Dissemination and Implementation of a Telehealth-Enabled Program for Providing Infectious Disease Expertise in Rural Settings

Abstract

Background

Telehealth can facilitate improving antibiotic use and related antimicrobial stewardship activities in facilities underserved by infectious diseases (IDs) expertise. We describe implementation of the Department of Veterans Affairs (VA) videoconference antimicrobial stewardship team (VAST) to connect multidisciplinary teams from rural VA medical centers (VAMCs) with geographically distant ID experts.

Methods

We implemented VASTs at 10 rural VAMCs from September 2021 to February 2024. VASTs consisted of regular meetings between rural VAMCs and an off-site ID expert who met by videoconference to discuss clinical cases, emphasizing recommendations for antibiotic prescribing. The VA Corporate Data Warehouse was used to collect information on patient medical encounter information. Interviews with healthcare professionals and surveys assessed perceptions of and experiences with VASTs.

Results

VASTs completed 624 clinical encounters on 531 unique patients. Half (53%) of the encounters required >20 minutes. The most frequently discussed infections were respiratory tract (35%), skin and soft tissue (19%), and genitourinary (17%). Of the 73 (53% of 138 contacted) professionals who responded to the survey, >90% perceived VASTs as improving the quality of veteran care and agreed that recommendations were timely. All 24 interviewees identified VASTs as meeting an important need at the rural site and that the virtual system facilitated collaboration.

Conclusions

These findings indicate successful implementation of a telehealth program to disseminate ID and antimicrobial stewardship expertise to rural VAMCs. This is a strong model augmenting antimicrobial stewardship in other healthcare systems.

The videoconference antimicrobial stewardship team (VAST) disseminated infectious disease and antimicrobial stewardship expertise to settings with limited access to infectious disease experts. VAST is scalable and can be disseminated to other healthcare systems and settings.

Antimicrobial stewardship principles seek to minimize unnecessary and inappropriate antimicrobial use in order to decrease microbial resistance, curtail the spread of infections caused by nosocomial pathogens and ultimately, improve patient safety [1]. Achieving successful antimicrobial stewardship is resource intensive and requires expertise not available to every healthcare setting. Guidelines for hospital-based antimicrobial stewardship programs call for an infectious diseases (IDs)-trained physician and clinical pharmacist as well as a clinical microbiologist, information system specialist, infection preventionists, and hospital epidemiologists [2]. Currently, the number of ID-trained physicians and pharmacists is insufficient to support comprehensive antimicrobial stewardship programs [3]. This holds true even within the Veterans Health Administration (VHA), the largest integrated health care system in the United States [4].

Telehealth can help disseminate expertise to healthcare institutions in geographic areas with limited access to specialists, including those trained in ID. Telehealth has addressed the care of people with acute infections such as community-acquired pneumonia, urinary tract infections, and skin and soft tissue infections, as well as chronic diseases such as tuberculosis, hepatitis C virus, and human immunodeficiency virus [5]. Telehealth is also a feasible strategy for providing antimicrobial stewardship to healthcare institutions underserved by ID expertise [6, 7]. Approaches include fully remote, collaborative, and integrated models, with the last involving off-site ID experts providing consultations and supporting antimicrobial stewardship activities by local team members [8].

Previously, we conducted a successful pilot study that used an integrated tele-antimicrobial stewardship model to support improved antibiotic use at two rural Veterans Affairs Medical Centers (VAMCs) without local ID expertise [9, 10]. The program consisted of weekly meetings between a multidisciplinary team at a rural VAMC and an ID-trained physician who joined by videoconference, collectively forming a videoconference antibiotic stewardship team (VAST). At each meeting, the VAST discussed patients with ID concerns, providing recommendations that addressed antibiotics, additional diagnostic tests, and imaging studies, as well as considerations should the patient develop a similar problem in the future, such as for those with aspiration pneumonitis or labeled as having recurrent urinary tract infections. While the initial pilot study was intended to last just 6 months, the VASTs at both sites continued for more than 5 years. Here, we describe the dissemination and implementation of VASTs by off-site ID clinicians partnering with rural VAMCs, summarizing the composition and schedules of the VASTs, the number of cases and types of infections discussed, the veterans served, and the experience of team members.

