veterans engagement with electronic health technologies jhu -evans 3.12.14 v final

Veteran Engagement with Electronic Health Technologies

MARCH 12, 2014

Neil C. Evans, MDCo-Director, Connected Health Office of Informatics and Analytics, Veterans Health Administration

VETERANS HEALTH ADMINISTRATION

About VA

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8.93 Million VA Health Care System Enrollees***

6.84 Million VA Supervised & Administered Life Insurance Policies* *

3.66 Million Veterans Receiving VA Disability Compensation * *

3.31 Million VA Maintained Gravesites * **

1.87 Million Active VA Home Loan Participants * *

950,000 VA Education Beneficiaries * *

300,000 Veterans Receiving VA Pension * *

300,000

VA Vital Statistics

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131VA National Cemeteries

56VBA

Regional Offices

1,600+VA Health

Care Sites

*As of FY 2012**As of 6/30/13

***As of FY 2013

Veteran family members receiving care through VA health care programs***


Hospital System to Health SystemIn 1996, VA began the creation of Veterans Integrated Service Networks (VISNs) to transform VA Health Care from a “Hospital System” to a “Health System.” VHA currently has 21 VISNs.

• 135 Community Living Centers

• 300 Vet Centers

• 151 Medical Centers• 985 Outpatient Clinics

820 Community-Based 151 Hospital-Based 8 Mobile

6 Independent

• 103 Domiciliary Residential Rehabilitation Programs

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• 70 Mobile Vet Centers

Source: FY 2012-2013 End-of-Year Pocket Card


Vision: VHA will continue to be the benchmark of excellence and value in health care and benefits by providing exemplary services that are both patient-centered and evidence-based.

This care will be delivered by engaged, collaborative teams in an integrated environment that supports learning, discovery and continuous improvement.

It will emphasize prevention and population health and contribute to the Nation’s well-being through education, research and service in national emergencies.

VHA’s Mission and Vision

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Mission: Honor America’s Veterans by providing exceptional health care that improves their health and well-being.


VHA Principles

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VHA’s principles are the philosophical pillars that are embedded in VHA’s vision. They are embodied in our goals,

objectives, and every initiative undertaken.

Data-Driven/Evidence Based

Patient Centered

Providing Value

Continuously Improving

Team Based

Prevention/Population Health


VHA’s Current Priorities

• Patient Aligned Care Teams (PACT)

• Connected Health Care

• Access

• Homelessness

• Mental Health Care

• Standardization

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Connected Health• VA: Connected Health is defined as extending the reach of healthcare, empowering

patients, and supporting healthcare teams through virtual systems of care• Connected Health is powered by consumer health technologies that engage

patients and connect them to their health care teams, enabling the extension of the health care relationship beyond the traditional in-person synchronous encounters that for so long have been the centerpiece of patient/provider interactions.

• Wikipedia: Connected health is a model for healthcare delivery that uses technology to provide healthcare remotely. Connected health aims to maximize healthcare resources and provide increased, flexible opportunities for consumers to engage with clinicians and better self-manage their care. It uses technology – often leveraging readily available consumer technologies – to deliver patient care outside of the hospital or doctor's office. Connected health encompasses programs in telehealth, remote care (such as home care) and disease and lifestyle management, often leverages existing technologies such as connected devices using existing cellular networks and is associated with efforts to improve chronic care.


VA Connected Health

VA is aligning virtual care technologies to create a seamless, unified experience for Veterans.

