Telehealth uses electronic communications to exchange medical information from one site to another. Some of the services that can be provided via telehealth can include the use of live interactive video or the store-and-forward transmission of diagnostic images, vital signs, and/or other patient data important for diagnosis and treatment. Telehealth can also apply to remote patient monitoring that utilizes devices that remotely collect and send data to a home health agency or a remote diagnostic testing facility for interpretation.
VA Telehealth Services uses health informatics, disease management and telehealth technologies to target care and improve access to care for all Veterans. VA telehealth helps to ensure that Veterans get the right care in the right place at the right time - and aims to make the home the preferred place of care, whenever possible. Some examples of VA telehealth include:
VA continues to add new telehealth specialties, including TeleCardiology, TeleGenomics, and TeleNeurology, to name a few.
Following are just some of the research studies HSR&D funds to help improve telehealth services for Veterans.
Depression is especially problematic for Veterans, with substantial depressive symptoms 2 to 5 times more likely than in their civilian counterparts. Cognitive behavioral therapies are the most recommended forms of psychotherapy for depression, but older Veterans can experience barriers to receiving care, such as mobility issues and living in rural areas. Telemedicine could increase access to evidence-based care for older Veterans; thus, this randomized study assessed the efficacy of psychotherapy delivered to older Veterans via telemedicine in their homes. Between April 2007 and July 2011, Veterans (n=241) aged >58 were recruited from the VA medical center and four associated community-based outpatient centers in Charleston, SC, and then were randomly assigned to either telemedicine or same-room psychotherapy. The primary outcome was treatment response: 50% reduction in symptoms from baseline to 12 months and no longer being diagnosed with major depressive disorder at 12 months, depending on the instrument used. Findings show:
Implications: This study represents a timely and significant addition to the field, as it provides novel results to inform implementation of evidence-based mental health treatment (Hoge & Rye, 2015). Findings suggest that home-based telemedicine can be used to overcome barriers to care associated with distance from - and difficulty with attendance at in-person sessions. Investigators suggest that resources be devoted to offering services directly into patients' homes via telemedicine methods.
Principal Investigator: Leonard Egede, MD, MS, is Director of HSR&D's Charleston Health Equity and Rural Outcomes Innovation Center (HEROIC) in Charleston, SC.
Egede L, Acierno R, Knapp R, et al. Psychotherapy for depression in older Veterans via telemedicine: A randomized, open-Label, non-inferiority trial. Lancet Psychiatry.August 2015;2(8):693-701.
Women Veterans are a rapidly growing proportion of VA patients. To address some of their unique healthcare issues, VA is implementing two innovations:
Combined, this women's health educational and virtual consultation program is referred to as "DWHP Support."
This ongoing HSR&D funded study is assessing the effect of DWHP Support on the quality and efficiency of women's healthcare by exploring its impact in changing DWHP clinical practices and self-rated women's health knowledge, skills, and self-efficacy. Investigators also are examining attitudes about DWHP support, its implementation, and other features that could influence effectiveness, sustainability and spread. Thus far, findings show:
Implications: Findings from this study have already impacted clinical operations by leading to its focus on GYN SCAN-ECHO - and by securing protected time for participating DWHPs. Investigators also anticipate that this study will inform the ongoing development of DWHP Support and other VA WH educational/clinical innovations. Moreover, findings on DWHP Support's effectiveness and implementation will influence VA's approach and use of technology-supported interventions for other clinical conditions and special populations.
Principal Investigator: Donna L. Washington, MD, MPH, and Co-principal investigator, Kristina M. Cordasco, MD, MPH, MSHS, HSR&D's Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, CA.
Cordasco K, Zuchowski J, Hamilton A, et al. Early lessons learned in implementing a women's health educational and virtual consultation program in VA. Medical Care. April 1, 2015;53(4 Suppl 1):S88-92.
Annually, about 30,000 Veterans receive inpatient detoxification (detox) for substance use disorders (SUDs). Detox inpatients who enter SUD treatment and peer-based mutual-help groups (e.g., Alcoholics Anonymous) have much better outcomes than those who do not, including less substance use, re-hospitalizations, and emergency department visits. However, because of their unique characteristics (severe and chronic addictions, comorbidities, lack of resources, self- and provider-perceptions as unsuitable for treatment), most Veterans discharged from inpatient detox do not enter SUD treatment. Therefore, the primary objective of this HSR&D ongoing study is to implement and evaluate Enhanced Telephone Monitoring (ETM) as a new and innovative telehealth intervention to facilitate the transition from inpatient detox to SUD specialty treatment (residential, outpatient, pharmacotherapy), thereby improving Veterans' outcomes and decreasing VA healthcare costs.
