The Use and Development of Telemedicine Technologies in the 

Department of Veterans Affairs 

Health Care System

Hearing

before the

Committee on 

Veterans’ Affairs

House of Representatives

Subcommittee on Health

one hundred ninth congress

first session

May 18, 2005

Printed for the use of the Committee on Veterans’ Affairs

Serial No. 109-8

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

Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800; DC area (202) 512-1800

Fax: (202) 512-2250 Mail: Stop SSOP, Washington, DC 20402-0001

u.s. government printing office

washington : 2006

22-362.PDF
Committee on Veterans’ Affairs

Steve Buyer, Indiana, Chairman

 Michael Bilirakis, Florida Lane Evans, Illinois, Ranking

 Terry Everett, Alabama Bob Filner, California

 Cliff Stearns, Florida Luis V. Gutierrez, Illinois

 dan burton, Indiana Corrine Brown, Florida

 Jerry Moran, Kansas Vic Snyder, Arkansas

 richard H. baker, Louisiana Michael H. Michaud, Maine

 Henry E. Brown, Jr., South Carolina Stephanie Herseth, South 

 Jeff Miller, Florida Dakota

 John Boozman, Arkansas Ted Strickland, Ohio

 Jeb Bradley, New Hampshire Darlene Hooley, Oregon

 Ginny Brown-Waite, Florida Silvestre Reyes, Texas

 Michael R. Turner, Ohio ShellEy Berkley, Nevada

 Tom Udall, New Mexico

Michael a. copher, Acting Staff Director

Subcommittee on Health

 Henry E. Brown, Jr., South Carolina, Chairman Michael H. Michaud, Maine

 Cliff Stearns, Florida, Vice Chairman Ranking

 Richard H. Baker, Louisiana Bob Filner, California 

 Jerry Moran, Kansas Luis V. Gutierrez, Illinois

 Jeff Miller, Florida Corrine Brown, Florida

 Michael R. Turner, Ohio Vic Snyder, Arkansas

Dolores Dunn, Acting Subcommittee Staff Director

(II)
CONTENTS

May 18, 2005

 Page

1

 1

2

35

106

3

37

12

46

18

57

20

61

22

66

The Use and Development of Telemedicine Technologies in

the Department of Veterans Affairs Health Care System ..

OPENING STATEMENTS

Chairman Brown ........................................................................ 

Hon. Michael H. Michaud, Ranking Democratic Member .......

Prepared statement of Mr. Michaud ........................................

STATEMENTS FOR THE RECORD

Poropatich, Ronald K. , MD, Colonel, United States Army, 

 U.S. Medical Research & Material Command, Fort Detrick,

 Maryland .................................................................................

Witnesses

Darkins, Adam, MD, MPHM, Chief Consultant for Care

 Coordination, Veterans Health Administration .................... 

Prepared statement of Dr. Darkins ...........................................

Clancy, Carolyn M., MD, Director, Agency for Healthcare Re-

 search and Quality, U.S. Department of Health and 

 Human Services ......................................................................

Prepared statement of Dr. Clancy .............................................

Godleski, Linda, MD, Associate Professor of Psychiatry at 

 Yale University Medical School, New Haven, CT, VA

 Connecticut Health Care System, Department of Veterans

 Affairs ......................................................................................

Prepared statement of Dr. Godleski ..........................................

Frueh, B. Christopher, Ph.D, Staff Psychologist, PTSD

Clinical Team, Veterans Affairs Medical Center, 

Charleston, SC, Associate Professor and Co-Director, Division of Public Psychiatry, Department of Psychiatry and Behavoiral Sciences, Medical University of South Carolina .....

Prepared statement of Dr. Frueh ...............................................

Wertenberger, Sydney, RN, MSN, CNAA, Associate Director

 for Patient Care Services/Nursing, John J. Pershing VAMC,

 Poplar Bluff, MO .....................................................................

Prepared statement of Ms. Wertenberger .................................

(III)
Levy, Charles E., MD, Chief of Physical Medicine and Rehab-

 ilitation, Director of the Low ADL Monitoring Program, 

 North Florida/South Georgia Veterans Health System, 

 Department of Veterans Affairs .............................................

Prepared statement of Dr. Levy .................................................

Ryan, Patricia, MS, RN, Director, VISN 8 Community Care

Coordination, Acting Associate Chief Consultant, VHA

  Office of Care Coordination, Department of Veterans Affairs

Prepared statement of Ms. Ryan ...............................................

Linkous, Jonathan D., Executive Director, The American Tel-

 emedicine Association .............................................................

Prepared statement of Mr. Linkous ...........................................

Wadhwa, Sandeep, MD, MBA, Chairman, Government Affairs

 Committee, Disease Management Association of America, 

 Vice President, Care Management Services, McKesson 

 Health Solutions, McKesson Corporation .............................

Prepared statement of Dr. Wadhwa ..........................................

POST-HEARING QUESTIONS FOR THE RECORD

Response by Department of Veterans Affairs to questions sub-

 mitted by Hon. Michael H. Michaud ......................................

Response by Mr. Linkous to questions submitted by Hon. 

 Michael H. Michaud ...............................................................

Response by Dr. Wadhwa to questions submitted by Hon.

 Michael H. Michaud ...............................................................

(IV)

24

70

 26

74

 28

78

30

82

89

104

106

page
(1)

OVERSIGHT HEARING ON THE USE AND

DEVELOPMENT OF TELEMEDICINE TECHNOLOGIES IN THE DEPARTMENT OF VETERANS AFFAIRS HEALTH CARE SYSTEM

Wednesday, May 18, 2005

U.S. House of Representatives, 

Subcommittee on Health,

Committee on Veterans’ Affairs,

Washington, D.C.

 The Subcommittee met, pursuant to notice, at 10:00 a.m., in Room 

334, Cannon House Office Building, Hon. Henry Brown

[Chairman of the Subcommittee] presiding.

 Present: Representatives Brown and Michaud.

Mr. Brown. Good morning. The Subcommittee will now come to 

order.

 I want to thank all in attendance for joining us this morning in 

our first Subcommittee hearing of the 109th Congress. I’m honored

to have been selected to serve as Chairman of the Subcommittee on 

Health, and am especially pleased that my friend, Mike Michaud, a 

man whom I shared a leadership role with for the last two years on 

the Benefits Subcommittee, was designated by his colleagues as our

new Ranking Member on Health. Welcome, Mike.

Telemedicine can be defined in many ways. Some prefer to use

the broader term “telehealth.” The core meaning of the word “telemedicine” is distance healing. What it does is make it possible for 

doctors and nurses to deliver care and interact with patients many 

miles away with the use of specialized video equipment, digital imaging equipment and electronic data transmission.

 These new patient-centered technologies have a great deal to offer veteran patients, particularly in the areas of mental health care, 

rehabilitation, non-institutional long term care, and delivery of care 

in rural areas.

 VA has and continues to substantially invest in telehealth technologies. The success of the use of telemedicine in caring for veteran 

patients depends on VA’s ability to transition individual telemedicine 

projects into safe, effective, reliable and sustainable health care ser-
2

vices that veterans can depend on.

 At our hearing today we will be hearing from VA and HHS officials, VA field practitioners and representatives from the private

sector about the use and development of telemedicine technologies. 

I’m looking forward to an exceptional discussion to learn more about 

telemedicine, how it works and what it holds for the future of patient 

care in VA. 

 Mr. Michaud, do you have any statement you would like to make?

 Mr. Michaud. Thank you, Mr. Chairman. It is good to be here for 

our first hearing of the Health Subcommittee for the 109th Congress.

I’m also pleased that we have an opportunity to continue to work together as Ranking Member and Chairman of this Subcommittee. We 

have many areas under the Health Subcommittee’s jurisdiction and 

we share a lot of common interests in those areas. I look forward to 

tackling those issues with you.

I agree that we must continue to push VA to be as efficient as possible, but there are still times that efficiency reaches its limits and you

must add real dollars to the VA. That is why the Democrats on this 

Committee recommended adding $3.2 billion to our budget request.

 Mr. Chairman, I want to thank you for holding the hearing today. 

I look forward to working with you throughout the Congress and request unanimous consent to extend and revise my remarks.

[The statement of Mr. Michaud appears on p. 35]

 Mr. Brown. So noted. Thank you, Mr. Michaud.

 We have with us today Dr. Adam Darkins. Dr. Darkins is the Chief 

Consultant of the Department of Veterans’ Affairs Office of Care Coordination. He trained as a neurosurgeon in the United Kingdom, 

where he established and directed an early telehealth program at 

the King’s Fund in London. Dr. Darkins has published and spoken 

widely on telehealth issues throughout the world.

 Dr. Darkins is accompanied by Dr. Ross Fletcher, Chief of Staff of 

VA Medical Center in Washington, D.C.

 Dr. Carolyn Clancy is the Director of the Agency for Health care 

Research and Quality at the Department of Health and Human Services. She also holds an academic appointment at George Washington University School of Medicine and is a member of the Institute of 

Medicine. She has edited and contributed to the publishing of seven 

books and is widely published in peer review journals.

 You may begin.
3

STATEMENTS OF ADAM DARKINS, CHIEF CONSULTANT, OF-

 FICE OF CARE COORDINATION, DEPARTMENT OF VETER-

 ANS’ AFFAIRS; ACCOMPANIED BY ROSS D. FLETCHER,

 CHIEF OF STAFF, VA MEDICAL CENTER, WASHINGTON,

 D.C.; AND CAROLYN M. CLANCY, DIRECTOR, AGENCY FOR

 HEALTH CARE RESEARCH AND QUALITY, DEPARTMENT

 OF HEALTH AND HUMAN SERVICES

STATEMENT OF ADAM DARKINS

Dr. Darkins. Thank you, Mr. Chairman and members of the Subcommittee.

 It’s an honor to be before the Subcommittee today and address the 

members’ interest in the VA’s use and development of telemedicine. I

want to thank the members of the Committee for raising this important area for us to discuss. 