VA’s virtual care technologies include:

• Clinical Video Telehealth• Home Telehealth• Store and Forward Telehealth• Telemental Health• Mobile Health• My HealtheVet• Secure Messaging• SCAN-ECHO• Mobile Apps• VA Point of Service Kiosks


VA Connected Health (Virtual Care)

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Connected Health Technologies Year Started Estimated Veterans Served in 2013

Home Telehealth 2003 144,250

Clinical Video Telehealth 2002 202,823

Store & Forward Telehealth 2000 311,369

eConsults 2010 257,949

SCAN-ECHO 2011 1,632

My HealtheVet 2003 2,487,000

Blue Button 2010 881,000

Secure Messaging 2008 795,000

Veteran Mobile Apps 2013 Field testing

Staff Mobile Apps 2013 Field testing

Veteran Point of Service Kiosks 2010 >4M transactions

VA Connected Health

VA Telehealth Services

• Recognized as an international leader in telehealth development/implementation

• Provided care from 151 VA Medical Centers (VAMCs) and over 705 Community Based Outpatient Clinics (CBOCs)

to 608,900 patients…

…amounting to 1,793,496 telehealth episodes of care


Scope of VA Telehealth Services

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Clinical Video Telehealth (CVT)Real-time video consultation that covers 44 clinical specialties including: Tele-Intensive Care, TeleMental Health, TeleCardiology, TeleNeurology, TeleSurgery, Women’s Telehealth, Tele-Primary Care, TeleSCI care, TeleAmputation Care, TeleAudiology, Remote Nursing Home Consultation, TelePathology, etc.

Home Telehealth (HT)Care and case management of chronic conditions and provision of non-institutional care support to patients. Uses in-home and mobile technologies to manage diabetes, chronic heart failure, hypertension, obesity , head injury, depression, etc.

Store and Forward Telehealth (SFT)TeleRetinal Imaging, TeleDermatology, TeleWound Care, TeleSpirometry, Tele-Sleep Studies TeleCardiology.


VHA Telehealth Services: Outcomes

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Reductions in Utilization FY 2012Home Telehealth - reduces bed days of care – 58%Home Telehealth – reduces hospital admissions – 38%Clinical Video Telehealth – reduces bed days of care 56% for mental health care

Patient SatisfactionHome Telehealth - 85% mean scoreStore-and-Forward Telehealth –96% mean scoreClinical Video Telehealth - 93% mean score

Travel Reduction SavingsClinical Video Telehealth – $34.45 per consultationStore and Forward Telehealth - $38.81 per consultation

Home Telehealth Savings$1,999 per annum per patient

My HealtheVet (www.myhealth.va.gov)


My HealtheVet A personal My HealtheVet account provides

Veterans with 24/7 online access to a variety of tools to manage their health care.

Communicate with Participating Patient Aligned Care Team

Members

View Appointments and Health Information

Refill Prescriptions Download and Share Personal Health

Record

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www.myhealth.va.gov

http://www.myhealth.va.gov/

VETERANS HEALTH ADMINISTRATION 23

www.myhealth.va.gov

• More than 107 million visits• Over 2.5 million registered users• More than 1.3 million users have a

Premium (authenticated) account• Over 47.3 million VA prescription

refills since August 2005• More than 918,000 unique VA

Blue Button users since August 2010• More than 5.2 million VA Blue

Button file downloads• More than 843,000 VA patients

opted in to use Secure Messaging

My HealtheVet Statistics (as of November 2013)


• VA Prescription Refill(s)• VA Prescription Refill History• Self-entered medication(s),

herbal(s), over-the-counters (OTCs) and supplement(s)

• VA Medication(s) List*• My Complete Medications

List (VA and self-entered)*

More than 47.3 million VA prescription refill requests since launched in August 2005

Encouraging VA patients to play an active role in the medication reconciliation process

*Requires Advanced account.

My HealtheVet: PharmacyVeterans’ Top Request for Online Services

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• Enhances Veteran access to personal health information from the VA Electronic Health Record and other key data sources

• Fosters patient engagement

• Encourages activation

• Supports patient-centered care

VA Blue Button


VA Blue Button®

: Download Results

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Secu

re M

ess

ag

ing

Patients and providers are able to communicate securely online through VA’s Secure Messaging accessible through My HealtheVet.

VA Mobile

VA mobile applications (Apps) deliver evidence-based tools and connections to health data and VA care teams while on-the-go.

