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Joseph M. Smith, M.D., Ph.D.

Joseph M. Smith, M.D., Ph.D., West Wireless Health Institute, La Jolla, CA, Chief Medical and Science Officer

Chairman Michaud and Ranking Member Brown, thank you for the opportunity to testify before the Committee about addressing the health care needs of veterans, particularly those living in rural areas, and how wireless health technologies can help overcome barriers to accessing care. My name is Dr. Joseph Smith, and I am the Chief Medical and Science Officer of the West Wireless Health Institute.  I have spent the last 25 years at the intersection of medicine and innovative technology, practicing medicine and the technology-intensive subspecialty of clinical cardiac electrophysiology in academic and clinical settings, and most recently, concentrating on advancing the development of emerging technologies to solve unmet needs in health care.

The West Wireless Health Institute is a non-profit medical research organization that was launched last year by two visionary entrepreneurs, Gary and Mary West, with the primary mission of advancing wireless health technologies to lower health care costs.  The Wests, through their family foundation, have granted almost $100 million to the Institute to date. We are focusing these resources to create a unique, cross-functional organization comprised of physicians, scientists, engineers, health economists, and experts in reimbursement and regulatory policy to drive systematic change in health care delivery.  With 42 members of the team already in place, we are hiring at a pace of about one person per week and hope to employ a world-class staff of 80 by the end of this year.   Toward our goal of dramatically lowering the cost of excellent health care, we are innovating and incubating promising technologies; validating their value to lower costs; actively engaging with policymakers and other stakeholders to accelerate the availability of these solutions; and collaborating across sectors including health care, technology, business, government, and academia.

Wireless sensors that enable remote diagnosis, monitoring and treatment support are among the innovations that will enable these aims to become a reality, as well as alleviate some of the burgeoning costs within the VA health care system. In general, wireless sensors and other mobile devices accurately monitor a variety of physiological functions and shifts, including respiration, body temperature, heart rate, and blood glucose levels. A patient with high blood pressure, for example, can be monitored with a wireless device that captures physiological changes and sends an alert to the patient’s provider, with the unprecedented potential of preventing acute and long-term complications such as stroke, heart attack and kidney disease.  

Because of their pervasiveness and low cost, cell phones and other wireless technologies are well-suited to cheaply transmit information and help patients and health care providers manage chronic diseases.  Wireless technology offers real-time and ongoing diagnosis and monitoring of a patient’s condition, whereas in-person, physician office visits present only a snapshot of the patient’s condition at a fixed time and place. Ultimately, these solutions are driving a new infrastructure independent model of health care, which translates into the right care, at the right time, wherever people need it.

For veterans residing in rural and remote areas, this means not having to incur the burden of finding considerable time and resources to make repeated visits to distant facilities. We know from talking to VA practitioners in rural areas that distance is one of the greatest barriers to accessing care, particularly for those with chronic conditions—the very patients who need the most support. We are continuing dialogue with the VA at local and national levels to identify solutions for making a significant impact on this front.

We also share the great concern that our nation’s health care system is itself ill, swollen and inflamed by excessive costs derived from an evolution of unfortunately perverse incentives.  Doctors and hospitals are fiscally incentivized by volumes of procedures and face-to-face encounters, while patients and families wish to maintain health and wellness and avoid costly and complex interactions with doctor’s offices, clinics and hospitals. And just earlier this year, we passed into law a sweeping reform of health care insurance that will dramatically increase access to a health care system that seems ill-poised to meet the challenge.  The imperative for change in health care delivery is undeniable, and the opportunities afforded by emerging wireless health care solutions are compelling. We believe the VA system has provided an illuminated path to the appropriate deployment of these promising technologies.

Specifically, we commend the VA for its Care Coordination/Home Telehealth (CCHT) program which has demonstrated a 25 percent reduction in bed days of care (including 50 percent for patients in highly rural areas) and a 19 percent reduction in hospital admissions by linking chronically ill veterans with health care providers and care managers through videoconferencing, messaging and biometric devices, and other telemonitoring equipment. The CCHT program appears to be the largest telehealth program in the world, with 43,000 senior veterans receiving home care for chronic disease management.  Under the VA CCHT program, one nurse is able to extend his or her reach to ‘touch’ 150 patients remotely on a daily basis.  With 32 million individuals soon to be provided comprehensive health insurance and the shortage of physicians expected to exceed 125,000 within 15 years (according to the Association of American Medical Colleges), the VA’s CCHT program offers substantive proof that wireless health technology can dramatically increase the efficiency of already overstretched health professionals to help patients no matter where they are or when they need care.

We believe the VA’s CCHT program should take the next step and incorporate innovations beyond traditional telehealth equipment, much of which still requires care within VA clinics or other fixed locations. We encourage the VA to evaluate and implement wireless health solutions that will complement and further extend the reach of the CCHT program, including wireless biometric sensors that monitor highly relevant physiologic parameters, track disease activity on a continuous basis, and transmit that information to the patient’s health care provider.  This technology enables providers and patients themselves to monitor and diagnose their conditions without a facility in-person visit.  

We understand the VA is now undertaking the construction of two new hospitals at the cost of $1.8 billion.  Certainly, those hospitals will offer important access for veterans in those discrete communities where the geographic density is sufficient to motivate such investment.  However, almost 40 percent of veterans enrolled in VA health care live in rural or highly rural areas; an even higher proportion of veterans returning from Iraq and Afghanistan reside in rural areas. Imagine how many veterans in remote areas across the country could be reached through wireless technologies with a similar expenditure of these 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.  And as the CCHT program demonstrated, these investments deliver a return in lower overall costs and greater patient satisfaction, carefully managing the VA’s limited resources while improving patient outcomes. 

