Spotlight on Telehealth
VA documented the first instance of “telehealth” in the early 1960s, when VA providers communicated with their patients via television1. When Internet-based telehealth became viable, VA was an early adopter. By 2013 VA was treating more than 600,000 Veterans in 1.7 million instances of telehealth care2.
In 2017 VA acted on a new regulation that allowed VA clinicians to provide telehealth services to Veterans anywhere in the country. This “anywhere to anywhere” practice used the VA Video Connect technology, allowing providers to use mobile devices to connect with Veterans on smartphones, tablets, and computers. At the time VA Secretary Shulkin said he expected the number of Veterans using telehealth services to dramatically increase from the 700,000 the previous year3. In 2018 VA provided approximately 2.3 million telehealth visits, including more than one million using VA Video Connect4. In 2019 telehealth visits increased again, to 2.6 million5. Before the COVID-19 pandemic struck, VA already had the biggest telehealth program in the US1.
As part of the Coronavirus Aid, Relief, and Economic Security (CARES) Act, VA was awarded $19.6 billion in additional funding to fight the pandemic. In April 2020, as the novel coronavirus appeared to be spreading rapidly throughout the United States, VA announced that it would ramp up telehealth services during the COVID-19 pandemic. Telehealth rapidly began playing a large role in VA’s ability to continue to deliver health care while mitigating virus transmission risk through physical distancing6. Veterans who needed care now had the option to use telehealth – if appropriate to their needs, instead of in-person visits. By mid-May Veterans increased use of phone or video appointments by more than 800%7. VA recently announced that telehealth visits increased from approximately 10,000 per month to approximately 120,000 per month – an increase of 1000%8.
In the short amount of time since this rapid increase started, HSR&D researchers have begun to design new studies of how nearly-universal use of telehealth is affecting vulnerable populations, quickly including physical distancing and other COVID-19 factors into existing studies, and collaborating with operational partners to ensure success. Following are briefs of several such studies and implementation investigations.
Impact: Rehospitalization is common among Veterans with chronic heart failure (CHF) and Chronic Obstructive Pulmonary Disease (COPD), and represents a significant expense for VA. With increasing numbers of Veterans with CHF and COPD being seen by VA clinicians, traditional transition interventions may not be sustainable. The virtual nurse intervention designed and evaluated in this study is intended to augment existing care transition practices by leveraging emerging communications technologies and identifying how to enhance and increase the use of Veteran-facing technologies. This project stands to improve Veteran outcomes through enhancements in quality, effectiveness, and efficiency of VA services.
Making the transition from hospital to home is a difficult undertaking for many Veterans, particularly those with complex, chronic healthcare needs. There has been a steady increase in the resources that VA uses to treat chronic heart failure (CHF) and Chronic Obstructive Pulmonary Disease (COPD), both of which are among the most common conditions for admission and re-admission to VA facilities. Veterans with CHF or COPD often receive limited support for the self-management tasks they must perform at home post-discharge, thus can feel overwhelmed. Clinicians face competing demands and cannot routinely engage in tailored post-discharge follow up with Veterans beyond the scope of usual care. As a result, Veterans are often readmitted to the hospital due to factors such as limited self-monitoring, suboptimal adherence, and lack of follow-up. Multi-component care transition interventions have been shown to be effective in some cases but can be costly to implement. An alternative approach is to augment care transition interventions with technology.
This technology-assisted care transition intervention is founded on the concept of a virtual nurse that interacts with Veterans with CHF or COPD through different technology channels. Building on evidence that care transition interventions having both an inpatient and outpatient component are more effective, the virtual nurse appears on a touchscreen during the inpatient stay and educates Veterans about the important elements of a care transition. After discharge, the virtual nurse coaches Veterans through two-way, automated, computer-tailored text messaging. Specific aims of this study are to: 1) Refine and test the virtual nurse's onscreen personality and the corresponding touchscreen technology for use with Veterans who have CHF or COPD. 2) Conduct a randomized trial of the technology-assisted virtual nurse care transition intervention, including the onscreen personality and the automated, computer-tailored text messaging. 3) Evaluate the intervention, including its effectiveness, implementation process, and budget impact.
