During the COVID-19 pandemic, many Americans are experiencing telehealth for the first time, as health care systems offer opportunities and encourage patients to connect remotely with their providers. This allows them to safely stay at home, limiting their exposure to the coronavirus while continuing to access care.

The same is true for the nation’s veterans, who are in vast numbers increasingly participating in telehealth services during the pandemic.

While many Americans were forced to use telehealth services for the first time due to the COVID-19 pandemic, many VA patients had been taking advantage of telehealth services for years.

But in fact, for many veterans, telehealth is nothing new. Recognized as a world leader in the development of telehealth services, the Department of Veterans Affairs (VA) has led the way in telehealth innovation for more than 50 years.

In 1968, closed-circuit television connected specialists at the University of Nebraska Medical Center with veterans at VA hospitals in Grand Island, Lincoln, and Omaha, Nebraska. In the five decades since, the VA has provided an increasing array of telehealth services, enhancing accessibility and quality of care for veterans anywhere in the country.

That expertise has positioned the VA to quickly increase its capacity and ability to provide these services during the pandemic.

 

CATEGORIES OF TELEHEALTH SERVICES

Current VA telehealth falls into three overlapping categories: remote patient monitoring/home telehealth; asynchronous telehealth; and synchronous telehealth.

According to Leonie Heyworth, MD, MPH, the VA national synchronous telehealth lead and primary care provider at San Diego VA Healthcare System, “In 2003, the home telehealth program, which was the original telehealth product, provided care for our more fragile homebased veterans in remote monitoring of vital signs, for example, and transmitting them under the supervision and care of a nurse.”

Remote patient monitoring continues functioning as an important telehealth category, utilizing advanced technology to collect and send health data for care management.

A second category, asynchronous telehealth, uses technologies to acquire and store clinical information – data, images, or sounds – that is later evaluated by a VA provider at another location.

“An example of this would be teledermatology or tele-eye, where images are taken by a technician and reviewed by a provider asynchronously; that is, the images may be taken at a different time from the time that the images are reviewed by the provider,” Heyworth explained. “It may be that whoever is reviewing those images doesn’t actually meet with that particular veteran, and it’s another provider who’s facilitating that care. That allows us to provide dermatology care or ophthalmology care in areas where they may not exist, by taking the same information that you would get in person but having that interpreted by an expert somewhere else.”

The third category, synchronous telehealth, uses real-time, interactive video conferencing to assess, treat, and provide care to veterans in a separate VA clinical location, and increasingly at home or another non-VA location.

“We evolved over the years, particularly in the 2011-2013 window, to doing more and more clinic-based telehealth, putting clinic-based telehealth staff in our clinics across the country to facilitate this care, and really building on that concept of providing the care where it’s needed,” Heyworth said. This has been implemented in more than 900 VA locations, allowing veterans to connect with VA specialist providers nationwide from local community clinics.

Each of the telehealth categories also weaves in mobile applications to deliver care, Heyworth said. “For example, asynchronous telehealth is coming out with a mobile application to allow veterans to take high-resolution images and short video clips to transmit to their providers from home. And we have a text-based application that we call Annie,” she said, which delivers automated text messages like medication reminders or healthrelated notifications and can be helpful used in conjunction with telehealth modalities.

 

EXPANDING TELEHEALTH CARE

While the concept of delivering telehealth care to veterans in the clinic space had matured, Heyworth said, efforts turned to providing that care in veterans’ homes, or other non-VA locations of their choice.

In 2018, a new federal rule allowed VA providers to deliver telehealth care to veterans regardless of where in the United States the veteran or the provider are located, including across state lines or outside a VA facility. “That was really a pivotal moment,” said Heyworth. “It really opened things up for us at VA for telehealth, because essentially with that [rule], which we call ‘Anywhere to Anywhere,’ we can have a VA provider in any state, in any town anywhere, deliver care to where it’s needed most, by telehealth.

With the authority to deliver care essentially anywhere, Heyworth continued, “That has really expanded over the past couple of years, but particularly over the past couple of months due to the pandemic, because of many veterans preferring to stay home for their care, concerned about COVID exposure, and [for] other veterans, because care is potentially easier for them to access at home, particularly those who live a distance from a VA facility.”

Veterans access telehealth in their home or other non-VA location by utilizing the VA Video Connect application, allowing live video on any computer, tablet, or mobile device with an internet connection.

