The Department of Veterans Affairs (VA) has long been a national and international leader in the implementation of health technologies for clinical purposes—through its national electronic system, in the area of telemedicine, and, in recent years, with the introduction of a series of patient-centered online tools, such as MyHealtheVet (an online portal through which veterans can access their medical information and message providers) and Blue Button (a feature of MyHealtheVet which allows veterans to save, download, and print their health information), and also increasing numbers of mobile applications (apps). With this background, the VA is in an excellent position to substantially expand and scale its use of health technologies and thereby gain added value from its experience in health technology and the skills of a large number of their staff, which match well the expertise in information technology (IT) of the younger generation of veterans now being served. The challenge for the VA is to take its current experience in health technologies and routinely and widely integrate a large range of disparate health technologies into clinical care processes throughout the VA health care system, while also connecting with providers outside of the VA to meet the needs of the current and future population of veterans. This chapter describes the current state of health technology at the VA as well as some of the barriers throughout the system that may inhibit the wider use of health technology among veterans and providers. It also summarizes committee site visits and survey findings related to health technology.
An electronic health record (EHR) is a digital version of a patient’s medical history. It is maintained by health providers and should include all clinical data related to a patient. This includes demographics, clinical notes, medication and clinical history, vital signs, labs, and any other information related to a patient’s care. At the VA, EHRs allow different providers within the system easy access to a veteran’s health data and streamline the sharing of clinical information across the system (CMS, 2017).
The VA pioneered EHR technology with the development of its VistA system, which originated in the 1970s but was implemented system-wide between February 1997 and December 1999. By 2009,
nearly half of hospitals in the United States with system-wide IT systems used VistA or a VistA derivative (Garber et al., 2014). The VistA EHR allowed for computerized order entry, electronic prescribing, bar code medication administration, and embedded clinical guidelines, and it also allowed for the easy sharing of records between providers within the system. In surveys from 2011 and 2012, VistA outscored a large majority of health IT competitors, including those offered by industry leaders Epic and McKesson (Garber et al., 2014).
In a recent assessment of VA health IT, however, MITRE reported that in the past decade the VA has diverted resources from the EHR to other IT development projects, hampering and delaying improvements to the EHR system and putting the VA EHR at risk of becoming obsolete (MITRE Corporation, 2015). At present, the VA EHR lacks many features currently found in commercially available EHR products (Commission on Care, 2016). The MITRE assessment revealed that while most of clinicians are reasonably satisfied with the current VA EHR, many want the same level of features and functionality that is emerging in EHRs in the commercial marketplace (such as greater integration and mobility) (MITRE Corporation, 2015).
Improving the VA’s EHR will require a working knowledge of the VistA system architecture, a platform that is not widely taught outside of the VA and that requires several years of training for developers to learn (MITRE Corporation, 2015). Furthermore, there are 130 modified instances of VistA across the VA system, making it more difficult to develop and improve the EHR system-wide. There is no environment within the VA to test any improvements across the 130 instances of VistA currently in use (MITRE Corporation, 2015).
The interoperability of the VA’s EHR, both with the Department of Defense (DoD) EHR system (needed when service members transition to veteran status) and with outside medical systems has been a long-standing issue for the VA, especially as veterans have been using non-VA services more frequently in recent years. To address interoperability issues and barriers to improving the EHR, in 2014 the VA established the VistA Evolution program. The goal of the program is to upgrade the technical infrastructure while reducing system complexity and to provide interoperability with DoD and other health care partners. In its assessment of VA health IT, MITRE determined that the VistA Evolution program is “not adequately staffed or organized to successfully manage the development and integration of a such a large complex software program, which increases the risk of schedule delays or failed delivery of clinical IT capabilities” (MITRE Corporation, 2015, p. 34). That report recommends that the VA complete a comprehensive cost–benefit analysis to determine if it makes sense to continue using and trying to modernize the current VistA EHR versus turning to a commercially available or open-source EHR. Nevertheless, improvements to the EHR, including interoperability with DoD and other health sector systems, are scheduled to be incrementally rolled out until they are completed in fiscal year (FY) 2018 (GAO, 2016).
In light of this and in acknowledgment of the many years and dollars spent trying to achieve interoperability, in 2017 the VA announced that it will abandon plans to improve the VistA EHR and adopt MHS GENESIS (based on the Cerner Millennium platform), the same EHR system in place at the DoD. While it will be an enormous undertaking to transfer all VA patient data to a new system, ultimately all patient data from both departments will reside in one common system. This will allow for a simple transition between departments without the added burden of manual and electronic reconciliation of data between the two systems. The announcement acknowledged that adopting the DoD EHR does not solve the problem of oper-ability with other systems outside the VA. However, the announcement stressed the importance of working toward interoperability with other platforms that are in use in the non-VA or DoD sectors (VA, 2017b).
Telemedicine is the use of electronic information and communication technologies to provide health care (IOM, 1996). Historically, telemedicine has included a variety of modalities to deliver care such
as telephone, email, Internet, fax, still imaging, and videoconferencing (Antonacci et al., 2008). A more recent and broader interpretation defines virtual health care as the use of communication and information technologies to bridge geographic distance and to facilitate the interactions and relationships necessary for providing accessible, coordinated, and high-quality care (Kizer, 2011). As such, it really includes all information technologies, even mobile apps, designed to be used at the patient–provider interface.