 In terms of telemedicine the areas I’m going to cover are how we’re 

using information and telecommunications technologies to deliver 

care to veteran patients in situations where practitioner and patient 

are separated by time and/or distance. I think it’s important just to 

say that what I’m--in my testimony I’m going to talk about builds on 

the use of the existing health information infrastructure.

 The Institute of Medicine has used the VA as an example of how 

it’s possible to use information technology to change the way health 

care is delivered and VA meets each benchmark, disease, prevention 

and treatment indices in terms of its ability to deliver care in this 

manner.

 But very much what I’m going to talk about today is that the technology is very important. It’s obviously a vital part to telemedicine. 

But why VA has been successful and the--so the platform on which 

VA is developing telemedicine is around the people and how it is delivering services to people. It’s very much for us about how we deliver 

the right care, in the right place, at the right time to veteran patients 

who it is our privilege to serve. 

 In doing so we are building a robust, sustainable infrastructure, 

one which is being based very much on patient need.

 So as you will hear that I will base what I’m talking about on the 

patient need that’s driving it and not on the technology.

 The need of the veteran population is changing and the care has 

to be delivered from finite, physical locations as it does for any health

care organization. In doing so there are trade offs against cost, quality, access, that are made by individual practitioners. Telemedicine is 

not a replacement for delivery of care. It is really an adjunct that al-
4

lows more flexibility in how that care is delivered and it’s a particular

applicability in rural areas where there are practitioner shortages. It 

helps solve what can otherwise be an insoluble equation about how 

you deliver care to patients.

 The way in which telemedicine is moving forward and has moved 

forward is very much around how it solves issues in the delivery of 

care and is rooted in the business of delivery of care within the VA, 

and it’s not so much around giving out grant monies that we have 

done so.

 There have been pilots of 32 clinical areas of telemedicine within 

VA, but in my testimony today I’d like to highlight five which are of

particular importance in relation to veteran patient need.

The first area that I’d like to talk about relates to home telehealth,

the delivery of care using technologies to reach in the home. The 

veteran population that VA treats, as with the general population, 

is growing older. As people grow older, counter to expectations in 

the past, they’re actually healthier and living longer and preferring 

wherever possible to stay in their own homes. So the focus for VA on 

the use of this technology is supporting the non-institutional care of 

patients.

 For veterans who fought for their own homes in times of war now 

to be fighting new adversaries, such as chronic heart failure and diabetes, our approach is really is much to help them stay in their own 

homes.

 So the telemedicine in terms of the home telehealth is addressing high areas of priority need related to diabetes, congestive heart 

failure, chronic pulmonary disease. It compliments the rest of care 

across the continuum, so it’s able to bring people to care in a more 

flexible and more timely fashion.

 We have a national program which is rolling out for this which 

is very much centered on patients in terms of delivery of care. The 

kind of patients we’re talking about are the sort of patients with complex care needs who would otherwise be going into institutional care. 

They are the sort of patients who traditionally, their paper charts 

may be in several volumes and if the chart is available if they’re going 

from scheduled clinics it is difficult to get through that kind of data.

 So the ability to monitor somebody in their home, to assess their 

health condition in their home, but also to base this on having a clinical health record is extraordinarily important and a vital part of how 

this has gone forward. 

 It’s possible to pick up the vital signs, pulse, weight and temperature of these patients and institute care before they run into trouble. 

So somebody with heart failure can be treated when they first become

symptomatic rather than when they become very seriously ill and 

they might have to go into the intensive care unit.

 The outcomes from this program has been that we’ve had reduc-
5

tions in inpatient stays, we’ve had reductions in ER visits, and very 

high levels of patient satisfaction. We are currently treating 5,800 

patients throughout the 21 VISNs in the VA and anticipate reaching 12,500 by the end of this financial year. It’s about appropriately

treating veterans and helping them to live independently in their 

own homes.

 I would say that simply stated the link to the information system is 

that in order to provide the right care, in the right place, at the right 

time it’s important that the right information is there to be able to do 

so as well.

 The next area I would like to turn, a major area of need, is that of 

mental health for which our telemental health programs are addressing. It uses real time video conferencing and is able to provide both 

generalist’s and specialist’s care to the community based outpatient 

clinics and save considerable time and inconvenience of travel to veterans to get into care.

 In 2004 there were 10,000, approximately 10,000 patients treated 

nationally, and that represented approximately 20,000 episodes of 

care. The care is currently taking place in 224 sites of which 120 are 

community based outpatient clinics, 74 are VA medical centers, 20 

are vet centers and 14 are home telehealth programs.

 In order to make sure this is robust and sustainable we have a 

lead clinician for telemental health. We’ve developed a telemental 

health toolkit that makes sure that things are systematized with how 

they’re done. It links to the mental health programs in the central 

office and we anticipate a 20 percent increase in the next financial

year of telemental health.

 The next area I would like turn to is teleretinal imaging, which 

is used to treat diabetes and diabetic eye disease. 20 percent of veterans have diabetes and VA is currently outperforming the private 

sector in terms of doing diabetic eye exams. The rationale of this is to 

maintain the site by picking up diabetic eye disease.

 We had a consensus group that met in 2001 to establish the 

groundwork for doing teleretinal imaging and will be working with 

the Department of Defense and the Joslin Vision Network in Boston. 

We are set to do a widespread implementation of teleretinal imaging 

and would see initially 75,000 patients being treated in the next year 

and 150,000 the year after. It uses store-and-forward technology and 

we’re setting up reading centers to be able to do this as we move forward.

 The next area I would like to talk about is teledermatology, again 

another area that uses store-and-forward technology. Dermatology 

is an area of high morbidity and it’s a shortage speciality, especially 

in rural areas.

 One program I’d like just to highlight is in the 1990’s Togus, Maine 

was a pioneer and linked to Providence, Rhode Island. The analyses 
6

of the outcomes have shown that using teledermatology in VA leads 

to earlier treatment, reduces the need for later face-to-face exams, 

and is certainly cost effective in getting definitive care.

Again, we have clinical and research leads, a field coordinator, and

would see this is going to be growing considerably again in the next 

financial year.

 The next topic I would like to turn to in terms of patient need is 

telerehabilitation, and it’s applicable to particularly spinal cord injury, multiple sclerosis and returning combat wounded veterans from 

Operations Iraqi and Enduring Freedom.

 There are four poly-trauma centers in the VA to which returning 

combat wounded are being transferred, particularly people with head 

injury, amputation, eye trauma and post-traumatic stress disorder. 

The ability to link other centers into this specialist’s care as they 

journey across the continuum to get home is extremely important.

 Let me just quickly give you the hypothetical example of a combat 

wounded veteran who may be an amputee, who may have had a head 

injury. Such a person, who if they’re back near home, they may well 

find their answer isn’t immediate access to some of the specialist’s

advice that may be necessary in relation to some of the prosthetic 

devices for example. Neither would such advice be necessarily available in the private sector.

 The ability to be able to link back to the specialist centers, get advice from people who’ve previously cared for the patient, means this 

could well save the inconvenience both to work and family in travel 

and also is a benefit to the family, as I mentioned.

 So the ability to link these heroes into specialist care is something 

which VA is working towards in linking these poly-traumas to other 

sites. We’re in the process of the next financial year developing linkages for multiple sclerosis care, for two multiple sclerosis centers on 

the West Cost and the East Coast to be able to make multiple sclerosis advice and care available to veterans at the local level where that 

degree of specialist’s advice may not be currently available.

 I’d next like to turn to telesurgery, and when I mention this it’s 

really about high levels of need in areas of chronic disease. It may 

seem somewhat strange that I would turn to surgery, but it is very 

applicable. 

 One of the things that we’ve found is that house prices have 

changed throughout the country. They’re changing their homes, and 

with difficulties in rental accommodations veterans are moving to

places which may not necessarily be where the major center of care 

is. So the ability to be able to do preoperative and post-operative 

evaluations and obviating the travel for the surgeon sometimes to 

peripheral clinics is a way in which it makes the surgery very much 

more easy and efficient in terms of being seen both to patients and

practitioners.
7

 Having highlighted these various areas, I’d like to look a little bit, if 

I may, just in my closing few minutes, to telemedicine and its future 

in VA. I think from the things which I’ve mentioned you all have seen 

that one of the themes that runs across them all is that of changing 

location of care to really make the care more--to improve ease of access to veterans, particularly in rural locations.

 The example of Iron Mountain VA Medical Center in Michigan is 

really illustrative of the kind of changes this can bring about. In the 

late 1990’s Iron Mountain had particular problems with recruiting a 

pathologist, a pathologist’s service being important as one of the core 

parts of the medical center.

 It was possible to set up a telemedicine service linking back down 

to Milwaukee, and from that the VA has got a sustainable network 

in VISN 12, which is probably the largest of its sort in the country, 

crossing five states and delivering speciality care to rural, the peninsula of Michigan, which is extraordinarily beneficial to the veteran

patients there.

 The evidence base is growing within VA to use telemedicine. Some 

50 peer review publications have emanated from VA since the early 1990’s. Typically evidence takes some five years to develop from

when practice starts and then some 15 years often to be included, 

though this is changing and it’s happening more rapidly.

 VA certainly is in a position to help accumulate the evidence to 

be able to do this. The evidence I mentioned is that, but also the 

right pragmatic reasons to deliver care using telemedicine at the moment. In order to develop this evidence VA is linking to the Quality 

Enhancement Research Initiative within the Veterans Administration to be able to gather the evidence in programs that we are taking 

forward.

 Other things that I would like to mention are the lead practitioners. All the areas of telehealth I’ve mentioned have lead practitioners. Standardizing the delivery of care so it’s done very much in an 

evidence based fashion, able to make sure that--to use a euphemism, 

the services plug and play so they fit together in a way that makes

sense.

