Robert Bosch Healthcare, Inc.
Mr. Chairman and other Members of the Committee: Thank you for giving Robert Bosch HealthCare (Bosch) the opportunity to provide testimony to the Committee. Bosch, which makes the Health Buddy and T-400 remote monitoring devices, has been providing remote patient monitoring in the Veterans Health Administration (VHA) since 2003. We’d like to address the role of telehealth in improving health outcomes for veterans and reducing the need for hospital services, such as emergency room visits, inpatient admissions and re-admissions. While these are important issues in any geographic area, the shortage of physicians in rural areas and the long distances patients must travel to receive medical care make it even more important that patients with complex chronic conditions learn self-management, and for providers to prevent exacerbations of chronic illness that can lead to a hospital visit. In many cases, emergency room visits, hospital admissions and readmissions have been proven to be preventable through regular monitoring, automated patient education and the intervention of a nurse case manager.
Thirty two percent of veterans treated by the VHA live in rural areas[i]. The care needs of an aging veteran population (the number of veterans aged 85 and older is set to triple by 2011 compared to 2000[ii]) have led the VHA to adopt health technology sooner than many other delivery systems. We applaud this foresight. As the Committee knows, between 2003 and 2007 the VHA implemented Care Coordination/Home Telehealth (CCHT), a national initiative that enables veterans with chronic conditions to remain in their communities and reduces the need for high cost acute care. This was after extensive evaluations of the intervention in the Sunshine Network Veterans Integrated Services Network (VISN). Bosch has been providing remote patient monitoring devices to veterans since the beginning of the CCHT initiative; currently we provide 70 percent of the remote monitoring technologies that serve veterans across 21 VISNs and 123 facilities nationally. We believe that our products, and remote monitoring in general, provide an opportunity to cost-effectively extend care to rural areas without compromising clinical effectiveness.
A. The Health Buddy and T400 Programs
Bosch participation in the VHA CCHT program is based on the premise that care management supplemented by technology (the Bosch Health Buddy and ViTelCare systems) can effectively decrease costs (most commonly due to repeated and/or prolonged hospitalizations) and improve the quality of life for veterans with chronic conditions by supporting education and self-care, increasing care based on evidence-based guidelines, and improving coordination of care.
I. Clinical Focus
Key diseases of focus for veterans are Congestive Heart Failure (CHF), Diabetes Mellitus (DM), Chronic Obstructive Pulmonary Disease (COPD), Hypertension (HTN), Post Traumatic Stress Disorder (PTSD), and Major Depression, though other conditions are monitored as well. We believe that the successful outcomes for PTSD, depression and other mental health disorders[iii] demonstrate the applicability of remote monitoring to younger “Wounded Warriors” who are not likely to have age-related conditions, but may suffer from service-related mental health conditions.
II. System of Care Management + Technology
The Health Buddy and ViTelCare Programs provide effective, efficient and consistent care management based on the Chronic Care Model.[iv] Its elements include the community, the provider system, self-management support, delivery system design, decision support, and clinical information flow. Care management is supported by an easy-to-use, in-home survey and data collection home health monitoring device (either the Health Buddy four-button appliance with text screen, or the ViTelCareT400 touch-screen monitor with adjustable audio and text screen) and an Internet-based web service for data management, care coordination, and decision support by healthcare providers.
III. Health Buddy and ViTelCare Systems
The Bosch devices gather information on vital signs (either through patient self report or peripheral devices such as glucose monitors), symptoms, behaviors and patient knowledge of their health conditions. The data collected is presented to the health care professional through a web-based application in a color-coded and risk-stratified format. The Health Buddy’s and ViTelCare’s scripted dialogues also provide education, feedback, and reminders for self-care behaviors, specifically diet, exercise and medication compliance. Patient responses from both the Health Buddy and T400 appliances are automatically sent to servers housed within VA data centers.
