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JUNE 24, 2010

SERIAL No. 111-87

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BOB FILNER, California, Chairman


VIC SNYDER, Arkansas
JOHN J. HALL, New York
TIMOTHY J. WALZ, Minnesota
JOHN H. ADLER, New Jersey
GLENN C. NYE, Virginia

STEVE BUYER,  Indiana, Ranking
HENRY E. BROWN, JR., South Carolina
BRIAN P. BILBRAY, California
DAVID P. ROE, Tennessee




Malcom A. Shorter, Staff Director

MICHAEL H. MICHAUD, Maine, Chairman

VIC SNYDER, Arkansas
GLENN C. NYE, Virginia
HENRY E. BROWN, JR., South Carolina, Ranking

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.



June 24, 2010

Overcoming Rural Health Care Barriers: Use of Innovative Wireless Health Technology Solutions


Chairman Michael H. Michaud
    Prepared statement of Chairman Michaud
Hon. Gus M. Bilirakis
    Prepared statement of Congressman Bilirakis


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


Altarum Institute, Ann Arbor, MI, Lincoln T. Smith, President and Chief Executive Officer, statement
Robert Bosch Healthcare, Inc., Palo Alto, CA, statement


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.


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.]


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.



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?


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?


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 importantFederal 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?

Mr. SNYDER.  Thank you, Mr. Chairman.  I am sorry I was late. 

I am actually a former family doctor, but still from Arkansas, so I appreciate the Arkansas plug.  But, also, my wife and I have three—18-month old triplets—boys, so we went through a lot of the high technology stuff recently.  And, of course you start running into a little network of folks with multiples.  And we were talking to the doctors, oh, yeah, we are following another case.  It turned out it was in North Arkansas, but they are doing it by telemedicine.  Is that the kind of program you are talking about, where they would go to their regular obstetrician (OB) perhaps up north but then they would have the specialist, the neonatal person online?  Is that what you are talking about? 

Mr. CATTELL-GORDON.  That is exactly what I am talking about.  It is called the Arkansas Angels program.  And I would invite all the Members of the Committee, go out and Google them.  They have just been highly successful in that, in women's health and in prevention and diabetes monitoring.  It is an example, along with many other telehealth programs. 

It is important to say that there is a telehealth program in every State in the United States.  A lot of the infrastructure is there now to build out what has been an important point-to-point connection.  Now we have the opportunity to move it from point to point to point to home to multiple points using wireless capability. 

Mr. SNYDER.  I wanted to ask a specific question that is not related just to veterans but to our whole country.  One of the issues that has come up here through the years is the shortage of mental health practitioners, both urban and rural, but you certainly notice it in rural areas, and we have had some terrible tragedies of social workers or people that work for programs going out to follow up on a patient who has a major schizophrenic diagnosis or something and an act of violence occurs towards the follow-up. 

Where do you see—I didn't see your written statements.  What do you see is the possibility for the kinds of technology improvements that you all are talking about with regard to helping people with devastating illnesses of schizophrenia, really the major psychoses? 

Dr. SMITH.  I can comment a little bit. 

It is now quite clear that, for schizophrenia, the notion of medical compliance is critical and can have tragic discontinuities.  After skipping a couple of days, attitudes about their medical therapy changes, and they can irrevocably walk away from therapy.  And there are excellent innovative approaches for guaranteeing compliance with medical therapies to the extent that if you are a half an hour late taking your medicine you can get an e-mail about it.  If you are a little bit longer than that, you can get a phone call about it.  And all of that can be enabled with nonparticipatory technologies, so that your pill cap may be able to be wirelessly connected to a care provider's office that lets them know that you haven't, in fact, opened your pill bottle today.  And so that—I think it can start there. 

And certainly there are connection paths between caregivers and patients that can be—through their cell phones or through the Internet that can be pleasant reminders and carry messages that can be engaging.  And so that there is a greater sense of connectedness, and that can mean so much for those who are struggling with psychological illnesses. 

Mr. SNYDER.  How much limit do you see in the kind of things that you all are talking about on the issue we still have with low education levels and poor literacy rates?  How much does that interfere with some of the things you all are talking about? 

Mr. CATTELL-GORDON.  I have spent most of my life working in the coalfields of Southwest Virginia; and we have lower educational attainment, limited income, lack of access to meaningful work, high rates of uninsurance, health factors, high cholesterol, obesity, smoking.  You know, you bundle all those things up and the consequence—and this includes our veterans in the region—to premature mortality. 

So, without being overly dramatic, these are life-and-death issues.  And we can't talk about how we are going to change access to health care without talking about how we are improving education.  And these same tools that we are talking about have to do with improving professional education, improving the skills of the work force, improving a family's understanding of the disease, a chronic disease, so it is a tool that integrates education and health in the most powerful ways.  And that is why I have become fully convinced that this is one of our most primary solutions to health issues in rural areas.

Mr. SNYDER.  Thank you, Mr. Chairman.

Mr. MICHAUD.  It is getting late.  Thank you to all three of you for coming here this morning.  You all provided very enlightening testimony.  I know that I will be submitting other questions in writing, so hopefully you can get the answers quickly. 

Once again, thank you very much.  I appreciate it. 

I would ask the second panel to come forward, and as they are coming forward I will introduce the second panel.  We have Dr. Powell, who is the President and Chief Medical Officer and Co-Founder of AirStrip Technologies in Texas.  We have Rick Cnossen, who is President and Chair of the Board of Directors of Continua Health Alliance in Texas.  We have Kent Dicks, who is the Chief Executive Officer (CEO), Chairman, and Founder of MedApps in Arizona.  We have Dan Frank, who is the Managing Partner of Three Wire Systems, LLC, in Virginia, and he is also here on behalf of MHN; and we have John Mize, who is Director of LifeWatch Federal, LifeWatch Services in Illinois. 

And I will turn it over to Mr. Miller to introduce one of his constituents.

Mr. MILLER.  You turned it over to me because you couldn't pronounce his name.

Mr. MICHAUD.  That is correct.

Mr. MILLER.  Thank you very much, Mr. Chairman. 

It is a pleasure for me to introduce to the Subcommittee today Dr. Huy Nguyen.  He is a constituent of mine from Pensacola.  He serves as CEO of Cogon Systems.  Cogon is setting a higher standard in health information technology (IT), bringing forth expertise on a topic of great importance to the VA Committee, electronic record sharing.  Cogon has already demonstrated success with the U.S. Department of Defense (DoD) at Naval Hospital Pensacola.  They are currently evaluating their system and are currently sharing information with other local hospitals in the area. 

As a Navy veteran in Iraq himself, he was well aware of the many needs and shortcomings of DoD and VA in their systems, and his knowledge will be valuable to this Committee as we keep seeking to improve services for our veterans. 

By demonstrating that a virtual health network can exist and at the same time safeguard information, Cogon, under Dr. Nguyen's leadership, has taken a step where I and many other Members of Congress wish to see VA and DoD go.  The electronic record formed during a soldier's service under DoD and immediately transitioned to VA upon separation from active duty is long overdue.  Not only will it ensure easier enrollment into the VA health care system, it will also help bring a better quality of care when those soldiers do in fact enroll. 

