FORUM
 translating research 

into quality health car

for veterans

A publication of the VA Office of Research 

& Development, Health Services Research 

& Development Service, Management 

Decision & Research Center, in conjunctio

with AcademyHealth 

June 2004 VA Health Services Research & Development Service 

Contents 

Director’s Letter 2 

Response to Commentary 3 

Dialogue 4 

Research Review 5 

Research Highlights 6 

n 

There’s No Place Like Home: Coordinating Care 

for Veterans 

By Adam Darkins, M.D., M.P.H.M., Chief Consultant for Care Coordination 

VA’s new Office of Care Coordination (OCC) fered or died unnecessarily. Anecdotal data, you 

has an ambitious mission: ensuring that all say? The meta-analysis of such stories becomes 

patients receive the right care in the right place the evidence for avoidable medical errors. 

at the right time. Although few would argue 

with that sentiment, the devil lies in the details. Individual components of care are not necessarily at fault, whether they are located in the 

How do we know what constitutes the right home, clinic, inpatient unit, operating room, or 

care, the right place, and the right time for any radiation therapy suite. Unfortunately, there 

given patient? That’s where health services are cracks in what is popularly called the conresearch and the vital work of HSR&D come in. tinuum of care, and patients are falling through 

them. Poor coordination of care is causing 

OCC’s vision—that the home should be the harm to patients, as well as inconvenience an

preferred place of care, whenever appropriate unnecessary cost, and it must be rectified. 

—places the environment of care on center Until it is, the term “health care system” seem

stage. But the combinations and permutations a misnomer. Sadly, the fragmentation of the 

of people, places, care provision, and timing of health care system means that the whole adds 

care across the VA system are virtually infinite. up to far less than the sum of its parts. 

Care coordination is a mammoth undertaking, 

and one where the journey is the destination. This brings us back to the environment of 

care. In the nineteenth century, hospitals wer

In VA, care coordination involves the use of places of sanctuary. Throughout most of the 

telehealth, disease management, and health twentieth century, human and capital assets in 

informatics technologies to enhance and health care were concentrated in hospitals as 

extend care and case management activities. the locus of health care delivery moved from 

VA is initially focusing its care coordination the community to institutional care. Average 

effort on the home and using home-telehealth life expectancy in the U.S. improved over the 

technologies. We describe this range of activi­ same period—because of better living condities as care coordination/home telehealth tions and nutrition, and proper sanitation, and 

(CCHT). We are finding these technologies not because of changes in health care delivery

particularly useful for extending care in rural 

and underserved areas. By focusing on CCHT, VA is addressing funda

mental questions about the relative mix of primar

Why is care coordination being adopted through­ secondary, and tertiary prevention. If HSR&D 

out the health care system? Ask your colleagues, is to follow care in this next phase as it moves 

friends, and relatives about their experiences with out into the home, the possibilities for the futur

the health care system. I would be astounded design of our health care system are fascinating

if you don’t hear stories of people who have suf­ continued on page 
2 ■ Forum/June 2004 

Again, let’s ask: What is the “right” environment for care? If, for example, appropriately selected patients with heart failure 

are monitored at home and their diuretic 

medications are adjusted when initial 

symptoms of breathlessness and signs of 

weight gain develop, acute hospital stays 

with probable ICU admissions are avoided

This approach, with corollaries across a 

wide range of chronic diseases, gives rise t

the concept of “just-in-time” care. 

In contrast, our traditional model of clinic 

visits is “just-in-case” care. Clinic visits 

every three, six, nine, or 12 months are arb

trary and not based on evidence of effective

ness or cost-effectiveness. Rates of 

unscheduled outpatient clinic appointmen

and emergency hospital admissions sugges

that this model is frequently inappropriate. 

Are clinic visits really supporting patients, o

are they reassuring practitioners? 

The hospital and the outpatient clinic will 

always be vital to our health care system. 

