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Hearing Transcript on Overcoming Rural Health Care Barriers: Use of Innovative Wireless Health Technology Solutions.
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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 For sale by the Superintendent of Documents, U.S. Government Printing Office
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CORRINE BROWN, Florida |
STEVE BUYER, Indiana, Ranking |
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Malcom A. Shorter, Staff Director SUBCOMMITTEE ON HEALTH
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. |
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C O N T E N T S
June 24, 2010
Overcoming Rural Health Care Barriers: Use of Innovative Wireless Health Technology Solutions
OPENING STATEMENTS
Chairman Michael H. Michaud
Prepared statement of Chairman Michaud
Hon. Gus M. Bilirakis
Prepared statement of Congressman Bilirakis
WITNESSES
Federal Communications Commission, Kerry McDermott, MPH, Expert Advisor
Prepared statement of Ms. McDermott
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
Prepared statement of Colonel Poropatich
U.S. Department of Veterans Affairs, Gail Graham, Deputy Chief Officer, Health Information Management, Office of Health Information, Veterans Health Administration
Prepared statement of Ms. Graham
AirStrip Technologies, San Antonio, TX, William Cameron Powell, M.D., FACOG, President, Chief Medical Officer and Co-Founder
Prepared statement of Dr. Powell
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
Prepared statement of Mr. Cattell-Gordon
Cogon Systems, Inc., Pensacola, FL, Huy Nguyen, M.D., Chief Executive Officer
Prepared statement of Dr. Nguyen
Continua Health Alliance, Rick Cnossen, President and Chair, Board of Directors, and Director of Personal Health Enabling, Intel Corporation Digital Health Group, Hillsboro, OR
Prepared statement of Mr. Cnossen
LifeWatch Services, Inc., Rosemont, IL, John Mize, Director, LifeWatch Federal
Prepared statement of Mr. Mize
MedApps, Inc., Scottsdale, AZ, Kent E. Dicks, Founder and Chief Executive Officer
Prepared statement of Mr. Dicks
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
Prepared statement of Mr. Frank
West, Darrell M., Ph.D., Vice President and Director of Governance Studies, and Director, Center for Technology Innovation, Brookings Institution
Prepared statement of Dr. West
West Wireless Health Institute, La Jolla, CA, Joseph M. Smith, M.D., Ph.D., Chief Medical and Science Officer
Prepared statement of Dr. Smith
SUBMISSIONS FOR THE RECORD
Altarum Institute, Ann Arbor, MI, Lincoln T. Smith, President and Chief Executive Officer, statement
Robert Bosch Healthcare, Inc., Palo Alto, CA, statement
OVERCOMING RURAL HEALTH CARE BARRIERS: USE OF INNOVATIVE WIRELESS HEALTH TECHNOLOGY SOLUTIONS
Thursday, June 24, 2010
U. S. House of Representatives,
Subcommittee on Health,
Committee on Veterans' Affairs,
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 in the Appendix.]
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 a 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 in the Appendix.]
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 in the Appendix.]
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 chart 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 in the Appendix.]
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 in the Appendix.]
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?
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