Telemedicine provides a mechanism by which many access barriers might be overcome, particularly with regard to wait times, the cost of care, travel distances to treatment facilities, and stigma (Bashshur et al., 2016; Pietrzak et al., 2009; Wong et al., 2007). The VA has been in the forefront of IT, and telemedicine has been a focus for recent VA funding—the FY 2016 budget requested $1.224 billion for telehealth, an increase of 11.5 percent from 2015 (Clancy, 2015). The VA has employed initiatives to expand services into a national tele-mental health clinical and technical infrastructure. In FY 2014, the VA provided more than 2 million consults to 717,000 veterans, and services grew 18 percent from the previous year (Clancy, 2015). In FY 2015, the VA reported using telemedicine across multiple specialties with 677,000 veterans during that year, or 12 percent of the total VA patient population of 5.6 million veterans (VA, 2016). Of all the veterans served by telehealth in FY 2014, 45 percent resided in rural locations with otherwise limited access to VA care. Clinical tele-mental health is one of the most commonly used VA telemedicine services. In FY 2016, 133,500 unique veterans used tele-mental health services for a total of 427,000 encounters, an increase of 16 percent from FY 2015 (VA, 2017a).
In the VA, tele-mental health is currently used to treat nearly every Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition diagnosis including posttraumatic stress disorder (PTSD), substance use disorders, depression, and anxiety disorders across nearly every treatment modality, including individual therapies, group therapies, medication management, cognitive behavioral therapy, psychological screening, and more (Godleski, 2014). However, PTSD, depression, and anxiety are more likely to be treated via tele-mental health than substance use and psychotic disorders. This difference in treatment by diagnosis is likely due to the fact that the evidence base for PTSD and depression treated via tele-mental health is stronger than for substance use and psychosis. Furthermore, substance use disorder is frequently treated in a group setting, and group tele-mental health is not widely practiced in the VA despite evidence suggesting its efficacy (Grubbs et al., 2015a). Clinicians from the VA, including psychiatrists, psychologists, social workers, advanced practice psychiatric nurses, and registered nurses, deliver telemental health to and from a variety of venues including VA medical centers (VAMCs), community-based outpatient centers (CBOCs), non-VA health care facilities, student health centers, homeless shelters, and private residences. A majority of VA-delivered tele-mental health, however, is general or specialty mental health care delivered from a VAMC to a CBOC primarily via videoconference.
In 2008 the VA created a comprehensive National Telemental Health Training Program to teach clinicians best practices in delivering tele-mental health (Godleski, 2012). The training curriculum covers a number of domains related to administering tele-mental health. These include (1) general information about tele-mental health (history, seminal studies); (2) clinical conduct, such as maximizing eye contact and information gathering about the patient’s site/location; (3) safety and legal issues; (4) initial competency, with clinicians assessed in a 1-hour simulated videoconference; (5) clinical scenarios, with clinicians receiving instruction on how to manage emergency situations via videoconference; and (6) ongoing competency, with clinicians receiving continued education to stay up to date about the expanding evidence base and best practices. Furthermore, the training program draws from a number of modalities for educational programming and also provides individualized training for clinicians new to tele-mental health and advanced training for providers interested in furthering their skills. The program monitors its effectiveness with post-training questionnaires (Godleski, 2012).
The VA National Telemental Health Center, based in the VA Connecticut Healthcare System, was created to unify the use of tele-mental health within the VA. The center works to ensure that universal
access to tele-mental health is available nationwide, and it strives to increase access to specialty care via telehealth. Furthermore, it convenes panels of experts to help further the field and acts as a resource bank for best practices (Godleski, 2014). For PTSD treatment, the VA National Telemental Health Center is promoting the delivery of prolonged exposure therapy and cognitive processing therapy via tele-mental health, particularly to veterans in rural areas where these therapies may not be otherwise available (IOM, 2014). Additionally, the VA has begun to establish 10 tele-mental health clinic resource hubs. While as of June 2017 not all of them were fully operational, since June 2016 they have contributed to nearly 55,000 tele-mental health visits (VA, 2017a).
It may be less expensive to provide care via telehealth than via in-person care. In a cost comparison of care delivered via a care coordination home telehealth (CCHT) model versus usual (in-person) care, Darkins et al. (2014) found that costs were significantly lower for veterans receiving CCHT. The in-person cohort’s cost of care increased by 48 percent from FY 2009 to FY 2012, whereas the cost of care for veterans receiving CCHT decreased by 4 percent over the same time period. Admissions also increased for the in-person care group and decreased for the intervention group (which would at least partly explain the expenditure patterns for both groups). In a 2016 review, Bashshur et al. (2016) also found that telemedicine interventions were more cost effective than in-person care; however, only five studies were reviewed, only one of which was veteran specific.
Some evidence suggests that patients may be more receptive to using health technologies than providers. A recent review of telepsychiatry outcomes (Hubley et al., 2016) revealed that a majority of studies on the topic reported high patient satisfaction with telepsychiatry services (the review was not veteran specific). Of the 31 studies examined in that review, 23 showed that patients rated their telepsychiatry experiences as “good” or “excellent,” while the others reported mixed reactions among patients. On the other hand, provider satisfaction was more mixed. Rural primary care providers were more satisfied than their suburban counterparts. Providers also perceived patients to be less satisfied with telepsychiatry than the patients actually felt. One study in the review found that providers resisted using telepsychiatry, and in another study providers reported perceiving technological challenges that they felt would hinder doctor–patient interactions (Hubley et al., 2016). Other studies documented providers expressing concerns about difficulty incorporating telepsychiatry into their practices and concern about therapeutic rapport. These were not, however, VA providers expressing those concerns.