 One of the things which is often not raised when it comes to talking about telemedicine is the issue of training. To have a sustainable 

telemedicine program within VA-- programs rather--the need to have 

those core competencies within staff so we have a telemedicine competent workforce is particularly important. We established a training 

center in January of 2004 concentrating on home telehealth. They 

have trained some 1,500 people face-to-face and some 1,100 people 

via distance learning technologies. We have training centers we’re 

establishing this financial year in Salt Lake City for general telehealth and also in Boston for store-and-forward.

 We work closely with other agencies. Just an example is the recent 
8

Indian Health Service, Veterans Health Administration Steering 

Group which met in Albuquerque about how we share expertise and 

particularly Native American patients we both have, it would be very 

applicable to use some of the distance health technologies.

 We participate actually in a joint working group for telehealth 

which is run by Health and Human Services and work with them 

on the issues of sustained services. And also in terms of sustainable 

services what is particularly important is to link into the regulatory 

and accreditation bodies whom we are working closely with.

So in conclusion, I would just like to finish by saying VA, I think-

-I’m very privileged to work for VA. VA has used this technology in 

a way to really enhance the delivery of care, and the areas I’ve mentioned would be a test to VA’s leadership.

 It is very--it is and will continue to be about collaborative relationships both within and outside. Of paramount importance this 

is about the relationship between practitioner and patient to deliver 

care. We are coordinating care across the continuum and are able to 

do this and bridging distance and geography. In doing so we’re linking to other resources within the organization. This is not creating 

a new silo.

 So I would conclude by saying I’m very grateful for the opportunity 

to provide testimony. The VA has a noble mission to serve veterans 

and one of the things that unites all those working to deliver care in 

telemedicine is how we do that and integrate that into the rest of the 

delivery of care.

 It’s my pleasure to introduce Dr. Ross Fletcher now if I may do. Dr. 

Fletcher is the Chief of Staff at the Washington, D.C. Medical Center. 

He also is a pioneer in this whole area and is the lead for the nationwide VA register on pacemaker and defibrillator surveillance center. 

We would both be very pleased to answer questions afterwards.

 [The statement of Dr. Darkins appears on p. 37]

 Mr. Brown. Thank you, Doctor. What a great testimony, and I

could just see the excitement in your voice as you were going through 

the process. It is an exciting time to be able to advance health care 

delivery through telemedicine.

 Dr. Fletcher, did you have something you wanted to say? You’re on 

the support team, right? Go ahead. 

 Dr. Fletcher. I have a presentation to make which actually shows 

how the care coordination program, the telehealth program, has been 

working very much hand-in-hand with the computerized system that 

we have at the VA.

 I think I’ll just start by opening that system and showing you a few 

patients that have been benefitting from our telehealth projects.

The first patient I’m going to show you is Mr. McNamara. That
9

isn’t his name and that isn’t his social security number, as you might 

guess, but this is the standard front sheet on the computerized record 

that we see. It has a cover sheet as you see. It has a lab package 

which is very easy to open up and display anything that might be 

present.

 The beauty of being able to do this is that I can actually do this 

in my home as I’m talking to other--to the patient on the telephone. 

So the ability to display the patient’s record and his white count for 

example, which in this instance was elevated when he first came into

our hospital, was very important because he was paralyzed and it 

turned out he had Lyme disease. We took care of that but then had 

to take care of the patient for quite some time thereafter.

 If you look at the additional tools, which is Vista Imaging which 

now can be seen--now can be seen at any point in the system including in my home through Comcast Cable. I can see that he has in actual fact a very large plural effusion that is in essence is heart failure. 

You can see that more clearly if I enlarge it.

 But now I am in addition able to follow many other things about 

him. When he first came to light, if I click on weight you can see

that all results show that he has a weight that started very low. He 

was emaciated when he was in--had his paralysis, but that gradually 

came up.

 And if I wanted to look more carefully at the latter portion of the 

record, which is obviously more dense, you can see that he had--his 

weight reached a peak which was typified by heart failure. We actually took the fluid off of his lung inside the hospital, but it rapidly recurred at home and we brought him back and took the fluid off again.

This time we saw it coming back but increased his Lasix.

 And in this--by this time we had placed him a telehealth program 

whereby he steps on a scale in his house and that number is immediately transmitted to a server which is transmitted to his electronic 

record so that this data point of weight was taken inside the hospital, 

but all of these were taken at home except for a few when he came 

back to the hospital. I sort of tell how that is because we don’t normally take temperatures at home but--so there are fewer of those. 

But we do take the pulses and we do take the blood pressures as well. 

As a matter of fact he starts out relatively high and then comes down 

to a much smoother zone. Very important on the weight scale to 

notice that he is sitting at 165 and gradually rising to this trigger 

point of 170. Now at 170 we’re afraid that he is going to go back into 

heart failure, but with the telehealth aspect where we can see exactly 

when he’s getting into trouble we can intervene at this point, and did 

as a matter of fact add his--increased his diuretic from 80 milligrams 

to 120 and his weight came back down. Now we changed the drug 

back to 80, but it gradually went up and obviously he needed another 

increase in the medication.
10

 Now throughout this time, this is now from April all the way 

through December, the patient never comes back to the hospital. He 

never has pulmonary edema. He never has--I got the telephone call 

on this occasion saying I’m very short of breath and I could hear him-

-over the telephone you can actually hear how fast someone is breathing--and I knew we had to move in quickly and took him right into the 

hospital. It was about a 45 minute drive in.

 But beyond that point this man never re-accumulated any of the 

fluid that’s in his lungs and he did quite well on the score. He wouldn’t

have if we weren’t following very carefully all of this information.

 And once again, the information is not just the weights for--which 

in congestive heart failure is critical, but it’s also the blood pressure 

which we are able to follow right along. For instance if this man had 

a very high blood pressure we could easily tell that it had been pulled 

down to normal, and see that it is normal, and we will see that it rises 

up.

 One of the fascinating things that we have in this system is a trigger point, and in this patient I set it at about 168. So if I set the trigger point to 168 I don’t have to know every time he calls in. I know 

that the minute it reaches that trigger point I will get a note in the 

medical record, the record I look at everyday, I will get a warning sign 

that Mr. McNamara has reached that trigger point. I need to get on 

the phone and change his medication.

 So I feel very comfortable about it and a lot of the physicians are 

worried that they’re going to be called too often, but in actual fact as 

long as he stays down in this zone I can follow him very nicely and I

feel very secure. Any time I want to glance at his record I could just 

pull him up and I actually see all of these values sitting in the chart.

 So we were able to manage his heart failure very securely and very 

well over a long period of time.

 Mr. Brown. Thank you, Dr. Fletcher. How much does the at home 

facilities cost? How expensive is that?

 Dr. Fletcher. The instrument that we have in his home happens 

to cost about $1,000. Some of them cost as low as 600, $500, some of 

them cost a little more, depending on what’s attached to them.

 Mr. Brown. But it’s transportable. If that patient ceases to need it 

then it can move--

 Dr. Fletcher. Yes.

 Mr. Brown.--to the other. Is the connect, is that an expensive process?

 Dr. Fletcher. No, it’s not an expensive process, and the value of 

having all these numbers being taken on a daily basis is extremely 

important. The cost of bringing him in every three months, which we 

were doing, with bad heart failure is not only costly inside the hospital where the costs are much higher on a daily basis, but it’s also 

costly to the patient. One of these episodes he might not live through, 
11

for example. So it’s very, very helpful to preempt the episode by actually following him in this very close way.

 Mr. Brown. And how often do you review his file? I notice you said

there’s some parameters that will set off a signal and how do you 

receive that signal?

 Dr. Fletcher. Well, actually, when I sign on, as I’ll show you. If I

sign on to a different patient I actually get a warning notification list

and on that list will be his name. I will read the note and it will say 

blood pressure has reached 170 over 60, and then I have to sign it. 

So now I know--

 Mr. Brown. I see.

 Dr. Fletcher.--it’s established that I have made contact, I’ve seen 

it, and I usually then make a call out to the patient and adjust his 

medication or test to see whether there could be some error in the 

value.

 Mr. Brown. Okay. Let me tell you a little bit about logistics. I

think we’ve got votes around 11:00 or somewhere thereabouts. We’ve 

got two other panels to bring testimony and I hate to cut you off, Dr. 

Fletcher. Do you have any other final summaries that you would like

to include in your presentation?

 Dr. Fletcher. One minute of final summary.

 Mr. Brown. Okay, sure. Go ahead.

 Dr. Fletcher. I will just show a slide or two. This is our hospital, 

which you are all welcome to come to anytime up the street, on North 

Capitol Street.

 We also have been following the patients with pacemakers. This 

was described. I’ve done now probably over a million house calls 

where we receive the electrocardiogram and can see it. The nice 

thing about the whole metrics is that we use the scales automatically 

going into CPRS with the trigger messages and our appointments are 

made just in time to take care of the problems.

 We had educational values that go back and forth to them and personal reminders as well. We are able to follow not just the weights 

and the blood pressure and the pulse which you saw, but also glucose 

measurements, temperature, oximetry--that’s an O2 saturation and 

it goes on the finger--and the pain score.

 We are setting goals for each patient, especially in heart failure. 

For blood pressure and in diabetes the glucose ceilings trigger the 

same sort of thing. We are managing the patients in these categories 

quite well and bringing their numbers down.

 We also have in conjunction, we have that site, where we can actually have the patient see his own record. So all of the pressures and 

vital signs that he records and goes into our record are something he 

can see in his home.

 And that’s all I have to say. Thank you very much.

 Mr. Brown. No, thank you. It’s certainly an exciting time in medi-
12

cine to be able to have that kind of connectivity.

 What do you need at home, just a regular telephone line or do you 

have to have special communication?

 Dr. Fletcher. A regular telephone line works very well and it just 

automatically--it has a modem and it makes the call out and delivers the information to the central site which then delivers it into the 

hospital record.

 Mr. Brown. Okay. Dr. Clancy, if you could contain your remarks 

to five minutes and then you can submit the total remarks to us. I

apologize just for the time. I think just to give the other two panels 

an opportunity to give testimony. And then we’ll have questions from 

Mr. Michaud when this is over. Thank you. Thank you, Dr. Clancy.

