The Department of Veteran’s Affairs operates the nation’s largest health care system, with almost half of the 20 million veterans living in the United States enrolled in their programming. There are nearly 1,700 facilities across the nation that make up the VHA or Veterans Health Administration. Contrary to what some may think, VA Care is not health insurance; it is a direct provider of care.
During the fiscal year 2018, the VHA served over 782,000 veteran patients through more than two million episodes of telehealth care. With so many to serve, the VA is criticized for inefficient treatment, extended waits for appointments, and complicated bureaucracies. To alleviate these and other issues veterans face in accessing healthcare, the VA began using telehealth as early as the 1960s.
A Primer on Telehealth, published by the Department of Veteran Affairs, explains that VA Care doctors initially used closed-circuit television screens to communicate remotely, “…to disseminate best practices and trainings on therapy and psychiatry with the goal of improving …health care outcomes” (Primer on Telehealth). Since then, telehealth and telemedicine have expanded to a multitude of uses, though some barriers to care still exist.
Over the last 15 years, the VA has passed multiple acts to improve veterans’ access to providers through telehealth and telemedicine services. This began in 2006 when the VA secretary was required to increase facilities that could provide telehealth resources. In 2008 the Veterans’ Mental Health and Other Care Improvement act required that the VA begin looking into peer outreach, support, and other mental health services using telehealth.
In 2010, the VA contracted with community mental health centers and other health facilities to expand access. Then in 2014 VA telehealth was made accessible through mobile health centers and medical facilities.
Telehealth became less cost-prohibitive in 2012, when the VA secretary waived some related copays for the first time. Even when veterans do have a copay, “…amounts for telehealth are usually less than for VA in-person care” (Primer). Appointment wait time decreased in 2016 when veteran patients were given the ability to make their own appointments for telehealth services.
Most recently geographic barriers were lifted when the “…Strengthening Integrated Outside Networks Act” was passed in 2018. This act allows veterans access to telehealth services in the United States, U.S. territories, D.C., and the commonwealth of Puerto Rico (Primer).
Why Telehealth and Telemedicine Work for Veterans
Telemedicine and telehealth target specific barriers for veterans, including “…being unable to schedule VA medical appointments in a timely manner, or having to travel long distances to reach health care facilities” (Primer). Veterans living in rural areas, which make up about 33% of the population using VA health care system, benefit the most from remote services. Geographic distance from medical centers and VA health locations, as well as lack of specialized providers, make treatment more difficult.
There are benefits to providers, as well, as telehealth continues to connect specialists over long distances. These connections have come a long way from meetings over CCTV, as Dr. Kevin Galpin, the executive director of telehealth services in the VHA explained. He is quoted in an article for the Federal News Network from Jared Serbu: “We focus a lot on ambulatory care, but the in-patient potential is dramatic…you can use it to build a specialty consultant network so that you have a button on the wall in an intensive care unit and say ‘I need to talk to an intensivist’ or ‘I need the neurologist right now.’ That’s critical, and that’s lifesaving” (Serbu).
Telehealth services allow for more patient independence, faster treatment, and has caused a decrease in hospital admissions across the board. When patients get the care they need faster, their conditions are treated sooner and addressed in early stages more often (Department of Veterans Affairs Fact Sheet). Serbu explains in his article that fast treatment is critical for patients such as stroke victims, who “…often need the right treatments within minutes in order to avoid permanent brain damage” (Serbu).
As of 2016, 97.9% of self-reported veterans enrolled in VA Care owned a smartphone and 78.3% owned a computer. In 2017, 77% of enrollees in a study of 43,600 reported “…using the internet on an occasional or more frequent basis.” Out of that population, most used the internet for telehealth related tasks, including scheduling medical appointments (33%), accessing electronic health records (45%), and searching for information on health (77%) (Primer).
This means that expanding the telehealth and telemedicine resources benefit most veterans as they have access to these resources with little to no barriers. A study of the three “modalities,” or modes of telehealth episodes, reveal positive trends in both number of veterans engaging with telehealth and the number of episodes that transpire.
The Primer breaks down all currently available telehealth services into seven distinct categories of service: consultative and evaluative, disease and illness-specific, gender-specific, preventative, rehabilitative, rural-specific, and wellness (Primer). These seven categories are offered through all three modalities under the umbrella of telehealth.
Home telehealth allows providers to connect with patients from remote locations. Providers assist with daily case management by looking at “…medical data and information” gathered remotely “…from a medical device…that the veteran wears” (Primer). Home telehealth can increase access to specialized care and decrease wait times for treatment. It also speeds up the transfer of information from patient to provider. In 2009, more than 56,000 veterans accessed care using home telehealth, compared to 2018, when more than 136,000 veterans did the same.