In its assessment of the VA’s IT, the MITRE Corporation (2015) found that while the VA was an early adopter of telehealth and generally provides good oversight and support for the technology, system-wide problems limit telehealth’s full potential to provide services to veterans. Problems with the VA’s existing telehealth system include the following:
- The Office of Information and Technology (the central office that manages the VA’s system-wide IT infrastructure) is slow to respond to the technical needs of the Veterans Integrated Service Networks (VISNs). MITRE reported that the responses for technical support and resolution requests often take very long or go unanswered due in part to confusion regarding which offices are responsible for various equipment. Furthermore, service ticket data are not tracked (MITRE Corporation, 2015).
- Limited technical support is available to veteran users of in-home telehealth. Technicians test the telehealth connection with veterans in advance of an appointment, but recruiting and retaining technicians has been challenging for the VA, which has limited the amount of time that technicians can spend helping veterans troubleshoot the installation. If veterans are unable to install and use the telehealth software, they cannot participate in their telehealth appointment
and must make another in-person appointment or go to a VA location that provides telehealth services (MITRE Corporation, 2015).
- It is difficult for clinicians to provide telehealth to veterans in other VISNs. While the VA is moving to address these issues, scheduling, patient records, credentialing, and provider privileges across VISN lines are restricted (MITRE Corporation, 2015).
Bashshur et al. (2016) completed a review of the empirical evidence concerning the feasibility, acceptance, cost, quality of care, and health outcomes of telemedicine interventions in mental health. The review included telemedicine studies of children, adults, the elderly, veterans, urban groups, rural groups, and different ethnic groups both within the United States and abroad. While the populations studied go far beyond the scope of this report, nearly all of the studies that were reviewed demonstrated the feasibility of telemedicine interventions using a variety of modalities to address a variety of mental health conditions across populations. The review found that telemedicine can improve access to mental health care and can effectively deliver psychotherapies and improve efficiency, the quality of care, and cost effectiveness.
Those findings essentially confirmed those of an earlier review (Hilty et al., 2013) that evaluated the effectiveness of tele-mental health compared to in-person care. The authors found that, generally speaking, tele-mental health services are effective for diagnosis and assessment across many populations, for many disorders, and in many settings, including when integrated in primary care, and that they are comparable to in-person mental health care. The authors did, however, call for more randomized trials to enhance the evidence base, particularly for disorders that have not been thoroughly evaluated (for example, anxiety, substance use, and psychotic disorders).
The review evaluated three PTSD trials with a veteran cohort (Frueh et al., 2007; Morland et al., 2010, 2011). Frueh et al. (2007) found equal outcomes (clinical and process) and satisfaction at 3-month follow-up, but less comfort among the tele-mental health group in talking to a therapist and worse adherence than the in-person group. Morland et al. (2011) evaluated group cognitive processing therapy delivered to veterans via telehealth and found no significant differences in clinical or process outcome variables. Morland et al. (2010) showed that rural veterans with PTSD receiving telehealth treatment for anger management showed reductions in PTSD-related anger that were similar to those receiving in-person treatment. Telemedicine may be effective for veterans with PTSD because the nature of the illness—with patients being commonly afraid, anxious, and avoidant—makes it a disorder that would seem to be suited to treatment with telemedicine and a range of other patient-focused health technologies. Such technologies allow patients to be treated in their homes or communities, rather than needing to travel to places such as hospitals and clinics in urban areas that may actually exacerbate their symptoms. For those reasons, the future standard of multimodal clinical care for patients with PTSD may include telemedicine and mobile technologies integrated into primary care systems (Chan et al., 2015; Yellowlees et al., 2015).
While the Hilty et al. (2013) review was not specific to veteran populations (although it did include some veteran studies), Godleski et al. (2012b) evaluated outcomes among a large sample of tele-mental health users in the VA between 2006 and 2010. The authors assessed the clinical outcomes (inpatient days and hospital admissions) for 98,609 mental health patients 6 months before and after enrollment in tele-mental health services. Overall, the analysis revealed that after enrolling in tele-mental health services, hospitalizations and the number of admissions and the number of days of hospitalization all decreased by about 25 percent. The decrease was similar for male and female veterans. The authors
surmised that the decrease may have been due to increased access to services, including evidence-based therapies, medication management, and patient education, delivered via tele-mental health. Furthermore, the authors suggested, in some instances tele-mental health may give providers an immediate opportunity to intervene with patients to avert and prevent an escalating crisis (and possibly avoid hospitalization). While there was no specific control group in the study, the authors noted that in contrast to the study participants, VA mental health users overall had a slight increase in hospitalization during the study period.
Fortney et al. (2015) compared a telemedicine-based collaborative model for PTSD to treatment as usual in a randomized clinical trial in 11 VA clinics and showed that patients in the telemedicine group had better overall engagement in their therapies. The study included 265 treatment-resistant rural-dwelling veterans. The collaborative model, Telemedicine Outreach for PTSD (TOP), was designed to support on-site CBOC providers managing patients with PTSD. The on-site providers included primary care physicians, psychiatric advance-practice nurses, social workers, and off-site telepsychiatrists. The off-site collaborative PTSD specialist teams included a nurse care manager, clinical pharmacist, telepsychologist, and telepsychiatrist. While both treatment groups improved, veterans randomized to the TOP intervention experienced significantly greater improvement in PTSD and depression severity, albeit with small to medium effect sizes. The veterans in the TOP group were 18 times more likely to start cognitive processing therapy (CPT) and eight times more likely to complete eight or more sessions of CPT. The authors suggested that the lower engagement in CPT in the cohort receiving in-person care was likely due to the long travel distance to the VAMC. The intervention did not affect medication adherence and had no effect on the likelihood of receiving PTSD medication (Fortney et al., 2015).
