The Promise And Limitations Of Telemedicine

Transcript

NEAL CONAN, HOST:

This is TALK OF THE NATION. I'm Neal Conan, in Washington. The doctor will see you now, words we've all heard many times, but more and more now doctors see their patients over a video link. For years, telemedicine has allowed doctors to treat patients anywhere, but as technology improves, new applications arise.

Mobile robots allow doctors to monitor hospital patients from afar, and that neurologist you've been waiting months to get an appointment, well now you don't have to fly across the country. Armed with a laptop, a Skype account and an Internet connection, you can consult a burn specialist, therapist, or a general practitioner from your living room.

Doctors, patients, tell us about your experience with telemedicine, 800-989-8255. Email talk@npr.org. You can also join the conversation on our website. That's at npr.org. Click on TALK OF THE NATION. Later in the program, genocide and the case of former Guatemalan dictator Rios Montt. But first the 21st-century exam room.

And Dr. Ray Dorsey joins us here in Studio 42. He's the director of the Movement Disorders Division and neurology telemedicine at Johns Hopkins Medicine. Good to have you with us today. Thanks for coming in.

RAY DORSEY: Thank you very much for having me.

CONAN: And I know you've been using telemedicine to treat Parkinson's patients for some time now. What does that allow you to do that you can't do in your office?

DORSEY: Well, telemedicine allows us to see anyone anywhere. We started doing this approximately six years ago with Tony Joseph at the Presbyterian Nursing Home in Upstate New York, and there they had about 50 residents who resided 150 miles from us, at the University of Rochester. And he asked us would we be willing to see his residents remotely via telemedicine, and we said sure.

CONAN: And is it just as good as seeing them in person?

DORSEY: There are certain things you can't replicate that you can do in person. You know, the human touch is very powerful. And certainly there's portions of an examination that we can't do remotely, that we can do in person. But we have found that, through our experience and randomized controlled trials, that providing care to patients remotely in nursing homes and later in their - directly in their homes is: one, feasible; two, generates clinical outcomes that are comparable to those in person; and three, offers tremendous value to patients.

CONAN: What about diagnosis? You'd think that's pretty difficult.

DORSEY: Well, for Parkinson's disease, Dr. Parkinson described people walking in the park in London two centuries ago. He actually never physically examined any of his patients except for two. We say that if Dr. Parkinson can diagnose people walking in the park in 1817, we should be able to diagnose people remotely in 2013.

CONAN: And as the technology improves, does that give you more access to more people?

DORSEY: Absolutely. Right now we at Johns Hopkins offer free, one-time consultations to anyone with Parkinson's disease residing in five states. So we can certainly reach out to patients across the country and provide care to them that previously to them might be inaccessible.

CONAN: Five states? Why five states?

DORSEY: I'm only licensed in five states, and currently state licensing laws, which are one barrier to broader adoption of telemedicine, require you to be licensed in the state where the patient is physically located at the time services are provided.

CONAN: But they could come to your office in Baltimore.

DORSEY: Yeah, so a patient from West Virginia often does come to see us in Baltimore, but I can't see them in West Virginia.

CONAN: That's a little strange. There's also, as I understand it, some insurance implications.

DORSEY: Yeah, so Medicare currently doesn't reimburse for care provided in the home via telemedicine. For us at Johns Hopkins, Medicare will reimburse us about $200 for a patient who comes into the hospital, into one of our hospital-based clinics, about $100 to one of our suburban clinics and zero dollars if we see the patient in their home.

CONAN: Zero?

DORSEY: Zero.

CONAN: Is there any way you can address that?

DORSEY: Well, Dr. Karen Edison has worked hard to expand Medicare reimbursement, which is available for certain services via telemedicine. But right now it's not. We're hoping that patients, listeners will help us in our battle to expand reimbursement to enable people anywhere to receive the care that they need.

CONAN: Well, we'd like to hear from people who've received treatment over telemedicine or through telemedicine, and from doctors, as well, about their experiences. Give us a call, 800-989-8255. Email talk@npr.org. And Doctor, could you just take us through a typical day?

DORSEY: For a visit?

CONAN: Yeah.

DORSEY: So right now if a patient calls us, we email them the videoconferencing link; it's a secure link. It's HIPPA compliant. My research...

CONAN: That's the privacy law.

