[House Hearing, 111 Congress]
[From the U.S. Government Publishing Office]



 
                      OVERCOMING RURAL HEALTH CARE

                  BARRIERS: USE OF INNOVATIVE WIRELESS

                      HEALTH TECHNOLOGY SOLUTIONS

=======================================================================



                                HEARING

                               before the

                         SUBCOMMITTEE ON HEALTH

                                 of the

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                     ONE HUNDRED ELEVENTH CONGRESS

                             SECOND SESSION

                               __________

                             JUNE 24, 2010

                               __________

                           Serial No. 111-87

                               __________

       Printed for the use of the Committee on Veterans' Affairs




                  U.S. GOVERNMENT PRINTING OFFICE
58-054                    WASHINGTON : 2010
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                     COMMITTEE ON VETERANS' AFFAIRS

                    BOB FILNER, California, Chairman

CORRINE BROWN, Florida               STEVE BUYER, Indiana, Ranking
VIC SNYDER, Arkansas                 CLIFF STEARNS, Florida
MICHAEL H. MICHAUD, Maine            JERRY MORAN, Kansas
STEPHANIE HERSETH SANDLIN, South     HENRY E. BROWN, Jr., South 
Dakota                               Carolina
HARRY E. MITCHELL, Arizona           JEFF MILLER, Florida
JOHN J. HALL, New York               JOHN BOOZMAN, Arkansas
DEBORAH L. HALVORSON, Illinois       BRIAN P. BILBRAY, California
THOMAS S.P. PERRIELLO, Virginia      DOUG LAMBORN, Colorado
HARRY TEAGUE, New Mexico             GUS M. BILIRAKIS, Florida
CIRO D. RODRIGUEZ, Texas             VERN BUCHANAN, Florida
JOE DONNELLY, Indiana                DAVID P. ROE, Tennessee
JERRY McNERNEY, California
ZACHARY T. SPACE, Ohio
TIMOTHY J. WALZ, Minnesota
JOHN H. ADLER, New Jersey
ANN KIRKPATRICK, Arizona
GLENN C. NYE, Virginia

                   Malcom A. Shorter, Staff Director

                         SUBCOMMITTEE ON HEALTH

                  MICHAEL H. MICHAUD, Maine, Chairman

CORRINE BROWN, Florida               HENRY E. BROWN, Jr., South 
VIC SNYDER, Arkansas                 Carolina, Ranking
HARRY TEAGUE, New Mexico             CLIFF STEARNS, Florida
CIRO D. RODRIGUEZ, Texas             JERRY MORAN, Kansas
JOE DONNELLY, Indiana                JOHN BOOZMAN, Arkansas
JERRY McNERNEY, California           GUS M. BILIRAKIS, Florida
GLENN C. NYE, Virginia               VERN BUCHANAN, Florida
DEBORAH L. HALVORSON, Illinois
THOMAS S.P. PERRIELLO, Virginia

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.


                            C O N T E N T S

                               __________

                             June 24, 2010

                                                                   Page
Overcoming Rural Health Care Barriers: Use of Innovative Wireless 
  Health Technology Solutions....................................     1

                           OPENING STATEMENTS

Chairman Michael Michaud.........................................     1
    Prepared statement of Chairman Michaud.......................    40
Hon. Gus M. Bilirakis............................................     2
    Prepared statement of Congressman Bilirakis..................    40

                               WITNESSES

Federal Communications Commission, Kerry McDermott, MPH, Expert 
  Advisor........................................................    34
    Prepared statement of Ms. McDermott..........................    77
U.S. Department of Defense, Colonel Ronald Poropatich, M.D., USA, 
  Deputy Director, Telemedicine and Advanced Technology Research 
  Center, U.S. Army Medical Research and Materiel Command, 
  Department of the Army.........................................    36
    Prepared statement of Colonel Poropatich.....................    80
U.S. Department of Veterans Affairs, Gail Graham, Deputy Chief 
  Officer, Health Information Management, Office of Health 
  Information, Veterans Health Administration....................    38
    Prepared statement of Ms. Graham.............................    83

                                 ______

AirStrip Technologies, San Antonio, TX, William Cameron Powell, 
  M.D., FACOG, President, Chief Medical Officer and Co-Founder...    20
    Prepared statement of Dr. Powell.............................    56
Cattell-Gordon, David, M.Div., MSW, Director, Rural Network 
  Development, Co-Director, The Healthy Appalachia Institute, and 
  Faculty, Public Health Sciences, Nursing, University of 
  Virginia Health System, Charlottesville, VA....................     7
    Prepared statement of Mr. Cattell-Gordon.....................    50
Cogon Systems, Inc., Pensacola, FL, Huy Nguyen, M.D., Chief 
  Executive Officer..............................................    26
    Prepared statement of Dr. Nguyen.............................    65
Continua Health Alliance, Rick Cnossen, President and Chair, 
  Board of Directors, and Director of Personal Health Enabling, 
  Intel Corporation Digital Health Group, Hillsboro, OR..........    22
    Prepared statement of Mr. Cnossen............................    57
LifeWatch Services, Inc., Rosemont, IL, John Mize, Director, 
  LifeWatch Federal..............................................    29
    Prepared statement of Mr. Mize...............................    75
MedApps, Inc., Scottsdale, AZ, Kent E. Dicks, Founder and Chief 
  Executive Officer..............................................    24
    Prepared statement of Mr. Dicks..............................    63
Three Wire Systems, LLC, Vienna, VA, Dan Frank, Managing Partner, 
  also on behalf of MHN, A Health Net Company, San Rafael, CA, on 
  the VetAdvisor' Support Program.....................    28
    Prepared statement of Mr. Frank..............................    71
West, Darrell M., Ph.D., Vice President and Director of 
  Governance Studies, and Director, Center for Technology 
  Innovation, Brookings Institution..............................     5
    Prepared statement of Dr. West...............................    44
West Wireless Health Institute, La Jolla, CA, Joseph M. Smith, 
  M.D., Ph.D., Chief Medical and Science Officer.................     3
    Prepared statement of Dr. Smith..............................    41

                       SUBMISSIONS FOR THE RECORD

Altarum Institute, Ann Arbor, MI, Lincoln T. Smith, President and 
  Chief Executive Officer, statement.............................    86
Robert Bosch Healthcare, Inc., Palo Alto, CA, statement..........    89


                      OVERCOMING RURAL HEALTH CARE


                  BARRIERS: USE OF INNOVATIVE WIRELESS


                      HEALTH TECHNOLOGY SOLUTIONS

                              ----------                              


                        THURSDAY, JUNE 24, 2010

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
                                    Subcommittee on Health,
                                                    Washington, DC.
    The Subcommittee met, pursuant to notice, at 10:05 a.m., in 
Room 334, Cannon House Office Building, Hon. Michael H. Michaud 
[Chairman of the Subcommittee] presiding.
    Present: Representatives Michaud, Snyder, Donnelly, 
McNerney, Perriello, and Bilirakis.
    Also Present: Representative Miller of Florida.

             OPENING STATEMENT OF CHAIRMAN MICHAUD

    Mr. Michaud. I would like to call the Subcommittee to 
order, and ask the first panel to come forward. I want to thank 
everyone for coming here this morning.
    The purpose of today's hearing is to learn about the wide 
range of innovative wireless health technology solutions and 
their potential application to help our veterans living in 
rural communities.
    Of the nearly 8 million veterans who are enrolled in the 
U.S. Department of Veterans Affairs (VA) health care system, 
about 3 million are from rural areas. This means that rural 
veterans make up about 40 percent of all enrolled veterans. For 
the 3 million veterans living in rural areas, access to health 
care remains a key barrier as they simply live too far away 
from the nearest VA medical facility. Unfortunately, this means 
that rural veterans cannot see a doctor or a health care case 
worker to receive the care they need when they need it. Given 
these barriers, it is no surprise that our rural veterans have 
worse health care outcomes compared to the general population.
    This is where I see the great potential in the innovative 
wireless health technologies. VA certainly is a recognized 
leader in using electronic health records (EHRs), telehealth, 
and telemedicine. However, wireless health technology also 
includes mobile health, which truly is the new frontier in 
health innovation. Mobile health makes it possible for health 
care professionals to receive real-time data such as vital 
signs, glucose levels, and medication compliance because data 
from the patient's mobile sensors are relayed over wireless 
connections. Mobile health also makes it possible for health 
care professionals to download health data using personal 
digital assistants (PDAs) and Smartphones. These innovations 
not only empower our rural veterans but can improve health care 
outcomes as veterans have the necessary tools to better manage 
chronic diseases and receive timely health care in the comfort 
of their own homes.
    I look forward to hearing from our witnesses today as we 
learn more about innovative wireless health technology and 
explore ways that we can best support wireless health solutions 
in the VA systems.
    I would now like to recognize Mr. Bilirakis for an opening 
statement.
    [The prepared statement of Chairman Michaud appears on p. 
40.]

           OPENING STATEMENT OF HON. GUS M. BILIRAKIS

    Mr. Bilirakis. Thank you, Mr. Chairman. I appreciate it 
very much. And good morning to everyone, all of our witnesses 
and audience members. I am excited to be here with you today to 
discuss wireless health technology within the VA, particularly 
how it can be utilized to increase access to care and improve 
patient outcomes for veterans in hard-to-reach rural areas.
    Approximately 40 percent of the veteran population resides 
in rural areas, and those numbers are expected to increase as 
veterans of Iraq and Afghanistan return to their rural homes. 
Living in a hard-to-reach area presents numerous barriers to 
care for veterans, who must often drive long distances and find 
overnight accommodations to make appointments at distant VA 
facilities. These factors would be significant for anyone but 
are especially burdensome to veterans who struggle with pain, 
disability, or chronic illness.
    I am proud of the work we have done on this Subcommittee to 
help ease the burden rural veterans face, but, as always, more 
work remains. The VA currently operates the largest telehealth 
program in the world, operating in 144 VA medical centers and 
350 VA Community-Based Outpatient Clinics. Estimates indicate 
that 263,000 veterans were cared for using VA's telehealth 
initiatives in fiscal year 2009 alone.
    Telehealth is the provision of health care services through 
telecommunications technologies, including cell phones, 
Smartphones, the Internet, and other networks. When a patient 
receives a text message reminder from their doctor, they are 
engaging in telehealth. When a doctor is able to monitor an at-
risk patient's blood pressure or heart rate through a remote 
monitoring device, they are engaging in telehealth. When a 
specialist at a VA medical center is able to communicate with 
and make a vital diagnosis on a veteran patient at a Community-
Based Outpatient Clinic many miles away, they are engaging in 
telehealth.
    Early results indicate that when wireless technology is 
utilized effectively it can be a tremendous benefit, especially 
for rural veterans. From these programs we are learning that 
when technology is incorporated into health care it can improve 
access, efficiency, innovation, and outcome, while reducing 
barriers to care.
    While such technology is not without its challenges, I am 
encouraged by the early successes of VA's telehealth programs, 
and I look forward to learning more from our discussions this 
morning.
    I yield back the balance of my time. Thank you, Mr. 
Chairman.
    [The prepared statement of Congressman Bilirakis appears on 
p. 40.]
    Mr. Michaud. Thank you, Mr. Bilirakis.
    We have many expert witnesses with us today; and with such 
full panels we need to make sure that there is adequate time 
for questions. We have also been notified that there will be 
votes between 11:00 and 12:00 over in the House Chamber.
    So I would like to remind each witness that you will have 5 
minutes to make your remarks. On the table, there is a timer; 
and the yellow light will indicate there is about 1 minute 
left.
    Also, your full written testimony will be submitted for the 
record.
    So, without any further ado, I would like to introduce our 
first panel: Dr. Joe Smith, who is the Chief Medical and 
Science Officer at West Wireless Health Institute in 
California; Darrell West, who is Vice President and Director of 
Governance Studies and Director, Center for Technology 
Innovation, Brookings Institution; and David Cattell-Gordon, 
who is the Director of Rural Health Network Development, Co-
director of The Health Appalachia Institute, and Faculty of 
Public Health Sciences, Nursing, University of Virginia (UVa) 
Health System in Virginia.
    So I want to welcome our three panelists on the first panel 
and I look forward to your testimony.
    We will start off with Dr. Smith.

 STATEMENTS OF JOSEPH M. SMITH, M.D., PH.D., CHIEF MEDICAL AND 
SCIENCE OFFICER, WEST WIRELESS HEALTH INSTITUTE, LA JOLLA, CA; 
    DARRELL M. WEST, PH.D., VICE PRESIDENT AND DIRECTOR OF 
    GOVERNANCE STUDIES, AND DIRECTOR, CENTER FOR TECHNOLOGY 
 INNOVATION, BROOKINGS INSTITUTION; AND DAVID CATTELL-GORDON, 
M.DIV., MSW, DIRECTOR, RURAL NETWORK DEVELOPMENT, CO-DIRECTOR, 
 THE HEALTHY APPALACHIA INSTITUTE, AND FACULTY, PUBLIC HEALTH 
   SCIENCES, NURSING, UNIVERSITY OF VIRGINIA HEALTH SYSTEM, 
                      CHARLOTTESVILLE, VA

           STATEMENT OF JOSEPH M. SMITH, M.D., PH.D.

    Dr. Smith. Thank you very much.
    I would like to first thank Chairman Michaud and Ranking 
Member Brown for the opportunity to testify today on meeting 
the needs of our veterans, particularly those who live in rural 
areas.
    My name is Dr. Joseph Smith. I am the Chief Medical and 
Chief Science Officer of the West Wireless Health Institute. 
Our institute is a nonprofit medical research organization 
launched last year by two visionary entrepreneurs, Gary and 
Mary West, with the primary mission of lowering health care 
costs through the use of wireless health solutions.
    The Wests, through their family foundation, have already 
granted nearly $100 million to this institute to date; and we 
are focusing those resources to innovate and incubate promising 
technologies, validate their ability to lower aggregate health 
care costs, and engage, as we are today, with policymakers and 
other stakeholders to accelerate the availability of these 
solutions.
    Wireless sensors that aid in remote diagnosis, monitoring, 
and treatment support are among the innovations that will 
enable the institute's mission. In general, wireless sensors 
deployed in, on, or near the body can accurately monitor 
physiologic functions, including body temperature, respiration, 
heart rate, physical activity, blood glucose levels, tissue 
oxygenation, relative hydration, among many.
    Because of their pervasiveness and low cost, cell phones 
and other wireless technologies are well suited to cheaply 
analyze, transmit, and display relevant information and help 
patients' families and health providers manage chronic disease. 
In this way, wireless technology can offer continuous care for 
chronic disease, instead of the snapshot of a patient's 
condition routinely available at a clinician's office and, in 
the process, replace expensive episodic rescue with cost-
effective prediction and prevention.
    Wireless health care enables a new infrastructure 
independent model in health care, which translates into the 
right care at the right time whenever people need it. For 
veterans residing in remote areas, this means avoiding the 
burden of time and expense required to make repeated visits to 
distant facilities.
    We believe the VA system has provided early validation of 
the value of these promising technologies. Specifically, we 
commend the VA for its Care Coordination/Home Telehealth (CCHT) 
program, which has demonstrated a 25 percent reduction in bed 
days of care, including a 50 percent reduction for patients in 
highly rural areas, and a 19 percent reduction in hospital 
admissions by simply taking chronically ill veterans and 
linking them with health care providers and care managers 
through videoconferencing, messaging, biometric devices, and 
other telemonitoring equipment.
    Dr. Darkins, the lead architect of this study, is on the 
panel to follow. And building on his success, we encourage the 
VA to evaluate and implement wireless health solutions beyond 
traditional telehealth that will complement and further extend 
the reach of the CCHT program, including wireless biometric 
centers that monitor disease-specific physiologic parameters 
and track disease activity on a continuous basis. These 
technologies enable patients, providers, and family members to 
monitor the metrics of their conditions without a facility 
inpatient visit.
    Relevant to this opportunity is the recent announcement of 
the new $80 million VA Innovation Initiative (VAi2) meant to 
improve veterans' care by tapping into private-sector expertise 
and creativity. We encourage VAi2 to accelerate the development 
and evaluation of more sophisticated wireless health care 
solutions comprised of advanced sensor technology, patient and 
population based learning algorithms, and remotely titrated 
therapies for a wide range of health care needs.
    The VA's early success in the use of health technology 
rests, in part, with the physician's ability to operate across 
State lines. For typical U.S. clinicians, geographic 
limitations of practice create a serious impediment to the wide 
deployment of wireless health solutions and frustrates the 
ability of our broader health care systems from reaping the 
cost and care efficiencies enabled by these solutions. We 
encourage a thoughtful review at the Federal level to address 
the interstate obstacle to widespread adoption of wireless 
health technology.
    Also imperative to extending veterans' access to wireless 
health technology is the rapid expansion of broadband to rural 
and remote areas. The Federal Communications Commission (FCC) 
has noted that as many as 24 million Americans do not have 
access to broadband where they live. We commend the commitment 
to expanding broadband access in the 2009 economic stimulus 
bill, and we support the FCC's plan to ask the Medicare program 
for a clear path for reimbursement for wireless health 
solutions.
    Finally, in our many stakeholder discussions it is clear 
that that current lack of regulatory clarity as to which 
components of wireless health solutions are and are not 
considered medical devices from the Food and Drug 
Administration (FDA) perspective is dampening investment in 
wireless health technology and chilling this promising engine 
of innovation.
    In summary, we encourage the VA to evaluate and deploy 
newer wireless health technologies within its CCHT program and 
take advantage of opportunities like the recently announced 
VAi2 initiative to develop and test biometric sensors and other 
solutions that facilitate remote use and remote access to care. 
We encourage Members of the Committee and Congress to support 
broadband expansion, as well as a clear and consistent 
regulatory and reimbursement environment to spur the types of 
innovation that will truly enable care anywhere, any time.
    Following the VA's lead, Congress should consider policies 
that facilitate health care delivery across State lines with 
the expansion of State-to-State reciprocity agreements being 
one potential first step.
    Thank you again for the opportunity to testify here today. 
I am reminded that it was 100 years ago that Abraham Flexner 
wrote what is thought to be one of the most impactful treatises 
on American health care and in that he called out that our 
Nation's smallest towns deserve the best and not the least 
adequate physicians. I think we can't wait another 100 years 
for that to take place and that wireless solutions will enable 
the best thinking and the best minds to be present in rural 
areas where our veterans live.
    Thank you.
    [The prepared statement of Dr. Smith appears on p. 41.]
    Mr. Michaud. Thank you very much, Dr. Smith; and I couldn't 
agree more with that last statement.
    Dr. West.

              STATEMENT OF DARRELL M. WEST, PH.D.

    Dr. West. Chairman Michaud, Ranking Member Brown, and the 
other Members of the Subcommittee, I am Darrell West. I am Vice 
President and Director of Governance Studies and also Director 
of the Center for Technology Innovation at the Brookings 
Institution.
    The United States has more than 23 million men and women 
who serve proudly in our military; and I think all of us would 
agree that, in response to their valuable service, providing 
quality and accessible health care is a major national 
priority. But yet we all recognize that that task has gotten 
much more difficult due to our Nation's $13 trillion national 
debt and the $1.4 trillion budgetary deficit that we face. I 
think this is especially the case for rural veterans who live 
great distances from medical facilities and often have had 
difficulty getting access to quality care. So for these and 
other individuals, I suggest that wireless health technologies 
represent a key ingredient in providing quality and accessible 
care, while also gaining budgetary efficiency in the process.
    I am going to suggest today that health care based on 
mobile health, remote monitor devices, electronic medical 
records (EMRs), social networking sites, videoconferencing, and 
Internet-based record keeping can make a positive difference 
for many people. So let me just briefly talk about each of 
those aspects.
    Today, there are almost as many mobile phones in existence 
that can browse the Internet and access e-mail as there are 
personal computers. Right now, there are an estimated 600 
million mobile phones, compared to 800 million personal 
computers.
    The fact that so much of our country, including veterans, 
has moved towards mobile devices gives us the opportunity to 
introduce new technologies for medical care. There are a number 
of new remote monitoring devices for various health care 
conditions that offer the virtue of putting patients in charge 
of their own test keeping and monitoring their own vital signs; 
and this will help keep them out of physicians' offices, at 
least for routine things.
    In the case of diabetes, you know, it is crucial that 
patients monitor their blood glucose levels. In the old days, 
they would have to physically go to a doctor's office or a lab 
to undertake those tests. Today, we have monitoring devices at 
home that can record their glucose levels instantaneously and 
electronically send them to health care providers.
    My colleague, Bob Litan, at Brookings undertook a research 
project a couple of years ago on remote monitoring devices; and 
he estimated that we would be able to save $197 billion over 
the next 25 years if we move towards these types of monitoring 
devices. So that would certainly represent a big advance.
    Another big problem in medical care is people forgetting to 
take their prescription drugs. There have been studies 
estimating that half of patients do not take their drugs either 
at the right time or in the right dosage. And so there are 
simple e-mail techniques or phone reminders that can tell 
people when and where they should be taking the medication. You 
know, if half the people are not taking their medication at the 
right time, that is an enormous source of waste right there. So 
technology can help be part of that solution through e-mail, 
automated phone calls, or text messages.
    Mobile phones have gotten much smarter. There are many 
interesting new applications that allow physicians to get test 
results on their mobile devices. They can look at blood 
pressure records and cha t them over time. They can see 
electrocardiograms. They can monitor fetal heart rates at a 
distance.
    So, again, for rural veterans, both men and women, these 
types of applications overcome the limitations of geography, 
help save money, while also providing better access to care. If 
veterans need a second opinion on a condition, those types of 
future help enable that.
    There are social networking sites that offer great 
potential for improving care by allowing veterans to share 
information about chronic conditions that they are suffering, 
both in terms of the symptoms they are experiencing as well as 
the treatment effects that they are experiencing.
    So I think in a lot of different ways technology is a major 
plus for us. What we need to do is make greater use of mobile 
health in rural areas. We need to focus on positive health 
outcomes. We need to reward good behavior by physicians and 
patients. And, if we do that, I think we can save money while 
also leading healthier lives.
    A lot of people want to say if we are cutting costs that 
automatically is going to cut quality. That is not necessarily 
the case. In other segments of American society we have seen 
cost efficiencies that also produce better service and better 
care.
    Thank you very much.
    [The prepared statement of Dr. West appears on p. 44.]
    Mr. Michaud. Thank you.
    Mr. Cattell-Gordon?