Data Mobility

Patient-Centered Care

Veterans Point of Service Kiosks

Empower Veterans

Improve access

Increase convenience

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&docid=3WwZP0OvA0iFtM&tbnid=DaVImIpV620lBM:&ved=0CAUQjRw&url=http://www.muskogee.va.gov/features/New_Self_Service_Kiosks.asp&ei=2OATU-LhIaemygH524CgDA&bvm=bv.61965928,d.aWc&psig=AFQjCNFrlVdvWflq1ds0U4nLf1uzkMDfiw&ust=1393898014849847

SC

AN

-EC

HO

Use of videoconferencing technology to seek expertise from specialists located 100-500 miles away


VA Connected Health (Virtual Care)Where is VA Going?


VA Mobile / mHealth

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mHEALTH


Is there interest in mHealth?

6.8 BILLION MOBILE-CELLULAR SUBSCRIPTIONS


Goals of VA Mobile Health

• Focus on health by engaging patients and Caregivers outside of traditional health care visits

• Improve data sharing to increase the value of communication

• Increase health care provider efficiency and satisfaction

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PTSD* Coach

*Post-Traumatic Stress Disorder

More 80,000 downloads in 70 countries

VA’s Office of Mental Health began VA Mobile App development with “stand alone” apps

VA’s Mobile Health Program Office focuses on Mobile Apps that connect into VA data systems


VA Mental Health Apps

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VA Mental Health Apps

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Available on iTunes

Apps are native and do not connect to VA


Washington, DC VA Medical Center Pilot Summary of Care App – Lab Results

• Significant desire for access to a robust set of clinical data

• High levels of enthusiasm for mobile tools

• Usability/security issues

• No lack of ideas for customized workflow-focused Apps

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VA Mobile Strategy Timeline2011 2012 2013

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

PROVIDER/STAFF MOBILE CAPABILITIES

VETERAN FACING MOBILE APPLICATIONS

CENTRAL MOBILE DEVICE MANAGEMENT AND CLOUD HOSTING

New Cloud MDM

Begin VA Mobile - Interim MDM - Initial Cap 1500 Mobile Devices Mobile

Validation

Field Enterprise App Library

Dedicated Cloud Environment Hosting – FISMA High Impact Certified

Mobile App Development Environment

Security Test and Certification Authority to Operate (ATO)

Certification and Governance

Veteran Mobile Credentialing Services

Delegation Authorization

Family Caregiver Pilot

Caregiver Evaluation Study

More Apps

Provider Mobile Pilot Mobile Display of Patient Data

Mobile Imaging

Nursing Apps

Mobile Browser Pilot

Scheduling App

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VA Mobile Framework

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Mobile Application Environment• Standardizing

Apps and their development; Reducing Costs

• Common Dev Tools

• Common Services & Software Library

• Dev Knowledge Base

• Development & Production Environments

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VA Mobile App Certification Process Requirements

Business Ownership Commitment Aligned with VA Business Objectives Sustainment Plan Usability Testing VA Branding Data and Terminology Standards Compliance Security Privacy System Performance Impact Assessment Patient Safety Assessment & Functional Testing 508 Accessibility Clinical Review for Medical Apps Help Screens Software Quality Assurance

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Mobile Health Development Strategy

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Build Apps at HTML5 so they will work on mobile browsers across platforms and on desktop browsers


VA Mobile Health Staff Apps

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Healthcare Team-Facing

Apps


Clinicians Interested in Using Mobile Apps

• 89 percent of primary care and internal medicine physicians use smartphones to communicate with other hospital staff

• 51 percent of clinicians use smartphones to reference health information

• 83 percent of clinicians would immediately utilize mobile EHR Apps to update patient charts, check labs and order medications if their current EHR vendor made those features available for mobile– Only eight percent currently use a mobile

device for these functionalities

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Source: Black Book Rankings, May 2013

Source: HIT Consultant


VA Health Care-Team Facing Apps in Development

• Patient Viewer App (Data review, Note Entry, Order Entry)

• Immunization App• Warfarin Monitoring• VA Mobile Imaging• Caring for Women Vets• Pre-Conception Care• Pregnancy

• Chronic Kidney Disease App• Safe Women Prescribing• Maternity Care Coordinator• Scheduling Calendar View• Secure Messaging• Joint VA-DOD Patient

Viewer• Launchpad• Mobile ECG Viewer

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VA Mobile Health Provider Program

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Photographs from Washington, DC VAMC Distribution


VA Mobile Health Veteran Apps

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Veteran-Facing Apps


Does someone in your family have a working cell phone?

