By Stephen Spotswood

Michael Ohl, MD, MSPH

IOWA CITY, IA ― Veterans living in rural areas face a lot of challenges, the most common of which is having to travel long distances to access VA medical care. While community-based outpatient clinics (CBOCs) have helped bridge the gap between urban VAMCs and these veterans, they don’t entirely alleviate the difficulties.

For rural veterans needing regular specialty care, such as veterans diagnosed with HIV, those challenges are magnified. Now, with the help of telehealth technology, VA physicians are finding ways to bridge the distance between HIV specialists and the rural veterans that need them.

Michael Ohl, MD, MSPH, an infectious disease specialist at the Iowa City, IA, VAMC, has been working with HIV-positive veterans since his days as an internal medicine resident in San Francisco during the 1990s. “I trained in VAs in San Francisco and Seattle and worked in care in VA in every job I’ve had. It’s really part of my mission, working with that population,” he recounted.

Now in Iowa City, Ohl sees patients who sometimes drive hours to receive HIV specialty care. “I think there are challenges for people everywhere,” he said. “But there are some that are heightened in rural areas. Issues come up all the way along the continuum, from HIV testing to diagnosis to treatment.”

Rural veterans are less likely to have an HIV test, so when they are tested and found to be positive, they’re more likely to be tested with a more-advanced HIV infection. “Part of it is due to stigmas,” Ohl explained. “People don’t talk about it as much. And there are fewer people around with HIV, so people are less likely to think about it.”

Once a veteran knows he or she has HIV, the barriers are mostly geographic. State-of-the-art HIV care is generally delivered by specialists, and those tend to be located in urban centers. “If you need short-term care, that’s one thing. But if you need lifelong care, that can become burdensome.”

With the advent of effective treatment for HIV, more and more HIV-positive veterans are living a normal lifespan. By the time he arrived in Iowa City, Ohl was dealing with a patient population that needed the normal course of age-related medical care more regularly than specialty HIV care. Having lived decades past their initial HIV diagnosis, they were now dealing with the same diabetes, high blood pressure and cholesterol other men and women their age were facing.

“It became clear that there were people traveling long distances to see me, oftentimes with their HIV under control but with issues of aging,” he said. “It wasn’t the sustainable model to have people travel hours and hours to see me in a specialty clinic for what was resembling geriatric care.”

In search of solutions to this, Ohl began experimenting with telehealth options in 2010. The goal was to engage a patient’s primary care physician in CBOCs closer to where the veteran lives. The veteran can teleconference with their HIV specialists in Iowa City while getting basic care from providers at the CBOC.

“The technology—two-way audio-video conferencing—is pretty common technology, but with better security,” Ohl explained. “We also have associated peripherals. We can have stethoscopes and an exam camera—a high-resolution camera—that we can use to examine sores on the skin and mouth. We’ll have a nurse on the far end assisting with that part of the exam.”

The video portion of the conference is especially important, Ohl said, allowing physicians on the other end to pick up on cues they might not catch over a regular phone call. “HIV care is often talking about behavior. Are they taking their medicines? Are they having side effects? And that goes well through audio-video conferencing. It’s important to have the nonverbal cues.”

Iowa City also has carved out a role for a nurse care navigator—someone who’s on call to assist veterans when they have questions about accessing care from their geographically spread-out team of providers. “We’ve discovered that it’s fundamentally not a tech problem but a care coordination issue and having people talk to each other across sites. The major barriers are the age-old ones in medicine of coordinating care with specialists and other clinics. I don’t think there’s an app for that.”

While Iowa City had a 90% buy-in to the program from patients who live closer to community-based outpatient clinics (CBOCs) than specialty clinics, the telehealth solution isn’t for everyone. Veterans who are recently diagnosed continue to travel to Iowa City until they are stabilized. “And some people just don’t like the audio-visual,” Ohl explained. “They prefer the human connection. And some like to go to the distant specialty clinic because it’s like a social event as well.”

Having shown success in Iowa City, the model is being expanded to rural communities surrounding VA facilities in Atlanta, Dallas, Houston and San Antonio, where Ohl expects to see similar results. But in the future, the model does not have to be limited to HIV patients, Ohl explained, adding, “I think this is a model for HIV care, but I think it may have relevance for people with other conditions who require distant specialists and general providers.”