Research comparing the efficacy of in-person to telehealth-delivered evidence-based therapies for PTSD is limited but increasing. In a randomized non-inferiority clinical trial, Morland et al. (2014) compared clinical and process outcomes of CPT delivered via telehealth to in-person delivery among rural-dwelling veterans with PTSD. The authors found that the outcomes among the telehealth treatment group were as good as the outcomes in the in-person treatment group. While both groups reported moderate PTSD symptoms at follow-up, at least 50 percent of both groups experienced significant symptom reductions. No significant differences were reported between the groups. Retention in both groups was high, with 85 percent completing 12 sessions. Furthermore, 54 percent of the participants were racial minorities (Morland et al., 2014). In a similar study of women with PTSD (both veterans and civilians), Morland et al. (2015) again found that CPT delivered via telemedicine was comparable and non-inferior to in-person care.
Some studies have found that using technologies to deliver care can lead to better outcomes. For example, a recent randomized trial of 666 active-duty service members (mean age = 31.1) with probable PTSD or depression found that patients receiving centrally assisted collaborative telecare with stepped psychosocial management demonstrated greater reductions of PTSD and depression symptoms than service members receiving care as usual (Engel et al., 2016). This study is one of a number of studies in tele-mental health that are starting to provide evidence that the use of these technologies in certain groups of patients, and also with some diagnostic groups, is actually leading to better standards of results than traditional in-person treatments (Chan et al., 2015; Grubbs et al., 2015b; Myers et al., 2015; Pakyurek et al., 2010; Yellowlees et al., 2015).
The evidence supporting the delivery of prolonged exposure therapy (PET) via telemedicine is less clear. In a randomized trial comparing the outcomes of veterans receiving PET via telemedicine to in-person delivery, Yuen et al. (2015) randomized 52 veterans with PTSD to receive either in-home delivered PET or standard in-person care for 8 to 12 weeks. Both groups experienced significant reductions in PTSD, depression, and anxiety symptoms after completing treatment. Clinician-reported PTSD and patient-reported anxiety showed non-inferiority between the delivery modes. However, the results
were inconclusive for self-report PTSD (using the PTSD checklist) and depression symptoms (using the Beck Depression Inventory-II). Dropout rates were 23.7 percent for in-person care and 36.1 percent for telemedicine-delivered care, although this difference was not significant (p = 0.21). While the authors did say that outcomes and satisfaction were comparable between telemedicine-delivered PE and in-person delivery, they cautioned that more research is needed comparing the non-inferiority of the delivery modalities (Yuen et al., 2015).
Earlier research comparing telemedicine-delivered PET to in-person delivery has also shown mixed results. Tuerk et al. (2010) showed that while the outcomes were similar for the two delivery modes, effect sizes were lower and non-completion was higher among veterans who received treatment via telehealth. In a study without a randomized design, Gros et al. (2011) found that the effect sizes for telehealth-delivered exposure therapy were comparable to effect sizes for in-person exposure-based treatment for PTSD published in the literature, but smaller than the effect sizes observed in their in-person treatment group. Also, Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans were less likely to complete exposure therapy treatment via telehealth than were older Vietnam-era veterans.
Site Visit and Survey Findings
Veteran and provider reports indicate that use of telemedicine varies across the VA. The VA’s Veterans Satisfaction Survey (VSS), the VA’s annual survey of veterans served by the VA, asks veterans to rate the statement, “I talk to my counselor/therapist by Telemental health,” using a scale of 1 to 5, where 1 is strongly disagree, 5 is strongly agree, and 3 is neither. For FY 2016,1 the VA reported a mean rating of 2.27 (standard deviation = 1.33) (VA, 2016), which possibly suggests some disagreement with this statement. (See Chapter 15 for details about the VSS.)
In all of the locations visited during the site visits, VA staff interviewees reported using telemedicine to varying degrees. In some cases, the technology is being used explicitly to overcome certain access challenges, such as long wait times for initial appointments and space constraints within the facilities:
We’re now moving toward tele-mental health to home, so that the veteran doesn’t even have to travel anywhere. We work from our office to his home to do PTSD therapy and outpatient care. If they have to wait longer than 2 or 3 weeks, we call our sister [facility] in Cincinnati and get them started with evidence-based practice type of care, exposure care, through tele-mental health. [VA administrator – Cleveland, Ohio]
How do you match an available provider at a certain time with a room that’s available at a certain time? We have been consulting with the VISN on making that happen. We have some software person writing code right now to make that happen. . . . To really make it so it’s no longer like, “Well, is this clinic in Seattle available?” It’s like, “Well, where is the next available person [provider] when the [veteran] is available” as well. [VA staff – Seattle, Washington]
Interviewees also described how the technology can help overcome many of the barriers veterans face in accessing services, such as long drives to get to a VA facility, difficulty getting out of work to come in for an appointment, and the ubiquitous parking challenges at VAMCs around the country:
I use telehealth to offer appointments to OEF-OIF veterans, for instance, that are working. They can take an hour-long break, have their appointment virtually at their place of employment, and then go back to work without having to take half a day off of work driving in from various locations. It’s specific to mental health outpatient, basically offering services closer to where they’re located. [VA staff – Battle Creek]
1 The FY 2016 report reviewed by the committee covers survey data collected through June 2016.
A lot of our medical centers across the country might have parking problems. Therefore, going into the home is really the way to provide treatment. In mental health it’s so easy. We don’t have to touch the patient, right? It doesn’t matter where they’re located. As long as we can see them, and they can see us. We can pick up on body cues, et cetera. [VA administrator – Charleston, South Carolina]
In East Orange, New Jersey, the VAMC created a special women’s telehealth initiative in 2012 explicitly to improve service access for women veterans, particularly those living in rural areas. Self-assessment data from the site visit indicated that in FY 2014, the New Jersey VAMC provided tele-mental health services to 107 unique women veterans.
