years and panasonic, i don't necessarily think about how people are watching tv. i think ten years from now you'll see a very, very different panasonic than what you see today. i think you'll still be watching panasonic displays of some sort, but i think panasonic will be much better nonfor nonconsumer products -- better known for nonconsumer products than consumer products. >>st why? >> guest: our growth, our sustainable, profitable growth, no question in my mind is going to come from avionics, from energy, from health care, from these markets that we're just scratching the surface in terms of technology applications. >> host: will panasonic still be manufacturing televisions? >> guest: i don't know. >> host: will the word "television" still be in use? >> guest: probably old people like me will still be using the word "television." and i think displays will still have a prominent role in the home for communicating content and information.

>> host: joe taylor, chairman and president of panasonic in north america, this is "the communicators" on c-span. "the communicators" is on location at ces international 2013, the technology trade show. more programming next week. >> just ahead, president obama speaks at a ceremony honoring recipients of this year's national medals for science, technology and innovation. after that we're live with a national health policy conference with industry leaders and representatives of government who will discuss what to expect in health care policy this year. and later more live coverage as former first lady laura bush speaks at the susan g. komen for the cure's global women's cancer summit. >> at age 65 she was the oldest first lady when her husband became president, but she never set foot in washington. her husband, benjamin harrison, died just one month after his inauguration. meet anna harrison and the ore

women who served as first lady over 44 administrations in c-span's new original series, "first ladies: influence and image, their public and private lives and their influence on the president." produced with the white house historical associate, season one begins presidents' day, february 18th, at 9 p.m. eastern and pacific on c-span, c-span radio and c-span.org. [applause] >> president obama recently honored this year's recipients of national awards in the areas of science and technology at a white house ceremony. he said the future of the nation depends on a spirit of curiosity and innovation. >> with well, it is my incredible pleasure and honor to welcome this incredibly talented group of men and women in the white house, and i want to congratulate them on earning america's highest honor for invention and discovery. the national medals of science, the national medals of technology and innovation.

before we start i want to acknowledge the head of the national science foundation, dr. subra sarish who are with us here today. where is everybody? [laughter] where'd you go? there you go. i just wanted to make sure they all showed up. [applause] i especially want to thank secretary steven chu who announced this morning that he will be leaving the department of energy. that will be a loss for us. steve has been a great friend, a tremendous colleague over the past four years working on a whole range of energy issues, but also designing a cap to plug a hole in the middle of the gulf of mexico when nobody else could figure it out, and that's typical of the incredible contributions he's made to this country. this country's further along on the path to energy independence, it's better positioned for the jobs and industries of the

future. so, steve, you have earned more than your fair share of relaxation time, but we are grateful for your extraordinary service. [applause] so thank you. now, this is the most collection of brain power we've had under this roof in a long time. [laughter] maybe since the last time we gave out these the medals -- these medals. i have no way to prove that, and i know this crowd likes proof. [laughter] but i can't imagine too many people competing with those who we honor here today. you know, there's one idea that sets this country apart, one idea that makes us different from every other nation on earth; that here in america success does not depend on where you were born or what your last name is, successing depends on the ideas that you can dream up, the possibilities that you

envisions, and the hard work, the blood, sweat and tears you're willing to put in to make them real. we don't always recognize the genius behind these ideas right away. "the new york times" once described robert goddard's belief that rockets could one day go to the moon as, quote, lacking the knowledge ladled out daily in high schools. [laughter] one engineer called einstein's brand new theory of relativity voodoo nonsense. but with enough time we usually come around. and, you know, we don't give folks the same treatment that galileo got when he came up with new ideas. [laughter] and today it's clearer than ever that our future as a nation depends on keeping that spirit of of curiosity and innovation alive in our time.

so these honorees are at the fore or front of that mission. -- forefront of that mission. thanks to the sacrifices they've made, the chances they've taken, the gallons of coffee they've consumed -- [laughter] we now have batteries that power everything from cell phones to electric cars, we have of a map of the human genome and new ways to produce renewable energy, we're learning to grow organs in the lab and better understand what's happening in our deepest oceans, and if that's not enough, the people on this stage are also going to be responsible for devising a formula to tame frizzy hair. [laughter] as well as inspiring the game tetris. [laughter] but what also makes these individuals unique is how they've gotten here, the obstacles they've overcome and the commitments they've made to push the boundaries of our understanding. jim gates' father, for example, was in the army, and by the time jim was in sixth grade, he had

attended six different schools, but he still remembers the day he came home and saw his father standing on the porch with a big smile on his face, and that's how jim knew he had gotten into mit on his way to becoming one of our foremost experts in super symmetry and strength theory -- string theory. when golam payman first accepted a position at the university of illinois, his office was a converted restroom. [laughter] but he carved out enough space for himself, his secretary and his lab equipment, and today he's known as the father of lasik eye surgery. sandra moore faber had a passion for astronomy from the very beginning, but when she visited one of our nation's top observatory as a grad student, they didn't have a dorm for females.

she became one of the world's foremost experts in the evolution of the universe. you know, in a global economy where the best jobs follow talent whether in calcutta or cleveland, we need to do everything we can to encourage that same kind of passion, make it easier for more young people to blaze a new trail. right now only about a third of undergraduate students are graduating with degrees in science, technology, engineering and math. areas that will be crucial if we expect the to complete the work that has been done by these folks and compete for the jobs of the future. and that's why we've worked to make more affordable college opportunities and set a goal of training 900,000 -- 100,000 new math and science teachers over the next decade. and we're working to train two million americans at our community colleges with the skills businesses are looking for right now.

we also need to do something about all the students who come here from around the world to study, but we then send home once they graduate. on tuesday i was in las vegas talking about the need for comprehensive immigration reform, and one important piece of that reform is allowing more of the best and brightest minds from around the world to start businesses, initiate new discoveries, create jobs here in the united states of america. if we want the to grow our economy and strengthen the middle class, we need an immigration system built for the 31st century, it's -- 21st century, the that simple. and one of the scientists being honored today is jan belgin. he was born in yugoslavia to jewish parents who fled the nazis during world war #-r. his parents placed him in an orphanage run by catholic nuns, and later he and his mother were

taken in by brave farmers in a slovac village and hiding. and today he's a pioneer in the treatment of inflammatory diseases like arthritis. you know, people like jan, obviously, had enormous talent in some fundamental ways they were destined to be on this stage. the minds they were born with, the drive they innately possessed, the positive forces that shaped their lives were more powerful than the forces aligned against them. so they beat the odds. but even with all those gives, every one of today's honorees also had somebody who offered them a happened, a teacher -- a hand; a teacher who sparked their interest, a scholarship that paved the way and an opportunity to come to america and bring even the most distant dream within our reach. and that reminds us of our obligations to each other and to this country. we can, you know, no matter how

many talented folks there are in this country if we're not offering a hand up, a hot of of those folks -- a lot of those folks are going to miss out on what might be their destiny. we can make it easier for our young people to learn the skills of the future. we can attract the brightest minds to our shore. we can celebrate and lift up and spotlight researchers and scientists like the ones here today so that somewhere a boy on an army base or a girl looking through a telescope or a young scientist working out of a converted bathroom can make it their goal to stand where these honorees will be standing when they receive their medals. that's what we can do, and that's what we must do. that's what i intend to do as long as i'm president. so i want to congratulate these extraordinary americans once again for all their

accomplishments. i want to wish our military aides the best of luck as they attempt to read the citations do -- [laughter] because i can assure you they practice hard on this all week long. [laughter] you good? you feel good? [laughter] all right. there are a lot of syllables in sol of these things. [laughter] all right. and i won't know the difference, but they will. [laughter] all right. congratulations, everybody. [applause] >> alan j.bard. 2011 national medal of science to alan j. bard, the university

of texas austin for contributions in electrochemistry including electrohuman necessary sense, semiconductor, photoelectrochemistry and the invention of the scanning electrochemical microscope. [applause] sally w. chism. [applause] 2011 national medal of science to sally w. chism, massachusetts institute of technology, for contributions to the discovery and understanding of the dominant photosynthetic organisms in the ocean,

promotion of the field of microbial oceanography, an influence on marine policy and management. [applause] [applause] >> sydney dr. drell. [applause] 2011 national medal of science to sidney d. drell, stanford university. for contributions to quantum

field theory, application of science to inform national policies in many security and intelligence and distinguished contributions as an adviser to the united states government. [applause] .. >> for leadership in numerous have breaking studies in galaxy

formation's and for oversight of the construction of important instruments, including the tech telescope. [applause] >> sylvester james gates, jr. [applause] >> 2011 national medal of science to sylvester james gates, jr., university of maryland for contributions to the mathematics of supersymmetry and particle field and string theory, and extorted efforts to engage the public on the beauty and wonder of fundamental civics. [applause]

>> solomon golomb. [applause] >> 2011 national medal of science to solomon golomb, university of southern california for pioneering work and ship register sequences that change the course of communication from analog to digital, and for numerous innovations in reliable and secure space, writer, cellular, wireless negations. [applause] >> john goodenough.

[applause] >> 2011 national medal of science to john b. goodenough, university of texas, austin, for groundbreaking research that led to the first commercial lithium ion battery which has since revolutionized consumer electronics with technical applications for portable and stationary power. [applause]

[laughter] >> m. frederick hawthorne. [applause] 2011 national medal of science to m. frederick hawthorne, university of missouri, for highly creative pioneering research in inorganic, organometallic chemistry, sustained up her found contribution to scientific and technical advice related to national security, and for effective and devoted service to the broad field of chemical sciences. [applause]

>> leroy hood. [applause] 2011 national medal of science to leroy hood, institute for systems biology, for pioneering spirit, passion, vision, interventions and leadership combined with unique cross disciplinary approaches resulted in entrepreneurial ventures, transformative commercial products, and several new scientific disciplines that a challenge and transform the fields of biotechnology, genomics, personalized medicine and science education. [applause]

>> barry c. mazur. [applause] >> 2011 national medal of science to barry c. mazur, harvard university, the original and landmark contributions to differential policy, number theory, algebraic geometry where him and other applications his work was fundamental to wild proof of fairmont theorem and for his dedication to communicating subtle mathematical ideas to the broader public. [applause] >> lucy shapiro. [applause]

>> 2011 national medal of science to lucy shapiro, stanford university, for the pioneering discoveries in bacterial cell controlled by an integrated genetic circuit functioning in time and space that serves as a systems engineering paradigm underlying cell differentiation and ultimately the generation of diversity in all organisms. [applause] >> anne m. treisman. [applause] >> 2011 national medal of science to anne m. treisman,

princeton university, for a 50 year career of penetrating originality and depth that has led to the understanding of fundamental limits and the human mind and brain. [applause] >> frances arnold. [applause] >> 2011 national medal of technology and innovation to frances h. arnold, california institute of technology for pioneering research on biofuels and chemicals that could lead to the replacement of pollution generating materials. [applause]

>> george carruthers. [applause] >> 2011 national medal of technology and innovation to george carruthers, u.s. naval research lab, for invention of the far uv in electric graphic camera, which significantly improved our understanding of space and earth science. [applause] >> robert langer.

[applause] >> 2011 national medal of technology and innovation to robert langer, massachusetts institute of technology, for inventions and discoveries that led to the development of controlled drug release systems, engineered tissues, and you inhibit or is a new biomaterials. [applause] [laughter] [applause] >> norman r. mccombs. [applause]

2011 national medal of technology and innovation to norman r. mccombs, for the development and commercialization of precious wing adsorption oxygen supply system with a wide range of medical and industrial applications that have led to improved health and substantially reduce health care costs. [applause] >> gholam a. peyman. [applause] >> 2011 national medal of technology and innovation to gholam a. peyman, university of arizona college of medicine and arizona retinal specialist, for invention of the lasik surgical

technique and for developing the field of drug administration and expanding the field of retinal surgery. [applause] >> arthur h. rosenfeld. [applause] >> 2011 national medal of technology and innovation to arthur h. rosenfeld, american council for an energy-efficient economy, and california institute for energy and environment, and lawrenceburg late national laboratory, for extraordinary leadership in the development of energy efficient building technologies and related standards anthology.

[applause] >> jan t. vilcek. [applause] >> 2011 national medal of technology and innovation to jan t. vilcek, new york university school of medicine, for pioneering work on key contributions to the development of therapeutic antibodies. [applause]

>> rangaswamy srinivasan. 2011 national medal of technology and innovation this annual them, rangaswamy srinivasan and james wynne, for the pioneering discovery of laser, photo decomposition of human and animal tissue, laying the foundation for laser refractive surgical tech needs that have revolutionized vision enhancement. [applause]

>> edward campbell. [applause] >> 2011 national medal of technology and innovation to transport technologies, cambridge, massachusetts, for sustained innovation through the engineering of the first of the kind practical systems in acoustics signal processing and information technology. [applause] >> that wasn't bad.

[laughter] >> well again, i just want to congratulate all the honors here today. can everyone please give them one more big round of applause. [applause] >> well, we are so grateful to all of you, the incredible contributions that you have made have enhanced our lives in immeasurable ways, in ways that are practical, but also

inspirational. and so we know that you're going to continue to inspire us, and in many cases, teach the next generation of inventors, scientists who will discover things that we can't even dream of at this point. so i thank you so much for everything that you have done. i hope that all of you enjoy this wonderful reception. feel free to, you know, party here. [laughter] you know, this looks like a somewhat wild crowd. [laughter] so, you know, just remember there are secret service here. [laughter] if you guys get out of hand. so thank you very much, everybody. [applause] spent if you missed any of the president's remark their available on our website. go to c-span.org. going now live to the research

for my cabinet health as a hosting a conference featuring health and human services secretary kathleen sebelius. she will be described the health care law known as the affordable care act, or sometimes referred to as obamacare. spent we focus on mobile health applications to solving some of her health issues. we are also focusing on the increasing importance in decision-making. of course, innovative payment model and also employers are going to tell us about what they are doing to try to promote employees health and productivity and to constrain costs. so if you look at the agenda, which thanks to a wonderful planning committee i think is really, really good, we have a wonderful session, and truly respected speakers. so i'm delighted to start this year's conference by introducing the first speaker, secretary kathleen sebelius. secretary sebelius was sworn in as the 21st secretary of the department of health and human services on april 28, 2009.

since taking office, she has led ambitious efforts to improve america's health and enhance its services, particularly to some of the nations most vulnerable populations, including children, those with disabilities, and the elderly. as part of the historic affordable care act, secretary sebelius isn't limiting reforms which will fundamentally alter the health insurance marketplace and will help 34 million uninsured americans can coach. under the law she is also carrying out a new and strong focus on wellness and preventi prevention, supporting the adoption of electronic health records and health information exchange, and helping to recruit and train more primary care providers. before her cabinet appointed him she served as governor of kansas, as the kansas insurance commissioner, and then the kansas house of representatives. and, in fact, i think public life is in her blood as she is the daughter of john gilligan, the former governor of ohio. secretary sebelius.

