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Rural Vets May See More Options for Telemedicine

Army Veteran Herbert Lang (seated, right) is examined by his Lovell FHCC cardiologist Dr. Eric Yeung (on screen) during a follow-up appointment at the McHenry Community Based Outpatient Clinic. (DoD photo)
Army Veteran Herbert Lang (seated, right) is examined by his Lovell FHCC cardiologist Dr. Eric Yeung (on screen) during a follow-up appointment at the McHenry Community Based Outpatient Clinic. (DoD photo)

The Veterans Affairs Department is researching how to improve the quality of care for veterans in rural areas with serious or chronic conditions.

A telehealth collaborative care study announced in January is surveying about 800 veterans in rural areas in Texas and Georgia who have been diagnosed with human immunodeficiency virus, or HIV. Led by Dr. Michael Ohl, the survey focuses on regions where VA has an HIV specialty clinic.

"Veterans should have easy access to HIV testing and state-of-the-art HIV care regardless of where they live," Ohl, an infectious disease specialist, said in a release. "We know that compared to their urban counterparts, rural veterans with HIV enter care with more advanced illness, are less likely to receive the latest advances in HIV treatment, and have lower survival rates. We want to change that."

In addition, providers and healthcare organizations of telehealth medicine in Alaska, where most communities are rural, may be able to offer their expertise to the effort.

Laurali Riley, a former Army combat medic and program manager of a statewide HIV initiative and outreach service through the Alaska Native Tribal Health Consortium, said the state is one of the forerunners for "having telemedicine for not only having it integrated into our healthcare system but as a solid health care delivery."

Riley said she has seen a daily average of 20 to 30 video appointments -- provided by AFHCAN Telehealth Solutions -- between physicians and patients.

Alaska is a low-incident state for HIV patients due to its overall low population. However, because communities are so small, care options are few and far between.

"But the issue is, if you've got a community of say 400 people, and you have one person affected by HIV, your option for care is going to be diminished greatly," Riley said in a recent interview with Military.com.

ANTHC supports the telehealth solutions network, which serves veterans with HIV.

Through the VAs research, Ohl, who works out of the Iowa City VA Health Care System, and his team are finding that those offered telehealth choose to use the option.

The "VA offers close to 50 telehealth specialties. During fiscal year 2016, more than 700,000 veterans completed approximately 2 million telehealth appointments," the department said.

The study, funded through September, claims that approximately 18 percent of the 24,000 veterans in care for HIV infection in the U.S. live in rural areas and have limited access to specialized health care for their disease.

From an outside perspective, Riley said it's now up to the VA to get patients to feel "confident in [telehealth] utilization."

Each state's healthcare system is reflective of the needs of the patient and the services offered. Alaska, for example, has only 268 miles of paved roads, Riley said. "Every place we have to go to is either by boat or plane," she said. But an infectious disease such as HIV requires constant communication between doctors and patients, Riley said.

"Live delivery is really setting up a patient-to-provider video visit, which makes a lot of sense for rural healthcare delivery if we have access to the technology -- which we do," she said. "And it really helps with a lot of chronic disease management, especially HIV," Riley said.

Whether the contact is face-to-face or via video, "were still getting the same information that we need" to treat the patient, Riley said. "It's like secure Skype. It's going to be on a secure platform."

Even though some of the systems have been available for quite some time, the technology is still evolving -- especially for patients who may not know how to approach telehealth as an option for medical care, she said.

"What I've seen the VA do is a lot of patient education on their options," Riley said. Because "people are very averse to change when it comes to their healthcare, and not just veterans. Everybody."

Riley said AFHCAN for HIV clinical delivery still encourages televideo conferencing outside the home in some type of clinical setting, because it's much easier to pair up with lab work, medication changes with either a nurse or mid-level physician assistant available to address questions or concerns.

Aside from video conferencing -- all provided by a clinic via computer webcam -- Alaska has also been experimenting with store-and-forward technologies for over a decade, she said.

"You're thinking about things like labs, you're thinking about things like health records … and if you ever need a referral … for somebody that is outside of primary care, accessing your records can [sometimes be] a nightmare," Riley said.

But with store-and-forward, a cloud-based system, "we can transfer that information securely … and be able to keep that information for the patient living outside of" a primary care network, she said.

"Telemedicine is all the about the technology that's available," Riley said. Furthermore as providers, "we need to make sure that if we're going to be delivering any sort of telemedicine -- whether it's live or store-it-forward -- that security options are not only put in place, but they've been tested and carried out."

Since providers more often than not are in a dense, city environment like Anchorage and patients can reside anywhere, Riley said work evolving in the telehealth field is now focused on deploying protocols, policies and procedures for credentialing purposes.

"All of our providers, including myself that deliver telemedicine, were under a telemedicine agreement with other clinics we are providing care to with patients that live outside the Anchorage area.

"So we need credentialing agreements that are set up between [a] hospital, and then the patient's … site, clinic or 'hub' hospital so that we can work with their nurse case managers," she said.

Riley said that while it's hard to quantify, the entire ANTHC -- in both store-and-forward care and live video conferencing for any ailment -- in fiscal 2015 had a total estimated travel cost avoidance of $10.8 million because of telehealth.

And as a credentialed service, "we can bill and get reimbursed for the telemedicine visits, which is great for our providers," she added.

The goal is simple: keep talking to patients at all costs.

"People with HIV, and especially veterans, need that continuity and care; they need that consistency," she said. "Not just in providers, but in a program. They need to know somebody's got their back -- they need to know they're not alone."

-- Oriana Pawlyk can be reached at oriana.pawlyk@military.com. Follow her on Twitter at @Oriana0214.