         STATEMENT OF DAVID CATTELL-GORDON, M.DIV., MSW

    Mr. Cattell-Gordon. Mr. Chairman, good morning, 
distinguished Members of the Subcommittee. I am David Cattell-
Gordon and serve as the Director of Rural Network Development, 
the Manager of Telemedicine and a Faculty Member in Nursing and 
Public Health Sciences at the University of Virginia. I also 
serve as the Co-Director of the Healthy Appalachia Institute, a 
Public Health Institute that serves the citizens of Central 
Appalachia.
    As the son of a distinguished World War II--rural World War 
II veteran from the Iron Men of Metz and as a child of the 
coalfields myself and as a health care professional that serves 
many rural patients and communities, I am honored to be here 
this morning to provide testimony on how we can utilize 
innovative technologies to overcome barriers to health care in 
rural areas.
    As a part of the University of Virginia's pioneering 
program in telemedicine, I have become convinced that 
telehealth and wireless capabilities can improve health 
outcomes, decrease isolation, reduce health disparities and, as 
you have heard, substantially reduce costs, a vital issue for 
our over 3 million rural veterans.
    Everyone on the Committee, I am sure, is aware of the 
award-winning show and book, Band of Brothers. What you 
probably don't know, as a Committee, is that one of its most 
famous members of Easy Company, Darrell Shifty Powers, came 
from Dickinson County in remote Virginia. Shifty, a Bronze Star 
recipient, went back home after the war to serve as a machinist 
for the Clinchfield Coal Company. Sadly, Shifty died last year 
of cancer on June 17.
    With his diagnosis of cancer, Shifty depended upon the VA 
and our systems of care, but the winding roads and the steep 
mountain ridges of Appalachia created huge barriers, as access 
to cancer care was literally hours away.
    So the evidence is overwhelming, in individuals and in 
large studies, that veterans who live in rural settings have 
lower health quality, they have increased co-morbidities, and 
reduced access to specialty services.
    Importantly, telehealth technologies, as this Subcommittee 
well knows, can reduce and overcome these barriers. The 
integration of telehealth into rural communities, including and 
importantly health information exchange through electronic 
medical records between the VA and rural health programs, has 
implications for the delivery of vital services for all rural 
people.
    Sound policies must facilitate ubiquitous and affordable 
access to broadband infrastructure to support the delivery of 
these services. While we have advanced, Congress still needs to 
continue to drive broadband enhancement into rural areas and 
the application of telehealth in these environments by 
continuing Federal funding of demonstration projects, reducing 
statutory and regulatory barriers to telehealth, especially in 
Medicare, aligning--and this is critically important--Federal 
definitions of rurality, ongoing support of the Universal 
Services Fund, improved interagency collaboration around 
telehealth, encouraging the use of and reimbursement for store 
and forward telemedicine, and ensuring health information 
exchange.
    While the expansion of broadband is the context for 
removing these barriers, perhaps the most innovative process is 
what these gentlemen have talked about this morning, wireless 
communications. The cell phone, taken with digital networks and 
remote monitoring capabilities, represents a critical turning 
point in health care. They have already proven to reduce 
isolation, provide a vehicle for public and personal health 
messaging, supporting monitoring chronic diseases, and on and 
on. We now need to consider bandwidth and wireless access as a 
prescribable medicine for the health of our rural communities.
    I want to thank this Subcommittee for your work, the 
Veterans Affairs Committee, as well as Congress, for the steps 
that have already been taken to enable this environment. But I 
also challenge you and challenge Congress that we need to 
engender an environment of investment by continuing to fund 
demonstration projects, ensuring health systems are 
incentivized to use wireless configurations, a standards-based 
environment for usage and, critically, doing what we can to 
ensure a Nation of seamless coverage without network 
fragmentation.
    It has been stated that genetics and the tools of molecular 
medicine will provide a new era of health care. While that is 
most certainly true, I contend that it is wireless devices, 
telehealth applications, and Internet-based health software 
that are precipitating the most important opportunities for 
improved health care for all veterans and for our rural 
communities.
    Thank you very much.
    [The prepared statement of Mr. Cattell-Gordon appears on p. 
50.]
    Mr. Michaud. Thank you very much, all three of you, for 
your testimony.
    I have a quick question, for all three of you. From your 
testimony I assume that all three of you, believe that there is 
a great opportunity for the VA to move forward with these 
wireless health solutions. So my question is, what steps should 
the VA, FCC, and FDA take to clear the way for this new 
technology? We will start with Dr. Smith. Keeping in mind that 
some States, like Maine, are very rural, and they might not 
have the broadband that we need for this type of technology. So 
we'll start with Dr. Smith.
    Dr. Smith. So I think it starts with assuring the wireless 
infrastructure is present. I think to the extent that we can 
avoid the health care delivery system being centered in 
hospitals and clinics and move it to being centered in 
patients' homes where they can be appropriately monitored with 
relatively low sophistication devices and that information be 
liberated from their homes and their bedsides to caregivers, 
independent of their location, I think that is critical.
    I think to achieve the great value that you speak of and 
the opportunity that is in front of us, we have to make sure 
that the regulatory and reimbursement path for the innovators 
who are on the front door making these things is quite clear to 
them; and at the moment it is clearly not clear. At the moment, 
there is great concern that aspects of the system, including 
the handsets, you know, the wireless handsets or, in fact, even 
the telecommunications companies can be part of an FDA-
regulated concept of a medical device, or that they can be the 
target for the plaintiff's bar in the event of some untoward 
event, and that those concerns are chilling the engine of 
innovation that could deliver the technologies that matter so 
much.
    And then I think, lastly, we need to incentivize the 
appropriate use of this technology once it is available. And 
that is not so simple as to say they are available. It is to 
provide the financial incentives for appropriate use. Because I 
think, as the VA program has demonstrated, there is dramatic 
cost savings and quality improvement and satisfaction of the 
patients waiting. And they are waiting. And what we need to do 
is make sure that we incentivize the use.
    You know, the Institute of Medicine has told us that it can 
take 16 years from the time novel technology has proven to be 
useful to the time it is fully adopted, and patients are 
waiting.
    Dr. West. Mr. Chairman, I would like to address the Food 
and Drug Administration part of your question. Because I think, 
in general, the VA has made tremendous progress on 
incorporating new technology. There is still work to be done, 
but they are ahead of many other parts of society.
    But the FDA, I think, has a problem in the sense that the 
policy and regulatory regime is way behind the technology. The 
FDA plays a role in certifying new devices that come on the 
market; and I think especially the pace of technology 
innovation has been very intense and very rapid in recent 
years, the remote monitoring devices that I have been talking 
about, some of the new apps that have been developed for 
Smartphones. The FDA needs to revamp its regulatory review 
process to speed up the approval of these new innovations, 
because there are tremendous new devices that are coming on to 
the market, but it has been a slow process to get approval of 
many of those things.
    So if there is one specific thing that I would recommend it 
would be taking a close look at the FDA and encouraging it to 
do all that it can to speed up its certification and preview 
process.
    Mr. Cattell-Gordon. I would very much agree with the points 
that my colleagues have made concerning this and further say 
that the VA is the leader. You guys wear that mantle of 
leadership in the Nation, and you need now because now is the 
time.
    I think for us to continue to debate this subject as to 
whether or not this is an effective capability, we are way 
beyond that. The data is overwhelming. Whether you look at what 
we do with traumatic brain injury and reminders for 
appointments, whether we look at how we monitor a veteran with 
diabetes to lower that A1C and prevent blindness and follow 
their care, or whether it's a weight loss program, the evidence 
is overwhelming.
    So we know that that is true. So now it is about adoption, 
and we have to push that across the government at a lot of 
levels, whether it is the definitions of rurality, whether it 
is encouraging and incentivizing investment by health systems 
to use this. Rural veterans use a variety of health systems, so 
we have to integrate that. We have to integrate their VA 
records into rural health care. There are a lot of things we 
need to do, and I would just encourage that the most important 
thing we can do is act now.
    Mr. Michaud. Thank you.
    Mr. Bilirakis.
    Mr. Bilirakis. Thank you Mr. Chairman. Appreciate it very 
much.
    For the whole panel, what lessons do you think the private 
sector can learn from VA's telehealth model of care and how can 
it be incorporated into private-sector telehealth solutions?
    Again, for the entire panel.
    Dr. Smith. I think the VA has effectively demonstrated that 
there are dramatic cost savings to be had while you get 
simultaneous improved satisfaction and improved outcomes. I 
think that that lesson is hard to learn in other more siloed 
health care systems, because the systems are not so well 
constructed that you can determine whether investments in one 
location result in cost savings in another. And so, because it 
is an encapsulated or closed system, they have been able to 
collect the data and demonstrate that; and I think that, by 
itself, is remarkable and it should impel further investment.
    But I do go back to the issue that, while the data is quite 
clear and the facts data analysis align, that there is a great 
improvement to be made, that there are hurdles, and those 
hurdles need to be addressed.
    I also mention the notion that practice across State lines 
is something that the VA is able to achieve that the private 
sector is not yet able to achieve, and I think there is an 
opportunity there as well.
    But the specific answer to your question, what did the 
private sector learn? I think they learned that this approach 
clearly works in improving outcome, improving patient 
satisfaction, and lowering costs; and that is a huge lesson.
    Dr. West. The big problem I see in the private sector is 
just the fragmentation and the organizational disunity that 
exists, just because we have a system where there are lots of 
different providers, lots of different services that are 
offered, and we have huge problems in terms of connectivity and 
integration. And so I think the lesson that the private sector 
can learn from the VA is just if you have a unified 
organizational structure it really makes a huge difference in 
terms of technology innovation.
    The big problem of technology innovation today is really 
not technology. It is organizational. The technologies are out 
there. We are seeing lots of innovation. The problem is the 
integration and the connectivity. And so I think the most 
important lesson that we can learn from the VA is when you 
solve some of those organizational problems the innovation, 
through technology, gets a lot easier.
    Mr. Cattell-Gordon. I am very proud to say that, under the 
very able leadership of Dr. Karen Rheuban and the Office of 
Telemedicine at the University of Virginia, last year, mandated 
coverage for telehealth services for the citizens of the 
Commonwealth. That is landmark. We are all very proud of it; 
and it is going to change the health care environment for all 
citizens, including rural citizens.
    And if there is any lesson it comes out of the data from 
the VA was an essential part of the arguments for why we need 
to move forward. So going back to your respective home 
communities and ensuring at the level of the States coverage 
for telehealth services, based on the data, is going to be the 
most critical thing to engender an atmosphere where we are 
successful.
    Mr. Bilirakis. Thank you.
    Another question for the entire panel. Given that the group 
of individuals who would arguably benefit the most from 
wireless health solutions are the elderly and the ill, how 
should we overcome their lack of familiarity and trust 
regarding modern technology in order to better implement these 
tools?
    Dr. Smith. I think there are already approaches that are 
proving successful there. I think we have seen in our own 
community--again sponsored by the West family--senior centers 
where we bring high school and college students in to run 
Internet cafes, where you can take seniors who are really 
unfamiliar and perhaps even ill poised to use wireless 
technologies and the Internet and introduce that to them in a 
fashion which is very unthreatening by much younger people who 
have grown up with this as really in their water. And so I 
think there are opportunities that are going to be unique to 
every location.
    But I am not a fan of the notion of throwing up our hands 
and saying that, you know, it is really not their era. They 
can't get it. That is just--that is false and defeatist. I 
think we can--you know, we are a country of innovators and 
educators as well, and so I think we can handle that problem. 
And the youngest among us is really terrific at these 
technologies, and putting those people together in the same 
room has proven very effective in our own community.
    Mr. Bilirakis. Thank you.
    Dr. West. Congressman, you are exactly right. There is a 
huge generation gap in the use of technology, and so it is a 
problem that we need to confront.
    I mean, I grew up in a rural area. My father was a farmer. 
And I remember years ago the Agricultural Extension Service was 
created as a means to extend innovation in the agricultural 
area, and I think that is a useful model to think about in the 
health care area as well.
    It doesn't have to be government run. I mean, there are 
volunteer organizations. There are nonprofits that are 
essentially taking on the training mission to kind of go into 
senior citizens centers to basically sit down with the elderly 
on a person-by-person basis and just show them the neat things 
that are out there. I mean, a lot of people, when they just see 
what you can do with it, it becomes a very easy sell. The 
problem is kind of getting over that initial hurdle of just 
showing them how you can do that.
    So I think, you know, AmeriCorps could play a role. There 
are nonprofits that are active, but I think we need to kind of 
take the training mission very seriously in order to deal with 
the problem of the elderly.
    Mr. Bilirakis. I agree. Thank you.
    Mr. Cattell-Gordon. I have to confess. I am still having a 
great deal of difficulty having my 91-year old mother to get 
her to use Skype, but I really want to Skype her. And, you 
know, for all of us and for all of us who are getting ready to 
move into retirement, and I hope very soon, these tools are 
going to be critically important. For the monitoring of our 
health, our connection to our families, Skype has been an 
incredible tool.
    We all have to acknowledge we have some ways to go. But I 
would point to the program of all-encompassing care for the 
elderly in Big Stone Gap. It is a Centers for Medicare and 
Medicaid Services (CMS) pro-capitated program, very efficient 
care down there in Big Stone Gap; and we use telehealth 
connectivity to reach those seniors with dermatologic care, 
endocrine care, psychiatric care. And they are used to watching 
TV. They are comfortable in the environment. They are using the 
tool, and it is demonstrated by the show rate for care. The 
show rate, we are demonstrating, can be higher, for instance, 
in telepsychiatry services than the person-to-person care. So 
while we still have a long way to go, we have made great 
strides, and I think it will apply across the generations.
    Mr. Bilirakis. Thank you.
    Thank you, Mr. Chairman. Appreciate it. I yield back.
    Mr. Michaud. Thank you.
    Mr. McNerney.
    Mr. McNerney. Thank you, Mr. Chairman.
    Dr. Smith, you cited reductions in hospital stays for vets 
that use wireless health services. Could you expand that a 
little bit by giving us sort of a typical example?
    And, also, what is the sort of basis of that percentage you 
gave? What was the universe that you were looking at at that 
point?
    Dr. Smith. So, to be clear, I won't steal Adam Darkins' 
thunder on too much of this, but it is--a prototypical example 
could be that a patient is discharged from the hospital after 
being hospitalized for congestive heart failure (CHF); and that 
is a complex, very common, and very expensive disease. But if 
left to their own devices, no pun intended, that disease is 
such that recurrent hospitalization is the norm. If one 
intervenes intermittently or nearly continuously daily with 
knowing and messaging back and forth about weight and blood 
pressure and medication reminders, one can greatly assuage the 
likelihood of those subsequent rehospitalizations; and the cost 
of those daily modest course corrections is trivial compared to 
the expense and complexity of a repeat hospitalization for 
heart failure.
    And that is just one particular chronic disease example. 
There are many that fall in that same line.
    Mr. McNerney. Okay. What was the basis of that percentage 
reduction? What was your sample? Was it a veterans--a group of 
veterans?
    Dr. Smith. So that study, again, Adam Darkins' study, is 
43,000 patients over a 5-year period of their publication in 
2008. So that is not an anecdote. That is the best we have.
    Mr. McNerney. Okay. Thank you.
    Mr. Cattell-Gordon--or Doctor--is it your sense that the 
lack of broadband expansion is limiting our rural veterans as 
well as the problems in rural areas receiving cell phone 
services?
    Mr. Cattell-Gordon. Absolutely.
    Interestingly, I was just in Tanzania on a cervical 
screening project, a country of 38 million people, size of 
Texas, 20 million people with cell phones. Everywhere I went, 
everywhere I went, ubiquitous cell phone coverage used for all 
kinds of transactions. I don't have the luxury of that in 
Southwest Virginia, and I want to. My beautiful iPhone, a tool 
I use most frequently as a paperweight. I want to see that 
change.
    And we were talking earlier--Dr. West and I were talking 
earlier we can't have a perfect environment. There will often 
be regions where we are not going to solve this, but let's 
shoot for good. Let's really redouble our efforts to ensure 
more seamless coverage, because that is going to be the 
critical thing then to use the tool for the very kind of 
project that has been described.
    Mr. McNerney. Okay. So that gives us just a little bit more 
incentive for the sake of the veterans to move forward with 
broadband access.
    Mr. Cattell-Gordon. Correct. Absolutely right. And as we 
think about guys and women coming back from Afghanistan and 
Iraq, they are coming back with their Smartphones. Let's 
remember that.
    Mr. McNerney. Dr. West, I was kind of encouraged by 
something you said. Part of the problem with medication 
compliance is the human error. Seniors are people that are a 
little bit less connected, tend to fall behind and not follow 
the regimen properly. You indicated that, using cellular or 
broadband, you can give the people the proper reminders so that 
they can keep up with their regimen and have better outcomes. 
So I am really glad that you mentioned that. I was going to 
sort of question you about that if you hadn't.
    The one thing that is missing here is we see there is a 
great opportunity for cost reduction here. But what about the 
cost of implementing this kind of a program? I haven't heard or 
seen much in terms of how long it will take in your estimate or 
how much this is going to cost as opposed to the savings that 
we might expect later on.
    Dr. West. I mean, that is a very interesting and important 
question. And it often has been true that to invest in 
technology takes up-front money, and then the cost savings 
unfold over a period of time. So you really have to have a 
longer time horizon to see the benefits.
    But when you look, for example, at the private sector where 
they have achieved great efficiencies and have enhanced 
productivity, generally they introduce new technology while 
also thinking about organizational changes that result from the 
improved worker productivity. And so to kind of just introduce 
technology and expect cost savings in isolation from 
organizational change is not a strategy that I would recommend.
    I think if you really want to achieve the budget 
efficiencies that you need to kind of introduce the technology, 
start to redefine worker roles. There can be a flattening of 
organizations that allow for cost savings. I mean, those are 
the things that I think produce more substantial cost savings 
over a period of time.
    Mr. McNerney. Thank you, Mr. Chairman.
    Mr. Michaud. Thank you.
    Mr. Miller.
    Mr. Miller. I have no questions.
    Mr. Michaud. Mr. Perriello.
    Mr. Perriello. Thank you, Chairman.
    First, let me just say how proud we are, Dr. Cattell-
Gordon, to have you at the University of Virginia and all of 
the amazing work you do for our veterans and in our rural 
communities; and it really has been amazing to see, both in the 
VA system and beyond. I was out at the community health center 
in Nelson County, as you know, looking at the telemedicine 
work, the number of specialists that can now treat people in 
rural communities without leaving University of Virginia 
Hospital. And particularly to note, as you did, that we are 
actually seeing increases in mental health visits in the 
telemedicine context, which I think was a surprise to many of 
us. But I think it is both a comfort level issue and simply an 
access issue. So we are very excited about that.
    And to echo Mr. McNerney, I think we sometimes talk about 
broadband being a barrier, but you and I drive a lot of roads 
where we are still talking about cell phone coverage and not 
even broadband.
    And, also, just thank you for your work in Tanzania. I 
think you were with Peyton Taylor on that trip as well, who I 
ran into the other day. It is just amazing what you all were 
able to do using very old school tactics of working through 
some of the community leaders, and some of the technology is 
incredible.
    Following up on all that we are very proud of in the area, 
one of the things that I just wanted to ask you about--you 
didn't touch on as much today but I know you have looked at--is 
issues of suicide and drug addiction concerns, particularly in 
Appalachia and some of the rural communities.
    To what extent does the telemedicine and some of the 
technology run the risk that we are not seeing some of the 
signs or screenings from people being physically present? Or is 
this an opportunity because we are going to be able to monitor 
things? What kind of dynamic do you see between the technology 
and that particular problem?
    Mr. Cattell-Gordon. I am very proud of the fact that we 
have a psychiatrist at the University of Virginia, Dr. Larry 
Merkle, who has done extensive review of rural issues and 
suicide. The numbers are overwhelming. You look at the Virginia 
Department of Health, you look at rural areas in particular, 
you look at the coalfields of Virginia, the suicide rate is 
twice that of what it is in the State as a whole.
    And then you look at issues like fatal unintentional 
overdoses from addiction to pain medications. The mortality 
rate in the coalfields of Virginia is 40 deaths per 100,000, 
adjusted, as opposed to 8.3 deaths for the rest of the State. 
These are huge problems. The level of disability, the lack of 
access to care, the isolation that people experience in rural 
areas create a perfect storm of problems for mental health 
issues.
    Then you add to that the absence of practitioners. There 
are just way too few practitioners, and there are going to be 
even greater shortages in primary care and mental health folks 
for these regions for our vets and for everyone else.
    So telehealth and the use of wireless capabilities become a 
key tool to reduce isolation, to send reminders, just the 
appointment reminders alone--and this has been a VA study--to 
look at folks with traumatic brain injury, and reminders over 
the cell phone for their appointments and daily contact has 
dramatically changed the number of people who show for their 
appointments.
    Those small things will add up to the large indicators 
about the way we can address mental health issues in rural 
areas.
    Mr. Perriello. Just one other question, which is, 
obviously, there is a lot of great stuff going on at UVa and at 
other teaching hospitals around the country. To what extent are 
we doing a good job of creating a partnership between the VA 
system and some of our research facilities and teaching 
hospitals? Are there barriers that exist for sharing the kind 
of research that you are talking about and making sure that is 
feeding into the VA system with rural and telemedicine and more 
broadly?
    Mr. Cattell-Gordon. We are very proud in Virginia and we 
would really like to hold it up as a model for the way the VA 
interacts with Federally qualified community health centers 
(FQHCS), that network. As we look at health care reform, the 
investment that we are making as a Nation in the FQHCs is 
enormous. And they are going to be a critical resource, and 
they are more and more coming into line as telehealth 
facilities. And then they integrate to the veterans' facilities 
that then integrate to the academic teaching facilities in 
Richmond and in Charlottesville and at EDMS in the eastern part 
of Virginia. These networks are going to ensure our success.
    We have a NASCAR word for it in Virginia called 
``coopertition'' and that is what we need to see in these 
networks, a commitment for an interrelated telehealth network. 
And whatever disease group you look at, whether it is mental 
health issues, whether it is cancer, whether it is heart 
disease, those networks are going to be essential for the 
success of our communities.
    Mr. Perriello. Well, thank you again for all you do.
    And certainly the CHCs have been tremendous as a primary 
care delivery tool you know, it is the first interface for so 
much of central and southern Virginia, and they are going to 
end up in the UVa emergency room one way or the other 
otherwise. So I think not only do we see the cost savings we 
have talked about in the VA system, but I think even beyond 
that where we are getting that telemedicine care. So I 
appreciate all the groundbreaking work you all have done and 
will continue to learn from that.
    Thank you very much.
    Mr. Michaud. Mr. Donnelly.
    Mr. Donnelly. Thank you Mr. Chairman.
    Following up on my colleague's question, with the different 
organizations that are involved in telehealth now, is there 
plans or is there a way to have a clearinghouse where best 
practices, in effect, are put down, so that what road maps you 
may have been able to achieve in Virginia can then be used in 
another State without having to try to reinvent the wheel?
    Mr. Cattell-Gordon. One of those tools, Health Resources 
and Services Administration (HRSA), has had investments through 
their office for the advancement of telehealth to create across 
the Nation, and in particular for rural regions, telehealth 
resource centers. And those telehealth resource centers become 
absolutely a vital resource in sharing best practice models.
    Let me give you an example, Arkansas. Arkansas does a 
fabulous job with reducing infant mortality by providing high-
risk obstetrical care through their telehealth network. They 
have shown a 26 percent decrease in infant mortality in 
Arkansas because of this program. It has been a huge success.
    And those best practices then get shared through these 
telehealth resource centers, along with the tools people need, 
the sort of ways to set up evaluative process, the ways to 
finance, sharing information on how to seek Federal and local 
fundings, ways to incentivize programs, curriculum for health 
care professionals, and how to use telehealth. So those 
telehealth resource centers that are funded through the Federal 
Government I really want to support and urge Congress to 
continue to support through HRSA funding.
    Mr. Donnelly. So when, as Ranking Member Bilirakis was 
discussing some of the elderly patients that may be involved 
probably have a long-term relationship with a primary care 
physician in the area. How is the primary care physician looped 
into the whole telehealth process?
    Mr. Cattell-Gordon. One of the important things about 
telehealth is that, as a principle, it is not designed to 
replace the fundamental importance of a good physician/patient 
relationship. I mean, that is a sacred part of medicine and one 
that has to continue to be reinforced.
    What it is, is a tool in that primary care physician's doc 
kit. You know, it is like his or her stethoscope, and they need 
to see it as such, that the referral of that patient, when they 
need a dermatologist and there is no dermatologist within 4 
hours, or it would take you 3\1/2\ months to get an appointment 
with a dermatologist for that elderly patient, that the use of 
telehealth becomes a critical tool for what that primary care 
physician can do.
    Now, do we have a systematic way where we are educating 
primary care physicians in this? No, we don't. And it needs to 
be incorporated into medical education.
    The role of nurses is going to be critical in the delivery 
of primary care in this Nation. I can't say enough about how 
important it is for us to look at what the role of the nurse 
practitioner is going to be in our communities in delivering 
care.
    And then using telehealth as a capability of providing 
access to specialty care. These are the things that we are 
going to be looking at over the next few years. And Congress 
has a critical role in continuing to serve as the leader 
through the VA system and how that is realized.
    Mr. Donnelly. Well, as Members who deal with veterans' 
issues as we all do, veterans' issues every day, we have such a 
concern for our rural Members who may not have the access to so 
many VA centers, so this telehealth is critically important. 
And whatever the veterans' network can do to be a good partner, 
please continue to let us know as time goes on. Chairman 
Michaud, Ranking Member Bilirakis I know are very in tune with 
this. And so we want to make sure that we are making the lives 
of our veterans easier and answering their health questions and 
letting them have peace of mind. So we appreciate you guys 
being here today. Thank you.
    Thank you, Mr. Chairman.
    Mr. Michaud. Thank you.
    Mr. Snyder.
    Mr. Snyder. Thank you, Mr. Chairman. I am sorry I was late.
    I am actually a former family doctor, but still from 
Arkansas, so I appreciate the Arkansas plug. But, also, my wife 
and I have three--18-month old triplets--boys, so we went 
through a lot of the high technology stuff recently. And, of 
course you start running into a little network of folks with 
multiples. And we were talking to the doctors, oh, yeah, we are 
following another case. It turned out it was in North Arkansas, 
but they are doing it by telemedicine. Is that the kind of 
program you are talking about, where they would go to their 
regular obstetrician (OB) perhaps up north but then they would 
have the specialist, the neonatal person online? Is that what 
you are talking about?
    Mr. Cattell-Gordon. That is exactly what I am talking 
about. It is called the Arkansas Angels program. And I would 
invite all the Members of the Committee, go out and Google 
them. They have just been highly successful in that, in women's 
health and in prevention and diabetes monitoring. It is an 
example, along with many other telehealth programs.
    It is important to say that there is a telehealth program 
in every State in the United States. A lot of the 
infrastructure is there now to build out what has been an 
important point-to-point connection. Now we have the 
opportunity to move it from point to point to point to home to 
multiple points using wireless capability.
    Mr. Snyder. I wanted to ask a specific question that is not 
related just to veterans but to our whole country. One of the 
issues that has come up here through the years is the shortage 
of mental health practitioners, both urban and rural, but you 
certainly notice it in rural areas, and we have had some 
terrible tragedies of social workers or people that work for 
programs going out to follow up on a patient who has a major 
schizophrenic diagnosis or something and an act of violence 
occurs towards the follow-up.
    Where do you see--I didn't see your written statements. 
What do you see is the possibility for the kinds of technology 
improvements that you all are talking about with regard to 
helping people with devastating illnesses of schizophrenia, 
really the major psychoses?
    Dr. Smith. I can comment a little bit.
    It is now quite clear that, for schizophrenia, the notion 
of medical compliance is critical and can have tragic 
discontinuities. After skipping a couple of days, attitudes 
about their medical therapy changes, and they can irrevocably 
walk away from therapy. And there are excellent innovative 
approaches for guaranteeing compliance with medical therapies 
to the extent that if you are \1/2\ an hour late taking your 
medicine you can get an e-mail about it. If you are a little 
bit longer than that, you can get a phone call about it. And 
all of that can be enabled with nonparticipatory technologies, 
so that your pill cap may be able to be wirelessly connected to 
a care provider's office that lets them know that you haven't, 
in fact, opened your pill bottle today. And so that--I think it 
can start there.
    And certainly there are connection paths between caregivers 
and patients that can be--through their cell phones or through 
the Internet that can be pleasant reminders and carry messages 
that can be engaging. And so that there is a greater sense of 
connectedness, and that can mean so much for those who are 
struggling with psychological illnesses.
    Mr. Snyder. How much limit do you see in the kind of things 
that you all are talking about on the issue we still have with 
low education levels and poor literacy rates? How much does 
that interfere with some of the things you all are talking 
about?
    Mr. Cattell-Gordon. I have spent most of my life working in 
the coalfields of Southwest Virginia; and we have lower 
educational attainment, limited income, lack of access to 
meaningful work, high rates of uninsurance, health factors, 
high cholesterol, obesity, smoking. You know, you bundle all 
those things up and the consequence--and this includes our 
veterans in the region--to premature mortality.
    So, without being overly dramatic, these are life-and-death 
issues. And we can't talk about how we are going to change 
access to health care without talking about how we are 
improving education. And these same tools that we are talking 
about have to do with improving professional education, 
improving the skills of the workforce, improving a family's 
understanding of the disease, a chronic disease, so it is a 
tool that integrates education and health in the most powerful 
ways. And that is why I have become fully convinced that this 
is one of our most primary solutions to health issues in rural 
areas.
    Mr. Snyder. Thank you, Mr. Chairman.
    Mr. Michaud. It is getting late. Thank you to all three of 
you for coming here this morning. You all provided very 
enlightening testimony. I know that I will be submitting other 
questions in writing, so hopefully you can get the answers 
quickly.
    Once again, thank you very much. I appreciate it.
    I would ask the second panel to come forward, and as they 
are coming forward I will introduce the second panel. We have 
Dr. Powell, who is the President and Chief Medical Officer and 
Co-Founder of AirStrip Technologies in Texas. We have Rick 
Cnossen, who is President and Chair of the Board of Directors 
of Continua Health Alliance in Texas. We have Kent Dicks, who 
is the Chief Executive Officer (CEO), Chairman, and Founder of 
MedApps in Arizona. We have Dan Frank, who is the Managing 
Partner of Three Wire Systems, LLC, in Virginia, and he is also 
here on behalf of MHN; and we have John Mize, who is Director 
of LifeWatch Federal, LifeWatch Services in Illinois.
    And I will turn it over to Mr. Miller to introduce one of 
his constituents.
    Mr. Miller. You turned it over to me because you couldn't 
pronounce his name.
    Mr. Michaud. That is correct.
    Mr. Miller. Thank you very much, Mr. Chairman.
    It is a pleasure for me to introduce to the Subcommittee 
today Dr. Huy Nguyen. He is a constituent of mine from 
Pensacola. He serves as CEO of Cogon Systems. Cogon is setting 
a higher standard in health information technology (IT), 
bringing forth expertise on a topic of great importance to the 
VA Committee, electronic record sharing. Cogon has already 
demonstrated success with the U.S. Department of Defense (DoD) 
at Naval Hospital Pensacola. They are currently evaluating 
their system and are currently sharing information with other 
local hospitals in the area.
    As a Navy veteran in Iraq himself, he was well aware of the 
many needs and shortcomings of DoD and VA in their systems, and 
his knowledge will be valuable to this Committee as we keep 
seeking to improve services for our veterans.
    By demonstrating that a virtual health network can exist 
and at the same time safeguard information, Cogon, under Dr. 
Nguyen's leadership, has taken a step where I and many other 
Members of Congress wish to see VA and DoD go. The electronic 
record formed during a soldier's service under DoD and 
immediately transitioned to VA upon separation from active duty 
is long overdue. Not only will it ensure easier enrollment into 
the VA health care system, it will also help bring a better 
quality of care when those soldiers do in fact enroll.
    I thank him for his contributions to our active-duty 
military and veterans community; and I thank you, Mr. Chairman, 
for agreeing to have him here to share his insight with your 
Subcommittee.
    Mr. Michaud. Thank you very much, Mr. Miller.
    I will also remind this panel, because of votes that will 
be coming up, we will try to stick to the 5-minute rule.
    We will start off with Dr. Powell.

 STATEMENTS OF WILLIAM CAMERON POWELL, M.D., FACOG, PRESIDENT, 
 CHIEF MEDICAL OFFICER AND CO-FOUNDER, AIRSTRIP TECHNOLOGIES, 
 SAN ANTONIO, TX; RICK CNOSSEN, PRESIDENT AND CHAIR, BOARD OF 
 DIRECTORS, CONTINUA HEALTH ALLIANCE, AND DIRECTOR OF PERSONAL 
   HEALTH ENABLING, INTEL CORPORATION DIGITAL HEALTH GROUP, 
   HILLSBORO, OR; KENT E. DICKS, FOUNDER AND CHIEF EXECUTIVE 
OFFICER, MEDAPPS, INC., SCOTTSDALE, AZ; HUY NGUYEN, M.D., CHIEF 
  EXECUTIVE OFFICER, COGON SYSTEMS, INC., PENSACOLA, FL; DAN 
 FRANK, MANAGING PARTNER, THREE WIRE SYSTEMS, LLC, VIENNA, VA, 
ALSO ON BEHALF OF MHN, A HEALTH NET COMPANY, SAN RAFAEL, CA, ON 
  THE VETADVISOR' SUPPORT PROGRAM; AND JOHN MIZE, 
    DIRECTOR, LIFEWATCH FEDERAL, LIFEWATCH SERVICES, INC., 
                          ROSEMONT, IL

        STATEMENT OF WILLIAM CAMERON POWELL, M.D., FACOG

    Dr. Powell. Thank you.
    Good morning, Chairman Michaud, Ranking Member Brown, and 
distinguished Members of the House Committee on Veterans' 
Affairs. My name is Cameron Powell. I am actually a Obstetrics/
Gynechologist physician by training and the co-founder of 
AirStrip Technologies.
    We are a health care IT-based medical software development 
company based out of San Antonio, Texas; and our technology 
actually improves patient safety and reduces risk and improves 
access to care, specifically by delivering real-time critical 
patient data through the cell phone network and wireless 
networks to mobile devices such as the iPhone with a real focus 
on patient monitoring data such as wave form data.
    Interestingly, this morning there has already been a lot of 
discussion about women's health and perinatal care, 
particularly referencing the triplets earlier and the Angel 
Network in Arkansas. Actually, our first product using our own 
technology that we developed, AirStrip OB, is one of the only 
FDA-cleared applications on these mobile devices, currently 
approaching about 200 hospital installations around the United 
States; and every day we have thousands of doctors relying on 
this real-time critical access to these babies' heart tracings 
to try and prevent adverse outcomes from occurring in 
obstetrics. And we just started in obstetrics. Soon we will be 
unveiling our critical care and cardiology applications.
    But I think as we all know in the U.S. we have a lot of 
problems in our health care system, and one of the core 
problems that we are focused on that is facing health care 
professionals is this increasing disparity between a growing 
number of patients that need to be monitored in any environment 
and the relative decreasing number of doctors and nurses that 
can actually monitor them. So what we are all focused on right 
at the end of the day is trying to figure out how do we get in 
a timely fashion the right data about the right patient to the 
right doctor or nurse at the right time to try and effect a 
positive outcome. So remote patient monitoring of critical 
patient data using these devices--iPhone, Blackberry, Android, 
iPad--is rapidly becoming a necessary technology within the 
health care IT space to try and better care for patients and 
improve outcomes, especially in rural communities.
    I want to briefly talk about several reasons that patient 
monitoring with mobile devices is important and a few examples.
    So, number one, doctors and nurses are a lot more mobile 
than we were 5, 10 years ago. We are covering multiple 
hospitals, we are covering multiple environments, and we know 
that patient access to care in remote areas continues to be a 
problem.
    And with recent advancements in technology there has been a 
paradigm shift in the health care community. There is an 
expectation now that technologies will allow health care 
providers to have access to this type of data. So the type of 
data that we deliver, which is this real-time critical wave 
form data and other types of analytics and decision support 
data on demand, very fast, securely, in a Health Insurance 
Portability and Accountability Act (HIPAA)-compliant fashion 
onto a mobile device.
    And if we think about this growing disparity, the number 
one cause in the United States of patient injury, at least in a 
hospital, is communication errors. And as you have a fear of 
physicians being able to take care of or required to take care 
of more patients, the probability that communication errors 
will grow is there. It is going to happen, and this shortage is 
not going to get better any time soon. So if you can, through 
wireless technologies, if you can close the communication gap 
and you can deliver that critical data on demand to a health 
care provider to help them make a better decision about a 
patient or what to do about a patient in a situation, then you 
have hopefully tried to reduce that risk.
    So we are working to solve this problem by inventing this 
AirStrip technology. And of course, we first went after the 
obstetrical market, but now our application is looking to apply 
across both women's health, all of inpatient monitoring, the 
intensive care unit, the operating room, the emergency room, 
but also into the home health space in rural communities.
    Some of the technologies that we hear about here today are 
people that are either our partners or becoming our partners as 
we take that data that is being generated in the home or in the 
rural environment and display it very rapidly on the mobile 
device to help the physician and the health care providers make 
a difference.
    And I want to speak a little bit about the type of data. 
You get numbers and vital signs. It is important. But there are 
specific types of data that require visual interpretation. We 
talked again earlier about obstetrics and a fetal heart trace. 
And the way we make decisions is based visually on how this 
data changes over time in real time and historically.
    So if you are able to take that critical wave form data and 
provide it to a physician anytime, anywhere, we have hundreds 
and hundreds and hundreds of physician testimonials talking to 
us, telling us about how this has helped to avoid a bad 
outcome.
    So I think we are in a very exciting place with our 
technology. We are considered agnostic to the market. So we are 
either partnered with or looking to partner with multiple 
patient monitoring companies, health information systems, EMR 
vendors, to effectively mobilize all of that data and at the 
end of the day try and improve outcomes by this type of 
compelling delivery system.
    And I think my time is up.
    [The prepared statement of Dr. Powell appears on p. 56.]
    Mr. Michaud. Thank you very much.
    Mr. Cnossen.

                   STATEMENT OF RICK CNOSSEN

    Mr. Cnossen. Good morning, Chairman Michaud, distinguished 
Members of the House Committee on Veterans' Affairs.
    My name is Rick Cnossen. I am the President of the Continua 
Health Alliance. On behalf of the members of the Alliance, it 
is my privilege to be here to testify in front of you on this 
very important issue.
    The Continua Health Alliance is an international, open, 
nonprofit company. It has about 237 companies at this point, 
and we are striving to put together an ecosystem of 
interoperable standard-based personal health technologies like 
the ones you are hearing about. It is similar to the Wi-Fi 
Alliance and what they have done for the ubiquity of Wi-Fi. We 
are trying to do that for personal health solutions.
    It is shown that standards-based solutions provide better 
quality, lower cost and higher innovation, and so that is what 
we are doing. We have been at it about 4 years, and we are 
making good traction. We have certified products from A&D, 
Cypar, Intel, Nonin, Omron, Panasonic, Roche, TI and Toshiba; 
and we have several mobile developments from the likes of 
Cambridge Consultants, MedApps, Qualcomm, and Vignet; and also 
IBM and Oracle are looking at how we can integrate into EHRs.
    In Continua, we use the term called eCare, and I would like 
to define that for you. It is the class of health information 
technologies that can facilitate the kind of virtual visit or 
electronic connectivity outside of traditional office visits. 
This can include in-home or mobile broadband devices, secure 
text messaging or video teleconferencing.
    There are four benefits of eCare I would like to point out, 
the first being tools and education. Like we heard in some of 
the earlier comments, eCare provides the opportunity to let 
people understand their disease better with education and also 
tools so that they can see the results of their lifestyle 
decisions. Hopefully those tools provide motivation so that 
they can keep taking their medication, and doing the things 
they are doing to make improvements.
    The second one is collecting vital signs data dynamically. 
Instead of going to the doctor's office once every 6 months, to 
take a single blood pressure reading, we now have the 
opportunity to take it on a regular basis in order to provide a 
much richer compilation of data from which a doctor can make a 
diagnosis. Also, if something were to happen, we can detect 
that and take action on it immediately, not 6 months from now.
    The third is to facilitate virtual visits between the 
provider and the patient so that we can utilize eCare when it 
is needed and where it is needed, particularly for veterans 
that might be in rural areas.
    And the last one, we provide social support networking so 
we can extend the framework of care beyond just the hospital to 
include friends and families where appropriate or people with 
the same type of disease that might be halfway across the 
world.
    There is plenty of evidence about this. You have heard of 
some of them, New England Healthcare Institute (NEHI) and the 
VA. There are reports out that show great quality of care for a 
much lower cost. You can see why we are excited about eCare.
    The Congress also recognized the value of eCare. In the 
health reform bill, they have about 20 different references to 
programs that include eCare. I will just list a few: the 
Accountable Care Organizations for Community-Based 
Collaborative Care Networks, the Independence at Home 
Demonstration Project, the Medicaid Health Home, and the CMS 
Innovation Center. All these include technologies that could be 
characterized as eCare.
    In order for the veterans and their families to realize the 
benefits of eCare that we have been talking about, the Continua 
Health Alliance has the following--respectfully submits the 
following recommendations, five of them:
    The first one, integrate eCare into CMS reimbursement 
policy. Right now, out of the $468 billion budget, Medicare 
pays $2 million for telehealth, or .00005 percent. We feel that 
if reimbursed procedures and services can be effectively 
offered with eCare, they should be reimbursed as well.
    The second one, establish blueprints for the use of eCare 
in the States and in communities. One of the earlier questions 
talked about how we can leverage that. The VA has done a great 
job, and other places are doing good work. We do not want to 
reinvent the wheel but rather pull these blueprints together so 
that other communities can leverage it.
    Third, establish a Federal regulation focused on eCare. 
There are many organizations involved in this, including the 
FDA, Office of the National Coordinator for Health Information, 
FCC; and we feel like there should be an organized approach 
such that it is proceeding in a coordinated, coupled fashion 
and we are learning from each other.
    Fourth, incorporate eCare as part of Meaningful Use. With 
the health care reform bill and with the American Recovery and 
Reinvestment Act of 2009 (ARRA), certainly we are going to have 
EHRs out there becoming broadly adopted. ECare provides 
valuable data to populate those EHRs such that doctors can have 
rich information to draw on.
    And, fifth, make broadband availability for all Americans a 
top priority. About 20 percent of Americans are not currently 
covered, including a lot of vets in rural areas. We can provide 
a much richer eCare experience with that.
    In closing, we have a unique opportunity to change and 
extend care from the home and manage to improve care and 
options for our veterans in a cost-efficient manner. We must 
take action through vision, leadership, and a national 
commitment to prepare for the demographic and economic changes 
that will bring changes to health care. America can be the 
leader in this, and we can start with the VA. Please let us 
know how we can work with the Committee to make this possible.
    Thank you.
    [The prepared statement of Mr. Cnossen appears on p. 57.]
    Mr. Michaud. Thank you very much.
    Mr. Dicks.

                   STATEMENT OF KENT E. DICKS

    Mr. Dicks. Good morning, Chairman Michaud, Ranking Member 
Bilirakis, and distinguished Members of the House Committee on 
Veterans' Affairs, Subcommittee on Health.
    My name is Ken Dicks, Founder and CEO of MedApps, a small 
business enterprise located in Scottsdale, Arizona. On behalf 
of the team at MedApps and the veteran-owned enterprise that 
manufactures our devices here in America, I would like to thank 
you for the opportunity to present this testimony.
    We are here today to speak about overcoming rural health 
care barriers through the use of innovative wireless health 
technology solutions. I am here today to talk about innovative 
digital wireless communications technologies, like those 
produced by my company MedApps, which are quickly becoming a 
key component in the delivery of health care in services across 
America via wireless remote patient monitoring.
    Medical devices, health sensors, and their applications 
rely upon mobile broadband functionality and interoperability 
to transmit raw data, diagnostic health information, critical 
aspects of care, emergency services, and related health 
information. These services are at the forefront of a 
revolution in the provision and delivery of health care in 
America, a revolution which collapses time, space, and distance 
to more effectively monitor patients, develop analytic trends, 
maximize strained medical resources, and save lives.
    First, a word on the nomenclature surrounding wireless 
health. There are many terms loosely used today to describe the 
different and often confusing aspects of wireless health 
information technology. For the purposes of today's hearing, I 
will use the term eCare, which is the term used by the Federal 
Communications Commission in Chapter 10 of the National 
Broadband Plan.
    ECare is the electronic exchange of information, electronic 
data, images, and video to aid in the practice of medicine and 
health care analytics. ECare is not a substitute for health 
care providers, physicians or clinicians. It is intended to 
augment the good work of medical professionals.
    In a landmark comprehensive pilot with 17,000 veterans, the 
Department of Veterans Affairs demonstrated that by 
implementing remote patient monitoring they experienced a 
reduction in hospitalizations by 25 percent, at an average cost 
of $1,600 per patient per year for remote patient monitoring, 
compared to an annual cost of $13,121 per patient for primary 
care and $77,745 for a patient for nursing home care.
    Amazingly, those encouraging results and statistics were 
achieved with the first generation of wired systems that are 
typically more costly, proprietary, and are tethered to a point 
of care, lacking mobility. If the pilot program was able to 
achieve those encouraging results for patients using that 
technology, imagine the potential wireless eCare technologies 
would hold.
    ECare technologies, like wireless mobile solutions, drive 
down costs and improve care by closely monitoring patients 
wherever they may be. Thus, they allow health care to be 
practiced in a more proactive manner, rather than a reactive 
manner, and can possibly head off a patient going to the 
emergency room or hospital setting in the first place.
    In my hand up here is our HealthPAL. HealthPAL is a 
technology that the sole purpose is to allow a patient to stay 
connected with their electronic health record and ultimately 
their caregiver. The HealthPAL is FDA cleared and communicates 
wireless, or wired, with other medical devices, such as this 
Nonin Pulse Oximeter which takes your Sp02 and your heart rate 
as well. A doctor may ask a veteran with chronic obstructive 
pulmonary disease or congestive heart failure to take a reading 
once a day in order to make sure that they are staying within 
the safe zone.
    The HealthPAL, like the one that I am holding in my hand, 
has mobile cellular technology, M2M technology like this, M2M 
technology I hold in my hand today. The 3G mobile broadband 
chipset by Qualcomm is about the size of a quarter, which is 
embedded in the HealthPAL, and is the key to connecting our 
veterans to their health care providers in an efficient and 
economical manner.
    The HealthPAL works as an agnostic hub or central device 
that connects to various medical devices and sensors and then 
transmits their data to a secure central server. The HealthPAL 
comes packaged together, including mobile wireless connectivity 
straight out of the box, ready to use. Nothing complicated to 
set up, provide or maintain. Everything is done remotely, 
including software upgrades, like the popular Kindle model.
    The MedApps solution is used in a variety of ways by 
everyday people including David Jesse, a truck driver from 
rural Ohio. David's erratic schedule makes it difficult to set 
up and keep appointments with his doctor, and his health 
suffered because of it. David often had to produce log books to 
take back to his doctor at the Cleveland Clinic every couple of 
months. His doctor attempted to adjust his medication based on 
the information. Today, David uses the HealthPAL in the cab of 
his semi truck and has taken his readings throughout 47 States.
    The technology has allowed David to substantially improve 
his health and need for medication. He no longer has to drive 
back to Ohio every 2 months to be checked by a doctor, who, 
along with David's wife, can stay connected to him remotely on 
the road, making sure he is okay and his medical conditions 
stay under control.
    At Meridian Health, a New Jersey health system, the 
technology is being used to help reduce readmissions of 
congestive heart failure patients. Typically across the 
country, 27 percent of congestive heart failure patients are 
admitted within 30 days with the same condition. An average CHF 
hospitalization is about $8,000. At Meridian Health, the 
HealthPAL and a wireless scale are provided to a CHF patient 
upon discharge to monitor a patient every 30 days to ensure 
patients with signs of worsening conditions are seen by their 
physician for early, less resource-intensive intervention. The 
equipment is returned to Meridian at the end of the 30-day 
period. So far, 30 patients from Meridian have experienced no 
readmission due to heart failure within the 30-day period.
    Thank you.
    [The prepared statement of Mr. Dicks appears on p. 63.]
    Mr. Michaud. Thank you.
    Doctor Nguyen.

                 STATEMENT OF HUY NGUYEN, M.D.

    Dr. Nguyen. Chairman Michaud, Ranking Member Brown, and 
distinguished Members of the Subcommittee, thank you for the 
opportunity to testify today.
    I also want to thank Representative Jeff Miller from my 
district for the introduction and to note that he has been a 
leader in advancing the use of health information technology 
for veterans.
    My name is Dr. Huy Nguyen. I am a Navy veteran who served 
in Iraq in 2003 as a physician attached to the Fleet Hospital 
Pensacola. During that tumultuous period, I saw up close and 
personal the cost of war and the utmost sacrifices that our 
veterans make in the service of their country. I have since 
separated from active duty. However, I continue to serve our 
military and veteran community as a civilian emergency 
physician at Naval Hospital Pensacola.
    In addition to my military affiliated duties, I am also the 
founder and CEO of Cogon Systems. Our mission at Cogon is to 
facilitate connected, value-driven health care. We achieve this 
by facilitating secure Web-based health information solutions 
leveraging cloud computing technology, which includes mobile 
technology.
    In my written testimony, I discussed a variety of mobile 
health issues. However, in my oral presentation, I would like 
to focus particularly on how health information exchanges can 
complement mobile technology by allowing comprehensive health 
information to be accessible on mobile devices. Secure mobile 
access to comprehensive health information can be particularly 
helpful to providers and veteran patients in rural communities.
    As context to today's testimony, I would like to highlight 
a significant Veterans Administration objective that guides 
Cogon's desire to facilitate better care for veterans and in 
the process be a beacon for the greater civilian health care 
community.
    The Department of Defense Military Health System and 
Veterans Administration are promoting the Virtual Lifetime 
Electronic Record initiative, otherwise known as VLER, which 
represents a major iteration of a new national capability to 
securely share electronic health information via the nationwide 
health information network. This is important in light of the 
fact that three out of four veterans receive a portion of their 
care from civilian providers.
    President Obama has also stated that it is important to, 
and I quote, allow health care providers access to 
servicemembers' and veterans' health records, in a secure and 
authorized way, regardless of whether that care is delivered in 
the private sector, Department of Defense, or VA.
    The TRICARE Health Information Exchange project in 
Pensacola to facilitate the sharing of health information 
between military and civilian providers was a Congressionally 
funded project. The basis of Congressional support for this 
endeavor is due to the fact that, by some estimates, more than 
60 percent of health care delivered to a DoD beneficiary is 
provided by private-sector health care providers.
    Civilian providers are unable to access health information 
regarding a patient's status--health status or care from the 
MHS electronic health records system today. Similarly, civilian 
medical records concerning military beneficiaries are not 
available to MHS providers. In essence, we are practicing 
medicine in an information vacuum. This is the reality of 
patient care in military communities today.
    Our Congressional funding for this project is fiscally 
managed by MHS' Telemedicine and Advanced Technology Research 
Center. To date, the project has successfully tested and 
deployed the largest instance of health information exchange 
between Federal and civilian providers. The project entails 
sharing protected health information between Naval Hospital 
Pensacola and private-sector health care providers in Pensacola 
by interfacing Cogon's health information platform with the 
DoD/Veterans Administration Bi-Directional Health Information 
Exchange, otherwise known as BHIE. Though not perfect, BHIE is 
the current health information exchange between the MHS and VA, 
and it is the largest health information exchange in our 
country and represents a significant investment on the part of 
both agencies.
    As far as I know, we are the only commercial entity that 
has been allowed to interoperate with the BHIE platform. So in 
Pensacola more than 30,000 records concerning patients jointly 
seen by the MHS and Pensacola civilian providers can now be 
shared. This data exchange is in compliance with the data use 
agreement between our company and the MHS TRICARE Management 
Activity Office. Furthermore, the Pensacola community is 
finalizing a Nationwide Health Information Network Data Use and 
Reciprocal Support Agreement as mandated to be part of any VLER 
demonstration.
    The Florida Gulf Coast boasts a large contingency of active 
duty and veterans. Escambia County in Florida is also fortunate 
not only to have Naval Hospital Pensacola but also the Veterans 
Administration Joint Ambulatory Care Clinic. Both facilities 
are not only supportive of this health information exchange, 
they also play a significant role in the governance structure 
of the exchange.
    Because of the significant presence of the Veterans 
Administration in the Pensacola community, we believe that it 
is important for the VA to consider establishing Pensacola as a 
VLER community. As health information becomes more 
interoperable, the potential for mobile health is limitless.
    Again, as a physician and a veteran, I would like to thank 
this Subcommittee for allowing me the opportunity to testify on 
a subject that is personally dear to me, the care of veterans.
    I hope that in my written and oral testimony I have 
established three things: One, the sharing of health 
information between MHS, the VA, and civilian providers as 
envisioned by the VLER initiative is important to coordinated 
care for our veterans. Two, this ambition to share information 
can be securely done today, as shown in Pensacola as we migrate 
toward a nationwide network. Three, a health information 
platform and exchange can augment mobile technology in striving 
to serve isolated rural communities.
    The VA, in conjunction with the MHS, has enormous 
opportunity and responsibility to maximize its leadership in 
health information in order to take care of veterans.
    Thank you very much.
    [The prepared statement of Dr. Nguyen appears on p. 65.]
    Mr. Michaud. Thank you.
    Mr. Frank.

