The term connected health refers to technologies 

that extend the health care relationship beyond 

the traditional in-person synchronous encounters that for so long have been the centerpiece 

of patient/provider interactions. Connected 

health technologies include telehealth, telemedicine, patient portals, mobile health applications 

(mHealth), wearable monitoring devices, and 

other technologies that connect patients to their 

health care team or health resources.

These connected health technologies are rapidly evolving, promoting a greater focus on 

patients and their caregivers, driving patient 

expectations for easier sharing of personal 

health information, and necessitating change 

in how health care teams interact. The U.S. 

Department of Veterans Affairs (VA) is taking 

advantage of these emerging technologies by 

developing new or enhancing existing Web, 

mobile, and point-of-care digital services to 

redefine traditional VA care delivery. 

Currently, more than one in four VA patients 

is engaged in the use of a connected health 

technology. One of VA’s goals is to increase 

participation even further, with an objective of 

improving the quality and experience of care 

for our patients and their caregivers, while simultaneously broadening access to care. 

Drivers of Connected Health

Driving the accelerated adoption of connected 

health is the simultaneous improvement in information technology and the emergence of the 

increasingly engaged and empowered patient. 

We anticipate increased demand for connected 

health technologies, which will be driven by 

consumers’ expectations that health information, knowledge, direct care, and support 

should be delivered virtually—when and where 

it is needed, with ease of access and use.1

As part of this health care consumer revolution, connected health technologies are expected to provide enhanced patient participation in 

self-care through remote health tracking, disease 

management support systems, and simple 

communication tools. Consumers prefer systems with an easy-to-use interface, trustworthy 

source, perceived value, and effective integration with the other communication channels 

of the business. The ability of these self-care 

connected health technologies to improve 

patient outcomes will likely continue to be 

driven by individual tailoring, personalization, 

behavioral feedback, and clinical integration.2, 3 

More effective bi-directional exchange of health data 

between patients and their health care teams is a second major shift occurring as a consequence of 

the growth in connected health technologies. 

Patients are empowered by the health care 

system’s newfound ability to make personal 

health data available in near real time via digital tools for their personal consumption. Increasingly, VA expects that patient-generated 

data, supported by powerful algorithms, will 

be a key ingredient used by health care organizations to personalize the patient experience. 

Patient-generated data will further drive the 

shift from the still common paradigm that 

patients neither own nor control their health 

data to the emerging concept that the data belongs to them. 

FORUM

Translating research into quality health care for Veterans

Commentary

VA Connected Health 

Neil C. Evans, M.D., and Kathleen L. Frisbee, Ph.Dc., M.P.H., Co-Directors, 

Connected Health, Office of Informatics and Analytics, Veterans Health Administration, 

VA Central Office, Washington, D.C.

 May 2014

Contents

Director’s Letter 2

Connected Health 3

The eHealth Measures 

Compendium 4

Update on VHA TeleICU 5

Providing Care Closer to Home: 

The Role of Virtual Points of Access 6 

Improving Digital Access to 

Evidence-Based Psychotherapy 7

Wilt Receives 2014 Under 

Secretary’s Award 7

A publication of the VA Office of Research & Development, 

Health Services Research & Development Service, Center 

for Information Dissemination and Education Resources, 

in conjunction with AcademyHealth. This and past issues 

of FORUM are available on the web at www.hsrd.research.

va.gov/publications/forum.
The increasing demand and interest in virtual 

care delivery, either synchronous (example: 

clinical video telehealth) or asynchronous (example: secure messaging) is a third major shift 

being powered by connected health technologies. These virtual care delivery modalities do 

not replace existing health care relationships, 

but augment them. Virtual care delivery has 

the potential to reduce inefficiencies in traditional health care delivery, allowing improved 

access to care and a reduction in geographyrelated disparities.

Priorities of VA’s Connected 

Health Office

In early 2013, VA created a dedicated Connected 

Health Office with responsibility for overseeing 

the execution of a unified connected health strategy and ensuring its alignment with VA’s overall 

strategic plan. The office’s overarching goals are 

three-fold: (1) increasing and improving access; 

(2) supporting Veteran self-care; and (3) enabling 

VA employees to better meet Veterans’ needs. 

These high-level goals have been further defined 

by the following priorities: (1) create a seamless, 

unified experience for Veterans across all VA 

patient-facing technologies; (2) expand Veteran 

access to care; (3) engage Veterans and their 

families in self-management of their health; (4) 

create patient-centered care through personalization of VA health care; (5) improve information 

sharing to increase the value of communication; 

(6) increase VA health care team efficiency and 

quality by moving relevant clinical data closer 

to the point of care; and (7) systematically and 

intentionally deliver innovations that will improve 

health care.

