Dec 31 2009

On Call

The Portland Veterans Affairs Medical Center uses handheld devices and other technologies to improve medical care for U.S. military veterans.

Veterans in Oregon will soon learn that
using a PDA every day helps keep the
doctor away. The Portland Veterans
Affairs Medical Center (VAMC) is
testing the use of personal digital
assistants to make it simpler and faster for veterans
to record and report their blood sugar levels, blood
pressure, cholesterol levels and heart rates. The
PDAs, which include cellular capabilities, will
remind diabetic patients to regularly test their vital
signs and send the test results
wirelessly to hospital staff.

Patients used to write their test
results on paper and visit doctors for
the sole purpose of passing on this
data. The mobile technology should
cut down doctor visits, while simultaneously improving
patient health care.

When veterans immediately notify hospital staff of
abnormal test results, health care workers can intervene
before problems worsen, says Dr. Adam Darkins, chief
consultant for care coordination at the Department of
Veterans Affairs.

"It's a way to pick up, really early on, when patients are
running into trouble," Darkins explains. "If all is well,
there's no need to intervene, but if there's a problem, the
doctor can immediately contact the patient."

The Portland project is one of numerous VA telehealth
efforts that are under way to improve patient health care
and to help the agency operate more efficiently and
effectively. Veterans across the country utilize various
technology devices—ranging from small handhelds with
LED screens to larger
units with video
capabilities—to send
vital health statistics
and to communicate
with hospital staff
from their homes.

Patients check
their blood sugar
levels with the lower-end equipment. The
higher-end equipment
lets hospital staff see and talk with patients via video to assess
a patient's condition.

This allows staff to determine if a patient's wounds are
healing. Seeing the individual's face also helps clinical staff
evaluate whether the patient is confused or suffering from
depression, Darkins says.

Technology Takes the Stage

"As more veterans—including our new combat veterans—come to the VA for health care, technology becomes more
and more important to meeting their needs," says VA Chief
Information Officer Robert McFarland.

Veterans Affairs first implemented telehealth technology
a few years ago, focusing on patients who suffer from
diabetes, depression, high blood pressure and heart
problems. Constant monitoring has resulted in improved
patient health, including
lower blood pressure
and better mental
health. It also has
helped patients avoid
emergency room visits
and long hospital stays
by 30 percent.

"Instead of people
having to come to a
medical care setting—a
hospital, clinic or
office-based model—to be treated, they can have the
advantage and convenience of a continuous, person-centered process that focuses on improving their health,"
says Dr. Robert Kolodner, VA acting chief health
informatics officer.

After two and a half years of
testing by hospital staff, the Portland
VAMC expects VA leadership to
expand testing this year to 220
veterans with diabetes. Although
the VA continues to evaluate PDA
usage, Darkins believes that the
devices will advance home
telehealth technology. The new
PDAs' cell phone capabilities offer
patients mobility that is not
available with the current
technology, which requires a
connection to hospitals through
the patient's home phone line.

If the PDA testing with diabetes
patients proves successful, the VA
could approve its use for mass
deployment next year to all
Portland VAMC diabetes patients,
says D. Keaka Loo, telehealth
project administrator at the
Portland VAMC.

An improved quality of life tops the list of benefits that
the PDA pilot offers veterans. Depending on their
condition, patients visit their doctors between once a week
and once every three months to submit their vital sign
reports. Because many patients live up to two hours from
the hospital, wirelessly sending the data from home can
save them a four-hour round-trip journey for a 30-minute
clinic visit, Loo points out.

The mobile device also gives patients more flexibility in
testing and reporting results. They can test blood sugar
levels at work, on the golf course or even on vacation. They
can be "anywhere in the country, and they can still
maintain their scheduled readings," Loo says.

Developing the Technology

Developed at Tripler Army Medical Center in Honolulu
through a Department of Defense grant, the telehealth
technology was later transferred to the Portland VA
Medical Center. The PDAs run on Microsoft Windows
Pocket PC Phone Edition and Windows servers. Microsoft's
SQL Server database powers the back end of the system.

The patients use separate testing equipment, such as blood
sugar and blood pressure monitors, and enter the results into
the PDA. The device's built-in cell phone automatically
transmits the data to a secure server that resides outside
the VA firewall.

The only data transferred is the PDA's serial number and
the numeric values entered by the patient for his or her
vital statistics. No patient identifying information is sent.

A VA server inside the firewall checks the outside server
every minute for new patient information, and then safely
pulls the data through the VA firewall. All communication
is encrypted, says Loo, who adds that the multiple steps
are security and privacy measures to ensure that Portland
VAMC meets guidelines
established by the Health
Insurance Portability &
Accountability Act.

After collecting the
data, the internal server
application examines the
serial number and verifies
the patient's identity.
Then the data is
accessible through a
hyperlink in the VA's
Computerized Patient
Record System. A case
manager at the hospital
regularly reviews the
patients' records.

However, if test results
show abnormalities, the
internal server application
immediately pages a
medical staffer, Loo

This proactive approach
to health care handles
minor medical issues
before they become major,
potentially dangerous
problems, explains Jeff
Bloom, the president of Honolulu-based CTA Solutions,
the company that developed the telemedicine application
for the VA hospital.

"The beauty of this is that it's both a PDA and a phone,"

Bloom says, "so a case worker can pick up the phone and
call you." Physicians and patients can even text message
each other.

