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OCR for page 99
11
Experiences of the VA and IHS
For the most part, the VA and the IHS work independently of one
another. However, they have a formal Memorandum of Agreement that
addresses how they should work cooperatively to serve veterans of mutual
interest. In this session, a panel of experts discussed the approach to tele-
health within each of these agencies, and the challenges and opportunities
that emerge with collaboration. The following sections reflect the individual
speaker's comments and reflections.
U.S. DEPARTMENT OF VETERANS AFFAIRS1
Adam Darkins, M.D., M.P.H.M., FRCS
U.S. Department of Veterans Affairs
The issue of telehealth is not about whether it will happen, but how it
will happen. The VA is recognized as a national leader in telehealth, and
defines several modalities within telehealth, including home telehealth,
clinical video teleconferencing, S&F telehealth, teleradiology, secure mes-
saging, and mobile health. The VA uses off-the-shelf technologies, and has
a dedicated national telehealth training center for their staff. Additionally,
they use standardized business processes because of the need for interoper-
ability. Developing telehealth services should be based on a demonstrable
patient need, and the VA introduced telehealth primarily in the interest of
1Datapresented in this section belong to the VA. Personal communication, A. Darkins, U.S.
Department of Veterans Affairs, August 17, 2012.
99
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100 THE ROLE OF TELEHEALTH
providing care to veterans. The reasons for doing telehealth include reduc-
ing costs, increasing quality, and improving access. Therefore, the VA's
vision of telehealth is that it should be veteran focused, forward looking,
and results oriented.
Telehealth Modalities in the VA
Home Telehealth
The value of home telehealth is based in the care of people with chronic
conditions. There is no evidence the traditional outpatient clinic is the
most effective way to care for individuals with long-term chronic condi-
tions. The VA uses home telehealth (e.g., video, mobile devices) to provide
non institutional care across the health care continuum: for chronic care
management, acute care management, and health promotion and disease
prevention. As shown in Figure 11-1, the census for VA patients receiving
home telehealth has grown steadily. In FY 2003, about 800 patients were
cared for with home telehealth. By the end of FY2012, the VA estimates
92,000 patients will receive home telehealth services annually.
100,000
90,000
Home telehealth census
80,000
70,000
60,000
50,000
40,000
30,000
20,000
10,000
0
2008 2009 2010 2011 2012
Fiscal year
FIGURE 11-1VA home telehealth
Figure patient census, FY2008-2011 and projected
11-1.eps
FY2012.
SOURCE: Reprinted with permission from Adam Darkins (2012).
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EXPERIENCES OF THE VA AND IHS 101
300,000
Store and forward encounters
250,000
200,000
150,000
100,000
50,000
0
2008 2009 2010 2011 2012
Fiscal year
FIGURE 11-2VA store and Figure
forward 11-2.eps
encounters, FY2008-2011 and projected
FY2012.
SOURCE: Reprinted with permission from Adam Darkins (2012).
Store and Forward Telehealth
In the VA, S&F telehealth is mainly used for teleimaging for diabetic
retinopathy and for teledermatology. Both of these serve a demonstrable
patient need. About 20 percent of the 5.6 million veterans in the United
States have diabetes, and screening for diabetic retinopathy is a way to
prevent avoidable blindness. Additionally, many VA organizations, particu-
larly those in rural areas, have difficulty finding dermatology services. The
VA is also exploring how to use this technology into wound care. Figure
11-2 shows the growth in S&F encounters. In 2005, about 1,500 patients
were managed by S&F telehealth; by the end of FY2012, this number is
estimated to be around 256,000.