STATEMENT OF CAROLYN M. CLANCY

 Dr. Clancy. Good morning, Mr. Chairman, members of the Subcommittee. I’m very pleased to be here this morning and have submitted 

a written statement for the record.

 The Department of Health of Human Services has a long- standing commitment to understanding and advancing the effective us of 

health information technologies, including telemedicine, to improve 

the health of all Americans.

 As we use the term, telemedicine is the use of telecommunications 

technology for medical diagnostic monitoring and therapeutic purposes when distance and/or time separate the participants.

 I’d like to note that while there is a great deal of activity and an increasing amount of activity in telehealth, we have a lot to learn about 

which applications work best for which patients and under what circumstances. We share a common interest with our colleagues at the 

Department of Veterans’ Affairs in attempting to build that evidence 

base to identify best practices and promising interventions.

 I’d like to offer seven observations about telemedicine that are discussed extensively in my written statement.

 First, the use of telemedicine in the private sector is relatively 

small but growing. Second, there’s evidence that the technology can 

work and can be used beneficially from a clinical and economic standpoint. But while there are many promising initiatives underway, 

there are few mature telemedicine programs and few good scientific

evaluations. So we have a lot to learn about what works under what 

circumstances and so forth.

Third, it’s difficult to assess the appropriateness, effectiveness or

cost effectiveness of telemedicine in the abstract or at large. It’s really much more effective to focus on the specific service that telemedicine is being used to provide. Whether that’s a provision of radiology 

services, specific home health, mental health, other types of applications that Dr. Darkins described.
13

 Fourth and perhaps most important, telemedicine is merely a 

means to an end. Too many evaluations that we’ve seen actually 

focus on the technology, but what we’re really wanting to know is 

whether the telemedicine service results in better patient care and 

at what cost. And these are the questions I’m hearing you ask, so 

specific applications should be assessed in those terms.

The fifth point is that the array of obstacles to adoption and the

use of this technology in the private sector is different in some ways 

from those confronted by the Department of Veterans’ Affairs in their 

relatively closed health system. So the questions you were asking 

about what does it cost to hook up, that’s going to be a different kind 

of equation obviously in the private sector.

 Sixth, with some exceptions such as teleradiology, clinicians and 

system leaders in the private sector have been relatively slow to adopt 

telemedicine. And it’s increasingly clear, as Dr. Darkins said, that a 

variety of factors need to be in place before clinicians believe that the 

value gained exceeds the effort required to use it.

 Finally, under Secretary Levitt’s leadership, HHS is giving the 

highest priority to fulfilling the President’s commitment to promote

widespread adoption of interoperable electronic health records. This 

movement could be a significant enabler for the future adoption of

telemedicine.

 The possibility of a direct linkage between telemedicine applications and an electronic health record across settings of care will dramatically alter the calculus for evaluating the effectiveness of telemedicine technology. HHS has supported telemedicine research of 

demonstrations through three decades and established an office for

the advancement of telehealth in HRSA as a focal point for coordinating programs within the department.

 It’s very clear that in a number of rural areas, through the HRSA’s 

program, that many of these communities would have no access to 

a number of services, including psychiatric services, dermatology, 

rheumology, specialized wound care and genetic counseling if those 

telemedicine services had not been available.

 The Indian Health Service also has extensive experience with telehealth and is probably the closest HHS parallel to how VA operates. 

IHS and tribal facilities report experience with over 30 different types 

of telemedicine, clinical services, and opportunities for expanded service delivery are now under development.

 CMS is also working on telehealth issues and we actually at the 

request of CMS developed a very comprehensive and systematic review of what is known about what works in telemedicine in 2001. 

The report identified a lot of areas where we simply don’t have a good

evidence base. We actually began to update that report late last year. 

It should be ready shortly and we’ll make sure that you get a copy.

 I’m almost out of time here. We also have another report that was--
14

there is a report from HHS mandated by the Medicare Modernization 

Act regarding the possibility of including skilled nursing facilities as 

a Medicare telehealth originating site for the purpose of reimbursement, and we will make sure that you get a copy of that report as 

well.

 Just in closing, this has long been viewed as a very promising tool 

for enhanced access to health care services, improved patient safety 

and timely decision making, and as you’ve seen from my colleagues 

here from Veterans, the opportunity to dramatically improve care 

management I think is self evident. And we’ve seen terrific examples

of how the IHS and the VA can and have continued to collaborate to 

benefit the populations that we serve.

 So with that and in the interest of time, I will stop, and we’d be 

happy to get questions on the record.

 

 [The statement of Dr. Clancy appears on p. 46]

 Mr. Brown. I really do thank you, Dr. Clancy. I apologize for--this 

is such an interesting topic. We’ll have an all day hearing just for 

you all three. It’s absolutely just incredible, you know, the knowledge 

that we have available and I guess the technology that we have and 

how we are implementing it.

 I would ask if you would, and it’s good to have both of you here on 

this, focused on the same idea, I guess the test projects you’re working on, when do you see it being across the whole spectrum in VA, 

telemedicine?

 Dr. Darkins. Dr. Fletcher or--

 Mr. Brown. Either one. Either one will be fine.

 Dr. Darkins. The main area that is moving forward is very much 

the area of home telehealth that was described. It fits very much as I

said the patient need, the elderly population. People really do want 

to stay in their own homes. Obviously some of those are appropriate 

to be in a nursing home, but I think Dr. Fletcher very eloquently and 

graphically described how this benefits. This is somebody who if ended up going in with heart failure they might not have survived. So 

VA is concentrating very much on that area and developing both the 

clinical, the technical and the management of business infrastructure to sustain it.

 But having said so, the other major area that’s going forward at 

the moment is telemental health. You’ll hear from some of my other 

colleagues later. Not only is there a large incident of PTSD in the 

population anyway, but there’s also the returning combat wounded 

to consider as well.

 So telemedicine is just part of the general armentarium. I wouldn’t 

for one moment suggest that it can replace the whole of care, but used 

appropriately as we are doing in the right area, it is absolutely an 
15

adjunct as I think Dr. Fletcher showed.

 Mr. Brown. I guess my question was is it being implemented at 

all the VA hospitals across the country or just concentrated in one or 

two?

 Dr. Darkins. With the home telehealth program it’s being developed at the VISN level, Veterans Integrated Service Network. All 

21 VISNs now have a program. We’ll have a minimal number of 500 

patients under care to provide the initial platform to be able to build 

from, and from that we will be spreading into other hospitals.

 So what we’re doing is making absolutely sure these are patients 

for non-institutional care. There’s an absolutely robust program in 

place that we will then build from. So we’ll then be able to expand it 

more rapidly just to begin with, making sure it’s nationwide.

 Mr. Brown. And I know there was a little bit of concern about the 

cost justification I guess between the private sector and the VA. How

do you sense the return on investment under the VA system? Is it 

saving us money or--I know it’s better for the patients to be able to 

stay in an environment they’re familiar with, but how is the cost association?

 Dr. Darkins. Well, I can put my hand on my heart and say it’s one 

of those pleasing situations where it’s a win on both sides. I mean, 

the sense is that it is something which does save money. It’s concentrated very much at the moment on patients who would be going 

very frequently into care. And as Dr. Fletcher showed, there is major 

inconvenience to those patients. So the cost of using the technology 

is justified absolutely by the reduction and the necessity to go into

care.

 Dr. Clancy pointed out, I think, that one of the things which radically transforms the ability to do telemedicine is having the patient 

record, the computerized record, because to be able to have a patient 

in one place, the practitioner in another, it’s great to be able to see 

them. But if you don’t have the patient’s chart, investigations otherwise. So I think there isn’t comparability, but I think the fact that VA

is an integrated health care system and the fact that it’s being used 

in the way it is, there is absolute cost justifications for why it’s being

done, and thankfully as well there are very good patient justifications

both clinically and in terms of patient satisfaction.

 Mr. Brown. Is there any privacy issues you see that would conflict

with moving this program forward?

 Dr. Darkins. In terms of how this moves forward, this fits into the

general IT policy that VA has for both, covering HIPPA, the privacy 

regulations and cyber security. So it’s down within the umbrella, absolutely securely of maintaining privacy and confidentiality for patients.

 Mr. Brown. I’m going to sign Dr. Fletcher up. I think I need to be 

on that monitoring system and--that’s a good program.
16

 Mr. Michaud, do you have any questions?

 Mr. Michaud. Thank you, Mr. Chairman. As the Chairman says, 

we could probably talk all day about this issue because it is exciting 

and I think it will save and will help veterans particularly in rural 

areas. I have several questions, most of them for the record. The one 

that I would like to ask is, currently the VA budget request spends 

$1.7 billion for information technology. I know the appropriators are 

meeting shortly, if they’re not already meeting, and they’re looking 

at probably removing about $400 million. My question is what effect 

will that have?

 My second question is with the $1.7 million how many veterans will 

be taken care of with that amount of money?

 Dr. Darkins. The telemedicine programs I’ve described today and 

our strategy for moving telemedicine forward in the short term is 

predicated on the VA’s existing information technology system. So as 

far as I’m aware we will be able to carry forward all we’ve currently 

got planned.

 What might be the effects on further developments and enhancements in the future by virtue of any projected budget cut I really 

wouldn’t be able to personally comment upon. Certainly I’m sure that 

information could be made available but I--in terms of what we’re describing we are actually using the current robust system which is in 

place to deliver what we have.

In terms of the wider figure and how that impacts on care generally,

I--again I don’t have those figures related to telemedicine, telehealth.

I can tell you directly what we’re spending on telehealth in terms of 

central support and otherwise if that’s of--

 Mr. Michaud. Yes, that would be helpful.

 Dr. Darkins. I mean currently the amount spent essentially on telehealth in the VA has increased from some 140,000 in 1997 to 10.24 

million currently. That is the central support in terms of office and

grant money and other support, but very much the other costs in telehealth within VA come within the delivery of care.

