[House Hearing, 109 Congress]
[From the U.S. Government Publishing Office]


 
OVERSIGHT HEARING ON THE USE AND 
DEVELOPMENT OF TELEMEDICINE TECHNOLOGIES 
IN THE DEPARTMENT OF VETERANS AFFAIRS 
HEALTH CARE SYSTEM

Wednesday, May 18, 2005

U.S. House of Representatives,     
Subcommittee on Health,
Committee on Veterans' Affairs,
Washington, D.C.

    The Subcommittee met, pursuant to notice, at 10:00 a.m., in Room 334, Cannon 
House Office Building, Hon. Henry Brown 
    [Chairman of the Subcommittee] presiding.
    Present:  Representatives Brown and Michaud.

    Mr. Brown. Good morning.  The Subcommittee will now come to order.
    I want to thank all in attendance for joining us this morning in our first 
Subcommittee hearing of the 109th Congress.  I'm honored to have been selected 
to serve as Chairman of the Subcommittee on Health, and am especially pleased 
that my friend, Mike Michaud, a man whom I shared a leadership role with for 
the last two years on the Benefits Subcommittee, was designated by his 
colleagues as our new Ranking Member on Health.  Welcome, Mike.
    Telemedicine can be defined in many ways.  Some prefer to use the broader 
term "telehealth."  The core meaning of the word "telemedicine" is distance 
healing.  What it does is make it possible for doctors and nurses to deliver 
care and interact with patients many miles away with the use of specialized 
video equipment, digital imaging equipment and electronic data transmission.
    These new patient-centered technologies have a great deal to offer veteran 
patients, particularly in the areas of mental health care, rehabilitation, 
non-institutional long term care, and delivery of care in rural areas.
     VA has and continues to substantially invest in telehealth technologies.  
The success of the use of telemedicine in caring for veteran patients depends 
on VA's ability to transition individual telemedicine projects into safe, 
effective, reliable and sustainable health care services that veterans can 
depend on.
    At our hearing today we will be hearing from VA and HHS officials, VA 
field practitioners and representatives from the private sector about the use 
and development of telemedicine technologies.  I'm looking forward to an 
exceptional discussion to learn more about telemedicine, how it works and what 
it holds for the future of patient care in VA.       
    Mr. Michaud, do you have any statement you would like to make?
    Mr. Michaud. Thank you, Mr. Chairman.  It is good to be here for our first 
hearing of the Health Subcommittee for the 109th Congress.  I'm also pleased 
that we have an opportunity to continue to work together as Ranking Member and 
Chairman of this Subcommittee.  We have many areas under the Health 
Subcommittee's jurisdiction and we share a lot of common interests in those 
areas.  I look forward to tackling those issues with you.
    I agree that we must continue to push VA to be as efficient as possible, 
but there are still times that efficiency reaches its limits and you must add 
real dollars to the VA.  That is why the Democrats on this Committee 
recommended adding $3.2 billion to our budget request.
    Mr. Chairman, I want to thank you for holding the hearing today.  I look 
forward to working with you throughout the Congress and request unanimous 
consent to extend and revise my remarks.

    [The statement of Mr. Michaud appears on p. 35]

    Mr. Brown. So noted.  Thank you, Mr. Michaud.
    We have with us today Dr. Adam Darkins.  Dr. Darkins is the Chief 
Consultant of the Department of Veterans' Affairs Office of Care Coordination. 
He trained as a neurosurgeon in the United Kingdom, where he established and 
directed an early telehealth program at the King's Fund in London.  Dr. 
Darkins has published and spoken widely on telehealth issues throughout the 
world.
    Dr. Darkins is accompanied by Dr. Ross Fletcher, Chief of Staff of VA 
Medical Center in Washington, D.C.
    Dr. Carolyn Clancy is the Director of the Agency for Health care Research 
and Quality at the Department of Health and Human Services.  She also holds an 
academic appointment at George Washington University School of Medicine and is 
a member of the Institute of Medicine.  She has edited and contributed to the 
publishing of seven books and is widely published in peer review journals.

    You may begin.

STATEMENTS OF ADAM DARKINS, CHIEF CONSULTANT, OF-
    FICE OF CARE COORDINATION, DEPARTMENT OF VETER-
    ANS' AFFAIRS; ACCOMPANIED BY ROSS D. FLETCHER,
    CHIEF OF STAFF, VA MEDICAL CENTER, WASHINGTON,
    D.C.; AND CAROLYN M. CLANCY, DIRECTOR, AGENCY FOR
    HEALTH CARE RESEARCH AND QUALITY, DEPARTMENT 
    OF HEALTH AND HUMAN SERVICES

