who remain unaware of the evidence base, but perhaps also researchers who repeat studies because they do not know other studies exist. We also heard that there is an explosion in technology that is rapidly changing, and it is difficult to keep pace with this change. In many ways, consumers are going to push us in different directions than we might expect, and may come up with their own solutions. If we are not proactive, these solutions may not be the best. For example, we heard about websites with misinformation. Also, stakeholders can be great advocates for telehealth, including for the applications that we do not always think about, such as for public health. One of the most impressive things is the amount of enthusiasm and activity at the state level. In the current political climate, top-down “stick” approaches to health care from the federal government are not popular. However, federal support for removing barriers in state-initiated approaches, including Medicaid waivers, will be critical. If states come up with solutions (e.g., Medicaid reimbursement), it will be easier to make federal policy changes. The VA and IHS showed us that there are good models out there to serve rural communities. We need to figure out how to get their “lessons learned” out to the rest of the population.

Kamal Jethwani, M.D., M.P.H.
Partners Healthcare Center for Connected Health;
Harvard Medical School

The evidence base for telehealth is strong, but maybe this evidence is enough to prove that it works, but not enough to motivate adoption. As we go forward, an immediate next step is to come up with standards for what kind of evidence is needed (e.g., cost-effectiveness data, return-on-investment data) in order to accelerate adoption. Additionally, health care can be made more efficient with all the data that are being generated, such as for the application of big datasets to public health at the population level. Health care has been lagging behind other industries for a long time. A recent article by Atul Gawande in The New Yorker talked about how health care can be made as efficient as The Cheesecake Factory, which reduced waste by benchmarking the activity of their customers (Gawande, 2012). In health care we collect so much data (e.g., electronic medical records, patient-generated data, remote monitoring), there must be opportunities to put these data together and make health care more efficient.

Nina M. Antoniotti, Ph.D., M.B.A., R.N.
Marshfield Clinic

Vision for the future can sometimes be held captive to bureaucracy. Even within HHS, there can be a dichotomy of pushing for the latest tech-



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