METHODS

Study Design and Setting

From September 2021 through February 2024, Veterans Affairs ID physicians were paired with rural VAMCs without ID physicians to form multidisciplinary VASTs. The purpose of VASTs was for multidisciplinary teams to discuss patients for whom there was a concern for infection and to make recommendations regarding antibiotic use and, when appropriate, other aspects of clinical care, such as radiologic studies or diagnostic tests. By discussing cases as a group, participants could learn from others' experiences and integrate that knowledge into their own practice, particularly aspects that pertained to antimicrobial stewardship. VAST attendees were encouraged to ask questions, share knowledge, and consider the circumstances of individual patients. ID experts could choose but were not required to offer formal and informal teaching during VAST meetings. Similarly, local champions could choose but were not expected to share local antibiotic use or surveillance data. The VA's Central Institutional Review Board approved the study protocol.

VA ID physicians and potential rural VAMCs were recruited through professional networks within VHA. While some VAST teams were created through existing relationships between the ID physician and the rural VAMC, other VASTs were established via outreach to the rural sites' infection preventionists and/or pharmacists involved in antimicrobial stewardship.

Implementation

The ID physicians received an implementation guide with recommendations on how to obtain clinical privileges at the rural VAMC, procedures to establish a clinic within the electronic medical record for documentation and workload capture, as well as methods to engage leadership and other key personnel at the rural site. The implementation guide also included a suggested workflow for VASTs to coordinate activities across both sites, offering note titles and templated language for use in documentation (Supplementary Appendix 1).

The recommended workflow began with “champion(s)” at the rural site, usually pharmacists or infection preventionists, selecting a suggested four patients for discussion each week. Selection of cases to discuss was at the discretion of the local champions. Cases could be active patients with ongoing infectious concerns or antibiotic use, or patients with a completed clinical episode for which the team wanted to debrief or to plan for future episodes of care. The ID physicians would review those cases independently and discuss the cases during meetings. Meetings were typically scheduled for 1 hour a week and conducted on Teams (Microsoft Corporation, 2025) with interactions via voice, camera, and text using the chat function. Pharmacists, infection preventionists, physicians, nurse practitioners, physician assistants, nurses, trainees, and any other interested staff from the rural VAMCs were invited, regardless of whether one of their patients was being discussed. Similarly, ID experts could also invite others at their institution to participate. After discussions, the VASTs' recommendations were documented in the patients' electronic health record (EHR) at both the site of ID physician to capture workload and at the rural site to support patient care. The core research team offered facilitation calls and was available via e-mail or phone calls to help each VAST get established.

Medical Encounter Data and Analysis

The research team obtained medical encounter data from the VHA Corporate Data Warehouse (CDW) for the 15-month study period following each VAST’s initial visit. Individual VAST encounters were identified based on the clinic name and stop codes, the note titles, and authors at the site of ID physicians. Data obtained from the CDW were summarized to describe VAST clinical encounters, including all Current Procedural Terminology (CPT) codes, International Classification of Diseases, Tenth Revision (ICD-10) codes, and patient demographic characteristics associated with the encounter. Inclusion in the analysis required an encounter to have both a CPT code and ≥1 ICD-10 code. ICD-10 codes associated with the encounters were grouped into broader syndromes to summarize the types of ID concerns discussed by VASTs (Supplementary Appendix 2). CPT codes indicated the time the ID physicians used to complete VAST clinical encounters. One of the participating rural sites (VAST G) had recently implemented a new EHR that differed from the EHR of their VAST's ID physicians; this hindered data collection as well as aspects of the workflow. Encounters without both ICD-10 and procedure codes or for which patient demographics could not be accessed (due to the limitations associated with implementation of a new EHR) were excluded.

