Welcome to the Virginia Telehealth Network Blog

The VTN blogs are written by guest bloggers on a variety of topics related to telehealth/telemedicine. The bloggers will be from Virginia, the country and the world. We have an exciting lineup of bloggers and topics

March 20, 2011. "Case Studies: Using #HCSM Tools to Enhance Patient Care." Blog article by Mark Ryan, M.D., Department of Family Medicine, Virginia Commonwealth University Medical Center. Dr. Ryan is also a member of the Mayo Clinic Center for Social Media Advisory Board and blogs at Social Media Healthcare.

"In medicine, much of how students are taught is through case studies. Typically, the teacher “presents” a patient to the students (including history of current illness, past medical/family/social history, current medications, and relevant physical exam findings. The students/learners are then expected to ask any clarifying questions that might be necessary, can ask for labs and imaging studies, and then puts together the list of possible diagnoses and possible treatment plans. The goal is for the learners to actively participate in the process: rather than passively listening to a lecture, the back and forth discussion promotes learning.

In the next few months, I am fortunate enough to be presenting lectures about healthcare communications and social media (hcsm) at various state and national conferences. In each case, part of the task will be to encourage physicians–who are often skeptical about hcsm–to consider exploring hcsm tools as a way to enhance patient care. As part of preparing for these presentations, I thought I would brainstorm some ideas as to how hcsm tools can enhance patient care. The basic question I am looking to address: How can hcsm tools and communication improve patient care, and what added value does hcsm provide to justify including it in an already busy day?

In the spirit of active learning, I present these ideas here as case studies: I have thought of ways that hcsm can be used, but I invite readers to comment, correct, or enhance these ideas. Ask questions, seek clarification, or dispute the ideas–it is through this active learning that we can develop ideas that will encourage physicians to participate in hcsm. Case studies and social media (SocMed) participation have similar goals: learning and reflection through social interactions and dialogue. Adult learning occurs over time and is inherently social–social media and case studies both encourage this process.

I have chosen to present cases demonstrating the value of hcsm from the perspective of an individual physician, a medical practice, a large medical system, and a public health organization respectively. A few ground rules:

My focus will involve YouTube, Facebook and Twitter.
Also included is a discussion of SMS and secure patient portals because of the need for private communication as part of providing healthcare services.
Some ideas are somewhat simplistic, but I have included them for comprehensive understanding.
There is some crossover: ideas listed under one category probably apply to others. Unless there is incredible value in doing so, I have chosen not to repeat the same ideas to avoid redundancy.
It is assumed you have at least some familiarity with SocMed. I will use jargon like “followers”, “tweet”, etc without further clarification. Please let me know if you require clarification.
Individual physician: example: my accounts, @RichmondDoc and RichmondDoc.blogspot.com.

Search for relevant health-related information that can you can forward to patients via who follow you. This includes local health fairs, free or low-cost clinic information, health care screenings, etc. This also includes forwarding links from national organizations such as American Diabetes Association, American Heart Association, American Medical Association, American Academy of Family Physicians, and other organizations.
Advocate for change/reform that you feel benefits patients by posting thoughts and links to important policy information.
Answer patients’ general health-related questions, and provide links to valid/trusted on-line resources that will help patients make decisions (such as linking to www.FamilyDoctor.org).
Use SocMed to keep on top of developments in medical care, health policy, and related health topics.
Participate in online Twitter discussions such as #hcsm, #MDChat, #hcsmLA to discover better uses for these tools, and to better understand what patients and other stakeholders expect from providers regarding hcsm.
Develop a YouTube channel where you can post discussions about relevant topics–either health-specific ideas, policy/politics discussions, etc.
Ask for help by surveying your account followers on questions they would like answered, and provide answers to others’ crowd-sourced questions.
Keep a blog that allows you to dig more deeply into complicated issues. This can become a resource for patients seeking more information on certain issues.
Reach out to other SocMed users and develop productive and meaningful collaborations. This very blog exists because of SocMed: the three authors “met” through Twitter and have communicated by e-mail and a few telephone calls, but have not actually met in person. Similarly, three of the four presentations I am scheduled to give in the next four months will be shared presentations with people I met via Twitter: I have met @NickDawson in person but originally first met him through Twitter; I have only met @Miller7 via Twitter, e-mail and one phone call. Even so, my involvement in hcsm has enhanced my professional skills and (I hope!) my position in the promotion/tenure process.
Each of these SocMed tools can be used for advocacy on behalf of patients, health reform, and health care delivery and payment reform.
Medical practice: example, MacArthur Ob/Gyn and its Facebook and Twitter accounts.

Broadcast information to patients who follow your accounts–this could include office hours, new services, vaccine availability, etc.
Send generic reminders to patients to take action for their health, such as checking blood sugars, taking medications, etc. Patients can choose to follow your account and receive notification via SMS, meaning that your reminder could promote real-time action. For added security, these messages could include encrypted SMS technology. Small studies have already suggested that text message reminders can promote adherence to treatment plans.
Send “broadcast” messages to account followers tagged with certain hashtags, such as #bloodpressure or #diabetes. Patients who choose to follow your account and who understand the hashtag (who have opted in) can then choose to contact the office for further action. For example: Tweet “How have your blood sugars been running? #VCUHSDiabetes” and patients who understand the hashtag may have already agreed to review their blood sugars and contact the office with the necessary information. This could be a way to enhance disease self-management and to encourage better control of chronic illnesses.
Send direct messages via Twitter or Facebook to individual followers asking them to follow-up with the office via private portals or through traditional communication. These messages do not align to HIPAA standards and would require discretion (and probably an in-house legal counsel review), but simply remind a particular person to contact the office through secure means. For example, a message sent privately on Facebook or Twitter that simply asks a patient to contact the office could encourage follow-up without revealing any personal health information.
Engage in dialogue with patients about office practices and procedures, whether good or bad. If patients have compliments, then one can respond positively. If a patient has a concern or negative comment, this could be addressed and the conversation could be taken off-line for resolution.
Invite patients to contact the practice with general questions or comments, and use that information to respond either publicly or privately (as indicated) in order to enhance patient-centeredness and patient-connectedness.
Healthcare system: example, Bon Secours Richmond’s Facebook and Twitter accounts, or Mayo Clinic’s YouTube channel and Facebook and Twitter accounts.

