As the informatics revolution spreads through the health care system there will be increasing opportunities to more effectively spread knowledge once confined to specialist visits more widely and with less expense. A natural experiment occurring in the VHA, will allow researchers to study how best to guide that transformation. Project SCAN-ECHO is based on a structured remote telemedical specialist generalist interaction model that has been shown to improve hepatitis C (HCV) care outcomes in rural areas within the University of New Mexico (UNM) health care system. Within the diverse fee-for service New Mexico health system, Project ECHO strongly incentivized rural non-VHA primary care providers, but differences in organizational context make this more difficult within the VHA. Moreover, the implementation of SCAN-ECHO will vary greatly even within the VHA.
Aim 1. To compare HCV and liver related quality of care among patients enrolled in SCAN-ECHO sites to those in structurally similar control sites.
Aim 2. To understand staff perceptions of the processes that facilitate collaboration between specialists and generalists and the implementation of HCV Project SCAN-ECHO.
Stratified by HCV Project SCAN-ECHO and control sites, we will first conduct a descriptive analysis capturing the number and proportion of HCV patients who received the HCV and liver quality indicators quarterly over a two year period. Among HCV Project SCAN-ECHO and control sites, we will conduct a sub-group analysis noting the receipt of HCV and liver indicators among rural and highly rural veterans. We will directly compare, between HCV Project SCAN-ECHO and control sites, patient characteristics and receipt of the aforementioned indicators.
We propose collecting and analyzing two types of qualitative data across two phases. In Phase 1, we will record HCV Project SCAN-ECHO sessions to understand the collaboration process between specialists and generalists caring for veterans with HCV. In Phase 2, we will build on Phase 1 analyses of HCV SCAN-ECHO sessions and preliminary studies by refining a semi-structured interview protocol to elicit information from clinical and administrative staff on the key elements that facilitated or hindered the acceptance, modification, and eventual adoption of HCV Project SCAN-ECHO.
From April 2011 through September 2013, eight HCV SCAN-ECHO centers were established and 882 unique patients were served. HCV SCAN-ECHO centers, in practice for two years or more, will discuss 113 unique patients per year.
Twelve HCV SCAN-ECHO sessions have been recorded and transcribed. The average duration of a SCAN-ECHO session is 47 minutes with an average of eight providers in attendance and 6 cases discussed. Generalists repeated the consultation question several times, an average of three, before it was addressed by the specialist. The specialist spoke longer than all generalists combined. The video- telemedicine sessions facilitated collaborative talk. Collaboration was most evident in case discussion (57.5% of total session length) and social talk (8.9% of total session length). During social talk, participants offered personal life experiences that demonstrated a collaborative interpersonal relationship.
Our proposed work will guide the implementation and dissemination of a health informatics initiative successful at the local level of another health system into the VHA, the largest integrated health care system in the US. We are conducting VACO-partnered research that employs health service and implementation research methodologies to elucidate the ground-level decisions that impact the success of a high value healthcare intervention.
None at this time.