Expanding the Patient-Provider Connection

From Combat & Casualty Care, Q2 2019 Issue

The U.S. Department of Veterans Affairs (VA) is working to advance communication options that bring patients and care providers closer to discuss important health concerns for the greater likelihood of positive outcomes both short and long term.

By Stephanie Deaner, PhD, Telehealth Program Manager, Great Lakes Veterans Integrated Service Network (VISN 12)

VA Video Connect is just one of the latest technologies available through VA’s Office of Connected Care. VA providers love it and veterans don’t know how they survived without it. Through VA Telehealth Services, veterans can access VA care at the time and place that’s most convenient to them. While some veterans may be reluctant to try something new, VA Video Connect is one of the fastest growing areas of virtual care.

“The idea can be a little intimidating to first-time users because it is a different experience,” said Jonathan Hessinger, Psy.D., a clinical psychologist who is part of the Trauma Services Program at Edward Hines, Jr. VA Hospital in suburban Chicago. “But veterans tell us that using video quickly becomes no different than standard face to face care.”

In 2018, more than 28,600 veterans received a video visit into their home or other place of choice. This is a 113% increase from the year before.

The Bigger Picture

VA Telehealth is delivered via several different avenues, including synchronous telehealth, asynchronous telehealth and remote monitoring. Synchronous Telehealth allows real-time interaction, through video conferencing, between patients and their VA care teams — increasingly from the veteran’s home or mobile device.
Asynchronous Telehealth allows clinical staff to capture and share images, sounds or data with other specialists for help in diagnosis and delivery of care. And Remote Patient Monitoring, referred to as Home Telehealth, uses remote monitoring technologies, sometimes combining elements of both Asynchronous and Synchronous Telehealth, to collect clinical information from veterans for case management by their Care Coordinator. VA Video Connect is part of the synchronous telehealth platform, which encompasses more than fifty clinical applications such as Primary Care, Mental Health and some Specialty Care services. VA Video Connect provides veterans access to their health care team from just about anywhere, using encryption to ensure a secure and private session. VA Video Connect works on nearly any device that has a mobile or internet connection and a web camera. This includes desktop computers, laptops, tablets, and smartphones.

“I have seen veterans on each of these platforms, and it truly depends on veteran preference what they use,” said Dr. Hessinger.

As technology has advanced, so have our options. Increasingly VA providers are seeing patients via their smartphones because they’re more convenient and allow veterans to schedule an appointment to take place without having to take time off from work or school. As mobile technology improves, so does the reliability and ease of using secure video on a wide range of mobile devices.

Miriam R. Mourad, Ph.D., is a clinical psychologist at the Capt. James A. Lovell Federal Health Care Center in north Chicago. She uses VA Video Connect in her work with veterans who have Post Traumatic Stress. “In the past, patients had to go to one of our community-based clinics for a video appointment with their provider at the medical center,” said. Dr. Mourad. “Now, if your device has internet access, a camera, and speakers, we are able to conduct the session. About forty to fifty percent of my patients are using their smartphones for their appointments.” It’s simple. The provider makes the appointment. Both provider and patient receive an email with a link to a secure connection. Each clicks the link and enters a virtual video chatroom at the time of the appointment.

Virtual as Preferred Choice

Virtual care eliminates commute time, other transportation issues and the need to take time off work or school. We’ve also heard from Veterans who find it difficult psychologically to walk through a waiting room filled with veterans on their way to an appointment. Virtual appointments give them access to the help they need without those concerns. These are among the many reasons more than 393,000 veterans used synchronous real-time telehealth in fiscal year 2018, up nearly 17% from the year prior.

Beyond convenience, virtual visits have been a gamechanger for U.S. Navy veteran, Mark Doyle who suffers from migraines that make it difficult for him to drive to his weekly appointments at Hines VA Hospital. “Without this technology, I wouldn’t be able to get the care I need,” said Doyle. “Virtual visits make it easy whether I’m feeling well that day or not. I still go to Hines for some appointments but having the option to use video has really made a difference in my life.”

While some veterans may be uncomfortable with the idea of seeing their provider in this manner, most indicate that it has become normalized after just a few sessions. Research also indicates there are no observed differences in mental health treatment outcomes whether a veteran is seen via telehealth or in person. Lenny Koehler served as a Gunner’s Mate in the Navy during the Vietnam War. He credits his therapy with Dr. Hessinger for helping him to work through night terrors, anxiety and anger management issues that he’s been dealing with for almost 50 years – and the two have never met in-person.