Broadcast information about seminars, services, physicians, etc.
Connect with patients re: good and bad experiences with the system and/or its providers.
Develop a YouTube channel to highlight important information regarding the organization. This would be easier for large systems than for individual providers, and can provide a great deal of information for patients in a very user-friendly way. YouTube and other video services also provide patients with an opportunity to see the information being presented, which is an asset for patients who are more visual learners.
Reach out to consulting practices and referring providers to enhance the connections between those practices and your healthcare system. This could improve referral patterns into one’s system (or a system’s hospital), and improve care for patients.
Reach out to public advocacy or local government agencies in order to provide the system’s expertise in addressing issues of health policy or health care.
Reach out to patient communities to offer information or speakers to promote the communities’ discussions about certain medical conditions.
Public health authorities: example, the Centers for Disease Control (CDC)’s YouTube channel, and its Facebook and Twitter accounts.

Provide information regarding healthy lifestyles and disease awareness and prevention messages.
Send out urgent information regarding developing health emergencies, epidemics, etc. The CDC has a separate account dealing with healthcare emergencies, and this account could be used to push out information to the public in a very timely way.
Receive incoming information from the public (or from healthcare workers or lay health promoters) about patterns of illness that are present in a certain community. The public health authorities can track these messages and look for any patterns that could indicate unusual events.
Actively develop a network of lay health workers and healthcare workers to act as surveillance in the community. This network could be linked by traditional SocMed tools, but can also use SMS notifications–especially in rural areas or developing nations. Communication could flow both ways to note unusual patterns of illness or other signs of concern.
Linking lay health promoters with central agencies can also promote health outreach and health maintenance activities. For example, a public health ministry in a developing nation could tweet its affiliated lay health promoters “Today is the day to provide anti-parasitic medications to your community.” With one message, lay health promoters could receive the Tweet directly from Twitter or via SMS notification, and could then distribute the necessary medications throughout their target communities.
Similarly, public health organizations could use SocMed communication to address environmental emergencies such as floods, earthquakes, or tropical storms. SocMed can be used for lay health workers to notify central authorities about events, and by central authorities to make communities of rescue and recovery plans.
Finally: any of these hcsm connections have to emphasize authenticity, relevance, trust, and bilateral communication and dialogue. There is some role for broadcasting information, but at its heart hcsm/SocMed involves community. Any user that is only sending information out without listening to any replies will be less successful than a user who is willing to talk with the target audience. At the end of they day, all health care services exist to improve patients’ health. In order to do that, we must listen to the patients’ voices.

Even if you choose to start working on only one or two of these ideas, you should start to see changes in your practice and your interactions with patients. If you note and monitor these changes, you will be able to quantify them and adapt your hcsm use accordingly."

March 5, 2011. "Mobile Helping Rural Communities in Jordan." Blog article by Mark H. Ryan, M.D., Department of Family Medicine, Virginia Commonwealth University Medical Center. Dr. Ryan is also a member of the Mayo Clinic Center for Social Media Advisory Board and blogs at Social Media Healthcare. [VTN note: Implications for marginalized communities in the United States]

"Earlier, I discussed how mobile health applications can provide benefits to underserved and marginalized communities in developing nations. Recently, I was referred to an article showing how this is already happening. In Jordan, women in Bedouin communities lack access to medical care for various reasons, including culture (women cannot seek outside help without their husband’s permission) and the lack of physicians in their communities.

The program is set up in such a way that women can text questions to central contact numbers, and can select which topic they need to address. Their questions are answered by physicians via return text messages, and the messages can be read so that even women with low levels of literacy can receive the information.

The article includes a few points that are especially interesting to me:

The first is that even women in poor, rural communities have access to mobile phones. I suspect this will increasingly be the case in other developing nations as mobile technology becomes more accessible and less expensive, and Jordan may be blazing a train for other countries to follow.
The second is that the program was developed to address barriers to care: low literacy levels, low educational levels, and the fact that women are not culturally empowered to access care even though they will often be responsible for coordinating care for themselves and for their children. Previous research has shows that one of the best ways to improve a family’s health is to educate and empower women. Jordan’s program seems to working on the same principle, and stands to provide broader benefits as a result.
The third is that the program is aimed at a broad community, including poor and rural residents, as opposed to being limited to those who may already have other resources available. Although text messages will not be able to address healthcare inequalities by themselves, a program that aims to provide benefits to those without access–and that has been well-received by members of the targeted community–may be an important step in that direction.
Mobile health, via SMS or low-cost smart phone applications, is a powerful tool to improve the health of marginalized communities either in developing nations or in the United States. Pilot projects such as this program in Jordan are worth our attention, and may be worth replicating."

February 21, 2011Blog: New app for iPad and iPhone gives Bon Secours doctors mobile access to support patient care. From Bon Secours Good Sharing Blog. Posted on February 21, 2011 by GoodSharing. Click here to access blog site.

"Need to check a patient’s medical history, allergies or potential problems?
Now that information can be at your fingertips…anywhere, anytime. A new handheld application called Haiku is linked into our ConnectCare system makes caregiving easier for physicians. Now, with the touch of a screen, physicians can find patients in the system and review information about their medical histories, active orders, admission information and more.

Haiku, which works with Apple iPhones and iPads, recently was implemented by Bon Secours. It allows physicians to remotely view patient lists, schedules, care team information and results. The read-only functionality provides physicians with detailed reports that enable them to make sound clinical decisions.

Information you need
The Haiku application is available to Bon Secours credentialed physicians and mid-levels. Highlights of the application include the ability to view surgery and office appointment schedules for a two-week window and to review patient notes, lab results and imaging result narratives.