STATEMENT OF ADAM DARKINS

    Dr. Darkins. Thank you, Mr. Chairman and members of the Subcommittee.
    It's an honor to be before the Subcommittee today and address the members' 
interest in the VA's use and development of telemedicine.  I want to thank the 
members of the Committee for raising this important area for us to discuss.  
    In terms of telemedicine the areas I'm going to cover are how we're using 
information and telecommunications technologies to deliver care to veteran 
patients in situations where practitioner and patient are separated by time 
and/or distance.  I think it's important just to say that what I'm--in my 
testimony I'm going to talk about builds on the use of the existing health 
information infrastructure.
     The Institute of Medicine has used the VA as an example of how it's 
possible to use information technology to change the way health care is 
delivered and VA meets each benchmark, disease, prevention and treatment 
indices in terms of its ability to deliver care in this manner.
    But very much what I'm going to talk about today is that the technology is 
very important.  It's obviously a vital part to telemedicine.  But why VA has 
been successful and the--so the platform on which VA is developing 
telemedicine is around the people and how it is delivering services to people.
It's very much for us about how we deliver the right care, in the right place, 
at the right time to veteran patients who it is our privilege to serve.  
    In doing so we are building a robust, sustainable infrastructure, one 
which is being based very much on patient need.
     So as you will hear that I will base what I'm talking about on the 
patient need that's driving it and not on the technology.
     The need of the veteran population is changing and the care has to be 
delivered from finite, physical locations as it does for any health care 
organization.  In doing so there are trade offs against cost, quality, access, 
that are made by individual practitioners.  Telemedicine is not a replacement 
for delivery of care.  It is really an adjunct that allows more flexibility in 
how that care is delivered and it's a particular applicability in rural areas 
where there are practitioner shortages.  It helps solve what can otherwise be 
an insoluble equation about how you deliver care to patients.
    The way in which telemedicine is moving forward and has moved forward is 
very much around how it solves issues in the delivery of care and is rooted in 
the business of delivery of care within the VA, and it's not so much around 
giving out grant monies that we have done so.
     There have been pilots of 32 clinical areas of telemedicine within VA, 
but in my testimony today I'd like to highlight five which are of particular 
importance in relation to veteran patient need.
     The first area that I'd like to talk about relates to home telehealth, 
the delivery of care using technologies to reach in the home.  The veteran 
population that VA treats, as with the general population, is growing older. 
As people grow older, counter to expectations in the past, they're actually 
healthier and living longer and preferring wherever possible to stay in their 
own homes.  So the focus for VA on the use of this technology is supporting 
the non-institutional care of patients.
     For veterans who fought for their own homes in times of war now to be 
fighting new adversaries, such as chronic heart failure and diabetes, our 
approach is really is much to help them stay in their own homes.
    So the telemedicine in terms of the home telehealth is addressing high 
areas of priority need related to diabetes, congestive heart failure, chronic 
pulmonary disease.  It compliments the rest of care across the continuum, so 
it's able to bring people to care in a more flexible and more timely fashion.
    We have a national program which is rolling out for this which is very 
much centered on patients in terms of delivery of care.  The kind of patients 
we're talking about are the sort of patients with complex care needs who 
would otherwise be going into institutional care.  They are the sort of 
patients who traditionally, their paper charts may be in several volumes and 
if the chart is available if they're going from scheduled clinics it is 
difficult to get through that kind of data.
    So the ability to monitor somebody in their home, to assess their health 
condition in their home, but also to base this on having a clinical health 
record is extraordinarily important and a vital part of how this has gone 
forward.  
    It's possible to pick up the vital signs, pulse, weight and temperature of 
these patients and institute care before they run into trouble.  So somebody 
with heart failure can be treated when they first become symptomatic rather 
than when they become very seriously ill and they might have to go into the 
intensive care unit.
    The outcomes from this program has been that we've had reductions in 
inpatient stays, we've had reductions in ER visits, and very high levels of 
patient satisfaction.  We are currently treating 5,800 patients throughout the 
21 VISNs in the VA and anticipate reaching 12,500 by the end of this financial 
year.  It's about appropriately treating veterans and helping them to live 
independently in their own homes.
    I would say that simply stated the link to the information system is that 
in order to provide the right care, in the right place, at the right time it's 
important that the right information is there to be able to do so as well.
    The next area I would like to turn, a major area of need, is that of 
mental health for which our telemental health programs are addressing.  It 
uses real time video conferencing and is able to provide both generalist's and 
specialist's care to the community based outpatient clinics and save 
considerable time and inconvenience of travel to veterans to get into care.
    In 2004 there were 10,000, approximately 10,000 patients treated 
nationally, and that represented approximately 20,000 episodes of care.  The 
care is currently taking place in 224 sites of which 120 are community based 
outpatient clinics, 74 are VA medical centers, 20 are vet centers and 14 are 
home telehealth programs.
    In order to make sure this is robust and sustainable we have a lead 
clinician for telemental health.  We've developed a telemental health toolkit 
that makes sure that things are systematized with how they're done.  It links 
to the mental health programs in the central office and we anticipate a 20 
percent increase in the next financial year of telemental health.
    The next area I would like turn to is teleretinal imaging, which is used 
to treat diabetes and diabetic eye disease.  20 percent of veterans have 
diabetes and VA is currently outperforming the private sector in terms of 
doing diabetic eye exams.  The rationale of this is to maintain the site by 
picking up diabetic eye disease.
    We had a consensus group that met in 2001 to establish the groundwork for 
doing teleretinal imaging and will be working with the Department of Defense 
and the Joslin Vision Network in Boston.  We are set to do a widespread 
implementation of teleretinal imaging and would see initially 75,000 patients 
being treated in the next year and 150,000 the year after.  It uses store-and-
forward technology and we're setting up reading centers to be able to do this 
as we move forward.
    The next area I would like to talk about is teledermatology, again another 
area that uses store-and-forward technology.  Dermatology is an area of high 
morbidity and it's a shortage speciality, especially in rural areas.
    One program I'd like just to highlight is in the 1990's Togus, Maine was a 
pioneer and linked to Providence, Rhode Island.  The analyses of the outcomes 
have shown that using teledermatology in VA leads to earlier treatment, 
reduces the need for later face-to-face exams, and is certainly cost effective 
in getting definitive care.
    Again, we have clinical and research leads, a field coordinator, and would 
see this is going to be growing considerably again in the next financial year.
    The next topic I would like to turn to in terms of patient need is 
telerehabilitation, and it's applicable to particularly spinal cord injury, 
multiple sclerosis and returning combat wounded veterans from Operations Iraqi 
and Enduring Freedom.
    There are four poly-trauma centers in the VA to which returning combat 
wounded are being transferred, particularly people with head injury, 
amputation, eye trauma and post-traumatic stress disorder.  The ability to 
link other centers into this specialist's care as they journey across the 
continuum to get home is extremely important.
    Let me just quickly give you the hypothetical example of a combat wounded 
veteran who may be an amputee, who may have had a head injury.  Such a person, 
who if they're back near home, they may well find their answer isn't immediate 
access to some of the specialist's advice that may be necessary in relation to 
some of the prosthetic devices for example.  Neither would such advice be 
necessarily available in the private sector.
    The ability to be able to link back to the specialist centers, get advice 
from people who've previously cared for the patient, means this could well 
save the inconvenience both to work and family in travel and also is a benefit 
to the family, as I mentioned.
    So the ability to link these heroes into specialist care is something 
which VA is working towards in linking these poly-traumas to other sites.  
We're in the process of the next financial year developing linkages for 
multiple sclerosis care, for two multiple sclerosis centers on the West Cost 
and the East Coast to be able to make multiple sclerosis advice and care 
available to veterans at the local level where that degree of specialist's 
advice may not be currently available.
    I'd next like to turn to telesurgery, and when I mention this it's really 
about high levels of need in areas of chronic disease.  It may seem somewhat 
strange that I would turn to surgery, but it is very applicable. 
    One of the things that we've found is that house prices have changed 
throughout the country.  They're changing their homes, and with difficulties 
in rental accommodations veterans are moving to places which may not 
necessarily be where the major center of care is.  So the ability to be able 
to do preoperative and post-operative evaluations and obviating the travel 
for the surgeon sometimes to peripheral clinics is a way in which it makes 
the surgery very much more easy and efficient in terms of being seen both to 
patients and practitioners.
    Having highlighted these various areas, I'd like to look a little bit, 
if I may, just in my closing few minutes, to telemedicine and its future in 
VA.  I think from the things which I've mentioned you all have seen that one 
of the themes that runs across them all is that of changing location of care 
to really make the care more--to improve ease of access to veterans, 
particularly in rural locations.
    The example of Iron Mountain VA Medical Center in Michigan is really 
illustrative of the kind of changes this can bring about.  In the late 1990's 
Iron Mountain had particular problems with recruiting a pathologist, a 
pathologist's service being important as one of the core parts of the medical 
center.
    It was possible to set up a telemedicine service linking back down to 
Milwaukee, and from that the VA has got a sustainable network in VISN 12, 
which is probably the largest of its sort in the country, crossing five states 
and delivering speciality care to rural, the peninsula of Michigan, which is 
extraordinarily beneficial to the veteran patients there.
    The evidence base is growing within VA to use telemedicine.  Some 50 peer 
review publications have emanated from VA since the early 1990's.  Typically 
evidence takes some five years to develop from when practice starts and then 
some 15 years often to be included, though this is changing and it's happening 
more rapidly.
    VA certainly is in a position to help accumulate the evidence to be able 
to do this.  The evidence I mentioned is that, but also the right pragmatic 
reasons to deliver care using telemedicine at the moment.  In order to develop 
this evidence VA is linking to the Quality Enhancement Research Initiative 
within the Veterans Administration to be able to gather the evidence in 
programs that we are taking forward.
    Other things that I would like to mention are the lead practitioners.  All 
the areas of telehealth I've mentioned have lead practitioners.  Standardizing 
the delivery of care so it's done very much in an evidence based fashion, able 
to make sure that--to use a euphemism, the services plug and play so they fit 
together in a way that makes sense.
    One of the things which is often not raised when it comes to talking about 
telemedicine is the issue of training. To have a sustainable telemedicine 
program within VA-- programs rather--the need to have those core competencies 
within staff so we have a telemedicine competent workforce is particularly 
important.  We established a training center in January of 2004 concentrating 
on home telehealth.  They have trained some 1,500 people face-to-face and some 
1,100 people via distance learning technologies.  We have training centers 
we're establishing this financial year in Salt Lake City for general 
telehealth and also in Boston for store-and-forward.
    We work closely with other agencies.  Just an example is the recent Indian 
Health Service, Veterans Health Administration Steering Group which met in 
Albuquerque about how we share expertise and particularly Native American 
patients we both have, it would be very applicable to use some of the distance 
health technologies.
    We participate actually in a joint working group for telehealth which is 
run by Health and Human Services and work with them on the issues of sustained 
services.  And also in terms of sustainable services what is particularly 
important is to link into the regulatory and accreditation bodies whom we are 
working closely with.
    So in conclusion, I would just like to finish by saying VA, I think--I'm 
very privileged to work for VA.  VA has used this technology in a way to 
really enhance the delivery of care, and the areas I've mentioned would be a 
test to VA's leadership.
    It is very--it is and will continue to be about collaborative 
relationships both within and outside.  Of paramount importance this is about 
the relationship between practitioner and patient to deliver care.  We are 
coordinating care across the continuum and are able to do this and bridging 
distance and geography.  In doing so we're linking to other resources within 
the organization.  This is not creating a new silo.
    So I would conclude by saying I'm very grateful for the opportunity to 
provide testimony.  The VA has a noble mission to serve veterans and one of 
the things that unites all those working to deliver care in telemedicine is 
how we do that and integrate that into the rest of the delivery of care.
    It's my pleasure to introduce Dr. Ross Fletcher now if I may do.  Dr. 
Fletcher is the Chief of Staff at the Washington, D.C. Medical Center.  He 
also is a pioneer in this whole area and is the lead for the nationwide VA 
register on pacemaker and defibrillator surveillance center.  We would both 
be very pleased to answer questions afterwards.

    [The statement of Dr. Darkins appears on p. 37]