I thank him for his contributions to our active-duty military and veterans community; and I thank you, Mr. Chairman, for agreeing to have him here to share his insight with your Subcommittee.

Mr. MICHAUD.  Thank you very much, Mr. Miller.

I will also remind this panel, because of votes that will be coming up, we will try to stick to the 5-minute rule. 

We will start off with Dr. Powell.



Dr. POWELL.  Thank you. 

Good morning, Chairman Michaud, Ranking Member Brown, and distinguished Members of the House Committee on Veterans' Affairs.  My name is Cameron Powell.  I am actually a Obstetrics/Gynechologist physician by training and the co-founder of AirStrip Technologies. 

We are a health care IT-based medical software development company based out of San Antonio, Texas; and our technology actually improves patient safety and reduces risk and improves access to care, specifically by delivering real-time critical patient data through the cell phone network and wireless networks to mobile devices such as the iPhone with a real focus on patient monitoring data such as wave form data. 

Interestingly, this morning there has already been a lot of discussion about women's health and perinatal care, particularly referencing the triplets earlier and the Angel Network in Arkansas.  Actually, our first product using our own technology that we developed, AirStrip OB, is one of the only FDA-cleared applications on these mobile devices, currently approaching about 200 hospital installations around the United States; and every day we have thousands of doctors relying on this real-time critical access to these babies' heart tracings to try and prevent adverse outcomes from occurring in obstetrics.  And we just started in obstetrics.  Soon we will be unveiling our critical care and cardiology applications. 

But I think as we all know in the U.S. we have a lot of problems in our health care system, and one of the core problems that we are focused on that is facing health care professionals is this increasing disparity between a growing number of patients that need to be monitored in any environment and the relative decreasing number of doctors and nurses that can actually monitor them.  So what we are all focused on right at the end of the day is trying to figure out how do we get in a timely fashion the right data about the right patient to the right doctor or nurse at the right time to try and effect a positive outcome.  So remote patient monitoring of critical patient data using these devices—iPhone, Blackberry, Android, iPad—is rapidly becoming a necessary technology within the health care IT space to try and better care for patients and improve outcomes, especially in rural communities. 

I want to briefly talk about several reasons that patient monitoring with mobile devices is important and a few examples. 

So, number one, doctors and nurses are a lot more mobile than we were 5, 10 years ago.  We are covering multiple hospitals, we are covering multiple environments, and we know that patient access to care in remote areas continues to be a problem. 

And with recent advancements in technology there has been a paradigm shift in the health care community.  There is an expectation now that technologies will allow health care providers to have access to this type of data.  So the type of data that we deliver, which is this real-time critical wave form data and other types of analytics and decision support data on demand, very fast, securely, in a Health Insurance Portability and Accountability Act (HIPAA)-compliant fashion onto a mobile device. 

And if we think about this growing disparity, the number one cause in the United States of patient injury, at least in a hospital, is communication errors.  And as you have a fear of physicians being able to take care of or required to take care of more patients, the probability that communication errors will grow is there.  It is going to happen, and this shortage is not going to get better any time soon.  So if you can, through wireless technologies, if you can close the communication gap and you can deliver that critical data on demand to a health care provider to help them make a better decision about a patient or what to do about a patient in a situation, then you have hopefully tried to reduce that risk. 

So we are working to solve this problem by inventing this AirStrip technology.  And of course, we first went after the obstetrical market, but now our application is looking to apply across both women's health, all of inpatient monitoring, the intensive care unit, the operating room, the emergency room, but also into the home health space in rural communities. 

Some of the technologies that we hear about here today are people that are either our partners or becoming our partners as we take that data that is being generated in the home or in the rural environment and display it very rapidly on the mobile device to help the physician and the health care providers make a difference. 

And I want to speak a little bit about the type of data.  You get numbers and vital signs.  It is important.  But there are specific types of data that require visual interpretation.  We talked again earlier about obstetrics and a fetal heart trace.  And the way we make decisions is based visually on how this data changes over time in real time and historically. 

So if you are able to take that critical wave form data and provide it to a physician anytime, anywhere, we have hundreds and hundreds and hundreds of physician testimonials talking to us, telling us about how this has helped to avoid a bad outcome. 

So I think we are in a very exciting place with our technology.  We are considered agnostic to the market.  So we are either partnered with or looking to partner with multiple patient monitoring companies, health information systems, EMR vendors, to effectively mobilize all of that data and at the end of the day try and improve outcomes by this type of compelling delivery system. 

And I think my time is up.

[The prepared statement of Dr. Powell appears in the Appendix.]

Mr. MICHAUD.  Thank you very much. 

Mr. Cnossen?


Mr. CNOSSEN.  Good morning, Chairman Michaud, distinguished Members of the House Committee on Veterans' Affairs. 

My name is Rick Cnossen.  I am the President of the Continua Health Alliance.  On behalf of the members of the Alliance, it is my privilege to be here to testify in front of you on this very important issue. 

The Continua Health Alliance is an international, open, nonprofit company.  It has about 237 companies at this point, and we are striving to put together an ecosystem of interoperable standard-based personal health technologies like the ones you are hearing about.  It is similar to the Wi-Fi Alliance and what they have done for the ubiquity of Wi-Fi.  We are trying to do that for personal health solutions. 

It is shown that standards-based solutions provide better quality, lower cost and higher innovation, and so that is what we are doing.  We have been at it about 4 years, and we are making good traction.  We have certified products from A&D, Cypar, Intel, Nonin, Omron, Panasonic, Roche, TI and Toshiba; and we have several mobile developments from the likes of Cambridge Consultants, MedApps, Qualcomm, and Vignet; and also IBM and Oracle are looking at how we can integrate into EHRs. 

In Continua, we use the term called eCare, and I would like to define that for you.  It is the class of health information technologies that can facilitate the kind of virtual visit or electronic connectivity outside of traditional office visits.  This can include in-home or mobile broadband devices, secure text messaging or video teleconferencing. 

There are four benefits of eCare I would like to point out, the first being tools and education.  Like we heard in some of the earlier comments, eCare provides the opportunity to let people understand their disease better with education and also tools so that they can see the results of their lifestyle decisions.  Hopefully those tools provide motivation so that they can keep taking their medication, and doing the things they are doing to make improvements. 

The second one is collecting vital signs data dynamically.  Instead of going to the doctor's office once every 6 months, to take a single blood pressure reading, we now have the opportunity to take it on a regular basis in order to provide a much richer compilation of data from which a doctor can make a diagnosis.  Also, if something were to happen, we can detect that and take action on it immediately, not 6 months from now. 

The third is to facilitate virtual visits between the provider and the patient so that we can utilize eCare when it is needed and where it is needed, particularly for veterans that might be in rural areas. 

And the last one, we provide social support networking so we can extend the framework of care beyond just the hospital to include friends and families where appropriate or people with the same type of disease that might be halfway across the world. 

There is plenty of evidence about this.  You have heard of some of them, New England Healthcare Institute (NEHI) and the VA.  There are reports out that show great quality of care for a much lower cost.  You can see why we are excited about eCare. 

