Veterans Affairs is Working to Give Its Patients Greater Access to Vasculitis Care, No Matter Where They Live
Dr. Paul Monach, chief of the rheumatology section at the Veterans Affairs (VA) Boston Healthcare System and an associate professor at Harvard Medical School, sees those needs every day. An expert in treating vasculitis, he works closely with veterans in managing their symptoms and trying to get them into remission.
While it appears vasculitis affects veterans at the same rate as the general population, giant cell arteritis (GCA) is the most common among the veterans being treated, largely because it affects an older population, which currently includes a large number of Vietnam veterans, Dr. Monach said.
The MISSION act ensures that veterans can receive care from non-VA sources if a nearby VA Medical Center (VAMC) does not have the relevant specialty care available in a timely manner.
Most VAMCs have a rheumatologist, but for those that don’t, the VA is working to leverage its network of interconnected health records and communication methods to improve access to VA specialists.
Dr. Monach is dedicated to using the VA’s nationwide electronic health records to build a “learning health system” that will expand the scope of clinical research and return results to providers to improve patient care. He said geographic barriers to care can disappear if the VA can expand the ability of VA providers to connect with experts.
“In my own medical center, we can do what we need to do pretty quickly,” Dr. Monach said. “I don’t have to convince an insurance company to pay for the diagnostic tools I need, such as a PET scan.”
He said veterans also can get access to any FDA approved drug without having to seek approval from insurance companies. But still geographic barriers can delay diagnosis and treatment.
Dr. Monach would like to see the VA expand the ability of its providers to connect with the experts. The same “telehealth” systems that are being developed to provide general subspecialty care could be used to give access nationwide to patients with diseases like vasculitis where VA employs an expert in the field. 
“If a VA rheumatologist was looking for an expert, they might not see me listed as a Vasculitis expert,” he said. “I’d like to put my name out there. It has to be easy to use, something people don’t have to take time to look for. In my own experience, long distance care only works if the local provider wants to make it happen and will work together.”
As a single healthcare network across the country, the email and instant-messaging/video-conferencing systems allow doctors to connect seamlessly. Doctors can easily share patient records and discuss cases and best treatment options for patients. The VA is working on expanding those connections and making them easier. They are even looking into easier telehealth connections for the veterans.
Using their network, the VA can register a patient at any of their clinics, although it may require an “interfacility consult” option is set up between a pair of VAMCs. Once the patient is registered, the specialist can meet them in telehealth appointments.
Dr. Monach admits there are administrative hurdles because things don’t happen automatically once a patient comes into the VA’s healthcare system.
They typically come into a clinic in their own geographic location, but if they need a certain specialist they may need to be registered as a patient in another
VAMC. If an interfacility arrangement is in place between VAMCs, or if it isn’t needed for a particular problem, registration at another VAMC is a simple process for patients.
“It takes time, but it’s not hard to do,” Dr. Monach said. “The Chief of Staff of my medical center is working with his colleagues to put together a network that can make communication easier among VA providers to do e-consults and eventually remote video visits with patients.”
The idea has already taken root in Nephrology at the VA and they are now starting the same concept in Rheumatology.
Dr. Monach is cautiously optimistic that telehealth will work with rheumatology but will be limited to conditions where a physical exam is not essential.
“Nephrologists can rely on numbers and statistics easier than rheumatologists can, although not for patients who require procedures like dialysis.” But with the healthcare providers working together and supporting the patient, he thinks TeleRheumatology it can be done.
“We can do it, we have fewer barriers than in the general population in that sense,” he said. In addition to lower barriers to diagnostic tests and treatment, a VA provider with a license in one state does not need to have a license in every state where telehealth will be done.
“It’s purely technical and human barriers, meaning IT and administrative effort, just like everyone in other healthcare systems sees,” Dr. Monach said. “But at the VA there are more robust methods for patients to get the care and treatment no matter where they live. There is a better safety net for VA care if they need it.”
— Photos by Grant Jefferies
