U.S. GOVERNMENT PRINTING OFFICE

WASHINGTON : 

For sale by the Superintendent of Documents, U.S. Government Printing Office,

http://bookstore.gpo.gov. For more information, contact the GPO Customer Contact Center,

U.S. Government Printing Office. Phone 202–512–1800, or 866–512–1800 (toll-free). E-mail, gpo@custhelp.com.

58–054 2010

OVERCOMING RURAL HEALTH CARE 

BARRIERS: USE OF INNOVATIVE WIRELESS 

HEALTH TECHNOLOGY SOLUTIONS 

HEARING 

BEFORE THE

SUBCOMMITTEE ON HEALTH 

OF THE

COMMITTEE ON VETERANS’ AFFAIRS 

U.S. HOUSE OF REPRESENTATIVES 

ONE HUNDRED ELEVENTH CONGRESS 

SECOND SESSION 

JUNE 24, 2010 

Serial No. 111–87 

Printed for the use of the Committee on Veterans’ Affairs 

( 


ebenthall on DSK9Q6SHH1PROD with HEARING
ii 

COMMITTEE ON VETERANS’ AFFAIRS 

BOB FILNER, California, Chairman 

CORRINE BROWN, Florida 

VIC SNYDER, Arkansas 

MICHAEL H. MICHAUD, Maine 

STEPHANIE HERSETH SANDLIN, South 

Dakota 

HARRY E. MITCHELL, Arizona 

JOHN J. HALL, New York 

DEBORAH L. HALVORSON, Illinois 

THOMAS S.P. PERRIELLO, Virginia 

HARRY TEAGUE, New Mexico 

CIRO D. RODRIGUEZ, Texas 

JOE DONNELLY, Indiana 

JERRY MCNERNEY, California 

ZACHARY T. SPACE, Ohio 

TIMOTHY J. WALZ, Minnesota 

JOHN H. ADLER, New Jersey 

ANN KIRKPATRICK, Arizona 

GLENN C. NYE, Virginia 

STEVE BUYER, Indiana, Ranking 

CLIFF STEARNS, Florida 

JERRY MORAN, Kansas 

HENRY E. BROWN, JR., South Carolina 

JEFF MILLER, Florida 

JOHN BOOZMAN, Arkansas 

BRIAN P. BILBRAY, California 

DOUG LAMBORN, Colorado 

GUS M. BILIRAKIS, Florida 

VERN BUCHANAN, Florida 

DAVID P. ROE, Tennessee 

MALCOM A. SHORTER, Staff Director 

SUBCOMMITTEE ON HEALTH 

MICHAEL H. MICHAUD, Maine, Chairman 

CORRINE BROWN, Florida 

VIC SNYDER, Arkansas 

HARRY TEAGUE, New Mexico 

CIRO D. RODRIGUEZ, Texas 

JOE DONNELLY, Indiana 

JERRY MCNERNEY, California 

GLENN C. NYE, Virginia 

DEBORAH L. HALVORSON, Illinois 

THOMAS S.P. PERRIELLO, Virginia 

HENRY E. BROWN, JR., South Carolina, 

Ranking 

CLIFF STEARNS, Florida 

JERRY MORAN, Kansas 

JOHN BOOZMAN, Arkansas 

GUS M. BILIRAKIS, Florida 

VERN BUCHANAN, Florida 

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. 


ebenthall on DSK9Q6SHH1PROD with HEARING
iii 

C O N T E N T S 

June 24, 2010 

Page 

Overcoming Rural Health Care Barriers: Use of Innovative Wireless Health 

Technology Solutions ........................................................................................... 1 

OPENING STATEMENTS 

Chairman Michael Michaud ................................................................................... 1 

Prepared statement of Chairman Michaud .................................................... 40 

Hon. Gus M. Bilirakis ............................................................................................. 2 

Prepared statement of Congressman Bilirakis .............................................. 40 

WITNESSES 

Federal Communications Commission, Kerry McDermott, MPH, Expert Advisor .......................................................................................................................... 34 

Prepared statement of Ms. McDermott .......................................................... 77 

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 .. 36 

Prepared statement of Colonel Poropatich ..................................................... 80 

U.S. Department of Veterans Affairs, Gail Graham, Deputy Chief Officer, 

Health Information Management, Office of Health Information, Veterans 

Health Administration ......................................................................................... 38 

Prepared statement of Ms. Graham ................................................................ 83 

AirStrip Technologies, San Antonio, TX, William Cameron Powell, M.D., 

FACOG, President, Chief Medical Officer and Co-Founder ............................. 20 

Prepared statement of Dr. Powell ................................................................... 56 

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 .......................................................................................................................... 7 

Prepared statement of Mr. Cattell-Gordon ..................................................... 50 

Cogon Systems, Inc., Pensacola, FL, Huy Nguyen, M.D., Chief Executive 

Officer .................................................................................................................... 26 

Prepared statement of Dr. Nguyen ................................................................. 65 

Continua Health Alliance, Rick Cnossen, President and Chair, Board of Directors, and Director of Personal Health Enabling, Intel Corporation Digital 

Health Group, Hillsboro, OR ............................................................................... 22 

Prepared statement of Mr. Cnossen ............................................................... 57 

LifeWatch Services, Inc., Rosemont, IL, John Mize, Director, LifeWatch Federal ........................................................................................................................ 29 

Prepared statement of Mr. Mize ..................................................................... 75 

MedApps, Inc., Scottsdale, AZ, Kent E. Dicks, Founder and Chief Executive 

Officer .................................................................................................................... 24 

Prepared statement of Mr. Dicks .................................................................... 63 

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 ............................................................................ 28 

Prepared statement of Mr. Frank ................................................................... 71 

West, Darrell M., Ph.D., Vice President and Director of Governance Studies, 

and Director, Center for Technology Innovation, Brookings Institution ......... 5 

Prepared statement of Dr. West ...................................................................... 44 

West Wireless Health Institute, La Jolla, CA, Joseph M. Smith, M.D., Ph.D., 

Chief Medical and Science Officer ...................................................................... 3 

Prepared statement of Dr. Smith .................................................................... 41 


ebenthall on DSK9Q6SHH1PROD with HEARING
Page

iv 

SUBMISSIONS FOR THE RECORD 

Altarum Institute, Ann Arbor, MI, Lincoln T. Smith, President and Chief 

Executive Officer, statement ............................................................................... 86 

Robert Bosch Healthcare, Inc., Palo Alto, CA, statement .................................... 89 


ebenthall on DSK9Q6SHH1PROD with HEARING
(1) 

OVERCOMING RURAL HEALTH CARE 

BARRIERS: USE OF INNOVATIVE WIRELESS 

HEALTH TECHNOLOGY SOLUTIONS 

THURSDAY, JUNE 24, 2010 

U.S. HOUSE OF REPRESENTATIVES, 

COMMITTEE ON VETERANS’ AFFAIRS, 

SUBCOMMITTEE ON HEALTH, 

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. 

OPENING STATEMENT OF CHAIRMAN MICHAUD 

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 


ebenthall on DSK9Q6SHH1PROD with HEARING
2 

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 on 

p. 40.] 

OPENING STATEMENT OF HON. GUS M. BILIRAKIS 

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 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. 


ebenthall on DSK9Q6SHH1PROD with HEARING
3 

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 on 

p. 40.] 

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. 

STATEMENTS OF JOSEPH M. SMITH, M.D., PH.D., CHIEF MEDICAL AND SCIENCE OFFICER, WEST WIRELESS HEALTH INSTITUTE, LA JOLLA, CA; DARRELL M. WEST, PH.D., VICE 

PRESIDENT AND DIRECTOR OF GOVERNANCE STUDIES, AND 

DIRECTOR, CENTER FOR TECHNOLOGY INNOVATION, 

BROOKINGS INSTITUTION; AND 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 

STATEMENT OF JOSEPH M. SMITH, M.D., PH.D. 

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 enVerDate Nov 24 2008 12:59 Dec 19, 2010 Jkt 058054 PO 00000 Frm 00007 Fmt 6633 Sfmt 6633 I:\VA\58054.XXX GPO1 PsN: 58054

ebenthall on DSK9Q6SHH1PROD with HEARING
4 

gage, 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 soluVerDate Nov 24 2008 09:28 Dec 17, 2010 Jkt 058054 PO 00000 Frm 00008 Fmt 6633 Sfmt 6633 I:\VA\58054.XXX GPO1 PsN: 58054

ebenthall on DSK9Q6SHH1PROD with HEARING
5 

tions. 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 on p. 41.] 

Mr. MICHAUD. Thank you very much, Dr. Smith; and I couldn’t 

agree more with that last statement. 

Dr. West. 

STATEMENT OF DARRELL M. WEST, PH.D. 

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 


ebenthall on DSK9Q6SHH1PROD with HEARING
6 

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 

cha t 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. 


ebenthall on DSK9Q6SHH1PROD with HEARING
7 

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 on p. 44.] 

Mr. MICHAUD. Thank you. 

Mr. Cattell-Gordon? 

STATEMENT OF DAVID CATTELL-GORDON, M.DIV., MSW 

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 awardwinning 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. 


ebenthall on DSK9Q6SHH1PROD with HEARING
8 

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 

important—Federal 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 on p. 50.] 

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 


ebenthall on DSK9Q6SHH1PROD with HEARING
9 

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 


ebenthall on DSK9Q6SHH1PROD with HEARING
10 

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 


ebenthall on DSK9Q6SHH1PROD with HEARING
11 

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. 


ebenthall on DSK9Q6SHH1PROD with HEARING
12 

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-toperson 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 


ebenthall on DSK9Q6SHH1PROD with HEARING
13 

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 


ebenthall on DSK9Q6SHH1PROD with HEARING
14 

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 


ebenthall on DSK9Q6SHH1PROD with HEARING
15 

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 


ebenthall on DSK9Q6SHH1PROD with HEARING
16 

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 31⁄2 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 


ebenthall on DSK9Q6SHH1PROD with HEARING
17 

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 


ebenthall on DSK9Q6SHH1PROD with HEARING
18 

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 1⁄2 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 

workforce, 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 CoFounder of AirStrip Technologies in Texas. We have Rick Cnossen, 

who is President and Chair of the Board of Directors of Continua 


ebenthall on DSK9Q6SHH1PROD with HEARING
19 

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. 


ebenthall on DSK9Q6SHH1PROD with HEARING
20 

STATEMENTS OF WILLIAM CAMERON POWELL, M.D., FACOG, 

PRESIDENT, CHIEF MEDICAL OFFICER AND CO-FOUNDER, 

AIRSTRIP TECHNOLOGIES, SAN ANTONIO, TX; RICK 

CNOSSEN, PRESIDENT AND CHAIR, BOARD OF DIRECTORS, 

CONTINUA HEALTH ALLIANCE, AND DIRECTOR OF PERSONAL HEALTH ENABLING, INTEL CORPORATION DIGITAL 

HEALTH GROUP, HILLSBORO, OR; KENT E. DICKS, FOUNDER 

AND CHIEF EXECUTIVE OFFICER, MEDAPPS, INC., SCOTTSDALE, AZ; HUY NGUYEN, M.D., CHIEF EXECUTIVE OFFICER, 

COGON SYSTEMS, INC., PENSACOLA, FL; 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; 

AND JOHN MIZE, DIRECTOR, LIFEWATCH FEDERAL, 

LIFEWATCH SERVICES, INC., ROSEMONT, IL 

STATEMENT OF WILLIAM CAMERON POWELL, M.D., FACOG 

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 


ebenthall on DSK9Q6SHH1PROD with HEARING
21 

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. 


ebenthall on DSK9Q6SHH1PROD with HEARING
22 

And I think my time is up. 

[The prepared statement of Dr. Powell appears on p. 56.] 

Mr. MICHAUD. Thank you very much. 

Mr. Cnossen. 

STATEMENT OF RICK 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 standardbased 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 inhome 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 


ebenthall on DSK9Q6SHH1PROD with HEARING
23 

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 on p. 57.] 


ebenthall on DSK9Q6SHH1PROD with HEARING
24 

Mr. MICHAUD. Thank you very much. 

Mr. Dicks. 

STATEMENT OF KENT E. 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 


ebenthall on DSK9Q6SHH1PROD with HEARING
25 

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 on p. 63.] 

Mr. MICHAUD. Thank you. 


ebenthall on DSK9Q6SHH1PROD with HEARING
26 

Doctor Nguyen. 

STATEMENT OF HUY NGUYEN, M.D. 

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 


ebenthall on DSK9Q6SHH1PROD with HEARING
27 

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. 


ebenthall on DSK9Q6SHH1PROD with HEARING
28 

[The prepared statement of Dr. Nguyen appears on p. 65.] 

Mr. MICHAUD. Thank you. 

Mr. Frank. 

STATEMENT OF DAN 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, vetVerDate Nov 24 2008 09:28 Dec 17, 2010 Jkt 058054 PO 00000 Frm 00032 Fmt 6633 Sfmt 6633 I:\VA\58054.XXX GPO1 PsN: 58054

ebenthall on DSK9Q6SHH1PROD with HEARING
29 

erans 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 patientcentered 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 on p. 71.] 

Mr. MICHAUD. Thank you. 

Mr. Mize. 

STATEMENT OF JOHN 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. 


ebenthall on DSK9Q6SHH1PROD with HEARING
30 

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 


ebenthall on DSK9Q6SHH1PROD with HEARING
31 

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 on p. 75.] 

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. 


ebenthall on DSK9Q6SHH1PROD with HEARING
32 

Briefly. 

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 


ebenthall on DSK9Q6SHH1PROD with HEARING
33 

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. 


ebenthall on DSK9Q6SHH1PROD with HEARING
34 

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. 

STATEMENTS OF KERRY MCDERMOTT, MPH, EXPERT ADVISOR, FEDERAL COMMUNICATIONS COMMISSION; 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; AND GAIL GRAHAM, DEPUTY CHIEF OFFICER, 

HEALTH INFORMATION MANAGEMENT, OFFICE OF HEALTH 

INFORMATION, VETERANS HEALTH ADMINISTRATION, U.S. 

DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY 

ADAM DARKINS, M.D., MPHM, FRCS, CHIEF CONSULTANT 

FOR CARE COORDINATION, OFFICE OF PATIENT CARE SERVICES, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; AND JAMES BREELING, DEPUTY EXECUTIVE DIRECTOR, OFFICE OF INFORMATION AND 

TECHNOLOGY, U.S. DEPARTMENT OF VETERANS AFFAIRS 

STATEMENT OF KERRY MCDERMOTT, MPH 

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: 


ebenthall on DSK9Q6SHH1PROD with HEARING
35 

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-forservice 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-forservice 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 outcomesbased 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. 


ebenthall on DSK9Q6SHH1PROD with HEARING
36 

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 on p. 77.] 

Mr. MICHAUD. Thank you. 

Colonel. 

STATEMENT OF COLONEL RONALD POROPATICH, M.D. 

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 


ebenthall on DSK9Q6SHH1PROD with HEARING
37 

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 on p. 80.] 

Mr. MICHAUD. Thank you very much, Colonel. 


ebenthall on DSK9Q6SHH1PROD with HEARING
38 

Ms. Graham, could you summarize your written testimony? 

STATEMENT OF GAIL GRAHAM 

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. 


ebenthall on DSK9Q6SHH1PROD with HEARING
39 

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 on p. 83.] 

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.] 


ebenthall on DSK9Q6SHH1PROD with HEARING
(40) 

A P P E N D I X 

Prepared Statement of Hon. Michael H. Michaud, Chairman, Subcommittee 

on Health 

The Subcommittee on Health will now come to order. I would like to thank everyone for attending this hearing. 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 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 center. Unfortunately, this means that rural veterans cannot see a doctor or a health care worker to receive the care that they need when 

they need it. Given these barriers, it is no surprise that our rural veterans have 

worse health outcomes compared to the general population. 

This is where I see the great potential of innovative wireless health technologies. 

VA certainly is a recognized leader in using electronic health records, telehealth, 

and telemedicine. However, wireless health technologies also include mobile health, 

which truly is the new frontier in health innovations. Mobile health makes it possible for health care professionals to receive real-time health 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 PDAs and 

Smartphones. These innovations not only empower our rural veterans, but can improve health outcomes as veterans have the necessary tools to better manage chronic diseases and receive timely health care in the comfort of their homes. 

I look forward to hearing from our witnesses today, as we learn more about innovative wireless health technologies and explore ways that we can best support wireless health solutions in the VA. 

f 

Prepared Statement of Hon. Gus M. Bilirakis, a Representative in Congress 

from the State of Florida 

Thank you, Mr. Chairman. And, good morning and welcome to our witnesses and 

audience members. 

I’m excited to be here with you all today to discuss wireless health technology 

within the VA, particularly how it can be 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 burdens rural veterans 

face but, as always, more work remains. 

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, Smart phones, the Internet, and other networks. 

When a patient receives a text message reminder from their doctor, they are engagVerDate Nov 24 2008 16:01 Dec 21, 2010 Jkt 058054 PO 00000 Frm 00044 Fmt 6604 Sfmt 6621 I:\VA\58054.XXX GPO1 PsN: 58054

ebenthall on DSK9Q6SHH1PROD with HEARING
41 

ing 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 

discussion this morning. 

I yield back the balance of my time. 

f 

Prepared Statement of Joseph M. Smith, M.D., Ph.D., Chief Medical and 

Science Officer, West Wireless Health Institute, La Jolla, CA 

Chairman Michaud and Ranking Member Brown, thank you for the opportunity 

to testify before the Committee about addressing the health care needs of veterans, 

particularly those living in rural areas, and how wireless health technologies can 

help overcome barriers to accessing care. My name is Dr. Joseph Smith, and I am 

the Chief Medical and Science Officer of the West Wireless Health Institute. I have 

spent the last 25 years at the intersection of medicine and innovative technology, 

practicing medicine and the technology-intensive subspecialty of clinical cardiac 

electrophysiology in academic and clinical settings, and most recently, concentrating 

on advancing the development of emerging technologies to solve unmet needs in 

health care. 

The West Wireless Health Institute is a non-profit medical research organization 

that was launched last year by two visionary entrepreneurs, Gary and Mary West, 

with the primary mission of advancing wireless health technologies to lower health 

care costs. The Wests, through their family foundation, have granted almost $100 

million to the Institute to date. We are focusing these resources to create a unique, 

cross-functional organization comprised of physicians, scientists, engineers, health 

economists, and experts in reimbursement and regulatory policy to drive systematic 

change in health care delivery. With 42 members of the team already in place, we 

are hiring at a pace of about one person per week and hope to employ a world-class 

staff of 80 by the end of this year. Toward our goal of dramatically lowering the 

cost of excellent health care, we are innovating and incubating promising technologies; validating their value to lower costs; actively engaging with policymakers 

and other stakeholders to accelerate the availability of these solutions; and collaborating across sectors including health care, technology, business, government, and 

academia. 

Wireless sensors that enable remote diagnosis, monitoring and treatment support 

are among the innovations that will enable these aims to become a reality, as well 

as alleviate some of the burgeoning costs within the VA health care system. In general, wireless sensors and other mobile devices accurately monitor a variety of physiological functions and shifts, including respiration, body temperature, heart rate, 

and blood glucose levels. A patient with high blood pressure, for example, can be 

monitored with a wireless device that captures physiological changes and sends an 

alert to the patient’s provider, with the unprecedented potential of preventing acute 

and long-term complications such as stroke, heart attack and kidney disease. 

Because of their pervasiveness and low cost, cell phones and other wireless technologies are well-suited to cheaply transmit information and help patients and 

health care providers manage chronic diseases. Wireless technology offers real-time 

and ongoing diagnosis and monitoring of a patient’s condition, whereas in-person, 

physician office visits present only a snapshot of the patient’s condition at a fixed 

time and place. Ultimately, these solutions are driving a new infrastructure independent model of health care, which translates into the right care, at the right time, 

wherever people need it. 

For veterans residing in rural and remote areas, this means not having to incur 

the burden of finding considerable time and resources to make repeated visits to distant facilities. We know from talking to VA practitioners in rural areas that distance is one of the greatest barriers to accessing care, particularly for those with 

chronic conditions—the very patients who need the most support. We are continuing 

dialogue with the VA at local and national levels to identify solutions for making 

a significant impact on this front. 


ebenthall on DSK9Q6SHH1PROD with HEARING
42 

We also share the great concern that our Nation’s health care system is itself ill, 

swollen and inflamed by excessive costs derived from an evolution of unfortunately 

perverse incentives. Doctors and hospitals are fiscally incentivized by volumes of 

procedures and face-to-face encounters, while patients and families wish to maintain 

health and wellness and avoid costly and complex interactions with doctor’s offices, 

clinics and hospitals. And just earlier this year, we passed into law a sweeping reform of health care insurance that will dramatically increase access to a health care 

system that seems ill-poised to meet the challenge. The imperative for change in 

health care delivery is undeniable, and the opportunities afforded by emerging wireless health care solutions are compelling. We believe the VA system has provided 

an illuminated path to the appropriate deployment 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 50 percent for patients in highly rural areas) and a 19 percent reduction 

in hospital admissions by linking chronically ill veterans with health care providers 

and care managers through videoconferencing, messaging and biometric devices, 

and other telemonitoring equipment. The CCHT program appears to be the largest 

telehealth program in the world, with 43,000 senior veterans receiving home care 

for chronic disease management. Under the VA CCHT program, one nurse is able 

to extend his or her reach to ‘touch’ 150 patients remotely on a daily basis. With 

32 million individuals soon to be provided comprehensive health insurance and the 

shortage of physicians expected to exceed 125,000 within 15 years (according to the 

Association of American Medical Colleges), the VA’s CCHT program offers substantive proof that wireless health technology can dramatically increase the efficiency of already overstretched health professionals to help patients no matter 

where they are or when they need care. 

We believe the VA’s CCHT program should take the next step and incorporate innovations beyond traditional telehealth equipment, much of which still requires care 

within VA clinics or other fixed locations. We encourage the VA to evaluate and implement wireless health solutions that will complement and further extend the 

reach of the CCHT program, including wireless biometric sensors that monitor highly relevant physiologic parameters, track disease activity on a continuous basis, and 

transmit that information to the patient’s health care provider. This technology enables providers and patients themselves to monitor and diagnose their conditions 

without a facility in-person visit. 

We understand the VA is now undertaking the construction of two new hospitals at the cost of $1.8 billion. Certainly, those hospitals will offer important access for 

veterans in those discrete communities where the geographic density is sufficient to 

motivate such investment. However, almost 40 percent of veterans enrolled in VA 

health care live in rural or highly rural areas; an even higher proportion of veterans 

returning from Iraq and Afghanistan reside in rural areas. Imagine how many veterans in remote areas across the country could be reached through wireless technologies with a similar expenditure of these precious resources: the CCHT’s program 

cost is $1,600 per patient per year—meaning an additional 225,000 veterans in remote areas could be reached for a comparable cost over a 5 year period. And as the 

CCHT program demonstrated, these investments deliver a return in lower overall 

costs and greater patient satisfaction, carefully managing the VA’s limited resources 

while improving patient outcomes. 

Unlike traditional fee-for-service health care where providers currently have little 

incentive to expend resources on technology that results in savings to a different 

‘‘silo,’’ an integrated, self-contained delivery system such as the VA can readily demonstrate the cost-savings that can be achieved by greater utilization of wireless 

health technologies by tracking the decreased hospitalizations, clinic visits, and 

other traumatic and acute interventions that result when chronic disease is met 

with continuous care as opposed to episodic and expensive rescue. 

To this end, the West Wireless Health Institute is currently exploring a demonstration research project with the VA in San Diego with a small cohort of recently 

diagnosed PTSD patients. The project will incorporate a mobile device with 

videoconferencing capabilities to enhance crisis management, regular ‘‘check-ins’’ 

and biofeedback therapies. We will be demonstrating the value of this inexpensive 

and integrated wireless health solution for increasing access to real time support 

for veterans with PTSD (and potentially decreasing hospital admissions and acute 

events). This outpatient model of support enables face-to-face access to a clinician 

off-site at any time and can be used across numerous disease states. 