The future impact of connected health technologies will depend upon both the effectiveness of 

the technologies and their reach—the number 

and percent of Veterans with access to, adoption 

of, and use of the technologies. VA should adopt 

strategies to enhance access to these technologies 

for all Veterans, including at-risk populations, 

such as Veterans with lower income, lower health 

and technology literacy—and those Veterans 

with health issues, including traumatic brain and 

spinal cord injuries that can make access to technologies more challenging. 

VA’s Under Secretary for Health, Dr. Robert A. 

Petzel, has maintained that VA’s goal is to put 

Veterans at the center of the agency’s care and 

treat the whole person, not just symptoms or 

diseases. He argues that connected health technologies are a critical tool to allow us to achieve 

that goal and that they are rapidly changing how 

Veterans access the resources and information available to them. At a recent showcase of 

VA’s leadership in connected health, Dr. Petzel 

remarked, “These technologies are helping us 

create a system of care without walls, a virtual 

system of care. This is where medicine is going—

the virtual care delivery system.”

References

1. Frist, W. H. “Connected Health and the Rise of the 

Patient-Consumer,” Health Affairs 2014; 33(2):191-3.

2. Gibbons, M.C. et al. “Impact of Consumer Health 

Informatics Applications,” AHRQ Publication No. 

09(10)-E019, Rockville, MD, 2009.

3. Jimison, H. et al. “Barriers and Drivers of Health Information Technology Use for the Elderly, Chronically 

Ill, and Underserved,” Evidence Report - Technology Assessment 2008; 175:1-1422.

FORUM — Translating research into quality health care for Veterans 2

Director’s Letter 

As VA works on solutions that will allow Veterans to use their 

mobile devices to interact with their health care team, learn 

about their medical needs, and access tools to help improve 

their health, it is important to consider the role of research in 

this fast-changing field. 

Research assessing the individual effectiveness of the thousands 

of health apps already in circulation isn’t possible, or even useful. Although one 

can simply assume the market will sort it out—that patients and clinicians will 

gravitate to those products they feel work best for them—this view sells short the 

value of research and research-derived knowledge. 

One role for research is to steer app developers to effective strategies for supporting behavior change. Apps should incorporate functions that increase self-efficacy, 

assist problem-solving, and provide context-sensitive prompts—all strategies 

shown to be effective. Similarly, research has proven the effectiveness of peer support, nurse-led care management, and caregiver support, approaches that can be 

facilitated by well-designed apps. To be fully effective, VA apps will need to communicate appropriately with the team members who can adjust treatments and 

determine need for follow up. 

So, what are key research questions for the development of mobile health applications? Here are two:

• How can we use mobile apps to collect patient-reported outcomes to better inform treatment decisions, performance measurements, and real-world effectiveness studies?

• How can mobile apps and Internet tools enhance approaches using peer support and community-based care? 

I will expand on these ideas in my blog, where I invite you to suggest additional 

questions worthy of research. VA readers can send comments to my blog and nonVA readers can send suggestions to cider.boston@va.gov.

 

David Atkins, M.D., M.P.H. 

Director, HSR&D

VA Office of Research & Development, Health Services Research & Development Service May 2014
VA Office of Research & Development, Health Services Research & Development Service May 2014

Connected health technologies, or virtual care, 

constitute a new “Model of Care” for augmenting efficient, safe, high-quality, continuous, 

coordinated delivery of evidence-based services 

to Veterans and families. In the prior sentence, 

“augmenting” is an important word. Connected 

health must not be viewed as a replacement for 

current high-quality care, but follows instead 

from the fundamental theorem of informatics: 

a person or teams (including health care providers, Veterans, and informal caregivers) working 

in partnership with a supportive technology or 

information resource is “better” than unassisted 

individuals working alone.1

 As with health informatics, a parent discipline, connected health is 

more about people, workflow, and the interactions between people than it is about the specific 

technology itself. 

Ongoing HSR&D and QUERI 

Research

Considerable research related to connected 

health, funded by HSR&D and QUERI, is 

underway. Example projects extend from 

observational analyses related to connected 

health implementation and efficiency, to 

implementation research initiatives testing 

the potential use of existing technologies. 

Like other health care systems across the nation, VA is committed to understanding the 

implications of connected health technologies 

for cost and value. Recognizing the need for 

evidence, VA investigators conducted a retrospective cohort study of 132 VA facilities 

that were implementing patient-to-clinicalteam secure messaging in primary care. The 

study revealed that higher secure messaging 

use was associated with lower urgent care 

utilization rates; early adopters of secure messaging achieved a greater decrease in urgent 

care utilization over time than later adopters 

(-20 urgent care visits per 1,000 patients per 

month).2

 Although these findings need 

replication, identification of potential return 

on investment (i.e., reduction in unnecessary 

urgent care) is critical to driving future connected health implementation. 

