[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\
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\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.
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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%
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College Graduation Rate 9.0% 29.5%
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Percent of Pop. Working 41.8% 62%
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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.*
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* 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.
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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.**
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** 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.
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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.***
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*** 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.
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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).
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\2\ See Centers for Medicare and Medicaid Services, ``Telemedicine
and Telehealth,'' http://www.cms.hhs.gov/Telemedicine/.
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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.
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\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.
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\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\
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\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
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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\
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\2\ The Office of Rural Health, Departement of Vererans Affairs
http://www.ruralhealth.va.gov/RURALHEALTH/About_Rural_Veterans.asp.
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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\
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\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.
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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\
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\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\
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\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).
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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\
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\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.
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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\
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\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.
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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.
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\9\ Chapter 9, ``Adoption and Utilization'', National Broadband
Plan.
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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.
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\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.
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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.
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\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.
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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.
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\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.
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\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.
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\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.
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\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:
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\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.