[applause] >> thank you. well, good morning, everybody. i'm delighted to start off a new week with all of you, and glad to have you in washington at this incredibly important time. i want to thank lisa for her leadership of the academy health, but also for her longtime service in health care. she's an alumni of hhs. she did spend a considerable amount of time at our agency for research and quality, as well as work in the private health system. so it's my pleasure to be with you again here i don't think there's any question that health researchers play an absolutely invaluable role in our efforts to build a more effective health

care system. we have to know we are doing. we have to be able to measure what we're doing, and we have to see if it's working. you are the ones who tell us where they need is greatest, which approaches are actually working, when we need to go back to the drawing board. and the foundation of a 21st century health system that actually works in this country has got to be the evidence-based that you are in the process of assembling. now, i know you're going to hear from a variety of hhs leaders, and i think right after this panel, dr. mostashari, who is our office of national coordinator leader in health i.t. is going to be speaking. but i want to spend just a minute acknowledging a leader who has done so much to advance health services research over the past few decades. as some of you know, doctor clancy has announced that she will be leaving our department after 23 years, including the

last 10 as the director. now, caroline's record of a congressman's speaks for itself. she's run arc at a time when its profile has never been higher, and the demands for its insight has never been greater. under her leadership, arc produce its first ever annual report on quality, safety and disparities. finally, giving us the important benchmarks we use to track our progress. and arc research has led to significant improvements in health outcomes in areas like health associated infection. caroline has generously agreed to stay on until we find someone to cover position, and i can guarantee you that will not be easy. but today i want to some half of the department, but more important on behalf of millions of americans benefiting from better, better, safer care, how grateful we are for her service. thank you, carolyn.

[applause] >> so the last time i spoke to this conference should -- conference was in 2010, a few weeks before the passage of the affordable care act. and when i look back, that seems like a very long time ago. now, the law has done a couple of things. when it comes to health insurance, consumers now have the strongest set of protections in history. already, more than 3 million young americans have gained coverage through their parents plan. preventive care is free for tens of millions of americans. and seniors with the highest drug costs are already getting big savings on their prescriptions. at the same time, and i like to tell people in my mind, this is so like synchronized swimming, so there's a lot of focus on the bathing caps, which is the health markets being formulated,

but underneath that water there is a lot going on in the delivery system. and not enough people i think are paying attention to that. we are beginning to see i think a remarkable transformation in the health care delivery system. new models of care are proliferating. already more than 250 health organizations, overly all shapes and sizes, have agreed to form accountable care organizations. and that means already as many as 4 million medicare beneficiaries get their care from providers whose bottom line is actually working to keep them healthy. and these new models are spreading rapidly in states and the private market. in response to the changes and new incentives, health care providers are embracing new data tools that make it easier to improve care and share information between providers and patients. they use of basic electronic

health records has doubled since 2008. and more than 80% of hospitals have committed to being meaningful users of electronic health records by 2015. now, this is an area that's been talked about for decades in this country, but very little had changed until recently, and this is a huge step forward. most importantly, the changes are translating into real improvements in people's lives. for example, hospital readmissions in medicare have fallen nationally and dropped 25% or more in some communities. meanwhile, we've had three years in a row of historically low growth in health care costs, and while we can contribute to drop entirely to the law, it's undoubtedly a positive sign. so the affordable care act, as lisa said, with the supreme court and now the election, is the law the land. it's here to stay, and it's beginning to show great promise.

the wheels of progress in american health care are turning, but we've only just begun to see the difference this law can make. in the coming months and years, we'll have a huge opportunity to speed up the transformation of health care in a way that will truly benefit all americans. that we will need to continued efforts of partners across the health care system and around the country to achieve the laws full potential. now again, it starts with coverage expansion. tens of millions of americans are still outside of the payment system. but as you know, new marketplaces are being put together in every state in the country that will make affordable coverage available to millions of americans, beginning january 12014. and in addition, and in state legislatures throughout the country there's a debate underway about expansion of medicaid programs.

for people without insurance, ma the benefits of coverage are huge. they are likely to get preventive care and checkups. federal have to weigh the cost of going to the emergency room when they're five euros wakes up with a fever, and there's no risk of losing everything you have if someone gets seriously ill and runs of a big hospital bill. but the truth is, when friends and neighbors can afford the health care they need, it's not just good for them. it's good for all of us. we all benefit when our premiums are no longer inflated with tens of billions of dollars in added costs for uncompensated care. we all benefit when workers can spend more time on the job, and kids can spend more time in school. and one reason we need influential voices like yours to make these points is that several states right now are still weighing the decision about whether to expand their medicaid program eric decisions that will affect whether

millions of americans get coverage. so the snapshot is that states are being offered in incredible deal, and i say that as a former governor who would've loved to have had this deal at any time from the federal government. if they expand their medicaid program to serve adults, making up to about $1200 a month in families making up to $2500 a month, then the federal government picks up 100% of the bill for the first three years, and gradually that share is reduced, but the lowest level at the end of 10 years is a 90-10 split. there's never been a federal-state partnershpartnersh ip that looks anything like this. it's an opportunity to provide insurance coverage to some of the lowest income working americans throughout the country. so in exchange for picking up a tiny fraction of the tab, states

can dramatically expand coverage for working families. they can help increase productivity, saves lives, and reduce the burden of uncompensated care. i would say it's as good a deal as any state is going to get, and i'd love your help in getting the facts into the debate. but merely expanding access to health insurance is not enough. and less people know that affordable coverage is available to them, and unless they know how to get it, they are likely to remain outside the health system looking in. and that means we have a huge job over the next year. we have to reach out to millions of americans who, in many cases, haven't spent a lot of time in the health insurance market, or thinking about health insurance. some of the people believe that affordable health insurance is just out of reach. they are so used to exorbitant premiums and insurance companies jerking them around, that they've understandably come to believe that having coverage for

themselves and their families is just never going to be an option. others our young people here can now, if you have children in their \20{l1}s{l0}\'20{l1}s{l0}, like i do, who know that health insurance may not be their top priority, sometimes i wonder what their top priority is, but i can pretty well guarantee you, it's not health insurance. and yet we know a lot of those young people take the biggest risk because they're less likely to have the resources they need to cover care out of pocket. so if we are going to fulfill the full promise of the affordable care act and ensure millions more americans, we need to reach these people. and we need your help to do that. part of it is educating people about the new marketplaces. they need to know there's a whole new way to shop for health insurance. they will be able to submit a single application defined all the plans that fit their budget. discrimination against preexisting conditions will be

outlawed, and there will be tax credits for most of the people who are newly eligible so that working families can save money on their coverage right away. now, we have a website up and running, healthcare.gov, which has up-to-date information about what's coming and what you think about. we are beginning to collect names so they can send people updates. but it is a strategy that is going to take a lot of outreach and effort. everyone can play a role in educating americans about the new coverage options that are coming. if you're a health care provider, you can start talking to your patients. if you here as a state or local official, you can share information with people who seek out government services are if you're one of the policy analyst in this room, you can help identify better ways to locate uninsured, and move them and motivate them to purchase coverage.

and if you're a researcher, you can help make sure that once people get coverage, they get the care they need. especially critical preventive services. so many of us in this room have been arguing for decades that making health coverage affordable to all americans is one of the best investment we can make as a nation. now we finally have the chance to make that happen. we need to do everything we can to make the most of it. but as i said before, those are the bathing caps. so, the coverage expansion isn't the only part of the law that is kicking into gear over the next year. in the years before the health law will pass, costs continue to rise at an unsustainable rate. america continues to spin and evidently more, about one and half times as much as any nation on earth, on per capita health care. and we live shorter lives and die sigir than many -- die sigir

than many of our neighbors and competitors. we often hear people talk about the rising cost and medicare and medicaid, but it's important to remember that that isn't a unique countries that have helped government programs. in fact, medicare and medicaid grow more slowly than private insurance premiums. the driver of a lot of this cost increase is the underlying cost of care, which put equal pressure on family lectures, on corporate balance sheets, and on local, state and federal budgets. so even though medicare is not a driver in the problem, we know it can be part of the solution. history shows that innovations in how we pay for care can often begin with medicare, and then spread to the private insurance industry. and a critical part of the affordable care act are the new payment models our department is

rolling out to help health organizations change the way they deliver care. some of our early results have been promising, and for the first time i would say ever in the history of the medicare program, we actually have our own research and development unit in the centers for medicaid innovation, where we can test a variety of models simultaneously and try to accelerate the adoption around the country. we've already seen an impressive results in our efforts to reduce health care associated infections. we've seen a drop in hospital readmissions, and those are two areas that we targeted or so low-hanging fruit to see if we could make a real dent. and our strong start initiative, so participating hospitals are reporting that they've reduced the early elective deliveries to close to zero. now, what that translates into is fewer at risk newborns and fewer admissions to the nick unit.

at an average cost savings of about $5000 per delivery. but for all those snapshots of progress we're seeing, change isn't happening nearly fast enough. far too many patients still experience a health care system that is fragmented, unreliable and often prohibitively expensive. far too many health care providers are still content to sit back and let others place the code, sort of 21st century health care systems. so my challenge to all of you today, and actually my plea to all of you, and especially to the provider community is help us speed up the rate of change. if you're already at the vanguard of transforming care now is the time to take the next step forward. if you've been considering participating in new care model, now is the time to take the plunge. if you've been waiting on the sidelines to see actually how this is going to shake out, now is the time to get in the game.

health service researchers -- excuse me -- and policy analysts have a huge role to play. for years, you've helped us identify our health care system's biggest problems, and help evaluate solutions. but too often -- [laughter] >> sounds like somebody caught in the system, i don't know. [laughter] spent too often as -- those results have come a 200 page result, five years after the study was launched. now, we can't any longer wait five years to find out what qualities make a successful aco. we need that information in real-time, and we need to be able to drive it in real-time. so we can use it to shape policy, to have the biggest impact on people's lives. so i want to be clear that transformations, i'm talking about today, won't happen

overnight. when this conversation convenes next february, there will still be uninsured americans we need to cover. there will still be rising cost we need to control, and there will still be models of care we need evaluated. but we have a rare opportunity over the next year to make huge strides working together in transforming our health care system. if we can take advantage of that opportunity, to pay off our american people and better care, better health and lower costs will be enormous. so thank you all for what you are doing, and have a great conference. [applause] >> thank you very much, secretary sebelius. i would now like to introduce the next panel by starting with its moderator, dr. david blumenthal who is president and

ceo of the commonwealth fund, but he is no stranger to washington. he is the health services researcher and a national authority on health i.t. at options. prior to joining the commonwealth funds, he served as the chief health information and innovation officer at partners health system in boston and was the samuel professor of medicine, i've got to take a breath to get all that data, and professor of health care policy at massachusetts general hospital and harvard medical school. from 2009-2011, doctor blumenthal was national coordinator for health information technology under president barack obama. initially was charged with building an interoperable private and secure nationwide health information system in supporting the widespread meaningful use of health i.t. at some of you may not is also an active manner of academy health and a former board chair of our organization. so today dr. blumenthal and his pen which he will introduce are

talking about life after hitech, health i.t. policy two-pointer. and will be able to reflect on the excitement of the last two years and hopefully provide us with what the future will be. so please join us on the stage with your panelists. >> [background sounds] >> good morning, everybody. thank you, lisa. it was great to hear secretary sebelius and i'm sure you will enjoy this panel. it's a supremely qualified panel. i think we are missing one of

our members who e-mailed us just a moment ago saying that she was, that sound you may have heard off to the side -- [laughter] that was make sure somewhere stock with a sting bechtel -- christine bechtel on it, but she promises to be here if humanly possible. but let me introduce the other members of the panel. first, my friend and successor at the office of national coordinate, dr. farzad mostashari, current coordinator for health information technology. before that he was a pioneer in promoting the adoption of electronic health records among physicians serving low-income americans in new york city, and is a trained internist and outlook health specialists. and then paul tang, who is board

certified practicing internist and vice president and chief innovation and technology officer at palo alto medical foundation in california. he also served during my tenure and since then at the office of national coordinate as a member and now as vice chair of the federal health information technology policy council, or committee, which was established by the congress to advise the office of national corner on health information technology policy. and the third member of our panel, hot summer underground, is christine bechtel, who is the vice president of the national partnership for women and families, where she is responsible for strategic direction and oversight of the organization's multifaceted work. she's also a member of the federal health i.t. policy committee and does high noon

work on the role of consumers with respect to health technology and technology generally. so i think the way we're going to proceed, we are one short, we are going to proceed by, i'm closing some questions -- posing some questions and then we will invite you all to suggest your questions. now, there's been obviously, in the last weeks and months, a certain amount of discussion of health information technology policy. so what i'd like to do is start with a general question for farzad and for paul. i would like them to each comment, to give us their sense of where we stand right now with respect to the implementation of hitech and with respect to the help of our health information technology policy agenda.

and, obviously, christian i've always -- authority introduce you. i don't know if you had to escape their an emergency exit or whether you managed to get -- >> [inaudible] >> but the question on the agenda, and i know that we have all heard this discussion, widespread discussion about where we stand right now with health information technology policy, one of the issues with fraud and abuse, what are the issues with payment, are we on target? are we missing the target? where do we stand? so i think we will start with farzad, and then let paul respond and then christine. >> thank accommodative. it's a pleasure to be on the panel, it's a pleasure to follow the secretary and speaking.

as i think the analogy that the secretary made to the synchronized swimming, a lot of activity underneath the bathing cap was a marvelous analogy to what's happening, and the synchronization between the reforms that you talked about how we pay for care, and a matching and synchronized activity that has to occur on the side of health care is delivered. so you can't just how you pay for care, and keep the same exact systems in terms of delivering care that has been really optimized for a fee-for-service world. and in a way, meaningful use of health information technology and opportunity afforded to us, the hitech act, was to prepare the ground for new models of payment. let's assume that a provider might actually need to know of all their patients, how many of them are not getting the right

care. let's assume that, because you can't assume that today because most -- when i was hoping practices in new york city a top electronic health records, talk to them about these wonderful things that you can now make a list of the patients and find out who did not get the right care, who did not come back to see you. they kind of looked at me a little -- like why would i need to know that? why would i need to do that? so in a way, it's in a transition phase that we find ourselves of preparing this infrastructure for the new models of paying for care, delivering care. and in that i believe we have been successful. when we, early on, put the vision of what implementation of hitech was going to look like, we said this is going to proceed in stages. there's going to be initially a collection of, and structuring

of data. you will understand the power of data and information. that's part one. part two we said it's going to be advanced care processes, redesigns we are not just saving -- reducing health care delivered today to finish at these new tools, and we said in the third stage, which could be some six years in a typical practice, individual practice, much less the country, then we would begin to see the outcomes that we are very much focused on. and i think on that we are very much hitting the milestones. as the secretary mentioned, the adoption of electronic health records has doubled and more, but more importantly, we don't just have more people having bought an electronic health records system, they're using them in ways that they never did before. information exchange is a huge challenge and stage two of meaningful use, to really step up in terms of that.