On a larger scale, an important step that the VA has recently announced is the 

new $80 million VA Innovation Initiative (VAi2), which will improve veterans’ care 

by tapping into private sector expertise and creativity. We encourage VAi2 to accelerate the evaluation of wireless health solutions that enable home and mobile moniVerDate Nov 24 2008 09:28 Dec 17, 2010 Jkt 058054 PO 00000 Frm 00046 Fmt 6604 Sfmt 6621 I:\VA\58054.XXX GPO1 PsN: 58054

ebenthall on DSK9Q6SHH1PROD with HEARING
43 

toring of diverse and complex signs, symptoms and biometrics, patient- and population-based dynamically learning treatment algorithms, and remotely titrated 

therapies for a wide range of chronic and acute care needs. 

It is important to note that a critical reason the VA can leverage wireless health 

technology is because its health care providers within the VA are able to operate 

across State lines. Currently, non-VA physicians are licensed by States and cannot 

routinely practice medicine across State lines, including through remote monitoring 

services. This creates a serious impediment to 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. The Federal Government 

must follow the VA’s lead in crafting a policy to address this inter-State 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 FCC has noted that 

14–24 million Americans do not have access to broadband where they live, even if 

they want it. Broadband access is more than connecting individuals to Google and 

YouTube; it’s about dramatically transforming the delivery of health care to people 

no matter where they live. We commend the commitment to expanding broadband 

access through the $7 billion for broadband networking 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. 

Certainly, many of the challenges of expanding utilization of wireless health technology—such as providing a clear, consistent and integrated regulatory and reimbursement environment that fosters innovation and commercialization of wireless 

health care solutions—are outside the specific purview of the Veterans Administration. Yet the current regulatory disclarity is dampening investment in wireless 

health technology and chilling this promising engine of innovation because many investors and some telecommunication companies fear FDA’s regulation of nonmedical 

devices (e.g. smartphones of all manner) if medical applications are utilized. The 

FDA should be supported in the view that the specific sensors, algorithms for interpretation, and specific therapeutic devices should remain the focus of regulatory activity, and the pathways for communication of the information (wireless networks, 

cell phones, etc.) should be understood to be the purview of the FCC. Regulatory 

and reimbursement clarity will specifically enhance the VA’s ability to adapt truly 

innovative and cost-saving wireless health solutions for its CCHT program, and will 

also facilitate the rapid generalizability of the benefits to the broader U.S. population. 

The VA has a unique opportunity to enhance the ability of providers and veterans 

themselves to monitor, diagnose and manage their health conditions more effectively. Just as email, Facebook and Twitter have transformed how we communicate 

with one another, wireless health solutions offer a remarkably new modality of care 

where patients can be diagnosed, monitored, and often treated wherever and whenever they need care, and in the process avoid the costly, complex, time-consuming, 

and inefficient interactions with an already over-stressed and geographically constrained health care system. 

In sum, we make the following recommendations that will ultimately increase veterans’ access to health care regardless of where they live: 

• Following the VA’s lead, Congress should create policies that facilitate health 

care delivery across State lines. Current laws restricting interstate medical 

practice are dampening innovations that could significantly benefit veterans 

across the country. 

• 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 competition to test biometric sensors and other solutions that 

facilitate remote access to care. 

• In addition, we encourage members of this Committee and Congress to support 

broadband expansion, as well as a clear and consistent regulatory and reimbursement environment to spur the types of innovations that will truly enable 

health care delivery ‘‘anytime, anyplace.’’ 

One-hundred years ago this Spring, Abraham Flexner was concluding the research for his ‘Flexner report’—widely viewed as one of the most impactful treatises 

in American medicine, credited for ushering in a revolution in medical education 

and practice. One pivotal observation in that report remains as true today as it was 

a century ago: ‘‘The small town needs the best, and not the worst, doctor procurable.’’ Our Nation’s veterans living in remote communities deserve access to the 

best thinking and the best care . . . and freeing that care of geographical and infraVerDate Nov 24 2008 09:28 Dec 17, 2010 Jkt 058054 PO 00000 Frm 00047 Fmt 6604 Sfmt 6621 I:\VA\58054.XXX GPO1 PsN: 58054

ebenthall on DSK9Q6SHH1PROD with HEARING
44 

structure limitations is a promise of wireless health care and one that cannot wait 

for the next century. 

We are on the threshold of a paradigm shift in health care delivery, one in which 

we realize the full potential of the digital and wireless revolution and make ‘anytime, anywhere’ care a reality. It is clear the VA is on a path to demonstrate that 

we can effectively reach many of our rural and remote veterans with these approaches, providing a continuous model of care for those dealing with chronic conditions, and in the process enhance satisfaction and drive down costs. It is vital that 

we learn and take the lead from the VA’s early successes to quicken our pace, as 

patients (veterans and others) are waiting. 

We look forward to working with the Committee and the VA in building upon its 

leadership role in telehealth and helping America’s veterans and all of its citizens 

benefit from the evolution of an infrastructure-independent model of health care. 

f 

Prepared Statement of Darrell M. West, Ph.D., Vice President and 

Director of Governance Studies, and Director, Center for Technology 

Innovation, Brookings Institution 

Chairman Michaud, Ranking Member Brown, and Members of the Subcommittee. 

Thank you for this opportunity to testify at this hearing on ‘‘Overcoming Rural 

Health Care Barriers through Wireless Health Technologies.’’ 

Since 2008, I have been Vice President and Director of Governance Studies and 

Director of the Center for Technology Innovation at the Brookings Institution. I am 

the author of 17 books, including, ‘‘Digital Medicine: Health Care in the Internet 

Era,’’ published by the Brookings Institution Press in 2009. Prior to my current position, I was a professor of political science and public policy at Brown University 

in Providence, Rhode Island. 

The United States has more than 23 million men and women who have served 

proudly in the military. While the vast bulk of these are men (94 percent), the percentage that is female has increased from four to six and one half percent over the 

last three decades. According to the U.S. Census, the largest veteran populations 

live in the South (9.9 million) and Midwest (6.1 million). The number living in the 

Northeast is 4.6 million. The cities with the highest percentage of veterans include: 

Hampton, VA (27.1 percent), Clarksville, TN (24.4 percent), Fayettesville, NC (23.7 

percent), Virginia Beach, VA (21.7 percent), Colorado Springs, CO (20.2 percent), 

and Norfolk, VA (19.9 percent). 

All of us would agree that in recognition of their valuable service, providing quality and accessible health care to veterans is a high national priority. Yet that task 

has become more difficult financially because of our Nation’s $13 trillion national 

debt and $1.4 trillion budgetary deficit. This is especially the case for rural veterans 

who live great distances from medical facilities and often have difficulty gaining access to quality care. 

For these and other individuals, I suggest that wireless health technologies represent a key ingredient in providing quality and accessible care, and gaining budgetary efficiencies in the process. Health care based on mobile health, remote monitors, electronic medical records, social networking sites, video conferencing, and 

Internet-based recordkeeping can make a positive difference for many people. We 

should encourage email reminders to take medicine, mechanisms to rate experiences 

with doctors and hospitals, and Web sites that make care ratings publicly available 

to other patients. 

Progress to Date for U.S. Veterans 

The U.S. Veterans Administration has made outstanding progress on several dimensions of health information technology. It has been a forerunner in the implementation of electronic health records. More so than many private physicians and 

hospitals, the VA has moved toward electronic management of recordkeeping and 

system-wide connectivity. Since 1999, with the establishment of the Veterans 

Health Information Systems and Technology Architecture (VistA), the system has 

‘‘linked 5.3 million patient records generated at the VA’s 153 medical centers, 882 

clinics, 207 veterans centers, 136 nursing homes, and 45 rehabilitation centers,’’ according to researcher Alan Naditz. 

The VA also has implemented MyHealtheVet, which enables veterans to schedule 

appointments online and refill prescriptions. They can track their medical tests, 

chart changes over time, and measure progress towards key goals. It further has 

established the Health Data Repository that contains a range of additional medical 

information such as allergies, body chemistry, and microbiology. 


ebenthall on DSK9Q6SHH1PROD with HEARING
45 

1This statement draws on my paper, ‘‘Customer-Driven Medicine: How To Create A New 

Health Care System’’ published by the Brookings Institution in October, 2009. Jenny Lu and 

Raffaela Wakeman provided research assistance for this testimony. 

These electronic systems have produced very high ratings from veterans. According to an analysis of American Customer Satisfaction Index Web site users by Kim 

Nazi, those employing these resources gave the VA an overall rating of 8.3 out of 

10. Most indicated they intend to keep using online resources and recommend the 

VA’s services to other veterans. 

Challenges for Rural Veterans 

There are three major challenges for veterans today. First, like every other part 

of government, the U.S. Veterans Administration faces budget pressures due to high 

national debt and budget deficits. The high cost of medical care demands attention 

to changes that improve the efficiency of the overall system. 

Second, there has been an increase in demand for medical services. The VA has 

taken on many more patients at its medical facilities compared to a decade ago. It 

now serves more than 8 million people, up from 3 million in 1999. This increase 

raises pressures on providers and makes it crucial to find efficiencies in the system 

that do not jeopardize quality care. 

Third, geographic disparities complicate the delivery of medical care. Rural and 

non-metropolitan counties had the highest concentrations of veterans, according to 

the U.S. Census. An American Customer Satisfaction Index survey of 53,788 visitors 

to the U.S. Department of Veterans Affairs Web site found that 37 percent of veterans say they have to travel an hour or more to their nearest VA facility, according 

to researcher Kim Nazi. 

Medical scientists such as Tam Dao have found that rural patients are more likely 

than urban ones to suffer depression and, after coronary artery bypass surgery, to 

require longer in-hospital stays and experience greater mortality rates. Others such 

as Amy Wallace and her colleagues report that urban veterans have better health 

care experiences than rural counterparts and that reduced access to medical care 

may contribute to these geographic differences. 

Changes in the System 

There is no magic bullet for rising health care costs, either for veterans or nonveterans making use of private medical care. But there have been technological advances that make it possible to improve quality, access, and affordability. Today, 

there are nearly as many mobile phones (600 million) in existence that can browse 

the Internet and access email as there are personal computers (800 million) so it 

makes sense to think about greater use of mobile health. 

One of the virtues of the Internet, electronic medical records, and cell phones is 

that it puts the patient in charge of certain activities. Using remote monitoring devices, people can measure their own weight, blood pressure, pulse, and sugar levels, 

and send test results electronically to health care providers. They get personalized 

feedback via email and reminders when they gain weight, have an uptick on their 

cholesterol levels, don’t take their medicine, or have high blood pressure. Social networking sites provide discussion forums and the benefit of collective experience from 

other people suffering similar problems. Patients take responsibility for their routine health care and rely on physicians for more serious medical conditions.1

This system is not a futuristic vision, but is within our grasp. It would cut costs 

by reducing professional responsibility for routine tasks and recordkeeping, while 

also making it possible for patients to receive higher quality care and be more satisfied with the end-result. As noted below, the technologies for this kind of system 

transformation currently are available through cell phones, remote monitoring devices, video conferencing, and the Internet. 

Remote Monitoring Devices 

There are a number of new remote monitors for various health care conditions 

that put patients in charge of their own test-taking and keep them out of doctor’s 

offices. For example, there are home pulse-taking and blood pressure devices that 

measure vital signs. AT&T has a new ‘‘device certification lab’’ that tracks health 

along high-speed broadband networks. Results are electronically sent to a family 

physician, specialist, or electronic medical record, depending on the wishes of the 

patient. Zeo is marketing a monitor that measures brainwaves and rates the quality 

of sleep. Bodybugg has an armband calorie-counter that charts the amount of energy 

burned through physical movements. 

The Triage Wireless company has a ‘‘wearable’’ monitor that records vital signs 

and transmits them to physicians. It records blood pressure on a continuous basis, 


ebenthall on DSK9Q6SHH1PROD with HEARING
46 

thereby providing regular information for health care providers. The Corventis corporation has a small sensor it calls PiiX that measures fluid status and respiration 

for runners. This helps people monitor their physical status during exercise. Intel 

has a ‘‘magic carpet’’ device that monitors physical movements. Geared for senior 

citizens at risk of a fall, it tracks people as they walk on a mat to determine who 

is vulnerable to falling down. 

In the area of diabetes, it is crucial that patients monitor their blood glucose levels and gear their insulin intake to proper levels. In the ‘‘old days’’, patients had 

to visit a doctor’s lab or medical office, take a test, and wait for results to be obtained. That process was expensive, time-consuming, and inconvenient for all-involved. Having to get regular tests for this and other conditions drives up the costs 

of medicine. 

However, it is possible to use remote monitoring devices at home that record glucose levels instantaneously and electronically send them to the appropriate health 

care provider. Patients are using with FDA-approved ‘‘Gluco Phones’’ that monitor 

and transmit glucose information to caregivers while also reminding patients when 

they need to undertake glucose tests. It is estimated that over 11 million Americans 

use home monitors for their glucose. Health authorities believe there are over 24 

million diabetics in the United States, and the disease is the seventh leading cause 

of death. 

Tiny monitors with magnetic nanoparticles have been developed by researchers at 

the Massachusetts Institute of Technology to track the development of cancer tumors. Small particles the size of a rice grain are injected during biopsies. Through 

follow-up MRI’s, doctors can measure whether these monitors clump with the tumor 

and grow in size. This allows them to get immediate feedback on the size of cancers 

and whether a specific therapy is working. 

Cardiologist Steven Greenberg of St. Francis Hospital in Roslyn, New York uses 

a wireless pacemaker made by St. Jude Medical connected to a home monitoring device to track heart rhythms and vital signs. Patient information automatically is 

transmitted to his medical office, which allows him to see which patient has abnormal heart beats and therefore is in need of immediate treatment. He feels this enables him to ‘‘stay a step ahead of potentially life-threatening problems’’. 

Personalized Reminders 

One of the biggest problems in medical treatment for either veterans or non-veterans is patients forgetting to take their prescription drugs. It is estimated that only 

50 percent of patients take their medication as prescribed. Either they forget to take 

the drug or they do not take it at the time or dosage set by their physician. This 

means that we lose half of the benefit of prescription drugs through human error. 

This costs the systems billions in poor health outcomes. 

Digital technology has the potential to help with this and other communications 

problems. Patients no longer need to visit doctors’ offices to be reminded to take 

their medicine. They can get personal reminders via email, automated phone calls, 

or text messages. One enterprising physician named David Green of Cape Town, 

South Africa noticed that his patients did not always take the prescribed Rifafol 

medicine for their tuberculosis. He knew that for the drug to be effective, people had 

to take the pill on a consistent basis. Otherwise, it would have little effect. Doctor 

Green set up a text messaging service called ‘‘On-Cue Compliance’’ for each of his 

patients that sent them a daily SMS in English, Afrikaans, or Xhosa. Over the 6- 

month course of treatment, his service would send a message at a pre-determined 

time each day reminding them to take their Rifafol. 

In the United States, Dynamed Solutions provides ‘‘HealtheTrax’’ software that 

reminds patients to take medications, set up appointments, and track compliance 

with medical instructions. This and other types of ‘‘virtual health assistants’’ are 

particularly helpful with those suffering from chronic illnesses. These individuals 

need to keep close track of their medical condition and stay in touch with their caregivers. The software is integrated with electronic medical records and can store information in patient’s personal records. 

Physicians at Children’s Hospital Medical Center in Cincinnati send teenagers 

text messages reminding them to take their asthma medication. For young people 

on the go, remembering to take medication is one of the biggest challenges. Researchers have found that text reminders is effective and that it helps teenagers develop good ‘‘self-care habits’’. 

A company called Proteus Biomedical has a tiny ‘‘digestible chip’’ that can be 

swallowed along with a prescription drug to notify health care providers that patients took their medication. Using a sensing device, it electronically transmits that 

information to physicians, who then know for sure that the individual is following 

the prescribed course of treatment. It is especially helpful with patients suffering 


ebenthall on DSK9Q6SHH1PROD with HEARING
47 

memory loss because those individuals have a high incidence of not taking their 

medicine regularly. Patients loved the idea of getting personalized reminders from 

their medical providers. One person wrote that these messages ‘‘keep you informed 

and mean you never forget to take your drugs.’’ 

In general, Americans say they would like to employ digital technologies in their 

medical care. For example, 77 percent in a national survey said they would like to 

get reminders via email from their doctors when they are due for a visit, 75 percent 

want the ability to schedule a doctor’s visit via the Internet, 74 percent would like 

to use email to communicate directly with their doctor, 67 percent would like to receive the results of diagnostic tests via email, 64 percent want access to an electronic medical record to capture information, and 57 percent would like to use a 

home monitoring device that allows them to email blood pressure readings to their 

doctor. 

Mobile Smartphones 

Cell phones and other mobile devices have gotten smarter and faster. 

Smartphones such as Apple’s I–Phone, Research in Motion’s Blackberry, Nokia’s 

E71, and Palm Pre offer advanced features such as mobile email, web browsing, and 

wireless communications. The sophistication of these devices has spawned a variety 

of new medical applications that help doctors and patients stay in touch and monitor health care needs. 

For example, Sprint has a mobile application that allows physicians to get test 

results on their mobile device. They can look at blood pressure records over time, 

see an electro-cardiogram, or monitor a fetal heart rate. AirStrip Technologies markets an application that makes it possible for obstetricians remotely to monitor the 

heart rates of fetuses and expecting mothers. This allows them to detect conditions 

that are placing either at risk. 

These applications make doctors more efficient because they don’t have to be in 

the physical presence of a patient to judge his or her condition. Digital technology 

allows people to overcome the limitations of geography in health care and access information at a distance. This makes it possible for veterans to get a second opinion 

without visiting another physician by sending that person relevant medical tests. If 

a personal conference is required, doctors can use video conferencing to speak to patients located in another city or State. 

Internet Information 

There has been an explosion of Web sites with detailed medical information. Web 

sites such as WebMD.com, MedlinePlus.gov, MerckSource.com, HealthFinder.gov, 

and MayoClinic.com answer questions and provide links to discussion groups about 

particular illnesses. In States such as Massachusetts, California, and New York, 

and Michigan, consumers can visit health department sites and compare quality 

performance data on provider care programs. Nationally, the U.S. government has 

a Web site, www.hospitalcompare.hhs.gov, that evaluates 2,500 hospitals on mortality rates, room cleanliness, call button responses, and how patients judge their 

quality of care. 

The most common Internet searches occurred in regard to specific diseases. Of 

those who went online, according to a Harris Interactive survey, 64 percent said 

they searched for information on particular illnesses, 51 percent looked for certain 

medical treatments, 49 percent surfed for material on diet and nutrition, 44 percent 

named exercise, 37 percent sought advice on medical drugs, and 29 percent looked 

for particular doctors or hospitals. 

This information had a positive impact on many people. National data demonstrate that 58 percent indicated that online material affected their health care decisions, 55 percent said the information changed their health care approach, and 54 

percent claimed the electronic resources made them ask new questions of their medical personnel. When asked how these materials made them feel, 74 percent said 

they felt reassured and 56 percent felt more confident. 

Social Networking for Medical Care 

Social networking sites offer great potential to improve care by sharing information among chronic condition sufferers. For example, a network developed by the 

company PatientsLike Me has 23,000 patients who have signed up to share information regarding five different illnesses: mood disorders, Parkinson’s, multiple sclerosis, HIV/AIDS, and Lou Gehrig’s disease. These individuals describe their symptoms, discuss various therapies, and talk about what works and doesn’t work very 

effectively. Not only does the site serve as a vital support group for these serious 

illnesses, it promotes better understanding through the detailed case histories based 

on personal experiences. 


ebenthall on DSK9Q6SHH1PROD with HEARING
48 

A similar idea draws on crowd-sourcing for feedback regarding medical care and 

treatment side-effects. It often takes years for patients, physicians, and medical researchers to get definitive results regarding the assessment of drugs and medical 

therapies. Clinical trials are expensive and time-consuming, and involve randomized 

assignment to various groups. Results sometimes are unclear and it is hard to recruit sufficient subjects to participate in the evaluations. 

While it is important to maintain rigorous approaches to medical research, it is 

helpful to take advantage of new techniques for getting feedback. Crowd-sourcing 

is a concept that takes advantage of the collective experience of large groups of people. It allows a variety of individuals to comment on and post experiences with specific treatments. This helps others compare data and see information on what works 

or doesn’t work. 

Dr. Amy Farber has developed an online resource called LAMsight that encourages people suffering from the LAM lung disease to share their symptoms and treatment experiences. Web operators take this patient-provided information and compile 

online databases that are used by researchers to find out what works, what doesn’t 

work, and what drugs generate unwelcome side-effects. Particularly for rare illnesses where it is hard to generate the patient numbers required for clinical trial, 

she says ‘‘patients have been a tremendously underutilized resource.’’ While large 

clinical trials with randomized assignment clearly need to remain central to drug 

assessment, digital technology that helps providers and researchers identify worrisome trends represents an additional way to gain useful feedback. 

Consumer Evaluations of Health Care Providers 

A big challenge with contemporary health care is lack of information among patients about the quality of physician and hospital care. There is some outcome-based 

information on how many mammograms or other medical tests various facilities perform, but few assessments of the quality of care from specific providers. 

Digital technology has the potential to empower the consumer voice in health care 

and to tie patient assessments to doctor performance. In the entertainment area, for 

example, the commercial company Netflix has devised a system by which film 

watchers order movies for home viewing. Upon returning the movie to the company, 

customers received an automatic email asking them to rate the movie on a five-point 

scale. This information is anonymously aggregated, and publicly available to other 

consumers so they can see which movies receive the highest ratings in various categories. 

It is possible to create a similar system for rating physicians, hospitals, and other 

health care providers. Following physician visits, consumers can fill out an email 

form allowing them to rate different dimensions of medical treatment from timeliness and personal attentiveness to level of knowledge and satisfaction with the 

overall visit. These quality measures are aggregated and are accessible at a public 

Web site so others could see the quality assessments. 

Consumer Reports has an online hospital rating service of 3,400 facilities based 

on the national government’s Hospital Consumer Assessments of Health care Providers and Systems Survey. Among the items examined include ‘‘overall patient experience, doctor and nurse communication, room cleanliness, discharge information, 

hospital staff attentiveness, communication about new medications, pain control and 

noise level’’. 

Proposed Changes 

There is little doubt that the technology for customer-driven health care is already 

available. What are needed are policy changes that alter the incentives for patients 

and health care providers to adopt necessary shifts, and reward good behavior and 

good health outcomes. 

Greater Use of Mobile Health in Rural Areas 

Too many parts of our system today do not cover mHealth, digital communications, or wellness programs. Physicians, for example, often are not covered for email 

or phone consultations. We need policy changes that encourage high quality medical 

care and make it possible for health providers to be reimbursed for the health they 

provide. 

This is problematic in rural areas because mobile health can improve quality, access and affordability. Video conferencing allows patients who live long distances 

from VA facilities to get consultations with specialists. 

The Geisinger Medical Center tested a ‘‘medical home’’ initiative among Medicare 

patients and found an 8 percent drop in hospital admissions and a 4 percent reduction in overall health costs over the first year. In this concept, patients are assigned 

a family physician who acts like a ‘‘personal health coach’’. This coach oversees a 

group of providers who monitor people’s medical condition and use emails and text 


ebenthall on DSK9Q6SHH1PROD with HEARING
49 

messages to encourage people to lose weight, stick to healthy diets, get exercise, and 

seek relevant care when their status deteriorates. 

A Focus on Positive Health Outcomes 

Right now, doctors and hospitals do not devote adequate attention to health outcomes. Doctors don’t get rewarded for healthy patients or preventive medical care. 

Indeed, one of the challenges in the current system is the lack of performance data 

on how patients do. The Federal Government collects statistics by city and state on 

causes of death, numbers of procedures, and other such information. But there is 

little outcome information for specific doctors or other health care providers. This 

makes it difficult to judge quality or create incentives for healthy outcomes. Doctors 

whose patients remain healthy should receive a bonus and should be encouraged to 

continue preventive medical care. 

Rewards for Good Behavior by Physicians and Patients 

We need rewards for good behavior modeled after ‘‘good driving’’ discounts on car 

insurance. Drivers who do not have accidents or are not cited for speeding or other 

traffic violations earn a 10 percent discount on their insurance. The program is costeffective for car insurance companies because safe drivers have fewer accidents and 

therefore cost the company less in accident repair reimbursements. 

Americans eat too much, get too little exercise, and have diets that are too fatty. 

The result is an obesity epidemic that will push health care costs higher in future 

and limit people’s quality of life. According to the American Obesity Association, 

over 30 percent of children today are over-weight. This ticking time bomb threatens 

to explode and have dramatic consequences for national health care spending. 