Clinical Video Telehealth
Clinical video telehealth replicates the face-to-face consultation (e.g.,
between provider and patient, provider to provider) and eliminates the need
to travel for certain services. The VA primarily uses this for real-time vid-
eoconferencing between VA medical centers and community-based outpa-
tient clinics. It is mostly used for the delivery of mental health services and
specialty consultations (e.g., telecardiology, teleneurology, tele-amputation
care, teleaudiology, telepathology). In the past year, the VA has been moving
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102 THE ROLE OF TELEHEALTH
Clinical video telehealth encounters 350,000
300,000
250,000
200,000
150,000
100,000
50,000
0
2008 2009 2010 2011 2012
Fiscal year
FIGURE 11-3 VA clinical video telehealth
Figure encounters, FY2008-2011 and projected
11-3.eps
FY2012.
SOURCE: Reprinted with permission from Adam Darkins (2012).
into tele-ICU. Over the past 7 years, the VA has built a dedicated national
network for clinical video telehealth. This network includes 4,000 video
endpoints within the VA system (e.g., hospitals, clinics), with everyone
using Internet protocol (IP) video. The VA is also extending IP video into
home care. As seen in Figure 11-3, the VA has had tremendous growth in
the use of clinical video telehealth.
Impact
In 2011, clinical video telehealth, home telehealth, and S&F telehealth
together accounted for care at more than 150 VA medical centers and 750
community-based outpatient clinics to 380,865 patients. Thirty-seven per-
cent of the patients were in rural areas and 3 percent were in highly rural
areas. For FY12, the VA estimates that 480,000 veterans (approximately
9 percent of the veteran population) will have been served by one of these
telehealth modalities, and that in FY13, the number will rise to 820,000,
or about 15 percent of the veteran population.
Outcomes assessments show reductions in bed days for home telehealth
programs (53 percent) and clinical video telehealth for mental health care
(25 percent). In terms of patient satisfaction, home telehealth programs
have a mean score of 86 percent and S&F telehealth has a mean score of 92
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EXPERIENCES OF THE VA AND IHS 103
percent. The VA pays for a certain amount of travel costs, and assessments
show an average savings of $34.45 per video consultation and $38.81 per
consultation for S&F. In previous years, savings associated with the home
telehealth program (above all other costs, including the cost of the program)
ranged from $1,238 to $1,999 per annum per patient.
Telemental Health
Mental health care is a major reason for implementing telehealth. In
FY2011, 146 hospitals provided 55,000 patients in 531 community-based
outpatient clinics with 140,000 telemental health visits. Home telemental
health programs provided care to more than 6,700 patients for conditions
such as depression and posttraumatic stress disorder. A review of more than
98,600 patients who received clinic-based telemental health care between
2006 and 2010 showed a 25 percent reduction in hospitalization. A review
of 1,041 mental health patients before and after enrollment in home tele-
mental health services by the VA in 2011 showed a 30 percent reduction in
admissions in their first 6 months of care as compared to a similar period
of time before enrollment.
Meeting Challenges and Ensuring Quality
Two challenges facing the VA are not unique to the VA: training often
is not part of the health professions' curricula, and there are no outside
resources to train VA providers on the use of telehealth. Currently, more
than 60 requirements exist to establish a telehealth program, and they are
often beyond the competency of most individual VA staff (e.g., privileging,
information technology compatibility). Furthermore, the Joint Commission
does not survey telehealth specifically, but will encounter telehealth during
their reviews.
To meet these and other challenges, and to ensure the quality of their
programs, the VA has three telehealth training centers that develop and
provide standardized training and resource materials. Additionally, a qual-
ity management team provides biannual reviews of each Veterans Integrated
Service Network (VISN) for integration of telehealth standards with Joint
Commission requirements for hospital- and home-based care. The VA also
has national databases, reports, and analyses for metrics of performance
and quality of telehealth programs at the levels of the local VA medical
center, the VISN, and nationwide. The VA also has national contracts and
contract support for telehealth technologies, including service and warran-
ties to ensure equipment quality and safety, and collaborates with national
clinical experts to develop standards of care for telehealth care. Lastly, the
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104 THE ROLE OF TELEHEALTH
VA collaborates and coordinates with stakeholders to ensure comprehensive
infrastructure for telehealth.
