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Specialty care services in the Veterans Health Administration (VHA) are commonly concentrated in urban medical centers, with fewer specialty care services offered in suburban and rural areas. In May 2011, the Office of Specialty Care (OSC) rolled out initiatives aimed at expanding access to specialty care, resulting in the development of two new consultation approaches: Electronic-Consults (E-Consults) and Specialty Care Access Network-Extension for Community Healthcare Outcomes (SCAN-ECHO). This article presents findings from an evaluation of these new approaches conducted by the Specialty Care Evaluation Center (SCEC) in collaboration with OSC.
E-Consults allow primary care providers (PCPs) to consult with specialists through the electronic medical record and to receive responses and recommendations without necessitating a Veteran face-to-face specialist visit.
SCAN-ECHO uses video-teleconferencing to hold monthly or bi-weekly scheduled sessions between a multi-disciplinary specialty care team at urban medical centers and PCPs, many of whom are at Community-Based Outpatient Clinics (CBOCs). Sessions begin with a didactic lesson and end with a case presentation, usually given by a PCP, followed by real-time discussion. Thus, all participating PCPs can gain expertise applicable to specific cases as well as to future patients.
The SCEC, which includes five VHA sites— Denver, Cleveland, Seattle, Ann Arbor, and East Orange—collaborated with OSC to achieve operational and research objectives with regard to these two new consultation approaches. Researchers combined elements from a formative evaluation, including administrator/provider cross-sectional interviews and surveys, with quantitative data on patterns of use from a summative evaluation.
From September 2011 to October 2013, VHA facilities reported 740,149 E-Consults across 121 VHA sites for 58 specialties. Providers reported that patients received timely treatment, traveled less for specialist appointments, and were more satisfied with their care after E-Consult implementation. One PCP stated, “E-Consults fit very well with this [pain program] because answers to questions can come quickly.”
Since 2011, specialty care teams at 12 VHA sites have developed SCAN-ECHO curricula based upon local expertise and need. From these sites, specialty programs were developed including, but not limited to, cardiology, diabetes, gastroenterology, geriatrics, hepatology, pain management, pulmonary, surgery, and women’s health.
PCPs from over 280 CBOCs regularly participate in SCAN-ECHO sessions, with over 3,000 patient cases presented from 2011 to 2013. Ninety-three percent of participating PCPs and 87 percent of specialists agreed SCAN-ECHO has increased PCP knowledge and competencies. One specialist said, “We have empowered PCPs to do more at their level… and therefore the complexity of patients they are referring is more [complex] because they are handling the lower complexity [patients].”
The impact of SCAN-ECHO participation on provider retention and recruitment in providing adequate access to care was apparent from the evaluation. Participating PCPs reported high levels of satisfaction with SCAN-ECHO and only quit attending SCAN-ECHO sessions to meet urgent patient care demands. Many providers reported that SCAN-ECHO increased job satisfaction and some described it as critical to avoiding burnout. One PCP noted, “I love it. It’s the face of the future. I was getting burned out in PC (primary care), but this has given me new life.” Further, one PCP stated, “What’s most important [about SCAN-ECHO] is that providers feel more satisfied in their career, it keeps them here. The turnover of PCPs is a huge upheaval.” Results also suggested stronger professional relationships were fostered between PCPs and specialists, facilitating improved knowledge sharing.
Eighty-eight percent of surveyed SCANECHO PCP participants agreed it has improved their ability to manage and treat patients. One PCP noted, “I feel empowered by the knowledge I learned at the SCAN-ECHO session. We receive detailed recommendations, and I can ask specialists anything. Sometimes during traditional consults we may not completely understand the reply. I think my quality of taking care of patients has improved dramatically.” While it was apparent that providers felt both initiatives were beneficial, providers stressed the importance of protected time to participate in these new consultation approaches. Providers reported that a lack of protected time was a significant barrier to participation. In fact, only 16 percent of SCAN-ECHO PCPs surveyed stated they had protected time to participate.
The SCEC has worked closely with OSC and has provided feedback on evaluation components that have been incorporated into guidance documents for subsequent rollout of both initiatives. For example, the SCEC has suggested further analytics for E-Consults and SCAN-ECHO (e.g., travel distance averted by using E-Consults instead of face-to-face consults) to support participants with emphasis on meeting the needs of individual VHA sites and OSC. Additionally, the SCEC has incorporated geospatial information systems mapping to analyze spread of E-Consults.
These evaluation findings suggest initiatives such as SCAN-ECHO and E-Consults show much promise in improving access to care for Veterans. However, providing protected time for participating providers to be involved in these initiatives is critical for sustainability and success.