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August 1, 2011

No Boundaries
By Susan Chapman
For The Record
Vol. 23 No. 14 P. 20

The VA’s far-reaching telehealth program continues to expand.

Telehealth continues to make inroads as a viable solution to providers seeking lower costs and improved care, particularly when it comes to the treatment of U.S. veterans. Founded to address the increasing number of chronically ill veterans who need its resources, the VA telehealth program has been so successful that earlier this year the agency awarded $1.38 billion in contracts to six IT firms (Cardiocom, Authentidate, HealthHero Network, American Telecare, Viterion TeleHealthcare, and Visual Telecommunication Network/ViTelCare) over the next five years.

The smallest of the six contracts—$150 million to Viterion TeleHealthcare—nearly equals the VA’s entire telehealth budget of the previous year, underscoring the agency’s commitment to this rapidly expanding healthcare technology.

The goal of the VA’s telehealth program is to ensure that patients receive correct and timely care at convenient locations. Its Office of Telehealth Services (OTS) utilizes an array of technologies to focus care and manage cases, changing where health services are provided and improving patients’ overall health. Services are composed of three areas: clinical video telehealth (CVT), care coordination/home telehealth, and store-and-forward telehealth.

In the past, veterans had to travel to VA hospitals or medical centers to obtain care. To increase access to care, the VA established more than 700 community-based outpatient clinics. Because veterans can require specialized treatment that these clinics do not provide, they are often referred to regional medical centers for further care. Depending on factors such as age, location, and severity of injuries, veterans can find such trips challenging, particularly if traveling from rural areas. With the availability of CVT, which employs video-technology conferencing to connect patients with health providers, veterans can continue to travel to community-based clinics where VA physicians can remotely offer diagnoses and care.

CVT is used to treat a wide range of cases, from polytrauma to diabetes and mental health. Besides treating illness, CVT enables telerehabilitation that links specialists and veterans to provide rehabilitative services, monitor patient status at home, and assess equipment needs. Additionally, telesurgery enables pre- and postoperative consultations between specialists and veterans, which is a significant benefit to patients in remote areas.

In 2010, VA CVT services provided 170,598 consultations, of which 45,000 were for veterans who lived in rural areas. While the majority of this activity has been to provide remote mental health services, there are more than 35 clinical specialties that are routinely offered.

As evidence of CVT’s continuing expansion, the OTS announced in April that the National Telemental Health Center (NTMHC), part of the VA Connecticut Healthcare System, performed the first international compensation and pension examination via CVT for a veteran in Okinawa, Japan. Through the use of this technology, the NTMHC, in collaboration with the Department of Defense and the U.S. Naval Hospital in Okinawa, hopes to reduce the number of overseas veterans waiting for exams while also decreasing costs.

Care Coordination/Home Telehealth
For many veterans, particularly older adults and those with chronic conditions, obtaining treatment can be difficult. By employing home telehealth, doctors and other healthcare providers can monitor vital signs and symptoms in the home. The technology, which uses regular telephone lines, can connect at-home veterans with VA hospitals.

According to Adam Darkins, MD, the VA’s chief consultant for telehealth services, veterans report high levels of patient satisfaction—an average of 89%—for home telehealth services. Nevertheless, he says, “Veteran patients are not obliged to use telehealth. They have the choice of face-to-face case management.”

Still, while the VA has found that not every patient is suitable for this kind of care, for many veterans, telehealth can help them remain at home and live independently. In 2010, the VA’s home telehealth programs supported 46,066 veteran patients, 20,000 of whom resided in rural areas.

“We love it,” says Helen*, caregiver for her husband, Harry, a World War II veteran. “When Harry gets up, I take his blood pressure, he gets weighed, and I enter everything into the keypad that the VA gave us. Then I answer a few questions. If the nurse doesn’t like something she sees, she gives us a call right away to see what’s going on.”

Helen also likes the convenience of the 24-hour telephone hotline that can be used in the event Harry has new symptoms or other health-related questions.

Store-and-Forward Telehealth
This form of telehealth involves obtaining and storing clinical information, including images and data, that is captured and forwarded to another location for evaluation. Radiology, dermatology, and retinal screening for diabetes are three primary areas where this technology is especially helpful. During fiscal year 2010, the VA’s store-and-forward programs provided 160,315 patient consultations, of which 77,000 were for veterans in rural areas. The majority of these consultations were to screen for diabetic eye disease, helping detect and prevent avoidable blindness.

Serving as an Example for Others
According to Andrew Watson, MD, vice president of the International and Commercial Services division at the University of Pittsburgh Medical Center (UPMC) and medical director at the Center for Connected Medicine, the VA’s telehealth program serves as a model for other healthcare providers and systems, especially in the home telehealth arena.

“VA particularly excels with home care,” he says. “Time spent in the emergency room is not logical. As technology has evolved, care has moved away from the home and back to the hospital. Now we can move into home care—based on patient wishes—engage patients sooner and diagnose sooner. Telemedicine allows a doctor to be on call over the world.”