Government programs should offer ‘‘good health’’ rewards to patients and physicians. For example, health programs could provide a preventive medicine fund that 

reimburses people for regular exercise, good health practices, flu shots, diet advice, 

and smoking/alcohol/drug cessation programs. This would encourage patients to lead 

healthy lifestyles. 

After the Safeway company instituted a ‘‘Healthy Measures’’ program of cholesterol screenings, blood pressure measurements, and weight loss initiatives, its 

health costs dropped by 13 percent. More than three-quarters of its employees enrolled in the program and they saved 20 percent on their individual insurance premiums. Pitney Bowes provides $100 gift cards to employees who enrolled in health 

courses. 

Saving Money and Leading Healthier Lives 

The ultimate goal of policy changes is to save money and get people to lead 

healthier lives. As others have pointed out, the United States spends $6,102 annually per capita, much more than the $3,165 spent by Canada, $3,159 by France, and 

$2,083 by the United Kingdom. Yet America ranks 42nd among developed nations 

in life expectancy. Our average life expectancy of 77.9 years falls well below that 

of Andorra, the Cayman Islands, and most European countries. We spend a higher 

percentage of Gross Domestic Product on health than most other nations, but get 

weaker results in terms of medical well-being. 

With America’s health care system now costing $2.4 trillion, we no longer can afford delays in making needed changes. As Peter Neupert of Microsoft’s Health Solutions Group has written, ‘‘let consumers do some of the work that expensive healthcare professionals shouldn’t be doing anymore. In the past 10 years, technology has 

removed travel agents, bank tellers and so on from the middleman position. Online 

systems, such as Kaiser Permanente’s, have increased patient satisfaction and allowed the work of expensive professionals to be replaced.’’ 

One of the reasons America spends more money per patient than other countries, 

but gets weak results, is our low usage of health information technology. Only 15 

percent of the 560,000 doctors in America use digital technology to order medication 

for patients. Industry advocates claim that a move to electronic prescriptions could 

save $29 billion over the next decade. According to health experts, digital technology 

would save money and ‘‘make transactions more efficient, reduce medication errors 

and entice doctors to prescribe less expensive drugs’’. 

A Brookings Institution analysis undertaken by economist Robert Litan found 

that remote monitoring technologies could save as much as $197 billion over the 

next 25 years. Cost savings are especially prevalent in the chronic disease areas of 

congestive heart failure, pulmonary disease, diabetes, and skin ulcers. With around 

the clock monitoring and electronic data transition to care-givers, remote devices 

could speed up the treatment of patients requiring medical intervention. Rather 

than having to wait for a patient to discover there is a problem, monitors could identify deteriorating conditions in real time. 


ebenthall on DSK9Q6SHH1PROD with HEARING
50 

A 2009 PriceWaterhouseCoopers Health Research Institute study meanwhile 

found that $210 billion is wasted through ‘‘defensive medicine—doctors ordering 

tests or procedures not based on need but concern over liability or increasing their 

income’’. Other examples of wasteful spending include inefficient claims processing 

($210 billion), ignoring doctor’s orders ($100 billion), ineffective use of technology 

($88 billion), hospital readmissions ($25 billion), medical errors ($17 billion), unnecessary emergency room visits ($14 billion), and hospital acquired infections ($3 billion). 

Better use of digital and mobile technology could help on each of these fronts, especially with rural veterans. Electronic medical records would reduce duplicate tests 

because various physicians would have easy access to the results of past procedures. 

Automated processing of medical reimbursements would save time and money. Not 

taking medicine at prescribing times and levels could be improved through remote 

monitoring and digital tracking. Unnecessary emergency room visits, hospital infections, and medical errors could be reduced through medicine that employs video conferencing and out-patient treatment. 

f 

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 

Chairman Michaud, Ranking Member Brown, distinguished Members of the Subcommittee on Health, my name is David Cattell-Gordon and I serve as the Director 

of Rural Network Development, manager of the Office of Telemedicine and a faculty 

member in Nursing and Public Health Sciences at University of Virginia. I also 

serve as the co-director of the Health Appalachia Institute, a public health institute 

serving the citizens of Central Appalachia. 

As the son of a distinguished, rural WWII veteran from the famed Iron Men of 

Metz of the 95th Infantry, a child of the coalfields and as a health care professional 

serving many rural patients and communities, I am honored to provide testimony 

on how the Veterans Health Administration (VA) can utilize innovative health technologies to overcome barriers to health care in rural communities. 

As a part of the University of Virginia’s pioneering program in telemedicine, I 

have come to appreciate how information technology can overcome barriers of access. In addition, telehealth and wireless capabilities have consistently demonstrated opportunities for improved health outcomes, decreased isolation, reduced 

health disparities and substantially reduced costs—a vital issue in ensuring the 

very best care for the over three million of veterans living in remote, rural communities. Simply put: why would we not invest in this capability? 

To make this simple case for investment, I will address today three well documented issues: 

1. The substantial, long-standing health disparities in rural Central Appalachian 

and for rural veterans; 

2. The role of telehealth in improving the delivery of health care and educational 

services to rural citizens especially veterans; and, 

3. The opportunities of expanded wireless capabilities to improve the health and 

quality of life for our rural veterans—men and women who should not be denied access to care based on the reality that their home is a rural community. 

Everyone on this Committee, I am certain, is familiar with the award winning 

production based on the book by acclaimed historian Stephen Ambrose, Band of 

Brothers. As the tagline for this story of Easy Company of the 101st Airborne reads: 

‘‘The world depended on them. They depended on each other.’’ 

What the Committee probably does not know was that one of this band on whom 

we all depended, Darrell Shifty Powers, came from Dickenson County in the rural 

coalfields of Southwest Virginia, a rugged and isolated region. Shifty, a bronze start 

recipient, returned home after the war to serve as a machinist for the Clinchfield 

Coal Company. Sadly, Powers died last year on June 17th of cancer 

As Power’s daughter said of her father: ‘‘He never bragged about what he did in 

the war. And for a lot of years, he never even talked much about what he did— 

unless someone asked him about it.’’ Bravery and dignity was a constant thread 

running through the life of Shifty. 


ebenthall on DSK9Q6SHH1PROD with HEARING
51 

1. Barriers to Care in Rural Appalachian Virginia and the Consequences 

With his diagnosis of cancer Shifty Powers depended on our systems of care but 

the geography created huge barriers for him in terms of access to care and communication with health specialists, as the trip to the nearest cancer facility was hours 

away. The evidence is overwhelming that our rural veterans in Appalachia and 

other communities suffer far worse health outcomes because of several factors: geographic and personal isolation, limited access to specialty care, lower educational attainment, limited income and often extremely poor conditions within which to manage health. 

Demographic Data* FD I & II Virginia 

Population Growth ¥4.9% +14.4% 

H.S. Graduation Rate 61.0% 81.0% 

College Graduation Rate 9.0% 29.5% 

Percent of Pop. Working 41.8% 62% 

Below Federal Poverty Line 19.5% 9.6% 

The seven coalfield counties and one city that make up Health Planning Districts 

I and II in Appalachian Southwestern Virginia, for instance, are a uniformly rural 

area of more than 3,200 square miles of mountainous landscape with a population 

of nearly 207,000. This mostly homogenous population lives primarily in small, geographically isolated communities and suffers from declining population, low educational attainment, high rates of poverty and approximately half the per capita income of the rest of the State. This is true of the many of the veterans of the region. 

These persistent social problems are intertwined with significant disease risk factors that contribute to disproportionately high rates of heart disease, cancer, respiratory disease, diabetes, and depression. To complicate these social and health 

issues, the sharp mountain ridges and deep valleys that divide the region make access to work and health care difficult. There are serious health care workforce shortages in the area and no large-scale population centers capable of financing a full 

spectrum of specialty medical practice. 

Health Risk Factors PD I & II Virginia 

Obesity 33.5% 25.1% 

Hypertension 38.2% 26.7% 

High Cholesterol 39.5% 36.2% 

Not in Wellness Activity 33.75% 22.6% 

Smoking (Adults) 29.1% 20.6% 

Smokeless Tobacco Use 16.8% 3.4% 

One only has to look at the 10-year history of the Remote Area Medical Expedition (RAM) in Wise, Virginia as an example of the magnitude of need. In 2008, the 

RAM-Wise expedition, the largest screening event in the United States, provided 

free medical, dental and vision care to over 3,000 people from the region over a single weekend at an abandoned strip mine. The University of Virginia Health System 

and its volunteer team of 217 health professionals staffed more than 6,150 patient 

encounters and contributed care valued at over $1 million to that event. 


ebenthall on DSK9Q6SHH1PROD with HEARING
52 

* All data is from the Virginia Department of Health (VDH) through health records of mortality and incidence rates between 1999 and 2005 as well as the Office of the State Medical Examiner. Socioeconomic and demographic information was extracted from census data from 1990 

and 2000 at the Census tract level. 

** William B. Weeks, MD, et al. Differences in Health-Related Quality of Life in Rural and 

Urban Veterans, American Journal of Public Health October 2004, vol. 94, No. 10. 

Weeks et al. Veterans Health Administration and Medicare Outpatient Health Care Utilization 

by Older Rural and Urban New England Veterans, Journal of Rural Health, Volume 21, 

Issue 2. 

Premature Mortality by Disease 

(adjusted rate per 100,000)* PD I & II Virginia 

Heart 341* 203 

Solid Tumor Cancer 253* 185 

Chronic Lower Respiratory 79* 38 

Stroke 64 54 

Diabetes 80 22 

Unintentional Injury 145* 82 

Suicide 20* 11 

*statistically significant variance 

Combined with significant heath risk factors like high cholesterol, hypertension, 

too much smoking, it has led to extraordinarily high rates of premature mortality 

from all causes—heart disease, cancer, diabetes. In the region we have twice the 

level of suicides. We are 30 percent more likely to die from diabetes, 44 percent 

more likely to die from lung disease. We have an epidemic of unintentional fatal 

overdoses from prescribed narcotics. We have twice the rate of poverty and half the 

per capita income of the rest of the Commonwealth. The consequence of these adverse socio-economic and health risk factors is that the residents of the region are 

26 percent more likely to die prematurely than residents of other regions in the 

Commonwealth. In addition, the coalfields of Virginia are experiencing a full-scale 

public health crisis in addiction levels to prescriptive narcotics leading to astronomically high rates of fatal, unintentional overdose. According to the State medical examiner, the adjusted mortality rate from unintentional overdose is 40 deaths per 

100,000 in the region compared to 8.3 per 100,000 for the State as a whole. Taken 

together, the health status of the region represents a significant geographicallybased health disparity.* 

This is the health environment of much of rural America that it is now time to 

address. I know this Subcommittee is well aware of the sad facts of the state of 

rural health care so let the VA lead the way. With some three million veterans who 

use VA medical services living in rural areas, the delivery of health care is more 

difficult and more costly. A survey of 767,000 veterans by the VA Health Services 

Research and Development Office found that rural veterans are in poorer physical 

and mental health compared to those who live in urban areas. 

Many studies, of which this Subcommittee is well aware, speak volumes about the 

health disparities faced by rural veterans. Veterans who live in rural settings have 

lower health-related quality-of-life scores than their suburban and urban counterparts. There is increased co-morbidity, more inefficient care, greater use of emergency rooms for primary services, less preventative care and reduced home care. 

These rural–urban disparities persist even after studies are corrected for age, gender, employment status, priority level, co-morbidity, and the U.S. census region in 

which the veteran lived. Disparities are evident in those who were both most and 

least dependent on the VA for health care services.** 

As you are also well aware, the VA provides much of its medical care, particularly 

specialized treatment, in urban settings, which may be difficult for rural veterans 

to access. VA enrollees also obtain much of their medical treatment in the private 

sector, particularly if they have Medicare or other insurance and VA care is far 

away. Rural veterans have lower incomes and less insurance and therefore many 

have less access to both VA and non-VA care. They report poorer health, which suggests that their medical needs may be not adequately met.** 


ebenthall on DSK9Q6SHH1PROD with HEARING
53 

*** Williams, JM et al, Emergency medical care in rural America, Ann Emer Med 2001: 

38(3):323–327. 

Burgiss, SG et al, Telemedicine for dermatology care in rural patients, Telemed Journal 1997; 

3: 227–33. 

Chiang, Michael, Lu Wang; Mihai Busuioc; Yunling E. Du et al, Telemedical Retinopathy of 

Prematurity: Diagnosis, Accuracy, Reliability, and Image Quality Arch Ophthalmol, 2007:125, 

1531–1538. 

Flowers, CW et al, Teleophthalmology: rationale, current issues, future directions, Telemed J, 

1997: 3(1): 43–52. 

Breslow, MJ, Effect of a multiple site intensive care unit telemedicine program on clinical and 

economic outcomes: An alternative paradigm for intensivist staffing, Crit Care Med 2004; 32(1): 

31–38. 

Swaamm, LE, et al. Virtual Telestroke for Emergency Department Evaluation of Acute Stroke, 

Acad Emer Med 2004: 11: 1193–1197. 

These findings offer clear evidence that living in a rural setting is associated with 

a worse health-related quality of life. As with other residents of rural regions, a variety of factors may account for these disparities such as access, lower educational 

attainment, limited specialty care and more infrequent use of the VA health system. 

The consequence of these disparities is simply that the rates of premature mortality are higher for rural veterans. While it sounds dramatic, it is true: the issue 

we are discussing today is a life and death matter. While Congress has appropriated 

millions to implement a rural health outreach and delivery program it is only one 

aspect that must be supplemented by continued investment in proven technologies 

as we will face many challenges not only by our aging and elderly veterans such 

as Shifty Powers but also by the nearly one-half of veterans who fought in Iraq and 

Afghanistan and now live in rural settings. 

2. The Role of Telehealth in the Delivery of Services to Rural Americans 

As a preface to discussions of what remarkable innovations and processes wireless 

capabilities bring to address health disparities, it is important to set the critical context of improving outcomes for our rural veterans, a service that this Subcommittee 

is well aware of: telehealth. 

Telehealth can reduce many of the barriers of access to locally unavailable health 

care services. The integration of telehealth into rural communities especially including health information exchange through electronic medical records between the VA 

and rural health programs has profound implications for the development, support 

and delivery of health care services in the digital era—an integrated systems approach focused on disease prevention, enhanced wellness, chronic disease management, decision support, quality, ease of access and patient safety. These are all critical resources if we are to achieve equality of care for rural veterans. 

Through the incorporation of telehealth into a strategy for the care of rural veterans, a decreasing workforce of clinicians will be able to satisfactorily manage the 

expanding volumes of medical information, research and decision support analytic 

tools. This incorporation of telehealth technologies into integrated systems of health 

care offers tools with the potential to address the challenges of access, specialty 

shortages, and changing patient needs in both the rural and urban setting. Clinical 

services delivered via telehealth technologies span the entire spectrum of health 

care, and across the continuum from prematurity to geriatric care, with evidence 

based applicability to more than 50 clinical specialties and subspecialties. Cardiology, dermatology, ophthalmology, neurology, high risk obstetrics, pulmonary medicine, mental health, pathology, radiology, critical care, and home telehealth, are 

some of the many applications in general use, and for which a number of specialty 

societies have developed telehealth standards These services can be provided in liveinteractive modes and some, asynchronously, using store and forward applications 

such as the acquisition of digital retinal images of veterans with diabetes by a 

trained nurse. These images can be sent for review by a retinal specialist to identify 

patients at risk for diabetic retinopathy, the number one cause of blindness in working adults.*** 

The aging of our veterans has also already created increased demand for specialty 

health care services to address both acute and chronic disease in the elderly. Such 

a demand, in the face of anticipated provider shortages, requires a fundamental 

shift from the model of physician centered care to one focused on patient centered 

care using interdisciplinary teams, evidence based medicine, the use of informatics 

in decision support and telehealth technologies. As an example, nationally, only 2 

percent of eligible (ischemic) stroke victims receive brain saving thrombolytic therapies, primarily because this treatment must be administered within 3 hours from 

the onset of an ischemic stroke under the direction of a trained neurologist. The use 

of telehealth technologies offers immediate access to stroke.*** 


ebenthall on DSK9Q6SHH1PROD with HEARING
54 

Again, simply put, telehealth capabilities are integral to rural health, professional 

educational and economic development by providing essential links to specialty care 

and continuing education. It also ensures a method of the efficient provision of resources as well as being a tool for the economic development of rural communities. 

In an effort to address these significant rural-urban disparities in the Commonwealth of Virginia, we established the University of Virginia Telemedicine program 

in 1995, specifically to enhance access to specialty health care services and health 

related education for rural patients and health professionals using broadband telecommunications technologies. With Federal and State support, we have created a 

60 site network of community hospitals, critical access hospitals, veteran’s clinics, 

federally qualified community health centers, rural clinics, prisons, schools and 

State health department clinics located primarily in rural communities in western, 

southwestern, central and eastern Virginia. 

To date, we have facilitated more than 18,000 patient encounters—including 

many veterans—linking remotely located patients and our University of Virginia 

health professionals representing more than 36 different medical and surgical subspecialties. These services are provided on a scheduled basis or emergently. We offer 

store and forward services such as screenings for diabetic retinopathy or breast and 

cervical cancer. We have provided more than 50,000 radiographic interpretations 

through our teleradiology program. We provide live interactive consultations using 

traditional models of video-teleconferencing and critical care applications, such as 

acute stroke evaluation and treatment, using traditional videoconferencing and 

robotic ‘‘remote presence’’ technologies connecting emergency physicians with stroke 

neurologists. We have saved lives, supported timely interventions, and spared patients and their caregiver’s unnecessary travel and expensive transfer when feasible. 

While we have advanced these capabilities, Congress still needs to continue actions to drive broadband enhancement into rural areas and the application of telehealth in this environment by: 

• Continuing Federal funding of demonstration projects; • Reducing statutory and regulatory barriers to telehealth in Medicare; • Aligning Federal agency definitions of rural with specialty health care shortages, in particular using the definitions of rural applied by the USDA Distance 

Learning and telemedicine Grant Program; • Ongoing support and refinement of the Universal Services Fund; • Improving inter-agency collaboration for telehealth services; • Encouraging the use of (and reimbursement for) store and forward telemedicine; 

and, • Ensuring health information exchange. 

3. Opportunities for Improving Care: A Strategic Inflection Point 

While the expansion of broadband is the context for removing barriers, and telehealth a critical application, perhaps the most innovative process for achieving the 

elimination of disparities is wireless communications. It is clear that the world is 

in the midst of a wireless revolution. 

One of the most visible aspects of this global revolution is the cell phone. This 

tool is no longer a novelty . . . it is estimated that there are now more than 233 

million cell phones in use in this country and almost 2.56 billion worldwide. I just 

returned, for example, from Tanzania where I was on a cervical cancer screening 

and prevention team seeking to achieve telemedicine connectivity back to the UVA 

Cancer Center. While we would screen rural Masai tribal women they would text 

messages to their family, conduct financial transactions and seek key resources. 

It should be noted that I maintained cell phone connectivity the entire time . . . 

even in the heart of the famed Ngorongoro Crater literally hours away from any 

populated areas. In fact, I had better cell phone coverage in Tanzania, one of the 

poorest countries in Africa, than I have in the coalfields of Southwest Virginia. 

The cell phone taken together with digital networks, remote monitoring capabilities including miniaturized sensors in a broadband wireless environment represents 

a strategic inflection point in health care which we will look back upon as a critical 

turning point much like the industrial revolution, the discovery of antibiotics or the 

invention of the personal computer. This capability, as the first Chief Technology 

Officer of the United States, Aneesh Chopra, said at the recent meeting of the 

American Telemedicine Association, is seemingly unlimited in job creation, in reducing health care cost and in improving the quality of life. 

Our rural veterans are entitled to access to this resource. And, it makes both clinical and economic sense. With servicemen and women returning from Iraq and Afghanistan—a majority of whom are cell phone users and many of whom are from 

rural areas—it is increasingly important that we use technologies to link the expertise of the VA medical centers to rural veterans alleviating some of the distanceVerDate Nov 24 2008 12:59 Dec 19, 2010 Jkt 058054 PO 00000 Frm 00058 Fmt 6604 Sfmt 6621 I:\VA\58054.XXX GPO1 PsN: 58054

ebenthall on DSK9Q6SHH1PROD with HEARING
55 

based challenges in the areas of primary care, mental health, traumatic brain injuries and even long-term or home-based care remote home monitoring. 

You will hear extensively about the critical aspects of the use of cell phones and 

other wireless monitors for health during these hearings. They are obvious in that 

this capability has already been proven to be well-suited for cardiac monitoring, 

blood glucose evaluation, medication compliance, post-surgical follow-up, vital signs 

monitoring psychological counseling, health information, public health alerts, patient engagement and doctor-patient relationship. These capabilities, in general: 

• Reduce the isolation that occurs in rural communities; 

• Provide a vehicle for messaging and key health information; 

• Support the monitoring of chronic diseases; 

• Promote compliance with medication; 

• Reduce readmission to the hospital post procedures; 

• Guide self-care; and, 

• Enable improved care by home nursing. 

This abbreviated list in and of itself warrants investment as it represents the perfect storm of improved health outcomes, efficient processes and reduced costs. Just 

one element in this list—the care of chronic disease—according to the California 

Healthcare Foundation accounts for more than four-fifths of all health care expenditures. Imagine what it could mean to ensure improved medication compliance, increased exercise, healthy diet and appropriate use of health care resources for the 

bourgeoning numbers of veterans with diabetes. The savings would be staggering. 

We now need to consider that bandwidth and wireless access are a prescribable 

medication for the health of our communities. 

In certain specialized applications it has already been shown to make dramatic 

impact whether it is the use of a mobile messaging service that provides health tips 

and appointment reminders to servicemen with TBI or the dramatic VA Care Coordination and Home Telehealth project that demonstrated a 19 percent reduction 

in readmission for the same diagnosis and a 25 percent reduction in hospital days. 

These are real savings, true efficiencies in the system but most importantly, improvement in the lives of a precious resource, veterans and their families. 

At the UVA Office of Telemedicine we are now engaged with corporate partners 

to use these everyday wireless capabilities to improve home monitoring for diabetic 

patients and engender an atmosphere to improve medication compliance, healthier 

lifestyles and the reduced use of emergency rooms for primary care. But access remains a critical issue. Imagine what we could have done for Shifty Powers, the Easy 

Company solider from Clintwood, Virginia. Wireless capability would have perhaps 

helped him to feel less isolated, provided invaluable education for him and his family and reminded them of appointments. This combined with improved access in 

rural communities to telemedicine connection to specialty care is what is needed 

now. 

I want to thank the Subcommittee and Committee as well as Congress for the 

steps they have already taken to enable this environment. But I also challenge Congress to engender an environment of investment by: 

• Continuing funding of demonstration projects that use wireless to enhance 

home monitoring, health promotion and education; 

• Ensuring health systems are incentivized to use wireless configurations; 

• Encouraging professional education to incorporate training in these devices and 

applications; 

• Providing for appropriate financial coverage for use of this capability; 

• Promoting a standards-based environment for usage; and critically; 

• Ensuring a Nation of seamless coverage without network fragmentation. 

It has been stated that genetics and the tools of molecular medicine will provide 

a new golden age of medicine. While this is most certainly true, I contend it is wireless devices, telehealth applications and internet-based health software that are precipitating opportunities for improved health care for all veterans and for the Nation. 

Through this, we have the opportunity to get the basic right of prevention, access, 

education and ongoing care. 

The hope is that these new, remarkable technologies, from smart-phones to EHRs 

to video-conferencing to sensor based health-monitoring devices, will empower patients, doctors and nurses to improve outcomes while cutting costs. For me, the 

ubiquitous presence of mobile phones is a major reason to think this world is now 

upon us. I strongly believe and hope this Committee is passionate that these capabilities are what will eliminate disparities in care for rural citizens, reduce the cost 

of care and stimulate remarkable new business models in the process. 


ebenthall on DSK9Q6SHH1PROD with HEARING
56 

As our Nation moves forward in restructuring its health care delivery system, the 

innovative uses of these telehealth tools will be an important driver of that change. 

With the adoption of favorable policies driven by Congress and innovation applied 

to the care of patients using integrated telehealth tools that includes wireless we 

stand at the threshold of eliminating disparities that have caused our rural veterans 

to suffer for far too long. 