Semi-Structured Interviews and Analysis

Six months after implementation began, we conducted semi-structured interviews to assess participants' perceptions of the VAST (Supplementary Appendix 3). ID physicians and champions who helped implement VAST at the rural sites were contacted for an interview, primarily through e-mail. Interviews were conducted via telephone or Microsoft Teams, digitally recorded, transcribed, and analyzed using NVivo software (Lumivero, Denver, Colorado). Two trained qualitative analysts conducted inductive and deductive content analysis, which identified salient themes, with deductive codes based on the domains of the Practical, Robust Implementation and Sustainability Model (PRISM) and Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) frameworks [9, 10]. Five transcripts were coded by both analysts to ensure consistency; the remaining transcripts were coded independently by one analyst. Coding disagreements between the analysts were resolved through discussion and consultation with the larger multidisciplinary study team. Qualitative data were analyzed as an aggregate, and site-level comparisons were not made.

Survey

Within 3 months of the end of each site's implementation of VAST, an internet-accessible survey was administered through VA Research Electronic Data Capture to healthcare staff who participated in at least 1 VAST session (Supplementary Appendix 4). Survey questions, informed in part by the semi-structured interviews, assessed perceptions and experiences related to participating in VAST, and responses were described using frequencies and percentages.

RESULTS

Videoconference Antimicrobial Stewardship Team Characteristics

Between January and November 2022, ID physicians established 8 VASTs (lettered A–H) with 10 rural VAMCs. Six VASTs (A, B, D, E, G, and H) were dyads with off-site ID physicians paired with a single rural site (Table 1). Of the 12 champions from the rural sites, 8 served as the antimicrobial stewardship pharmacist for their VAMC. VAST C involved two rural VAMCs that met at shared sessions; VAST F established separate meetings for their two rural sites (F-1 and F-2). Three VASTs involved pre-existing relationships. VASTs D and F-1 originated during the pilot study preceding this implementation expansion by 5 years. For VAST D, the pharmacist and infection preventionist involved during this study period were new to the rural site; the partnering ID physician had not participated previously. The ID physician and pharmacist involved in VAST F-1 had worked together for several years. VAST B built upon a previous telehealth-supported stewardship relationship between the ID expert and personnel at the rural VAMC [12]. For VASTs A, C, E, F-2, G, and H, there were no known pre-existing ongoing professional relationships regarding ID or antimicrobial stewardship between the ID experts and the personnel at the rural sites. VASTs A, C, and E–H met weekly; VAST B met twice weekly while VAST D met every 2 weeks.

Table 1.

Characteristics of the VASTs Formed by the Rural VA Medical Centers Partnering With Infectious Disease Experts

VAST	Rural VAMCs	Within the Same VISN	Same Time Zone	Medical Complexity Group of Rural Sitea	Acute Care Beds	Community Living Center Beds	Role (number) of ID Experts	Role (number) of Champions	Frequency of VAST Meetings	Continued After Initial Period?	Additional Comments
A	1	Yes	Yes	2	26–50	51–100	Physician (1)	PharmD (1)	Weekly	Yes	…
B	1	No	No	2	26–50	101–200	Physician (1)	PharmD (1)	Twice weekly	Yes	The rural site created a new VAST with the ID physician from VAST E, which was geographically closer and within the same VISN
C	2	Yes	Yes	3	11–25; 11–25	≤50; ≤50	Physician (2), PharmD (1)	PharmD (2); PharmD (1)	Weekly	Yes	Two rural sites participate in the same VAST sessions
D	1	No	No	2	≤10	101–200	Physician (1)	PharmD (1), Infection Preventionist (1)	Every 2 weeks	Yes	The rural site created a new VAST with an ID physician who was geographically closer and within the same VISN
E	1	No	Yes	2	≤10	101–200	Physician (2)	PharmD (1)	Weekly	Yes	The rural site created a new VAST with an ID physician who was geographically closer and within the same VISN
F-1	1	Yes	Yes	3	≤10	101–200	Physician (1)	BPharm (1)	Weekly	Yes	…
F-2	1	Yes	Yes	3	11–25	51–100	Physician (1)b	PharmD (1)	Weekly	No	The rural site ended participation after 10 months. They medical staff had other established pathways for obtaining infectious disease recommendations and elected to continue those to streamline local processes
G	1	Yes	Yes	3	11–25	≤50	Physician (2)	PharmD (2)	Weekly	No	Differences in the electronic health record (EHR) hindered chart review and clinical documentation. The recommendation was for the rural site to form a VAST with ID experts working within the same EHR
H	1	Yes	Yes	3	≤10	>200	Physician (1)	PharmD (1)	Weekly	No	The low number of clinical encounters indicates a VAST with limited engagement

