Bridging Distance with Innovation: Dr. Andrew Neck and Dr. Brett Cohen’s Tele-Emergency Care Revolution

Summary

Dr. Andrew Neck, Section Chief of Emergency Medicine at VA Tennessee Valley Healthcare System, and Dr. Brett Cohen, board-certified emergency medicine physician, launched Tele-Emergency Care in January 2025 to eliminate the barriers that keep rural veterans from accessing urgent medical attention. Dr. Cohen built the program’s custom application from scratch, creating a system that connects veterans with emergency physicians through video consultations within minutes of their initial call. Since launch, 85% of veterans who use Tele-EC have been successfully treated at home without requiring emergency department visits, saving hours of drive time and eliminating unnecessary hospital trips. The program has expanded beyond its original scope to support multiple VA initiatives including Care Coordination and Integrated Case Management, Remote Patient Monitoring, and Employee Health, proving that virtual care can deliver the same clinical expertise as in-person emergency medicine while meeting veterans exactly where they are.

The call comes in from a veteran with chest pain. He refuses to go to the emergency room. He has work. He doesn’t have a ride. The triage nurse is uncomfortable because the symptoms are concerning, but the veteran won’t budge.

“That made all of our triage nurses really uncomfortable,” Dr. Brett Cohen explains. “Because they hear some concerning story and think the answer is they got to be seen. The veteran says, no.”

Before January 2025, that scenario ended in a stalemate. Today, within five minutes of that call, the veteran is face-to-face with a board-certified emergency physician on his cell phone screen. The physician takes a history, assesses the situation, and either successfully convinces him to go to the ER or determines the symptoms aren’t as severe as initially thought and develops a safe plan to keep him home with proper follow-up.

That’s Tele-Emergency Care at Tennessee Valley Healthcare System, and it’s changing everything about how veterans access urgent medical attention.

The Gap That Needed Closing

Before Tele-EC existed, veterans calling the VA’s nurse triage line faced limited options. Registered nurses would assess their symptoms using clinical algorithms, and the output was often the same: go to the emergency department.

“For our veterans, that can be very far in very rural areas,” Dr. Cohen explains. “Many times they don’t have access to vehicles or cars. That requires things like a 911 call. And in some cases, the veterans disagreed. They wanted to be seen for the issue, but don’t think they needed the emergency room for it.”

The mismatch was painful. There was a disconnect between what veterans wanted and their ability to access care. “There really weren’t any great mechanisms outside of the emergency room or finding the local urgent care they’ve got to go out and find on their own to get seen for these problems,” Dr. Cohen says.

Some veterans would call in, use the triage tool, and get told that since the VA couldn’t see them any sooner with anything scheduled, they’d send them to the emergency room. For veterans, that meant headaches or other experiences that could have been handled differently. Some would go to the community and not be hooked into the VA system, where no one knew their meds, their history.

“Or they want to stay at the VA, and they took a two to three hour drive into their closest VA ED, and had a visit,” Dr. Cohen continues. “The result, which may have been, you can go home, you’re potentially, you know, no emergencies were found, you have been over-triaged. They get examined to figure that out, but they actually got sent home.”

Building Something from Nothing

The program began as a national VA mandate. Dr. Andrew Neck believes it emerged from a convergence of factors.

“I’m not sure the data that they used or the historical background to it,” Dr. Neck says. “But I think probably it was a convergence of technology and need, because this wouldn’t have been possible 20 years ago. And now everyone has a cell phone. People don’t look at their smartphones as strange devices. It’s almost like now it’s just like, where is my cell phone? I’ve left it at home. I can’t survive.”

Dr. Neck also suspects financial considerations played a role. “I think it also probably someone higher up in the VA system looked at how much resources and dollars were back and forth between community and fragmented care.”

Dr. Cohen took that mandate and built something remarkable. Working with Nicholas Young from VA LIT, he created an entirely new application from scratch. The challenge was coordination. Multiple stakeholders in different locations needed to communicate seamlessly.

“We’ve got multiple stakeholders at different places,” Dr. Cohen explains. “We’ve got the patient at their home, calling into the call center, who’s been communicating with the doctor, not physically in the same place. And there’s additionally this step we use called the test call, where we have VA telehealth staff call the veteran and help them get set up, because some of them may be hard of hearing or have difficulty managing technology. They’re experts in walking veterans through that. They’re the same ones who help you sign up for My HealtheVet.”

