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By Robert
Roswell, M.D.
Under
Secretary for Health, Department of Veterans Affairs |
The Department
of Veterans Affairs (VA) and its patients have gone high
tech.
Using home
computers, high speed Internet connections, handheld electronic devises and
cameras, some chronically ill veterans are now able to electronically send
daily health updates to health care professionals at VA hospitals nationwide
from the comfort of their homes.
By simply typing a few keystrokes on their home computer,
veterans are able to input vital information that's extremely important to
their health care providers, especially those caring for veterans with
congestive heart failure because it alerts them to potential health problems
such as fluid retention and worsening heart failure - which could be life
threatening if not monitored regularly by a trained health care
professional.
Lufkin Clinic Communicates with Houston VA Medical
Center
In
other cases, veterans go to a VA clinic such as the one in Lufkin, Texas, to
take part in videoconferences that originate from the Houston VA Medical Center
(VAMC), 150 miles away. The telehealth mental health program began a year ago
on a temporary basis due to a staffing shortage at the clinic. But its success
of the past year may prompt VA officials to consider changing its status to
permanent.
Annapurni Teague, M.D., a staff psychiatrist at the Houston
VAMC, conducts videoconferencing consultations with several patients every
week. "I've been evaluating and seeing patients for follow-up in a telemed
clinic for the last year," she said.
The eighty to one hundred patients that Teague has
held videoconferences with this past year are generally enthusiastic about the
program, because it eliminates the more than two-hour commute from Lufkin to
Houston, a drive that for some veterans is traumatic experience in itself.
"Most patients have so far given very positive feedback," said Teague. This
technology is not limited to one or two geographic areas. For example, a
veteran in West Virginia requiring a psychiatric consultation can connect via
teleconference with a mental health expert in Louisville,
KY.
The
videoconference process is quite simple as Teague explained. It's a
face-to-face meeting, except the doctor and patient are not physically in the
same room. But through the aid of electronic wizardry, the two are able to see
and talk to each other as if they would in a regular office visit and maintain
a doctor-patient relationship.
Sometimes it's staff, not patients, who are equipped with the
telehealth technology, according to Dr. Jordan Train, medical director for
home-based primary care at the Houston VAMC. Due to slow transmission of data
over telephone lines, staff in this case found it better to provide nurses with
laptops and digital cameras and send them out to patients' homes. "This allows
clinicians to make sequential comparisons of how wounds are healing," said
Train. Thirty-nine patients are currently taking part in this particular
program.
VA's
telehealth program involves many types of technology that helps physicians and
other medical personnel bridge the health care gap that in some cases extends
across hundreds of miles.
Telemedicine and Telehealth is Encouraged As VA's under
secretary for health, I have spearheaded the telemedicine and telehealth
campaign by strongly encouraging the use of new technologies to help veterans
better manage their health care. We're finding new ways to manage our patients'
disease processes continuously, 24 hours a day, 365 days a
year.
Through
telemedicine and telehealth, veterans can stay in their homes, in surroundings
that are familiar and comfortable to them. Institutional care is very costly
and may impair a long-term spousal relationship and reduce the overall quality
of life. It's important to keep the bond between husband and wife
intact.
Telemedicine generally refers to physicians providing services
to patients who are in a different location while telehealth generally applies
to the technology used to provide clinical care, patient education,
professional education and hospital administration from a
distance.
Changing Dynamics of the VA
No longer is VA a hospital system but
rather a health care system that has extended its continuum of care to include
community and home-based extended care services in addition to nursing home
care and telehealth programs. Our goal is to provide the best care in the least
restrictive setting.
The number of VA hospitals has tripled in size since 1930 from
54 to 162, making it the nation's largest health care system. The health care
giant that made the shift in 1995 from inpatient to outpatient care - consists
of more than 850 community and hospital outpatient clinics, 137 nursing homes,
206 readjustment counseling centers and 43 domiciliaries.
Last year, VA provided medical care to
more than 4.3 million veterans and over 4.9 million veterans are expected to
receive VA medical care this year.
This increased popularity among veterans has resulted in
appointment delays and backlogs, and last January VA Secretary Anthony J.
Principi announced that VA must limit enrollment of higher income veterans with
no service-connected disability.
This action allows VA to focus more closely on providing care
to service connected veterans, low-income, and special needs veterans, as well
as future veterans who may suffer disability resulting from combat
service.
Chronically ill, elderly and frail, and veterans traumatized by
wartime experiences who are unable or unwilling to go to a hospital may benefit
from telehealth care technology.
Telehealth brings health care closer to and in some cases into
veterans' homes. Eighty-seven percent of patients live within thirty minutes of
a VA medical facility, but the goal is to make health care services even more
accessible.
Telehealth is not a new concept but its popularity has
increased over the years because the technology used today is less expensive
than it was ten or twenty years ago.
Telemedicine significantly reduces or eliminates
travel time. "Our health care system is based on patients traveling in order to
receive care, but telemedicine eliminates the need to travel," said Dr. Adam
Darkins, director of VA's telemedicine program. He added, however, that
telehealth does not take the place of regular office visits and it is not for
everyone.