It is now time for us to stand up for those upon whom we depended for our health 

and freedom. 

f 

Prepared Statement of William Cameron Powell, M.D., FACOG, President, 

Chief Medical Officer and Co-Founder, AirStrip Technologies, 

San Antonio, TX 

Remote patient monitoring of critical patient data via mobile devices (i.e., iPhone, 

Blackberry, etc) is rapidly becoming a necessary technology within the health care 

IT space in order to better care for patients and improve outcomes. 

There are several reasons that patient monitoring with mobile devices is important. A few examples are as follows: 

1. Doctors and nurses are mobile and the need for them to monitor more patients 

at different locations is growing. 

2. There is an increasing shortage of health care providers relative to the increasing number of patients that need to be monitored either in the hospital, clinic 

or at home. 

3. This shortage leads to a communication gap between caregivers. 

4. The number one cause of patient injury in a hospital is communication errors 

between caregivers about a patient’s condition. 

5. There is now an expectation for real time, anywhere access to critical data. 

6. The health care community needs to improve patient safety, reduce risk and 

improve communication as Federal regulation continues to drive technologies 

that improve outcomes. 

7. Remote patient monitoring of real time data via mobile devices can close the 

communication gap, lead to better outcomes, improve patient safety and make 

the overall delivery of quality health care more affordable and more efficient. 

There is a myriad of problems with the health care delivery system in the United 

States. One of the core problems facing health care professionals and the patients 

they serve is an increasing discrepancy between the number of patients that need 

to be monitored and the number of doctors, nurses and other health care providers 

that are available to monitor them. 

In the United States, the number one cause of patient injury in a hospital is communication errors between caregivers. The demands of a doctor’s or nurse’s day necessitate their periodic absence from the patient care environment and it is during 

this time that communication errors can occur. 

Doctors are often in surgery, covering patients at more than one hospital, making 

rounds, on call, at the office, at home and thus not at the bedside all the time. 

Nurses and hospitalists are often dealing with new patient admissions, managing 

patient discharges or engaged in other work related activities that preclude them 

from always being at the patient’s bedside. 

Within the hospital acute care environment, as in the Intensive Care Unit or in 

the Labor and Delivery unit, physicians and nurses rely on their ability to communicate about data that changes moment to moment. Much of the data that requires 

bi-directional communication involves visual data such as waveform data. 

Waveform data is the moving line across a screen that provides a graphical representation of a heart tracing, an unborn baby’s heart rhythm, a brain wave, a 

mother’s contraction pattern or a host of other monitored data. Being able to visually interpret and describe changes in these waveforms helps a care provider who 

is remote to be able to effectively understand what is happening to that patient in 

real time as well as the recent past. 

In this day and age of health care with such increasing demands on a doctor’s 

or nurse’s time, these health care providers are increasingly mobile. The health care 

system is burdened with solving the problem of effectively getting the right data 

about the right patient to the right health care provider to hopefully affect the right 

outcome. 

Real time remote patient monitoring through the use of mobility has received a 

lot of attention lately because the focus on remote monitoring through a de-centralVerDate Nov 24 2008 12:59 Dec 19, 2010 Jkt 058054 PO 00000 Frm 00060 Fmt 6604 Sfmt 6621 I:\VA\58054.XXX GPO1 PsN: 58054

ebenthall on DSK9Q6SHH1PROD with HEARING
57 

ized model has become a reality via cutting edge technologies and breakthroughs 

across a wide swath of solutions from cell phones to wireless communications. 

AirStrip’s first product, AirStrip OB, is now installed in nearly 200 hospitals in 

the U.S. and there are several thousand physician users. AirStrip allows Obstetricians to view the real time fetal heart tracing, a mother’s contraction pattern or 

other critical data via a mobile device (i.e. iPhone) anytime or anywhere. Given that 

up to 60 percent of adverse outcomes in Labor and Delivery are due to communication errors about the baby’s heart tracing, providing this service to physicians when 

they are temporarily away from the bedside will result in fewer adverse outcomes, 

reduced patient injury and greatly improved physician and nursing workflow. AirStrip OB is the only known FDA cleared mobility solution of its kind. 

AirStrip is also about to go to market with its next product line, AirStrip Critical 

Care and Cardiology. These solutions will provide physicians with real time remote 

access to critical waveforms, patient vitals, decision support information and a tremendous amount of other patient data that will help physicians better care for their 

patients and make more informed decisions when they are temporarily away from 

the hospital. These additional AirStrip products are currently pending FDA clearance. 

Finally, AirStrip Technologies has developed a completely reusable and fully 

scaleable software development platform called AppPoint that can cut software development timelines by 80 percent and cost by 60 percent. AirStrip and soon AirStrip partners will use this platform to rapidly develop and bring to market an additional compelling suite of mobile applications that will allow health care providers 

to securely use mobile devices and cellular/wireless networks to provide real time 

remote patient monitoring service in virtually any environment. 

The communication gap that currently exists between doctors and nurses that 

leads to patient injury can be closed through the use of remote patient monitoring 

solutions such as the AirStrip suite of mobile products. 

f 

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 

Good Morning Chairman Michaud, Ranking Member Brown and Distinguished 

Members of the House Committee on Veterans’ Affairs, Subcommittee on Health. 

My name is Rick Cnossen, President of the Continua Health Alliance, a non-profit, open industry coalition of health care and technology companies that are joined 

to collaborate and improve the quality of personal health care. On behalf of the 

members of Continua, I would like to thank you for the opportunity to present testimony on the important issue of bringing health care to our veterans. 

Continua has 237 member companies from around the world that are dedicated 

to establishing a system of interoperable personal health solutions that fosters independence, empowers individuals and provides the opportunity for truly personalized 

health and wellness management. Continua is not a standards body—the Alliance 

selects existing commercially available standards and works to test and certify those 

standards so that personal telehealth solutions are interoperable, ubiquitous and 

contribute toward improved health management. Additionally, the Alliance writes 

guidelines on how to use those existing standards to achieve true interoperability 

across many companies and many devices. 

I. Introduction to Personal Connected Health, Telehealth, and eCare 

Continua uses the term ‘‘eCare’’ to refer to the class of health information technologies that can facilitate any kind of virtual visit or electronic connectivity outside 

of traditional office visits among patients, family members, and medical professionals. eCare includes personal connected health as well as telehealth. It can be 

secure text messaging between a senior patient and their doctor to change a medication dosage, an audio chat, or a full video web cam visit. It can also be personal 

connected health with an in-home or mobile broadband device that can help providers track and trend data like blood pressure and weight fluctuations that seniors 

and other patients can take by themselves on a regular basis. eCare may also include using connectivity to help patients remember to take a medication, capture 

a vital sign, or view customized content sent to them by their clinician to teach 

them about managing their own disease. eCare expands and extends the efforts of 

medical professionals by providing information to and from patients without geographic obstacles. 


ebenthall on DSK9Q6SHH1PROD with HEARING
58 

To realize the quality improvement and cost-containment goals of health care reform, our Nation must harness the benefits of technologies that allow patients and 

care providers to use real-world, remotely-collected data to make decisions about 

their health on a continual basis, rather than waiting until a condition has set in 

that requires them to schedule an urgent office visit or go to the emergency room. 

By tracking vital signs and other health data on a more regular basis and sharing 

it through secure systems, eCare offers many beneficial clinical capabilities: 

• Empowers patients with tools that help them make sense of—and help manage—their own care; 

• Collects real-world biological and behavioral data and trends on a regular basis 

with alerts for out-of-norm situations; 

• Facilitates virtual visits with providers, whenever and wherever appropriate, 

via a range of electronic media; 

• Enables social networking, awareness, and care support from family and friends 

who are nearby or distant; 

• Personalizes care plans and educational content for each individual based on 

their needs, preferences, data, and capabilities; and 

• Triages precious medical resources to enable the right amount of care to occur 

in the right place and time. 

II. Successful Case Studies 

These current services and future health information technologies will be the key 

to improving the delivery of clinical services and health care quality, as well as containing health care costs. Many studies have shown the value of personal connected 

health. For example, the New England Healthcare Institute (NEHI) ‘‘2008 Research 

Update, Remote Physiological Monitoring’’ found that remote patient monitoring resulted in a 60 percent reduction in hospital readmissions compared to standard care 

and a 50 percent reduction in hospital readmissions compared to disease management programs without monitoring. The same study found that remote patient monitoring has the potential to prevent between 460,000 and 627,000 heart failure related hospital readmissions each year. Based on this reduction in readmissions, 

NEHI estimated annual national cost savings of up to $6.4 billion dollars. 

As our Nation looks for ways to improve quality, access, and costs of health care, 

it is important to realize that eCare technologies can save lives and dollars. For example, the Department of Veterans Affairs (VA) examined this issue in its report, 

‘‘Care Coordination/Home Telehealth: The Systemic Implementation of Health 

Informatics, Home Telehealth and DM to support the Coordination of Veteran Patients with Chronic Conditions.’’ The VA found that implementing telehealth to coordinate patient care led to a 25 percent reduction in the number of bed days and 

a 20 percent reduction in hospital admissions. The report showed a cost of $1,600 

per patient per annum for the telehealth program compared to $13,121 for traditional primary care and $77,745 for nursing home care. Not only were patients able 

to avoid readmission and improve their health status faster through telehealth services, but taxpayers also saved money. 

III. Role of Personal Connected Health, Telehealth and eCare as Clinical 

Services and as Improving Health Care Quality in the Patient Protection and Affordability Act (PPACA) 

eCare, including personal connected health and telehealth, complements clinic 

and hospital visits and improves health care quality. By monitoring their own data 

from home, patients and their caregivers become more engaged in self-care and 

aware of health trends. eCare can also improve consumers’ access to care, particularly in rural areas, by easing logistical burdens and reducing or eliminating the 

need to travel to a provider’s office for routine visits. In addition, through the use 

of personal connected health, providers have more information on a timely basis 

upon which to make medical decisions that can assist in addressing health problems 

before they become crises. As eCare removes geographical restrictions, patients will 

gain access to needed specialists who may not be local. 

Recognizing these challenges and opportunities, the Patient Protection and Affordable Care Act (PPACA) includes numerous provisions designed to promote personal 

connected health, telehealth, and other eCare services. For example, the Secretary 

of HHS is required to develop guidelines for a payment structure that provides increased reimbursement or other incentives for: improving health outcomes through 

quality reports, case management, care coordination, chronic disease management, 

medication and care compliance initiatives (including medical home); activities to reduce hospital readmissions; activities to improve patient safety and reduce medical 

errors through the appropriate use of best clinical practices, evidence-based mediVerDate Nov 24 2008 10:26 Dec 17, 2010 Jkt 058054 PO 00000 Frm 00062 Fmt 6604 Sfmt 6621 I:\VA\58054.XXX GPO1 PsN: 58054

ebenthall on DSK9Q6SHH1PROD with HEARING
59 

cine, and health information technology; and wellness and health promotion activities. eCare is at the crux of all of these services. (PPACA § 1311) 

PPACA also recognizes that many meaningful physician encounters can occur remotely. Specifically, the Act allows certification or re-certification of a patient for 

home health services or durable medical equipment to occur through a face-to-face 

physician encounter or through the use of telehealth. (PPACA § 6407) In another example, a Medicare health risk assessment may be furnished through an interactive 

telephonic or web-based program that meets standards to be established by the Secretary of HHS. (PPACA § 4103) PPACA also provides for investment in communitybased collaborative care networks that expand capacity through telehealth and 

medication management services that are provided either in-person or through telehealth technologies. (PPACA §§ 10333, 10328) These programs will both encourage 

the uptake of beneficial health information technologies throughout the health care 

system and address critical shortages of health care providers. Expanding the use 

of eCare will be paramount to providing high quality care for the increasing number 

of individuals who are living with chronic and expensive health conditions for longer 

than ever before. Without buy-in across government and private payers, the opportunities for eCare to enhance our health care system as recognized in PPACA will 

not be realized across our health care system. 

Many of the most promising ideas for health care delivery innovation depend on 

eCare services. PPACA looks to increase the use of eCare services to provide for future improvement in health care delivery. For example, the Independence at Home 

Demonstration Project, designed to improve care for chronically ill Medicare beneficiaries, defines an ‘‘independence at home medical practice’’ as one that ‘‘uses electronic health information systems, remote monitoring, and mobile diagnostic technology.’’ (PPACA § 3024) Accountable Care Organizations participating in shared 

savings programs under PPACA are required to ‘‘define processes to promote evidence-based medicine and patient engagement, report on quality and cost measures, 

and coordinate care, such as through the use of telehealth, personal connected 

health, and other such enabling technologies.’’ (PPACA § 3022) Further, the Center 

for Medicare and Medicaid Innovation created by PPACA may test models that support care coordination through ‘‘a health information technology-enabled provider 

network that includes care coordinators, a chronic disease registry, and home telehealth technology,’’ and may consider whether a model under review ‘‘utilizes technology, such as electronic health records and patient-based remote monitoring systems, to coordinate care over time and across settings.’’ (PPACA § 3021) Without inclusion of eCare, from the beginning, as a clinical service or service that improves 

quality, our health care system will not benefit from or encourage the use of personal connected health or telehealth services. We urge policymakers to look to the 

future of what health care delivery can be through the use of wired, wireless, mobile 

broadband and whatever new forms of technology may appear to allow our uniquely 

American health care system to benefit from eCare as we know it and as we might 

know it in the future. eCare truly promises to be a disruptive approach that transforms the way that we provide health care and becomes an indispensible tool in the 

future. 

Services that change patient behavior, assist in treatment and compliance, and 

improve quality are supported by information technologies. These technologies serve 

as the backbone for the provision of a variety of activities including wellness, disease management, medication management services and illness prevention—all important goals of PPACA. Over time, this infrastructure will need to be improved and 

augmented in order to support these activities particularly as these services become 

better integrated into our overall health care delivery system. As our reliance on 

information technology systems grows, they should also be considered a part of 

those services that improve quality. Without the vital services of eCare, our health 

care delivery system will be limited and not help move health care into the 21st 

century. 

Technology is evolving rapidly. The rapid societal uptake of now-commonplace devices from smartphones, to netbooks, to smartbooks, demonstrates the pervasive 

role of mobile wireless technology in our daily lives and the opportunities they bring 

to improve our access to health care. As we learn and develop ‘‘best practices’’ for 

eCare—and invest in comparative effectiveness studies to know the right balance 

of in-home, in-clinic, and eCare consultations for different conditions and needs— 

these technologies will ultimately help us move beyond a quantity oriented system 

(e.g., number of visits done or tests or drugs prescribed) to one of quality. 

IV. Continua Utilizes Voluntary Industry Interoperable Standards for eCare 

Health care costs continue to spiral upwards to the point of prompting national 

mandates for change. Technology has advanced to a point where personal telehealth 


ebenthall on DSK9Q6SHH1PROD with HEARING
60 

1www.ContinuaAlliance.org 

systems provide viable, cost-effective solutions and represent a very real opportunity 

to help control costs. In order for deployment to become widespread, an ecosystem 

of standards-based interoperable components (starting with the consumer-facing device) is essential. The Continua Health Alliance was established to address this 

need. Technological advances, such as innovations in networking technologies and 

the rapid increase and availability of wireless internet-connected devices, enable the 

development of solutions that address user needs in a cost-effective manner. These 

technologies also allow people to remain safely in their own homes longer. Personal 

telehealth systems composed of an ecosystem of commercially available standardsbased interoperable components are the building blocks of these solutions.1

V. Need for Device Interoperability 

While there are many challenges associated with the successful design, implementation and deployment of personal telehealth systems, one of the more obvious problems in early telehealth solutions has been the lack of device interoperability which 

requires broad industry support behind particular standards. 

Integrator/Purchaser 

Integrators (companies producing eCare solutions made up of components 

from a number of different vendors) and purchasers (health care providers that 

will be purchasing these solutions and offering them to their patients or members) both require a wide variety of system vendors and components to select 

from. 

Interoperability is important as it allows integrators and purchasers to select 

from a wide variety of personal health devices offered by multiple vendors. 

Product Designer 

From the perspective of a product designer, device interoperability is essential. If the objective of the product designer is to design equipment that will 

communicate with a wide range of telehealth peripherals (for example, weight 

scales, blood pressure monitors, glucose meters), it is very likely that the desired set of peripherals be developed by multiple vendors. Interoperable solutions will minimize cost, improve design and development efficiencies and enable separation of concerns that device vendors can focus on devices, software 

vendors can focus on software development, and service providers can focus on 

service delivery by utilizing well-defined, unambiguous commercial standards 

and guidelines. 

VI. Continua Solution 

Approach 

Continua Health Alliance was founded in 2006. The Alliance leveraged examples 

from other solution domains such as home networking (for example, Wi-Fi Alliance 

and Digital Living Network Alliance) in order to help define its overall approach. 

The result was the following methodology: 

• Select existing, applicable industry standards 

• Extend these selected standards where required (to meet user needs identified 

in use cases and requirements) 

• Eliminate ambiguity in interpretation of these standards through a collection 

of interoperability guidelines 

• Develop a certification process that guarantees products meet the guidelines 

and provide the consumer a high-quality user experience 

Continua put in place a flexible architecture that allows for a common approach 

but also accommodates regulated and unregulated products from the various application domains. The figure below shows the various components and the interfaces 

that constitute an end-to-end solution. 


ebenthall on DSK9Q6SHH1PROD with HEARING
61 

2See Centers for Medicare and Medicaid Services, ‘‘Telemedicine and Telehealth,’’ http:// 

www.cms.hhs.gov/Telemedicine/. 

VII. Recommendations for eCare integration 

Despite the success Continua members have achieved in developing devices and 

services as assistive technologies for patients with chronic disease and succeeded in 

making sure that these devices interoperate, significant barriers restrict the integration of eCare into patient care plans. In order to ensure that patients and clinicians 

have full access for their optimum health care, we respectfully submit the following 

recommendations: 

1. Establish a Federal Organization Focused on eCare: 

The U.S. Congress realized the benefits of eCare by including references to technologies for personal connected health in more than 20 provisions in Patient Protection and Accountable Care Act (PPACA). However, we find that Federal agencies 

may lack a coordinated approach to unlocking the potential of these powerful, cost 

efficient and life saving technologies. In order to maximize information sharing on 

an interagency basis, we urge the U.S. Government to consider the establishment 

of an ‘‘Office of eCare’’. Much like the Office of the National Coordinator for Health 

Information Technologies was formed in 2004 through an Executive Order to accelerate the use of health IT, the expansion of eCare across various care delivery models is a timely and fruitful objective. 

2. Payment Reform for eCare 

As noted in the Federal Communications Commission National Broadband Plan, 

reimbursement reforms are essential to incentivize the meaningful use and widespread adoption of eCare technologies. Simply stated, reimbursement issues are a 

barrier to the adoption of health IT. The Centers for Medicare and Medicaid Services (CMS) define telehealth services as the use of medical information exchanged 

from one site to another via electronic communications to improve a patient’s 

health.2 Electronic communication means the use of interactive telecommunications 

equipment that includes, at minimum, audio and video equipment permitting twoway, real-time (with limited exceptions) interactive communication between the patient, and the physician or practitioner at the distant site. The definition includes 

limitations on the types of originating sites of care that can be used, in addition to 

the requirement that an originating site must be located in either a health professional shortage area (HPSA) or in a county not classified as a metropolitan statistical area (MSA). 

eCare reimbursement should be permitted everywhere and at anytime and not 

limited to geographically rural areas. The limitations on which types of originating 

institutions and which fields of health care are eligible for telehealth reimbursement 

are outdated. Health care management should not be limited to only live encounters, where store-and-forward technologies are perfectly capable of providing reliable, consistent, diagnostic care. Interoperable personal telehealth and remote monitoring of data can be used for disease management, safety, health and wellness. If 


ebenthall on DSK9Q6SHH1PROD with HEARING58054A.000
62 

a Medicare benefit plan covers a service, then that plan should also cover the same 

service when it is performed via eCare. 

3. Establish Blueprints for the use of eCare in States and communities. 

We can learn from the successful deployment of 35,000 chronic care patients 

served by remote patient monitoring through the Department of Veterans Affairs. 

Although a closed system, the results are for patients with the same illnesses that 

Americans across the Nation face. We need to do the hard work of factoring new 

payment plans, work flow systems and efficiently using community resources to care 

for our patients at home. We offer the resources of the Continua Health Alliance 

to convene the appropriate participants—hospital systems, doctors, technology companies to work with Congress and HHS to design a system that works for all stakeholders. 

4. Incorporate eCare as part of ‘‘meaningful use’’. 

The significant investments in health information technology (HIT infrastructure 

made through the American Recovery and Reinvestment Act (ARRA) and health 

care reform are an important starting place for improving our country’s capacity to 

provide high quality and efficient care. Without a national infrastructure—an ‘‘electronic highway’’ for health information—it will be impossible for the United States 

to deliver quality care to more people at lower costs as the Nation ages. With the 

passage of AARA, our Nation took a leap forward in relation to electronic health 

records (EHRs) by allocating $19.2 billion towards the adoption of HIT. That investment is just one step. eCare is the next step forward, and without its inclusion in 

the ‘‘Meaningful Use’’ requirements, the significant dollar investment made by the 

Federal Government stops short of moving the system beyond just the use of 

records. eCare can populate electronic medical records with trend data and other 

timely information to provide a more complete picture of a patient and to empower 

providers to make clinical decisions that improve the health and lives of Americans. 

We urge HHS to ensure that a mechanism is in place to allow Personal Health summaries to be integrated into EHRs in a standard fashion (e.g., Continua’s Health 

Record Network standard). 

5. Make home broadband adoption for all Americans a top priority following recommendations in the FCC’s National Broadband Plan. 

Extending broadband adoption is especially important in rural parts of the country to enable new independent living and home health care solutions. Similar to the 

National Broadband Plan, Continua supports the FCC’s notion that a Health Care 

Broadband Infrastructure Fund should be established to subsidize fixed, wireless 

and mobile network deployments to augment health care delivery in locations where 

existing networks are insufficient. 

VIII. Future Vision of what eCare can deliver 

In 2005, the Center for Aging Technologies (CAST), developed Imagine—the Future of Aging. Rather than describe what the future could be, I invite you to watch 

the video which will give you a glimpse, through the eyes of one family, of what 

the future could look like with help from developing technologies that are possible, 

practical, affordable and ethical. You will also see how these technologies have the 

potential to improve care, preserve independence, and ensure quality of life while 

reducing costs. 

We must, however, take action through vision, leadership and national commitment to prepare for the demographic and economic changes that will inevitably 

transform health care. 

http://www.youtube.com/watch?v=SBH9dkCZsXQ. 


ebenthall on DSK9Q6SHH1PROD with HEARING
63 

1See: FCC National Broadband Plan: Connecting America, released March 16, 2010, at Page 

200. See U.S. Senate Special Committee on Aging, Committee Hearing on April 22, 2010 ‘‘Aging 

in Place: The National Broadband Plan and Bringing Health Care Technology Home’’ http:// 

aging.senate.gov/hearingldetail.cfm?id=324102&. 

f 

Prepared Statement of Kent E. Dicks, Founder and Chief Executive Officer, 

MedApps, Inc., Scottsdale, AZ 

Good Morning Chairman Michaud, Ranking Member Brown and Distinguished 

Members of the House Committee on Veterans’ Affairs, Subcommittee on Health. 

My name is Kent 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 speak 

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 and 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 analytical 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 differing and often confusing aspects of 

wireless health information technologies. Terms such as mHealth, e-Health, telehealth and telemedicine are but a few of many descriptive names being used in the 

wireless health space. Some terms have industry meaning, others are regulatory 

terms with strict Federal definitions and criteria. 

For 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 for America.1 eCare is the electronic exchange of information—electronic data, images and video—to aid in the practice of medicine and health care 

analytics. eCare encompasses technologies that enable remote monitoring or ‘‘storeand-forward’’ transmissions over wireless fixed or mobile networks. eCare is not a 

substitute for health care providers, physicians or clinicians—it is intended to augment the good work of medical professionals and improve patient care by making 


ebenthall on DSK9Q6SHH1PROD with HEARING58054A.001
64 

2See: Bringing Broadband to Rural America, Report on a Rural Broadband Strategy, released 

May 22, 2009, at Pgs. 12–13. In making that finding, the Commission defined networks based 

on EV–DO and WCDMA/HSPA as constituting mobile broadband. The Commission used the 

same definition of mobile broadband in its annual reports on the state of competition in the U.S. 

wireless market in 2009, 2008, and 2007. See Thirteenth Report, Annual Report and Analysis 

of Competitive Market Conditions with Respect to Commercial Mobile Services, WT Docket No. 

