dr. barrierer. >> handicap everyone we're really excited for before you and talk with you about the opportunity to bring health care into this area and i'd like to start by telling you a little bit about sutter pacific medical foundation that can be it there you go. >> and what we would like to achieve with having a clinic in this area sutter pacific medical foundations is part of the sutter health network and our function consists of doctors and clinicians that provide direct career neutron an ambulancey are office space south setting we have clinics and decreases in san francisco and mri county we use electronic records to patient can move seam thely to spreadsheet care in the event they need to be in a hospital the hospital is on the electronic medical records to make it easier for patients the suitor foundation has been recognized throughout california and even nationally for our preventive care our patient satisfaction and we're rigorous about quality improvements we take to seriously and hold ours to top performances and many decreases are known as leaders in their specialists nationally

dr. barrierer. >> handicap everyone we're really excited for before you and talk with you about the

barrier in some situations. >> okay. any other comments on that? did any of you, dr. salvo, have you seen that? >> in my capacity as a woc appointment within the va, i have had to deal almost nothing with veterans choice act personally. it's purely administrative by other departments. >> i did want to say with the veterans choice act it has been interpreted to not include physician assistance by some facilities. if you want to talk about increasing recruitment, the jobs aren't even posted, physician assistants aren't able to apply for those jobs. that's not going to increase access for care for veterans. >> it isn't really hard to figure out your needs when you just call the people scheduling the appointments and find out you have a six-month wait. it ain't rocket science. i've been doing it for four decades and you find out and all of you there know, if you have a long waiting list for patients to come in, you need to hire people to take care of waiting lists or make the shop more efficient. it's not complicated. i did it for years. and i mean, the way i learned if i needed advice, i would go

barrier wall. >> translator: and that's it. there was an explosion. and i lost consciousness. >> dr. alberto crescenti is one of the first responders on the scene. >> translator: we received a message from headquarters. a radio operator told us a train had crashed along the station with a fire and people trapped inside. >> the doctor and his team arrive at the station within ten minutes. trip. >> translator: we didn't know yet, but we were estimating the number. once the people arrived at the steps, then we realized it was a major problem. >> with more than 30 years of experience in medical emergencies, the doctor is trained in triage, determining priorities in critical situations. >> translator: the idea is to quickly make a mental list of the things we are going to encounter. clear your mind. be totally cool. not to be guided by your emotions. it's impossible to do if you're guided by your emotions. >> the impact leaves the first three train cars collapsed like an accordion. the collapsing cars throw some passengers around and compress other passengers together. >> translator: and

barrier in some situations. >> okay. any other comments on that? did any of you, dr. salvo, have you seen that? >> in my capacity as a woc appointment within the va, i have had to deal almost nothing with veterans choice act personally. it's purely administrative by other departments. >> i did want to say with the veterans choice act it has been interpreted to not include physician assistance by some facilities. if you want to talk about increasing recruitment, the jobs aren't even posted physician assistants aren't able to apply for those jobs. that's not going to increase access for care for veterans. >> it isn't really hard to figure out your needs when you just call the people scheduling the appointments and find out you have a six-month wait. it ain't rocket science. i've been doing it for four decades and you find out and all fl you there know, if you have a long waiting list for patients to come in, you need to hire people to take care of waiting lists or make the shop more efficient. it's not complicated. i did it for years. and i mean, the way i learned if i needed advice, i would go t

dr. disalvo, despite the federal support that you mentioned in your testimony, i can -- i continue to hear from smaller health care providers about the barriers that they face with electronic health record implementation. just yesterday i met with a physician from maine who shared with me that putting in place a conference of electronic -- comprehensive electronic system for his small practice would cost in excess of $230,000. this was just for the software, not for the hardware. that is no small amount, particularly for a smaller independent practice that is not hospital owned. to access information about individuals to improve diagnosis , treatment, and prevention of diseases, you discussed the important roles of health information technology and an operability, including standards and technology that will be needed. as you work to build these health i.t. systems, for precision medicine, how can we assure that we are not leaving out rural america, smaller practices, rural hospitals health clinics, because of the cost? dr. desalvo: thank you for the question. it particularly spotlights one of the challenges of smaller practices. there was a