National Telehealth Training Centers
The mission of the telehealth training centers is the right training, in the
right place, and at the right time. Because of the size of the VA network, it
is important that people are trained in a standardized way. The emphasis
is on virtual training (98 percent of the training is provided virtually) and
strategic partnerships with the Employee Education System. These centers
provide the training, tools, and resources to
· successfully plan, deploy, and manage telehealth programs;
· standardize organizational, clinical, technical, and business
infrastructures;
· assess programs to identify clinical needs that telehealth can
address;
· improve and expand the delivery of care via telehealth to ensure
the efficiency, quality, and sustainability of services; and
· integrate with existing programs.
Through the third quarter of FY12, the VA has had 150 training
courses or forums available from the three centers. The clinical video tele-
health training center has trained more than 4,000 staff through more than
600 events. The S&F training center has trained more than 3,200 unique
staff through more than 250 training events, and the home telehealth na-
tional training center has trained more than 2,500 staff through 800 events.
Training innovations include clinical practice forums, integrated tele-
health master preceptor programs, interactive meeting rooms, new and
improved methods of training, out options for super users, the use of video
to capture the human element, scenario-based instruction evaluation, the
use of animation, and rapid response training.
INDIAN HEALTH SERVICE2
Mark Carroll, M.D.
Flagstaff Medical Center
Where are we trying to go in telehealth? The widespread adoption of
telehealth seems to be an important and major goal. Why is this so difficult,
2Dr. Carroll indicated that while he worked for the IHS for 20 years, his comments did not
necessarily reflect those of the agency.
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EXPERIENCES OF THE VA AND IHS 105
and are we approaching it in the right way? The easy answer is that the
problem is all about reimbursement, and that telehealth payment should
be equivalent to in-person care. However, perhaps the widespread adop-
tion of telehealth is not really the goal. Instead, the real goal is quality, as
conceptualized by the triple aim of the Institute for Healthcare Improve-
ment: experience of care, cost, and population health (IHI, 2012). So, the
real question is how can telehealth innovation help achieve the triple aim?
The IHS includes more than 600 facilities, some full-time and some
part-time, across the country. These facilities include hospitals, health cen-
ters, Alaskan village clinics, and health stations. Most of these facilities are
under tribal self-governance. Partnerships and collaborations are critical,
and tribal governance is an important part of that. Indian health care is
mainly rural, but it also occurs in urban environments. A differentiating
point for IHS as compared to other federal systems of care (e.g., the VA) is
that more than half of annual operating budgets of many IHS facilities is
from third party billing, so business models matter.
Telehealth is not new to the IHS. In the 1970s, the STARPAHC proj-
ect was jointly sponsored by the IHS; NASA; the Department of Health,
Education, and Welfare (predecessor to HHS); and the Papago Tribe. In the
project, health care providers traveled in a van to deliver health care via
"two-way television," radio, and remote telemetry, applying some of the
same basic precepts of care that we talk about today.
New Service Models
Since that time, many new tools have been embraced with the devel-
opment of new service models. However, one model does not fit all. Some
of the models are driven by necessity, such as the complete lack of access
to specific specialty care. Many of the models for these new services rely
on new partnerships, including ones that seem unfamiliar. For example,
Coconino County in northern Arizona is the second largest county in
the United States, and it sits adjacent to the Navajo nation and the Hopi
nation. Currently, shared models are being developed for psychiatry and
other services. Some models add very robust efficiencies. For example, the
use of S&F consultation across the state of Alaska has resulted in dramatic
improvements in speed of reply. However, efficiencies cannot be reached in
some places because the models are not integrated into the care systems.
