SCAN-ECHO Program Provides “Telenephrology” Care for Veterans

Nephrology care is increasingly difficult to provide in rural and medically underserved areas. Because of the need for more invasive procedures, imaging, and monitoring, nephrology care tends to be clustered in larger academic and urban settings, forcing some patients to travel long distances for nephrology care. At a cost of roughly $50 billion, the Department of Veteran Affairs (VA) provides primary care for more than 8 million veterans, more than 41 percent of whom live in rural or medically underserved areas without access to specialty care, particularly nephrology care. Given the number of rural veterans and those in medically underserved areas, the VA implemented the Specialty Care Access Networks–Extension for Community Health Outcomes (SCAN-ECHO) program, a provider-to-provider telehealth program sponsored by the Office of Specialty Care Transformation. The SCAN-ECHO program is designed to afford greater access of primary care providers to specialty care using the extensive VA telemedicine infrastructure and videoconferencing equipment.

Telemedicine, which is defined as the exchange of medical information using electronic means to improve patient health, utilizes many electronic applications to provide medical care. “Telenephrology” is defined as the use of these measures to evaluate and treat patients with kidney disease. The VA uses a variety of telemedicine applications, ranging from the online personal health record—called My HealtheVet—to the electronic consults available through the VA electronic medical record (EMR) available to all clinicians across the country for any veteran enrolled within the VA. The SCAN-ECHO program uses all the above telemedicine applications to improve nephrology specialty access for rural veterans.

SCAN-ECHO is based on Project ECHO, a community outreach program initially developed to address disparities in hepatitis C treatment in rural New Mexico. Project ECHO, led by Sanjeev Arora, MD, developed primary care–specialty partnerships that facilitate education and collaboration between primary care providers and an interdisciplinary primary care team located at a tertiary facility. Using weekly telemedicine clinics that include 20- to 30-minute didactic presentations on essential clinical topics, virtual clinics are conducted during which providers received regular education and case-based consultations on patients actively being treated for hepatitis C. The results showed primary care providers were able to achieve similar outcomes in hepatitis C treatment compared to specialists, and that telemedicine could be used to provide specialty care remotely.

The VA currently has five renal SCAN-ECHO programs that partner with primary care within a defined geographic area to increase primary care provider access to nephrology specialty care for patients with severe chronic kidney disease (CKD). During the SCAN-ECHO conference, primary care providers are given education on a relevant topic and receive case-based consultation on clinical cases presented using telemedicine videoconferencing equipment. A few of these programs are highlighted here.

VISN 20 SCAN-ECHO

Veterans Integrated Health Care System 20 (VISN 20) is the largest VISN by geographical area, accounting for 23 percent of the U.S. land mass, including Alaska, Washington, Oregon, Idaho, and parts of Montana and California. Specialty care is provided by two major medical center hubs: the Seattle VA Puget Sound Health Care System in Seattle, WA, and the Portland VA Medical Center in Portland, OR. The VISN 20 SCAN-ECHO site consists of nephrologists Raimund Pichler, MD, and Bessie Young, MD, MPH, who receive consults from primary care providers located in Alaska, eastern and western Washington, and Idaho. A 30-minute didactic is presented, followed by case-based presentation of consults that lasts from 30 to 45 minutes. Clinicians are linked by videoconferencing technology, provided by secure PC meeting equipment or videoconferencing equipment, which allows for presentation of patients and viewing of secure clinical information. Consults were initiated in early 2013 and are derived primarily from electronic consults (e-consults). The program has expanded to include CKD education classes for patients at remote sites who are approaching the need for dialysis.

VISN 1 SCAN-ECHO

The VISN 1 SCAN-ECHO program encompasses most of Connecticut, Rhode Island, and adjacent areas of Massachusetts and New York. Additionally, partnerships with VISN 2 and 3 have been forged. The program began with a strong emphasis on hepatitis C therapy and pain management. The latter program provided the infrastructure to expand beyond our geographic boundaries. Under the leadership of Susan Crowley, MD, FASN, director of nephrology at the West Haven VA, each member of the renal division participates in monthly hour-long didactic/case-discussion lectures directed toward a primary care audience. This model is being used to address consults received from primary care and embed them in the lectures as SCAN-ECHO consults in real-time face-to-face presentations and case discussions.

Greater Los Angeles SCAN-ECHO

The Greater Los Angeles Healthcare System (GLAHS) SCAN-ECHO program commenced in May of 2012 and is led by nephrologist Richard Treger, MD. GLAHS has a diverse patient population located in distant geographic sites, stretching as far north as Bakersfield and as far west as San Luis Obispo. Nephrology consults initiated by primary care providers are handled by videoconference, facilitating the subspecialty care of patients at distant sites. During a typical 60-minute session two cases are discussed, including recommendations for further clinical care and follow-up, and a 20- to 30-minute didactic is presented. The goal of the program is not only to handle the specific cases, but to augment the ability of primary care providers to care for nephrology patients. As such, an online nephrology curriculum has been created with topics available for review by primary care providers, covering such common disorders as CKD, hypertension, electrolyte disorders, and kidney stones.

Denver VA SCAN-ECHO

The Denver SCAN-ECHO program initiated their program in April of 2012 by providing education to primary care providers. A nephrology team at the Denver VA provides a kidney disease curriculum for primary care provider education. To date, over 39 sessions with over 600 participants from 206 sites covering three VISNS (VISN 15, VISN 19, and VISN 23) have been conducted. After initiation of continuing medical education credit, participation increased significantly and has expanded to VISN 16.

SCAN-ECHO is an exciting new tool in the health information technology armamentarium that allows nephrologists to partner with primary care providers in order to facilitate improved nephrology care for rural and medically underserved veterans. SCAN-ECHO aims to improve the care of veterans with all stages of kidney disease, providing direct patient and provider education to combat the growing epidemic of kidney disease in the United States. The extensive VA EMR and videoconferencing infrastructure will allow VA to continue to be at the forefront of providing nephrology specialty care for all veterans.

Notes

[1] Bessie A. Young, MD, MPH, and Raimund Pichler, MD, are affiliated with the Division of Nephrology, Veterans Affairs Puget Sound Health Care System in Seattle, WA. Dr. Young is also affiliated with the Health Services Research and Development Center of Excellence, Seattle VA. Richard Treger, MD, is affiliated with the Division of Nephrology, Greater Los Angeles Veterans Affairs, Los Angeles, CA. Robert Safirstein, MD, is affiliated with the VA Connecticut Health Care System in West Haven.


February 2014 (Vol. 6, Number 2)