The Congress also recognized the value of eCare.  In the health reform bill, they have about 20 different references to programs that include eCare.  I will just list a few: the Accountable Care Organizations for Community-Based Collaborative Care Networks, the Independence at Home Demonstration Project, the Medicaid Health Home, and the CMS Innovation Center.  All these include technologies that could be characterized as eCare. 

In order for the veterans and their families to realize the benefits of eCare that we have been talking about, the Continua Health Alliance has the following—respectfully submits the following recommendations, five of them: 

The first one, integrate eCare into CMS reimbursement policy.  Right now, out of the $468 billion budget, Medicare pays $2 million for telehealth, or .00005 percent.  We feel that if reimbursed procedures and services can be effectively offered with eCare, they should be reimbursed as well. 

The second one, establish blueprints for the use of eCare in the States and in communities.  One of the earlier questions talked about how we can leverage that.  The VA has done a great job, and other places are doing good work.  We do not want to reinvent the wheel but rather pull these blueprints together so that other communities can leverage it. 

Third, establish a Federal regulation focused on eCare.  There are many organizations involved in this, including the FDA, Office of the National Coordinator for Health Information, FCC; and we feel like there should be an organized approach such that it is proceeding in a coordinated, coupled fashion and we are learning from each other. 

Fourth, incorporate eCare as part of Meaningful Use.  With the health care reform bill and with the American Recovery and Reinvestment Act of 2009 (ARRA), certainly we are going to have EHRs out there becoming broadly adopted.  ECare provides valuable data to populate those EHRs such that doctors can have rich information to draw on. 

And, fifth, make broadband availability for all Americans a top priority.  About 20 percent of Americans are not currently covered, including a lot of vets in rural areas.  We can provide a much richer eCare experience with that. 

In closing, we have a unique opportunity to change and extend care from the home and manage to improve care and options for our veterans in a cost-efficient manner.  We must take action through vision, leadership, and a national commitment to prepare for the demographic and economic changes that will bring changes to health care.  America can be the leader in this, and we can start with the VA.  Please let us know how we can work with the Committee to make this possible. 

Thank you.

[The prepared statement of Mr. Cnossen appears in the Appendix.]

Mr. MICHAUD.  Thank you very much. 

Mr. Dicks?


Mr. DICKS.  Good morning, Chairman Michaud, Ranking Member Bilirakis, and distinguished Members of the House Committee on Veterans Affairs, Subcommittee on Health. 

My name is Ken Dicks, Founder and CEO of MedApps, a small business enterprise located in Scottsdale, Arizona.  On behalf of the team at MedApps and the veteran-owned enterprise that manufactures our devices here in America, I would like to thank you for the opportunity to present this testimony. 

We are here today to speak about overcoming rural health care barriers through the use of innovative wireless health technology solutions.  I am here today to talk about innovative digital wireless communications technologies, like those produced by my company MedApps, which are quickly becoming a key component in the delivery of health care in services across America via wireless remote patient monitoring. 

Medical devices, health sensors, and their applications rely upon mobile broadband functionality and interoperability to transmit raw data, diagnostic health information, critical aspects of care, emergency services, and related health information.  These services are at the forefront of a revolution in the provision and delivery of health care in America, a revolution which collapses time, space, and distance to more effectively monitor patients, develop analytic trends, maximize strained medical resources, and save lives. 

First, a word on the nomenclature surrounding wireless health.  There are many terms loosely used today to describe the different and often confusing aspects of wireless health information technology.  For the purposes of today's hearing, I will use the term eCare, which is the term used by the Federal Communications Commission in Chapter 10 of the National Broadband Plan. 

ECare is the electronic exchange of information, electronic data, images, and video to aid in the practice of medicine and health care analytics.  ECare is not a substitute for health care providers, physicians or clinicians.  It is intended to augment the good work of medical professionals. 

In a landmark comprehensive pilot with 17,000 veterans, the Department of Veterans Affairs demonstrated that by implementing remote patient monitoring they experienced a reduction in hospitalizations by 25 percent, at an average cost of $1,600 per patient per year for remote patient monitoring, compared to an annual cost of $13,121 per patient for primary care and $77,745 for a patient for nursing home care. 

Amazingly, those encouraging results and statistics were achieved with the first generation of wired systems that are typically more costly, proprietary, and are tethered to a point of care, lacking mobility.  If the pilot program was able to achieve those encouraging results for patients using that technology, imagine the potential wireless eCare technologies would hold. 

ECare technologies, like wireless mobile solutions, drive down costs and improve care by closely monitoring patients wherever they may be.  Thus, they allow health care to be practiced in a more proactive manner, rather than a reactive manner, and can possibly head off a patient going to the emergency room or hospital setting in the first place. 

In my hand up here is our HealthPAL.  HealthPAL is a technology that the sole purpose is to allow a patient to stay connected with their electronic health record and ultimately their caregiver.  The HealthPAL is FDA cleared and communicates wireless, or wired, with other medical devices, such as this Nonin Pulse Oximeter which takes your Sp02 and your heart rate as well.  A doctor may ask a veteran with chronic obstructive pulmonary disease or congestive heart failure to take a reading once a day in order to make sure that they are staying within the safe zone. 

The HealthPAL, like the one that I am holding in my hand, has mobile cellular technology, M2M technology like this, M2M technology I hold in my hand today.  The 3G mobile broadband chipset by Qualcomm is about the size of a quarter, which is embedded in the HealthPAL, and is the key to connecting our veterans to their health care providers in an efficient and economical manner. 

The HealthPAL works as an agnostic hub or central device that connects to various medical devices and sensors and then transmits their data to a secure central server.  The HealthPAL comes packaged together, including mobile wireless connectivity straight out of the box, ready to use.  Nothing complicated to set up, provide or maintain.  Everything is done remotely, including software upgrades, like the popular Kindle model. 

The MedApps solution is used in a variety of ways by everyday people including David Jesse, a truck driver from rural Ohio.  David's erratic schedule makes it difficult to set up and keep appointments with his doctor, and his health suffered because of it.  David often had to produce log books to take back to his doctor at the Cleveland Clinic every couple of months.  His doctor attempted to adjust his medication based on the information.  Today, David uses the HealthPAL in the cab of his semi truck and has taken his readings throughout 47 States. 

The technology has allowed David to substantially improve his health and need for medication.  He no longer has to drive back to Ohio every 2 months to be checked by a doctor, who, along with David's wife, can stay connected to him remotely on the road, making sure he is okay and his medical conditions stay under control. 

At Meridian Health, a New Jersey health system, the technology is being used to help reduce readmissions of congestive heart failure patients.  Typically across the country, 27 percent of congestive heart failure patients are admitted within 30 days with the same condition.  An average CHF hospitalization is about $8,000.  At Meridian Health, the HealthPAL and a wireless scale are provided to a CHF patient upon discharge to monitor a patient every 30 days to ensure patients with signs of worsening conditions are seen by their physician for early, less resource-intensive intervention.  The equipment is returned to Meridian at the end of the 30-day period.  So far, 30 patients from Meridian have experienced no readmission due to heart failure within the 30-day period. 