                     STATEMENT OF DAN FRANK

    Mr. Frank. Mr. Chairman and distinguished Members of the 
Subcommittee, thank you for the opportunity to testify on the 
use of wireless technology to overcome rural health barriers.
    My name is Dan Frank. I am the Managing Partner of Three 
Wire Systems, LLC, a service-disabled, veteran-owned small 
business. I am joined by my colleague, Dr. Ian Schaeffer, the 
Chief Medical Officer of MHN, a Health Net Behavioral Health 
Company.
    We are here today to talk about VetAdvisor, an innovative 
evidence-based program that provides mental health outreach 
screening and health coaching services to Operation Enduring 
Freedom/Operation Iraqi Freedom veterans and their families in 
both urban and rural areas. VetAdvisor is a program which 
augments and supports existing VA behavioral health care 
services and assists veterans with challenges they face during 
reintegration into civilian life. It uses traditional and 
nontraditional telehealth delivery platforms to reach out to 
veterans and to improve their awareness of and access to mental 
health support for issues such as tobacco cessation, weight 
management, or understanding post-traumatic stress disorder 
management.
    VetAdvisor assists veterans and their families, providing 
nonclinical health coaching services via telehealth platforms, 
which allow veterans to focus on areas of concern to them 
without leaving their homes. The program identifies and works 
with veterans who have or are at risk for post-traumatic stress 
disorder, depression, substance abuse, suicide, and 
homelessness. This telehealth approach to outreach screening 
and coaching helps eliminate the stigma veterans often 
associate with seeking mental health services and assists them 
in getting treatment.
    Health coaching services are provided to veterans through 
telephonic communication or virtual collaboration technology, 
which we call the VetAdvisor virtual room. In the virtual room, 
the veteran and the coach interact as avatars. This highly 
immersive virtual environment provides strong feedback that 
enhances collaboration and communication.
    Use of this virtual technology assists veterans in their 
reintegration efforts in a number of ways.
    First of all, it allows the veteran to discuss personal 
issues from the privacy of his or her home or private setting 
of choice. Veterans may be more willing to acknowledge the 
magnitude of their issues in this private environment.
    Second, it saves the veteran time and travel costs 
associated with office visits by bringing nonclinical support 
virtually to them. For today's Internet-savvy generation of 
veterans and their families, this form of communication feels 
more natural than traditional communication methods.
    In the past, veterans who opted to use virtual room health 
coaching required wired broadband Internet connectivity for 
their desktop or laptop computers to access this virtual world. 
However, veterans who reside in rural areas can face challenges 
acquiring such broadband services. Recognizing this limitation, 
VetAdvisor worked with our technology partners to leverage the 
most ubiquitous of consumer electronic devices, the mobile 
phone.
    Mobile devices will allow patients to wirelessly access 
health care and is an important component in VA's transition to 
the patient-centered medical home model. To address this 
effort, VetAdvisor will launch a virtual world mobile phone 
capability, for example, an Apple iPhone, in the fall of 2010. 
By extending the virtual world to mobile phones, we can 
significantly increase the veteran user base in rural areas 
where broadband services are not available but cellular service 
is.
    For veterans who opt not to use the virtual world, they 
simply may use their mobile phones to obtain health coaching 
services. We envision veterans using these mobile devices 
anywhere and anytime they desire to work with their health 
coach. So, for example, if you had a veteran who wanted to 
conduct a session with their health coach during their work 
lunch break, they could do that from their car, their office, 
or other location that provides privacy.
    The VetAdvisor program can be offered throughout VHA to 
ensure that veterans do not fall through the cracks. It 
provides VA with an effective mechanism to overcome access to 
care challenges in rural areas by using wireless solutions to 
provide outreach and ongoing support to veterans regardless of 
where they live. Without this program, many of these veterans 
might not return to VA to get the help they need or have as 
successful a return to their jobs, schools, and families.
    On behalf of Three Wire and MHN Health Net, we would like 
to thank you again for your interest in the wireless 
capabilities of the VetAdvisor program and how we serve 
veterans and their families in geographically remote areas. We 
are grateful to the Subcommittee for its leadership and 
commitment in identifying innovative programs that assist 
veterans.
    Thank you.
    [The prepared statement of Mr. Frank appears on p. 71.]
    Mr. Michaud. Thank you.
    Mr. Mize.

                     STATEMENT OF JOHN MIZE

    Mr. Mize. Chairman Michaud, Ranking Member Brown, and 
Members of the Subcommittee, thank you for the opportunity to 
testify this morning.
    LifeWatch is a health IT telemedicine company based in 
Rosemont, Illinois. We provide monitoring services nationally 
for over 15 years, and we represent the future of medicine in 
the United States. It is our privilege to serve the Department 
of Veterans Affairs in almost 40 facilities.
    Currently, our service has helped diagnose patients 
suffering from cardiac arrhythmia and obstructive sleep apnea 
in a near, ambulatory, and real-time environment. This virtual 
service environment is a launching pad for future disease-
specific management of health data, supporting improved patient 
outcomes, continuity of care, reduction of emergency room 
visits, and unnecessary hospital readmissions.
    The LifeStar Ambulatory Cardiac Telemetry service is based 
upon an algorithm that automatically detects and transmits via 
cellular networks clinically significant changes in heart rate 
and rhythm. I am actually connected on the device right now. 
So, for example, if you are feeling dizzy, your cardiologist 
might prescribe our service to help diagnose what is causing 
the changes in your heart rate or heart rhythm. The VA medical 
center completes the physician's enrollment order to LifeWatch; 
and we, in turn, ship the device to the patient's house with 
all the necessary equipment.
    The LifeStar ACT service increases the diagnostic yield 
compared to antiquated technology, increasing the likelihood 
that a diagnosis will be made and a treatment plan 
incorporated, which ultimately improves patient outcomes and 
reduces the cost of treating cardiovascular disease and stroke 
for the Department of Veterans Affairs.
    Additionally, the service allows veterans to remain in 
their home, reduces travel reimbursement expenses, and allows 
VA medical expenses to ship employee resources to other 
responsibilities that cannot be provided in the home. The 
impact for rural veterans is even more pronounced in regards to 
cost savings, access to care, and improved outcomes.
    LifeWatch has also recently introduced a home sleep testing 
service for the diagnosis of obstructive sleep apnea. Wait 
times for sleep labs within many VA facilities exceeds 6 
months, and as a solution many facilities utilize fee service 
to push patients to commercial sleep labs at Medicare rates. 
Our service is less than half the price of utilizing a 
commercial sleep lab, stands to eliminate chronic patient 
waiting lists, and helps improve compliance as the testing is 
all done in the patient's home.
    According to a recent article published in the USA Today a 
couple of weeks ago, veterans are four times more likely than 
other Americans to suffer from sleep apnea. About 5 percent of 
Americans suffer from sleep apnea, compared to 20 percent of 
veterans.
    While there are many success stories, we have also had our 
fair share of struggles within the Department. We are a General 
Services Administration small business vendor; and, despite our 
status on the schedule, procurement remains a struggle, 
necessitating contracting at the facility level. It can take 
upwards of 2 years for some facilities to finalize the 
budgeting and contracting process, despite clinicians requests 
to utilize the beneficial service.
    We have seen some success with Project Hero as an in-
network provider. The program appears to expedite the process 
and simplify procurement for facilities in the four Veterans 
Integrated Service Networks under the demonstration project.
    Additionally, we have struggled with a lack of quality of 
care in terms of standard of care for remote cardiac 
monitoring. In 2004, Medicare placed a requirement on remote 
cardiac monitoring, which included the necessity of providing 
24-hour live attended coverage for patients wearing ambulatory 
cardiac devices. The VA does not follow the same standard 
across the board.
    Lastly, we have struggled with a lack of clarity on how to 
interface our data with Vista Imaging/CPRS electronic medical 
record system within the VA. Multiple clinics have requested 
our data be interfaced, and in fact many facilities will not 
use our service until we are interfaced. Despite the demand 
among cardiology, we have hit multiple roadblocks in terms of 
how to move forward. We are eager and ready to provide a secure 
interface with the Department of Veterans Affairs, which will 
most certainly improve the standard and efficiency of care for 
our veteran.
    Despite our challenges, we have still been impressed with 
the many facilities that utilize our wireless services. We also 
commend the Department of Veterans Affairs for their proactive 
approach to treating rural veterans with the use of 
telemedicine under the Office of Care Coordination. The VA is 
clearly a leader in delivering telemedicine.
    Mr. Chairman and Members of the Subcommittee, LifeWatch 
sincerely appreciates the opportunity to submit testimony and 
looks forward to working with you and your colleagues on 
improving the quality of care for our Nation's veterans with 
the use of advanced technology.
    Thank you.
    [The prepared statement of Mr. Mize appears on p. 75.]
    Mr. Michaud. Thank you very much, and I would like to thank 
each of you for your testimony this morning.
    Since the votes will be called very shortly and we still 
have one more panel, I will submit my questions in writing. 
Hopefully, you will be able to answer them when you receive 
them.
    Mr. Bilirakis.
    Mr. Bilirakis. Thank you, Mr. Chairman. And I would like to 
do the same. I would like to submit my questions in writing as 
well.
    Mr. Michaud. Mr. McNerney, do you have any questions?
    Mr. McNerney. Thank you, Mr. Chairman.
    I feel a little bit pressured to do the same thing, but I 
just have one comment.
    What you are saying, what everyone is saying, sounds really 
great. The VA or the veterans--group of veterans is a great 
sample. It is a great group of people to try new technology on.
    But I also get a feeling inside that some of the technology 
is not going to work, and some of our veterans are going to get 
hurt by the sort of--the new technology that is not done yet, 
that has not been tested out. Do any of you have any comment on 
that?
    Mr. Dicks. My personal feeling is that we are not really 
inventing new technology here, at least in our company, and a 
lot of us aren't doing that. It is technology that is already 
available today. We are just repackaging it. And I believe we 
are at--in health care, we are at the tipping point to a point 
where it is causing them more harm to not be with the 
technology than to be without it.
    You let a disease exacerbate--right now, we are wasting 
taxpayers' money on a regular proportion of bases for not 
implementing this technology. Because they are in rural areas, 
you can't get them in to the doctor on a regular time. They 
don't go to the doctor because it takes 2, 3, 4 hours to get 
there. Then it exacerbates to where it is an $8,000 emergency 
room visit.
    You want to try to put technology like this in place that 
is simple, that is accountable, and creates a sense of 
accountability for them to start following their doctors' 
orders, and that leads to compliance through them taking their 
medication and staying out of the hospital.
    Mr. McNerney. Thank you.
    Briefly.
    Dr. Nguyen. I will just add real quick that the VA through 
its history has been an innovator in showing how technology can 
be used to control cost and increase care. And I think that is 
particularly important now that as we look in a world of health 
care reform--to me, as a physician, what I see very clearly is 
we are making a significant bet in our country that we can 
provide more Americans into structure-coordinated care and in 
the process save money, and I don't see how we can do that 
without leveraging innovations. And I think there are very--all 
the technology we are talking about today in most industry, 
finance and otherwise, has already been done. We are just 
trying to bring them into health care.
    Mr. McNerney. I want to yield back to the Chairman at this 
point.
    Mr. Michaud. Thank you.
    Mr. Snyder.
    Mr. Snyder. Thank you, Mr. Chairman.
    Thank you, gentlemen, for being here.
    Why aren't there any women CEOs of these companies?
    Dr. Nguyen. We have a woman Chief Operating Officer.
    Mr. Snyder. There you go. It seems like we are 
perpetuating--may be perpetuating the problem of leaving women 
out of health care.
    I wanted to ask just one quick question of Mr. Cnossen. I 
was struck by one of the things you said, which was I think you 
used the example in your oral statement of a person may get a 
blood pressure reading every 6 months at home. Maybe just 
hearing from you generally on the issue of I don't think 
technology--the goal for technology should not necessarily be 
just more information. It should be more helpful information.
    I mean, for years, if we had wanted blood pressures more 
often than every 6 months, we would just teach the person how 
to take the blood pressure daily, four times a day.
    Thirty years ago, I sent a teenager home who was an early 
preeclamptic and showed her how to take the blood pressure at 
age 16 because she was, I thought, the only person in the 
household that really could handle that. And I got a phone call 
one night that said, Dr. Snyder, it is--whatever it was--and I 
went out to the house, and we sent her to the hospital, and she 
delivered.
    So this is one of the issues that we have to make sure--we 
can overload our monitors, our doctors, with too much 
information. I mean, I, frankly, don't know. I don't want to 
know what my heart is doing every minute. In fact, that is not 
what the studies on arrhythmia are based on. They are not based 
on constant monitoring. They are based on what is my blood 
pressure in 6 months, in 3 months, whatever it is. That is an 
important distinction, is it not?
    We want helpful information, information that leads to 
proper decision-making. We don't want to flood the system with 
information which may in fact not be helpful but just flood the 
system.
    Mr. Cnossen, I will let you respond to that.
    Mr. Cnossen. Sure, absolutely.
    And clinician acceptance is key to making these 
technologies become more readily available. What we need in 
addition to these technologies are some tools that take the 
data, aggregate it into graphs and trending, such that there 
aren't a bunch of data points but rather an indication over 
time of what a reading would do.
    Personally, I have a little bit of hypertension. And since 
I am an engineer I use an Excel spreadsheet and take my 
readings maybe four times a week, put them in a spreadsheet, 
and show that to my doctor. And you know he sort of looks at 
it, throws it away, and takes it with his own certified blood 
pressure reading.
    Mr. Snyder. My kind of guy.
    Because information doesn't always lead to better outcomes. 
In fact, I can take some patients and--I mean, we all know 
that. Maybe I am one of those--and I can get them on edge. I 
can get them going to the emergency room frequently.
    I mean, the reality may be on your patient the doctor may 
be saying 6 months is fine. You know, we know that blood 
pressure is one of those things that kills people over years 
and decades, not over 6 months. So we need to be sure that we 
are using the technology to help outcomes.
    And flooding a doctor's office with information may not 
necessarily lead to better outcomes. That is part of I think 
what ongoing research will show. Mr. Mize's using my bedroom as 
a sleep lab for greatly reduced cost, I think is the kind of 
technology that is helpful.
    Mr. Dicks.
    Mr. Dicks. The one thing we are really trying to do with 
this is not emphasize the technology. What we are trying to do 
is emphasize--you know, compliance is an overused word, right? 
We don't want to try to create the Central Intelligence Agency 
effect here where you get rid of all the operatives in the 
field and you try to deluge with all the data there is and 
nobody can make heads or tails of it. We want to keep the 
operatives in the field--those are the nurses, those are the 
doctors--and we want to provide them with clean data for them 
on a regular basis.
    But let's just talk about the technology. For the lowest 
cost possible, the flexibility and simplicity, all I am trying 
to do is create a sense of accountability between the patient 
and the caregiver. So if that patient is knowing that somebody 
on the other end is looking for that reading to come in they 
are more likely to take the reading, they are more likely to 
take the medication, and they are more likely to stay out of 
the hospital.
    So we are trying to put that sense of accountability on. We 
call our technology, 20 percent technology and about 80 percent 
psychology, right? It is not about the technology. It is about 
that connectivity you have between the two and that 
accountability that you set up that is going to drive down 
health care costs.
    Mr. Snyder. Another issue--and my time is running out. I 
know we have votes coming up. I will say this as an M.D. We are 
talking a lot here today about compliance with patients. 
Several of you up there--I guess Dr. Nguyen is the only 
physician there--and Dr. Powell.
    The providers might benefit from these kind of things, like 
an airline pilot checklist. We don't do that very well as 
providers. We think that--a lot of us think, well, we are kind 
of magic. We just have a sense of it. And the reality is we 
would probably benefit from some of these technologies within 
the practice setting, also.
    Thank you, Mr. Chairman.
    Mr. Michaud. Thank you very much, Mr. Snyder.
    Once again, I would like to thank all of you for coming 
here today.
    On the last panel we have Kerry McDermott, who is an expert 
advisor for the Federal Communications Commission. We have 
Colonel Poropatich, who is the Deputy Director, Telemedicine 
and Advanced Technology Research Center; and Gail Graham, who 
is the Deputy Chief Officer for Health Information Management 
within the VA, and she is accompanied by Dr. Darkins and Dr. 
Breeling.
    I want to thank you for coming today. And if you could try 
to just summarize your testimony, that would be greatly 
appreciated as well.
    We will start off with Ms. McDermott.

  STATEMENTS OF KERRY McDERMOTT, MPH, EXPERT ADVISOR, FEDERAL 
  COMMUNICATIONS COMMISSION; COLONEL RONALD POROPATICH, M.D., 
  USA, DEPUTY DIRECTOR, TELEMEDICINE AND ADVANCED TECHNOLOGY 
   RESEARCH CENTER, U.S. ARMY MEDICAL RESEARCH AND MATERIEL 
 COMMAND, DEPARTMENT OF THE ARMY, U.S. DEPARTMENT OF DEFENSE; 
   AND GAIL GRAHAM, DEPUTY CHIEF OFFICER, HEALTH INFORMATION 
   MANAGEMENT, OFFICE OF HEALTH INFORMATION, VETERANS HEALTH 
     ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; 
ACCOMPANIED BY ADAM DARKINS, M.D., MPHM, FRCS, CHIEF CONSULTANT 
    FOR CARE COORDINATION, OFFICE OF PATIENT CARE SERVICES, 
  VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS 
AFFAIRS; AND JAMES BREELING, DEPUTY EXECUTIVE DIRECTOR, OFFICE 
  OF INFORMATION AND TECHNOLOGY, U.S. DEPARTMENT OF VETERANS 
                            AFFAIRS

               STATEMENT OF KERRY McDERMOTT, MPH

    Ms. McDermott. Good morning, Chairman Michaud and 
distinguished Members of the Subcommittee. Thank you for the 
opportunity to overview the health care recommendations of the 
National Broadband Plan.
    As you know, Congress mandated that the FCC prepare a 
National Broadband Plan that ``shall seek to ensure that all 
people of the United States have access to broadband 
capability'' and include a strategy for affordability and 
adoption of broadband. The FCC was also asked by Congress to 
address how broadband can be harnessed to tackle important 
national purposes, including health care. So here are the Cliff 
Notes.
    The U.S. has serious health challenges. There are promising 
broadband-enabled health information technologies that have the 
potential to help us improve health outcomes and quality of 
life, reduce costs, and extend the reach of a limited supply of 
health care professionals.
    However, despite the great promise of these technologies, 
the U.S. lags behind other developed countries in health IT 
adoption; and so the plan identifies some of these barriers and 
makes recommendations to address them. They fall into three 
main categories:
    First, a connectivity gap. Broadband is either unavailable 
or too expensive.
    Second, outdated regulations. Rules that were created when 
our only interactions with physicians were in their offices not 
via remote monitoring and video consultations.
    Third, misaligned economic incentives. The prevailing fee-
for-service reimbursement system pays for volume, rather than 
outcomes, and places the financial burden on providers while 
the benefits are realized elsewhere.
    So let me briefly overview each.
    First, connectivity. When we analyzed connectivity for 
health care providers, we found that many providers lack 
adequate connectivity to support full utilization of health IT. 
For example, approximately 3,600 small physicians' offices are 
not even served by existing mass market broadband 
infrastructure. Of these, 70 percent are in rural locations. 
And 29 percent of rural health clinics do not have access to 
adequate mass market broadband.
    The National Broadband Plan addresses the health care 
connectivity gap by proposing to revamp the FCC's rural health 
care program. The program is for public and nonprofit health 
care providers and is the largest sustainable government fund 
for health care connectivity. Proposed changes include, one, 
creating a permanent infrastructure fund; two, broadening 
coverage for monthly recurring costs to all types of broadband 
services; and, three, expanding eligibility for the program.
    Second barrier, outdated regulations. Dr. Smith highlighted 
some that the plan addresses, so I will reinforce one specific 
to the wireless arena, regulatory uncertainty surrounding the 
convergence of communications and medical devices. With new 
solutions that enable clinicians and patients to give and 
receive care anywhere at any time comes a new challenge, 
blurred regulatory lines. This uncertainty regarding regulatory 
frameworks and approval processes can discourage private-sector 
innovation and investment in wireless health and ultimately 
delay or prevent the availability of such solutions.
    The plan calls for the FCC and the FDA to build on their 
long history of collaboration to resolve these issues. The 
agencies have already begun to act on this recommendation and 
are holding a joint public meeting on July 26th and 27th. 
Through this forum, we will bring together various stakeholders 
to begin to better understand the types of devices and 
applications that are being introduced, clarify the 
requirements that apply, and improve the regulatory processes 
to the extent possible.
    Third barrier, misaligned economic incentives. Within a 
fee-for-service reimbursement system, providers bear the cost 
of health IT implementation and changes to workflow but don't 
fully capture the economic gains created through improved 
clinical outcomes. The plan recommends several steps to move 
toward an outcomes-based reimbursement mechanism for e-care 
technologies and urges HHS to propose specific programs and 
reimbursement changes that will help realize the value. Without 
reimbursement reform, the market for wireless health IT 
solutions is limited; this in turn, inhibits investment and 
innovation.
    In summation, the National Broadband Plan's health care 
recommendations address the infrastructure, supply, and demand 
concerns associated with utilization of promising health IT 
solutions so that all citizens may realize their health 
benefits and cost savings.
    I thank you all for giving me the opportunity to speak 
today.
    [The prepared statement of Ms. McDermott appears on p. 77.]
    Mr. Michaud. Thank you.
    Colonel.

          STATEMENT OF COLONEL RONALD POROPATICH, M.D.

    Colonel Poropatich. Good morning, Chairman Michaud and 
distinguished Members of the Subcommittee. I am Ron Poropatich. 
It is a pleasure to be able to talk to you a little bit about 
the Army Medical Department's mobile health projects, future 
initiatives, and challenges in implementing these kinds of 
capabilities both stateside and overseas. I would like to focus 
on three projects and succinctly go over an overview of what 
they entail.
    We currently have 11 active projects that we are doing at 
the Telemedicine and Advanced Technology Research Center 
located at Fort Detrick, about 50 miles northwest of 
Washington. The first project deals with soldiers back from the 
war with a variety of wounds, traumatic brain injuries, 
psychological health. They get care at Walter Reed, let's say. 
Then they go back to their homes to recover. These are 
Reservists and National Guardsmen. The question is, how do we 
reach out to them on a regular basis?
    We have a care team located at a community based warrior 
transition unit. There are nine of them in the States. We are 
currently up and running as of May of last year at five of 
these sites located in Massachusetts, Virginia, Florida, Rock 
Island, Illinois, and Alabama, covering 26 States. Many of 
these soldiers are living in remote areas. We push down onto 
their own cell phones secure messages that are HIPAA compliant 
that allows us to give them wellness tips on sleep, pain 
issues, reminders about job opportunities and educational 
issues, as well as announcements and overall projects dealing 
with appointment reminders. In the Army, we have about 10,000 
missed appointments per month currently. And, again, 
appointment reminders are a key part of the program as well.
    This project has been successful in that we, as of 1 year--
and this is the first of a five-phase rollout--we have 300 
soldiers enrolled in the first phase, we have reached out to 
over 100 case managers, and have generated over 20,000 
messages. Of those 20,000 messages, 63 percent are appointment 
reminders, 17 percent are health and wellness tips, and 12 
percent are unit-specific announcements.
    There are challenges to overcome any of these kinds of 
projects. We have to push the content onto the soldier's cell 
phone. We are not buying them one. We have to deal with over 
300 different types of cell phones that are out there going 
across four different wireless telecommunications companies. We 
have been able to work through those challenges at no cost to 
the soldier.
    That, however, is important to understand the challenges in 
just getting to that stage. We are also aware of the need to 
expand this across the Navy, the Air Force, and the VA; and we 
have generated discussions at three different VA institutions.
    The second project I would like to highlight briefly is 
maternal fetal health, Text4Baby. It is a public-private 
partnership that has already been up and running for the last 4 
months, 46,000 women, over 2 million text messages being pushed 
out onto pregnant women's cell phones.
    We are going to be rolling this particular project out as a 
DoD partner, an outreach partner to this program, going to the 
Madigan Army Medical Center at Joint Base Lewis McChord in 
Washington State. We are going to be studying this under our 
research protocol looking at smoking cessation and postpartum 
depression, realizing that many of our pregnant mothers are 
dealing with other children, with a spouse who is deployed, 
adding new stresses to that mother.
    The third wireless application again is a little bit 
different than the first two. Here we are pushing video onto a 
smart phone for a diabetic patient population in hopes of 
changing behavior to make patients more compliant with home 
blood glucose monitoring, nutrition, and exercise. This is a 
research project approved at Walter Reed Army Medical Center, 
where I practice medicine 1 day a week. It has been up and 
running for a year, 170 patients enrolled in this study.
    We found that of the patients that have the video versus 
those that don't only half the people actually looked at the 
video, but those that did had a statistically significant 
reduction in their glucose, which is important to realize.
    Regarding the big Army, we want to leverage what the big 
Army is doing. They have gone out to Cupertino, looking at 
Apple and BlackBerry and other labs. The Research, Development, 
and Electronic Command out of Fort Monmouth, New Jersey, has a 
big interest in seeing how we can take mobile health onto the 
battlefield.
    We are interested in leveraging in big Army's interest and 
applying this same capability to further health care outreach 
within the U.S. Army Medical Department.
    We also realize, based on a recent document approved--that 
DoD instruction May--of last month looking at medical stability 
operations and realized that the rest of the world's cell phone 
penetration is even greater than America's when you look at it. 
Therefore, we see great opportunity in leveraging the cell 
phone capabilities that we are doing stateside and offering it 
as potential solutions to the developing world.
    There are many opportunities, but there are considerable 
challenges. Challenges include integrating this content into an 
electronic medical record, the security issues that we talked 
about, the regulatory issues with the FDA, is it a medical 
device or is it still just a cell phone, and information 
overload to physicians where clinical business practices have 
to change.
    We are committed to developing and expanding mobile health 
in the military. I would like to thank you for allowing me to 
highlight briefly some of the Army Medical Department's 
accomplishments, and thank you for your continued support to 
those who serve our Nation.
    [The prepared statement of Colonel Poropatich appears on p. 
80.]
    Mr. Michaud. Thank you very much, Colonel.
    Ms. Graham, could you summarize your written testimony?

                    STATEMENT OF GAIL GRAHAM

    Ms. Graham. Good morning, Mr. Chairman and Members. Thank 
you for the opportunity to testify about VA's efforts to 
deliver optimal health care to veterans in rural areas through 
the use of innovative wireless health technologies.
    I am accompanied today by Dr. Adam Darkins, Chief 
Consultant of Health Services for the Office of Patient Care 
Services, who has been referenced multiple times during the 
earlier testimonies; and Dr. James Breeling, Deputy Executive 
Director, Office of Information and Technology, Department of 
Veterans Affairs.
    Wireless technologies are part of an overall continuum of 
care and not a stand-alone entity within VA. We are currently 
undertaking the most significant change to our model of care 
delivery since the rapid expansion of the Community-Based 
Outpatient Clinics that began in the 1990s. But, in many ways, 
this new innovative approach is actually a continuation of the 
same strategy that VA has pursued to bring care closer to our 
veterans and make it as accessible as possible.
    Our mission of veterans-centered care engages veterans, 
families, health care teams in partnership to improve 
communication and ensure the needs and the preferences of the 
patient are met. Delivering optimal treatment to veterans in 
rural areas involves significant challenges, as have been noted 
by many previous speakers. Emerging technology and new models 
of care promise to improve clinical quality and reduce cost.
    VA is committed to pursuing strategies that will achieve 
these ends. Our aim is to ensure that our rural veterans 
receive the same quality of care. VA is exploring applications 
of wireless technologies to enhance care. For example, VA has 
installed various small aperture terminal satellites on the 50 
mobile Vet Centers that were purchased recently, which are used 
primarily in rural areas for veterans outreach and readjustment 
counseling services to veterans but can be also used in case of 
emergency for provision of care.
    We also use wireless technology to assist our veterans with 
disabilities with quick access to information and to foster 
opportunities to live at the highest level of functionality 
possible.
    In our medical facilities, we are completing wireless local 
area network projects to improve the coverage and reliability 
of mobile devices, including those used for bar code medication 
administration and laptop computers for our clinicians to use 
in the delivery of care and the access to VA's electronic 
health record.
    VA dental providers are using wireless technology to access 
software designed to improve point-of-care decision, and this 
technology significantly improves medication safety by 
providing important direct interaction analysis and side effect 
profiles for treatment outcomes to a vast knowledge base 
available at the provider's fingertips.
    My HealtheVet, the VA's online personal health record, is 
yet another area of significant progress for wireless 
technology. My HealtheVet provides veterans with online access 
to VA health care featuring patient-friendly health education 
information and wellness reminders for preventative care.
    A veteran who was an early adopter in the pilot program 
described the application's impact to his life by saying, I 
feel more in control and aware of my health care choices.
    Having veterans as a partner in their health care is 
essential for the success at VA. VA was awarded a rural health 
grant to improve access to care by engaging our veterans in co-
designing improvements to My HealtheVet. We have conducted 
sessions in five rural communities with veterans who suggest 
specific changes to My HealtheVet, including the addition of a 
mobile version of this application. This prototype will be 
evaluated by veterans and approved for concept environment, and 
the second phase of this project will support further meetings 
with veterans for feedback on visually modeling the complete 
set of functions they desire, recognizing that many times 
taking things from the electronic health record or full view on 
the Internet has its challenges.
    Around the world, mobile and wireless devices are 
increasingly used to connect people to the Internet. In early 
2009, VA launched a mobile-friendly version of its Internet Web 
site. VA's mobile site tailors key VA content from mobile 
devices and is designed to be compatible with multiple bands of 
cell-based Internet browsers. We want to be accessible and 
transparent to our veterans and their families wherever they 
may be.
    Looking ahead, VA is examining the potential for additional 
innovative applications targeting specific populations of 
veterans such as those with traumatic brain injury, post-
traumatic stress disorder, or visual impairments. We also 
anticipate development of more resources and tools for 
clinicians and veterans. Like you, VA strives to ensure that 
every veteran who receives care from VA has access to its 
world-class care and benefits.
    Mr. Chairman, this concludes my prepared statement and I am 
pleased to address any questions. Thank you.
    [The prepared statement of Ms. Graham appears on p. 83.]
    Mr. Michaud. Thank you very much, and I would like to thank 
all of you.
    Since we only have 3 minutes to go vote, we have a choice 
of either holding everyone here for about an hour or for us to 
submit questions in writing. So we have decided to submit 
questions in writing.
    But I really appreciate all the testimony here today from 
this panel and the other two panels, and we will definitely 
have a lot of questions as well. So I want to thank you very 
much. This is a very important issue and one that there is a 
lot of interest in.
    Mr. Michaud. So, without any further ado, I will adjourn 
the hearing. Thank you.
    [Whereupon, at 12:00 p.m., the Subcommittee was adjourned.]



                            A P P E N D I X

                              ----------                              

 Prepared Statement of Hon. Michael H. Michaud, Chairman, Subcommittee 
                               on Health

    The Subcommittee on Health will now come to order. I would like to 
thank everyone for attending this hearing. The purpose of today's 
hearing is to learn about the wide range of innovative wireless health 
technology solutions and their potential application to help our 
veterans living in rural communities.
    Of the nearly 8 million veterans who are enrolled in the VA health 
care system, about 3 million are from rural areas. This means that 
rural veterans make up about 40 percent of all enrolled veterans. For 
the 3 million veterans living in rural areas, access to health care 
remains a key barrier, as they simply live too far away from the 
nearest VA medical center. Unfortunately, this means that rural 
veterans cannot see a doctor or a health care worker to receive the 
care that they need when they need it. Given these barriers, it is no 
surprise that our rural veterans have worse health outcomes compared to 
the general population.
    This is where I see the great potential of innovative wireless 
health technologies. VA certainly is a recognized leader in using 
electronic health records, telehealth, and telemedicine. However, 
wireless health technologies also include mobile health, which truly is 
the new frontier in health innovations. Mobile health makes it possible 
for health care professionals to receive real-time health data such as 
vital signs, glucose levels, and medication compliance because data 
from the patient's mobile sensors are relayed over wireless 
connections. Mobile health also makes it possible for health care 
professionals to download health data using PDAs and Smartphones. These 
innovations not only empower our rural veterans, but can improve health 
outcomes as veterans have the necessary tools to better manage chronic 
diseases and receive timely health care in the comfort of their homes.
    I look forward to hearing from our witnesses today, as we learn 
more about innovative wireless health technologies and explore ways 
that we can best support wireless health solutions in the VA.

                                 
   Prepared Statement of Hon. Gus M. Bilirakis, a Representative in 
                   Congress from the State of Florida

    Thank you, Mr. Chairman. And, good morning and welcome to our 
witnesses and audience members.
    I'm excited to be here with you all today to discuss wireless 
health technology within the VA, particularly how it can be utilized to 
increase access to care and improve patient outcomes for veterans in 
hard-to-reach rural areas.
    Approximately 40 percent of the veteran population resides in rural 
areas and those numbers are expected to increase as veterans of Iraq 
and Afghanistan return to their rural homes. Living in a hard-to-reach 
area presents numerous barriers to care for veterans who must often 
drive long distances and find overnight accommodations to make 
appointments at distant VA facilities.
    These factors would be significant for anyone but are especially 
burdensome to veterans who struggle with pain, disability, or chronic 
illness. I am proud of the work we have done on this Subcommittee to 
help ease the burdens rural veterans face but, as always, more work 
remains.
    VA currently operates the largest telehealth program in the world, 
operating in 144 VA medical centers and 350 VA community-based 
outpatient clinics. Estimates indicate that 263,000 veterans were cared 
for using VA's telehealth initiatives in fiscal year 2009 alone.
    Telehealth is the provision of health care services through 
telecommunications technologies including cell phones, Smart phones, 
the Internet, and other networks. When a patient receives a text 
message reminder from their doctor, they are engaging in telehealth. 
When a doctor is able to monitor an at-risk patient's blood pressure or 
heart rate through a remote monitoring device, they are engaging in 
telehealth. When a specialist at a VA medical center is able to 
communicate with and make a vital diagnosis on a veteran patient at a 
community-based outpatient clinic many miles away, they are engaging in 
telehealth.
    Early results indicate that when wireless technology is utilized 
effectively, it can be a tremendous benefit, especially for rural 
veterans. From these programs we are learning that when technology is 
incorporated into health care, it can improve access, efficiency, 
innovation, and outcome while reducing barriers to care.
    While such technology is not without its challenges, I am 
encouraged by the early successes of VA's telehealth programs and I 
look forward to learning more from our discussion this morning.
    I yield back the balance of my time.