 So this is using current physicians who are delivering care in real 

time situations. So it’s an adjunct. Those figures I don’t currently

have in detail. We are working out--a new coding system is being 

introduced that--because there isn’t this coding in telehealth. Next 

year we will be able to capture very accurately, after this financial

year, the workload expenses associated with telehealth throughout 

the VA.

 Mr. Brown. I want to ask one final question, Dr. Darkins, if I could.

Are we partnering with the private sector in sharing technology to be 

absolutely sure that we aren’t reinventing the wheel?

 Dr. Darkins. Absolutely, we’re doing so. The technology we’ve 

talked about in terms of telehealth is off the shelf technology which 

is basically commercially available, exactly as it would be in the pri-
17

vate sector. We are to some degree at the leading edge of this in 

terms of where it’s moving, so working collaboratively with the vendor community in terms of how we’ve contracted with them to take 

this forward we are dependent upon a vibrant vendor community to 

be able to support this in the future. And this is all using tried, tested 

technology which is going to be available, and as such I think we’re 

also benefitting the wider private sector’s access to that technology

in the future.

 Mr. Brown. Dr. Clancy, Dr. Darkins, and Dr. Fletcher, I’ve been in 

this process for a long time. I don’t know if I’ve ever been so enlightened by a panel. Thank you so very much for coming and sharing 

your time with us this morning.

 Dr. Darkins. Thank you.

 Mr. Brown. The second panel, will they come forward, please.

 Good morning. The Subcommittee will now welcome our second 

panel of the day, and included in that panel is Dr. Linda Godleski. 

She is the Associate Chief of Staff for Education at the VA Connecticut Health Care System and Associate Professor of Psychiatry at Yale 

School of Medicine. She serves as VA’s national lead for telemental 

health.

 Dr. Christopher Frueh is the director of the Post Traumatic Stress 

Disorder Clinical Team at the Charleston VA Medical Center and 

a tenured associate professor at the Medical University of South 

Carolina. Dr. Frueh provides full-time clinical services to veterans 

suffering from PTSD and serves as a primary clinical supervisor for 

pre-doctoral clinical psychology interns at the Charleston VA Medical 

Center in my home state.

 Sydney Wertenberger--is that close? I’m sorry, okay--is an Associate Director for Patient Care Services at the VA Medical Center 

in Poplar Bluff, Missouri. Ms. Wertenberger has expertise in rural 

health care and home care initiatives.

Patricia Ryan is the Associate Chief Consultant for the Office of

Care Coordination, and the Director of VISN 8 Community Care Coordination Services in Bay Pines, Florida.

Welcome, and please proceed. Ms. Godleski, or who will go first?

STATEMENTS OF LINDA GODLESKI, VHA LEAD FOR TELE-

 MENTAL HEALTH, OFFICE OF CARE COORDINATION, 

 ASSOCIATE CHIEF OF STAFF FOR EDUCATION, VA

 CONNECTICUT HEALTH CARE SYSTEM; B. CHRISTOPHER

 FRUEH, STAFF PSYCHOLOGIST, VA MEDICAL CENTER, 

 CHARLESTON, SOUTH CAROLINA; SYDNEY WERTENBERG-

 ER, ASSOCIATE DIRECTOR, PATIENT CARE SERVICES,

 VA MEDICAL CENTER, POPLAR BLUFF, MISSOURI; 

 CHARLES E. LEVY, CHIEF OF PHYSICAL MEDICINE AND

 REHABILITATION SERVICE, NORTH FLORIDA/SOUTH
18

 GEORGIA VETERANS HEALTH SERVICE, GAINESVILLE, 

 FLORIDA; AND PATRICIA RYAN, ASSOCIATE CHIEF CON-

 SULTANT OCC/DIRECTOR VISN 8 CCCS, OFFICE OF CARE

 COORDINATION, BAY PINES, FLORIDA

STATEMENT OF LINDA GODLESKI

 Dr. Godleski. Mr. Chairman and members of the Subcommittee, it 

is indeed an honor for me to be here before this Subcommittee today 

to provide you with testimony on the VA’s use and development of 

telemedicine.

 I am a psychiatrist who has practiced in a number of health care 

settings and currently I also serve as the associate chief of staff for 

education at the VA Connecticut Health care System in West Haven 

and as the VA’s national lead for telemental health. I’m involved in 

telemedicine in each of these three roles and will provide the Committee with perspectives from each role because I believe they will all 

help to highlight how VA is using and developing telemedicine.

 Like the majority of my colleagues in psychiatry I was trained to 

care for patients through face-to-face interactions, and it was only 

when I came to the VA that I first learned about telemental health as

a very different way of practicing my profession. Furthermore, after 

reviewing the relevant health care literature I appreciated how telemental health had a place in the delivery of care and could replicate 

a face-to-face interaction. Most importantly I was reassured that patients were satisfied with receiving care in this way while providing

them with improved access and saving them the cost, inconvenience 

and time involved in the travel.

 My initial exposure to telemental health was in VISN 9, the VA

Integrated Service Network 9 which is Kentucky, Tennessee, and 

part of West Virginia, when I was the mental health service manager 

there. The Huntington VA Medical Center had been using telemental health successfully since 1997 to provide care to patients in distant Vet Centers and community based outpatient clinics.

 I became involved directly in the establishment and running of telemental health services to connect all of the VISN facilities for expert 

telemental health consultation as well as ongoing treatment. I could 

see firsthand how our veteran patients were very comfortable with it

and how much easier it made it for them to receive their care.

 Of course there are always and always will be times when patients 

will need to be seen face-to-face in a clinic if there’s need for in depth 

physical examination or an imminent need for hospitalization, but in 

numerous instances telemental health can provide general psychiatry and also specialty psychiatry services such as substance abuse 

and PTSD treatment.
19

 As the VA lead for telemental health I am what is generally referred to as a clinical champion. A clinical champion is a practitioner 

who helps introduce and develop new practices in health care and 

acts as an advocate for these new practices with their colleagues. It 

is indeed a privilege to help the VA and my colleagues lead the way 

with a new health care development like telemental health.

 I am one of the many clinical leads for telemedicine in VA. There 

are also leads for telerehabilitation, telesurgery, teleendocrinology, 

teledermatology and teleretinal imaging. We all receive support 

from the National Care Coordination Program Office. I believe what

makes the VA leads for telemedicine most effective is that we are 

truly committed to serve veteran patients and our colleagues realize 

and recognize that we are using telemedicine in ways that truly work 

for patients and ensure excellence of care.

 The clinical leads for telemedicine have established a network of 

telemedicine clinicians and VISN leaders, and in the VA all of the 

clinical leads have developed toolkits for our respective areas of telemedicine. The toolkits help new programs get started, allow new 

programs to learn from the experience of other VA established programs rather than having to reinvent the wheel. These toolkits are 

also very useful for staff training and the telemental health toolkit 

formalizes the requirements to develop a telemental health service 

and educate all the staff involved.

 This is where my role as the associate chief of staff for education 

has a bearing on the development of telemedicine since one of the 

challenges in sustaining telemedicine is to make sure that there are 

practitioners with the requisite skills and competencies who are committed to the program. In my own speciality for example, medical 

schools and residency programs are just beginning to train the next 

generation of psychiatrists in the use of telemental health.

 In the VA we are starting to explore what a telemental health component to a residency program might look like. I believe the ability to 

recruit newly trained psychiatrists who are familiar with telemental 

health would be of great benefit to the VA in sustaining telemental

health programs and incorporating telehealth into all specialty residency programs in the future may have a catalytic effect in terms of 

promoting the initiation of telehealth in the wider health care system.

 Dr. Darkins mentioned the numbers of programs that involve telemental health, including 74 facilities and 120 community based clinics, but I would like to just finally conclude by leaving you with a

specific telemental health example.

 Currently I practice in VISN 1, the VA New England Health care 

System, and the VISN has recently established a telemental health 

service between Togus and Caribou, Maine. The development of this 

service was presented at the VA’s Care Coordination Telehealth 
20

Leadership Meeting in Salt Lake City in April 2005.

 The service was established because of the 240 mile--excuse me--

249 mile distance that veteran patients previously had to travel between Caribou and Togus for mental health care. The normal seasonal snowfall I’m told is nine and a half feet, and even if it doesn’t 

snow it’s a ten hour round trip, not to mention the cost of gasoline. 

The telemental health toolkit was established and implemented, and 

the program connecting Caribou and Togus led to 100 percent satisfaction with patients and a decrease in the no show rate for treatment.

 In conclusion I am delighted to be able to advocate for telemental 

health within the VA and I will now be glad to answer any questions the Subcommittee may have. This concludes my statement, 

Mr. Chairman.

 [The statement of Dr. Godleski appears on p. 57]

 Mr. Brown. Thank you, Dr. Godleski.

 Dr. Frueh, we welcome you back from the greatest congressional 

district in the country, and we’re glad to have you up here today.

STATEMENT OF B. CHRISTOPHER FRUEH

 Dr. Frueh. Thank you, Mr. Chairman. It is an honor to be here and 

speaking before you, and I am grateful for the opportunity to present 

my views.

 The President’s new Freedom Commission on Mental Health highlighted how people who live in rural areas experience significant disparities in health status and access to care, and this includes many 

veterans. There’s currently a significant shortage of qualified mental

health service providers in rural and remote areas of the country, 

including my own state, our state of South Carolina.

 Today my testimony will focus on how research evidence that supports the incorporation of telemedicine into clinical practice is being 

used to guide the development of telemental health services with the 

specific intent of improving access to care for veterans who are in

need of treatment for mental health conditions in the Veterans Integrated Service Network 7.

 VISN 7 constitutes VA’s southeast network and geographically 

encompasses the states of South Carolina, Georgia and Alabama. 

