Starting a telehealth revolution

Before the pandemic struck, David Cole and his wife, Donna, traveled to the West Haven Veterans Medical Center for a routine visit. Cole, a retired Vietnam veteran, is wheelchair bound. He and Donna boarded a service van to ride the 40 miles from their home in Norwalk, Conn. to the hospital. Everything was fine until after the appointment. A gap in service left them waiting two hours for the van to return them home.

“I was not happy,” said David, a Purple Heart recipient.

But since mid-March of 2020, Cole has been able to visit Juliette Spelman, MD, his primary care physician at the VA Connecticut Healthcare System (VACHS) West Haven Medical Center, via telephone and video from home. Cole is one of the many veterans to have access to their primary care physician at VACHS through the use of telemedicine in the midst of the COVID-19 pandemic.

“I feel fine using it,” said Cole of telemedicine. “I like it better than going to see her. It’s such as hassle.” In a follow-up, Cole said that he’d prefer to continue virtual MD visits after the pandemic is over.

VA Connecticut Healthcare System is able to provide quality health care through the use of telemedicine due to its operations under the umbrella of the Veterans Health Administration and its partnership YSM.

“We are a federal health care delivery model,” said Alfred Montoya, director of VA Connecticut Healthcare System. “Telemedicine has become extremely important, especially due to the pandemic. We still have a mission to take care of veterans. We very quickly pivoted to telemedicine.”

The expertise of physicians from YSM helped to make the transition to telemedicine possible by ensuring the continuity of quality health care. “We have a very vibrant academic relationship with Yale. Not all VA medical centers have an academic relationship with an educational institution,” Montoya said. “As a VA facility, we share providers across the system [and] we provide state-of-the-art care in HIV, PTSD, and oncology among others.”

Most of the physicians who work at VACHS also serve as faculty at YSM. In fact, 561 Yale faculty members have privileges within VACHS. This alliance gives Yale medical students, residents, and fellows the opportunity to train as they take care of veterans with chronic health conditions and injuries. More than 1,000 Yale medical students, residents, and fellows rotate annually at VACHS.

“Yale has been an incredible partner in delivering care to veterans. Yale faculty, both VA paid and volunteers, deliver state-of-the-art care to veterans while training the new generation of physicians,” said Michael Kozal, MD, chief of staff for the VA Connecticut Healthcare System and associate dean for Veteran Affairs at YSM.

“Yale faculty also treat veterans through care in the community mechanisms. Having trainees on site in 40 different specialties with Yale faculty attendings allows for veterans to receive the highest quality of care at the cutting edge of medicine. Yale researchers based at the VA have contributed significantly to developing new knowledge and medical advances to serve veterans in areas of PTSD, Cancer, HIV, liver diseases, and cardiovascular disease, to name just a few,” said Kozal.

Community-based centers within VACHS were using some form of telemedicine on a limited basis even before the pandemic hit the nation.

“The VA is one of the nation’s leaders in telemedicine and has been using some form of virtual care for nearly a decade,” said Christopher Ruser, MD, chief of primary care for VACHS and an associate professor of medicine (general medicine) at YSM.

Ruser oversees the use of telemedicine within VACHS. “We already had a platform, [a] website, that was up and running and was used by every veteran-patient in the state,” he said. The VA website was “pioneering in the virtual care sphere” when it was developed about 10 years ago. The website gives veterans access to pharmacy services, appointment scheduling, their personal medical records, and secure email messaging to their VA health care team.

In addition to the website, VA Video Connect, a mobile application that gives patients the ability to schedule an at-home video health care visit with a primary care physician, was in use before the pandemic. Then, it made up less than 1% of the care that was provided, said Ruser. Most telephone care, pre-pandemic, was done using existing VA phone lines because no clinical providers were working from home.

VACHS clinical staff began online training with telemedicine about two years ago. By fiscal year 2019, all clinicians had been trained to use phone, video, and secure email messaging, and had done at least one video visit with a patient.

When the national stay-at-home mandate was announced by the federal government in mid-March, VACHS was already following VA directives to put a hold on face-to-face doctor visits and provide full virtual care to patients.

“There aren’t many silver linings to the pandemic, but within VACHS, it gave us the motivating energy for us to embrace these platforms,” said Ruser.

