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Mr. Chairman and Members of the Committee:
I am privileged to appear before you today to discuss rural tele-medicine and describe the positive impact it is having on our ability to provide care to the veterans we proudly serve. I represent a dedicated team of health care professionals who are committed to improving access to care for veterans who live in rural settings. We care for these veteran patients at the John J. Pershing VA Medical Center (VAMC) in Poplar Bluff, Missouri and its associated community based outpatient clinics (CBOCs) that are located in Paragould, Arkansas, Cape Girardeau, Missouri, Farmington, Missouri, West Plains, Missouri, and Salem, Missouri. However, I believe that our success in improving access to care for the veterans we serve is transferable to other rural areas. Our veteran population includes those who served in past wars and conflicts, as well as those who are now returning from Operation Enduring Freedom and Operation Iraqi Freedom.
The commitment and leadership of our Facility Director, Chief of Staff and the Network Director in Veterans Integrated Service Network (VISN) 15, together with direction and support from senior management in VA Central Office, have been key elements to inspiring our team to focus on re-configuring the services we provide to incorporate telemedicine and improve access to care for veteran patients.

The John J. Pershing VAMC is a small rural medical center located in the center of the nation's heartland that focuses on the delivery of primary care-based services. We are approximately 156 miles south of St. Louis, Missouri, and 156 miles North of Memphis, Tennessee. Our remote location means we face very different challenges in providing care to veteran patients than a VAMC in more populous areas. The general population in rural communities like ours tends to be older, poorer and have greater health needs. Typically, the low density of population, geographic distance, and lack of big city amenities means there are fewer health care resources and support services in rural areas. Proportionately more rural inhabitants pursue military service and for those that do not, or return to rural areas after being in the service, rural occupations have high rates of morbidity and mortality.
Those of us who choose to live in a rural environment usually do so because we feel that facing these challenges is well worth the reward we get from living where we do. The cost of living is usually lower and members of our community usually value self-reliance and independence, although this can make seeking healthcare services early and preventive care more challenging. For many of the veteran patients we treat, health and well-being means living where traffic is limited, and there is peace and quiet shared with folks you know. They view being "home" as worth more than money can ever buy, and that home is not a house, but a place and a way of life.
Those of us who are privileged to be charged with providing health care to veterans who live in this environment are sensitive to the unique culture and needs of veteran patients in the rural communities we serve to the need to provide care at the same high level of professional expertise elsewhere. Tele-medicine has been a tremendous benefit to us in delivering care in a rural community. Instead of the traditional requirement in healthcare for the patient to travel to the care, we can take the care directly to the patient. It means we can truly practice patient-centered care. Access to specialty care is a particular issue for us in a primary care-focused VAMC. Telemedicine has enabled us to improve access to care for veteran patients while decreasing travel for patients and staff and in doing so reduce costs. I will try not to make telemedicine sound too much like a panacea, but it has helped us deal with the challenges of bad roads, limited numbers of providers, social isolation, coping with the weather and staff education. Telemedicine means local staff is usually available to be with the patients and speak the patient’s language. This really assists with effective communication between patients, their families and providers of their health care. It has offered us new opportunities to support caregivers without which many of our veteran patients would need institutional care.
We currently support thirty-nine tele-medicine clinics in our CBOCs and draw on specialty care providers in our medical center from as far away as the Kansas City, VAMC in Missouri which is 500 miles away. We estimate that our telemedicine services have saved the need for over 56,000 miles of patient and staff travel. The range of telemedicine clinics we offer include: tele-dermatology, tele-cardiology, tele-retinal imaging, tele-major medical evaluation, tele-pain management, tele-radiology, tele-speech therapy, tele-physical therapy, tele-mental health services, tele-substance abuse treatment programs, multi-point patient education for diabetes, multi-point patient education for congestive heart failure, tele-smoking cessation, tele-pharmacy education, distant staff education and care coordination/home telehealth. Having these programs means patients can receive prompt effective care within their own home or local community. Access to specialist care clinics from CBOCs via telemedicine is resulting in a 30% lower no show rate in tele-mental health clinic compared to previously when it meant having to travel and see the provider in a face to face clinic. We have seen a doubling of patient attendance at telemedicine-mediated education clinics. Our outcome data indicates that there is a 22-24% reduction blood glucose levels for patients in the tele-education clinics and that 20% of these patients cease smoking. Access to care for our veteran patients is greatly enhanced with appointments in specialty clinics decreasing from six months to less than 30 days. We estimate that we are recouping the cost of the tele-medicine equipment within 14 months of purchase because of the resulting cost savings/cost avoidance.
Cost is something that we are all acutely aware of in health care but there are some things we are able to do that are priceless. To illustrate how telemedicine can bring intangible benefits that statistics cannot describe, I would like to share the story of a veteran patient we cared for several years ago. This elderly gentleman was frail and his clinical condition meant he could not travel to be with his wife who was critically ill in a hospital over 100 miles away. It was possible for us to use telemedicine for this veteran to be with his wife one last time.
Patient satisfaction with care provided utilizing this technology has been high. Staff satisfaction has been high. Clinical outcomes have been positive. We are excited and proud of how our telemedicine programs and the processes that support them are contributing to the health and well being of the rural veterans we are dedicated to serve. Our experience is that this technology represents a major tool we can routinely use in the provision of health care for veterans and in doing so address issues of access to care, quality, patient safety, cost effectiveness, and at the same time put compassion for our patients into action. I am grateful to the committee for the opportunity to describe how we are making this difference in caring for veteran patients.