Nationwide Interdisciplinary E-Consultation on Transgender Care in the Veterans Health Administration

Abstract

Background: Veteran's Health Administration (VHA) requires the provision of quality transgender care for the relatively large number of transgender veterans using VHA services. Introduction: The Office of Patient Care Services has taken a multimethod approach to improving provider knowledge and skill for transgender veteran care. However, unique patient-specific questions can arise. Thus, VHA implemented a 3-year feasibility program to determine if nationwide interdisciplinary e-consultation can offer veteran-specific consultation to providers who treat transgender veterans in VHA. Materials and Methods: Launch of this program is described along with use to date, types of questions submitted by providers, and length of time to complete a response in the veteran's electronic medical record. Results: In 17 months, the program responded to 303 e-consults, with consultation provided on the care of 230 unique veterans. Nationwide coverage was achieved 1 year after the launch of the program. Common consult questions have been about medications, including hormones (n = 125); primary care concerns (n = 97); mental health evaluations (n = 63); and psychotherapy (n = 18). Consistent with the interdisciplinary model, multiple disciplines typically responded to each consult (x = 2.27). Average time to completion of a consult was 5.9 calendar days (range = 2.4–7.7 days). Discussion: VHA has established a nationwide interdisciplinary e-consultation program. Additional outreach about the program will be needed if funding is continued. Conclusions: E-consultation on transgender health within VHA is feasible and complements the suite of trainings offered within VHA. Other healthcare organizations may benefit from a similar program.

Introduction

In 2011, the Veteran's Health Administration (VHA) established a national policy on transgender care with a Directive (now VHA Directive 2013–003).¹ The prevalence of transgender veterans (trans-vets) is not known, but among those who use VHA services, it is possible to identify a subset with transgender-related diagnostic codes (e.g., gender identity disorder [GID])² in their electronic medical records (eMR). Administrative searches of ICD-9 diagnostic codes indicated that the number of trans-vets has increased since 2008 with a significant increase after 2011.³ In 2013, a search of three diagnostic codes (GID, GID NOS, and transsexualism) identified 2,567 unique cases of living veterans with transgender-related diagnoses in the previous 8 years;³ other broader searches have resulted in higher numbers.⁴

These findings are consistent with earlier reports, with one survey in the transgender community reporting a threefold elevation in rates of veteran status.⁵ GID diagnoses in VHA patients are elevated as much as five times relative to general population estimates of GID.⁶ Thus, some preliminary data suggest that transgender people disproportionately join military service compared to the general population, which is consistent with theoretical conceptualizations.⁷ While the actual number of transgender-identified veterans is unknown, an increasing number of veterans are accessing transgender-related services such as cross-sex hormone therapy (CSHT) in VHA.³

These results are startling given that Department of Defense (DoD) policy prohibits transgender people from serving openly in the military. This DoD policy (much like the Don't Ask, Don't Tell policy) does not apply to VHA, where sexual and gender minority veterans have always been treated. However, the military culture does impact the VHA culture of care,⁸ making it essential for facilities to reduce stigma and create a more welcoming environment for trans-vets. Fortunately, DoD regulations prohibiting transgender service are anticipated to be overturned in the spring of 2016, making it even more important for VHA providers to be knowledgeable about transgender veteran care.

The mandate to provide culturally informed care to trans-vets has raised challenges for VHA medical centers nationwide. Providing comprehensive transgender healthcare can be highly complex, involving coordination across multiple specialties and services.^9,10 Although increasing in number system-wide, the transgender population within any one medical center is usually small. Moreover, few VHA providers have any training or experience in treatment of trans-vets.^11,12 Services that VHA providers are expected to deliver to trans-vets as per Directive 2013–003 include therapy focused on gender identity exploration and/or gender transition, mental health and physical evaluations for CSHT, prescribing hormones, evaluation for (but not provision of) gender affirming surgeries, postsurgical care (including medically necessary surgical revision), and support letters for legal name and gender marker change both within the VHA system and externally (e.g., driver's license). However, for VHA providers with little or no experience or training in this specialized care, the mandate to provide culturally competent transgender healthcare can be daunting.