                                 
 Prepared Statement of Joseph M. Smith, M.D., Ph.D., Chief Medical and 
     Science Officer, West Wireless Health Institute, La Jolla, CA

    Chairman Michaud and Ranking Member Brown, thank you for the 
opportunity to testify before the Committee about addressing the health 
care needs of veterans, particularly those living in rural areas, and 
how wireless health technologies can help overcome barriers to 
accessing care. My name is Dr. Joseph Smith, and I am the Chief Medical 
and Science Officer of the West Wireless Health Institute. I have spent 
the last 25 years at the intersection of medicine and innovative 
technology, practicing medicine and the technology-intensive 
subspecialty of clinical cardiac electrophysiology in academic and 
clinical settings, and most recently, concentrating on advancing the 
development of emerging technologies to solve unmet needs in health 
care.
    The West Wireless Health Institute is a non-profit medical research 
organization that was launched last year by two visionary 
entrepreneurs, Gary and Mary West, with the primary mission of 
advancing wireless health technologies to lower health care costs. The 
Wests, through their family foundation, have granted almost $100 
million to the Institute to date. We are focusing these resources to 
create a unique, cross-functional organization comprised of physicians, 
scientists, engineers, health economists, and experts in reimbursement 
and regulatory policy to drive systematic change in health care 
delivery. With 42 members of the team already in place, we are hiring 
at a pace of about one person per week and hope to employ a world-class 
staff of 80 by the end of this year. Toward our goal of dramatically 
lowering the cost of excellent health care, we are innovating and 
incubating promising technologies; validating their value to lower 
costs; actively engaging with policymakers and other stakeholders to 
accelerate the availability of these solutions; and collaborating 
across sectors including health care, technology, business, government, 
and academia.
    Wireless sensors that enable remote diagnosis, monitoring and 
treatment support are among the innovations that will enable these aims 
to become a reality, as well as alleviate some of the burgeoning costs 
within the VA health care system. In general, wireless sensors and 
other mobile devices accurately monitor a variety of physiological 
functions and shifts, including respiration, body temperature, heart 
rate, and blood glucose levels. A patient with high blood pressure, for 
example, can be monitored with a wireless device that captures 
physiological changes and sends an alert to the patient's provider, 
with the unprecedented potential of preventing acute and long-term 
complications such as stroke, heart attack and kidney disease.
    Because of their pervasiveness and low cost, cell phones and other 
wireless technologies are well-suited to cheaply transmit information 
and help patients and health care providers manage chronic diseases. 
Wireless technology offers real-time and ongoing diagnosis and 
monitoring of a patient's condition, whereas in-person, physician 
office visits present only a snapshot of the patient's condition at a 
fixed time and place. Ultimately, these solutions are driving a new 
infrastructure independent model of health care, which translates into 
the right care, at the right time, wherever people need it.
    For veterans residing in rural and remote areas, this means not 
having to incur the burden of finding considerable time and resources 
to make repeated visits to distant facilities. We know from talking to 
VA practitioners in rural areas that distance is one of the greatest 
barriers to accessing care, particularly for those with chronic 
conditions--the very patients who need the most support. We are 
continuing dialogue with the VA at local and national levels to 
identify solutions for making a significant impact on this front.
    We also share the great concern that our Nation's health care 
system is itself ill, swollen and inflamed by excessive costs derived 
from an evolution of unfortunately perverse incentives. Doctors and 
hospitals are fiscally incentivized by volumes of procedures and face-
to-face encounters, while patients and families wish to maintain health 
and wellness and avoid costly and complex interactions with doctor's 
offices, clinics and hospitals. And just earlier this year, we passed 
into law a sweeping reform of health care insurance that will 
dramatically increase access to a health care system that seems ill-
poised to meet the challenge. The imperative for change in health care 
delivery is undeniable, and the opportunities afforded by emerging 
wireless health care solutions are compelling. We believe the VA system 
has provided an illuminated path to the appropriate deployment of these 
promising technologies.
    Specifically, we commend the VA for its Care Coordination/Home 
Telehealth (CCHT) program which has demonstrated a 25 percent reduction 
in bed days of care (including 50 percent for patients in highly rural 
areas) and a 19 percent reduction in hospital admissions by linking 
chronically ill veterans with health care providers and care managers 
through videoconferencing, messaging and biometric devices, and other 
telemonitoring equipment. The CCHT program appears to be the largest 
telehealth program in the world, with 43,000 senior veterans receiving 
home care for chronic disease management. Under the VA CCHT program, 
one nurse is able to extend his or her reach to `touch' 150 patients 
remotely on a daily basis. With 32 million individuals soon to be 
provided comprehensive health insurance and the shortage of physicians 
expected to exceed 125,000 within 15 years (according to the 
Association of American Medical Colleges), the VA's CCHT program offers 
substantive proof that wireless health technology can dramatically 
increase the efficiency of already overstretched health professionals 
to help patients no matter where they are or when they need care.
    We believe the VA's CCHT program should take the next step and 
incorporate innovations beyond traditional telehealth equipment, much 
of which still requires care within VA clinics or other fixed 
locations. We encourage the VA to evaluate and implement wireless 
health solutions that will complement and further extend the reach of 
the CCHT program, including wireless biometric sensors that monitor 
highly relevant physiologic parameters, track disease activity on a 
continuous basis, and transmit that information to the patient's health 
care provider. This technology enables providers and patients 
themselves to monitor and diagnose their conditions without a facility 
in-person visit.
    We understand the VA is now undertaking the construction of two new 
hospitals at the cost of $1.8 billion. Certainly, those hospitals will 
offer important access for veterans in those discrete communities where 
the geographic density is sufficient to motivate such investment. 
However, almost 40 percent of veterans enrolled in VA health care live 
in rural or highly rural areas; an even higher proportion of veterans 
returning from Iraq and Afghanistan reside in rural areas. Imagine how 
many veterans in remote areas across the country could be reached 
through wireless technologies with a similar expenditure of these 
precious resources: the CCHT's program cost is $1,600 per patient per 
year--meaning an additional 225,000 veterans in remote areas could be 
reached for a comparable cost over a 5 year period. And as the CCHT 
program demonstrated, these investments deliver a return in lower 
overall costs and greater patient satisfaction, carefully managing the 
VA's limited resources while improving patient outcomes.
    Unlike traditional fee-for-service health care where providers 
currently have little incentive to expend resources on technology that 
results in savings to a different ``silo,'' an integrated, self-
contained delivery system such as the VA can readily demonstrate the 
cost-savings that can be achieved by greater utilization of wireless 
health technologies by tracking the decreased hospitalizations, clinic 
visits, and other traumatic and acute interventions that result when 
chronic disease is met with continuous care as opposed to episodic and 
expensive rescue.
    To this end, the West Wireless Health Institute is currently 
exploring a demonstration research project with the VA in San Diego 
with a small cohort of recently diagnosed PTSD patients. The project 
will incorporate a mobile device with videoconferencing capabilities to 
enhance crisis management, regular ``check-ins'' and biofeedback 
therapies. We will be demonstrating the value of this inexpensive and 
integrated wireless health solution for increasing access to real time 
support for veterans with PTSD (and potentially decreasing hospital 
admissions and acute events). This outpatient model of support enables 
face-to-face access to a clinician off-site at any time and can be used 
across numerous disease states.
    On a larger scale, an important step that the VA has recently 
announced is the new $80 million VA Innovation Initiative (VAi2), which 
will improve veterans' care by tapping into private sector expertise 
and creativity. We encourage VAi2 to accelerate the evaluation of 
wireless health solutions that enable home and mobile monitoring of 
diverse and complex signs, symptoms and biometrics, patient- and 
population-based dynamically learning treatment algorithms, and 
remotely titrated therapies for a wide range of chronic and acute care 
needs.
    It is important to note that a critical reason the VA can leverage 
wireless health technology is because its health care providers within 
the VA are able to operate across State lines. Currently, non-VA 
physicians are licensed by States and cannot routinely practice 
medicine across State lines, including through remote monitoring 
services. This creates a serious impediment to wide deployment of 
wireless health solutions and frustrates the ability of our broader 
health care systems from reaping the cost and care efficiencies enabled 
by these solutions. The Federal Government must follow the VA's lead in 
crafting a policy to address this inter-State obstacle to widespread 
adoption of wireless health technology.
    Also imperative to extending veterans' access to wireless health 
technology is the rapid expansion of broadband to rural and remote 
areas. The FCC has noted that 14-24 million Americans do not have 
access to broadband where they live, even if they want it. Broadband 
access is more than connecting individuals to Google and YouTube; it's 
about dramatically transforming the delivery of health care to people 
no matter where they live. We commend the commitment to expanding 
broadband access through the $7 billion for broadband networking in the 
2009 economic stimulus bill, and we support the FCC's plan to ask the 
Medicare program for a clear path for reimbursement for wireless health 
solutions.
    Certainly, many of the challenges of expanding utilization of 
wireless health technology--such as providing a clear, consistent and 
integrated regulatory and reimbursement environment that fosters 
innovation and commercialization of wireless health care solutions--are 
outside the specific purview of the Veterans Administration. Yet the 
current regulatory disclarity is dampening investment in wireless 
health technology and chilling this promising engine of innovation 
because many investors and some telecommunication companies fear FDA's 
regulation of nonmedical devices (e.g. smartphones of all manner) if 
medical applications are utilized. The FDA should be supported in the 
view that the specific sensors, algorithms for interpretation, and 
specific therapeutic devices should remain the focus of regulatory 
activity, and the pathways for communication of the information 
(wireless networks, cell phones, etc.) should be understood to be the 
purview of the FCC. Regulatory and reimbursement clarity will 
specifically enhance the VA's ability to adapt truly innovative and 
cost-saving wireless health solutions for its CCHT program, and will 
also facilitate the rapid generalizability of the benefits to the 
broader U.S. population.
    The VA has a unique opportunity to enhance the ability of providers 
and veterans themselves to monitor, diagnose and manage their health 
conditions more effectively. Just as email, Facebook and Twitter have 
transformed how we communicate with one another, wireless health 
solutions offer a remarkably new modality of care where patients can be 
diagnosed, monitored, and often treated wherever and whenever they need 
care, and in the process avoid the costly, complex, time-consuming, and 
inefficient interactions with an already over-stressed and 
geographically constrained health care system.
    In sum, we make the following recommendations that will ultimately 
increase veterans' access to health care regardless of where they live:

      Following the VA's lead, Congress should create policies 
that facilitate health care delivery across State lines. Current laws 
restricting interstate medical practice are dampening innovations that 
could significantly benefit veterans across the country.
      We encourage the VA to evaluate and deploy newer wireless 
health technologies within its CCHT program, and take advantage of 
opportunities like the recently announced VAi2 competition to test 
biometric sensors and other solutions that facilitate remote access to 
care.
      In addition, we encourage members of this Committee and 
Congress to support broadband expansion, as well as a clear and 
consistent regulatory and reimbursement environment to spur the types 
of innovations that will truly enable health care delivery ``anytime, 
anyplace.''

    One-hundred years ago this Spring, Abraham Flexner was concluding 
the research for his `Flexner report'--widely viewed as one of the most 
impactful treatises in American medicine, credited for ushering in a 
revolution in medical education and practice. One pivotal observation 
in that report remains as true today as it was a century ago: ``The 
small town needs the best, and not the worst, doctor procurable.'' Our 
Nation's veterans living in remote communities deserve access to the 
best thinking and the best care . . . and freeing that care of 
geographical and infrastructure limitations is a promise of wireless 
health care and one that cannot wait for the next century.
    We are on the threshold of a paradigm shift in health care 
delivery, one in which we realize the full potential of the digital and 
wireless revolution and make `anytime, anywhere' care a reality. It is 
clear the VA is on a path to demonstrate that we can effectively reach 
many of our rural and remote veterans with these approaches, providing 
a continuous model of care for those dealing with chronic conditions, 
and in the process enhance satisfaction and drive down costs. It is 
vital that we learn and take the lead from the VA's early successes to 
quicken our pace, as patients (veterans and others) are waiting.
    We look forward to working with the Committee and the VA in 
building upon its leadership role in telehealth and helping America's 
veterans and all of its citizens benefit from the evolution of an 
infrastructure-independent model of health care.

                                 
    Prepared Statement of Darrell M. West, Ph.D., Vice President and
  Director of Governance Studies, and Director, Center for Technology
                   Innovation, Brookings Institution

    Chairman Michaud, Ranking Member Brown, and Members of the 
Subcommittee. Thank you for this opportunity to testify at this hearing 
on ``Overcoming Rural Health Care Barriers through Wireless Health 
Technologies.''
    Since 2008, I have been Vice President and Director of Governance 
Studies and Director of the Center for Technology Innovation at the 
Brookings Institution. I am the author of 17 books, including, 
``Digital Medicine: Health Care in the Internet Era,'' published by the 
Brookings Institution Press in 2009. Prior to my current position, I 
was a professor of political science and public policy at Brown 
University in Providence, Rhode Island.
    The United States has more than 23 million men and women who have 
served proudly in the military. While the vast bulk of these are men 
(94 percent), the percentage that is female has increased from four to 
six and one half percent over the last three decades. According to the 
U.S. Census, the largest veteran populations live in the South (9.9 
million) and Midwest (6.1 million). The number living in the Northeast 
is 4.6 million. The cities with the highest percentage of veterans 
include: Hampton, VA (27.1 percent), Clarksville, TN (24.4 percent), 
Fayettesville, NC (23.7 percent), Virginia Beach, VA (21.7 percent), 
Colorado Springs, CO (20.2 percent), and Norfolk, VA (19.9 percent).
    All of us would agree that in recognition of their valuable 
service, providing quality and accessible health care to veterans is a 
high national priority. Yet that task has become more difficult 
financially because of our Nation's $13 trillion national debt and $1.4 
trillion budgetary deficit. This is especially the case for rural 
veterans who live great distances from medical facilities and often 
have difficulty gaining access to quality care.
    For these and other individuals, I suggest that wireless health 
technologies represent a key ingredient in providing quality and 
accessible care, and gaining budgetary efficiencies in the process. 
Health care based on mobile health, remote monitors, electronic medical 
records, social networking sites, video conferencing, and Internet-
based recordkeeping can make a positive difference for many people. We 
should encourage email reminders to take medicine, mechanisms to rate 
experiences with doctors and hospitals, and Web sites that make care 
ratings publicly available to other patients.
Progress to Date for U.S. Veterans
    The U.S. Veterans Administration has made outstanding progress on 
several dimensions of health information technology. It has been a 
forerunner in the implementation of electronic health records. More so 
than many private physicians and hospitals, the VA has moved toward 
electronic management of recordkeeping and system-wide connectivity. 
Since 1999, with the establishment of the Veterans Health Information 
Systems and Technology Architecture (VistA), the system has ``linked 
5.3 million patient records generated at the VA's 153 medical centers, 
882 clinics, 207 veterans centers, 136 nursing homes, and 45 
rehabilitation centers,'' according to researcher Alan Naditz.
    The VA also has implemented MyHealtheVet, which enables veterans to 
schedule appointments online and refill prescriptions. They can track 
their medical tests, chart changes over time, and measure progress 
towards key goals. It further has established the Health Data 
Repository that contains a range of additional medical information such 
as allergies, body chemistry, and microbiology.
    These electronic systems have produced very high ratings from 
veterans. According to an analysis of American Customer Satisfaction 
Index Web site users by Kim Nazi, those employing these resources gave 
the VA an overall rating of 8.3 out of 10. Most indicated they intend 
to keep using online resources and recommend the VA's services to other 
veterans.
Challenges for Rural Veterans
    There are three major challenges for veterans today. First, like 
every other part of government, the U.S. Veterans Administration faces 
budget pressures due to high national debt and budget deficits. The 
high cost of medical care demands attention to changes that improve the 
efficiency of the overall system.
    Second, there has been an increase in demand for medical services. 
The VA has taken on many more patients at its medical facilities 
compared to a decade ago. It now serves more than 8 million people, up 
from 3 million in 1999. This increase raises pressures on providers and 
makes it crucial to find efficiencies in the system that do not 
jeopardize quality care.
    Third, geographic disparities complicate the delivery of medical 
care. Rural and non-metropolitan counties had the highest 
concentrations of veterans, according to the U.S. Census. An American 
Customer Satisfaction Index survey of 53,788 visitors to the U.S. 
Department of Veterans Affairs Web site found that 37 percent of 
veterans say they have to travel an hour or more to their nearest VA 
facility, according to researcher Kim Nazi.
    Medical scientists such as Tam Dao have found that rural patients 
are more likely than urban ones to suffer depression and, after 
coronary artery bypass surgery, to require longer in-hospital stays and 
experience greater mortality rates. Others such as Amy Wallace and her 
colleagues report that urban veterans have better health care 
experiences than rural counterparts and that reduced access to medical 
care may contribute to these geographic differences.
Changes in the System
    There is no magic bullet for rising health care costs, either for 
veterans or non-veterans making use of private medical care. But there 
have been technological advances that make it possible to improve 
quality, access, and affordability. Today, there are nearly as many 
mobile phones (600 million) in existence that can browse the Internet 
and access email as there are personal computers (800 million) so it 
makes sense to think about greater use of mobile health.
    One of the virtues of the Internet, electronic medical records, and 
cell phones is that it puts the patient in charge of certain 
activities. Using remote monitoring devices, people can measure their 
own weight, blood pressure, pulse, and sugar levels, and send test 
results electronically to health care providers. They get personalized 
feedback via email and reminders when they gain weight, have an uptick 
on their cholesterol levels, don't take their medicine, or have high 
blood pressure. Social networking sites provide discussion forums and 
the benefit of collective experience from other people suffering 
similar problems. Patients take responsibility for their routine health 
care and rely on physicians for more serious medical conditions.\1\
---------------------------------------------------------------------------
    \1\ This statement draws on my paper, ``Customer-Driven Medicine: 
How To Create A New Health Care System'' published by the Brookings 
Institution in October, 2009. Jenny Lu and Raffaela Wakeman provided 
research assistance for this testimony.
---------------------------------------------------------------------------
    This system is not a futuristic vision, but is within our grasp. It 
would cut costs by reducing professional responsibility for routine 
tasks and recordkeeping, while also making it possible for patients to 
receive higher quality care and be more satisfied with the end-result. 
As noted below, the technologies for this kind of system transformation 
currently are available through cell phones, remote monitoring devices, 
video conferencing, and the Internet.
Remote Monitoring Devices
    There are a number of new remote monitors for various health care 
conditions that put patients in charge of their own test-taking and 
keep them out of doctor's offices. For example, there are home pulse-
taking and blood pressure devices that measure vital signs. AT&T has a 
new ``device certification lab'' that tracks health along high-speed 
broadband networks. Results are electronically sent to a family 
physician, specialist, or electronic medical record, depending on the 
wishes of the patient. Zeo is marketing a monitor that measures 
brainwaves and rates the quality of sleep. Bodybugg has an armband 
calorie-counter that charts the amount of energy burned through 
physical movements.
    The Triage Wireless company has a ``wearable'' monitor that records 
vital signs and transmits them to physicians. It records blood pressure 
on a continuous basis, thereby providing regular information for health 
care providers. The Corventis corporation has a small sensor it calls 
PiiX that measures fluid status and respiration for runners. This helps 
people monitor their physical status during exercise. Intel has a 
``magic carpet'' device that monitors physical movements. Geared for 
senior citizens at risk of a fall, it tracks people as they walk on a 
mat to determine who is vulnerable to falling down.
    In the area of diabetes, it is crucial that patients monitor their 
blood glucose levels and gear their insulin intake to proper levels. In 
the ``old days'', patients had to visit a doctor's lab or medical 
office, take a test, and wait for results to be obtained. That process 
was expensive, time-consuming, and inconvenient for all-involved. 
Having to get regular tests for this and other conditions drives up the 
costs of medicine.
    However, it is possible to use remote monitoring devices at home 
that record glucose levels instantaneously and electronically send them 
to the appropriate health care provider. Patients are using with FDA-
approved ``Gluco Phones'' that monitor and transmit glucose information 
to caregivers while also reminding patients when they need to undertake 
glucose tests. It is estimated that over 11 million Americans use home 
monitors for their glucose. Health authorities believe there are over 
24 million diabetics in the United States, and the disease is the 
seventh leading cause of death.
    Tiny monitors with magnetic nanoparticles have been developed by 
researchers at the Massachusetts Institute of Technology to track the 
development of cancer tumors. Small particles the size of a rice grain 
are injected during biopsies. Through follow-up MRI's, doctors can 
measure whether these monitors clump with the tumor and grow in size. 
This allows them to get immediate feedback on the size of cancers and 
whether a specific therapy is working.
    Cardiologist Steven Greenberg of St. Francis Hospital in Roslyn, 
New York uses a wireless pacemaker made by St. Jude Medical connected 
to a home monitoring device to track heart rhythms and vital signs. 
Patient information automatically is transmitted to his medical office, 
which allows him to see which patient has abnormal heart beats and 
therefore is in need of immediate treatment. He feels this enables him 
to ``stay a step ahead of potentially life-threatening problems''.
Personalized Reminders
    One of the biggest problems in medical treatment for either 
veterans or non-veterans is patients forgetting to take their 
prescription drugs. It is estimated that only 50 percent of patients 
take their medication as prescribed. Either they forget to take the 
drug or they do not take it at the time or dosage set by their 
physician. This means that we lose half of the benefit of prescription 
drugs through human error. This costs the systems billions in poor 
health outcomes.
    Digital technology has the potential to help with this and other 
communications problems. Patients no longer need to visit doctors' 
offices to be reminded to take their medicine. They can get personal 
reminders via email, automated phone calls, or text messages. One 
enterprising physician named David Green of Cape Town, South Africa 
noticed that his patients did not always take the prescribed Rifafol 
medicine for their tuberculosis. He knew that for the drug to be 
effective, people had to take the pill on a consistent basis. 
Otherwise, it would have little effect. Doctor Green set up a text 
messaging service called ``On-Cue Compliance'' for each of his patients 
that sent them a daily SMS in English, Afrikaans, or Xhosa. Over the 6-
month course of treatment, his service would send a message at a pre-
determined time each day reminding them to take their Rifafol.
    In the United States, Dynamed Solutions provides ``HealtheTrax'' 
software that reminds patients to take medications, set up 
appointments, and track compliance with medical instructions. This and 
other types of ``virtual health assistants'' are particularly helpful 
with those suffering from chronic illnesses. These individuals need to 
keep close track of their medical condition and stay in touch with 
their caregivers. The software is integrated with electronic medical 
records and can store information in patient's personal records.
    Physicians at Children's Hospital Medical Center in Cincinnati send 
teenagers text messages reminding them to take their asthma medication. 
For young people on the go, remembering to take medication is one of 
the biggest challenges. Researchers have found that text reminders is 
effective and that it helps teenagers develop good ``self-care 
habits''.
    A company called Proteus Biomedical has a tiny ``digestible chip'' 
that can be swallowed along with a prescription drug to notify health 
care providers that patients took their medication. Using a sensing 
device, it electronically transmits that information to physicians, who 
then know for sure that the individual is following the prescribed 
course of treatment. It is especially helpful with patients suffering 
memory loss because those individuals have a high incidence of not 
taking their medicine regularly. Patients loved the idea of getting 
personalized reminders from their medical providers. One person wrote 
that these messages ``keep you informed and mean you never forget to 
take your drugs.''
    In general, Americans say they would like to employ digital 
technologies in their medical care. For example, 77 percent in a 
national survey said they would like to get reminders via email from 
their doctors when they are due for a visit, 75 percent want the 
ability to schedule a doctor's visit via the Internet, 74 percent would 
like to use email to communicate directly with their doctor, 67 percent 
would like to receive the results of diagnostic tests via email, 64 
percent want access to an electronic medical record to capture 
information, and 57 percent would like to use a home monitoring device 
that allows them to email blood pressure readings to their doctor.
Mobile Smartphones
    Cell phones and other mobile devices have gotten smarter and 
faster. Smartphones such as Apple's I-Phone, Research in Motion's 
Blackberry, Nokia's E71, and Palm Pre offer advanced features such as 
mobile email, web browsing, and wireless communications. The 
sophistication of these devices has spawned a variety of new medical 
applications that help doctors and patients stay in touch and monitor 
health care needs.
    For example, Sprint has a mobile application that allows physicians 
to get test results on their mobile device. They can look at blood 
pressure records over time, see an electro-cardiogram, or monitor a 
fetal heart rate. AirStrip Technologies markets an application that 
makes it possible for obstetricians remotely to monitor the heart rates 
of fetuses and expecting mothers. This allows them to detect conditions 
that are placing either at risk.
    These applications make doctors more efficient because they don't 
have to be in the physical presence of a patient to judge his or her 
condition. Digital technology allows people to overcome the limitations 
of geography in health care and access information at a distance. This 
makes it possible for veterans to get a second opinion without visiting 
another physician by sending that person relevant medical tests. If a 
personal conference is required, doctors can use video conferencing to 
speak to patients located in another city or State.
Internet Information
    There has been an explosion of Web sites with detailed medical 
information. Web sites such as WebMD.com, MedlinePlus.gov, 
MerckSource.com, HealthFinder.gov, and MayoClinic.com answer questions 
and provide links to discussion groups about particular illnesses. In 
States such as Massachusetts, California, and New York, and Michigan, 
consumers can visit health department sites and compare quality 
performance data on provider care programs. Nationally, the U.S. 
government has a Web site, www.hospitalcompare.hhs.gov, that evaluates 
2,500 hospitals on mortality rates, room cleanliness, call button 
responses, and how patients judge their quality of care.
    The most common Internet searches occurred in regard to specific 
diseases. Of those who went online, according to a Harris Interactive 
survey, 64 percent said they searched for information on particular 
illnesses, 51 percent looked for certain medical treatments, 49 percent 
surfed for material on diet and nutrition, 44 percent named exercise, 
37 percent sought advice on medical drugs, and 29 percent looked for 
particular doctors or hospitals.
    This information had a positive impact on many people. National 
data demonstrate that 58 percent indicated that online material 
affected their health care decisions, 55 percent said the information 
changed their health care approach, and 54 percent claimed the 
electronic resources made them ask new questions of their medical 
personnel. When asked how these materials made them feel, 74 percent 
said they felt reassured and 56 percent felt more confident.
Social Networking for Medical Care
    Social networking sites offer great potential to improve care by 
sharing information among chronic condition sufferers. For example, a 
network developed by the company PatientsLike Me has 23,000 patients 
who have signed up to share information regarding five different 
illnesses: mood disorders, Parkinson's, multiple sclerosis, HIV/AIDS, 
and Lou Gehrig's disease. These individuals describe their symptoms, 
discuss various therapies, and talk about what works and doesn't work 
very effectively. Not only does the site serve as a vital support group 
for these serious illnesses, it promotes better understanding through 
the detailed case histories based on personal experiences.
    A similar idea draws on crowd-sourcing for feedback regarding 
medical care and treatment side-effects. It often takes years for 
patients, physicians, and medical researchers to get definitive results 
regarding the assessment of drugs and medical therapies. Clinical 
trials are expensive and time-consuming, and involve randomized 
assignment to various groups. Results sometimes are unclear and it is 
hard to recruit sufficient subjects to participate in the evaluations.
    While it is important to maintain rigorous approaches to medical 
research, it is helpful to take advantage of new techniques for getting 
feedback. Crowd-sourcing is a concept that takes advantage of the 
collective experience of large groups of people. It allows a variety of 
individuals to comment on and post experiences with specific 
treatments. This helps others compare data and see information on what 
works or doesn't work.
    Dr. Amy Farber has developed an online resource called LAMsight 
that encourages people suffering from the LAM lung disease to share 
their symptoms and treatment experiences. Web operators take this 
patient-provided information and compile online databases that are used 
by researchers to find out what works, what doesn't work, and what 
drugs generate unwelcome side-effects. Particularly for rare illnesses 
where it is hard to generate the patient numbers required for clinical 
trial, she says ``patients have been a tremendously underutilized 
resource.'' While large clinical trials with randomized assignment 
clearly need to remain central to drug assessment, digital technology 
that helps providers and researchers identify worrisome trends 
represents an additional way to gain useful feedback.
Consumer Evaluations of Health Care Providers
    A big challenge with contemporary health care is lack of 
information among patients about the quality of physician and hospital 
care. There is some outcome-based information on how many mammograms or 
other medical tests various facilities perform, but few assessments of 
the quality of care from specific providers.
    Digital technology has the potential to empower the consumer voice 
in health care and to tie patient assessments to doctor performance. In 
the entertainment area, for example, the commercial company Netflix has 
devised a system by which film watchers order movies for home viewing. 
Upon returning the movie to the company, customers received an 
automatic email asking them to rate the movie on a five-point scale. 
This information is anonymously aggregated, and publicly available to 
other consumers so they can see which movies receive the highest 
ratings in various categories.
    It is possible to create a similar system for rating physicians, 
hospitals, and other health care providers. Following physician visits, 
consumers can fill out an email form allowing them to rate different 
dimensions of medical treatment from timeliness and personal 
attentiveness to level of knowledge and satisfaction with the overall 
visit. These quality measures are aggregated and are accessible at a 
public Web site so others could see the quality assessments.
    Consumer Reports has an online hospital rating service of 3,400 
facilities based on the national government's Hospital Consumer 
Assessments of Health care Providers and Systems Survey. Among the 
items examined include ``overall patient experience, doctor and nurse 
communication, room cleanliness, discharge information, hospital staff 
attentiveness, communication about new medications, pain control and 
noise level''.
Proposed Changes
    There is little doubt that the technology for customer-driven 
health care is already available. What are needed are policy changes 
that alter the incentives for patients and health care providers to 
adopt necessary shifts, and reward good behavior and good health 
outcomes.
Greater Use of Mobile Health in Rural Areas
    Too many parts of our system today do not cover mHealth, digital 
communications, or wellness programs. Physicians, for example, often 
are not covered for email or phone consultations. We need policy 
changes that encourage high quality medical care and make it possible 
for health providers to be reimbursed for the health they provide.
    This is problematic in rural areas because mobile health can 
improve quality, access and affordability. Video conferencing allows 
patients who live long distances from VA facilities to get 
consultations with specialists.
    The Geisinger Medical Center tested a ``medical home'' initiative 
among Medicare patients and found an 8 percent drop in hospital 
admissions and a 4 percent reduction in overall health costs over the 
first year. In this concept, patients are assigned a family physician 
who acts like a ``personal health coach''. This coach oversees a group 
of providers who monitor people's medical condition and use emails and 
text messages to encourage people to lose weight, stick to healthy 
diets, get exercise, and seek relevant care when their status 
deteriorates.
A Focus on Positive Health Outcomes
    Right now, doctors and hospitals do not devote adequate attention 
to health outcomes. Doctors don't get rewarded for healthy patients or 
preventive medical care. Indeed, one of the challenges in the current 
system is the lack of performance data on how patients do. The Federal 
Government collects statistics by city and state on causes of death, 
numbers of procedures, and other such information. But there is little 
outcome information for specific doctors or other health care 
providers. This makes it difficult to judge quality or create 
incentives for healthy outcomes. Doctors whose patients remain healthy 
should receive a bonus and should be encouraged to continue preventive 
medical care.
Rewards for Good Behavior by Physicians and Patients
    We need rewards for good behavior modeled after ``good driving'' 
discounts on car insurance. Drivers who do not have accidents or are 
not cited for speeding or other traffic violations earn a 10 percent 
discount on their insurance. The program is cost-effective for car 
insurance companies because safe drivers have fewer accidents and 
therefore cost the company less in accident repair reimbursements.
    Americans eat too much, get too little exercise, and have diets 
that are too fatty. The result is an obesity epidemic that will push 
health care costs higher in future and limit people's quality of life. 
According to the American Obesity Association, over 30 percent of 
children today are over-weight. This ticking time bomb threatens to 
explode and have dramatic consequences for national health care 
spending.
    Government programs should offer ``good health'' rewards to 
patients and physicians. For example, health programs could provide a 
preventive medicine fund that reimburses people for regular exercise, 
good health practices, flu shots, diet advice, and smoking/alcohol/drug 
cessation programs. This would encourage patients to lead healthy 
lifestyles.
    After the Safeway company instituted a ``Healthy Measures'' program 
of cholesterol screenings, blood pressure measurements, and weight loss 
initiatives, its health costs dropped by 13 percent. More than three-
quarters of its employees enrolled in the program and they saved 20 
percent on their individual insurance premiums. Pitney Bowes provides 
$100 gift cards to employees who enrolled in health courses.
Saving Money and Leading Healthier Lives
    The ultimate goal of policy changes is to save money and get people 
to lead healthier lives. As others have pointed out, the United States 
spends $6,102 annually per capita, much more than the $3,165 spent by 
Canada, $3,159 by France, and $2,083 by the United Kingdom. Yet America 
ranks 42nd among developed nations in life expectancy. Our average life 
expectancy of 77.9 years falls well below that of Andorra, the Cayman 
Islands, and most European countries. We spend a higher percentage of 
Gross Domestic Product on health than most other nations, but get 
weaker results in terms of medical well-being.
    With America's health care system now costing $2.4 trillion, we no 
longer can afford delays in making needed changes. As Peter Neupert of 
Microsoft's Health Solutions Group has written, ``let consumers do some 
of the work that expensive health-care professionals shouldn't be doing 
anymore. In the past 10 years, technology has removed travel agents, 
bank tellers and so on from the middleman position. Online systems, 
such as Kaiser Permanente's, have increased patient satisfaction and 
allowed the work of expensive professionals to be replaced.''
    One of the reasons America spends more money per patient than other 
countries, but gets weak results, is our low usage of health 
information technology. Only 15 percent of the 560,000 doctors in 
America use digital technology to order medication for patients. 
Industry advocates claim that a move to electronic prescriptions could 
save $29 billion over the next decade. According to health experts, 
digital technology would save money and ``make transactions more 
efficient, reduce medication errors and entice doctors to prescribe 
less expensive drugs''.
    A Brookings Institution analysis undertaken by economist Robert 
Litan found that remote monitoring technologies could save as much as 
$197 billion over the next 25 years. Cost savings are especially 
prevalent in the chronic disease areas of congestive heart failure, 
pulmonary disease, diabetes, and skin ulcers. With around the clock 
monitoring and electronic data transition to care-givers, remote 
devices could speed up the treatment of patients requiring medical 
intervention. Rather than having to wait for a patient to discover 
there is a problem, monitors could identify deteriorating conditions in 
real time.
    A 2009 PriceWaterhouseCoopers Health Research Institute study 
meanwhile found that $210 billion is wasted through ``defensive 
medicine--doctors ordering tests or procedures not based on need but 
concern over liability or increasing their income''. Other examples of 
wasteful spending include inefficient claims processing ($210 billion), 
ignoring doctor's orders ($100 billion), ineffective use of technology 
($88 billion), hospital readmissions ($25 billion), medical errors ($17 
billion), unnecessary emergency room visits ($14 billion), and hospital 
acquired infections ($3 billion).
    Better use of digital and mobile technology could help on each of 
these fronts, especially with rural veterans. Electronic medical 
records would reduce duplicate tests because various physicians would 
have easy access to the results of past procedures. Automated 
processing of medical reimbursements would save time and money. Not 
taking medicine at prescribing times and levels could be improved 
through remote monitoring and digital tracking. Unnecessary emergency 
room visits, hospital infections, and medical errors could be reduced 
through medicine that employs video conferencing and out-patient 
treatment.

                                 
   Prepared Statement of David Cattell-Gordon, M.Div., MSW, Director,
     Rural Network Development, Co-Director, The Healthy Appalachia
 Institute, and Faculty, Public Health Sciences, Nursing, University of
              Virginia Health System, Charlottesville, VA

    Chairman Michaud, Ranking Member Brown, distinguished Members of 
the Subcommittee on Health, my name is David Cattell-Gordon and I serve 
as the Director of Rural Network Development, manager of the Office of 
Telemedicine and a faculty member in Nursing and Public Health Sciences 
at University of Virginia. I also serve as the co-director of the 
Health Appalachia Institute, a public health institute serving the 
citizens of Central Appalachia.
    As the son of a distinguished, rural WWII veteran from the famed 
Iron Men of Metz of the 95th Infantry, a child of the coalfields and as 
a health care professional serving many rural patients and communities, 
I am honored to provide testimony on how the Veterans Health 
Administration (VA) can utilize innovative health technologies to 
overcome barriers to health care in rural communities.
    As a part of the University of Virginia's pioneering program in 
telemedicine, I have come to appreciate how information technology can 
overcome barriers of access. In addition, telehealth and wireless 
capabilities have consistently demonstrated opportunities for improved 
health outcomes, decreased isolation, reduced health disparities and 
substantially reduced costs--a vital issue in ensuring the very best 
care for the over three million of veterans living in remote, rural 
communities. Simply put: why would we not invest in this capability?
    To make this simple case for investment, I will address today three 
well documented issues:

    1.  The substantial, long-standing health disparities in rural 
Central Appalachian and for rural veterans;
    2.  The role of telehealth in improving the delivery of health care 
and educational services to rural citizens especially veterans; and,
    3.  The opportunities of expanded wireless capabilities to improve 
the health and quality of life for our rural veterans--men and women 
who should not be denied access to care based on the reality that their 
home is a rural community.

