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Using Telemedicine to Reduce Wait Times for Veterans

By Richard J. Boxer, MD
May 10, 2016
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Although it’s not a replacement for all face-to-face care, telemedicine could make a significant impact for those with simpler needs.

—Richard J. Boxer, MD

John Farrow, a 67-year-old Vietnam veteran, had not been able to sleep for days. A week ago, his primary care doctor at his local outpatient Veterans Administration (VA) clinic told him that his prostate-specific antigen (PSA) blood level was rapidly increasing, and his prostate was abnormal on examination. His brother and father had similar findings years ago, and they had prostate cancer.

To learn more, Mr. Farrow (not his real name) would need to see a specialist in West Los Angeles, the closest fully staffed VA in the state. But to get there, he’d have to drive 5 hours from his home in Atascadero, California, and back.

Over the past year, the VA has been accused of wrongdoing, ranging from administrative inefficiency to straight-out fraud. According to reports, many veterans were made to wait for months before receiving care—delays that are thought to account for upward of a few dozen preventable deaths. Three of the patients had prostate and bladder diseases and died as a result of delay in treatments.

The unconscionable behavior of a few has thrown a shadow across the efforts of the dedicated caregivers who work in earnest to fulfill the VA’s stated mission: “To serve those who serve.” But it has also given us a chance to rethink how we approach our service in the future.

Amid this fallout, Congress has allocated an additional $15 billion to help the VA address these issues.1 The challenge now is in using that funding effectively and efficiently to reshape its approach to patient care.

The New World of Connected Health

One avenue the VA could take to modernize its operations, provide more patients timely care, maintain quality standards, and save money at the same time is telemedicine. The new world of connected health has given rise to novel approaches, ranging from the simple availability of doctors via instant chat to military applications allowing instantaneous response and relief for wounded soldiers. This technology let’s them contact teletrauma specialists directly from the field, drastically improving the odds of survival.

Thus far, the VA’s use of telemedicine has been effective but limited. At the West Los Angeles VA, a new teleurology clinic opened 18 months ago, allowing veterans to opt for private video consultations with board-certified physicians instead of in-person meetings. Already, these efforts have brought down wait times from an average of 7 weeks to about 1.5 weeks—an 85% decrease. Not only that, but it has also increased the number of initial patient visits by nearly 10%—a remarkable number considering that 3,000 veterans seek new urologic consultations at the West Los Angeles VA alone.

As any doctor will tell you, getting patients to come in sooner has a tremendous impact on their odds for survival before the illness progresses too far. Early diagnosis could mean the difference between a bad cough and pneumonia or between a sore leg and a pulmonary embolism.

Although it’s not a replacement for all face-to-face care, telemedicine could make a significant impact for those with simpler needs. Digital health care is just as effective as in-person care in these scenarios, according to the American Medical Association.

In 2016, nearly 100 million outpatient visits will occur at the VA.2 Included in that number are a projected 800,000 televisits across 44 specialties. Based upon studies in the private sector, where 80 million doctor visits occur each month, estimates show that as many as 30% of visits could be performed via technology.3 Thus, in the VA system, there will be less than 5% of the potential televisits.

Changing that ratio could mean not only that more veterans will be able to see doctors sooner, but that they may be more likely to see them in the first place. In the long haul, it could significantly expand veterans’ access to quality care and add efficiencies across the system.

Telemedicine in Action

For Mr. Farrow, the choice was easy to make.

After our 30-minute video session, I ultimately recommended that he receive a biopsy, followed by a telemedicine visit to discuss the results of the test. In the end, he came to Los Angeles for the procedure—an outcome that could have taken two 10-hour drives and another 6 weeks of waiting had he gone the traditional route. Removing that wait time allowed him to make up his mind more quickly—and to receive care more swiftly.

“He would not admit it, but the stress of not knowing immediately was nearly overwhelming,” Mrs. Farrow confided to me during the initial consultation. “I never saw him that way before. Now, I can tell there has been a cloud lifted from him.” ■

Disclosure: Dr. Boxer reported no potential conflicts of interest.

References

1. VA got $15B from Congress,
still can’t fix problems. Newsmax. April 30, 2015. Available at http://www
.newsmax.com/Newsfront/va-billions-wait-times/2015/04/30/id/641658/. Accessed April 20, 2016.

2. U.S. Department of Veterans Affairs: Trends in the utilization of VA programs and services. Available athttp://www.va.gov/vetdata/docs/quickfacts/Utilization_trends_2012.pdf. Accessed April 20, 2016.

3. New England Healthcare Institute: A matter of urgency: Reducing emergency department overuse. An NEHI Research Brief, March 2010. Available at http://www.nehi.net/writable/
publication_files/file/nehi_ed_overuse_issue_brief_032610finaledits.pdf. Accessed April 20, 2016.

December 09, 2015

Vaccinations: Protect you and your community

December 09, 2015/ Richard Boxer

Each year the Centers for Disease Control (CDC) encourages Americans to receive the flu vaccine to significantly reduce the chance of contracting the miserable illness that causes fever 100o F or higher, chills, muscle aches, cough, congestion, runny nose, headaches, sore throat, and fatigue. The flu is not just an annoyance: More than 200,000 people are hospitalized in the United States from flu complications each year. The flu also can be deadly. Over a period of 30 years, between 1976 and 2006, estimates of yearly flu-associated deaths in the United States range from a low of about 3,000 to a high of about 49,000 people during the most severe season.

Most people who skip the influenza vaccination every year because of myths: they will never get the flu; the flu isn't dangerous; the vaccination gives you the flu; I will notget terribly sick from the flu if I'm infected.

Of all these reasons, only the last is true -- and only for a certain group of people. For healthy young adults, it is unlikely that the flu will be deadly or dangerous enough to require hospitalization. But there is an extremely good reason to get vaccinated:

Receiving the flu vaccine does more than provide a very high rate of immunity to you, it affords your loved ones and your entire community reduced chances of getting the flu. The process of conferring immunity to those within a highly immunized population is called “herd” or community immunity. Even those who are not eligible for certain vaccines—such as infants, pregnant women, people allergic to eggs from which the vaccine is created, or immune-compromised individuals (AIDS, cancer) —get some protection because the spread of contagious disease is contained.

The principle of community immunity applies to control of a variety of contagious diseases, including influenza, measles, mumps, polio, and pneumococcal disease.

Reluctance to get a shot every year is part of the reason why national flu vaccination rates are so dismal -- about 40 percent of the country each year -- far below the 80 percent to 90 percent needed to achieve herd immunity and protect the most vulnerable in the population.

In the illustration (http://www.vaccines.gov/basics/protection/) the top box depicts a community in which no one is immunized and an outbreak occurs. In the middle box, some of the population is immunized but not enough to confer community immunity. In the bottom box, a critical portion of the population is immunized, protecting most community members.

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Using Telemedicine to Reduce Wait Times for Veterans

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