6
The Experiences of Other Health Care Systems
George Demiris, University of Pennsylvania, moderated the workshop’s fifth session, featuring Leonie Heyworth, Veterans Affairs (VA); Jonathan Zivony, Veterans Health Administration (VHA); and Steven Shook, Cleveland Clinic.
VA TELEHEALTH EVALUATIONS
Leonie Heyworth, U.S. Department of Veterans Affairs
Leonie Heyworth, deputy director for clinical services in the VA Office of Connected Care, discussed telehealth for care delivery in the VA health system.
Heyworth explained that before the pandemic, VA was increasingly using telehealth to deliver care. VA telehealth services include video visits via VA Video Connect (VVC), telephone visits, a patient portal, prescription refills, an automated text reminder service, in-home and mobile patient monitoring, patient-generated health data, and device loans. She noted that during the COVID-19 pandemic, the overall use of video telehealth rose across many groups, though older adults and rural residents had lower video visit uptake (see Figure 6-1) (Ferguson et al., 2021). Minoritized, female, and younger veterans were more likely to engage in video telehealth, and female clinicians were more likely to provide video care (Zachrison et al., 2021). She added that across all demographic groups, patients tend to prefer VVC visits after their first video appointment. Interest in video visits has not slackened despite the availability of COVID-19 vaccines and opportunities to return to in-person care (see Figure 6-2).
Heyworth said VA has taken several steps to address the digital divide. Since 2017, VA has shipped more than 100,000 user-friendly and tech-supported devices to veterans, including those who are unhoused or living in group homes, to ensure health care access for all specialties. VA also collaborated with mobile carriers to minimize the data charges associated with VVC visits to reduce patient expense. In addition, VA staff members work to connect veterans with programs that help defray technology costs, such as
the Affordable Connectivity Program (ACP), the Federal Communications Commission’s Lifeline program, and EveryoneOn (EveryoneOn, 2022; FCC, 2022).
Heyworth explained that for veterans in remote areas, the ATLAS (Accessing Telehealth via Local Area Stations) program enables telehealth via private rooms in select Walmart stores, American Legion halls, and Veterans of Foreign Wars halls. In addition, VA plans to expand its hub-and-spokes model to deliver specialty care to rural and remote sites via “virtual hospitals” that can provide more and better services over time, Heyworth said.
OVERVIEW OF VHA DISABILITY EXAMS VIA TELEHEALTH
Jonathan Zivony, Veterans Health Administration
Jonathan Zivony is associate chief officer for the Veterans Health Administration’s Office of Disability and Medical Assessment. He discussed the use of telehealth in compensation and pension (C&P) medical evaluations.
Zivony explained that C&P evaluations, also known as VA disability claim exams, are used to determine a veteran’s level of service-connected disability, and therefore benefits, on behalf of the Veterans Benefits Administration (VBA). C&P examiners use condition-specific disability benefits questionnaires to document the medical evidence VBA needs to adjudicate claims. Zivony noted that C&Ps may not be adaptable to SSA disability assess-
ments, however, because they focus on determining whether the disability is connected to the patient’s military service.
C&Ps can be done in person, virtually, or by using certain forms of clinical evidence from a veteran’s medical records. Clinicians including physicians, psychologists, nurse practitioners, audiologists, and dentists can conduct C&Ps in every state and U.S. territory. He noted that VHA administers the extensive training and certification required to perform C&Ps, which includes telehealth-specific modules.
Zivony said tele-C&Ps have been offered since 2011, with continual service expansions to improve accessibility. During the pandemic, many C&Ps shifted to using medical records instead of in-person or telehealth visits, as C&P staff were reallocated to emergency response operations. He added that currently about 75 percent of assessments are done in person. While VHA is hoping to increase tele-C&Ps, Zivony said many veterans—particularly older individuals—prefer in-person assessments. He said there are clinical benefits to in-person visits as well. For example, for mental health assessments there may be a need for urgent onsite treatment or care, and musculoskeletal assessments often require a thorough physical exam. VHA is studying telehealth approaches to these assessments. Zivony explained that tele-C&Ps also require a specially trained telepresenter to be at the veteran’s side to help facilitate the exam as well as high-speed Internet access. He said that addressing these barriers, ensuring proper coding practices, and expanding the conditions eligible for tele-C&Ps will make the process safer, more convenient, and more efficient.
CLEVELAND CLINIC BUILDING THE NEXT GENERATION OF TELEHEALTH
Steven Shook, Cleveland Clinic
Steven Shook, lead for virtual health at Cleveland Clinic, discussed telehealth approaches and challenges at Cleveland Clinic, which offers synchronous and asynchronous options for patients and staff along the entire care spectrum. The hospital’s goal for telehealth is to deliver smarter, more affordable, and more accessible care to provide patients with a personal, frictionless, intuitive, continuous, and empathic experience, he said.
