Q&A: The VA Is Focused on Its Telehealth Experience Beyond the Pandemic

FEDTECH: What technology changes did the Office of Connected Care make to expand telehealth during the pandemic?

GALPIN: We were not prepared, from a technology standpoint, to expand the capacity quickly. We had to do a lot of re-engineering, so there was a transition from on-premises technology to cloud-based services. We had to re-engineer the way we did scheduling because the demand increased so much.

Beyond that, though, there was a ton of innovation. We had to take a lot of the platforms that we already had and do something different with them. We developed new disease management protocols to manage infectious diseases. We wanted to track veterans in their homes. We used our Annie application, which is a text-based protocol application that will send veterans text messages and allows for self-management. We developed protocols that could help veterans self-manage at home when they had COVID.

We took our existing TeleCritical Care capability and — because we might lose staff to illness or get a significant increase in demand — re-engineered that program so that any facility, if it needed help, could get service from one of our TeleCritical Care hubs.

One of the biggest things we did was authorize and support our providers working from home. That was a huge transition. Suddenly, we had providers who had never done telehealth before serving veterans who had never participated in telehealth, and we had to make sure everyone had the guidance to do it successfully and safely. In that first year, you saw the results in the data. Our video-to-home program grew by over 1,000 percent in the first year.

FEDTECH: What are the biggest challenges your office faces going forward?

GALPIN: I think there are two: the changing authorities at the end of the pandemic and the digital divide. We’ve been saying this ever since we started doing video in the home; that is such a key barrier that we alone cannot independently overcome. That needs to be a whole-of-government, private sector combined effort. Everyone needs access to the internet.

FEDTECH: How is your office preparing for the end of the public health emergency declaration?

GALPIN: We’ve been leaning on our telehealth strategies. We have an exciting vision and operating plan for how we're going to deliver and integrate digital technologies into our care. The end of the pandemic marks the end of an era in which we had to do some very critical things very quickly. We do not expect, in any way, to go backward.

There are a few authority changes that we’ve had to prepare for. During the pandemic, the Drug Enforcement Agency provided significant flexibility in controlled substance prescribing, and that was key to making sure our veterans could receive the highest-quality care. We've been working very closely with both the administration and Congress, and assuming they continue to work with us, we hope there will be no disruption. So, I think we’re prepared.

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FEDTECH: What programs has the VA initiated to help veterans get connected to services and the internet?

GALPIN: We launched what we call our Digital Divide Consult effort during the pandemic. When a provider identifies veterans who can't access our telehealth services because they don't have internet or technology, he or she can put in a consult to a VA social worker. The social worker does an assessment on the veterans and has some tools in their toolbelt that we've developed to help veterans get connected.

We have VA tablets, internet-connected 4G iPads. Those veterans who are eligible can get iPads and keep them as long as they need them for their clinical services. Our Connected Devices Program educates them on the iPad and does test calls with them using video. We've completed over 100,000 digital divide consults. We have over 100,000 tablets in the community with our veterans.

Not every veteran will meet the clinical criteria for the iPad, but we help veterans connect to Federal Communications Commission programs, like the Affordable Connectivity Program or the Lifeline program, so they can get discounts or subsidies on their own technology and internet at home. We’ve also partnered with a company that advertises discounts, so you can look in your area and see what type you can get.

We also developed something called our ATLAS program, and that’s Accessing Telehealth Through Local Area Stations. We will partner with private sector or public sector partners, so we may partner with a veterans service organization or Walmart, a library or a Federally Qualified Health Center. We will take a space they provide us, set it up with technology, create a scheduling application and book veterans in those spaces in their communities. It’s still a small program, and we’re still evaluating the best way to implement it, but it’s an exciting opportunity to get to those veterans who are in the most rural locations. That was started formally in 2018, and at this point we have 13 sites.

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FEDTECH: What technologies are you focused on upgrading through the end of 2023?

GALPIN: It’s less about individual technologies and more about integration and standardization. Our office really focuses on three core technologies: remote patient monitoring, video telehealth and asynchronous telehealth. What we’re working on right now is implementing a national framework for organization around clinical resource sharing.

When we look at how our organization is set up, we have facilities, we have VA regions that have a director and we have a national healthcare system. At the facility level we say, "Every provider, where clinically appropriate, should be offering telehealth to increase the accessibility of care." That’s moving the care that you would have in the hospital to a clinic or to the home.

At the regional level, in what we call our Veterans Integrated Services Networks (VISN), we talk about sharing clinical resources to make sure we have consistent access, particularly for high-volume services. We look at things like TelePrimary Care, mental health, some specialty services like dermatology or eye care screenings. There are times when, in our rural communities, we may lose access because someone retires or someone leaves the VA, but with telehealth, we can replace those provider services so that care to veterans is never disrupted.

At the national level, if there’s a scarce service — a rare diagnosis and there are only a few people in the country that are experts in treating this condition — let’s make sure their expertise is available to all veterans at all facilities.

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FEDTECH: How mature is the VA in those three areas?

GALPIN: They’re at different levels of maturity, and it’s service-specific. In areas like eye care screening, we have services at most of our community-based clinics. In other areas, we’re starting new programs.

The idea of national program sharing at the VISN level, that’s our ability to hire providers in a large urban area and distribute their services to rural areas. We have 18 regions. In each VISN, we currently have a clinical resource hub, which can distribute some of those high-volume services — mental health, primary care — across the network.

We have some national programs that make their services available to any facility that has need. TeleCritical Care, Telestroke and TeleGenomics are examples. We have a National TeleMental Health Center for rare expertise. A lot of this infrastructure is in place. We are trying to take it to the next level and make sure it’s truly available everywhere, to all veterans.