the patient to come to NMVAHCS. I had one patient who
suddenly started getting chest pains during the exam, so
we called the CBOC primary care doctor to immediately
move the patient to the local hospital. I had another patient who started talking about suicide. I kept the patient
on the phone, but we got the primary care doctor in the
room. We do have backup.
Dr. Geppert. You mentioned that you often involve family and that you work with local CBOC registered nurses
(RNs). Can you tell us how you extend the reach of teleneurology through self-care and family education?
Dr. Davis. We have 2 qualified RN patient educators.
One is an expert in Parkinson disease; the other follows
up with the patient who has had a stroke, to reduce risk
factors for a second stroke.
When I see a patient for a limited time, I deal with the
drugs and things like that. I am less focused on what type
of chair the patient should sit on, whether the patient
might fall, how to safely get up, etc. So I set up a separate
appointment with the nurse educator, who goes through
all the day-to-day activities that the patient has to be able
to do. Patients with Parkinson disease do not like to sit
on low sofas, for example. What are the tricks for constipation? If a patient falls, how do you safely get up? The
nurse will have the patient get down right in front of the
camera and walk them through how to get up.
Dr. Geppert. I know that in many rural areas, especially
in our state, there are real shortages of neurologists and
psychiatrists. Can you talk about how this helps multiply
your ability to care for patients?
Dr. Davis. With the exception of 3 different communities, there are no neurologists within 50 to 100 miles.
Dr. Geppert. Or neuropsychiatrists.
Dr. Davis. Or neuropsychiatrists or even a psychiatry office. So patients are very limited. We have an extremely
loyal population of VA patients because it isn’t easy to say,
“I’m just going to go down the street and get another doc.”
Dr. Geppert. What type of feedback do you get from patients and family about doing this virtually?
Telehealth and Epilepsy Care
Epilepsy care at the VA is coordinated by the Epilepsy Centers of Excellence (ECoE) from 16 sites.
Federal Practitioner recently spoke with John Hixson, MD, associate professor at the University of
California San Francisco School of Medicine and
ECoE staff physician about self care, the role of
ECoEs, and strategies for providing epilepsy care
to rural veterans. The entire interview can be found
Dr. Hixson. We will try to see rural patients in person at least once, even if that means arranging for
transportation for that patient to come down to
the VA ECoE clinic. Once we’ve made a diagnosis,
and we feel that we know the person, we actively
use a variety of technological tools for visiting with
those patients frequently and not requiring them to
The VA system has a very robust video teleconferencing system. Typically, we have a clinic a week
where we will perform video-to-video sessions at
CBOCs. The patient shows up to the appointment
and then we conduct the visit over video. Those
still require the patients to go to those clinics, and,
for some, that is still a fairly significant burden.
Within the past 6 months here in San Francisco,
we have started video-to-home consultations
where we use a mobile device with the patient,
usually an iPad, sometimes a laptop, and we have
a video chat platform; and so we can set a time
with the patient and actually have the visit in their
home. There are technological considerations
there in terms of bandwidth, but we are ramping
We actively promote patient self-management and
self-learning. We have a variety of online modules
to encourage patients to watch videos and engage with other veterans and other patients with
epilepsy so that they can learn more about their
condition. The good thing about this is it’s entirely
directed by the patient. It’s what we call asynchronous, which simply means that we don't have to
be talking to the patient face to face at the same
The patient can go online. If he or she was having
a sleepless night and wanted to look up a question
about epilepsy at 2 AM, it’s there available online.
And, they could also, potentially, join a peer group
online that would allow them to have that same
dialogue at their own time and convenience… It’s
something that the VA does that is very unique.