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.
Telemedicine Program Improving HCV Care for Rural Veterans Cont
Building Access in the VA
The VA is funding 11 VA medical centers through grants to provide SCAN ECHO specialty training, with four centers providing it for HCV. Officials say they believe at least 300 ECHO consults have been completed, a number that includes not only HCV but all SCAN-ECHO specialty clinics, since the program has been expanded to other chronic diseases.
The VA’s use of the model is new and is one of multiple strategies being employed to make hepatitis C treatment more accessible. Jain pointed out that VA providers like to have a “menu of options” for care delivery, and this model might not fit the need of all rural providers or facilities.
“The only way, as a VA primary-care provider, where this would make sense is if I am practicing in a community where either the prevalence of hepatitis C in my community is relatively high, or in my panel I happen to have several patients with hepatitis C,” he said. “Then the motivation for me to understand and learn more about the management of hepatitis C is a lot more than if I had one patient or two amongst the 1,200 or 1,400 panel that I had.”
Jain noted that provider participation is optional. The biggest challenge so far in expanding the program is the healthcare providers’ full schedules. Finding time to allot for SCAN-ECHO sessions, which last about 90 minutes., might be difficult, Jain said.
Still, he said he is enthusiastic about this model because it can enhance the ability of primary-care providers to care for HCV patients without requiring difficult travel for patients.
Those using SCAN-ECHO also see its potential. The San Francisco VA is one of the centers currently launching SCAN-ECHO, and Rongey suggested the model has the potential not only to link providers in more rural areas with specialty knowledge, but also those in urban centers who have patients who would prefer to receive care from their primary-care providers instead of seeing a specialist they do not know.
“Many of our downtown or urban health clinic providers really do provide a unique environment that is very sensitive to veterans that are unstably housed or have mental-health conditions, so much so that those veterans would prefer to receive hepatitis C therapy at those urban centers rather than come to see us,” she said.
Across the country at the VA Connecticut, a team also is sharing HCV expertise with providers across the region.
One of the specialists involved with the program, Joseph Lim, MD, said he believes the providers and patients benefit from the program’s sessions that include a didactic portion as well as a discussion on specific patient cases that the providers submit.
“We review these cases in advance and then at the time of an actual SCAN session, the individual sites–whether they are in Idaho, Pittsburgh, Boston or here in Connecticut –they present the case to all participants. Then there will be discussion about management issues and questions. The moderator of the session will have reviewed the case in advance and, when appropriate, will provide contribution of experience to advise on patient care, as well as literature,when available.”
After the session, formal documentation of the recommendations is placed in the electronic medical record of the patient under discussion. For learning purposes, these cases are reviewed at later sessions to understand the patient outcomes or for further discussion or education, he said.
“I think this has increased satisfaction for providers where they feel like they can get input from other people to help them out, as well as for veterans who feel like they are getting access to quality of care from teams of physicians who advise on care,” he said.
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