Inside Oversight

Hello, and welcome back to another episode of Inside Oversight. This is your host, Adam Roy. The following episode you’re about to hear was previously published last year.
We’re republishing it here under Inside Oversight to ensure it reaches more listeners’ ears and further highlights the pandemic oversight work completed by the Veterans Affairs Office of Inspector General.
This episode focused on the Veterans Health Administration’s virtual primary care response to the COVID-19 pandemic. In it, you’ll hear from two directors with the Office of Healthcare Inspections as they discuss VHA’s pivot to virtual care during the pandemic and the challenges created by introducing technology to veteran patients.
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Meredith Magner-Perlin:
Hello, I am Meredith Magner-Perlin, an associate director at OIG and a co-team lead for the recently published report, Review of Veteran Health Administration’s Virtual Primary Care Response to the COVID-19 Pandemic. Today, I am speaking with my co-team lead, Laura Tovar, who is also an associate director with the OIG. The report we are going to discuss focuses on the Veterans Health Administration’s virtual primary care response to the COVID-19 pandemic. The time frame for this review was February 7, 2020 through June 16, 2020. We will refer to the Veterans Health Administration as VHA during our discussion.

Laura, why did the OIG conduct this review?

Laura Tovar:
Thanks Meredith. The onset of the COVID-19 pandemic presented significant challenges to healthcare delivery nationally, which included VHA. The OIG wanted to understand how VHA was delivering primary care during the early months of the pandemic. We focused our review on primary care, since it is traditionally delivered face-to-face in an office setting. At the time, VHA encouraged outpatient providers to deliver virtual care, as appropriate, supporting the safety of veterans and employees.

Meredith Magner-Perlin:
You said VHA encouraged virtual care, what does that mean?

Laura Tovar:
Simply put, virtual care is any care that is not provided face-to-face. This includes telephone and video conferencing. Prior to the pandemic, VHA allowed for virtual care to be conducted over the telephone or through VA Video Connect or VVC, a VA-specific video conferencing tool where veterans can virtually meet with their providers in an encrypted and secure environment. To use VVC, providers and veterans must have access to a computer, tablet, or smart phone as well as an internet connection. Also, at the start of the pandemic, VHA authorized the use of other video conferencing applications such as Zoom, FaceTime, and Skype—to maximize access to virtual care.

Meredith Magner-Perlin:
So, what did the review find?

Laura Tovar:
Well, Meredith, we found that VHA primary care did pivot to virtual care. Face-to-face primary care visits decreased by 75 percent during the time frame we reviewed. We also looked at VA-to-VA virtual primary care visits, a type of virtual visit occurring when the veteran and provider are in different VA facilities. These types of appointments decreased by 49 percent. Virtual care provided to veterans at home, which included telephone, VVC, and other video applications, increased during our study period. Interestingly, appointments by telephone were the most used method for virtual care—representing 81 percent of all appointments during that time.

Meredith Magner-Perlin:
Today, so many of us use smartphones as our primary tool to communicate. Our phones have so much technological capability built into them. Why were so many of the visits during the review period conducted over a simple phone call instead of using VA’s video conferencing tool or other authorized commercial applications?

Laura Tovar:
That is a great question. The review team wondered the same thing. We spoke with VHA leaders and they explained that at the beginning of the pandemic there were concerns about VVC capacity. To avoid any disruption of care, VHA encouraged staff to use the telephone if it was clinically appropriate, and if it was easier for them.

Meredith Magner-Perlin:
What were the capacity concerns?

Laura Tovar:
VHA had concerns about the number of concurrent VVC sessions that VHA could host at one time. This concern was especially relevant during the beginning of the pandemic, which, as you know, was our review period. VHA addressed its capacity concerns by adding additional video conference hardware and a cloud hosting environment to the system. This effort allowed for greater use of VVC.

Meredith Magner-Perlin:
You mentioned that the team spoke with VHA leaders, who else did you communicate with during this review?

Laura Tovar:
The OIG sent a brief questionnaire to primary care providers at 20 VHA facilities selected for this review.