    Mr. Brown. Thank you, Doctor.  What a great testimony, and I could just 
see the excitement in your voice as you were going through the process.  It 
is an exciting time to be able to advance health care delivery through 
telemedicine.
    Dr. Fletcher, did you have something you wanted to say?  You're on the 
support team, right?  Go ahead.  
    Dr. Fletcher. I have a presentation to make which actually shows how the 
care coordination program, the telehealth program, has been working very much 
hand-in-hand with the computerized system that we have at the VA.
    I think I'll just start by opening that system and showing you a few 
patients that have been benefitting from our telehealth projects.
    The first patient I'm going to show you is Mr. McNamara.  That isn't his 
name and that isn't his social security number, as you might guess, but this 
is the standard front sheet on the computerized record that we see.  It has a 
cover sheet as you see.  It has a lab package which is very easy to open up 
and display anything that might be present.
    The beauty of being able to do this is that I can actually do this in my 
home as I'm talking to other--to the patient on the telephone.  So the ability 
to display the patient's record and his white count for example, which in this 
instance was elevated when he first came into our hospital, was very important 
because he was paralyzed and it turned out he had Lyme disease.  We took care 
of that but then had to take care of the patient for quite some time 
thereafter.
    If you look at the additional tools, which is Vista Imaging which now can 
be seen--now can be seen at any point in the system including in my home 
through Comcast Cable.  I can see that he has in actual fact a very large 
plural effusion that is in essence is heart failure.  You can see that more 
clearly if I enlarge it.
    But now I am in addition able to follow many other things about him.  When 
he first came to light, if I click on weight you can see that all results show 
that he has a weight that started very low.  He was emaciated when he was in--
had his paralysis, but that gradually came up.
    And if I wanted to look more carefully at the latter portion of the 
record, which is obviously more dense, you can see that he had--his weight 
reached a peak which was typified by heart failure.  We actually took the 
fluid off of his lung inside the hospital, but it rapidly recurred at home 
and we brought him back and took the fluid off again.  This time we saw it 
coming back but increased his Lasix.
    And in this--by this time we had placed him a telehealth program whereby 
the steps on a scale in his house and that number is immediately transmitted 
to a server which is transmitted to his electronic record so that this data 
point of weight was taken inside the hospital, but all of these were taken at 
home except for a few when he came back to the hospital.  I sort of tell how 
that is because we don't normally take temperatures at home but--so there are 
fewer of those.  But we do take the pulses and we do take the blood pressures 
as well.  As a matter of fact he starts out relatively high and then comes 
down to a much smoother zone.
     Very important on the weight scale to notice that he is sitting at 165 
and gradually rising to this trigger point of 170.  Now at 170 we're afraid 
that he is going to go back into heart failure, but with the telehealth 
aspect where we can see exactly when he's getting into trouble we can 
intervene at this point, and did as a matter of fact add his--increased his 
diuretic from 80 milligrams to 120 and his weight came back down.  Now we 
changed the drug back to 80, but it gradually went up and obviously he 
needed another increase in the medication.
    Now throughout this time, this is now from April all the way through 
December, the patient never comes back to the hospital.  He never has 
pulmonary edema.  He never has--I got the telephone call on this occasion 
saying I'm very short of breath and I could hear him--over the telephone you 
can actually hear how fast someone is breathing--and I knew we had to move in 
quickly and took him right into the hospital. It was about a 45 minute drive 
in.
    But beyond that point this man never re-accumulated any of the fluid 
that's in his lungs and he did quite well on the score.  He wouldn't have if 
we weren't following very carefully all of this information.
    And once again, the information is not just the weights for--which in 
congestive heart failure is critical, but it's also the blood pressure which 
we are able to follow right along.  For instance if this man had a very high 
blood pressure we could easily tell that it had been pulled down to normal, 
and see that it is normal, and we will see that it rises up.
    One of the fascinating things that we have in this system is a trigger 
point, and in this patient I set it at about 168.  So if I set the trigger 
point to 168 I don't have to know every time he calls in.  I know that the 
minute it reaches that trigger point I will get a note in the medical record, 
the record I look at everyday, I will get a warning sign that Mr. McNamara 
has reached that trigger point.  I need to get on the phone and change his 
medication.
    So I feel very comfortable about it and a lot of the physicians are 
worried that they're going to be called too often, but in actual fact as long 
as he stays down in this zone I can follow him very nicely and I feel very 
secure.  Any time I want to glance at his record I could just pull him up and 
I actually see all of these values sitting in the chart.
    So we were able to manage his heart failure very securely and very well 
over a long period of time.
    Mr. Brown. Thank you, Dr. Fletcher.  How much does the at home facilities 
cost?  How expensive is that?
    Dr. Fletcher. The instrument that we have in his home happens to cost 
about $1,000.  Some of them cost as low as 600, $500, some of them cost a 
little more, depending on what's attached to them.
    Mr. Brown. But it's transportable.  If that patient ceases to need it 
then it can move--
    Dr. Fletcher. Yes.
    Mr. Brown.--to the other.  Is the connect, is that an expensive process?
    Dr. Fletcher. No, it's not an expensive process, and the value of having 
all these numbers being taken on a daily basis is extremely important.  The 
cost of bringing him in every three months, which we were doing, with bad 
heart failure is not only costly inside the hospital where the costs are much 
higher on a daily basis, but it's also costly to the patient.  One of these 
episodes he might not live through, for example.  So it's very, very helpful 
to preempt the episode by actually following him in this very close way.
    Mr. Brown. And how often do you review his file? I notice you said there's 
some parameters that will set off a signal and how do you receive that signal?
    Dr. Fletcher. Well, actually, when I sign on, as I'll show you.  If I sign 
on to a different patient I actually get a warning notification list and on 
that list will be his name.  I will read the note and it will say blood 
pressure has reached 170 over 60, and then I have to sign it.  So now I know--
    Mr. Brown. I see.
    Dr. Fletcher.--it's established that I have made contact, I've seen it, 
and I usually then make a call out to the patient and adjust his medication 
or test to see whether there could be some error in the value.
    Mr. Brown. Okay.  Let me tell you a little bit about logistics.  I think 
we've got votes around 11:00 or somewhere thereabouts.  We've got two other 
panels to bring testimony and I hate to cut you off, Dr. Fletcher.  Do you 
have any  other final summaries that you would like to include in your 
presentation?
    Dr. Fletcher. One minute of final summary.
    Mr. Brown. Okay, sure.  Go ahead.
    Dr. Fletcher. I will just show a slide or two. This is our hospital, which 
you are all welcome to come to anytime up the street, on North Capitol Street.
    We also have been following the patients with pacemakers.  This was 
described.  I've done now probably over a million house calls where we receive 
the electrocardiogram and can see it.  The nice thing about the whole metrics 
is that we use the scales automatically going into CPRS with the trigger 
messages and our appointments are made just in time to take care of the 
problems.
    We had educational values that go back and forth to them and personal 
reminders as well.  We are able to follow not just the weights and the blood 
pressure and the pulse which you saw, but also glucose measurements, 
temperature, oximetry--that's an O2 saturation and it goes on the finger--and 
the pain score.
    We are setting goals for each patient, especially in heart failure.  For 
blood pressure and in diabetes the glucose ceilings trigger the same sort of 
thing.  We are managing the patients in these categories quite well and 
bringing their numbers down.
    We also have in conjunction, we have that site, where we can actually have 
the patient see his own record.  So all of the pressures and vital signs that 
the records and goes into our record are something he can see in his home.
    And that's all I have to say.  Thank you very much.
    Mr. Brown. No, thank you.  It's certainly an exciting time in medicine to 
be able to have that kind of connectivity.
    What do you need at home, just a regular telephone line or do you have to 
have special communication?
    Dr. Fletcher. A regular telephone line works very well and it just 
automatically--it has a modem and it makes the call out and delivers the 
information to the central site which then delivers it into the hospital 
record.
    Mr. Brown. Okay.  Dr. Clancy, if you could contain your remarks to five 
minutes and then you can submit the total remarks to us.  I apologize just for 
the time.  I think just to give the other two panels an opportunity to give 
testimony.  And then we'll have questions from Mr. Michaud when this is over.  
Thank you.  Thank you, Dr. Clancy.

STATEMENT OF CAROLYN M. CLANCY

    Dr. Clancy. Good morning, Mr. Chairman, members of the Subcommittee.  I'm 
very pleased to be here this morning and have submitted a written statement 
for the record.
    The Department of Health of Human Services has a long- standing commitment 
to understanding and advancing the effective us of health information 
technologies, including telemedicine, to improve the health of all Americans.
    As we use the term, telemedicine is the use of telecommunications 
technology for medical diagnostic monitoring and therapeutic purposes when 
distance and/or time separate the participants.
    I'd like to note that while there is a great deal of activity and an 
increasing amount of activity in telehealth, we have a lot to learn about 
which applications work best for which patients and under what circumstances. 
We share a common interest with our colleagues at the Department of Veterans' 
Affairs in attempting to build that evidence base to identify best practices 
and promising interventions.
    I'd like to offer seven observations about telemedicine that are discussed 
extensively in my written statement.
    First, the use of telemedicine in the private sector is relatively small 
but growing.  Second, there's evidence that the technology can work and can be 
used beneficially from a clinical and economic standpoint.  But while there 
are many promising initiatives underway, there are few mature telemedicine 
programs and few good scientific evaluations.  So we have a lot to learn about 
what works under what circumstances and so forth.
    Third, it's difficult to assess the appropriateness, effectiveness or cost 
effectiveness of telemedicine in the abstract or at large.  It's really much 
more effective to focus on the specific service that telemedicine is being 
used to provide.  Whether that's a provision of radiology services, specific 
home health, mental health, other types of applications that Dr. Darkins 
described.
    Fourth and perhaps most important, telemedicine is merely a means to an 
end.  Too many evaluations that we've seen actually focus on the technology, 
but what we're really wanting to know is whether the telemedicine service 
results in better patient care and at what cost.  And these are the questions 
I'm hearing you ask, so specific applications should be assessed in those 
terms.
    The fifth point is that the array of obstacles to adoption and the use of 
this technology in the private sector is different in some ways from those 
confronted by the Department of Veterans' Affairs in their relatively closed 
health system.  So the questions you were asking about what does it cost to 
hook up, that's going to be a different kind of equation obviously in the 
private sector.
    Sixth, with some exceptions such as teleradiology, clinicians and system 
leaders in the private sector have been relatively slow to adopt telemedicine.  
And it's increasingly clear, as Dr. Darkins said, that a variety of factors 
need to be in place before clinicians believe that the value gained exceeds 
the effort required to use it.
    Finally, under Secretary Levitt's leadership, HHS is giving the highest 
priority to fulfilling the President's commitment to promote widespread 
adoption of interoperable electronic health records.  This movement could be 
a significant enabler for the future adoption of telemedicine.
    The possibility of a direct linkage between telemedicine applications and 
an electronic health record across settings of care will dramatically alter 
the calculus for evaluating the effectiveness of telemedicine technology.  
HHS has supported telemedicine research of demonstrations through three 
decades and established an office for the advancement of telehealth in HRSA 
as a focal point for coordinating programs within the department.
    It's very clear that in a number of rural areas, through the HRSA's 
program, that many of these communities would have no access to a number of 
services, including psychiatric services, dermatology, rheumology, specialized 
wound care and genetic counseling if those telemedicine services had not been 
available.
    The Indian Health Service also has extensive experience with telehealth 
and is probably the closest HHS parallel to how VA operates.  IHS and tribal 
facilities report experience with over 30 different types of telemedicine, 
clinical services, and opportunities for expanded service delivery are now 
under development.
    CMS is also working on telehealth issues and we actually at the request of 
CMS developed a very comprehensive and systematic review of what is known 
about what works in telemedicine in 2001.  The report identified a lot of 
areas where we simply don't have a good evidence base.  We actually began to 
update that report late last year.  It should be ready shortly and we'll make 
sure that you get a copy.
    I'm almost out of time here.  We also have another report that was--there 
is a report from HHS mandated by the Medicare Modernization Act regarding the 
possibility of including skilled nursing facilities as a Medicare telehealth 
originating site for the purpose of reimbursement, and we will make sure that 
you get a copy of that report as well.
    Just in closing, this has long been viewed as a very promising tool for 
enhanced access to health care services, improved patient safety and timely 
decision making, and as you've seen from my colleagues here from Veterans, the 
opportunity to dramatically improve care management I think is self evident.  
And we've seen terrific examples of how the IHS and the VA can and have 
continued to collaborate to benefit the populations that we serve.
    So with that and in the interest of time, I will stop, and we'd be happy 
to get questions on the record.
  
