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Access to VA Health Care in the Digital Age

The U.S. health care system has been characterized as fragmented, delivering acute episodic treatment with little information sharing across providers and minimal care coordination over time.¹ The U.S. health care system also relies predominantly on face-to-face encounters between patients and providers, with hardly any communication in between encounters. In contrast, the VHA health care system is an integrated system of care that has an assortment of e-health technologies that promote patientprovider communication outside the context of a face-to-face clinical encounter, and an electronic medical record that facilitates provider-to-provider communication.² VHA is also embracing the patient centered medical home model with its emphasis on care teams and enhanced patient access through digital channels of communication.³ One can envision a future VHA health care system that relies less on the episodic delivery of treatment during face-to-face encounters between Veterans and their providers, and more on proactive non-encounter-based digital communications between Veterans and their care teams. With access being one of Secretary Shinseki's three major themes, the VHA health care system should be an exemplar for how to deliver continuous and coordinated health care in the digital age.

Digital Health Care Utilization

Digital communication modalities include cell phones, smart phones, interactive voice response, text messages, emails, clinic-based interactive video, home-based webcams, personal monitoring devices, kiosks, dashboards, electronic medical records, personal health records, Web-based portals, social networking sites, secure chat rooms, and online forums. There are at least five categories of digital health care utilization that use these communication modalities as an alternative to face-to-face interactions. Synchronous digital patient-to-provider encounters include encounters in real time where the Veteran and the provider are located in different geographic locations. Asynchronous digital patient-to-provider communications include interactions between the Veteran and the provider where there are time lags in communication. Digital provider-to-provider communications include synchronous and asynchronous discussions between the members of a virtual caregiver team (including informal caregivers). Digital peer-to-peer communications include synchronous and asynchronous discussions among Veterans to share information and practical advice, and to provide mutual support. Synchronous digital interactions between patients and computers include personal computer- and smart-phonebased applications that present information or deliver therapeutic treatments.

Digital Access

The traditional conceptualizations and measures of access (e.g., providers per population, travel times, usual source of care, out-ofpocket costs) focus exclusively on face-toface, patient-to-provider encounters and are not well suited to measuring access to digital encounterless communications. As the paradigm of VHA health care delivery evolves, it is imperative that our conceptualization of access undergoes a concurrent paradigm shift to make it more relevant for the digital age. For the digital age, access to care should be redefined more broadly as the opportunity and potential ease of having face-to-face and virtual interactions among a care team (including a patient and their formal providers, informal caregivers, peers, and computer applications). Access is a multidimensional concept that includes the following domains: geographical, temporal, financial, cultural, and digital. Digital access represents the connectivity that enables synchronous or asynchronous digital communications with providers, peers and computerized health applications, and the connectivity that enables communications among the caregiver team and the sharing of relevant clinical information. Improvements in digital access could drastically diminish the geographical, temporal, and cultural access problems faced by many Veterans. Synchronous digital communications can alleviate the travel burden associated with utilizing many, but not all, types of health care services. Asynchronous digital communication can diminish the time burden, as Veterans upload and download clinical information at times that are convenient to them. Computer applications can be designed to educate Veterans in order to help them better understand their treatment options/plans, thereby improving the cultural acceptability of treatment. On the other hand, a growing digital divide for low income, minority, rural, and elderly Veterans could create greater access disparities for these Veteran populations.

Access Research

To address these important issues, the 2010 VA State of the Art (SOTA) conference focused on Veterans' access to the VHA health care system. The objectives of the conference were to synthesize the literature on access in order to summarize accumulated knowledge and make policy recommendations, and to identify gaps in knowledge and make recommendations about HSR&D research priorities. Just as improving access is a priority for Secretary Shinseki, enhancing access research must be a priority for HSR&D. HSR&D investigators need to develop and evaluate interventions that improve digital access to care, including programs designed to improve connectivity and the usability of digital communication modalities. In addition, HSR&D investigators need to develop and validate access measures that are relevant in the digital age so that VHA can monitor and adapt itself to better accomodate the needs of Veterans in the 21st century.

References

1. Bashshur RL, Shannon GW. National Telemedicine Initiatives: Essential to Healthcare Reform. Telemedicine and e-Health 2009; 15(6):600-10.
2. Naditz A. Telemedicine at the VA: VistA, My-HealtheVet, and other VA programs. Telemedicine Journal and e-Health 2008; 14(4):330-32.
3. Rosenthal TC. The Medical Home: Growing Evidence to Support a New Approach to Primary Care. Journal of the American Board of Family Medicine 2008;21(5):427-40