Information is not stored on the iPad or iPhone, so users need a live wireless connection to view information. To gain access, users must be competent in Hyperspace after a ConnectCare go-live for three to six weeks.

High-tech solutions
Haiku is designed to run on the iPhone 3G (or later), iPod touch (running i0S4), and the iPad.

The iPad tablet computer, introduced in April 2010, has gained a huge market share. It runs on the same operating system as the iPhone.

A recent survey by Frost & Sullivan shows that iPad usage in office workplaces is linked to the goals of increased employee productivity, reduced paperwork, and increased revenue. The research firm estimated that mobile-office application market in North America may reach $6.85 billion in 2015, up from an estimated $1.76 billion in 2010.

Developing technology
Though Haiku was designed for iPhone use, it can run on the iPad with smaller screen resolution. Bon Secours also may add another application, Canto, specifically designed for the iPad, when its developer, Epic, releases it.

Placing orders or writing notes is not supported yet in either Haiku or Canto, but plans include advanced read and write features.

As ConnectCare and technology continue to evolve, our physicians and nurses will find that delivering world-class care will become even easier, more efficient and more cost-effective."

January 30, 2011Blog: How mHealth Will Change Healthcare. Blog article by Mark Mark H. Ryan, M.D., Department of Family Medicine, Virginia Commonwealth University Medical Center. Dr. Ryan is also a member of the Mayo Clinic Center for Social Media Advisory Board and blogs at Social Media Healthcare.

"In a recent post, I noted the role that I believe mobile health applications (mHealth) could impact healthcare in developing nations. In the last few days, I have come across other articles that reinforce the value of mHealth approaches to health promotion and for providing care over distances.

First, Kent Bottles (@KentBottles on Twitter) has written an article that emphasizes his belief that mHealth applications will be a major direction for healthcare development in the near future. He makes a compelling case that the availability, flexibility and mobility inherent in mHealth approaches to care will be valuable tools to make health care more accessible.

Second, a recent series of articles in Perspectives in Health Information Management evaluates the role of mHealth in improving the health of minority communities in the United States. I only just found the articles and have not yet read them fully, but the big picture summarized here and here is that access to mHealth tools helps overcome barriers to health care that minority communities face, and represent a new approach to addressing health care inequalities. I suspect that much more discussion (and more posts) will be forthcoming on these topics.

It appears that mHealth and social media approaches will allow nations—both our own, and developing nations overseas—to expand healthcare services to marginalized or underserved communities."

November 29, 2010 Blog: Telemedicine Mandate Points in Response to Virginia Medical Group Management Association Article. Blog article by Virginia Association of Health Plans.

[VTN note: To access article titled "Online Doctor Visits a Reality: Virginia Mandates Payment for Telemedicine Services," by Jonathan M. Joseph, Esq. that was in the VMGMA newsletter click here.]

1. The telemedicine mandate does not cover all commercial insurance policies, but applies only to the fully insured market. Self-insured entities, which typically includes large employers, are not subject to these requirements.

2. Insurers have the ability to create and maintain viable provider networks and to craft products that offer various in and out of network coverage options. Depending upon the purchased plan coverage, services provided by an out of network provider may not be covered or may have different cost-sharing requirements.

3. Virginia Medicaid has required coverage of certain telemedicine services for several years and is not new to the service.

4. Insurers do not directly reimburse for provider practice equipment. For example, insurers do not provide direct funding for the addition of an MRI machine for a physician practice so the same would apply to equipment needed to enhance telemedicine capabilities.

5. Interactions between physicians and patients would still be subject to quality standards applied to face to face meetings. This would include documentation, staff support, and other requirements. Late night communications over Skype may not hold-up under this standard.

6. Passage of this mandate does not remove quality, professional, and medical standards associated with a particular service. Not all medical services can be provided appropriately via telemedicine. To ensure the smooth provision of services to patients, insurers should be contacted regarding coverage and billing requirements.

November 11, 2010 Blog: A Nursing Student's Perspective on Telehealth. By Jennifer Anderson

In December 2010, I will graduate with a Bachelors Degree in Nursing. Even though I have learned a great deal in my nursing education, I feel one piece was missing: education regarding telehealth.  Without this knowledge, I am missing out on an avenue to provide health care to a significant portion of the population.

According to the 2000 Census, approximately 21 percent of the population resides in rural areas. In Virginia, the Economic Research Service estimates that in 2009, approximately 14 percent of Virginians lived in rural areas. Residing in a rural area presents many challenges to health care access. In July 2010, I volunteered for a weekend with Remote Area Medical in Wise, VA. One of the comments made over the weekend event was the lack of providers in the area and long distances to health care facilities. Telehealth serves to address these problems by providing access to providers in urban areas and eliminating most trips to distant facilities.
Nurses are a key component in developing telehealth to its full potential. Almost everyone knows a nurse, whether they are a relative, friend, or acquaintance. These extensive networks can be utilized to spread information about the benefits of telehealth. Additionally, nurses generally have the longest healthcare interactions with their patients and provide much of the health related teaching. Due to this, it is vital that nurses are familiar with telehealth and how it can positively impact patients. Unfortunately, I have had conversations with fellow nursing students who were unaware of what telehealth even was or the role of nursing in its implementation.

Throughout nursing school, stress has been placed on the ability to both recognize barriers to care and determine how to overcome them. Rural location and its impact on access to health care are barriers which telehealth can overcome. By educating the new generation of nurses, many of whom are tech-savvy, about the positive impact of telehealth on the rural population, we as a health professional community are encouraging this new generation to utilize technology in a new way to benefit their patients. I encourage schools of nursing, in Virginia and across the nation, to explore placing telehealth education into their undergraduate curriculum. 

August 23, 2010 Blog: “There’s An App For That”

By J.P. Auffret, Managing Director, Center for Advanced Technology
Strategy, and Vice Chair, NoVaRHIO

Gartner projects that 21.6 billion mobile apps will be sold in 2013.