The flow he designed works precisely: The veteran calls from home, gets to the call center, the call center triages, they offer Tele-EC. “Vet has to accept,” Dr. Cohen emphasizes. “We don’t just, if they say no, we don’t do it, of course.”

Once the veteran accepts the visit, they’re added into the application, which alerts the doctor. The doctor then requests the test call to be done. “Think of this like rooming someone in clinic,” Dr. Cohen says. “It creates the video encounter, gets them on camera, teaches them how to use the technology just at the point of use, just in case they don’t know how to. And then once they’re on video, the doctor joins the visit, completes the clinical encounter.”

The options from there are extensive. “We can order labs and X-rays that requires the veteran to go somewhere to get that done, of course, but it’s all ordered. They still walk in and do it. And we can also overnight medications by overnight delivery, just get it sent right there, or we can send meds to their local pharmacy if they prefer, but many are just like, great, I don’t have an extra car, I’d like this to come in the mail tomorrow, and they take that.”

After completing the visit and documenting everything in the medical record, the team loops in the patient’s primary care teams. “Hey, they saw us for this acute, unscheduled need. Here’s what we did. We’ll follow up and check on them and see how they did.”

The application also includes an internal follow-up system. “When we order labs, let’s say we order an X-ray, in case it’s not done the same day, we’ve got a way to file that patient and our team, the person working the following day, will check the results of the labs or X-ray, call the veteran, follow up on everything, and give recommendations for next steps,” Dr. Cohen explains. “For things that we order and we own, or for just any general concerns, like some of those ER refusals, sometimes we touch base with them and they still say no, but we’re kind of worried. We may add them to lists just for ourselves for peace of mind, check in, see how they’re doing.”

The numbers tell the story. “As of right now for all of our calls, about 85% of patients that call in, we keep home and can treat them right then at home, in the community, in their home,” Dr. Cohen reports. “15% need to go into an ER because their symptoms were warranted for that.”

When Hands-On Isn’t Possible

The biggest clinical challenge is obvious: no hands-on examination.

“We can’t auscultate or listen to the heart and lungs,” Dr. Cohen says. “We can’t pressure the abdomen to feel for tenderness. If there’s concerns for like an orthopedic or kind of a traumatic, like fractures potentially, we can’t press around the arms and legs to see what could be injured. We can’t look at an ear to see if they have an ear infection. All those hands-on maneuvers, we are not able to do. I think it’s the biggest clinical barrier. However, despite that, we still are able to do quite a bit with just a history and being able to order labs and images alone.”

The team built solutions. They created a collaboration with primary care services to access same-day clinics.

“If we have a veteran that, say, we’re concerned about an ear infection and we just can’t look at the ear, they don’t even need to go to the ER for that, but where are we going to ask them to go? Because we don’t want to just give them antibiotics for what could be viral without good cause,” Dr. Cohen explains. “We have the ability to send them to one of six or seven different primary care walk-in clinics where they can get pre-scheduled, they can show up day of, have that quick exam and do that one hands-on that’s needed.”

The clinics know they’re coming. “There’s not a mismatch in expectations there and then they can just simply get seen for that one small thing that we couldn’t have finished in our exam and complete the visit,” Dr. Cohen says. “This is a way to keep people in the VA. And from the veteran’s perspective, things feel a little bit more convenient because they know exactly where they’ve got to go.”

This matters because for many people with limited access to healthcare for anything acute and unscheduled, their local ER is the only place they can be seen in a timely manner. “Us saying primary care will call you back with an appointment in the next three weeks is not helpful with your ear pain right now,” Dr. Cohen notes.

He clarifies one important distinction: “This is all just for physical health. This has nothing to do with mental health. There’s a completely different process for acute mental health complaints. The main mental health things that we do are mostly things like medication side effects. If someone’s having a side effect of treatment, we’re happy to kind of weigh in on that, and is it truly the medication or is it something else that’s going on, trying to tease that out. But we don’t see patients for primary mental health reasons.”

Should something come up unexpectedly during a visit, however, the team has connections. “We do have connections and avenues to then do a very warm handoff to connect them with the psychiatry team if that were to come up,” Dr. Cohen says.