    [The statement of Dr. Clancy appears on p. 46]

    Mr. Brown. I really do thank you, Dr. Clancy.  I apologize for--this is 
such an interesting topic.  We'll have an all day hearing just for you all 
three.  It's absolutely just incredible, you know, the knowledge that we have 
available and I guess the technology that we have and how we are implementing 
it.
    I would ask if you would, and it's good to have both of you here on this, 
focused on the same idea, I guess the test projects you're working on, when do 
you see it being across the whole spectrum in VA, telemedicine?
    Dr. Darkins. Dr. Fletcher or--
    Mr. Brown. Either one.  Either one will be fine.
    Dr. Darkins. The main area that is moving forward is very much the area of 
home telehealth that was described. It fits very much as I said the patient 
need, the elderly population.  People really do want to stay in their own 
homes. Obviously some of those are appropriate to be in a nursing home, but I 
think Dr. Fletcher very eloquently and graphically described how this 
benefits.  This is somebody who if ended up going in with heart failure they 
might not have survived.  So VA is concentrating very much on that area and 
developing both the clinical, the technical and the management of business 
infrastructure to sustain it.
    But having said so, the other major area that's going forward at the 
moment is telemental health.  You'll hear from some of my other colleagues 
later.  Not only is there a large incident of PTSD in the population anyway, 
but there's also the returning combat wounded to consider as well.
    So telemedicine is just part of the general armentarium.  I wouldn't for 
one moment suggest that it can replace the whole of care, but used 
appropriately as we are doing in the right area, it is absolutely an adjunct 
as I think Dr. Fletcher showed.
    Mr. Brown. I guess my question was is it being implemented at all the VA 
hospitals across the country or just concentrated in one or two?
    Dr. Darkins. With the home telehealth program it's being developed at the 
VISN level, Veterans Integrated Service Network.  All 21 VISNs now have a 
program.  We'll have a minimal number of 500 patients under care to provide 
the initial platform to be able to build from, and from that we will be 
spreading into other hospitals.
    So what we're doing is making absolutely sure these are patients for non-
institutional care.  There's an absolutely robust program in place that we 
will then build from.  So we'll then be able to expand it more rapidly just 
to begin with, making sure it's nationwide.
    Mr. Brown. And I know there was a little bit of concern about the cost 
justification I guess between the private sector and the VA.  How do you sense 
the return on investment under the VA system?  Is it saving us money or--I 
know it's better for the patients to be able to stay in an environment they're 
familiar with, but how is the cost association?
    Dr. Darkins. Well, I can put my hand on my heart and say it's one of those 
pleasing situations where it's a win on both sides.  I mean, the sense is that 
it is something which does save money.  It's concentrated very much at the 
moment on patients who would be going very frequently into care.  And as Dr. 
Fletcher showed, there is major inconvenience to those patients.  So the cost 
of using the technology is justified absolutely by the reduction and the 
necessity to go into care.
    Dr. Clancy pointed out, I think, that one of the things which radically 
transforms the ability to do telemedicine is having the patient record, the 
computerized record, because to be able to have a patient in one place, the 
practitioner in another, it's great to be able to see them. But if you don't 
have the patient's chart, investigations otherwise.  So I think there isn't 
comparability, but I think the fact that VA is an integrated health care 
system and the fact that it's being used in the way it is, there is absolute 
cost justifications for why it's being done, and thankfully as well there are 
very good patient justifications both clinically and in terms of patient 
satisfaction.
    Mr. Brown. Is there any privacy issues you see that would conflict with 
moving this program forward?
    Dr. Darkins. In terms of how this moves forward, this fits into the 
general IT policy that VA has for both, covering HIPPA, the privacy 
regulations and cyber security. So it's down within the umbrella, absolutely 
securely of maintaining privacy and confidentiality for patients.
    Mr. Brown. I'm going to sign Dr. Fletcher up.  I think I need to be on 
that monitoring system and--that's a good program.
    Mr. Michaud, do you have any questions?
    Mr. Michaud. Thank you, Mr. Chairman.  As the Chairman says, we could 
probably talk all day about this issue because it is exciting and I think it 
will save and will help veterans particularly in rural areas.  I have several 
questions, most of them for the record.  The one that I would like to ask is, 
currently the VA budget request spends $1.7 billion for information 
technology.  I know the appropriators are meeting shortly, if they're not 
already meeting, and they're looking at probably removing about $400 million. 
My question is what effect will that have?
    My second question is with the $1.7 million how many veterans will be 
taken care of with that amount of money?
    Dr. Darkins. The telemedicine programs I've described today and our 
strategy for moving telemedicine forward in the short term is predicated on 
the VA's existing information technology system.  So as far as I'm aware we 
will be able to carry forward all we've currently got planned.
    What might be the effects on further developments and enhancements in the 
future by virtue of any projected budget cut I really wouldn't be able to 
personally comment upon.  Certainly I'm sure that information could be made 
available but I--in terms of what we're describing we are actually using the 
current robust system which is in place to deliver what we have.
    In terms of the wider figure and how that impacts on care generally, I--
again I don't have those figures related to telemedicine, telehealth.  I can 
tell you directly what we're spending on telehealth in terms of central 
support and otherwise if that's of--
    Mr. Michaud. Yes, that would be helpful.
    Dr. Darkins. I mean currently the amount spent essentially on telehealth 
in the VA has increased from some 140,000 in 1997 to 10.24 million currently. 
That is the central support in terms of office and grant money and other 
support, but very much the other costs in telehealth within VA come within 
the delivery of care.
    So this is using current physicians who are delivering care in real time 
situations.  So it's an adjunct. Those figures I don't currently have in 
detail.  We are working out--a new coding system is being introduced 
that--because there isn't this coding in telehealth.  Next year we will be 
able to capture very accurately, after this financial year, the workload 
expenses associated with telehealth throughout the VA.
    Mr. Brown. I want to ask one final question, Dr. Darkins, if I could.  Are 
we partnering with the private sector in sharing technology to be absolutely 
sure that we aren't reinventing the wheel?
    Dr. Darkins. Absolutely, we're doing so.  The technology we've talked 
about in terms of telehealth is off the shelf technology which is basically 
commercially available, exactly as it would be in the private sector.  We are 
to some degree at the leading edge of this in terms of where it's moving, so 
working collaboratively with the vendor community in terms of how we've 
contracted with them to take this forward we are dependent upon a vibrant 
vendor community to be able to support this in the future.  And this is all 
using tried, tested technology which is going to be available, and as such I 
think we're also benefitting the wider private sector's access to that 
technology in the future.
    Mr. Brown. Dr. Clancy, Dr. Darkins, and Dr. Fletcher, I've been in this 
process for a long time.  I don't know if I've ever been so enlightened by a 
panel.  Thank you so very much for coming and sharing your time with us this 
morning.
    Dr. Darkins. Thank you.
    Mr. Brown. The second panel, will they come forward, please.
    Good morning.  The Subcommittee will now welcome our second panel of the 
day, and included in that panel is Dr. Linda Godleski.  She is the Associate 
Chief of Staff for Education at the VA Connecticut Health Care System and 
Associate Professor of Psychiatry at Yale School of Medicine. She serves as 
VA's national lead for telemental health.
    Dr. Christopher Frueh is the director of the Post Traumatic Stress 
Disorder Clinical Team at the Charleston VA Medical Center and a tenured 
associate professor at the Medical University of South Carolina.  Dr. Frueh 
provides full-time clinical services to veterans suffering from PTSD and 
serves as a primary clinical supervisor for pre-doctoral clinical psychology 
interns at the Charleston VA Medical Center in my home state.
    Sydney Wertenberger--is that close?  I'm sorry, okay--is an Associate 
Director for Patient Care Services at the VA Medical Center in Poplar Bluff, 
Missouri.  Ms. Wertenberger has expertise in rural health care and home care 
initiatives.
    Patricia Ryan is the Associate Chief Consultant for the Office of Care 
Coordination, and the Director of VISN 8 Community Care Coordination Services 
in Bay Pines, Florida.
    Welcome, and please proceed.  Ms. Godleski, or who will go first?