Of these, many will be entertainment and games  related, but there will be also be many that provide benefits in most every industry and walk of life including in healthcare. 

Two early examples that show the potential are:            

The two applications have quite different objectives with AsthmaMD having a goal of enhancing communications and information flow between  a physician and patient about a patient’s asthma,  and WebMD having a goal of providing physicians with current drug information in an easily accessible format.
The type of applications that are possible and being developed range across the full health care value chain including clinical care, public health, hospital and health care administration.   And the potential and types of impacts and public benefits are worldwide as mobiles are the most widely and fastest adopted ICT device in history with 4.6 billion subscribers in 2009 (ITU).  

The foundation for mobile apps for healthcare has been set by the rapid adoption of mobiles and by:

• Evolution of networks and phones catalyzed by increasing transmission speeds, storage capability and processing power.
• Development and strengthening of mobile ecosystems with mobile network operators (such as AT&T and Verizon) and phone and platform providers (such as Apple and Google) all playing major roles.
• Development of the mobile app market sparked by Apple and the App Store but now with app stores from most major industry participants as well as independent app stores.
• Future industry evolution with new mobile enabled devices such as the iPad,  development of  Machine2Machine (M2M) capability and applications,  development of location based services, and network upgrades to 4G and network layering with WiFi and WiMAX.

Without doubt there will be many innovative and beneficial mobile applications for healthcare of the 21.6 billion app sales that Gartner is projecting by 2013.  But what challenges are there for mobile applications to reach their full potential in enhancing information flows between different parts of the healthcare value chain?

One of the main challenges is achieving scale and in turn achieving network effects for mobile healthcare apps.   For many apps, especially apps that enhance information flows between different parts of the healthcare value chain, their benefit and utility increases as they are more widely adopted.  Providers of the more widely adopted apps will also have greater financial ability to enhance the app, adapt the app to other mobile platforms, and develop interfaces with other health systems thereby further enhancing their benefit.     

Other challenges include the effective planning for and integration of mobile apps within current health care workflows and in potential new workflows; and developing a track record of mobile healthcare app success including with security and privacy. 

Virginia with its strong healthcare institutions and leadership, and vibrant mobile and ICT community, is particularly well placed to benefit from the mobile revolution.   As Virginians consider ramifications of healthcare reform, and healthcare challenges including enhancing continuity of care for patients with chronic illnesses, one question that might be asked at each stage is, how can mobile and mobile apps help?

August 9 Blog: Witness testimony of David Cattell-Gordon, M.Div., MSW before the U.S. House Committee on Veterans' Affairs Subcommittee on Health "Overcoming Rural Health Care Barriers: Use of Innovative Wireless Health Technology Solutions" on June 24, 2010.

David Cattell-Gordon is Director, Rural Network Development Co-Director, The Healthy Appalachia Institute, and Faculty, Public Health Sciences, Nursing, University of Virginia Health System, Charlottesville, VA. The following is a slightly edited version of the full testimony.

"As a part of the University of Virginia’s program in telemedicine, I have come to appreciate how information technology can overcome barriers of access. In addition, telehealth and wireless capabilities have consistently demonstrated opportunities for improved health outcomes, decreased isolation, reduced health disparities and substantially reduced costs—a vital issue in ensuring the very best care for the over three million of veterans living in remote, rural communities. Simply put: why would we not invest in this capability?

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

The substantial, long-standing health disparities in rural Central Appalachian and for rural veterans;

The role of telehealth in improving the delivery of healthcare and educational services to rural citizens especially veterans; and

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

1. Barriers to Care in Rural Appalachian Virginia and the Consequences
The evidence is overwhelming that our rural veterans in Appalachia and other communities suffer far worse health outcomes because of several factors: geographic and personal isolation, limited access to specialty care, lower educational attainment, limited income and often extremely poor conditions within which to manage health.

The seven coalfield counties and one city that make up Health Planning Districts I and II in Appalachian Southwestern Virginia, for instance, are a uniformly rural area of more than 3,200 square miles of mountainous landscape with a population of nearly 207,000. This mostly homogenous population lives primarily in small, geographically isolated communities and suffers from declining population, low educational attainment, high rates of poverty and approximately half the per capita income of the rest of the state. This is true of the many of the veterans of the region.

These persistent social problems are intertwined with significant disease risk factors that contribute to disproportionately high rates of heart disease, cancer, respiratory disease, diabetes, and depression. To complicate these social and health issues, the sharp mountain ridges and deep valleys that divide the region make access to work and health care difficult. There are serious healthcare workforce shortages in the area and no large-scale population centers capable of financing a full spectrum of specialty medical practice.

One only has to look at the ten-year history of the Remote Area Medical Expedition (RAM) in Wise, Virginia as an example of the magnitude of need. In 2008, the RAM-Wise expedition, the largest screening event in the United States, provided free medical, dental and vision care to over 3,000 people from the region over a single weekend at an abandoned strip mine.

*statistically significant variance

Combined with significant heath risk factors like high cholesterol, hypertension, too much smoking, it has lead to extraordinarily high rates of premature mortality from all causes—heart disease, cancer, diabetes. In the region we have twice the level of suicides. We are 30 percent more likely to die from diabetes, 44 percent more likely to die from lung disease. We have an epidemic of unintentional fatal overdoses from prescribed narcotics. We have twice the rate of poverty and half the per capita income of the rest of the Commonwealth. The consequence of these adverse socio-economic and health risk factors is that the residents of the region are 26 percent more likely to die prematurely than residents of other regions in the Commonwealth.

In addition, the coalfields of Virginia are experiencing a full-scale public health crisis in addiction levels to prescriptive narcotics leading to astronomically high rates of fatal, unintentional overdose. According to the state medical examiner, the adjusted mortality rate from unintentional overdose is 40 deaths per 100,000 in the region compared to 8.3 per 100,000 for the state as a whole. Taken together, the health status of the region represents a significant geographically-based health disparity.*

This is the health environment of much of rural America that it is now time to address. I know this sub-committee is well aware of the sad facts of the state of rural health care so let the VA lead the way. With some three million veterans who use VA medical services living in rural areas, the delivery of health care is more difficult and more costly. A survey of 767,000 veterans by the VA Health Services Research and Development Office found that rural veterans are in poorer physical and mental health compared to those who live in urban areas.