However, if we use new information, communication, and telecommunications technologies to engage in dialogues with patients

the focal point of care may shift to the 

home. There is an inexorable logic in educating patients to lose weight, exercise, and 

stop smoking to ameliorate the progression 

of cardiac failure—as there is in educating 

them not to be stoic and wait until they are 

at death’s door before seeking hospital care

As the demographics of veteran patients 

change and they live longer while coping wit

one or more chronic diseases, the salient 

decisions become whether to treat, when to 

treat, how to treat, and where to treat. Onc

again, we are back to the environment of 

care and the importance of understanding 

patients and their preferences for care. 

Take, for example, falls among the elderly. 

Why do people fall at home? The generally 

accepted reasons are extrapolated from 

research studies on falls in hospitals. Is 

alcohol use related to depression resulting 

from living alone and being less mobile a 

precipitating cause? We don’t know, 

because this question has received less 

continued on page 

Director’s Letter 

I am pleased to announce that HSR&D has decided to fund 

three new Centers of Excellence. 

The first of these centers will be located at the Boston VAMC

and will focus on management research. Martin Charns, 

D.B.A., will lead this new center. Dr. Charns had been director of our Management Decision and Research Center 

(MDRC) for the last 10 years. This decision underscores the

importance HSR&D places on the science of management 

and the need to develop more evidence-based management. 

The other two centers will focus on implementation 

research, an increasingly important area for HSR&D, in particular, and VA in general. The two centers will be based at 

the Iowa City VAMC and the Indianapolis VAMC. The directors of the centers are Gary Rosenthal, M.D., and Brad Doebbeling, M.D., M.Sc., respectively. 

Congratulations to the three new directors, their staffs, and their facilities. The competition 

was rigorous, with several excellent proposals received. This will bring to a total 16 Centers of 

Excellence funded by HSR&D. 

We also are pleased to announce four special academic partnership awards to enhance implementation research. The awardees are Rod Hayward, M.D., Ann Arbor VAMC; Joseph 

Conigliaro, M.D., M.P.H., Pittsburgh VAMC; Lisa Rubenstein, M.D., M.S.P.H., Sepulveda VAMC; 

and Fran Weaver, Ph.D., Hines VAMC. Congratulations to all. 

Finally, as many of you know, I will retire on July 2, after serving as HSR&D Director for almost 

seven years. As I prepare to leave, I want you all to know what an honor it has been for me to 

serve in this capacity. I thank the entire HSR&D community in Central Office and in the field for 

their support, cooperation, and hard work. 

Together, we have accomplished much. HSR&D has grown from a $33 million research enterprise to one with more than $60 million dollars. Another $10 million in medical care funds 

have been awarded for our Quality Enhancement Research Initiative (QUERI) projects and 

other implementation research endeavors. 

Across the board, we can see how HSR&D has grown: Funded projects have increased in number from 109 to 150; we’ve nearly doubled our career development awards, from 37 to 70; and 

we’ve added seven Centers of Excellence over the years. We have instituted new centers 

(Resource Centers, the Research Enhancement Awards Program, and the Targeted Research 

Enhancement Program); awarded career development for non-clinical Ph.D.s (the Merit Review 

Entry Program); and, of course, successfully implemented QUERI. This continued expansion 

would not have been possible without the significant increase in our funding. 

And for that, we have to thank the outstanding work of our researchers in the field and the 

impact they have had on our health care delivery system. 

Thank you again for all your hard work and dedication. I know you will continue to give that 

same hard work and dedication to my successors. 

John G. Demakis, M.D. 

Director, HSR&D 
Forum/June 2004 ■ 

attention than treating the fractured necks 

or femurs that result from falls at home. 

Should more attention be paid to dealing 

with loneliness and depression in elders as 

well as secondary and tertiary care? 

These questions have never been addressed 

adequately, because the relationship 

between the health care system and the 

patient has been episodic and based on 

clinic visits and hospital admissions. 