Abbreviations: ID, infectious disease; VAMC, Veteran Affairs Medical Center; VAST, videoconference antimicrobial stewardship team; VISN, Veterans Integrated Service Network; these are regional systems of care that work together to meet local healthcare needs of veterans.

^aMedical Complexity Group considers the patient population, clinical service, as well as education and research at VAMCs. Level 2 indicates facilities with medium volume, low-risk patients, few complex clinical programs, and small or no teaching or research programs. Level 3 indicates facilities with low volume, low-risk patients, few or no complex clinical programs, and small or no teaching or research programs [11].

^bThis was the same physician participating in F-1.

Following their initial 15-month study periods, 7 of the 10 rural VAMCs remained engaged with a VAST; three (B, D, and E) created novel dyads with ID physicians who were geographically closer. Of the three rural sites that did not continue, VAST F-2 elected to end their participation prior to the end of the study period, favoring asynchronous interfacility electronic consultations, which was the previously established pathway their clinicians used to obtain ID expertise. VAST G was hindered by an EHR mismatch between rural site and the ID physicians, as previously noted. At the conclusion of the study period, the participants recommended that the rural VAMC should form a new VAST with ID experts working within the same EHR. The rural site and ID physicians involved with VAST H had only limited engagement, as indicated by few documented clinical encounters throughout the study period.

Videoconference Antimicrobial Stewardship Team Clinical Activities

Collectively, the VASTs reported 658 clinical encounters, of which 624 (95%) met our inclusion criteria. The VASTs discussed 531 unique patients across acute care (42%), ambulatory clinics (24%), and Community Living Centers (CLCs; 34%), which provide an array of services including skilled nursing and long-term care (Supplementary Table S1). The patients had a mean age of 72.4 (±12.3) years and were predominantly male (95%) (Supplementary Table S2). Over 80% of the patients were White for all VASTs, except for VAST B in which 37% of the patients were Black. The most common chronic medical condition present among patients reviewed by VASTs patients was diabetes mellitus (51%) followed by chronic lung (41%), cardiac (30%), and peripheral vascular diseases (29%). Based on CPT codes, 331 (53%) of the encounters required >20 minutes to complete (Figure 1). Among the ICD-10 codes entered by physicians, respiratory tract infections (35%) were the most common ID syndrome documented, followed by skin and soft tissue infections (19%) and genitourinary tract infections (17%) (Figure 2).

Figure 1.

The number of consults completed at each VAST site, stratified by the length of time to complete the encounter.

Figure 2.

International classification of diseases-10th edition (ICD-10) codes specific to infectious disease syndromes associated with VAST consults at each site. The Other category includes gastrointestinal, renal, dental, neurological, and vascular infections.

Experience of Videoconference Antimicrobial Stewardship Team Members

All ID physicians and rural champions who were approached agreed to be interviewed (n = 24) with an average interview time of 30 minutes (range 11–57 minutes). Qualitative findings aligned with various PRISM framework domains and RE-AIM framework dimensions (Supplementary Table S3). Regarding the Intervention PRISM domain, participants understood the purpose of VAST from the outset and felt that VAST addressed an important need at the rural site. For the Implementation and Sustainability Infrastructure PRISM domain, participants identified assistance from the ID experts as a strength of VAST that supported the implementation and sustainability of the program. ID physicians provided access to expertise, were approachable and made people feel comfortable, and exhibited good “teaching” qualities. For the Recipients PRISM domain, many participants felt that the virtual meeting system of VAST worked well given the systems and space to which they had access. Some pointed out specific instances where the virtual meeting format presented challenges due to technical issues, such as cameras being turned off or the visualization of information shared via the EHR. Some also noted that EHR-specific aspects of the interfacility consult system, through which veterans can receive electronic consultative or telemedicine services from a geographically distant VAMC, did not work well.