and we are going to have to work very hard to realize the potential of stage two in 2013. and we are seeing just the embrace i would say of the fact that we do need to change. and i think that's been in many ways what held us back has been the belief that health care can change, and no one is challenging that now. everyone recognizes health care must change them both in terms of how it's a but also how it is delivered. >> paul, you want to add a comment? >> sure. if people were recall the hitech provision came in a year before aca, and that was for telling of what would come. we have never lost track of the hitech was all about reforming health care system. it was a year ahead. it should've been two or three years ahead, but it was very, very fortunate because, in fact,

in david blumenthal's study before hitech, only 3% of physicians had accompanied of information system, not even meaning in a full -- the criteria as it is now. so now two-thirds have been taken a third of physicians have been taken and we are really on track and is a tremendous reflection uptake in this technology. but also the way people are using the technology as far as farzad said. a couple thoughts undermine in terms of some of the talk about town on this program. first of all, the implication and benefit realization, this is measured in years. speaking from one who has done this a few times, and not months. so it's way too early in the digital program for hitech or meaningful use to consider whether the game is even being won or not, but i can assure people that were very much on track, and the game is preparing all those providers to be able to deliver better care and to measure what would you. just as example, at the palo

alto medical foundation, as beth pointed out, 50% what we know to be good medicine, the diabetes, 50% of diabetics, less than 7%, and as much opposition, our organization, two-thirds are controlled, hypertension the same kind of data, about half of the country hypertension patients are controlled, and where i practice it's about three quarters. and the reason is because, look, you could not have achieved those kind of things without -- i do think it's imaginable but uncertain when not be able to achieve health reform, the aca provisions without h.r. so as necessary as far as pointing out how we transform ourselves compelled transform the care team and how we and all patients. we can't do without the. and fortunate we are on the way because of this program. >> christine, doing to edit anything from a standpoint of a

consumer, observer of the hitech act of? >> so, i think paul's item, and, of course, farzad is always right, right? i think although hexagon head which it does feel like we're in a transition phase in the proximity of the aca and hitech. i think actually increased expectations around what health information technologtechnolog y can do now, and i think it's a challenge always to balance, here's the technology that can do these things, we know you don't get paid to do these things but we want you to do these things, and you know, how those two broader dynamics move down a path and stay connected, and yet balance in real-time i think is a challenge. from a consumer viewpoint, and what we know is that consumers want of i.t. we did a survey about a year ago, and there was brought consumer support for physicians use of electronic health records, and i figured has a real potential to be a game changer for them, but their expectations are now beginning

to change, too, in the transition phase. and what we saw in the data was that only a fairly small percentage of consumers had online access to their medical records. about 26% people who also had -- that had any h.r., but for those that did them their views were very different and expenses were very different. they are more engaged in the care. they're more motivated to do something to improve their care. they felt more confident in their clinicians ability to manage their care within. and it began to really set up more of a partnership construct. and i think will be very interesting to see in stage two where now the requirement will be applicable to every participating physician or hospital, the public can you go online and simply view, but you can download and you can transmit. and i think that's going to be really interesting. so we are at a point at least in the consumer viewpoint where

they are expecting some tangible benefits, you know, called mention it's early in the program, and that's fabulous. but i think what's about to happen it's really going to be transformational. >> so let me, farzad, push a little bit on this. one allegation related to electronic health, which is by making it easier to bill, and maybe even by jazzing up the billing a little bit, electronic health records are actually increasing the cost of care, not reducing the cost of care. and that they're going to be part of the problem, not part of the solution. what is your response to that allegation? >> well, some of the -- went to separate out the two issues. one is fraud or if someone is documenting care that didn't occur, whether with an

electronic health record or not, that is fraud. and with the secretary and the attorney general has said is that we're going to take a very strictly. and affect electronic health record give us tools now to go to audit and investigate and prosecute those fraud in ways that we never had before. but then there's the second category, which is just using electronic health records as tools within the given rules of the road. and i think that's a more, more challenging issue to look at. these trends as reported have been going on for a decade in terms of a shift in billing patterns, and there's many regulatory approaches to deal with the shift in the patterns of billing intensity codes your we are going, we've asked the health i.t. policy committee to look to see if there's thing the could do in terms of the

certification of electronic health records to minimize inappropriate use of the records, but fundamentally we've got to change how we pay for care. the colbert here is not electronic health records. the culprit here is a system of reimbursement this is you're going to be paid based on how many visits you can squeeze in on how many elements you can document as quickly as possible, regardless of the quality of the cure, the outcomes of the care, regardless of the patient component. so, you know, i don't think there's any evidence actually that says it on net balance, electronic health records have at all increased the cost of care, and the shift in those patterns i think is something that is certainly predates hitech. but it does get us to the cost issue, how, what is our theory of the case about electronic health records are going to reduce costs. and i think it's got to be within the context of how health

care is paid for. >> didn't the ram study say that electronic health records are increasing the cost of care? wasn't that what the article said? >> as david knows well, that's not at all, not at all what the rand study said, even though there are some journalists who misread perhaps the accounts that way. >> just to expand on that a little bit, it seems to me what the rand study after said was they had predicted dramatic reduction in the cost of care, and that was wrong. is that correct is because i thought the rand article itself, written by art kellerman, was a thoughtful piece. and what they actually said was that when the improvements in

cost are going to occur, are not after you write a paper, or even after you passed a law. it's after you get 90% adoption of the electronic health records, after get interoperability, and they gave us a lot of credit for progress on that, after you let patients get their data, not just in pdf but the actual structured data, and when you pay for care. that's what the rand study, if you actually read the article, few journalists apparently did, that's what the study actually said. and it's not even a study really, because there's no real data analysis. it's a perspective piece, i think, on that. it's interesting. it's been an education, you know, what makes news. if there's one thing that i would ask this crowd here is, you guys are about understanding

that money may talk but information is power. and data matters. evidence matters. it matters what they say. it matters what they actually found. it matters what the data say. and i think that is something that is sometimes lost in the public discourse, is people are more interested in writing about what the news article said, rather than what the research showed. and i think you serve a critical role in keeping the discourse on us, which is sometimes -- discourse honest, which is sometimes a difficult task. >> let me switch perspective a little bit right now, and turn to christine. there's been interesting discussion in the leg press the last few days about european versus american privacy laws. and for those of you who aren't

absorbed by this kind of discussion, it's a little bit arcane, but the basic point of view is that european, the european union has a comprehensive set of commercial privacy regulation that the united states has something else. and this is not irrelevant to the question we're discussing because a lot of what we are concerned about in hitech and ehr policy is exchange of information and interoperability. so we very much want, and one of the points of discussion has been, with respect to hitech, whether we've gotten interoperability that was expected and promised. can you talk about, christine, about what we are with respect to the privacy and security protections that we would like to have in place to create the

interoperability role we are looking for? >> so, it's a complex and multifaceted issue i think in terms of the way consumers view it. we have a brand-new final omnibus privacy rule that just came out, and have some really terrific advancements for consumers that will address some of the things that i think made many of us think twice about electronic records when you, you know, go to the doctor for an exam and then you get marketing materials a couple days later that were suspiciously specific to whatever you choose where therefore. and so those types of practices i think are going to be less and less amongst others, with this fund will but i think that's a terrific advancement. from a consumer viewpoint though, it's interesting because when you ask consumers, are you worried about electronic health records will lead to more breaches, they say yes, absolutely no doubt about it. but when you ask those consumers who have a position that has an electronic record, and even

better, if they have online access to that record and at some level of transparency about what's in it, their levels of trust are sky high in comparison. .. >> we do lack, most consumers aren't necessarily worried if you think about it about the privacy of the security. what they're worried about is what happens next, and we don't have a comprehensive set of antidiscrimination policies in this country that would protect us from those breaches and what, you know, how that data gets

used going forward. and so i do think that feeds the concern. we did a series of focus groups in a national survey with a different research project, um, and we asked consumers what, you know, what -- when you go to the health care system, what's your experience like? their or number one pain point was care coordination. they said i just want my doctors to talk to each other. and we said, okay, this was pack in the aca debate. and we said, okay, you know, we're thinking of some ideas in the international level, this patient-centered medical home which is not a nursing home, but that's a long story -- [laughter] we tried, by the way, medical home base. totally didn't work. we tried payment reform. we tested quality measurement and public reporting, and we tested some shared decision making aspects, and i almost fell off my chair when the number one delivery system solution that spoke to their most pressing concerns was information technology. so at the same time, they're absolutely concerned about

privacy and security. they also really want the benefits that technology can enable of that safe and secure trusted data sharing. so as they are now able to access, view, download and transmit their own health information, i think that their experiences in privacy and security will be changing. >> can i -- >> hopefully positively. >> sure. >> david, can i -- [laughter] add on to that. this issue of having the systems talk to each other, right? we've paid $10 billion to get adoption of these systems, but they still don't talk to each other. >> right. >> that is, has to be challenged on three levels. one is on the technology level. there have to be standards that they agree to, that the different vendors agree to for being able to exchange really the complex information. it's not an atm that has seven data fields for, you know, $2.50. it's thousands of data fields. so they've got to agree on those standards which prior to hitech,

you'll remember well, there wasn't really a push and a way to accelerate consensus among these proprietary standards and vendors' interests. and we have that now. and in meaningful use stage two that that was promulgated in august in the final rules, we set out a set of very clear and ambitious standards for information exchange, and all the vendors are now over the next ten months or so going to be really working very hard to upgrade their systems to be able to meet those interoperability standards. that is part one. part two is you've got to have a business reason to exchange information with the hospital across the street. and oftentimes, you know, you can have all the technology standards in the world, and if it's against the business interests of the hospital, that information will not move. and what we're seeing is not just the accumulation of new i payment models, a readmission adjustment, just that has restarted the conversation for

every hospital in the country that now if i just discharged a patient and they show up in another perp's emergency room -- person's emergency room, i want them to know the information i have on them. patient-centered medical home, value-based purchasing, all of these are adding up, and the direction whether it's private plans, whether it's commercial, whether it's medicare, the direction is arcing towards you've got to be able to coordinate better. and that's getting the business case in place. and it's not there yet, but i think most ceos can see that it's trending in that direction. and then the third part is trust. so you get the cost of the interfaces down, you get the value proposition up, information can flow at the speed of trust. and establishing that trust is, is the really critical aspect which relates to the privacy and security. the disrupter here, and we've made it really easy, i think, for people whenever they have a business interest and in the course of treatment per patient

to have that discharge summary follow the patient, to have the lab results and all that. but the transformative potential here over the next year i see is patients everywhere being able to get their own data and share it with whoever they want to share it with. >> or whatever app they want to use. >> whatever app -- there'll be an app for that. >> yes, there is. >> there already is an app for that. [laughter] i have it, actually. so that, i think, making it real for people to be able to exercise their hipaa right to get an electronic copy of their health information, the same depth of information that the clinicians have and to be able to maybe not even understand it, but to be able to share it with the next provider they want to share it with. that is going to be the fact on the ground 12 months from now. and i think it is largely unappreciated at the current time. >> the analogy maybe that you're

looking for is that you could be the joe flacco of image information exchange, but if you don't have receivers down the field, you're in trouble? [laughter] is that -- paul, what does it feel like from a delivery system standpoint, this press to create interoperability? you've had at palo alto medical foundation, you've had electronic health records for a very long time. are you able to do what you want? and if not, what do you need? >> well, i think it's -- we've had the luxury of time. we started this in 1999, so that's about 14 years ago, and, um, to go back to synchronized swimming, it's not just the caps, it's not just the underneath, there's a lot of training time that it takes to get to that kind of sin crony and orchestration. and so we are, we have had the dreams and visions that christine and farzad have talked about, and i think we're realizing some of those benefits, or our patients are realizing those benefits and

telling us. but it takes an awful long time. just to put time into perspective, it may take at the minimum a year to decide to do something and get it implemented for a small practice, and in a larger system it's year, and then you start the optimization and benefits realization. and i think hitech has really been -- well, the meaningful use program has started maybe less than two years ago. a lot of people coming as the end of 2011. it would be infeasible and unreasonable to expect that we would know what's been accomplished. i gave some stats earlier about what you can accomplish once you get this system in place, and i think the most exciting and, frankly, the most fun part about it has been what we have been doing with our patients. so in terms of the slight twist that the policy committee and onc and cms put into medical use was the engaged patients and family. so not only was this ehr provider-facing which is sort of the default assumption for

meaningful use, but making sure it gets out to the patients, and the big strong point, the transformation is it gets to the patient. not just it, the data, but the knowledge and the tools we provide for patients to take much stronger interest, and they're much more active, participatory role in their own health and health care has been wonderful. the kinds of feedback we get from our patients, we have more than three-quarters of our patients are online with us. for example, they get a return to their messages that they send online within a day. that really is transformative in terms of what people feel like in terms of support for their own health. and the caregivers, the family members' support. as you know, most of health and health care outside of the organization even for us who spend all our time in health, most of our health and health care's outside the organization. this is the only thing that's made that possible. so that's been, you know, when you say what's been the change, that's been an enormous change.

we have a ways to go, though, both on the technology and the standards way, but there's much more we can do. >> so, david, if we could just jump in and kind of put a fine point on it, i agree. i think the challenge is, this town is not patient, right? so we have a challenge here because we have lots of pressure to really deliver because we see the rand study, or we see the poll that i think apvc did that says 48% of consumers want to cut i.t. spending which, by the way, i don't believe. i spent some time up on capitol hill last week, and the senior committee staff just wanted to know when's the money going to pay off? because y'all promised us, you know? so that's what they want to know. and they don't really respond well to things like, well, you need the patient cases, your reform is coming, but we're innovating, and we're testing. that doesn't work. what works is the stories like paul or like the work that farzad did when he was at the department of health and the

transformation that happens, that has already happened among the systems who have tone this before. and i think the gap in the larger public dialogue that i'm not seeing as much are the success stories. the people who are saying i couldn't have done this without information technology. and, yeah, i did a lot of other things, and it wasn't just i.t., but that was central. and the reason i think that that narrative is critical is because it's not just as paul talked about, technology and training, this is absolutely about culture. not just in a broader implementation of technology and how it's used, but particularly also, of course, the way we engage patients and families as partners and the way we do things with them and not to them or for them. so i just, i would say i think we have a gap that is we're not accelerating the drive towards a different culture as much as we could and that we need the exemplars like palo alto and others and the small practices, you know, like jim morrow who's a family physician in georgia who called me two weeks ago to

complain that he shouldn't get stage -- he couldn't get stage two this year because it's been delayed one year. that's what we need. laugh after. >> let me -- to the health policy analysts and researchers out there, one request maybe. you know, it may actually be easier today to get an article published about how health i.t. has failed to meet expectations than how it has succeeded. that's probably true, right? >> uh-huh. >> it's always, you know, whatever the trend is now, right? but the reality is that what we really need are not uninflected stories either positive or negative about it works, it doesn't work. it's how, it's not whether, it's how. and too few studies look below the surface of, you know, did it or did it not achieve whatever

outcome to say obviously it can, it's obvious that health i.t. implemented appropriately can improve safety, can improve quality, can improve patient -- because clearly we have scores of those articles and evidences that it does. but the question is not whether, it's how. how did they do it in such a way as to accomplish that in ways that can be generalized. and that's what we really need. because this is happening, right? no one's going back to paper. it's a one-way process. it's a one-way process. so this is inevitable. but whether we get the most gains out of it is going to be dependent on how well we implement and how well we learn from those successful implementations. >> well, um, i'm going to now turn to our audience and invite questions about the how, when, why, whether.