Thank you.

[The prepared statement of Mr. Dicks appears in the Appendix.]

Mr. MICHAUD.  Thank you. 

Doctor Nguyen?


Dr. NGUYEN.  Chairman Michaud, Ranking Member Brown, and distinguished Members of the Subcommittee, thank you for the opportunity to testify today. 

I also want to thank Representative Jeff Miller from my district for the introduction and to note that he has been a leader in advancing the use of health information technology for veterans. 

My name is Dr. Huy Nguyen.  I am a Navy veteran who served in Iraq in 2003 as a physician attached to the Fleet Hospital Pensacola.  During that tumultuous period, I saw up close and personal the cost of war and the utmost sacrifices that our veterans make in the service of their country.  I have since separated from active duty.  However, I continue to serve our military and veteran community as a civilian emergency physician at Naval Hospital Pensacola. 

In addition to my military affiliated duties, I am also the founder and CEO of Cogon Systems.  Our mission at Cogon is to facilitate connected, value-driven health care.  We achieve this by facilitating secure Web-based health information solutions leveraging cloud computing technology, which includes mobile technology. 

In my written testimony, I discussed a variety of mobile health issues.  However, in my oral presentation, I would like to focus particularly on how health information exchanges can complement mobile technology by allowing comprehensive health information to be accessible on mobile devices.  Secure mobile access to comprehensive health information can be particularly helpful to providers and veteran patients in rural communities. 

As context to today's testimony, I would like to highlight a significant Veterans Administration objective that guides Cogon's desire to facilitate better care for veterans and in the process be a beacon for the greater civilian health care community. 

The Department of Defense Military Health System and Veterans Administration are promoting the Virtual Lifetime Electronic Record initiative, otherwise known as VLER, which represents a major iteration of a new national capability to securely share electronic health information via the nationwide health information network.  This is important in light of the fact that three out of four veterans receive a portion of their care from civilian providers. 

President Obama has also stated that it is important to, and I quote, allow health care providers access to servicemembers' and veterans' health records, in a secure and authorized way, regardless of whether that care is delivered in the private sector, Department of Defense, or VA. 

The TRICARE Health Information Exchange project in Pensacola to facilitate the sharing of health information between military and civilian providers was a Congressionally funded project.  The basis of Congressional support for this endeavor is due to the fact that, by some estimates, more than 60 percent of health care delivered to a DoD beneficiary is provided by private-sector health care providers. 

Civilian providers are unable to access health information regarding a patient's status—health status or care from the MHS electronic health records system today.  Similarly, civilian medical records concerning military beneficiaries are not available to MHS providers.  In essence, we are practicing medicine in an information vacuum.  This is the reality of patient care in military communities today. 

Our Congressional funding for this project is fiscally managed by MHS' Telemedicine and Advanced Technology Research Center.  To date, the project has successfully tested and deployed the largest instance of health information exchange between Federal and civilian providers.  The project entails sharing protected health information between Naval Hospital Pensacola and private-sector health care providers in Pensacola by interfacing Cogon's health information platform with the DoD/Veterans Administration Bi-Directional Health Information Exchange, otherwise known as BHIE.  Though not perfect, BHIE is the current health information exchange between the MHS and VA, and it is the largest health information exchange in our country and represents a significant investment on the part of both agencies. 

As far as I know, we are the only commercial entity that has been allowed to interoperate with the BHIE platform.  So in Pensacola more than 30,000 records concerning patients jointly seen by the MHS and Pensacola civilian providers can now be shared.  This data exchange is in compliance with the data use agreement between our company and the MHS TRICARE Management Activity Office.  Furthermore, the Pensacola community is finalizing a Nationwide Health Information Network Data Use and Reciprocal Support Agreement as mandated to be part of any VLER demonstration. 

The Florida Gulf Coast boasts a large contingency of active duty and veterans.  Escambia County in Florida is also fortunate not only to have Naval Hospital Pensacola but also the Veterans Administration Joint Ambulatory Care Clinic.  Both facilities are not only supportive of this health information exchange, they also play a significant role in the governance structure of the exchange. 

Because of the significant presence of the Veterans Administration in the Pensacola community, we believe that it is important for the VA to consider establishing Pensacola as a VLER community.  As health information becomes more interoperable, the potential for mobile health is limitless. 

Again, as a physician and a veteran, I would like to thank this Subcommittee for allowing me the opportunity to testify on a subject that is personally dear to me, the care of veterans. 

I hope that in my written and oral testimony I have established three things:  One, the sharing of health information between MHS, the VA, and civilian providers as envisioned by the VLER initiative is important to coordinated care for our veterans.  Two, this ambition to share information can be securely done today, as shown in Pensacola as we migrate toward a nationwide network.  Three, a health information platform and exchange can augment mobile technology in striving to serve isolated rural communities. 

The VA, in conjunction with the MHS, has enormous opportunity and responsibility to maximize its leadership in health information in order to take care of veterans. 

Thank you very much.

[The prepared statement of Dr. Nguyen appears in the Appendix.]

Mr. MICHAUD.  Thank you. 

Mr. Frank?


Mr. FRANK.  Mr. Chairman and distinguished Members of the Subcommittee, thank you for the opportunity to testify on the use of wireless technology to overcome rural health barriers. 

My name is Dan Frank.  I am the Managing Partner of Three Wire Systems, LLC, a service-disabled, veteran-owned small business.  I am joined by my colleague, Dr. Ian Schaeffer, the Chief Medical Officer of MHN, a Health Net Behavioral Health Company. 

We are here today to talk about VetAdvisor, an innovative evidence-based program that provides mental health outreach screening and health coaching services to Operation Enduring Freedom/Operation Iraqi Freedom veterans and their families in both urban and rural areas.  VetAdvisor is a program which augments and supports existing VA behavioral health care services and assists veterans with challenges they face during reintegration into civilian life.  It uses traditional and nontraditional telehealth delivery platforms to reach out to veterans and to improve their awareness of and access to mental health support for issues such as tobacco cessation, weight management, or understanding post-traumatic stress disorder management. 

VetAdvisor assists veterans and their families, providing nonclinical health coaching services via telehealth platforms, which allow veterans to focus on areas of concern to them without leaving their homes.  The program identifies and works with veterans who have or are at risk for post-traumatic stress disorder, depression, substance abuse, suicide, and homelessness.  This telehealth approach to outreach screening and coaching helps eliminate the stigma veterans often associate with seeking mental health services and assists them in getting treatment. 

Health coaching services are provided to veterans through telephonic communication or virtual collaboration technology, which we call the VetAdvisor virtual room.  In the virtual room, the veteran and the coach interact as avatars.  This highly immersive virtual environment provides strong feedback that enhances collaboration and communication. 

Use of this virtual technology assists veterans in their reintegration efforts in a number of ways.

First of all, it allows the veteran to discuss personal issues from the privacy of his or her home or private setting of choice.  Veterans may be more willing to acknowledge the magnitude of their issues in this private environment. 