“The goals and objectives are really to provide patient-centered care and to allow veterans to access care in a way of their choosing,” said Heyworth. “Uniquely, VA enrolls veterans in locations where we have no facilities, so for those veterans, it may mean that they have to travel a certain distance to get to a VA facility in order to receive care. The concept of being able to deliver care remotely, and particularly into the home, by the use of video telehealth, through the use of mobile applications to monitor conditions in veterans’ homes, not only makes sense because of how VA delivers care geographically and how veterans are enrolled, but also speaks to the assets in this new digital era and our desire as a VA to make sure that our veterans are getting the most innovative services and products.”

Heyworth added, “The exciting thing about being at VA and doing telehealth is that we have a whole geographic enterprise of providers from which we can draw to provide VA services,” including to veterans who live in rural areas far from a VA facility or academic center.

“We really are positioned uniquely to be able to [deliver that care], and I think we will see this concept of sharing expertise grow significantly across all our categories of care.”

 

TELEHEALTH IN EMERGENCIES

Along with standard care, emergency and urgent care situations can also be managed with the VA Video Connect platform. Heyworth explained that if, during a video visit with a patient, the provider determines there is a medical or psychiatric emergency such as a heart attack or suicide threat, the built-in E911 feature allows the provider to contact the veteran’s local emergency service, identifying the patient’s location and the nature of the emergency.

“VA Video Connect is a VA-built product, and we identified early on the E911 feature being a key need as far as the effective management of emergencies,” Heyworth said. “So functionally, in a video visit, the provider has tools to manage those emergencies.”

For urgent-care situations, Heyworth said, “There is a growing movement across VA to be able to offer same-day services by telephone and video, and there are multiple sites that have established this and attached these services to their call centers.” With providers attached to the call centers, she continued, “We have the ability, in cases and conditions that need to be seen right away and can be done virtually, to offer veterans that option.”

 

COVID-19 RESPONSE

Heyworth attributes the VA’s ability to deliver the increased volume of telehealth services since the pandemic began to its early and ongoing efforts dating back to the original programs, and having staff across facilities familiar with these services.

“We had the benefit of having [telehealth] rolled out, having a system to schedule it, and having providers trained and educated on it, and an initiative underway since 2018 with the goal of having every ambulatory provider at VA capable of doing a VA Video Connect visit,” Heyworth said. With the “Anywhere to Anywhere” rule granting the ability to provide telehealth services to veterans in their homes no matter where they live, she added, “We were positioned legally with the authority, and operationally with the tools and the training of our frontline staff, to be able to pivot quickly.”

Heyworth added that another component in delivering the exponential growth was the ability of their IT partners at the VA to rapidly expand the capacity of VA Video Connect and accommodate the demand surge in a matter of weeks.

For example, the volume of video telehealth to home visits exceeded 167,000 for the week of Aug. 16 to Aug. 22, 2020. “That really speaks to the growth that we’ve seen over the course of the pandemic, because that is almost a 1,400 percent increase in the weekly volume of VA Video Connect visits to home from the end of February 2020,” Heyworth said. “So, VA really leveraged virtual care with the onset of the pandemic and continues to do so. … The growth is going strong.”

Another factor in the growth, Heyworth said, has been recognition of “the need for veterans to have the equipment and the connectivity to participate. And to do that during the COVID months, we distributed over 7,000 tablets to veterans without their own devices and without connectivity to enable them to connect with us.”

While tablet distribution expanded since the onset of the pandemic, more than 50,000 tablets have been distributed to veterans since the program’s inception in 2016. Heyworth said that the Coronavirus Aid, Relief, and Economic Security Act (CARES Act) also provided funding for veterans enrolled in the VA supportive housing program to receive smartphones to further increase connectivity.

Since the pandemic began, Heyworth said, VA providers are increasingly enthusiastic about the capabilities of doing a remote physical examination using peripheral Bluetooth-connected devices such as a digital stethoscope, blood pressure cuff, thermometer, or pulse oximeter. “They enable a VA provider to do a more comprehensive exam, with the tools that they’re familiar with using in person in the clinic space,” said Heyworth. “The range of options that we have – from a simple video telehealth setup to using our digital stethoscope and actually seeing the rhythm strip like you would see on an EKG across the video screen – really speaks to a breadth of applications for the use of video, and something that has been surprising in a really great way during this pandemic, as people try and push the limits of understanding how they can do more and more video telehealth.”

With the huge increased use of telehealth since the pandemic began, the VA is offering support to providers. Heyworth said, “Our goal of getting every provider to do one visit first has been a good strategy in making sure that people are comfortable and that we’re not saying, ‘Here’s a certain minimum volume we want you to achieve.’ We’re saying, ‘Let’s get you comfortable just doing one. Let’s make sure that you have the training.’ We encourage people to do a test call with the telehealth team or with their colleagues to make sure they have what they need in order to do the visit. We have a national telehealth technology help desk so people can call if they have any difficulties with the technology or if they need any help with troubleshooting.”

