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Director's Letter

VA is the leading provider of telehealth in the United States. Thanks to the forward-thinking leadership of prior Under Secretaries for Health and in the Office of Connected Care, VA has recognized for two decades that offering more options for remote care could be better for Veterans. Because VA serves patients who often live far from major medical centers and because we are not constrained by payment structures that disincentivize telehealth visits, VA has developed a robust set of tele- health interventions including store-and-forward technology for services such as radiology and diabetic eye screening; video patient visits, initially between VAMCs and CBOCs but now directly to the home; and text and email communications between patients and provider teams.

As telehealth has advanced, our research needs to catch up. Early telehealth research often focused on the simple question of whether a telehealth visit led to comparable outcomes as a face- to-face visit. In a world where patients will increasingly get their care through a combination of in-person visits and remote contacts, we need to adapt our research priorities to a new set of critical questions.

1) What level of in-person care is optimal for which patients? The paradox is that those high-risk patients whom clinicians most want to see in person are often those for whom travel is most difficult. Given that we have precious little evidence to determine optimal visit frequency, we have even less to inform how to opti- mize the mix of visit types.

2) What are the long-term effects of more remote care on important patient outcomes such as trust, patient engagement, and continuity? What role does in-person contact, especially with different team members, and human touch play in building a lasting relationship with a provider and a care team? With whom can telehealth increase engagement by reducing barriers to access?

3) How do we integrate team care into a virtual environment and how can technology help us do that more effectively? We know in the COVID-19 pandemic that certain aspects of team-based care suffered; handoffs were harder, intake screenings were foregone, basic data for measurement-based care were often missing (e.g., depression screening scores).

4) How can we conduct group visits effectively in a remote environment? There are many services for which group visits have proven very effective and efficient, such as diabetes education. Many counseling services work more effectively with a peer group. How can we transition those group meetings into a remote environment?

The COVID-19 pandemic has shown us that we can deliver a lot more care remotely than we thought. We are never going back to the pre-COVID-19 era where face-to-face care was the default standard for medical care, any more than we are going back to a world where we spend 100 percent of our work life in an office.
The challenge for researchers, in this fast-changing world, is to help our partners learn how to capitalize on all the potential benefits of this new paradigm while reducing and mitigating the potential downsides.

David Atkins, MD, MPH, Director, HSR&D