He explains what that means. “A warm handoff would be, hey, I’ve got Mr. Jones. He’s got worsening depression with me right now. Can you see him? Yes, I can see him. Okay, Mr. Jones, this is Dr. So-and-so.” That’s different from what he calls a cold handoff: “So, your primary care doctor, best wishes, and it’s on the patient. Who knows what actually happens.”

The team can also connect veterans directly to specialists when needed. “Because we’re all clinical, and if we know from our initial visit, yeah, you have to see GI for the potential blood in your stool, let’s just get you straight into GI and not wait for you to go through primary care, because we can just put that in and make it happen much more conveniently.”

When Seconds Matter Across Miles

For genuine emergencies, the team built protocols directly into the application.

“At the time of visit, at the time we get them on video, we ask for their physical location,” Dr. Cohen explains. “Where are you right now, physically located? And we can actually enter that into the software. Should there be an on-camera emergency, and we’ve had these before, for instance someone had a seizure on camera, if there’s an on-camera emergency, we’re able to actually dispatch EMS to their physical location directly. So, we can activate emergency services to go right then and there.”

There’s another scenario the team prepared for. “The other scenario, which has not happened yet, and I hope it never happens, would be if we have a sudden, unexpected mental health something where someone makes, God forbid, some suicidal gesture that leads to something during the visit,” Dr. Cohen says. “What do you do about that? We can then activate emergency services to go and check on them. It has not happened, but we’ve got protocols in place just for that potential rare event. And similar for medical emergencies, if someone were to pass out or clutch their chest and faint in front of the viewer, who knows what.”

The Spidey Senses That Save Lives

What qualifies someone to make potentially life-or-death decisions through a screen? Experience. Lots of it.

“All the folks that work in the Tele-EC realm are board-certified or board-eligible emergency medicine physicians who actually work clinically in those high-pressure environments,” Dr. Neck says. “And I would say of the cohort of providers from the 40 that work in our emergency department, I think we had, what, 17 or 18? Probably the average level of experience exceeds a decade, on average, close to a decade. Amidst a variety of subspecialty trainings, all of which, they may not be able to use an ultrasound machine during the encounter, but they may have a toxicology background, they may have an education background, they may have a SIM training background. They may have a sports medicine background. They’ll be able to bring whatever skills they can to that video evaluation. So, I think we have a highly trained, highly experienced group of providers who continue to use their skill set both in Tele-EC and in the real emergency department encounters.”

Dr. Cohen agrees and expands on why this matters. “No one goes straight to this program without extensive hands-on clinical experience already. And so by doing that job, part of that job of working in the emergency department is growing that skill of identifying who is potentially seriously ill and who may not be. Almost eventually getting that in a glance. Just looking at a patient, you can tell who’s sick and not sick, the way that we think of sick. And those skills are very transferable to overcome some of those barriers with a telehealth visit, where there are certain things, ways patients breathe, just things that you pick up through your experience of working to know that this patient may need a higher level of care or may not.”

Dr. Neck emphasizes the intentional decision to staff the program exclusively with physicians rather than including nurse practitioners or physician assistants.

“I remember when we were discussing how this would be put together, there was the option of including mid-levels or APPs, so nurse practitioners or physician assistants, because that’s done in other facilities,” Dr. Neck recalls. “And we had enough bandwidth in our shop to be able to start with physician-only providers. I’m not trying to make a hierarchy out of it, but I do think that does feed into the general sense of who is sick, who is not sick, and just a general gestalt, whether you know, in the Marvel Comics world, your spidey senses of who might be a problem. So, I think some of those intangibles really do go a long way. I think certainly mid-levels can have that as well, but it’s a combination of training and years of experience.”

What Veterans Feel

The impact on veterans has been profound. Many are shocked at how quickly they’re seeing a doctor.

“One of the easiest ways that a veteran can speak to a doctor or healthcare professional from home, without physically walking into the clinic and asking to be seen right then and there,” Dr. Cohen says. “A lot of veterans that call in are shocked that they are already seeing a doctor after five minutes after making the phone call, who’s asking clinical questions and putting in orders and consults and referrals. And a lot of them feel really seen by that because before this, the traditional pathway was you can go to the ER now or we can put a primary care note in and they’ll reach out to you when they can see you. And while we try to do our best, just capacity makes it to where that may take several days to weeks to make that happen.”