Many studies, of which this sub-committee is well aware, speak volumes about the health disparities faced by rural veterans. Veterans who live in rural settings have lower health-related quality-of-life scores than their suburban and urban counterparts. There is increased co-morbidity, more inefficient care, greater use of emergency rooms for primary services, less preventative care and reduced home care. These rural–urban disparities persist even after studies are corrected forage, gender, employment status, priority level, co-morbidity, and the US census region in which the veteran lived. Disparities are evident in those who were both most and least dependent on the VA for health care services.**

As you are also well aware, the VA provides much of its medical care, particularly specialized treatment, in urban settings, which may be difficult for rural veterans to access. VA enrollees also obtain much of their medical treatment in the private sector, particularly if they have Medicare or other insurance and VA care is far away. Rural veterans have lower incomes and less insurance and therefore many have less access to both VA and non-VA care. They report poorer health, which suggests that their medical needs may be not adequately met.**

These findings offer clear evidence that living in a rural setting is associated with a worse health-related quality of life. As with other residents of rural regions, a variety of factors may account for these disparities such as access, lower educational attainment, limited specialty care and more infrequent use of the VA health system.

The consequence of these disparities is simply that the rates of pre-mature mortality are higher for rural veterans. While it sounds dramatic, it is true: the issue we are discussing today is a life and death matter. While Congress has appropriated millions to implement a rural health outreach and delivery program it is only one aspect that must be supplemented by continued investment in proven technologies as we will face many challenges not only by our aging and elderly veterans such as Shifty Powers but also by the nearly one-half of veterans who fought in Iraq and Afghanistan and now live in rural settings.

2. The Role of Telehealth in the Delivery of Services to Rural Americans
As a preface to discussions of what remarkable innovations and processes wireless capabilities bring to address health disparities, it is important to set the critical context of improving outcomes for our rural veterans, a service that this sub-committee is well aware of: telehealth.

Telehealth can reduce many of the barriers of access to locally unavailable healthcare services. The integration of telehealth into rural communities especially including health information exchange through electronic medical records between the VA and rural health programs has profound implications for the development, support and delivery of healthcare services in the digital era—an integrated systems approach focused on disease prevention, enhanced wellness, chronic disease management, decision support, quality, ease of access and patient safety. These are all critical resources if we are to achieve equality of care for rural veterans.

Through the incorporation of telehealth into a strategy for the care of rural veterans, a decreasing workforce of clinicians will be able to satisfactorily manage the expanding volumes of medical information, research and decision support analytic tools. This incorporation of telehealth technologies into integrated systems of healthcare offers tools with the potential to address the challenges of access, specialty shortages, and changing patient needs in both the rural and urban setting.

Clinical services delivered via telehealth technologies span the entire spectrum of healthcare, and across the continuum from pre-maturity to geriatric care, with evidence based applicability to more than 50 clinical specialties and subspecialties. Cardiology, dermatology, ophthalmology, neurology, high risk obstetrics, pulmonary medicine, mental health, pathology, radiology, critical care, and home telehealth, are some of the many applications in general use, and for which a number of specialty societies have developed telehealth standards. These services can be provided in live-interactive modes and some, asynchronously, using store and forward applications such as the acquisition of digital retinal images of veterans with diabetes by a trained nurse. These images can be sent for review by a retinal specialist to identify patients at risk for diabetic retinopathy, the number one cause of blindness in working adults. ***

The aging of our veterans has also already created increased demand for specialty healthcare services to address both acute and chronic disease in the elderly. Such a demand, in the face of anticipated provider shortages, requires a fundamental shift from the model of physician centered care to one focused on patient centered care using interdisciplinary teams, evidence based medicine, the use of informatics in decision support and telehealth technologies. As an example, nationally, only 2 percent of eligible (ischemic) stroke victims receive brain saving thrombolytic therapies, primarily because this treatment must be administered within three hours from the onset of an ischemic stroke under the direction of a trained neurologist. The use of telehealth technologies offers immediate access to stroke.***

Again, simply put, telehealth capabilities are integral to rural health, professional educational and economic development by providing essential links to specialty care and continuing education. It also ensures a method of the efficient provision of resources as well as being a tool for the economic development of rural communities.

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

Continuing federal funding of demonstration projects;
Reducing statutory and regulatory barriers to telehealth in Medicare;
Aligning federal agency definitions of rural with specialty healthcare shortages, in particular using the definitions of rural applied by the USDA Distance Learning and telemedicine Grant Program;
Ongoing support and refinement of the Universal Services Fund;
Improving inter-agency collaboration for telehealth services;
Encouraging the use of (and reimbursement for) store and forward telemedicine; and,
Ensuring health information exchange

3. Opportunities for Improving Care: A Strategic Inflection Point
While the expansion of broadband is the context for removing barriers and telehealth a critical application, perhaps the most innovative process for achieving the elimination of disparities is wireless communications. It is clear that the world is in the midst of a wireless revolution.

One of the most visible aspects of this global revolution is the cell phone. This tool is no longer a novelty….it is estimated that there are now more than 233 million cell phones in use in this country and almost 2.56 billion worldwide. The cell phone taken together with digital networks, remote monitoring capabilities including miniaturized sensors in a broadband wireless environment represents a strategic inflection point in healthcare which we will look back upon as a critical turning point much like the industrial revolution, the discovery of antibiotics or the invention of the personal computer. This capability, as the first Chief Technology Officer of the United States, Aneesh Chopra, said at the recent meeting of the American Telemedicine Association, is seemingly unlimited in job creation, in reducing healthcare cost and in improving the quality of life.

