research, University of Maine ................. 34 

Maureen McCarthy, M.D., Deputy Chief Patient Care Services Officer, Veterans Health Administration, and Acting Chief Consultant for Telehealth

Services, U.S. Department of Veterans Affairs ................................................. 37 

Marjorie Skubic, Ph.D., Professor of Electrical and Computer Engineering,

and Director, Center for Eldercare and Rehabilitation Technology, University of Missouri ..................................................................................................... 41 

Charles S. Strickler, Caregiver ............................................................................... 43 

QUESTIONS FOR THE RECORD

Laurie M. Orlov, Founder, Aging in Place Technology Watch ............................. 51 

Marjorie Skubic, Ph.D., Professor of Electrical and Computer Engineering,

and Director, Center for Eldercare and Rehabilitation Technology, University of Missouri ..................................................................................................... 53 

STATEMENTS FOR THE RECORD

Laurie M. Orlov - Technology for Aging in Place .................................................. 59 

Marjorie Skubic, Ph.D. - Aging in Place and Eldertech Research at the University of Missouri ............................................................................................... 100 

(1) 

AGING IN PLACE:

CAN ADVANCES IN TECHNOLOGY

HELP SENIORS LIVE INDEPENDENTLY?

WEDNESDAY, MAY 6, 2015

U.S. SENATE,

SPECIAL COMMITTEE ON AGING, 

Washington, DC.

The Committee met, pursuant to notice, at 2:07 p.m., Room 216,

Hart Senate Office Building, Hon. Susan M. Collins, Chairman of

the Committee, presiding.

Present: Senators Collins, Cotton, Perdue, Sasse, McCaskill,

Casey, Blumenthal, Donnelly, and Kaine.

OPENING STATEMENT OF SENATOR

SUSAN M. COLLINS, CHAIRMAN

The CHAIRMAN. This hearing will come to order. Good afternoon.

This afternoon’s hearing will explore the potential of new technologies to help seniors age in place safely and to retain their independence.

The U.S. population is aging. According to Census Bureau projections, 21 percent of our population will be age 65 and older by the

year 2040. That is up from just under 14 percent in 2012. Every

day, 10,000 Baby Boomers turn 65. As many as 90 percent of them

have one or more chronic health conditions.

Americans aged 85 and older, our oldest old, are the fastestgrowing segment of our population, and this is the very population

that is most at risk of multiple and interacting health problems

that can lead to disability and the need for long-term care.

At the very time that our population is growing older, the need

for care and support is increasing. The population of professional

and informal caregivers is, however, declining. Today there are

seven potential caregivers for each person over age 80 and at the

highest risk of requiring long-term care. By the year 2030, there

will be four, and by 2050, the number drops to fewer than three.

As a consequence, in the future more and more people will have to

rely on fewer and fewer caregivers.

As people age, they naturally want to remain active and independent for as long as possible. Aging in place is the ability to live

in one’s own home and community safely, independently, and comfortably, regardless of age or ability level.

Surveys taken by AARP consistently reflect the fact that aging

in place is the preferred option for seniors who want to continue
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living independently and avoiding nursing homes and other institutionalize care for as long as possible.

Today’s hearing will examine some of the recent advances in

technology that are providing new options to allow seniors to remain in their homes longer by monitoring their health status, detecting emergency situations such as debilitating falls, and notifying families and health care providers of potential changes in

health status or emergencies.

While it is not a replacement for professional care or personal attention from family members, technology can help to bridge the

care gap and extend the amount and length of time a person is able

to live independently. Technology can also help to reduce isolation

and enrich the lives of seniors by keeping them engaged and connected to their families and their communities.

We will also hear this afternoon about technologies that can

make the lives of family caregivers easier by giving them the tools

they need to support their loved ones as they age in place.

Finally, we will hear from the Veterans Administration, a real

pioneer in telehealth, which has used technologies such as

videoconferencing and smart monitors to reduce hospital admissions and to shorten hospital stays. This has resulted in lower costs

and has also allowed some of our older veterans with chronic

health conditions to live independently at home right where they

want to be.

Many of us are familiar with the decades-old and well-known

phrase, ‘‘I’ve fallen and I can’t get up.’’ That phrase, of course, was

an advertisement for a medical alert system. While many seniors

still rely on this device, breakthroughs in modern technology have

brought us a long, long way, providing many new options for seniors and for their families.

Technological solutions can be cost-effective and tailored to meet

the specific needs of a senior and his or her living situation. Companies that develop these technologies are starting to realize that

not only is there a growing need to design products that meet seniors’ needs, but also that there are many seniors who want technology and devices that look just like those used by younger generations.

For example, this phone is an older-generation device that is specifically designed for seniors to be easy to use. It has large numbers, for example. This new-generation version of the phone is a

smartphone that still has the same ease of use as this old version

of the Jitterbug phone, but looks like the smartphones that people’s

children and grandchildren use.

Much more important than its appearance, however, this new

generation device also includes technologies that help seniors maintain their independence. For example, it has features to help with

medication adherence, provide 24/7 access to medical emergency

operators, as well as an app that the family caregiver can download

to keep them up-to-date on their loved one’s well-being.

We will also explore the challenges posed by these technological

advances such as privacy concerns and the unequal access to the

Internet that exists across our country.

Before I turn to Senator McCaskill for her opening statement, I

want to give a special welcome today to Dr. Carol Kim, the vice
3 

president for research at the University of Maine. Dr. Kim oversees

the university’s Successful Aging Initiative for Living, or SAIL, program. She has traveled to Washington today to tell us about

Maine’s aging and thriving in place movement that will benefit significantly from the development of new technologies, products, and

devices. I look forward to hearing not only from her but from all

of our witnesses this afternoon.

Senator McCaskill.

OPENING STATEMENT OF SENATOR

CLAIRE MCCASKILL, RANKING MEMBER

Senator MCCASKILL. Thank you, Chairman Collins. Helping our

seniors remain in their communities and age with dignity is an important issue and a top priority of this Committee. You have assembled a great panel today, and I am looking forward to hearing

about the exciting innovations that can help seniors and their families.

There is a real disconnect between the number of seniors who

say they want to stay in their homes and communities and the

number of seniors who end up having to move to nursing homes.

In fact, a recent AARP study found that 87 percent of older adults

would prefer to remain in their own communities as they age.

While it may not be possible for every person, depending on a number of factors, to remain in their homes, for many of us, with the

right supports, it is possible, and it is preferable both in terms of

quality of life and certainly for financial implications.

Recent advances in technology are providing these new options

for seniors and their families that can allow them to remain at

home for longer by monitoring health status, detecting emergency

situations, and notifying health care providers about changes in

health status. These technologies can also make family members’

and caregivers’ lives easier by providing them with tools to support

their loved ones and giving them peace of mind. This really is a

win-win situation. Seniors are much happier continuing their normal routines and social activities where they feel comfortable, family members can make sure their loved ones are safe, and society

as a whole benefits from significantly reduced health care and longterm-care costs.

There are many assistive technologies that are already on the

market. Home improvement stores, other big-box retailers, and

even telecommunications companies all sell versions of connected

home systems that can keep seniors secure in their homes. Developers are creating senior-specific monitoring devices such as bed,

toilet, and pillbox sensors that can monitor activity within the

home. Pillbox sensors are so simple in nature, but can prevent

tragic accidents by making sure that seniors are not mixing medications or taking too many pills. Wearable devices are also popular

for tracking physical activity and helping to prevent falls. Falls are

the leading cause of injuries in older adults, with one out of every

three seniors falling each year. Some of the newer fall-monitoring

devices do not even require the push of a button; they can detect

when a person has fallen using an accelerometer. Technology has

also been critical to the growth of telehealth and particularly helpful for seniors who, by using telehealth services, can have their
4 

most of their health monitored from the comfort of their home rather than the doctor’s office.