barriers to entry were nonexistent in that name. i guess on the show when they reported earnings, dr.e out and said that that was one he would be interested on a dip buying because of somebody getting interested in some m and a activity. kudos to him on that. i definitely see why someone like a google or apple -- because they have that payment services, why they'd be interested in the infrastructure that's already set up with yelp. but for me it is probably a no-touch at this point even though it is extremely volatile. >> i'm wondering, mike what you think about the general m and a environment. because we are seeing a lot of companies -- i don't know if you can call it throwing in the towel. but i'm thinking avon starwood all of these companies that are evaluating strategic alternatives. it makes you wonder if they believe their stock market valuation is high if they believe the market for competition is too high or if they just think that there will be buyers who are willing to go to the bond market and borrow. >> i think this many years into an economic recovery this many years into

dr. volcow: i agree and developingopportunities that are more amenable, like prison and jail, there's no reason they shouldn't get access to medication. chairman murphy: ok. and another barrier that patients face is lack of available treatment providers who can prescribe m.a.t.'s. director botticelli, can you comment on this dearth of providers that can prescribe buprenorphine, for example? what are the reasons for the shortage, what can we do to address it? >> director botticelli: one of the other opportunities we have is ensuring all of our treatment programs either -- low percentage of them incorporated medication assisted therapy into their programs. some of this, congressman, quite honestly, has been by myth and misunderstanding and this divide between abstinence based care and medication assisted treatment which i think is really unfortunate that we have here. we really want to make sure if a client is entering a treatment program that has particularly federal funding, needs to offer by way of its own offering or through referral medication assisted treatment. chairman murphy: thank you very much. and thank you to the entire panel for guiding us on this entire situatio

dr. desalvo despite the federal support that you mentioned in your testimony i continue to hear from smaller health care providers about the barriersat they face with electronic health record implementation. just yesterday i met with a physician from bangor, maine who shared with me that putting in place a comprehensive data collection for his small practice was going to cause in excess of $230,000. this was just for the software, not for the hardware. that's no small amount particularly for a smaller independent practice that is not hospital owned. to access information about individuals to improve diagnosis treatment and prevention of diseases. you discuss the important role the absolutely essential role of health information technology and interoperatability including the standards in technology that are going to be needed. as you were to build these health i.t. systems for precision medicine. how can we assure that we're not leaving out rural america? smaller practices? rural hospitals health clinics because of the cost? >> thank you for the question and for -- particularly spotlighting one of the challenges of small practices

dr. gibance: certainly one of the areas of concern with asthma, the leading chronic condition affecting children relates to being able to transsquend those geographic barriers where there's a particular problem. a lot of times it's getting a sense of the child's symptoms and course of disease. and that's where there's an opportunity to use leverage technologies that enables that information to get to the experts necessary to manage that care. other technologies that actually exist on the smart phone now are able to assess the breathing capacity of the child. and we have a program that we're funding that leverages resources that are local such as schools where this information can be ascertained the child's symptoms and disease course, developed, and a treatment transmitd in that local environment. leveraging those local resources. so we're looking at using these new mobile technologies in different ways to enhance care for both children and adults. >> thank you. and let me just make a small point about telemedicine telehealth. this has been something that people have been working on for decades and as a result people think of vtc or telemedicine sensor-base

barriers where there's a particular problem. a lot of times it's getting a sense of the child's symptoms and course of disease. that's where there's an opportunity dr collins alluded to to use leverage technologies that enables that information to get to the experts necessary to manage that care. other technology that actually exist on a smartphone now. they're able to assess the breathing capacity of the child. we have a program that we are funding leverages resources that are local such a schools where this information can be ascertained, the child's symptoms and disease course developed, and the treatment again transmitted into local environment, leveraging those local resources. we are looking at using these new mobile technologies in different ways to enhance care for both the children and adults. >> let me just make a small point about telemedicine, telehealth. this has been something people been working on for decades and as a result people think of vtc or telemedicine center-based delivery of care and i think it is entirely possible that for at least some treatments that the mobile phone just sort of outpaced all of that. i want to make sur