DORSEY: Exactly, that's the privacy law. My research assistant walks them through the installation of the software on their computer, much like downloading Skype, does a test connection to make sure that the audio and visual works. And then I do a regular history just as I would do on clinic and then a focused neurological exam and then address any concerns that they have, then provide recommendations both to them and to a local physician via a letter.

CONAN: And because - if they need medication, you can prescribe that as well because you're licensed in that state.

DORSEY: Yes - yes.

(LAUGHTER)

CONAN: That gets into that other part of it. And how many - I assume this enables you actually to see more patients a day than you might otherwise.

DORSEY: It's a little bit more efficient for the clinician once you get familiar with it. What it really does is not so much focus on the efficiency of the clinician, it focuses on providing access to people who previously didn't have access. At your outset, you had a patient who was talking about driving six hours to see their endocrinologist. Rather than the patient now coming to the doctor, the doctor can now come to the patient.

CONAN: And obviously some Parkinson's patients are pretty limited in what they can do.

DORSEY: Yes, I mean patients right now are limited by what we call the three D's: distance, disability and the distribution of doctors. And technology such as Web-based video conferencing can overcome those.

CONAN: How many of your colleagues use this?

DORSEY: You know, adoption has been limited in the United States, predominately because of licensure and reimbursement. In Canada, where there aren't these restrictions on reimbursement and licensure, telemedicine is used widely. And in fact in the United States in many different circumstances, telemedicine is used widely for veterans, for those in the military and even for prisoners.

CONAN: Even for prisoners?

DORSEY: Yes, so if you're in California, and you have HIV, you're very likely receiving your care from an infectious disease specialist remotely because you can imagine the transportation costs are considerable for both getting a physician into a prison or prisoner into a clinic. And we say if we - if this mode of providing care is good enough for prisoners, is good enough for veterans, is good enough for those in the military, why isn't it good enough for people in the civilian population.

CONAN: Did you start out in your career with telemedicine?

DORSEY: No, we've just - we just said yes to an unsolicited call from someone who was looking for help.

CONAN: So is there a story that illustrates the difference for you?

DORSEY: I guess one patient who's almost our spokesperson for it is a patient who resides outside this community in New Hartford, New York. And she said to us that for her, she was finally able to get access to the care that she couldn't need because of one, her condition, and two of where she lived.

CONAN: Let's get some callers in on the conversation, 800-989-8255. Email us, talk@npr.org. Our guest Dr. Ray Dorsey, associate professor of neurology, director of the Movement Disorders Division and neurology telemedicine at Johns Hopkins Medicine. And we'll start with Tina, and Tina's on the line with us from Denver.

TINA: Hi Neal, thank you. I'm calling because my company, Aprendi Interpreting, is located all throughout Colorado. And we provide medical interpreting for limited-English-proficient patients, whether it's American Sign Language or (unintelligible) languages, which is - so we have interpreters at their computer terminal, and at another location at a clinic, we have the doctor with the patient, who they can't communicate because of the English language barrier.

CONAN: So communications technology enables you to make maximum use of interpreters.

TINA: Exactly, where it may be a remote area, a mountainous region, and otherwise it would be cost-prohibitive to send an interpreter in person. Or maybe the quality of interpreting would be reduced if they used a telephonic interpreter. We can provide so that they can see the interpreter, the insurer can see the patient, the doctor, where they're pointing, that kind of thing.

CONAN: Because you can obviously - it's a lot easier to interpret if you can see what's going on.

TINA: That's the argument. In many cases that is the case.

CONAN: That's interesting, thanks very much. I hadn't thought about that. Have you ever used an interpreter, Doctor?

DORSEY: We haven't, but Tina points out that really this opens a door to providing services that we previously couldn't. We have done three-way calls where we've done physician to patient, and the caregiver's in a third remote location. You can also start thinking about bringing additional services to the patient - therapist, exercise, other physicians, other clinicians to the patient.

CONAN: We have our challenges using Skype here. At NPR, live radio, we've often heard the line go down. I assume you have your difficulties, as well.

DORSEY: Yeah, it's not perfect. It's not as user-friendly as, you know, you can just push one button and be connected. To date we've yet to fail to make a connection to the patient. We've come close, and we've had to use the phone supplemented by video, but the technology is only going to get better and only going to be easier to use.