Watson notes that as technology matures, equipment becomes more affordable. But challenges to widespread adoption remain, with reimbursement being a particularly thorny issue. “The VA has specific dollars at risk,” he says. “It’s an accountable care organization, and the organization is cost-efficient for home medicine.”

Jonathan D. Linkous, CEO of American Telemedicine Association, agrees: “The VA is a closed, single-payer system, structured differently. It’s much more successful at deploying telehealth. Most of the medical world is fee for service. A patient goes to the doctor, he bills, and he makes more money the more services he provides. VA doctors are on salary, part of a capitated system. There isn’t the same incentive to do a lot of services. For other systems, the barrier to deploying telehealth is payment.”

Linkous notes that Medicare currently does not provide coverage for most telehealth services but believes that will change in a few years. He cites the VA’s ability to use telehealth to better manage care for chronically ill individuals who are expensive to treat, helping defray the enormous costs associated with hospital stays. In fact, the largest study on telehealth—which involved 17,025 patients enrolled in the VA’s home telehealth service—revealed that daily home monitoring decreased hospital stays by 25% and hospital visits by 19%, presenting a strong case for the technology’s cost-effectiveness.

“Another advantage the VA has in widespread expansion of telehealth is that it has no licensure issues. Other healthcare services need to be licensed in each state,” says Linkous, adding that the VA has more experience than most in this area, thanks to its systemwide guidelines.

Linkous says the VA also gains an edge in that it’s able to offer a training program for nurses and physicians, as well as for patients and caregivers, who receive instruction from care coordinators. In other systems, training healthcare providers and ensuring the uniformity of technology can be a challenge.

“Training is what is important,” Linkous notes. “We need to be clear on what the image does and doesn’t provide. For instance, in teledermatology, the color of the image has to be right. … Beyond that, practitioners have to have a certain comfort level with computers.”

“At some point, we’ll be able to use tablets, like the Playbook, to run healthcare. We need to have something so easy, something that runs everything as the core component of what we do,” Watson says.

Getting patients to adapt to telehealth should not be a significant hurdle, according to Linkous and Watson. “Older patients have an opposite response to what we would expect. Often older patients have people drive them to their appointments. However, they’d prefer the geography of healthcare coming to them over their having to physically be with their doctors,” Watson says.

“We’re witnessing behavioral changes in medicine. Before the healer would touch the patient. Now it’s geography over proximity,” Linkous says.

The VA’s ability to share patient information through its systemwide EMR makes it easier for the organization to enjoy the benefits of telehealth, notes Watson, adding that healthcare organizations lacking the ability to share data with other providers face more obstacles. “Right now, the free market environment for electronic health records means that health records don’t ‘talk’ to each other,” Watson says. This lack of interoperability creates significant hurdles for healthcare organizations looking to get the most out of telehealth, he adds.

No matter its inherent advantages, the VA is to be commended for its work in advancing the use of telehealth technology, says Linkous, adding that the agency has created a road map for other companies and providers to follow. “The VA is a pioneer. From them, we’ve learned about telehealth. We know it can reduce cost, improve care, and enhance access to care and specialists. We hope to work closely with them as we move ahead,” he says.

Expanding Telehealth
Recently, UPMC and Alcatel-Lucent agreed to develop a telemedicine platform and applications to allow patients to receive care via telehealth. With an expected 2013 launch, the solution will offer secure, real-time clinical meetings in virtual examination rooms that will correlate with the workflow of healthcare providers and patients’ mobility. Using a secure Web portal, patients will have access to emergency and scheduled care from any location at any time through a range of mobile devices. The system will also generate, retrieve, and store patient information.

Since 1997, UPMC has expanded its use of telemedicine into 16 service lines, including cardiology, stroke care, pathology, dermatology, and ophthalmology. It plans to consolidate its telemedicine offerings on this new platform, with the goal of lowering costs and improving access to high-quality care.

“Advances in telecommunications technology and the widespread adoption of mobile devices have paved the way for eliminating the restrictions that bricks and mortar have placed on healthcare,” says Rebecca Kaul, president of UPMC’s Technology Development Center. “By combining our clinical and technological expertise, UPMC and Alcatel-Lucent are poised to deliver on the promise of providing seamless care to patients that is only a click away.”

The new system takes advantage of cloud-based communications in which data are stored on servers rather than on individual computers.

“The challenge involved in creating this next-generation telemedicine system is designing a true multipoint communication platform that allows everyone involved in the medical case to securely view the same data and medical records at the same time regardless of the communication device used,” says Sid Ahuja, vice president of Alcatel-Lucent Ventures. “With cloud-based technologies, services and software applications are delivered from the Internet rather than a dedicated enterprise network in a single location, enabling a new level of medical collaboration and information sharing via secure real-time audio, video, and data links.”

*Full name withheld to protect privacy.

— Susan Chapman is a Los Angeles-based writer and author.