Fortunately, the VHA Lesbian, Gay, Bisexual, and Transgender (LGBT) Program within the Office of Patient Care Services in VHA Central Office in Washington, DC has developed a multimethod approach to educating and offering clinical support to VHA staff providing transgender care.¹³ Several trainings on transgender veteran healthcare are available in a variety of formats and depth of content. These formats include national presentations, webinars, and fact sheets, which are archived with other resources and available to all VHA staff on an internal website. Three online trainings are available to all VHA employees on demand and now available to non-VHA providers, including a general course, one for mental health providers, and one on prescribing CSHT (https://vha.train.org/). These three online courses also include testimonials of trans-vets describing their experiences and preferences in healthcare. In addition, the LGBT Program has supported a 7-month virtual training program for interdisciplinary teams of providers interested in learning more about treating trans-vets, which has already trained 35 teams of 214 providers nationwide and is currently training another 20 teams of 198 providers.^10,14

Yet, even with the breadth of training programs, it can be difficult to translate this information into practical guidance. Each veteran's healthcare needs are unique and individualized, making general guidance difficult to apply, especially for those who are new to transgender care or treating complicated comorbidities. Unfortunately, the treatment literature for trans-vets is sparse and where it exists is limited to specific disciplines.¹⁵ Furthermore, no large randomized clinical trials are available to inform treatment planning for trans-vets. Whether new to transgender care or an experienced provider, it can be beneficial to consult with experienced providers and seek input into the treatment planning process for any one patient. To aid VHA providers with specific clinical questions about care for their transgender patient, a system-wide transgender e-consultation program was established.

VHA has a history of utilizing e-consultation to assure access to regionally based expertise in specialty care. To our knowledge, this e-consult program is the first nationwide interdisciplinary program in VHA, where providers at any location can request patient-specific consultation on care from a range of experienced providers, rather than consultation from only one specialty. In this study, we describe the launch of a 3-year feasibility project of the nationwide transgender e-consultation program and typical questions from providers.

Methods

Three teams of providers (Loma Linda, CA; Tucson, AZ; and Minneapolis, MN) were identified as already having an integrated team approach to transgender veteran care and served as the specialty teams to respond to consults from around the country. Each team's configuration differed slightly, but consisted of at least four interdisciplinary members (e.g., primary care physician, psychologist, psychiatrist, pharmacist, social worker, endocrinologist, or nurse), as well as program support assistant (PSA). It was not known how many e-consults would be completed by each team, but salary support for 5 h of time per week for four clinicians and 10 h per week for a PSA was offered per team. Some teams had additional clinicians who contributed their time without salary support. These teams were recruited as consultants and underwent more than a year of training and consensus-building across teams. This process included a 2-day intensive face-to-face training by teachers with 10+ years of transgender treatment each, including a trainer who was a contributor to the World Professional Association for Transgender Health (WPATH) Standards of Care seventh edition (see Kauth et al. for more detail on specialty team training).¹⁴

In addition, a volunteer technical support person was recruited to develop a template for the e-consultation requests. Weekly teleconference calls with the LGBT Program staff, clinical providers, trainers, and the technical developer allowed for the creation and modification of the eMR template that would allow providers to submit questions. Once the template was finalized by the team, it was uploaded individually into each VHA facility's record system, which required a high level of effort and coordination by the PSAs. This template was linked back to the team providing the consultation; therefore, technical support was coordinated through the facility that would answer the consult. A de-identified monitoring system was also created, including location of consultee, names and disciplines of consultants, and minutes spent responding. Each of the three PSAs updated the national monitoring log weekly and reviewed the data with the LGBT Program staff.

The e-consultation program was designed to provide veteran-specific consultation through the eMR, allowing the consultant to review all relevant notes, laboratory results, diagnoses, etc., to provide a tailored response about that veteran's care. Therefore, each facility needed to recognize the clinical privileges for all of the providers who were offering consultation, which was another time consuming task that the PSAs coordinated. This allowed those providers to view the entire medical chart and permitted these providers to write their response to the consult question in the veteran's medical record. Thus, patient-specific responses to questions about care were possible, while the veteran continued to be seen by local providers. No diagnosis was required to receive consultation, but verbal consent from the veteran was mandatory. The goal of the program was to provide veteran-specific responses within 1 week of the question and document through the eMR. Through this system, every VHA provider nationwide has access to expert consultation about various aspects of transgender care.