These states have large rural populations. VISN 7’s pro-active approach to making services geographically accessible to veterans 

has included establishing 24 community based outpatient clients or 

CBOCs as they’re known. Unfortunately the recruitment of qualified mental health professionals, particularly specialists to provide

care for substance abuse and post traumatic stress disorder in rural 
21

CBOCs, poses a challenge to VISN 7’s goal of offering locally based 

services to meet the mental health care needs of veterans that we are 

privileged to serve.

I’d like to make a few remarks about what we know scientifically

with regard to telemedicine and mental health care drawing on research that has been published from all over the world, including a 

large number of studies conducted within the VA and including my 

own.

 First, as reported in the President’s new Freedom Commission on 

Mental Health, people who live in rural areas experience significant

disparities in health status and access to care. Telemedicine has introduced an affordable means of solving these long-standing workforce shortage problems and improving access to mental health care 

for people in remote geographical areas.

 Second, mental health evaluations, including psychiatric interviews and neuropsychological assessments conducted via telemedicine, appear to be accurate and reliable. This is true for even those 

patients who are suffering the most severe mental disorders or cognitive impairment.

 Third, it is clearly feasible to provide both psychotherapy and pharmacotherapy services via telemedicine.

 Fourth, both patients and clinicians report high levels of satisfaction and acceptance with telemedicine interventions. A therapeutic 

relationship can be established even when the patient and clinician 

never meet face-to-face.

 Finally, telemedicine services have been shown to lead to improved 

clinical status. In fact there’s growing evidence that the quality and 

effectiveness of telemedicine services service delivery of mental health 

care is virtually equivalent to traditional face-to-face services and is 

far superior to the more frequent alternative--no mental health care 

at all.

 Although more research is needed to help delineate the parameters 

of how to best provide telemedicine services for mental health, I have 

little doubt that telemedicine offers a safe, acceptable and effective 

mode of service delivery.

 Based upon this evidence VISN 7 is implementing a strategy whereby our VA medical centers will provide support via telemedicine to 

supplement the mental health care that is currently available in our 

CBOCs, and in doing so provide much needed specialty services such 

as treatment of PTSD and substance abuse disorders.

 Together with the VISN 7 network mental health director, Dr. 

Morris Springer, we have developed and implemented a telemedicine 

training program for mental health clinicians within our network 

and so far we’ve conducted the initial rounds of this training with the 

VA mental health clinicians in Charleston, Birmingham and Huntsville, Alabama. Clinicians at the Atlanta VA will be next to receive 
22

this training.

 VISN 7 is planning how at both the local VA medical center and 

network levels we can build on our telemental health strategy to support the use of telemedicine in providing outreach and educational 

services to the operations Iraqi and Enduring Freedom veterans who 

are now returning to South Carolina, Georgia and Alabama.

 I believe the evidence based manner in which we are enhancing 

the mental health care services we provide in VISN 7 using telemedicine will enable us to coordinate care provision between VA medical 

centers, CBOCs, Department of Defense, and other local community agencies. I and many of my colleagues in VISNs throughout the 

country who have affiliations and associations with major academic

institutions, we can tailor locally to make sure it is appropriate for 

the needs of our unique veteran population.

 We are also undertaking the research required to grow the evidence 

base necessary to shape how this care continues to evolve in the future. To do so we are working with such agencies as the Agency for 

Health care Quality and Research, the National Institute of Mental 

Health, VHA Office of Research and Development, and the National

Center for PTSD in Honolulu.

 Mr. Chairman and members of the Committee, I thank you.

 [The statement of Dr. Frueh appears on p. 61]

 Mr. Brown. Thank you very much.

 Ms. Wertenberger, are you ready?

 Ms. Wertenberger. Okay.

 Mr. Brown. What I’m going to ask you to do, and I know we’re going 

to have votes in just a few minutes, I want to give everybody a chance, 

at least have a chance to speak. If we could sort of summarize your 

remarks and try to limit them within three to five minutes we would

certainly appreciate it. And I apologize for that inconvenience, but 

when we go to vote we might not ever come back. It could be 30 minutes or two hours. So it really is kind of crazy.

 But, anyway, thank you. I hope you all understand.

STATEMENT OF SYDNEY WERTENBERGER

 Ms. Wertenberger. Mr. Chairman and members of the Committee, I’m privileged to appear before you today to discuss rural telemedicine and describe the positive impact it’s having on our ability to 

provide care to the veterans we proudly serve. I ask that my written 

testimony be entered into the record, and I will give you a synopsis 

of it now.

 Although I’m the person testifying before the Committee today I

represent a dedicated team of health care professionals who are com-
23

mitted to improving access to care for veterans who live in the rural 

setting. My testimony relates to how we care for veterans at the John 

J. Pershing VA Medical Center in Poplar Bluff, Missouri, and our 

community based outpatient clinics which are located in Paragould, 

Arkansas, Cape Girardeau, Farmington, West Plains and Salem, 

Missouri.

 I believe that our success in improving access to care for our veterans is transferable to other rural areas. The commitment and leadership of our facility director, chief of staff, our VISN 15 network director, combined with support and direction from senior management in 

VA’s central office have been key elements in inspiring our teams to

refocus and reconfigure the services we provide to incorporate telemedicine and improve access to care for our veterans.

 The John J. Pershing VA Medical Center is a small, rural facility 

located in our nation’s heartland. Our mission focus is on the delivery 

of primary care services. Our remote location means we face very different challenges in providing care to our veteran patients compared 

to a VA medical center located in a more metropolitan area.

 Those of us who choose to live in a rural environment do so because 

we feel that facing these challenges is well worth the reward we get 

from living where we do. The cost of living is lower, members of 

our community value self-reliance and independence. At times this 

makes convincing veterans to seek health care services early and providing preventative health care true challenges.

 For the veterans we treat health and well-being means living where 

traffic is limited and there is peace and quiet with folks you know. 

They view being home as worth more than money can ever buy, and 

that home is not a house, but a place and way of life.

 Those of us privileged to be charged with providing health care 

to veterans living in a rural environment are sensitive to its unique 

culture. We know that veteran patients living in a rural environment need the same level of professional expertise as those who live 

anywhere else.

 Telemedicine has been a great boon to us in delivering care in a 

rural community. Instead of the traditional requirement in health 

care that the patient travels to the care, we can take the care to the 

patient. It means we can truly practice patient centered care. It offers us opportunity to successfully meet the challenge of providing 

health care in a rural environment.

 I will try not to make telemedicine sound too much like a panacea, but it has opened multiple care options and possibilities for our 

veterans. Telemedicine is a tool which assists us in addressing the 

issues of access, quality, patient safety and cost effectiveness. Value 

is another commodity. Some things are very difficult to be able to put

a price tag on.

I’d like to share with you very briefly an experience we had several
24

years ago with one of our veterans.

 We had a gentleman under nursing home care with us, very frail, 

elderly. His wife was with his son. Unfortunately the wife became 

acutely ill. He couldn’t make the trip to be able to say goodbye. 

Through telemedicine we could achieve that. They had their last 

moments, their last opportunity to say goodbye. Imagine what a gift 

that is.

 We currently have 39 telemedicine clinics working with our community based clinics and medical center giving a full range of speciality care. Clinical outcomes have been positive. The technology costs 

we believe will be recouped within 14 months due to cost avoidance 

and savings.

 Telemedicine technology has offered us a way to put compassion 

for our patients into action. I am grateful to you for this opportunity. 

Thank you.

 [The statement of Ms. Wertenberger appears on p. 66]

 Mr. Brown. Thank you, Ms. Wertenberger. Being from a rural part 

of South Carolina and a Ranking Member from up in Maine where 

the travel is a real problem, and the veterans certainly like living in 

those rural settings and we appreciate your working in that arena.

 Ms. Wertenberger. It is our pleasure and privilege.

 Mr. Brown. And ours too. Thank you.

Dr. Levy, we overlooked you in our first announcements there, so

let me recognize you.

 Dr. Charles Levy is the Chief of Physical Medicine and Rehabilitiation Services North Florida, South Georgia Veterans Health Services 

in Gainesville, Florida. Dr. Levy also serves as an associate professor in the Department of Occupational Therapy at the University of 

Florida. He is a nationally recognized expert in rural mobility and 

amputee care and rehabilitation, and I welcome you, Dr. Levy.

STATEMENT OF CHARLES E. LEVY

 Dr. Levy. Thank you very much. I’m going to get through this as 

quickly as I can in respect for you, also. If it seems a little scattered, 

I apologize.

 I’m a physician specializing in physical medicine and rehab and I’m 

privileged to be serving veterans in the North Florida, South Georgia 

Veterans Health System. It is particularly pleasing to work for the 

VA because the modern roots of rehabilitation medicine grew in response to the need to improve the abilities, opportunities and quality 

of life of injured soldiers during and following World War II.

 I feel that we’re at a very dramatic moment where health care is 

changing; telemedicine and telerehabilitation is the key to this great 
25

paradigm shift.

 Within rehabilitation medicine there is a great enthusiasm from 

physicians, therapists and nurses to use the tool of rehabilitation 

medicine to finally bring care into the home and into the home environments. This is an area that we really haven’t been able to get to 

prior, and Telerehabilitation offers a great solution to actually to get 

to the home and really make changes.

Telerehabilitation can be described using four models. The first

model simply recreates the clinic using telecommunication to bring 

service to closer to veterans’ home. Typically these clinics deliver one 

time assessments as opposed to ongoing care. Veterans with multiple 

sclerosis, spinal cord injury, amputations, diabetes, cardiopulmonary 

and orthopedic problems and other disorders are right now interacting with their clinicians in real time using television screens and 

telecommunication in Cleveland, Ohio, and Nashville, and Minneapolis, and Denver, and Fresno, in Ann Arbor, Tampa and elsewhere. 

Patients are being served by telerehabilitation in wheelchair clinics. 

They’re getting their wound care, they’re getting neuropsychological 

care and prosthetic and orthotic assessments.

 For an example, a spinal cord injured veteran in Dayton, Ohio with 

skin breakdown related to his wheelchair seating will be presented 

by his or her local therapists to an expert panel in Cleveland. The 

Cleveland team can instantly see the results of pressure mapping and 

work with the Dayton therapist to come up with the optimal wheelchair cushion and seating solution. A byproduct of this is cross education and elevation of the standard of care throughout the region.

