STATEMENT OF
ADAM DARKINS, MD
CHIEF CONSULTANT, CARE COORDINATION
OFFICE OF PATIENT CARE SERVICES
VETERANS HEALTH ADMINISTRATION
DEPARTMENT OF VETERANS AFFAIRS
BEFORE THE
SENATE COMMITTEE ON VETERANS' AFFAIRS

FEBRUARY 26, 2009
* *
Good morning, Mr. Chairman.  I appreciate the interest of the committee in the Department of Veterans Affairs' (VA's) telehealth programs and welcome the opportunity to brief you on their current status.  Telehealth involves the use of information and telecommunications technologies to deliver services in situations in which patient and health care provider are separated by geographical distance.  The benefits to Veteran patients that accrue from VA's implementation of telehealth include increasing access to specialist care and reducing travel times for patients and health care providers.  These benefits make telehealth of particular relevance to service delivery in rural areas where recruitment of health care providers can be problematic for all health care organizations, not just VA.  Telehealth also reduces the need for travel which can be costly, inconvenient and may act as a barrier to care.
In this context, it is important to note that telehealth is not a panacea that addresses all the challenges of health care delivery in rural areas.  There is a real need for face-to-face services in many instances.  Therefore, given the necessary clinical, technological and business processes that underpin safe, effective and efficient care, telehealth services fit into a continuum of appropriate services for meeting the health care needs of the enrolled Veteran population.
VA is predominantly targeting chronic disease in the Veteran population through our telehealth programs.  Care of patients with chronic disease is a major challenge that all health care organizations face and which telehealth can help address.  VA's vision for telehealth is to provide the right care in the right place at the right time with a goal of making the home and local community the preferred place of care when it is possible and when it is the Veteran's preference. In pursuit of this goal, VA has implemented three large, standardized telehealth programs that are available for urban, rural and highly rural Veterans.  VA's telehealth programs also extend to American Indian/Alaskan Native, Native Hawaiian, and Pacific Island Insular Area communities.  VA currently operates seven such programs that include Hawaii and the Pacific Island Insular Area and Alaska.  Four more await connectivity and 11 others are in various stages of deployment for 15 Tribes in the continental United States.
The first major program is Care Coordination/Home Telehealth (CCHT).  This program uses telehealth devices to connect enrolled Veterans with a VA practitioner, usually a nurse or social worker, who can routinely monitor vital sign data, disease management responses and engage in video consultations.  VA has implemented a national technology platform to support standardized clinical and business processes.  Through the adoption of this systematic approach to CCHT, VA has built a program that provides care to 36,400 patients, 20,000 of whom are receiving non-institutional care.  Thirty eight percent of CCHT patients in VA are in rural areas and two percent are in highly rural areas. These proportions of rural and non-rural patients mirror the proportions in the Veteran population as a whole. This is important because CCHT is equally useful and available in rural and urban settings.  Routine clinical outcomes data from VA's CCHT program published in December 2008 showed an 25 percent reduction in the average number of days patients enrolled in CCHT are hospitalized and a 19 percent reduction in hospital admissions.  The data also reveal a 17 percent reduction in hospital admissions for rural Veterans using CCHT and a 50 percent reduction for highly rural Veterans.  Currently over 140 VA Medical Centers provide CCHT in addition to 28 CCHT clinics located in rural and highly rural areas.
The second major area of telehealth in VA is Care Coordination/General Telehealth (CCGT), which uses real-time clinical videoconferencing systems to deliver services between VA Medical Centers (VAMCs) and community-based outpatient clinics (CBOCs) over VA's telecommunications networks.  In Fiscal Year (FY) 2008, more than 48,000 Veterans received care nationally through this program. Over 35 clinical specialties in VA participate in the delivery of services via CCGT.  CCGT mainly addresses care related to mental health and rehabilitation.  In FY 2008, VA provided mental health care to 29,000 Veterans through tele-mental health.  Patients received care at 171 sites in rural or highly rural areas.  Tele-mental health is part of the overall framework of the mental health universal service plan. Routine outcomes data for tele-mental health in VHA have shown a 24.6 percent reduction in hospital admissions and 24.4 percent reduction in bed days of care.
In FY 2007 VA implemented a Polytrauma Telehealth Network to link VA's sites of care for polytrauma patients and offers CCGT tele-rehabilitation services and provide access to Walter Reed Army Medical Center and Bethesda Naval Hospital.  In FY 2009, VA is seeking to extend this concept of networked services further by developing a national CCGT technology infrastructure called the Clinical Enterprise Video-conferencing Network.  This Fiscal Year VA plans to establish a national tele-mental health center to coordinate delivery of specialist mental health services via tele-mental health for conditions such as bipolar disorder and post-traumatic stress disorder.  Part of this initiative will focus on delivery of these services in rural areas.
The final major area of telehealth is Care Coordination/Store-and-Forwards (CCSF), which involves the capture and storage of digital images that are transmitted to a remote location where a health care provider can report the image and return it to the patient site for use in the diagnosis and management of various conditions.  VA's most significant advances in this area involve screening Veterans for diabetic eye disease.  Twenty percent of the Veteran patient population has diabetes.  Screening for diabetic eye disease is important because if it is recognized and treated before complications arise, we can prevent avoidable blindness.  In other specialty areas, VA made tele-retinal imaging services available to 98,000 Veterans last year and 54 of the 219 sites at which this care took place were in rural or highly rural clinics.   The remainder of the CCSF was for was tele-dermatology.  Currently VA is working toward a standardized approach to tele-dermatology with the intent of future enterprise-wide adoption. 
Training is an essential component of any successful new technology or service.  VA staff is trained to use CCHT technology and adhere to clinical and business processes through courses developed and instituted by a VA home telehealth training center in Lake City, Florida.  This training draws, wherever possible, on technologies that enable virtual participation.  VA has a training center for CCGT in Salt Lake City, Utah and a CCSF training center in Boston, Massachusetts.  Training center curricula are standardized and we emphasize virtual training whenever practical and possible.  The three VA telehealth training centers have enabled over 6,000 staff to be trained and have helped sustain a rapid pace of telehealth expansion that makes VA a recognized national leader in the field of telehealth. VA has also implemented an internal system to assess the quality and consistency of its telehealth programs at a VISN level that is conducted in each VISN biannually.
In conclusion I would like to recognize the dedication of staff throughout VA in developing these ground-breaking services.  Their energy and enthusiasm supports the independence of the Veterans we serve by providing access to high quality care via telehealth.  Fundamental to our success is VA's electronic health record system. Without an electronic health record, telehealth systems are of limited benefit because without clinical information, laboratory results and clinical images, it is impossible to change the location of care and proactively address many health issues.
Mr. Chairman, this concludes my prepared statement.  I would like to take this opportunity to offer my services to you to demonstrate this technology at a future time.  I would be pleased to answer any questions you may have.