Relevant to the Implementation RE-AIM framework dimension, many participants felt that the planned format of the VAST sessions worked well. Some pointed out issues with the session frequency, or less often, the session duration. For the Reach RE-AIM dimension, participants saw an increasing number of providers participating in the VAST sessions or saw greater unprompted interest and engagement from the providers. Some participants mentioned, however, that providers did not join the sessions at all or did not join if the provider's own patient was not being discussed. Other participants observed a general lack of engagement and discussion amongst the providers during the sessions. With regard to the Maintenance RE-AIM dimension, participants endorsed general plans to sustain the activities of their VAST after the study period ended, sometimes particularly mentioning continuing regular meetings or maintaining a relationship and communication with either their ID physician(s) in particular or the between the sites generally.

Finally, two additional themes emerged inductively and outside of the PRISM and RE-AIM frameworks. The most frequent suggestion for improving VAST was to encourage providers to attend the VAST meetings when their cases would be discussed, and especially to have the provider present their own case. Participants also suggested expansions to the VAST program or pairing sites within the same Veterans Integrated Service Network (VISN), which are regional systems of care within VA.

Among the 138 healthcare professionals to whom surveys were sent, a total of 73 (53%) responded, 52 of whom were from the rural VAMCs. Most of the respondents were clinicians (n = 33; 45%) or pharmacists (n = 24; 33%). Participants' perceptions of VAST were highly favorable with over 90% indicating that their VAST improved the quality of veteran care, that VAST recommendations were timely, and that VAST supported both giving and receiving ID expertise for patient care (Table 2). Notably, most survey respondents (56, 77%) agreed with the statement that the VAST improved facility antibiotic use at their facility. Supplementary Table S4 summarizes responses regarding the adequacy of the equipment and technology to participate in VAST activities.

Table 2.

Participants' Perceptions of VAST

Evaluated Statements About VAST C, No. (%)	Agree or Strongly Agree, No. (%)	Neither Agree Nor Disagree, No. (%)	Disagree or Strongly Disagree, No. (%)
Leadership is supportive	67 (92)	6 (8)	0 (0)
Team is collaborative	69 (95)	3 (4)	1 (1)
Recommendations are timely	72 (99)	1 (1)	0 (0)
Supports giving ID expertise for patient care	72 (99)	1 (1)	0 (0)
Supports receiving ID expertise for patient care	70 (96)	3 (4)	0 (0)
Improved facility antibiotic use	56 (77)	16 (22)	1 (1)
Improved quality of veteran care	68 (93)	5 (7)	0 (0)
Dissemination of VAST would improve quality of veteran carea	62 (85)	3 (4)	8 (11)
Difficult to access recommendationsa	4 (5)	12 (16)	57 (78)
Not educationala	0 (0)	5 (7)	68 (93)
Did not positively influence practice	0 (0)	7 (10)	66 (90)
Negatively influenced how I use antimicrobials	1 (1)	7 (10)	65 (89)

Abbreviations: ID, infectious disease; VAST, videoconference antimicrobial stewardship team.

^aIncludes 1 and 2 missing responses which were grouped into neither agree nor disagree.

DISCUSSION

We describe a successful dissemination and implementation of a telehealth program that emphasizes antimicrobial stewardship to rural VAMCs with limited access to local ID expertise. Designed to improve antibiotic use at rural VAMCs, the VASTs accomplish this by collaboratively discussing ID cases among a team of healthcare professionals. During the 15-month study period, VASTs fostered collaborative care from ID physicians and rural clinicians for over 500 veterans. Most VASTs addressed common ID syndromes, namely those affecting the respiratory tract, skin and soft tissue, and genitourinary tract. Participating healthcare professionals indicated the VASTs had a positive effect on veteran care and enjoyed the experience.