That wait is something everyone has experienced. “Veterans really feel seen because they just get that visit right then and there, without having to go to the ER, which is the other option,” Dr. Cohen continues. “They’re like, if you want to see a doctor today, you walk into your ER, you’ll see a doctor today. That will happen. But that comes with some pain on your end, whether it’s financial or the wait or whatever else it may be. So, this is a way that they feel seen because they get seen really, really quickly.”

The staff reaction surprised Dr. Cohen most. He had worried that adding Tele-EC would burden the already-busy call center nurses.

“Specific to the call center, coming into this, I was worried that this was an additional ask of them,” Dr. Cohen admits. “Because they are graded on how many calls they take a day, how long they’re with the veteran, how efficient they are. And adding in this step of offering a video visit, putting them in the application, that’s extra time that they didn’t have to do, and one more thing to think about. It’s another task for them. And that’s how I thought earlier, coming into this. I was worried that if it was difficult to get someone into Tele-EC, they just wouldn’t use it, because it just takes too much time and effort on their part.”

That’s not what happened.

“All of them, I’ve mentioned this earlier, but speak to really being thankful for having us there, for some of the veterans that don’t follow the recommendations to go to the ER would be the most common example,” Dr. Cohen says. “And being able to hand it off to a clinician who will then see the veteran gives them a sense of relief with what the potential outcome could be. And I think that’s one area where I was expecting a little bit more kind of pushback with how I got this all rolling because it’s asking people who are already really busy to do more things and think about more things. But instead it became a solution to problems that they’ve had and had no solution for in the past.”

Growing Into Something Bigger

Dr. Neck has been pleasantly surprised by how Tele-EC has expanded. “More recently I’m pleasantly surprised and encouraged how Tele-EC and what Brett has been able to create from scratch has allowed a beautiful intersection of other services other than just emergency medicine,” he says.

What started as emergency care has become something larger. The application Dr. Cohen built now supports multiple VA initiatives beyond its original scope.

“There is an abundance of need for solutions to unscheduled medical care,” Dr. Cohen observes.

The Care Coordination and Integrated Case Management team now uses the system. “CCICM stands for Care Coordination and Integrated Case Management,” Dr. Cohen explains. “It’s essentially a program that pairs nurses and social workers with veterans who have lots of medical and social problems. And they try to really offer an abundance of resources, check in with those veterans multiple times a week to make sure to try to keep them out of the hospital and give them what they need, because a lot of these veterans utilize the healthcare system more than the average.”

The barrier they had was significant. “Well, as a veteran deviates from ‘I’m okay,’ they didn’t really have anything actual they could offer them,” Dr. Cohen says. “So, it’s great to check in, but the veteran says, actually, my blood pressure’s been running really, really high, what should I do? They’re not clinical. So, they couldn’t really have a solution in real time for that. And they would ask primary care to weigh in, which can take some time, or they would send them to the ED to ask someone to check it out. But now, same system, they heard about Tele-EC, worked with them, and when they’ve got someone that they follow who has some new medical complaint, we’ve got a process where they can give us that patient, and we will see them right then and there for these high-risk people.”

The Remote Patient Monitoring team also connects through the system. “These are patients who have a scale or glucometer and someone calls in to check what their blood pressure’s been, what their weight’s been like,” Dr. Cohen explains. “But if there’s something else that comes up in that call, oh, by the way, I’ve been having X, Y, or Z, there’s no plan for what to do about that outside of ER or primary care, and we’re a solution there as well.”

Dr. Neck adds one more recent development. “Employee health just recently reached out, and for a different reason, but also there’s a telehealth opportunity there.”

The program is even exploring primary care clinic overflow. “When people come to primary care clinics for same-day appointments without calling ahead and show up and they say, we can’t see you, where should I go? Well, I guess the ER,” Dr. Cohen says. “They can’t really do much. Are there ways for Tele-EC to see them instead? And that’s something that is not live, that’s a new initiative we’re currently in the planning stages of working through right now, but kind of a future thought.”