- Veterans have reported positive feedback on the virtual nurse, scripted dialog, and automated texting protocols.
- Barriers to participation have included Veteran comfort levels with the technologies that comprise the intervention, discharge unpredictability, and competing healthcare demands of the target populations.
- Facilitators to participation have included close communication with inpatient clinical teams and engaging informal caregivers of Veterans.
Principal Investigator: Timothy Hogan, PhD, MS, is an investigator at the Center for Healthcare Organization & Implementation Research (CHOIR) at the Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA.
Veterans Access Research Consortium (VARC)
The Veterans Access Research Consortium (VARC) is a VA HSR&D COnsortium of REsearch (CORE) led by several senior researchers and directors of HSR&D Centers of Innovation (COINs). VARC’s mission includes supporting the Access Research Consortium (ARC) Network, an interactive and collaborative network of researchers interested in contributing to access-related research and innovation, identifying high-priority access research and metric questions to help shape VA’s access-related research portfolio, and advancing impactful research through the development of access metrics and guidance on data sources. In April VARC put out a call for ARC Network members to share their works in progress, with a specific focus on how research and evaluation studies currently underway, or recently completed, might inform solutions to the access challenges being presented by the COVID-19 pandemic. The following are briefs of projects that were presented in the resulting Cyberseminar.
VA Virtual Care Delivered by Video-Enabled Tablet Met with Veteran Satisfaction
Impact: Strong satisfaction ratings for tablets and the fact that characteristics such as age, health literacy, and prior technology use were not significantly associated with tablet preference suggest that engagement in video-based care is possible for many types of patients, including those often considered to be on the wrong side of the “digital divide.”
The expansion of virtual healthcare services includes the use of video visits with patients via mobile or web-based applications. In 2016, VA’s Offices of Rural Health and Connected Care developed a pilot initiative to distribute video-enabled tablets to Veterans who did not have the necessary technology and who had a geographic, clinical, or social barrier to in-person healthcare. During this pilot, 5,000 tablets were distributed to 6,745 patients at 86 VA facilities, with approximately half of the tablet recipients living in rural areas. Tablets were predominantly used for mental healthcare, but also for spinal cord injury care, primary care, palliative care, rehabilitation, and other services. To help inform optimal tablet distribution and technical support, investigators evaluated patient experiences with tablets through baseline and follow-up surveys. Primary objectives were to: 1) identify healthcare access barriers, 2) examine patient experiences with tablets and any changes in perceived satisfaction with VA care, and 3) investigate the patient characteristics associated with preferences for video vs. in-person care. A baseline survey was sent to 2,120 tablet recipients and a follow-up survey was sent to respondents 3-6 months later. A total of 764 Veterans completed both the baseline and follow-up survey and are included in the following results.
- Many recipients of VA-issued tablets reported that video care is equivalent to or preferred to in-person care. Among follow-up survey respondents, 32% of tablet recipients indicated that they would prefer to conduct their future VA appointments by video; 32% indicated they would prefer these visits in person; and 36% indicated their preference was “about the same.”
- The most common barriers to in person care were travel time (66%), travel cost (55%), health conditions (54%), bad weather (57%), and feeling uncomfortable or uneasy at VA (33%).
- Between baseline and follow-up surveys, there were statistically significant increases in patient satisfaction regarding overall VA care, as well as primary care and mental healthcare. Satisfaction regarding technology and technical assistance also was high: 86% agreed or strongly agreed with statements regarding the ease of using the equipment, receiving help needed to learn the technology (84%), and that it was easy to ask questions (88%) and understand instructions (87%).
More recently, study investigators have begun researching tablet deployment during the COVID-19 pandemic. More than 7,000 tablets were shipped in the early stages of the “stay at home” effort. Patterns show rapid uptake, especially in areas of the US where COVID-19 infection rates were high. The team continues to study Veteran and facility characteristics and virtual care use in general during the rapid scale-up of virtual care during the pandemic.
Investigators: This study was partly funded through eHealth QUERI and VA’s Office of Rural Health. Cindie Slightam, MPH, and Drs. Zulman, Hu, Jacobs, Gurmess, Kimerling, and Blonigen are part of HSR&D’s Center for Innovation to Implementation (Ci2i), Palo Alto VA Healthcare System.
