Witness Testimony of David Cattell-Gordon, M.Div., MSW, Co-Director, The Healthy Appalachia Institute, and Faculty, Public Health Sciences, Nursing, Director, Rural Network Development, 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 healthcare 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:
- The substantial, long-standing health disparities in rural Central Appalachian and for rural veterans;
- The role of telehealth in improving the delivery of healthcare and educational services to rural citizens especially veterans; and,
- 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|
|H.S. Graduation Rate||61.0%||81.0%|
|College Graduation Rate||9.0%||29.5%|
|Percent of Pop. Working||41.8%||62%|
|Below Federal Poverty Line||19.5%||9.6%|
The seven coalfield counties and one city that make up Health Planning Districts I and II in Appalachian Southwestern Virginia, for instance, are a uniformly rural area of more than 3,200 square miles of mountainous landscape with a population of nearly 207,000. This mostly homogenous population lives primarily in small, geographically isolated communities and suffers from declining population, low educational attainment, high rates of poverty and approximately half the per capita income of the rest of the state. This is true of the many of the veterans of the region.
These persistent social problems are intertwined with significant disease risk factors that contribute to disproportionately high rates of heart disease, cancer, respiratory disease, diabetes, and depression. To complicate these social and health issues, the sharp mountain ridges and deep valleys that divide the region make access to work and health care difficult. There are serious healthcare 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|
|Not in Wellness Activity||33.75%||22.6%|
|Smokeless Tobacco Use||16.8%||3.4%|
One only has to look at the ten-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|
|Solid Tumor Cancer||253*||185|
|Chronic Lower Respiratory||79*||38|
*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.*
This is the health environment of much of rural America that it is now time to address. I know this sub-committee 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 sub-committee 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 US 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.**
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 sub-committee is well aware of: telehealth.
Telehealth can reduce many of the barriers of access to locally unavailable healthcare 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 healthcare 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 healthcare 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 healthcare, 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. ***
The aging of our veterans has also already created increased demand for specialty healthcare 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 three 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 healthcare 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 healthcare 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 healthcare 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 healthcare 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 healthcare expenditures. Imagine what it could mean to ensure improved medication compliance, increased exercise, healthy diet and appropriate use of healthcare 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 healthcare 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.
* 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.
** 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
*** Williams, JM et al, Emergency medical care in rural America, Ann Emer Med 2001: 38(3):323-327.
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