Second, it saves the veteran time and travel costs associated with office visits by bringing nonclinical support virtually to them.  For today's Internet-savvy generation of veterans and their families, this form of communication feels more natural than traditional communication methods. 

In the past, veterans who opted to use virtual room health coaching required wired broadband Internet connectivity for their desktop or laptop computers to access this virtual world.  However, veterans who reside in rural areas can face challenges acquiring such broadband services.  Recognizing this limitation, VetAdvisor worked with our technology partners to leverage the most ubiquitous of consumer electronic devices, the mobile phone. 

Mobile devices will allow patients to wirelessly access health care and is an important component in VA's transition to the patient-centered medical home model.  To address this effort, VetAdvisor will launch a virtual world mobile phone capability, for example, an Apple iPhone, in the fall of 2010.  By extending the virtual world to mobile phones, we can significantly increase the veteran user base in rural areas where broadband services are not available but cellular service is. 

For veterans who opt not to use the virtual world, they simply may use their mobile phones to obtain health coaching services.  We envision veterans using these mobile devices anywhere and anytime they desire to work with their health coach.  So, for example, if you had a veteran who wanted to conduct a session with their health coach during their work lunch break, they could do that from their car, their office, or other location that provides privacy. 

The VetAdvisor program can be offered throughout VHA to ensure that veterans do not fall through the cracks.  It provides VA with an effective mechanism to overcome access to care challenges in rural areas by using wireless solutions to provide outreach and ongoing support to veterans regardless of where they live.  Without this program, many of these veterans might not return to VA to get the help they need or have as successful a return to their jobs, schools, and families. 

On behalf of Three Wire and MHN Health Net, we would like to thank you again for your interest in the wireless capabilities of the VetAdvisor program and how we serve veterans and their families in geographically remote areas.  We are grateful to the Subcommittee for its leadership and commitment in identifying innovative programs that assist veterans. 

Thank you.

[The prepared statement of Mr. Frank appears in the Appendix.]

Mr. MICHAUD.  Thank you. 

Mr. Mize?


Mr. MIZE.  Chairman Michaud, Ranking Member Brown, and Members of the Subcommittee, thank you for the opportunity to testify this morning. 

LifeWatch is a health IT telemedicine company based in Rosemont, Illinois.  We provide monitoring services nationally for over 15 years, and we represent the future of medicine in the United States.  It is our privilege to serve the Department of Veterans Affairs in almost 40 facilities. 

Currently, our service has helped diagnose patients suffering from cardiac arrhythmia and obstructive sleep apnea in a near, ambulatory, and real-time environment.  This virtual service environment is a launching pad for future disease-specific management of health data, supporting improved patient outcomes, continuity of care, reduction of emergency room visits, and unnecessary hospital readmissions. 

The LifeStar Ambulatory Cardiac Telemetry service is based upon an algorithm that automatically detects and transmits via cellular networks clinically significant changes in heart rate and rhythm.  I am actually connected on the device right now.  So, for example, if you are feeling dizzy, your cardiologist might prescribe our service to help diagnose what is causing the changes in your heart rate or heart rhythm.  The VA medical center completes the physician's enrollment order to LifeWatch; and we, in turn, ship the device to the patient's house with all the necessary equipment. 

The LifeStar ACT service increases the diagnostic yield compared to antiquated technology, increasing the likelihood that a diagnosis will be made and a treatment plan incorporated, which ultimately improves patient outcomes and reduces the cost of treating cardiovascular disease and stroke for the Department of Veterans Affairs. 

Additionally, the service allows veterans to remain in their home, reduces travel reimbursement expenses, and allows VA medical expenses to ship employee resources to other responsibilities that cannot be provided in the home.  The impact for rural veterans is even more pronounced in regards to cost savings, access to care, and improved outcomes. 

LifeWatch has also recently introduced a home sleep testing service for the diagnosis of obstructive sleep apnea.  Wait times for sleep labs within many VA facilities exceeds 6 months, and as a solution many facilities utilize fee service to push patients to commercial sleep labs at Medicare rates.  Our service is less than half the price of utilizing a commercial sleep lab, stands to eliminate chronic patient waiting lists, and helps improve compliance as the testing is all done in the patient's home. 

According to a recent article published in the USA Today a couple of weeks ago, veterans are four times more likely than other Americans to suffer from sleep apnea.  About 5 percent of Americans suffer from sleep apnea, compared to 20 percent of veterans. 

While there are many success stories, we have also had our fair share of struggles within the Department.  We are a General Services Administration small business vendor; and, despite our status on the schedule, procurement remains a struggle, necessitating contracting at the facility level.  It can take upwards of 2 years for some facilities to finalize the budgeting and contracting process, despite clinicians requests to utilize the beneficial service. 

We have seen some success with Project Hero as an in-network provider.  The program appears to expedite the process and simplify procurement for facilities in the four Veterans Integrated Service Networks under the demonstration project. 

Additionally, we have struggled with a lack of quality of care in terms of standard of care for remote cardiac monitoring.  In 2004, Medicare placed a requirement on remote cardiac monitoring, which included the necessity of providing 24-hour live attended coverage for patients wearing ambulatory cardiac devices.  The VA does not follow the same standard across the board. 

Lastly, we have struggled with a lack of clarity on how to interface our data with Vista Imaging/CPRS electronic medical record system within the VA.  Multiple clinics have requested our data be interfaced, and in fact many facilities will not use our service until we are interfaced.  Despite the demand among cardiology, we have hit multiple roadblocks in terms of how to move forward.  We are eager and ready to provide a secure interface with the Department of Veterans Affairs, which will most certainly improve the standard and efficiency of care for our veteran. 

Despite our challenges, we have still been impressed with the many facilities that utilize our wireless services.  We also commend the Department of Veterans Affairs for their proactive approach to treating rural veterans with the use of telemedicine under the Office of Care Coordination.  The VA is clearly a leader in delivering telemedicine. 

Mr. Chairman and Members of the Subcommittee, LifeWatch sincerely appreciates the opportunity to submit testimony and looks forward to working with you and your colleagues on improving the quality of care for our Nation's veterans with the use of advanced technology. 

Thank you.

[The prepared statement of Mr. Mize appears in the Appendix.]

Mr. MICHAUD.  Thank you very much, and I would like to thank each of you for your testimony this morning. 

Since the votes will be called very shortly and we still have one more panel, I will submit my questions in writing.  Hopefully, you will be able to answer them when you receive them. 

Mr. Bilirakis?

Mr. BILIRAKIS.  Thank you, Mr. Chairman.  And I would like to do the same.  I would like to submit my questions in writing as well.

Mr. MICHAUD.  Mr. McNerney, do you have any questions? 

Mr. MCNERNEY.  Thank you, Mr. Chairman. 

I feel a little bit pressured to do the same thing, but I just have one comment. 

What you are saying, what everyone is saying, sounds really great.  The VA or the veterans—group of veterans is a great sample.  It is a great group of people to try new technology on. 

But I also get a feeling inside that some of the technology is not going to work, and some of our veterans are going to get hurt by the sort of—the new technology that is not done yet, that has not been tested out.  Do any of you have any comment on that? 

