Psychologist Lisa Burroughs is in the middle of a therapy session in her office at the Wilmington VA Medical Center.
But her client, Army veteran Kevin Braunksill, isn't sitting on the comfortable recliner in the corner of the office. His face appears on a big computer screen on a table by Burroughs' desk.
Braunskill gets therapy once a week via a secure video connection. That allows him to go to the Dover outpatient clinic, just five minutes away from his home, instead of driving almost an hour to the main VA medical center in Wilmington.
"I can just imagine if I lived downstate and had to drive two hours ... I can tell you right now I wouldn't go, I would skip my sessions," Braunskill said. "And (with) PTSD and TBI (Traumatic Brain Injury) it's about consistency, and working on things on a every day basis."
Braunskill lives with post-traumatic stress disorder after serving in combat zones and hospitals in Iraq.
"It's kind of easier, especially in the beginning, to tell my story, to get my story out totally, to a screen, than to actually see her reaction (in person)," Braunskill said.
Burroughs started offering therapy over video about a year ago, and now treats about ten veterans that way. She also offers remote participation in two therapy groups.
"Usually by the end of the first session," Burroughs said, "almost all of them will say to me, 'I kind of forget that you're on a television screen.'"
Bring specialist care closer to home
The U.S. Department of Veteran's Affairs has been beefing up its telemedicine services for the past decade. In 2012, nine percent of VA patients got care remotely. This year, the VA plans to boost that number to 15 percent. Leaders hope to bring care closer to veterans as they age, and, increasingly, monitor chronic illnesses in the home to keep veterans independent as long as possible.
The Wilmington VA's Virginia Yelland said remote services make sense locally, where about half of primary care patients see doctors at one of five community clinics in southern Delaware or New Jersey.
"Before telehealth they really didn't have access to specialists unless they drove to Wilmington," Yelland said. "This is an exciting way to provide those services close to where they're at home."
The Wilmington VA does home health monitoring with telemedicine, where vitals and other health indicators are measured at home and transmitted to healthcare providers. It also offers video-based diabetes and nutritional counseling, support groups, as well as spinal cord injury and dermatology consults. It hopes to add primary-care check-ups over video this year.
In a recent demonstration of the technology, a technician in Dover used a tongue depressor with a camera attached to examine a patient's throat. Staffers in Wilmington watched a big-screen TV as the technician and patient interacted in real-time. Suddenly, a close-up of the back of the patient's throat popped onto the screen. Similar technology will capture skin problems and vitals to send to doctors in Wilmington.
Future growth projected
Delaware Governor Markell, in his January State of the State address, called for more providers to offer behavioral health services remotely, in an attempt to increase access to care. That is especially necessary in downstate Delaware, where there have historically been shortages of some medical types of providers.
Last summer, Delaware became one of the last states in the country to start paying for telemedicine through its Medicaid program. The policy change was largely at the urging of a group of downstate residents, said Dr. Gerard Gallucci, medical director for the Delaware Department of Health and Human Services.
"I think it took that sort of critical mass of interest before Medicaid was convinced that this was a service that was needed in Delaware," Gallucci said.
Nationwide, an analysis done by the market research group IMS Research projects that telehealth will grow six-fold in the next five years as health leaders try to control healthcare costs.
Critics say more evidence is needed
Despite its growing popularity, critics say the VA and others are taking a leap of faith in investing heavily in telemedicine.
"Just because you have a neat technology that can transmit information doesn't mean it's going to translate into better outcomes for the patients," said Yale cardiologist Harlan Krumholz.
Krumholz thinks methods like those at the VA have a lot of promise, but there is not yet a preponderance of data to show that they work.
"All of these things, I think, need to be studied, we can't just adopt them and expect that they're going to do good without checking to be sure there aren't unintended adverse consequences," Krumholz said.
A study Krumholz conducted found that phone-based check-ups with heart patients after hospitalization did not reduce re-admission rates. Other studies have found a benefit: including showing that telemedicine is effective at treating rural diabetes patients, and in reducing mortality among people with certain chronic diseases.
'It was like we already knew eachother'
Back at the Wilmington VA, psychologist Lisa Burroughs said video therapy sessions are not exactly the same as in-person sessions. Still, she feels she can make a good connection by making sure her clients feel heard.
"Making sure that I am not always staring at my monitor, that I am paying attention to look into the actual camera lens," Burroughs said, "so that it is perceived by them that I am making eye contact with them."
Army veteran Martin Formento has been working through the anxiety and anger that stem from his post-traumatic stress disorder. His sessions with Burroughs have helped him beat a fear of crowded spaces.
"I could go out in public, and not hesitate or avoid crowded places, restaurants, Walmart. I just go, I don't even really think about it," Formento said. "And she helped me get to that point."
When Formento finally met Burroughs face-to-face for the first time, he said, "it was like we already knew each other."
A version of this story will air on a WHYY-TV First Extra: Health+Technology. The half-hour special explores the ways tech innovations are driving medicine and airs at 5:30 p.m. on March 28 on WHYY-TV. It will be re-broadcasted on April 2 at 7:30 p.m.