Factors Associated with Secure Messaging Use Among Homeless-Experienced Veterans
Impact: While secure messaging has been available since 2010, little is known about the uptake and acceptability among vulnerable Veterans. This ongoing study provides the first national estimates of secure messaging use in a homeless experienced population. Findings of low uptake, especially among homeless-experienced Veterans who are older, non-Latino Black, and those with substance use disorders, suggest vulnerable Veterans may benefit from help engaging with health technology. As VA adopts more telehealth options in response to the COVID-19 pandemic, it will be important to retain low technology alternatives, such as telephone-only visits and text messaging, for patients with technology barriers.
VA has accelerated uptake of telehealth in response to the COVID-19 pandemic, including telephone visits, virtual care visits, and secure messaging through a patient health portal. Since Veterans who have been homeless experience significant health challenges and difficulty accessing mainstream primary care, whether they can fully partake of expanded telehealth opportunities such as secure messaging is unknown. Prior studies have documented health technology barriers such as lost/stolen devices and lack of access to Internet-enabled devices, which could result in low uptake of secure messaging among this population. Investigators surveyed 5,766 Veterans with experiences of homelessness about their VA primary care experience; in part, assessing secure messaging use and satisfaction.
- In preliminary analyses, 21% of homeless-experienced Veterans affirmed they had used secure messaging through My HealtheVet, and 87% of these Veterans found the service to be useful.
- Characteristics associated with greater likelihood of using secure messaging were female gender, more than high school education, mental health diagnoses, and having 3 or more chronic conditions.
- Uptake of secure messaging was lower for older Veterans, non-Latino Black Veterans, and those with a history of substance use disorders – especially opioid use disorder.
Investigator Audrey L Jones, PhD, is an investigator with the Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center of Innovation at the VA Salt Lake City Health Care System.
Clinician-Supported PTSD Coach
Impact: Bringing Clinician-Supported PTSD Coach into primary care could be an initial step in establishing effective and easily disseminated mobile health interventions for Veterans with PTSD. If this approach is found to be effective at reducing PTSD symptoms and increasing use of mental health care, it could be an initial stage in a stepped-care approach to provide patient-centered treatment that facilitates shared decision making on treatment options, reduces PTSD symptoms, and prepares Veterans for more intensive treatments, if needed.
Veterans seen in VA primary care exhibiting symptoms of PTSD are referred to specialty mental health (MH) clinics that are equipped to provide appropriate psychotherapies. Unfortunately, many Veterans refuse such referrals or do not attend enough sessions to receive adequate treatment. To address the gap this creates, between need for and engagement in effective PTSD treatment, VA's National Center for PTSD has developed PTSD Coach. PTSD Coach is a self-management mobile app that offers PTSD education, symptom monitoring, coping skills, and links to social support and professional resources. While research shows that technology-based self-management programs for MH conditions are effective, self-management programs by themselves are often underutilized. Interventions that include clinician support increase treatment utilization and effectiveness. This study sought to evaluate a treatment package that combines the PTSD Coach mobile technology with primary care clinician support (CS PTSD Coach).
CS PTSD Coach consists of four 20-30-minute sessions over eight weeks focused on instructions for app use, setting symptom reduction goals, and assigning specific PTSD Coach activities for the Veteran to complete between sessions. Two hundred sixty Veterans were recruited from two sites and randomized into the intervention (CS PTSD Coach) and treatment as usual (referral to primary care mental health integration (PC-MHI) provider.
Modifications to Increase Access During the COVID-19 Pandemic: Prior to the pandemic, Veterans attended in-person meetings for consent and assessment procedures, as well as therapy sessions. Study procedures were modified to continue all study activities via phone, mail, and VA Video Connect. Potential participants are mailed the consent, and consent is administered by phone. Baseline assessments are administered by phone and online. Veterans without access to the internet may complete assessments solely by phone or by a combination of phone and mail. Research staff initiate VA Video Connect meetings to provide participants with a virtual “warm hand off” to the study clinicians. Study interventions are delivered via phone if the Veterans does not have a smart phone or internet access. Research staff and clinicians record assessments and therapy sessions. This study demonstrates how multiple VA-approved programs and apps can work in conjunction to conduct virtual research.
