In the U.S., no organization has shown a more powerful commitment to mHealth adoption than the VA. The second largest government department after the Department of Defense, the VA manages a $100B budget, with 300,000 employees. Half of the budget and nearly all the employees are part of the Veterans Health Administration (VHA), which delivers health benefits and services to 8.3 million patients per year, with 5.3 million unique patients per year, through 152 medical centers and 1,400 community clinics. As an early and rapid adopter of mHealth, the VHA represents half of the 300,000 chronic disease remote monitoring patients in the U.S. It has awarded contracts for $1.4B to mHealth technology vendors for devices and services, and it has published the most comprehensive studies on the costs and benefits of deploying mHealth and remote patient monitoring across multiple chronic disease, geographies, and socio-demographics.
The VHA has grown its telehealth and remote patient monitoring from an initial program of 2,000 patients in 2003 to over 150,000 in 2012. It provides services to primarily men between the ages of 50-90 years of age with specific disease programs addressing diabetes (48%), hypertension (40%), congestive heart failure (CHR) (25%), chronic obstructive pulmonary disease (COPD) (12%), and mental health (about 5%). Two thirds of these patients had a single condition, while the remainder had two or more. Half of these lived in highly rural locations, while 30% lived in urban locations, and the remainder in semi-rural areas. About 90% of patients offered this form of care have eagerly accepted it due to the increased convenience and control they experience in their care and patient satisfaction for these services is at 86%.
The annual cost to deploy these programs is $1,600 per patient per year, compared to over $13,000 for traditional home-based care and over $77,000 for nursing home care. But the key economic benefit occurs from the cost avoidance associated with telehealth and mHealth remote monitoring services that have led to 25% reduction in number of bed days of care and a 19% reduction in hospital admissions. However, the benefits are not the same among all disease conditions, just as the solutions must differ by type of disease and level of acuity. For example, the reduction in hospitalization for mental health patients exceeds 40%, while those for CHF and hypertension range from 25%-30% and diabetes and COPD average about 20%.
When looking at the cost benefit analysis, the VHA has found that a $1,600 per patient per annum mHealth program can enable a call centre nurse or social worker to predict and prevent expensive emergency department visits and hospitalizations that can cost in excess of $16,000 per patient per event. When analyzed across its entire population, and when taking into account the “frequent flyers” (the 5% of patients that represent 30% of costs), the VHA finds that a $1,600 investment per annum for these patients decreases average costs by over $6,500 per year, producing an ROI of 4:1.
The VHA’s unparalleled success and breadth in the application of these technologies has led the U.K.’s National Health System in their 3 Million Lives and Whole Systems Demonstrator projects to specifically reference the VHA’s work as the example they wish to follow in addressing the same fundamental challenges:
- More patients: Rapidly aging population needing greater healthcare services.
- Fewer healthcare professionals: Shortages of healthcare professionals, the ratio of health professionals to patients declines from 10:1 to 3:1.
- Insufficient healthcare facilities: Shortage of hospital or institutional facilities and budget constraints to build more.
- Budget shortages: Few resources to finance healthcare services like those provided in the past.
- Complex adaptive system: Deploying transformational change in a complex system among diverse, semi-independent, and autonomous agents (e.g., doctors, hospitals, patients).
As Dr. Adam Darkin, Chief Consultant for Telehealth Services at the VHA, has pointed out on many occasions, the VHA, and all healthcare systems around the world, have these same challenges, although the VHA began to experience them and address them earlier than most. He points out that nothing short of a revolution in the delivery of care will enable us to address these issues, and the connected technologies we have and deploy through mHealth can enable us to change workflow, medical practice, and healthcare economics in such a way that we can move most of future healthcare associated with prevention and chronic disease management into the home. He is quick to point out that those acute episodes that require hospitals will always need to be in hospitals, but with 75% of our healthcare costs associated with chronic disease management, and the fact that hospitals were never designed to manage these diseases, means that we have a hospital infrastructure that is inappropriate for managing most of the costs of our systems and therefore demands a new model and delivery of care. This new model is a home-based mHealth model that is more consumer-centric, more empowering, pushing more of the care to the patient and family members, and improving outcomes, quality, and satisfaction, as evidenced by the VHA experience, while at the same time significantly decreasing costs.