we can evidently break. you don't have to use an electronic health record to ask a question. you don't even know, have to know how to program. i see a shadow out there. is that tom? >> i don't think these are hooked up. [inaudible conversations] >> i recognize the voice. >> i'm tom delbanco from boston. i've been having a lot of fun, um, experimenting with the notion of open notes, inviting patients to read the records that we write. and i'll twit you, paul tang. you're famous. you've done a lot. why don't the patients at the palo alto clinic read the notes that their doctors write? more importantly, what are the generic issues you think we'll face before we get to that

point? >> well, right now the software we use doesn't have that feature, but i think it'll just be a matter of a short time when, in fact, we're already talking about this based on the work in open notes. we're talking about it at palo alto medical foundation, but also nationally in terms of the policy committee looking at how including that as part of meaningful use. i think it's a wonderful contribution. i think, actually, we could stand with better notes because some of the issues that farzad talked about this terms of documentation -- we're having a hearing about this, by the way, next week to look at not just documentation in the context of fraud and abuse, but documentation, can't we make it more useful, meaningful for both providers and patients. the dream might be, you know, we have this documentation rule because we're on this fee for doing things, and you had to write down what you did. if we could go back to the old days and have it for communicating the interests of

the patients, the patients' health, the patients' care, it'd be more meaningful for all of us. and ironically, aca gives us a chance to do that. so the dream could be if we could go back to documenting the care process and away from the billing process, that would make it -- that would be a win/win. and that, i think, is almost a prerequisite for the meaningfulness for notes to patients. i'd like to get our act cleaned up and say have meaningful documentation and share it with everyone, so that would be sort of a dream that i have. but there's nothing, um, in -- we're on the way of going there, and i think in a big way for the country. >> thank you. next in line. i don't see anyone on this side of the room, so i'll keep going with who's at that mic. >> norm vinn, president-elect of the american osteopathic association. wonderful remarks, great perspective. and as i was briefly looking through the attendee list, um,

clearly there's a great representation here today from academics, government people, policy, deep thinkers i always like to say. but we represent a large contingent of docs in the trenches, on the front lines. and i don't want to forget that perspective here. when you raised a great question, dr. blumenthal, about this increasing the cost of care and then dr. tang says, well, this all takes time, i mean, you're sort of both right. what we hear from the docs on the front lines is this is actually reducing productivity in our arcane system of billing and practice because it takes them longer to document. now, the paradox is in our arcane system of billing and practice the health record also affords the opportunity to create more thorough documentation. let's put fraud aside for a

moment. the whole rbrbs system is based on complexity of thinking, complexity of decision making, risk. and all of a sudden you can create a template, a checklist which we know does improve quality and consistency to go through all those complex issues, externalize the documentation and magically that seems to justify a higher code. so we're at a weird crossroads. even in our own association we have to go to the government agencies and advocate for optimal payment under an arcane system while we're trying to help our clinicians pass the large psychological kidney stone of translating, translating to a new system of payment and a new way of thinking. and in my own practice we take care of the homebound, frail elderly. and we would love to share records with emergency rooms and improved care transitions. we would love to instantly receive records from hospitals

to improve care transition. we've already reduced hospital readmissions. i'd love to see what more we could do wefect -- with effective communication. we constantly run into silos and information walls. so this is a tough question. and i also want to support that issue of the journalists running to find drama and conflict about how this doesn't work. think of the longitudinal paradigm shift that has to occur in how we change our behavior as doctors. when we were trying to qualify -- i was at a conference with christine ten days ago, and we were discussing that when we tried to do meaningful use part one, we had to put aside a task force in our or small practice and meet for two hours every week fors and months and months and months not only to make sure we were documenting everything, but we were training our clinicians and our staff to capture everything. i think there's some underestimation of what happens

at the grassroots when you're trying to create transformational behavior. and i just want that to be on the record. thank you. >> again, we seem to be clustered over there on my left. so whoever's next in line. we've got lights in our eyes here, so we can't really see very well where you all are. >> diana mason, center for health media and policy at hunter college. i very much, i want to go back to the issue of patient engagement and using the electronic health record for that purpose. i loved being able to access my own record online, but i'm also a nurse, and i know that there are low literacy populations for which that would be a challenge. i'm really interested in what have you seen or know of that is exciting and promising in terms of, um, somebody who's looking at how to work with low literacy populations and engaging them in their electronic health records.

>> i think that's a great question. and not always are the two connected. so we have lots of health literacy improvement efforts, really innovative things, too, happening. but thai not always -- they're not always connected to the information technology component. so i think that is one area where the trajectory of meaningful use at least insofar as it connect toss the ability -- connects to the ability to create a technical capability, um, for certified electronic records, i think it t can be really helpful. so there's so much, i think there's only so much that the technology can do by itself to address health literacy, but i think there are absolutely things that are happening. we've seen things ranging from, um, so there's a display on the page, but everything is hyperlinked or translation services that will bring the reading level down to a particular level, um, that suits the reader. i think there's also a lot,

actually, that we could learn from the disability community in this respect and some of the technologies that they have. um, the other, i think, element of health literacy is also electronic health literacy, and i know there are some terrific programs, generations online was one of them and a number of others that are trying to increase, um, our capability to be, you know, online citizens, if you will. but i think your point is right, which is the trajectory of meaningful use could be a helpful enabler. i don't know that it would be a drive, but i think it could be a helpful enabler. >> one of the, i guess it's a philosophy/strategy question of whether you make the information most usable before release, or you release it, and you remain open to other people helping make that data interpretible and usable. and i think kind of the open data movement has been to say,

you know what? you don't -- most of the smart people in the world don't work for you, and it's very hard to get everything exactly right. but there are a lot of other people out there who would love to help provide services and products that can help make this information usable. so let the data go, and let the patient be able to or the caregiver be able to access services that can help them make use of that. that's a theory that, i think, has a lot going for it. but, you know, you have to first let the data go before those service providers can actually build those products to make the information usable. but that's the direction, that's the philosophy, i guess, that we as well as, i think, you know, what tom's doing with open notes says don't, you know, don't use that as an excuse not to release information. >> uh-huh. >> and i think this technology really helps us personalize the information in ways both from a language and, um, ethnic

background kind of point of view, cultural competency point of view, but also the literacy. i was talking to the zero divide board just a week ago, this is an organization dedicated to crossing the divide with the underserved. and i think one of the ways it's a bit like farzad said, this technology allows us to personalize. so we actually could not do anything with the literacy issue on paper, because you just can't print that many. and it's not even that many meaning different languages or whatever, it's really -- [inaudible] that's where we engage the most. so we are setting up not only does the technology provide -- have the capability to enable this, but we're setting up meaningful use to try to facilitate that. but it's when we get personalized to an individual, and you can imagine some intake that assesses, essentially, their health literacy about their own condition and then directing the educational resources to that individual. that's another example of a

transformative outcome. >> maybe this is an imperfect analogy, but how many folks know about the blue button? okay. so a lot of folks still don't know about it. so this is the idea that, um, pioneered by the veterans administration that you should just give patients a copy, ability the download easily online a copy of their record. and cms implemented this. you can actually go if you're one of 37 million medicare beneficiaries, you can go online, register for my medicare account on mymedicare dot governor and -- mymedicare.gov and download three years of claims data in text. now, this is what it looks like for my mom. and it's pretty incomprehensible. [laughter] because it says, you know, procedure code description

92134, rendering provider number 131787 zasq, right? but it's all the data. and we did an app challenge, and the winner of our app challenge turns that into this, which is a pretty nicely-formatted ability for me for the first time ever to really be able to have a list of all her providers with their address, their specialty and their phone number. i can see all of -- she can see, for the first time, what diagnoses they askyped to her. -- ascribed to her. and it's pretty simple to then reach out to nih and pull down the relevant information or educational material about her medications, her diagnoses, the procedures, the lake stories sts and -- the laboratories and so forth. >> if you know where to go and how to get there. >> if -- it makes it open, it

makes it possible. and today, i think, you know, when my dad went to the friday after thanksgiving acute eye issue, had to find an ophthalmologist, they're hundreds of miles away, and he showed up to a doctor who had never seen him before and said, here, this is my record. and without that it would have been very hard to do that. so, you know, long and interesting issue, but -- >> an interesting answer, thank you. [laughter] >> so, moving on. >> yes, good morning. gordon josephson from bay state health. i echo the comment that was made previously, very provocative discussion. i'd like to take this, um, to a different level, a little bit more of the humanistic level. many of us are familiar with publications that have discussed

the amount of time that providers now spend in the documentation phase versus the talk to your patient phase, you know? the allegation being that it'salmost doubled from something like 25% to almost 50% of the visit is expended in that area. and i think that i'm entered in any of our panel that's commenting on what we envisions in the future that could move us back to a period where the interfaces to take what's in the provider's brain and commit it to some kind of electronic format are easier. we are sort of stuck in the typewriter, even the drag-in voice recognition piece, and i don't want see a lot beyond that. -- i don't see a lot beyond that. so perhaps what i'm really asking is what's on the horizon

that will, hopefully, move us back to a time when the provider can actually have more quality time and interchange with their patients? >> so let me just make a brief comment here, and then i'll turn to my panelists. there's no question that the electronic health record does add to the requirements for physician documentation. the question is when you add that into the mix and ask net-net are physicians happier or more unhappy with the paper, with the electronic record situation than with the paper situation they had before, polls consistently show that users of electronic health records are satisfied with their electronic health records. so there's no question it's a downside. but we could come away with the impression that physicians right and left are giving up electronic health records and going back to paper.

they're not doing that. there are people who are very unhappy with their electronic health records, but there are also people who are very happy with them. there are, there also is enormous variability from one record to another in terms of usability. and we are in a situation of kind of a shakeout. we've got hundreds of different vendors selling electronic records, and it is true that in a free market there's a certain amount of caveat everyone to have going on here -- 'em to have going on here, and people are making bad choices, and some choices are worse than others. but you can find testimonies to the time-saving value of electronic health records as well as to the productivity losses. so i think we're going to have to wait a little while. i would also make one other point which is that the market for usability, the demand for

usability is soaring. >> yeah. >> there was no demand for usability before electronic health records were widely used. there was no reason for vendors to focus on it. because they were, there just wasn't enough sales or enough selectivity on the part of purchasers. so having said that, i'm going to turn to my panelists and let them add any comments they may want to work. >> l so i want to address the lin call documentation ans issue. -- clinical documentation as an issue and refer again to the hearing we're having next week. so maybe potentially stimulated by the fraud and abuse discussion, but we've expanded to talking about clinical documentation, both the challenges and the opportunities. from an opportunity point of view, i might go back to what tom was talking about and refer or to the vision of if we don't, if we no longer have to bill on a fee for doing things basis and

reduce the record back down to what is needed for care, that would be good. so the aca, the new reformed way of looking at it from a population health point of view would give us that permission to make the records then useful as a clinical tool. so what i look forward to is the day when this is a shared, in a sense, a shared care plan and discussion about an individual's health. we have secure patient messaging, so when you're online, that is coming securely, but it's also in the medical record. and the discussions you have not only are more sensitive to an individual's need and their individual literacy, it's a discussion of what's getting in the way of these -- what's an obstacle to you improving your health, and how can we deal with it. that's a far more rewarding and productive discussion than the things we had, than the things that are documented in the

record now. so i'd look to, it's more like open notes, a shared document that the whole team -- that's the patient, the caregiver and the professional team -- can share together as a communication and discussion device about an individual's health. and if we had that, and that's, essentially, a by-product and has nothing to do with billing because we get paid on, essentially, achieving health outcomes goal. that would be a much better world, and i think it'd be more fulfilling. it still may take time, but i think the end result would be far better. >> so i'll add to that. yes, we do need to make it easier and, frankly, more pleasurable to get what's in the head into the record. and, you know, the voice stuff you mentioned, actually, is coming along nicely, and i think some of the new form factors, the ipad or whatever, are making a big difference on usability. we do need to shrink maybe or expand as needed, but the information that's documented

has to be clinically relevant, not for the purpose of billing only. it really has to be focused on what's the medical necessity to communicate. um, and, you know, who are we communicating to is the real question. one of the docs i talked to said when i started practice, my notes were little reminders to myself. that's all -- that's the only person who's going to read these notes was me. and i could be very efficient in that, because i know me. [laughter] but then he said my notes became a conversation or a dialogue with an auditor for billing purposes. and then, he said, the next iteration of this was we all agreed in this ipa with 50 different independent practices that we could look at each other's notes. and then he said i realized it's not my note anymore, it's the patient's notes across all these providers, and the goal of this note is to communicate to somebody else what i'm thinking

and what i'm doing. and i need to write down a lot more for that. and then he said now my notes, communication with the patient. and that makes it even more freighted. and one of the things that, you know, we're talking about the how to make it work. one of the bright spots that i've heard from clinicians who really like using this as a tool is to make the record a three-way conversation. so it's a triangle between them, the patient and the medical record. and they'll say, okay, either watch what i'm doing, or i'll tell you out loud as i'm typing. it's not wasted time. it's communication and shared decision making time. where i say, okay, so let me see if i've got it right. you've said that you've had this for about three weeks? no, that's two weeks. okay. and this is what i'm -- and as they're talking, they're really using that as a way of communicating better with the patient. so that's not wasted time. >> so if i could just say

limited time in the office is a common pain point for physicians and patients and families alike, right in and i think dr. vinn made a really important point. transformation is hard, no doubt. but we're tending to overlook one of the most underutilized resources in health care which is patients and families themselves as partners in the transformation process. so we've seen examples of this across the country where practices have had a pain point where it's limited time in the offices because i've got to do all this documentation or whether it is, you know, the after-visit summary doesn't make sense to us or to you. come, sit down, have lunch, let's fix it together. and we've seen this idea of partnership producing benefits that are both incredibly meaningful and impactful, but also they happen on a timeline that is much faster than they otherwise would have. so as we're going through this transformation, as we're waiting and watching these ability markets evolve, those are -- b

this is the time when partnering directly with patients and families as resources to problem solve is critical. we've seen it happen where the clinician will say, okay, we only have, like, 7, 12 minutes in the office visit, so what i'd like for you to do ahead of time is log on to the portal. create a previsit agenda. tell me what your questions are. i will take the time to look at it before i walk in the room, and then i'll be prepared, you'll be prepared, and we can focus on what matters. so patients as partners, i think, is a key part of the solution. >> have another microphone active here. >> ah, very good. >> right up to the front. >> dora, and i want to thank you for the question of how can we make electronic health records work. and one of the approaches that we've taken is really looking at it from a public health lens, and the opportunity to take realtime electronic health records and layer that on top of community data is mind-boggling in terms of the care continuum. but one of the challenges that