Unlike traditional fee-for-service health care where providers currently have little incentive to expend resources on technology that result in savings to a different “silo,”  an integrated, self-contained delivery system such as the VA can readily demonstrate the cost-savings that can be achieved by greater utilization of wireless health technologies by tracking the decreased hospitalizations, clinic visits, and other traumatic and acute interventions that results when chronic disease is met with continuous care as opposed to episodic and expensive rescue. 

To this end, the West Wireless Health Institute is currently exploring a demonstration research project with the VA in San Diego with a small cohort of recently diagnosed PTSD patients. The project will incorporate a mobile device with videoconferencing capabilities to enhance crisis management, regular “check-ins” and biofeedback therapies. We will be demonstrating the value of this inexpensive and integrated wireless health solution for increasing access to real time support for veterans with PTSD (and potentially decreasing hospital admissions and acute events).  This outpatient model of support enables face-to-face access to a clinician off-site at any time and can be used across numerous disease states. 

On a larger scale, an important step that the VA has recently announced is the new $80 million VA Innovation Initiative (VAi2), which will improve veterans’ care by tapping into private sector expertise and creativity.  We encourage VAi2 to accelerate the evaluation of wireless health solutions that enable home and mobile monitoring of diverse and complex signs, symptoms and biometrics, patient- and population-based dynamically learning treatment algorithms, and remotely titrated therapies for a wide range of chronic and acute care needs.

It is important to note that a critical reason the VA can leverage wireless health technology is because its health care providers within the VA are able to operate across state lines.  Currently, non-VA physicians are licensed by states and cannot routinely practice medicine across state lines, including through remote monitoring services.  This creates a serious impediment to wide deployment of wireless health solutions and frustrates the ability of our broader healthcare systems from reaping the cost and care efficiencies enabled by these solutions.  The Federal Government must follow the VA’s lead in crafting a policy to address this inter-State obstacle to widespread adoption of wireless health technology.

Also imperative to extending veterans’ access to wireless health technology is the rapid expansion of broadband to rural and remote areas. The FCC has noted that 14-24 million Americans do not have access to broadband where they live, even if they want it.  Broadband access is more than connecting individuals to Google and YouTube; it’s about dramatically transforming the delivery of healthcare to people no matter where they live.  We commend the commitment to expanding broadband access through the $7 billion for broadband networking in the 2009 economic stimulus bill, and we support the FCC’s plan to ask the Medicare program for a clear path for reimbursement for wireless health solutions.

Certainly, many of the challenges of expanding utilization of wireless health technology—such as providing a clear, consistent and integrated regulatory and reimbursement environment that fosters innovation and commercialization of wireless healthcare solutions - are outside the specific purview of the Veterans Administration.  Yet 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 nonmedical 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 (wireless networks, cell phones, etc.) should be understood to be the purview of the FCC. Regulatory and reimbursement clarity will specifically enhance the VA’s ability to adapt truly innovative and cost-saving wireless health solutions for its CCHT program, and will also facilitate the rapid generalizability of the benefits to the broader US population.

The VA has a unique opportunity to enhance the ability of providers and veterans themselves to monitor, diagnose and manage their health conditions more effectively.  Just as email, Facebook and Twitter have transformed how we communicate with one another, wireless health solutions offer a remarkably new modality of care where patients can be diagnosed, monitored, and often treated wherever and whenever they need care, and in the process avoid the costly, complex, time-consuming, and inefficient interactions with an already over-stressed and geographically constrained healthcare system.

In sum, we make the following recommendations that will ultimately increase veterans’ access to health care regardless of where they live:

  • Following the VA’s lead, Congress should create policies that facilitate health care delivery across State lines. Current laws restricting interstate medical practice are dampening innovations that could significantly benefit veterans across the country.
  • We encourage the VA to evaluate and deploy newer wireless health technologies within its CCHT program, and take advantage of opportunities like the recently announced VAi2 competition to test biometric sensors and other solutions that facilitate remote access to care.
  • In addition, we encourage members of this Committee and Congress to support broadband expansion, as well as a clear and consistent regulatory and reimbursement environment to spur the types of innovations that will truly enable health care delivery “anytime, anyplace.”  

One-hundred years ago this Spring, Abraham Flexner was concluding the research for his ‘Flexner report’—widely viewed as one of the most impactful treatises in American medicine, credited for ushering in a revolution in medical education and practice. One pivotal observation in that report remains as true today as it was a century ago: “The small town needs the best, and not the worst, doctor procurable.” Our nation’s veterans living in remote communities deserve access to the best thinking and the best care... and freeing that care of geographical and infrastructure limitations is a promise of wireless healthcare and one that cannot wait for the next century.

We are on the threshold of a paradigm shift in health care delivery, one in which we realize the full potential of the digital and wireless revolution and make ‘anytime, anywhere’ care a reality. It is clear the VA is on a path to demonstrate that we can effectively reach many of our rural and remote veterans with these approaches, providing a continuous model of care for those dealing with chronic conditions, and in the process enhance satisfaction and drive down costs. It is vital that we learn and take the lead from the VA’s early successes to quicken our pace, as patients (veterans and others) are waiting.

We look forward to working with the Committee and the VA in building upon its leadership role in telehealth and helping America’s veterans and all of its citizens benefit from the evolution of an infrastructure-independent model of health care.