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Mr. Chairman and Members of the Subcommittee:

It is an honor for me to be here before this Subcommittee today and provide you with testimony on VA’s use and development of telemedicine. I am a psychiatrist who has practiced in a number of healthcare settings, and currently, I also serve as the Associate Chief of Staff for Education (ACOS) at the VA Connecticut Health Care System in West Haven, Connecticut, and as the VA’s National Lead for Telemental Health. I am involved in telemedicine in each of these three roles and will provide the Committee with perspectives from each role because I believe they all help highlight how VA is using and developing telemedicine. My testimony will focus particularly on what I see as the “people” issues involved in using and developing telemedicine.
Like the majority of my colleagues in psychiatry I was trained to care for patients through face-to-face interactions. It was only when I came to the VA that I first learned about telemental health as a very different way of practicing my profession. Furthermore, after reviewing the relevant healthcare literature, I appreciated how telemental health had a place in the delivery of care and could replicate a face-to-face interaction. Most importantly, I was reassured that patients were satisfied with receiving care in this way while providing them improved access and saving them the cost, inconvenience and time involved in travel.
My initial exposure to telemental health was in Veterans Integrated Service Network (VISN) 9 when I was the Mental Health Services Manager there. The Huntington VA medical center (VAMC) had been using tele-mental health successfully to provide care to patients in distant Vet Centers and community-based outpatient clinics (CBOC’s). I became involved directly in the establishment and running of tele-mental services to connect all VISN facilities for expert tele-mental health consultation and on-going treatment. I could see first hand how our veteran patients were very comfortable with it and how much easier it made it for them to receive care. Of course, there are, and always will be times, when a patient will need to be seen face-to-face in a clinic, but in numerous instances tele-mental health can provide general psychiatry and also specialty psychiatry services such as for substance abuse care and care for post-traumatic stress disorder (PTSD).
As VA’s lead for tele-mental health, I am what is generally referred to as a “clinical champion”. A clinical champion is a practitioner who helps introduce and develop new practices in healthcare and acts as an advocate for these new practices with their colleagues. It is a privilege to help VA and my colleagues lead the way with a new healthcare development like tele-mental health. I am one of many clinical leads for telemedicine in VA. There are also leads for tele-rehabilitation, tele-surgery, tele-endocrinology, tele-dermatology and for tele-retinal imaging. We all receive support from the national Care Coordination Program Office, and I think it is important to share with you what I feel is a commonality between us all that makes us effective in what we do. I believe it is the fact that VA’s leads for telemedicine are committed to serve veteran patients, and that our colleagues know we are using telemedicine in ways that truly work for patients and ensure excellence of care.
The clinical leads for telemedicine have established a network of telemedicine clinicians and VISN leaders. In VA all of the clinical leads for telemedicine have developed “toolkits” for our respective areas of telemedicine. These toolkits help new programs get started and allow new programs to learn from the experience of other VA established programs, rather than having to re-invent the wheel. These toolkits are also very useful for staff training. The tele-mental toolkit formalizes the requirements to develop a tele-mental health service and educate all staff involved. This is where my role as ACOS for Education has a bearing on the development of telemedicine.
One of the challenges in sustaining telemedicine is to make sure that there are practitioners with the requisite skills and competencies who are committed to the program. If the tele-mental health service depends upon an individual mental health practitioner who is enthusiastic about telemedicine then what happens if this practitioner leaves? There is the risk that the service will cease, and the service will no longer be available to our patients, unless there is another practitioner available to maintain it.
The situation I have just described at the micro-level of the individual clinic also needs to be considered at the macro-level of educating health practitioners of the future. In my own specialty, medical schools and residency programs are just beginning to train the next generation of psychiatrists in the use of tele-mental health. In VA, we are starting to explore what a tele-mental health component to a residency program might look like. I believe that the ability to recruit newly trained psychiatrists who are familiar with tele-mental health would be of great benefit to VA in sustaining tele-mental health programs. Incorporating tele-mental health into residency programs in the future may have a catalytic effect in terms of promoting the initiation of tele-mental health in the wider healthcare system. My reason for making this assertion is as follows. Over recent years, I have regularly seen medical students and residents who have come to train in VA and in doing so have gained experience with VA’s electronic patient record. If students and residents then return to a medical center that does not have an electronic record, they appreciate the importance of the electronic record as compared to the paper chart in the delivery of care to the patient, and the students and residents become great advocates for computerized patient records. I predict that there would be this same effect with tele-mental health.
Currently, I practice in VISN 1, the VA New England Healthcare System. The VISN has recently established a tele-mental service between Togus and Caribou, Maine. The development of this service was presented at VA’s Care Coordination Telehealth Leadership Meeting in Salt Lake City in April 2005. The service was established because of the 249-mile distance that veteran patients previously had to travel between Caribou and Togus for mental health care. The normal seasonal snowfall is nine and a half feet. Even if it doesn’t snow, it is a 10 hour round trip and there is also the cost of gasoline for the veteran patient. Our tele-mental health toolkit was used to systematically work through the clinical, technical, and business processes necessary to establish this tele-mental health clinic, and it is now up and running. The outcomes after initial evaluation have been one hundred percent patient satisfaction and a no show rate that is lower with telemedicine than it was at the face-to-face clinic.
The success of this clinic means that VISN 1 is preparing to extend the service to other CBOCs in Maine. Other considerations are:
• expanding this to services beyond psychiatry,
• using the link for conferencing and consultation,
• facillitating remote case conferencing,
• conducting family interviews/intervention, and
• providing in-service training.
Installing the necessary telecommunications connection between Togus and Caribou and setting up the equipment at either end made tele-mental health feasible. I hope that in my testimony I have been able to give you a sense of how recognizing and attending to the people processes at both a patient and practitioner level are vital to developing and sustaining telemedicine services. As someone who had no experience with tele-mental health until I began working at VA, I am privileged to help champion telemedicine I would like to conclude with a quote from one of VISN 1’s satisfied veteran patients from Caribou who no longer has to drive to Togus for care. He said of the service, “Thank God there’s telemedicine.”
Mr. Chairman, this concludes my statement. I will now be happy any questions the Subcommittee might have.