These innovative technologies are being developed by researchers

all across the country, one of whom is with us here today. I am so

pleased and proud to introduce Dr. Marjorie Skubic. Dr. Skubic is

the director of the Center for Eldercare and Rehabilitation Technology at my university, the University of Missouri. The Center at

Mizzou, in partnership with Americare, has created TigerPlace, a

specifically designed continuing-care living environment that utilizes a number of advanced technologies in the senior apartments.

Dr. Skubic and her team have even found a way to use radar and

3-D sensors to monitor seniors’ risk level for falls. I look forward

to learning more about this and other emerging technologies from

Dr. Skubic’s testimony.

I know there are some concerns about preserving the privacy of

seniors and that using webcams and video-monitoring might

present some challenges. We definitely want to ensure the privacy

of seniors and their dignity using this technology, but we also want

to make sure that we are looking out for their safety. I know that

Mizzou has utilized privacy-preserving techniques, such as using

only silhouettes on video monitors that can help ease some of the

privacy concerns of older adults. The challenge for those who develop these technologies is to find ways to maximize safety with a

minimal invasion of privacy.

Thank you to Chairman Collins and to our witnesses for taking

the time to be here today, and I look forward to listening and

learning from your testimony.

The CHAIRMAN. Thank you very much for that excellent statement.

I want to note that we have been joined by Senator Perdue, Senator Kaine, Senator Sasse, and Senator Casey, and I am very

pleased that you could join us this afternoon.

We are now going to turn to our panel. We will first hear from

Laurie Orlov, who is a tech industry veteran and the founder of

Aging in Place Technology Watch. I understand that she also has

the wisdom to have a summer home in the State of Maine on Frye

Island. That cinched it for me as far as inviting you to testify

today. 

I have already introduced Dr. Carol Kim, who is the vice president for research at the University of Maine.

Our next witness will be Dr. Maureen McCarthy from the Department of Veterans Affairs. She is the Acting Chief Consultant

for Telehealth Services and will discuss the VA’s telehealth program, which by many measures has been a success and has helped

to reduce costs.

Professor Marjorie Skubic from the University of Missouri has already been introduced by the Committee’s Ranking Member.

Finally, I would like to welcome Charles Strickler to today’s

hearing. Mr. Strickler, who is from Virginia, knows all too well the

challenges of caring for seniors who have a desire to age in place,

and he will share his personal story with us and how he has used

technology to assist in the care of his mother and mother-in-law.

First we will start with Ms. Orlov.
5 

STATEMENT OF LAURIE M. ORLOV, FOUNDER,

AGING IN PLACE TECHNOLOGY WATCH

Ms. ORLOV. Thank you. Chairman Collins, Ranking Member

McCaskill, and members of the Committee, I want to thank you for

the opportunity to testify today about the potential and requirement for technology innovation to help older adults age in place.

As you have noted, demographics make this technology market

essential. These categories of enabling technology will help make it

feasible for older adults to meet their needs as they age, and as we

have already noted, nearly 90 percent of adults age 65 want to remain in their own homes and, in fact, today actually are remaining

in their own homes.

Successful aging has been described as ‘‘the ability to do things

for myself; feel safe; and have good health.’’ Aging in place, therefore, is the ability to successfully age in your home of choice, and

aging-in-place products and services, including technology, provide

a useful underpinning and enhancement of the quality of life for

seniors as they age in place.

We have talked a bit about demographics. I just want to add a

couple of refinements of what we have already heard.

We know there are 46 million adults who are 65 or older today,

and of those, 20 million are 75 or older; 46 percent of women aged

75-plus today are living alone. The Society of Actuaries recently updated life expectancy at age 65 to reflect a new reality that women

age 65 can now expect to live on average to be 88.8, with 25 percent of them living to 90 or more. Men at 65 are going to live on

average to 86.6. The average 1-year cost of assisted living in the

United States will be $51,000 a year by 2020, and in the Northeast,

San Francisco, Chicago, and most memory-care units, that number

has already been reached and exceeded. Seniors know this, and

they are deferring move-in to assisted living communities until

they reach their mid–80’s, but most of them still remain at home.

Let us talk about the categories of technology for aging in place.

If you could bring up that slide? Thank you.

They are best represented by what I describe as ‘‘interlocking

pieces of a puzzle’’, and the puzzle paradigm is specifically used

here to show that if you leave out any one of these pieces of the

puzzle, people are at risk of depression, of isolation, and undetected

illnesses, and all kinds of complications in their lives. Older adults

benefit from innovations, and particularly related training and how

to benefit from them, that address their ability to connect with

other people and opportunities, stay engaged in their communities,

be safe, and manage their health and well-being, so looking at each

category, starting with the upper-left puzzle piece, let us examine

them one at a time.

In the category of communication and engagement technologies,

while the devices may change over time—and have changed significantly as you showed by your examples of phones—their purpose

remains the same: They help older adults stay connected to others,

through e-mail, online text, and video chat, searching the Internet,

participating in forums, playing games, finding people with shared

interests, and just as important, finding services and resources that

meet their changing needs, and in particular, with video it can be

used to monitor but can also be used to engage people in some so-
6 

cial connections with their families and friends. Today, while 59

percent of the 65-plus population has access to the Internet and 27

percent have smartphones, both percentages drop off noticeably at

age 75.

The second category on the right upper corner is the safety and

security category. The most important aspect in this category is a

home alarm system that can monitor and alert about fire, temperature, and excessive moisture in the home. Without it, the other

technologies are just nice-to-haves. Other useful technologies listed

here include personal emergency response system pendants, which

we have already talked about, and safety watches; fall detectors in

the home; home-based motion sensors; and activity monitors that

can now monitor absence of activity and decline over time. Increasingly, information from various devices will be combined to detect

changes in patterns over time and we are hoping detect gait

changes or other signs that indicate a risk of falling.

Health and wellness technologies is the category at the bottom

right that includes telehealth, as we have heard, but also

wearables, smartphone apps—as people acquire smartphones, that

may be useful—and online health information, and there are new

tools being developed all the time to help with dementia care, support care coordination, and help find home care workers, and a variety of these new devices can also assist with people of low vision

and people with hearing impairment.

The bottom left-hand corner is about learning and contribution

and how we stay engaged in our society, continue to learn new

things, which is how we remain content with our lives and interested, and it helps keep our minds sharp. Tools that help people

tell and record their life stories, for example, online sites that enable them to volunteer, enable them to find work, 20 percent of

people after the age of 65 these days are actually working, many

of them full-time.

People can learn new skills. They can learn new skills that are

leisure-related and work-related, and all of this online training is

free. This is the times we live in now. It is free. Forums are available to find expertise and ask questions. The biggest problem we

have is that mobile device data plans today average between $60

and 80 a month, and WiFi access is typically being used by people

in coffee shops and libraries because having a high-speed Internet

connection into the home can be quite costly, $50 a month or more.

That is a limitation on access for lots of folks.

As people age, all the four categories are enhanced by inclusion

of the role of the formal and informal caregiver, which you can see

in the middle, and that could include the professional caregiver.

There are newer technologies that not only track time and attendance of caregivers but also communicate care status—that is, what

is going on with activities of daily living, communications with family members, mobility, eating, and cognitive function.

One last point. The future market potential of this market is

greater availability of smartphone features, in-car technologies, and

will move even into robotics. It has been sized at the low end at

$20 billion by 2020, but in the future, you will see fewer specialpurpose offerings for seniors. There will be more examples of standard hardware and device platforms with customizable software that
7 

will meet the specific needs of the user, so we will not have to invent special-purposes technologies for everything. That concept is

called ‘‘Design for All’’ and can be seen today in the customizable

features in your car, in tablets, in smartphones, in television, and

consumer electronics. Design once, customize for the individual.