    Everyone on this Committee, I am certain, is familiar with the 
award winning production based on the book by acclaimed historian 
Stephen Ambrose, Band of Brothers. As the tagline for this story of 
Easy Company of the 101st Airborne reads: ``The world depended on them. 
They depended on each other.''
    What the Committee probably does not know was that one of this band 
on whom we all depended, Darrell Shifty Powers, came from Dickenson 
County in the rural coalfields of Southwest Virginia, a rugged and 
isolated region. Shifty, a bronze start recipient, returned home after 
the war to serve as a machinist for the Clinchfield Coal Company. 
Sadly, Powers died last year on June 17th of cancer
    As Power's daughter said of her father: ``He never bragged about 
what he did in the war. And for a lot of years, he never even talked 
much about what he did--unless someone asked him about it.'' Bravery 
and dignity was a constant thread running through the life of Shifty.
1. Barriers to Care in Rural Appalachian Virginia and the Consequences
    With his diagnosis of cancer Shifty Powers depended on our systems 
of care but the geography created huge barriers for him in terms of 
access to care and communication with health specialists, as the trip 
to the nearest cancer facility was hours away. The evidence is 
overwhelming that our rural veterans in Appalachia and other 
communities suffer far worse health outcomes because of several 
factors: geographic and personal isolation, limited access to specialty 
care, lower educational attainment, limited income and often extremely 
poor conditions within which to manage health.

------------------------------------------------------------------------
               Demographic Data*                 FD I & II     Virginia
------------------------------------------------------------------------
Population Growth                                     -4.9%       +14.4%
------------------------------------------------------------------------
H.S. Graduation Rate                                  61.0%        81.0%
------------------------------------------------------------------------
College Graduation Rate                                9.0%        29.5%
------------------------------------------------------------------------
Percent of Pop. Working                               41.8%          62%
------------------------------------------------------------------------
Below Federal Poverty Line                            19.5%         9.6%
------------------------------------------------------------------------

    The seven coalfield counties and one city that make up Health 
Planning Districts I and II in Appalachian Southwestern Virginia, for 
instance, are a uniformly rural area of more than 3,200 square miles of 
mountainous landscape with a population of nearly 207,000. This mostly 
homogenous population lives primarily in small, geographically isolated 
communities and suffers from declining population, low educational 
attainment, high rates of poverty and approximately half the per capita 
income of the rest of the State. This is true of the many of the 
veterans of the region.
    These persistent social problems are intertwined with significant 
disease risk factors that contribute to disproportionately high rates 
of heart disease, cancer, respiratory disease, diabetes, and 
depression. To complicate these social and health issues, the sharp 
mountain ridges and deep valleys that divide the region make access to 
work and health care difficult. There are serious health care workforce 
shortages in the area and no large-scale population centers capable of 
financing a full spectrum of specialty medical practice.

------------------------------------------------------------------------
              Health Risk Factors                PD I & II     Virginia
------------------------------------------------------------------------
Obesity                                               33.5%        25.1%
------------------------------------------------------------------------
Hypertension                                          38.2%        26.7%
------------------------------------------------------------------------
High Cholesterol                                      39.5%        36.2%
------------------------------------------------------------------------
Not in Wellness Activity                             33.75%        22.6%
------------------------------------------------------------------------
Smoking (Adults)                                      29.1%        20.6%
------------------------------------------------------------------------
Smokeless Tobacco Use                                 16.8%         3.4%
------------------------------------------------------------------------

    One only has to look at the 10-year history of the Remote Area 
Medical Expedition (RAM) in Wise, Virginia as an example of the 
magnitude of need. In 2008, the RAM-Wise expedition, the largest 
screening event in the United States, provided free medical, dental and 
vision care to over 3,000 people from the region over a single weekend 
at an abandoned strip mine. The University of Virginia Health System 
and its volunteer team of 217 health professionals staffed more than 
6,150 patient encounters and contributed care valued at over $1 million 
to that event.

------------------------------------------------------------------------
 Premature Mortality by Disease (adjusted rate
                 per 100,000)*                   PD I & II     Virginia
------------------------------------------------------------------------
Heart                                                  341*          203
------------------------------------------------------------------------
Solid Tumor Cancer                                     253*          185
------------------------------------------------------------------------
Chronic Lower Respiratory                               79*           38
------------------------------------------------------------------------
Stroke                                                   64           54
------------------------------------------------------------------------
Diabetes                                                 80           22
------------------------------------------------------------------------
Unintentional Injury                                   145*           82
------------------------------------------------------------------------
Suicide                                                 20*           11
------------------------------------------------------------------------
*statistically significant variance

    Combined with significant heath risk factors like high cholesterol, 
hypertension, too much smoking, it has led to extraordinarily high 
rates of premature mortality from all causes--heart disease, cancer, 
diabetes. In the region we have twice the level of suicides. We are 30 
percent more likely to die from diabetes, 44 percent more likely to die 
from lung disease. We have an epidemic of unintentional fatal overdoses 
from prescribed narcotics. We have twice the rate of poverty and half 
the per capita income of the rest of the Commonwealth. The consequence 
of these adverse socio-economic and health risk factors is that the 
residents of the region are 26 percent more likely to die prematurely 
than residents of other regions in the Commonwealth. In addition, the 
coalfields of Virginia are experiencing a full-scale public health 
crisis in addiction levels to prescriptive narcotics leading to 
astronomically high rates of fatal, unintentional overdose. According 
to the State medical examiner, the adjusted mortality rate from 
unintentional overdose is 40 deaths per 100,000 in the region compared 
to 8.3 per 100,000 for the State as a whole. Taken together, the health 
status of the region represents a significant geographically-based 
health disparity.*
---------------------------------------------------------------------------
    * All data is from the Virginia Department of Health (VDH) through 
health records of mortality and incidence rates between 1999 and 2005 
as well as the Office of the State Medical Examiner. Socioeconomic and 
demographic information was extracted from census data from 1990 and 
2000 at the Census tract level.
---------------------------------------------------------------------------
    This is the health environment of much of rural America that it is 
now time to address. I know this Subcommittee is well aware of the sad 
facts of the state of rural health care so let the VA lead the way. 
With some three million veterans who use VA medical services living in 
rural areas, the delivery of health care is more difficult and more 
costly. A survey of 767,000 veterans by the VA Health Services Research 
and Development Office found that rural veterans are in poorer physical 
and mental health compared to those who live in urban areas.
    Many studies, of which this Subcommittee is well aware, speak 
volumes about the health disparities faced by rural veterans. Veterans 
who live in rural settings have lower health-related quality-of-life 
scores than their suburban and urban counterparts. There is increased 
co-morbidity, more inefficient care, greater use of emergency rooms for 
primary services, less preventative care and reduced home care. These 
rural-urban disparities persist even after studies are corrected for 
age, gender, employment status, priority level, co-morbidity, and the 
U.S. census region in which the veteran lived. Disparities are evident 
in those who were both most and least dependent on the VA for health 
care services.**
---------------------------------------------------------------------------
    ** William B. Weeks, MD, et al. Differences in Health-Related 
Quality of Life in Rural and Urban Veterans, American Journal of Public 
Health October 2004, vol. 94, No. 10.
    Weeks et al. Veterans Health Administration and Medicare Outpatient 
Health Care Utilization by Older Rural and Urban New England Veterans, 
Journal of Rural Health, Volume 21,
Issue 2.
---------------------------------------------------------------------------
    As you are also well aware, the VA provides much of its medical 
care, particularly specialized treatment, in urban settings, which may 
be difficult for rural veterans to access. VA enrollees also obtain 
much of their medical treatment in the private sector, particularly if 
they have Medicare or other insurance and VA care is far away. Rural 
veterans have lower incomes and less insurance and therefore many have 
less access to both VA and non-VA care. They report poorer health, 
which suggests that their medical needs may be not adequately met.**
    These findings offer clear evidence that living in a rural setting 
is associated with a worse health-related quality of life. As with 
other residents of rural regions, a variety of factors may account for 
these disparities such as access, lower educational attainment, limited 
specialty care and more infrequent use of the VA health system.
    The consequence of these disparities is simply that the rates of 
premature mortality are higher for rural veterans. While it sounds 
dramatic, it is true: the issue we are discussing today is a life and 
death matter. While Congress has appropriated millions to implement a 
rural health outreach and delivery program it is only one aspect that 
must be supplemented by continued investment in proven technologies as 
we will face many challenges not only by our aging and elderly veterans 
such as Shifty Powers but also by the nearly one-half of veterans who 
fought in Iraq and Afghanistan and now live in rural settings.
2. The Role of Telehealth in the Delivery of Services to Rural 
        Americans
    As a preface to discussions of what remarkable innovations and 
processes wireless capabilities bring to address health disparities, it 
is important to set the critical context of improving outcomes for our 
rural veterans, a service that this Subcommittee is well aware of: 
telehealth.
    Telehealth can reduce many of the barriers of access to locally 
unavailable health care services. The integration of telehealth into 
rural communities especially including health information exchange 
through electronic medical records between the VA and rural health 
programs has profound implications for the development, support and 
delivery of health care services in the digital era--an integrated 
systems approach focused on disease prevention, enhanced wellness, 
chronic disease management, decision support, quality, ease of access 
and patient safety. These are all critical resources if we are to 
achieve equality of care for rural veterans.
    Through the incorporation of telehealth into a strategy for the 
care of rural veterans, a decreasing workforce of clinicians will be 
able to satisfactorily manage the expanding volumes of medical 
information, research and decision support analytic tools. This 
incorporation of telehealth technologies into integrated systems of 
health care offers tools with the potential to address the challenges 
of access, specialty shortages, and changing patient needs in both the 
rural and urban setting. Clinical services delivered via telehealth 
technologies span the entire spectrum of health care, and across the 
continuum from prematurity to geriatric care, with evidence based 
applicability to more than 50 clinical specialties and subspecialties. 
Cardiology, dermatology, ophthalmology, neurology, high risk 
obstetrics, pulmonary medicine, mental health, pathology, radiology, 
critical care, and home telehealth, are some of the many applications 
in general use, and for which a number of specialty societies have 
developed telehealth standards These services can be provided in live-
interactive modes and some, asynchronously, using store and forward 
applications such as the acquisition of digital retinal images of 
veterans with diabetes by a trained nurse. These images can be sent for 
review by a retinal specialist to identify patients at risk for 
diabetic retinopathy, the number one cause of blindness in working 
adults.***
---------------------------------------------------------------------------
    *** Williams, JM et al, Emergency medical care in rural America, 
Ann Emer Med 2001: 38(3):323-327.
    Burgiss, SG et al, Telemedicine for dermatology care in rural 
patients, Telemed Journal 1997; 3: 227-33.
    Chiang, Michael, Lu Wang; Mihai Busuioc; Yunling E. Du et al, 
Telemedical Retinopathy of Prematurity: Diagnosis, Accuracy, 
Reliability, and Image Quality Arch Ophthalmol, 2007:125, 1531-1538.
    Flowers, CW et al, Teleophthalmology: rationale, current issues, 
future directions, Telemed J, 1997: 3(1): 43-52.
    Breslow, MJ, Effect of a multiple site intensive care unit 
telemedicine program on clinical and economic outcomes: An alternative 
paradigm for intensivist staffing, Crit Care Med 2004; 32(1): 31-38.
    Swaamm, LE, et al. Virtual Telestroke for Emergency Department 
Evaluation of Acute Stroke, Acad Emer Med 2004: 11: 1193-1197.
---------------------------------------------------------------------------
    The aging of our veterans has also already created increased demand 
for specialty health care services to address both acute and chronic 
disease in the elderly. Such a demand, in the face of anticipated 
provider shortages, requires a fundamental shift from the model of 
physician centered care to one focused on patient centered care using 
interdisciplinary teams, evidence based medicine, the use of 
informatics in decision support and telehealth technologies. As an 
example, nationally, only 2 percent of eligible (ischemic) stroke 
victims receive brain saving thrombolytic therapies, primarily because 
this treatment must be administered within 3 hours from the onset of an 
ischemic stroke under the direction of a trained neurologist. The use 
of telehealth technologies offers immediate access to stroke.***
    Again, simply put, telehealth capabilities are integral to rural 
health, professional educational and economic development by providing 
essential links to specialty care and continuing education. It also 
ensures a method of the efficient provision of resources as well as 
being a tool for the economic development of rural communities.
    In an effort to address these significant rural-urban disparities 
in the Commonwealth of Virginia, we established the University of 
Virginia Telemedicine program in 1995, specifically to enhance access 
to specialty health care services and health related education for 
rural patients and health professionals using broadband 
telecommunications technologies. With Federal and State support, we 
have created a 60 site network of community hospitals, critical access 
hospitals, veteran's clinics, federally qualified community health 
centers, rural clinics, prisons, schools and State health department 
clinics located primarily in rural communities in western, 
southwestern, central and eastern Virginia.
    To date, we have facilitated more than 18,000 patient encounters--
including many veterans--linking remotely located patients and our 
University of Virginia health professionals representing more than 36 
different medical and surgical subspecialties. These services are 
provided on a scheduled basis or emergently. We offer store and forward 
services such as screenings for diabetic retinopathy or breast and 
cervical cancer. We have provided more than 50,000 radiographic 
interpretations through our teleradiology program. We provide live 
interactive consultations using traditional models of video-
teleconferencing and critical care applications, such as acute stroke 
evaluation and treatment, using traditional videoconferencing and 
robotic ``remote presence'' technologies connecting emergency 
physicians with stroke neurologists. We have saved lives, supported 
timely interventions, and spared patients and their caregiver's 
unnecessary travel and expensive transfer when feasible.
    While we have advanced these capabilities, Congress still needs to 
continue actions to drive broadband enhancement into rural areas and 
the application of telehealth in this environment by:

      Continuing Federal funding of demonstration projects;
      Reducing statutory and regulatory barriers to telehealth 
in Medicare;
      Aligning Federal agency definitions of rural with 
specialty health care shortages, in particular using the definitions of 
rural applied by the USDA Distance Learning and telemedicine Grant 
Program;
      Ongoing support and refinement of the Universal Services 
Fund;
      Improving inter-agency collaboration for telehealth 
services;
      Encouraging the use of (and reimbursement for) store and 
forward telemedicine; and,
      Ensuring health information exchange.
3. Opportunities for Improving Care: A Strategic Inflection Point
    While the expansion of broadband is the context for removing 
barriers, and telehealth a critical application, perhaps the most 
innovative process for achieving the elimination of disparities is 
wireless communications. It is clear that the world is in the midst of 
a wireless revolution.
    One of the most visible aspects of this global revolution is the 
cell phone. This tool is no longer a novelty . . . it is estimated that 
there are now more than 233 million cell phones in use in this country 
and almost 2.56 billion worldwide. I just returned, for example, from 
Tanzania where I was on a cervical cancer screening and prevention team 
seeking to achieve telemedicine connectivity back to the UVA Cancer 
Center. While we would screen rural Masai tribal women they would text 
messages to their family, conduct financial transactions and seek key 
resources.
    It should be noted that I maintained cell phone connectivity the 
entire time . . . even in the heart of the famed Ngorongoro Crater 
literally hours away from any populated areas. In fact, I had better 
cell phone coverage in Tanzania, one of the poorest countries in 
Africa, than I have in the coalfields of Southwest Virginia.
    The cell phone taken together with digital networks, remote 
monitoring capabilities including miniaturized sensors in a broadband 
wireless environment represents a strategic inflection point in health 
care which we will look back upon as a critical turning point much like 
the industrial revolution, the discovery of antibiotics or the 
invention of the personal computer. This capability, as the first Chief 
Technology Officer of the United States, Aneesh Chopra, said at the 
recent meeting of the American Telemedicine Association, is seemingly 
unlimited in job creation, in reducing health care cost and in 
improving the quality of life.
    Our rural veterans are entitled to access to this resource. And, it 
makes both clinical and economic sense. With servicemen and women 
returning from Iraq and Afghanistan--a majority of whom are cell phone 
users and many of whom are from rural areas--it is increasingly 
important that we use technologies to link the expertise of the VA 
medical centers to rural veterans alleviating some of the distance-
based challenges in the areas of primary care, mental health, traumatic 
brain injuries and even long-term or home-based care remote home 
monitoring.
    You will hear extensively about the critical aspects of the use of 
cell phones and other wireless monitors for health during these 
hearings. They are obvious in that this capability has already been 
proven to be well-suited for cardiac monitoring, blood glucose 
evaluation, medication compliance, post-surgical follow-up, vital signs 
monitoring psychological counseling, health information, public health 
alerts, patient engagement and doctor-patient relationship. These 
capabilities, in general:

      Reduce the isolation that occurs in rural communities;
      Provide a vehicle for messaging and key health 
information;
      Support the monitoring of chronic diseases;
      Promote compliance with medication;
      Reduce readmission to the hospital post procedures;
      Guide self-care; and,
      Enable improved care by home nursing.

    This abbreviated list in and of itself warrants investment as it 
represents the perfect storm of improved health outcomes, efficient 
processes and reduced costs. Just one element in this list--the care of 
chronic disease--according to the California Healthcare Foundation 
accounts for more than four-fifths of all health care expenditures. 
Imagine what it could mean to ensure improved medication compliance, 
increased exercise, healthy diet and appropriate use of health care 
resources for the bourgeoning numbers of veterans with diabetes. The 
savings would be staggering. We now need to consider that bandwidth and 
wireless access are a prescribable medication for the health of our 
communities.
    In certain specialized applications it has already been shown to 
make dramatic impact whether it is the use of a mobile messaging 
service that provides health tips and appointment reminders to 
servicemen with TBI or the dramatic VA Care Coordination and Home 
Telehealth project that demonstrated a 19 percent reduction in 
readmission for the same diagnosis and a 25 percent reduction in 
hospital days. These are real savings, true efficiencies in the system 
but most importantly, improvement in the lives of a precious resource, 
veterans and their families.
    At the UVA Office of Telemedicine we are now engaged with corporate 
partners to use these everyday wireless capabilities to improve home 
monitoring for diabetic patients and engender an atmosphere to improve 
medication compliance, healthier lifestyles and the reduced use of 
emergency rooms for primary care. But access remains a critical issue. 
Imagine what we could have done for Shifty Powers, the Easy Company 
solider from Clintwood, Virginia. Wireless capability would have 
perhaps helped him to feel less isolated, provided invaluable education 
for him and his family and reminded them of appointments. This combined 
with improved access in rural communities to telemedicine connection to 
specialty care is what is needed now.
    I want to thank the Subcommittee and Committee as well as Congress 
for the steps they have already taken to enable this environment. But I 
also challenge Congress to engender an environment of investment by:

      Continuing funding of demonstration projects that use 
wireless to enhance home monitoring, health promotion and education;
      Ensuring health systems are incentivized to use wireless 
configurations;
      Encouraging professional education to incorporate 
training in these devices and applications;
      Providing for appropriate financial coverage for use of 
this capability;
      Promoting a standards-based environment for usage; and 
critically;
      Ensuring a Nation of seamless coverage without network 
fragmentation.

    It has been stated that genetics and the tools of molecular 
medicine will provide a new golden age of medicine. While this is most 
certainly true, I contend it is wireless devices, telehealth 
applications and internet-based health software that are precipitating 
opportunities for improved health care for all veterans and for the 
Nation. Through this, we have the opportunity to get the basic right of 
prevention, access, education and ongoing care.
    The hope is that these new, remarkable technologies, from smart-
phones to EHRs to video-conferencing to sensor based health-monitoring 
devices, will empower patients, doctors and nurses to improve outcomes 
while cutting costs. For me, the ubiquitous presence of mobile phones 
is a major reason to think this world is now upon us. I strongly 
believe and hope this Committee is passionate that these capabilities 
are what will eliminate disparities in care for rural citizens, reduce 
the cost of care and stimulate remarkable new business models in the 
process.
    As our Nation moves forward in restructuring its health care 
delivery system, the innovative uses of these telehealth tools will be 
an important driver of that change. With the adoption of favorable 
policies driven by Congress and innovation applied to the care of 
patients using integrated telehealth tools that includes wireless we 
stand at the threshold of eliminating disparities that have caused our 
rural veterans to suffer for far too long.
    It is now time for us to stand up for those upon whom we depended 
for our health and freedom.

                                 
 Prepared Statement of William Cameron Powell, M.D., FACOG, President,
      Chief Medical Officer and Co-Founder, AirStrip Technologies,
                            San Antonio, TX

    Remote patient monitoring of critical patient data via mobile 
devices (i.e., iPhone, Blackberry, etc) is rapidly becoming a necessary 
technology within the health care IT space in order to better care for 
patients and improve outcomes.
    There are several reasons that patient monitoring with mobile 
devices is important. A few examples are as follows:

    1.  Doctors and nurses are mobile and the need for them to monitor 
more patients at different locations is growing.
    2.  There is an increasing shortage of health care providers 
relative to the increasing number of patients that need to be monitored 
either in the hospital, clinic or at home.
    3.  This shortage leads to a communication gap between caregivers.
    4.  The number one cause of patient injury in a hospital is 
communication errors between caregivers about a patient's condition.
    5.  There is now an expectation for real time, anywhere access to 
critical data.
    6.  The health care community needs to improve patient safety, 
reduce risk and improve communication as Federal regulation continues 
to drive technologies that improve outcomes.
    7.  Remote patient monitoring of real time data via mobile devices 
can close the communication gap, lead to better outcomes, improve 
patient safety and make the overall delivery of quality health care 
more affordable and more efficient.

    There is a myriad of problems with the health care delivery system 
in the United States. One of the core problems facing health care 
professionals and the patients they serve is an increasing discrepancy 
between the number of patients that need to be monitored and the number 
of doctors, nurses and other health care providers that are available 
to monitor them.
    In the United States, the number one cause of patient injury in a 
hospital is communication errors between caregivers. The demands of a 
doctor's or nurse's day necessitate their periodic absence from the 
patient care environment and it is during this time that communication 
errors can occur.
    Doctors are often in surgery, covering patients at more than one 
hospital, making rounds, on call, at the office, at home and thus not 
at the bedside all the time. Nurses and hospitalists are often dealing 
with new patient admissions, managing patient discharges or engaged in 
other work related activities that preclude them from always being at 
the patient's bedside.
    Within the hospital acute care environment, as in the Intensive 
Care Unit or in the Labor and Delivery unit, physicians and nurses rely 
on their ability to communicate about data that changes moment to 
moment. Much of the data that requires bi-directional communication 
involves visual data such as waveform data.
    Waveform data is the moving line across a screen that provides a 
graphical representation of a heart tracing, an unborn baby's heart 
rhythm, a brain wave, a mother's contraction pattern or a host of other 
monitored data. Being able to visually interpret and describe changes 
in these waveforms helps a care provider who is remote to be able to 
effectively understand what is happening to that patient in real time 
as well as the recent past.
    In this day and age of health care with such increasing demands on 
a doctor's or nurse's time, these health care providers are 
increasingly mobile. The health care system is burdened with solving 
the problem of effectively getting the right data about the right 
patient to the right health care provider to hopefully affect the right 
outcome.
    Real time remote patient monitoring through the use of mobility has 
received a lot of attention lately because the focus on remote 
monitoring through a de-centralized model has become a reality via 
cutting edge technologies and breakthroughs across a wide swath of 
solutions from cell phones to wireless communications.
    AirStrip's first product, AirStrip OB, is now installed in nearly 
200 hospitals in the U.S. and there are several thousand physician 
users. AirStrip allows Obstetricians to view the real time fetal heart 
tracing, a mother's contraction pattern or other critical data via a 
mobile device (i.e. iPhone) anytime or anywhere. Given that up to 60 
percent of adverse outcomes in Labor and Delivery are due to 
communication errors about the baby's heart tracing, providing this 
service to physicians when they are temporarily away from the bedside 
will result in fewer adverse outcomes, reduced patient injury and 
greatly improved physician and nursing workflow. AirStrip OB is the 
only known FDA cleared mobility solution of its kind.
    AirStrip is also about to go to market with its next product line, 
AirStrip Critical Care and Cardiology. These solutions will provide 
physicians with real time remote access to critical waveforms, patient 
vitals, decision support information and a tremendous amount of other 
patient data that will help physicians better care for their patients 
and make more informed decisions when they are temporarily away from 
the hospital. These additional AirStrip products are currently pending 
FDA clearance.
    Finally, AirStrip Technologies has developed a completely reusable 
and fully scaleable software development platform called AppPoint that 
can cut software development timelines by 80 percent and cost by 60 
percent. AirStrip and soon AirStrip partners will use this platform to 
rapidly develop and bring to market an additional compelling suite of 
mobile applications that will allow health care providers to securely 
use mobile devices and cellular/wireless networks to provide real time 
remote patient monitoring service in virtually any environment.
    The communication gap that currently exists between doctors and 
nurses that leads to patient injury can be closed through the use of 
remote patient monitoring solutions such as the AirStrip suite of 
mobile products.

                                 
   Prepared Statement of Rick Cnossen, President and Chair, Board of
  Directors, Continua Health Alliance, and Director of Personal Health
    Enabling, Intel Corporation Digital Health Group, Hillsboro, OR

    Good Morning Chairman Michaud, Ranking Member Brown and 
Distinguished Members of the House Committee on Veterans' Affairs, 
Subcommittee on Health.
    My name is Rick Cnossen, President of the Continua Health Alliance, 
a non-profit, open industry coalition of health care and technology 
companies that are joined to collaborate and improve the quality of 
personal health care. On behalf of the members of Continua, I would 
like to thank you for the opportunity to present testimony on the 
important issue of bringing health care to our veterans.
    Continua has 237 member companies from around the world that are 
dedicated to establishing a system of interoperable personal health 
solutions that fosters independence, empowers individuals and provides 
the opportunity for truly personalized health and wellness management. 
Continua is not a standards body--the Alliance selects existing 
commercially available standards and works to test and certify those 
standards so that personal telehealth solutions are interoperable, 
ubiquitous and contribute toward improved health management. 
Additionally, the Alliance writes guidelines on how to use those 
existing standards to achieve true interoperability across many 
companies and many devices.
I. Introduction to Personal Connected Health, Telehealth, and eCare
    Continua uses the term ``eCare'' to refer to the class of health 
information technologies that can facilitate any kind of virtual visit 
or electronic connectivity outside of traditional office visits among 
patients, family members, and medical professionals. eCare includes 
personal connected health as well as telehealth. It can be secure text 
messaging between a senior patient and their doctor to change a 
medication dosage, an audio chat, or a full video web cam visit. It can 
also be personal connected health with an in-home or mobile broadband 
device that can help providers track and trend data like blood pressure 
and weight fluctuations that seniors and other patients can take by 
themselves on a regular basis. eCare may also include using 
connectivity to help patients remember to take a medication, capture a 
vital sign, or view customized content sent to them by their clinician 
to teach them about managing their own disease. eCare expands and 
extends the efforts of medical professionals by providing information 
to and from patients without geographic obstacles.
    To realize the quality improvement and cost-containment goals of 
health care reform, our Nation must harness the benefits of 
technologies that allow patients and care providers to use real-world, 
remotely-collected data to make decisions about their health on a 
continual basis, rather than waiting until a condition has set in that 
requires them to schedule an urgent office visit or go to the emergency 
room. By tracking vital signs and other health data on a more regular 
basis and sharing it through secure systems, eCare offers many 
beneficial clinical capabilities:

      Empowers patients with tools that help them make sense 
of--and help manage--their own care;
      Collects real-world biological and behavioral data and 
trends on a regular basis with alerts for out-of-norm situations;
      Facilitates virtual visits with providers, whenever and 
wherever appropriate, via a range of electronic media;
      Enables social networking, awareness, and care support 
from family and friends who are nearby or distant;
      Personalizes care plans and educational content for each 
individual based on their needs, preferences, data, and capabilities; 
and
      Triages precious medical resources to enable the right 
amount of care to occur in the right place and time.
II. Successful Case Studies
    These current services and future health information technologies 
will be the key to improving the delivery of clinical services and 
health care quality, as well as containing health care costs. Many 
studies have shown the value of personal connected health. For example, 
the New England Healthcare Institute (NEHI) ``2008 Research Update, 
Remote Physiological Monitoring'' found that remote patient monitoring 
resulted in a 60 percent reduction in hospital readmissions compared to 
standard care and a 50 percent reduction in hospital readmissions 
compared to disease management programs without monitoring. The same 
study found that remote patient monitoring has the potential to prevent 
between 460,000 and 627,000 heart failure related hospital readmissions 
each year. Based on this reduction in readmissions, NEHI estimated 
annual national cost savings of up to $6.4 billion dollars.

    As our Nation looks for ways to improve quality, access, and costs 
of health care, it is important to realize that eCare technologies can 
save lives and dollars. For example, the Department of Veterans Affairs 
(VA) examined this issue in its report, ``Care Coordination/Home 
Telehealth: The Systemic Implementation of Health Informatics, Home 
Telehealth and DM to support the Coordination of Veteran Patients with 
Chronic Conditions.'' The VA found that implementing telehealth to 
coordinate patient care led to a 25 percent reduction in the number of 
bed days and a 20 percent reduction in hospital admissions. The report 
showed a cost of $1,600 per patient per annum for the telehealth 
program compared to $13,121 for traditional primary care and $77,745 
for nursing home care. Not only were patients able to avoid readmission 
and improve their health status faster through telehealth services, but 
taxpayers also saved money.
III. Role of Personal Connected Health, Telehealth and eCare as 
        Clinical Services and as Improving Health Care Quality in the 
        Patient Protection and Affordability Act (PPACA)
    eCare, including personal connected health and telehealth, 
complements clinic and hospital visits and improves health care 
quality. By monitoring their own data from home, patients and their 
caregivers become more engaged in self-care and aware of health trends. 
eCare can also improve consumers' access to care, particularly in rural 
areas, by easing logistical burdens and reducing or eliminating the 
need to travel to a provider's office for routine visits. In addition, 
through the use of personal connected health, providers have more 
information on a timely basis upon which to make medical decisions that 
can assist in addressing health problems before they become crises. As 
eCare removes geographical restrictions, patients will gain access to 
needed specialists who may not be local.
    Recognizing these challenges and opportunities, the Patient 
Protection and Affordable Care Act (PPACA) includes numerous provisions 
designed to promote personal connected health, telehealth, and other 
eCare services. For example, the Secretary of HHS is required to 
develop guidelines for a payment structure that provides increased 
reimbursement or other incentives for: improving health outcomes 
through quality reports, case management, care coordination, chronic 
disease management, medication and care compliance initiatives 
(including medical home); activities to reduce hospital readmissions; 
activities to improve patient safety and reduce medical errors through 
the appropriate use of best clinical practices, evidence-based 
medicine, and health information technology; and wellness and health 
promotion activities. eCare is at the crux of all of these services. 
(PPACA Sec. 1311)
    PPACA also recognizes that many meaningful physician encounters can 
occur remotely. Specifically, the Act allows certification or re-
certification of a patient for home health services or durable medical 
equipment to occur through a face-to-face physician encounter or 
through the use of telehealth. (PPACA Sec. 6407) In another example, a 
Medicare health risk assessment may be furnished through an interactive 
telephonic or web-based program that meets standards to be established 
by the Secretary of HHS. (PPACA Sec. 4103) PPACA also provides for 
investment in community-based collaborative care networks that expand 
capacity through telehealth and medication management services that are 
provided either in-person or through telehealth technologies. (PPACA 
Sec. Sec. 10333, 10328) These programs will both encourage the uptake 
of beneficial health information technologies throughout the health 
care system and address critical shortages of health care providers. 
Expanding the use of eCare will be paramount to providing high quality 
care for the increasing number of individuals who are living with 
chronic and expensive health conditions for longer than ever before. 
Without buy-in across government and private payers, the opportunities 
for eCare to enhance our health care system as recognized in PPACA will 
not be realized across our health care system.
    Many of the most promising ideas for health care delivery 
innovation depend on eCare services. PPACA looks to increase the use of 
eCare services to provide for future improvement in health care 
delivery. For example, the Independence at Home Demonstration Project, 
designed to improve care for chronically ill Medicare beneficiaries, 
defines an ``independence at home medical practice'' as one that ``uses 
electronic health information systems, remote monitoring, and mobile 
diagnostic technology.'' (PPACA Sec. 3024) Accountable Care 
Organizations participating in shared savings programs under PPACA are 
required to ``define processes to promote evidence-based medicine and 
patient engagement, report on quality and cost measures, and coordinate 
care, such as through the use of telehealth, personal connected health, 
and other such enabling technologies.'' (PPACA Sec. 3022) Further, the 
Center for Medicare and Medicaid Innovation created by PPACA may test 
models that support care coordination through ``a health information 
technology-enabled provider network that includes care coordinators, a 
chronic disease registry, and home telehealth technology,'' and may 
consider whether a model under review ``utilizes technology, such as 
electronic health records and patient-based remote monitoring systems, 
to coordinate care over time and across settings.'' (PPACA Sec. 3021) 
Without inclusion of eCare, from the beginning, as a clinical service 
or service that improves quality, our health care system will not 
benefit from or encourage the use of personal connected health or 
telehealth services. We urge policymakers to look to the future of what 
health care delivery can be through the use of wired, wireless, mobile 
broadband and whatever new forms of technology may appear to allow our 
uniquely American health care system to benefit from eCare as we know 
it and as we might know it in the future. eCare truly promises to be a 
disruptive approach that transforms the way that we provide health care 
and becomes an indispensible tool in the future.
    Services that change patient behavior, assist in treatment and 
compliance, and improve quality are supported by information 
technologies. These technologies serve as the backbone for the 
provision of a variety of activities including wellness, disease 
management, medication management services and illness prevention--all 
important goals of PPACA. Over time, this infrastructure will need to 
be improved and augmented in order to support these activities 
particularly as these services become better integrated into our 
overall health care delivery system. As our reliance on information 
technology systems grows, they should also be considered a part of 
those services that improve quality. Without the vital services of 
eCare, our health care delivery system will be limited and not help 
move health care into the 21st century.
    Technology is evolving rapidly. The rapid societal uptake of now-
commonplace devices from smartphones, to netbooks, to smartbooks, 
demonstrates the pervasive role of mobile wireless technology in our 
daily lives and the opportunities they bring to improve our access to 
health care. As we learn and develop ``best practices'' for eCare--and 
invest in comparative effectiveness studies to know the right balance 
of in-home, in-clinic, and eCare consultations for different conditions 
and needs--these technologies will ultimately help us move beyond a 
quantity oriented system (e.g., number of visits done or tests or drugs 
prescribed) to one of quality.
IV. Continua Utilizes Voluntary Industry Interoperable Standards for 
        eCare
    Health care costs continue to spiral upwards to the point of 
prompting national mandates for change. Technology has advanced to a 
point where personal telehealth systems provide viable, cost-effective 
solutions and represent a very real opportunity to help control costs. 
In order for deployment to become widespread, an ecosystem of 
standards-based interoperable components (starting with the consumer-
facing device) is essential. The Continua Health Alliance was 
established to address this need. Technological advances, such as 
innovations in networking technologies and the rapid increase and 
availability of wireless internet-connected devices, enable the 
development of solutions that address user needs in a cost-effective 
manner. These technologies also allow people to remain safely in their 
own homes longer. Personal telehealth systems composed of an ecosystem 
of commercially available standards-based interoperable components are 
the building blocks of these solutions.\1\
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    \1\ www.ContinuaAlliance.org
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V. Need for Device Interoperability
    While there are many challenges associated with the successful 
design, implementation and deployment of personal telehealth systems, 
one of the more obvious problems in early telehealth solutions has been 
the lack of device interoperability which requires broad industry 
support behind particular standards.
    Integrator/Purchaser
          Integrators (companies producing eCare solutions made up of 
        components from a number of different vendors) and purchasers 
        (health care providers that will be purchasing these solutions 
        and offering them to their patients or members) both require a 
        wide variety of system vendors and components to select from.
          Interoperability is important as it allows integrators and 
        purchasers to select from a wide variety of personal health 
        devices offered by multiple vendors.
    Product Designer
          From the perspective of a product designer, device 
        interoperability is essential. If the objective of the product 
        designer is to design equipment that will communicate with a 
        wide range of telehealth peripherals (for example, weight 
        scales, blood pressure monitors, glucose meters), it is very 
        likely that the desired set of peripherals be developed by 
        multiple vendors. Interoperable solutions will minimize cost, 
        improve design and development efficiencies and enable 
        separation of concerns that device vendors can focus on 
        devices, software vendors can focus on software development, 
        and service providers can focus on service delivery by 
        utilizing well-defined, unambiguous commercial standards and 
        guidelines.
VI. Continua Solution
Approach
    Continua Health Alliance was founded in 2006. The Alliance 
leveraged examples from other solution domains such as home networking 
(for example, Wi-Fi Alliance and Digital Living Network Alliance) in 
order to help define its overall approach. The result was the following 
methodology:

      Select existing, applicable industry standards
      Extend these selected standards where required (to meet 
user needs identified in use cases and requirements)
      Eliminate ambiguity in interpretation of these standards 
through a collection of interoperability guidelines
      Develop a certification process that guarantees products 
meet the guidelines and provide the consumer a high-quality user 
experience

    Continua put in place a flexible architecture that allows for a 
common approach but also accommodates regulated and unregulated 
products from the various application domains. The figure below shows 
the various components and the interfaces that constitute an end-to-end 
solution.
[GRAPHIC] [TIFF OMITTED] T8054A.000