STATEMENTS OF LINDA GODLESKI, VHA LEAD FOR TELE-
    MENTAL HEALTH, OFFICE OF CARE COORDINATION, 
    ASSOCIATE CHIEF OF STAFF FOR EDUCATION, VA 
    CONNECTICUT HEALTH CARE SYSTEM; B. CHRISTOPHER
    FRUEH, STAFF PSYCHOLOGIST, VA MEDICAL CENTER, 
    CHARLESTON, SOUTH CAROLINA; SYDNEY WERTENBERG-
    ER, ASSOCIATE DIRECTOR, PATIENT CARE SERVICES,
    VA MEDICAL CENTER, POPLAR BLUFF, MISSOURI; 
    CHARLES E. LEVY, CHIEF OF PHYSICAL MEDICINE AND
    REHABILITATION SERVICE, NORTH FLORIDA/SOUTH 
    GEORGIA VETERANS HEALTH SERVICE, GAINESVILLE, 
    FLORIDA; AND PATRICIA RYAN, ASSOCIATE CHIEF CON-
    SULTANT OCC/DIRECTOR VISN 8 CCCS, OFFICE OF CARE
    COORDINATION, BAY PINES, FLORIDA


STATEMENT OF LINDA GODLESKI

    Dr. Godleski. Mr. Chairman and members of the Subcommittee, it is indeed 
an honor for me to be here before this Subcommittee today to provide you with 
testimony on the VA's use and development of telemedicine.
    I am a psychiatrist who has practiced in a number of health care settings 
and currently I also serve as the associate chief of staff for education at 
the VA Connecticut Health care System in West Haven and as the VA's national 
lead for telemental health.  I'm involved in telemedicine in each of these 
three roles and will provide the Committee with perspectives from each role 
because I believe they will all help to highlight how VA is using and 
developing telemedicine.
    Like the majority of my colleagues in psychiatry I was trained to care for 
patients through face-to-face interactions, and it was only when I came to the 
VA that I first learned about telemental health as a very different way of 
practicing my profession.  Furthermore, after reviewing the relevant health care 
literature I appreciated how telemental health had a place in the delivery of 
care and could replicate a face-to-face interaction.  Most importantly I was 
reassured that patients were satisfied with receiving care in this way while 
providing them with improved access and saving them the cost, inconvenience and 
time involved in the travel.
    My initial exposure to telemental health was in VISN 9, the VA Integrated 
Service Network 9 which is Kentucky, Tennessee, and part of West Virginia, when 
I was the mental health service manager there.  The Huntington VA Medical Center 
had been using telemental health successfully since 1997 to provide care to 
patients in distant Vet Centers and community based outpatient clinics.
    I became involved directly in the establishment and running of telemental 
health services to connect all of the VISN facilities for expert telemental 
health consultation as well as ongoing treatment.  I could see firsthand how 
our veteran patients were very comfortable with it and how much easier it made 
it for them to receive their care.
    Of course there are always and always will be times when patients will 
need to be seen face-to-face in a clinic if there's need for in depth physical 
examination or an imminent need for hospitalization, but in numerous instances 
telemental health can provide general psychiatry and also specialty psychiatry 
services such as substance abuse and PTSD treatment.
    As the VA lead for telemental health I am what is generally referred to 
as a clinical champion.  A clinical champion is a practitioner who helps 
introduce and develop new practices in health care and acts as an advocate for 
these new practices with their colleagues.  It is indeed a privilege to help 
the VA and my colleagues lead the way with a new health care development like 
telemental health.
    I am one of the many clinical leads for telemedicine in VA.  There are 
also leads for telerehabilitation, telesurgery, teleendocrinology, 
teledermatology and teleretinal imaging.  We all receive support from the 
National Care Coordination Program Office.  I believe what makes the VA leads 
for telemedicine most effective is that we are truly committed to serve 
veteran patients and our colleagues realize and recognize that we are using 
telemedicine in ways that truly work for patients and ensure excellence of 
care.
    The clinical leads for telemedicine have established a network of 
telemedicine clinicians and VISN leaders, and in the VA all of the clinical 
leads have developed toolkits for our respective areas of telemedicine.  The 
toolkits help new programs get started, allow new programs to learn from the 
experience of other VA established programs rather than having to reinvent the 
wheel.  These toolkits are also very useful for staff training and the 
telemental health toolkit formalizes the requirements to develop a telemental 
health service and educate all the staff involved.
    This is where my role as the associate chief of staff for education has a 
bearing on the development of telemedicine since one of the challenges in 
sustaining telemedicine is to make sure that there are practitioners with the 
requisite skills and competencies who are committed to the program.  In my own 
speciality for example, medical schools and residency programs are just 
beginning to train the next generation of psychiatrists in the use of 
telemental health.
    In the VA we are starting to explore what a telemental health component to 
a residency program might look like.  I believe the ability to recruit newly 
trained psychiatrists who are familiar with telemental health would be of 
great benefit to the VA in sustaining telemental health programs and 
incorporating telehealth into all specialty residency programs in the future 
may have a catalytic effect in terms of promoting the initiation of telehealth 
in the wider health care system.
    Dr. Darkins mentioned the numbers of programs that involve telemental 
health, including 74 facilities and 120 community based clinics, but I would 
like to just finally conclude by leaving you with a specific telemental health 
example.
    Currently I practice in VISN 1, the VA New England Health care System, and 
the VISN has recently established a telemental health service between Togus 
and Caribou, Maine. The development of this service was presented at the VA's 
Care Coordination Telehealth Leadership Meeting in Salt Lake City in April 
2005.
    The service was established because of the 240 mile--excuse me--249 mile 
distance that veteran patients previously had to travel between Caribou and 
Togus for mental health care.  The normal seasonal snowfall I'm told is nine 
and a half feet, and even if it doesn't snow it's a ten hour round trip, not 
to mention the cost of gasoline.  The telemental health toolkit was 
established and implemented, and the program connecting Caribou and Togus led 
to 100 percent satisfaction with patients and a decrease in the no show rate 
for treatment.
    In conclusion I am delighted to be able to advocate for telemental health 
within the VA and I will now be glad to answer any questions the Subcommittee 
may have.  This concludes my statement, Mr. Chairman.

    [The statement of Dr. Godleski appears on p. 57]

    Mr. Brown. Thank you, Dr. Godleski.
    Dr. Frueh, we welcome you back from the greatest congressional district in 
the country, and we're glad to have you up here today.

STATEMENT OF B. CHRISTOPHER FRUEH

    Dr. Frueh. Thank you, Mr. Chairman.  It is an honor to be here and speaking 
before you, and I am grateful for the opportunity to present my views.
    The President's new Freedom Commission on Mental Health highlighted how 
people who live in rural areas experience significant disparities in health 
status and access to care, and this includes many veterans.  There's currently 
a significant shortage of qualified mental health service providers in rural 
and remote areas of the country, including my own state, our state of South 
Carolina.
    Today my testimony will focus on how research evidence that supports the 
incorporation of telemedicine into clinical practice is being used to guide 
the development of telemental health services with the specific intent of 
improving access to care for veterans who are in need of treatment for mental 
health conditions in the Veterans Integrated Service Network 7.
    VISN 7 constitutes VA's southeast network and geographically encompasses 
the states of South Carolina, Georgia and Alabama.  These states have large 
rural populations.  VISN 7's pro-active approach to making services 
geographically accessible to veterans has included establishing 24 community 
based outpatient clients or CBOCs as they're known.  Unfortunately the 
recruitment of qualified mental health professionals, particularly specialists 
to provide care for substance abuse and post traumatic stress disorder in 
rural CBOCs, poses a challenge to VISN 7's goal of offering locally based 
services to meet the mental health care needs of veterans that we are privileged to serve.
    I'd like to make a few remarks about what we know scientifically with 
regard to telemedicine and mental health care drawing on research that has 
been published from all over the world, including a large number of studies 
conducted within the VA and including my own.
    First, as reported in the President's new Freedom Commission on Mental 
Health, people who live in rural areas experience significant disparities in 
health status and access to care.  Telemedicine has introduced an affordable 
means of solving these long-standing workforce shortage problems and improving 
access to mental health care for people in remote geographical areas.
    Second, mental health evaluations, including psychiatric interviews and 
neuropsychological assessments conducted via telemedicine, appear to be 
accurate and reliable.  This is true for even those patients who are suffering 
the most severe mental disorders or cognitive impairment.
    Third, it is clearly feasible to provide both psychotherapy and 
pharmacotherapy services via telemedicine.
    Fourth, both patients and clinicians report high levels of satisfaction 
and acceptance with telemedicine interventions.  A therapeutic relationship 
can be established even when the patient and clinician never meet 
face-to-face.
    Finally, telemedicine services have been shown to lead to improved 
clinical status.  In fact there's growing evidence that the quality and 
effectiveness of telemedicine services service delivery of mental health 
care is virtually equivalent to traditional face-to-face services and is far 
superior to the more frequent alternative--no mental health care at all.
    Although more research is needed to help delineate the parameters of how 
to best provide telemedicine services for mental health, I have little doubt 
that telemedicine offers a safe, acceptable and effective mode of service 
delivery.
    Based upon this evidence VISN 7 is implementing a strategy whereby our VA 
medical centers will provide support via telemedicine to supplement the mental 
health care that is currently available in our CBOCs, and in doing so provide 
much needed specialty services such as treatment of PTSD and substance abuse 
disorders.
    Together with the VISN 7 network mental health director, Dr. Morris 
Springer, we have developed and implemented a telemedicine training program 
for mental health clinicians within our network and so far we've conducted the 
initial rounds of this training with the VA mental health clinicians in 
Charleston, Birmingham and Huntsville, Alabama.  Clinicians at the Atlanta VA 
will be next to receive this training.
    VISN 7 is planning how at both the local VA medical center and network 
levels we can build on our telemental health strategy to support the use of 
telemedicine in providing outreach and educational services to the operations 
Iraqi and Enduring Freedom veterans who are now returning to South Carolina, 
Georgia and Alabama.
    I believe the evidence based manner in which we are enhancing the mental 
health care services we provide in VISN 7 using telemedicine will enable us to 
coordinate care provision between VA medical centers, CBOCs, Department of 
Defense, and other local community agencies.  I and many of my colleagues in 
VISNs throughout the country who have affiliations and associations with major 
academic institutions, we can tailor locally to make sure it is appropriate 
for the needs of our unique veteran population.
    We are also undertaking the research required to grow the evidence base 
necessary to shape how this care continues to evolve in the future.  To do 
so we are working with such agencies as the Agency for Health care Quality and 
Research, the National Institute of Mental Health, VHA Office of Research and 
Development, and the National Center for PTSD in Honolulu.
    Mr. Chairman and members of the Committee, I thank you.