I hope this overview has been helpful to you, and I want to thank

you very much for your time.

The CHAIRMAN. Thank you for your testimony.

Dr. Kim.

STATEMENT OF CAROL KIM, PH.D.,

VICE PRESIDENT FOR RESEARCH, UNIVERSITY OF MAINE

Dr. KIM. Good afternoon, Chairman Collins, Ranking Member

McCaskill, and distinguished members of the Senate

Special Committee on Aging. My name is Dr. Carol Kim, and I

am appreciative of the opportunity to share with you the technologies that the University of Maine is developing to allow older

individuals to age and thrive in place.

It could not be timelier. We are convinced that the aging and

thriving in place movement is destined to benefit greatly from the

rapid deployment of technologies, products, and devices that maximize human performance; improve mobility, navigation, home environments, and intelligent living; improve emergency detection; and

contribute to older adult falls prevention, mitigation, and response.

The University of Maine has launched a major cross-campus

aging research initiative in partnership with community agencies

and organizations and has established an interdisciplinary research

incubator from social work to engineering to disability studies that

is responding to major public health issues that affect aging Americans.

In the area of home safety optimization and falls prevention, we

are developing technologies to promote mobility, avert falling, increase contrast sensitivity, promote outdoor exercise, and improve

balance. 

One of the most common challenges that occurs with age is loss

of visual contrast sensitivity. This can be extremely dangerous for

older adults as it turns commonplace low-contrast features—show

here in this slide—such as cement stairs, curbs, or benches into

falling hazards. Our goal is to improve safety and reduce falling via

a cost-efficient solution that can be implemented without any infrastructure build-out. To do this, we are exploring the use of computer vision as a means to detect low-contrast edges in the environment and improve their visibility. This technology is likely to reduce the falling problem because it is optimized to address known

perceptual and cognitive changes that occur with age.

Although walkers, crutches, and canes have long been available,

these are minimally functional for outdoor exercise and are perceived as stigmatizing and inconvenient, so in this movie, the assistive jogger was created to fill an unmet need for populations

who, without adequate mobility support, would be less likely, unable, or unwilling to participate in ambulatory exercise. The assistive jogger is an aesthetically designed, convenient, foldable, actively steered, three-wheeled standing support device that improves

balance and weight-bearing assistance during walking, jogging or
8 

running. It is fitted with biofeedback and innovative load-sensing

technology and is currently in the early phase of commercialization.

In the area of falls mitigation and impact minimization, we are

developing advanced energy-absorbing clothing technology. A team

at the University of Maine is currently working to develop non-stigmatizing protective gear to mitigate injury for individuals at risk

for falls. The Maine company, Alba-Technic, a UMaine corporate

partner, has developed a highly effective, impact-resisting material

system and offers a head gear option for older adults that can be

integrated into fashionable headwear while providing protection

against head injury, as shown in this slide. This technology is lightweight and can be incorporated into caps, scarves, and hats. Performance tests demonstrated a significant potential for reducing

head injury.

In 2013, 258,000 people over the age of 65 were admitted for

treatment of hip fracture. The Hip Project expands our current

work with head gear to innovative, wearable hip protection for elders. UMaine researchers are collaborating with Alba-Technic to

design aesthetically pleasing hip protection consisting of undergarments in a changeable shell that will be regularly worn by elders

at risk for falling, and I have samples of this material here if anyone is interested in taking a look at that.

In the areas of fall response, we are developing wireless networking technologies with wireless detection and vital sign sensors

to assist first responders.

Loss of sensory, cognitive, and motor function that occurs as people age can lead to many safety risks for older adults living independently. Current responses to this concern involve installation of

expensive and obtrusive video monitoring. We have re-created a

typical apartment setting for testing a new extensible system that

makes use of minute and low-cost technology such as RFID tags

and micro controllers. RFID tags can easily be embedded into the

physical structure of an apartment—under carpets, behind the

paint on walls and ceilings. Our RFID reading device is small and

designed to be worn comfortably by an individual. The system

tracks the user’s location as they move about their home and sends

an alert if there is a problem. The system will help to reduce inhome falls and improve safety, efficiency, and independence.

Finally, I would like to thank the Committee for the opportunity

to describe some of the exciting and necessary technologies that researchers at the University of Maine are pursuing to improve the

quality of life for our older population.

The CHAIRMAN. Thank you very much, Dr. Kim.

Dr. McCarthy.

STATEMENT OF MAUREEN MCCARTHY, M.D., DEPUTY CHIEF

PATIENT CARE SERVICES OFFICER, VETERANS

HEALTH ADMINISTRATION, AND ACTING CHIEF

CONSULTANT FOR TELEHEALTH SERVICES,

U.S. DEPARTMENT OF VETERANS AFFAIRS

Dr. MCCARTHY. Thank you. Chairwoman Collins, Ranking Member McCaskill, and distinguished members of the Senate Committee on Aging, thank you for the opportunity to discuss the highquality care and support that the Department of Veterans Affairs,

Veterans Health Administration, Telehealth Services programs are
9 

privileged to provide to our Nation’s veterans. Joining me today are

Dr. Richard Allman, Chief Consultant for Geriatrics and LongTerm Services, and Ms Catherine Buck, National Home Telehealth

Lead and Clinical Nurse Analyst for Telehealth Services. Senator

Kaine, she is from Richmond.

VA is recognized as a world leader in the development and use

of telehealth. Telehealth Services are mission-critical to the future

direction of VA care to veterans, and they are one of the VA’s major

transformational initiatives aimed at ensuring care is convenient,

accessible, and patient-centered.

Telehealth increases access to high-quality-care services by utilizing secure information and telecommunication technologies to

provide health services when the patient and practitioner are separated by geographical distance. In Fiscal Year 2014, VA telehealth

occurred in over 900 sites of care, allowing more than 717,000 patients—that would be 12.6 percent of our enrolled veterans—to receive care through telehealth. This amounted to over two million

telehealth episodes of care. Currently, telehealth is available in

over 45 specialty care areas.

At VA, we use three telehealth modalities to ensure excellence in

care delivery.

Clinical Video Telehealth is the use of real-time interactive

videoconferencing, sometimes with supportive peripheral technologies, to assess, treat, and provide care to a patient remotely.

Home Telehealth is a program for veterans that applies care and

case management principles to coordinate care using health

informatics, disease management protocols, and technologies such

as in-home and mobile monitoring, messaging, and video technologies.

Last, Store and Forward Telehealth is the use of technologies to

asynchronously acquire and store clinical information that is then

forwarded to or retrieved by a provider at another location for clinical evaluation.

Home-Based Primary Care began in 1970 and provides long-term

primary medical care to chronically ill veterans in their homes

under the coordination of an interdisciplinary treatment team.

Telehealth support for chronically ill veterans can include recording the weight of the patient, sending regular reminders about

medication, taking medication, asking key symptoms that indicate

the need for a particular intervention.

Telehealth support also allows the patient to send pictures of

healing wounds to a nurse or doctor who can then advise on what

additional care is needed. In addition, telehealth can act as an educational tool and a support system for a caregiver.

For example, a spouse who might be overwhelmed by the complexity of caring for a loved one is provided with the needed knowledge and skills as well as access to emotional support.

VA Telehealth Services have delivered many positive outcomes.