Further, in an ongoing QUERI Service-Directed Project (SDP 12-258), VA investigators 

are evaluating the potential of proactive, previsit secure messaging. After training patientaligned care teams in the potential of pre-visit 

planning to support patient engagement and 

effective doctor-patient communication, 

secure messages are being sent to Veterans 

to encourage them to plan for their visit and 

reply to the message with “three things” they 

would like to talk to their health care provider 

about during their upcoming appointment. 

The investigators are evaluating the impact 

of an external implementation program on 

adopting the practice of pre-visit secure messaging in a randomized stepped wedge implementation trial. A review of HSR&D and 

QUERI databases reveals a variety of other 

projects related to connected health, including several that advance the basic science of 

health informatics through efforts to mine 

clinical data and provide patient-centered decision support (HIR 09-005, Qing Zeng). 

Importantly, connected health should not be 

viewed as focused solely on Veterans. As noted 

in the commentary by Evans and Frisbee, codirectors of the Connected Health Office, in 

its ideal state, connected health is bi-directional 

and involves both Veterans and the teams of 

professionals providing VA health care. All technologies that connect with our Veterans have 

reciprocal repercussions for health care providers 

and the clinical system, some intended and positive, some unintended and negative. Research 

in this area must consider the perspectives and 

experiences of all stakeholders: Veterans, their 

families, their health care providers, and broader 

health care systems. 

Framework to Guide Future 

Research

Studies should also be designed to detect potential positive effects on health care and health, 

and also the unintended consequences of these 

technologies. VA investigators have published 

a new eight-dimensional sociotechnical model 

specifically designed to address the challenges 

involved in design, development, implementation, use, and evaluation of information technology (such as connected health) within complex 

adaptive health care systems.3 Highlighting the 

interdependent factors that influence connected 

health, this sociotechnical model is being used 

to guide a project recently funded by QUERI. 

Dr. Stephanie Shimada is principal investigator 

of this rapid response project titled, “Developing 

a Taxonomy of Unintended Consequences of 

eHealth Implementation.” This ground-breaking 

pre-implementation project hopes to lay a framework to guide future research initiatives. 

Technologies are currently reshaping the experience and practice of health care as much as they 

have in finance, commerce, and other sectors 

of the economy. In approaching this exciting 

transformation, VA scientists must balance 

understanding of connected health from the 

patient and from the health care system perspectives. We must also be mindful of the duality of 

positive effects and possible unintended consequences. The commentary also addresses the 

important issue of equity. As we implement connected health strategies, we must avoid health 

care disparities—and encourage approaches 

that will ensure adoption of connected health 

by all Veterans. Challenges, both new and those 

yet to be identified, may emerge as health care 

systems attempt to pursue connected health as 

a model for augmenting efficient, safe, highquality, continuous, and coordinated health care. 

VA HSR&D and QUERI programs have begun 

and must continue to lead the way in researching 

these promising technologies.

References

1. Friedman, C.P. “A ‘Fundamental Theorem’ of Biomedical 

Informatics,” Journal of the American Medical Informatics Association 2009; 16(2):169-70.

2. Shimada, S.L. et al. “Patient-provider Secure Messaging in 

VA: Variations in Adoption and Association with Urgent 

Care Utilization,” Medical Care 2013; 51(3 Suppl 1):S21-8.

3. Sittig, D.F. and H. Singh. “A New Sociotechnical Model 

for Studying Health Information Technology in Complex Adaptive Healthcare Systems,” Quality & Safety in 

Health Care 2010; 19 Suppl 3:i68-74.

Response to Commentary

Connected Health

Thomas K. Houston, M.D., M.P.H., FACMI, Timothy P. Hogan, Ph.D., 

and Lorilei Michaud Richardson, Ph.Dc., M.S., all with the VA eHealth Quality 

Enhancement Research Initiative (QUERI), Bedford, Massachusetts

FORUM — Translating research into quality health care for Veterans 3
eHealth is a multidisciplinary field focused 

on the delivery or enhancement of health 

information and health services through 

information and communication technologies.1 eHealth also improves access to health 

care services by offering novel channels 

for communication and information flow 

that complement existing systems.2 eHealth 

QUERI investigators are leading a project 

focused on identifying and evaluating patientfacing eHealth-specific metrics. The goal of 

this project is to conduct a thorough review 

of potential metrics that could be used in 

any study involving eHealth interventions in 

Veterans, and to create a standardized compendium of recommended metrics that will 

support both U.S. Department of Veterans 

Affairs (VA) operations and research. 