Since implementing the Computerized 

Patient Record System (CPRS), VA has 

achieved major improvements in health 

care quality indicators. CCHT is extending 

our new electronic patient record system 

into the home, where CPRS captures and 

directly incorporates vital sign and disease 

management data. 

Imagine a scenario whereby veterans with 

chronic diseases can understand the health 

issues they face in terms of the primary, 

secondary, and tertiary prevention choices 

from consistent, coherent, and evidencebased e-health information. Further imagine that these same veterans use this information to make choices based upon data 

from their own health record. Finally, 

imagine these veterans engaging with VA 

practitioners to exercise their preferences 

for care, based on VA’s evidence-based clinical guidelines. 

This type of self-management system will 

soon be possible in VA for appropriate veteran patients. OCC is working with other 

VA offices to coordinate clinical input into 

VA’s patient handheld record system, 

MyHealth-eVet; to give e-health information 

to patients; and to support the caregiver to 

make these systems work. 

HSR&D will be crucial to achieving this 

agenda. We need solid health services 

research to inform the design of these 

systems and ensure that those who cannot 

use these systems are not disenfranchised. 

Finally, amidst all these technological developments, we need to maintain our vision 

of connecting with patients in ways that are 

human, meaningful, and necessary— 

whatever the environment of care. ■ 

Response to Commentary
 

Shared Goal of Evidence-Based Care Will Spur 

Improvements in Care Coordination by VA 

By Neil Thakur, Ph.D., Assistant Director, Management Consultation, 

and John G. Demakis, M.D., Director, HSR&D 

Dr. Darkins’ commentary describes the strategies of the OCC suggest the opportumany ways in which VA’s new Office of nity to create home-based care patient regCare Coordination (OCC) taps into core istries and databases that open up new 

areas of health services research. He offers research opportunities. Most importantly, 

us yet another example of the exciting and VA has natural organizational divisions 

complex ways in which an intramural (facilities and networks) that allow the 

health services research program can sup­ simultaneous implementation of different 

port health care delivery and innovation. strategies that can be scientifically compared

VA’s care coordination agenda hits four Dr. Darkins’ agenda presents exciting 

broad areas of inquiry central to the opportunities for OCC and HSR&D 

HSR&D research agenda. These are: researchers to advance a goal fundamental 

to both groups: that care, organization, an

■ chronic disease management; management of clinical services for veter­

■ organization and delivery of services; ans should be evidence-based. To make 

this happen, we will need to address imme

■ infrastructure to support and monitor diate operational needs and begin our care in home-based settings, including longer-term planning. informatics, telehealth, and quality assurance; and First, our mutual commitment to evidence

■ implementation of new services and based decisions means care coordination 

models, including training and staffing should be implemented in stages, with con

changes. current summative and formative evaluations

These evaluations will determine which 

HSR&D already devotes considerable aspects of care coordination work and should 

resources to these areas. We currently fund be expanded, and how best to expand them

more than 40 studies on disease manage­ This strategy may lead to implementation 

ment, management and organizational of different aspects of the model in differresearch, and telehealth. In addition, our ent networks and/or for different disease 

Quality Enhancement Research Initiative groups, possibly on a randomized basis. 

(QUERI) projects and Veterans Integrated HSR&D field programs can facilitate the 

Service Network collaboratives focus on the design and execution of these efforts. 

art of implementation itself. This synergy, 

as well as new studies, can be used to sup­ Second, HSR&D needs to begin research 

port and inform the OCC in its work. now on the issues that OCC will face in the 

next five to 10 years. We look to our field 

These efforts are facilitated by VA’s natural investigators to design studies that are 

strengths. Data and planning efforts are mindful of the major shifts in care delivery 

relatively easy to centralize in VA, compared that the OCC proposes, and to explore 

to the private sector. The process of collect­ opportunities with local clinical sites for 

ing and disseminating research and quality potential improvements to care coordination

improvement findings unfolds within clearly defined boundaries. The particular continued on page 
4 ■ Forum/June 2004 

Dialogue
 

Telemedicine Technologies: What is the Cost of 

Improving Access to Health Care Services in 

Rural Areas? 