    [The statement of Dr. Frueh appears on p. 61]

    Mr. Brown. Thank you very much.
    Ms. Wertenberger, are you ready?
    Ms. Wertenberger. Okay.
    Mr. Brown. What I'm going to ask you to do, and I know we're going to have 
votes in just a few minutes, I want to give everybody a chance, at least have a 
chance to speak.  If we could sort of summarize your remarks and try to limit 
them within three to five minutes we would certainly appreciate it.  And I 
apologize for that inconvenience, but when we go to vote we might not ever 
come back.  It could be 30 minutes or two hours.  So it really is kind of 
crazy.
    But, anyway, thank you.  I hope you all understand.

STATEMENT OF SYDNEY WERTENBERGER

    Ms. Wertenberger. Mr. Chairman and members of the Committee, I'm 
privileged to appear before you today to discuss rural telemedicine and 
describe the positive impact it's having on our ability to provide care to 
the veterans we proudly serve.  I ask that my written testimony be entered 
into the record, and I will give you a synopsis of it now.
    Although I'm the person testifying before the Committee today I represent 
a dedicated team of health care professionals who are committed to improving 
access to care for veterans who live in the rural setting.  My testimony 
relates to how we care for veterans at the John J. Pershing VA Medical Center 
in Poplar Bluff, Missouri, and our community based outpatient clinics which 
are located in Paragould, Arkansas, Cape Girardeau, Farmington, West Plains 
and Salem, Missouri.
    I believe that our success in improving access to care for our veterans is 
transferable to other rural areas. The commitment and leadership of our 
facility director, chief of staff, our VISN 15 network director, combined with 
support and direction from senior management in VA's central office have been 
key elements in inspiring our teams to refocus and reconfigure the services we 
provide to incorporate telemedicine and improve access to care for our 
veterans.
    The John J. Pershing VA Medical Center is a small, rural facility located 
in our nation's heartland.  Our mission focus is on the delivery of primary 
care services.  Our remote location means we face very different challenges in 
providing care to our veteran patients compared to a VA medical center located 
in a more metropolitan area.
    Those of us who choose to live in a rural environment do so because we 
feel that facing these challenges is well worth the reward we get from living 
where we do.  The cost of living is lower, members of our community value 
self-reliance and independence.  At times this makes convincing veterans to 
seek health care services early and providing preventative health care true 
challenges.
    For the veterans we treat health and well-being means living where traffic 
is limited and there is peace and quiet with folks you know.  They view being 
home as worth more than money can ever buy, and that home is not a house, but 
a place and way of life.
    Those of us privileged to be charged with providing health care to 
veterans living in a rural environment are sensitive to its unique culture. 
We know that veteran patients living in a rural environment need the same 
level of professional expertise as those who live anywhere else.
    Telemedicine has been a great boon to us in delivering care in a rural 
community.  Instead of the traditional requirement in health care that the 
patient travels to the care, we can take the care to the patient.  It means we 
can truly practice patient centered care.  It offers us opportunity to 
successfully meet the challenge of providing health care in a rural 
environment.
    I will try not to make telemedicine sound too much like a panacea, but it 
has opened multiple care options and possibilities for our veterans.  
Telemedicine is a tool which assists us in addressing the issues of access, 
quality, patient safety and cost effectiveness.  Value is another commodity.  
Some things are very difficult to be able to put a price tag on.
    I'd like to share with you very briefly an experience we had several years 
ago with one of our veterans.
    We had a gentleman under nursing home care with us, very frail, elderly.  
His wife was with his son. Unfortunately the wife became acutely ill.  He 
couldn't make the trip to be able to say goodbye.  Through telemedicine we 
could achieve that.  They had their last moments, their last opportunity to 
say goodbye.  Imagine what a gift that is.
    We currently have 39 telemedicine clinics working with our community based 
clinics and medical center giving a full range of speciality care.  Clinical 
outcomes have been positive.  The technology costs we believe will be recouped 
within 14 months due to cost avoidance and savings.
    Telemedicine technology has offered us a way to put compassion for our 
patients into action.  I am grateful to you for this opportunity.  Thank you.

    [The statement of Ms. Wertenberger appears on p. 66]

    Mr. Brown. Thank you, Ms. Wertenberger.  Being from a rural part of South 
Carolina and a Ranking Member from up in Maine where the travel is a real 
problem, and the veterans certainly like living in those rural settings and we 
appreciate your working in that arena.
    Ms. Wertenberger. It is our pleasure and privilege.
    Mr. Brown. And ours too.  Thank you.
    Dr. Levy, we overlooked you in our first announcements there, so let me 
recognize you.
    Dr. Charles Levy is the Chief of Physical Medicine and Rehabilitiation 
Services North Florida, South Georgia Veterans Health Services in Gainesville, 
Florida.  Dr. Levy also serves as an associate professor in the Department of 
Occupational Therapy at the University of Florida.  He is a nationally 
recognized expert in rural mobility and amputee care and rehabilitation, and I 
welcome you, Dr. Levy.

STATEMENT OF CHARLES E. LEVY

    Dr. Levy. Thank you very much.  I'm going to get through this as quickly 
as I can in respect for you, also.  If it seems a little scattered, I 
apologize.
    I'm a physician specializing in physical medicine and rehab and I'm 
privileged to be serving veterans in the North Florida, South Georgia Veterans 
Health System.  It is particularly pleasing to work for the VA because the 
modern roots of rehabilitation medicine grew in response to the need to 
improve the abilities, opportunities and quality of life of injured soldiers 
during and following World War II.
    I feel that we're at a very dramatic moment where health care is changing; 
telemedicine and telerehabilitation is the key to this great paradigm shift.
    Within rehabilitation medicine there is a great enthusiasm from 
physicians, therapists and nurses to use the tool of rehabilitation medicine 
to finally bring care into the home and into the home environments. This is 
an area that we really haven't been able to get to prior, and 
Telerehabilitation offers a great solution to actually to get to the home and 
really make changes.
    Telerehabilitation can be described using four models.  The first model 
simply recreates the clinic using telecommunication to bring service to closer 
to veterans' home. Typically these clinics deliver one time assessments as 
opposed to ongoing care.  Veterans with multiple sclerosis, spinal cord 
injury, amputations, diabetes, cardiopulmonary and orthopedic problems and 
other disorders are right now interacting with their clinicians in real time 
using television screens and telecommunication in Cleveland, Ohio, and 
Nashville, and Minneapolis, and Denver, and Fresno, in Ann Arbor, Tampa and 
elsewhere.  Patients are being served by telerehabilitation in wheelchair 
clinics.  They're getting their wound care, they're getting neuropsychological 
care and prosthetic and orthotic assessments.
    For an example, a spinal cord injured veteran in Dayton, Ohio with skin 
breakdown related to his wheelchair seating will be presented by his or her 
local therapists to an expert panel in Cleveland.  The Cleveland team can 
instantly see the results of pressure mapping and work with the Dayton 
therapist to come up with the optimal wheelchair cushion and seating solution.  
A byproduct of this is cross education and elevation of the standard of care 
throughout the region.
    A second model delivers ongoing care to veterans at distant clinics.  
Examples include speech therapy, occupational and physical therapy, 
psychological and social services.  For example, therapists in Denver 
assisted a veteran hundreds of miles away using video conferencing units 
located in the local clinics and in the medical center.  They were able to 
help the veteran with a traumatic brain injury who had difficulties with 
mobility, self care, bladder management and decision making.  Therapists were 
able to see how the patient functioned and to speak to the patient's wife 
about problems the veteran was having.  From this they were able to determine 
practical ways they could help the wife care for her husband by providing 
ongoing education and training to both improve transfers, walking and stair 
climbing.
    While improving the quality and the availability of care in local clinics 
is critical, if we have our choice most of us would prefer to receive care in 
our own homes.  A third model of telerehabilitation does just that.
    A VA study in Raleigh, North Carolina is using remote video links to 
deliver physiotherapy in the home and comparing the outcomes to traditional 
physical therapy.  The preliminary data looks favorable.
    Another project, the Low ADL Monitoring Program, is targeting frail 
veterans in north Florida and south Georgia.  These veterans at high risk for 
failure and are visited at home by an occupational therapist and a technician 
who prescribe and install necessary assistive devices such as grab bars, tub 
transfer seats, canes, reachers, long handled shoe horns, dressing aids and 
adapted eating utensils.  The patients are then monitored daily either by text 
messaging, phone, computer or desktop devices.  This way pro-active and 
practical interventions can reach the veteran before  problems become 
disasters.
    Data from the first 150 veterans show reduced hospitalization and 
emergency room use and reduced nursing home bed days of care.  A comparison 
of six months prior to enrollment to the six months post enrollment showed a 
savings of $1,200,000.
    A fourth model links teams at great distances from the medical centers' 
experts of care.  I'll skip that in the interest of time.
    I've given you some examples of telerehabilitation today.  However, I 
believe the greater excitement will be seen as telerehabilitation becomes 
integrated into the standard care for veterans.  I envision a day soon when 
returning war injured veterans needing rehabilitation are embraced by a fully 
integrated care system that follows the veterans from the DOD to VA centers of 
excellence, to the local VA medical centers, to their community-based 
outpatient clinics, and then into their homes.
    Thank you very much.  I'd be glad to take questions.