Fully remote and collaborative approaches to telehealth-based antimicrobial stewardship emphasize programmatic aspects, including education, coaching calls, data support and analysis, antibiotic use protocols, and preparation for accreditation surveys, often aligning with the Centers for Disease Control and Prevention's core elements for antimicrobial stewardship [8, 13–16]. Integrated models embed ID-trained clinician into these efforts, which was associated with a reduction in antibiotic use when introduced to small community hospitals [17–19]. VASTs differ from other integrated models in part because they were implemented within the VA, which has required all VA facilities to have an antimicrobial stewardship program since January 2014. Concomitant with this requirement came an array of resources: monthly educational conferences available nationally; several policies and interventions; development of a national dashboard to measure and compare facility-level antibiotic use; and a robust community of subject matter experts [20]. Accordingly, VASTs did not have to support these VA-wide programmatic aspects of antibiotic stewardship and could emphasize case-based discussions as a means to build trust and influence the practice of prescribing clinicians. Unlike a formal ID consultative service with availability 24 hours a day, 7 days a week, VAST meetings were typically limited to 1 hour each week. For clinical concerns that were not conducive to scheduling during those meetings, clinicians at the rural sites had several options, including contacting the ID expert, collaborating with the local antimicrobial stewardship pharmacists, or using interfacility electronic consults outside of VAST.

The VA was a pioneer in adopting telehealth services for both clinician-to-patient and clinician-to-clinician interactions, including the Specialty Care Access Network Extension for Community Healthcare Outcomes (SCAN-ECHO) program, which integrates patient care with clinical education to increase veterans' access to specialty care expertise [21, 22]. Aside from case-based and ad hoc education, VASTs did not implement a formal curriculum that is typical of SCAN-ECHO programs [23]. Despite the absence of curricula, the vast majority of our study participants agreed that VASTs were educational and improved their practice and antimicrobial use. Overall, our qualitative data was consistent with descriptions of providers' experiences with SCAN-ECHO programs, which emphasizes positive relationships, good communication, and improvements in patient care [24]. The challenges reported by VAST participants also aligned with previous descriptions, including a desire for more engagement from the providers at the rural site who provide direct patient care. While some of this may have related to individuals' time constraints, a willingness to adopt and use technology in support of telehealth may have also influenced provider behavior [25].

Out of 10 rural VAMCs that participated, 7 elected to continue a VAST collaboration beyond the study period. Among these, three VASTs, accounting for four rural VAMCs, continued the program with no modifications, indicating the program was well-received by both ID physicians and rural VAMCs. Three rural VAMCs partnered with ID physicians at a VAMC geographically closer and within the same VISN, indicating that regional proximity helped facilitate inter-institutional partnerships, which may be rooted in institutional- or systems-based knowledge. The fact that three rural VAMCs invested time and resources to reconfigure their VASTs indicates that the program addressed previously unmet need for ID expertise. The reasons why the remaining three VASTs did not continue varied. First, the rural site for VAST F-2 favored using previously established consultative options, suggesting their existing pathways were sufficient to obtain ID expertise. Second, VAST G encountered challenges associated with the implementation of a new EHR into the rural VAMC that hindered the ID experts' ability to access and review patient charts [26]. This outcome emphasizes the importance of reliable and shared access to the same EHR to facilitate patient care recommendations. Finally, VAST H documented only six clinical encounters, suggesting low engagement throughout the study period.

Overall, the population served by VASTs was predominantly older, White, non-Latino males with a burden of chronic medical conditions, reflecting the VA patient population [27–29]. Champions at the rural sites selected cases for discussion, drawing from those in inpatient, outpatient, and in VA CLCs, with proportions that varied across sites. While we did not formally explore reasons for these differences, anecdotal information suggested that in addition to patient characteristics and operational factors, interactions with clinical providers, both harmonious and antagonistic, also influenced case selection. While the proportions varied across the rural sites, about a third of clinical encounters were for veterans living in VA CLCs, suggesting that ID expertise may augment the care of people living in postacute and long-term care settings. In addition to supporting clinical care, further integration of antibiotic stewardship principles may help, over time, to reduce the prevalence of multidrug-resistant organisms (MDROs) and Clostridioides difficile infections in these settings [30, 31].