By Julie Lowery, Ph.D., VA HSR&D Center of Excellence, Ann Arbor, MI 

“What are some of the more effective and less 

expensive telehealth technologies that can be 

used to provide VA care for the many veterans 

who live in rural America?” 

— Al Perry, M.H.A., FACHE, Director, V

Central California Healthcare System 

A 

Of the two major types of telemedicine systems available—store-and-forward vs. realtime videoconferencing—store-and-forward

is much less expensive, but probably just as

effective. (I say “probably,” because we 

really don’t know—more on that later.) 

Store-and-forward systems consist of the 

collection of clinical data (in electronic format) by the patient, caregiver, or provider at

the patient’s home or health care facility, 

that are then transmitted to a Web site, 

e-mail address, or remote storage device for

review by the telemedicine physician at a 

later time. The clinical data can be in the 

form of digital photographs, video streams, 

direct output from peripheral devices for 

measuring vital signs, and/or simple text. 

Videoconferencing systems require the 

installation of more expensive equipment, 

including video capture and display units, 

at both ends of the communications link. 

These systems also need greater bandwidth

for the real-time transmission of video and 

audio. Plus there’s the challenge of coordinating patients’ and providers’ schedules. 

In that sense, videoconferencing is similar 

to in-person visits between patient and 

provider. 

By contrast, the equipment used in storeand-forward applications (such as digital 

cameras, PCs, or laptops) is much less 

expensive (or already available), more reliable, and easier to use than videoconferencing equipment. In addition, the store-andforward method can be more convenient for 

providers, enabling them to review the data 

when they have the time to do so, without 

the delays associated with late appointments 

or patient no-shows for videoconferencing 

consultations. 

Furthermore, the data can be easily stored 

in an electronic database for subsequent 

retrieval and review. Some more sophisticated (and expensive) store-and-forward 

applications have the added benefit of a 

computer program that analyzes the data 

and flags those items requiring immediate 

attention, thereby precluding the need for 

the telemedicine provider to review all of 

the data submitted. 

The primary disadvantages of store-and-forward applications, in contrast to videoconferencing, are: lack of direct communication between patients and their telemedicine providers; and, in cases requiring the 

review of patients’ physical characteristics, 

the inability to request different/additional 

views in real time. 

Both store-and-forward and videoconferencing systems can be used to collect and 

transmit data from patients in their homes 

or patients seen in rural health care facilities. The former is necessarily more expensive, because the equipment has to be 

installed in many more locations. 

Equipment placed in rural health care faci

ties, in contrast, can serve multiple patient

However, systems based in homes maximizes patients’ access to care, and may be 

the only option for veterans who live many 

miles from a primary care clinic. 

Unfortunately, rigorous evaluations of 

telemedicine applications—both store-and

forward and videoconferencing—are few 

and far between. Rarely do evaluations of 

telemedicine intervention include a contro

group for comparison, let alone randomiza

tion between intervention and control. So

while most “evaluations” of telemedicine 

applications show benefits, the methods 

and results should be carefully reviewed. 

“We still don’t know for certain 

whether telemedicine will prove 

cost-effective, in terms of reducing 

morbidity, mortality, visits, or 

admissions to tertiary care 

facilities, or at improving patients

quality of life.” 

Having said that, the applications most fre

quently reported in the literature and presented at conferences include: pathology, 

radiology, psychiatry, home care (for variou

chronic illnesses), dermatology, and ophthalmology. All have shown promising 

results. But we still don’t know for certain 

whether telemedicine will prove cost-effective, in terms of reducing morbidity, morta

ity, visits, or admissions to tertiary care 

facilities, or at improving patients’ quality 

life. Certainly, improving patients’ access t

care is a benefit. But that benefit does not 

come without a cost. ■ 
Research Review
 

The Benefits of Telehome Care: What Does the 

Research Show? 