Meredith Magner-Perlin:
What were some of the questions asked?

Laura Tovar:
We asked questions like whether providers had conducted at least one virtual care visit, and if they had, which virtual care method they used most. We asked if the providers and their patients were equipped with the technology needed to use VVC. We also gave providers an opportunity to comment on what helped or hindered the use of VVC.

Meredith Magner-Perlin:
What were some of the important takeaways from the questionnaire?

Laura Tovar:
It’s important to remember, that our time frame for the review was during the first few months after the pandemic started. Healthcare providers and patients were in a learning mode. Many patients had never used virtual care prior to the pandemic. Providers stated that while they were trained to use VVC, many of their patients were not, or they lacked the technology required, such as an internet connection or capable device. Patients with poor internet connections would experience broken or dropped calls, creating appointment delays and/or cancellations. Early on providers noted that making pre-appointment test calls on VVC were helpful. Providers also suggested increasing VVC technical support to patients with connectivity issues.

Meredith Magner-Perlin:
Outside of technology issues, did providers report any other barriers to using VVC?

Laura Tovar:
They did. Some providers noted that it was hard to schedule and re-schedule VVC appointments. To understand more about the VVC scheduling process, we spoke with VHA Connected Care leaders. They told us that VVC scheduling is complicated. The VVC scheduling process requires the use of two independent scheduling systems, which is more complicated than scheduling face-to-face or telephone appointments.

Meredith Magner-Perlin:
Did OIG find any opportunities for VHA to make improvements?

Laura Tovar:
Yes, we did. The team made two recommendations to VHA. First, we recommended that VHA evaluate veteran access to VVC, which included access to technology and the internet. The VA recognizes the adverse impact of the digital divide on veterans. Internet access, particularly during the COVID-19 pandemic, is critical for health care access, social engagement, employment, and education. Meredith, based on a Federal Communications Commission report from 2019, about 2.2 million veteran households lack either fixed or mobile broadband connections at home. In response, VA has established several mitigation initiatives over the last several years and accelerated key efforts during the pandemic.

Meredith Magner-Perlin:
Tell me more about the mitigation initiatives.

Laura Tovar:
No problem. Most recently, VA implemented a national digital divide consult integrated within the electronic health record. The consult is used when a veteran could benefit from telehealth services but lacks the technology or internet connection necessary to participate. The consult can lead to multiple mitigation strategies, like the Federal Communications Lifeline Program that assists veterans in establishing a Federal subsidy to pay for internet and technology.

Or the VA connected device program, where veterans without the technology and internet needed for telehealth, are loaned a 4G connected device. As of the end of November 2020, VA has distributed over 87,000 devices to veterans. The VA concurred with our first recommendation and intends to expand its current efforts and make improvements across several related areas by September 2021.

Meredith Magner-Perlin:
What about the second recommendation?

Laura Tovar:
For the second recommendation, OIG requested VA review its VVC training and technical support to veterans. VA concurred and is taking several steps to implement this recommendation. Each VA facility is establishing a VA Video Connect test call service to educate and support veterans who may not be comfortable with technology or are using telehealth for the first time. As part of the test call service, a VA staff member or volunteer will connect with the veteran and conduct a test call prior to his or her first clinical visit. VA is also establishing a support contract for its connected device program. When veterans receive a VA issued video device, a technician will help them set it up, educate them on its functions, and conduct an initial test call to prepare them for their first clinical telehealth encounter.

Meredith Magner-Perlin:
Thank you for your insight today, Laura.
Listeners, I hope you enjoyed this companion podcast. Read the full report at www.va.gov/oig. Also, check out our signup page and subscribe to receive every report in your inbox the day it publishes.

This has been an official companion podcast of the VA Office of Inspector General. Companion podcasts are produced by the Office of Communications and Public Affairs and are available at va.gov/oig. Please subscribe and tune in monthly to hear how our work is helping to improve the lives of veterans. Visit the website to learn more about how the VA OIG serves veterans by conducting meaningful independent oversight.

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