CONAN: Let's see if we can get another caller in. This is John(ph), and John's on the line with us from Flint, Michigan.

JOHN: Hi.

CONAN: Hi, go ahead, please.

JOHN: I'm a family physician. I just - I've been using telemedicine for close to 30 years. I worked with the Navy for a long time, and we typically were oversubscribed in our clinic, and we'd often have patients who would call in with their problems. So I would do a lot of triage, not with anything fancy like video, but we would go through a lot of the questions.

Interestingly enough, there's some studies that show that most of what you hear in the doctor's office is quickly forgotten, whereas if you do something from home, you can write it down and remember a lot more of what's said.

CONAN: People don't take notebooks into their doctor's office?

JOHN: Well, most don't. Some do. But some of those patients we like to avoid - just kidding.

(LAUGHTER)

JOHN: But actually the ones that do really well are sometimes my elderly patients who don't hear as well. They may have telephone assist devices, allowing them to hear more of what I'm saying. They're less nervous when they're at home.

CONAN: Because if you're wearing a headset, effectively headphones, you can actually hear better. You can turn it up if you're not hearing too well.

JOHN: Exactly, exactly. They remember to ask the questions they needed to ask. If they don't have their pill bottles with them, all they have to do is go to the kitchen. I find I get a lot more information. I get a lot more interaction with my patients, and I even open them up to email so they can email me first, tell me what's going on, and then I can call them back.

CONAN: Email, well, Dr. Dorsey, that's not strictly telemedicine, but is that part of your arsenal, as well?

DORSEY: We haven't used email much in our telemedicine applications. There's some restrictions, again, around privacy and security that prevent its broader adoption.

JOHN: Absolutely. It should be password-protected.

DORSEY: But the caller points out that patients are much more relaxed. You as a clinician get a lot more history. You lose something in the examination, but you gain much more. You see what their social circumstances are. You see other family members. You get a sense of their socioeconomic status. Patients are more relaxed.

One of my patients wrote: I like the interaction being personal despite the 3,000-mile distance. It felt somehow protected by the veil of technology, which enabled the exchange to be more honest.

CONAN: John, has there been a circumstance where you wished - wait a minute, you need to come in, I need to see you in person?

JOHN: Oh that's easy. We can always work that out. The biggest problem is I worked as a teacher in residency programs. One of the problems is our clinics are almost always oversubscribed. It's very hard to get patients in for visits. So we can work something out right there on the phone as far as working them into the schedule.

CONAN: And that avoids that - somehow the schedule, once the patient gets to the doctor's office, never seems to be on time.

JOHN: That's correct. This saves a lot of that.

CONAN: Well, thanks very much, John, appreciate the phone call.

JOHN: Appreciate you taking it.

CONAN: We want to - if you met with your doctor or patient through telemedicine, we'd like to hear about your experience, 800-989-8255 is our phone number. You can also send us an email, don't worry about the privacy laws. The address is talk@npr.org. We'll have more with Dr. Dorsey in just a minute. Stay with us. I'm Neal Conan. It's the TALK OF THE NATION from NPR News.

(SOUNDBITE OF MUSIC)

CONAN: This is TALK OF THE NATION. I'm Neal Conan. Areas that are considered by many to be less desirable to live in - inner cities, especially rural areas - have a hard time attracting and retaining doctors. Primary care physicians are especially scarce. So the sick and injured have to travel long distances and endure long stretches in waiting rooms for appointments, if they can find doctors at all.

There are a number of ideas about how to fix that problem: get new doctors in through medical schools with less debt, entice physicians to underserved areas with business and quality-of-life incentives. And telemedicine, too, can help alleviate cost, inconvenience and wait times for doctors and patients alike.

If you've used telemedicine, either as a doctor or a patient, call and tell us about your experience and about the limitations, if any, 800-989-8255. Email us, talk@npr.org. Dr. Ray Dorsey of Johns Hopkins is our guest. Joining us now by phone from Columbia, Missouri, is Dr. Karen Edison. She's a dermatologist and medical director of the Missouri Telehealth Network at the University of Missouri. Good to have you with us today.

KAREN EDISON: Thank you.

CONAN: And how does telemedicine address the problems of rural communities?

EDISON: Telemedicine addresses the needs of rural communities by helping to provide access to a whole variety of different types of health care providers that those patients need. We've been doing telehealth - we call it telehealth. We used to call it telemedicine, but it's a little broader than just medicine - we've been doing telehealth since 1994 all throughout rural, underserved Missouri.