We have increased to primary care and specialist consultations

leading to reduced wait times. Telehealth has improved patient

outcomes resulting in reduced utilization of inpatient care. For example, in Fiscal Year 2014, when we studied veterans receiving

Home Telehealth services for non-institutional care needs and

chronic care management, those enrolled veterans had a 54-percent
10 

decrease in VA bed days of care and a 32-percent decrease in VA

hospital admissions compared when those veterans were compared

to themselves in the year prior to their enrollment in Home Telehealth.

Veterans receiving mental health services via Clinical Video

Telehealth, what we call ‘‘TeleMental Health,’’ had a 35-percent reduction in acute psychiatric bed days of care.

In addition, VA Telehealth Services programs reduce the necessity for veterans to travel to VA facilities for care. Clinic Video

Telehealth and Store and Forward Telehealth have been shown to

result in an average cost savings of $35 to $40 per patient per consultation. Home Telehealth has also decreased costs for VA and

non-VA care and has been shown to reduce VA net patient costs

by $2,000 per veteran per year that were Home Telehealth that

year. 

Most importantly, veteran satisfaction scores have rated high

with between 88 and 94 percent approval for these kinds of telehealth modalities.

In conclusion, VA is transforming health services from being provider-centric to being veteran-centric. For many veterans and their

loved ones, travel to the VA medical centers can be a complicated

and sometimes arduous task. Not only that, travel time is time

away from the veteran’s work or family. VA’s Telehealth Services

programs revolutionize this travel time challenge by changing the

location where health care services are routinely provided, improving access to care for veterans, and helping veterans take a more

active role in the management of their health and well-being.

Madam Chair, this concludes my testimony, and I am prepared

to answer any questions you or other members of the Committee

may have.

The CHAIRMAN. Thank you very much.

Dr. Skubic.

STATEMENT OF MARJORIE SKUBIC, PH.D., PROFESSOR OF

ELECTRICAL AND COMPUTER ENGINEERING, AND DIRECTOR,

CENTER FOR ELDERCARE AND REHABILITATION

TECHNOLOGY, UNIVERSITY OF MISSOURI

Dr. SKUBIC. Thank you for the opportunity to be here among this

distinguished panel and all the Senators and the visitors.

I want to tell you a story about Eva who lived a TigerPlace, the

facility that Senator McCaskill mentioned, an aging-in-place senior

housing facility in Columbia, Missouri, with 54 independent apartments. Residents can stay there through the end of life. If they

need extra help, services are delivered to them.

A private corporation, Americare, build TigerPlace and operates

the housing, housekeeping, and dining. Clinical operations are handled through the nursing school at the University of Missouri.

Dr. Marilyn Rantz, a nursing professor at MU, set up TigerPlace

to investigate new ways to help seniors age in place. We started

testing technology there in 2005.

Back to my story, Eva had a history of congestive heart failure

and a cycle of rehospitalization as her condition worsened, got better, and then worsened again. She volunteered to be a participant

in our sensor study. We installed motion bed and chair sensors in

her apartment. The sensor system detected changes in Eva’s pat-
11 

terns. When Marilyn saw this, she knew that Eva’s health was

again worsening. If we did not act now, she would have to go back

to the hospital again.

In this case, it meant changing her medication. Eva’s doctor was

resistant to this request because Eva had not gained enough

weight to satisfy his standards protocol. However, his one-size-fitsall protocol did not work for Eva. She needed the change now.

Marilyn finally convinced the doctor to change Eva’s medications,

and she never went back to the hospital for heart failure again.

This broke the cycle of rehospitalization. The sensors in Eva’s

apartment picked up subtle changes before Eva or her doctor noticed it.

Since then, we have developed a clinical decision support system

with automated health alerts sent to nursing staff. The system now

includes a bed sensor that captures pulse, respiration, and restlessness; a fall detection system; and a walking gait analysis system.

Sensors are discreetly mounted in the environment and operate

without the client required to wear anything or do anything special.

For example, the bed sensor is installed under the bed mattress.

Two sensors can be installed in the same bed for couples. To respect the senior’s privacy, no surveillance cameras are used. Instead, we use depth images that produce shadowy silhouettes.

The sensor system observes the seniors, learns their typical patterns, and sends alerts to clinical staff when there are signs of

health problems. We have detected early signs of pneumonia, urinary tract infections, pain, delirium, and hypoglycemia. In one

case, we were able to recognize changes in walking speed and

stride length of the husband in the home that corresponded to his

early dementia, even when his wife was living there and they had

many visitors coming into the home.

In the case of a fall, alerts are sent to staff with a link to a depth

video so they can see what happened leading up to the fall. Residents get help immediately.

I do not have a presentation, but pictures and links are included

in my written testimony so you can see what these look like, and

I would be happy to show them to anybody. As a professor, I carry

all of my slides with me, and I have lots.

I have another story about my mother-in-law, Yvette, who did

not have this technology. She got up in the middle of the night, fell

down and broke her shoulder. My father-in-law, Andy, was sleeping

soundly without his hearing aids, so he did not hear her call. She

lay on the floor for hours in pain. The next morning, Andy found

her, but by then the damage had been done. Her shoulder never

healed properly, and she was in constant pain for the rest of her

life. 

With her damaged shoulder, her mobility was severely limited.

She could not cook or bake anymore or pick up her great-grandchildren, and the constant pain was a drain. Even though she survived the fall, her quality of life was drastically diminished. I can

imagine a different outcome if she had had our sensors in her home

and gotten help immediately.

Research studies have shown that the in-home health alert system works. Seniors with the sensors have better health outcomes.
12 

Seniors with sensors have a longer stay in independent apartments

at TigerPlace compared to those without sensors by nearly two

years longer. We now have a commercial partner, Forsyth

Healthcare, that is bringing this technology to seniors. Many of my

colleagues at other universities have also developed exciting technology to help seniors, such as we have already heard today.

The potential for proactive health care is significant. Detecting

health problems early so that early treatment can be offered is

more effective and less expensive than the current approach and

will help keep seniors healthier so they can stay in their own

homes. 

We have seen this work in Missouri. I would like to see it used

throughout our country so that others can benefit, including my

Mom and Dad in South Dakota and your loved ones, too.

The CHAIRMAN. Thank you very much for your testimony.

Mr. Strickler.

STATEMENT OF CHARLES S. STRICKLER, CAREGIVER

Mr. STRICKLER. Good afternoon, Chairman Collins, Ranking

Member McCaskill, and members of the Committee. On behalf of

caregivers of aging parents, thank you all for the opportunity to

testify before you today.

It has been a difficult process to find the right assistive technologies to help our parents achieve their goal to age in place in

a home environment. My wife and I have widowed mothers who

are ages 85 and 76, respectively. Both have always desired to live

at home as long as possible. Needless to say, it has been a challenge to stay in tune with their state of mind, safety, and wellbeing while respecting their spirit of independence and privacy.

Living several hours apart makes it even more challenging.

My mother is very independent and lives alone. She is active in

her community and continues to enjoy gardening. Consequently,

she uses a cellular pendant so she can remain independent and yet

have the security of an alert system that enables her to summon

help with the touch of a button or automatically if she is incapacitated. It works wherever she goes. Unlike most PERS customers,

she is diligent about wearing her pendant. However, we know

PERS solutions have been ineffective for the vast majority of users

for many reasons.

My mother-in-law’s aging experience is one such case. My mother-in-law has experienced a much different aging scenario than my

mother. She has dementia. After arriving at her home and finding

a toaster oven had been left on for more than 24 hours, it was apparent she needed more assistance and we needed to have her closer to us. We modified a cottage next to our home by incorporating

a walk-in tub and handicap accessibility features. She moved in

full-time in September 2012.

Our existing home security system would alert us to doors opening and detect motion in each of the four rooms of the cottage, so

we were able to know when she was active.

As the dementia progressed, we became concerned about falls.

