Although telemedicine has become 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, to our knowledge, there is no research regarding the use of telehealth services in response to a large-scale disaster event such as the COVID-19 pandemic. Claudia Der-Martirosian and colleagues 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, especially for the medically vulnerable, such as patients in cardiology and home-based primary care (HBPC) clinics. However, it is unknown how telehealth is being implemented at VA during the COVID-19 outbreak. To minimize the spread of this novel coronavirus, public health officials throughout the United States are advising all members of the community, including US Military Veterans, to stay home and use social distancing. 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.
Research on emergency preparedness for infectious diseases has predominantly focused on hospital emergency room surge capacity, not paying close attention to the critical role primary or specialty care clinics play in providing continuity of care to medically vulnerable patients. This proposed study will examine how telehealth services were, or are being, used at three types of outpatient clinics (primary, specialty, and home-based primary care) within one VA site, since VA telehealth programs vary both by clinic and by site. Primary care is a gateway to all other care in the VA, and Veterans rely on it for the management of both acute and chronic conditions; cardiology manages a highly acute and medically vulnerable population; and HBPC has both a highly vulnerable population and a unique framework for supporting patients in their homes. A more detailed examination of what types of resources, protocols, and procedures were, or are being, used at each of these clinics will provide preliminary data to create a larger, multi-site, multi-clinic study to understand the successes and failures of telehealth during this first wave of COVID-19 and, in turn, to improve quality and access to care. This will better prepare VA for future waves, if needed, and other pandemic situations.
The VA Greater Los Angeles Healthcare System (VAGLAHS) began implementing mitigation and response efforts to the COVID-19 outbreak in the first week of March. Many of the project investigators and staff are located at VAGLAHS. Therefore, this preparatory to research proposed study will be conducted at this site. The main objectives of the proposed study are: 1) To understand telemedicine capabilities at VHAGLA's primary, cardiology, and HBPC clinics. 2) To understand how telemedicine capabilities at these three clinics were implemented in response to the COVID-19 crisis.
This study has two aims:
Aim #1. To illustrate the use of telemedicine for each of the three clinics. a) We will be guided by clinical experts and key respondents as to what was logged into the encounter system during the outbreak, and using the VA administrative and clinical encounter data from the VA Corporate Data Warehouse (CDW), we will examine the rate and utilization patterns of tele-visits (telephone, VA Video Connect, private services such as Skype that have recently been approved, etc.) 12-months before the COVID-19 outbreak (to create a baseline) and compare to during and post-COVID-19 tele-visit activities at each clinic. b) We will also identify the patient characteristics of telemedicine users at each clinic by examining demographic data, various risk scores, and CDC guided risk factors (see Data Sources section below).
Aim #2. To evaluate barriers and facilitators to achieving rapid implementation of telemedicine delivery. We will conduct individual interviews with 30 (total) 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.
To address the two study aims, we will use a sequential mixed methods approach, where the quantitative part of the study will be conducted first, followed by the qualitative, one-on-one interviews. For the quantitative portion, we will be querying data from the VA CDW, with a focus on outpatient visits to identify telehealth-related encounters. Based on input from the project clinical co-Investigators, guidance from the telemedicine outpatient protocols, and previously published work, we will identify telehealth visits by filtering the patient encounter data on clinic stop codes, location names, and CHAR4. Clinic stop codes are three-digit numeric identifiers that correspond to a stop or service that a patient received in conjunction with a clinic visit (e.g. 338, Telephone Primary Care). Location name identifies the encounter location, such as "WLA-Telephone Cardiology". CHAR4 is a four-character national code used in the VHA data which identifies visits to a particular clinic or type of clinic, beyond the clinic stop codes. Triangulating information from these three data fields will allow us to identify telehealth-related encounters in CDW. With the information from each of these fields, we can further categorize telehealth visits by primary care, cardiology, and home-based primary care. In order to identify patient characteristics of telehealth users, we will use various approaches readily accessible in CDW, including demographic data, Care Assessment Need (CAN) scores, the Nosos risk scores, diagnostic codes and services, number of outpatient visits, rate of ER use and hospitalization. We will also apply the guidelines set by the Centers for Disease Control and Prevention (CDC) to identify vulnerable patients during this outbreak, such as age, heart and lung conditions, obesity, diabetes, and immunocompromised conditions.
For the qualitative part, we will conduct one-on-one semi-structured interviews with 30 key stakeholders and informants. In order to understand the breadth of the implementation across the entire clinic structure we will include 8 to 10 respondents from each clinic, including providers, administrators, and other staff. The respondents will be queried on: 1) facility and clinic preparedness policies and procedures on the transition to telemedicine, 2) what types of support were received when transitioning to telemedicine, 3) how telehealth services were tracked and coded, 4) whether the healthcare providers were able to maintain continuity of care with their patients, and 5) what types of facilitators and barriers were experienced during the implementation of the telemedicine response.
None at this time.
TRL - Applied/Translational
Care Management Tools, Technology Development
None at this time.