IV. Data Flow
Data from the patient takes place through traditional telephone connection, Ethernet, and, for the Health Buddy, through wireless modem (the T400 will introduce wireless capability later in 2010). Bosch is exploring additional means of expanding patient-provider connectivity that would make remote monitoring more accessible to veterans in rural areas.
V. Workflow Result
The provision of risk-stratified information to nurse case managers is a critical component of detecting exacerbations of illness early, before a hospital visit becomes necessary. Moreover, it enables case managers to target resources to patients most in need and manage a larger patient panel (a typical nurse to patient ratio in the Health Buddy Program is 1:125 or 1:75 for mental health conditions).
The CCHT initiative has shown great success, as demonstrated by a 25 percent reduction in inpatient days, 19 percent reduction in hospital admissions and 86 percent patient satisfaction after enrollment[v]. As a provider of 70 percent of the remote monitoring devices used within the VHA, we believe we have been a significant contributor to the VHA’s ability to successfully improve patients’ quality of life and transition care away from high cost acute care settings and into the home and community.
C. Opportunities for Expanding the Reach of Telehealth
The CCHT initiative represents wisdom and foresight in caring for a growing and geographically dispersed veteran population, yet we believe there is even more potential to extend care to rural areas in a clinically- and cost-effective manner with modest modifications. Research has shown that reductions in utilization for veterans in rural areas lag behind those in urban areas[vi], showing potential for greater returns to the VHA. Specifically, we note:
- The ability to expand the successes of the CCHT initiative has been limited by institutional constraints related to hiring staff and by the time required for development of new clinical practices and protocols.
- Currently, Health Buddy and T400 appliances are procured by the VHA prosthetics department, which is set up to purchase material goods such as telehealth devices or prosthetic limbs. Telehealth, on the other hand, is a system of care and as such it includes material goods, as well as less tangible items, such as services, software, data management and data storage. Prosthetics does not have a mechanism to pay for ongoing service and other non-material fees? in essence, the current payment structure does not support wider adoption of health technology, which is increasingly becoming more virtual. We are hopeful that this barrier will be addressed by the proposed transition of procurement to the Denver Acquisitions and Logistics Center.
These suggestions aside, we again would like to take the opportunity to commend the VHA for taking a leadership role in adoption of technology as a primary component of patient care. As the largest health care system in the nation, VHA’s vision in adapting to a new technological age will lead other health care providers to do likewise, resulting in reduced costs and better patient outcomes.
D. Technology on the Horizon
The promise of telehealth ultimately resides in the notion that inter-networked technologies can create a system in which health maintenance and care are moved to wherever someone with severe disabilities or chronic illness is?particularly their home. Over time, we believe that the ability to support an individual’s independence will rely on increasingly intelligent sensor-based technologies that can predict with increasing degrees of certainty that an ‘adverse event’ is looming. We also see a role for video as broadband-penetration rates continue to rise.
We believe the VHA’s technology-based care coordination program has driven the development of the budding, US-based home telehealth industry. We believe that the VHA CCHT program’s next wave of growth, with its increasing sophistication of how to refine its toolbox of options for veteran health management and monitoring, will drive a new wave of innovation in the industry. Bosch looks forward to supporting the VHA in its ongoing drive to improve care for veterans by moving that care to their homes, wherever ?including rural areas?those veterans are.
[i] Darkins, A., Ryan, P., Kobb, R., Foster, L., Edmonson, E., Wakefield, B., Lancaster, A. Care coordination/home telehealth: a systematic implementation of health informatics, home telehealth and disease management to support the care of veteran patients with chronic conditions. Telemedicine and e Health 14(10):1118-1126.
[ii] Ibid. Page 1118.
[iii] Ibid. Page 1123.
[iv] Group Health Research Institute. 2006-2010 Improving Chronic Illness Care. https://www.improvingchroniccare.org/index.php?p=The_Chronic Care_Model&s=2
[v] Darkins et al. op cit. Page 1118.
[vi] Ibid. Page 1123.