The project team includes investigators from 

the Iowa City (Bonnie Wakefield, Carolyn 

Turvey) and Bedford (Tim Hogan, Stephanie 

Shimada) VAs, and the My HealtheVet program office (Kim Nazi) under the auspices 

of the eHealth QUERI, directed by Thomas 

Houston. Following a systematic review of 

the literature to identify potential metrics, investigators are utilizing a standardized review 

form to document metric properties. We also 

invite investigators across VA to submit suggested measures for review and inclusion in 

the compendium.

Unique Characteristics of eHealth 

Implementation

eHealth implementation has several unique 

characteristics that warrant investigation of 

effective metrics. First, eHealth implementation requires the evaluation of technology 

platforms for their usability, functionality, and 

availability to target users. Metrics pertaining to technology platforms are most often 

seen in design, technology, and engineering 

literature. For eHealth implementation, however, these metrics must be tailored for use in 

health care settings. Second, eHealth implementation assumes that a particular technology is being promoted to improve aspects 

of quality like efficiency or accessibility. For 

example, eHealth may reduce the distance between services and the target user, or reduce 

physician or patient work load for a specific 

task. Though intervention studies may include metrics that attempt to quantify these 

characteristics, as of yet, there are no widely 

agreed upon measures. Without such metrics, 

one can imagine how cost analyses and related initiatives may fall short in determining 

the full benefit of an eHealth intervention 

to Veterans and to VA. Finally, almost all 

eHealth interventions aim to improve communication in one form or another. Metrics 

are needed that quantify the degree to which 

communication is improved.

Metrics for eHealth Interventions

Ultimately, consistent and well-validated 

metrics of design, efficiency, and improved 

communication are necessary to determine 

the true benefit of any eHealth intervention. Without such metrics, VA cannot: (1) 

calculate return on investment of eHealth 

technology; (2) effectively address barriers to 

adoption that are revealed by these metrics 

(i.e., usability, accessibility of a technology); 

or (3) accurately estimate the likelihood of 

adoption. For example, VA operations may 

use My HealtheVet Secure Messaging to disseminate a health education message. Optimally, that approach would be evaluated both 

in terms of the workload burden on providers 

and the accuracy of patient comprehension of 

medical advice provided electronically. Metrics identified in this project could inform VA 

operations of the value of using Secure Messaging versus other dissemination strategies. 

Furthermore, the identification of metrics will 

assist VA operations offices to select effective 

measures that support ‘post-market surveillance’ of currently deployed technologies.

VA has made a substantial investment in 

eHealth technologies to improve care for 

Veterans. The proportion of proposals in 

both the HSR&D and QUERI pipeline 

where eHealth is a component has risen dramatically. VA’s ability to gauge the impact of 

this work hinges on the measurement tools 

that investigators have available and ultimately choose to use. The measures identified 

by this project will be critical to initiatives 

across a number of operations offices, including the My HealtheVet Program Office, the 

Connected Health Office, the broader Office of Informatics and Analytics, the Office 

of Telehealth Services, and even resource 

centers like VIReC. The results of this project will provide critical insights into existing 

eHealth measures and identify gaps where 

new metrics are needed. The results can also 

inform future studies, ensuring that investigators can meaningfully compare and synthesize 

across projects. 

The author invites investigators across VA to submit 

suggested measures for review and inclusion in the 

compendium to bonnie.wakefield@va.gov

References

1. Eysenbach G. “What is e-health?” Journal of Medical 

Internet Research 2001; 3(2).

2. Hogan, T.P. et al. “Promoting Access through 

Complementary eHealth Technologies: Recommendations for VA’s Home Telehealth and Personal Health 

Record Programs,” Journal of General Internal Medicine 

2011; 2:628-35.

FORUM — Translating research into quality health care for Veterans 4

VA Office of Research & Development, Health Services Research & Development Service May 2014

Research Highlight

The eHealth Measures Compendium

Bonnie J. Wakefield, Ph.D., R.N., FAAN, eHealth Quality Enhancement Research 

Initiative (QUERI), and HSR&D Center for Comprehensive Access & Delivery Research 

and Evaluation, Iowa VA Healthcare System, Iowa City, Iowa
VA Office of Research & Development, Health Services Research & Development Service May 2014

FORUM — Translating research into quality health care for Veterans 5

Multiple studies have demonstrated mortality reduction in intensive care units (ICUs) 

that implemented evidence-based practices, 

improved ICU organization and teamwork, 

and used a high intensity critical care physician model. The Veterans Health Administration (VHA), responding to this evidence 

base, developed a system to track ICU performance and implemented national initiatives to reduce hospital-acquired infections. 

