San Diego Veterans Affairs to make major push to get patients to embrace telemedicine in 2020
By PAUL SISSON FEB. 21, 2020
Retired JAG lawyer Neil Harrington enjoys visiting in person with a doctor, but the drive from his Carlsbad home to the Veterans Affairs medical office in Sorrento Valley means at least an hour-long round trip.
On a recent morning, Harrington skipped the drive. Instead, his face popped up on a computer monitor in one of the clinic’s exam rooms even though his person remained comfortably at home. A nurse helped him check his blood pressure using an at-home cuff the VA supplied. Then Dr. Nilesh Shah sat down in front of the camera attached to his computer workstation to discuss how the readings have been going lately.
“Nothing in the 130s to 140s?” Shah asked.
“No,” Harrington replied.
“Well, that’s perfect,” Shah said, proceeding to chat for a few minutes about family matters.
It was a quick visit, just a bit more than five minutes.
“Obviously, if it had been about something serious, I would have jumped in the car and driven down there, but for this kind of thing, video visits are just so much more efficient,” Harrington said.
The retiree has been availing himself of telemedicine appointments for about a year now, and VA San Diego hopes to persuade more of his colleagues to do the same. At present, about 60 percent of VA San Diego’s nearly 400 primary care physicians offer the service, and the organization is pushing hard for that number to hit 100 percent in 2020. The VA has long been a leader in the adoption of video-enabled remote visits. Locally, Shah, who also serves as the local VA’s telemedicine director, said that somewhere between 7 percent and 8 percent of patient encounters are conducted through a telehealth conduit of one sort or another with the percentage for mental health being much higher. That’s actually a bit lower than the national average. According to a white paper published by the VA, 12 percent of veterans received elements of their care electronically in 2016.
Dr. Nilesh Shah, who is at the VA Sorrento Valley Clinic, works with patient Neil Harrington, who is up in north county, on January 17, 2020 in San Diego, California. (Eduardo Contreras / The San Diego Union-Tribune) Compared to the rate of adoption nationwide, though, the VA is way out ahead. A deep-dive analysis released in July by FAIR Health Inc., a nonprofit data services firm, examined more than 29 billion private health care records and found that telehealth use for all medical claim lines increased 624 percent from 2014 to 2018, though such claims still represented less than 1 percent of all billing.
The VA, which gets the money it spends on care directly from the federal government, enjoys fewer barriers than the private sector does. For a long time, said Robin Gelburd, FAIR Health’s president, it has often been a struggle to get private health insurance companies to reimburse telehealth visits as they would were they conducted in person, and there are also licensing barriers that have slowed adoption rates in the wider health care world.
But telehealth, long posited as a way to increase the overall efficiency of health care by allowing medical professionals to move from patient to patient more quickly, has started to take on a certain inevitability, especially at the VA which has made wider adoption a national goal of its transformation efforts which have been driven by a national scandal that showed a dearth of available appointments that was deemed severe in some locations but less so in San Diego.
The key to the inevitability of telehealth, Gelburd said, is that its benefits are double-ended. Medical providers can increase efficiency while patients can benefit from convenience.
“There is a real opportunity for both sides to kind of marry that need for convenience and bridge what might be a dearth of access to services in a particular area,” Gelburd said.
Of course, this is far from a universal tool. Doctors still need to do in-person examinations in many cases, and while digital blood pressure cuffs, scales, pulse oxygen meters and blood glucose meters allow some important measurements to be handled remotely, there are still plenty of instrument-aided observations that require a trip to a doctor’s office.
The FAIR Health study found that certain conditions such as consultations about upper respiratory infections, mood disorders, contraceptive management and follow up on certain heart conditions made up the bulk of the national telehealth claims it analyzed. That’s roughly the case for VA San Diego, but Shah said there has been a significant emphasis with veterans on follow-up appointments for chronic conditions such as diabetes and chronic obstructive pulmonary disease. Today, the VA has about 700 patients under active monitoring for such conditions throughout the region.
Video visits, Shah said, seem to reach a peak of efficiency when they’re helping him to track a patient’s progress in reaching long-term goals such as lowering blood pressure or weight.
The VA’s teleconferencing system also allows him to bring in family members who may not be in the same city or state as a patient. For a long time now doctors have been using teleconferencing systems to connect remote family members to the exam room, but video, he said, just seems to deliver a different level of presence.
“I feel like seeing people, rather than just hearing them over the speakerphone, sometimes just provides a bit more, I don’t know, depth to the care,” Shah said.
Of course, video links, even though they do tend to be in high definition these days, still don’t convey the full body language of an in-person visit. A big part of what’s often called the art of medicine involves doctors sussing out not just what patients are saying but what they’re not saying. While body language definitely does not come through a video link as well as it does in person, Shah said that the kinds of follow-up appointments that tend to work well for telehealth usually don’t require such a nuanced approach. Usually, there is plenty of information on hand to show where a patient’s condition is headed in comparison to where it has been.
“I look at all of my patient charts before they come in, so I see how often they’ve refilled their meds, I see what their labs show, and that’s where I’m being clued in to what’s happening,” Shah said.
More than 80,000 local veterans get their primary care from VA doctors, and they will begin to notice increased offers of video visits this year, Shah said. A program on the horizon also aims to conduct in-home initial evaluations for cardiothoracic surgery over a telehealth link. Because the San Diego VA is a regional center for these types of procedures, it’s likely that patients as far away as Loma Linda or Long Beach may be able to avoid traveling to San Diego for initial visits.