08–27, DA 09–54, released January 16, 2009 at Pgs. 69, 73–74; Twelfth Report, Annual Report 

and Analysis of Competitive Market Conditions with Respect to Commercial Mobile Services, WT 

Docket No, 07–71, released Feb. 4, 2008, at Pgs. 8, 68–69; Eleventh Report, Annual Report and 

Analysis of Competitive Market Conditions with Respect to Commercial Mobile Services, WT 

Docket No, 06–17, released Sept. 29, 2006, at Pg. 54. 3See: http://www.amazon.com/dp/B0015T963C. 

important information available to patients, their loved ones and care providers anywhere, at anytime. 

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 hospitalization by 25 percent and an average cost of 

$1,600 per patient per year for remote monitoring compared to annual costs of 

$13,121 per patient for primary care and $77,745 per patient for nursing home care. 

Amazingly, those encouraging results and statistics were achieved with 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 this 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 in 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 is an example of the technology that I am talking about. This is called 

the HealthPAL. The HealthPAL’s 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 wirelessly (or wired) with other medical devices designed for use outside the hospital, such as this Nonin 9560 Pulse Oximeter. 

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 zones. And as you can see, the Pulse Oximeter reading went 

over automatically to the HealthPAL without the patient having to press any buttons whatsoever (hands off), using Bluetooth wireless technology. It’s that simple. 

The HealthPAL, like the one that I am holding in my hand, has mobile phone 

technology embedded into it directly, using a technology called ‘‘Machine 2 Machine’’ 

(M2M). This 3G mobile broadband chipset by Qualcomm is about the size of a U.S. 

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. 

You will be hearing a lot about M2M services and mobile chipsets in the near future, in relation to health care and smart grid technologies, in particular. Mobile 

chipset powered modules allow us to connect ubiquitously to cellular and mobile 

broadband networks throughout the U.S., and globally. According to the Federal 

Communications Commission nearly 96 percent of the U.S. population is covered by 

a mobile broadband network and 99 percent of the non-rural U.S. population and 

nearly 83 percent of the rural U.S. population is so covered.2 At the heart of science, 

medicine, energy and engineering, mobile wireless and broadband technologies are 

reliably and invisibly working in the background on economical rate plans. 

Innovative technologies like the HealthPAL are targeted towards 10 percent of 

the population that consume 70 percent of the health care resources; the sickest of 

the sick. Often this population is older, and does not have access to ‘‘state of the 

art’’ technology or Internet access. 

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 and ready to use. Nothing complicated to setup, 

provide or maintain—everything is done remotely, including software upgrades, 

much like popular ‘‘KindleTM’’.3 e-reading devices. 

Let me be clear about what we are trying to achieve in using ‘‘off the shelf’’ devices and mobile wireless technology. It is not to over engineer a gadget for the sake 

of fancy bells and whistles. Rather, it is about creating a sense of accountability and 

reliability between the patient and the caregiver, at the lowest cost possible. If a 


ebenthall on DSK9Q6SHH1PROD with HEARING
65 

patient is ‘‘connected’’ and accountable, then they are more likely to follow their doctor’s instructions, take their readings, take their medication, and thus stay out of 

the hospital. 

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 and his doctor attempted to adjust his 

medication based on dated information. Today David uses the HealthPAL in the cab 

of his truck, and has taken his readings throughout 47 States. This 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 his doctor, who 

along with David’s wife can stay connected to him remotely while he’s on the road, 

making sure he is ok and his medical conditions stay under control. 

At Meridian Health, a NJ based Health system, the technology is being used to 

help reduce re-admissions of congestive heart failure patients (‘‘CHF’’). Typically 

across the country, 27 percent of congestive heart failure patients are readmitted 

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 the patient for thirty days to ensure patients with signs of worsening conditions are seen by their physician for early, less 

resource intensive interventions. The equipment is returned to Meridian at the end 

of the 30-day period. So far, out of 30 patients, Meridian has experienced no re-admissions due to heart failure within the 30-day period. 

eCare made this possible—today. The examination room of the future will be 

wherever the patient is located. Underserved patients are not just those typically 

found in rural America or in geographic areas of low population density, but can 

be anywhere our Veterans live. Now with an aging baby boomer demographic, more 

people will continue to place greater demands on the Nation’s health care infrastructure everywhere. We need to provide the tools to help absorb those demands 

and make the provision of care available everywhere and at any time. 

In conclusion, the VA could potentially extend its capacity for remote monitoring 

on a daily basis from 35,000 patients currently, to over 100,000 patients by utilizing 

innovative mobile enabled medical technologies. 

Wireless mobile technology is a solution that is available today. Robust mobile 

networks exist to start bringing care to those who so desperately need and, in fact, 

deserve it, no matter where they live. The VA and U.S. tax payers would save a 

significant amount of time, money and natural resources by using mobile wireless 

enabled medical technology. 

Mr. Chairman, this concludes my prepared statement. I would like to extend an 

invitation to you and the distinguished members of the House Committee on Veterans’ Affairs, Subcommittee on Health to observe a demonstration of this technology at a future time. I would be pleased to answer any questions you may have 

and on behalf of the team at MedApps, I thank you for the opportunity to discuss 

these issues with you today. 

f 

Prepared Statement of Huy Nguyen, M.D., Chief Executive Officer, 

Cogon Systems, Inc., Pensacola, FL 

Background 

Thank you for the opportunity to testify before the Subcommittee on Health of the 

House Committee on Veterans Affairs. My name is Dr. Huy Nguyen. I am a Navy 

veteran who served in Iraq in 2003 as a physician attached to 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 service of their county. I have 

since separated from active duty; however, I continue to serve our military and veteran community presently as a civilian Emergency Department physician at my 

cherished Naval Hospital Pensacola. In addition to being a military-affiliated provider, I am also the Founder and Chief Executive Officer 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. My personal interest in health care mobile technology and 

clinical information systems dates back to my years as a medical student and was 

developed further as a naval physician utilizing the military’s electronic health 

record. 


ebenthall on DSK9Q6SHH1PROD with HEARING
66 

1 Jia H, et al. ‘‘Long-Term Effect of Home Telehealth Services in Preventable Hospitalization 

Use,’’ Journal of Rehabilitation Research and Development 46, no. 5 (2008): 557–566. 2Darkins A, et al. ‘‘Care Coordination/Home Telehealth’’ The Systematic Implementation of 

Health Informatics, Home Telehealth, and Disease Management to Support the Care of Veteran 

Patients with Chronic Conditions,’’ Telemedicine and e-Health, 14, no. 10 (2008): 1118–1126. 

This hearing is broadly intended to examine how the Nation can utilize new and 

innovative wireless technologies to expand access and quality of care for veterans 

in remote areas. In my testimony today, I will certainly discuss my company’s experience with mobile health care technology and how it can impact veteran care. However, I would like to begin my testimony by discussing health information exchange 

and interoperability which complements mobile technology by allowing comprehensive health information available to be accessible to mobile devices. Secure mobile 

access to comprehensive health information can be particularly helpful to providers 

and veteran patients in rural communities. 

In discussing the potential of health information exchange, I will draw on my 

company’s project in Pensacola which has facilitated the largest instance of secure 

data sharing between Federal and civilian health care providers. I believe that this 

project is in keeping with the spirit and intent of the Obama Administration’s Virtual Electronic Health Record (VLER) efforts. Finally, I would like to discuss some 

innovative ideas that can empower our veterans in rural communities to assume 

greater ownership of their health. 

The Department of Veterans Affairs’ Stated Objectives and Mandates 

As context to today’s testimony, I would like to highlight some significant objectives that guide 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 (MHS) and Veterans Administration (VA) are promoting the VLER initiative which represents the first iteration 

of a new national capability to securely share electronic health and administrative 

information. In order to ensure a seamless transition of health services from one 

agency to another, MHS and the VA are implementing these critical elements: 

• a full understanding of medical care capabilities within both agencies by all 

medical providers involved, 

• clear communications of the transition plan between providers in each agency 

and with the patient and patient’s family, 

• timely transfer of all pertinent medical records before or at the time of transfer 

of the patient, and 

• ongoing communication after the transfer of the patient between the medical 

providers in each agency and with the patient and patient’s family. 

On April 9, 2009, President Obama directed the Department of Defense and the Department of Veterans Affairs to create the Virtual Lifetime Electronic Record: 

‘‘. . . will ultimately contain administrative and medical information from 

the day an individual enters military service throughout their military career and after they leave the military.’’ 

In light of the fact that 3 out of 4 Veterans receive a portion of their care from 

a civilian private sector provider, President Obama has also stated it is important 

to: 

Allow health care providers access to servicemembers’ and Veterans’ health 

records, in a secure and authorized way, regardless of whether care is delivered in the private sector, Department of Defense, or VA 

The MHS and VA have been pioneers in adopting electronic health records well 

before their civilian providers. Therefore, in my humble opinion, the VLER initiative 

is an ambitious and natural progression of the investments that the MHS and VA 

have made in the realm of digital health care. Furthermore, the VLER initiative can 

shed light to the greater health care community’s efforts to share health information 

via the Nationwide Health Information Network (NHIN). The question here today 

then is can the MHS and VA leverage its past and current focus on health information technology to translate into better care for our military personnel and veterans 

especially in underserved communities. 

As an example, the VA has stated that it has decreased unnecessary hospitalizations through a wide-ranging effort to help veterans manage chronic conditions at 

home. 1,2 Hospital use decreased 25 percent overall and 50 percent for patients in 

highly rural areas by linking 32,000 chronically ill veterans with health care proVerDate Nov 24 2008 09:28 Dec 17, 2010 Jkt 058054 PO 00000 Frm 00070 Fmt 6604 Sfmt 6621 I:\VA\58054.XXX GPO1 PsN: 58054

ebenthall on DSK9Q6SHH1PROD with HEARING
67 

3Presentation of Adam Darkins, Veterans Health Administration Presentation at the Second 

National Rural Health Information Technology Conference, September 12–14, 2007. 

viders and care managers through video phones, digital cameras, and messaging 

and telemonitoring. This is an example of how the VA’s investment in an electronic 

health record can ‘springboard’ better patient care and cost savings. 

In FY 2006 an estimated 8.3 percent of the populations are Veterans. The Veteran 

enrollee population was about 7.8 million. About 38 percent of such enrollees live 

in rural or highly rural areas.3 In these rural communities, access to a VA care facility is logistically and often financially challenging for most of these veterans. As 

I see it, our veterans have often gone to isolated places to serve us, so now it is 

imperative that we find means to serve them wherever they may reside. I believe 

that technology coupled with the internet and increasing digital broadband will 

allow for innovative means such as the example above to provide care in the rural 

communities. 

Health Information Exchange as the System Behind Access to Information 

to Help Veterans Care and Drive Mobile Technology 

Cogon’s health information exchange is designed to (1) ensure first and foremost 

electronic security; (2) facilitate data interoperability from disparate systems; (3) 

handle network scalability as required by the Nationwide Health Information Network (NHIN); and to facilitate other applications and innovations. The VIRTUAL 

HEALTH NETWORK (VHN) is Cogon Systems, Inc. (Cogon) underlying software 

platform. The platform integrates with providers such as hospital’s existing information systems. The VHN is agnostic toward specific types of electronic health records 

software. The VHN is not meant to replace electronic health records but as an augmenting data broker that will find, compile, and present this data to caregivers in 

a manner that will allow them to make the best decisions possible at the moment 

of care. 

Furthermore, the VHN was designed to leverage ‘cloud computing’ so that providers do not have to make any capital investment such as buying unnecessary 

hardware and incurring significant software licensing. It is Cogon’s focus to utilize 

the internet coupled to a utility business model to lay a foundation of flexibility and 

sustainability that we believe is critical for provider adoption. Health information 

exchange (HIE) provides for the sharing of clinical and administrative data across 

the boundaries of health care institutions, health data repositories, and States. The 

full potential is going to take time and multiple-steps to achieve. 

Health information exchange includes core fundamentals such as participation, 

connectivity, data use agreements, privacy and security, record location, basic 

functionality, and return on investment. Our proposal for a sustainable model starts 

by focusing on these issues. For the next decade we need systems where institutions 

at different levels of sophistication may participate, be connected and have sustainable arrangement for sharing data where there is a business advantage. These institutions such as rural hospitals will migrate to more sophisticated systems such as 

disease management on time frames related to their circumstances and return on 

investment. With health information technology (HIT), we should never let perfection be the enemy of good. 

Providers have significant HIT issues to consider over at least 5 to 10 years: 

meaningful use requirements, new privacy and security rules, updating billing and 

coding standards for transactions, dozens of new reporting and operational requirements, new technologies, changes in practice, new pressure to control costs, changes 

that flow from health care reform changes to the insurance market, evidence based 

medicine, personalized medicine, and more. There is a lot of uncertainty over how 

these issues will roll out. There are regulations, penalties, and financial risks from 

any investment. It is important to allow providers to participate at the level in exchange at the level that fits their schedule. This approach is in keeping with our 

continued belief that health care should adhere to market forces as an impetus to 

innovation and better care. 

The Pensacola Model: Strategic Health Intelligence 

The health information exchange (THIE) 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 DoD beneficiaries is provided by private sector health care providers. Those providers are unable to access information regarding a patient’s health status or care 

episodes from the MHS’ electronic health/medical record systems. Similarly, patient 

visits to private sector health care providers which capture an enormous amount of 


ebenthall on DSK9Q6SHH1PROD with HEARING
68 

information regarding care, health and readiness are not available to MHS providers. This is the reality of patient care in MTF communities across the country. 

The project is fiscally managed by the MHS’ Telemedicine and Advanced Technology Research Center (TATRC) that successfully tested the concept of exchanging 

protected health information between Naval Hospital Pensacola and private sector 

health care providers in Pensacola using DoD/VHA Bi-Directional Health Information Exchange (BHIE) interfaced to Cogon Systems’ Virtual Health Network. The 

following data set can currently be accessed transiently by military and civilian providers via Web services: C32 Patient Summary, patient demographics, diagnoses/ 

problem list, providers, allergies, medications, laboratory results, radiology results 

and clinical notes. This is the reality of patient care in Pensacola today. To date, 

more that 30,000 patient records concerning patients jointly seen by the MHS and 

Pensacola civilian providers can be shared. This data exchange is in compliance 

with the Data Use Agreement between our company and the MHS’ TRICARE Management Activity office. 

At the onset of the project, TATRC made it clear that there was no sustainment 

budget for this project regardless of its success. In looking at the sustainment of this 

project, we felt that a utility business model that allowed civilian and Federal providers to cost share this project was the most market-based approach. Among civilian providers, we also had to contend with the sensitivity of a highly competitive 

environment where a common-value proposition may be a tough sell. Therefore, critical to a successful utility was the need for a trusted community broker that could 

govern and manage the utility. In our community, the Pensacola Bay Chamber of 

Commerce fit the profile of a neutral entity that could ‘cut through the clutter. ‘ 

Under the auspices of the Pensacola Bay Chamber of Commerce, an organization 

called Strategic Health Intelligence has been established to manage the Federal-civilian health information utility (HIU). 

Pensacola/Escambia County is now one of the advanced digital health care communities in America. Pensacola pioneered shared governance involving Federal and 

civilian providers across the entire community for its health information exchange. 

Furthermore, the Health information utility (HIU) business model is a template for 

sustaining shared costs between Federal and competing civilian providers to effect 

‘‘game changing’’ community-wide clinical decision support. The HIU is the first and 

largest instance of operational data sharing between civilian and Federal providers 

to date. Pensacola/Escambia County also has a high rate of electronic health records 

(EHR) adoption (>40 percent). 

The Florida Gulf Coast boasts a large contingency of active duty and retired military. Escambia County is fortunate to have not only the Naval Hospital Pensacola, 

but also a VA Joint Ambulatory Care Clinic. Both facilities are not only supportive 

of this application, they also play a significant role in the Chamber’s HIU and are 

board members of the Strategic Health Intelligence, LLC. 

The Chamber’s health information utility (HIU) has a successful track record in 

connecting and exchanging health data between civilian and Federal Government 

networks. Initiated in 2008, the Chamber’s HIU has facilitated the largest instance 

of data sharing between Federal and civilian providers by integrating 300,000+ 

unique civilian patient records from local hospitals and correlating those records 

with over 23,000+ unique Federal records from the current health information exchange (HIE) between the DoD and VA. With demonstrable market penetration the 

Chamber is operating one of the largest sustained HIE systems in existence to date. 

This system is currently the largest operation connecting military data to civilian 

providers and demonstrating success and lessons learned can directly contribute to 

business and technologies in the emerging Virtual Lifetime Electronic Record/Nationwide Health Information Network (VLER/NHIN) pilot projects such as Phase 1a. 

The VA has a highly adopted electronic health record, VistA, and an advanced personal health record (MyHealth-Vet). However, to assure appropriate transitions of 

care as noted by President Obama, the VA and MHS’ electronic health records must 

be interoperate with civilian providers’. As I have mentioned we are exchanging 

data in Pensacola with the MHS under a data use agreement. This exchange is with 

the Bidirectional Health Information Exchange (BHIE) program that connects MHS 

and the VA. Though the BHIE is not yet want to include the VA in the exchange 

so we can help veterans make sure their transitions of care are coordinated. Right 

now less than 20 percent private providers have adopted EHR’s. This does not have 

to be an impediment to all exchange. If we make hospital, VA and DoD information 

available to providers via the web, this helps transitions of care. 

In moving forward, we plan on transitioning to the National Health Information 

Network (NHIN) and to a sustainment model for health information exchange as 

a public utility under the auspices of Pensacola Chamber of Commerce. As we embark on health information exchange, we need to remember that the perfect is the 


ebenthall on DSK9Q6SHH1PROD with HEARING
69 

enemy of the good. Community-wide health information exchange between civilian 

and military health care providers is a good place to start. And a market-based approach to cost sharing is the key to long term sustainment of VLER-like communities. 

Mobile Technology As a Value-Added Adjunct 

In addition to our experience with health information exchange involving Federal 

providers, we are also under contract with TATRC to deploy a next-generation mobile solutions so that military providers at Madigan can access critical health information securely on the latest mobile devices over wide-area cellular network. I absolutely believe that over the next 10 years, mobile technology will undergo the seismic changes that we have experienced over the past 20 years with desktop/laptop 

computing. With increased mobile bandwidth coupled to greater computing power 

coupled to pervasive communication media (voice, email, text, video, etc.), the days 

of Dick Tracy’s video watch is not far off. Since health care involves inherently a 

mobile workflow, I am excited as a physician and technologist how mobile technology will transform the practice of care. Finally, I am also excited about how mobile technology in conjunction with health care data interoperability will empower 

our patients and veterans to assume true ownership of their care and health. I 

think that mobile technology can send alerts to our patients to make appropriate 

follow-ups, refill medications, and interface with their providers in virtual manners 

that will decrease the burden on our emergency rooms and medical practices while 

potentially keeping them out of expensive hospitalizations. 

Transitions of Care for Wounded Warriors and Broadening Health Information Technology Incentives 

On the issue utilizing health information and mobile technology to provide better, 

comprehensive care for our veterans, I would like to highlight an issue of incentives 

for ancillary providers, who play critical roles in the holistic care of our wounded 

warriors. In consideration of transitions of care for returning wounded warriors, the 

2007 Report of the President’s Commission on Care for America’s Returning Wounded Warriors notes: 

. . . Injured servicemembers receive clinical care in many settings. It may 

be provided in military hospital inpatient units and outpatient departments, in the private practices of physicians and mental health care professionals, and in various physical rehabilitation programs connected with the 

hospital, the nearby community, the VA, or back home in their own communities. They also are eligible for numerous education, training, and employment programs that, although not clinical, depend for their effectiveness on 

servicemembers’ level of physical and mental functioning. . . 

. . . With our proposed comprehensive Recovery Plan, patient records 

would need to be electronically available to the Recovery Coordinator, 

health care professionals, and program staff across the continuum—from 

acute care, to rehabilitation, to long-term support, education, and employment programs, if needed. The system must be secure and designed so that 

various professionals have access to the information germane to their 

work. . . 

This means groups that provide orthotics and prosthetics, physical therapists, 

psychologists and more need to be part of the continuum of care with respect to electronic records and exchange. By leaving key groups out of incentives we are not only 

failing the recommendations of the Commission but delaying the day when full coordination across the continuum of care will apply. 

Unfortunately, the ARRA funding for health information technology adoption left 

these critical groups out. The exclusion of these groups from the HIT puts care coordination and exchange even further behind. Cogon and Pensacola are focusing on 

the transitions of care between military and civilian providers. Wounded warriors 

are a particularly important use case to promote and we look to Congress to assist 

with this effort. Again, by leaving key groups out of the incentives programs, we 

are undermining this vision and ignoring critical stakeholders in VLER communities. 


ebenthall on DSK9Q6SHH1PROD with HEARING
70 

4Presentation of Neal Neuberger, Executive Director, National Rural Health Association, 

Rural Health Policy Institute before the Institute for eHealth Policy, January 25, 2010. 

Challenges for Rural Communities 

According to the National Rural Health Policy Institute challenges for rural communities include: 4

• Patients may be isolated, must travel long distances or are homebound; Access 

is a major problem • Rural residents and minorities may be older, and often with certain chronic conditions • Cultural and Language Barriers • Low patient volume • Longer wait times for Care • Disjointed care; Lower quality of care • Lower income, and less private insurance • Many are Less Likely to Own or Use Computers • Limited (but growing) Use of Internet • Underserved Health care Providers may have no IT support let alone an IT Department; HIT Worker Shortages • Hard to find M.D. or Admin. leaders/Change agents • Other business priorities i.e. ‘‘surviving’’ • No business case for connectivity/linkages to other institutions • No aggregate buying power (hence pooled vendor selection processes & need for 

Networking) • Need to address critical referral pattern issues, disruptions, patient flows etc. 

These are all very significant that I believe highlights the need for web-based 

health information technology and mobile technology to help mitigate issues. Obviously, web-based exchange needs broad-band access, and I believe that the Federal 

Communications Commission is making significant investments to address rural 

broad-band. It must be noted that in Pensacola, the Chamber is also the lead agency 

in rolling out the Lambda Rail, which provides large bandwidth via a fiberoptic 

cable. Web-based software as a service in conjunction with broadband access will 

allow for ‘cloud computing’ offerings that will lower the barriers for rural communities to implement leading-edge approaches to better physical and mental health 

care. Below are some approaches that I believe could be championed by the VA in 

rural communities: 

1. Social Networking—Modern health care is an inherent social network with the 

patient/veteran at its core. So some of the concept of FacebookTM and other social sites can be adopted to bring a level of transparency that will allow for 

multiple providers to better coordinate the complex, remote care of veterans in 

rural communities. Furthermore, I believe that social networking can be a 

means for veterans to support themselves as ‘brothers in arms’ in their transition to civilian life. 

2. Interactive Mobile Personal Health Records—Personal Health Records (PHR) 

including My HealtheVet have had challenges of adoption by patients. At 

Cogon, we are working toward a mobile approach to PHR that will interact 

with patients via cell phones. We believe that health information needs to be 

available to the patients wherever and whenever they may be. And the same 

mobile mechanism can be utilized to reinforce specific care goals such as medication compliance via alerts and text messaging. 

3. Care and Referral Management—The sustained care of wounded warriors often 

entails a coordinated complex care management scheme involving military, VA, 

and civilian providers. The coordination of care can be better automated and 

tracked, 

4. Tele-medicine—Access to the cumulative record of veterans in rural communities will facilitate for veterans to make more ‘virtual’ visits to providers such 

as specialists. 

5. Disease Management—As more health information becomes integrated and 

standardized, it will allow for the greater use of sophistical analytics tools to 

maximize patient care. 

Summation 

As a physician and a veteran, I would like to thank this Committee for allowing 

me the opportunity to testify on a subject that is personally dear to me—the care 

of veterans. I believe that VA in conjunction with the MHS has an enormous opportunity and responsibility to maximize its leadership in health information techVerDate Nov 24 2008 09:28 Dec 17, 2010 Jkt 058054 PO 00000 Frm 00074 Fmt 6604 Sfmt 6621 I:\VA\58054.XXX GPO1 PsN: 58054

ebenthall on DSK9Q6SHH1PROD with HEARING
71 

nology in order to take care of our veterans. We hope the Subcommittee will support 

efforts to add exchange with the VA to our current civilian-DoD exchange efforts 

in Pensacola to improve veterans care. 

f 

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 

Mr. Chairman and distinguished Members of the Committee, we are grateful for 

the opportunity to provide testimony on Overcoming Rural Health Care Barriers: 

Use of Innovative Wireless Health Technology Solutions. My name is Dan Frank 

and I am the Managing Partner of Three Wire Systems, LLC (Three Wire). I am 

joined by my colleague, Dr. Ian Shaffer. Dr. Shaffer is the Chief Medical Officer for 

MHN. Three Wire is the prime contractor and MHN provides clinical support for 

the VetAdvisor Support Program which is the topic of our testimony. 

