Telehealth, Telemedicine and VA Medicine
WASHINGTON (March 12, 2003) -- Operating the nation's largest health
care system, the Department of Veterans Affairs (VA) uses a wide variety of
communication and information technologies to ensure excellence in the
health care it delivers to the nation's veterans.
The term "telehealth" applies to technology used to provide clinical
care, patient education, professional education and hospital administration
when those providing services and those receiving them are separated by
distance. "Telemedicine" generally refers to physicians providing services
at a distance. VA considers telemedicine part of the wider spectrum of
"telehealth" services given by many types of caregivers.
Telehealth helps VA meet a growing need to give care in
non-institutional settings to elderly veterans who have chronic conditions
and transportation problems getting to treatment. Telehealth technologies
make it possible not only to move care to primary and ambulatory treatment
sites but to extend it into the home, helping patients maintain independent
lives and avoid unnecessary hospitalization and long-term care. Telehealth
will also help VA make the best use of its physical facilities as it
allocates resources to care for more veterans.
Advantages of Telehealth to Veteran Patients
Information technology in health care can ensure that all data
related to a patient's conditions are current and available to medical
providers exactly when needed. Timely access to health information improves
care and reduces the risk of medical errors. The Institute of Medicine has
recognized VA's leadership role in this area.
Telehealth electronic information and communications sometimes
involve high-resolution images and sound through live video. An example of
this is providing veterans in remote, rural areas prompt access to expert
advice from a cardiologist. Sometimes it involves simply transmitting text
records and digital images, as can happen in remotely assessing patients
with diabetes for possible diabetes-related eye disease. Because telehealth
moves information, rather than people, it can be more efficient and less
expensive than traditional care and provide expert advice when a patient
needs it. Improving access to care, and permitting more frequent monitoring
of patients and their health status, are the features of telehealth that
produce high-quality care and satisfaction among patients.
continued...
As impressive as the technology is, the key to telehealth success is
the way it helps in coordinating patient care. Successful home telehealth
that matches a patient's needs to
technology that the caregiver or patient can manage also reduces
clinic visits. As a veteran ages, the need for services is frequently
determined by expert advice on appropriate treatment of chronic conditions.
Making this advice available in the home is convenient and can expedite or
defer hospital admission. The philosophy of care coordinators using
telehealth is "the right care for the veteran patient in the right place and
at the right time."
Telehealth makes it possible to exchange routine clinical data and
visual assessments among medical facilities locally, regionally and
nationally. There are parts of the country where distance and weather are a
barrier to care. Telehealth brings care to the patient and avoids the cost
and inconvenience of travel. Telepharmacy, a component of telehealth, makes
medications authorized at hospitals rapidly available to veterans in VA
community clinics. Telehealth permits a northern "snowbird" veteran
receiving care at home through telehealth to continue a care regimen in
Florida in the winter.
Examples of Telehealth in Use
In VA's Sunshine Healthcare Network, including most of Florida,
south Georgia and Puerto Rico medical facilities, about 1,500 patients
receive telehealth care in their homes. Many of them use handheld messaging
devices to report their vital signs and other medical information to
hospital staff monitoring the reports daily. Staff sends patients
reminders, tips and feedback on their progress. VA patients in Colorado,
Utah, Wyoming, central Texas, New York State, Georgia and Indianapolis use
this device and others. Many of the patients have congestive heart failure,
high blood pressure, pulmonary disease, diabetes or depression.
Many VA medical centers use an interactive voice-response system to
take questions from patients and leave phone messages for them automatically
about appointment scheduling and prescriptions. The system permits
clinicians to pose questions to patients and have their responses recorded,
becoming progress notes. Results of the calls are forwarded to a
telemedicine computer so local clinicians can follow up.
Clinicians providing telehealth care in the Sunshine network and
other locations studied their patients' outcomes. They found improvements
in blood glucose levels, blood pressure and mental health, along with fewer
emergency room visits, days of hospitalization, clinic visits and less
extended care.