 A second model delivers ongoing care to veterans at distant clinics. 

Examples include speech therapy, occupational and physical therapy, 

psychological and social services. For example, therapists in Denver 

assisted a veteran hundreds of miles away using video conferencing 

units located in the local clinics and in the medical center. They were 

able to help the veteran with a traumatic brain injury who had difficulties with mobility, self care, bladder management and decision

making. Therapists were able to see how the patient functioned and 

to speak to the patient’s wife about problems the veteran was having. 

From this they were able to determine practical ways they could help 

the wife care for her husband by providing ongoing education and 

training to both improve transfers, walking and stair climbing.

 While improving the quality and the availability of care in local 

clinics is critical, if we have our choice most of us would prefer to 

receive care in our own homes. A third model of telerehabilitation 

does just that.

 A VA study in Raleigh, North Carolina is using remote video links 

to deliver physiotherapy in the home and comparing the outcomes to 

traditional physical therapy. The preliminary data looks favorable.

 Another project, the Low ADL Monitoring Program, is targeting 
26

frail veterans in north Florida and south Georgia. These veterans at 

high risk for failure and are visited at home by an occupational therapist and a technician who prescribe and install necessary assistive 

devices such as grab bars, tub transfer seats, canes, reachers, long 

handled shoe horns, dressing aids and adapted eating utensils. The 

patients are then monitored daily either by text messaging, phone, 

computer or desktop devices. This way pro-active and practical interventions can reach the veteran before problems become disasters.

Data from the first 150 veterans show reduced hospitalization and

emergency room use and reduced nursing home bed days of care. A

comparison of six months prior to enrollment to the six months post 

enrollment showed a savings of $1,200,000.

 A fourth model links teams at great distances from the medical 

centers’ experts of care. I’ll skip that in the interest of time.

 I’ve given you some examples of telerehabilitation today. However, 

I believe the greater excitement will be seen as telerehabilitation becomes integrated into the standard care for veterans. I envision a 

day soon when returning war injured veterans needing rehabilitation 

are embraced by a fully integrated care system that follows the veterans from the DOD to VA centers of excellence, to the local VA medical 

centers, to their community-based outpatient clinics, and then into 

their homes.

 Thank you very much. I’d be glad to take questions.

 [The statement of Dr. Levy appears on p. 70]

 Mr. Brown. Thank you, Dr. Levy.

 Ms. Ryan?

STATEMENT OF PATRICIA RYAN

 Ms. Ryan. Good morning. I want to thank you for this opportunity to meet with you today. VISN 8 began enrolling patients in the 

care coordination home telehealth program in April of 2000. Most 

of the veterans that we enroll are the clinically complex, older, adult 

veterans, and we serve most of the chronic population, the populations that have the chronic health problems that you’ve heard about 

already.

 Forty-nine percent of the veteran population is over 65 and average 

three or more chronic health problems. They live in their own communities, they live in their own homes, and frequently when you get 

to be of a certain age you’re really afraid to go to the doctor but you 

really have problems managing your own health care. What the care 

coordination program does for them is gives them the ability to manage their own chronic diseases.

 Our goal is to improve access to care and to provide the right care 
27

at the right time at the right place. Through the use of the electronic 

medical record the role of the care coordinator is combined with home 

telehealth technologies to provide that link to all of the clinical specialists that a veteran may need to see and get data to, as Dr. Fletcher 

showed you this morning.

 Frequently clinic visits are followed up just in case a person declines or to evaluate the type of information that’s been going on in 

the progress of treatment. The ongoing connection through home 

telehealth provides just in time care that is both based on subjective 

and objective clinical information.

 The VISN 8 care coordination program has served over 3,500 veterans in the last five years with the current census of over 2,400. We

have 21 programs across the network that serve many populations, 

from frail, older adults with multiple chronic medical conditions, veterans with mental health problems, a large of population of veterans 

with both diabetes and heart failure, and a wound care program that 

for the very special spinal cord population at the San Juan VA. And 

some of those veterans would have to travel from St. Thomas to San 

Juan via air transport if they needed to come there for their wound 

care. So we’re able to do that remotely.

 Our success has been outstanding and customer service has been 

measured annually for the last five years with the results of over 95

percent satisfaction with both the care coordination process, which is 

really important, as well as with the use of the technology. There are 

four components to care coordination: care and case management, 

disease management, self management of chronic disease, and then 

as we said before the technology to provide all of these.

 We’ve been able to reduce in our heart failure programs, reduce 

blood pressures on an average from 131 over 70 to 119 over 69. We’ve 

had weight reductions that have averaged 5 to 10 pounds. We’ve had 

clinically significant improvement in both of our--in all of our diabetics across the network.

 Over 80 percent of our veterans use the in home messaging device 

and we will be able to produce results similar to what Dr. Fletcher 

has shown you.

 One population that we serve is the palliative care population that 

grew out of a cancer program that we started in conjunction with the 

National Cancer Institute. We have a chaplain that serves as a care 

coordinator and the care coordinator is a registered professional that 

must be a team member with all of the different specialties that we 

have.

 This veteran was near the end of his life and his son, who was a 

police officer in a distant town, was shot in the face and the veteran

could not travel to see his son. Through care coordination programs 

that we have all over our state we were able to serve with the care 

coordinators. We were able to set up video conferencing equipment 
28

between the son in the hospital and the veteran at home. During--towards the end of his life he was able to share some precious moments 

with his father.

 Mr. Chairman, my father and all of my uncles--except for one--

were World War II veterans. So I grew up knowing what the value 

of veterans are to this country, and I really value my ability to serve 

veterans in this manner, and I’m ready to answer any questions that 

you may have.

 [The statement of Ms. Ryan appears on p. 74]

 Mr. Brown. And I really do appreciate you all coming and we certainly have a compassion for our veterans on this Committee. We’re 

grateful for the testimony that you’ve come to bring this morning.

 Mr. Michaud, do you have any questions?

 Mr. Michaud. I have several questions, but in the interest of time 

I’ll submit them for the record, Mr. Chairman.

 Mr. Brown. Well, let me tell you it was a great, informative few 

minutes. I apologize for the urgency of moving forward so we can 

speak to the last panel, but thank you all very much for coming and I

thank you every day for what you all are doing for our veterans.

 Ms. Ryan. Thank you.

 Mr. Michaud. That doesn’t mean you’re off the hook as far as answering questions.

 Mr. Brown. Our third panel is Mr. Jonathan Linkous, Executive 

Director of American Telemedicine, and Dr. Sandeep Wadhwa, the 

Vice President of Care Management Services for McKesson Health 

Solutions and a member of the board of the Disease Management Association of America.

 And gentleman, I know you’ve been hearing my pleas all along. 

The horn hasn’t sounded yet. We certainly welcome you, and Mr. 

Linkous, if you would begin.

STATEMENTS OF JONATHAN D. LINKOUS, EXECUTIVE DI-

 RECTOR, AMERICAN TELEMEDICINE ASSOCIATION; AND

 SANDEEP WADHWA, VICE PRESIDENT, CARE MANAGE-

 MENT SERVICES, MCKESSON HEALTH SOLUTIONS AND

 MEMBER OF THE BOARD, DISEASE MANAGEMENT ASSO-

 CIATION OF AMERICA

STATEMENT OF JONATHAN D. LINKOUS

 Mr. Linkous. I appreciate the opportunity to speak here on behalf 

of the American Telemedicine Association. 

 Telemedicine is a very important subject, and the ATA greatly appreciates the Committee’s leadership in this area.
29

 I would like to take just a moment to give you a little background 

on telemedicine from ATA’s perspective. You’ve had some great testimony so far on applications within the VA. Telemedicine has been 

around for about 30 years in this country in various aspects. Right 

now there are about 200 active networks in the country, outside of 

the Veterans Administration, including about 2,000 hospitals that 

are all involved in telemedicine. About 60 specialties and sub-specialties, medical specialties, have been used in telemedicine. It is 

a very active and growing area around the country. Certainly one 

of the most important areas is telemedicine in home care, in areas 

where the Veterans Administration has done quite a bit of groundbreaking work.

 With the aging of the population in this country, home telehealth 

has probably one of the greatest potentials for growth. In telemedicine today, there is about 15,000 providers of home care services carrying about 7 million individuals nationwide in cases of acute illness, 

long term care conditions and force forward disease management.

 Throughout the past two decades, the home monitoring industry 

and government, as well as the private sector, have been developing 

electronic and telecommunications equipment which can do anything 

from collecting vital signs to allowing you to see a nurse from your 

own home.

 There are a number of challenges that are facing this industry 

as we move forward. One is moving--taking advantage of the new 

technologies that are available, both in wireless applications as well 

as cheaper applications that will make--drive the price down. I understand your comments about the price, and I will tell you that in 

the last ten years, the prices for telemedicine equipment are probably about 15 percent of what they were when I first started getting

involved in telemedicine 10, 12 years ago.

 The industry also must be able to meet the diverse demands of 

home care agencies. One of the things you will see within the Veterans Administration, and elsewhere--is they’re not just using one type 

of telemedicine in the home, they’re using a number of different types 

of technologies, and it depends upon the need of the patient, such 

as trans-telephonic monitoring of heart signals, for example. If you 

have an implanted pacemaker, you can have it monitored remotely 

using a telephone, a fairly simple device active throughout the country--event recorders for people with heart problems, health status 

monitors that might just ask patients certain question. Certainly the 

applications we saw, taking weight and vital signs and even pushing 

a button and seeing the nurse--having that interaction on a daily basis is another thing that we’re seeing regularly.

 The Veterans Administration has certainly been a leader in this 

area in the country. With over 5,000 patients enrolled in their home 

telehealth program alone, the Department is administering one of 
30

the largest arenas--activities, rather, in telemedicine throughout 

this country. The Department has been working hard to set forth 

guidelines and the appropriate use and administration of these technologies, including developing appropriate technology standards, and 

protocols, and initiating specialized training for VHA employees involved in the use of telehealth in the home.

