Use of the Veterans Health Administration's telehealth platform has exploded during the COVID-19 pandemic. But the agency's infrastructure has struggled to keep pace.
Since providers and patients started self-quarantining in early March, the number of virtual visits using the Department of Veterans Affairs telehealth app has spiked from about 2,000 per day to nearly 20,000.
Patients and practitioners say that's straining the system. They say many virtual appointments are hampered or have to be canceled because of technology problems.
Antonio, an Army veteran in his thirties, is one patient who's had trouble with the VA's Video Connect app. He asked to remain anonymous because he has ongoing disability claims with the department.
Antonio says a video visit with his social worker devolved into sign language.
"Immediately we had video but no audio," Antonio remembered. "I could see that she was talking. I looked at her and pointed to my ear and nodded my head, like, 'No I can't hear you.'"
The provider made some adjustments on her end, but the audio and video feeds kept alternating.
"Then we can hear each other, but not see each other," he said. "It just wasn't working at all."
The two opted to finish the appointment using Apple FaceTime instead.
Antonio said he doesn't think the problem was on his end. He has high speed internet and considers himself tech savvy. Instead, he said he believes the issue was either user error or a bad connection on the provider's side.
Two subsequent telehealth visits were a mixed bag: one went flawlessly, the other had audio issues.
"The quality's kind of all over the place," Antonio said. "It's either really smooth or really bad. There’s no in-between."
A quick shift to telehealth
The VA has been building its telehealth infrastructure for years, initially catering to rural veterans who lived far from VA facilities. From there, the agency began to offer new services and expanded to include more veterans who needed or wanted to remain at home.
In response to the COVID-19 pandemic, the VA has rushed to expand its virtual health programs. Last month, the department got more than $2 billion from Congress to support its quick shift to telehealth.
Among other things, the funding will help build on existing IT networks and enhance the VA's ability to offer telehealth visits. Users hope the expansion will relieve some of the issues that have plagued the telehealth platform.
"Probably the most common difficulty is having a hard time understanding what the veterans are saying, which is usually a bandwidth or reception issue on their end," said Dr. Ira Kedson, president of the American Federation of Government Employees chapter in Coatesville, Penn. and a VA psychologist. "But who knows, because we're all sharing the same VA Video Connect bandwidth.”
Kedson said getting onto the platform — and staying on — can be a challenge for VA clinicians as well as patients.
"There are times when providers can't get into the sessions. We get an error message saying that the resource is not available," he said. "There are times when people will get kicked off."
Internal medicine doctor Leonie Heyworth, the VA's head of synchronous telehealth, said the agency built its own telehealth infrastructure in order to meet privacy standards and allow for certain veteran-focused functions.
"The architecture by which we deliver the connections and the actual link to connect to the video visit is something that … we have built for VA uniquely," Heyworth said.
In response to the pandemic, the VA has tried to increase the amount of bandwidth available to providers who are working remotely. It's also beefing up its servers to allow more people to use VA Video Connect at once.
"We had planned to increase the capacity gradually over time," Heyworth said. "But because of the time-sensitive need - a real pivot to the virtual care offerings - we wanted to make sure that there were plenty of connections available for people to be in session at the same time."
The VA doesn't track how many video visits fail or drop out, though it's working toward that. Heyworth admits the transition to telehealth has been challenging. But she pointed out that many factors influence how well virtual visits go.
"Because of the variability in cellular signal where some of our veterans live, variability in broadband access, it can be difficult to know, connectivity-wise, without really doing an analysis," Heyworth said.
While the telehealth ramp-up continues, the VA has made it possible for patients and practitioners to use other private video platforms as alternatives, like FaceTime, Doxy.me and Cisco WebEx.
If all else fails, appointments also can take place on another very familiar conferencing tool: the telephone.
This story was produced by the American Homefront Project, a public media collaboration that reports on American military life and veterans. Funding comes from the Corporation for Public Broadcasting.