By Faith Hopp, Ph.D., and Julie Lowery, Ph.D., Ann Arbor HSR&D Center of Excellence, 

and Peter Woodbridge, M.D., M.B.A., and Richard L. Roudebush, VAMC 

Through the Office of Care Coordination, 

VA devotes considerable resources to the 

implementation of home telehealth, under 

the assumption that, when appropriate, 

home should be the care setting of choice. 

As Dr. Darkins points out in his commentary, HSR&D can play an important role in 

determining when home telehealth is most 

effective. Many descriptions of telehome 

care have been reported, and the vast 

majority show positive outcomes, in terms 

of both patient and provider satisfaction. 

However, few studies of this technology 

have included comparable control groups. 

In addition, most studies have been conducted outside VA, and most have shown 

equivocal results. 

A large-scale, randomized study conducted 

by Kaiser Permanente involving home 

video technology reported a 25 percent 

decrease in health care costs (excluding 

those for home care) in the intervention 

group, compared with patients receiving 

usual home care. The savings were largely 

due to a 43 percent decrease in hospital 

costs, but they were offset by a 36 percent 

increase in home care costs (including technology) in the group that received the home 

video technology. No differences in patient 

satisfaction were found between the telehealth group and usual home care group. 

A recently published study randomized 

congestive heart failure patients to telehome care, telephone follow-up, or usual 

care to compare use of health resources. 

Findings suggested that telehome care did 

not offer an incremental benefit beyond 

that obtained from usual telephone followup. (For more information, see Jerant, et al. 

in Medical Care 2001; 39:1234–45.) 

A VA study evaluated a multi-faceted intervention involving the use of care coordinators, home video, and messaging devices. 

The results showed lower use of hospital 

services in the intervention group, but the 

findings were compromised by lack of comparability between the intervention and 

comparison groups. Moreover, the intervention included both care coordination and 

telehealth components, making it difficult 

to tease out the individual contributions of 

telehealth versus care coordination as predictors of patient outcomes. 

The Ann Arbor HSR&D Center of 

Excellence has conducted VA’s only randomized control study of telehome care. 

Although the study was very small, it 

showed a significant improvement in mental health ratings among patients receiving 

telehome care services, compared with 

patients who received usual home care services. However, no group differences were 

observed for physical health and patient satisfaction, or for use of health care resources, 

including inpatient days of care, emergency 

room visits, in-person home care services, 

or primary and specialty outpatient services. 

Like most other studies, patients rated telehome care services positively. 

The findings from these studies should not 

deter us from pursing the laudable goals put 

forth by the Office of Care Coordination, 

but we must be cautious in our expectations. 

Certainly, telehome care can improve 

patients’ access to care, particularly for veterans who live far from VA medical center

But this will not necessarily translate into 

reductions in service use or cost savings. 

In addition, the question of whether 

improved access from this technology will 

improve morbidity and mortality remains 

to be answered. More randomized studies 

are needed to determine whether telehome 

care can provide more cost-effective and 

better strategies for coordinating care of 

persons with chronic conditions. ■ 

Under Secretary’s Award for
 

Outstanding Achievement in
 

HSR Presented to Carol Ashton
 

Carol Ashton, M.D., M.P.H., director of 

Health Services Research and Development’s 

(HSR&D) Houston Center for Quality Care 

and Utilization Studies, has received the 2004 

Under Secretary’s Award for Outstanding 

Achievement in Health Services Research. 

In accepting the award, which was presented at HSR&D’s National Meeting, Ashton 

thanked all of HSR&D’s “scientists, colleagues, and mentors,” as well as “all the 

veterans who have shared themselves and 

their stories with me since I became a VA 

staff physician in 1983, and who never let 

me lose sight of why I chose to devote my 

professional life to this system.” 