Mr. DICKS.  My personal feeling is that we are not really inventing new technology here, at least in our company, and a lot of us aren't doing that.  It is technology that is already available today.  We are just repackaging it.  And I believe we are at—in health care, we are at the tipping point to a point where it is causing them more harm to not be with the technology than to be without it. 

You let a disease exacerbate—right now, we are wasting taxpayers' money on a regular proportion of bases for not implementing this technology.  Because they are in rural areas, you can't get them in to the doctor on a regular time.  They don't go to the doctor because it takes 2, 3, 4 hours to get there.  Then it exacerbates to where it is an $8,000 emergency room visit. 

You want to try to put technology like this in place that is simple, that is accountable, and creates a sense of accountability for them to start following their doctors' orders, and that leads to compliance through them taking their medication and staying out of the hospital.

Mr. MCNERNEY.  Thank you. 


Dr. NGUYEN.  I will just add real quick that the VA through its history has been an innovator in showing how technology can be used to control cost and increase care.  And I think that is particularly important now that as we look in a world of health care reform—to me, as a physician, what I see very clearly is we are making a significant bet in our country that we can provide more Americans into structure-coordinated care and in the process save money, and I don't see how we can do that without leveraging innovations.  And I think there are very—all the technology we are talking about today in most industry, finance and otherwise, has already been done.  We are just trying to bring them into health care.

Mr. MCNERNEY.  I want to yield back to the Chairman at this point.

Mr. MICHAUD.  Thank you. 

Mr. Snyder. 

Mr. SNYDER.  Thank you, Mr. Chairman. 

Thank you, gentlemen, for being here. 

Why aren't there any women CEOs of these companies? 

Dr. NGUYEN.  We have a woman Chief Operating Officer.

Mr. SNYDER.  There you go.  It seems like we are perpetuating—may be perpetuating the problem of leaving women out of health care. 

I wanted to ask just one quick question of Mr. Cnossen.  I was struck by one of the things you said, which was I think you used the example in your oral statement of a person may get a blood pressure reading every 6 months at home.  Maybe just hearing from you generally on the issue of I don't think technology—the goal for technology should not necessarily be just more information.  It should be more helpful information. 

I mean, for years, if we had wanted blood pressures more often than every 6 months, we would just teach the person how to take the blood pressure daily, four times a day. 

Thirty years ago, I sent a teenager home who was an early preeclamptic and showed her how to take the blood pressure at age 16 because she was, I thought, the only person in the household that really could handle that.  And I got a phone call one night that said, Dr. Snyder, it is—whatever it was—and I went out to the house, and we sent her to the hospital, and she delivered. 

So this is one of the issues that we have to make sure—we can overload our monitors, our doctors, with too much information.  I mean, I, frankly, don't know.  I don't want to know what my heart is doing every minute.  In fact, that is not what the studies on arrhythmia are based on.  They are not based on constant monitoring.  They are based on what is my blood pressure in 6 months, in 3 months, whatever it is.  That is an important distinction, is it not? 

We want helpful information, information that leads to proper decision making.  We don't want to flood the system with information which may in fact not be helpful but just flood the system. 

Mr. Cnossen, I will let you respond to that.

Mr. CNOSSEN.  Sure, absolutely. 

And clinician acceptance is key to making these technologies become more readily available.  What we need in addition to these technologies are some tools that take the data, aggregate it into graphs and trending, such that there aren't a bunch of data points but rather an indication over time of what a reading would do. 

Personally, I have a little bit of hypertension.  And since I am an engineer I use an Excel spreadsheet and take my readings maybe four times a week, put them in a spreadsheet, and show that to my doctor.  And you know he sort of looks at it, throws it away, and takes it with his own certified blood pressure reading.

Mr. SNYDER.  My kind of guy. 

Because information doesn't always lead to better outcomes.  In fact, I can take some patients and—I mean, we all know that.  Maybe I am one of those—and I can get them on edge.  I can get them going to the emergency room frequently. 

I mean, the reality may be on your patient the doctor may be saying 6 months is fine.  You know, we know that blood pressure is one of those things that kills people over years and decades, not over 6 months.  So we need to be sure that we are using the technology to help outcomes. 

And flooding a doctor's office with information may not necessarily lead to better outcomes.  That is part of I think what ongoing research will show.  Mr. Mize's using my bedroom as a sleep lab for greatly reduced cost, I think is the kind of technology that is helpful. 

Mr. Dicks?

Mr. DICKS.  The one thing we are really trying to do with this is not emphasize the technology.  What we are trying to do is emphasize—you know, compliance is an overused word, right?  We don't want to try to create the Central Intelligence Agency effect here where you get rid of all the operatives in the field and you try to deluge with all the data there is and nobody can make heads or tails of it.  We want to keep the operatives in the field—those are the nurses, those are the doctors—and we want to provide them with clean data for them on a regular basis. 

But let's just talk about the technology.  For the lowest cost possible, the flexibility and simplicity, all I am trying to do is create a sense of accountability between the patient and the caregiver.  So if that patient is knowing that somebody on the other end is looking for that reading to come in they are more likely to take the reading, they are more likely to take the medication, and they are more likely to stay out of the hospital. 

So we are trying to put that sense of accountability on.  We call our technology, 20 percent technology and about 80 percent psychology, right?  It is not about the technology.  It is about that connectivity you have between the two and that accountability that you set up that is going to drive down health care costs.

Mr. SNYDER.  Another issue—and my time is running out.  I know we have votes coming up.  I will say this as an M.D.  We are talking a lot here today about compliance with patients.  Several of you up there—I guess Dr. Nguyen is the only physician there—and Dr. Powell. 

The providers might benefit from these kind of things, like an airline pilot checklist.  We don't do that very well as providers.  We think that—a lot of us think, well, we are kind of magic.  We just have a sense of it.  And the reality is we would probably benefit from some of these technologies within the practice setting, also. 

Thank you, Mr. Chairman.

Mr. MICHAUD.  Thank you very much, Mr. Snyder. 

Once again, I would like to thank all of you for coming here today. 

On the last panel we have Kerry McDermott, who is an expert advisor for the Federal Communications Commission.  We have Colonel Poropatich, who is the Deputy Director, Telemedicine and Advanced Technology Research Center; and Gail Graham, who is the Deputy Chief Officer for Health Information Management within the VA, and she is accompanied by Dr. Darkins and Dr. Breeling. 

I want to thank you for coming today.  And if you could try to just summarize your testimony, that would be greatly appreciated as well. 

We will start off with Ms. McDermott.



Ms. MCDERMOTT.  Good morning, Chairman Michaud and distinguished Members of the Subcommittee.  Thank you for the opportunity to overview the health care recommendations of the National Broadband Plan. 

As you know, Congress mandated that the FCC prepare a National Broadband Plan that “shall seek to ensure that all people of the United States have access to broadband capability” and include a strategy for affordability and adoption of broadband.  The FCC was also asked by Congress to address how broadband can be harnessed to tackle important national purposes, including health care.  So here are the Cliff Notes. 