Telemedicine significantly reduces or eliminates travel time.
"Our health care system is based on patients traveling in order to receive
care, but telemedicine eliminates the need to travel," said Dr. Adam Darkins,
director of VA's telemedicine program. He added, however, that telehealth does
not take the place of regular office visits and it is not for
everyone.
VA
Prepares for an Aging Veteran Population VA expects to experience a 200 percent
increase in veterans over age 85 by the end of the decade. This projected peak
is expected to occur approximately twenty years before the rest of the general
U.S. population.
Like distance learning, telemedicine and telehealth is quickly
gaining momentum in VA's twenty-one integrated service networks. Currently,
about 5,000 veterans in one VA network that includes most of Florida, south
Georgia and Puerto Rico, receive telehealth care in their
homes.
Although
these patients represented less than four percent of the network's veteran
population, they consumed more than forty percent of the network's health care
budget. That was before they joined the telehealth program.
Telemedicine
Works
An
initial pilot program shows that we can reduce the cost of comprehensive care
by over sixty-five percent and reduce acute admissions, emergency visits, the
number of prescription drugs a patient takes and almost any type of medical
care can be reduced by applying these techniques.
In 2000, VA completed eighteen
telemedicine demonstration projects aimed at improving veterans' access to
health care and the quality of care they receive. Three specific areas were
targeted: geriatrics and extended care medicine, mental health, and organ
transplant follow-up services.
A collaborative effort between the Iron Mountain, MI, and
Milwaukee, WI VA hospitals provided mental health services to a VA community
clinic in Marquette, Michigan. Several hundred miles away in Richmond,
Virginia, the VA hospital implemented a telehealth follow-up program for
transplant patients.
In the case of both programs, no-show rates among patients
declined because patients didn't have to travel to a medical
center.
VA also
conducted thirteen demonstration projects in the homes of veterans who had
suffered spinal cord injuries. In addition to using videophones to monitor
patients' progress and visiting patients in their homes, VA provided in-home
training to patients, caregivers and home care staff as well as rehabilitation
services.
By
combining traditional care with telehealth home care, VA was able to reduce
hospital readmissions while increasing access to specialist care. VA also plans
to extend its vast telehealth network and establish two telehealth centers
specializing in multiple sclerosis and one in Parkinson's disease, and is
working closely with experts in diabetes care to create a telehealth network to
detect retinopathy, a disease of the retina, which causes blindness in many
diabetic patients.
The Cost and Benefits of Technology
Today, many VA hospitals use an
interactive voice-response system that asks patients pertinent questions. This
information is recorded and is frequently used by clinicians in progress notes.
These systems can also leave phone messages for patients about appointments and
prescriptions.
Then, there's the Telemonitor, a sophisticated audio-visual
system with peripheral attachments. With a price tag of $5,000, this technology
is used primarily in group settings such as assisted living
facilities.
A
cheaper but equally as important piece of equipment is the instamatic camera,
which is frequently given to dermatology patients, so they can take pictures to
show how wounds are healing.
This space-age approach to health care appears to be
straight from the pages of Gene Roddenbury's Star Trek. However, instead of
patients being "beamed up" to another dimension, health data including
photographs are electronically transmitted, or in some cases, mailed to health
care providers.
What was impossible a few years ago, is now possible today
thanks to computers, the Internet, digital cameras and other more sophisticated
technology.
HHome-based Health Care Aids Florida
Veterans
Three
years ago in Florida, VA implemented its Community Care Coordination Service
(CCCS), which provides home care services to patients with chronic health care
problems using the Internet, telephone and telemedicine. Since April 2000, more
than 2,100 veterans have enrolled in the program and by December 2004, VA
expects that number to jump to over 17,000 veterans as VA expands the program
to other networks. One veteran said the program gives him a sense of security
that he didn't have before.
The CCCS program is definitely making a difference. Four
hundred veterans with chronic health problems - currently enrolled in the
program - have not had to be hospitalized in the past two years thanks to this
revolutionary program.
Nationwide VA conducts more than 350,000 consultations annually
using telemedicine. By using interactive technology such as telemedicine to
coordinate health care and monitor veterans in a home setting, we can
significantly reduce hospitalizations, emergency room visits and prescription
drug requirements, while providing veterans with a more rewarding quality of
life and greater functional independence.
Another program that is slated to start this fall is
VA's HealtheVet initiative, which allows veterans to access their medical
records through a secure on-line connection with a VA hospital. Concerned about
privacy and confidentially issues, VA is taking the necessary precautions to
safeguard the system.
VA's experimentation with telemedicine and telehealth has led
to the development of teleradiology and a filmless radiology archival and
communications system known as PACS. The days of hand carrying x-rays from one
clinic to another may soon be a thing of the past with this new technology that
replaces processed films with digital images. These digital images are
downloaded into computers and can be sent electronically to other VA hospital
computers.
VA
continues to expand its telemedicine and telehealth horizons in an effort to
meet the changing health care needs of the millions of veterans who receive
health care at VA hospitals nationwide.
As the world of technology changes, so
does the world of VA health care.
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