The time to complete consults, as assessed by CPT codes, varied among the ID providers. The individual workflow patterns of each VAST may account for some of the differences. VASTs for which most encounters were documented as requiring <20 minutes of ID physician time may have relied on the rural site to review and present cases as well as document the VAST recommendations. VASTs with longer documented encounter times may indicate that the ID physician independently reviewed patients prior to the VAST meeting. Differing approaches to medical billing, rather than the complexity of clinical cases, may have also contributed [32, 33].

The types of cases discussed, as ascertained by ICD-10 codes, included common infectious syndromes. Some cases were medically complicated and required care beyond what could be provided solely through VASTs. All rural VA medical centers participating in VASTs had established processes for transferring patients with clinical needs that exceeded the services they could provide locally. Depending on the clinical urgency and geographic location, veterans may have been transferred to a local hospital or to a regional VA Medical Center that offered a greater array of specialty services, including IDs. VASTs could be involved during any phase of this process, including a decision to escalate care, a retrospective discussion or debrief of a significant clinical event, or to assist with management after a patient returned to the rural VAMC to receive further medical care or transferred to the CLC. For recent cases, the ID experts could, when appropriate, couch recommendations as agreeing with the clinical decisions made, offering recommendations for subsequent follow-up, and consideration on how to reduce the risk of complications. These forward-looking recommendations might recommend specific empiric antibiotic choices for veterans known to have MDROs or suggestions for management of veterans with a history of infections that might recur (ie, C. difficile infection, aspiration pneumonia, diabetic foot infections, etc.).

Our study has limitations. First, this work was conducted within the VHA, which has established processes for telehealth services, including interprofessional consultation and workload capture, that may limit generalizability to non-VA settings. Second, not all the VASTs were robust or sustained. In general, those with a higher volume of consults tended to continue, sometimes connecting with an ID expert within the same VISN. Those with fewer cases may not have had sufficient volume to sustain engagement or did not cultivate the informal professional relationships that often facilitate trust and open communication [34]. Future iterations may consider having more than one rural VAMC interact with an ID expert to increase the number of cases available for discussion each week while also conferring the benefits of a sense of community and peer support among participants [35]. Third, in this version of VAST, only physicians served as ID experts. We did not assess the potential for ID pharmacists to partner with rural sites, who would bring additional skills and potentially expand the capacity of VASTs. Fourth, the semi-structured interviews occurred during the active phase of the program. Done in order to inform development of the survey questions, this may have affected the responses of those interviewed. Similarly, VASTs D and F-1 were both established during the pilot study, which may also have influenced participants’ perceptions. To mitigate these potential biases, the individuals conducting the interviews reminded participants that no identifying information would be shared with the remainder of the research team. Finally, we elected to defer assessment of VAST on overall antibiotic use pending analysis of data from the sustainment period and consideration of the influence of a monthly audit and feedback report shared with a randomized subset of the rural sites.

CONCLUSIONS

VASTs successfully leveraged VHA's robust telehealth infrastructure to extend the expertise of ID-trained professionals to rural healthcare settings as a means to enhance ongoing antimicrobial stewardship efforts. The results underscore the benefit of telehealth modalities to improve patient care, in this case specifically using synchronous interprofessional communication in conjunction with documentation within a common EHR. The VAST is a scalable program that can be further disseminated to other VAMCs and provides a strong model for implementing similar programs in non-VA settings with limited access to ID experts, such as community-based critical access hospitals, as well as postacute and long-term care settings.

Supplementary Data

Supplementary materials are available at Open Forum Infectious Diseases online. Consisting of data provided by the authors to benefit the reader, the posted materials are not copyedited and are the sole responsibility of the authors, so questions or comments should be addressed to the corresponding author.