Our rural veterans are entitled to access to this resource. And, it makes both clinical and economic sense. With servicemen and women returning from Iraq and Afghanistan—a majority of whom are cell phone users and many of whom are from rural areas--it is increasingly important that we use technologies to link the expertise of the VA medical centers to rural veterans alleviating some of the distance-based challenges in the areas of primary care, mental health, traumatic brain injuries and even long-term or home-based care remote home monitoring

You will hear extensively about the critical aspects of the use of cell phones and other wireless monitors for health during these hearings. They are obvious in that this capability has already been proven to be well-suited to for cardiac monitoring, blood glucose evaluation, medication compliance, post-surgical follow-up, vital signs monitoring psychological counseling, health information, public health alerts, patient engagement and doctor patient relationship. These capabilities, in general:

Reduce the isolation that occurs in rural communities;
Provide a vehicle for messaging and key health information;
Support the monitoring of chronic diseases;
Promote compliance with medication;
Reduce readmission to the hospital post procedures;
Guide self-care; and
Enable improved care by home nursing.

This abbreviated list in and of itself warrants investment as it represents the perfect storm of improved health outcomes, efficient processes and reduced costs. Just one element in this list—the care of chronic disease—according to the California Healthcare Foundation accounts for more than four-fifths of all healthcare expenditures. Imagine what it could mean to ensure improved medication compliance, increased exercise, healthy diet and appropriate use of healthcare resources for the bourgeoning numbers of veterans with diabetes. The savings would be staggering.

We now need to consider that bandwidth and wireless access are a prescribable medication for the health of our communities.

In certain specialized applications it has already been shown to make dramatic impact whether it is the use of a mobile messaging service that provides health tips and appointment reminders to serviceman with TBI or the dramatic VA Care Coordination and Home Telehealth project that demonstrated a 19 percent reduction in readmission for the same diagnosis and a 25 percent reduction in hospital days. These are real savings, true efficiencies in the system but most importantly, improvement in the lives of a precious resource, veterans and their families.

But access remains a critical issue. Wireless capability combined with improved access in rural communities to telemedicine connection to specialty care is what is needed now.

I want to thank the Subcommittee and Committee as well as Congress for the steps they have already taken to enable this environment. But I also challenge Congress to engender an environment of investment by:

Continuing funding of demonstration projects that use wireless to enhance home monitoring, health promotion and education;
Ensuring health systems are incentivized to use wireless configurations;
Encouraging professional education to incorporate training in these devices and applications;
Providing for appropriate financial coverage for use of this capability;
Promoting a standards based environment for usage; and critically,
Ensuring a Nation of seamless coverage without network fragmentation

It has been stated that genetics and the tools of molecular medicine will provide a new golden age of medicine. While this is most certainly true, I contend it is wireless devices, telehealth applications and internet-based health software that are precipitating opportunities for improved health care for all veterans and for the Nation. Through this, we have the opportunity to get the basics right of prevention, access, education and ongoing care.

The hope is that these new, remarkable technologies, from smart-phones to EHRs to video-conferencing to senor based health-monitoring devices, will empower patients, doctors and nurses to improve outcomes while cutting costs. For me, the ubiquitous presence of mobile phones is a major reason to think this world is now upon us. I strongly believe and hope this committee is passionate that these capabilities are what will eliminate disparities in care for rural citizens, reduce the cost of care and stimulate remarkable new business models in the process.

As our Nation moves forward in restructuring its healthcare delivery system, the innovative uses of these telehealth tools will be an important driver of that change. With the adoption of favorable policies driven by Congress and innovation applied to the care of patients using integrated telehealth tools that includes wireless we stand at the threshold of eliminating disparities that have caused our rural veterans to suffer for far too long.

* All data is from the Virginia Department of Health (VDH) through health records of mortality and incidence rates between 1999 and 2005 as well as the Office of the State Medical Examiner. Socioeconomic and demographic information was extracted from census data from 1990 and 2000 at the Census tract level
** William B. Weeks, MD, et al. Differences in Health-Related Quality of Life in Rural and Urban Veterans, American Journal of Public Health October 2004, vol. 94, No. 10 Weeks et al. Veterans Health Administration and Medicare Outpatient Health Care Utilization by Older Rural and Urban New England Veterans, Journal of Rural Health, Volume 21, Issue 2
*** Williams, JM et al, Emergency medical care in rural America, Ann Emer Med 2001: 38(3):323-327.
Burgiss, SG et al, Telemedicine for dermatology care in rural patients, Telemed Journal 1997; 3 227-33
Chiang, Michael, Lu Wang; Mihai Busuioc; Yunling E. Du et al, Telemedical Retinopathy of Prematurity: Diagnosis, Accuracy, Reliability, and Image Quality Arch Ophthalmol, 2007:125 1531 – 1538.
Flowers, CW et al, Teleophthalmology: rationale, current issues, future directions, Telemed J , 1997: 3(1): 43-52
Breslow, MJ, Effect of a multiple site intensive care unit telemedicine program on clinical and economic outcomes: An alternative paradigm for intensivist staffing, Crit Care Med 2004 32(1): 31-38
Swaamm, LE et al. Virtual Telestroke for Emergency Department Evaluation of Acute Stroke, Acad Emer Med 2004: 11 1193-1197

August 2 Blog: SCHOOL-BASED TELEHEALTH: AN INNOVATIVE APPROACH TO MEET THE HEALTH CARE NEEDS OF CHILDREN

Jenny Kattlove, Director, Strategic Health Initiatives, The Children’s Partnership

Telehealth is emerging as a valuable way to complement and expand the capacity of schools to meet the health care needs of children, particularly those who are low-income and living in medically underserved areas, while keeping them in school and their parents at work. Because the vast majority of children attend school, schools are singularly well-positioned to help fill the gaps in health care that so many of our children face. And they are highly motivated to do so. Healthy children learn best, and schools receive payment based on how many children attend school each day.

Furthermore, schools are increasingly using computers and other technologies to improve learning, teaching, and administration. This confluence of emerging technologies in schools and schools’ desire to keep children healthy has led schools to identify ways to leverage digital tools to meet the health care needs of their students.