“My experiences in Vietnam created problems after I got back,” said Koehler. “Therapy’s been a real blessing. I am seeing good, positive changes because I recognized that nothing’s going to change unless I seek out something that’s going to get this to change. I’m glad that I did.”

VA providers work with their patients to see which services are clinically appropriate. Veterans can then decide whether they want in-person care or telehealth. Many veterans choose to use both, depending upon the specific care and the timing of the appointment.

Increased Capacity, Efficiency, and Productivity

Veterans aren’t alone in saving time by using VA Video Connect. VA providers can see more patients by cutting down on travel. For example, telehealth allows providers from Hines VA to see patients in rural areas across Chicago’s surrounding counties without ever leaving their office. Because many veterans rely on others for transportation to their appointments, they often cancel or simply fail to show up for appointments for reasons outside of their own control. Whether it’s bad weather, a bad day, or chronic pain, virtual appointments eliminate many of the issues that keep veterans from showing up for their appointments.

“I have a patient who suffers from migraines,” said Dr. Hessinger. “On days where he can’t drive, he would have canceled his appointment. Now, I am still able to meet with him by setting up a virtual appointment in place of our scheduled face-to-face meeting. I get to see my patient and he appreciates the flexibility that still allows him to get the care he needs.”

No shows are a real problem with nearly 14% of appointments scheduled in fiscal 2017 resulting in no shows. This creates real issues because that’s time that a provider could have used to see another veteran.

What’s Included

VA currently sees patients using telehealth across the system of care. For instance, trained nurses or health care technicians at community-based outpatient clinics can use telehealth instruments to take pictures for dermatology or optometry that were previously offered only at the medical center. The specialist reviews the images to determine if treatment is necessary, an example of Asynchronous Telehealth.

One of the most popular uses of telehealth at the Lovell Federal Health Care Center in north Chicago is a program for weight loss that involves healthy eating and exercise, a Synchronous Telehealth program. “Many of our patients truly enjoy the MOVE! program,” said Dr. Mourad. “VA Video Connect makes it convenient for them to access all of the features and benefits of this program. Without that convenience, it’s very unlikely they would have the same level of commitment or success.”

Even rehabilitation services such as speech and language pathology are available through VA Video Connect. And in the coming years, all providers will have the training and equipment they need to offer virtual appointments where it makes sense. “As a psychologist, many times people are visiting me due to high levels of stress that are interfering with their daily lives,” said Dr. Hessinger. “The way I see it, if the flexibility of telehealth can decrease the stress of accessing care, then telehealth is actually a vital part of the plan to address their recovery goals.”

There are many reasons why the number of virtual appointments continues to grow, but they may not be the right choice for every veteran or every appointment. Some services still need to take place in person and in a health care setting. These are decisions that are best discussed between veterans and their providers to come up with the best individual plan.

Truly Visionary

Telehealth is at the leading edge of VA’s vision for connected care. The relationship between provider and patient is changing with advances in technology, and the connected patient is a more satisfied patient. VA Video Connect is increasing access to care one veteran at a time, but in the future, it could be groups of veterans in virtual chat rooms helping one another. You can imagine how this could change the lives of veterans who could benefit from group activities but struggle in large rooms or noisy settings.

In addition to VA Video Connect, My HealtheVet www.myhealth.va.gov, VA’s award-winning online personal health record, gives veterans, service members and their dependents access to VA health care information and services anytime, from just about anywhere. With more than 4.6 million users, My HealtheVet, lets veterans use Secure Messaging to communicate about non-emergency matters with their VA care teams; review lab results, clinical notes and other records from their VA electronic health record; schedule and manage medical appointments online; refill VA prescriptions; record their diet, exercise and health history; and more.

The proliferation of apps could be considered the next frontier in healthcare. VA Mobile develops health apps for veterans and VA care teams that increase access, communication and coordination of care. The apps provide veterans with increased opportunities to actively participate in their health care and lead healthier lives. Apps for VA care teams transform the way clinicians and patients interact and ultimately improve the health of Veterans by leveraging the power of mobile technology. VA Mobile apps are available now from the VA App Store: www.mobile.va.gov/appstore.

“When working with veterans with PTSD, I often recommend apps as part of their treatment,” said Dr. Mourad. “There are apps that allow patients to complete homework assignments, log their thoughts, or access relaxation techniques on their own devices and I’ve found that many patients prefer this to paper handouts,” she added.

We’ve only scratched the surface with connected care. Aligning these programs and technologies enables VA to deliver on our promise to provide personalized, proactive, patient-driven health care to our nation’s veterans.