This depicts the care approach and the culturally appropriate plan-do-study-
act cycle in the Chinle Service Unit on the Navajo reservation. New types
of innovation that do not work in this type of model and depiction are not
easily integrated. Many models require new commitments. For example, the
IHS ran telenutrition services from northern Arizona in Indian health sites
in multiple states for years, resulting in thousands of interactions. When the
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106 THE ROLE OF TELEHEALTH
commitment went away, so did the ability to continue that model of care.
Most models are not successful without a lot of effort. In another example,
the IHS uses the Joslin Vision Network for a t eleophthalmology program
for retinopathy screening. The program improves access to screening and it
improves access to laser treatment for diabetic patients already cared for in
the clinic. The costs are lower, and the screening and care is better than
in-person exams. This took a long time to get up to speed, and while eye
screening rates across the IHS have improved by 20 percent in the facilities
that have embraced this program, there is still much room for improvement.
Diffusion of Innovations
In Diffusion of Innovations (Rogers, 1962), Rogers highlighted issues
relevant to telehealth. Many care models using telehealth do not diffuse
the same way, yet these models are still isolated in specific categories (e.g.,
real time, S&F, remote monitoring). A different stratification system may
be needed to distinguish telehealth innovations by their ability to diffuse
easily rather than by the modality. For example, first there are innovations
that can integrate more easily into conventional models of care because
fundamental process and payment changes are not required. Teleradiology
may be an example of that. Next are innovations that require important,
but non-fundamental, changes within a closed health care system. Examples
may include the use of telehealth within the Kaiser health system and the
VA. Finally, there are the telehealth innovations that require fundamental
changes, especially for open systems, systems that are collaborative in na-
ture, and not within particular organizations. An example is chronic care
coordination after hospital discharge.
Telehealth-enabled care is not necessarily the same as in-person care.
They are different models of care and should not necessarily be reimbursed
in the same way. Instead, new models of reimbursement are needed care.
For some care models, there is no in-person option, and so reimbursing
the same way across video makes sense. For some care models, a new tool
(i.e., telehealth) does not necessarily bring added value. However, there is
a growing evidence base for certain models that shows that telehealth care
is just as good as conventional care; and sometimes it is better. We need to
remember that not all of telehealth is exactly the same.
Relationships and Connectedness
In research, we need to consider the value of relationships and con-
nectedness in some of these new care models. Part of the purpose of in-
novation in health care is to activate certain intermediate behaviors and
activities, such as self-efficacy, self-management, and medication compli-
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EXPERIENCES OF THE VA AND IHS 107
ance to achieve the triple aim. Relationship supports (e.g., social supports,
behavioral health screenings, health coaching) are critical to this activation.
A 2010 study of patients hospitalized for heart failure concluded that
telemonitoring did not improve outcomes (Chaudhry et al., 2010). How-
ever, important details might affect that interpretation. For example, this
multisite trial was based on an earlier single-site trial that resulted in a 44
percent reduction in the rate of readmission, and was associated with sig-
nificant cost savings. In the attempt to scale the model, a single skilled nurse
case manager (who had one-on-one conversations with the responsible phy-
sician) was replaced with an automated monitoring system. Therefore, an
alternate conclusion is that the non-relationship based model did not work.
Learning from that, Care Beyond Walls and Wires, a collaborative
project in northern Arizona among private industry, the IHS, community
health centers, and the Flagstaff Medical Center, is built on the need for
relationships. This model uses tools like smartphones and a 3G signal so
patients who live in remote areas can stay in communication with health
care coordinators, especially after a hospital discharge. At the heart of this
and other telehealth models is the relationship and regular communication
between the patient and the care provider.
Concluding Remarks
Carroll reflected that changing care models is a daunting task, and
challenges health care teams and policy makers alike. To facilitate these
changes, telehealth innovations need to be stratified differently so that we
can identify and learn from the different obstacles to diffusion. Also, more
collaboration is needed in open health systems to work toward achieving
better experience of care, lower costs, and improved population health.