Store-and-forward connects providers with each other. This is where the patient sees a provider on site, but their clinical data is sent off to a secondary medical professional. This allows providers to rely on the expertise of specialists who may be geographically unreachable. With digitized records and test results, the patient gets diagnosis and treatment information from experts in the field of their ailment. In 2009, more than 166,000 veterans used the store-and-forward modality, compared to more than 314,000 in 2018. This steady increase shows that “…VA providers are increasingly seeking the expertise of their peers” (Primer).
Finally, clinical video uses an interactive live video to connect the patient and provider. Once again, this increases access to specialized care especially for those in rural areas who do not have as many providers in close proximity. This modality has seen the most dramatic increase in veteran usage, from 58,600 veterans in 2009 to 393,370 in 2018.
This modality is used most often in telemental health to provide remote care in real-time. An article for the Federal News Network quotes Marine Corps and Army Reserve veteran Evelyn Thomas regarding her positive experience with the Clinical Video modality:
Thomas suffers from post-traumatic stress disorder, and the process of driving to, parking and entering the facility created anxiety. ‘It’s a tremendous relief,’ she said. ‘Not only does it help me, but it helps my family. There were times in the old practice when I would have my appointments, I couldn’t remember leaving the VA, driving down the freeway and getting home. By the time I got home, I was still angry and still upset just from that experience. Now when I use telehealth…I just sit for an hour. My mind rests. I’m peaceful. (ellipses from original publication) (Ogrysko).
The department believes that expanding the reach of the VA care system will encourage more veterans to become active participants in their health care. They hope that telehealth will help circumvent some of the stigma related to mental health, and, like Thomas, help veterans feel more comfortable seeking help. VA secretary Robert Wilkie touched on this at the Anywhere to Anywhere Together Summit. “Telehealth, to me, is the first step in finally breaking those last barriers” (Ogrysko).
Advancements: VA Mobile Health, VA Video Connect, and Private Partnerships
VA Mobile Health
VA mobile health is a function of telehealth that allows veterans to access resources via mobile applications on their phone or other internet-connected device. All the apps are free to download and use, though the device needs enough space to store and run the app, and the user needs login credentials from federal or privately-operated accounts. These login credentials are one way of securing the information transmitted through the app. All accounts that provide access are free to veterans. Some of these apps also require audio/visual access through the device on which they are downloaded.
According to the Primer,
VA Mobile has four overall functions: first, it allows veteran patients to connect and schedule medical appointments with VA providers; second, it provides veterans with access to health care information…third, it allows VA providers to provide case management…from afar; and fourth, it allows VA providers to disseminate best practices among themselves… (Primer).
The VA App store has 47 mobile apps for veterans, caregivers, and providers. While most of the apps are for those enrolled in the Veterans Health Administration, some are accessible without enrollment. Many apps relate to health care, though some are for reference or connecting socially with other veterans or active servicemembers (Primer).
The applications available through mobile health provide a wide variety of resources, from accessing disability benefits to ordering prescriptions. One particularly robust app is the PTSD Coach. The VA Mobile health site describes the app’s full capabilities:
This app provides you with education about PTSD, information about professional care, a self-assessment for PTSD, opportunities to find support, and tools that can help you manage the stresses of daily life with PTSD. Tools range from relaxation skills and positive self-talk to anger management and other common self-help strategies. You can customize tools based on your preferences and can integrate your own contacts, photos, and music. This app can be used by people who are in treatment as well as those who are not (PTSD Coach).
VA Video Connect
In 2017 VA Video Connect launched, which marked a massive expansion for telehealth and the VA. The service is a specific mobile app that allows “…veterans access to doctors from more than 50 specialties, from dermatology to dentistry, with a special focus on providing mental health services…” (Wired). To use the app, veterans need a mobile device with a camera, microphone, and speakers as well as internet connectivity and access.
VA Video Connect can only be downloaded from the virtual VA app store. Upon launch in August 2017, VA Video Connect was available through “…300 medical providers at 67 VA hospitals and clinics across the country” (Wired). In its first year, the app recorded over 105,300 telehealth visits. Each session is encrypted for privacy.
The VA has connected with T-Mobile, Walmart, and Philips Healthcare in the last two years to improve access for veterans to telehealth services. According to the Federal News Network, “The announcement came at VA’s first-ever ‘Anywhere to Anywhere Together’ summit in Washington” (Ogrysko). This announcement, from the 2018 summit, explained how the three companies as well as two veteran service organizations would work together “…to address challenges and create more convenient opportunities…” for veterans accessing health care options (Ogrysko).