Although intensivists provided primary 

ICU care in more than 44 percent of VA 

ICUs compared to 24 percent in the private 

sector, 71 percent (135/188) of VA ICUs 

in 2007 experienced difficulty in recruiting 

intensive care physicians like the private 

sector. Demand for intensivists continues 

to be greater than supply in the United 

States, driving compensation for critical care 

services upward. A variety of strategies can 

manage the shortage of intensivists, including use of mid-level providers, regionalization, and contracting for tele-intensive care 

services (TeleICU). 

VISN Implementation of TeleICU 

Models

Interest in improving ICU outcomes as well 

as increasing access to intensivist care in 

VHA led leaders in VISNs 10, 19, and 23 to 

pilot models of TeleICU that ranged from 

systematic utilization of existing VHA information technology (IT) (V19), to adoption 

of advanced commercial TeleICU systems 

(V10, V23). These systems include real time 

visualization, communication, and integrative software with advanced algorithms to 

alert clinicians about changes in patient 

status. In the VISN 19 system, expert nurses 

review patient status and new admissions 

in each VISN ICU, consult where needed, and 

facilitate access to services, procedures, and 

expertise. In VISNs 10 and 23, expert nurses 

monitor 25 to 35 patients 24/7, while physicians may follow as many as 100 patients in the 

TeleICU monitoring center. Physicians, nurse 

clinicians, and informatics experts lead VISN 

implementation of these programs. VA TeleHealth Services facilitated learning and planning 

across the pilots through a variety of means, 

creating a national TeleICU workgroup, developing an implementation checklist, and funding 

leadership and coordinator positions. Implementation of the pilots across hospitals within 

each VISN took place sequentially to allow for 

the development of workflow analysis, training, 

and communication systems. 

Most of the TeleICU programs described in the 

literature involve either a single large hospital or 

hospitals in the same community. The VISNs’ 

innovative regional approaches to TeleICU 

implementation add some complexity compared 

to programs in single hospitals. The qualitative 

evaluation of VISN 23’s TeleICU implementation highlights the socio-cultural elements that 

contribute to staff acceptance, including training, local coordination, needs assessment, interpersonal relationships (particularly development 

of trust), and system design.1

TeleICU Best Practices

The importance of a strong relationship between the physical ICU staff and the TeleICU 

staff can be inferred from a study of more than 

118,000 patients in 56 ICUs across 32 hospitals 

and 19 health care systems that identified four 

best practices associated with improved outcomes in TeleICU: (1) intensivist case review 

within one hour of admission; (2) timely use of 

performance data; (3) adherence to ICU best 

practices; and (4) faster alert response times.2

Creating the tools and relationships important in user acceptance requires development, 

testing, and revision to manage needs of 

multiple ICU cultures and staffing scenarios 

and, most of all, time. In a study that reviewed the logs of TeleICU nurses, Anders 

described an increase in interaction initiated 

by the unit nurse caring for the patient and in 

coordinating activities by the TeleICU nurse 

over two years.3 Studies of other technologies 

also describe such a shift—where changes in 

attitudes and beliefs over time can translate 

to increased use of the technology. Valid 

and reliable analyses regarding the impact of 

TeleICU on VHA ICU outcomes will need 

to span multiple years. 

Funded by the Networks, ICUs in VISNs 

7 and 15 will be added to the TeleICU system in VISNs 10 and 23 respectively; and 

VISN 21 is adopting the VISN 19 approach, 

resulting in TeleICU support of 24 percent 

of VHA ICU beds. Work by the national 

TeleICU Workgroup and the TeleHealth Service facilitates a system-wide approach where 

appropriate. Once established, the Networks 

will need to analyze their utilization of the 

best TeleICU practices described above to 

achieve the full promise of TeleICU. 

References 

1. Moeckli, J. et al. “Staff Acceptance of a Telemedicine 

Intensive Care Unit Program: a Qualitative Study,” 

Journal of Critical Care 2013; 28(6):890-901.

2. Lilly, C.M. et al. “A Multicenter Study of ICU Telemedicine Reengineering of Adult Critical Care,” Chest

2014; 145(3):500-7.

3. Anders, S.H. et al. “The Effects of Health Information Technology Change Over Time: a Study of 

Tele-ICU Functions,” Applied Clinical Informatics 2012; 

3(2):239-47.

Research Highlight

Update on VHA TeleICU 

Marta L. Render, M.D., VHA National Program Director for Pulmonary/Critical 

Care/Sleep Medicine, Cincinnati VA Medical Center, Cincinnati, Ohio
FORUM — Translating research into quality health care for Veterans 6

VA Office of Research & Development, Health Services Research & Development Service May 2014

Ensuring access to health care has been a VA 

focus and is highlighted in the work of HSR&D 

through its measurement and interventions to 

improve access. Fortney, et al. expanded upon 

the traditional definition of access to “represent 

the potential ease of having virtual or face-toface interactions with a broad array of health 

care providers including clinicians, caregivers, 

peers, and computer applications.”1

 This new 

definition further describes actual access (i.e., 

directly observable and objectively measurable 

dimensions) and perceived access (i.e., selfreported and subjective dimensions). Fortney et 

al. demonstrate that, in fact, geographic distance 

is just one of many barriers that prevent Veterans from getting the care they need. 