    [The statement of Dr. Levy appears on p. 70]

    Mr. Brown. Thank you, Dr. Levy.
    Ms. Ryan?

STATEMENT OF PATRICIA RYAN

    Ms. Ryan. Good morning.  I want to thank you for this opportunity to meet 
with you today.  VISN 8 began enrolling patients in the care coordination home 
telehealth program in April of 2000.  Most of the veterans that we enroll are 
the clinically complex, older, adult veterans, and we serve most of the 
chronic population, the populations that have the chronic health problems that 
you've heard about already.
    Forty-nine percent of the veteran population is over 65 and average three 
or more chronic health problems.  They live in their own communities, they 
live in their own homes, and frequently when you get to be of a certain age 
you're really afraid to go to the doctor but you really have problems managing 
your own health care.  What the care coordination program does for them is 
gives them the ability to manage their own chronic diseases.
    Our goal is to improve access to care and to provide the right care at the 
right time at the right place.  Through the use of the electronic medical 
record the role of the care coordinator is combined with home telehealth 
technologies to provide that link to all of the clinical specialists that a 
veteran may need to see and get data to, as Dr. Fletcher showed you this 
morning.
    Frequently clinic visits are followed up just in case a person declines or 
to evaluate the type of information that's been going on in the progress of 
treatment.  The ongoing connection through home telehealth provides just in 
time care that is both based on subjective and objective clinical information.
    The VISN 8 care coordination program has served over 3,500 veterans in the 
last five years with the current census of over 2,400.  We have 21 programs 
across the network that serve many populations, from frail, older adults with 
multiple chronic medical conditions, veterans with mental health problems, a 
large of population of veterans with both diabetes and heart failure, and a 
wound care program that for the very special spinal cord population at the San 
Juan VA.  And some of those veterans would have to travel from St. Thomas to 
San Juan via air transport if they needed to come there for their wound care.  
So we're able to do that remotely.
    Our success has been outstanding and customer service has been measured 
annually for the last five years with the results of over 95 percent 
satisfaction with both the care coordination process, which is really 
important, as well as with the use of the technology.  There are four 
components to care coordination:  care and case management, disease 
management, self management of chronic disease, and then as we said before 
the technology to provide all of these.
    We've been able to reduce in our heart failure programs, reduce blood 
pressures on an average from 131 over 70 to 119 over 69.  We've had weight 
reductions that have averaged 5 to 10 pounds.  We've had clinically 
significant improvement in both of our--in all of our diabetics across the 
network.
    Over 80 percent of our veterans use the in home messaging device and we 
will be able to produce results similar to what Dr. Fletcher has shown you.
    One population that we serve is the palliative care population that 
grew out of a cancer program that we started in conjunction with the National 
Cancer Institute.  We have a chaplain that serves as a care coordinator and 
the care coordinator is a registered professional that must be a team member 
with all of the different specialties that we have.
    This veteran was near the end of his life and his son, who was a police 
officer in a distant town, was shot in the face and the veteran could not 
travel to see his son. Through care coordination programs that we have all 
over our state we were able to serve with the care coordinators.  We were 
able to set up video conferencing equipment between the son in the hospital 
and the veteran at home. During--towards the end of his life he was able to 
share some precious moments with his father.
    Mr. Chairman, my father and all of my uncles--except for one--were World 
War II veterans.  So I grew up knowing what the value of veterans are to this 
country, and I really value my ability to serve veterans in this manner, and 
I'm ready to answer any questions that you may have.

    [The statement of Ms. Ryan appears on p. 74]

    Mr. Brown. And I really do appreciate you all coming and we certainly have 
a compassion for our veterans on this Committee.  We're grateful for the 
testimony that you've come to bring this morning.
    Mr. Michaud, do you have any questions?
    Mr. Michaud. I have several questions, but in the interest of time I'll 
submit them for the record, Mr. Chairman.
    Mr. Brown. Well, let me tell you it was a great, informative few minutes.  I 
apologize for the urgency of moving forward so we can speak to the last panel, 
but thank you all very much for coming and I thank you every day for what you 
all are doing for our veterans.
    Ms. Ryan. Thank you.
    Mr. Michaud. That doesn't mean you're off the hook as far as answering 
questions.
    Mr. Brown. Our third panel is Mr. Jonathan Linkous, Executive Director of 
American Telemedicine, and Dr. Sandeep Wadhwa, the Vice President of Care 
Management Services for McKesson Health Solutions and a member of the board of 
the Disease Management Association of America.
    And gentleman, I know you've been hearing my pleas all along.  The horn 
hasn't sounded yet.  We certainly welcome you, and Mr. Linkous, if you would 
begin.

STATEMENTS OF JONATHAN D. LINKOUS, EXECUTIVE DI-
    RECTOR, AMERICAN TELEMEDICINE ASSOCIATION; AND
    SANDEEP WADHWA, VICE PRESIDENT, CARE MANAGE-
    MENT SERVICES, MCKESSON HEALTH SOLUTIONS AND
    MEMBER OF THE BOARD, DISEASE MANAGEMENT ASSO-
    CIATION OF AMERICA

STATEMENT OF JONATHAN D. LINKOUS

    Mr. Linkous. I appreciate the opportunity to speak here on behalf of the 
American Telemedicine Association.  
    Telemedicine is a very important subject, and the ATA greatly appreciates 
the Committee's leadership in this area.
    I would like to take just a moment to give you a little background on 
telemedicine from ATA's perspective. You've had some great testimony so far on 
applications within the VA.  Telemedicine has been around for about 30 years 
in this country in various aspects.  Right now there are about 200 active 
networks in the country, outside of the Veterans Administration, including 
about 2,000 hospitals that are all involved in telemedicine.  About 60 
specialties and sub-specialties, medical specialties, have been used in 
telemedicine.  It is a very active and growing area around the country. 
Certainly one of the most important areas is telemedicine in home care, in 
areas where the Veterans Administration has done quite a bit of 
groundbreaking work.
    With the aging of the population in this country, home telehealth has 
probably one of the greatest potentials for growth.  In telemedicine today, 
there is about 15,000 providers of home care services carrying about 7 million 
individuals nationwide in cases of acute illness, long term care conditions 
and force forward disease management.
    Throughout the past two decades, the home monitoring industry and 
government, as well as the private sector, have been developing electronic and 
telecommunications equipment which can do anything from collecting vital signs 
to allowing you to see a nurse from your own home.
    There are a number of challenges that are facing this industry as we move 
forward.  One is moving--taking advantage of the new technologies that are 
available, both in wireless applications as well as cheaper applications that 
will make--drive the price down.  I understand your comments about the price, 
and I will tell you that in the last ten years, the prices for telemedicine 
equipment are probably about 15 percent of what they were when I first started 
getting involved in telemedicine 10, 12 years ago.
    The industry also must be able to meet the diverse demands of home care 
agencies.  One of the things you will see within the Veterans Administration, 
and elsewhere--is they're not just using one type of telemedicine in the home, 
they're using a number of different types of technologies, and it depends upon 
the need of the patient, such as trans-telephonic monitoring of heart signals, 
for example.  If you have an implanted pacemaker, you can have it monitored 
remotely using a telephone, a fairly simple device active throughout the 
country--event recorders for people with heart problems, health status 
monitors that might just ask patients certain question.  Certainly the 
applications we saw, taking weight and vital signs and even pushing a button 
and seeing the nurse--having that interaction on a daily basis is another 
thing that we're seeing regularly.
    The Veterans Administration has certainly been a leader in this area in 
the country.  With over 5,000 patients enrolled in their home telehealth 
program alone, the Department is administering one of the largest 
arenas--activities, rather, in telemedicine throughout this country.  The 
Department has been working hard to set forth guidelines and the appropriate 
use and administration of these technologies, including developing appropriate 
technology standards, and protocols, and initiating specialized training for 
VHA employees involved in the use of telehealth in the home.
    ATA's membership includes many of the staff from the Veterans 
Administration.  We've actually had two members of the VA serve on our board 
of directors.  The chair of our home telehealth task force is from the 
Veterans Administration and we also have just completed a set of guidelines 
and tasks--and standards--involving the VA as well as the military, another 
major player in telemedicine in this country.
    The experience and lessons learned from the VA's use of telemedicine in 
the home can be a valuable resource for others in the medical community 
outside of the Veterans Administration.  At the same time, others outside of 
the VA also have a lot of experience in this same field.  For example, at our 
recent annual meeting in Denver, Colorado, we had over 2,000 people and 50 
presentations just in the field of home telehealth.
    ATA applauds the Department of Veterans' Affairs for its efforts to deploy 
telemedicine.  We appreciate the progress they are making in this critical 
field and stand ready to help them, as well as this Committee, with a 
cross-fertilization of ideas between the Department and others involved in 
this very rapidly growing area of health care. I thank you very much.