VII. Recommendations for eCare integration
    Despite the success Continua members have achieved in developing 
devices and services as assistive technologies for patients with 
chronic disease and succeeded in making sure that these devices 
interoperate, significant barriers restrict the integration of eCare 
into patient care plans. In order to ensure that patients and 
clinicians have full access for their optimum health care, we 
respectfully submit the following recommendations:
1. Establish a Federal Organization Focused on eCare:
    The U.S. Congress realized the benefits of eCare by including 
references to technologies for personal connected health in more than 
20 provisions in Patient Protection and Accountable Care Act (PPACA). 
However, we find that Federal agencies may lack a coordinated approach 
to unlocking the potential of these powerful, cost efficient and life 
saving technologies. In order to maximize information sharing on an 
interagency basis, we urge the U.S. Government to consider the 
establishment of an ``Office of eCare''. Much like the Office of the 
National Coordinator for Health Information Technologies was formed in 
2004 through an Executive Order to accelerate the use of health IT, the 
expansion of eCare across various care delivery models is a timely and 
fruitful objective.
2. Payment Reform for eCare
    As noted in the Federal Communications Commission National 
Broadband Plan, reimbursement reforms are essential to incentivize the 
meaningful use and widespread adoption of eCare technologies. Simply 
stated, reimbursement issues are a barrier to the adoption of health 
IT. The Centers for Medicare and Medicaid Services (CMS) define 
telehealth services as the use of medical information exchanged from 
one site to another via electronic communications to improve a 
patient's health.\2\ Electronic communication means the use of 
interactive telecommunications equipment that includes, at minimum, 
audio and video equipment permitting two-way, real-time (with limited 
exceptions) interactive communication between the patient, and the 
physician or practitioner at the distant site. The definition includes 
limitations on the types of originating sites of care that can be used, 
in addition to the requirement that an originating site must be located 
in either a health professional shortage area (HPSA) or in a county not 
classified as a metropolitan statistical area (MSA).
---------------------------------------------------------------------------
    \2\ See Centers for Medicare and Medicaid Services, ``Telemedicine 
and Telehealth,'' http://www.cms.hhs.gov/Telemedicine/.
---------------------------------------------------------------------------
    eCare reimbursement should be permitted everywhere and at anytime 
and not limited to geographically rural areas. The limitations on which 
types of originating institutions and which fields of health care are 
eligible for telehealth reimbursement are outdated. Health care 
management should not be limited to only live encounters, where store-
and-forward technologies are perfectly capable of providing reliable, 
consistent, diagnostic care. Interoperable personal telehealth and 
remote monitoring of data can be used for disease management, safety, 
health and wellness. If a Medicare benefit plan covers a service, then 
that plan should also cover the same service when it is performed via 
eCare.
3. Establish Blueprints for the use of eCare in States and communities.
    We can learn from the successful deployment of 35,000 chronic care 
patients served by remote patient monitoring through the Department of 
Veterans Affairs. Although a closed system, the results are for 
patients with the same illnesses that Americans across the Nation face. 
We need to do the hard work of factoring new payment plans, work flow 
systems and efficiently using community resources to care for our 
patients at home. We offer the resources of the Continua Health 
Alliance to convene the appropriate participants--hospital systems, 
doctors, technology companies to work with Congress and HHS to design a 
system that works for all stakeholders.
4. Incorporate eCare as part of ``meaningful use''.
    The significant investments in health information technology (HIT 
infrastructure made through the American Recovery and Reinvestment Act 
(ARRA) and health care reform are an important starting place for 
improving our country's capacity to provide high quality and efficient 
care. Without a national infrastructure--an ``electronic highway'' for 
health information--it will be impossible for the United States to 
deliver quality care to more people at lower costs as the Nation ages. 
With the passage of AARA, our Nation took a leap forward in relation to 
electronic health records (EHRs) by allocating $19.2 billion towards 
the adoption of HIT. That investment is just one step. eCare is the 
next step forward, and without its inclusion in the ``Meaningful Use'' 
requirements, the significant dollar investment made by the Federal 
Government stops short of moving the system beyond just the use of 
records. eCare can populate electronic medical records with trend data 
and other timely information to provide a more complete picture of a 
patient and to empower providers to make clinical decisions that 
improve the health and lives of Americans. We urge HHS to ensure that a 
mechanism is in place to allow Personal Health summaries to be 
integrated into EHRs in a standard fashion (e.g., Continua's Health 
Record Network standard).
5. Make home broadband adoption for all Americans a top priority 
        following recommendations in the FCC's National Broadband Plan.
    Extending broadband adoption is especially important in rural parts 
of the country to enable new independent living and home health care 
solutions. Similar to the National Broadband Plan, Continua supports 
the FCC's notion that a Health Care Broadband Infrastructure Fund 
should be established to subsidize fixed, wireless and mobile network 
deployments to augment health care delivery in locations where existing 
networks are insufficient.
VIII. Future Vision of what eCare can deliver
    In 2005, the Center for Aging Technologies (CAST), developed 
Imagine--the Future of Aging. Rather than describe what the future 
could be, I invite you to watch the video which will give you a 
glimpse, through the eyes of one family, of what the future could look 
like with help from developing technologies that are possible, 
practical, affordable and ethical. You will also see how these 
technologies have the potential to improve care, preserve independence, 
and ensure quality of life while reducing costs.
    We must, however, take action through vision, leadership and 
national commitment to prepare for the demographic and economic changes 
that will inevitably transform health care.
    http://www.youtube.com/watch?v=SBH9dkCZsXQ.
    [GRAPHIC] [TIFF OMITTED] T8054A.001
    

                                 
   Prepared Statement of Kent E. Dicks, Founder and Chief Executive 
                 Officer, MedApps, Inc., Scottsdale, AZ

    Good Morning Chairman Michaud, Ranking Member Brown and 
Distinguished Members of the House Committee on Veterans' Affairs, 
Subcommittee on Health.
    My name is Kent Dicks, Founder and CEO of MedApps, a small business 
enterprise located in Scottsdale, Arizona. On behalf of the Team at 
MedApps and the veteran-owned enterprise that manufactures our devices 
here in America, I would like to thank you for the opportunity to 
present this testimony.
    We are here today to speak about overcoming rural health care 
barriers through the use of innovative wireless health technology 
solutions. I am here today to speak about innovative digital wireless 
communications technologies, like those produced by my company MedApps, 
which are quickly becoming a key component in the delivery of health 
care and services across America, via Wireless Remote Patient 
Monitoring.
    Medical devices, health sensors and their applications rely upon 
mobile broadband functionality and interoperability to transmit raw 
data, diagnostic health information, critical aspects of care, 
emergency services and related health information. These services are 
at the forefront of a revolution in the provision and delivery of 
health care in America; a revolution which collapses time, space and 
distance to more effectively monitor patients, develop analytical 
trends, maximize strained medical resources and save lives.
    First, a word on the nomenclature surrounding wireless health. 
There are many terms loosely used today to describe the differing and 
often confusing aspects of wireless health information technologies. 
Terms such as mHealth, e-Health, telehealth and telemedicine are but a 
few of many descriptive names being used in the wireless health space. 
Some terms have industry meaning, others are regulatory terms with 
strict Federal definitions and criteria.
    For purposes of today's hearing I will use the term ``eCare'', 
which is the term used by the Federal Communications Commission in 
Chapter 10 of the National Broadband Plan for America.\1\ eCare is the 
electronic exchange of information--electronic data, images and video--
to aid in the practice of medicine and health care analytics. eCare 
encompasses technologies that enable remote monitoring or ``store-and-
forward'' transmissions over wireless fixed or mobile networks. eCare 
is not a substitute for health care providers, physicians or 
clinicians--it is intended to augment the good work of medical 
professionals and improve patient care by making important information 
available to patients, their loved ones and care providers anywhere, at 
anytime.
---------------------------------------------------------------------------
    \1\ See: FCC National Broadband Plan: Connecting America, released 
March 16, 2010, at Page 200. See U.S. Senate Special Committee on 
Aging, Committee Hearing on April 22, 2010 ``Aging in Place: The 
National Broadband Plan and Bringing Health Care Technology Home'' 
http://aging.senate.gov/hearing_detail.cfm?id=324102&.
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    In a landmark comprehensive pilot with 17,000 veterans, the 
Department of Veterans Affairs demonstrated that by implementing remote 
patient monitoring they experienced a reduction in hospitalization by 
25 percent and an average cost of $1,600 per patient per year for 
remote monitoring compared to annual costs of $13,121 per patient for 
primary care and $77,745 per patient for nursing home care.
    Amazingly, those encouraging results and statistics were achieved 
with first generation of wired systems that are typically more costly, 
proprietary and are tethered to a point of care, lacking mobility. If 
the pilot program was able to achieve those encouraging results for 
patients using this technology, imagine the potential wireless eCare 
technologies would hold?
    eCare technologies like wireless mobile solutions drive down costs 
and improve care by closely monitoring patients wherever they may be. 
Thus, they allow health care to be practiced in a more ``Proactive'' 
manner, rather than in a ``Reactive'' manner, and can possibly head off 
a patient going to the emergency room or hospital setting in the first 
place.
    In my hand is an example of the technology that I am talking about. 
This is called the HealthPAL. The HealthPAL's sole purpose is to allow 
a patient to stay connected with their ``Electronic Health Record'' and 
ultimately their caregiver. The HealthPAL is FDA cleared and 
communicates wirelessly (or wired) with other medical devices designed 
for use outside the hospital, such as this Nonin 9560 Pulse Oximeter.
    A doctor may ask a veteran with chronic obstructive pulmonary 
disease or congestive heart failure to take a reading once a day in 
order to make sure that they are staying within the safe zones. And as 
you can see, the Pulse Oximeter reading went over automatically to the 
HealthPAL without the patient having to press any buttons whatsoever 
(hands off), using Bluetooth wireless technology. It's that simple.
    The HealthPAL, like the one that I am holding in my hand, has 
mobile phone technology embedded into it directly, using a technology 
called ``Machine 2 Machine'' (M2M). This 3G mobile broadband chipset by 
Qualcomm is about the size of a U.S. quarter, which is embedded in the 
HealthPAL, and is the key to connecting our Veterans to their health 
care providers, in an efficient and economical manner.
    You will be hearing a lot about M2M services and mobile chipsets in 
the near future, in relation to health care and smart grid 
technologies, in particular. Mobile chipset powered modules allow us to 
connect ubiquitously to cellular and mobile broadband networks 
throughout the U.S., and globally. According to the Federal 
Communications Commission nearly 96 percent of the U.S. population is 
covered by a mobile broadband network and 99 percent of the non-rural 
U.S. population and nearly 83 percent of the rural U.S. population is 
so covered.\2\ At the heart of science, medicine, energy and 
engineering, mobile wireless and broadband technologies are reliably 
and invisibly working in the background on economical rate plans.
---------------------------------------------------------------------------
    \2\ See: Bringing Broadband to Rural America, Report on a Rural 
Broadband Strategy, released May 22, 2009, at Pgs. 12-13. In making 
that finding, the Commission defined networks based on EV-DO and WCDMA/
HSPA as constituting mobile broadband. The Commission used the same 
definition of mobile broadband in its annual reports on the state of 
competition in the U.S. wireless market in 2009, 2008, and 2007. See 
Thirteenth Report, Annual Report and Analysis of Competitive Market 
Conditions with Respect to Commercial Mobile Services, WT Docket No. 
08-27, DA 09-54, released January 16, 2009 at Pgs. 69, 73-74; Twelfth 
Report, Annual Report and Analysis of Competitive Market Conditions 
with Respect to Commercial Mobile Services, WT Docket No, 07-71, 
released Feb. 4, 2008, at Pgs. 8, 68-69; Eleventh Report, Annual Report 
and Analysis of Competitive Market Conditions with Respect to 
Commercial Mobile Services, WT Docket No, 06-17, released Sept. 29, 
2006, at Pg. 54.
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    Innovative technologies like the HealthPAL are targeted towards 10 
percent of the population that consume 70 percent of the health care 
resources; the sickest of the sick. Often this population is older, and 
does not have access to ``state of the art'' technology or Internet 
access.
    The HealthPAL works as an agnostic hub or central device that 
connects to various medical devices and sensors and then transmits 
their data to a secure central server. The HealthPAL comes packaged 
together, including mobile wireless connectivity straight out of the 
box and ready to use. Nothing complicated to setup, provide or 
maintain--everything is done remotely, including software upgrades, 
much like popular ``KindleTM''.\3\ e-reading devices.
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    \3\ See: http://www.amazon.com/dp/B0015T963C.
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    Let me be clear about what we are trying to achieve in using ``off 
the shelf'' devices and mobile wireless technology. It is not to over 
engineer a gadget for the sake of fancy bells and whistles. Rather, it 
is about creating a sense of accountability and reliability between the 
patient and the caregiver, at the lowest cost possible. If a patient is 
``connected'' and accountable, then they are more likely to follow 
their doctor's instructions, take their readings, take their 
medication, and thus stay out of the hospital.
    The MedApps solution is used in a variety of ways, by everyday 
people including David Jesse, a Truck Driver from Rural Ohio. David's 
erratic schedule makes it difficult to set up and keep appointments 
with his doctor--and his health suffered because of it. David often had 
to produce log books to take back to his doctor at the Cleveland Clinic 
every couple of months and his doctor attempted to adjust his 
medication based on dated information. Today David uses the HealthPAL 
in the cab of his truck, and has taken his readings throughout 47 
States. This technology has allowed David to substantially improve his 
health and need for medication. He no longer has to drive back to Ohio 
every 2 months to be checked by his doctor, who along with David's wife 
can stay connected to him remotely while he's on the road, making sure 
he is ok and his medical conditions stay under control.
    At Meridian Health, a NJ based Health system, the technology is 
being used to help reduce re-admissions of congestive heart failure 
patients (``CHF''). Typically across the country, 27 percent of 
congestive heart failure patients are readmitted within 30 days with 
the same condition. An average CHF hospitalization is about $8,000. At 
Meridian Health, the HealthPAL and a wireless scale are provided to a 
CHF patient upon discharge to monitor the patient for thirty days to 
ensure patients with signs of worsening conditions are seen by their 
physician for early, less resource intensive interventions. The 
equipment is returned to Meridian at the end of the 30-day period. So 
far, out of 30 patients, Meridian has experienced no re-admissions due 
to heart failure within the 30-day period.
    eCare made this possible--today. The examination room of the future 
will be wherever the patient is located. Underserved patients are not 
just those typically found in rural America or in geographic areas of 
low population density, but can be anywhere our Veterans live. Now with 
an aging baby boomer demographic, more people will continue to place 
greater demands on the Nation's health care infrastructure everywhere. 
We need to provide the tools to help absorb those demands and make the 
provision of care available everywhere and at any time.
    In conclusion, the VA could potentially extend its capacity for 
remote monitoring on a daily basis from 35,000 patients currently, to 
over 100,000 patients by utilizing innovative mobile enabled medical 
technologies.
    Wireless mobile technology is a solution that is available today. 
Robust mobile networks exist to start bringing care to those who so 
desperately need and, in fact, deserve it, no matter where they live. 
The VA and U.S. tax payers would save a significant amount of time, 
money and natural resources by using mobile wireless enabled medical 
technology.
    Mr. Chairman, this concludes my prepared statement. I would like to 
extend an invitation to you and the distinguished members of the House 
Committee on Veterans' Affairs, Subcommittee on Health to observe a 
demonstration of this technology at a future time. I would be pleased 
to answer any questions you may have and on behalf of the team at 
MedApps, I thank you for the opportunity to discuss these issues with 
you today.

                                 
    Prepared Statement of Huy Nguyen, M.D., Chief Executive Officer,
                   Cogon Systems, Inc., Pensacola, FL

Background
    Thank you for the opportunity to testify before the Subcommittee on 
Health of the House Committee on Veterans Affairs. My name is Dr. Huy 
Nguyen. I am a Navy veteran who served in Iraq in 2003 as a physician 
attached to Fleet Hospital Pensacola. During that tumultuous period, I 
saw up close and personal the cost of war and the utmost sacrifices 
that our veterans make in service of their county. I have since 
separated from active duty; however, I continue to serve our military 
and veteran community presently as a civilian Emergency Department 
physician at my cherished Naval Hospital Pensacola. In addition to 
being a military-affiliated provider, I am also the Founder and Chief 
Executive Officer of Cogon Systems. Our mission at Cogon is to 
facilitate Connected, Value-Driven Health care. We achieve this by 
facilitating secure web-based health information solutions leveraging 
`cloud computing' technology. My personal interest in health care 
mobile technology and clinical information systems dates back to my 
years as a medical student and was developed further as a naval 
physician utilizing the military's electronic health record.
    This hearing is broadly intended to examine how the Nation can 
utilize new and innovative wireless technologies to expand access and 
quality of care for veterans in remote areas. In my testimony today, I 
will certainly discuss my company's experience with mobile health care 
technology and how it can impact veteran care. However, I would like to 
begin my testimony by discussing health information exchange and 
interoperability which complements mobile technology by allowing 
comprehensive health information available to be accessible to mobile 
devices. Secure mobile access to comprehensive health information can 
be particularly helpful to providers and veteran patients in rural 
communities.
    In discussing the potential of health information exchange, I will 
draw on my company's project in Pensacola which has facilitated the 
largest instance of secure data sharing between Federal and civilian 
health care providers. I believe that this project is in keeping with 
the spirit and intent of the Obama Administration's Virtual Electronic 
Health Record (VLER) efforts. Finally, I would like to discuss some 
innovative ideas that can empower our veterans in rural communities to 
assume greater ownership of their health.
The Department of Veterans Affairs' Stated Objectives and Mandates
    As context to today's testimony, I would like to highlight some 
significant objectives that guide Cogon's desire to facilitate better 
care for veterans and in the process be a beacon for the greater 
civilian health care community.
    The Department of Defense Military Health System (MHS) and Veterans 
Administration (VA) are promoting the VLER initiative which represents 
the first iteration of a new national capability to securely share 
electronic health and administrative information. In order to ensure a 
seamless transition of health services from one agency to another, MHS 
and the VA are implementing these critical elements:

      a full understanding of medical care capabilities within 
both agencies by all medical providers involved,
      clear communications of the transition plan between 
providers in each agency and with the patient and patient's family,
      timely transfer of all pertinent medical records before 
or at the time of transfer of the patient, and
      ongoing communication after the transfer of the patient 
between the medical providers in each agency and with the patient and 
patient's family.
On April 9, 2009, President Obama directed the Department of Defense 
        and the Department of Veterans Affairs to create the Virtual 
        Lifetime Electronic Record:

        ``. . . will ultimately contain administrative and medical 
        information from the day an individual enters military service 
        throughout their military career and after they leave the 
        military.''

    In light of the fact that 3 out of 4 Veterans receive a portion of 
their care from a civilian private sector provider, President Obama has 
also stated it is important to:

        Allow health care providers access to servicemembers' and 
        Veterans' health records, in a secure and authorized way, 
        regardless of whether care is delivered in the private sector, 
        Department of Defense, or VA

    The MHS and VA have been pioneers in adopting electronic health 
records well before their civilian providers. Therefore, in my humble 
opinion, the VLER initiative is an ambitious and natural progression of 
the investments that the MHS and VA have made in the realm of digital 
health care. Furthermore, the VLER initiative can shed light to the 
greater health care community's efforts to share health information via 
the Nationwide Health Information Network (NHIN). The question here 
today then is can the MHS and VA leverage its past and current focus on 
health information technology to translate into better care for our 
military personnel and veterans especially in underserved communities.

    As an example, the VA has stated that it has decreased unnecessary 
hospitalizations through a wide-ranging effort to help veterans manage 
chronic conditions at home. 1,2 Hospital use decreased 25 
percent overall and 50 percent for patients in highly rural areas by 
linking 32,000 chronically ill veterans with health care providers and 
care managers through video phones, digital cameras, and messaging and 
telemonitoring. This is an example of how the VA's investment in an 
electronic health record can `springboard' better patient care and cost 
savings.
---------------------------------------------------------------------------
    \1\ Jia H, et al. ``Long-Term Effect of Home Telehealth Services in 
Preventable Hospitalization Use,'' Journal of Rehabilitation Research 
and Development 46, no. 5 (2008): 557-566.
    \2\ Darkins A, et al. ``Care Coordination/Home Telehealth'' The 
Systematic Implementation of Health Informatics, Home Telehealth, and 
Disease Management to Support the Care of Veteran Patients with Chronic 
Conditions,'' Telemedicine and e-Health, 14, no. 10 (2008): 1118-1126.
---------------------------------------------------------------------------
    In FY 2006 an estimated 8.3 percent of the populations are 
Veterans. The Veteran enrollee population was about 7.8 million. About 
38 percent of such enrollees live in rural or highly rural areas.\3\ In 
these rural communities, access to a VA care facility is logistically 
and often financially challenging for most of these veterans. As I see 
it, our veterans have often gone to isolated places to serve us, so now 
it is imperative that we find means to serve them wherever they may 
reside. I believe that technology coupled with the internet and 
increasing digital broadband will allow for innovative means such as 
the example above to provide care in the rural communities.
---------------------------------------------------------------------------
    \3\ Presentation of Adam Darkins, Veterans Health Administration 
Presentation at the Second National Rural Health Information Technology 
Conference, September 12-14, 2007.
---------------------------------------------------------------------------
Health Information Exchange as the System Behind Access to Information 
        to Help Veterans Care and Drive Mobile Technology
    Cogon's health information exchange is designed to (1) ensure first 
and foremost electronic security; (2) facilitate data interoperability 
from disparate systems; (3) handle network scalability as required by 
the Nationwide Health Information Network (NHIN); and to facilitate 
other applications and innovations. The VIRTUAL HEALTH 
NETWORK' (VHN) is Cogon Systems, Inc. (Cogon) underlying 
software platform. The platform integrates with providers such as 
hospital's existing information systems. The VHN is agnostic toward 
specific types of electronic health records software. The VHN is not 
meant to replace electronic health records but as an augmenting data 
broker that will find, compile, and present this data to caregivers in 
a manner that will allow them to make the best decisions possible at 
the moment of care.
    Furthermore, the VHN was designed to leverage `cloud computing' so 
that providers do not have to make any capital investment such as 
buying unnecessary hardware and incurring significant software 
licensing. It is Cogon's focus to utilize the internet coupled to a 
utility business model to lay a foundation of flexibility and 
sustainability that we believe is critical for provider adoption. 
Health information exchange (HIE) provides for the sharing of clinical 
and administrative data across the boundaries of health care 
institutions, health data repositories, and States. The full potential 
is going to take time and multiple-steps to achieve.
    Health information exchange includes core fundamentals such as 
participation, connectivity, data use agreements, privacy and security, 
record location, basic functionality, and return on investment. Our 
proposal for a sustainable model starts by focusing on these issues. 
For the next decade we need systems where institutions at different 
levels of sophistication may participate, be connected and have 
sustainable arrangement for sharing data where there is a business 
advantage. These institutions such as rural hospitals will migrate to 
more sophisticated systems such as disease management on time frames 
related to their circumstances and return on investment. With health 
information technology (HIT), we should never let perfection be the 
enemy of good.
    Providers have significant HIT issues to consider over at least 5 
to 10 years: meaningful use requirements, new privacy and security 
rules, updating billing and coding standards for transactions, dozens 
of new reporting and operational requirements, new technologies, 
changes in practice, new pressure to control costs, changes that flow 
from health care reform changes to the insurance market, evidence based 
medicine, personalized medicine, and more. There is a lot of 
uncertainty over how these issues will roll out. There are regulations, 
penalties, and financial risks from any investment. It is important to 
allow providers to participate at the level in exchange at the level 
that fits their schedule. This approach is in keeping with our 
continued belief that health care should adhere to market forces as an 
impetus to innovation and better care.
The Pensacola Model: Strategic Health Intelligence
    The health information exchange (THIE) project in Pensacola to 
facilitate the sharing of health information between military and 
civilian providers was a congressionally-funded project. The basis of 
congressional support for this endeavor is due to the fact that by some 
estimates, more than 60 percent of health care delivered to DoD 
beneficiaries is provided by private sector health care providers. 
Those providers are unable to access information regarding a patient's 
health status or care episodes from the MHS' electronic health/medical 
record systems. Similarly, patient visits to private sector health care 
providers which capture an enormous amount of information regarding 
care, health and readiness are not available to MHS providers. This is 
the reality of patient care in MTF communities across the country.
    The project is fiscally managed by the MHS' Telemedicine and 
Advanced Technology Research Center (TATRC) that successfully tested 
the concept of exchanging protected health information between Naval 
Hospital Pensacola and private sector health care providers in 
Pensacola using DoD/VHA Bi-Directional Health Information Exchange 
(BHIE) interfaced to Cogon Systems' Virtual Health Network. The 
following data set can currently be accessed transiently by military 
and civilian providers via Web services: C32 Patient Summary, patient 
demographics, diagnoses/problem list, providers, allergies, 
medications, laboratory results, radiology results and clinical notes. 
This is the reality of patient care in Pensacola today. To date, more 
that 30,000 patient records concerning patients jointly seen by the MHS 
and Pensacola civilian providers can be shared. This data exchange is 
in compliance with the Data Use Agreement between our company and the 
MHS' TRICARE Management Activity office.
    At the onset of the project, TATRC made it clear that there was no 
sustainment budget for this project regardless of its success. In 
looking at the sustainment of this project, we felt that a utility 
business model that allowed civilian and Federal providers to cost 
share this project was the most market-based approach. Among civilian 
providers, we also had to contend with the sensitivity of a highly 
competitive environment where a common-value proposition may be a tough 
sell. Therefore, critical to a successful utility was the need for a 
trusted community broker that could govern and manage the utility. In 
our community, the Pensacola Bay Chamber of Commerce fit the profile of 
a neutral entity that could `cut through the clutter. ` Under the 
auspices of the Pensacola Bay Chamber of Commerce, an organization 
called Strategic Health Intelligence has been established to manage the 
Federal-civilian health information utility (HIU).
    Pensacola/Escambia County is now one of the advanced digital health 
care communities in America. Pensacola pioneered shared governance 
involving Federal and civilian providers across the entire community 
for its health information exchange. Furthermore, the Health 
information utility (HIU) business model is a template for sustaining 
shared costs between Federal and competing civilian providers to effect 
``game changing'' community-wide clinical decision support. The HIU is 
the first and largest instance of operational data sharing between 
civilian and Federal providers to date. Pensacola/Escambia County also 
has a high rate of electronic health records (EHR) adoption (>40 
percent).
    The Florida Gulf Coast boasts a large contingency of active duty 
and retired military. Escambia County is fortunate to have not only the 
Naval Hospital Pensacola, but also a VA Joint Ambulatory Care Clinic. 
Both facilities are not only supportive of this application, they also 
play a significant role in the Chamber's HIU and are board members of 
the Strategic Health Intelligence, LLC.
    The Chamber's health information utility (HIU) has a successful 
track record in connecting and exchanging health data between civilian 
and Federal Government networks. Initiated in 2008, the Chamber's HIU 
has facilitated the largest instance of data sharing between Federal 
and civilian providers by integrating 300,000+ unique civilian patient 
records from local hospitals and correlating those records with over 
23,000+ unique Federal records from the current health information 
exchange (HIE) between the DoD and VA. With demonstrable market 
penetration the Chamber is operating one of the largest sustained HIE 
systems in existence to date. This system is currently the largest 
operation connecting military data to civilian providers and 
demonstrating success and lessons learned can directly contribute to 
business and technologies in the emerging Virtual Lifetime Electronic 
Record/Nationwide Health Information Network (VLER/NHIN) pilot projects 
such as Phase 1a. The VA has a highly adopted electronic health record, 
VistA, and an advanced personal health record (MyHealth-Vet). However, 
to assure appropriate transitions of care as noted by President Obama, 
the VA and MHS' electronic health records must be interoperate with 
civilian providers'. As I have mentioned we are exchanging data in 
Pensacola with the MHS under a data use agreement. This exchange is 
with the Bidirectional Health Information Exchange (BHIE) program that 
connects MHS and the VA. Though the BHIE is not yet want to include the 
VA in the exchange so we can help veterans make sure their transitions 
of care are coordinated. Right now less than 20 percent private 
providers have adopted EHR's. This does not have to be an impediment to 
all exchange. If we make hospital, VA and DoD information available to 
providers via the web, this helps transitions of care.
    In moving forward, we plan on transitioning to the National Health 
Information Network (NHIN) and to a sustainment model for health 
information exchange as a public utility under the auspices of 
Pensacola Chamber of Commerce. As we embark on health information 
exchange, we need to remember that the perfect is the enemy of the 
good. Community-wide health information exchange between civilian and 
military health care providers is a good place to start. And a market-
based approach to cost sharing is the key to long term sustainment of 
VLER-like communities.
Mobile Technology As a Value-Added Adjunct
    In addition to our experience with health information exchange 
involving Federal providers, we are also under contract with TATRC to 
deploy a next-generation mobile solutions so that military providers at 
Madigan can access critical health information securely on the latest 
mobile devices over wide-area cellular network. I absolutely believe 
that over the next 10 years, mobile technology will undergo the seismic 
changes that we have experienced over the past 20 years with desktop/
laptop computing. With increased mobile bandwidth coupled to greater 
computing power coupled to pervasive communication media (voice, email, 
text, video, etc.), the days of Dick Tracy's video watch is not far 
off. Since health care involves inherently a mobile workflow, I am 
excited as a physician and technologist how mobile technology will 
transform the practice of care. Finally, I am also excited about how 
mobile technology in conjunction with health care data interoperability 
will empower our patients and veterans to assume true ownership of 
their care and health. I think that mobile technology can send alerts 
to our patients to make appropriate follow-ups, refill medications, and 
interface with their providers in virtual manners that will decrease 
the burden on our emergency rooms and medical practices while 
potentially keeping them out of expensive hospitalizations.
Transitions of Care for Wounded Warriors and Broadening Health 
        Information Technology Incentives
    On the issue utilizing health information and mobile technology to 
provide better, comprehensive care for our veterans, I would like to 
highlight an issue of incentives for ancillary providers, who play 
critical roles in the holistic care of our wounded warriors. In 
consideration of transitions of care for returning wounded warriors, 
the 2007 Report of the President's Commission on Care for America's 
Returning Wounded Warriors notes:

        . . . Injured servicemembers receive clinical care in many 
        settings. It may be provided in military hospital inpatient 
        units and outpatient departments, in the private practices of 
        physicians and mental health care professionals, and in various 
        physical rehabilitation programs connected with the hospital, 
        the nearby community, the VA, or back home in their own 
        communities. They also are eligible for numerous education, 
        training, and employment programs that, although not clinical, 
        depend for their effectiveness on servicemembers' level of 
        physical and mental functioning. . .

        . . . With our proposed comprehensive Recovery Plan, patient 
        records would need to be electronically available to the 
        Recovery Coordinator, health care professionals, and program 
        staff across the continuum--from acute care, to rehabilitation, 
        to long-term support, education, and employment programs, if 
        needed. The system must be secure and designed so that various 
        professionals have access to the information germane to their 
        work. . .

    This means groups that provide orthotics and prosthetics, physical 
therapists, psychologists and more need to be part of the continuum of 
care with respect to electronic records and exchange. By leaving key 
groups out of incentives we are not only failing the recommendations of 
the Commission but delaying the day when full coordination across the 
continuum of care will apply.
    Unfortunately, the ARRA funding for health information technology 
adoption left these critical groups out. The exclusion of these groups 
from the HIT puts care coordination and exchange even further behind. 
Cogon and Pensacola are focusing on the transitions of care between 
military and civilian providers. Wounded warriors are a particularly 
important use case to promote and we look to Congress to assist with 
this effort. Again, by leaving key groups out of the incentives 
programs, we are undermining this vision and ignoring critical 
stakeholders in VLER communities.
Challenges for Rural Communities
    According to the National Rural Health Policy Institute challenges 
for rural communities include: \4\
---------------------------------------------------------------------------
    \4\ Presentation of Neal Neuberger, Executive Director, National 
Rural Health Association, Rural Health Policy Institute before the 
Institute for eHealth Policy, January 25, 2010.

      Patients may be isolated, must travel long distances or 
are homebound; Access is a major problem
      Rural residents and minorities may be older, and often 
with certain chronic conditions
      Cultural and Language Barriers
      Low patient volume
      Longer wait times for Care
      Disjointed care; Lower quality of care
      Lower income, and less private insurance
      Many are Less Likely to Own or Use Computers
      Limited (but growing) Use of Internet
      Underserved Health care Providers may have no IT support 
let alone an IT Department; HIT Worker Shortages
      Hard to find M.D. or Admin. leaders/Change agents
      Other business priorities i.e. ``surviving''
      No business case for connectivity/linkages to other 
institutions
      No aggregate buying power (hence pooled vendor selection 
processes & need for Networking)
      Need to address critical referral pattern issues, 
disruptions, patient flows etc.

    These are all very significant that I believe highlights the need 
for web-based health information technology and mobile technology to 
help mitigate issues. Obviously, web-based exchange needs broad-band 
access, and I believe that the Federal Communications Commission is 
making significant investments to address rural broad-band. It must be 
noted that in Pensacola, the Chamber is also the lead agency in rolling 
out the Lambda Rail, which provides large bandwidth via a fiberoptic 
cable. Web-based software as a service in conjunction with broadband 
access will allow for `cloud computing' offerings that will lower the 
barriers for rural communities to implement leading-edge approaches to 
better physical and mental health care. Below are some approaches that 
I believe could be championed by the VA in rural communities:

    1.  Social Networking--Modern health care is an inherent social 
network with the patient/veteran at its core. So some of the concept of 
FacebookTM and other social sites can be adopted to bring a 
level of transparency that will allow for multiple providers to better 
coordinate the complex, remote care of veterans in rural communities. 
Furthermore, I believe that social networking can be a means for 
veterans to support themselves as `brothers in arms' in their 
transition to civilian life.
    2.  Interactive Mobile Personal Health Records--Personal Health 
Records (PHR) including My HealtheVet have had challenges of adoption 
by patients. At Cogon, we are working toward a mobile approach to PHR 
that will interact with patients via cell phones. We believe that 
health information needs to be available to the patients wherever and 
whenever they may be. And the same mobile mechanism can be utilized to 
reinforce specific care goals such as medication compliance via alerts 
and text messaging.
    3.  Care and Referral Management--The sustained care of wounded 
warriors often entails a coordinated complex care management scheme 
involving military, VA, and civilian providers. The coordination of 
care can be better automated and tracked,
    4.  Tele-medicine--Access to the cumulative record of veterans in 
rural communities will facilitate for veterans to make more `virtual' 
visits to providers such as specialists.
    5.  Disease Management--As more health information becomes 
integrated and standardized, it will allow for the greater use of 
sophistical analytics tools to maximize patient care.
Summation
    As a physician and a veteran, I would like to thank this Committee 
for allowing me the opportunity to testify on a subject that is 
personally dear to me--the care of veterans. I believe that VA in 
conjunction with the MHS has an enormous opportunity and responsibility 
to maximize its leadership in health information technology in order to 
take care of our veterans. We hope the Subcommittee will support 
efforts to add exchange with the VA to our current civilian-DoD 
exchange efforts in Pensacola to improve veterans care.