Though VA providers have a broad array of 

telehealth technologies at their fingertips, care 

for Veterans with complex chronic conditions 

requires innovative applications of these tools, 

for considerable barriers to care remain. The 

technology used—be it clinical video telehealth 

(CVT), home monitoring, or mobile devices—

needs to match the clinical need. Whatever 

technology selected, the innovation must also 

address cultural, workflow, workload, and 

policy issues that affect access.

Three Telehealth Innovations

We will describe three examples of telehealth 

innovations that take a comprehensive approach to overcoming barriers to access, and 

where technology is just one component 

of the intervention. These projects, funded 

through collaborations between the VA Office of Rural Health, Veterans Rural Health 

Resource Center-Central Region, and the 

Comprehensive Access and Delivery Research and Evaluation (CADRE) Center at 

the Iowa City VA Healthcare System, all address identified disparities in access to care 

for rural Veterans, but can be applied to 

other populations with access barriers.

The first example overcomes an often 

under-recognized form of access for rural 

Veterans: availability of multidisciplinary 

treatment team approaches to complex 

chronic illnesses. Ohl et al. have expanded 

upon standard single provider CVT use to 

create a Telehealth Collaborative Care (TCC) 

model that provides access to team-based 

consultation for rural Veterans with HIV.2

TCC integrates team-based HIV specialty 

care delivered in Community Based Outpatient Clinics (CBOCs) using CVT with primary care delivered by local Patient Aligned 

Care Teams (PACTs). Preliminary studies 

at the Iowa City VA indicate that TCC is 

well-accepted by Veterans and PACTs and 

it maintains previously-existing high quality 

HIV care. Planned studies will evaluate factors influencing spread of TCC serving rural 

Veterans with HIV.

The second example addresses improving access for rural Veterans through greater VA 

collaboration with local non-VA health systems. 

A team headed by Carolyn Turvey established 

a campus-based tele-mental health clinic at 

Western Illinois University (WIU) in Macomb, 

IL through extensive negotiation between the 

Iowa City VA Mental Health Service Line and 

Student Health Services at WIU. Now, Veterans making use of their military benefit to 

pursue a college degree can receive expert care 

for service-related mental health issues directly 

from VA providers using CVT.

Finally, a novel home-based cardiac rehabilitation program developed by Bonnie Wakefield 

provides Phase 2 cardiac rehabilitation in the 

home of eligible Veterans.3

 Only 25 percent of 

VA hospitals provide cardiac rehabilitation onsite. Thus, most Veterans who receive cardiac 

rehabilitation are enrolled in community-based 

programs through non-VA care. To provide 

an alternative, the team developed a home 

program that uses two forms of telehealth. 

The first uses the most basic modality, the

telephone, to engage patients in weekly sessions 

covering important topics such as activity, diet, 

and stress management. The second utilizes 

CVT to enroll patients from CBOCs. In this 

program, Veterans are offered the option of 

a home-based or center-based program. 

Not only does the majority choose the home 

program, but completion rates are higher. 

This intervention goes beyond standard homebased symptom monitoring and actually conducts a much needed clinical service right in the 

Veteran’s home. 

Lessons Learned

The unifying principle of all these programs 

is the desire to bring a broad range of health 

care services closer to Veterans’ homes, improving the convenience of these services 

and thus, improving compliance. Although 

all three examples were ultimately successful, 

each was accompanied by significant implementation barriers that are common across 

VA: workflow barriers to multidisciplinary 

care, administrative barriers to closer collaboration with non-VA providers, health 

information technology issues, hiring of personnel, and under-recognition of the value 

of actual care delivery closer to home. 

Though the ever-expanding availability of 

sophisticated communication technologies is 

dazzling, implementing the technology was 

the easiest aspect of the three interventions described. Rethinking clinical roles, optimal site of 

care, and the role of VA within the larger health 

care system was far more challenging. 

References

1. Fortney, J. et al. “A Re-conceptualization of Access 

for 21st Century Healthcare,” Journal of General Internal Medicine 2011; 26(Suppl 2):639-47.

2. Ohl, M. et al. “Mixed-methods Evaluation of a Telehealth Collaborative Care Program for Persons with 

HIV Infection in a Rural Setting,” Journal of General 

Internal Medicine 2013; 28(9):1165-73.