After e-consultation was launched, ongoing teleconference meetings twice per month allowed continued team development and building of standard language to common questions. In this way, it was possible to assure that responses from one team were comparable to those of a different team. Rollout of the e-consult program began at the consultant team's own facility in April, 2014. Rollout then expanded to all VHA hospitals and community-based outpatient clinics (CBOCs) in the teams' initial catchment area (geographically nearby) over the next 4 months. This process included uploading and testing the e-consult template and recognizing the clinical privileges of the consultation team as described above. Next, the team expanded to facilities in additional VHA regions until every facility nationwide had functioning e-consultation. Eight months into the rollout of the program (December, 2014), the majority of VHA facilities had access to e-consultation. Complete nationwide coverage was achieved on March, 2015, ∼1 year after the launch of the system. As a national program, data are reported in aggregate across all three teams from April 2014 through September 31, 2015, including 7 months of nationwide coverage.

Results

In the first 17 months of the program, 303 e-consults have been completed from 130 facilities with consultation provided on the care of 230 unique veterans. More than half of these were submitted by providers at VA hospitals (n = 177, 58%), and the rest (n = 126, 41%) were from CBOCs. An additional 19 were cancelled (e.g., policy issues not specific to a veteran, missing information, and unresponsive consultee provider). Figure 1 depicts the increasing use of the e-consult program for each fiscal quarter.

Fig. 1.

Use of the e-consult program by fiscal quarter.

The primary questions have been about medications, including CSHT (n = 125); primary care medical comorbidity and screening questions (n = 97); mental health evaluations for CSHT and/or gender confirming surgeries (n = 63); and questions about psychotherapy (n = 18). In some (n = 79) cases, there was also a formal secondary question, including 31 about mental health issues, 22 about medications, 14 about primary care, and 12 about psychotherapy. For example, one consult contained questions about how to conduct a mental health evaluation for CSHT and questions about how anxiety and PTSD symptomology interact with CSHT. Another consult asked about testosterone dosing and the relationship between tobacco use and necrosis following mastectomy. Many consults asked if the veteran's comorbidities were contraindications for starting hormone therapy (e.g., migraines, deep vein thrombosis, cardiovascular diagnoses, high PSAs, and mental health diagnoses such as schizophrenia and depression).

Consistent with the interdisciplinary model of transgender health, multiple disciplines typically responded to each consult, even when there was one question. In this way, it is possible to respond to concerns from an interdisciplinary perspective. An average of 2.27 providers (range = 1–7) contributed to responses with a minority 39% (n = 118) receiving a response from only one provider. Consults where a formal second consult question was identified had even more providers working on the consult response (mean = 2.71; range = 1–7).

Across teams and disciplines, the average amount of time spent on reviewing the chart and responding to the consult question was 78 min (63–94 min) total per consult. On average, each discipline took roughly the same amount of time (18–58 min) contributing to the consult, although endocrinologists took more time (58 min) and nurses were faster (18 min) than other disciplines (Pharmacology averaged 40 min; Primary Care averaged 39 min; Social Work averaged 32 min; Psychology averaged 30 min; and Psychiatry averaged 21 min) in reviewing the chart and responding to consults. Average days elapsed between submitting the consult and receiving a response in the veteran's chart were 5.9 calendar days (range = 2.4–7.7 days). This elapsed time includes weekends when VHA consulting teams were not operating.

VHA providers submitted e-consult questions from locations all over the country; however, no e-consults have been received yet from facilities in seven states (Delaware, Hawaii, Mississippi, New Jersey, New Mexico, Rhode Island, and South Carolina). Among providers who sought consultation, 231 were unique providers, 26 submitted 2 consults, 15 have submitted between 3 and 5 consults, and 1 provider placed 10 consults.