We have over 200 units in 62 different counties, and we've had over 70 different health care providers use it in the last year from 30 different specialties, and we've provided about 25,000 visits over the entire network last year.

CONAN: And what has changed as technology's changed?

EDISON: Well, technology has gotten better, it's more reliable, and it's certainly become more affordable. When I first started doing telemedicine, it was quite expensive, and you had to have big, fancy videoconferencing equipment. And now telemedicine is moving more toward the tablet environment or more toward the computer environment, where people can see their health care providers from wherever they are, not just their home communities but even their homes or, you know, on their iPhone.

That's where we're going. That's the future. It's about taking health care to people right where they are.

CONAN: Wherever that may be, and a lot of patients have problems with mobility.

EDISON: That's correct. Many people can't leave their home communities for health care for a variety of reasons. You've mentioned many of them in your introduction. You know, it costs money to drive places and, you know, gas costs money, time off work, time out of school. Telehealth is also an economic development engine for rural communities.

If I see a patient over telehealth, and I diagnose a condition that requires a blood test or maybe an imaging test, or if I prescribe medication, those tests are done in their local community typically, and those medication prescriptions are refilled in the local pharmacy.

CONAN: Oh I see, so they don't - they're not enriching labs or radiology departments in the big city, they're doing it right there at home.

EDISON: That's right.

CONAN: And are there limitations? Are there things that can't be done?

EDISON: Well, that's always a question that comes up, and I used to say, you know, is seeing a patient in dermatology over telemedicine the same as seeing that patient in person? It's not just the same, but it's just a little different. And for many of my patients, it's not, you know, 100 percent versus 99 percent, it might be 99 percent versus nothing, if you follow my logic.

CONAN: Yeah.

EDISON: So it's not just that it's not exactly the same, but it's care for those patients where they may not have gotten care otherwise.

CONAN: We were also talking with our guest, Dr. Dorsey, about the problems of reimbursement, particularly in Medicare. Is this being - is this - you're just doing it one state there, Missouri. Is that a problem there, too?

EDISON: Well, Medicare pays the same as if we saw that patient in person if the patient is in a rural underserved area. And the federal government calls that a non-metropolitan statistical area. If that patient is in a community health center or a critical access hospital in that rural area, they pay the professional fee just as if we saw that patient in person.

Our Medicaid program, our state-based Medicaid program, also pays the same as if we saw that patient in person. And most of our private payers, our private insurance companies, now pay just the same as if we saw that patient in person.

And I always say any question you have about how telemedicine works, the answer is almost always it works just like it does in person. The only difference is you're using technology to bridge distance.

CONAN: There was just a big telemedicine conference in Austin. I wonder: What did you find out there that surprised you?

EDISON: Well, I hadn't been for a couple of years. I used to go to the American Telemedicine Association meeting every year, and I was on the board for a long time. I took a little break from it, and I went back this year, so I was in Austin last week. And I was quite frankly blown away by the explosion of interest in telemedicine.

We had all the big companies there. We had folks there from all over the world. China was well-represented. The Taiwanese were very well-represented. Telemedicine, we believe, is the future of health care. And that telemedicine takes on a lot of different, a lot of different programs. It's not just using videoconferencing to connect. It can also mean connecting to people in their homes with remote monitoring and telehome care so that their chronic diseases can be monitored on an everyday basis, rather than just coming into the office every month.

CONAN: Here's an email question that has some aspects of that that I wanted to ask you about, this from James(ph) in Massachusetts: The Home Care Alliance of Massachusetts is advocating for Mass Health, a state Medicaid program, reimbursement of telehealth used by home health agencies.

Many agencies part of our association use telehealth already because it improves their quality and efficiency. They use wireless weight scales, blood oximeter, blood pressure cuffs, et cetera, and depending on their condition. So in other words you can collect data over these same circuits.

EDISON: Right.

CONAN: Do you use that as well?

EDISON: Yes, so we do a lot of telehome care and remote monitoring here in Missouri. One of our large home health agencies in the southwest part of the state is probably the leader in that area. One of the challenges, of course, is the inter-operability of the health information systems. So as health information technology matures, and the companies become more inter-operable, they can talk to each other and transmit information easily.