3. Wakefield, B. et al. “Feasibility and Effectiveness of 

Remote, Telephone-based Delivery of Cardiac Rehabilitation,” Telemedicine Journal and e-health: The Official Journal of 

the American Telemedicine Association 2014; 20(1):32-8.

Research Highlight

Providing Care Closer to Home: 

The Role of Virtual Points of Access 

Peter J. Kaboli, M.D., M.S. and Carolyn Turvey, Ph.D., HSR&D Comprehensive Access 

and Delivery Research and Evaluation (CADRE) Center, Iowa City VA Healthcare 

System, Iowa City, Iowa
VA Office of Research & Development, Health Services Research & Development Service May 2014

FORUM — Translating research into quality health care for Veterans 7

The “population impact” of a treatment depends not only on its clinical effectiveness, but 

also on the degree to which it reaches the target 

population. Highly effective treatments that are 

delivered face to face in specialty health care settings often have limited population impact due to 

barriers to care. To maximize population impact, 

it is critical that VA develop treatments that are 

both clinically effective and highly accessible. 

Participants of VA’s 2010 State of the Art (SOTA) 

Conference on Improving Access to Care envisioned a 

new conceptualization of access for the digital 

age. Participants redefined access as the potential 

ease of having virtual or face-to-face interactions with a broad array of health care providers, 

including clinicians, caregivers, peers, and computer applications.1

 By adopting mHealth and 

eHealth technologies, VA can improve digital 

access to care in order to overcome geographical, 

temporal, and cultural barriers to care. 

Models of Virtual Delivery

Protocol-driven, evidence-based psychotherapy 

is an example of an efficacious specialty care 

treatment that could potentially have a greater 

population impact if it were more accessible to 

Veterans. Psychotherapy lends itself well to virtual delivery. While VA has been an early adopter 

of interactive video, relatively few telepsychiatry 

encounters entail the delivery of psychotherapy.2

In two recent HSR&D-funded randomized 

non-inferiority trials (PIs: Agha, Morland) 

conducted in Community Based Outpatient 

Clinics (CBOCs), cognitive processing therapy 

(CPT) was shown to generate equivalent PTSD 

outcomes when delivered face to face and via 

interactive video. HSR&D investigators need 

to replicate these findings for home-based 

computer video technologies, which have the 

potential to improve digital access to psychotherapy even more than clinic-based interactive 

video technologies. 

Building on these non-inferiority trials, investigators at the HSR&D Center of Innovation 

(COIN) at the Central Arkansas Veterans 

Healthcare System recently completed the 

Telemedicine Outreach for PTSD (TOP) study (PI: 

Fortney), which focused on improving digital 

access to CPT for rural Veterans with PTSD. 

Embedded within a telemedicine-based collaborative care management model, CPT was 

offered to Veterans at CBOCs via interactive 

video. Nurse care managers encouraged initiation of CPT and promoted session attendance 

and homework adherence. Over half of the 

Veterans randomized to the intervention 

group initiated CPT, which contributed to 

improved outcomes compared to treatment 

as usual. This randomized trial demonstrates 

that one evidence-based model of integrating 

mental health into primary care (Collaborative 

Care Management) can be delivered virtually to increase population impact. Building 

on these findings, investigators at HSR&D’s 

COIN at the Central Arkansas Veterans 

Healthcare System recently received funding 

approval for a study (PI: Fortney) designed 

to test whether the other predominant model 

of integrated care (Co-Located Collaborative Care) can be delivered virtually to CBOC 

patients. The co-located collaborative care 

model involves primary care providers facilitating warm handoffs of patients with mental 

health problems to physically co-located mental health specialists staffing open access clinics, thereby maximizing both geographic and 

temporal access.3

 This study will test whether 

an open access clinic can be staffed with “virtually co-located” mental health specialists delivering brief evidence-based psychotherapies.

Potential of SmartPhone Apps

Protocol-driven psychotherapy can also be 

delivered effectively by a computer program, 

further improving digital access for Veterans. 

Based on a recent literature review conducted 

by the Evidence Based Synthesis program, 

HSR&D implementation researchers should 

consider developing strategies to promote the 

adoption of computer-delivered Cognitive 

Behavioral Therapy programs. SmartPhone 

apps are another technology that have great 

potential to improve digital access to evidencebased psychotherapy. Investigators at the Palo 

Alto VA Medical Center have developed a suite 

Research Highlight

Improving Digital Access to EvidenceBased Psychotherapy

John C. Fortney, Ph.D., and Kathleen M. Grubbs, Ph.D., HSR&D Center for 

Mental Healthcare and Outcomes Research, Mental Health QUERI, South Central 

Mental Illness Research, Education, and Clinical Center, 

Central Arkansas Veterans Health Care System, Little Rock, Arkansas

Timothy J. Wilt, M.D., 

M.P.H., is the recipient 

of the 2014 Under 

Secretary’s Award for 

Outstanding Achievement in Health Services 

Research, the highest 

honor for a VA health services researcher. 

