In various previous blog notes, I have strongly advocated for the expansion of telemedicine across most sectors of the healthcare system. My rationale for this recommendation is that it's one of the only ways to expand healthcare delivery in a cost-effective manner. The approach also avoids the rigidity of a bricks-and-morter strategy with physical facilities becoming quickly outmoded as the style of practice changes. The VA is now finalizing plans for its telehealth program. In order to achieve this goal, the VA is circumventing the various state rules governing the licensing of providers. All of this was described in a recent article (see: VA finalizes telehealth rule to let providers practice across state lines). Below is an excerpt from it:
The U.S. Department of Veterans Affairs finalized its federal rule to allow providers to deliver patient care across state lines and outside of a VA facility using telemedicine. Former VA Secretary David Shulkin, MD, and President Donald Trump first began to push for telemedicine expansion in August through the Anywhere-to-Anywhere initiative....This final rule gives the VA the needed authority to override state restrictions that would inhibit providers from treating patients outside of the agency or their region.....The preemption of state laws was necessary, according to officials, as it would be impractical for VA to lobby each State to remove any restrictions that impair VA’s ability to furnish telehealth services to beneficiaries and then wait for the State to implement appropriate changes. In doing so, the growth of telemedicine usage within the agency would be delayed. And officials are banking on this tool to combat wait times and improve care access to patients. The agency was plagued with scandal in 2014 due to egregious wait times and staff incorrectly recording those numbers. Officials said the rule will also support veterans in rural areas who would have to travel a long distance or cross state lines to see a doctor. The rule will expand access to critical care, like mental health, to provide faster service through the platform.
I believe that the VA will probably not be successful in this telemedicine venture despite having the handy legal ability to work around state licensure rules. My reasons for such a prediction is that, first of all, the VA has never been strong in a managerial sense (see: Why the Military and the VA Healthcare Systems Are Not Amenable to Change). Superimposed upon the previous history of the VA as bureaucratically and managerially inept is the recent chaos imposed on the VA by Present Trump causing political upheavals (see: V.A. Medical System Staggers as Chaos Engulfs Its Leadership). In other words, the VA medical system is probably incapable of even minor reforms let alone the deployment of a major telemedicine initiative.
I also think that it's possible that VA administrators might perceive that the deployment of telemedicine would be relatively easy because no changes in physical facilities are involved. Not only does telemedicine require a sophisticated IT infrastructure but also a comprehensive retraining of physicians and nurses. Systems like the Cleveland Clinic (see: Details of Cleveland Clinic's MyCare Online Virtual Telemedicine Visits) and Intermountain (see: Intermountain Healthcare Launches Telemedicine Program with Connect Care) have rolled out such programs incrementally, refining the process over time. American Well is the purveyor of the IT platform used by the Cleveland Clinic and other major health systems. I found an interesting article by the company that identified three factors that were responsible for a the successful telehealth program at the Clinic (see: How telehealth has enhanced Cleveland Clinic’s value-based care strategy). They are listed below.
- Staff engagement.
- EMR integration.
- Patient awareness.
All of these three points are extremely salient and I think that they all will pose challenges for the VA. For example and given that the VA has only now finalized its EHR contract with Cerner, it will be preoccupied with this EHR installation for years to come (see: VA Signs $10 Billion Health Records Contract With Cerner).