```

[Senate Hearing 114-868]
[From the U.S. Government Publishing Office]

                                                        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
         
         
         
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]         
         

        Available via the World Wide Web: http://www.govinfo.gov
        
        
        
                             ______
 
              U.S. GOVERNMENT PUBLISHING OFFICE 
49-523 PDF             WASHINGTON : 2022        
        
        
                       SPECIAL COMMITTEE ON AGING

                   SUSAN M. COLLINS, Maine, Chairman

ORRIN G. HATCH, Utah                 CLAIRE McCASKILL, Missouri
MARK KIRK, Illinois                  BILL NELSON, Florida
JEFF FLAKE, Arizona                  ROBERT P. CASEY, JR., Pennsylvania
TIM SCOTT, South Carolina            SHELDON WHITEHOUSE, Rhode Island
BOB CORKER, Tennessee                KIRSTEN E. GILLIBRAND, New York
DEAN HELLER, Nevada                  RICHARD BLUMENTHAL, Connecticut
TOM COTTON, Arkansas                 JOE DONNELLY, Indiana
DAVID PERDUE, Georgia                ELIZABETH WARREN, Massachusetts
THOM TILLIS, North Carolina          TIM KAINE, Virginia
BEN SASSE, Nebraska
                              ----------                              
               Priscilla Hanley, Majority Staff Director
                 Derron Parks, Minority Staff Director
                 
                         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

                            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 
fastest-growing 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 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 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 long-term-
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 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.

            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 social 
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 special-purpose offerings for seniors. There 
will be more examples of standard hardware and device platforms 
with customizable software that 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 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 in-home 
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 high-
quality care and support that the Department of Veterans 
Affairs, Veterans Health Administration, Telehealth Services 
programs are privileged to provide to our Nation's veterans. 
Joining me today are Dr. Richard Allman, Chief Consultant for 
Geriatrics and Long-Term 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 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 patterns. 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-fits-all 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. 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 well-being 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 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.
    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 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 decline, 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 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 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.
    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.
    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 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 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 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.
    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.
    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

=======================================================================

      
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]   
      
      
      
      
      
      
      
      
      
      
      
      
=======================================================================

                        Questions for the Record

=======================================================================

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
      
    
      
      
      
      
      
      
      
      
      
=======================================================================

                       Statements for the Record

=======================================================================

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
```