Discussion

Study findings support the feasibility of the national interdisciplinary transgender e-consultation program. The interdisciplinary approach to transgender health in VHA is reflected in the number of provider disciplines who responded to the 303 completed e-consults for 230 unique trans-vets. This interdisciplinary approach in e-consultation to trans-vet care is consistent with the VHA model of integrated healthcare (VHA Handbook)¹⁶ and clinical trainings on transgender care in VHA.^10,14 Typically, more than one discipline contributed to the consult response (61%). The amount of time spent looking at the veteran's chart, including laboratory results, as well as crafting a response to the e-consult, was similar across professions. Each profession took an average of about 34 min (range = 18–58) to respond to the e-consult. An exception is the time taken by endocrinologists to respond to the consults (average 58 min). However, endocrinologists also responded to fewer consults overall, suggesting that the amount of time to respond to consults may lessen with practice. Overall, the amount of time spent on responding to consults, attending team meetings, and getting ongoing continuing education on transgender care was consistent with the salary support for team members. The amount of time needed by the PSA to coordinate the dissemination of the e-consult template and the sharing of provider credentials was intensive at the start, but lessened over time as processes were established. As start-up work decreased, tracking and coordination of responses to consults increased, with net time allocated being appropriate to the work.

Consult questions were submitted by VHA providers from around the country, and included both hospital-based settings (n = 177), as well as CBOCs (n = 126). This finding was surprising to the team, as it was anticipated that trans-vets would gravitate to urban centers where VA hospitals are located. These data suggest that this program may be of particular benefit to rural providers who do not have ready access to colleagues with more experience. However, these data must be interpreted cautiously, as it is possible that there are more trans-vets seeking care at urban hospitals, but that their providers aren't utilizing the e-consult service. Indeed, it is possible that the interdisciplinary team-based 7-month long training that is occurring within VHA is preempting the use of e-consult by those teams, as they have access to consultation through that program.

Future program development work should include an examination of the transgender-related diagnoses in the system and access of the e-consult system. Then, if there are patients being seen in areas where e-consult is not used, targeted outreach about the program may be useful. There has been increasing use of the transgender e-consult program across each quarter since its inception, although additional outreach and dissemination about the program are needed, given that there is a leveling off of e-consult use.

To date, 230 unique veterans have had national specialty consultation on their local provider's treatment plan. However, published data using VHA data show that in 2013, there were at least 2,567 living veterans who had a transgender-related diagnosis in their medical record.³ Thus, e-consultation was provided on ∼9% of the known trans-vets in our system from 2013. It is possible that some of these veterans did not access any VHA services from April 2014 through September 2015. However, it is unclear why more trans-vets have not had consultation on their care. Given the context of multiple training efforts, including on-demand online training about transgender health in the VHA,^10,14 it is possible that providers who are treating these veterans feel confident in the treatment plan and don't need consultation. However, it is also possible that these providers would be interested in consultation, but are simply unaware of this resource. In particular, VHA providers at facilities in seven states have never submitted a transgender e-consult, indicating that targeted outreach may be needed in these facilities.

Even though providers can ask both a primary and a secondary question in the e-consult, about 18% of providers have submitted more than one e-consult, suggesting that these providers find the program useful. Unfortunately, our main limitations are that no data exist about user satisfaction, how treatment plans have changed, or patient outcomes for those who have had consultation versus those who have not. Future work should examine provider satisfaction with the program, as well as comparing transgender veteran care quality with and without e-consultation.

Other limitations of this program include that the future of this program is uncertain as the initial feasibility project is soon coming to a close. Ongoing funding for this program is not guaranteed, particularly as it only impacts a small number of veterans. However, the majority of effort needed to launch this program (establishing and training consultants, creating and disseminating the template, sharing of provider credentials, generating a tracking system, and quality assurance program for consults) has already been achieved. Should funding continue, examinations of provider and trans-vet satisfaction with this program and potential impact on healthcare outcomes will be considered.

For other healthcare systems looking to implement a similar program, the challenges of starting such a program are many in the initial years. Identifying consultants, training them, and establishing and disseminating an e-consult template, as well as sharing credentials between facilities, were among our biggest challenges. Other systems would need an eMR system with capacity to share information across sites and consult drafting capability to establish a similar program. However, once these initial obstacles are overcome, the maintenance of the system is straightforward; although provider turnover and ongoing training of consulting teams are vital. At present, the VHA nationwide transgender e-consultation program is part of an arsenal of resources, including training opportunities and internal website repositories of information, now available to VHA providers in support of culturally and clinically competent care to trans-vets at whichever VHA facility where they receive care.

Footnotes

Disclosure Statement

No competing financial interests exist.

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