 ATA’s membership includes many of the staff from the Veterans 

Administration. We’ve actually had two members of the VA serve on 

our board of directors. The chair of our home telehealth task force is 

from the Veterans Administration and we also have just completed a 

set of guidelines and tasks--and standards--involving the VA as well 

as the military, another major player in telemedicine in this country.

 The experience and lessons learned from the VA’s use of telemedicine in the home can be a valuable resource for others in the medical community outside of the Veterans Administration. At the same 

time, others outside of the VA also have a lot of experience in this 

same field. For example, at our recent annual meeting in Denver,

Colorado, we had over 2,000 people and 50 presentations just in the 

field of home telehealth.

 ATA applauds the Department of Veterans’ Affairs for its efforts to 

deploy telemedicine. We appreciate the progress they are making in 

this critical field and stand ready to help them, as well as this Committee, with a cross-fertilization of ideas between the Department 

and others involved in this very rapidly growing area of health care. 

I thank you very much.

 [The statement of Mr. Linkous appears on p. 78]

 Mr. Brown. Thank you very much.

 Sandeep Wadhwa.

STATEMENT OF SANDEEP WADHWA

 Dr. Wadhwa. That’s it. You nailed it.

 Mr. Brown. Okay.

 Dr. Wadhwa. Chairman Brown, I have the pleasure of returning 

from Kiawah Island this weekend and can attest to the stunning 

beauty of your district.

 I will summarize my already summarized remarks and get us back 

on track.

 My name is Dr. Sandeep Wadhwa and I’m the Chairman of Government Affairs of the Disease Management Association of America, and 

I also oversee disease management programs for McKesson Corporation, which is one of the largest providers of disease management 

services to government health payers. I’m also a practicing geriatri-
31

cian and am familiar with the long term and chronic care needs of 

veterans from my five years of practice at the Philadelphia VA Medical Center.

The Disease Management Association of America is a non-profit

organization representing all aspects of the disease management 

community, and disease management emphasizes the prevention or 

exacerbation of disease and complications by using evidence based 

medicine and practice guidelines and patient empowerment strategies. We strongly encourage and support the VA’s adoption of telehealth initiatives. The VA has done extensive evaluations of telemonitoring devices which have demonstrated their efficacy in improving

patient health status and reducing avoidable utilization of VA’s acute 

care resources.

 The VA’s use of telenursing however is in its early stages. Telenursing leverages the telephone as a no additional cost and nearly universal device to establish a therapeutic relationship between a nurse 

and a patient for education, counseling and monitoring. Our member 

organizations have demonstrated the value of using the telephone 

across a variety of settings to improve the health of vulnerable populations cost effectively. To that end we encourage the VA to leverage 

the ubiquity and utility of the telephone as well in its telehealth initiatives. Thank you.

 [The statement of Dr. Wadhwa appears on p. 82]

 Mr. Brown. I do thank both of you for coming and thank you for 

confirming my assessment of my district.

 Mr. Michaud, do you have any questions you want to ask?

 Mr. Michaud. First of all, I would like to thank all the panelists 

that we heard this morning as they all did an enlightening job, and I

really appreciate the information.

 My concern, being from the rural state of Maine, is whether or not 

the funding will be there to make sure that the need is met for our 

veterans throughout the State of Maine and other rural areas.

 I guess the assessment that was given earlier about Caribou and 

Togus is appropriate, but actually you could fit all of New England

into the State of Maine. And my big concern is when you look at 

the number of facilities--well, the hospital and the clinics we have in 

Maine is equal to the amount that’s in New Hampshire. My concern 

is whether veterans in rural areas are getting that access.

 I guess my question is I know VA had done a great job as far as 

telemedicine, but as far as the standard when you look at the Department of Defense, the VA, as well as the American Hospital Association, is there a standard for all three that everyone is complying with 

or will there be a mismatch between the technology that is being used 

particularly among the DOD and the VA?
32

 Mr. Linkous. I think that’s an excellent question and a very timely 

question. Within Maine alone, there’s a separate telemedicine network that includes over 100 hospitals. It’s quite a remarkable network that they have going on and they have a lot of experience.

 As the technology improves, as the practice becomes more widespread, certainly one of the challenges that we face right now is adopting standards and clinical protocols that are the same throughout the 

Veterans Administration, the military, the prison systems that use 

telemedicine, and of course, into the private sector, as well.

 The Veterans Administration has made a lot of progress in developing some standards and some protocols. We have on a couple of 

occasions, worked with them on developing some standards that are 

based on some of the work that they’ve done, and then we move it out 

further. But I think that is a challenge as we move ahead, to make 

sure that the protocols are there, that the standards are in place, so 

that when you have a telemedicine system in Maine, or in South Carolina, or in California, basically, the patient can expect the same level 

of care and the same types of services, no matter where they are.

 Mr. Michaud. My second question is for both panelists. Since you’re 

familiar with the VA, do you think the VA should be doing something 

differently or should they be focusing in certain areas as far as telemedicine goes?

 Dr. Wadhwa. We’re very pleased with the care coordination efforts 

that are coming out of the VA’s office, and I guess from our perspective we’re looking for a balance between the use of telemonitoring 

equipment which, as was discussed earlier does have costs associated 

with it, as well as using the telephone and the ability to in a very low 

cost way to establish a relationship has been shown in a lot of peer 

reviewed studies. So we think that both of those telehealth solutions 

should be promoted in the system.

 Mr. Michaud. I guess what my final question if I might, Mr. Chairman? It has been stated that one out of every six servicemen and 

women will come back from Iraq and Afghanistan is going to need 

some type of assistance, particularly as it relates to mental health. 

Do you think that currently there’s enough funding within VA to deal 

with that particular issue? And I guess my second question is how 

important is one-on-one immediacy going to be? You know, I assume 

that telemedicine is going to be available during the daylight hours. 

What’s going to happen to the veteran who needs the assistance at 

nighttime, particularly when we hear about all the people who die 

over in Iraq and Afghanistan, but we don’t hear much about the suicides or attempted suicides that are currently there and my concern 

is the immediacy of getting assistance.

 Mr. Linkous. One of the benefits of telemedicine is that you can

extend the services provided to the individual beyond just the hours 

of the clinic, just when a particular practitioner happens to be in the 
33

office. You can link into a network and get those services no matter

where they are.

 The Veterans Administration has done a lot of work in telemental 

health, brought a lot of leadership in that area. I am concerned about 

the funding level. I’m very concerned about what we’re hearing, and 

certainly, the Chair and you are hearing about the appropriations 

this year for the Veterans Administration. I think it is not a good 

time to be reducing any money for an agency that is providing services to our veterans when we are involved in conflicts.

 Dr. Wadhwa. And I’ll just build on that, that response just ever 

so briefly, in that many of these services are set up to be available

around the clock with immediate access to a telenurse and teleadvice. 

That is exactly for patients in distress and they may not have a good 

grasp of judging their own symptom and calling 911, but feel comfortable talking around the clock to a nurse and have that symptom 

triaged at the appropriate level of care. So that is a concern I think 

that telehealth does, can be set up to address that, to provide around 

the clock service.

 Mr. Michaud. And if I might, as I said, there’s a lot of questions. 

You just happen to be the last panel before the bell rings. The last 

question I have and I promise, Mr. Chairman, is do you think the 

technology, the system out there, particularly in a rural state like 

Maine and given the number of veterans that we currently have in 

Maine, that the use of the system, is it available, the technology in 

the rural areas?

 Mr. Linkous. Is the technology available currently?

 Mr. Michaud. Yes. Will there be a problem with overload? I mean, 

if you look at Maine, 16 percent of our population are veterans. We’re 

the highest in the country as far as veterans. We’re a rural state. We 

definitely do need to improve on the technology. You look at Maine’s

National Guard, we’re at the top there as well. If the BRAC process 

goes through where 7,000 jobs are going to be lost in Maine and it’s 

going to throw more veterans probably onto the system. Will the system be able to withstand the needs?

 Mr. Linkous. Well, I would say there’s a problem currently serving 

those needs, and part of that problem is the fact that we have a system that is still relying very much on individual face-to-face consultations and services. Telemedicine does allow you to actually increase 

the number of patients that you see, and it increases the efficiency of

the system. So hopefully, as we get it deployed further throughout 

the State of Maine, or South Carolina, or throughout the country, we 

can increase the number of services and access to those services for 

all of the patients that are out there.

 The technology is--the changes in technology are just phenomenal, 

even for the last 12 months. So I think we are going to be able to have 

a technology available that will be able to be deployed in all of the 
34

homes. It’s very important, though, that the appropriate technology 

be selected for the appropriate need.

 Dr. Wadhwa. And just to very quickly build on that comment, the 

technology is, as we said earlier, becoming much less expensive and 

very easy for the veterans to install themselves without a lot of technical guidance or people coming out. And so our strong sense is that 

the technology is here.

 Mr. Brown. Let me say not just to you two but the whole panel, all 

three panels that were presenting today, what a real refreshment to 

the sense of where we’re moving in our health care delivery, and I

thank you both for being part of, plus the other two panels, and thank 

you all for coming. And as the mystery of this process moves forward 

the two--the 11:00 votes did not show, nor did the 11:15, nor did the 

11:30 apparently. So we’re still--it’s still amazing how this process 

goes.

 Mr. Michaud. I do not have a question but, Mr. Chairman, this is 

Susan’s last hearing after eight years as Democratic Staff Director 

for this Subcommittee. She’s done an outstanding job. I want to wish 

her the very best in her future endeavors. Thank you very much.

 Mr. Brown. Well, Susan, thank you for your service, and we will 

miss you.

 [Applause.]

 Mr. Brown. With that, the meeting is adjourned.

 [Whereupon, at 11:33 a.m., the Subcommittee was adjourned.]
(35)

APPENDIX
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120