we've had is that, you know, that taking the electronic health record, um, some of the vendors and making the data, you know, to use gis technology spatially enabled has been a very lonely conversation. and data isn't good unless we have address validation and to really look at the address being an important part of the electronic health record. and vendors have said that, um, you know, customers basically are not asking for this. and this is, i think, an amazing opportunity to look into the future and to have just that next layer of, you know, really community health. so where is this conversation being elevated, and where can we find partners to continue that? >> interestingly, part of where this conversation's happening is sort of at the hit policy committee. a lot of requests go unvocalized or unheard. in the old days, no matter how

big a customer you were of an ehr vendor, the wishes, the dreams, the ideas of the sort you mention would be met with, well, okay, that's a nice idea. next release. and you never know when that next release would show up. meaningful use is trying to set, um, started with david the vision of where it could be. public health is one of those things. as you know, they're not included in hitech, but yet we're still pushing that envelope in what can the vendors provide us, and how can we have a more realtime interaction with public health issue. so in some sense part of the visioning is getting a big voice through meaningful use. >> yeah. as a public health doctor and a medical epidemiologist, the thinking about this as infrastructure that could be used for population health is something that's very meaningful to me. but one of the things that, um, that i think is important to recognize the perspective of the

providers out there and the customers and the vendors is it works best when it's really dual benefit. so in that case the address verification, i wouldn't talk about the reason why we need to do this for public healthen reasons and community gi fmaping. i would say you need to improve the accuracy of your address for patient matching and demographic, data quality integrity purposes. and that's a great example of where, you know, the primary use is for better patient care, safer patient care, better clinical, you know, actions, but there are really huge multipliers in terms of the benefits for whether it's research, public health and other potential uses of the information. >> so i think we have time for one more question in the back. >> thank you. my name is susie dade, i'm with puget sound health alliance in seattle which is in the real

washington. [laughter] and we are a regional health improvement collaborative and spend quite a little -- quite a lot of time and energy focusing on performance measurement and reporting and transparency. and while, so my question is really taking us in a different tact with regards to confidentiality. we need access to patient-identifiable information not because we report patient-identifiable information, but you need it even to aggregate across millions of lives to be able to report on quality and utilization and cost. we also need access to reimbursable amounts from health insurance companies which are often protected by planned provider confidentiality clauses. and so my question for any of you is how are we going to really strike this balance between this desire for

confidentiality and a desire for openness and transparency when we really need to be able to do both through the exchange of electronic information? >> christine, do you want to -- >> sure, i'll start. you know, i think the question is whose confidentiality, right? because from a patient and family perspective we want to see the quality information. we want the value data. we want to know, and that does require access to that data set. and, you know, i think that the tiger team of the policy committee has done some great work thinking through this idea of meaningful choice which, in a nutshell, is i shouldn't be surprised by the use of my data or the reuse of my data. that should not come as a surprise to me. so if we have that as our guide, then i think the question becomes really the confidentiality and the business practices that happen around us outside of the consumer, um, that do tend to block access to it or maybe not tend to,

definitely block access to a lot of that data. so from a consumer viewpoint, we much love to see quality and value data. i think the challenges were, um, as a whole individual consumers, patients and families aren't probably ready to be the demand force for unlocking that information as much as we would like them to. because they're simply not using public reporting and other data, quality measurement data for choosing physicians or etc. at the volume that we'd like to. and it's a chicken and egg in part because there's a lot of data out there that's not particularly meaningful or usable or understandable to consumers. so i think it is a, an important question, and my hope is that as we begin to see quality measurement strategies evolve to ones that are multisetting, multisite, longitudinal, begin to connect the dots, we really take a whole person orientation to quality measurement and think more holistically about how a

patient experiences an episode of care and measure around that. >> okay. we have two more minutes. eric, do you want to -- >> yeah, thank you very much for giving me two minutes. eric schneider from rand boston, and i just wanted to make a note that one of the great things about commentaries is that they are forgotten within a month after they've been written. [laughter] in fact, i think you know we published one in june in the new england journal about the i.t. productivity paradox and how industries always have difficulty incorporating new technologies. there's a sort of waning, lagging productivity that goes along with that. until they realize how to measure the benefits of the new technology. but i wanted to ask a question about the performance measurement space because as we move to the performance-based payment schemes, the new infrastructure for assessing payment or assigning payment is actually the information systems that we have and the ability to use them for performance pressurement.

and i wonder if you could just reflect a bit on where you think we are with respect to that. my own view is that we have a lot of work to do, but there's no real sort of central coordinating activity that a lot of developers, a lot of interests, but it's not clear what our next steps are. >> farzad? >> yeah, i'll take that. um, there's measurement, and there's improvement. and i think right now we, the bulk of measurement for accountability purposes is still chart reviews and claims-based data. and if we aren't going to be paying for making those quality measures a larger and larger part of health care reimbursement, we need better measures. we need measures that matter. we need more outcome-based measures, longitudinal measures all of which are nearly impossible to do at -- with the acceptable burden particularly in primary care practices or specialist practices, outpatient care. so i think we have to make the

automated ehr using the data from clinical care, the exhaust from that process as tools for measuring quality in ways that matter. that's going to take a lot of work not just in terms of getting the ehr vendors to code the, you know, specifications correctly, but all the way upstream to how do you define the measures. do we have the measures we need that matter, are we putting in so many exclusions and exceptions that make it impossible to really use routinely-collected information for that purpose all the way downstream to are we using this just to measure or to actually improve? when i talk to a small community hospital and i say what's been the biggest difference for you with meaningful use, they said we went from doing quality measurement retrospect ily on a sample of charts we pulled after of the patient had left the hospital to running our quality measures concurrently when their

still on the ward. -- when they're still on the ward. and we're able to actually address any care gaps while they're still in the hospital. that's the fundamental, i think, transformation that comes not just from being able to measure better, but from being able to tie that measurement and accountability to improvement. and the difference there then becomes just astronomical. i refer you to the randy seebel article in the new england journal that said when you ally records to improvement processes, you go from 7% of patients with diabetes getting the right care in paper-based practices -- 7% -- to 51% getting all the process measures and 44% getting the outcomes versus 14% getting the outcomes. that's the real, you know? when we get the processes in place, when we get improvement as the goal and when we get electronic health records appropriately used, that's when we're going to get the

transformation. >> and i'll just add that since we have so many big thinkers in this room, one of the big opportunities that i think is really worth exploring, um, is the idea that in meaningful use stage two you have kind of two options for reporting. i think we ought to create a third pathway, and it's an innovation track. if you have some measure development expertise or you want to work with a measured developer, meaningful use is not an accountability program in terms of performance. so you can report pretty bad, you know, quality, and as long as you can report, all right. that's not the purpose of that program, right? there are many others, and i know beth's over here laughing because we harmonize for, like, 10,000 of them. anyway, so if we had an a innovation track that might allow for the measurement to get us on a pathway to where payment does genuinely change, i think there's some real potential there. but there's a loot of work that needs -- a lot of work that needs to be done to figure that out, and i would love if very smart folks could sit down and

say not -- no, no, no, we can't do that because, but, yeah, we can do that if the following occurs. how could we use meaningful use to innovate? and then we can see about bringing it to farzad and his team. >> the last thing -- sorry, david. there is more hope now than i think we've seen ever in terms of getting these alignments in place, everything from the nqs and the buying value initiative to really the fact at hhs we are absolutely committed to getting these synchronized across the payment programs. so i see great hope though a lot of work remains. >> thank you all for your attention. enjoy your break and have a great conference. [applause] >> a wonderful panel. so as david says, you have a break now and recurrent session. join us back here for plenary --

from texas who is also the founder and chairman of the congressional health care caucus. so very important perspective on the year ahead. [inaudible conversations] [inaudible conversations] >> this health care event taking a break for now. if you missed any of this morning's speakers, by the way, you can see them again online at c-span.org/videolibrary. we have more live programming coming up. former first lady laura bush

will give the keynote address at the susan g. komen for the cure women's cancer summit live at 12:30 eastern here on c-span2. a little bit later we'll come back to the health care event when congress month michael burgess will speak. he'll talking about congress and health care. that will be live at 1:30 eastern also here on c-span2. well, congress is back today. the house is in at 2 p.m. eastern to take up a small number of bills with votes at 6:30. this week the house plans to work on a measure requiring the president to submit a balanced budget to congress. the senate is also in at 2 eastern for general speeches, at 5:30 they'll vote to advance a bill reauthorizing the violence against women act, a domestic violence law that expired in 2011. members of both parties are attending retreats this week, and as a result the senate will be out on tuesday and wednesday and in the house no legislative business on thursday or friday. as always, watch the house live on c-span and the senate on c-span2.

>> if you've got some hot shot that just got his ph.d. in computer science from stanford, she's getting offers from are all over the world. and to say, well, you can stay in some limbo for six years, that's not really competitive. >> so, yeah, government -- congress can do a lot, and you don't have to be efficient on your iphone or blackberry to understand the applications of tech policy and what makes it work and what doesn't make it work. >> it's very difficult to make investment decisions and expect any kind of return on investment when you have no way to predict the future. and our difficulty right now is there's no consistency or certainty in our policy decisions. >> the government's role in technology and policy from this year's ces international communicators" 8 eastern on c-span2. >> coming up next, women who served in the u.s. military discuss their experiences and challenges and comment on the

pentagon's recently lifting of its ban on women in combat. they're joined by women who are served in the canadian and norwegian military. this event held here in washington d.c. it's about an hour. [inaudible conversations] >> thank you very much. [inaudible conversations] >> good morning. >> talking about new standards. so, anyway -- >> so all i can say is, wow. wow. i mean, it's really an honor to be here and to hear the testimonies of those amazing women who not only are deck candidated -- decorated combat veterans but are ridiculously articulate and to hear what their experiences were and what they had to share this morning. i'm truly honored to be here

with this panel. all of these women are truly accomplished and have lifted the groundwork on lift -- they've been part of women forging areas into new paths of previously hi reticket -- previously-restricted service, and they have expertise on gender integration in the military. so their full bios are available in your program, but i'll give them each a brief introduction. captain joellen osland was one of the first six women accept today navy flight school. she became the navy's first female helicopter pilot and between 1975 and 1978 she was a plaintiff in a lawsuit that successfully challenged the restriction on women flying and serving at least temporarily aboard noncombat ships. she's remained politically active on behalf of women in the military thought her life -- throughout her life. next to her is colonel martha

mcsally. she was one of the first seven women in the air force selected for combat aircraft cockpit when that restriction fell. as an a-10 thunderbolt pilot, she was the first american woman to fly into combat, and she completed multiple deployments associated with operations southern watch, enduring freedom and iraqi freedom. she was the first woman in u.s. history to command a combat aviation unit, and she did so during active combat. in recognition of her leadership and her performance, she received a bronze star and multiple air medals. she's continued to have an illustrious military and now postmilitary career. next to her is karen davis, retired left tent from the canadian forces. i'm sorry, lieutenant commander. it's a canadian structure that's difficult for me. [laughter] following her service in the canadian forces, she has become a defense scientist on their behalf, and she's the editor and

contributing writer to several books about women in the canadian forces. she's an expert in culture, diversity, gender, leadership and women in the combat arms. she's completed her ph.d. dissertation entitled negotiations gender in the canadian forces, 1970-1999. next to her is captain lori manning, she spent 25 years in the navy, served on many high-level staff including those of the chief of naval affairs, commander u.s. forces europe and the cno. she is the direct or of the women in military project at the women's research and education institute. she served for six years on secretary of veterans affairs advisory committee on women vets and was a member of the military advisory committee at the service members' legal defense network for three years. and on the end next to her is colonel ingrid gjerde with

operational experience in the norwegian army. she began active duty in 1987 and has ground combat experience to share with us. she served as a platoon commander in southern lebanon, a rifle company commander in boss any ca and as the national -- bosnia and as the national contingent commander in the afghanistan responsible for all norwegian troops. i'm joy bronson smith, i was a former navy pilot during the gulf war era and am now a documentary film maker. i'm working on a film about what i call the fight to fight, so about the evolution of the u.s. military in regard to women in combat. so i think we should start our discussion talking a little bit -- and we're going too this more as a discussion. i'll direct questions to the panelists around various topics. but i think we should start talking a little bit about the political climate regarding women's equality and the military in different, um, countries. so here, you know, we've just had this announcement by the

secretary of defense and the joint chiefs of staff, um, you know, rescinding the combat restriction policy. and it came specifically from the military. so it came to the secretary at the request of the military. but i think that things have gone differently in different countries. so i don't know, ms. davis, what prompted canada to remove the restrictions on women in armed services? >> in canada throughout the 1980s, um, the military was dealing with the requirements of our canadian heym rights act and then -- human rights act and the charter of rights and freedom which became part of the canadian constitution in 1985. so, um, at that point it was considered discriminatory to treat women different in terms of employment and a range of other things. throughout the 1980s several women, and one man, submitted complaints to our canadian human rights commission. the women, none of the complaints were related to combat, but they were related to restrictions on the employment of women either because there

was a minimum male component in a unit, so women were denied entry because there were already enough women, or because they weren't allowed to serve in certain units even though their occupation, one of them was an administration clerk, but she was denied employment in a particular unit because it was considered too close to combat. one man, um, submitted a complaint. he was a fighter pilot, and he complained that men bore, um, disproportionate responsibility for risk in combat because women weren't allowed to participate in combat. so the tribunal looked at all of these cases, they opened up a complete review of the canadian military and how it treated gender. it looked very closely at the issue of operational effectiveness because the military sent several witnesses to the tribunal, and the tribunal determined that operational effectiveness was a gender-neutral concept and ordered the canadian forces to completely integrate women into all environments and roles in the following ten years. and the tribunal does carry the

weight of law in canada, so the canadian forces was legally obligated to move forward with that direction. >> and, colonel gjerde, how did it occur in norway? >> honestly, i don't know too many details about the history before we opened in 1984. but we have society where equal rights for men and women is very deep founded. so i'm quite sure that was a political issue. because at this time there were so, such a small percentage of women in the armed forces in the outer branches which were opened in the '70s. so i think that's the norwegian society where every man and woman should be treated equal, have the same opportunities. that's deep-founded, and it's never, ever questioned these days. having these services open or the branches open to women.