Different health organizations have different business drivers and motiva-
tors. Because of that, more study is needed on the role of connectedness in
regional partnerships to improve transitional care for patients. Finally, care
model change on a larger scale can be supported by focusing on key loca-
tions such as IHS facilities and community health centers, where national
projects to study the effects of systematic uses of telehealth innovation can
lead to policy and legislative changes.
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108 THE ROLE OF TELEHEALTH
CRITICAL RELATIONSHIPS IN TELEHEALTH WITH
AMERICAN INDIANS AND ALASKAN NATIVES
Jay H. Shore, M.D., M.P.H.
U.S. Department of Veterans Affairs;
University of Colorado Denver
Telehealth is not about the technology itself, but is a bridge to the
relationship with the patient needed to provide care. In a lot of ways, the
most important treatment we give is the healing relationship between the
patient and a provider. As seen in Figure 11-4, that relationship is the core
of telehealth care, but that does not happen without a series of relationships
that need to occur to allow a provider to see a patient in a rural community.
In fact, although that relationship is critical, it is not the most important
relationship for successful telehealth clinics. In rural populations, the most
important relationship is often the relationship between the provider and
the community, because without it the service will not exist. Embedded in
that are organization-to-organization relationships, and particularly for na-
tive patients; this relates to eligibility across multiple systems. For example,
Community-
to-community
relationships
Organization-
to-organization
relationships
Program-
to-program
relationships
Patient-to-
provider
relationships
FIGURE 11-4 Multiple relationships of telehealth care.
Figurefrom
SOURCE: Reprinted with permission 11-4.eps
Jay H. Shore (2012).
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EXPERIENCES OF THE VA AND IHS 109
evidence shows that native patients in particular use various systems of
care; so, native veterans might get primary care from the IHS, and then
choose to get specialty mental health care from the VA. Finally, in specific
programs, there are internal and external relationships that need to occur
for successful clinical interaction.
Mental health has a unique fit for telehealth in that most of mental
health care can be accomplished in some form over videoconferencing. This
has been shown in the growing literature over the past decades, across age
groups, populations, and treatments, although even more research is still
needed. Particularly in the past 5 years, the emerging technologies of direct
in-home video conferencing, mobile health, and Web-based care have been
changing how providers interact with patients. Telehealth and telemental
health are especially relevant for native communities with geographic barri-
ers to access, as well as cultural and institutional barriers that may prevent
them from accessing care. RCTs are certainly needed to demonstrate that
these treatments are as rigorous as any other treatment, but more nuanced
approaches are also needed to understand this tool of technology and how
it interacts in relationships. Each type of technology has strengths and
weaknesses. There are appropriate pairings of technology with diseases
and populations, but we do not necessarily understand in a systematic way
how to make those pairings.
Patient-Provider Relationships
Good data show that there are some situations where telehealth may
be more effective than face-to-face visits. For example, Shore related that
in working with female natives with a history of domestic violence or post-
traumatic stress disorder, the women often say it is easier to begin work-
ing with an unknown provider over video because in the initial visits, the
distance helps facilitate a feeling of safety. As the relationship builds over
subsequent sessions, the need for this feeling of safety through distance
lessens as the patient develops trust with the provider. Counterpoints to that
distance include the loss of cues and the perception of emotional distance.
RCTs in telemental health show equal outcomes, but there are some hints of
an impact on the patient-provider relationship and the clinical process. We
do not know how that translates and how that ultimately impacts clinical
outcomes. Telemental health clinicians will say it is different than seeing
someone face-to-face. The good clinicians and systems understand that and
make adaptations.
