The San Francisco VA Medical Center (SFVAMC) has started a new program to increase access to specialty care for Veterans in rural and medically underserved areas. This program, called the Specialty Care Access Network-Extension for Community Healthcare Outcomes (or, SCAN-ECHO), has taken video teleconferencing to the next level of excellence in serving our Veterans.
Unlike usual video teleconferencing, or VTEL, which visually and audibly links one patient with one primary care provider in another location, SCAN-ECHO uses VTEL technology to link several primary care providers, many of whom are in different rural communities within our service area, simultaneously to a specialist here at SFVAMC.
The exchange of information that ensues enables rural primary care clinicians to gain the knowledge needed to provide care that was not previously available in their communities. It also saves Veterans with chronic conditions who require complex care, from having to travel to San Francisco VA to get the medical care they need.
“SCAN-ECHO uses existing wall-mounted teleconferencing units and a bridge that allows multiple providers to dial in at once,” said Gastroenterologist and Hepatologist Catherine Rongey, MD, who applied for and acquired the grant to start SCAN-ECHO at SFVAMC. “All participating providers can be viewed on the screen.” The provider speaking is shown in a large center square, and the other teleconferencing participants appear in small squares surrounding the center.
During a SCAN-ECHO session, primary care providers take turns presenting cases using a standardized format, other providers listen to the discussion, and the specialist and/or specialty care team recommends a treatment plan. A formal clinical education segment follows.
Rongey, who is also VISN21 Scan Echo Director, explained, “It’s a community of learning. This technology allows a multidisciplinary, collaborative approach which empowers our community of providers.” Here at SFVAMC, cases are presented to Dr. Rongey and other specialists by primary care providers about their patients who have Hepatitis C, liver disease, HIV, inflammatory bowel disease (IBD), and epilepsy. “We’ll also soon be adding a Pharmacy SCAN-ECHO,” said Rongey.
Nurse Practitioner Erica Trimble is involved in SCAN-ECHO behind the scenes, creating educational binders, arranging logistics, fielding consultations and identifying patients whose cases would be suitable to present during weekly SCAN-ECHO sessions. “We initially bring primary care providers to SFVAMC for a day or more to learn more about liver disease by going through the educational materials that we’ve put together for them, and by seeing patients together. Part of the value of this program is the opportunity for primary care providers to develop their knowledge and skill in different specialties.”
Cyndi Bakir, CNS, who assists with the organizational aspects of SCAN-ECHO, explains its origins: “Dr. Sanjeev Arora of New Mexico used telemedicine technology to extend expert specialist care to rural areas by recruiting primary care providers who were interested in treating people with Hepatitis C. After two days of training in Albuquerque, these providers are able to dial in every Wednesday afternoon, present their cases to Dr. Arora and his multidisciplinary team, and receive expert advice without leaving their offices. In addition, they earn CME credit.”
“Many Veterans who have Hepatitis C live closer to the Ukiah, Clearlake, Eureka, Santa Rosa, or Downtown VA Clinics,” said Bakir. “Distance and mental health issues such as PTSD are barriers that may prevent them from coming to SFVAMC, where our hepatology experts are located, for treatment. The ability to provide weekly guidance via telemedicine to trained providers who are treating patients where they live is a prime example of patient-centered care.”
“Mental Health is a critical component of care in treating Hepatitis C and HIV patients, many of whom have mental health and substance use disorders, said SFVAMC Staff Psychologist Maggie Chartier, PsyD, MPH, who works locally with Dr. Rongey on SCAN-ECHO. “There are behavioral interactions we can advise about. It’s very rewarding being part of an innovative way of delivering health care for those patients who might not otherwise seek treatment.”
Administrative Researcher Shawn Green is the administrator for SFVAMC’s SCAN-ECHO program. He orders the equipment, handles the financial and administrative aspects, and coordinates the SCAN-ECHO calls. “There’s a need out there, and this is a great program,” he said. “Veterans shouldn’t have to drive or travel hundreds of miles to receive care, especially those with PTSD, if they are able to receive the care they need locally. As a patient, if you know you can go to your local physician, you might be more inclined to seek that help. For all Veterans have done for our country, for all that they’ve sacrificed, we need to take care of them in the best possible manner and provide the care they need in the best possible fashion.”
Green is also coordinating a visit to SFVAMC by Dr. Sanjeev Arora on September 24. (Any trainees interested in attending this breakfast and research seminar should contact Dr. Rongey at ext. 2636.)
Ken McQuaid, MD, SFVAMC’s IBD Specialist, uses SCAN-ECHO to treat patients with ulcerative colitis and Crohn’s disease. “What’s important about both of these diseases is, we really need a multi-disciplinary approach to the treatment of patients,” said McQuaid. “We have benefitted from excellent nursing support…Maggie Roma, NP, in Palo Alto, and Isabelle Lynch, NP, at SFVAMC.” Other team members involve surgeons, dietitians, social workers, and mental health providers. McQuaid explained that while IBD isn’t a rare disease, it isn’t common either. It takes a lot of case experience because it’s so varied in the types of problems patients develop. “In the VA, most gastroenterologists don’t have enough experience with treating these diseases to feel really comfortable with it, so SCAN-ECHO provides that experience.” McQuaid leads “Meta ECHO” sessions, specialist-to-specialist, with providers in Reno, Fresno, Northern California, and other places within our VISN. “Those specialists are looking to us for advice even though they are specialists, too, and they like the idea, because there aren’t enough patients with IBD to get one provider comfortable with treating them, for a long time, so it actually made sense to centralize our IBD care.”
“Our health care system is unique in providing care to Veterans who live a long way away from centers where the expertise is the greatest,” said McQuaid, “And we’re accomplishing something that’s not typical within the VISN—having sites working together in a non-competitive fashion to do multi-disciplinary, integrated programs, to really serve our Veterans by providing them with a very high level of care for these complex disorders.”