                                 
 Prepared Statement of Dan Frank, Managing Partner, Three Wire Systems,
     LLC, Vienna, VA, Also on behalf of MHN, A Health Net Company,
     San Rafael, CA, on the VetAdvisor' Support Program

    Mr. Chairman and distinguished Members of the Committee, we are 
grateful for the opportunity to provide testimony on Overcoming Rural 
Health Care Barriers: Use of Innovative Wireless Health Technology 
Solutions. My name is Dan Frank and I am the Managing Partner of Three 
Wire Systems, LLC (Three Wire). I am joined by my colleague, Dr. Ian 
Shaffer. Dr. Shaffer is the Chief Medical Officer for MHN. Three Wire 
is the prime contractor and MHN provides clinical support for the 
VetAdvisor' Support Program which is the topic of our 
testimony.
    We will provide an overview and results to date of the VetAdvisor 
Support Program (VetAdvisor), an innovative evidence-based program that 
provides mental health outreach and health coaching services to 
Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) 
Veterans and their families, in both urban and rural areas. VetAdvisor 
uses non-traditional telehealth/virtual health delivery platforms to 
reach out to, and improve Veteran awareness of, and access to, the 
mental health support for which they are eligible.
What Is VetAdvisor?:
    Telehealth is the underpinning of this ongoing program to ensure 
Veterans who have enrolled in VA and who may have mental health issues 
do not fall through the cracks. VetAdvisor is a two-part program--
sponsored during the past 3 years by Veterans Integrated Service 
Network (VISN) 12, which augments and supports existing VA behavioral 
health care services, and assists Veterans with challenges they face 
during reintegration into civilian life. Using a call center that makes 
outgoing calls to conduct VA-approved behavioral health screenings, 
VetAdvisor identifies and refers to VA Veterans who may be in need of 
clinical behavioral health assistance. In addition, health coaching is 
a newer component of the program, which provides Veterans with an 
opportunity to participate in individual or group health coaching 
sessions using a virtual room on a computer, or by phone, if the 
computer is not an option. For example, a Veteran may work with a 
health coach on issues such as tobacco cessation, weight management, or 
understanding Post Traumatic Stress Disorder (PTSD) management.
    VetAdvisor assists Veterans and their families, providing 
complementary, non-clinical support to Veterans identified and referred 
to the program by VA. Telehealth platforms allow enrolled OIF/OEF 
Veterans to stay connected and focus on areas of concern to them 
without leaving their homes. VetAdvisor's trained health coaches (i.e., 
Licensed Clinical Social Workers) who conduct these sessions are 
critical to the popularity and growing success of this innovative VISN 
12 initiative.
    VetAdvisor, as an extender of VA face-to-face clinical services, 
focuses on identifying and working with Veterans who have, or are at 
risk for, PTSD, depression, substance abuse, suicide and homelessness. 
This telehealth approach to outreach, screening and coaching helps 
eliminate the stigma Veterans often associate with seeking mental 
health services and assists them in getting treatment.
    From Wired Broadband to Mobile Wireless Health Platforms
    In the past, Veterans who opted to use the virtual world health 
coaching program required wired broadband internet connectivity for 
their desktop or laptop computers to access a 3D collaboration 
environment to work with their health coach as depicted below.
[GRAPHIC] [TIFF OMITTED] T8054A.002


    However, Veterans who reside in rural areas can face challenges 
acquiring such wired services. Recognizing this limitation, VetAdvisor 
worked with our technology partners to leverage the most ubiquitous of 
consumer electronic devices: the mobile phone. In the United States, 
there are over 285 million mobile phones in use, which equates to a 91 
percent market penetration. The use of mobile devices to wirelessly 
provide highly mobile or rural populations direct access to a health 
care system is an important component in VA's transition to the Patient 
Centered Medical Home model. VetAdvisor will launch a virtual world 
smartphone capability (i.e., iPhone) in the fall of 2010. By extending 
the virtual world to smartphones, we can significantly increase the 
Veteran user base in rural areas where broadband service is not 
available but cellular service is. Additionally, please note that if 
Veterans opt to not to use the virtual world, they can simply use their 
cell phones to obtain health coaching services.
    Today's Veterans are increasingly reliant on mobile devices for 
communication and entertainment. VetAdvisor allows Veterans to access 
their health coach/virtual room on their own terms at a time and place 
that is most advantageous to them. The image below is an example of the 
VetAdvisor Virtual Room (VVR) as hosted by an Apple iPhone. We envision 
Veterans using these mobile devices anywhere and anytime they desire to 
work with their health coach within the virtual world. The scene below 
depicts a Veteran working with his medical team in the VVR to discuss 
the loss of a limb.
[GRAPHIC] [TIFF OMITTED] T8054A.003


    Leveraging the latest wireless technology employing telephonic and 
virtual world platforms, this program provides a cost-effective, 
appropriate and popular expansion of VA's telehealth capability to 
allow for convenient follow-up with Veterans in urban and especially 
rural communities that VA identifies as at risk. Without this program, 
many of these Veterans might not return to VA to get the help they need 
or have as successful a return to their jobs, school and families.
The Evolution of VetAdvisor
    VetAdvisor was initiated as a competitively awarded contract in 
2007 by VISN 12, to Three Wire Systems, LLC (Three Wire), a Service 
Disabled Veteran Owned Small Business, and MHN, a Health Net behavioral 
health company.
    Veterans who enroll in VA after returning home do not always seek 
clinical help until their mental health needs are critical. This may be 
due to a lack of understanding of symptoms, denial that a problem 
exists, lack of awareness of available mental health support, or 
stigma. VetAdvisor overcomes these barriers through its telephonic/
virtual approach to identifying behavioral health care issues and 
virtual health coaching. VetAdvisor contacts those Veterans who may not 
take the initiative to get involved in mental health care before a 
tragedy or issues occur. VetAdvisor does this by using a proactive 
outreach approach:

      Using Computerized Patient Records provided by VA, 
VetAdvisor representatives call Veterans to thank them for their 
service
      During the phone call or at a scheduled date/time that is 
convenient to the Veteran, the health coach assesses the Veteran 
through a series of VA-approved screenings. The screenings cover both 
medical and behavioral health conditions associated with serving in 
combat to include: PTSD, Traumatic Brain Injury (TBI), suicide risk. 
substance abuse, depression and common medical disorders.
      If needed, a referral is made (and followed up on) to a 
VA mental health clinician.
      The VA medical facility is provided with the results of 
these screenings. The VA uses the results for follow-up and further 
evaluation. Once Veterans with behavioral issues are identified, they 
are encouraged to enroll in the VetAdvisor Health Coaching Program.
      The Health Coaching Program facilitates and supports 
Veteran involvement in existing VA services. A health coach is assigned 
to the Veteran for regular contact, advocacy, skill building, support 
and to provide motivation to seek treatment.
      Coordination continues with the Veteran, health coach, 
and primary care physician for as long as necessary.

    Health coaching services are provided to Veterans through 
telephonic communication and/or virtual collaboration technology--the 
VetAdvisor Virtual Room (VVR). In the VVR, the Veteran and the coach 
interact as avatars. This highly immersive virtual environment provides 
strong feedback that enhances collaboration and communication. Virtual 
technology assists Veterans in their reintegration efforts in a number 
of ways. One of the major advantages is that it allows for the Veteran 
to discuss personal issues from the privacy of his or her own home or 
private setting of choice. Veterans maybe more willing to acknowledge 
the magnitude of their issues in this private environment. Secondly, it 
saves the veteran time and travel costs associated with office visits. 
For today's Internet savvy generation of Veterans and their families, 
this form of communication feels more natural than traditional 
communication methods.
[GRAPHIC] [TIFF OMITTED] T8054A.004


VetAdvisor Coaching Groups
    During the 18 month pilot period, VetAdvisor engaged over 10,000 
Veterans from VISN 12. As a result of the program, over 1,100 Veterans 
were directed to VA medical facilities for follow up on positive 
screening results. The statistics support the program's success: when a 
Veteran was successfully contacted, there was a 95 percent acceptance 
for health coach screening appointments. The types of issues discussed 
in health coaching sessions cover a wide range. The top issues are 
occupational, anxiety, health lifestyle management and depression.
    The figure below illustrates the range of issues addressed in the 
sessions.
[GRAPHIC] [TIFF OMITTED] T8054A.005


    VetAdvisor's proactive outreach and screening for behavioral issues 
has proven to be an effective tool in assisting Veterans ability to 
access services to treat or prevent potential issues such PTSD, 
depression, or substance abuse that can lead to a downward spiral in 
their life and even result in homelessness. It is designed to provide 
support when and where the veteran chooses, and to motivate those who 
realize they may benefit from assistance to access services. It 
augments existing VA services by being pro-active rather than just 
waiting for the Veteran to seek care. The VetAdvisor program is a 
successfully demonstrated approach to increase and improve the VA's 
involvement and assistance to OEF/OIF Veterans. The VetAdvisor program 
can be offered throughout VHA to ensure that Veterans do not fall 
through the cracks following their initial visit to and enrollment in 
VA. VetAdvisor provides the VA a mechanism to overcome access to care 
challenges for Veterans living in rural areas by using technology, 
including wireless technology, and solutions to provide outreach and 
ongoing support to Veterans, regardless of where they live.
    On behalf of Three Wire Systems and MHN/Health Net, we would like 
to thank you again for your interest in ways telehealth solutions like 
the VetAdvisor program can help our Veterans and their families in 
geographically remote areas receive the care and services they have 
earned through service to our country. We are grateful to the 
Subcommittee for its leadership and commitment to identifying 
innovative programs to improve access to and promote quality of care 
that can support the unique needs of enrolled Veterans residing in 
geographically remote areas.

                                 
Prepared Statement of John Mize, Director, LifeWatch Federal, LifeWatch 
                      Services, Inc., Rosemont, IL

    Thank you for the opportunity to testify this morning. LifeWatch is 
a Health IT telemedicine service provider that represents the future of 
medicine in the United States. It is our privilege to serve The 
Department of Veterans Affairs in almost 40 facilities. Currently our 
services help diagnose patients suffering from arrhythmia and 
obstructive sleep apnea in an ambulatory and near real time 
environment. LifeWatch has built a virtual health care service solution 
that supports efficient data transfer of critical health data to 
providers for diagnosis and treatment. This virtual service environment 
is a launching pad for future disease specific management of health 
data supporting improved patient outcomes, continuity of care, 
reduction of Emergency Room visits and unnecessary hospital 
readmissions.
    We are most certainly at a crossroads in health care. As the 
estimated 40 million Americans aged 65 and older enter the insurance 
pool in the coming years, our Nation's health care system will be faced 
with many challenges to effectively meet the needs of our Aging 
population. Older patients with chronic diseases will consume an ever 
increasing portion of total health care spending. Moreover, funding 
constraints coupled with an increasing shortage of health care 
providers and a deficient hospital capacity to meet this ever-growing 
demand will further challenge our present system.
    The Department of Veterans Affairs in particular will be serving a 
significant percentage of our Aging population with one or more chronic 
health care diseases, and the increased demand for limited health care 
resources is an issue that has and will continue to be an issue for the 
VA. According to data from Department of Veterans Affairs the 
percentage of Veterans age 65 or greater is expected to increase 
roughly 7 percent in the next 20 years.\1\
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    \1\ Veteran Population Model; VetPop 2007. Office of the Assistant 
Secretary for Policy and Planning Office of Policy (008A2). http://
www1.va.gov/VETDATA/Demographics/Demographics.asp
---------------------------------------------------------------------------
    Given this environment it is critical that we continue to identify, 
research, and incentivize new delivery methods for health care in the 
United States. Telemedicine offers significant promise for reducing 
barriers regarding supply & demand, geography, a changing patient-
provider relationship, and most importantly for reducing cost and 
improving outcomes for chronic diseases. The technology is here now. 
Whether it is provider-to-provider video consultations, remote 
telediagnostics, remote chronic disease management, or wireless 
monitoring, the technology is all readily available today and in many 
cases proven many times over.
    Despite overwhelming evidence regarding the benefits of 
telemedicine, CMS has been slow to adopt reimbursement structures that 
incentivize providers to adopt the technology in addition to supporting 
innovation among device manufacturers, software providers, and medical 
services. CMS has been challenged with managing costs without abuse to 
the system because telemedicine is a new method of health care delivery 
with unique costs.
    The Department of Veterans Affairs has been a bright spot in terms 
of the adoption of innovative wireless and land based telemedicine 
solutions which have been proven to reduce cost, improve outcomes, and 
support the large population of rural veterans in geographically 
challenging locations. According to the Office of Rural Health an 
estimated 38 percent of all veterans live in either rural or very rural 
geographies.\2\
---------------------------------------------------------------------------
    \2\ The Office of Rural Health, Departement of Vererans Affairs 
http://www.ruralhealth.va.gov/RURALHEALTH/About_Rural_Veterans.asp.
---------------------------------------------------------------------------
    The Office of Care Coordination under the leadership of Dr. Adam 
Darkins has proven that telemedicine overcomes challenges in managing 
chronic diseases even among the most difficult to treat and 
historically noncompliant patient population. According to Dr. Darkin's 
research, the VA telemedicine program managed a 25 percent reduction in 
number of bed days of care as well as a 19 percent reduction in 
hospital admissions for patients using telemedicine to manage chronic 
diseases.\3\
---------------------------------------------------------------------------
    \3\ Darkins A, Ryan P, Kobb R, Foster L, Edmonson E, Wakefield B, 
Lancaster A. Care Coordination/Home Telehealth: The Systematic 
Implementation of Health Informatics, Home Telehealth, and Disease 
Management to Support the Care of Veteran Patients with Chronic 
Conditions. Telemedicine and E-Health December 2008;vol. 14 no 10 1119.
---------------------------------------------------------------------------
    While telediagnostics with the use of our services has not been as 
centrally driven as chronic disease telemonitoring, we have a number of 
shining examples of VA facilities utilizing our wireless service to 
overcome challenges in treating rural patients.
    The LifeStar Ambulatory Cardiac Telemetry (ACT) service platform is 
based upon an algorithm that automatically and instantly detects and 
transmits clinically significant changes in heart rate and rhythm. For 
example, if you are complaining of feeling dizzy, lightheaded or a 
racing heart your cardiologist might prescribe our service for 30 days 
to help diagnose what is causing the changes in your heart rate or 
rhythm. The VA Medical Center completes the enrollment to LifeWatch and 
we in turn ship the device directly to the patient's house with all the 
necessary equipment and a prepaid envelope to mail it back following 
completion of the study. Following a successful implementation of the 
service the patient simply goes about their daily activity while the 
device and service continues to work.
    The transmission is sent via a cellular network such as Verizon to 
one of our Joint Commission Accredited monitoring facilities in which 
certified cardiovascular technicians are staffed 24 hours a day, 7 days 
a week. The technicians view transmission, edit the ekg data, create a 
report, and provide it back to the clinician via a secure password 
enabled Web site or a direct EMR interface. The LifeStar ACT service 
increases the diagnostic yield compared to antiquated technology 
increasing the likelihood that a diagnosis will be made and a treatment 
plan incorporated which ultimately improves patient outcomes and 
reduces the cost of cardiovascular disease and stroke.
    An improvement in the incidence of stroke increases quality of care 
and at the same time significantly reduces cost. Research from the 
Stroke Queri team based out of the Indianapolis VAMC indicates that 
stroke cost the Department $315 million in FY 2005 with a cost per 
patient of over $18,000. The importance of stroke within the VA is 
emphasized by the fact that stroke patients account for over 10 percent 
of the VA's complex caseload, with a cost per patient that is over 3.4 
times the overall VA average.\4\
---------------------------------------------------------------------------
    \4\ Department of Veterans Affairs, Stroke Queri Strategic Plan and 
Annual Report, 2007;
8-9.
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    Additionally the service allows veterans to remain in their home, 
reduces travel reimbursement expenses, and allows VA medical centers to 
shift employee resources to other more important responsibilities. The 
impact for rural veterans is even more pronounced in regards to cost 
savings, access to care, and improved outcomes.
    We have seen significant success stories of VA Medical Centers that 
have made the leap into utilizing advanced technology like the LifeStar 
ACT to the benefit of their patient population. For example prior to 
utilizing the LifeStar ACT service, the Las Vegas VA Medical Center was 
flying patients to San Diego to be hooked up on antiquated technology. 
The clinic made the decision to utilize our service which significantly 
reduced travel reimbursement expenses, allowed the VA to shift employee 
resources to other more important responsibilities, and allowed 
veterans to remain in their homes for extended diagnostic care.
    LifeWatch has also recently introduced a home sleep testing service 
to the market for the diagnosis of Obstructive Sleep Apnea. The 
NiteWatch service has the potential of significantly reducing costs for 
severely overburdened sleep labs within the Department of Veterans 
Affairs, and at the same time stands to save the VA millions in lost 
revenue from fee service commercial sleep labs. Wait times for sleep 
labs within many VA facilities exceeds 6 months and as a partial 
solution many facilities utilize Fee Service to push patients to 
commercial sleep labs at Medicare rates. Our service is less than half 
the price of using a commercial sleep lab, stands to eliminate chronic 
patient waiting lists, and helps improve compliance as the testing is 
all completed in the home. According to a recent article published in 
the USA Today, ``veterans are four times more likely than other 
Americans to suffer from Sleep apnea. About 5 percent of all Americans 
suffer from sleep apnea compared to 20 percent of veterans''. The 
number of claims for the sleep apnea has gone from 39,145 in 2008 to 
63,118 in 2010.
    While there are many success stories we have also had our fair 
share of struggles within the VA. We are a GSA small business vendor 
and despite our status on the Schedule, procurement remains a struggle. 
It can take upwards of 2 years for some facilities to finalize the 
budgeting and contracting process despite the clinicians request to 
utilize the service. The disjointed nature of contracting and 
procurement necessitates that we work facility by facility on the 
contracting and procurement process. We have seen some success with 
Project Hero. As an in-network provider the program appears to expedite 
the process and simplify procurement for facilities in the four VISN's 
under the demonstration project.
    Additionally we've struggled with a lack of a quality standard of 
care for remote cardiac monitoring. In 2004 CMS placed a requirement on 
remote cardiac monitoring which included the necessity of providing 24 
hour live attended coverage for patients wearing ambulatory devices. 
The VA does not follow the same standard of care across the board. 
While there are many VA facilities that do utilize LifeWatch or a 
similar service, many VA Medical Centers own their own antiquated 
equipment and provide their patients with their own monitoring often 
without providing 24 hour live coverage. For example, if a patient were 
put on a VA owned monitor and had a serious cardiac event on Friday 
evening the clinic would not hear about it until the patient call to 
transmit the data on Monday.
    Lastly we have struggled with a lack of clarity on how to interface 
our data with the Vista Imaging/CPRS electronic medical record system 
within the VA. Multiple cardiology clinics have requested that our data 
be interfaced and in fact many facilities will not use our service 
until we are interfaced. Despite the demand among cardiology clinics, 
we have hit multiple road blocks in terms of how to move forward. We 
are eager and ready to provide a secure interface with the Department 
of Veterans Affairs which will most certainly improve the standard and 
efficiency of care for our VA customers.
    Mr. Chairman and Members of the Subcommittee, LifeWatch sincerely 
appreciates the opportunity to submit testimony and looks forward to 
working with you and your colleagues on improving the quality of care 
for our Nation's veterans with the use of advanced technology.
    That concludes my written statement and I would welcome any 
questions you may have.

                                 
  Prepared Statement of Kerry McDermott, MPH, Expert Advisor, Federal 
                       Communications Commission

    Good afternoon Chairman Michaud, Ranking Member Brown, and 
distinguished Members of the Veterans Affairs Subcommittee on Health. 
My name is Kerry McDermott and I'm a member of the health care team for 
the National Broadband Plan at the Federal Communications Commission.
    As you know, Congress mandated that the FCC prepare a ``national 
broadband plan'' that ``shall seek to ensure that all people of the 
United States have access to broadband capability,'' and include a 
strategy for affordability and adoption of broadband. The FCC was also 
asked by Congress to address how broadband can be harnessed to tackle 
important ``National Purposes,'' including health care.
    Improving America's health and America's health care system is one 
of the most important tasks for the Nation. Health care already 
accounts for 17 percent of U.S. gross domestic product (GDP) and by 
2020, it will top 20 percent.\1\ This is due to many factors but one of 
the most important is that America is aging. There is a direct 
correlation between the elderly and chronic disease, which already 
accounts for 75 percent of the nations health care costs.\2\ 5 percent 
of Medicare beneficiaries, who in most cases have one or more chronic 
conditions, constitute 43 percent of Medicare spending.\3\ By 2040, 
there will be twice as many Americans older than 65 as there are 
today.\4\ Exacerbating this situation is a health care supply problem. 
A shortage of tens of thousands of physicians is expected by 2020.\5\
---------------------------------------------------------------------------
    \1\ CTR FOR MEDICARE & MEDICAID SERV., NATIONAL HEALTH EXPENDITURE 
PROJECTIONS 2008-2018, http://www.cms.hhs.gov/NationalHealthExpendData/
downloads/proj2008.pdf (last visited Jan. 21, 2010).
    \2\ Susan Dentzer, Reform Chronic Illness Care? Yes, We Can, 28 
HEALTH AFF. 12, 12 (Jan./Feb. 2009), available at http://
content.healthaffairs.org/cgi/reprint/28/1/12.
    \3\ http://www.cbo.gov/ftpdocs/63xx/doc6332/05-03-MediSpending.pdf.
    \4\ http://www.census.gov/population/www/projections/
summarytables.html.
    \5\ See Health Res. & Serv. Admin., U.S. Dep't of Health & Human 
Serv., The Physician Workforce: Projections and Research into Current 
Issues Affecting Supply and Demand (2008), ftp://ftp.hrsa.gov/bhpr/
workforce/physicianworkforce.pdf (HRSA, Physician Workforce); Michael 
J. Dill & Edwa rd S. Salsberg, Ass'n of Am. Med. Coll., The 
Complexities of Physician Supply and Demand: Projections Through 2025, 
at 6 (2008) (estimating a shortage of 124,000 physicians by 2025), 
https://services.aamc.org/publications/
index.cfm?fuseaction=Product.displayForm&prd_
id=244 (download report from this page).
---------------------------------------------------------------------------
    But there's a set of broadband-enabled health information 
technologies (health IT), both now and emerging from development, that 
have the potential to improve clinical outcomes while reducing the cost 
of care and extending the reach of the limited pool of health care 
professionals. The New England Healthcare Institute found that remote 
patient monitoring for heart failure can save up to $6.4 billion 
annually through reduced hospital readmissions.\6\ The Veterans 
Hospital System's Care Coordination/Home Telehealth Program (CCHT) for 
veterans with chronic conditions has resulted in a 19 percent reduction 
in hospital admissions and a 25 percent reduction in bed days for those 
who are admitted.\7\
---------------------------------------------------------------------------
    \6\ New England Healthcare Institute, Research Update: Remote 
Physiological Monitoring (Jan. 2009), available at http://www.nehi.net/
publications/36/remote_physiological_monitoring_
research_update.
    \7\ Adam Darkins et al., Care Coordination/Home Telehealth: The 
Systematic Implementation of Health Informatics, Home Telehealth, and 
Disease Management to Support the Care of Veteran Patients with Chronic 
Conditions, 10 Telemed. & e-Health 1118, 1118 (2008), available at 
http://www.liebertonline.com/doi/pdf/10.1089/tmj.2008.0021?cookieSet=1.
---------------------------------------------------------------------------
    Even though these technologies hold great promise, the U.S. lags 
behind other developed countries in health IT adoption, with one study 
ranking it in the bottom half (out of 11 developed countries) on every 
metric used to measure adoption.\8\
---------------------------------------------------------------------------
    \8\ CATHY SCHOEN & ROBIN OSBORN, THE COMMONWEALTH FUND, THE 
COMMONWEALTH FUND 2009 INTERNATIONAL HEALTH POLICY SURVEY OF PRIMARY 
CARE PHYSICIANS IN ELEVEN COUNTRIES 10 (2009), http://
www.commonwealthfund.org//media/
Files / Publications / In%20the%20Literature / 2009 / Nov / 
PDF _ Schoen _ 2009 _ Commonwealth _ 
Fund_11country_intl_survey_chartpack_white_bkgd_PF.pdf. Count of 14 
functions includes: (1) electronic medical record; (2, 3) electronic 
prescribing and ordering of tests; (4-6) electronic access to test 
results, Rx alerts, and clinical notes; (7-10) computerized system for 
tracking lab tests, guidelines, alerts to provide patients with test 
results, and preventive/follow-up care reminders; and (11-14) 
computerized list of patients by diagnosis, by medications, and due for 
tests or preventive care.
---------------------------------------------------------------------------
    The Broadband Plan identifies some of the barriers that hinder the 
adoption of broadband-enabled, wireless health solutions and provides 
specific recommendations the government should undertake to remove 
these barriers, as well as foster innovation and investment in these 
new, life-saving devices.
    With respect to e-care technologies, these barriers and subsequent 
proposed solutions fall into three main categories:

    1.  The connectivity gap. Broadband is either unavailable or too 
expensive.
    2.  Outdated regulations. Rules that were created when our only 
interactions with physicians were in their offices--not via remote 
monitoring and video consultations.
    3.  Misaligned economic incentives. The prevailing fee-for-service 
reimbursement system pays for volume rather than outcomes, and hence 
prevents reimbursement for many of these technologies.

    Let me now discuss each in detail:

    The first issue is connectivity, including both broadband at home 
as well as connectivity to health providers. With respect to the home, 
the plan estimates that 93 million Americans are not connected to 
broadband. We estimate that 14-24 million Americans do not have access 
to broadband where they live, even if they want it. It's hard to 
identify what proportion of the 14-24 million, who don't have the 
necessary infrastructure, is over the age of 65, let alone veterans. 
But what we do know is that individuals over the age of 65 are poor 
adopters of broadband, estimated to be 35 percent as compared to the 
national average of 65 percent.\9\ This is due to multiple reasons such 
as cost, digital literacy, and perceived lack of relevant digital 
content delivered over the Internet. In order to respond to these 
challenges, the plan recommends the launch of a National Digital 
Literacy Corps and that public and private partners prioritize efforts 
to increase the relevance of broadband for older Americans. The plan 
also sets the goal of providing access for every American to robust and 
affordable broadband service. This will be accelerated by a once-in-a-
generation transformation of the Universal Service Fund, which includes 
the creation of a ``Connect America Fund'' as well as reforming the 
Lifeline and Link-Up programs. Mobile solutions are an important piece 
of the Broadband Plan's strategy for home broadband. Some States have 
materially lower 3G deployment than the national average and the 
proposed ``Mobility Fund'' would help bring all States to a minimum 
level of 3G or better wireless coverage.
---------------------------------------------------------------------------
    \9\ Chapter 9, ``Adoption and Utilization'', National Broadband 
Plan.
---------------------------------------------------------------------------
    A focus of mine has been the connectivity issues for health care 
providers. It is imperative that hospitals and physician offices have 
adequate connectivity as any care that will be delivered to an 
individual's home will originate in a health care facility of some 
description. Our analysis highlighted that some providers are not 
served by existing ``mass-market'' broadband infrastructure. 
Approximately 3,600 small physicians' offices fall into this gap. Of 
these, 70 percent are in rural locations. Furthermore, 29 percent of 
rural health clinics do not have access to adequate mass-market 
broadband. Larger providers must purchase ``Dedicated Internet Access'' 
(DIA) to meet their quality-of-service requirements, but DIA solutions 
are often at least 4X more expensive than mass-market solutions. This 
cost issue is further exacerbated by the fact that DIA solutions differ 
greatly in price, thus preventing all providers from having affordable 
broadband available to them.
    The National Broadband Plan addresses the health care provider 
connectivity issues by proposing to revamp the FCC's Rural Health Care 
Program. The program provides three types of subsidies to public and 
nonprofit health care providers. It is the largest sustainable fund for 
health care connectivity within the government. The Commission will be 
considering ways to make the program more effective without changing 
the program's funding cap by creating a permanent infrastructure fund, 
broadening coverage for monthly recurring costs to all types of 
broadband services, and expanding eligibility for the program. 
Importantly, any FCC funding must ensure that broadband for health care 
providers is resulting in improved health outcomes, and we are working 
closely with the Office of the National Coordinator to understand the 
evolving ``Meaningful Use'' criteria as we consider how such criteria 
could be incorporated into FCC programs. These proposed changes will 
enable more institutions to acquire the infrastructure needed to 
support a realm of health IT solutions, opening the possibility for 
greater investment and innovation. A Notice of Proposed Rulemaking is 
expected to be released shortly, opening the formal comment cycle on 
this proposal to revamp the FCC's Rural Health Care Program.
    The second set of barriers pertains to a range of regulations that 
prevent e-care solutions from being adopted. State licensing, 
credentialing, and privileging rules may prevent physicians from 
providing remote broadband-enabled care across State lines and even at 
in-state hospitals other than their usual place of work. Patient safety 
must be addressed by ensuring that physicians are suitably skilled--but 
regulations must not stifle the innovation and gains promised by health 
IT. To this end, the Broadband Plan recommends that credentialing, 
privileging, and licensing rules be re-evaluated. We are pleased that 
CMS is seeking comments on a proposed rule to revise privileging 
requirements to allow for the advancement of telemedicine nationwide 
while protecting the health and safety of patients.
    There is regulatory uncertainty regarding the convergence of 
communications and medical devices. The combination of devices, 
applications, and communications networks is enabling clinicians and 
patients to give and receive care anywhere at any time. For example, 
mobile sensors in the form of disposable bandages and ingestible pills 
relay real-time health data over wireless connections. Diabetics can 
receive continuous, flexible insulin delivery through real-time glucose 
monitoring sensors that transmit data to wearable insulin pumps. 
Medical body area networks monitor various vital signs and detect the 
onset of a patient ``crash'' while in a hospital in time for treatment.
    With these new solutions come new challenges. When medical and 
wireless devices and applications converge, the regulatory lines become 
blurred. At one end, general-purpose communications devices such as 
smartphones, wireless routers, and certain videoconferencing equipment 
are regulated by the FCC. At the other end, medical devices that 
critically monitor patient health or provide treatment or therapy are 
regulated by the FDA. Devices that do provide critical care and also 
use communications, such as life-critical wireless devices like 
remotely controlled drug-release mechanisms, are regulated by both 
agencies. In addition, device applications that would not be governed 
by the FCC but transmit over wireless networks might warrant FDA 
oversight, while the FCC might have better capability to assess the 
reliability of their communications capability.
    Uncertainty regarding regulatory frameworks and approval processes 
can discourage private sector innovation and investment, and ultimately 
delay or prevent the availability of such solutions. The Plan calls for 
the FCC and the FDA to build on their long history of collaboration to 
resolve these issues. The agencies are holding a joint public meeting 
on July 26 and 27, 2010, to address these challenges. We propose to 
bring together various stakeholders from manufacturers to practitioners 
to patients to better understand the types of devices and applications 
that are being introduced, clarify the requirements that apply, and 
improve the regulatory and approval processes to the extent possible. 
Our aim at the FCC is to protect patient safety while promoting 
innovation and investment.
    Lastly, although broadband connectivity and regulatory 
uncertainties are issues, the greater barrier is on the demand side of 
the equation. Within a fee-for-service reimbursement system, providers 
bear the costs of health IT implementation and changes to workflow, but 
don't fully capture the economic gains created through improved 
clinical outcomes. The plan recommends that well-understood use cases 
of e-care technologies should be incented with outcomes-based 
reimbursement, similar to the Meaningful Use program for Electronic 
Health Records. In addition, novel technologies should be tested for 
their clinical efficacy, as well as within payment model pilots, in 
order to ascertain their economic value. Given that it will take many 
years to implement an outcomes-based payment model, reimbursement 
should be expanded for e-care technologies that will prove system-wide 
expenditure reductions under CMS's fee-for-service model. It is 
imperative that there be economic incentives for physicians of various 
specialties to collaborate and better manage elderly patients with 
chronic conditions that often require multiple specialty inputs. In 
addition, incentives must be aligned to promote the prevention and 
better management of disease within the community rather than 
reactively and at greater expense within hospitals. The Plan recommends 
a dedicated effort by HHS to propose specific programs and 
reimbursement changes that will help realize the value of e-care 
technologies. Without reimbursement reform, the market for health IT 
solutions is limited. This, in turn, inhibits investment and 
innovation; the FCC believes this trend must be reversed.
    There are multiple barriers that must be resolved in order to fully 
develop the ecosystem of broadband-enabled health IT. The underlying 
infrastructure must provide a solid foundation to build upon. Yet, 
technology alone will not solve our health care challenges; it must be 
coupled with payment reform, innovation in service delivery, and 
improved regulatory transparency. It is imperative that government 
action--and inaction--do not hinder investment and innovation. The 
recommendations of the National Broadband Plan seek to unlock the value 
of health IT so all citizens may realize its benefits and cost savings. 
Any government approach to solve these issues must be coordinated--not 
only across the government, but with the private sector and the entire 
health care community.
    I thank you all for giving me the opportunity to speak today.

                                 
      Prepared Statement of Colonel Ronald Poropatich, M.D., USA,
 Deputy Director, Telemedicine and Advanced Technology Research Center,
   U.S. Army Medical Research and Materiel Command, Department of the
                    Army, U.S. Department of Defense

    Chairman Michaud, Representative Brown, Members of the Committee 
thank you for this opportunity to discuss the U.S. Army Medical 
Department current mobile health projects, future initiatives and 
challenges in implementing wireless technology across health care 
organizations.
    The U.S. Army recognizes that mobile devices represent an enormous 
opportunity for health care outreach, not only within the active duty 
and dependent population, but also within the global community. 
Globally, there are currently over 4.6 billion cell phones and 
approximately sixty percent of the world's population owns cell phones. 
Social networks, too, have come to go hand in hand with mobile devices. 
Facebook has surged past Yahoo! as the second most popular site in the 
U.S., drawing nearly 400 million visitors. Statistics also show that 
more people access social networks using the mobile web than they do 
using desktop computers. Mobile devices are superseding desktop and 
even laptop computers as the tool of choice for communication in the 
virtual sphere.
    Mobile health or ``mHealth''--defined broadly as emerging mobile 
communications and network technologies for health care systems--can be 
an agent for behavior change, impacting health care challenges such as 
smoking cessation, diabetes, and appointment attendance. Applications 
for cell phone and smart phone platforms are emerging that enable 
clinical consultation, patient and provider education, research, 
biosurveillance, and disease management.
    The development, implementation and maintenance of any mobile cell 
phone solution presents a number of innovations, challenges and 
solutions not widely seen in other aspects of telemedicine. Wireless 
device and carrier credentialing and certification, lack of 
interoperability, Health Insurance Portability and Accountability Act 
(HIPAA) considerations, and maintaining currency in an ever-changing 
landscape of devices and operating systems requires strategic planning 
and long range focus. There are numerous current obstacles and 
challenges to launching a comprehensive mobile solution, yet many 
successes are evident. Today I would like to discuss three initiatives 
the U.S. Army's Telemedicine and Advanced Technology Research Center is 
currently investigating to improve patient outreach and health outcomes 
using wireless technology.
    The U.S. Army has developed, deployed, and is currently evaluating 
a mobile telephone-based secure messaging system called ``mCare''. The 
``m'' in mCare stands for mobile. The project explores the potential of 
mobile devices, specifically personal cell phones, for use in the 
Military Healthcare System. The mCare system is a secure, HIPAA 
compliant, bi-directional messaging system that allows information to 
be sent to the servicemember's personal cell phone. The Soldiers' 
responses are returned securely to the mCare web portal. Presently, 
mCare provides daily messages via cell phone to wounded Warriors in the 
outpatient phase of their recovery, while they are recuperating in 
their homes. The servicemembers' own personal cell phones are utilized.
    Patients with mild traumatic brain injury are a target population 
for mCare. Health tips, appointment reminders and general announcements 
are distributed from a secure central Web site where health care 
providers can enter and control message content, as well as review 
acknowledgements and delivery confirmations. Each mCare patient 
receives a minimum of 6 messages per week, meeting or exceeding the 
U.S. Army's required contact rates for wounded Warriors receiving 
outpatient care in their home communities.
    The initial group of mCare's targeted participants are Warriors in 
Transition (WTs) assigned to Community Based Warrior in Transition 
Units (CBWTUs). Soldiers assigned to a CBWTU are typically National 
Guard or Army Reservists who receive outpatient care in their home 
community and are monitored remotely by a case manager/care team from a 
regional case management center. mCare is not intended to replace all 
face-to-face or telephone based encounters from the CBWTU team, rather 
it is designed to complement these efforts with additional means of 
communication. Initially mCare has been offered to patients assigned to 
5 selected CBWTU sites in Alabama; Florida; Illinois; Massachusetts; 
and Virginia that cover 26 States. Future locations for mCare are being 
explored at this time at 4 additional sites.
    The mCare system incorporates modified commercial off the shelf 
technologies under the oversight of the U.S. Army Medical Research and 
Material Command's Telemedicine and Advanced Technology Research 
Center. During the development of mCare particular attention was paid 
to network security and privacy considerations. Information that is 
sent to the Soldier's mobile phone is transmitted through a secure 
Virtual Private Net (VPN) tunnel, and is only accessible with a six-
digit personal identification number (PIN) code. Cell phone users are 
prompted to open this application through a standard text message 
whenever critical new information has been sent to the mCare 
application.
    As of 1 June 2010, mCare has delivered over 18,500 messages to over 
300 WTs. Sixty-three percent of this message activity is related to 
appointment reminders, which are sent to the patient 24 hours and 90 
minutes prior to each scheduled clinical encounter. The system has 
demonstrated improvement in appointment attendance rates. Seventeen 
percent of the message activity is attributed to health and wellness 
tips, which are customized to the needs of each patient from a library 
of validated resources within the mCare application. Twelve percent of 
the message traffic is related to unit specific announcements.
    There has been no appreciable age bias to the acceptance of mCare 
by patients; there are as many users over the age of 30 participating 
in the project as are within the 18-30 age groups. Additionally, 84 
percent of the mCare patient participants are enlisted servicemembers; 
16 percent are officers. More than 90 percent of the volunteer users 
surveyed found the mCare application on their phone easy to use or 
somewhat easy to use. Nearly 75 percent of the users surveyed preferred 
to receive contact through mCare more than once a week, and 65 percent 
reported that mCare improved their communications with their unit.
    There have been a number of challenges to overcome to achieve 
success with the mCare project to date. Because the goal was to 
leverage the patient's personal cell phone, and not introduce a new 
technology to the Soldier, a wide variety of phone models and wireless 
carriers needed to be accommodated. Each wireless carrier has separate 
testing and certification processes, and specific devices have 
different installation processes, which all result in a complex 
technological process to navigate for the clinical teams. Developing a 
streamlined process that was as simple as possible for the care team, 
while negotiating with each wireless carrier to allow the application 
to be accessible to patients at no cost has been a time consuming 
process that is still ongoing. Full integration with the patient health 
record (PHR) is not currently part of mCare's model but the feasibility 
and cost to incorporate PHR is being explored.
    There is increasing interest in expanding the mCare to incorporate 
additional use cases and support other services outside the Army. The 
Veterans Health Administration and the medical departments of the U.S. 
Navy and Air Force have shown interest in utilizing mCare to support 
their case management activities. The Defense Veterans Brain Injury 
Center would like to utilize mCare for patient follow up. Additionally, 
other use cases such as medication monitoring, polypharmacy assessment, 
continuous positive airway pressure monitoring at home for sleep 
disorders, pain management and medical student well being evaluation 
have been proposed as additional use cases for mCare, with funding 
identified to enable this expansion.
    The second initiative I would like to highlight is Text4Baby. 
Text4Baby (T4B) is a free mobile health information service that 
provides timely health information to women from early pregnancy 
through their babies' first year. Led by the National Healthy Mothers 
Healthy Babies Coalition, the T4B campaign has forged a new public-
private partnership between government, private sector businesses, non-
profits and academic institutions to develop innovative new models for 
leveraging mobile phones and the extensive cellular infrastructure to 
address critical health care challenges in the U.S.
    The T4B service aims to use one of the most widely used 
technologies in America--the mobile phone--to promote maternal and 
child health. Women who sign up for the service receive three free text 
messages each week timed to their due date or baby's date of birth. The 
messages focus on topics critical to the health of mothers and babies, 
including nutrition, seasonal flu prevention and treatment, mental 
health issues, risks of tobacco use, oral health, immunization 
schedules, and safe sleep.
    The Army Medical Department plans to introduce T4B to military 
mothers at Madigan Army Medical Center at Joint Base Lewis McChord in 
Washington as part of a demonstration to formally evaluate the 
acceptability and utility of using text messaging to deliver 
information and encourage healthy behaviors as part of its overall 
maternal health outreach initiatives.
    The third wireless application that the U.S. Army is investigating 
is the impact of a video cell phone reminder system on glycemic control 
in patients with diabetes mellitus (diabetes). Diabetes affects 
approximately 24 million people in the U.S. and is associated with 
devastating complications in both personal and financial terms. 
Diabetes is the leading cause of blindness, non-traumatic amputations, 
and renal failure in adults and reduces life expectancy by 5-10 years. 
Maintaining glycemic control is critical for the health of diabetes 
patients. The reasons why more patients do not reach appropriate goals 
for glycemic control are multiple and complex, among them poor 
compliance with self monitoring of blood glucose (SMBG) and medication 
non-adherence. Despite the evidence showing the positive impact of 
SMBG, compliance with SMBG remains suboptimal. Approximately one-third 
of patients with diabetes are non-adherent to their medications--a 
compliance rate which is lower than many other medical conditions.
    The hypothesis of this study being conducted at the Walter Reed 
Army Medical Center is that a cell phone video reminder system will 
improve self-care and glycemic control in patients with diabetes when 
compared with standard of care. The primary endpoint is improvement of 
glycemic control as measured by A1C and the secondary endpoints are 
mean daily glucose levels, the number of both hypoglycemic and 
hyperglycemic events, the amount of time spent in target blood glucose, 
and the perceived level of diabetes-related stress between the two 
groups.
    Preliminary results show that A1C improves more in those patients 
who are provided with video reminders compared with those who did not 
receive them. Overall, the viewership was about 50 percent which 
exceeds that of most other e-Health studies. Among subjects who watched 
at least two-thirds of the daily, cell phone-based video tips/reminders 
the decline in A1C was greater than it was for subjects who used the 
technology less. Using reminders delivered via the ubiquitous 
technology of cell phones appears to be an effective way to improve 
glycemic control and thereby long-term outcomes. This approach could be 
modified for use in other chronic illnesses and in other unique 
populations such as the elderly and disabled.
    Currently, the U.S. Army Research and Development Command (RDECOM) 
is evaluating commercial handheld solutions such as iPad, iPhone, iPod, 
and other platforms and their applicability in a tactical setting. 
RDECOM has developed numerous handheld command and control solutions 
and is supporting the development and transition of MilSpace, a 
combined planning and social networking environment. The Telemedicine 
and Advanced Technology Research Center is working with the RDECOM to 
leverage U.S. Army investments in mobile technology and apply it to 
health care both here in the U.S. as well as in deployed settings 
overseas.
    The U.S. Army's evolving role in humanitarian operations represents 
another opportunity to utilize mobile technology as it pertains to 
recently approved DoD policy on Medical Stability Operations. The 
relative ubiquity of cell phones throughout the world makes them, 
potentially, a vital tool in creating medical infrastructure and 
sharing medical knowledge where they are most needed.
    The opportunities presented by mHealth are considerable, yet there 
are several challenges to overcome. It will be necessary to ensure that 
mobile applications are integrated with legacy information systems. A 
wide variety of mobile devices will have to be supported, as well 
network connections of many types. The security, privacy, and 
confidentiality of patient data both on the device and during its 
transmission remain important considerations. Furthermore, regulatory 
issues may, ultimately, enter the picture. As mobile phones evolve from 
simple communication tools into complex physiological data-gathering 
devices, the line between cell phone and medical device is blurring. 
Finally, from a practical perspective, it is important to avoid 
overloading already-busy clinicians with more information than they are 
able to use.
    The U.S. Army Medical Department is committed to developing a 
strong research portfolio in mHealth. The convergence of health care 
and mobile technologies has the potential to change the lives of 
individuals in rural and austere settings and contribute to improved 
care, healthier lifestyle choices, and ultimately, increased quality of 
life for servicemembers as well as those in need throughout the world. 
Thank you again for allowing me to highlight the Army Medical 
Department's accomplishments and thank you for your continued support 
to those who serve our Nation.