The National Cancer Institute has funded a study by the VA Sunshine
network and the University of Florida to evaluate whether telehealth can
deliver more effective care to cancer patients in their homes. Already,
VA's Puget Sound Healthcare Center (Seattle/Tacoma, Wash.) telehealth
program allows cancer patients to be treated through teleconferences at
other VA centers in the Northwest closer to home. Patients' cases are
presented to multi-disciplinary teams of physicians at Seattle in a single
session.
Home telehealth technologies used in VA locations range from the
most expensive - a telemonitor to examine a wound, for example - to the
least costly - a telephone. In between are personal computers and
videophones. Some patients receive a Polaroid camera, take photos of their
wound and mail them to the hospital every week.
In 2000, VA completed 18 telemedicine demonstration projects to
improve access and quality of three kinds of care: geriatrics and extended
care, mental health and organ transplant follow-up services. Among the
successful results:
* The Iron Mountain, Mich., VA Medical Center collaborated
with Milwaukee VA hospital psychiatrists to provide mental health services
at a Marquette, Mich., community clinic through videoconferences.
* In that project and in the Richmond, Va., telehealth
transplant program, no-show rates among patients declined because patients
didn't have to travel the greater distance to the medical center.
Also in 2000, VA facilities conducted 13 demonstration projects in
the homes of veterans who had suffered spinal cord injuries. Most of the
telehealth care came through weekly, real-time monitoring of skin ulcers or
surgical wounds using mounted or handheld cameras connected to videophones
answered at hospital nurse stations. VA also provided the computer
videophones in patients' homes. VA coordinators provided in-home training
in wound care and rehabilitation to patients, caregivers and local homecare
agency staff. They visited in person and made referrals to VA's spinal cord
injury centers to prevent complications. Supplementing traditional care,
the telehome care visits reduced the need for readmissions to the centers
for chronic conditions, yet increased patients' access to specialist care.
Recently, the Grace Hopper Government Technology Leadership Award
went to a federal health care access partnership in Alaska in which VA
participates. Several agencies created a telehealth network to serve the
most isolated Alaskans. The network enables health aides in rural areas to
send images and information over the Internet to physicians who provide
diagnoses and treatment options. About 400 cases are handled each month.
New Initiatives - The Future
VA is establishing two centers to give veteran patients nationwide
access to advice from experts in the care of multiple sclerosis. With
telemedicine, a veteran who is seen at a VA clinic or medical center
anywhere in the country can have a consultation with a specialist in MS. A
network of MS experts is being coordinated by the Baltimore VA Medical
Center, the Portland (Ore.) VAMC and the Seattle VAMC. (The last two
collaborate as one MS center.) Similarly, seven VA Parkinson's disease
centers specialize in treatment, education and research related to that
neurological condition. They are developing a telehealth network to extend
care to veterans nationwide.
VA is working with experts in diabetes care to create a telehealth
network to detect retinopathy, a disease of the retina of the eye prevalent
in diabetic patients. Preventing diabetes-related blindness ranks as a
major VA priority.
Four other VA regional networks plan to duplicate the success of the
Sunshine Network's telehealth programs with home-based primary and mental
health care.
VA will soon distribute "toolkits" to its medical facilities for
home telehealth and mental health to connect those who are considering
introducing telehealth with a network of practitioners. The kits contain
resource materials, including templates and guides to best practices being
used.
VA will continue to work with the Joint Commission on Accreditation
of Healthcare Organizations to ensure the quality of its telehealth
services. A joint activity underway will develop ways to credential
professionals who provide telehealth care. Since telehealth provides
clinical services at multiple sites where medical staff may not know the
qualifications and professional privileges of others, credentialing can be
important both to caregivers and patients.
The role of telehealth in meeting medical needs during natural or
manmade disasters figures into VA's planning for future uses.
Other challenges in the future include developing large information
networks that will support compatible hardware and software systems,
deciding whether to standardize treatment approaches and equipment and
developing standard procedure coding for workload credit. VA is working to
give patients access to an electronic patient-held record. That achievement
will be an important part of the partnership between VA, its care providers
and its patients.
VA's telehealth expertise makes it an industry leader. VA officials
foresee a time when the home can become the preferred place of treatment,
where a multimedia patient record, technology and a system for making
medical decisions will help coordinate better access and the best possible
care of veterans who increasingly accept telecommunications in their lives.