Dr. Wilt has made significant contributions 

to VA health care through his research, particularly in his efforts to synthesize evidence 

in order to provide clarity on issues of importance to Veterans’ health. Dr. Wilt’s Prostate 

Cancer Intervention Versus Observation Trial 

(PIVOT), with results published in The New 

England Journal of Medicine, demonstrated 

the lack of benefit and increased harms associated with radical prostatectomy in localized 

prostate cancer compared to observation, 

thus having immediate implications for the 

10,000 Veterans diagnosed with prostate 

cancer in VA each year. These findings were 

incorporated into practice guidelines issued 

by VA and the U.S. Preventive Services Task 

Force, the American College of Physicians, 

the American Society of Clinical Oncology, 

and the American and European Urological 

Associations. 

Dr. Wilt is a Professor of Medicine and 

staff physician at the Minneapolis VA 

Health Care System and University of 

Minnesota Medical School; he is also a 

core investigator with HSR&D’s Center for 

Chronic Disease Outcomes Research, also 

located in Minneapolis. 

Wilt Receives 2014 Under Secretary’s Award
Peter L. Almenoff, M.D., FCCP, 

Director of Operational

Analytics and Reporting, Office 

of Informatics and Analytics, 

Washington, D.C.

David Atkins, M.D., M.P.H.,

Director, HSR&D

VA Central Office,

Washington, D.C.

Cynthia Caroselli, Ph.D., R.N.,

Associate Director for Patient 

Services & Chief Nurse

Executive, VA New York

Harbor Health Care System, 

New York, NY

Martin P. Charns, D.B.A.,

Director, VA HSR&D Center

of Innovation, Boston, MA

Joseph Francis, M.D., M.P.H.,

Director of Clinical Analytics 

and Reporting, Office of

Informatics and Analytics, 

Washington, D.C.

Skye McDougall, Ph.D.,

Chief Medical Officer

VAMC Long Beach,

Long Beach, CA

Richard Owen, M.D., Director, 

VA HSR&D Center of

Innovation, Little Rock, AR

DeAnne M. Seekins, MBA, VA 

Medical Center Director,

Durham, NC

Frances Weaver, Ph.D.,

Director, VA HSR&D Center 

of Innovation, Hines, IL

FORUM

Geraldine McGlynn, Editor-in-Chief

Margaret Trinity, Editor

Editorial Board

FORUM

Translating research into quality health care for Veterans

Center for Information Dissemination and Education Resources 

VA Boston Healthcare System (152C) 

150 South Huntington Avenue, Boston, MA 02130-4893

Organization

U.S. Postage

PAID

Permit No. 3999

Washington, DC

of SmartPhone apps designed to deliver or 

augment provider-delivered, evidence-based 

psychotherapies. Apps include CPT Coach for 

Cognitive Processing Therapy, PE Coach for 

Prolonged Exposure Therapy, ACT Coach

for Acceptance and Commitment Therapy, 

CBT-I Coach for cognitive behavioral therapy 

for insomnia, Mood Coach for Behavioral Activation, Moving Forward for Problem Solving 

Therapy, and Stay Quit Coach for smoking 

cessation. These apps have the potential to 

greatly improve both temporal and geographic access for Veterans and are in the 

early stages of empirical testing. 

Two ongoing pilot studies are underway at 

the HSR&D COIN at the Central Arkansas 

Veterans Healthcare System. The Moving 

Forward app is being evaluated with HSR&D 

pilot funding (PI: Grubbs) and the Mood Coach 

app is being evaluated with pilot funding (PI: 

Brady) from the South Central Mental Illness 

Research, Education, and Clinical Center 

(MIRECC). Due to the potential for these 

SmartPhone apps to be highly cost-effective, 

HSR&D implementation researchers should 

consider developing strategies to promote 

adoption among Veterans and their providers. 

References 

1. Fortney, J.C. et al. “A Re-conceptualization of 

Access for 21st Century Healthcare,” Journal of 

General Internal Medicine 2011; 26(Suppl 2): 639-47. 

2. Deen, T.L., Godleski L., and Fortney J.C. “A Description of Telemental Health Services Provided by 

the Veterans Health Administration in 2006-2010,” 

Psychiatric Services 2012; 63[11]: 1131-3. 

3. Pomerantz, A.S. and S. L. Sayers. “Primary CareMental Health Integration in Healthcare in the 

Department of Veterans Affairs,” Families, Systems, 

and Health 2010; 28(2): 78-82.