We tried several different PERS products, but she refused to wear

the pendants and would not respond to the unfamiliar ‘‘voice in the
13 

box.’’ In short, these products were ineffective and failed to solve

our concerns.

We worked with our home security company to find and install

some alternative technologies, including a bed sensor, chair sensors, a toilet sensor, a refrigerator sensor, and three big easy buttons to summon help. Incorporated with the existing door and motion sensors, this system enabled Lib to continue to have some

independence and privacy while we were able to monitor her normal schedule and get alerts when patterns changed or when issues

arose that required immediate assistance. We were able to set parameters that allowed us to be alerted via cell phones to potential

falls or wandering alerts, so we could immediately check on her.

For example, bed sensors facilitated tracking normal and changing sleep patterns. The refrigerator sensor helped recognize when

she would forget to eat.

Before she had full-time caregiving, pressing the help button

summoned help. While the system provides many of the alerts

based on individual sensors, it provides a comprehensive wellness

overview, including data summary tools that make it much easier

to see trends and patterns. User-friendly graphics make it easy to

understand what is gradually changing in Lib’s lifestyle. Thus, the

system has enabled to us to know when to layer in additional care

and assistance, matching it to her state of health as her capabilities changed.

My wife and her twin sister, who are the two primary caregivers,

will tell you the three most valued benefits of the system are encompassed by the breadth and totality of the solution.

First and foremost, the system provides a tremendous ‘‘peace of

mind, assuring us Mom is safe, even allowing us to check on her

even when we are not in her cottage.’’

The second major benefit is that the technology is a ‘‘priceless

gift enabling us to honor Mom’s request to stay at home and live

as independently as her capabilities allow.’’ My wife also said, ‘‘Financially, it has been a relief to be able to preserve her resources

allowing us to provide the best possible one-on-one care now that

she needs it.’’ Had we moved her into assisted living, the costs

would have been significant. To date, the cumulative cost for 2091/

2 years, moving into an average Virginia nursing home, would have

been $223,000 plus an additional $104,000 for homemaker and

health aide services. In contrast, the cost of our system was about

$2,200, plus a $59 monthly fee.

While we still need to supplement our own caregiving efforts

with contracted home care support, the nominal investment in

technology has clearly provided a huge cost savings and a higher

standard of care in a more comfortable environment.

The company we are working with has continued to innovate,

and now our system has even more capabilities that would have

been very useful for our family when Lib was more mobile: a stove

sensor alerting caregivers when the stove is left on for prolonged

periods; remote control over thermostats, lights, and locks; motion

sensors activating lights; alert pendants which can unlock the

doors; PERS functionality in their app for quick emergency notifications away from home.
14 

Aging-in-place technologies are not a magic solution that will

solve all of our problems of cost-effectively caring for our aging population, but from our experience, they can be a very integral part

of the solution. These technologies can be objective tools that can

help with the difficult conversations, prolong independence, and

help guide assistance intervention, all in a very cost effective and

non-intrusive manner, affording both caregivers and their aging

loved ones excellent lifestyle choices.

Thank you.

The CHAIRMAN. Thank you very much for your firsthand experience and sharing it with the Committee.

Dr. Kim, as I watched the technology that you illustrated for us

today, I could not help but think that I could have thought for

years and never come up with the assistive jogger. I realize that

there is a certain stigma that is associated with walkers, for example, and that seniors are very eager to avoid those, but how do you

come up with the technologies and the products that you are developing at the University of Maine?

Dr. KIM. In terms of that assistive jogger, for instance, that started with two faculty members in disability studies. One of the faculty members, she herself has walking and balance issues and

wanted to develop some kind of system so that she could exercise

outside and remain active in part of the community. Her goal was

to participate in a 5K.

She partnered with a professor in mechanical engineering, and

students as well, and developed this assistive jogger, and she was

able to complete the 5K, so even though the technology was originally designed for someone with walking issues and who had disabilities, easily you could see that this assistive jogger would be a

great piece of equipment for someone who is aging or someone who

has had a knee or hip replacement and is going through rehabilitation.

As I mentioned in my testimony, there are also sensors that are

included in the assistive jogger so that you can make sure that you

are not putting too much weight on a joint, especially if you are,

again, rehabbing, so there are lots of technologies that can come

from this original technology that can be transferred to the aging

people. 

The CHAIRMAN. That is an example of where some professors

came up with it. Do you survey seniors to see what their biggest

problems are? Do you reach out to health care providers, home

health agencies?

Dr. KIM. All the above, so as an example, you know, even with

a small group of students going to the local assisted living facility

in Orono—that is right there—the students in engineering met

with residents at this facility, and in a 1-hour period of time, you

know, they were asked—the residents were asked, ‘‘Well, what

could we design that would help you in your daily lives?’’ In a 1-

hour period, they came up with 50 different items that they would

like to have designed.

The CHAIRMAN. That is incredible. That just shows that there

really is such a need for this kind of innovative devices.

Ms. Orlov, let us look at the other side of this issue. I read an

article in which you were quoted as observing that, ‘‘Aging in place
15 

does not imply watching us age.’’ I do understand the concerns

about privacy that some of these technologies may raise, particularly web cams, implanted devices even. How can we make sure

that we are striking the right balance between maximizing safety

so that people can stay in their own homes and yet not making

them feel that Big Brother—or maybe actually not Big Brother but

the adult child who is watching them?

Ms. ORLOV. Well, the first thing I would like to say about the use

of any monitoring technologies, there is a concept opting in and giving permission basically that you are willing, and I know a lot of

implementations of monitoring technology have been done under

sort of the—I would not call it the ‘‘guise,’’ but on a basis of threats

basically: ‘‘If you do not let me put this technology in your home,

I am going to have to have you move to assisted living because I

am too nervous about your well-being to leave you living alone.’’ I

would call that sort of the ‘‘loving threat.’’ The loving threat has

worked in many cases, but it is very important that people understand what they are opting into. They are not opting in necessarily

to having their every move watched, and people who design technology properly design for alerts that show, for example, the absence of activity in a particular window of time or the absence of

going near the refrigerator, the presence of a cat or a dog that may

jump by the sensors, the idea that you may go on vacation and, you

know, there are your sensors saying you are not moving but you

are really away for several weeks, I mean, a lot of thought has to

go into how these things are set up and configured, but when configured properly, they can work well.

The CHAIRMAN. Thank you.

Senator McCaskill?

Senator MCCASKILL. Thank you.

I would like to talk a little bit about cost savings and the financial implications of all this and taking things to scale. Professor

Skubic, what are the cost savings that you all can attribute to some

of these advancements as it relates—one of the things we have

tried to stress in this Committee that I think many people out

there who are not directly involved, they do not understand that

a huge proportion of the Medicaid dollars that are spent in this

country are not spent on struggling families who are not working

but, rather, are spent on our seniors who are in nursing homes,

and that the high proportion of nursing home beds that are Medicaid beds makes this a really important hearing for our debt and

our deficit, because if we can figure this out, the cost savings and

the implications of those cost savings are dramatic to the long-term

problem we have with the demographic bubble that is represented

with my generation going into Medicare and ultimately, if not having sufficient money saved, into a Medicaid nursing home bed.

What kind of savings can you actually quantify at this point that

we might be able to realize if we started embracing these monitors

in people’s homes, these sensors?

Dr. SKUBIC. Well, first I want to clarify something. You know, I

am talking about a relatively narrow aspect of this technology rather than the very broad array that Laurie had mentioned, but in the

context of what we are doing, we are specifically looking for early

signs of health changes, early signs of illness and functional de-
16 

cline, and when we first started working with the nurses, they

talked about the typical trajectory of aging and functional decline

in a stairstep fashion where you will go on a trajectory—you will

go on a plateau for a while until something dramatic happens, and

you get dropped down to the next level very quickly until the next,

you know, dramatic thing happens.