The Children’s Partnership set out to understand how the application of telehealth in schools has been improving children’s health and to identify lessons learned from school-based telehealth programs from across the country. We reviewed 17 school-based telehealth programs, which represent a diversity of urban and rural programs, programs that serve different ages of children, and various models for delivering care. We compiled our research in an issue brief to help policymakers and other state and community leaders apply this innovation to meet the health care needs of children in their communities.

Schools are truly being creative in making sure their telehealth applications meet the needs of the children they serve. They are applying telehealth to increase access to acute and specialty care for children; help children and families manage chronic conditions; facilitate health education for children, families, and school personnel; and increase the capacity of school nurses and school-based health centers to meet the health care needs of students. By bringing health care into schools, telehealth is improving children’s health, while allowing children to stay at school and parents to stay at work.

We also learned that the development and implementation of school-based telehealth take careful consideration, research, planning, and resources. Successful efforts involve representatives from education, school health, the local and distant health care communities, the technology arena, and other stakeholders to ensure the many diverse components to school-based telehealth are addressed.

Today, there is unprecedented interest in and funding for modernizing and strengthening the delivery of health care through wise use of technology and school-based care. The American Recovery and Reinvestment Act of 2009 and the Patient Protection and Affordability Care Act of 2010 both demonstrate these commitments. Communities across the country can take advantage of this momentum to improve the health of children and other populations, build on the experience of school-based telehealth programs from around the country, and apply this innovation to better meet the health care needs of the nation’s underserved children.

To learn more about school-based telehealth, visit http://www.childrenspartnership.org/Report/SchoolTelehealth

About The Children’s Partnership
Since 1993, The Children’s Partnership, a national, nonprofit organization, has worked to ensure that all children—especially those at risk of being left behind—have the resources and the opportunities they need to grow up healthy and lead productive lives. Consistent with that mission, we have educated the public and policy-makers about how technology can measurably improve children’s lives. We have also worked at the state and national levels to enact policies and build programs that extend digital opportunity to all children.

July 26 Blog: Place Matters, by Michael O. Royster, MD, MPH, and Kathy H. Wibberly, PhD.

Michael O. Royster, MD, MPH, is Director of the Office of Minority Health and Public Health Policy in the Virginia Department of Health (VDH). Kathy Wibberly, PhD, is Director of the Division of Primary Care and Rural Health in the Office of Minority Health and Public Health Policy.

The mission of the VDH Office of Minority Health and Public Health Policy (OMHPHP) is to identify health inequities, assess their root causes, and address them by promoting social justice, influencing policy, establishing partnerships, providing resources and educating the public. Click here to learn more about the VDH Office of Minority Health and Public Health Policy and the Division of Primary Care and Rural Health.

PLACE MATTERS

"Those who live in rural communities do worse on many health measures including life expectancy, mortality and morbidity when compared to their urban or suburban counterparts. Rural residents face many challenges when we look at the social determinants of health:

Poverty: Those living in rural areas are more likely to be poor. In the United-States, the rural-urban income gap has been calculated at 23%.

Education: Those living in rural areas have lower educational attainment. School-aged children in large and small rural areas are more likely than urban children to have repeated a grade: 13.1 percent of children aged 6-17 in large rural areas and 13.3 percent of children in small or isolated rural areas have repeated a grade, compared to 10.8 percent of children in urban-focused areas. Not surprisingly, young people from rural locations are also less likely to pursue post-secondary education.

Employment and Working Conditions: Those living in rural areas experience higher rates of unemployment. Those who are employed are more likely to be employed in hazardous occupations (e.g., those that use complex machinery, have regular exposure to chemicals and rely more on physical/manual labor that lead to a greater likelihood of injury).

Environmental Conditions: Those living in rural areas frequently report poorer water quality, poorer road and lighting conditions, greater exposure to agricultural chemicals and little to no access to public transportation.

Health Practices: Those living in rural areas have higher rates of smoking leading to higher exposures to second-hand smoke, higher overweight/obesity rates, lower rates of fruits and vegetable consumption, higher suicide rates and higher rates of injury.

Health Care Services: Those living in rural areas have greater difficulties accessing health care. Rural areas have greater difficulties recruiting and retaining qualified and skilled professionals in the health care field. Therefore, rural residents must travel a greater distance for care and are more likely to be uninsured. Rural residents are also less likely to have access to wellness and other health promotion programs and activities.

Telehealth is certainly one way to begin to address some of these challenges. With telehealth, there is often improved quality of health care, expanded scope of medical services, increased access to health information, reduced travel time and transportation expenses, decreased time missed at work and more. However, place also matters with respect to access to broadband. According to a USDA report, “whereas an estimated 55 percent of U.S. adults had broadband access at home in 2008, only 41 percent of adults in rural households had broadband access....Areas with low population size, locations that have experienced persistent population loss and an aging population, or places where population is widely dispersed over demanding terrain generally have difficulty attracting broadband service providers.

Should rurality - where a person lives, works and plays - determine their health status?"

VTN Notes:

For information about rural health resources click on: Virginia Rural Health Resource Center (VRHRC). VRHRC is a 501(c)(3) not-for-profit organization, which serves as a clearinghouse for local, state and national rural health information. VRHRC provides technical assistance, facilitates rural health research and collaborates with various public and private organizations to identify and address rural health issues in the Commonwealth, thus ensuring access to quality health care for all rural Virginians.

For information about rural health events click on the Virginia Rural Health Association (VRHA). VRHA is a 501(c)(3) not for profit organization comprised of a diverse group of individuals from communities spread across Virginia - individuals that care about improving the health of Virginia 's rural residents.