The first priority was keeping clinical staff and patients safe and preventing both from being exposed to the coronavirus in a risky health care environment. Physicians, nurses, and medical support staff were directed to establish home telework rotations and were assigned mandatory virtual training. In-person medical appointments were only allowed with the approval of a primary care physician and patients were pre-screened for COVID-19 symptoms before any visit. West Haven remained open for emergency care.

Ruser and several colleagues examined the clinical intervention to virtualize care within VACHS during the early weeks of the pandemic. The results were published in the Journal of General Internal Medicine last July.

According to the peer-reviewed article, “A Model for Rapid Transition to Virtual Care, VA Connecticut Primary Care Response to COVID-19,” within “two weeks of the first confirmed COVID-19 case in Connecticut, and by the time the VA mandated a transition to virtual care, 83% of all primary care visits at VACHS were conducted using telemedicine modalities. Three weeks after the first case in Connecticut, 97% of all primary care visits were virtual.”

Physicians, who began working remotely during the early weeks of the pandemic, said some patients adapted well to the use of telemedicine because of its convenience and the ability to safely deliver quality health care.

“I don’t think patients need to drive miles for a visit or hassle with parking. Especially older veterans who may have mobility issues and need to find a ride,” said Spelman, a primary care provider at West Haven and an assistant professor of medicine (general medicine). She is a co-author of the study.

Susan Kashaf, MD, MPH, also a primary care provider at West Haven and an associate professor of medicine (general medicine), says telemedicine made it possible for her to examine a 93-year-old veteran in an assisted living facility who needed to qualify for Medicaid so he could be transferred to hospice care.

She spoke with the patient’s son and they arranged a video visit using his smartphone and Doximity, a secure telephone video channel.

“We did it without having to move him,” Kashaf said. “We got him into hospice care in two days. The son was very grateful and happy.”

Ruser said VACHS adopted Doximity and other platforms to help physicians deliver virtual care from home. The use of the VA Video Connect app jumped to about 5% of all patient encounters during the push to switch to telemedicine.

James Csisar, 77, a retired veteran and patient of Kashaf for almost 20 years, said he prefers using telemedicine for his doctor visits.

“There are two primary benefits for me. I don’t have to drive the two hours on the highway to get there and I don’t have to deal with the VA COVID-19 protocols,” wrote Csisar in an email. He lives in Mystic, Conn.

“Dr. Kashaf and I have an excellent working relationship, which makes our communication easy and efficient.”

But not all veterans can take advantage of the technology. Some older veterans don’t use smartphones, while others have trouble downloading the video app or they don’t have email to access a video visit. “The VA is also somewhat unique in that we do have a mechanism under certain circumstances to issue technology like iPads and even cellphones to veterans,” Ruser noted in an email. “The pandemic challenged our operations in this regard and gave us some insights about how to expand these programs.”

Other patients prefer face-to-face medical visits because they feel more comfortable relating to their physician in person.

Veteran Robert Vera, 67, has been a patient of Lucille Burgo, MD, a general internist and an assistant clinical professor at Yale School of Medicine (YSM), for eight years. He said he would like to return to in-person visits.

“I get more by being seen in person,” said Vera, who lives in Danielson, Conn. “I like to talk face-to-face rather than over the phone. It’s just a lot more personable.”

Burgo, national co-director of the Post Deployment Integrated Care Initiative with the VHA Office of Primary Care, was an early adopter of telemedicine and has been caring for veterans for more than 35 years.

She said she encouraged her patients to use the VA website before COVID-19. Today Burgo helps to train clinicians and residents to use telemedicine modalities, particularly VA Video Connect.

“There’s a learning curve [with telemedicine],” she said. “Some doctors couldn’t get their heads around treating a patient without touching a patient. You can’t listen to a heart. You can’t do a physical exam. That was a barrier.”

However, telemedicine has “revolutionized” modern health care by making it possible to deliver care to veterans no matter where they live, Burgo said, particularly veterans in rural areas who make up about 35% of VA patients. Most importantly the technology can be used for most other primary care concerns, she said. For example, primary care teams are using video platforms to teach patients how to take their vital signs, while physicians can use the video technology to examine a patient’s skin, limbs, or to watch them walk short distances.

Ruser said his post-pandemic strategic goal for VACHS is for telemedicine to make up 25% to 30% of patient visits.

“We’ve taken a cautious approach,” he said. “We are using telemedicine depending on the situation in the community and the status of COVID-19. We’re taking a middle course.”