This matters because access to care is a major issue. “Not only at the VA, but in the US healthcare system, in worldwide healthcare system, access to care is huge,” Dr. Cohen says. “Specific to Tennessee Valley, I think that we are the most rapidly growing VA nationwide, to where our veteran growth is exceeding our clinic capacity growth. That’s an access issue. And with telemedicine, there’s, in theory, virtually limitless capacity, because you don’t have a building to put people in, you can just see people at their home. This is kind of the ground stages of that, but as access to care becomes a bigger and bigger issue, this is being seen as a way to offset those access issues and get people seen when they need to be seen.”

The Future Is Already Here

When asked about emerging technology, both physicians point to artificial intelligence.

“Clearly artificial intelligence is impossible to really fully grasp kind of how quickly things will change,” Dr. Neck says. “When I think of emergency medicine in the emergency department from a standpoint, there’s certain activities that you just must have physical hands on, you must have equipment to save lives. You can’t do this on the other side of a screen. So, I feel protected from, I feel like I’ll have a role as an emergency department physician down the road, despite very rapidly emerging technological innovations and artificial intelligence.”

But he sees promise too. “However, the converse is true when we’re not needed at the bedside. And I think artificial intelligence can certainly improve what we do, maybe improve protocols quickly, standardize things so everyone gets the highest level of care through artificial intelligence. I would hope that would not negate the need for a physician, but I don’t know. I think you might be able to expand this exponentially through artificial intelligence.”

Dr. Cohen agrees AI is the answer. “If you asked the same question five, ten years ago, it would have been telemedicine, because what we’re doing now seems futuristic. If you asked about this ten years ago. So, we’re there and active and live, but what’s the next step? I think I’d agree, it’s going to be AI.”

He sees AI’s promise specifically in documentation, the administrative burden that keeps doctors at computers instead of with patients.

“There’s a reason that in general public opinion is that doctors spend more time at the computer than with their patients,” Dr. Cohen says. “And that’s because of documentation. There’s a lot of buttons we’ve got to click, a lot of things we’ve got to write. When we see someone, we’ve got to write a whole note that involves typing up the story they told us, typing up the exam that we did, and then typing up all of our thoughts about the case and what we’re doing and why we’re doing it. And my, say, three minutes talking to you, taking a history, can translate into 15 minutes of charting about what we talked about.”

His hope for the immediate future is clear. “At least in the immediate future, I’m hopeful that AI and those tools can shrink that time down dramatically. That is already kind of coming out right now. There’s a lot of new AI scribe softwares that are being utilized, one of which is utilized at Vanderbilt where I work across the street, that listens to the visit and writes up those things.”

His dream goes further. “The dream to me is that the computer will just have the orders done. We tell the patient, we’re gonna check this out, we’re going to order this test, all these things we’re gonna do. So, the patient hears from me what I’m going to do. And then the computer will just have the orders done. Because right now, we tell the patient we’ll do some tests, what that means is kind of a mystery, and then I spend 15 minutes specifically writing out to the computer what those tests are and why. And I think that there’s a disconnect there. And I think that’s probably, in my view, what I’m hopeful the next emerging technology is gonna look like, is minimize that doctor-computer time and maximize the doctor-patient time.”

What Service Means Now

Neither Dr. Neck nor Dr. Cohen are veterans themselves, but their work has deepened their understanding of military service in ways they didn’t anticipate.

Dr. Neck has been at the VA since 2010. “I can honestly say that as a non-veteran, I don’t think I really fully appreciated or realized the contribution of veterans,” he admits. “I mean, it seems so cliché to say thank you for your service and blah, blah, blah, but what’s beautiful about where we work is we don’t really take care of veterans, we actually work with veterans who take care of veterans. So, a lot of our nurses, a lot of our docs, we have people on our staff that served in the military.”

Over 15 years, his perspective has shifted profoundly. “It’s just been a gradual appreciation, but also realizing that I don’t think I was as appreciative of their sacrifice. And so now when I say thank you for your service, it just has a deeper context for me.”

He sees military psychological trauma regularly. “We see so much military psychological trauma that it’s hard not to be impacted by that. And we see psychiatric disease in the non-VA setting across the street at Vanderbilt, but it’s completely different. And the level to which the VA, Tennessee Valley in our experience, is such a well-oiled machine in how they care for our veterans from their mental health issues, that’s motivating to want to come to work and actually take care of that, and that’s not cliché.”