We will provide an overview and results to date of the VetAdvisor Support Program (VetAdvisor), an innovative evidence-based program that provides mental 

health outreach and health coaching services to Operation Enduring Freedom and 

Operation Iraqi Freedom (OEF/OIF) Veterans and their families, in both urban and 

rural areas. VetAdvisor uses non-traditional telehealth/virtual health delivery platforms to reach out to, and improve Veteran awareness of, and access to, the mental 

health support for which they are eligible. 

What Is VetAdvisor?: 

Telehealth is the underpinning of this ongoing program to ensure Veterans who 

have enrolled in VA and who may have mental health issues do not fall through 

the cracks. VetAdvisor is a two-part program—sponsored during the past 3 years 

by Veterans Integrated Service Network (VISN) 12, which augments and supports 

existing VA behavioral health care services, and assists Veterans with challenges 

they face during reintegration into civilian life. Using a call center that makes outgoing calls to conduct VA-approved behavioral health screenings, VetAdvisor identifies and refers to VA Veterans who may be in need of clinical behavioral health assistance. In addition, health coaching is a newer component of the program, which 

provides Veterans with an opportunity to participate in individual or group health 

coaching sessions using a virtual room on a computer, or by phone, if the computer 

is not an option. For example, a Veteran may work with a health coach on issues 

such as tobacco cessation, weight management, or understanding Post Traumatic 

Stress Disorder (PTSD) management. 

VetAdvisor assists Veterans and their families, providing complementary, nonclinical support to Veterans identified and referred to the program by VA. Telehealth platforms allow enrolled OIF/OEF Veterans to stay connected and focus on 

areas of concern to them without leaving their homes. VetAdvisor’s trained health 

coaches (i.e., Licensed Clinical Social Workers) who conduct these sessions are critical to the popularity and growing success of this innovative VISN 12 initiative. 

VetAdvisor, as an extender of VA face-to-face clinical services, focuses on identifying and working with Veterans who have, or are at risk for, PTSD, 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. 

From Wired Broadband to Mobile Wireless Health Platforms 

In the past, Veterans who opted to use the virtual world health coaching program 

required wired broadband internet connectivity for their desktop or laptop 

computers to access a 3D collaboration environment to work with their health coach 

as depicted below. 


ebenthall on DSK9Q6SHH1PROD with HEARING
72 

However, Veterans who reside in rural areas can face challenges acquiring such 

wired services. Recognizing this limitation, VetAdvisor worked with our technology 

partners to leverage the most ubiquitous of consumer electronic devices: the mobile 

phone. In the United States, there are over 285 million mobile phones in use, 

which equates to a 91 percent market penetration. The use of mobile devices to 

wirelessly provide highly mobile or rural populations direct access to a health care 

system is an important component in VA’s transition to the Patient Centered Medical Home model. VetAdvisor will launch a virtual world smartphone capability (i.e., 

iPhone) in the fall of 2010. By extending the virtual world to smartphones, we can 

significantly increase the Veteran user base in rural areas where broadband service 

is not available but cellular service is. Additionally, please note that if Veterans opt 

to not to use the virtual world, they can simply use their cell phones to obtain 

health coaching services. 

Today’s Veterans are increasingly reliant on mobile devices for communication 

and entertainment. VetAdvisor allows Veterans to access their health coach/virtual 

room on their own terms at a time and place that is most advantageous to them. 

The image below is an example of the VetAdvisor Virtual Room (VVR) as hosted 

by an Apple iPhone. We envision Veterans using these mobile devices anywhere and 

anytime they desire to work with their health coach within the virtual world. The 

scene below depicts a Veteran working with his medical team in the VVR to discuss 

the loss of a limb. 


ebenthall on DSK9Q6SHH1PROD with HEARING58054A.002
73 

Leveraging the latest wireless technology employing telephonic and virtual world 

platforms, this program provides a cost-effective, appropriate and popular expansion 

of VA’s telehealth capability to allow for convenient follow-up with Veterans in 

urban and especially rural communities that VA identifies as at risk. 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, school and families. 

The Evolution of VetAdvisor 

VetAdvisor was initiated as a competitively awarded contract in 2007 by VISN 12, 

to Three Wire Systems, LLC (Three Wire), a Service Disabled Veteran Owned Small 

Business, and MHN, a Health Net behavioral health company. 

Veterans who enroll in VA after returning home do not always seek clinical help 

until their mental health needs are critical. This may be due to a lack of understanding of symptoms, denial that a problem exists, lack of awareness of available 

mental health support, or stigma. VetAdvisor overcomes these barriers through its 

telephonic/virtual approach to identifying behavioral health care issues and virtual 

health coaching. VetAdvisor contacts those Veterans who may not take the initiative 

to get involved in mental health care before a tragedy or issues occur. VetAdvisor 

does this by using a proactive outreach approach: 

• Using Computerized Patient Records provided by VA, VetAdvisor representatives call Veterans to thank them for their service • During the phone call or at a scheduled date/time that is convenient to the Veteran, the health coach assesses the Veteran through a series of VA-approved 

screenings. The screenings cover both medical and behavioral health conditions 

associated with serving in combat to include: PTSD, Traumatic Brain Injury 

(TBI), suicide risk. substance abuse, depression and common medical disorders. • If needed, a referral is made (and followed up on) to a VA mental health clinician. • The VA medical facility is provided with the results of these screenings. The 

VA uses the results for follow-up and further evaluation. Once Veterans with 

behavioral issues are identified, they are encouraged to enroll in the VetAdvisor 

Health Coaching Program. • The Health Coaching Program facilitates and supports Veteran involvement in 

existing VA services. A health coach is assigned to the Veteran for regular contact, advocacy, skill building, support and to provide motivation to seek treatment. • Coordination continues with the Veteran, health coach, and primary care physician for as long as necessary. 

Health coaching services are provided to Veterans through telephonic communication and/or virtual collaboration technology—the VetAdvisor Virtual Room (VVR). In 

the VVR, the Veteran and the coach interact as avatars. This highly immersive virtual environment provides strong feedback that enhances collaboration and communication. Virtual technology assists Veterans in their reintegration efforts in a number of ways. One of the major advantages is that it allows for the Veteran to discuss 

personal issues from the privacy of his or her own home or private setting of choice. 

Veterans maybe more willing to acknowledge the magnitude of their issues in this 

private environment. Secondly, it saves the veteran time and travel costs associated 


ebenthall on DSK9Q6SHH1PROD with HEARING58054A.003
74 

with office visits. For today’s Internet savvy generation of Veterans and their families, this form of communication feels more natural than traditional communication 

methods. 

VetAdvisor Coaching Groups 

During the 18 month pilot period, VetAdvisor engaged over 10,000 Veterans from 

VISN 12. As a result of the program, over 1,100 Veterans were directed to VA medical facilities for follow up on positive screening results. The statistics support the 

program’s success: when a Veteran was successfully contacted, there was a 95 percent acceptance for health coach screening appointments. The types of issues discussed in health coaching sessions cover a wide range. The top issues are occupational, anxiety, health lifestyle management and depression. 

The figure below illustrates the range of issues addressed in the sessions. 

VetAdvisor’s proactive outreach and screening for behavioral issues has proven to 

be an effective tool in assisting Veterans ability to access services to treat or prevent 

potential issues such PTSD, depression, or substance abuse that can lead to a downward spiral in their life and even result in homelessness. It is designed to provide 

support when and where the veteran chooses, and to motivate those who realize 

they may benefit from assistance to access services. It augments existing VA services by being pro-active rather than just waiting for the Veteran to seek care. The 

VetAdvisor program is a successfully demonstrated approach to increase and improve the VA’s involvement and assistance to OEF/OIF Veterans. The VetAdvisor 

program can be offered throughout VHA to ensure that Veterans do not fall through 

the cracks following their initial visit to and enrollment in VA. VetAdvisor provides 

the VA a mechanism to overcome access to care challenges for Veterans living in 


ebenthall on DSK9Q6SHH1PROD with HEARING58054A.004 58054A.005
75 

1 Veteran Population Model; VetPop 2007. Office of the Assistant Secretary for Policy and 

Planning Office of Policy (008A2). http://www1.va.gov/VETDATA/Demographics/Demographics.asp 2The Office of Rural Health, Departement of Vererans Affairs http://www.ruralhealth.va.gov/ 

RURALHEALTH/AboutlRurallVeterans.asp. 

rural areas by using technology, including wireless technology, and solutions to provide outreach and ongoing support to Veterans, regardless of where they live. 

On behalf of Three Wire Systems and MHN/Health Net, we would like to thank 

you again for your interest in ways telehealth solutions like the VetAdvisor program 

can help our Veterans and their families in geographically remote areas receive the 

care and services they have earned through service to our country. We are grateful 

to the Subcommittee for its leadership and commitment to identifying innovative 

programs to improve access to and promote quality of care that can support the 

unique needs of enrolled Veterans residing in geographically remote areas. 

f 

Prepared Statement of John Mize, Director, LifeWatch Federal, LifeWatch 

Services, Inc., Rosemont, IL 

Thank you for the opportunity to testify this morning. LifeWatch is a Health IT 

telemedicine service provider that represents 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 services help diagnose patients suffering from arrhythmia and obstructive sleep apnea in an ambulatory and near real time environment. 

LifeWatch has built a virtual health care service solution that supports efficient 

data transfer of critical health data to providers for diagnosis and treatment. 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. 

We are most certainly at a crossroads in health care. As the estimated 40 million 

Americans aged 65 and older enter the insurance pool in the coming years, our Nation’s health care system will be faced with many challenges to effectively meet the 

needs of our Aging population. Older patients with chronic diseases will consume 

an ever increasing portion of total health care spending. Moreover, funding constraints coupled with an increasing shortage of health care providers and a deficient 

hospital capacity to meet this ever-growing demand will further challenge our 

present system. 

The Department of Veterans Affairs in particular will be serving a significant percentage of our Aging population with one or more chronic health care diseases, and 

the increased demand for limited health care resources is an issue that has and will 

continue to be an issue for the VA. According to data from Department of Veterans 

Affairs the percentage of Veterans age 65 or greater is expected to increase roughly 

7 percent in the next 20 years.1

Given this environment it is critical that we continue to identify, research, and 

incentivize new delivery methods for health care in the United States. Telemedicine 

offers significant promise for reducing barriers regarding supply & demand, geography, a changing patient-provider relationship, and most importantly for reducing 

cost and improving outcomes for chronic diseases. The technology is here now. 

Whether it is provider-to-provider video consultations, remote telediagnostics, remote chronic disease management, or wireless monitoring, the technology is all 

readily available today and in many cases proven many times over. 

Despite overwhelming evidence regarding the benefits of telemedicine, CMS has 

been slow to adopt reimbursement structures that incentivize providers to adopt the 

technology in addition to supporting innovation among device manufacturers, software providers, and medical services. CMS has been challenged with managing 

costs without abuse to the system because telemedicine is a new method of health 

care delivery with unique costs. 

The Department of Veterans Affairs has been a bright spot in terms of the adoption of innovative wireless and land based telemedicine solutions which have been 

proven to reduce cost, improve outcomes, and support the large population of rural 

veterans in geographically challenging locations. According to the Office of Rural 

Health an estimated 38 percent of all veterans live in either rural or very rural geographies.2

The Office of Care Coordination under the leadership of Dr. Adam Darkins has 

proven that telemedicine overcomes challenges in managing chronic diseases even 

among the most difficult to treat and historically noncompliant patient population. 


ebenthall on DSK9Q6SHH1PROD with HEARING
76 

3Darkins A, Ryan P, Kobb R, Foster L, Edmonson E, Wakefield B, Lancaster A. Care Coordination/Home Telehealth: The Systematic Implementation of Health Informatics, Home Telehealth, and Disease Management to Support the Care of Veteran Patients with Chronic Conditions. Telemedicine and E–Health December 2008;vol. 14 no 10 1119. 4Department of Veterans Affairs, Stroke Queri Strategic Plan and Annual Report, 2007; 

8–9. 

According to Dr. Darkin’s research, the VA telemedicine program managed a 25 percent reduction in number of bed days of care as well as a 19 percent reduction in 

hospital admissions for patients using telemedicine to manage chronic diseases.3

While telediagnostics with the use of our services has not been as centrally driven 

as chronic disease telemonitoring, we have a number of shining examples of VA facilities utilizing our wireless service to overcome challenges in treating rural patients. 

The LifeStar Ambulatory Cardiac Telemetry (ACT) service platform is based upon 

an algorithm that automatically and instantly detects and transmits clinically significant changes in heart rate and rhythm. For example, if you are complaining of 

feeling dizzy, lightheaded or a racing heart your cardiologist might prescribe our 

service for 30 days to help diagnose what is causing the changes in your heart rate 

or rhythm. The VA Medical Center completes the enrollment to LifeWatch and we 

in turn ship the device directly to the patient’s house with all the necessary equipment and a prepaid envelope to mail it back following completion of the study. Following a successful implementation of the service the patient simply goes about 

their daily activity while the device and service continues to work. 

The transmission is sent via a cellular network such as Verizon to one of our Joint 

Commission Accredited monitoring facilities in which certified cardiovascular technicians are staffed 24 hours a day, 7 days a week. The technicians view transmission, 

edit the ekg data, create a report, and provide it back to the clinician via a secure 

password enabled Web site or a direct EMR interface. 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 cardiovascular disease 

and stroke. 

An improvement in the incidence of stroke increases quality of care and at the 

same time significantly reduces cost. Research from the Stroke Queri team based 

out of the Indianapolis VAMC indicates that stroke cost the Department $315 million in FY 2005 with a cost per patient of over $18,000. The importance of stroke 

within the VA is emphasized by the fact that stroke patients account for over 10 

percent of the VA’s complex caseload, with a cost per patient that is over 3.4 times 

the overall VA average.4

Additionally the service allows veterans to remain in their home, reduces travel 

reimbursement expenses, and allows VA medical centers to shift employee resources 

to other more important responsibilities. The impact for rural veterans is even more 

pronounced in regards to cost savings, access to care, and improved outcomes. 

We have seen significant success stories of VA Medical Centers that have made 

the leap into utilizing advanced technology like the LifeStar ACT to the benefit of 

their patient population. For example prior to utilizing the LifeStar ACT service, the 

Las Vegas VA Medical Center was flying patients to San Diego to be hooked up on 

antiquated technology. The clinic made the decision to utilize our service which significantly reduced travel reimbursement expenses, allowed the VA to shift employee 

resources to other more important responsibilities, and allowed veterans to remain 

in their homes for extended diagnostic care. 

LifeWatch has also recently introduced a home sleep testing service to the market 

for the diagnosis of Obstructive Sleep Apnea. The NiteWatch service has the potential of significantly reducing costs for severely overburdened sleep labs within the 

Department of Veterans Affairs, and at the same time stands to save the VA millions in lost revenue from fee service commercial sleep labs. Wait times for sleep 

labs within many VA facilities exceeds 6 months and as a partial 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 using a commercial sleep lab, stands 

to eliminate chronic patient waiting lists, and helps improve compliance as the testing is all completed in the home. According to a recent article published in the USA 

Today, ‘‘veterans are four times more likely than other Americans to suffer from 

Sleep apnea. About 5 percent of all Americans suffer from sleep apnea compared 

to 20 percent of veterans’’. The number of claims for the sleep apnea has gone from 

39,145 in 2008 to 63,118 in 2010. 

While there are many success stories we have also had our fair share of struggles 

within the VA. We are a GSA small business vendor and despite our status on the 


ebenthall on DSK9Q6SHH1PROD with HEARING
77 

1 CTR FOR MEDICARE & MEDICAID SERV., NATIONAL HEALTH EXPENDITURE PROJECTIONS 2008–2018, http://www.cms.hhs.gov/NationalHealthExpendData/downloads/ 

proj2008.pdf (last visited Jan. 21, 2010). 2Susan Dentzer, Reform Chronic Illness Care? Yes, We Can, 28 HEALTH AFF. 12, 12 (Jan./ 

Feb. 2009), available at http://content.healthaffairs.org/cgi/reprint/28/1/12. 3http://www.cbo.gov/ftpdocs/63xx/doc6332/05-03-MediSpending.pdf. 

4http://www.census.gov/population/www/projections/summarytables.html. 

5See Health Res. & Serv. Admin., U.S. Dep’t of Health & Human Serv., The Physician Workforce: Projections and Research into Current Issues Affecting Supply and Demand (2008), ftp:// 

ftp.hrsa.gov/bhpr/workforce/physicianworkforce.pdf (HRSA, Physician Workforce); Michael J. Dill 

& Edwa rd S. Salsberg, Ass’n of Am. Med. Coll., The Complexities of Physician Supply and DeContinued 

Schedule, procurement remains a struggle. It can take upwards of 2 years for some 

facilities to finalize the budgeting and contracting process despite the clinicians request to utilize the service. The disjointed nature of contracting and procurement 

necessitates that we work facility by facility on the contracting and procurement 

process. 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 VISN’s under the demonstration project. 

Additionally we’ve struggled with a lack of a quality standard of care for remote 

cardiac monitoring. In 2004 CMS placed a requirement on remote cardiac monitoring which included the necessity of providing 24 hour live attended coverage for 

patients wearing ambulatory devices. The VA does not follow the same standard of 

care across the board. While there are many VA facilities that do utilize LifeWatch 

or a similar service, many VA Medical Centers own their own antiquated equipment 

and provide their patients with their own monitoring often without providing 24 

hour live coverage. For example, if a patient were put on a VA owned monitor and 

had a serious cardiac event on Friday evening the clinic would not hear about it 

until the patient call to transmit the data on Monday. 

Lastly we have struggled with a lack of clarity on how to interface our data with 

the Vista Imaging/CPRS electronic medical record system within the VA. Multiple 

cardiology clinics have requested that our data be interfaced and in fact many facilities will not use our service until we are interfaced. Despite the demand among cardiology clinics, we have hit multiple road blocks 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 VA customers. 

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. 

That concludes my written statement and I would welcome any questions you 

may have. 

f 

Prepared Statement of Kerry McDermott, MPH, Expert Advisor, Federal 

Communications Commission 

Good afternoon Chairman Michaud, Ranking Member Brown, and distinguished 

Members of the Veterans Affairs Subcommittee on Health. My name is Kerry 

McDermott and I’m a member of the health care team for the National Broadband 

Plan at the Federal Communications Commission. 

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. 

Improving America’s health and America’s health care system is one of the most 

important tasks for the Nation. Health care already accounts for 17 percent of U.S. 

gross domestic product (GDP) and by 2020, it will top 20 percent.1 This is due to 

many factors but one of the most important is that America is aging. There is a 

direct correlation between the elderly and chronic disease, which already accounts 

for 75 percent of the nations health care costs.2 5 percent of Medicare beneficiaries, 

who in most cases have one or more chronic conditions, constitute 43 percent of 

Medicare spending.3 By 2040, there will be twice as many Americans older than 65 

as there are today.4 Exacerbating this situation is a health care supply problem. A 

shortage of tens of thousands of physicians is expected by 2020.5


ebenthall on DSK9Q6SHH1PROD with HEARING
78 

mand: Projections Through 2025, at 6 (2008) (estimating a shortage of 124,000 physicians by 

2025), https://services.aamc.org/publications/index.cfm?fuseaction=Product.displayForm&prdl 

id=244 (download report from this page). 6 New England Healthcare Institute, Research Update: Remote Physiological Monitoring (Jan. 

2009), available at http://www.nehi.net/publications/36/remotelphysiologicallmonitoringl researchlupdate. 7 Adam Darkins et al., Care Coordination/Home Telehealth: The Systematic Implementation 

of Health Informatics, Home Telehealth, and Disease Management to Support the Care of Veteran 

Patients with Chronic Conditions, 10 Telemed. & e-Health 1118, 1118 (2008), available at http:// 

www.liebertonline.com/doi/pdf/10.1089/tmj.2008.0021?cookieSet=1. 8 CATHY SCHOEN & ROBIN OSBORN, THE COMMONWEALTH FUND, THE COMMONWEALTH FUND 2009 INTERNATIONAL HEALTH POLICY SURVEY OF PRIMARY CARE 

PHYSICIANS IN ELEVEN COUNTRIES 10 (2009), http://www.commonwealthfund.org/∼/media/ 

Files /Publications / In%20the%20Literature / 2009 / Nov /PDFlSchoenl2009lCommonwealthl Fundl11countrylintllsurveylchartpacklwhitelbkgdlPF.pdf. Count of 14 functions includes: (1) electronic medical record; (2, 3) electronic prescribing and ordering of tests; (4–6) electronic access to test results, Rx alerts, and clinical notes; (7–10) computerized system for tracking lab tests, guidelines, alerts to provide patients with test results, and preventive/follow-up 

care reminders; and (11–14) computerized list of patients by diagnosis, by medications, and due 

for tests or preventive care. 9 Chapter 9, ‘‘Adoption and Utilization’’, National Broadband Plan. 

But there’s a set of broadband-enabled health information technologies (health 

IT), both now and emerging from development, that have the potential to improve 

clinical outcomes while reducing the cost of care and extending the reach of the limited pool of health care professionals. The New England Healthcare Institute found 

that remote patient monitoring for heart failure can save up to $6.4 billion annually 

through reduced hospital readmissions.6 The Veterans Hospital System’s Care Coordination/Home Telehealth Program (CCHT) for veterans with chronic conditions 

has resulted in a 19 percent reduction in hospital admissions and a 25 percent reduction in bed days for those who are admitted.7

Even though these technologies hold great promise, the U.S. lags behind other developed countries in health IT adoption, with one study ranking it in the bottom 

half (out of 11 developed countries) on every metric used to measure adoption.8

The Broadband Plan identifies some of the barriers that hinder the adoption of 

broadband-enabled, wireless health solutions and provides specific recommendations 

the government should undertake to remove these barriers, as well as foster innovation and investment in these new, life-saving devices. 

With respect to e-care technologies, these barriers and subsequent proposed solutions fall into three main categories: 

1. The connectivity gap. Broadband is either unavailable or too expensive. 

2. Outdated regulations. Rules that were created when our only interactions with 

physicians were in their offices—not via remote monitoring and video consultations. 

3. Misaligned economic incentives. The prevailing fee-for-service reimbursement 

system pays for volume rather than outcomes, and hence prevents reimbursement for many of these technologies. 

Let me now discuss each in detail: 

The first issue is connectivity, including both broadband at home as well as 

connectivity to health providers. With respect to the home, the plan estimates that 

93 million Americans are not connected to broadband. We estimate that 14–24 million Americans do not have access to broadband where they live, even if they want 

it. It’s hard to identify what proportion of the 14–24 million, who don’t have the necessary infrastructure, is over the age of 65, let alone veterans. But what we do know 

is that individuals over the age of 65 are poor adopters of broadband, estimated to 

be 35 percent as compared to the national average of 65 percent.9 This is due to 

multiple reasons such as cost, digital literacy, and perceived lack of relevant digital 

content delivered over the Internet. In order to respond to these challenges, the plan 

recommends the launch of a National Digital Literacy Corps and that public and 

private partners prioritize efforts to increase the relevance of broadband for older 

Americans. The plan also sets the goal of providing access for every American to 

robust and affordable broadband service. This will be accelerated by a once-in-a-generation transformation of the Universal Service Fund, which includes the creation 

of a ‘‘Connect America Fund’’ as well as reforming the Lifeline and Link-Up programs. Mobile solutions are an important piece of the Broadband Plan’s strategy for 

home broadband. Some States have materially lower 3G deployment than the national average and the proposed ‘‘Mobility Fund’’ would help bring all States to a 

minimum level of 3G or better wireless coverage. 


ebenthall on DSK9Q6SHH1PROD with HEARING
79 

A focus of mine has been the connectivity issues for health care providers. It is 

imperative that hospitals and physician offices have adequate connectivity as any 

care that will be delivered to an individual’s home will originate in a health care 

facility of some description. Our analysis highlighted that some providers are not 

served by existing ‘‘mass-market’’ broadband infrastructure. Approximately 3,600 

small physicians’ offices fall into this gap. Of these, 70 percent are in rural locations. Furthermore, 29 percent of rural health clinics do not have access to adequate 

mass-market broadband. Larger providers must purchase ‘‘Dedicated Internet Access’’ (DIA) to meet their quality-of-service requirements, but DIA solutions are 

often at least 4X more expensive than mass-market solutions. This cost issue is further exacerbated by the fact that DIA solutions differ greatly in price, thus preventing all providers from having affordable broadband available to them. 