Dr.Darkins points out that the VHA’s impressive achievements have been hard won and required rethinking the approach to healthcare in a large system. He sees the VHA as a complex adaptive system that cannot be forced to adopt these new medical practices through command and control. As a student of complexity theory he has designed the VHA’s system in a way that enables the emergence of new practices across the system in an organic manner by providing key enablers that support the transformation of the system. What the VHA has found is that merely offering to pay providers for offering these services does not mean providers will deliver them. These enablers must address the following six barriers to adoption that the VHA has faced over the nearly decade-long exponential growth of the system:
1. Lack of training in the new paradigm of remote practice: No medical schools train physicians or nurses in how to practice care on a distant and remote basis. Providers can be paid to delivery only those services they know how to deliver. The VHA has trained nearly 10,000 providers around the U.S. on how to use technologies to augment, supplement, and in some cases replace their current practices.
2. Validation of clinical and economic efficacy: Clinicians are scientists, and as such want research and empirical evidence that this new paradigm creates greater value than the existing one. This Kuhnian logic has required the VHA to create the extensive documentation of their structures, practices, and processes to identify, quantify, and measure the clinical and economic value of telehealth and mHealth services.
3. Data integration with existing digital health records: Unlike most EHR systems that have an ability to integrate patient generated data through remote care, the VHA has anticipated this need and provided the integration of this information so that nurses and social workers can better manage these patients in a ratio of 150:1. Such an approach ensured that they can meet the Meaningful Use Level 3 requirements for patient-generated data.
4. Deployment varies by geography and socio- demographics: As a complex adaptive system, no one size can fit all patients and markets. Providers must be able to construct and deploy telehealth and mHealth on a modular basis so that it can meet the specific and unique needs of each segment.
5. Technology interoperability and integration: While much of the sensor and monitoring technology is simple, straight forward, and tried and tested, the rapid growth of mobile technologies has dramatically decreased the cost of deployment by as much as 90% versus the alternatives of just five years ago. However, providers need technology support to stitch various new technologies together so that they can be easily deployed and used to gather and integrate data into new clinical services.
Only after placing these enablers in place could local VHA providers, within the larger complex, adaptive VHA system, create their own local solutions to address their individual needs.
The VHA continues to innovate the practice of medicine through mHealth services. During the past two years it has announced the following mHealth initiatives:
- Issuing and running IT Innovation Challenges and selecting the top 26 best IT innovations.
- Enabling clinicians to use mobile devices in VHA facilities. Partnering with the Continua Health Alliance to promote standards for mHealth interoperability.
- Providing cloud-based services for clinician collaboration.
- Opening the VHA app store for clinicians and patients to download mobile apps. Launching a new diabetes mHealth remote patient monitoring program.
- Purchasing 100,000 iPads.
- Issuing a new study showing that remote monitoring decreases mortality by 45%.
- Launching a new tele-psychiatry program.
- Issuing local press releases by regional VHA providers indicating cost and clinical benefits of mHealth. Eliminating co-pays for mHealth services.
- Launching an iPhone EHR app.
- Launching home as the hospital program.
- Upgrading Wi-Fi capabilities.
Dr. Darkins believes that other public and private healthcare systems can learn a lot from the VHA’s experience. He is pleased to mention that when they initially began their remote monitoring programs and their successes around 2005, people often said, “If the VHA can do this, then any one can do this.” But now nearly ten years since the VHA launched their programs and others have stubbed their toes trying to replicate it, he hears a different refrain: “Only the VHA could do something like this.” He disagrees with both statements. He believes that no system has a choice in adopting mHealth, that all systems can learn from the VHA, and that all can successfully develop such programs if they apply the enablers to overcome the barriers. By so doing, access and quality will improve while costs decline.