                                 
    Prepared Statement of Gail Graham, Deputy Chief Officer, Health
 Information Management, Office of Health Information, Veterans Health
          Administration, U.S. Department of Veterans Affairs

    Good morning, Mr. Chairman. Thank you for the opportunity to 
testify about the Department of Veterans Affairs' (VA) efforts to 
deliver optimal health care to Veterans in rural areas and our use of 
innovative wireless health technology solutions to better serve our 
Veterans. I am accompanied today by Dr. Adam Darkins, Chief Consultant 
for Care Coordination in the Office of Patient Care Services, and Dr. 
James Breeling, Deputy Executive Director, Office of Information and 
Technology, Department of Veterans Affairs.
    As the Committee well knows, all health care providers, including 
VA, face significant challenges in providing optimal treatment to 
patients in rural and highly rural areas. Emerging technologies and new 
models of care promise to improve clinical quality and reduce costs 
while at the same time, expand our options for delivering health care 
to all patients. VA is committed to pursuing strategies that harness 
such technologies and models of care to enhance health care delivery. 
Our aim is to ensure our rural Veterans receive the quality health care 
they earned through service to this country.
    My testimony today will describe the latest wireless technologies 
VA is using, detail our plans for further expansion, and conclude by 
discussing a new model of care that is more Veteran-centered, results-
driven, and forward-looking.
Current Use of Wireless Technologies
    VA is exploring many potential applications of wireless 
technologies. For example, VA has installed Very Small Aperture 
Terminal (VSAT) Satellites on its 50 Mobile Vet Centers, which are used 
primarily in rural areas by the Readjustment Counseling Service (Vet 
Centers) to provide outreach and readjustment counseling service to 
Veterans wherever it is needed. While not located in a rural area, the 
Washington D.C. VA medical center is undertaking a pilot program 
through which physicians can access electrocardiogram (EKG) data on 
their BlackBerry handheld devices.
    VA uses wireless technology and services to assist our Veterans 
with disabilities with quick access to information and to foster 
opportunities to live at the highest level of functionality possible. 
VA provides various critical cueing aids for our Veterans who struggle 
with memory loss, spatial disorientation, sensory loss and other 
cognitive difficulties. Cueing aids can assist a Veteran in remembering 
appointments, medication schedules, and work or academic appointments--
essentially helping create a better quality of life for the Veteran. 
These devices include personal digital assistants (PDA), smartphones, 
personal pocket computers, global positioning system (GPS) devices, and 
the Livescribe Pulse Smart Pen. VA's Blind Rehabilitation Service 
partners with VA's prosthetics programs on Veterans training and 
support through assistive devices and technologies with embedded 
wireless functionality, such as GPS tools or PDAs; wireless computer 
towers, laptops and notebooks that provide our Veterans the ability to 
read screen print through speech output and Braille; audible 
prescription reading devices; and other items, such as the K-NFB 
Reader, that can scan and read print aloud, function as a GPS, PDA and 
mobile telephone with email and internet capabilities. These 
technological avenues are just part of the important work we are doing 
for our Veterans and their families.
    In our medical facilities, we are completing Wireless Local Area 
Network (LAN) projects to improve the coverage and reliability of 
mobile devices such as Bar Code Medication Administration (BCMA) carts 
and laptop computers so that our clinical staff can access a Veteran's 
electronic health records. VA's BCMA application is used to quickly 
document and thoroughly validate administration of medication at VA 
facilities through barcode applications and handheld devices. Well 
ahead of many of VA's medical counterparts in the private sector, a 
wireless infrastructure has been in place within each VA facility since 
1999. This wireless network has vastly improved access to critical 
patient information used for clinical decision-making at the very point 
where treatment is provided. VA uses this access and mobility of 
information, provided by wireless connectivity, for positive patient 
identification and to accurately administer the proper medications at 
the Veteran's bedside using barcode scanning technology. To date, VA 
has administered over 1 billion medications using this technology to 
ensure our Nation's Veterans receive the correct medication, in the 
correct dose, at the correct time. We are developing new projects 
within VA that will expand the use of wireless connectivity and barcode 
technology to accurately administer blood products and collect 
laboratory specimens for both clinical laboratory and anatomic 
pathology.
    VA dental providers are using wireless technology to access 
software designed to improve point of care decisions. This platform is 
available to all VA dental providers for download onto wireless 
devices, and many of our providers have taken advantage of this unique 
opportunity. For example, Lexi-Comp provides convenient, immediate 
access to time-sensitive, dentistry-specific pharmacology and clinical 
reference information via wireless devices. Providers can quickly 
access important information about drugs and natural therapeutics, oral 
diseases, implants, endodontics, clinical periodontics, oral surgery, 
treatment of medically compromised patients and medical emergencies, to 
name a few examples. This technology significantly improves medication 
safety by providing important drug interaction analysis and side effect 
profiles while increasing positive treatment outcomes through a vast 
knowledge base available at the provider's fingertips. To keep up with 
today's demands, many of our providers report using this technology 
repeatedly throughout the day and even after hours when making 
determinations about patient care.
    My HealtheVet, VA's online personal health record (PHR), is yet 
another area of significant progress in wireless technology for VA. As 
a complement to traditional health care services, the My HealtheVet PHR 
provides Veterans with personal online access to VA health care, 
featuring patient-friendly health education information and wellness 
reminders for preventive care, to enhance patient engagement and 
informed decision-making. My HealtheVet provides our Veterans with new 
and innovative options to connect with our team at VA. A Veteran who 
was an early adopter in the pilot program and now uses the national 
system has described this application's impact by stating, ``I feel 
more in control and aware of my choices.'' Having our Veterans as 
partners in their health care is essential to our success at VA.
    VA has seen the use of My HealtheVet grow significantly. To date, 
it serves over one million registered users, which represents 14.5 
percent of VA patients receiving health care services. The total number 
of visits to My HealtheVet since it was launched in November 2003 now 
exceeds 40 million. Veterans have refilled more than 15 million 
prescriptions, at a rate of approximately 600 per hour, through My 
HealtheVet since VA made available online interactive ordering of 
prescription refills in August 2005--all from the comfort of the 
Veteran's own home.
    For fiscal years (FY) 2009 and 2010, VA's Office of Rural Health 
awarded a grant for $981,852 to improve access to care by engaging our 
Veterans in co-designing improvements to My HealtheVet. VA conducted 
working sessions with Veterans in five rural communities, where 
Veterans suggested specific changes to My HealtheVet including the 
addition of features they desired in a mobile version of the 
application. In the first phase, our Veterans defined core 
functionality for a mobile version of My HealtheVet, and VA is now 
extending this work by using the models generated in the initial phase 
to build a working prototype that will be implemented on a generic 
internet-enabled mobile phone as well as brand-specific versions. The 
mobile prototype will be evaluated by our Veterans in a proof-of-
concept environment. This testing will focus on the user's experience 
in important areas such as functionality, usability and appeal. Phase 
II will also support further meetings with our Veterans for feedback on 
how to visually model the complete set of functions they desire in a 
mobile version of My HealtheVet.
    Around the world, mobile and wireless devices are increasingly a 
primary tool for connecting people to the internet. In early 2009, VA 
launched a mobile-friendly version of its internet Web site at http://
m.va.gov. VA's mobile site tailors key VA content for mobile devices 
and is designed to be compatible with multiple brands of cell-based 
internet browsers. This site provides access for our Veterans to 
benefits information, facility locations, eligibility details for 
returning Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) 
Servicemembers, VA news, and multimedia content. On smartphones (such 
as the iPhone), users can plot VA facilities on a satellite map, 
perform integrated phone dialing via VA's Facility Locator, watch VA 
videos on YouTube, use the mobile VA Gravesite Locator, and share 
articles of interest via social networking Web sites. We want to be 
accessible and transparent to our Veterans and their families wherever 
they may be.
Future Expansions of Wireless Technologies
    Looking ahead, VA's Veterans Health Administration (VHA) has 
examined potential for additional innovative applications targeting 
specific populations of Veterans, such as those with TBI, post-
traumatic stress disorder (PTSD) or visual impairments. We further 
anticipate development of more resources for our clinicians. VA has 
initiated plans to develop and deploy a nationwide program to use 
wireless networking (separate from the VA wireless LANs) for internet 
use at VA health care facilities. Veterans and their families will be 
able to use this technology for communications, email, and otherwise 
therapeutic activity during patient stays at VA facilities. VHA has 
recently established a Program Office dedicated to using Real Time 
Location Systems (RTLS) to support locating and tracking equipment, 
clinical staff, patients, and patient or staff movement. This type of 
information will help improve the quality and efficiency of health care 
delivery to our Veterans by improving workflow, to cite one example. 
RTSL uses wireless LAN, Radio Frequency Identification (RFID), Infrared 
and other technologies. Future plans for expansion include developing 
requirements, standards and overseeing broader RTLS deployment.
New Model of Care
    Wireless technologies are part of an overall continuum of care at 
VA and not a ``stand alone'' entity. We are undertaking the most 
significant change in our model of care delivery since the rapid 
expansion of community-based outpatient clinics began in the 1990s. But 
in many ways, this new and innovative approach is actually a 
continuation of the same strategy VA has always pursued: bringing care 
closer to our Veterans and making it as accessible as possible. Our 
mission of Veteran-Centered care engages the Veteran, family and health 
care team in a partnership to improve communication and assure that the 
needs and preferences of the patient are considered.
    To support this significant effort, VA has joined the Patient-
Centered Primary Care Collaborative, a national coalition of other 
public and private sector members dedicated to improving primary care. 
We are re-designing our systems around the needs of our patients and 
improving care coordination and virtual access through enhanced secure 
messaging, social networking, telehealth, and telephone access. An 
essential component of this approach is transforming our primary care 
programs to increase our focus on health promotion, disease prevention, 
and chronic disease management through multidisciplinary teams. These 
changes will focus on improving the experience patients and their 
families have when seeking care from VA. We will benchmark with private 
sector organizations such as Kaiser-Permanente and Geisinger Health 
System. As always, we will seek patient input to help guide this 
important transformation.
    The President's FY 2011 budget submission describes this new model 
of care in greater detail. VA will use the latest technology to remove 
barriers to our Veterans and increase access to VA services. This 
important initiative will enable VA to become a national leader in 
transforming primary care services to a medical home model of health 
care delivery that improves patient satisfaction, clinical quality, 
safety and efficiencies. VA Tele-Health and Home Care Model will 
develop a new generation of communication tools (i.e. social 
networking, micro-blogging, text messaging, and self management groups) 
that can be used to disseminate and collect critical information 
related to health, benefits and other VA services.
    VHA's Preventive Care Program, a component of the new model of 
care, will develop and implement a program to provide telephone-based 
health behavior counseling for Veterans with risky health behaviors, 
including physical inactivity, unhealthy eating, smoking, and problem 
alcohol use, and health behavior-related conditions such as obesity. 
Using a health coaching model to assist our Veterans in making behavior 
changes by setting goals, developing action plans, using self-
monitoring, and applying other self-management techniques, the 
Telephone Lifestyle Coaching (TLC) Center will increase Veterans' 
access to care to keep them as healthy as we can. We used this approach 
in a smaller pilot project for weight management among Veterans and 
found a significantly high level of patient satisfaction.
    The new model of care will improve health outcomes and the care 
experience for our Veterans and their families. The model will 
standardize health care policies, practices and infrastructure to 
consistently prioritize Veterans' health care over any other factor 
without increasing cost or adversely affecting the quality of care. VA 
looks forward to working with our critical partners in Congress to 
ensure these important plans become a reality for our Veterans and 
their families of all eras across the country.
Conclusion
    VA sincerely appreciates the continued support of Congress in 
supporting rural health initiatives that enable us to focus on 
extending current enterprise telehealth solutions as well as developing 
new telehealth solutions to serve our Veterans throughout the Nation 
for whom geographical distance from VA's physical health care assets 
often presents a challenge to receiving care. Like you, VA strives to 
ensure that every Veteran who qualifies has access to VA's world class 
health care.
    Mr. Chairman, this concludes my prepared statement. I am pleased to 
address any questions the Committee may have.

                                 
 Statement of Lincoln T. Smith, President and Chief Executive Officer, 
                    Altarum Institute, Ann Arbor, MI

    Good morning, Chairman Michaud, Ranking Member Brown, and Members 
of the Subcommittee.
    Thank you for inviting Altarum Institute to testify on how the 
Department of Veterans Affairs can utilize new and innovative wireless 
technologies to expand access to care for veterans. In our testimony,we 
will address a unique research study that we have successfully 
implemented at the Pathway Home, a residential veterans treatment 
center for returning warriors afflicted with mild traumatic brain 
injury and post-traumatic stress disorder. We will also share how we 
have been able to integrate clinical treatment, technology, and 
research to enhance the recovery of servicemembers who have served this 
country so valiantly.
    Altarum Institute is a nonprofit health systems research and 
consulting organization serving government and private-sector clients. 
We provide objective research and tailored consulting services that 
assist our clients in understanding and solving the complex systems 
problems that impact health and health care. Our unique model combines 
the analytical rigor of a research institution with the business acumen 
of a traditional consultancy to deliver comprehensive, systems-based 
solutions that meet unique needs.
    Altarum has a very strong commitment to serving the needs of our 
Nation's servicemembers and veterans. For over 30 years, Altarum and 
our predecessor organizations have worked to improve military and 
veterans health care serving such diverse clients as the TRICARE 
Management Activity, the Army, Navy, and Air Force medical services, 
and the Department of Veterans Affairs. Our commitment to our Nation's 
current and former servicemembers does not stop with our client-based 
work. Starting in 2008, we launched our $7 million Mission Projects 
Initiative, which includes the multiyear Veterans Community Action 
Teams project which we have discussed with this Subcommittee in the 
past. Recently, we committed to continuing the use of our own funds to 
benefit servicemembers when we initiated our Veterans Transition to 
Community Project, which my testimony today will focus on.
    Altarum's Veterans Transition to Community Project was initiated to 
address one of the most critical issues affecting the almost two 
million Americans who have directly served or supported Operation 
Enduring Freedom and Operation Iraqi Freedom. As in previous conflicts, 
many servicemembers were subjected to blast-related injuries. Estimates 
of 12-20 percent \1\ of them were close enough in proximity to a 
concussive event while deployed to screen positive for mild traumatic 
brain injury (mTBI). Many recover fully; however, others recover only 
partially and have their injuries revisit, and sometimes debilitate, 
them without warning.
---------------------------------------------------------------------------
    \1\ Ramchand et al. (2010, February). Disparate prevalence 
estimates of PTSD among servicemembers who served in Iraq and 
Afghanistan: Possible explanations. Journal of Traumatic Stress, 23, 
59-68.
---------------------------------------------------------------------------
    Treatment teams have always struggled to develop comprehensive 
treatment plans from bits and pieces of information. Problems such as 
post-traumatic stress disorder (PTSD), substance use disorders (SUD), 
major depressive disorders (MDD) and/or mild traumatic brain injury all 
result in some level of short-term memory loss. The science of 
treatment is too often limited because of an incomplete picture of what 
is going on in the servicemembers' lives. To complicate things further, 
a large number of our warriors are Reserve or National Guard members 
who, because of the nature of their service obligations, did not stay 
on a post following mobilization, but instead dispersed after their 
release from duty to every corner of the Nation, making follow-up 
treatment and observation much harder.
    An unfortunate reality is that many of our returning servicemembers 
simply do not receive treatment to address these serious health issues. 
TBI is estimated to have occurred in 12-20 percent of Iraq and 
Afghanistan veterans. Only 7 percent of veterans presenting for 
treatment through the VA have received treatment for their brain 
injury. The remaining 3-13 percent of the almost 2 million veterans 
have not received treatment at this time.\2\ It has been projected 
these numbers could be as high as 300,000 troops.\3\ The number of 
military treatment facilities, VA facilities, and contracted facilities 
that have the requisite skills, knowledge, and training to address 
theses psychological health needs is simply insufficient to meet this 
demand. New techniques are required.
---------------------------------------------------------------------------
    \2\ Carlson et al. (2010, February). Psychiatric diagnoses among 
Iraq and Afghanistan war veterans screened for deployment-related 
traumatic brain injury. Journal of Traumatic Stress, 23, 117-24.
    \3\ Kehle et al. (2010, February). Early mental health treatment-
seeking among U.W. national guard soldiers deployed to Iraq. Journal of 
Traumatic Stress, 23, 33-40.
---------------------------------------------------------------------------
    Through our Veterans Transition to Community Project, Altarum has 
implemented a novel but elegant solution that has significant potential 
to dramatically impact the lives of servicemembers and ease the burden 
on providers. Our solution not only facilitates health and wellness for 
returning servicemembers and their families, but it also leverages the 
time and resources of existing clinical and treatment staff. The 
Veterans Transition to Community Project is exploring methods and 
technologies to connect servicemembers to the care they need using 
technology that is already owned by virtually all returning 
servicemembers--a cell phone. This technology builds on skills and 
knowledge that warriors already possess. The criteria are simple. Can 
you e-mail? Can you text? Do you like pictures? How about music? Can 
you answer questions with a scale of 1-9? This reduces training and 
implementation time to almost zero and also reduces participation 
resistance.
    Our project addresses treatment in all phases of care. During the 
initial treatment phase, we make use of a simple Palm PDA to begin 
collecting information on mental well-being. We use the PDA to collect 
multiple ecological momentary assessments (EMA) from servicemembers 
diagnosed with PTSD, SUD, MDD, and/or mTBI. EMAs are short multiple 
choice questions that document items such as stress, rejection, fear, 
craving, pain, and coping several times daily over a period of months. 
Data are collected and analyzed to create a composite picture of the 
servicemember or veteran--not at the single instance of treatment, but 
across time and daily activity. These data improve the accuracy and 
applicability of treatment.
    Once the servicemember or veteran begins the transition to home, we 
implement an innovative application of mobile phone technology to 
extend treatment and maintain contact with the patient. EMA data 
collected from the individual are compared with information gathered 
during the clinical treatment phases. Data are then used to tailor 
individualized two-way interactions with the servicemember or veteran 
customized to their strengths, needs, and recovery resources. Altarum 
uses EMA data, clinical observations, and patient input to offset 
patient-specific triggers while augmenting motivators and support 
system contacts. Reminders, supportive messages, pictures of 
pleasurable memories, inspirational music, and an interactive pain-
scale support the servicemembers and veterans to avert crises that may 
affect them in their transition from the therapeutic environment to 
work and community life.
    Altarum's Veterans Transition to Community Project extends 
treatment beyond the walls of any facility. All that is necessary is a 
cell phone connection. Our original test cohort continues to receive 
support and, when necessary, treatment as they disperse across the 
country. Because the core of the system depends on automation, time 
zones and work schedules do not affect service delivery. This 
intervention is driven by the demands of the servicemember, not the 
availability of clinical treatment staffs.
    The advantages of our method of supporting treatment through this 
flexible yet common technology are manifold.
    First, in a time of increasingly tight budgets, the incremental 
cost of maintaining a servicemember in this program is negligible. A 
month of effective contact can be maintained with servicemembers for 
far less than the cost of a single office visit. Altarum's project uses 
the veteran's existing cell phone. Once implemented, the secure Web-
based treatment interface can be accessed from anywhere and updated in 
real-time by existing clinical or support staffs. No servers, 
computers, hardware, software, or expensive equipment are required.
    Second, our technique is flexible and adaptable to the individual 
needs of each servicemember. Our armed forces are a composite of 
American society, and one size does not and cannot fit all. The 
Veterans Transition to Community Project is designed to be adapted to 
each participant with minimum of effort. Altarum developed the core 
technology and processes, but the servicemember works with a treatment 
team to develop personalized interventions that best suit his or her 
needs. Using the unique Life:WIRE Web-based interface, treatment is 
customized to the needs, language, and preferences of each client. Our 
solution even allows each warrior to develop a personal support group 
which can be automatically prompted to text, e-mail, call, or call for 
help in later stages of treatment as the situation dictates.
    Third, our method creates a stream of data--data that can be 
evaluated against multiple criteria to help inform treatment, 
diagnoses, and progress. Often the data provide insight into related 
factors affecting recovery that were not readily apparent and can have 
tremendous benefits not only to the individual patient, but to the 
wider needs of the research and treatment community. Through our 
partnership with Chesapeake Research and Review, Inc., we have 
developed a model that protects human subjects and addresses all areas 
of Federal privacy rights and regulations. Secure, de-identified data 
can be extracted to isolate potential factors affecting recovery. EMA 
data can be extracted and compared to original assessment instruments 
to validate the predictability of current assessment technologies. With 
sufficient cross-site implementation to justify statistical validity, 
substrates of these data can be analyzed to identify potential 
differences in recovery by theater of conflict, service, gender, age, 
etc.
    Altarum has provided the research design, funding, and analytical 
support of all periodic and outcomes data and is the originator and 
managing partner for the Veterans Transition to Community Project. But 
we could not conduct this project on our own. Altarum has partnered 
with three organizations whose expertise has been critical in the 
development and application of our techniques. The Pathway Home, a 
veterans' treatment center in Napa Valley, California, specializing in 
PTSD, is our research and implementation site. 
BrainPCheckers' provides an electronic PDA-based assessment 
tool for PTSD. Daily assessments are collected using an automated 
survey system. Our cell phone interaction, support, and messaging is 
provided by Life:WIRE. Each partner provides an integral piece of the 
project.
    Altarum has learned many critical lessons as we work through the 
successful implementation of this research study. One size does not fit 
all. An early participant explained that, ``he didn't feel like he 
could answer a question if he didn't know what all of the words were 
really asking.'' Every part of treatment must be adapted to the context 
of the person being served. Servicemembers and veterans are more likely 
to stay involved in their continued treatment when they feel the 
treatment was made for them and not a generic regimen. Clients are even 
more likely to stay involved when they feel they have input in adapting 
their treatment as they recover and their needs change. Finally, we 
learned that when the treatment meets the needs of those it serves, the 
clients will monitor and encourage one another. Peer support continues 
to proportionately increase utilization for every person involved in 
our research study.
    The ultimate measure of success, for Altarum, is improving and 
protecting the lives of veterans. The following words relayed from one 
of Altarum's research staff members tells it all:

        During our weekly status call, the director of our research 
        partner, the Pathway Home, reported that our cell phone follow-
        up had made a big difference in the well-being, perhaps even 
        the future, of one of the veterans. This warrior wasn't one of 
        our study participants, but one of the graduates of the Pathway 
        Home working with us to fine-tune the delivery system. He had 
        completed his therapy. He is living at home in another State 
        with his wife and family and has begun normal work. Last 
        weekend he used his phone to trigger a crisis response. But, 
        this crisis wasn't a test--it was his. His response immediately 
        text messaged his clinician who was able to call the veteran 
        and de-escalate a serious episode. The episode resolved with a 
        short visit to an emergency room rather than what seemed to be 
        another extended relapse into a mental institution. This father 
        is back at home with his family.

    Altarum's Veterans Transition to Community Project has already 
changed lives. Our solution has the advantages of low cost, rapid 
deployment, facility for remote distribution, and adaptability to the 
needs and environment of those it serves. This makes it ideal for 
implementation across multiple systems--particularly for those 
suffering from mTBI, PTSD, SUDs, and MDDs. We are pleased to be able to 
brief this Committee on the measurable success available to our 
returning servicemembers through this innovative program. Thank you for 
this opportunity.
    Mr. Chairman, this concludes my statement.
    Thank you.

                                 
       Statement of Robert Bosch Healthcare, Inc., Palo Alto, CA
    Mr. Chairman and other Members of the Committee: Thank you for 
giving Robert Bosch Healthcare (Bosch) the opportunity to provide 
testimony to the Committee. Bosch, which makes the Health Buddy and T-
400 remote monitoring devices, has been providing remote patient 
monitoring in the Veterans Health Administration (VHA) since 2003. We'd 
like to address the role of telehealth in improving health outcomes for 
veterans and reducing the need for hospital services, such as emergency 
room visits, inpatient admissions and re-admissions. While these are 
important issues in any geographic area, the shortage of physicians in 
rural areas and the long distances patients must travel to receive 
medical care make it even more important that patients with complex 
chronic conditions learn self-management, and for providers to prevent 
exacerbations of chronic illness that can lead to a hospital visit. In 
many cases, emergency room visits, hospital admissions and readmissions 
have been proven to be preventable through regular monitoring, 
automated patient education and the intervention of a nurse case 
manager.
    Thirty two percent of veterans treated by the VHA live in rural 
areas.i The care needs of an aging veteran population (the 
number of veterans aged 85 and older is set to triple by 2011 compared 
to 2000 ii) have led the VHA to adopt health technology 
sooner than many other delivery systems. We applaud this foresight. As 
the Committee knows, between 2003 and 2007 the VHA implemented Care 
Coordination/Home Telehealth (CCHT), a national initiative that enables 
veterans with chronic conditions to remain in their communities and 
reduces the need for high cost acute care. This was after extensive 
evaluations of the intervention in the Sunshine Network Veterans 
Integrated Services Network (VISN). Bosch has been providing remote 
patient monitoring devices to veterans since the beginning of the CCHT 
initiative; currently we provide 70 percent of the remote monitoring 
technologies that serve veterans across 21 VISNs and 123 facilities 
nationally. We believe that our products, and remote monitoring in 
general, provide an opportunity to cost-effectively extend care to 
rural areas without compromising clinical effectiveness.
---------------------------------------------------------------------------
    \i\ Darkins, A., Ryan, P., Kobb, R., Foster, L., Edmonson, E., 
Wakefield, B., Lancaster, A. Care coordination/home telehealth: a 
systematic implementation of health informatics, home telehealth and 
disease management to support the care of veteran patients with chronic 
conditions. Telemedicine and e Health 14(10):1118-1126.
    \ii\ Ibid. Page 1118.
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A. The Health Buddy and T400 Programs
    Bosch participation in the VHA CCHT program is based on the premise 
that care management supplemented by technology (the Bosch Health Buddy 
and ViTelCare systems) can effectively decrease costs (most commonly 
due to repeated and/or prolonged hospitalizations) and improve the 
quality of life for veterans with chronic conditions by supporting 
education and self-care, increasing care based on evidence-based 
guidelines, and improving coordination of care.
I. Clinical Focus
    Key diseases of focus for veterans are Congestive Heart Failure 
(CHF), Diabetes Mellitus (DM), Chronic Obstructive Pulmonary Disease 
(COPD), Hypertension (HTN), Post Traumatic Stress Disorder (PTSD), and 
Major Depression, though other conditions are monitored as well. We 
believe that the successful outcomes for PTSD, depression and other 
mental health disorders iii demonstrate the applicability of 
remote monitoring to younger ``Wounded Warriors'' who are not likely to 
have age-related conditions, but may suffer from service-related mental 
health conditions.
---------------------------------------------------------------------------
    \iii\ Ibid. Page 1123.
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II. System of Care Management + Technology
    The Health Buddy and ViTelCare Programs provide effective, 
efficient and consistent care management based on the Chronic Care 
Model.iv Its elements include the community, the provider 
system, self-management support, delivery system design, decision 
support, and clinical information flow. Care management is supported by 
an easy-to-use, in-home survey and data collection home health 
monitoring device (either the Health Buddy four-button appliance with 
text screen, or the ViTelCareT400 touch-screen monitor with adjustable 
audio and text screen) and an Internet-based web service for data 
management, care coordination, and decision support by health care 
providers.
---------------------------------------------------------------------------
    \iv\ Group Health Research Institute. 2006-2010 Improving Chronic 
Illness Care. http://www.improvingchroniccare.org/
index.php?p=The_Chronic Care_Model&s=2
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III. Health Buddy and ViTelCare Systems
    The Bosch devices gather information on vital signs (either through 
patient self report or peripheral devices such as glucose monitors), 
symptoms, behaviors and patient knowledge of their health conditions. 
The data collected is presented to the health care professional through 
a web-based application in a color-coded and risk-stratified format. 
The Health Buddy's and ViTelCare's scripted dialogues also provide 
education, feedback, and reminders for self-care behaviors, 
specifically diet, exercise and medication compliance. Patient 
responses from both the Health Buddy and T400 appliances are 
automatically sent to servers housed within VA data centers.
IV. Data Flow
    Data from the patient takes place through traditional telephone 
connection, Ethernet, and, for the Health Buddy, through wireless modem 
(the T400 will introduce wireless capability later in 2010). Bosch is 
exploring additional means of expanding patient-provider connectivity 
that would make remote monitoring more accessible to veterans in rural 
areas.
V. Workflow Result
    The provision of risk-stratified information to nurse case managers 
is a critical component of detecting exacerbations of illness early, 
before a hospital visit becomes necessary. Moreover, it enables case 
managers to target resources to patients most in need and manage a 
larger patient panel (a typical nurse to patient ratio in the Health 
Buddy Program is 1:125 or 1:75 for mental health conditions).
B. Results
    The CCHT initiative has shown great success, as demonstrated by a 
25 percent reduction in inpatient days, 19 percent reduction in 
hospital admissions and 86 percent patient satisfaction after 
enrollment.v As a provider of 70 percent of the remote 
monitoring devices used within the VHA, we believe we have been a 
significant contributor to the VHA's ability to successfully improve 
patients' quality of life and transition care away from high cost acute 
care settings and into the home and community.
---------------------------------------------------------------------------
    \v\ Darkins et al. op cit. Page 1118.
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C. Opportunities for Expanding the Reach of Telehealth
    The CCHT initiative represents wisdom and foresight in caring for a 
growing and geographically dispersed veteran population, yet we believe 
there is even more potential to extend care to rural areas in a 
clinically- and cost-effective manner with modest modifications. 
Research has shown that reductions in utilization for veterans in rural 
areas lag behind those in urban areas vi, showing potential 
for greater returns to the VHA. Specifically, we note:
---------------------------------------------------------------------------
    \vi\ Ibid. Page 1123.

      The ability to expand the successes of the CCHT 
initiative has been limited by institutional constraints related to 
hiring staff and by the time required for development of new clinical 
practices and protocols.
      Currently, Health Buddy and T400 appliances are procured 
by the VHA prosthetics department, which is set up to purchase material 
goods such as telehealth devices or prosthetic limbs. Telehealth, on 
the other hand, is a system of care and as such it includes material 
goods, as well as less tangible items, such as services, software, data 
management and data storage. Prosthetics does not have a mechanism to 
pay for ongoing service and other non-material fees--in essence, the 
current payment structure does not support wider adoption of health 
technology, which is increasingly becoming more virtual. We are hopeful 
that this barrier will be addressed by the proposed transition of 
procurement to the Denver Acquisitions and Logistics Center.

    These suggestions aside, we again would like to take the 
opportunity to commend the VHA for taking a leadership role in adoption 
of technology as a primary component of patient care. As the largest 
health care system in the Nation, VHA's vision in adapting to a new 
technological age will lead other health care providers to do likewise, 
resulting in reduced costs and better patient outcomes.
D. Technology on the Horizon
    The promise of telehealth ultimately resides in the notion that 
inter-networked technologies can create a system in which health 
maintenance and care are moved to wherever someone with severe 
disabilities or chronic illness is--particularly their home. Over time, 
we believe that the ability to support an individual's independence 
will rely on increasingly intelligent sensor-based technologies that 
can predict with increasing degrees of certainty that an `adverse 
event' is looming. We also see a role for video as broadband-
penetration rates continue to rise.
    We believe the VHA's technology-based care coordination program has 
driven the development of the budding, U.S.-based home telehealth 
industry. We believe that the VHA CCHT program's next wave of growth, 
with its increasing sophistication of how to refine its toolbox of 
options for veteran health management and monitoring, will drive a new 
wave of innovation in the industry. Bosch looks forward to supporting 
the VHA in its ongoing drive to improve care for veterans by moving 
that care to their homes, wherever--including rural areas--those 
veterans are.

                                 
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