There are many different adaptations to bridge patient-provider gaps,
such as provider contextual training. Providers are often from urban areas,
and may not have spent much time in rural communities, so they may feel
disconnected when caring for remote patients by video. Unless these provid-
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110 THE ROLE OF TELEHEALTH
ers make real efforts to understand the patient's environment and the issues
impacting the patient in terms of community events, they may lose touch
with what is going on contextually. Cultural and clinical facilitators are
also useful. For example, the tribal outreach worker is a native veteran who
lives in the community, does scheduling, builds rapport, and helps bring in
patients who traditionally may have been reluctant to get care from federal
health care systems. Veterans without a history of care for mental health
issues may come for care for the first time not because of a stranger coming
over video from an urban location, but because of the community member
involved in the clinic. That is one adaptation at the patient-provider level.
Additional adaptations include collaboration with traditional healers and
family members.
Program-Program Relationships
Telehealth requires multiple internal and external collaborations among
programs that may not come together in the traditional course of health
care (e.g., primary care providers and information technology specialists).
These programmatic areas may also have different languages, cultures,
structures, models, and philosophies. The need to work together compels
an increased level of coordination, continuity, and consistency in care,
and leads to more holistic approaches. It also requires new models of care
integration and health care team configuration. The conceptualization of
health care teams has not kept pace with the technologies and the models
that are delivering these technologies.
Organizational Relationships
Providing care may also involve multiple organizational collaborations.
For example, one of Shore's clinics has six different partners: two VAs,
a university site, the IHS, and two tribal partners. The cooperation and
coordination of multiple systems of care is possible and, at times, highly
desirable. Whereas one institution might not have all of the necessary re-
sources, this cooperation provides more options for patients and increases
care coordination. Also, with multiple systems, there may be better collec-
tive sources of funding. However, challenges include the identification of
the correct configuration of partners. In addition, the technologies in the
different organizations need to be able to interact, and managing multiple
compliance and regulatory issues across systems can also be very challeng-
ing. Other sensitive issues include the designation of the primary funder and
determination of who will pay for which programs or services. Organiza-
tional collaborations often start off based on individual relationships, and
are critical in native communities. Overall, success depends on systematiz-
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EXPERIENCES OF THE VA AND IHS 111
ing the right communication and collaboration processes that work within
the local context, so that when the champions and other individuals move
on, the infrastructure remains.
Concluding Remarks
Shore concluded that we need to do a better job of investigating, ex-
ploring, and codifying models that are successful at each relationship level
in order to understand the importance of the impact of the relationships--
how they are successful or how they do not work. We also need to under-
stand how technology affects the process of health care, either positively or
negatively. Finally, we need to learn more about appropriate adaptations to
make sure that the development of telehealth services and networks focuses
on enhancing the quality of and access to care in order to fulfill the promise
of telehealth, especially for American Indians and Alaskan Natives.
REACTION AND DISCUSSION
Moderator: Spero M. Manson, Ph.D.
University of Colorado Denver
An open discussion followed the panelists' presentations. Manson be-
gan the session by noting the speakers' emphasis on relationship building
not just at the provider-patient level, but throughout the hierarchy of
relationships that underpin health care. He added that these relationships
relate directly to the success of health care services in both the short and
long terms. Audience members were then able to give comments and ask
questions of the panelists. The following sections summarize the discussion
session.
Reducing Federal Silos
One participant asked how to facilitate more successful collaboration
among federal agencies and reduce silos. Carroll stated that recognition
of the differences in the organizations and systems (including their mis-
sions) is critical. He noted that the IHS and the VA have a Memorandum
of Understanding that allows for the exchange of information, tools, and
experiences, but the respective missions of the organizations have guided
the focus of their collaborations on service for native veterans. Carroll
stated that better understanding of why certain models diffuse well in some
systems and not others can serve as guideposts to steer expectations of dif-
fusion because not all systems will work the same way. For example, there
have been some great programs that work well within closed systems, but
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112 THE ROLE OF TELEHEALTH
are challenged when translated into systems that require interactive part-
nerships. Shore added that growth is needed both from the "top down"
and the "bottom up." He cited the Memorandum of Understanding as an
example of growth from the top. He added that the best IHS-VA collabora-
tive successes occur when individuals at the local level look for how to use
national processes to serve veterans. He noted that this, in turn, often leads
to changes at the structural level.
