Access to specialized services has been a consistently complex problem for many integrated health care systems, including the Veterans Health Administration (VHA). About two-thirds of veterans experience significant barriers when trying to obtain medical care.1 While these problems partly mirror difficulties that nonveterans face as well, there is a unique obligation toward those who put life and health at risk during their military service.2
To better meet demands, the VHA expanded personnel and clinic infrastructure with more providers and a network of community-based outpatient clinics (CBOC) that created more openings for clinic visits.3 Yet regional variability remains a significant problem for primary and even more so for specialty medical services.
Recent data show that more than one-fifth of all veterans live in areas with low population density and shortages of health care providers.4 The data point at a special problem in this context because these veterans often face long travel times to centers offering specialty services. The introduction of electronic consults functions as an alternative venue to obtain expert input but amounts to only 2% of total consult volume.5 A more interactive approach with face-to-face teleconferencing, case discussions, and special training led by expert clinicians has further improved access in such underserved areas and played a key role in the success of the VHA hepatitis C treatment initiative.6
Despite its clearly proven role and success, these e-consults come with some conceptual shortcomings. A key caveat is the lack of direct patient involvement. Obtaining information from the source rather than relying on symptoms documented by a third person can be essential in approaching medical problems. Experts may be able to tease out the often essential details of a history when making a diagnosis. A direct contact adds an additional, perhaps less tangible, component to the interaction that relies on verbal and nonverbal components of personal interactions and plays an important role in treatment success. Prior studies strongly link credibility of and trust in a provider as well as the related treatment success to such aspects of communication.7,8
Gastroenterology Telemedicine Services
The George E. Wahlen VA Medical Center in Salt Lake City, Utah, draws from a large catchment area that extends from the southern border of Utah to the neighboring states of Idaho, Wyoming, Nevada, and Montana. Large stretches of this territory are remote with population densities well below 5 persons per square mile. The authors therefore devised a specialty outreach program relying on telemedicine for patients with gastrointestinal and liver diseases and present the initial experience with the implementation of this program.
Phase 1: Finding the Champions
Prior studies clearly emphasized that most successful telemedicine clinics relied on key persons (“champions”) promoting the idea and carrying the additional logistic and time issues required to start and maintain the new program.9,10 Thus we created a small team that defined and refined goals, identified target groups, and worked out the logistics. Based on prior experiences, we focused initially on veterans with more chronic and likely functional disorders, such as diarrhea, constipation, dyspepsia, or nausea. The team also planned to accept patients with chronic liver disorders or abnormal test results that required further clarification. By consensus, the group excluded acute problems and bleeding as well as disorders with pain as primary manifestations. The underlying assumption was that a direct physical examination was less critical in most of these cases.