Despite its potential advantages, and the literature indicating its effectiveness, some VA clinicians asserted that remote services are not appropriate for every client:
You . . . [have some] patients who are not reliable, not safe, you don’t want to be seeing them in a position where you’re in less control. Patients who it’s good for them, therapeutic for them to come in, and get out of the house, and actually exercise their independence . . . tele can stunt that. With the right case, I think that it helps access a great deal. [Jesse Brown – Chicago, Illinois]
That [telehealth] is available for our very rural veterans that cannot get here. The problem is with a lot of those veterans, there’s usually substance abuse involved or they’re suicidal. That prevents us sometimes from doing the home health VTEL services. . . . [Altoona, Pennsylvania]
Some of the veterans are also talking about the only time that they socialize is when they come into a VA for an appointment. So by having telehealth, they are still able to isolate because they’re not coming out, they’re not joining in with others. [East Orange, New Jersey]
In addition, some veterans interviewed by the site visit teams did not provide a favorable assessment of this approach to mental health treatment:
I didn’t particularly care for it because some of the things that we were saying I didn’t particularly agree. The other piece of it is that sometimes to me you get better results in seeing somebody face-to-face. . . . I’m not saying it doesn’t work, but it didn’t work for me. [Charleston, South Carolina]
I didn’t have Internet and I didn’t have cable TV because I didn’t have any money. Tele whatever. I’m not going to the library and sit down in front of a computer and listen to someone else hear me talk about how screwed up I feel like I am. I’m not going to do that. [Battle Creek, Michigan]
It is likely that the presence of such responses reflects a selection effect as these veterans were the ones who were able and willing to drive to a location to meet face-to-face with the study team. Veterans living in rural areas or those who had no means of transportation may have had more—and better—experiences with receiving mental health services remotely, but were not interviewed by the study team. Data from the committee’s survey of veterans, reported in Chapter 6, indicate that about 14 percent of veterans surveyed with a need for mental health services self-reported living more than an hour from the nearest VA facility. Among VA users with a need for services, 10 percent reported they live more than 1 hour away from the nearest VA facility offering mental health services (see Chapter 6, Table 6-16). This group of veterans may already be well represented among the current users of tele-mental health in the VA. However, it is notable that living a long distance from a VA facility with mental health services significantly decreased the odds of using VA mental health care over non-VA mental health care (see Chapter 6, Table 6-38). This suggests that further expanding telemedicine options to rural-dwelling veterans may improve access for those who see the distance to the nearest VA mental health facility as a barrier to choosing the VA for their care. Furthermore, rural-dwelling veterans with mental health
conditions are known to use VA services at a lower rate and to have a higher rate of unmet mental health needs than their urban counterparts (Teich et al., 2016).
While it was true in all age groups that when veterans were asked which modes of mental health services they were likely to use in the future, more of them indicated in-person service than chose services delivered via the Internet or phone (see Chapter 6, Table 6-35), the results from the committee’s survey showed that veterans 50 years or older were less willing to use the Internet than veterans in younger age groups. In particular, the survey showed that 50 percent of younger veterans (ages 17–29), 46 percent of 30- to 39-year-old veterans, and 50 percent of 40- to 49-year-old veterans said that they were willing to use the Internet for mental health services in the future, whereas only 37 percent of veterans 50 and older did (see Chapter 6, Table 6-36). This suggests that as the veteran population ages, the overall willingness of veterans to use Internet-delivered care may increase.
The use of technology by the VA to deliver and manage mental health treatment extends beyond tele-mental health. The VA is also using websites and mobile smartphone applications (“mHealth”) to help keep veterans engaged in care between appointments. For example, the VA and DoD’s PTSD Coach is a free mobile application that allows users to track and manage their PTSD symptoms and also connects users to support resources (VA, 2014). A new Veteran Appointment Request app, launched in 2016, allows veterans to view, schedule, and cancel primary care and mental health appointments as well as track the status of the appointment request and review upcoming appointments.2 The VA also has its own app store3 with over a dozen apps for both veterans and VA providers. Websites such as Make the Connection4 and the National Center for PTSD website5 both provide PTSD resources such as program locators, screening tools, and other PTSD-related information for veterans and their families (IOM, 2014).
Effectiveness studies of online and mobile technologies are emerging. MyHealtheVet6 is an online portal for VA health system users to refill prescriptions, communicate with their providers via secure messaging, track appointments, and access health records. The users of MyHealtheVet generally like the service and feel that it improves their care (Nazi et al., 2013). In a study of veterans’ use of the Internet and, in particular, of MyHealtheVet, Tsai and Rosenheck (2012) found that the veterans in a nationally representative sample generally liked and frequently used the Internet, but few of them used MyHealtheVet. Among the participants who were VA mental health service users (N = 229), 90 percent used e-mail, 85 percent used the Internet at least once per week, and 79 percent said they liked to receive VA information through the Internet, but only 25 percent used MyHealtheVet. OEF/OIF/Operation New Dawn (OND) veterans were more than twice as likely to use MyHealtheVet than other veterans (odds ratio = 2.48). The study did not reveal why veterans were not using MyHealtheVet, but it did show that the adoption of the portal has been slow (Tsai and Rosenheck, 2012).
