In 2019 the U.S. Department of Veterans’ Affairs (VA)’ s Office of Rural Health launched a National Teleneurology Program to help address challenges veterans were facing accessing timely neurological care, especially in rural areas. Linda S. Williams, M.D., a neurologist who is a Regenstrief Institute and VA clinician-researcher in Indianapolis, recently spoke with Healthcare Innovation about research she has led to evaluate the program.
HCI: Could you talk about why accessing neurology care often presents challenges to patients — maybe especially in the VA, and why the VA decided to launch this teleneurology program in 2019?
Williams: There's good evidence that two things are occurring. There's a shortage of neurologists, especially as the population ages. There was a nice analysis in 2021 looking at the prevalence of practicing neurology physicians and neurology diagnoses, according to Medicare, and there's, of course, a large mismatch in where the neurologists are located, but there's not really much difference in where the diseases are distributed. So we know that for rural patients, in particular, accessing specialty care, and especially neurology care is particularly difficult. That's even more acute in the VA, which has a larger than expected rural population of veterans.
VA has been very interested in telehealth for quite some time. The National Teleneurology Program was developed just prior to the pandemic, so it actually turned out to be good timing that it was in place. There was a congressional act, the Mission Act, that said if you're a veteran who doesn't have access to a specialty, then the VA will pay for you to go see someone in the community. But for rural patients, that often doesn't really help that much. There's probably not a neurologist in a three-hour radius for some patients in some areas of the country. The National Teleneurology Program provides a general neurology video consultation for veterans at participating facilities.
HCI: What kind of wait times were people seeing before they could actually get in for an in-person visit?
Williams: In general, I can tell you from our evaluation of this program, the community care wait times for neurology average about 100 days. That is a big disincentive to patients who want to get care sooner than that. And if that's the average, you can imagine some patients are waiting five, six months to see a neurologist. That is one of the things that we continue to monitor in the program — what are the program’s wait times now? The VA can't manufacture more neurologist to take care of all of this need. The wait times for any neurology care are probably not ideal, but we monitor those in the teleneurology program compared to the community and we try to ensure that we're using our resources effectively. Based on the number of neurologists we have and the places that have need, where can we best meet the need in a way that's going to be meaningful? And that was really the point of our analysis was to say, ‘Are we just throwing drops of water into the ocean and it's not really making a dent? Or are we able to really help in a meaningful way with the need to improve access to specialty care?’
HCI: What did your research find about the impact of the program on the timeliness of access and the effect on the volume of veteran neurology consultations completed outside the VA.
Williams: The findings were that teleneurology care could be completed more quickly, both to schedule the consult and to see the neurologist, so we're happy to see that was maintained over time.
When you start a new medical consultation service, you have lots of room for new patients and then you have to start seeing the follow-up patients, so there's a natural curve where that slows down. We were happy to see that over time that difference was able to be maintained in terms of the time to access to care. There are some VA facilities we work with that are quite large. They might submit 1,500 outpatient neurology consults a year to the community. We're not putting enough neurologists at that facility to take care of all of those. So the modeling question was: Do we make enough of a dent? And is that persisting over time? Or if we're such a small service, maybe they just get frustrated with it and they keep going down the usual path, which is to refer them into the community. The figure in our paper shows there's an immediate drop in the volume of community care consultations and that is maintained over time once the program is implemented at a given facility. And that's true across facilities that are larger or smaller and more rural. So that was a nice thing to see.
Some of that also helps us try to understand where the program is most effective. It is true that we can be most effective at sites that are relatively smaller. That helps us as a program think about if we're going to go to a bigger site and say let's work together, how many people do we really need? How many days of clinic do we really need there to make an appreciable difference and to make it worth everyone's time? That was part of our analysis — to try to help the program leadership understand where we can be most effective and what resources we need to think about if we're going to be going to smaller versus larger places.
HCI: It sounds like this was outside the scope of your research project, but is it important to measure the efficacy of the teleneurology versus in-person visits, and is that challenging to do?
Williams: Congress has just told the VA we need to do that. There's a new act that has mandated that the VA study where it's using telehealth and comparing it to in-person care, but it is difficult to do and sometimes it can be a bit of a of a false comparison in the sense that if someone does not have access to the care, then telehealth versus in person care, you might really say what's the difference between telehealth care and not getting to see the specialist and continuing to be managed by their primary care doctor?
There are lots of debates about that in the telehealth world, but there have been some direct head-to-head comparisons for other types of telehealth. For instance, telestroke care has been compared to direct in-person care and has been found to be similar in terms of quality and patient selection for acute treatment.
HCI: It seems like the VA has a kind of freedom that other health systems don't to fund initiatives like this, to experiment and then decide if this is working or is not working. They don't have to wait for CMS to tell them it's okay to do something. But then they also have to do these evaluations to make decisions about whether to continue funding programs like this or not, right?
Williams: That's exactly right. And you've just explained why I have stayed in the VA for my career, because it's such a fascinating system for somebody who thinks about health systems and wants to experiment with them. It's a great laboratory. And I think to the VA’s credit, they have increasingly realized how important it is to bring researchers like me in partnership with the operational folks from the very beginning to say, ‘Okay, we have this new initiative; we think there's a need and we're going to do this. Let's bring in some researchers who understand the VA but are external to the program to really evaluate it,’ and that's what the VA has actually done now for any national program implementations that are funded by the Office of Rural Health, It's a requirement that there's an external group that does a stand-alone evaluation.
Our group in Indianapolis has the freedom to say ‘hey, this is working or this isn't working. We're going to plan our analyses, conduct them and tell you the results, no matter what it is. And the VA tries to learn from those evaluations. They actually have a center based in Iowa called the Center for Enterprise-wide Evaluations. They look at all of these reports to try to synthesize lessons learned that can apply to other VA programs. So I do give the VA a lot of kudos for doing that. I think it's a very forward-thinking thing for a healthcare system to try to do.
HCI: Is this the only teleneurology program in the country or do other health systems have them? Could other health systems learn from the VA’s experience with it?
Williams: There are others. Vanderbilt has a large telehealth program that includes outpatient teleneurology. But there are not a lot of really robust outpatient teleneurology programs, at least that we're aware of. I think telehealth care in neurology has been more utilized for acute care — either in hospital or ER consultations, with telestroke being one of the key applications that has been very successful.
I do think there are things that can be learned outside the VA from the VA’s experience with teleneurology. I work in Indiana, which is a somewhat of a rural state and my academic appointment is at Indiana University. They're a healthcare system that like many academic systems is expanding and putting satellite hospitals out in different parts of the state. You can usually do satellite primary care, but it's very difficult to have enough specialists who can travel out to those areas, so telehealth is an important application for an academic health system. I think what the VA is doing could be very applicable.