    [The statement of Mr. Linkous appears on p. 78]

    Mr. Brown. Thank you very much.
    Sandeep Wadhwa.

STATEMENT OF SANDEEP WADHWA

    Dr. Wadhwa. That's it.  You nailed it.
    Mr. Brown. Okay.
    Dr. Wadhwa. Chairman Brown, I have the pleasure of returning from Kiawah 
Island this weekend and can attest to the stunning beauty of your district.
    I will summarize my already summarized remarks and get us back on track.
    My name is Dr. Sandeep Wadhwa and I'm the Chairman of Government Affairs of 
the Disease Management Association of America, and I also oversee disease 
management programs for McKesson Corporation, which is one of the largest 
providers of disease management services to government health payers.  I'm 
also a practicing geriatrician and am familiar with the long term and chronic 
care needs of veterans from my five years of practice at the Philadelphia VA 
Medical Center.
    The Disease Management Association of America is a non-profit organization 
representing all aspects of the disease management community, and disease 
management emphasizes the prevention or exacerbation of disease and 
complications by using evidence based medicine and practice guidelines and 
patient empowerment strategies.  We strongly encourage and support the VA's 
adoption of telehealth initiatives.  The VA has done extensive evaluations of 
telemonitoring devices which have demonstrated their efficacy in improving 
patient health status and reducing avoidable utilization of VA's acute care 
resources.
    The VA's use of telenursing however is in its early stages.  Telenursing 
leverages the telephone as a no additional cost and nearly universal device to 
establish a therapeutic relationship between a nurse and a patient for 
education, counseling and monitoring.  Our member organizations have 
demonstrated the value of using the telephone across a variety of settings to 
improve the health of vulnerable populations cost effectively.  To that end we 
encourage the VA to leverage the ubiquity and utility of the telephone as well 
in its telehealth initiatives.  Thank you.

    [The statement of Dr. Wadhwa appears on p. 82]

    Mr. Brown. I do thank both of you for coming and thank you for confirming 
my assessment of my district.
    Mr. Michaud, do you have any questions you want to ask?
    Mr. Michaud. First of all, I would like to thank all the panelists that we 
heard this morning as they all did an enlightening job, and I really 
appreciate the information.
    My concern, being from the rural state of Maine, is whether or not the 
funding will be there to make sure that the need is met for our veterans 
throughout the State of Maine and other rural areas.
    I guess the assessment that was given earlier about Caribou and Togus is 
appropriate, but actually you could fit all of New England into the State of 
Maine.  And my big concern is when you look at the number of facilities--well, 
the hospital and the clinics we have in Maine is equal to the amount that's in 
New Hampshire.  My concern is whether veterans in rural areas are getting that 
access.
    I guess my question is I know VA had done a great job as far as 
telemedicine, but as far as the standard when you look at the Department of 
Defense, the VA, as well as the American Hospital Association, is there a 
standard for all three that everyone is complying with or will there be a 
mismatch between the technology that is being used particularly among the DOD 
and the VA?
    Mr. Linkous. I think that's an excellent question and a very timely 
question.  Within Maine alone, there's a separate telemedicine network that 
includes over 100 hospitals.  It's quite a remarkable network that they have 
going on and they have a lot of experience.
    As the technology improves, as the practice becomes more widespread, 
certainly one of the challenges that we face right now is adopting standards 
and clinical protocols that are the same throughout the Veterans 
Administration, the military, the prison systems that use telemedicine, and 
of course, into the private sector, as well.
    The Veterans Administration has made a lot of progress in developing some 
standards and some protocols.  We have on a couple of occasions, worked with 
them on developing some standards that are based on some of the work that 
they've done, and then we move it out further.  But I think that is a 
challenge as we move ahead, to make sure that the protocols are there, that 
the standards are in place, so that when you have a telemedicine system in 
Maine, or in South Carolina, or in California, basically, the patient can 
expect the same level of care and the same types of services, no matter where 
they are.
    Mr. Michaud. My second question is for both panelists.  Since you're 
familiar with the VA, do you think the VA should be doing something 
differently or should they be focusing in certain areas as far as 
telemedicine goes?
    Dr. Wadhwa. We're very pleased with the care coordination efforts that are 
coming out of the VA's office, and I guess from our perspective we're looking 
for a balance between the use of telemonitoring equipment which, as was 
discussed earlier does have costs associated with it, as well as using the 
telephone and the ability to in a very low cost way to establish a 
relationship has been shown in a lot of peer reviewed studies.  So we think 
that both of those telehealth solutions should be promoted in the system.
    Mr. Michaud. I guess what my final question if I might, Mr. Chairman?  It 
has been stated that one out of every six servicemen and women will come back 
from Iraq and Afghanistan is going to need some type of assistance, 
particularly as it relates to mental health.  Do you think that currently 
there's enough funding within VA to deal with that particular issue?  And I 
guess my second question is how important is one-on-one immediacy going to 
be?  You know, I assume that telemedicine is going to be available during the 
daylight hours.  What's going to happen to the veteran who needs the 
assistance at nighttime, particularly when we hear about all the people who 
die over in Iraq and Afghanistan, but we don't hear much about the suicides 
or attempted suicides that are currently there and my concern is the 
immediacy of getting assistance.
    Mr. Linkous. One of the benefits of telemedicine is that you can extend 
the services provided to the individual beyond just the hours of the clinic, 
just when a particular practitioner happens to be in the office.  You can 
link into a network and get those services no matter where they are.
    The Veterans Administration has done a lot of work in telemental health, 
brought a lot of leadership in that area.  I am concerned about the funding 
level.  I'm very concerned about what we're hearing, and certainly, the Chair 
and you are hearing about the appropriations this year for the Veterans 
Administration.  I think it is not a good time to be reducing any money for an 
agency that is providing services to our veterans when we are involved in 
conflicts.
    Dr. Wadhwa. And I'll just build on that, that response just ever so 
briefly, in that many of these services are set up to be available around the 
clock with immediate access to a telenurse and teleadvice.  That is exactly 
for patients in distress and they may not have a good grasp of judging their 
own symptom and calling 911, but feel comfortable talking around the clock to 
a nurse and have that symptom triaged at the appropriate level of care.  So 
that is a concern I think that telehealth does, can be set up to address that, 
to provide around the clock service.
    Mr. Michaud. And if I might, as I said, there's a lot of questions.  You 
just happen to be the last panel before the bell rings.  The last question I 
have and I promise, Mr. Chairman, is do you think the technology, the system 
out there, particularly in a rural state like Maine and given the number of 
veterans that we currently have in Maine, that the use of the system, is it 
available, the technology in the rural areas?
    Mr. Linkous. Is the technology available currently?
    Mr. Michaud. Yes.  Will there be a problem with overload?  I mean, if you 
look at Maine, 16 percent of our population are veterans.  We're the highest 
in the country as far as veterans.  We're a rural state.  We definitely do 
need to improve on the technology.  You look at Maine's National Guard, we're 
at the top there as well.  If the BRAC process goes through where 7,000 jobs 
are going to be lost in Maine and it's going to throw more veterans probably 
onto the system.  Will the system be able to withstand the needs?
    Mr. Linkous. Well, I would say there's a problem currently serving those 
needs, and part of that problem is the fact that we have a system that is 
still relying very much on individual face-to-face consultations and services. 
Telemedicine does allow you to actually increase the number of patients that 
you see, and it increases the efficiency of the system.  So hopefully, as we 
get it deployed further throughout the State of Maine, or South Carolina, or 
throughout the country, we can increase the number of services and access to 
those services for all of the patients that are out there.
    The technology is--the changes in technology are just phenomenal, even for 
the last 12 months.  So I think we are going to be able to have a technology 
available that will be able to be deployed in all of the homes.  It's very 
important, though, that the appropriate technology be selected for the 
appropriate need.
    Dr. Wadhwa.  And just to very quickly build on that comment, the 
technology is, as we said earlier, becoming much less expensive and very easy 
for the veterans to install themselves without a lot of technical guidance or 
people coming out.  And so our strong sense is that the technology is here.
    Mr. Brown. Let me say not just to you two but the whole panel, all three 
panels that were presenting today, what a real refreshment to the sense of 
where we're moving in our health care delivery, and I thank you both for 
being part of, plus the other two panels, and thank you all for coming. And 
as the mystery of this process moves forward the two--the 11:00 votes did not 
show, nor did the 11:15, nor did the 11:30 apparently.  So we're still--it's 
still amazing how this process goes.
    Mr. Michaud. I do not have a question but, Mr. Chairman, this is Susan's 
last hearing after eight years as Democratic Staff Director for this 
Subcommittee.  She's done an outstanding job.  I want to wish her the very 
best in her future endeavors.  Thank you very much.
    Mr. Brown. Well, Susan, thank you for your service, and we will miss you.
    [Applause.]
    Mr. Brown. With that, the meeting is adjourned.
    [Whereupon, at 11:33 a.m., the Subcommittee was adjourned.]
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