The award recognizes a VA researcher 

whose work has led to major improvements 

in the quality of veterans’ health care, has 

made significant contributions to the future 

of HSR&D through excellence in training 

and mentorship, and has enhanced the 

visibility and reputation of VA research 

through national leadership. 

Ashton is an exceptional health services 

researcher, excellent mentor, and respected 

VA leader. Her dedication to improving 

veterans’ health care has led to the development and implementation of new measures 

and procedures that improve quality while 

addressing patients’ needs and preferences. 

Forum/June 2004 ■ 
6 ■ Forum/June 2004 

Research Highlight
 

Telecare Shows Promise for Treating Depression 

in Rural Primary Care Settings, According to 

TEAM Study Results 

By John Fortney, Ph.D., and Jeffrey Pyne, M.D., Central Arkansas Veterans Healthcare System and 

Department of Psychiatry, College of Medicine, University of Arkansas for Medical Sciences 

“Because of the many treatment barriers facing patients 

and providers, the clinical 

outcomes of routine primary 

care depression treatment 

are not optimal, especially 

for rural patients.” 

Telemedicine technologies may offer an effective means for providing evidence-based 

depression treatment to veterans living in rural 

areas, according to preliminary data from the 

Telemedicine Antidepressant Management 

(TEAM) study conducted by the HSR&D 

Center for Mental Health and Outcomes 

Research (CeMHOR), and the South Central 

Mental Illness Research Education and Clinical 

Center (MIRECC). 

The purpose of the study is to determine the 

effectiveness and cost-effectiveness of using 

telemedicine technologies (e.g., telephones, 

interactive video, electronic medical records, 

and the Internet) to improve the outcomes of 

depression in small rural Community-Based 

Outpatient Clinics (CBOCs). 

Over the last 10 years, 573 CBOCs have been 

established to improve veterans’ access to care. 

However, specialty mental health services are 

not provided in 74 percent of rural CBOCs. 

Because of the many treatment barriers facing 

patients and providers, the clinical outcomes of 

routine primary care depression treatment are 

not optimal, especially for rural patients with 

poor geographic access to care. 

Collaborative care teaming primary care 

providers (PCPs) and mental health specialists 

has been identified as the best practice for 

addressing depression in primary care settings. 

Originally, collaborative care models were 

designed for (and evaluated in) large urban primary care practices with on-site mental health 

specialists. Implementing collaborative care in 

small rural CBOCs is more challenging because 

it typically is not feasible to employ mental 

health specialists on site. 

TEAM investigators adapted the collaborative 

care model for small rural CBOCs using telecare technologies and three types of off-site 

mental health specialists: depression nurse 

care managers, mental health clinical pharma

cists, and consult tele-psychiatrists. Using tele

care technologies, off-site mental health specialists support on-site PCPs in providing evidence-based depression treatment. Within a 

stepped-care framework, the depression nurse 

care manager conducts patient education, acti

vation, and barrier assessment, as well as 

symptom and medication monitoring. The 

clinical pharmacist provides medication management and treatment recommendations to 

PCPs. Consult tele-psychiatrists conduct inter

active video encounters with patients and provide treatment recommendations to PCPs. 

The intervention was implemented at small 

rural CBOCs in the South Central VA 

Healthcare Network, with matched CBOCs 

serving as controls. Six-month follow-up data 

indicate that the TEAM intervention significantly improved both the process and outcomes 

of care. More than 16,000 primary care patient

were screened for depression, with 6.8 percent 

screening positive. More than 90 percent of 

eligible patients enrolled in the study, and 93 

percent of those patients completed six-month 

follow-up interviews. 