You know, as that gets - as that whole industry matures, this is going to get easier and easier so that instead of the home health agency monitoring those patients, actually the patients' - patient-centered health care home or medical home, their actual health providers would be monitoring those patients on a daily basis.

CONAN: Well Dr. Edison, I wanted to thank you for your time today. We know you ducked out of a meeting to speak with us. We appreciate it.

EDISON: Thank you, it was a pleasure.

CONAN: Dr. Karen Edison is medical director of the Missouri Telehealth Network and joined us by phone from Columbia, Missouri. And let's see if we can get another caller in on the conversation. Let's go to Ed(ph), Ed's on with us from Catonsville in Maryland.

ED: Yeah, this is Ed Flattery(ph). My son was severely injured in a terrible truck crash two and a half years ago and had a traumatic brain injury. And in fact, Dr. Dorsey, he goes to Kennedy Krieger Institute, which you should know very well.

CONAN: He's nodding, yes.

ED: He - Matthew uses what's called a hand tutor, and it's a glove. It's an electronic glove that he wears, and he plays computer games with this device. And his therapist is in Israel, where this device was invented. And Matthew plays computer games using different fingers or using his wrist, adduction, abduction movement, even his elbow and his shoulder, and he plays computer games.

And Alan(ph) in Israel sees us on Skype. We can see him, and he is reading all of the input. He sees exactly the same thing on his computer as Matthew and I see on ours in Catonsville.

CONAN: Oh, so he's seeing the same readouts from the computer games, so he can tell how well your son is doing?

ED: Yeah, and he encourages him and, you know, applauds him and, you know, kind of keeps him on task. And the thing about Skype is he can see if Matthew's doing compensating movements with his shoulders, for instance, in order to get the computer to respond, instead of using his wrists.

CONAN: I see. So you have to use your wrist to get those aliens over on the left side of the screen, and not your shoulder.

ED: That's - exactly.

(LAUGHTER)

CONAN: That's pretty good.

ED: Well, exactly right. I mean - and physical therapists know about compensation all the time. I mean, if you are taking batting practice and you're starting to get tired, you start to compensate by using other muscles, and so your swing starts to deteriorate. Well, it's the same thing with kids in therapy. So I - and this - when Matthew left Kennedy Krieger inpatient care, he could move his left index finger. And now he's talking. He's walking, you know, in a walker a little bit, and he's using his left hand, mostly.

And we're still working on that right hand, but he's beginning to use it more to assist in, you know, other activities. So, I mean, now, this company even has a way for us to do these therapies at home by ourselves, and they get the readout. So they can see compliance, you know, are we complying with the regimen. They can see, are his - if his degree of motion's getting better or not. And so I can't lie to Alan about whether we did our therapy.

(LAUGHTER)

CONAN: Ed, thanks very much. We wish your son...

ED: Sure.

CONAN: ...the best of luck and continued improvement.

ED: OK. Thank you. Bye, now.

CONAN: And, Dr. Dorsey, when you hear stories like that - I mean, I know this is not your field, specifically, but you may want to evangelize a little for telemedicine.

DORSEY: Sure. So in the 19th century, medicine developed anesthetics, which led us - enabled us to operate on the inoperable. In the 20th century, we developed antibiotics, which let us cure the incurable. In the 21st century, we have telecommunications technology, which lets us reach the unreachable. And not only we're reaching people that were previously not able to be reached, but we're reaching them in ways that we previously couldn't even imagine.

I mean, to hear the story that he's receiving care from a therapist in an entirely new - entirely different country with entirely novel technologies and making a difference for his children is just incredible.

CONAN: I don't even want to ask about the licensing problems there. Anyway, this email from Ellen: I have a rare neuromuscular disorder. There are a few specialists who treat my disorder in the country. I see a specialist three hours from me three times per year. My husband and I have been hesitant to move, even when a better job has been available elsewhere, because we want to be within easy access to his care. I look forward to the day when we can consult with him remotely, as does my doctor, who sees patients from all over the country and recognizes the inconvenience for them. He's waiting for precedents to be set before he attempts it. Again, this is another field.

DORSEY: Well, no, this is for rare orphan indications, or for people who have devastating neurological or medical disorders, telemedicine is often the only way that individuals can receive care and to be able - and to say that we can't provide care to people with rare neuromuscular disorders because of licensing laws seems to be counter to the interests of patients. And as we go forward and with the aging of baby boomers, people are having to make decisions about where they live based on their proximity to medical centers.