Our premise was always if we can recognize the beginning of

that decline so that an intervention could be offered, we can keep

people up at the top of that level, and some people call this ‘‘squaring the life curve,’’ where you go along for some period of time and

then there is a sharp dropoff when you die. I mean, I am hoping

this is what happens to my parents actually.

Senator MCCASKILL. And to me.

Dr. SKUBIC. To all of us, right. Yes, to all of us, that we would

end up being very functionally active until the end.

Senator MCCASKILL. Right.

Dr. SKUBIC. Now, trying to quantify that in terms of cost savings

is really hard. We have not yet done the study that really quantifies the effectiveness in those terms, in economic terms, of the

technology alone. We are involved in an NIH-funded randomized

controlled study right now that has scaled up this work beyond

TigerPlace, and we are hoping to have some economic cost-savings

figures associated with this.

I can tell you that my collaborate, Marilyn Rantz, has looked at

the economic impact of—or the cost savings of using nursing care

coordination in this context, which is what they are doing at

TigerPlace as well. It is how they do the nursing care as well as

how you add the technology part on top of that, and they have

shown quite a dramatic potential cost savings associated with what

they have been able to do with just the organized and coordinated

care, and we have seen, as we have compared the standard level

of care at TigerPlace with those—between those who have sensors

and those who do not, we see much improved health outcomes and

a longer stay in independent living, so I am extrapolating and saying—I do not have the actual quantitative numbers for you, but I

suspect that they are quite significant.

If you look in my written testimony, I did include some numbers

that are based on just the nursing care coordination, part of it, and

those are pretty dramatic by themselves, too. This one statement

that is in here—and this comes from Marilyn’s work—that ‘‘About

10 million people need long-term care in the U.S.’’ Of these, 4.6

million are older than 65 and live in the community. These 4.5 million represent a potential $89 billion in cost savings if everyone

had access and participated in the RN nurse care coordinator intervention that has been tested at the University of Missouri. That is

huge. 

Senator MCCASKILL. Yes, we would love to get the details of that

survey, and just as soon as the academic community can begin to

put some numbers on some of these advancements.

I know that TigerPlace is more expensive than some of the other

facilities that are in the area in terms of care, but I understand it

is small, and you guys are doing a lot of research, and I understand

all that, but I think we have got to start monetizing these savings

as quickly as possible, because the more quickly we can monetize
17 

them, the more quickly we can begin adopting them as part of public policy preferences, which would have a huge impact on their

availability to most people.

Dr. SKUBIC. Actually, TigerPlace is not that much more expensive than a lot of other facilities.

Senator MCCASKILL. Just slightly more.

Dr. SKUBIC. Yes, it is not too much more.

Senator MCCASKILL. Yes, that is right. Listen, I am a big fan of

what you are doing there. I am not trying to—I am just saying I

want to try to deliver this to as many people as possible. I think

in the long run not only does it help their lives, but it helps us

struggle with how we are going to make sure our grandchildren are

not inheriting a debt that they cannot swallow.

Thank you very much.

Dr. SKUBIC. Yes, and I am all in support of that.

The CHAIRMAN. Thank you.

Senator Perdue?

Senator PERDUE. Well, I want to echo the Ranking Member for

her comments. There is an ulterior motive. First of all, we want the

best care we can for our parents and that generation. They have

earned it, and second is this is—I am hearing an opportunity here,

a tremendous opportunity to deal with one of the largest cost items

we have coming at us in the next 20 to 30 years to affect this debt.

Like several of you, Mr. Strickler and others, I have a personal

experience with this. Contrary to some of my political opponents,

I do have a mother, and she is 89, and she is very tech savvy. She

is independent, but this ‘‘aging in place’’ is a new phrase for me.

It is a new phrase for her, but she is living that out.

Contrary to that, my wife’s mother is a bit younger and has just

been diagnose with Alzheimer’s disease, and so we have a different

trajectory there to deal with.

Dr. McCarthy, I am very excited about what you are doing with

the VA. I think you have got a perfect laboratory to answer some

of these questions that you are hearing today, particularly about

cost, about accessibility, acceptability. You have got a perfect laboratory. You have independent patients who are sometimes in denial about need. Second, you have got a medical staff that might

be less than receptive potentially to some of these sort of new technologies, or not. Maybe it is a perfect lab to develop these.

I would like to get your experience about cost, just give us a general sense of that, acceptability with the patients, and also with the

medical staffs that you deal with.

Dr. MCCARTHY. I would like to start by answering about home

telehealth in particular. We have an example of a little device that

would be placed, for instance, in the veteran’s home. I am not going

to turn it on, but this is a device that would monitor, for instance,

the blood pressure or the weight or the temperature or something

of the veteran, and we provide those devices. A device like that

costs about $350 and can be repurposed when one veteran is finished with it, cleaned and used for someone else. The costs of using

a device like that are about $1,600 a year.

When I talked about the cost savings, I did not translate the bed

days of care or the hospital admissions into savings, but if you

think a veteran before the use of a device like this and after the
18 

use of a device like this, for last year, for the patients we started

last year, they had a 54-percent decrease in bed days of care, numbers of days in a facility, and then a 32-percent decrease in actual

numbers of admissions, so that translates into a significant cost

savings. 

I think it is important, though, to know that the devices do not

exist alone. The devices are part of a system, and for us, we have

home telehealth coordinators, so for about every 100 veterans who

are enrolled in our program—and patients need to be selected. It

needs to be the right population of patients. For about every 100,

we have one care coordinator. We—people smart than me—have

published about this data, and we have had inquiries—I have been

in the role of Acting Chief Consultant for Telehealth since September. I have inquiries from all over the world where people want

to reproduce our results, and some of the problems that people in

other countries have experienced, for instance, not having the care

coordinator available or perhaps selecting the wrong group of patients. There are four disease conditions for which these are extremely helpful.

One is congestive heart failure that people have mentioned before. Congestive heart failure basically means that the heart is not

functioning as strongly, as effectively as it used to, and ‘‘congestive’’

because it backs up, the fluids back up. When the fluids back up,

you see things like weight gain, and so weight is an incredibly important sensor for when someone with congestive heart failure is

starting to deteriorate because of their diet or because of some

other condition, and so when the data about weight is conveyed to,

for instance, the home telehealth coordinator, that is a very important piece of information to notice the trend.

Another one is COPD, lung disease, chronic obstructive pulmonary disease, what people sometimes call ‘‘emphysema.’’ Pulse

oximetry devices are attached which can measure, for instance, oxygen saturation and give us a hint when someone needs to intervene.

The beauty of the devices is that for us, the veteran and the caregiver do not have to get in the car and travel, but the intervention

can be made based on the result that is available.

I also wanted to mention PTSD, which is a very important condition for us, where people are able to track their moods or their

symptoms and so forth.

The fourth one I wanted to mention was diabetes, where blood

sugars can be monitored and with that other conditions as well.

The care coordinator serves such a crucial role in trending the

data, in communicating with the patient, communicating with the

health care team, to make sure the interventions happen appropriately.

Senator PERDUE. Well, thank you for that very thorough answer,

and thank you all for your contributions today. Thank you.

Thank you, Ms. Chairman.

The CHAIRMAN. Thank you.

Senator Blumenthal?

Senator BLUMENTHAL. Thank you, Madam Chair, and thank you

very much for holding this very important hearing.
19 

I want to focus on an aspect of security, which perhaps has not

been mentioned so far, and that is the security of the data and the

information that is collected, and perhaps begin with you, Ms.