In a qualitative study Mishuris et al. (2014) explored why the adoption of MyHealtheVet has been slow. In interviews with 14 veterans receiving home-based primary care, the authors identified several themes that suggested why usage of MyHealtheVet was low. Among those veterans in the sample, knowledge of the platform was low and satisfaction with care was high (suggesting that users did not see a need to use MyHealtheVet). Furthermore, the veterans in the sample (which differed from the sample in Tsai and Rosenheck ) had limited Internet and computer access and many had surrogates or caretakers who managed their care. Despite this, once the veterans had learned about MyHealtheVet, they expressed great interest in using it (Mishuris et al., 2014).
The committee is not aware of a health outcomes evaluation of MyHealtheVet users. However, in a systematic review of patient access to medical records and health outcomes, Davis Giardina et al. (2014) found that despite high patient satisfaction with access to their records, there is little evidence that such access improved outcomes or the quality of care. However, as described above, access to medical records is only one component of MyHealtheVet.
Blue Button is a feature of MyHealtheVet that allows its users to access their medical histories, medications, past and future appointments, laboratory results, procedures, vitals, and immunization records. It is also used by DoD, the Centers for Medicare & Medicaid Services, and United Healthcare Insurance (Turvey et al., 2014). An online survey of 18,398 MyHealtheVet users revealed that 33 percent used the Blue Button feature. Most of the users (73 percent) felt that Blue Button enabled them to understand their health information better because it was all in one place. Interestingly, 20 percent of Blue Button users shared their health information from Blue Button with their non-VA providers—87 percent of whom reported that their non-VA providers found this to be helpful. Veteran computer literacy was the greatest predictor of using Blue Button and sharing information with non-VA providers. Low awareness of Blue Button and difficulty using the feature were the greatest barriers to use revealed by the survey (Turvey et al., 2014).
Mobile health or “mHealth” technologies are applications for cell phones, smartphones, and tablets that are designed to deliver treatment or to help manage symptoms and care. No one knows how many health apps exist, but these are widely available in the civilian world—for example, as of January 2014 there were nearly 7,000 mental health related apps in the Apple App Store and on Google Play (Breslau and Engel, 2015), while in September 2015, 165,000 total health apps were reported to exist, with mental health apps being the largest group of disease-specific apps (QuintilesIMS, 2015). While very few of the available apps are based on evidence-based treatments (Huguet et al., 2016), there are a handful that deliver CPT and PET. There are also many apps designed to help patients track and manage symptoms associated with PTSD, depression, substance use, and general mental health. Some of these applications, such as the PE Coach and the PTSD Coach, were designed in collaboration with the VA and are in use in some VA settings but not system-wide (Shore et al., 2014). As of June 2017, the VA had developed 15 mobile apps to support mental health care. All 15 are stand-alone and intended for self-help or to be used in conjunction with face-to-face therapy (VA, 2017a).
The VA is currently focused on developing an integrated mobile app that will support mental health symptom monitoring as part of measurement-based care for mental health. It will be the first app to facilitate veteran–provider communications concerning the completion of symptom monitoring assessments. Assessment data will automatically be synced with the veteran’s EHR (VA, 2017a).
Much of the literature on mHealth technologies is descriptive in nature or based on uncontrolled observational methods, making it difficult to determine which applications are most effective or might
be used most effectively in the future. Additionally, the pace of development of mHealth is currently far outpacing the research necessary to determine what is and is not working (Breslau and Engel, 2015; Torous et al., 2016). The quality of available mHealth apps varies greatly, and there is little guidance available for consumers, providers, and decision makers to help in identifying promising new applications (Breslau and Engel, 2015; Huguet et al., 2016; Luxton et al., 2011).
In light of this, a recent commentary provided a framework for clinicians to refer to when considering different psychiatric mHealth in their practices (Torous et al., 2016). The ASPECTS framework sets forth six items to consider when evaluating an application for use (although not all items will apply to every application). The framework states that clinicians should consider applications that are actionable (e.g., collect data that is actionable within a health care setting); secure (e.g., have two-step verification and data-encryption features); professional (e.g., should meet professional and Health Insurance Portability and Accountability Act [HIPAA] standards); evidence based (e.g., should have some clinical evidence and efficacy data available); customizable (e.g., should be flexible and applicable to different patient needs); and transparent (e.g., it should be clear how the application works and how it uses patient data).
Although the research base is not yet well developed, research on the effectiveness and acceptability of mobile applications among veterans and providers in the VA system is emerging, and some mHealth apps are showing promising results. PTSD Coach, which helps patients with PTSD manage their symptoms, is widely used in the VA. Users report high acceptability and high perceived helpfulness for the application (Kuhn et al., 2014), and those who use the symptom management tool within the application reported a decrease in distress both initially and after repeated use (Owen and Jaworski, 2015). One small study showed that the application is helpful to veterans with or without clinician support; however, use of the application with clinician support resulted in a greater decrease in symptoms than did self-managed use (Possemato et al., 2016).
In a study of PE Coach, a smartphone app designed as a treatment companion for patients receiving prolonged exposure therapy, most providers agreed that using the app would offer a relative advantage compared to existing prolonged exposure (PE) practices. Generally, study participants felt they could use the app with relative ease and that it was compatible with their values and needs as well as with those of their patients. Clinicians younger than 40, who owned a smartphone, and who had previously used an app in a clinical setting were more receptive to incorporating PE Coach into their care routine than those who were older, did not have a smartphone, and who had not used an mHealth app before (Rickard et al., 2014).
