Learning about the promise of wireless health is like taking a journey through a medical Disneyland, a pathway from Fantasyland ... to Frontierland ... to Tomorrowland.
But nowhere does the potential benefit for wireless health seem more real than in the area of healthcare for our nation’s veterans, three million of whom live in rural areas.
That focused message was delivered loud and clear last Thursday in testimony from more than a dozen high-level technology wonks who appeared before a subcommittee of the U.S. House Committee on Veteran’s Affairs.
Rural veterans who return to their home towns, the places from which many were recruited, stand to gain the most from this technology as more than one-third must drive over an hour to access healthcare. Moreover they are more likely than their urban counterparts to need care because they have higher rates of severe chronic illness and are also more likely to die prematurely.
In the House testimony, speakers noted that an even higher proportion of vets returning from Iraq and Afghanistan—some with brain injuries and other chronic problems that need consistent management—are going home to rural areas where they will be far from the care they need.
Many of the individuals testifying in the Washington, D.C. hearing described a number of helpful wireless applications—once only fantasies—that can now being put into clinical practice to bridge the gap for these vets.
These include brainwave and sleep monitors, calorie use and respiration counters, cardiac pacemakers, glucose reading transmitters, and a “magic carpet” wireless device that measures fall risk as vulnerable seniors walk on a mat. Wireless markers installed during biopsies can help track tumor growth, and give prompt feedback to oncologists wondering whether therapies are having any effect, and the list of promising applications seems to go on and on.
Committee Chairman, Rep. Michael F. Michaud, D-Maine urged the VA to do more to implement wireless healthcare technologies. “The VA is certainly a recognized leader in using electronic health records, telehealth and telemedicine. However, wireless health technology also includes mobile health, which is truly a new frontier in health innovations,” he said. “For the 3 million veterans living in rural areas, access to healthcare remains a key barrier as they simply live too far away from the nearest VA medical facility.
“Unfortunately, this means that rural veterans cannot see a doctor or healthcare caseworker to receive the care they need when they need it given these barriers. It’s no surprise that our rural veterans have worse healthcare outcomes than the general population.”
The speakers, many from companies hoping to develop and sell more products, chimed in. What better population to explore the balance of costs versus benefits of wireless health technology, they proclaimed. The Veterans Health Administration is already way ahead on telehealth implementation, with more than 263,000 vets receiving telehealth services in 2009 alone. It’s not much more of a reach to expand its wireless capabilities too, they said.
For example, the VA’s Care Coordination/Home Telehealth (CCHT) program—the largest telehealth program in the world—has documented a 25% decline in bed days, a 50% decline for patients in rural areas, and a 19% reduction in hospital admissions from using telehealth technologies.
Joseph Smith, MD, chief medical and science officer for the West Wireless Health Institute in San Diego, attributes this to “linking chronically ill veterans with healthcare providers and care managers through video-conferencing, messaging and biometric devices and other telemonitoring equipment.”
But the VA should take it one step further, Smith suggested. Wireless biometric sensors can track disease activity continuously, transmitting information to the patient’s providers without requiring that the patient make a long-trip for an in-person visit.
Perhaps, Smith says, the VA should think about the $1.8 billion it intends to spend building two new hospitals. “Imagine how many veterans in remote areas across the country could be reached through wireless technologies with a similar expenditure of those precious resources: The CCHT’s program cost is $1,600 per patient per year, meaning an additional 225,000 veterans in remote areas could be reached for a comparable cost over a five-year period.”
Certainly the VA has done a lot, said Gail Graham, the VA’s deputy chief officer for Health Information Management, who points out in an interview that $1,600 per patient cost used to be $13,121 per patient for primary care and $77,745 per patient for nursing home care. The VA is also partnering with the Department of Defense, which is spending research money to equip newly returning service members with different sophisticated wireless devices to monitor their health.
For example, the VA is using or experimenting with:
- Very Small Aperture Terminal (VSAT) satellites, installed in its 50 mobile centers which its readjustment counseling service uses to provide outreach and counseling in primarily rural areas.
- Cueing aids sent to PDAs, smartphones, personal pocket computers, GPS devices and the Livescribe Pulse Smart Pen all help veterans remember appointments or medication schedules, which is especially helpful for vets with memory loss, spatial disorientation or other cognitive difficulties.
- Bar Code Medication Administration carts and laptop computers are now wireless offering “vastly improved access to critical patient information used for clinical decision making at the very point treatment is provided,” Graham said. “To date the VA has administered over 1 billion medications using this technology” to assure doses are correct.
- Through the VA’s “My HealtheVet,” online personal health record, vets have been able to fill more than 15 million prescriptions, and efforts are underway through the VA’s Office of Rural Health to adapt the application for mobile use.
But, as several of those testifying pointed out, there are significant obstacles. For starters, there’s the U.S. Food and Drug Administration, which has been criticized as being too slow to approve life-saving devices.
There’s also a problem of state licensing purview, which requires that physicians be approved by a medical board before providing care in a given state. With electronic and wireless health that may dampen the ability for care provided across state lines. While the VA’s doctors don’t have to worry about that, wider application of the technology may require civilian doctors to practice across state lines.
Additionally, there is limited access to broadband communication. Kerry McDermott, an expert advisor for the Federal Communications Commission, told the Congressional committee that 29% of rural health clinics do not have access to adequate mass-market broadband. And, he said, “We estimate that 14-24 million Americans do not have access to broadband where they live, even if they want it.”
Though he did not testify at the hearing, Alan Morgan, executive director of the National Rural Health Association applauded the VA for “making significant efforts to reach rural America through focused outreach efforts. However, we certainly would like to see them increase their partnership efforts with local existing rural providers.”
In an interview this week, Adam Darkins, MD, the Veterans Health Administration’s chief consultant for Care Coordination, points out that "the devil is in the details" with wireless health technology, much of it may not be quite ready for widespread application in rural areas.
“There’s still quite a lot of work that needs to be done,” he says. “If you’re going to have that kind of ability to monitor, you really must have the ability to intervene if necessary,” which means if a wireless monitor does detect a problem, what should providers do about it when the patient is far away. Additionally, he says, these technologies still produce a lot of false positives as well as false negatives.
And, he says, “telehealth, whether it links to wired systems or wireless isn’t going to replace the need to go to a hospital and clinic.”
Smith, of the West Wireless Health Institute summed up yet another issue.
“The current regulatory disclarity is dampening investment in wireless health technology and chilling this promising engine of innovation because many investors and some telecommunication companies fear FDA’s regulation of non-medical devices (e.g., smartphones of all manner) if medical applications are utilized.
“The FDA should be supported in the view that the specific sensors, algorithms for interpretation, and specific therapeutic devices should remain the focus of regulatory activity, and the pathways for communication of the information should be understood to be the purview of the Federal Communications Commission.”
As the VA’s Darkins says, there are a lot of issues still to sort out, and much more research that needs to be done.
It would be a bad idea to install a lot of technology that can’t be used in rural settings, whether because of lack of provider oversight, poor broadband links, or too many inaccurate signals.
But if I know one thing about technology, as it is in Disneyland, Fantasyland and Tomorrowland are just around the corner from each other.