The National Broadband Plan addresses the health care provider connectivity 

issues by proposing to revamp the FCC’s Rural Health Care Program. The program 

provides three types of subsidies to public and nonprofit health care providers. It 

is the largest sustainable fund for health care connectivity within the government. 

The Commission will be considering ways to make the program more effective without changing the program’s funding cap by creating a permanent infrastructure 

fund, broadening coverage for monthly recurring costs to all types of broadband 

services, and expanding eligibility for the program. Importantly, any FCC funding 

must ensure that broadband for health care providers is resulting in improved 

health outcomes, and we are working closely with the Office of the National Coordinator to understand the evolving ‘‘Meaningful Use’’ criteria as we consider how such 

criteria could be incorporated into FCC programs. These proposed changes will enable more institutions to acquire the infrastructure needed to support a realm of 

health IT solutions, opening the possibility for greater investment and innovation. 

A Notice of Proposed Rulemaking is expected to be released shortly, opening the formal comment cycle on this proposal to revamp the FCC’s Rural Health Care Program. 

The second set of barriers pertains to a range of regulations that prevent e-care 

solutions from being adopted. State licensing, credentialing, and privileging rules 

may prevent physicians from providing remote broadband-enabled care across State 

lines and even at in-state hospitals other than their usual place of work. Patient 

safety must be addressed by ensuring that physicians are suitably skilled—but regulations must not stifle the innovation and gains promised by health IT. To this 

end, the Broadband Plan recommends that credentialing, privileging, and licensing 

rules be re-evaluated. We are pleased that CMS is seeking comments on a proposed 

rule to revise privileging requirements to allow for the advancement of telemedicine 

nationwide while protecting the health and safety of patients. 

There is regulatory uncertainty regarding the convergence of communications and 

medical devices. The combination of devices, applications, and communications networks is enabling clinicians and patients to give and receive care anywhere at any 

time. For example, mobile sensors in the form of disposable bandages and ingestible 

pills relay real-time health data over wireless connections. Diabetics can receive continuous, flexible insulin delivery through real-time glucose monitoring sensors that 

transmit data to wearable insulin pumps. Medical body area networks monitor various vital signs and detect the onset of a patient ‘‘crash’’ while in a hospital in time 

for treatment. 

With these new solutions come new challenges. When medical and wireless devices and applications converge, the regulatory lines become blurred. At one end, 

general-purpose communications devices such as smartphones, wireless routers, and 

certain videoconferencing equipment are regulated by the FCC. At the other end, 

medical devices that critically monitor patient health or provide treatment or therapy are regulated by the FDA. Devices that do provide critical care and also use 

communications, such as life-critical wireless devices like remotely controlled drugrelease mechanisms, are regulated by both agencies. In addition, device applications 

that would not be governed by the FCC but transmit over wireless networks might 

warrant FDA oversight, while the FCC might have better capability to assess the 

reliability of their communications capability. 

Uncertainty regarding regulatory frameworks and approval processes can discourage private sector innovation and investment, 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 are holding 

a joint public meeting on July 26 and 27, 2010, to address these challenges. We propose to bring together various stakeholders from manufacturers to practitioners to 

patients to better understand the types of devices and applications that are being 

introduced, clarify the requirements that apply, and improve the regulatory and apVerDate Nov 24 2008 09:28 Dec 17, 2010 Jkt 058054 PO 00000 Frm 00083 Fmt 6604 Sfmt 6621 I:\VA\58054.XXX GPO1 PsN: 58054

ebenthall on DSK9Q6SHH1PROD with HEARING
80 

proval processes to the extent possible. Our aim at the FCC is to protect patient 

safety while promoting innovation and investment. 

Lastly, although broadband connectivity and regulatory uncertainties are issues, 

the greater barrier is on the demand side of the equation. Within a fee-for-service 

reimbursement system, providers bear the costs of health IT implementation and 

changes to workflow, but don’t fully capture the economic gains created through improved clinical outcomes. The plan recommends that well-understood use cases of 

e-care technologies should be incented with outcomes-based reimbursement, similar 

to the Meaningful Use program for Electronic Health Records. In addition, novel 

technologies should be tested for their clinical efficacy, as well as within payment 

model pilots, in order to ascertain their economic value. Given that it will take 

many years to implement an outcomes-based payment model, reimbursement should 

be expanded for e-care technologies that will prove system-wide expenditure reductions under CMS’s fee-for-service model. It is imperative that there be economic incentives for physicians of various specialties to collaborate and better manage elderly patients with chronic conditions that often require multiple specialty inputs. In 

addition, incentives must be aligned to promote the prevention and better management of disease within the community rather than reactively and at greater expense 

within hospitals. The Plan recommends a dedicated effort by HHS to propose specific programs and reimbursement changes that will help realize the value of e-care 

technologies. Without reimbursement reform, the market for health IT solutions is 

limited. This, in turn, inhibits investment and innovation; the FCC believes this 

trend must be reversed. 

There are multiple barriers that must be resolved in order to fully develop the 

ecosystem of broadband-enabled health IT. The underlying infrastructure must provide a solid foundation to build upon. Yet, technology alone will not solve our health 

care challenges; it must be coupled with payment reform, innovation in service delivery, and improved regulatory transparency. It is imperative that government action—and inaction—do not hinder investment and innovation. The recommendations 

of the National Broadband Plan seek to unlock the value of health IT so all citizens 

may realize its benefits and cost savings. Any government approach to solve these 

issues must be coordinated—not only across the government, but with the private 

sector and the entire health care community. 

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

f 

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 

Chairman Michaud, Representative Brown, Members of the Committee thank you 

for this opportunity to discuss the U.S. Army Medical Department current mobile 

health projects, future initiatives and challenges in implementing wireless technology across health care organizations. 

The U.S. Army recognizes that mobile devices represent an enormous opportunity 

for health care outreach, not only within the active duty and dependent population, 

but also within the global community. Globally, there are currently over 4.6 billion 

cell phones and approximately sixty percent of the world’s population owns cell 

phones. Social networks, too, have come to go hand in hand with mobile devices. 

Facebook has surged past Yahoo! as the second most popular site in the U.S., drawing nearly 400 million visitors. Statistics also show that more people access social 

networks using the mobile web than they do using desktop computers. Mobile devices are superseding desktop and even laptop computers as the tool of choice for 

communication in the virtual sphere. 

Mobile health or ‘‘mHealth’’—defined broadly as emerging mobile communications 

and network technologies for health care systems—can be an agent for behavior 

change, impacting health care challenges such as smoking cessation, diabetes, and 

appointment attendance. Applications for cell phone and smart phone platforms are 

emerging that enable clinical consultation, patient and provider education, research, 

biosurveillance, and disease management. 

The development, implementation and maintenance of any mobile cell phone solution presents a number of innovations, challenges and solutions not widely seen in 

other aspects of telemedicine. Wireless device and carrier credentialing and certification, lack of interoperability, Health Insurance Portability and Accountability Act 

(HIPAA) considerations, and maintaining currency in an ever-changing landscape of 

devices and operating systems requires strategic planning and long range focus. 


ebenthall on DSK9Q6SHH1PROD with HEARING
81 

There are numerous current obstacles and challenges to launching a comprehensive 

mobile solution, yet many successes are evident. Today I would like to discuss three 

initiatives the U.S. Army’s Telemedicine and Advanced Technology Research Center 

is currently investigating to improve patient outreach and health outcomes using 

wireless technology. 

The U.S. Army has developed, deployed, and is currently evaluating a mobile telephone-based secure messaging system called ‘‘mCare’’. The ‘‘m’’ in mCare stands for 

mobile. The project explores the potential of mobile devices, specifically personal cell 

phones, for use in the Military Healthcare System. The mCare system is a secure, 

HIPAA compliant, bi-directional messaging system that allows information to be 

sent to the servicemember’s personal cell phone. The Soldiers’ responses are returned securely to the mCare web portal. Presently, mCare provides daily messages 

via cell phone to wounded Warriors in the outpatient phase of their recovery, while 

they are recuperating in their homes. The servicemembers’ own personal cell phones 

are utilized. 

Patients with mild traumatic brain injury are a target population for mCare. 

Health tips, appointment reminders and general announcements are distributed 

from a secure central Web site where health care providers can enter and control 

message content, as well as review acknowledgements and delivery confirmations. 

Each mCare patient receives a minimum of 6 messages per week, meeting or exceeding the U.S. Army’s required contact rates for wounded Warriors receiving outpatient care in their home communities. 

The initial group of mCare’s targeted participants are Warriors in Transition 

(WTs) assigned to Community Based Warrior in Transition Units (CBWTUs). Soldiers assigned to a CBWTU are typically National Guard or Army Reservists who 

receive outpatient care in their home community and are monitored remotely by a 

case manager/care team from a regional case management center. mCare is not intended to replace all face-to-face or telephone based encounters from the CBWTU 

team, rather it is designed to complement these efforts with additional means of 

communication. Initially mCare has been offered to patients assigned to 5 selected 

CBWTU sites in Alabama; Florida; Illinois; Massachusetts; and Virginia that cover 

26 States. Future locations for mCare are being explored at this time at 4 additional 

sites. 

The mCare system incorporates modified commercial off the shelf technologies 

under the oversight of the U.S. Army Medical Research and Material Command’s 

Telemedicine and Advanced Technology Research Center. During the development 

of mCare particular attention was paid to network security and privacy considerations. Information that is sent to the Soldier’s mobile phone is transmitted through 

a secure Virtual Private Net (VPN) tunnel, and is only accessible with a six-digit 

personal identification number (PIN) code. Cell phone users are prompted to open 

this application through a standard text message whenever critical new information 

has been sent to the mCare application. 

As of 1 June 2010, mCare has delivered over 18,500 messages to over 300 WTs. 

Sixty-three percent of this message activity is related to appointment reminders, 

which are sent to the patient 24 hours and 90 minutes prior to each scheduled clinical encounter. The system has demonstrated improvement in appointment attendance rates. Seventeen percent of the message activity is attributed to health and 

wellness tips, which are customized to the needs of each patient from a library of 

validated resources within the mCare application. Twelve percent of the message 

traffic is related to unit specific announcements. 

There has been no appreciable age bias to the acceptance of mCare by patients; 

there are as many users over the age of 30 participating in the project as are within 

the 18–30 age groups. Additionally, 84 percent of the mCare patient participants are 

enlisted servicemembers; 16 percent are officers. More than 90 percent of the volunteer users surveyed found the mCare application on their phone easy to use or 

somewhat easy to use. Nearly 75 percent of the users surveyed preferred to receive 

contact through mCare more than once a week, and 65 percent reported that mCare 

improved their communications with their unit. 

There have been a number of challenges to overcome to achieve success with the 

mCare project to date. Because the goal was to leverage the patient’s personal cell 

phone, and not introduce a new technology to the Soldier, a wide variety of phone 

models and wireless carriers needed to be accommodated. Each wireless carrier has 

separate testing and certification processes, and specific devices have different installation processes, which all result in a complex technological process to navigate 

for the clinical teams. Developing a streamlined process that was as simple as possible for the care team, while negotiating with each wireless carrier to allow the application to be accessible to patients at no cost has been a time consuming process 

that is still ongoing. Full integration with the patient health record (PHR) is not 


ebenthall on DSK9Q6SHH1PROD with HEARING
82 

currently part of mCare’s model but the feasibility and cost to incorporate PHR is 

being explored. 

There is increasing interest in expanding the mCare to incorporate additional use 

cases and support other services outside the Army. The Veterans Health Administration and the medical departments of the U.S. Navy and Air Force have shown 

interest in utilizing mCare to support their case management activities. The Defense Veterans Brain Injury Center would like to utilize mCare for patient follow 

up. Additionally, other use cases such as medication monitoring, polypharmacy assessment, continuous positive airway pressure monitoring at home for sleep disorders, pain management and medical student well being evaluation have been proposed as additional use cases for mCare, with funding identified to enable this expansion. 

The second initiative I would like to highlight is Text4Baby. Text4Baby (T4B) is 

a free mobile health information service that provides timely health information to 

women from early pregnancy through their babies’ first year. Led by the National 

Healthy Mothers Healthy Babies Coalition, the T4B campaign has forged a new 

public-private partnership between government, private sector businesses, non-profits and academic institutions to develop innovative new models for leveraging mobile phones and the extensive cellular infrastructure to address critical health care 

challenges in the U.S. 

The T4B service aims to use one of the most widely used technologies in America—the mobile phone—to promote maternal and child health. Women who sign up 

for the service receive three free text messages each week timed to their due date 

or baby’s date of birth. The messages focus on topics critical to the health of mothers 

and babies, including nutrition, seasonal flu prevention and treatment, mental 

health issues, risks of tobacco use, oral health, immunization schedules, and safe 

sleep. 

The Army Medical Department plans to introduce T4B to military mothers at 

Madigan Army Medical Center at Joint Base Lewis McChord in Washington as part 

of a demonstration to formally evaluate the acceptability and utility of using text 

messaging to deliver information and encourage healthy behaviors as part of its 

overall maternal health outreach initiatives. 

The third wireless application that the U.S. Army is investigating is the impact 

of a video cell phone reminder system on glycemic control in patients with diabetes 

mellitus (diabetes). Diabetes affects approximately 24 million people in the U.S. and 

is associated with devastating complications in both personal and financial terms. 

Diabetes is the leading cause of blindness, non-traumatic amputations, and renal 

failure in adults and reduces life expectancy by 5–10 years. Maintaining glycemic 

control is critical for the health of diabetes patients. The reasons why more patients 

do not reach appropriate goals for glycemic control are multiple and complex, among 

them poor compliance with self monitoring of blood glucose (SMBG) and medication 

non-adherence. Despite the evidence showing the positive impact of SMBG, compliance with SMBG remains suboptimal. Approximately one-third of patients with diabetes are non-adherent to their medications—a compliance rate which is lower than 

many other medical conditions. 

The hypothesis of this study being conducted at the Walter Reed Army Medical 

Center is that a cell phone video reminder system will improve self-care and glycemic control in patients with diabetes when compared with standard of care. The 

primary endpoint is improvement of glycemic control as measured by A1C and the 

secondary endpoints are mean daily glucose levels, the number of both hypoglycemic 

and hyperglycemic events, the amount of time spent in target blood glucose, and the 

perceived level of diabetes-related stress between the two groups. 

Preliminary results show that A1C improves more in those patients who are provided with video reminders compared with those who did not receive them. Overall, 

the viewership was about 50 percent which exceeds that of most other e-Health 

studies. Among subjects who watched at least two-thirds of the daily, cell phonebased video tips/reminders the decline in A1C was greater than it was for subjects 

who used the technology less. Using reminders delivered via the ubiquitous technology of cell phones appears to be an effective way to improve glycemic control and 

thereby long-term outcomes. This approach could be modified for use in other chronic illnesses and in other unique populations such as the elderly and disabled. 

Currently, the U.S. Army Research and Development Command (RDECOM) is 

evaluating commercial handheld solutions such as iPad, iPhone, iPod, and other 

platforms and their applicability in a tactical setting. RDECOM has developed numerous handheld command and control solutions and is supporting the development 

and transition of MilSpace, a combined planning and social networking environment. The Telemedicine and Advanced Technology Research Center is working with 


ebenthall on DSK9Q6SHH1PROD with HEARING
83 

the RDECOM to leverage U.S. Army investments in mobile technology and apply 

it to health care both here in the U.S. as well as in deployed settings overseas. 

The U.S. Army’s evolving role in humanitarian operations represents another opportunity to utilize mobile technology as it pertains to recently approved DoD policy 

on Medical Stability Operations. The relative ubiquity of cell phones throughout the 

world makes them, potentially, a vital tool in creating medical infrastructure and 

sharing medical knowledge where they are most needed. 

The opportunities presented by mHealth are considerable, yet there are several 

challenges to overcome. It will be necessary to ensure that mobile applications are 

integrated with legacy information systems. A wide variety of mobile devices will 

have to be supported, as well network connections of many types. The security, privacy, and confidentiality of patient data both on the device and during its transmission remain important considerations. Furthermore, regulatory issues may, ultimately, enter the picture. As mobile phones evolve from simple communication tools 

into complex physiological data-gathering devices, the line between cell phone and 

medical device is blurring. Finally, from a practical perspective, it is important to 

avoid overloading already-busy clinicians with more information than they are able 

to use. 

The U.S. Army Medical Department is committed to developing a strong research 

portfolio in mHealth. The convergence of health care and mobile technologies has 

the potential to change the lives of individuals in rural and austere settings and 

contribute to improved care, healthier lifestyle choices, and ultimately, increased 

quality of life for servicemembers as well as those in need throughout the world. 

Thank you again for allowing me to highlight the Army Medical Department’s accomplishments and thank you for your continued support to those who serve our 

Nation. 

f 

Prepared Statement of Gail Graham, Deputy Chief Officer, Health 

Information Management, Office of Health Information, Veterans Health 

Administration, U.S. Department of Veterans Affairs 

Good morning, Mr. Chairman. Thank you for the opportunity to testify about the 

Department of Veterans Affairs’ (VA) efforts to deliver optimal health care to Veterans in rural areas and our use of innovative wireless health technology solutions 

to better serve our Veterans. I am accompanied today by Dr. Adam Darkins, Chief 

Consultant for Care Coordination in the Office of Patient Care Services, and Dr. 

James Breeling, Deputy Executive Director, Office of Information and Technology, 

Department of Veterans Affairs. 

As the Committee well knows, all health care providers, including VA, face significant challenges in providing optimal treatment to patients in rural and highly rural 

areas. Emerging technologies and new models of care promise to improve clinical 

quality and reduce costs while at the same time, expand our options for delivering 

health care to all patients. VA is committed to pursuing strategies that harness 

such technologies and models of care to enhance health care delivery. Our aim is 

to ensure our rural Veterans receive the quality health care they earned through 

service to this country. 

My testimony today will describe the latest wireless technologies VA is using, detail our plans for further expansion, and conclude by discussing a new model of care 

that is more Veteran-centered, results-driven, and forward-looking. 

Current Use of Wireless Technologies 

VA is exploring many potential applications of wireless technologies. For example, 

VA has installed Very Small Aperture Terminal (VSAT) Satellites on its 50 Mobile 

Vet Centers, which are used primarily in rural areas by the Readjustment Counseling Service (Vet Centers) to provide outreach and readjustment counseling service to Veterans wherever it is needed. While not located in a rural area, the Washington D.C. VA medical center is undertaking a pilot program through which physicians can access electrocardiogram (EKG) data on their BlackBerry handheld devices. 

VA uses wireless technology and services to assist our Veterans with disabilities 

with quick access to information and to foster opportunities to live at the highest 

level of functionality possible. VA provides various critical cueing aids for our Veterans who struggle with memory loss, spatial disorientation, sensory loss and other 

cognitive difficulties. Cueing aids can assist a Veteran in remembering appointments, medication schedules, and work or academic appointments—essentially helping create a better quality of life for the Veteran. These devices include personal 


ebenthall on DSK9Q6SHH1PROD with HEARING
84 

digital assistants (PDA), smartphones, personal pocket computers, global positioning 

system (GPS) devices, and the Livescribe Pulse Smart Pen. VA’s Blind Rehabilitation Service partners with VA’s prosthetics programs on Veterans training and support through assistive devices and technologies with embedded wireless 

functionality, such as GPS tools or PDAs; wireless computer towers, laptops and 

notebooks that provide our Veterans the ability to read screen print through speech 

output and Braille; audible prescription reading devices; and other items, such as 

the K–NFB Reader, that can scan and read print aloud, function as a GPS, PDA 

and mobile telephone with email and internet capabilities. These technological avenues are just part of the important work we are doing for our Veterans and their 

families. 

In our medical facilities, we are completing Wireless Local Area Network (LAN) 

projects to improve the coverage and reliability of mobile devices such as Bar Code 

Medication Administration (BCMA) carts and laptop computers so that our clinical 

staff can access a Veteran’s electronic health records. VA’s BCMA application is 

used to quickly document and thoroughly validate administration of medication at 

VA facilities through barcode applications and handheld devices. Well ahead of 

many of VA’s medical counterparts in the private sector, a wireless infrastructure 

has been in place within each VA facility since 1999. This wireless network has 

vastly improved access to critical patient information used for clinical decision-making at the very point where treatment is provided. VA uses this access and mobility 

of information, provided by wireless connectivity, for positive patient identification 

and to accurately administer the proper medications at the Veteran’s bedside using 

barcode scanning technology. To date, VA has administered over 1 billion medications using this technology to ensure our Nation’s Veterans receive the correct medication, in the correct dose, at the correct time. We are developing new projects within VA that will expand the use of wireless connectivity and barcode technology to 

accurately administer blood products and collect laboratory specimens for both clinical laboratory and anatomic pathology. 

VA dental providers are using wireless technology to access software designed to 

improve point of care decisions. This platform is available to all VA dental providers 

for download onto wireless devices, and many of our providers have taken advantage of this unique opportunity. For example, Lexi-Comp provides convenient, immediate access to time-sensitive, dentistry-specific pharmacology and clinical reference 

information via wireless devices. Providers can quickly access important information 

about drugs and natural therapeutics, oral diseases, implants, endodontics, clinical 

periodontics, oral surgery, treatment of medically compromised patients and medical 

emergencies, to name a few examples. This technology significantly improves medication safety by providing important drug interaction analysis and side effect profiles while increasing positive treatment outcomes through a vast knowledge base 

available at the provider’s fingertips. To keep up with today’s demands, many of our 

providers report using this technology repeatedly throughout the day and even after 

hours when making determinations about patient care. 

My HealtheVet, VA’s online personal health record (PHR), is yet another area of 

significant progress in wireless technology for VA. As a complement to traditional 

health care services, the My HealtheVet PHR provides Veterans with personal online access to VA health care, featuring patient-friendly health education information and wellness reminders for preventive care, to enhance patient engagement and 

informed decision-making. My HealtheVet provides our Veterans with new and innovative options to connect with our team at VA. A Veteran who was an early 

adopter in the pilot program and now uses the national system has described this 

application’s impact by stating, ‘‘I feel more in control and aware of my choices.’’ 

Having our Veterans as partners in their health care is essential to our success at 

VA. 

VA has seen the use of My HealtheVet grow significantly. To date, it serves over 

one million registered users, which represents 14.5 percent of VA patients receiving 

health care services. The total number of visits to My HealtheVet since it was 

launched in November 2003 now exceeds 40 million. Veterans have refilled more 

than 15 million prescriptions, at a rate of approximately 600 per hour, through My 

HealtheVet since VA made available online interactive ordering of prescription refills in August 2005—all from the comfort of the Veteran’s own home. 

For fiscal years (FY) 2009 and 2010, VA’s Office of Rural Health awarded a grant 

for $981,852 to improve access to care by engaging our Veterans in co-designing improvements to My HealtheVet. VA conducted working sessions with Veterans in five 

rural communities, where Veterans suggested specific changes to My HealtheVet including the addition of features they desired in a mobile version of the application. 

In the first phase, our Veterans defined core functionality for a mobile version of 

My HealtheVet, and VA is now extending this work by using the models generated 


ebenthall on DSK9Q6SHH1PROD with HEARING
85 

in the initial phase to build a working prototype that will be implemented on a generic internet-enabled mobile phone as well as brand-specific versions. The mobile 

prototype will be evaluated by our Veterans in a proof-of-concept environment. This 

testing will focus on the user’s experience in important areas such as functionality, 

usability and appeal. Phase II will also support further meetings with our Veterans 

for feedback on how to visually model the complete set of functions they desire in 

a mobile version of My HealtheVet. 