July 19 Blog by Greg Billings: The CMS Credentialing and Privileging Crisis

Greg Billings is the Senior Government Relations Director for the Center for Telemedicine & E-Health Law (CTeL). CTeL is the national telehealth resource center. CTeL provides a mechanism for sharing experiences across the nation in addressing legal and regulatory barriers to the effective implementation of telehealth technologies. Mr. Billings presented at the VTN Telehealth Summit. A Power Point of his presentation, "Telehealth Legal and Regulatory Issues," is available at Virginia News. Click and scroll down. In reading this summary regarding the history of this crisis and current status, note that time is of the essence as the deadline for comments to CMS are due on or before July 26th, 2010.

"For over a year, telehealth programs, hospitals, and telehealth practitioners have known that a crisis was looming for telehealth.  That crisis was the expected enforcement by the Centers for Medicare and Medicaid Services (CMS) of complete credentialing and privileging of all telehealth providers at each originating site (the site where the patient is located).

Many described this requirement as a bigger impediment to the expansion of telehealth than other longstanding hurdles, like interstate licensure.  Telehealth programs would have stopped upon implementation of this CMS requirement.

Since 2004, Joint Commission (JC) accredited hospitals relied on JC telemedicine standards, which allowed the exchange of credentialing and privileging decisions between JC facilities. Congressional action in 2008 required JC to reapply to CMS for authority to provide accreditation services.  In order to continue in that role, JC had to come into compliance with CMS requirements, effective July 15th.
Watching telehealth programs close down was not an acceptable alternative for many telehealth leaders. 

Virginia (and the entire telehealth community) is fortunate to have Dr. Karen Rheuban leading the charge on telehealth policy.  She didn’t leave a stone unturned in getting the message to Congress and CMS that this policy would be a major problem for telehealth.  She arranged meetings with Congressman Rick Boucher (D-VA), and top level CMS officials, including an onsite visit to see the UVA telehealth program.

The result? CMS has proposed changing their telehealth credentialing and privileging requirements.  You can see the CMS announcement by clicking here.  Also, CMS effectively extended JC telemedicine standards until March 2011.

CMS wants to hear how these changes will impact the telehealth community.  Be sure to take a moment and let them know.  It’s very important that they hear from the telehealth community."

[VTN notes:

On July 19th CTeL also released its comprehensive report: "Credentialing and Privileging Proposed Rule from Centers for Medicare and Medicaid Service." Click here to access CTeL's report. Comments are due on or before July 26, 2010

The CTeL June Brown Bag Telehealth Seminar was on " Credentialing and Privileging - The Latest Status." Presenters were: Karen Rheuban, MD, Professor of Pediatrics, Senior Associate Dean for External Affairs and Continuing Medical Education and Medical Director of the Office of Telemedicine at the University of Virginia and Jeannie Miller, RN, MPH, Deputy Director of the Clinical Standards Group in the Office of Clinical Standards and Quality at the Centers for Medicare and Medicaid Services (CMS). For an extension summary of that presentation click on CTeL. To print a PDF file of the proposed rules, as published in the May 26, 2010 Federal Register, click here. To see the announcement from the Joint Commission: "Telemedicine requirements for hospitals and CAHs are delayed until March 2011" click here.]

July 12 Inaugural Blog by Karen R. Jackson: A Question and a Challenge.

The inaugural blog was by Karen R. Jackson, Virginia Deputy Secretary of Technology. Ms. Jackson formerly served as the director of the Office of Telework Promotion and Broadband Assistance, where she promoted and encouraged telework alternatives in Virginia's public and private sectors and advised the secretary of technology on broadband-related issues. Ms. Jackson has been engaged in broadband issues contained in the American Recovery and Reinvestment Act and the National Broadband Plan, according to the governor's office. She was named to Government Technology's 2010 list of the Top 25 Doers, Dreamers and Drivers. She serves on a number of boards, including the Virginia Telehealth Network and the Virginia Health IT Advisory Commission.

"First of all, let me express my gratitude (and I have to admit a bit of amazement to those who thought it would be a good idea to have me as the inaugural blogger!). As a matter of course, I guess I should point out that the ideas/thoughts contained in this blog are mine – and are not intended to represent the opinion of the McDonnell Administration or any other group or political sub-division. Now that we have that out of the way…here we go!!

As I sit here on my patio on this gloriously sunny Sunday afternoon, I am awed that during the span of my career, I have been witness to a technology revolution (evolution if you prefer) that has strained and redefined business practices, rewritten societal norms, challenged traditional government service delivery models, and is now underpinning a monumental reinvention of healthcare delivery and payment paradigms.

The advent and proliferation of technology, specifically those centered on broadband telecommunications, has provided the emphasis for breaking down political silos and geographic boundaries to facilitate the delivery of services and applications to citizens.  For economic development, social networking and citizen engagement (governmental activities), technology means “more, better, faster, and enhanced services”, but in healthcare, we are entering a new realm of intensity and responsibility…empowering data exchange and healthcare support systems (telemedicine, home-health monitoring) related to life and death decisions.

Once I came to the daunting realization of what was at stake with all the emerging healthcare initiatives, I started researching and reading all I could find about what was going on at the federal, state, and practitioner levels; and I realized that it is a much bigger challenge than I initially thought… in the weeks and months that ensued, I have read countless articles discussing workforce, business practices, payment protocols, efficiencies, modernization, and the roles of government (federal/state). Interestingly, only a few articles even make mention of the patients-parents, grandparents, children (born and unborn), sisters, brothers and aunts and uncles that these systems are designed to benefit. WOW…somewhere in the midst of worrying about the “bits and bytes,” the mandates, the gadgets, geography, and “making” the system work, have we forgotten the “other” human side of the equation and the intended beneficiaries of all we struggle to accomplish…is that possible?? To be honest, I’m not sure…so I will end this inaugural blog with a question and a challenge.

As we press for technology innovations and “better” ways to “do” whatever we are challenged to do as professionals, let’s not lose sight of the bigger prize – changing and improving the way we care for those we care for, love, or, sometime in the future, how we would want someone to care for us. As we all jump into the week, let’s look at our technical challenges in a new light and with renewed commitment to agree to partner, collaborate and leverage technology to provide the highest quality of life for those we serve."