Darkins responded that reducing silos is not merely about agreeing to
work together, but that developing networks and standardized processes
has real challenges, including issues of privacy and confidentiality. He
suggested that telehealth could be defined as a multimedia patient record.
Without the ability to exchange information, he said, the utility of video
alone is relatively limited because telehealth is really about decision making
for patients, and so successful collaboration is about building communities
that link different systems. Darkins further noted that building a standard-
ized process even within one system of care is challenging, adding that the
VA is no different from other organizations when it comes to funding. He
stated that the VA does not mandate the use of telehealth, nor is there cen-
tralized funding, so the values to growing these programs are largely access
and local savings. For example, he said, it took nearly 5 years to build the
data to support home telehealth.
One participant stated that NASA would be a good collaborative
partner for the IHS and VA for the sharing of electronic medical record
modules.
Linking Data Sources
One participant asked if federal data might be made available for use
by the private sector, especially to do point-in-time evaluations. Darkins
agreed, stating that linking data is the challenge of health care systems
worldwide. He noted that the VA is working toward how information
can be shared like this. Carroll also agreed, adding that the VA has been
involved in information system development for many decades, and is in-
terested in the bidirectional and contiguous exchange of data.
Involvement of Decision Makers
Manson asked how each system of care has educated and involved key
decision makers, especially within the local community. Shore stated that
the involvement of both the VA system leadership and the tribal leader-
ship have been critical to his work. He said that in each community where
they set up telemental health services, they have discussions with the tribal
council and engage that leadership, as well as the local VA leadership. He
agreed that support of the local and regional leadership is critical to success.
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EXPERIENCES OF THE VA AND IHS 113
He added that engaging leaders at the national level is key to expanding
models to other locations. Manson agreed, stating that generating an early
series of small but effective models can inform other advocacy levels. For
example, Manson and Shore discussed the role of the VA in supporting the
development and further adoption of local models of care that were based
on existing tribal relationships. Darkins stated that population health is
really the driver for the development of telehealth. Perhaps there will be
collaborations at the state level to allow for telecommunications resources
to be pooled and used in different ways to serve multiple organizations.
However, he said, there are many complexities, including privacy and con-
fidentiality, to making this happen.
One participant asked how to get CMS to accept the work and data of
the VA and IHS as evidence for coverage decisions. Carroll answered that
the IHS has been working with CMS on these issues. He noted that the IHS
also has tremendous data to share on outcomes, process, and costs related
to the use of telehealth for national coverage determinations for telehealth.
Carroll noted that a U.S. Senate bill had previously been proposed to autho-
rize Medicare telehealth reimbursement for community health centers and
Indian health sites. Darkins stated that CMS has been actively supporting
telehealth development with many pilot programs. He added that telehealth
is not being carried out in a standardized way across the United States, and
that creating standardized systems for telehealth within the VA is a key to
success. Darkins stated that CMS bases investment decisions on effective-
ness, and they will determine if and when there is sufficient evidence to
support the development of larger telehealth networks, and which, if any,
of the models they believe can be transferred.
Cultural Competency
One participant raised the issue of the importance of cultural compe-
tency to the patient-provider relationship. Shore responded that in each
community he and his team have served, they have tried to establish either
a formal or an informal network with traditional healers. He said they
have had ceremonies and blessings for the use of videoconferencing. They
also will refer patients interested in traditional healers for sweat lodges to
help with posttraumatic stress disorder, and that occasionally, those healers
(with the patient's permission) will come in to discuss the patient's treat-
ment. Shore stressed that this demonstrates to the individual patient that
his or her perspective on health care and treatment is being considered, and
it is an indication to the community that the individual provider and the
larger health care organization are considering the community needs. Shore
further asserted that demonstration of collaboration and partnership at the
community level is critical to relationships.
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