Around the world, mobile and wireless devices are increasingly a primary tool for 

connecting people to the internet. In early 2009, VA launched a mobile-friendly 

version of its internet Web site at http://m.va.gov. VA’s mobile site tailors key VA 

content for mobile devices and is designed to be compatible with multiple brands 

of cell-based internet browsers. This site provides access for our Veterans to benefits 

information, facility locations, eligibility details for returning Operation Enduring 

Freedom/Operation Iraqi Freedom (OEF/OIF) Servicemembers, VA news, and multimedia content. On smartphones (such as the iPhone), users can plot VA facilities 

on a satellite map, perform integrated phone dialing via VA’s Facility Locator, 

watch VA videos on YouTube, use the mobile VA Gravesite Locator, and share articles of interest via social networking Web sites. We want to be accessible and transparent to our Veterans and their families wherever they may be. 

Future Expansions of Wireless Technologies 

Looking ahead, VA’s Veterans Health Administration (VHA) has examined potential for additional innovative applications targeting specific populations of Veterans, 

such as those with TBI, post-traumatic stress disorder (PTSD) or visual impairments. We further anticipate development of more resources for our clinicians. VA 

has initiated plans to develop and deploy a nationwide program to use wireless networking (separate from the VA wireless LANs) for internet use at VA health care 

facilities. Veterans and their families will be able to use this technology for communications, email, and otherwise therapeutic activity during patient stays at VA facilities. VHA has recently established a Program Office dedicated to using Real 

Time Location Systems (RTLS) to support locating and tracking equipment, clinical 

staff, patients, and patient or staff movement. This type of information will help improve the quality and efficiency of health care delivery to our Veterans by improving 

workflow, to cite one example. RTSL uses wireless LAN, Radio Frequency Identification (RFID), Infrared and other technologies. Future plans for expansion include developing requirements, standards and overseeing broader RTLS deployment. 

New Model of Care 

Wireless technologies are part of an overall continuum of care at VA and not a 

‘‘stand alone’’ entity. We are undertaking the most significant change in our model 

of care delivery since the rapid expansion of community-based outpatient clinics 

began in the 1990s. But in many ways, this new and innovative approach is actually 

a continuation of the same strategy VA has always pursued: bringing care closer 

to our Veterans and making it as accessible as possible. Our mission of VeteranCentered care engages the Veteran, family and health care team in a partnership 

to improve communication and assure that the needs and preferences of the patient 

are considered. 

To support this significant effort, VA has joined the Patient-Centered Primary 

Care Collaborative, a national coalition of other public and private sector members 

dedicated to improving primary care. We are re-designing our systems around the 

needs of our patients and improving care coordination and virtual access through 

enhanced secure messaging, social networking, telehealth, and telephone access. An 

essential component of this approach is transforming our primary care programs to 

increase our focus on health promotion, disease prevention, and chronic disease 

management through multidisciplinary teams. These changes will focus on improving the experience patients and their families have when seeking care from VA. We 

will benchmark with private sector organizations such as Kaiser-Permanente and 

Geisinger Health System. As always, we will seek patient input to help guide this 

important transformation. 

The President’s FY 2011 budget submission describes this new model of care in 

greater detail. VA will use the latest technology to remove barriers to our Veterans 

and increase access to VA services. This important initiative will enable VA to become a national leader in transforming primary care services to a medical home 

model of health care delivery that improves patient satisfaction, clinical quality, 

safety and efficiencies. VA Tele-Health and Home Care Model will develop a new 

generation of communication tools (i.e. social networking, micro-blogging, text messaging, and self management groups) that can be used to disseminate and collect 

critical information related to health, benefits and other VA services. 


ebenthall on DSK9Q6SHH1PROD with HEARING
86 

VHA’s Preventive Care Program, a component of the new model of care, will develop and implement a program to provide telephone-based health behavior counseling for Veterans with risky health behaviors, including physical inactivity, 

unhealthy eating, smoking, and problem alcohol use, and health behavior-related 

conditions such as obesity. Using a health coaching model to assist our Veterans in 

making behavior changes by setting goals, developing action plans, using self-monitoring, and applying other self-management techniques, the Telephone Lifestyle 

Coaching (TLC) Center will increase Veterans’ access to care to keep them as 

healthy as we can. We used this approach in a smaller pilot project for weight management among Veterans and found a significantly high level of patient satisfaction. 

The new model of care will improve health outcomes and the care experience for 

our Veterans and their families. The model will standardize health care policies, 

practices and infrastructure to consistently prioritize Veterans’ health care over any 

other factor without increasing cost or adversely affecting the quality of care. VA 

looks forward to working with our critical partners in Congress to ensure these important plans become a reality for our Veterans and their families of all eras across 

the country. 

Conclusion 

VA sincerely appreciates the continued support of Congress in supporting rural 

health initiatives that enable us to focus on extending current enterprise telehealth 

solutions as well as developing new telehealth solutions to serve our Veterans 

throughout the Nation for whom geographical distance from VA’s physical health 

care assets often presents a challenge to receiving care. Like you, VA strives to ensure that every Veteran who qualifies has access to VA’s world class health care. 

Mr. Chairman, this concludes my prepared statement. I am pleased to address 

any questions the Committee may have. 

f 

Statement of Lincoln T. Smith, President and Chief Executive Officer, 

Altarum Institute, Ann Arbor, MI 

Good morning, Chairman Michaud, Ranking Member Brown, and Members of the 

Subcommittee. 

Thank you for inviting Altarum Institute to testify on how the Department of Veterans Affairs can utilize new and innovative wireless technologies to expand access 

to care for veterans. In our testimony,we will address a unique research study that 

we have successfully implemented at the Pathway Home, a residential veterans 

treatment center for returning warriors afflicted with mild traumatic brain injury 

and post-traumatic stress disorder. We will also share how we have been able to 

integrate clinical treatment, technology, and research to enhance the recovery of 

servicemembers who have served this country so valiantly. 

Altarum Institute is a nonprofit health systems research and consulting organization serving government and private-sector clients. We provide objective research 

and tailored consulting services that assist our clients in understanding and solving 

the complex systems problems that impact health and health care. Our unique 

model combines the analytical rigor of a research institution with the business acumen of a traditional consultancy to deliver comprehensive, systems-based solutions 

that meet unique needs. 

Altarum has a very strong commitment to serving the needs of our Nation’s 

servicemembers and veterans. For over 30 years, Altarum and our predecessor organizations have worked to improve military and veterans health care serving such 

diverse clients as the TRICARE Management Activity, the Army, Navy, and Air 

Force medical services, and the Department of Veterans Affairs. Our commitment 

to our Nation’s current and former servicemembers does not stop with our clientbased work. Starting in 2008, we launched our $7 million Mission Projects Initiative, which includes the multiyear Veterans Community Action Teams project which 

we have discussed with this Subcommittee in the past. Recently, we committed to 

continuing the use of our own funds to benefit servicemembers when we initiated 

our Veterans Transition to Community Project, which my testimony today will focus 

on. 

Altarum’s Veterans Transition to Community Project was initiated to address one 

of the most critical issues affecting the almost two million Americans who have directly served or supported Operation Enduring Freedom and Operation Iraqi Freedom. As in previous conflicts, many servicemembers were subjected to blast-related 


ebenthall on DSK9Q6SHH1PROD with HEARING
87 

1 Ramchand et al. (2010, February). Disparate prevalence estimates of PTSD among servicemembers who served in Iraq and Afghanistan: Possible explanations. Journal of Traumatic 

Stress, 23, 59–68. 2 Carlson et al. (2010, February). Psychiatric diagnoses among Iraq and Afghanistan war veterans screened for deployment-related traumatic brain injury. Journal of Traumatic Stress, 23, 

117–24. 3Kehle et al. (2010, February). Early mental health treatment-seeking among U.W. national 

guard soldiers deployed to Iraq. Journal of Traumatic Stress, 23, 33–40. 

injuries. Estimates of 12–20 percent 1 of them were close enough in proximity to a 

concussive event while deployed to screen positive for mild traumatic brain injury 

(mTBI). Many recover fully; however, others recover only partially and have their 

injuries revisit, and sometimes debilitate, them without warning. 

Treatment teams have always struggled to develop comprehensive treatment 

plans from bits and pieces of information. Problems such as post-traumatic stress 

disorder (PTSD), substance use disorders (SUD), major depressive disorders (MDD) 

and/or mild traumatic brain injury all result in some level of short-term memory 

loss. The science of treatment is too often limited because of an incomplete picture 

of what is going on in the servicemembers’ lives. To complicate things further, a 

large number of our warriors are Reserve or National Guard members who, because 

of the nature of their service obligations, did not stay on a post following mobilization, but instead dispersed after their release from duty to every corner of the Nation, making follow-up treatment and observation much harder. 

An unfortunate reality is that many of our returning servicemembers simply do 

not receive treatment to address these serious health issues. TBI is estimated to 

have occurred in 12–20 percent of Iraq and Afghanistan veterans. Only 7 percent 

of veterans presenting for treatment through the VA have received treatment for 

their brain injury. The remaining 3–13 percent of the almost 2 million veterans 

have not received treatment at this time.2 It has been projected these numbers 

could be as high as 300,000 troops.3 The number of military treatment facilities, VA 

facilities, and contracted facilities that have the requisite skills, knowledge, and 

training to address theses psychological health needs is simply insufficient to meet 

this demand. New techniques are required. 

Through our Veterans Transition to Community Project, Altarum has implemented a novel but elegant solution that has significant potential to dramatically 

impact the lives of servicemembers and ease the burden on providers. Our solution 

not only facilitates health and wellness for returning servicemembers and their families, but it also leverages the time and resources of existing clinical and treatment 

staff. The Veterans Transition to Community Project is exploring methods and technologies to connect servicemembers to the care they need using technology that is 

already owned by virtually all returning servicemembers—a cell phone. This technology builds on skills and knowledge that warriors already possess. The criteria 

are simple. Can you e-mail? Can you text? Do you like pictures? How about music? 

Can you answer questions with a scale of 1–9? This reduces training and implementation time to almost zero and also reduces participation resistance. 

Our project addresses treatment in all phases of care. During the initial treatment 

phase, we make use of a simple Palm PDA to begin collecting information on mental 

well-being. We use the PDA to collect multiple ecological momentary assessments 

(EMA) from servicemembers diagnosed with PTSD, SUD, MDD, and/or mTBI. 

EMAs are short multiple choice questions that document items such as stress, rejection, fear, craving, pain, and coping several times daily over a period of months. 

Data are collected and analyzed to create a composite picture of the servicemember 

or veteran—not at the single instance of treatment, but across time and daily activity. These data improve the accuracy and applicability of treatment. 

Once the servicemember or veteran begins the transition to home, we implement 

an innovative application of mobile phone technology to extend treatment and maintain contact with the patient. EMA data collected from the individual are compared 

with information gathered during the clinical treatment phases. Data are then used 

to tailor individualized two-way interactions with the servicemember or veteran customized to their strengths, needs, and recovery resources. Altarum uses EMA data, 

clinical observations, and patient input to offset patient-specific triggers while augmenting motivators and support system contacts. Reminders, supportive messages, 

pictures of pleasurable memories, inspirational music, and an interactive pain-scale 

support the servicemembers and veterans to avert crises that may affect them in 

their transition from the therapeutic environment to work and community life. 

Altarum’s Veterans Transition to Community Project extends treatment beyond 

the walls of any facility. All that is necessary is a cell phone connection. Our original test cohort continues to receive support and, when necessary, treatment as they 


ebenthall on DSK9Q6SHH1PROD with HEARING
88 

disperse across the country. Because the core of the system depends on automation, 

time zones and work schedules do not affect service delivery. This intervention is 

driven by the demands of the servicemember, not the availability of clinical treatment staffs. 

The advantages of our method of supporting treatment through this flexible yet 

common technology are manifold. 

First, in a time of increasingly tight budgets, the incremental cost of maintaining 

a servicemember in this program is negligible. A month of effective contact can be 

maintained with servicemembers for far less than the cost of a single office visit. 

Altarum’s project uses the veteran’s existing cell phone. Once implemented, the secure Web-based treatment interface can be accessed from anywhere and updated in 

real-time by existing clinical or support staffs. No servers, computers, hardware, 

software, or expensive equipment are required. 

Second, our technique is flexible and adaptable to the individual needs of each 

servicemember. Our armed forces are a composite of American society, and one size 

does not and cannot fit all. The Veterans Transition to Community Project is designed to be adapted to each participant with minimum of effort. Altarum developed 

the core technology and processes, but the servicemember works with a treatment 

team to develop personalized interventions that best suit his or her needs. Using 

the unique Life:WIRE Web-based interface, treatment is customized to the needs, 

language, and preferences of each client. Our solution even allows each warrior to 

develop a personal support group which can be automatically prompted to text, email, call, or call for help in later stages of treatment as the situation dictates. 

Third, our method creates a stream of data—data that can be evaluated against 

multiple criteria to help inform treatment, diagnoses, and progress. Often the data 

provide insight into related factors affecting recovery that were not readily apparent 

and can have tremendous benefits not only to the individual patient, but to the 

wider needs of the research and treatment community. Through our partnership 

with Chesapeake Research and Review, Inc., we have developed a model that protects human subjects and addresses all areas of Federal privacy rights and regulations. Secure, de-identified data can be extracted to isolate potential factors affecting 

recovery. EMA data can be extracted and compared to original assessment instruments to validate the predictability of current assessment technologies. With sufficient cross-site implementation to justify statistical validity, substrates of these data 

can be analyzed to identify potential differences in recovery by theater of conflict, 

service, gender, age, etc. 

Altarum has provided the research design, funding, and analytical support of all 

periodic and outcomes data and is the originator and managing partner for the Veterans Transition to Community Project. But we could not conduct this project on 

our own. Altarum has partnered with three organizations whose expertise has been 

critical in the development and application of our techniques. The Pathway Home, 

a veterans’ treatment center in Napa Valley, California, specializing in PTSD, is our 

research and implementation site. BrainPCheckers provides an electronic PDAbased assessment tool for PTSD. Daily assessments are collected using an automated survey system. Our cell phone interaction, support, and messaging is provided by Life:WIRE. Each partner provides an integral piece of the project. 

Altarum has learned many critical lessons as we work through the successful implementation of this research study. One size does not fit all. An early participant 

explained that, ‘‘he didn’t feel like he could answer a question if he didn’t know 

what all of the words were really asking.’’ Every part of treatment must be adapted 

to the context of the person being served. Servicemembers and veterans are more 

likely to stay involved in their continued treatment when they feel the treatment 

was made for them and not a generic regimen. Clients are even more likely to stay 

involved when they feel they have input in adapting their treatment as they recover 

and their needs change. Finally, we learned that when the treatment meets the 

needs of those it serves, the clients will monitor and encourage one another. Peer 

support continues to proportionately increase utilization for every person involved 

in our research study. 

The ultimate measure of success, for Altarum, is improving and protecting the 

lives of veterans. The following words relayed from one of Altarum’s research staff 

members tells it all: 

During our weekly status call, the director of our research partner, the Pathway Home, reported that our cell phone follow-up had made a big difference 

in the well-being, perhaps even the future, of one of the veterans. This warrior wasn’t one of our study participants, but one of the graduates of the 

Pathway Home working with us to fine-tune the delivery system. He had 

completed his therapy. He is living at home in another State with his wife 


ebenthall on DSK9Q6SHH1PROD with HEARING
89 

iDarkins, A., Ryan, P., Kobb, R., Foster, L., Edmonson, E., Wakefield, B., Lancaster, A. Care 

coordination/home telehealth: a systematic implementation of health informatics, home telehealth and disease management to support the care of veteran patients with chronic conditions. 

Telemedicine and e Health 14(10):1118–1126. ii Ibid. Page 1118. 

and family and has begun normal work. Last weekend he used his phone 

to trigger a crisis response. But, this crisis wasn’t a test—it was his. His response immediately text messaged his clinician who was able to call the veteran and de-escalate a serious episode. The episode resolved with a short 

visit to an emergency room rather than what seemed to be another extended 

relapse into a mental institution. This father is back at home with his family. 

Altarum’s Veterans Transition to Community Project has already changed lives. 

Our solution has the advantages of low cost, rapid deployment, facility for remote 

distribution, and adaptability to the needs and environment of those it serves. This 

makes it ideal for implementation across multiple systems—particularly for those 

suffering from mTBI, PTSD, SUDs, and MDDs. We are pleased to be able to brief 

this Committee on the measurable success available to our returning servicemembers through this innovative program. Thank you for this opportunity. 

Mr. Chairman, this concludes my statement. 

Thank you. 

f 

Statement of Robert Bosch Healthcare, Inc., Palo Alto, CA 

Mr. Chairman and other Members of the Committee: Thank you for giving Robert 

Bosch Healthcare (Bosch) the opportunity to provide testimony to the Committee. 

Bosch, which makes the Health Buddy and T–400 remote monitoring devices, has 

been providing remote patient monitoring in the Veterans Health Administration 

(VHA) since 2003. We’d like to address the role of telehealth in improving health 

outcomes for veterans and reducing the need for hospital services, such as emergency room visits, inpatient admissions and re-admissions. While these are important issues in any geographic area, the shortage of physicians in rural areas and 

the long distances patients must travel to receive medical care make it even more 

important that patients with complex chronic conditions learn self-management, and 

for providers to prevent exacerbations of chronic illness that can lead to a hospital 

visit. In many cases, emergency room visits, hospital admissions and readmissions 

have been proven to be preventable through regular monitoring, automated patient 

education and the intervention of a nurse case manager. 

Thirty two percent of veterans treated by the VHA live in rural areas.i The care 

needs of an aging veteran population (the number of veterans aged 85 and older is 

set to triple by 2011 compared to 2000 ii) have led the VHA to adopt health technology sooner than many other delivery systems. We applaud this foresight. As the 

Committee knows, between 2003 and 2007 the VHA implemented Care Coordination/Home Telehealth (CCHT), a national initiative that enables veterans with 

chronic conditions to remain in their communities and reduces the need for high 

cost acute care. This was after extensive evaluations of the intervention in the Sunshine Network Veterans Integrated Services Network (VISN). Bosch has been providing remote patient monitoring devices to veterans since the beginning of the 

CCHT initiative; currently we provide 70 percent of the remote monitoring technologies that serve veterans across 21 VISNs and 123 facilities nationally. We believe that our products, and remote monitoring in general, provide an opportunity 

to cost-effectively extend care to rural areas without compromising clinical effectiveness. 

A. The Health Buddy and T400 Programs 

Bosch participation in the VHA CCHT program is based on the premise that care 

management supplemented by technology (the Bosch Health Buddy and ViTelCare 

systems) can effectively decrease costs (most commonly due to repeated and/or prolonged hospitalizations) and improve the quality of life for veterans with chronic 

conditions by supporting education and self-care, increasing care based on evidencebased guidelines, and improving coordination of care. 

I. Clinical Focus 

Key diseases of focus for veterans are Congestive Heart Failure (CHF), Diabetes 

Mellitus (DM), Chronic Obstructive Pulmonary Disease (COPD), Hypertension 


ebenthall on DSK9Q6SHH1PROD with HEARING
90 

iii Ibid. Page 1123. ivGroup Health Research Institute. 2006–2010 Improving Chronic Illness Care. http:// 

www.improvingchroniccare.org/index.php?p=ThelChronic CarelModel&s=2 vDarkins et al. op cit. Page 1118. 

vi Ibid. Page 1123. 

(HTN), Post Traumatic Stress Disorder (PTSD), and Major Depression, though other 

conditions are monitored as well. We believe that the successful outcomes for PTSD, 

depression and other mental health disorders iii demonstrate the applicability of remote monitoring to younger ‘‘Wounded Warriors’’ who are not likely to have age-related conditions, but may suffer from service-related mental health conditions. 

II. System of Care Management + Technology 

The Health Buddy and ViTelCare Programs provide effective, efficient and consistent care management based on the Chronic Care Model.iv Its elements include 

the community, the provider system, self-management support, delivery system design, decision support, and clinical information flow. Care management is supported 

by an easy-to-use, in-home survey and data collection home health monitoring device (either the Health Buddy four-button appliance with text screen, or the 

ViTelCareT400 touch-screen monitor with adjustable audio and text screen) and an 

Internet-based web service for data management, care coordination, and decision 

support by health care providers. 

III. Health Buddy and ViTelCare Systems 

The Bosch devices gather information on vital signs (either through patient self 

report or peripheral devices such as glucose monitors), symptoms, behaviors and patient knowledge of their health conditions. The data collected is presented to the 

health care professional through a web-based application in a color-coded and riskstratified format. The Health Buddy’s and ViTelCare’s scripted dialogues also provide education, feedback, and reminders for self-care behaviors, specifically diet, exercise and medication compliance. Patient responses from both the Health Buddy 

and T400 appliances are automatically sent to servers housed within VA data centers. 

IV. Data Flow 

Data from the patient takes place through traditional telephone connection, 

Ethernet, and, for the Health Buddy, through wireless modem (the T400 will introduce wireless capability later in 2010). Bosch is exploring additional means of expanding patient-provider connectivity that would make remote monitoring more accessible to veterans in rural areas. 

V. Workflow Result 

The provision of risk-stratified information to nurse case managers is a critical 

component of detecting exacerbations of illness early, before a hospital visit becomes 

necessary. Moreover, it enables case managers to target resources to patients most 

in need and manage a larger patient panel (a typical nurse to patient ratio in the 

Health Buddy Program is 1:125 or 1:75 for mental health conditions). 

B. Results 

The CCHT initiative has shown great success, as demonstrated by a 25 percent 

reduction in inpatient days, 19 percent reduction in hospital admissions and 86 percent patient satisfaction after enrollment.v As a provider of 70 percent of the remote 

monitoring devices used within the VHA, we believe we have been a significant contributor to the VHA’s ability to successfully improve patients’ quality of life and 

transition care away from high cost acute care settings and into the home and community. 

C. Opportunities for Expanding the Reach of Telehealth 

The CCHT initiative represents wisdom and foresight in caring for a growing and 

geographically dispersed veteran population, yet we believe there is even more potential to extend care to rural areas in a clinically- and cost-effective manner with 

modest modifications. Research has shown that reductions in utilization for veterans 

in rural areas lag behind those in urban areas vi, showing potential for greater returns to the VHA. Specifically, we note: 

• The ability to expand the successes of the CCHT initiative has been limited by 

institutional constraints related to hiring staff and by the time required for development of new clinical practices and protocols. 

• Currently, Health Buddy and T400 appliances are procured by the VHA prosthetics department, which is set up to purchase material goods such as teleVerDate Nov 24 2008 12:59 Dec 19, 2010 Jkt 058054 PO 00000 Frm 00094 Fmt 6604 Sfmt 6621 I:\VA\58054.XXX GPO1 PsN: 58054

ebenthall on DSK9Q6SHH1PROD with HEARING
91 

health devices or prosthetic limbs. Telehealth, on the other hand, is a system 

of care and as such it includes material goods, as well as less tangible items, 

such as services, software, data management and data storage. Prosthetics does 

not have a mechanism to pay for ongoing service and other non-material fees— 

in essence, the current payment structure does not support wider adoption of 

health technology, which is increasingly becoming more virtual. We are hopeful 

that this barrier will be addressed by the proposed transition of procurement 

to the Denver Acquisitions and Logistics Center. 

These suggestions aside, we again would like to take the opportunity to commend 

the VHA for taking a leadership role in adoption of technology as a primary component of patient care. As the largest health care system in the Nation, VHA’s vision 

in adapting to a new technological age will lead other health care providers to do 

likewise, resulting in reduced costs and better patient outcomes. 

D. Technology on the Horizon 

The promise of telehealth ultimately resides in the notion that inter-networked 

technologies can create a system in which health maintenance and care are moved 

to wherever someone with severe disabilities or chronic illness is—particularly their 

home. Over time, we believe that the ability to support an individual’s independence 

will rely on increasingly intelligent sensor-based technologies that can predict with 

increasing degrees of certainty that an ‘adverse event’ is looming. We also see a role 

for video as broadband-penetration rates continue to rise. 

We believe the VHA’s technology-based care coordination program has driven the 

development of the budding, U.S.-based home telehealth industry. We believe that 

the VHA CCHT program’s next wave of growth, with its increasing sophistication 

of how to refine its toolbox of options for veteran health management and monitoring, will drive a new wave of innovation in the industry. Bosch looks forward to 

supporting the VHA in its ongoing drive to improve care for veterans by moving 

that care to their homes, wherever—including rural areas—those veterans are. 

Æ 


ebenthall on DSK9Q6SHH1PROD with HEARING