The U.S. has serious health challenges.  There are promising broadband-enabled health information technologies that have the potential to help us improve health outcomes and quality of life, reduce costs, and extend the reach of a limited supply of health care professionals. 

However, despite the great promise of these technologies, the U.S. lags behind other developed countries in health IT adoption; and so the plan identifies some of these barriers and makes recommendations to address them.  They fall into three main categories:

First, a connectivity gap.  Broadband is either unavailable or too expensive. 

Second, outdated regulations.  Rules that were created when our only interactions with physicians were in their offices not via remote monitoring and video consultations. 

Third, misaligned economic incentives.  The prevailing fee-for-service reimbursement system pays for volume, rather than outcomes, and places the financial burden on providers while the benefits are realized elsewhere. 

So let me briefly overview each. 

First, connectivity.  When we analyzed connectivity for health care providers, we found that many providers lack adequate connectivity to support full utilization of health IT.  For example, approximately 3,600 small physicians' offices are not even served by existing mass market broadband infrastructure.  Of these, 70 percent are in rural locations.  And 29 percent of rural health clinics do not have access to adequate mass market broadband. 

The National Broadband Plan addresses the health care connectivity gap by proposing to revamp the FCC's rural health care program.  The program is for public and nonprofit health care providers and is the largest sustainable government fund for health care connectivity.  Proposed changes include, one, creating a permanent infrastructure fund; two, broadening coverage for monthly recurring costs to all types of broadband services; and, three, expanding eligibility for the program. 

Second barrier, outdated regulations.  Dr. Smith highlighted some that the plan addresses, so I will reinforce one specific to the wireless arena, regulatory uncertainty surrounding the convergence of communications and medical devices.  With new solutions that enable clinicians and patients to give and receive care anywhere at any time comes a new challenge, blurred regulatory lines.  This uncertainty regarding regulatory frameworks and approval processes can discourage private-sector innovation and investment in wireless health and ultimately delay or prevent the availability of such solutions. 

The plan calls for the FCC and the FDA to build on their long history of collaboration to resolve these issues.  The agencies have already begun to act on this recommendation and are holding a joint public meeting on July 26th and 27th.  Through this forum, we will bring together various stakeholders to begin to better understand the types of devices and applications that are being introduced, clarify the requirements that apply, and improve the regulatory processes to the extent possible. 

Third barrier, misaligned economic incentives.  Within a fee-for-service reimbursement system, providers bear the cost of health IT implementation and changes to workflow but don't fully capture the economic gains created through improved clinical outcomes.  The plan recommends several steps to move toward an outcomes-based reimbursement mechanism for e-care technologies and urges HHS to propose specific programs and reimbursement changes that will help realize the value.  Without reimbursement reform, the market for wireless health IT solutions is limited; this in turn, inhibits investment and innovation. 

In summation, the National Broadband Plan's health care recommendations address the infrastructure, supply, and demand concerns associated with utilization of promising health IT solutions so that all citizens may realize their health benefits and cost savings. 

I thank you all for giving me the opportunity to speak today.

[The prepared statement of Ms. McDermott appears in the Appendix.]

Mr. MICHAUD.  Thank you. 



Colonel POROPATICH.  Good morning, Chairman Michaud and distinguished Members of the Subcommittee.  I am Ron Poropatich.  It is a pleasure to be able to talk to you a little bit about the Army Medical Department's mobile health projects, future initiatives, and challenges in implementing these kinds of capabilities both stateside and overseas.  I would like to focus on three projects and succinctly go over an overview of what they entail. 

We currently have 11 active projects that we are doing at the Telemedicine and Advanced Technology Research Center located at Fort Detrick, about 50 miles northwest of Washington.  The first project deals with soldiers back from the war with a variety of wounds, traumatic brain injuries, psychological health.  They get care at Walter Reed, let's say.  Then they go back to their homes to recover.  These are Reservists and National Guardsmen.  The question is, how do we reach out to them on a regular basis? 

We have a care team located at a community based warrior transition unit.  There are nine of them in the States.  We are currently up and running as of May of last year at five of these sites located in Massachusetts, Virginia, Florida, Rock Island, Illinois, and Alabama, covering 26 States.  Many of these soldiers are living in remote areas.  We push down onto their own cell phones secure messages that are HIPAA compliant that allows us to give them wellness tips on sleep, pain issues, reminders about job opportunities and educational issues, as well as announcements and overall projects dealing with appointment reminders.  In the Army, we have about 10,000 missed appointments per month currently.  And, again, appointment reminders are a key part of the program as well. 

This project has been successful in that we, as of 1 year—and this is the first of a five-phase rollout—we have 300 soldiers enrolled in the first phase, we have reached out to over 100 case managers, and have generated over 20,000 messages.  Of those 20,000 messages, 63 percent are appointment reminders, 17 percent are health and wellness tips, and 12 percent are unit-specific announcements. 

There are challenges to overcome any of these kinds of projects.  We have to push the content onto the soldier's cell phone.  We are not buying them one.  We have to deal with over 300 different types of cell phones that are out there going across four different wireless telecommunications companies.  We have been able to work through those challenges at no cost to the soldier. 

That, however, is important to understand the challenges in just getting to that stage.  We are also aware of the need to expand this across the Navy, the Air Force, and the VA; and we have generated discussions at three different VA institutions. 

The second project I would like to highlight briefly is maternal fetal health, Text4Baby.  It is a public-private partnership that has already been up and running for the last 4 months, 46,000 women, over 2 million text messages being pushed out onto pregnant women's cell phones. 

We are going to be rolling this particular project out as a DoD partner, an outreach partner to this program, going to the Madigan Army Medical Center at Joint Base Lewis McChord in Washington State.  We are going to be studying this under our research protocol looking at smoking cessation and postpartum depression, realizing that many of our pregnant mothers are dealing with other children, with a spouse who is deployed, adding new stresses to that mother. 

The third wireless application again is a little bit different than the first two.  Here we are pushing video onto a smart phone for a diabetic patient population in hopes of changing behavior to make patients more compliant with home blood glucose monitoring, nutrition, and exercise.  This is a research project approved at Walter Reed Army Medical Center, where I practice medicine 1 day a week.  It has been up and running for a year, 170 patients enrolled in this study. 

We found that of the patients that have the video versus those that don't only half the people actually looked at the video, but those that did had a statistically significant reduction in their glucose, which is important to realize. 

Regarding the big Army, we want to leverage what the big Army is doing.  They have gone out to Cupertino, looking at Apple and BlackBerry and other labs.  The Research, Development, and Electronic Command out of Fort Monmouth, New Jersey, has a big interest in seeing how we can take mobile health onto the battlefield. 

We are interested in leveraging in big Army's interest and applying this same capability to further health care outreach within the U.S. Army Medical Department. 

We also realize, based on a recent document approved—that DoD instruction May—of last month looking at medical stability operations and realized that the rest of the world's cell phone penetration is even greater than America's when you look at it.  Therefore, we see great opportunity in leveraging the cell phone capabilities that we are doing stateside and offering it as potential solutions to the developing world. 