Intervention patients had more antidepressant 

trials, reported more days taking antidepressants

and were more likely to experience a greater 

than 50 percent improvement in their depressive symptoms. Future analysis will focus on 

the cost-effectiveness of this approach. For 

more information about the TEAM study, visit 

our web site at www.va.gov/team/. ■ 
Forum/June 2004 ■ 

Telemedicine Systems May Help SCI Patients Get Specialized Care Sooner 

By Julie Lowery, Ph.D., Ann Arbor HSR&D Center of Excellence, and Bonnie Wakefield, Ph.D., R.N., Iowa City VAMC 

The special needs of spinal cord injury 

(SCI) patients make it especially difficult for 

them to travel long distances for care. To 

improve access for these patients, several 

VA networks and medical centers have 

implemented telemedicine systems for 

monitoring and providing treatment. 

Research on the effectiveness of telemedicine for SCI patients is still in its infancy, 

but two VA studies have yielded encouraging—though mixed—results, and more 

research is underway. 

A 2000 study evaluated a telemedicine system established at the VA Palo Alto Health 

Care System’s SCI Center, which served as 

the “hub,” with “spokes” at medical centers 

in Fresno, Honolulu, and Reno. Patients 

and their providers in the spoke centers 

communicated with SCI specialists in Palo 

Alto via videoconference. Consultation was 

sought for a variety of conditions, including 

genito-urinary, pain, gastrointestinal, neurological, functional loss, skin, medication, 

spasticity, fatigue, and psychosocial issues. 

Multiple conditions were usually addressed 

in each telehealth session. 

Patient and provider evaluations of the system were extremely positive, and access to 

care for veterans with SCI improved. 

Notably, more than half of the telehealth 

consultations provided were for patients 

who had never been seen at the SCI Center. 

More than 70 percent of the telehealth consultations were believed to have expedited 

diagnosis and treatment of patient conditions, according to the provider evaluations. 

Patient and provider surveys alike showed 

telehealth consultation to be a comfortable 

and desirable way to provide services when 

patients are located at a great distance from 

available experts. 

In response to these findings, the Spinal 

Cord Injury Telehealth Consultation 

Program has become firmly established at 

the Palo Alto VAMC and continues to show 

benefits by providing care to new patients 

and reducing the need to travel to Palo Alto. 

A similar system has been established 

between the Iowa City and Hines VAMCs 

in which Iowa City patients are seen via 

videoconference by wound care specialists 

at Hines. 

“Research on the effectiveness 

of telemedicine for SCI patients 

is still in its infancy, but two VA 

studies have yielded encouraging 

—though mixed—results, and 

more research is underway.” 

Investigators at the Ann Arbor HSR&D 

Center of Excellence completed a study 

assessing the accuracy of using digital photographs for evaluating chronic wounds, 

including pressure ulcers in SCI patients. 

Although the diagnoses made from the digital images were not as accurate as they had 

hoped, the study investigators concluded 

that the technology is a viable way to 

increase access to specialized wound care 

services. 

Based on these findings, the Ann Arbor 

COE is conducting a pilot study of a “storeand-forward” telehealth system that provides treatment recommendations from a 

specialized wound care team in the Ann 

Arbor VA Medical Center to wound care 

nurses in referring primary care facilities. 

(For more information on “store-and-forward” technologies, see the Dialogue 

article on page 4.) The study researchers 

hope to use the results from the pilot study 

to submit a proposal for conducting a randomized controlled trial comparing the 

costs and effectiveness of the store-andforward system versus the usual referral 

process. 

Investigators at the Palo Alto SCI Center 

also are examining the use of telehome car

for patients with SCI. Specifically, they hav

been evaluating the use of telephone and 

telephone plus video care for assessing 

three secondary conditions common in 

patients with SCI (pressure sores, transfer 

mobility, and spasticity). The results of the 

telephone and televideo assessments will b

compared with findings from an in-person 

assessment. Data analysis from the study 

underway, and the findings are expected to 

contribute substantially toward the validation of telemedicine approaches in home 

settings. 