T-Mobile joined the VA in 2018 to offer access to VA Video Connect “…without incurring additional charges or reducing plan data allotments,” regardless of the veteran’s phone plan (Primer). At the time of the program’s launch, veterans with T-Mobile phone service did not have to go through any additional steps in order to benefit from the program.
As of July, 2019, “…the VA has not yet announced any plans to partner with all wireless service providers to ensure that veteran patients who access the VVC app on their mobile devices will not incur additional charges” (Primer). However, Deborah Scher, executive adviser to the Secretary’s Center for Strategic Partnerships at the VA, says that “More partnerships are in the works.” Eventually, the goal is to connect veterans to VA Video Connect for free regardless of their wireless network (Ogrysko).
Philips and the VA worked together to bring the company’s “virtual medical center” to 10 different veteran service organization (VSO) locations. The American Legion and Veterans of Foreign Wars host “remote examination services,” where “Philips will provide video screens and other remote medical devices, so veterans can go visit their closest VSO post to see a VA medical professional, who, in some cases, may be based hundreds or even thousands of miles away” (Ogrysko). These programs are available to VSO members and non-members alike. A secondary outcome of offering these services in VSO locations is to “…encourage veterans who are not members of VSOs to visit VSO sites…” (Primer). This would provide more veterans with support and resources they may not have previously accessed.
Another partnership the VA hopes will bring medical services to underserved veterans places telehealth resources in donated spaces in Walmart stores. Scher explains the decision behind the relationship: “We mapped out where our veterans are in greatest concentration against VA facilities, and then we put the Walmart map on to of that. Ninety percent of Americans live within 10 miles of a Walmart. Ninety percent of veterans don’t live within 10 miles of a VA medical center” (Ogrysko). Placing these services in Walmart stores, however, may face some of the challenges already standing between veterans in rural area and access to care, “…such as keeping pace with technology for virtual care and the expansion of bandwith” (Primer).
Telehealth and Telemedicine Outcomes
Telemedicine and telehealth are not meant to replace in-person care. As Serbu explains, “The decision to use telehealth is ultimately up to the patient, and whether it works at all is highly dependent on the type of care the patient needs” (Serbu). The first large-scale assessment of telemental health services was conducted from 2006-2010. This assessment looked at over 98,000 veteran patients and compared “…number of inpatient psychiatric admissions and days of psychiatric hospitalization…before and after their enrollment in the telemental health services.” (Godleski) The study found that “…after initiation of such services, patients’ hospitalization utilization decreased by an average of approximately 25%” (Godleski).
Other studies have found similarly positive results. Interventions to Improve Veterans’ Access to Care: A Systematic Review of the Literature examined 19 articles and reported on the overall results. Some significant findings include that “18.5% in the teledermatology condition did not require an in-person dermatology clinic visit…” after using teledermatology services. Further, “Veterans assigned to teledermatology initiated treatment significantly more quickly (73.8 vs 114.3 days).” (Kehle) The Systematic Review also found that, in 2004, 92% of veterans reported telemedicine made it easier to see a specialist and receive targeted care. 81% reported satisfaction with the telemedicine consultation process. Almost all (92.8%) participants were satisfied with their experience using telemedicine for wound care in 2007 (Kehle).
As the Department of Veteran Affairs continues to expand its telehealth and telemedicine services, there remain some barriers between veterans and their care. In fact, some of the goals of telemedicine are at this time “…technically illegal because of state-by-state medical licensing requirements…” (Serbu).
State to State Legislation
As long as a patient is on federal property, they can be treated by any doctor also on federal property, regardless of geographic location. That changes when the patient leaves federal property “…say, at his or her home, or at a private-sector medical clinic. In that case, the VA clinician would have to be licensed in the state where the patient happens to be sitting” (Serbu). This means any veteran who splits their time between two locations, or is on a vacation, may not be able to legally access their physician’s care through telemedicine.
There are also conflicting prescription guidelines for controlled substances across state lines. This can stop a doctor from filling a prescription, or a patient from picking up their medication. While the Ryan Haight Act took several steps toward remedying this problem, there are still multiple conditions that must be met, and it still does not allow for all possible situations (Primer).
Overall, the VA has about 45,000 vacancies, “…most of them in health care operations” (Serbu). Vacancies cause delays in treatment, which are even more dramatic in rural areas, where finding a replacement could take a year or more. When VA providers are entirely unavailable, patients may instead be referred to services in the private sector, which “…might stem from the agency’s shortage of VA providers” (Primer). While the VA offers telehealth training to all its providers, it is not a requirement. The Telehealth Master Preceptor Certificate is offered through the VHA Telehealth Services National Training Center.