That support is also available to veterans, Heyworth continued. “We are beginning a process where we’ve asked facilities to establish a test call program for veterans, understanding that some veterans may need more support than others, particularly veterans who may be less familiar with the technology, or don’t use it as much as other veterans, to make sure that they feel confident ahead of their first visit in the use of the technology.”

ACCESS AND INCLUSION

Looking ahead regarding VA telehealth, Heyworth said, “I think the future is that of inclusion. We want to make sure that every veteran has this opportunity.

“To that end, we’ve done a number of things,” she continued. “We have our ‘zero-rating’ option for those veterans who have internet connectivity, but are concerned about data use and cost of the video visit. We’ve worked with select mobile carriers on a so-called ‘zero rate,’ to identify the VA Video Connect domain name and not charge veterans against their personal data for the use of VA Video Connect as a health service.”

And for those veterans who don’t have connectivity in their home, Heyworth said, an initiative called ATLAS, Accessing Telehealth through Local Area Stations, places telehealth access points in select Walmart and veterans service organization locations, further increasing convenient access to care. There are currently seven pilot sites across the country.

“If we can’t bring care services to your home, let’s at least bring them to ‘Main Street,’ so that care is more accessible to every veteran, and every veteran who is enrolled in VA services really has the opportunity to fully use them,” said Heyworth.

“Our hope is that veterans will give [telehealth] a try and really let us know what they think about it. Our goal is to make this veteran-centric,” concluded Heyworth, “and we’re very committed to making sure we understand their experiences and are positioned to respond meaningfully to them.”

 

VA TELEMENTAL HEALTH

Telehealth encompasses a wide spectrum of health care, including mental health.

Telemental Health in the Department of Veterans Affairs (VA)  increases access to care and provides a broad scope of mental health services for veterans that includes every diagnosis, every type of therapy, and multiple locations, according to Linda Godleski, MD, Veterans Health Administration lead for telemental health, and director, VA National Telemental Health Center, and professor, Department of Psychiatry, Yale School of Medicine.

“In terms of being used for every diagnosis, it’s at the clinical discretion of the mental health clinician whether telemedicine is the optimal modality for any given patient, but there are no absolute exclusion criteria,” Godleski said. “We have patients with PTSD [post-traumatic stress disorder], depression, schizophrenia, and substance use disorder who are all being treated by telemental health.”

“Where [telemental health] is really useful is in preventing hospitalizations,” said Godleski. “It can be used to assess and address patients who are in an acute crisis, even at times suicidal, so that whereas in the past, the veteran would have to physically go to the emergency room to be evaluated to see whether or not they needed to be hospitalized, now they can go to the community-based outpatient clinic or even be seen in their home.”

In 2010, the VA launched the National Telemental Health Center (NTMHC). “The purpose was to deliver the highest level of care to veterans no matter where they were located,” explained Godleski. This nationwide model, composed of clinical experts in diagnoses such as bipolar disorder, substance use disorder, and psychosis, and who are located throughout the country, provides teleconsultations to veterans anywhere. “[Veterans] don’t have to live right outside of a medical center or in a big city to be able to access the same level of expertise,” she said.

Against a backdrop of more than 6 million VA telemental health visits since the early 2000s, according to Godleski, the volume has “exponentially grown,” with a huge increase since the onset of the COVID-19 pandemic. Cumulatively, FY 20 year-to-date figures as of Sept. 24 show that the VA has provided telemental health services to nearly 534,000 veterans during almost 2.3 million visits, with more than 428,500 of those veterans receiving over 1,983,500 total telemental health sessions directly into their homes or other place of choice. Telemental health visits into the home comprised 86 percent of all telemental health visits, compared to 26 percent in FY 19.

When the pandemic began and clinics were shut down, Godleski said they needed to quickly get mental health services to their patients, including very seriously mentally ill patients.
“In the COVID world, it was even more important to reach out to provide support and decrease isolation, decrease anxiety,” she said. “What we learned from COVID is that telehealth has been an enormously useful tool to deliver mental health services to patients, even with the most severe illnesses, under the most unpredictable and stressful circumstances.

“VA telemental health care is really a game-changer in the delivery of mental health services,” Godleski said. “With telemental health, we can bring the necessary services right to the individual without disrupting their life, without disrupting their day, and exactly when they need it.”

 

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