There are many opportunities, but there are considerable challenges.  Challenges include integrating this content into an electronic medical record, the security issues that we talked about, the regulatory issues with the FDA, is it a medical device or is it still just a cell phone, and information overload to physicians where clinical business practices have to change. 

We are committed to developing and expanding mobile health in the military.  I would like to thank you for allowing me to highlight briefly some of the Army Medical Department's accomplishments, and thank you for your continued support to those who serve our Nation.

[The prepared statement of Colonel Poropatich appears in the Appendix.]

Mr. MICHAUD.  Thank you very much, Colonel. 

Ms. Graham, could you summarize your written testimony?


Ms. GRAHAM.  Good morning, Mr. Chairman and Members.  Thank you for the opportunity to testify about VA's efforts to deliver optimal health care to veterans in rural areas through the use of innovative wireless health technologies. 

I am accompanied today by Dr. Adam Darkins, Chief Consultant of Health Services for the Office of Patient Care Services, who has been referenced multiple times during the earlier testimonies; and Dr. James Breeling, Deputy Executive Director, Office of Information and Technology, Department of Veterans Affairs. 

Wireless technologies are part of an overall continuum of care and not a stand-alone entity within VA.  We are currently undertaking the most significant change to our model of care delivery since the rapid expansion of the Community-Based Outpatient Clinics that began in the 1990s.  But, in many ways, this new innovative approach is actually a continuation of the same strategy that VA has pursued to bring care closer to our veterans and make it as accessible as possible. 

Our mission of veterans-centered care engages veterans, families, health care teams in partnership to improve communication and ensure the needs and the preferences of the patient are met.  Delivering optimal treatment to veterans in rural areas involves significant challenges, as have been noted by many previous speakers.  Emerging technology and new models of care promise to improve clinical quality and reduce cost. 

VA is committed to pursuing strategies that will achieve these ends.  Our aim is to ensure that our rural veterans receive the same quality of care.  VA is exploring applications of wireless technologies to enhance care.  For example, VA has installed various small aperture terminal satellites on the 50 mobile Vet Centers that were purchased recently, which are used primarily in rural areas for veterans outreach and readjustment counseling services to veterans but can be also used in case of emergency for provision of care. 

We also use wireless technology to assist our veterans with disabilities with quick access to information and to foster opportunities to live at the highest level of functionality possible. 

In our medical facilities, we are completing wireless local area network projects to improve the coverage and reliability of mobile devices, including those used for bar code medication administration and laptop computers for our clinicians to use in the delivery of care and the access to VA's electronic health record. 

VA dental providers are using wireless technology to access software designed to improve point-of-care decision, and this technology significantly improves medication safety by providing important direct interaction analysis and side effect profiles for treatment outcomes to a vast knowledge base available at the provider's fingertips. 

My HealtheVet, the VA's online personal health record, is yet another area of significant progress for wireless technology.  My HealtheVet provides veterans with online access to VA health care featuring patient-friendly health education information and wellness reminders for preventative care. 

A veteran who was an early adopter in the pilot program described the application's impact to his life by saying, I feel more in control and aware of my health care choices. 

Having veterans as a partner in their health care is essential for the success at VA.  VA was awarded a rural health grant to improve access to care by engaging our veterans in co-designing improvements to My HealtheVet.  We have conducted sessions in five rural communities with veterans who suggest specific changes to My HealtheVet, including the addition of a mobile version of this application.  This prototype will be evaluated by veterans and approved for concept environment, and the second phase of this project will support further meetings with veterans for feedback on visually modeling the complete set of functions they desire, recognizing that many times taking things from the electronic health record or full view on the Internet has its challenges. 

Around the world, mobile and wireless devices are increasingly used to connect people to the Internet.  In early 2009, VA launched a mobile-friendly version of its Internet Web site.  VA's mobile site tailors key VA content from mobile devices and is designed to be compatible with multiple bands of cell-based Internet browsers.  We want to be accessible and transparent to our veterans and their families wherever they may be. 

Looking ahead, VA is examining the potential for additional innovative applications targeting specific populations of veterans such as those with traumatic brain injury, post-traumatic stress disorder, or visual impairments.  We also anticipate development of more resources and tools for clinicians and veterans.  Like you, VA strives to ensure that every veteran who receives care from VA has access to its world-class care and benefits. 

Mr. Chairman, this concludes my prepared statement and I am pleased to address any questions.  Thank you.

[The prepared statement of Ms. Graham appears in the Appendix.]

Mr. MICHAUD.  Thank you very much, and I would like to thank all of you. 

Since we only have 3 minutes to go vote, we have a choice of either holding everyone here for about an hour or for us to submit questions in writing.  So we have decided to submit questions in writing. 

But I really appreciate all the testimony here today from  this panel and the other two panels, and we will definitely have a lot of questions as well.  So I want to thank you very much.  This is a very important issue and one that there is a lot of interest in.

Mr. MICHAUD.  So, without any further ado, I will adjourn the hearing.  Thank you.

[Whereupon, at 12:00 p.m., the Subcommittee was adjourned.]


Prepared Opening Statements:

Prepared statement of Hon. Michael H. Michaud, Chairman, Subcommittee on Health, and a Representative in Congress from the State of Maine
Prepared statement of Hon. Gus M. Bilirakis, a Representative in Congress from the State of Florida

Witness Prepared Statements:

Prepared statement of Joseph M. Smith, M.D., Ph.D., Chief Medical and Science Officer, West Wireless Health Institute, La Jolla, CA
Prepared statement of Darrell M. West, Ph.D., Vice President and Director of Governance Studies, and Director, Center for Technology Innovation, Brookings Institution
Prepared statement of 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
Prepared statement of William Cameron Powell, M.D., FACOG, President, Chief Medical Officer and Co-Founder, AirStrip Technologies, San Antonio, TX
Prepared statement of Rick Cnossen, President and Chair, Board of Directors, Continua Health Alliance, and Director of Personal Health Enabling, Intel Corporation Digital Health Group, Hillsboro, OR
Prepared statement of Kent E. Dicks, Founder and Chief Executive Officer, MedApps, Inc., Scottsdale, AZ
Prepared statement of Huy Nguyen, M.D., Chief Executive Officer, Cogon Systems, Inc., Pensacola, FL
Prepared statement of Dan Frank, Managing Partner, Three Wire Systems, LLC, Vienna, VA, Also on behalf of MHN, A Health Net Company, San Rafael, CA, on the VetAdvisor® Support Program
Prepared statement of John Mize, Director, LifeWatch Federal, LifeWatch Services, Inc., Rosemont, IL
Prepared statement of Kerry McDermott, MPH, Expert Advisor, Federal Communications Commission
Prepared statement of 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, U.S. Department of Defense
Prepared statement of Gail Graham, Deputy Chief Officer, Health Information Management, Office of Health Information, Veterans Health Administration, U.S. Department of Veterans Affairs

Submissions for the Record:

Prepared statement of Lincoln T. Smith, President and Chief Executive Officer, Altarum Institute, Ann Arbor, MI
Prepared statement of Robert Bosch Healthcare, Inc., Palo Alto, CA