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Director's Letter

David Atkins, M.D., M.P.H., Director, HSR&D

Prior to reforms of the 1990s, the VA health system was largely a hospital-based system dominated by specialty care. The emergence of a strong primary care system has not lessened the importance of specialty care to Veterans, many of whom have complex illnesses. Providing consistent access to specialists, however, has been a persistent challenge. In the latest Survey of Health Experiences of Patients (SHEP) in VA, Veterans using specialty care rated their clinicians highly but only half reported that they “always” could access care when they needed it. As a result, only 53 percent reported they were “very satisfied” with specialty care. The problems with access are familiar—many Veterans live far from the larger VA medical centers where many specialists are based, yet the volume of patients may not justify specialists at smaller facilities. With new access standards under the MISSION Act, any Veteran who lives more than 60 minutes from needed specialty care will be eligible to seek care in the community. This standard will place additional pressure on VA to solve problems in specialty access lest facilities start to lose specialty patients and the associated research and training programs built around them.

Over the past decade, VA has instituted many innovations to try to improve access to specialists, and HSR&D researchers have been involved in helping evaluate them. Strategies include making it easier for patients to access specialty care remotely through synchronous telehealth; e-consults to allow primary care providers to get advice from specialists without requiring an in-person consult; and training up the skills of generalist providers through structured programs of education, case learning, and consultation (the Specialty Care Access Networks-Extension for Community Healthcare Outcomes [SCAN-ECHO], and mini-residencies). Research has confirmed that video telehealth can deliver comparable results and satisfaction in areas such as mental health and it is expanding rapidly in other specialties, especially areas where frequent follow-up is more important than face-to-face visits—for example, sleep apnea management and cardiac rehab. E-consults have also grown rapidly with generally high satisfaction, whereas SCAN-ECHO has proven harder to scale.1,2 While clinicians found it an effective training format, many found it hard to fit the regular virtual sessions into their busy schedules.

It will be hard to maintain a robust VA health system without strong specialty care. Moreover, as the experience of Medicare-eligible Veterans suggests, the coordination, quality, and outcomes of care can decline when patients divide their care between VA and community providers.3 Health services research will be critical for evaluating and refining programs that will improve access to and efficiency of specialty care while maintaining the quality of that care.

David Atkins, MD, MPH, Director, HSR&D

  1. Kirsh S, Carey E, Aron DC, et al. “Impact of a National Specialty e-consultation Imple­mentation Project on Access,” American Journal of Managed Care 2015; 21(12):e648-54.
  2. Sayre GG, Haverhals LM, Ball S, et al. “Adopting SCAN-ECHO: The Providers’ Experi­ences,” Health Care: The Journal of Delivery Science and Innovation 2017; 5(1):29-33.
  3. Health Services Research and Development. “Research into Dual Use of Healthcare Coverage.” August 2016.


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