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VA kicks Project ECHO telemedicine service into high gear

The Department of Veterans Affairs launches a large telemedicine service pilot connecting remote vets with VA physician specialists in Cleveland.

Mainstream hospitals and public payers are slowly embracing the potential of telemedicine services in health care. But the U.S. Department of Veterans Affairs -- the largest integrated health care system in the country -- has accelerated its own video health care initiatives by launching a large pilot program to treat vets remotely who suffer from such persistent, care-intensive conditions as heart failure, hepatitis C and chronic pain.

Despite the reach and the high quality of our health care services … one of our biggest challenges is that many millions of our patients live in highly rural areas.

Dr. Robert Petzel,
VA under secretary for health

The pilot, VA Specialty Care Access Network-Extension for Community Healthcare Outcomes (SCAN-ECHO), replicates on a national scale the University of New Mexico (UNM) Project ECHO telemedicine service, which is funded by state and multiple federal grants, as well as by a private grant from the Robert Wood Johnson Foundation.

Project ECHO extends the reach of specialists to thousands of patients with severe disease in remote areas of New Mexico and Washington. SCAN-ECHO's goal is to use that model of a telemedicine service to enable specialists at the Louis Stokes VA Medical Center in Cleveland to help primary care physicians treat veterans nationwide. More importantly, it aims to train physicians along the way in evidence-based-care best practices that they can apply in treating other patients with similar conditions. So, while Project ECHO does have a patient-care aspect, physician education is its main goal.

"Knowledge is exploding at a logarithmic scale," said Project ECHO founder Dr. Sanjeev Arora, of the University of New Mexico (UNM) Health Sciences Center, in a VA-sponsored introduction of SCAN-ECHO in July. "More knowledge has been created in the last 100 years than was created in the last 5,000, and more will be created in the next 50 years than has ever occurred before. ... [Y]ou have an explosion of best practices, and how do you take these best practices to underserved [patient] populations?"

Lectures for primary care physicians aren't enough to convert them to junior experts on a condition, Arora said. That takes case-based learning. SCAN-ECHO uses video conferencing and teleconferencing to do that while the primary care doctor is treating a patient and collaborating with remote specialists for care coordination and management. "We will learn by doing," he said, "and monitor outcomes."

The ultimate hope is that rural primary care physicians practicing close to one other will choose different disease-specific special interests, then network with their colleagues nearby -- and achieve better outcomes with that collaboration. Some research on Project ECHO sites, supported by the Agency for Healthcare Research and Quality, suggests it could work. Arora's 2011 study published in the New England Journal of Medicine shows primary care docs trained by Project ECHO achieved cure rates for hepatitis C that were similar to those of UNM specialists and better than other community-based hep C treatment programs.

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The information flows two ways: Primary care doctors update the specialists, and the specialists can avail themselves of the opportunity to deal with real-time problems via video. SCAN-ECHO is a larger implementation of a smaller pilot already running in 11 VA medical centers. Once the Cleveland VA medical center pilot succeeds, the hope is to roll it out systemwide.

"Despite the reach and the high quality of our health care services in our system, one of our biggest challenges is that many millions of our patients live in highly rural areas," said Dr. Robert Petzel, VA's under secretary for health, at the SCAN-ECHO introduction. He added that there are six million patients in the VA system now and there will be an estimated million more over the next five years, as currently active soldiers return from 10 years of conflict in the Middle East. "It's difficult to bring specialty care -- and best practices of specialty care -- into these rural areas," he said.

Telemedicine services even out technology disparities

These difficulties with providing specialty care lead to lower quality-of-life scores for vets residing in rural areas compared with their urban peers, as well as to higher acuity of illness, VA research shows, according to Petzel. At the same time, rural veterans have less access to the health services they need. Telemedicine services and secure online messaging can be technology equalizers that even out those disparities when patients don't want to -- or can't -- make a long drive for a face-to-face visit with a specialist, VA leaders hope.

SCAN-ECHO does what many health IT initiatives aren't doing, Gary Capistrant, American Telemedicine Association's senior director of public policy, told It focuses on specialists and -- at a time when there's a dire shortage of physicians in many specialties -- attempts to extend their knowledge beyond the physical borders of office walls. There might be a lot of investment in and federal support of accountable care organizations, for example, but they and other quality-driven programs focus on primary care practice, he pointed out.

VA has been one of the biggest national proving grounds for telemedicine service initiatives, Capistrant said. He sees a big potential boost for telehealth in the mainstream if SCAN-ECHO scales up nationally, as VA hopes it will. So far, VA's aggregate telehealth initiatives, which include 80,000 patients currently being monitored remotely, exceed other providers' networks in size, and demonstrate how telemedicine projects can grow to scale and become more cost-effective as larger numbers of patients participate.

"There's a lot [of health care providers] who will talk about telemedicine, [but] VA is doing it," Capistrant said. "CMS talks about it but doesn't do much."

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