By Sandra Basu
WEST HAVEN, CT — Twice-a-month online sessions hosted by the VA Connecticut Healthcare System are not typical telemedicine initiatives in which clinicians provide care to individual patients over electronic media.
Instead, hepatitis C (HCV) specialists are training primary-care providers to improve care in multiple locations where specialty expertise is scarce. During these SCAN-ECHO sessions, specialists review specific patient cases and offer presentations to help generalists build their knowledge base.
“Typically, the expertise for treating hepatitis C is usually based at our VA medical centers and not in the community-based outpatient clinics that the VA has in the rural communities,” Rajiv Jain, MD, VHA’s chief officer for Patient Care Services told U.S. Medicine. “What SCAN-ECHO allows us to do is to enhance the expertise that the primary-care providers have in taking care of patients with hepatitis C by connecting them with a specialist at a medical center and transferring some of that expertise over a period of time by ongoing discussions to the primary-care providers, so they are more comfortable in managing these patients in their day-to-day practice.”
The program also is being tested in urban areas to train primary-care providers whose patient populations would have difficulty seeing a specialist in an unfamiliar setting.
The ECHO group at work in Connecticut. Photo by Jim Salemi/The Middletown Press. Used with permission.
Many rural veterans with HCV live far from urban centers where much of the VA’s specialty care is available. Research conducted by Catherine Rongey, MD, a staff physician and assistant professor in gastroenterology and hepatology at University of California, San Francisco and director of the San Francisco VA Medical Center’s SCAN-ECHO program, found that about 40% of all VHA patients live in rural areas, and about 30% of veterans with HCV live in rural areas.
Her research, delivered as an oral presentation at the 2011 American Association for the Study of Liver Diseases, also found that 45% of rural veterans with HCV had never seen a gastroenterologist/liver specialist over the five years analyzed, a figure that was much lower than the researchers had anticipated.
The study did not examine why these veterans were not accessing specialty care, but Rongey suggested it could be for a variety of reasons, including geographical distance.
“If the community-based outpatient clinic (CBOC) does not have a telemedicine or telehealth clinic, then the veteran may have to travel up to eight hours in a van to access a specialist,” she told U.S. Medicine. “That is especially problematic as approximately 70% to 80% of our veterans with HCV have a concomitant mental-health or substance-use diagnosis. So that can be a very uncomfortable experience for anybody, but much [more so] for someone with potential anxiety or PTSD concerns being in an enclosed van, traveling over long distances, over bridges, through tunnels to see a specialist.”
New Mexico Project
VA’s SCAN-ECHO is based on the University of New Mexico Project ECHO model, which was developed by University of New Mexico Health Sciences Center (UNMHSC) hepatologist Sanjeev Arora, MD. As one of the few specialists in hepatology in New Mexico, he found that his patients often were driving long distances, multiple times a year to receive treatment. In addition, there was a waiting list for appointments.
“I used to run a dedicated clinic for HCV at the University of New Mexico and there was an eight-month wait to see me. People would have to drive 200 to 250 miles every time to see me if they were coming from rural New Mexico,” he told U.S Medicine.
With the development of Project ECHO, primary-care providers now can access lectures given weekly by UNMHSC specialists on caring for hepatitis C patients. They also have the opportunity to present specific patient cases for discussion with the specialists.
While traditional modes of telemedicine solve the geographic divide, Arora said this model provides something extra: expertise in caring for HCV patients that builds permanent capacity to provide specialty care.
Moreover, a study published in the New England Journal of Medicine last June by Arora and his colleagues suggests that patient care did not suffer when this model is used.
The prospective study compared the treatment for HCV infection at the UNMHSC HCV clinic with treatment by primary-care clinicians at 21 ECHO sites in rural areas and prisons in New Mexico. A total of 407 patients with chronic HCV infection who had received no previous treatment for the infection were enrolled. Cure rates were 58.2% for patients treated through Project ECHO and 57.5% for the group treated at UNM.