Dr. Neck also reflects on earlier times in his VA career. “I can remember, 15 years ago, there was a time when I would see many more World War II veterans. It was incredible. And I remember walking into a patient’s room, and he had served at the Battle of the Bulge. And of course I had heard of it, but I quickly did a quick Google search so I could walk into the room, and then it was just like, wow, my eyes just opened up as to what he had experienced. And those are things that you don’t get in a community hospital emergency department setting, generally. But the same’s true with Iraq War veterans, Korean War veterans, Vietnam War veterans.”

Dr. Cohen, newer to VA care, describes how working with veterans reframed his understanding of service.

“This is the first VA hospital I’ve worked at,” he says. “And really getting an appreciation for how much after their service they take away and carry both mentally and physically in their bodies. A lot of people my age that served when they were younger have the bodies of someone much older, because, whether it’s orthopedic injuries or some exposure they had while in service, there’s a lot of people that get sick after and need care.”

What struck him is how much remains invisible. “It just kind of reframed some of that for me, because some of the things we see them for aren’t directly related to the service. Sometimes it’s not, but it can be like a secondary effect of it. And I think that it just gave me a greater appreciation for what they carry, even stuff you can’t see. Most of it you can’t see. There are very visible injuries, but most of them are not like that.”

The medical record reveals the fuller picture. “Now I’m in their medical record, I see what their medical problems are and what they’re going through and why they’re trying to see certain specialists for something, and how I can, it motivates me to help connect the care however I can and give them what they need to live healthily after they’ve served.”

The Partnership That Makes It Work

Dr. Neck doesn’t hesitate when asked what he wants people to understand about his team.

“As the section chief of emergency medicine, I want people to understand how grateful we are to Dr. Cohen, who is passionate about this, has a skill set that many do not, and has an organizational level and an ability to communicate with others that exceeds his years,” he says. “And I think our success so far comes directly from his contribution. He may not toot his own horn, but I will toot it for him.”

For the veterans across Middle Tennessee who live hours from their nearest VA facility, who face transportation barriers, who might otherwise go without care or end up in fragmented community systems, Tele-EC represents something profound. Distance no longer stands between them and the care they’ve earned. A board-certified emergency physician is five minutes away, right there on their cell phone screen, ready to bridge that gap. For the veterans who served, it matters that someone finally meets them where they are.

Resources for Veterans & Healthcare Professionals

VA Healthcare & Patient Care Services

VA Health Care Enrollment: va.gov/health-care/how-to-apply

My HealtheVet: myhealth.va.gov

Veterans Crisis Line: Dial 988, then press 1 | Text 838255

Mental Health & Wellness Support

Vet Centers: va.gov/find-locations

National Center for PTSD: ptsd.va.gov

Emergency & Telehealth Services

VA Telehealth Services: telehealth.va.gov

Tennessee Valley Healthcare System: va.gov/tennessee-valley-health-care

VA Careers & Employment

VA Careers: vacareers.va.gov

Tennessee Valley Healthcare System Careers: va.gov/tennessee-valley-health-care/work-with-us

Academic Partnerships

Vanderbilt University Medical Center: vumc.org

VA Office of Academic Affiliations: va.gov/oaa

About Dr. Andrew Neck

Dr. Andrew Neck serves as Section Chief of Emergency Medicine at VA Tennessee Valley Healthcare System, where he has worked since 2010. With over 15 years of experience in VA emergency care and clinical leadership, he provides strategic oversight for the Tele-EC program while continuing to practice clinically in the emergency department. His leadership ensures the program maintains the highest standards of emergency medicine practice through physician-led virtual care.

About Dr. Brett Cohen

Dr. Brett Cohen is a board-certified emergency medicine physician at VA Tennessee Valley Healthcare System and the architect of the Tele-EC program. He designed and built the custom application that coordinates virtual emergency consultations from scratch, working with VA LIT to create the infrastructure that connects veterans with emergency physicians within minutes. Dr. Cohen continues to practice clinically in the emergency department while expanding Tele-EC’s reach across multiple VA service lines, driven by his commitment to solving access-to-care challenges for rural veterans across Middle Tennessee.