Apps are also available for caregivers for help in managing the care they provide to veterans. In a study of caregivers of veterans and their use of mHealth apps, Frisbee (2016) found that caregivers of veterans with more severe disabilities were less likely to use mHealth apps. Other predictors of greater mHealth application usage were living in a rural location, being younger, having higher computer competence, being a spouse caregiver (as opposed to a parent), and caring for a veteran with a mental health condition (other than PTSD). Rural residence has often been associated with lower mHealth use because of the likelihood of having limited Internet access. However, in this study participants were given a tablet with a service plan, which eliminated this access barrier (Frisbee, 2016).
Godleski et al. (2012a) assessed the outcomes of a home-messaging tele-mental health program. Program participants were Connecticut VA mental health patients with a PTSD, depression, substance use disorder, or schizophrenia diagnosis, and they received a home-messaging device connected to their phone line. Participants received questions daily based on disease management protocols and educational components. Patient responses were sent daily to a nurse practitioner for triage and follow-up if necessary. After at least 6 months of use (before-and-after study design), hospitalizations and emergency
room visits decreased significantly; however, there was no comparison group in the study. Participants reported high satisfaction with the program (Godleski et al., 2012a).
Luxton et al. (2011) described current and emerging technologies for suicide prevention. Using Web-based applications and social media (Facebook, MySpace) user groups are ways to engage users and provide access to people in crisis at all times of day. Similarly, podcasting and e-mail outreach are ways to distribute information and reach at-risk populations. The authors also described smartphone apps that help users self-assess and monitor psychiatric symptoms, text messaging services that people in crisis can use to seek help or report incidents, and “virtual worlds” that allow users to interact with each other via avatars and provide suicide prevention information and support. Luxton et al. (2011) noted that many of these technologies and applications were not yet tested and warned that the quality of many technological resources was unregulated.
Other research has explored the use of social networks and virtual reality to help support veterans and engage them in therapy (Parish et al., 2014; Yellowlees et al., 2012a). With virtual reality, researchers have gone as far as creating virtual worlds in which veterans can be immersed and where the experience of, for instance, being a bomb victim, can be re-experienced with a therapist on site (Yellowlees et al., 2012a).
Electronic consultations (e-consults) are asynchronous communication between providers within a shared electronic medical record. E-consults are a relatively new practice at the VA and are used primarily by primary care physicians to seek input from specialty care providers. The practice is designed to increase access to specialty care expertise while avoiding face-to-face visits with specialists. Any provider with ordering privileges may request an e-consult through the EHR. Consulting physicians are expected to respond to an e-consult request within 3 working days (Kessler et al., 2015). Employing e-consults for specialty care improves access by reducing travel burden and cost (Kirsh et al., 2015). E-consults are feasible in a variety of settings, and they facilitate timely specialty advice (Vimalananda et al., 2015). A VA primary care provider located at a CBOC, for example, may e-consult with a specialist located at a VAMC to help a veteran avoid traveling to the VAMC to seek specialty care. Thus, when appropriate, veterans can avoid a potentially time-consuming, expensive, and disruptive trip to the VAMC. Research suggests that e-consults are satisfying to both providers and patients at the VA (Rodriguez and Burkitt, 2015). The study of e-consults is new, however, and limited in the VA setting. The limited research that does exist is not mental health specific. However, it suggests that e-consults appear to be an efficient practice for improving access to care. In FY 2016, 20,938 unique patients received a mental health e-consult. FY 2017 data suggest that the VA is on track to exceed that number this year—as of June 2017, 15,900 unique veterans had received a mental health e-consult (VA, 2017a).
In a mixed-methods study of e-consults in a large VA health center, Gupte and Vimalananda (2016) looked at veterans’ electronic health records and completed semistructured interviews to describe the process, challenges, and usability of e-consults at the VA Boston Healthcare System (VABHS). E-consults launched at VABHS in 2011 and by 2013 had expanded to all clinical services. The study revealed that all specialties used e-consults in 2012 and 2013 with the exception of radiology. A total of 7,097 e-consults were completed in the VABHS during the study period—some of which originated outside the health system. Less than 2 percent of e-consults were for psychiatry or mental health. The analysis was limited to the 5,141 e-consults that originated from within VABHS. Most providers (83 percent) spent less than 15 minutes completing their consult; only 5 percent spent more than 30 minutes. E-consults took a median of 2.2 days to complete. After collecting and analyzing the EHR data, researchers recruited and interviewed a variety of doctors, nurse practitioners, and administrators (N = 31) representing 21 specialties in order to understand barriers and facilitators of e-consult usage. The interviews revealed that some e-consults were requested within the same specialty in order to facilitate appointment scheduling
at either VABHS or another facility closer to the veteran’s home. This was not the intended purpose of e-consults, but it suggests that e-consults are filling a structural shortcoming in the VA system. The authors suggested that the appropriateness of these unintended uses of e-consults should be explored (Gupte and Vimalananda, 2016).
Primary care physicians who were frequent users unanimously agreed that e-consults were easy to use and useful and that they increased access to specialty care (Gupte and Vimalananda, 2016). They also spoke of having more efficient and thorough consultation through e-consults, which largely replaced hallway conversations. Specialists reported that e-consults reduced unnecessary face-to-face consultations and allowed them to have more time with patients who truly needed face-to-face attention. They also reported that e-consults could contribute to primary care education, perhaps reducing the need for specialist consultation in the future. Some specialists did feel overburdened with e-consults, however, and others complained that they often received the same questions from the same primary care physicians, suggesting that some physicians were using e-consults for documentation only and not for true consultation (Gupte and Vimalananda, 2016).