You know, telemedicine enables people to - patients to live wherever they want to live in the future, and feel - and have that freedom to do so and still be able to connect - be connected to their physicians.

CONAN: We're talking about the improvement in communications and improvements in telemedicine. You're listening to TALK OF THE NATION, from NPR News. And let me reintroduce our guest, is Dr. Ray Dorsey, associate professor of neurology, director of the movement disorders division and neurology telemedicine at Johns Hopkins Medicine. And let's see if we can get another caller in. This is Walt, and Walt's with us from northwest Arkansas.

WALT: Good afternoon.

CONAN: Afternoon.

WALT: I just wanted to add one comment, for any potential skeptics out there. I work in professional aviation, corporate airline aviation. And in our field, this sort of technology has actually been a mature technology for about 10 years. Most airliners and a lot of corporate aircraft are equipped with a - with what they call a doctor in a box. It's a pod that can be connected to a passenger that's having a problem. The ones I've seen where they would put on a glove and they set up a video camera in the seat, and they can downlink to a trauma center in Phoenix and begin diagnosing the patient in-flight.

And it's my understanding they use these on the order of dozens of times a year in the major airlines, and in some cases have even been able to, you know, divert an aircraft to a more appropriate emergency landing field based on the diagnosis of the patient en route. And so I say it's worked very, very well there for a long time. It's an accepted technology, and it would seem that if it can work in flight for an emergency medicine scenario, that it should probably be pretty deployable elsewhere.

CONAN: And this is all data-link, I assume.

WALT: All satellite data-link, I believe. There may be some other methods now, but I think generally, it travels - the data travels over the same channels as the aircraft communications.

CONAN: Any prospect of getting video involved in that?

WALT: I think most of them involve video. The one unit that I've seen demoed a couple of times is - essentially sets up in the seat either in front of, or next to the patient. And it has essentially a videoconferencing module on top of it, so the doctor can see and speak to the patient. He can get the vitals in real time, and depending on who else is on board, can even begin to administer care, you know, through a remote set of hands, if necessary. And it's my understanding it's led to a lot of saves.

CONAN: All right, Dr. Dorsey, of course, this is applied to emergency responses on the ground, as well, to first responders and to EMTs.

DORSEY: Yes. You know, in Alaska, this is widely used where there's a large geographical separation between patients and physicians. As Walt indicated, if it can be applied in airlines, it certainly can be applied on the ground.

CONAN: Walt, thanks very much.

WALT: Thanks, guys.

CONAN: Here's an email from Barbara in Walla Walla: I'm a telereader for the VA, a specially trained and certified eye doctor reviewing eye photos from over 20 different sites throughout Alaska, Washington, Idaho and Oregon. I "see" - quote, unquote - 50 patients per day who have diabetes, and we're monitoring them to detect diabetic retinopathy at its earliest stages, well before vision loss can occur. The VA has been doing this since 2001, very successfully. So that is another use of this, well, communications technology to, I guess, force multiplier, as the military might call it.

DORSEY: Yes. And the VA now has a requirement that half of its beneficiaries need to be using telehealth in some capacity by 2014.

CONAN: And this from Dusty in Panama City: I used telehealth as a VA patient in San Diego. I live in the Imperial Valley. My psychiatrist was in San Diego, about an hour and a half or two hours away. So I would go to the local VA clinic and have my appointments with her through video monitors. I loved it. I wouldn't have been able to see her otherwise, and she was amazing. Of course, psychotherapy psychiatry, another field in which this could be useful.

DORSEY: Absolutely.

CONAN: Well, Dr. Dorsey, thank you very much for your time today. We appreciate it.

DORSEY: My pleasure.

CONAN: Dr. Ray Dorsey joined us here in Studio 42. He's down from Baltimore, where he's director of the Movement Disorders Division and Neurology Telemedicine at Johns Hopkins Medicine. Coming up, former dictator Rios Montt of Guatemala got 80 years for genocide and crimes against humanity. We'll learn why that's being called an historic verdict after a short break. Stay with us. I'm Neal Conan. It's the TALK OF THE NATION, from NPR News. Transcript provided by NPR, Copyright NPR.