Shook said that prior to the pandemic, virtual care comprised a small but growing percentage of Cleveland Clinic visits. Telehealth use radically and rapidly expanded during the pandemic. He added that in addition to supporting virtual interactions between patients and clinicians, the hospital’s leadership added virtual options for family visitation, medical education, second
opinions, and staff meetings (Cleveland Clinic, 2020). Shook said clinicians now see 16 percent of outpatients virtually, and the organization expects that number to continue to grow.
Shook identified a few challenges with telehealth adoption. At the national level, he said the largest telehealth challenges relate to reimbursement uncertainty and state licensing issues. A more local challenge is the need to overcome digital inequities. He noted that while patients have indicated that they are very satisfied with virtual care at Cleveland Clinic, familiarity with the technology is an important factor influencing how highly patients rate the experience. He added that the quality of the device used can also affect performance, making it challenging for the organization to support consistently high-quality interactions with patients using a wide variety of devices.
Shook said that it is critical to address whether negative patient outcomes, such as diagnostic errors or poorly handled care transitions, could be attributed to telehealth. Cleveland Clinic uses a robust review system to identify any issues that affect patient safety. He said that future telehealth implementations or optimizations should be patient centered, tailored to patient population segments, strive to be frictionless across all aspects of care, and include remote patient monitoring and hybrid care models to offer the best of virtual and in-person care.
DISCUSSION
Speakers reflected on the repercussions of the pivot to telehealth during the pandemic along with considerations related to reimbursements, metrics, and documentation.
Repercussions of the Pivot to Telehealth
Shook commented that even though Cleveland Clinic was not new to telehealth, the organization’s pivot toward telehealth modalities during the pandemic was largely reactive. Staff implemented changes after extensive reviews of telehealth processes, and ultimately there were very few instances in which telehealth was identified as the root cause of poor outcomes. He noted that clinicians who feel they cannot meet the standard of care via telehealth are encouraged to see patients in person. He added that it is important to continue to study telehealth delivery and the reliability of medical evidence obtained via telehealth visits.
Heyworth noted that VA’s pivot toward greater telehealth adoption was helped by a technical team dedicated to preventing systemwide or individual
outages. Like Cleveland Clinic, VA is also retrospectively studying outcomes to identify any areas of telehealth failure. She added that the review process has thus far found very few instances of problems resulting from telehealth.
Telehealth Reimbursements
Demiris pointed out that asynchronous forms of telehealth are not always reimbursable. Shook replied that because asynchronous telehealth is particularly effective for urgent care, and most patients rate it positively, Cleveland Clinic is advocating at the state and federal level for the inclusion of asynchronous modalities in how telehealth is defined for reimbursement purposes. He said that many legislators assume in-person care is better than telehealth, when in fact, evidence shows that telehealth is equally—or even more—effective in many situations. Shook added that initial appointments via telehealth, for example, not only overcome patient reluctance, but also streamline subsequent in-person visits.
Heyworth agreed, noting that veterans prefer longer initial visits to take place from the comfort of their homes, with shorter in-person follow-ups as needed to confirm key points or facilitate a focused physical exam. She added that VA is expanding asynchronous telehealth for multiple specialties. Heyworth also acknowledged that VA does not face the same reimbursement challenges as other health care entities, giving the organization more flexibility to adapt protocols to address patient needs.
Metrics and Documentation
Speakers also discussed approaches to documentation and metrics for telehealth interactions. Shook said Cleveland Clinic tracks telehealth access, experience, reimbursement, effectiveness, and equity. In addition, tracking financial metrics can help show how telehealth can expand an organization’s patient pool, especially if telehealth offerings are filling unmet needs. He noted that active quality, safety, and equity measurements (such as tracking access by zip code) are also important to identify areas for improvement.
Heyworth noted that equity is an important metric for VA, both for telehealth patients and telehealth clinicians. She said their analyses found that female clinicians are more likely to offer virtual care, which can influence patient attitudes. VA also studies various cost-effectiveness and quality metrics for telehealth. Heyworth explained that to capture quantitative data, such as vital signs during virtual exams, veterans are given a suite of peripheral devices, and remote monitoring devices can also be used to provide relevant health data directly to VA. She added that VA is working to implement new infrared
technology, pending approval, which will enable device cameras to accurately record vital signs for a more seamless experience.
In response to a comment from Demiris, Shook agreed that hybrid and telehealth approaches could potentially fragment a patient’s medical history without appropriate and careful documentation. He emphasized that every aspect of a patient’s health care journey should be recorded in the electronic health record to enable transparency, communication, and collaboration across multiple clinicians to avoid fragmenting care and to improve the patient experience. Heyworth agreed, noting that VA has a centralized location for patient data that can be periodically reviewed.
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