>> so what about in the u.s.? so, captain manning, you know, do you think that here we look at, um, at the military as just another opportunity for employment, or do we look at it as somehow distinctly different from business or other types of employment opportunities for women? >> i think we're all, we're all over the place on it, but the prevailing view has been that it's different. um, in the u.s. what women have been allowed to do in the military if you go back to 1901 when we started the army nurse corpses, it depends on -- corps, it depends on, a, what the military needs, what women are already doing, and mixed into that is a great big dollop of what society thinks emotionally is fitting for women to do x. those things have changed over time. but every time something new

opens for women, even if it was probable just moving from the desk to the standing up at the file cabinet -- [laughter] back during world war i involved this whole political discussion. um, the biggest mess that i've seen when things really erupted was in the mid '70s. e.r.a., most people thought it was going to pass, that's the equal rights amendment for those of you who weren't born then -- [laughter] um, there were some lawsuits out there by both men and women saying it's -- and members of congress saying it's time to open the service academies to women. that is the only change that i know of that's been made with respect to women in the military that the services fought tooth and nail. you know, that is their sacred place, and the coming of women to those academies was going to

defile it somehow. if you go back and look at the congressional testimony then, one of the -- he was, i think, the cadet commander at west point said this is our school, and if you bring them in, you're wrecking it. i mean, i've heard the same arguments coming last week on the television. [laughter] so as long as those are still out there, they're still very vocal, and, you know, if you look back through the history, there's a whole political go round every time we open something. some things happen pretty quietly, but for the rest of us, it's been a political tangle. you know, you're told the doom is upon us, we're wrecking the civilization, and a year later it's like, oh, what was the big deal? [laughter] and i suspect the same thing is going to happen here. it will happen, and ten years from now everybody will say why did anybody oppose that?

>> so, colonel mcsally and captain osland, you're both first-wave women. so i guess we can take it chronologically. >> okay. >> so -- [laughter] so you were the first wave when women were first allowed into flight school. what was your experience, um, sort of integrating and, um with the reception you received? >> well, you know, the way the flight program was open to women was a little bit similar to what secretary panetta has just done. they kind of said a la jean luc picard, pick it so, and there it was. our chief of operations, admiral zumwalt, was probably one of the most forward thinkers that the navy has had. and in 1972-'73 he was taking into account a number of factors. one of them was the e.r.a., as

lory mentioned. the other one was the end of the draft. the draft had ended in 1970, i believe, and the navy had about a 10% retention rate, i think, in the 1972 following the vietnam or war. so the big push was where are we going to find people, and the obvious choice -- at least as far as admiral zumwalt was concerned -- was to start recruiting more women and get more women in the services. his service was the navy, and the way he saw to make that more attractive to women was to start opening up some of the specialties that had been closed to them. now, the -- you have to think about what was going on in the '70s in an historic context. women were still being discharged for pregnancy up until 1975. you were still -- we didn't even have the uniforms that were correct for the jobs that were being opened up. when i first started standing watch in my squadron, i had to walk the flight line in heels

and a skirt, and the flight line was two miles long, and you did it several times during every walk. one day i showed up in enlisted boots -- [laughter] and pants to try and walk the flight line, and i got blasted for it pretty good. but i was allowed to slip into pants, slacks to walk the flight line during every watch as captain of the watch. um, you know, other things, the flight suits, the flight clothing was kind of, you know, didn't fit real well. that was not a problem except that i did have one pilot ask me why i wore that unattractive flight suit, you know? [laughter] it was, it was an amazing experience. and i would have to say that on the whole the helicopter or community was very welcoming. it wasn't, it was higher up the chain of command at the wing level, the air pac level. i was on the west coast at the time. as you got more senior officers

involved, there was more and more resistance. part of that, i think, was because of the way that the program was instituted. they didn't give us, give a lot of thought to an actual career path for the women. they thought that it would be cute to have us around for a few years and that we'd find a guy and get married and go away. and then they could sort of sit around and think about what was going on. it came as a real shock to them to find out that the first six of us actually had plans to stay armed. [laughter] and we had a few other ideas about how this whole thing was going to be handled. >> colonel mcsally, i think you had a slightly less welcoming experience. [laughter] could you tell us about that? >> sure. and let me just say that among my other hobbies since i retired is starring with neanderthal mindsets on fox news channel. [laughter] yesterday was the most intriguing. anyway, you can go back and check the tapes if you don't

know what i'm talking about. anyway, i would say that in general though i wallet to comment this is a leadership issue. this is about leadership, this is about making sure we have the most capable fighting force. um, this is about good order and discipline. and, i mean, that is the bottom line. and so, um, when they opened up in the air force, anyway, fighters to women, i would say what it felt like on our end -- i'm not sure what actually happened across the chain of command. they were like, good luck, hope it all works out for you. [laughter] and i look at some of what they've gone through with the overturning of don't ask, don't tell and the extraordinary measures through the chain of command to make sure that the leadership climates continue to be for the mission good order and discipline, and i would just say that none of that actually happened when we transitioned to fighters. they thought, hey, just let 'em go and, you know, if we create any more attention to it, maybe that'll add to the problems which is, actually, not true. i would say that my, um, i mean,

i knew it was going to be a rough environment, you know? you guys have all seen top gun, so trying to integrate into that sort of, you know, bastion of -- oh, i don't know, i can't say the right word without saying the wrong word. [laughter] but anyway -- it was challenging. so, i mean, i knew that. i used to have a brother, i was the youngest of five brothers, i knew how to hold my own, so i was ready for it. but what i wasn't ready for was being ignored. what i wasn't ready for was having my -- literally, my back was turned on me by my squadron commander when i first went up to introduce myself to him. i found out later that he had a meeting with all the pilots. what he should have said is, hey, everybody, we're about to get another pilot who's been through the same training as you, who's qualified and capable who's going to go to war with us, and we've got a mission to

do, and i expect even's going to be professional. we've got a long history and heritage in the bulldogs for what we've done in combat, and we're going to uphold that. and if anyone is acting unprofessionally, i'm going to cut their head off. instead what he did was said the worst possible thing is about to happen. [laughter] you know? i mean, i wasn't there, so i'm assuming that my colleagues and my buddies are telling me the truth. you know, we're about to get a woman. so that was of sort of the climate that was set when i first walked in to the environment. luckily, within a month he traded out, and i had a new commander come in who had the mindset that i first conveyed. and luckily for me, we deployed fairly quickly. within a month of me being in my squadron, saddam hussein was threatening to come south again, they wanted to ramp up and bring in an a-10 squadron quickly, and so we deployed. there's nothing like a

deployment to get rid of all the nonsense of people feeling threatened in their careers or whatever that is to sort of put that aside. um, i will say in general my experience has been that when you get into your unit and you prove yourself and you show that you're capable, it's the same thing that the last panel was talking about. i mean, you go out, you go to the bombing range, you're going to either hit the target or not. it's a single-seat fighter. no one else is going to fly the airplane if you can't do the mission. so you prove yourself by your scores, by your performance. and very quickly my teammates and my units would very quickly accept me as one of the team. i would say in general the challenge for me, and, you know, the other women was i often was -- i continued having hostility throughout my career from people i've never met before, people outside my unit that i've never worked with, never flown with, i don't even know who they are. but, by gosh, you know, they had all sorts of interesting things to say about me and my

capabilities. i think other women experience that as well. your teammated become your teammates, and you're very well respected, but you still have some of that mythical hostility. especially for me when i started to upgrade. it's one thing to be a wingman where the flight lead tells you what to do, and you just put bombs on target. but then you become a flight lead, that's another interesting dynamic. then you become an instructor pilot, then i got promoted two years ahead of my peers. so that's when a lot -- when i saw some of the worst dynamics happening was when i started to succeed in that environment. and then all the emotions came in of, well, of course, you know, you were only promoted because you're a woman and all the kinds of things that come with that. so i would just say that i would imagine in those units that still remain exclusionary even though they may have experienced having women attached with them, there's going to be similar dynamics going on. it is a leadership issue, is the bottom line. from the top down. they need to make sure that they set the standards, and they need

to make sure that they set the right leadership professional climate and that they hold the line on that. and that should go, you know, the integration should go just fine. the other thing i'll point out, and i know you've got a lot of other questions, but i know it's going to happen again, and i've seen it even in the discussions in the last week is there's -- people will make an assumption that the standard's going to be lowered for you, and then they're pissed off about it and they take it out on you. but it's all in their head, right? [laughter] it's just ridiculous. you wouldn't believe the number of altercations in the officers' club that i had over this issue. [laughter] you know, where they would just assume that, you know, if you don't have what it takes, then i'm going to be told that you have to stay anyway, and that just pisss me off. did you get a memo down the chain of command that says you need to lower the standards? well, no, i know it's going to happen. it's happened in the past. when did it happen in the past?

don't try to be rational. laugh don't make me deal with facts now. you know, and seeing it again in a conversation i had yesterday with an elected officialment there's an assumption -- official. there's an assumption the standards will be lowered that makes people very angry, and they just take it out on you as if you don't belong there. and this is all just going on in people's heads. so they need to go get counseling, you know? [laughter] momental health is available. but this is not real. it's not real. so there's no policies coming down doing that. so we just need to battle that and know that it's out there. >> yeah. i just wanted to comment on this because i very much agree, and i think it's very much a fear about the masculine image of this branches. we see that in norway after, yeah, several, 20 years with female in these positions. but many of our male colleagues have their images built up from american hollywood movies -- [laughter]

>> yeah, right. >> and they are often very far away from the truth. but that's what they fear, is the issue. >> actually, i have a specific question for you. go ahead and -- >> i was going to say i ran the navy's pt policy for a while, and in the entire time i followed stuff on women in the military for all services, bothousally and with respect to pt standards, i've only seen one lowered, and it was the navy test of flexibility. the navy test of flexibility is part of the regular pt testing. you sit on the floor with your legs straight ahead of you, you bend from the hips, and you have to be able to touch your toes, extra points if you're getting beyond. we had to change that because too many men could not get extra points for going beyond. [laughter] and the thing that gets under men's craw more than anything i've seen is the sex

differential in pt. not occupational, but pt. i've never heard one of them complain about the age differential. >> yeah. >> anyway -- >> so i did want to ask you specifically as we talk about previous integrations and how it goes, one of the things you're hearing now is people saying if you open the combat arms to women, you're going to have fewer women interested in joining the army or joining the marine corps because they fear those assignments if they don't want them. ..

>> there was great fear in the navy that once we open the combat ships to women, and women would find they would go to sea as often as men and whatever the particular job rating was, that women would be bailing out, that women who didn't sign up for that would quit. it didn't happen. there may have been somebody that got out, and, certainly, women and men in the navy and all the services have a family pull, particularly, once they are married or there are children. it's no different from men and women. it did not happen in the navy. women are a much higher percentage of the navy than they were back in 1994. women kept joining and joining in bigger numbers. >> in my experience, along the

way, a lot more women got out because of the opportunities denied to them rather than offer to them. >> good point. >> exactly. >> in the canadian forces, how did that disintegration occur? what's the lessons to be learned from the way it was implemented? >> well, in 1987, the canadian forces saw it coming with the complaints before the tribunal and hearings takes place. in 1987, there was the trials designed to determine if, when, and how the restrictions to the oi point -- appointment of women could be changed. in hindsight, they look back and see it as a natural part of the progression to put women in combat arms, but looking back and what happened, it was very much set up to test the impact of women on combat operational units. an important point here is when we talk about quotas and critical mass and talk about

goals, the crew trials, which they were coinedded, demanded that a certain proportion of women be in each unit so they could evaluate impact on operational effectiveness. that drove a quo that system to get the women into units which created a whole series of perceptions around the motivations of women, abilities of women, that sort of thing. in the tribunal rules, there's not crew trials, but just get on with it. furthermore, the trials will no longer will be used to evaluate women, but effectively integrate women. the ruling said, right, we'll change all policies. over the next year or two, it was an administrative process in the headquarters. by 1994, they said, great, we integrated women. there's equal opportunity and equal liability for all women in the canadian forces except the part of crew that was actually supposed to be monitoring and

helping the effective integration, helping leaders adapt, that sort of thing. it was not happening. my 1997, progress, you know, in the words of one of the senior officers, we wasted a decade almost by possibly thinking that women, well, they could just get in there, and so it was on women. the women who were successful, i maintain they were leaders from the very beginning. as soon as they joined, they had to integrate themselves into the unit. by 1997, we conducted research and started looking closely at the barriers and why leadership at all levels of the chape of command had to be engaged. it was not just the top saying it will happen, but it had to be effective in every single level of the chain, and it meant, you know, some of the things that the colonel mcsalary referred to, and if men were not effectively working with the women that were coming in, they left it to the team to sort it

out rather than leadership shaping a standard team, those sort of things. it took a good decade to get on board and actually get effective progress moving so much different today. >> thank you. so the nor wee january forces were integrated when you joined or open to women. i know everyone wants to hear about your experience as an infantry officer. what was your role? talk about what it was like in a fully integrated military. >> yeah, you can say "full integrated," but we have issues today, not just for infantry cavalier, but all overment i'm so excited for my american sisters in arms. this is such great news this week, but i also have to tell you, you have some hard work in front of you.

after 28 years, we still have issues. we're struggling with theming and it will still take time until we can say we are truly, fully integrated. my personal experience, i am -- i've been privileged to be able to have the jumps i've had. i had been very lucky to have the right commanders with the right approach to having women in their unites, and i think, like, martha said, leadership is vital to make this diverge. military leadership at every level, but also the political leadership. they encourage females to come into the forces and that we are very hard on those leaders who are not able to handle having women in their units, and i

question those men who are not able to handle or can't accept women, how are they able to handle the missions we have? handling local populations where we deploy and so on? this is important, but personally, i've done the same job, the same training as my male colleague, and i felt that i recognized what the former panel here said. it's all about being part of the team, and one of my commanders when i was going to bosnia was in the media, and i remember that, how is it you have a female company commander? he said, well, i have not really thought about it because i never had a male commander.

[laughter] okay, and that's all about being one of the team, doing your job, and my experience is also -- that's my male colleagues, as we are out doing our missions in norway or deployed, they are so dedicated about the job, the missions they are there to do, and so they are not caring about if there's a female next to them or another one. they are -- the question is are you doing your job or not? therefore, i've felt support. i've been respected. i've really felt appreciated for the job i've done throughout these years. both as a peer, a subordinate, but also as the commander. we have issues. i have to add -- admit that as a commander i've struggled with female troops that had a hard time with kind of sexual harassment so we have

to work continuously to make sure that every individual in our troops, male and female, are handled like you should do, with people you are responsible for. >> you hit on the same things that the first panel who gave their testimony about ground combat hit on. you know, being part of the team, doing your job, you know, knowing that the person next to you is going to be there to take a bullet for you and cover you. >> yeah. >> tell us just a little bit about your own personal ground combat experience and sort of what the characteristics are that you think are important to being, you know, to holding that mls and doing that job in the right way regardless of gender. >> yeah, yeah, i'm humbled listens to the former panel. i've been in violent situations. we had both wounded and losses, but i have a lot of the high

intensity combat experience spending several years deployed, but about the characters, which i find important. it's very much what was mentioned from the former panels that it's about being calm in very tough situations. make the right judgments, and that's not only for me as a commander, but that's the same for the troops because they, when you have a rifle pointed at you, you have to take this very quick decisions to answer to support the one next to you and all of this very, very hard questions, so that's an important one. team, absolutely agree, very much about your team, and they say when you're fighting, and i recognize that, when you are fighting i don't think you think about the flag and your country and all the very important

things. you are thinking about the comrade next to you. we are the team. we have a job to do, and we better do it well together. >> did you have something you wanted to ask? >> the one thing i was going to add, you just mentioned the issue of harassment in in canada, what was important is paying attention to other policy changes and implementation changing at the same time. we just implemented sexual harassment policy, and the strong message went from senior leadership there was zero tolerance so leadership in the combat unit doesn't live women feeling ill equipped to properly discipline, properly train, motivate a standard team because they were afraid of being accused of harassment. paying attention to other policy issues and other things at the same time was important for us as well.