- In April, May, and June of 2020 monthly enrollment more than tripled over the previous 3 years prior to COVID.
- Treatment session completion decreased slightly, but assessment completion was 100%.
- Veterans commented that they never would have participated if they needed to come in-person.
- Staff efficiency increased, allowing more research assessment completions.
- Early reports indicate high Veteran and staff satisfaction with pandemic-related modifications.
Investigators: Eric R Kuhn, PhD is with the VA Center for Integrated Healthcare and the VA Palo Alto Health Care System, Palo Alto, CA. Kyle Possemato, PhD is with the National Center for PTSD and the Syracuse VA Medical Center, Syracuse, NY.
Impact: Findings from this rapid pilot will be of immediate relevance and impact for VA operations partners who include VA Analytics and Business Intelligence, VA Pharmacy Benefits Management and VA MED-SAFE, and VA Office of Connected Care. Further, the results of this pilot study will facilitate submission of a larger proposal examining the individual impact of telemental health treatment for high risk Veterans during COVID-19, with the goal of developing a toolkit enabling VHA to better respond to future natural disasters and other healthcare system disruptions.
VA was an early adopter of telehealth care starting in 2003. As a result of a number of telehealth initiatives, VA conducted over a million telehealth visits in 2018. More than half of these visits provided care to Veterans located in rural areas, and 10% of these were conducted using VA Video Connect (VVC) which allows providers to see Veterans on their mobile devices or personal computers at Veterans' location of choice. In 2018, as part of the MISSION Act, the VA set the "Anywhere to Anywhere" telehealth initiative, seeking to ensure that by 2021, 100% of providers in outpatient Mental Health and Primary Care service lines nationwide would be both capable and experienced with telehealth service delivery into the home.
COVID-19 has potentially left individuals with opioid use disorder at risk of not receiving evidence-based treatment. Access to healthcare for all Veterans has been significantly decreased due to social distancing guidelines which has left some of our most high-risk Veterans - those with opioid use disorder (OUD) vulnerable to poorer health outcomes. Individuals with an OUD are at a significantly high risk of overdose, unintentional death, and a wide range of negative health-related consequences.
Evidence-based medications for OUD exist including buprenorphine. However, due to the potential for misuse, there are additional training requirements for providers to be certified to prescribe these types of medications, resulting in inadequate numbers of providers in some areas, particularly rural ones. Telehealth is a potentially effective method of service delivery to mitigate this access to care issue, but the Ryan Haight Act of 2008 mandates that the first visit with a prescriber of schedule II-IV controlled substances must be done in person. This is particularly challenging for rural Veterans who live in areas that already have a limited number of eligible prescribers and face significant time and travel constraints. Due to the public health emergency caused by COVID-19, the Diversion Control Division of the U.S. Drug Enforcement Agency has temporarily waived (as of March 16, 2020) the in-person requirement for OUD prescriptions issued for a legitimate medical purpose and which are in accordance with state and federal law.
Waiver of the Ryan Haight Act due to COVID-19 creates potential for treatment retention for high-risk Veterans with OUD and presents a unique opportunity to study the impact of the VHA's preexisting telehealth structure for the treatment of OUD, as well as the costs and benefits of this 12-year-old policy. Study investigators are interested in the following questions:
- Will telehealth allow for prescription maintenance, or will prescriptions drop?
- Will relaxing this requirement lead to a dramatic increase in prescriptions for controlled substances?
- What are the barriers and facilitators associated with this policy change for substance use providers?
- How can this information inform VA’s response to future public health crises, particularly for high-risk Veterans?
To meet the goal of designing robust analyses assessing the impact of COVID-19 related changes in policy and service design on access to care and medication management for Veterans with OUD, investigators will conduct qualitative interviews with providers and key local stakeholders in the Substance Treatment and Recovery (STAR) and telehealth clinics.