It comes as no surprise that a number of 

VA medical centers have already implemented telemedicine systems to help provide specialized care to SCI patients in 

remote areas. However, much more 

research is needed to determine the benefits of these systems relative to their costs. 

A comparison of store-and-forward versus 

videoconferencing technology would be 

particularly helpful to VA managers who 

are considering these systems for their 

facilities. ■ 
HSR&D National Meeting 2004: Meeting the Changing Needs 

of Veterans 

“Meeting the Changing Needs of Veterans: The Quality/Cost Equation” was the theme of 

VA’s Health Services Research & Development Service (HSR&D) 22nd National Meeting, 

held March 9–11, in Washington, D.C. During the meeting, nearly 600 researchers, clinicians, 

and policymakers participated in an array of activities, including plenary paper sessions, 

exhibits, workshops, and a poster session—all focusing on meeting the changing health 

care needs of veterans while providing high-quality, cost-effective care. 

Hosted by HSR&D’s Center for Health Quality, Outcomes, and Economics Research 

(Bedford, Mass.), the conference addressed a broad spectrum of health care issues, such 

as: the relationship between research and practice, health care disparities, use of patientcentered data to improve quality, mental health care coordination, comprehensive care for 

women veterans, and doctor-patient communication. Researchers also addressed a wide 

array of diseases and conditions affecting veterans, including chronic pain, colorectal cancer, 

diabetes, hypertension, HIV/AIDS, problem drinking, suicidal risk, and stroke. 

Jonathan Perlin, M.D., Ph.D., VA’s Deputy Under Secretary for Health and Acting Chief 

Research and Development Officer, addressed participants about the remarkable improvements in quality of care within the VA health care system, such as better diabetes control, 

increased screening for cervical cancer, and higher use of beta blockers for heart attack 

patients at discharge from hospital. Other meeting highlights included the presentation of 

the 2004 Under Secretary’s Award for Outstanding Achievement in Health Services 

Research to Carol M. Ashton, M.D., M.P.H., director of HSR&D’s Houston Center for 

Quality of Care and Utilization Studies. The keynote address, “Assessing Quality of Care for 

Persons with Disabilities,” was given by Lisa Iezzoni, M.D., M.Sc., with Harvard Medical 

School and the Beth Israel Deaconess Medical Center. This is a topic of great importance, 

especially for veterans who return from war with substantial, long-term impairments. 

This year’s meeting also included a special tribute to John G. Demakis, M.D., who will retire 

as director of VA’s Health Services Research early this summer. Dr. Demakis was presented 

with the Under Secretary’s Exemplary Service Award—the highest honor this office bestows. 

Response continued from page 3 

HSR&D can work with the OCC to develop 

and better focus this agenda. 

The challenges ahead are considerable. 

Care coordination draws from multiple 

areas of health services research, and 

HSR&D will have to be especially creative 

and collaborative. 

Fortunately, both tasks are mutually reinforcing, leading to shared success, wider 

support of HSR&D and the OCC, and further progress toward evidence-based care. 

The ultimate winners will be veterans and 

their caregivers. ■ 

FORUM 

Martin P. Charns, D.B.A., Editor-in-Chief 

Mary Darby, Editor 

Geraldine McGlynn, Co-editor 

Advisory Committee 

John G. Demakis, M.D., Director, VA HSR&D 

Rodney A. Hayward, M.D., VA HSR&D Center of 

Excellence, Ann Arbor 

Elwood Headley, M.D., VA Network #8, 

Bay Pines, FL 

Shirley Meehan, M.B.A., Ph.D., VA HSR&D 

Laura Miller, Under Secretary for Health for 

Operations and Management, Washington, DC 

Alan S. Perry, M.H.A., FACHE, VA Medical 

Center, Fresno, CA 

Hanna B. Rubins, M.D., M.P.H., VA HSR&D 

Center of Excellence, Minneapolis