Another form of e-consults, currently known as “asynchronous” or “store and forward” telepsychiatry (ATP), has been developed in recent years (Yellowlees et al., 2010, 2012b, 2013, 2015). ATP consultations are a cross between traditional curbside consults and e-consults. A semi-structured clinical interview between a patient and a physician extender is video recorded, typically 20 to 30 minutes in length, and then sent to a psychiatrist who reviews the interview (which shows the patient’s mental state) and any other clinical information, such as a referral or EHR notes. The psychiatrist writes a diagnostic and treatment plan for the referring primary care physician to follow. Studies have demonstrated feasibility, diagnostic reliability, and cost effectiveness (Butler and Yellowlees, 2012; Yellowlees et al., 2011), and ATP consultations have been implemented in some non-VA systems as part of an integrated mental health service to primary care.
A number of barriers limit the potential of tele-mental health within the VA (IOM, 2014). Aside from institutional barriers such as equipment shortages and a lack of computer literacy among providers and veterans, policy barriers exist as well. For example, HIPAA requires a secure platform for providers to e-mail or text message their patients regarding appointment reminders (45 C.F.R., parts 160, 162, and 164), which limits the use of text messaging. Similarly, veterans who would like to receive tele-mental health in their homes must use computer equipment provided by the VA (IOM, 2014). Finally, the provision of equipment and infrastructure to deliver tele-mental health does not necessarily alleviate the staff shortages that may be present at some VA facilities (IOM, 2014).
Site Visit and Survey Findings
Interviewees described numerous technological and bureaucratic challenges regarding the implementation and use of telehealth services at the VA, and the committee’s site visits revealed variability in the knowledge, use, and implementation of telemedicine across the VA system:
One of the biggest challenges is some [veterans] really don’t have the equipment and constant Internet access at their house, and those are the prerequisites to be enrolled in the program. We do have several providers that have used CPT to home on an as-needed basis . . . with certain people who have those capabilities at their house. . . . We are trying to increase it, particularly the CPT to home use, but it does come with its challenges. [Syracuse, New York]
There’s all these competencies that you have to be able to do. . . . The other thing is that there is a whole tele-health clerk setup that’s not located in the mental health clinic . . . . It would be better if you could have a tele-health clerk in the clinic all the time. . . . You need one at every location, and we have two for the system. [Biloxi, Mississippi]
That was one of the first things we worked on when we got here about a year or so ago. . . . We ended up getting an MOU [memorandum of understanding] from the Battle Creek VA, and we brought it here. Then, it just died on the vine. It went to lawyers, and it never came out. [Battle Creek, Michigan]
These barrier examples are unfortunate but not surprising, as the literature shows that patients have a higher rate of preference for telemedicine consultations than do providers (Hubley et al., 2016). The latter tend to have to make more changes to their practices to deliver telemedicine consultations, and they obtain fewer advantages than patients. One of the tasks of any telemedicine implementation is to convince providers to change their approach to care delivery, and this is evidently still a challenge within many parts of the VA. The committee’s survey data detailed in Chapter 6 (see Table 6-35) showed that a large proportion (45 percent) of veterans of all ages indicated they would be willing to use the Internet to receive mental health services in the future. Veterans in younger age groups (17 to 29, 30 to 39, and 40 to 49) in the OEF/OIF/OND cohort were more willing to use the Internet to access mental health care in the future than veterans 50 and older (see Chapter 6, Table 6-36). While the survey did not inquire about attitudes to technology of rural or geographically isolated veterans, the literature is clear that these individuals typically show high satisfaction with receiving their care electronically (Yellowlees and Shore, in press). To further maximize the benefits of health technology, the VA needs greater buy-in from local leaders, providers, and veterans so that the technologies become a standard part of routine care, often used in a hybrid way combined with in-person care to give veterans more choice and access to mental health expertise.
This chapter describes the state of health technology at the VA as well as some of the barriers throughout the system that may inhibit the wider use of health technology among veterans and providers. It also summarizes committee site visits and survey findings related to health technology. A summary of the committee’s findings on this topic is outlined below.
- The VA is a pioneer in the implementation of telehealth and other clinically related technologies, such as the EHR, and processes to deliver mental health care.
- The VA’s substantial past expenditure on electronic and telehealth infrastructure demonstrates the department’s commitment to using technology to deliver care.
- The VA also is a pioneer in tele-mental health research and app development.
- While there is now a strong evidence base supporting the use of tele-mental health technologies for PTSD and depression, long-term outcome studies are needed for the use of tele-mental health for other conditions.
- Further research also is needed for the use of tele-mental health for evidence-based therapies, within primary care and integrated care systems, for delivery in the home and in mobile settings, and for technologies other than video conferencing, such as the effectiveness of smartphone applications and virtual reality.
- The VA currently delivers clinical telehealth services across all disciplines to up to 12 percent of all veterans using VA services, with approximately 25 percent of these services being for mental health.
- In most facilities, the VA is technologically equipped to provide tele-mental health services; however, the committee’s site visits revealed variability in the knowledge, use, and implementation of telemedicine across the VA system.
- Nearly half of veterans surveyed by the committee were open to receiving mental health care electronically in the future.
- Distance barriers experienced by these veterans may be overcome through the use of telehealth.
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