Telehealth breaks down many barriers in rural areas, however, these places still may not have high speed internet. “A lot of [veterans in rural areas] don’t have broadband access in their home yet…We think that will change. But either they can’t afford it or it’s not available where they live. One third of our veterans are in rural areas, and it’s spotty” (Ogrysko). In order to combat this issues, “…the VA provided 6,000 tablets with 4G LTE connectivity to low-income and rural veterans with the goal of reducing the veterans’ broadband infrastructure barriers to telehealth in their home” (Primer).
Some veterans may hesitate to use telehealth or telemedicine services due to a fear that their health information is not entirely safe when transmitted online. While there are many measures in place to prevent a security breach, no network is always safe. “According to the Federal Bureau of Investigation, mobile devices and internet connections can be compromised when accessed by an unauthorized party” (Primer). Public networks at places like libraries or community centers are specifically vulnerable.
In his opening remarks to the 2018 Anywhere to Anywhere Together summit, Secretary Wilkie summed up the VA attitude toward telehealth and telemedicine. “Virtual care is the future of medicine. It is our most powerful emerging tool” (Adapting Tech).
Issues of cybersecurity and remaining access barriers are currently being combated, especially in rural and underserved areas. Programs that distribute government funded tablets and high-speed internet/phone line connections, as well as partnerships with private companies, are just a few steps currently being taken and further researched.
These issues are outweighed by the massive benefits that telemedicine and telehealth provide to veterans. “…The use of information and communication technology to deliver telehealth services does not disrupt a veteran patient’s daily life activities, such as working and going to school” (Primer). Legislation had brought down or eliminated copays.
Telemedicine and telehealth care make access to care much easier and provide veterans with more independence. They can receive care from their home, a family member’s home, or a community resource like a library or activity center. Telehealth has possibly contributed to lower hospitalizations and higher treatment rates among the veteran population. Telemental health care is especially beneficial, as PTSD and anxiety, as well as other conditions, can be made worse or triggered by unpredictable conditions.
Overall, the Department of Veteran Affairs has made huge strides in its telehealth resources for patients, providers, and caretakers. However, there is still work to do for better access and more conducive legislation across state lines.
Contributor, VAntage Point. Telehealth: Adapting Tech to Improve VA Health Care. VAntage Point, Department of Veteran Affairs, 20 Dec. 2018, www.blogs.va.gov/VAntage/55049/va-telehealth/
Department of Veterans Affairs Fact Sheet: VA Telehealth Services. VA Telehealth Services, Office of Public Affairs Media Relations, www.va.gov/COMMUNITYCARE/docs/news/VA_Telehealth_Services.pdf
Elliott, Victoria. Department of Veterans Affairs (VA): A Primer on Telehealth. Federation of American Scientists, Congressional Research Service, 26 July 2019, fas.org/sgp/crs/misc/R45834.pdf
Godleski, L., Darkins, A., & Peters, J. (2012). Outcomes of 98,609 U.S. Department of Veterans Affairs Patients Enrolled in Telemental Health Services, 2006–2010. Psychiatric Services, 63(4), 383–385. doi: 10.1176/appi.ps.201100206
Kehle, S. M., Greer, N., Rutks, I., & Wilt, T. (2011). Interventions to Improve Veterans’ Access to Care: A Systematic Review of the Literature. Journal of General Internal Medicine, 26(S2), 689–696. doi: 10.1007/s11606-011-1849-8
Lapowsky, Issie. The VA’s New App Tries to Reach Vets Wherever They Live. Wired, Conde Nast, 3 Aug. 2017, www.wired.com/story/va-video-telemedicine-app/
Ogrysko, Nicole. VA’s Telehealth Program Is Already the Largest in the Nation. It’s about to Get Bigger. Federal News Network, 7 Dec. 2018, federalnewsnetwork.com/veterans-affairs/2018/12/vas-telehealth-program-is-already-the-largest-in-the-nation-its-about-to-get-bigger/
Serbu, Jared. VA Wants to Make Telehealth Part of Its Day-to-Day Business But Says State Licensing Laws Stand in the Way. Federal News Network, 8 May 2017, federalnewsnetwork.com/veterans-affairs/2017/05/va-wants-to-make-telehealth-part-of-its-day-to-day-business-but-says-state-licensing-laws-stand-in-the-way/
VA Web Mobile Solutions. PTSD Coach. VA Mobile, 2019, mobile.va.gov/app/ptsd-coach