>> yeah. i would like to add one more thing which is an important part of your character, or what i find vital. that's having the right values, and that's also absolutely the same for men and women, but that's what builds the right culture in a unit, and that's what you have to focus on continuously as a leader or as a troop to build the right culture, and that's also the vital thing to handle what we're doing in this, not only the combat branches, but every branch. handle everything from really high intensity to very delicate situations to dealing with humanitarian assistance and so on. you have to be able to do your job in such a variety of tasks. >> we touched a little on this,

the non-physical requirements for excellence in these positions, but let's talk just a little bit about the standards. so, i think, you know, as we go forward, it circulates on the establishment of standards, and, you know, just i'm curious with the canadian forces, i think initially you took a gender norms approach; is that correct? to the typical standard? >> that was one of the big lessons we learned is that the standards, of course, have to be gender neutral, but, also, more importantly, the standards have to be job related. not a set of physical standards that have nothing to do with performing the job. today, when canadian force soldiers deploy, it doesn't matter if you're an administration clerk, medic, or infantry officer. everyone does the combat fitness test together in preparation for the deployment. everyone meets the same deployment standards, and those who are deploying have to continue to meet the standards of their specific occupation.

there are not arbitrary standards and like a certain number of pushups to be in infantry, but completely related to the job. >> working with the australians as they start to begin integration; is that correct? >> we sent a team, four of us went to australia last may and briefed the headquarters level out to the operational unit and shared lessons learned. for us, the two big ones, you know, that a lot of people look at our experience and question critical mass and this whole idea of training to do a job and not training to meet a physical standards, and although, of course, there's overlap, is there's a different philosophy involved there. >> on the subject of physical standards, this was a huge issue when women were taken into the flight program, and, you know, next year is the 40-year anniversary of the day i got my wings, and i have to say it was disheartening to 39 years later

to hear that the issue was still over body strength and bathrooms. [laughter] i turned to my husband saying i'm stunned we have not moved past there. there's a huge emotional component with the physical standards, and one of the ways i handled it on the subject of the bathroom issue, if i made, was how do you do this in a cockpit in a helicopter? of course, the men have something called the relief tube. we are familiar with that, and, you know, it was nothing -- occasionally since the helicopter had two hour legs or so, and we didn't flight refuel or anything, there was not too much of an issue, but on occasion, it was an issue for me, and i have to say one of the first things that happened to me when i got into the squadron, the men, you know, all were talking about this and presented me with a gift, i think, along about my third flight, and it was an oxygen mask with a large

tube and sponge attached, and this was supposed to be my version of the relief tube, and i actually thought it was a good idea at the time. [laughter] >> they have improved. >> good to hear that. it is an emotional issue. you can't avoid the fact for guys it's about the upper body strength. we're stronger than you. the truth of the matter is that's not what it takes, 99% of the time, that's not what it take, and so, again, gender neutral, physical requirements, i think, that's the way to go, and, also, very related to the job. i can't say that i was fortunate -- i had a lot of upper body strength i got mostly through riding horses and shoveling what comes out the other end, and i will say that served me well in the military, that particular skill. [laughter]

but, you know, it really wasn't an issue except in the minds of the people who opened the flight program to women. >> colonel mcsally, curious what you thought. touching on the idea of critical mass, and when general dempsey and the secretary of defense, leon panetta, have their press conference, general dempsey started talking -- someone from the press specifically asked about women in the special forces, and he talked a little bit about, you know, standards, and he talked about critical mass. i'll quote what he said because it's important to listen to, but, you know, he said, "i think we believe there's women who can meet the standards. the other part of the equation is in order to account for the safety and their success in those kinds of units, we have to have enough of them so that you know they have mentors and leaders above them. you know, you don't want one woman who meets the standard and put in another unit. the issue is not privacy. it's the ability of upward

mobility and keep the command if she's one of one. we have to work the standards and the critical mass." i'm curious, and i know everyone has an opinion on critical mass, and while it's nice and there's targets and quotas and all of that, most of us have gone through as one of one, but what do you think about the idea, and what is the idea of one of one that sounds like evaluation language to me >> -- to me. >> i was really shocked, and i agree with what general dempsey said other than that. i don't know where that came from whether it was a stray electron or under advisement. [laughter] that makes no sense. first of all, you don't need women mentors for women. all of my mentors, actually, were men so any time you talk a language where you need women to be with each other and women mentors, that's just the wrong climate to be setting from a leadership climate. i was the only woman in my

fighter squadron for a very long time because i was just the only one. if they tried to figure out how to put us in pairs, usually, we are our own worst enemies, a separate issue. we don't like how you behave because that impacts how i look. you are better off with just one of you when you get going. the reality we needed, like, women to be with each other and that critical mass was not how we integrated women into fighters or flying. they tried when i was in pilot training, actually, the instructor, to divide students, female flight students, like this put them together in a flight rather than separating them. i actually stopped that. why are you doing that? the policy and discussion of that creates resentment in men. women have to be together in this time. they go to the units and they are not together. it's not smart all around. the one on one comment makes no sense. you are evaluated on peer group, not your gender. that evaluation language that somehow a woman would be looked

at by herself for promotion unless there was two in a unit, is, again, that was a stray electron. i hope. that's -- if that's really how they form how they do this, it's the wrong direction. we need to make sure we recruit, continue to recruit the most capable force for our all volunteer force. get out to high schools, recruit the best men and women for jobs, set the right standards, and then we just got to pick the best man for the job, even if it's a woman. if you're the only woman in your unit, then that's fine. it's a leadership issue. it's a leadership that sets the climate. whether that comes down to bathrooms, work it out. it's all been worked out. this is really silliness. i just say and encourage them not to be considering those kind of dynamics, but to ensure they have the right command chain to ensure the qualified people in the units are treated and able to be mentored and compete for

promotions like everybody else. thirty-seconds on physical standard because it continues to be a red herring out there. when they debated whether to open fighters to women, there was the same dynamic. women don't have the upper body strength as men. i just completed the iron man triathlon, won the women's division by an hour, beat all infantry special forces, kicked their butts, and guys said women don't have the endurance to do combat missions. i sat there just, like, just breathe, and, you know, you can't help yourself. dude, you want to go outside and talk about this? [laughter] let's go for a run. let's settle this out there. the difficulty and the reason why it's now in the debates going on, even though the train's left the station, there's a lot of people who are against this that can get away with you've been excluded from

doing this so you have not done it, and i've done it. therefore, you can't do it. all right? so just because you -- sure, you've been in combat, and i don't know if you see the nuances on tv lately. sure, you've been in combat, engaged with the enemy, responded to fire power, but that's different than sustained offensive operations. that's the language you hear right now, on fox anyway. [laughter] there's a difference, and so now what it takes, the strength it takes to engage in sustained on offensive operations is something a woman can't do. justin bieber can do it, but venus williams can want? -- cannot? [laughter] seriously? [laughter] i mean, this honestly comes down to, and i encourage you all, the talking appointments, it's about individuals, standards, capabilities, and take the best person to the job. yes, men, upper body strength's bell curve is the right of

women, but they do overlap. treat people as individuals. as of the challenges in the combat zone with conduct and behavior of our soldiers, having issues, it's never about physical strength. it's usually about discipline and restraint, leadership, you know, just strategic errors. you know, we had no problem lowering the standard in 2005 and 2006 in high school education and in medical conditions and in aptitude tests and felony records. we had no problem lowering the standards to meet the force, but didn't look at the other 51% of the force and treat them like individuals. they need strength and endurance, but they also need leadership, team work, courage, restraint, wisdom, all of those things you saw in the last pam. that makes up the strategic corporal these days and the environment we're in. strength is one minor issue. get over it. >> i agree with most of what martha said.

[laughter] i think it's very important when we're discussing females, nothing -- we are talking about very physical demanding jobs. you have to have a certain physical standard, and it's very tough to be in one of these units if you do not meet the requirements so -- >> i agree. >> it is heavy. you have to leave your -- it seems like many -- that's what i hear in norway, well, we're so technology advanced, we don't need the physical standard anymore. that's not the truth. patrolling in afghanistan, i did that last year, it's still -- i wouldn't used words, but it's still very hard. [laughter] >> i totally agree. >> yeah, good. the other part, i was also concerned when i heard dempsey about the critical mass because i think you will have a very

hard time implementing female in these branches if you are obsessed by certain shares and numbers. at the same time, honestly, i've been the only one for many years, and it's worked very fine, but i have had a better time in units with more women because it does something to the culture, and i think you need a certain amount, really, to influence the culture. we shouldn't say we need specific shares, but we should work hard to increase the numbers if we want to do something about the culture, if you really believe that as women we bring something unique to the table so that's my approach to it. i also can mention one little thing from norway.

we have this discussions with our female troops about how sphweg grated they are in the units because some of them are complaining. they say, you put us in specific rooms or specific barracks, and then we are not part of the team 24/7 like our male colleagues are. some of the information, some of the close contacts, we miss that. when we are deployed, that's not an issue. we live, and, yeah, we're -- exercise, live, of course, in the same tents close to each other. about the barracks, one of our border units now, at the border to russia, we have the team of soldiers sleeping in the same rooms as their male colleagues all year round. in my battalion in norway, i

didn't want this, and we separated, and the reason for this is that when deployed, there is a no alcohol, we don't have all these issues going out, but the combination with alcohol, young women and men together, that's not always easy. when they came home from, i think, the few harassment issues we've had, they were always combinedded with alcohol, and, therefore, i was a little concerned to have them sleeping in the same room, not about ability to lock their doors and so on. it's sad to tell, but that's the truth. >> do you have something to say? >> i did. the critical mass thing put me on alert since i've been

listening to that. particularly, after i saw the article in "usa today" yesterday talking about general amos talking about what he thinks it means. i don't think they know what they mean by the term "critical mass" and having been on staff duty a lot and seeing the compromises that have had to be made to come to accord. i'm thinking that to get all four of the service chiefs and the jcs in line with the policy, which is what they would want, that was put in there as a way of walking the dog back, and i think it's the one thing that those of us who watch implementation have got to watch very carefully because of all the dangerouses that colonel mcsally and has been mentioned. it's in there, and i don't think we should send a 19-year-old right out of boot camp to remote duty where she's the only woman in 26 miles.

on the other hand, it should not be a barrier to occupations. we'd have no coast guard rescue swimmers, female or probably -- no army people going through the leader course, women -- the army send women to if there was a critical mass necessary, and for the rest of us, those of us sitting here, we'd be back in the 1950s for a critical mass. that's the thing, i think, that's got to be watched. >> i think we have time for maybe one, possibly two questions. yes, go ahead. >> hi, i'm jennifer, one of the plaintiffs with the mj, and you started to hit on it just not sending the single 19-year-old female out, problem with being 19, and at 19, i didn't know anything about the military or life in general. would you like to see, might ma, officers and senior ncos moved

into the positions first and then open it up to enlisting directly into the positions? >> you know, there's not a one size fits all for this. i don't think you can have one plan and say that's the way it's goinged to be. you know, when i was in the navy, i was an infant, and i was the only officer sent with a group of 20 women out of boot camp with no other training out to a communications facility. i spent a lot of time instead of working in communications, but telling the chiefs this is what the haircut regulations are, and what the uniforms have to look like. i think a lot of that has already been dope, but i don't think there's a one size fits all. i think you do have to look at where the unit is. you know, i would not send one 19-year-old woman by herself with a squadron when there were no other american women or women of any kind anywhere.

on the other hand, if i was not allowed to be the only woman, i couldn't have been the xo of the communication squad i was at or the co. this was the only woman on the ship, the first woman co of a navy ship so it's got to be done individually, and very carefully and with thought, but this stuff about one of one, i read it exactly the same way, that's language, and that's -- i don't know if i answered the question, but it's god to be -- got to be done with common sense and it's situational. >> another question, miss. >> thank you, all, so much. this is very informative. this is mostly for the navy captains. i wanted to know what you two thought of navy's decision to

integrate women into fast attack submarines. >> well, very much, i think, similar to the decision to put women in flight training. a little bit different. submarines require a little bit more of a pipeline. there's a flight training program for aviators, it's a little more extensive for submarines, and there's the quarters issue and the long time deployment and underwater and everything. i think it was a long time coming. i think they true threw up a lot of artificial barriers that have finally come down, and i expect the women will do fine in submarines, but, yeah, it's an interesting environment. let's put it that way. [laughter] >> change opens the fast attack submarines to women. previously -- that's where all the fun is. that's where every submarinerments to go. the others sit there and wait for the balloon to go up.