Refining the Technology

Loo, who has been running tests during the past year,
initially found some bugs that have since been fixed.

For example, when he tried to send data but couldn't
get a cell signal, the PDA would stop trying to send the
information after several tries. Since the technology has
been reworked, the PDA continues to dial every minute
until the cell signal is strong enough to send the data.

The VA and Microsoft plan to connect testing
equipment, such as tests for blood sugar levels and blood
pressure, directly to the PDA, letting the device
automatically capture and send test results. The automated
procedure will prevent potential mistakes by patients who
now input the data themselves, says Randy Siegel, manager
of Microsoft's U.S. Federal Mobility Business Development.

The telemedicine software on the PDA provides several
other benefits to patients. For example, color codes warn
patients if test results are outside a specified range.

If a patient's pulse rate is normal, around 70, readings
are green. If it's slightly high, around 125, patients get a
yellow warning. If it's dangerously high, around 200, a red
message warns the patient to contact his or her doctor

Patients can also see
graphical charts of their
test results dating back
several months, letting
them see at a glance how
well they are doing over
time, says CTA's Bloom.

Patients' use of the tool
encourages them to be
more aware of their health.
"If they're taking readings
and writing it on paper," he
says, "they may say, 'I can't
tell anything from these
readings. I'll just have
another piece of pie, it
doesn't matter.'

"But with the color
codes and the graphical
charts, if they start seeing
spikes in their results,
they'll think, 'Maybe I
shouldn't have that extra

The technology "gets
them more engaged in
managing their health
care," Bloom says.


Home health care technology may become mainstream in
years to come, predicts Dr. Adam Darkins, Department of
Veterans Affairs' chief consultant for care coordination.
Currently, about 4,500 of VA's 5 million patients use home
telehealth technology, but that's because it's still a fairly new
concept, he says.

VA first piloted the technology with 1,000 patients
in Florida five years ago. "We are beginning to use
it as a standard fashion for the delivery of care,"
Darkins reports. "We're scaling up in stages, and
we're making sure the technology is fully worked
through and tested. We're dealing with chronic diseases, so
we need to make sure the platforms are robust."

The VA invests in home telehealth technology to
help older veterans continue living independently.
Many veterans move from their own home into
nursing homes to receive daily monitoring. The
ability to measure their own vital signs should allow
these veterans to retain more autonomy. "This is enabling
technology—very simple to use and it doesn't require complex
computer skills—allowing people with chronic diseases to live
independently in their own home," Darkins says.

About seven years ago, the VA noticed numerous
grassroots telehealth efforts springing up at
many of its regional medical centers and health clinics.
As a consequence, agency leaders created a central
office to coordinate projects and help nurture
the use of technology in medicine. The VA's Office
of Care Coordination promotes telehealth efforts
throughout VA's medical facilities and helps them
with the logistics of collaborating with one another.

Technology Is Spreading

Since the pilot project in Florida, home telehealth
implementations have spread to other regions, including
Colorado, Utah, Wyoming, Texas and New York.

For the past year, the VA in New England has
tested an interactive phone-based telehealth system
that may go national in the future. The interactive voice-response
system allows clinical staff to call patients on a daily, weekly or
monthly basis to check on their health. A recorded voice asks
them a series of standard questions, such as: "How are you
feeling?" and "Did you take your blood sugar level?"

Patients can respond verbally or by punching in
answers on the touchtone phone, says Pat Ryan,
the VA's acting associate chief consultant for care
coordination. For example, when the recorded voice asks
patients if they took their blood sugar level, they can punch
"1" for yes or "2" for no. The responses are then captured,
translated into a graphic and viewed on computers by
medical staff members.

Doctors also use telehealth technology to get visual
updates to assess whether patients' wounds are
getting better. In most cases, the VA supplies patients
with instant cameras, so they can take pictures of their
wounds and mail them to medical clinics,
Ryan says. That enables doctors to check the
healing process and change the treatment, if necessary, without
forcing patients to travel to a clinic.

In limited cases, the VA has outfitted some
patients with telemonitor devices that have
built-in digital cameras. These devices enable
doctors and nurses to view a patient's wounds in real
time, she adds.

Veterans Affairs also invests heavily in
technology that reduces the distances between
local, regional and national medical facilities, as well as
the vast distances that sometimes separate patients and

Doctors in rural clinics, for example, can use
the agency's secure wide area network to send X-rays or
other digital images to larger hospitals where medical
specialists provide diagnoses and treatment options.
Similarly, rural patients needing counseling can
visit their local clinic and videoconference with a
psychologist at a distant medical facility.


The number of veterans using home telehealth technology has nearly
quadrupled in three years, from 1,176 in 2002 to 4,430 in 2004.

Telemedicine Chart

Veterans Integrated Service Networks (VISNs) are Veterans Affairs' regional health networks located
throughout the United States.

Source: Department of Veterans Affairs

Here's How The Project Works

1. The patient inputs test results into a hybrid
personal digital assistant (PDA)/cell phone device,
which automatically places a call and wirelessly
transmits the encrypted data to a secure server residing
outside the VA firewall.

2. A server inside the VA firewall captures the
information, then makes the data accessible
through a hyperlink in the Computerized Patient
Record System. Full integration into this system will take
place in the future.

3. Hospital staffers review the patient's records. If
test results show abnormalities, the application
immediately pages hospital staff. A health care
professional can then call the patient on the PDA device
to provide care.