Orlov, if you could tell us what specific steps have been taken and

what more has to be done to make sure that the personal information, confidential medical and other information, can be kept secure.

Ms. ORLOV. Well, we are in the midst of a data crisis right now

in the United States. You all know about the Anthem 80 million

records that were stolen and the identity theft that is associated

with that. I would say this has created a heightened awareness of

all of the players that are in the continuum of care for not just

older adults but for everyone, and that includes insurance companies, for which this data was, in fact, stolen, but also includes

health care providers and their management of electronic medical

records, so the good news is that awareness has been dramatically

heightened in the past four to six months.

Senator BLUMENTHAL. Well, awareness has been increased, but

should have been heightened years ago.

Ms. ORLOV. Years ago, yes.

Senator BLUMENTHAL. And Anthem’s data, for example, was not

encrypted. Is yours?

Ms. ORLOV. Are you talking to me? I do not have any data, thank

God. The VA maybe you could ask.

Dr. MCCARTHY. Ours is encrypted, yes, sir.

Senator BLUMENTHAL. Would you recommend that data be

encrypted as part of this program to provide that kind of insurance?

Dr. MCCARTHY. We certainly would recommend the protection of

privacy. It is interesting for us because our journey started in the

early 2000’s decade, and the technology that was available to ensure privacy and security has changed, and so some of our rules

and requirements reflect what was available then. Some of our care

into the veteran’s home, for instance, is using devices or technology

that was required at that point. There are newer means to conduct

those kinds of visits, the telehealth visits, and we are migrating

our technology that way, but without compromising security and

safety. 

Senator BLUMENTHAL. I want to ask what may seem to be a complicated question. I am going to try to make it simple. As you

know—and I am the Ranking Member of the Veteran’ Affairs Committee—we have an ongoing controversy about the 40-mile rule,

whether the 40-mile rule should apply to clinics or to the clinics

that can provide the care that the veteran needs. A veteran may

be within 40 miles of a clinic, but the clinic may not be able to provide the care that is needed, so then a veteran is able to go to a

private health provider.

What I am wondering is whether the telehealth program from

hospitals, the 100-plus hospitals that there are, to the hundreds of

clinics would fill a gap that would enable more veterans to go to

the clinics and get the care that they need. How much of that potential have we explored and actually fulfilled? I hope my question

is comprehensible to you.
20 

Dr. MCCARTHY. It is, sir, and thanks for your service on the Veterans’ Affairs Committee. We appreciate it.

What you are talking about is the part of telehealth that we call

‘‘clinical video telehealth,’’ in particular, in which a provider sees

a patient, and a lot of folks are familiar with Skype or Facebook—

not Facebook. FaceTime, I am sorry, but that is the technology that

people are most familiar with, which replicates what goes on with

clinical video telehealth. In VA Central Office, I provide care, continue to provide care now as a psychiatrist to patients I had seen

in the Salem, Virginia, VA Medical Center from time to time, so

those clinical visits can happen from one of our parent hospitals to

the community-based outpatient clinics. They can happen from one

community-based outpatient clinic to another. They are also happening into the patient’s home, and with us, space is a challenge.

We are also looking at exploring ways for the provider to not have

to take up the space of a medical center to be able to provide this

kind of care.

We have probably about 12.7 percent of our patients are engaged

in clinical video telehealth or other kinds of telehealth. There is a

large opportunity for expansion. It is music to my ears that you

ask, and we are working down the barriers that we see and expanding this as an option. I can tell you that someone who wrote

in the mid–1990’s wrote that the biggest barriers to the expansion

of telehealth are not the technologies; they are the administrative

burdens, and what we often refer to as the fact that our Nation has

a health care system that is excellent, but it is a bricks-and-mortar

kind of base health care system based on hospitals.

In Third World countries where there is not a system of hospitals

but there are many smartphones, telehealth has taken off in an incredible way to provide access to patients who have the

smartphones. It is our goal that we will get to the point where the

care can be provided timely, in a veteran-centered way, not clunky,

so that it is easy for the provider, easy for the veteran and the family member to be able to have that care.

Senator BLUMENTHAL. And you used percentage, I think, 12 to 20

percent, is that——

Dr. MCCARTHY. I said 12.7 percent.

Senator BLUMENTHAL. 12.7.

Dr. MCCARTHY. Yes.

Senator BLUMENTHAL. Okay, now use the telehealth.

Dr. MCCARTHY. Yes.

Senator BLUMENTHAL. Thank you. Thank you all for your excellent work.

Dr. MCCARTHY. Thank you

The CHAIRMAN. Thank you.

Senator Cotton, welcome.

Senator COTTON. Thank you, and thank you all, as Senator

Blumenthal said, for your excellent work on a very critical topic

that we will all face one day in our life sooner or later.

Dr. McCarthy, I would like to continue along the lines that Senator Blumenthal was discussing. At the VA, you have focused a lot

on various telehealth approaches. I want to expand that a little bit

and talk more about home telehealth. In a rural State like Arkansas, we face a couple challenges that are relevant here. One is the
21 

small number of health care providers in rural areas. Second is

also the sometimes slow nature of broadband services in rural

areas, in particular areas like eastern Arkansas, where we have

very low population density or the Ozarks or the Ouachita Mountains, given the line-of-sight issues.

In what you have experienced at the VA, how much of the telehealth challenges do you think are going to revolve around that

kind of infrastructure limitation? How much is going to revolve

around the novelty of it or the resistance to change that we all

have a natural human instinct?

Dr. MCCARTHY. That is a good question. I think there is a requirement for buy-in on multiple parts, administratively from the

provider’s perspective and from the patient’s perspective. We can

tell you stories of elderly patients that have kind of coached our

younger providers through their first telehealth visit in a way that

has been very positive for everybody engaged.

Technology is an issue. We have for home telehealth three kinds

of technology that we use: we use device connections; we use the

interactive voice responses; and then we use the Web browsers.

The interactive voice responses is how a lot of people used to do

their banking. They would put in their number in the phone and

what they want to do with what account and so forth, and you can

do that either by pushing buttons or by voice recognition.

The device connections can be through the telephone system, just

a regular telephone system—it is sometimes called the ‘‘P-O-T-S’’

for ‘‘plain old telephone system’’—the cellular system or with an

Internet type protocol, and then through the Web browser.

We have some devices that we are rolling out that have built-in

cellular antennae that allow for that kind of connection, but sometimes the technology is a barrier, and adoption of the technology,

but it has been my experience that so many of our aging veterans

who have grandchildren at a distance are becoming more and more

familiar with the FaceTime and the Skype and so forth, so they are

very engaged in this.

The incredible convenience of not having to travel, to park, to

kind of figure out what is going on, to move around the medical

centers and so forth, to kind of have an appointment at two and

see your provider at two and be done and not have to engage in

all that whole process has been very well received by them. The

home telehealth they are very positive about as well.

Senator COTTON. Ms. Orlov, in your work have you developed a

perspective on this question about infrastructure challenges on the

one hand and consumer taste preferences and habits on the other

hand? 

Ms. ORLOV. Well, I have looked into it. One of the things we have

not talked about is the role of carriers, telecommunications carriers, in boosting connectivity for older adults. There have been

pilot programs in the United States to provide discounts for Internet connectivity for seniors, but at this point there is not a standard program across all the carriers in the United States that would

make Internet access affordable for many people of lower income,

so that is an opportunity, it seems to me, that can be—we can do

a lot more with. The same thing with cell plans, so I think the average cellular plan in the United States now is around $50 to $60
22 

a month, and an Internet service plan at $60 a month now means

you are out $120 a month, which is beyond the means of many people of lower income, so I believe there is an opportunity to work

with the carriers and come up with a better idea.