the fast attack submarines is where you get whatever the submarine version of the wings are. it's where you do the tactics, where you are engaged in the operations, and, where, if you want to be a submarine admiral, you have to spend time. >> [inaudible] you know, that type of a thing, and any concern there? >> all that stuff can be worked out with a little common sense or a poncho or something. >> exactly. [laughter] >> all right, well, we're running -- oh, go ahead. >> question has to do with implementation. a lawsuit ruled in her favor, and it was ruled unconstitutional, took 15 years before navy ships opened, combat ships opened to women, and 15 years for aircraft to be flown

by women, took another 20 years until earlier this month when the navy finally approved captains to be a carrier air wing commander, what's your thoughts quickly on how do you speed up the implementation recognizes you have to grow the young women at the basic, you know, private level not to be benign or entrance of second attendants and to be admiral? >> i think that, you know, one of the reasons it so long, and that's my cousin, by the way, but i did not plant the question to be clear. [laughter] he did not log that to me, but one of the reasons it took so long is foot dragging. it there was an opportunity to delay a decision to say we need more study, and that's frankly how i see the critical mass thing, a great excuse to delay

implementation to foot drag to somehow obstruct the great announcement that was made, and, you know, after the lawsuit which was handed down in 1978, i would say that the 80s were a period of very, you know, two steps forward, one step back, two steps back, one step forward. it was, you know, if they could make a decision that obstructed the implementation of the laws, then that's what they did, starting with the fact as soon as it was struck down in the 9th circuit court that they promptly had a new version of it passed with the national defense authorization act in 1979, and that instituted the 180tad thing which we struggled with until 1991. so, and, then there was the jag interpretation of things. 6015 itself didn't have to be restrictive as it was. it said women couldn't be, quote, instructed duty upon

ship. if it was in san diego bay, i couldn't hover over the ship. that's the obstruction it occurred. it was news to the men they were assigned duty to board that ship. it's something to watch for, something to be watched very carefully. >> yes? >> i think we have to caution that. we shouldn't be fast forwarding, like, moving women ahead to higher leadership positions without the necessary experiences they need because you set them up to fail. there's that piece. sometimes it takes time. it took time changing the policy in 1993 for me to be a squadron commander in 2004 which was actually fast because i was older, you know, a little more experience under my belt. we got to be caution there. there are things that we -- you've seen in the last panel, 280,000 women deployed to afghanistan and iraq. women are in combat now that could make lateral moves based on the experience they already have into positions they have been, you know, closed from

serving in right away. they could get the training they should have had before they did the job they were asked to do on the battlefield in order to fill the square for the, you know, the qualification that they need. we shouldn't have to start from scratch. like, in our case, we had to start with scratch, brand new fighter pilot wings, move them up. be creative enough to say there's females enlisted officers that have the experience, even though they were not coded in that way, lat right -- laterally move them over so they can move forward without waiting 20 years to get women into leadership positions based on the experience they already have. >> we have to cut the discussion off here. i know you had something to say, but thank you for sharing your wisdom, experience, the discussion has begun. the work is in front of us. i have a fabulous captive audience here and three minutes of your time. >> more live programming coming up. former first lady laura bush in

washington today to give the keynote address for the susan g. komen race for the cure summit. that's 12:30 eastern on c-span 2. later, back at the health care event when the congressman burgess talks about congress and health care. that's live at 1:30 p.m. here here on c-span 2. the house is in at 2 p.m. eastern to take up a small number of bills with votes at 6:30. this week, the house plans to work on a measure requiring the president to submit a balanced budget to congress. the senate is also in at two eastern for general speeches. at 5:30, voting to advance a bill to reauthorize the violence against women act, a law that expired in 2011. members of both parties attended retreats this week, and as a result, the senate is out tuesday and wednesday, and in the house, no legislative business on thursday or friday. as always, watch the house live

on c-span and senate on c-span2. >> if you've got some hot shot that just got his ph.d. in computer science from stanford, she's getting offers from all over the world, and to say, well, you can stay in some limbo for six years is not competitive. >> so, yeah, government -- congress can do a lot, and you don't have to be efficient on your iphone or blackberry to understand the application of tech policy and what makes it work and what doesn't make it work. it's very difficult to make investment decisions and expect any kind of return on investment when there's no way to predict the future. our difficulty now is there's no consistency or certainty in the policy decisions. >> the government's role in technology and policy from this year's ces consumer electronics show tonight on "the

communicators" on c-span 2. >> leon panetta announced they will drop the ban on women in combat. a group of men and women spoke about their experiences with interrogation and gave their recommendations on how best to proceed with the policy shift. this is about an hour. >> fantastic panels already this morning. now, we're going to move into the third panel and look a little bit on the subject of implementation. we heard a lot about experiences and how things have been in the military, but as of a week and a half ago, the combat exclusion policy was repealed, and now we are moving forward, and in less than three years, it will be fully implemented, and there are a number of milestones to accomplish on that path. we have a very distinguished group of folks here to talk about implementation of the repeal of the combat exclusion policy, and some of their thoughts on the overall combat exclusion policy itself.

before i begin the introduction with the pam members. there's a slight change. i'm brandon denecke, commanded units of mixed gender. gender was never an issue. above and beyond the fact, commanding is a challenge. people are people. you have to build that team. you got to make and lead that team to work. i feel like i have a little bit of skin in the game in terms of repeal of the combat exclusion policy. our family, we have a daughter who is currently on active duty in the military. we have two sons who are military age and who may be serving in the military, and i think this is important. it's just as important for men as it is for women. it's important for americans and important for our partners. of course, i have -- there's an army colonel in my life whom i'm fond and have the highest regard and utmost respect, and that's

my wife. today on the panel, we are joined by michael o'hanlin and his writing, his thoughts, his books on many themes related to defense, but, also, in particular on the combat exclusion policy. he had the opportunity to observe the course, and he'll share thoughts on that subject. we are joined by mr. greg jacob, a former marine corp. officer who commanded a mixed gender marine company, and he's very familiar with the challenges of trying to have people work together in an environment of equality, in particular in the marine corp., and after he left the marines, he's been a very strong advocate for -- and supporter of women in combat unites. we also have dr. michelle,

actually also retired colonel, graduate of the u.s. military academy, one of the first classes to have women in them, and she has extensive combat experience as well as academic experience. she commanded support and the conduct -- logistic support activity anaconda in iraq, very familiar with the challenges as a leader above and beyond being a woman herself in leading men and women in combat. we have dr. laura miller. dr. miller is a distinguished academic who has written and researched extensively at the rand corporation. she's studied women in combat and women in the military for many, many years. not that many years, obviously -- [laughter] and she has written about repealing the combat exclusion policy, and she will share with

us her thoughts about the combat exclusion policy and now what the repeal means. the format will be some -- i have the opportunity to ask the panelists questions and solicit their thoughts, and we'll try to stay on time or stay on time to have the distinguished audience ask questions. there's a saying at the army war college that if you're in the room, you're in the game so we want to hear from you, and we want to hear your thoughts on this very important issue. dr. o'hanlon, you wrote extensively about women in the military. you published an article recently, a thought piece, on whether or not the marine corp. and services in general were ready for the repeal of the combat exclusion policy. i'm wondering if you would talk with all of us about your thoughts on that subject. >> thanks, brandon, and thanks for the honor of being here. congratulations to all of those who have done so much on this

issue for so long. i was reviewing the subject in the evolution of the role of women in combat and in war in general the other day digging up an old book at brookings, "women in the military" from 1976 from my predecessor who wrote a book on the all volunteer force and nature of the military, and in the early 1970s, women were 2% of the uniformed military, and by the mid-70s, it was up to 5%, and now we are more like in the range of 15 headed presumably upward, and we know how much a debt we owe to many women in combat for all they have done in all various jobs they perform. i think any conversation needs to begin, even though it's said before today, and it will be said again, i'm sure, needs to begin by saying that, and i feel honored and grate iful to say that. i have not served, but many women have, and i feel safer and protected because of you and

what you have done. i think it's generally a good thing that we're headed the way we are. i got questions to go along with my general happiness about where we are headed though, and i think a lot of people do, but any doubt that i have at the article i wrote last fall in the "wall street journal" about the subject was seen as strictly pro-women was immediately erased by my sisters giving me a hard time about the fact that i was not 100% sure that women should be in all jobs just yet, and that's the basic steering of the argument was, and, again, a lot less experience of people in the room of both genders. i have not been in the american military. before and after women joined the infantry officer course, the intense course that officers take after the basic school. the basic school has been integrated for a long time, where all women marines already go, essentially, but the

infantry officer course is a specialized course for infantry, and this is, you know, gets to the heart of the question of whether women should be in the main combat formations, and so what i observed, i saw this incredibly intensive series of drills and exercises that marines did over about a 13-week period before they had any women, and then i had the honor of watching the two women who attempted the course in the fall, and as most of you probably know, neither one passed. that, by itself, does not tell us a lot. one thing, 25% of all the men fail, if that's even the right word. secondly, sometimes, it's a matter of getting injured. do we say that robert griffin iii failed because he didn't completed playoff game? that's hair much. i mean, one of the two women failed, and i'm not going to talk about the name or specifics of her case, and i don't know all of them, but, you know, her body suffered injury. whether that's, in some ways related to the fact she's a

woman or not, i don't know. i had no doubt watching her that she had the capacity to pass this course. the first woman who failed was an amazing endurance athlete that didn't have the upper body strength. that cut to the core issue debated in this, and when we get to the physiology of the subject of whether most women have the upper body strength that the marines encyst upon, and then there's a separate debate about whether the marine standards are correct. i think all of these debates should be alive and well despite the decision because i think one thing we're going to find is that we're probably not going to see a lot of women who want to do this or who can do this. i'll be blunt and say those two things. that doesn't make you all happy with me, but i think you'll find, because it's not the first time we opened these positions to women and some of the reluctance is cultural and because it takes a courageous person to break into the bashtan of male culture. it's going to be hard for

awhile. there's the question, we all know it's a hard physical thing to carry a 150-pound load on a 10-mile march. i know women who can. by the way, i can't. when i went to these things, i walked with a light pack, not the 150-pound mortar on my back. the marines, some say they are caught up in the macho world. there may be a little bit of that, but there's a reality that infantry forces still fight by walking through terrain for five or ten miles with stuff op their back and uses that equipment once they get there. it's a legitimate question whether the standards are right or not. i think they are right. to me, a situation -- i'll finish on this point. the most likely scenario now we see assumes the marines and army don't try to ask for leniency but open up ground combat position, the most likely thing is we're going to see a very

modest number of women try to do this and women obtain the numbers. it will be impressive as heck. anyone who passes the course walks on water in my opinion. they are tough. the percentage success rate for the typical male marine is 70% or 75%. i could be wrong, but i think the typical rate will be 50% for women, only a few women per course who want to do it. there's the question, and i think the marines and army have to teach us about this and other panelists can say more about it than i can, what are the challenges of essentially working women into the main p ground combat formations of the marine corp. and army, and is it worth, to the institution, is it worth it as a war fighting force if you only have 10-30 throughout the entire ranks? that, to me, is a question, i'm not trying to give an answer. that's why i finished the op-ed. i have the answer right now that

to me the most natural progression is to take women into the special forces. nobody says that a woman is a wimp or being given a second tiered job because she's a navy seal or army delta force soldier. that's what i proposed. if they meet standards, they do those things. the unites are smaller. they are in a culture of smallness. they are in a culture where you can imagine a few people working their way in and doing very specific and very important things, and then depending on how that goes, it would be easier in two or three years for me to feel i could evaluate the proposition women could go into the ranks. that's where i wound up. the policies moved beyond me, i guess, for me, as a question now as to implementation, and to what extent we will see a lot of women going to the main ground combat ranks and to what extent they want to, what extent we have to encourage volunteers capable to go into the special forces instead.

for example, these are questions that are still on my mind. the debate is alive and well and honored to be a part of it today. >> i think you raised interesting point, and i suspect the audience will have good follow-up questions for you. i would like to follow up, just in terms of the analysis that you did and the assessment you've done so far, is it your sense that much has been informed through impressions, opinions, antedotal experience, and the marine corp., the closest level of cooperation, has the marine corp. begun a process of deliberately studying combat and men and women in combat? do you know if they are assessing the types of activities that folks who go to afghanistan and iraq participate in to try to identify the very themes you discussed? what is most important? is physicality -- what is the level of physicality required? we hear from many women today who made the comment, and i

think very accurately assess thee most important quality in combat, while physicality is critical, the aid and abet is to function in combat, step up, grab a rifle when others are reclined to do so regardless of gender. have we done the study empirically to determine what qualities are required for effective combat soldiers and leaders? >> well, that's a great question, and, of course, i'm glad other people probably know more about the issue, including yourself, will follow me and say other things. a couple points. oh, a lot, by the way, my thinking on this is from a few good women friends while in the military. one of the favorite is ann gildroy fox specialed with another marine in the "new york times" magazine a few years ago doing innovative work in southeastern iraq creating a shia awakening of sorts at the time when the anbar awakening

happened in the west with the sunnies, and she was my body guard in my trip to iraq, and i was very happy with that body guard selection. she was tough as nails. she did the deployments one of only a one marines out, very isolated, and i'm not going to speak for her today, obviously, in term of her views, but speaking with her and others has taught me is certainly in combat the ability to be resilient, functioning with limited food for an extended period of time, perhaps, and, obviously to deal with the complexities of counter insurgency, these things are slightly more important than upper body strength. the question becomes, realm, if that's the case, -- well, if that's the case, are the marines exaggerating the standards in the upper body strength in training or not? i'm agnostic on that so far because, you know, marines point to individual bat les, for -- battles for example, other battles in the iraq or afghanistan campaigns where

wearing a lot of body armor, pulling one's self- over walls repeatedly because there were ieds, and if you didn't have the upper body strength, you couldn't do that. for those battles, those standards were right, hard, and demanding and the upper body strength was crucial. there's other cases as well. that was a relatively modest percent of the overall fighting or day-to-day operations done by the marines. you could argue that we need to be just as rigorous about how people relate to afghan or iraqi or arab or another culture. that's just important or more so than upper body strength. how you train a marine for that in the basic level, the infantry officer course, the ioc has to be focused on basic warrior skills. as you see, i'm conflicted. i'm not directly answering the question about what the marines are studying. i think the marines' intention

was to hope women go through the course and see how they doment up fortunately, in some -- unfortunate in the scientific case of what the study was intended to do, few women volunteered, and then the policy changed before there was the information. that was the strategy learning about this last year. there's a marine to correct that if it's an unfair portrayal, but my take is it's an age-old debates you can't resolve. there's so many things you have to be good at in combat. upper body strength is one of them, but it may not be thee most important, and i'll put it this way and finish on this. let's say a woman squad leader or platoon leader, is, you know, and there's some who could carry the 175 pounds and do the mar of. i'm not claiming otherwise. say she carries a hundred pounds, does fine, and somebody else, a big football player on her squad carries 170, and it equals out. they respect the heck out of her for her ability to lead and

understand the place they are working and fighting, and i think that works. that's my impression, but if she carries 50 pounds or 40 or 30 and the other guy carries 1 -- carries 200 to make up for it. i can't justify that. you can have some flex the. not everybody has to be equally strong or good in the aspect of the broader soldiering, but you have to at least approach the current standards because i think there are some combat scenarios where they are still important. >> i don't think anyone in the audience would disagree with the physical component to combat. i think what's going to be interested, and you hit on the theme, and i'm sure the audience has questions on this is what should the standards be? what are we doing to study the sanders? in-- standards? in the next two years and ten months we have remaining, how will they be justified? let's ask mr. jacobs to talk about his experience in gender training, your thoughts on standards, and how we move

forward, and there's a theme not yet addressed which is as we move forward in the evolution of having women in combat units, it is -- you -- some contended, and, perhaps rightfully so this is going to help the military address the issues with sexual harassment and move forward and begin to put that issue behind us so that it's a safe environment for all folks in the military regardless of gender. mr. jacobs, if you'd like to address those issues for us. >> well, my experience regarding my time as an integrated company commander was pretty enlight ping for me. i have to be honest. i joined the marines as a pfc after four years of infantry marine, i crossed to the dark side of the forest, ocs and became an officer. i had six years of an infantry

officer, in harm's way, a deployment officer, prior to 9/11. i was in low intensity conflicts and the dirty little wars happening in the 1990s in the clinton administration. my time tour was at the school of infantry, and when i showed up there, it was like a welcome back scenario, going through the private, coming back as a captain, so there was a company commanded infantry training unite, and sort of complete the circle of life in the "lion king" sense i guess. i got assigned to a battalion that trains noninfantry nonspecialty combat skills. every marine is a rifleman regardless your job. prepare to pick up your weapon or launch an assault regardless of your contract job. i showed up, half the unit was made upof