To conduct preliminary analyses of temporal trends in schedule II-IV narcotic prescription rates for Veterans who would normally fall under the parameters of the Ryan Haight Act, investigators will assess changes in prescribing behavior potentially attributable to the waiver of the Ryan Haight Act. Specific aims are to: a) Examine and compare the rate of prescriptions for buprenorphine, and b) Examine and compare the rate of prescriptions for other schedule II-IV narcotics related to OUD. These study methods allow for the assessment of long-term effects on an outcome attributable to a specific event in time such as the implementation of legislative mandates. Additionally, differences in the effect of the intervention by rurality, age, gender, and race/ethnicity will be measured.
Principal Investigator: Ursula S. Myers, PhD, is with the Health Equity and Rural Outreach Innovation Center (HEROIC), clinical psychologist in the PTSD clinic at the Ralph H. Johnson VA Medical Center, and research Assistant Professor at the Medical University of South Carolina in Charleston, SC.
Impact: Use of telehealth services at the VA Greater Los Angeles Healthcare System has increased substantially during the COVID-19 pandemic outbreak with an expected positive impact on patient care. The demonstration of telemedicine use and evaluation of barriers and facilitators will provide valuable information regarding facility preparedness and Veteran use of telehealth delivery methods. Continuity of care during a prolonged response period may be improved through ascertainment of best practices in delivery of healthcare services using telehealth.
Although telemedicine is becoming common, research on the use of telemedicine during major disasters, within and outside of VA, is new. Being able to successfully transition from face-to-face to virtual care during a major crisis, such as the COVID-19 pandemic, can potentially assist with continuity of tele-appropriate outpatient care. However, there is no readily apparent research regarding the use of telehealth services in response to a large-scale disaster event such as the COVID-19 pandemic.
Investigators at the Veterans Emergency Management Evaluation Center (VEMEC) observed a substantial increase in telehealth use during Hurricanes Sandy (2012), Harvey, Irma, and Maria (2017), when continuity of routine face-to-face care was disrupted. During these hurricanes, telehealth was critical in providing virtual access to primary, specialty, and home-based services. These existing studies have focused on natural disasters with a defined response period. In the case of an outbreak of an infectious disease with uncertain timelines and prolonged response periods, continuity of care and management of chronic disease, for both newly diagnosed COVID-19 as well as non-COVID-19 VA patients, is even more critical. This is especially true for the medically vulnerable such as patients in cardiology and home-based primary care (HBPC) clinics.
To minimize the spread of this novel coronavirus, public health officials throughout the United States are advising all members of the community, including Veterans, to stay home and use physical distancing methods. Given these new public health guidelines, there has been a shift within VA to increase use of telemedicine/telehealth for outpatient care visits, as this approach can potentially decrease exposure to COVID-19 and minimize infection.
This study will examine how telehealth services were, or are, being used at primary, specialty, and home-based primary care outpatient clinics within the VA Greater Los Angeles Healthcare System (VHAGLAHS). Its main objectives are:
- To understand telemedicine capabilities at VHAGLAH's primary, cardiology, and HBPC clinics.
- To understand how telemedicine capabilities at these three clinics were implemented in response to the COVID-19 crisis.
To illustrate the use of telemedicine for each of the three clinics, research will be guided by clinical experts and key respondents based on what was logged into the encounter system during the outbreak. Using the VA Corporate Data Warehouse (CDW), investigators will create a baseline from 12 months prior to the COVID-19 outbreak and compare that with the rate and utilization patterns of tele-visits during, and post-COVID-19. Investigators will also identify characteristics of telemedicine patients at each clinic by examining demographic data, various risk scores, and CDC guided risk factors.
To evaluate barriers and facilitators to achieving rapid implementation of telemedicine delivery, investigators will conduct individual interviews with 30 key stakeholders and informants including healthcare providers, hospital administrators, and staff at the three clinics. Interviews will query respondents about facility preparedness policies and procedures with regards to telehealth, what types of telehealth resources were made available and what types of telehealth services were actually used, how telehealth services were tracked and coded (to assess data validity), types of support received to transition to telemedicine, ability to maintain continuity of care, and facilitators and barriers to implementing the telemedicine response during the outbreak.
Principal Investigator: Claudia Der-Martirosian, PhD, MA, is the Associate Director of the Veterans Emergency Management Evaluation Center (VEMEC) at the VA Greater Los Angeles Healthcare System.