In a randomized trial at two sites (VA Palo Alto and VA Boston), Veterans with substance use disorder receiving ETM will be compared to Veterans with SUD in usual care. Patients in the ETM condition are receiving an in-person session while in detox, followed by coaching over the telephone for three months after discharge. The intervention incorporates motivational interviewing as well as reinforcement to provide support for Veterans while they wait for treatment. The intervention also facilitates entry into treatment and mutual-help, and improves responses to crises. Veterans are assessed at baseline, and three and six months post-discharge for outcomes.
Implications: Telehealth interventions have not yet been used to help inpatients going through detoxification. Therefore, this project will help increase Veterans' access to, engagement in, and benefit from SUD treatment services, particularly among Veterans who need SUD services but are not receiving them.
Principal Investigator: Christine Timko, PhD, HSR&D's Center for Innovation to Implementation (Ci2i): Fostering High-Value Care, Palo Alto, CA.
Most Veterans with post-traumatic stress disorder (PTSD) experience chronic insomnia that has independent, negative effects on quality of life and may exacerbate other symptoms of PTSD. Cognitive behavioral therapy for insomnia (CBT-I) is highly effective in patients with primary insomnia, but the lack of clinicians trained in CBT-I limits Veterans' access to this treatment. Video teleconferencing holds the promise of increasing access to care for Veterans living in rural and remote areas. This ongoing HSR&D study is evaluating the delivery of CBT-I to groups of Veterans with PTSD and chronic insomnia via video teleconferencing. Specifically, investigators will:
Veterans with PTSD and chronic insomnia who receive their primary care at community-based outpatient clinics (CBOC) affiliated with the Philadelphia VAMC are being randomized to receive one of the following interventions in a group setting at their CBOC: 1) manual-based CBT-I program delivered via video teleconferencing; 2) CBT-I program delivered in-person; and 3) in-person delivery of sleep hygiene education, a known active control intervention. Study participants are being assessed at baseline, and two weeks and every three months following the intervention. Thus far, investigators have completed participant enrollment, and data collection is expected to be completed by October 31, 2016.
Implications: Study findings are expected to provide the evidence needed to justify clinical implementation of this telemedicine model for CBT-I delivery to Veterans with PTSD. This will significantly increase access to treatment, particularly for Veterans residing in remote and rural settings, and also will decrease treatment-related costs.
Principal Investigator: Sam Kuna, MD, HSR&D's Center for Health Equity Research & Promotion (CHERP), Philadelphia, PA.
Parkinson's disease (PD) is the second most common neurodegenerative disease, affecting more than one million Americans. The principal clinical manifestations of PD are motoric, which limits functional mobility leading to difficulty working, caring for family members, or managing a household - and to overall decreased independence and quality of life. Increasing data indicate tremendous benefits of exercise for patients with PD. Not only have exercise programs been shown to improve motor function and reduce the risk of falls, but they also improve overall quality of life and possibly the course of disease pathology. However, programs that involve supervision in the home of people with PD are expensive to roll out widely, and programs that involve people with PD traveling to a central site not only result in non-compliance over time because of difficulty getting to the site, but also rule out the involvement of a large number of people with PD who simply live too far from larger centers where such programs are typically established.
The goal of this ongoing HSR&D study is to evaluate the effectiveness of a home-based approach to providing the known benefits of a safe exercise program for Veterans with PD. This randomized controlled trial of a structured exercise program will examine the effects on fall rates, physical functioning, and quality of life. Community-dwelling Veterans with PD will be randomized either to a group who receives structured and remote exercise instruction and supervision in real-time, or a group who receives an educational healthy lifestyle program. The interventions will last one year.
Implications: Study findings will help make effective exercise programs available to the many Veterans with Parkinson's disease who are currently unable to participate in such programs due to distance from a facility providing such a program, or limited functional mobility making travel to a facility-based program difficult.
Principal Investigator: Daniel Sparrow, DSc, is part of the VA Boston Healthcare System.
Many patients with chronic medical illnesses continue to smoke, and there is a strong interrelationship between depression and chronic medical illness. Depression can derail sustained smoking cessation and may be an important barrier to smoking cessation for Veterans with chronic medical illness; thus, depressed smokers are more likely to quit when behavioral mood-management is added to traditional cessation approaches. Telephone counseling can deliver intensive and effective treatment to people who smoke, yet its implementation has been limited among smokers with depression. The aims of this ongoing HSR&D study are to:
Using VA data, investigators will identify Veterans with chronic disease who receive treatment at the Durham VA Medical Center, and who were screened for tobacco use and depressive symptoms. The main outcome they will examine is prolonged smoking abstinence at 6-month and 12-month follow-up. If there is a significant intervention effect on smoking cessation, further analysis will be conducted to assess whether changes in self-efficacy, affect, and motivation to quit mediate the impact of the mood management intervention.
Implications: By studying the impact of mood enhancement on Veterans who smoke and have depression, along with chronic disease, VA may better understand how to sustain abstinence from smoking among patients in this group.
Principal Investigator: Jennifer Gierisch, PhD, is part of HSR&D's Center for Health Services Research in Primary Care in Durham, NC.