Senator COTTON. I would say for the record it is just another example of the importance of rural broadband.

Ms. ORLOV. Absolutely.

Senator COTTON. It may provide some cost on the up-front, but

the savings that we can achieve through the Government in Medicare or in our society as a whole through private insurance are no

doubt substantial.

Ms. Orlov, building on some of the work you have done, I have

no doubt that there are very strong incentives in the market to provide this kind of technology given that seniors are a rapidly growing population as the Baby-Boom generation retires. They are generally some of the most affluent citizens in our country as well, so

there are strong market incentives. Are there strong legal barriers

for markets for aging in place to develop, things that we could address as a Congress?

Ms. ORLOV. Legal barriers? Well, I mean, just looking at the

physical environment for aging in place, which is the home—

right?—and looking at building code and looking at the way even

new housing for older adults is being designed, there is no nationwide building code that would make homes even modestly accessible. There is nothing that requires smooth thresholds, nothing

that requires wide doorways and bathrooms, nothing that requires

sink heights that could potentially enable faucets to be accessed if

you are, in fact, in a wheelchair, so if you want to think about

something that could be done to enable people to age longer in

their home from a policy standpoint, it would be to talk to organizations that lobby on behalf of builders, like the National Association of Home Builders, and look at what are the barriers, and there

are probably barriers at the State level in 50 States one way or the

other to enabling use of standards. Even if, in fact, you move into

the home and you are completely able-bodied and have no issues

at all, is your home able to age with you? That is the question.

Senator COTTON. Great. Thank you all again.

The CHAIRMAN. Thank you very much, Senator Cotton. I am very

glad you brought up the issue of rural broadband because that is

a real issue in my State as well, and I was thinking about some

of these sensors and other devices would simply not work in some

parts of the State of Maine. It is something that nationwide we

really need to do more work on.

I am just going to ask a couple of other questions. Mr. Strickler,

I noticed that you did do the cost comparison that all of us are interested in, and you have talked about the cost of the setup was

$2,000 and then a monthly fee of $59, and if my math is right,

when you look over the 2091/2 years, if you had had nursing home

plus home health, it is more than $300,000, and so I think this

does have very important cost implications for us, and one of the

issues I think we as Congress need to work with the administration on is what is reimbursable to health care providers under the

Medicare and Medicaid program, because a lot of times we will pay

for the consequences of unchecked diabetes, but we will not pay for
23 

the ongoing consultation that prevents the person from having the

complications, and I can see many of you nodding on this, so that

is something we need to look at as well.

Mr. Strickler, one final question that I want to ask you, and that

is, in your testimony, you mentioned that I think it was your mother-in-law did not want to wear that emergency alert pendant. How

did you find out about the alternative ways of keeping her safe by

the use of sensors, by putting them all over—it sounds like all over

the house. To make sure she is eating, you put on in the refrigerator door. I do not think most people would even know where to

begin. How did you get the advice you needed on what you should

purchase for her and what was available?

Mr. STRICKLER. I think the approach that we tried to take was

to find a trusted adviser that could help us. Honestly, we started

grappling in the dark, groping in the dark a little bit, if you would,

and explored a couple things that were not successful, and we really reached out and visited with other people that had found solutions that did work, and then said, okay, let us find somebody that

really knows and understands technologies and can help sort of

guide us through this process, so my advice to anybody also trying

to do that would be find a trusted adviser, and then they can help

you identify which technologies are appropriate, because different

technologies are appropriate in different circumstances, and so I

think in our case we reached out to our home security folks, and

they were able to sort of help us zero in on things that really spoke

to the needs that my mother-in-law had, and when we couldn’t get

her to wear a pendant, we needed to be alerted if she fell, so having those sensors, being able to identify if she was up and about

and did not reach Point A or Point B in a timely fashion, it would

send us cellular alerts to let us know, hey, you need to go check

on her and make sure if something is amiss, and so that was very

helpful to be able to reach out and have that resource.

The CHAIRMAN. Thank you, and my final question is for Dr.

McCarthy, and that is, you mentioned that you were doing telemedicine I believe from 900 sites. Is that correct on that?

Dr. MCCARTHY. Let me just check. I believe that is the correct

figure, yes.

The CHAIRMAN. I guess my real question about that is: Is this

happening from your community-based clinics and your VA hospitals?

Dr. MCCARTHY. Yes.

The CHAIRMAN. Or it is not individual outside providers that you

are contracting with?

Dr. MCCARTHY. It could include that, but that is primarily VA

driven from our community-based outpatients and our clinics, and

some of the sites where the care is provided to would be other clinics or other parts across the country; you know, as a network we

are supporting one another, but also the veteran’s home as much

as possible, too.

The CHAIRMAN. I think the cost savings that you have quoted of

$2,000 per veteran per year, when you start multiplying that, you

get into real numbers very quickly.

This has been a very interesting hearing. I want to call on Senator McCaskill for any final questions she might have.
24 

Senator MCCASKILL. I really do not have any final questions, but

I do think we need to go back and look and see how we began distributing scooters with reckless abandon. At one point in time in

the Medicare program, I know when I began talking about scooters,

we actually found a couple of—one woman who worked in my office

whose grandmother had three, and the lift chairs and all of those

things where we are—in many cases they are needed, but how do

we get approval for all those to be paid for by the Medicare program? And what do we need to, instead of paying for those, pay for

sensors that can monitor things that will allow us to intervene in

a way that is cost-effective and healthy and allow seniors to age in

place? And the more quickly the entrepreneurial free market in

this country comes with products that can be brought to scale that

they can present to the Medicare system for possible reimbursement that would result in these savings, I think the more quickly

we could really turn this thing.

I certainly urge all of you that are in academia to continue to

reach out in the public-private partnerships that I know many of

you are engaged in with your companies at the University of Maine

and with your partners at the University of Missouri, and I know

the VA has a lot of commercial partners, the more quickly we can

get this technology to the point that you do not have to have—I

mean, most of us do not have a trusted tech adviser. Therein lies

the problem. Most Americans do not even know where to find a

trusted tech adviser, because if you look up online for a trusted

tech adviser, you are liable to get somebody who is not a trusted

tech adviser.

I think the more quickly we can do that, the more quickly we can

really make some progress in this area, and I really appreciate this

hearing. I learned a lot. I think all of us are motivated at this point

to see if we cannot push this envelope, and I thank all of you for

your work, and thank you once again, Chairman, for a really good

hearing. 

The CHAIRMAN. Thank you very much. I think your comments

are very well taken. This Committee has held a number of hearings

on scams, and we want to make sure that as we start promoting

this kind of new technology that can give peace of mind to caregivers and help our seniors age in place and be in the comfort, security, and privacy of their own homes, that we are not opening a

whole new avenue for con artists out there who will exploit any

possible opening as we have found in our various investigations.

I want to thank all of our witnesses for being here today. Dr.

Kim, I love the fact that you are involving the students at the University of Maine and taking them, I suspect, to Dirigo Pines to talk

with seniors there, and it is incredible that that 1-hour visit came

up with 50 different ideas. That should keep them busy for quite

some time.

Each of our witnesses has contributed to our understanding of

this issue, and I thank you for taking the time to testify before us

today. 

Committee members will have until Friday, May 22nd, to submit

questions to any of our witnesses or additional materials for the

record. 
25 

I want to thank Senator McCaskill and all the members of our

Committee who participated, as well as the Committee staff who

put together an excellent hearing for us today. Most of all, thank

you to our witnesses.

This hearing is now adjourned.

[Whereupon, at 3:31 p.m., the Committee was adjourned.

APPENDIX 

Prepared Witness Statements

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Questions for the Record

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Statements for the Record

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