Do you use the Internet?

Do you access the Internetthrough a Cellular Network?

Have you downloaded Health-related information to your phone?

0102030405060708090

100 91

65

21

10

92

73

30

12

92

76

40

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Veterans enrolled in VAVeterans not enrolled in VANon-Veterans

Veteran Mobile Device Access

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2012 Health Information National Trends Survey

Expert Care and Self Care

Information Sharing

Transactions

Communications


Veteran-Facing VA Mobile Apps

In Pilot Testing• Family Caregiver Suite of Apps • Veteran Appointment Request App • My Story• Mobile Blue ButtonSoon-to-be Released• Summary of Care• Mobile Blue Button• LaunchPad

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Family Caregiver Mobile Health Pilot

• Cohort: Seriously Injured post-9/11 Veterans and their Family Caregivers in the VA’s Family Caregiver Program

• Suite of Apps designed based on needs of Caregivers and Veterans

• iPads loaded with Apps loaned to Caregivers for one year

August 2012

Mailing to Notify of Selection, Request Loaner Agreement,

Invite into Study

1,200 Caregivers Responded “Yes”

Distribute 800+ iPads

Mailing to 4,000+ Caregivers

September 2012

November 2012

May2013

Timeline

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Family Caregiver Apps

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1) Pain Coach – Supports Pain Management

2) Care4Caregiver – Supports Caregiver Stress

3) Journal – Record Vitals/Exercise/Food/Contacts

4) RxRefill – Refill Prescriptions

5) Summary of Care – Display Data from HER

6) PTSD Coach – Supports PTSD management

7) Health Advocate – Allows Veteran to Designate a Health Advocate

8) Notifications and Reminders – Sets Medication Reminders and Receive Notifications from Health Care Team


Login• Uses Department of

Defense LogOn (DS LogOn) credentials.

• Delegation App will allow Veterans to authorize sharing of their VA clinical data with Family Caregivers using DS LogOn credentials.

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VA Mobile Launchpad (iOS Version)

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• Medications

• Labs

• Problem List

• Radiology Reports

• Progress Notes

• Demographics

• Vitals

Summary of Care App Displays EHR Data

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• Vitals

• Exercise

• Diet

• Mood

• Communications

Journal App

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RxRefill App

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• Allows Veterans to request prescription refills


How Caregivers are Supported

• Training – Quick Start Guide– Videos

• Help Desk • Newsletter

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Family Caregiver Mobile Health Evaluation Study

Primary Quasi-Experimental Study

• Caregiver burden levels and Veterans Health Care utilization

Longitudinal Cohort Study

• How does exposure to apps relate to outcomes• Statistical model to predict utilization of apps

Qualitative Study

• Phone interview with high and low app users

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VA Family Caregiver PilotCharacteristics of iPad Recipients

• 879 iPads distributed• Average age (of both Caregivers and Veterans) – 40 years old• 95% of caregivers are female• 90% are spouses of the Veterans• Majority of Veterans are rated with a service-connected

disability of 80% or greater– PTSD– Nerve/Fracture related injuries– TBI

• 60% Urban, 40% Rural

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VA Family Caregiver Pilot – Baseline Caregiver Strain

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Average: 5.54 STD: 3.68 Median: 5


Unique Users by Month by App

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Pain Coach

Journ

al

Care 4 Care

givers

VA PTSD Coach

Rx Refill

Notifications

Summary of Care

0200400600800

1000120014001600

630 Caregiver/Veteran diads (72%) have used at least one of the ten apps in the suite.


Family Caregiver Pilot App Utilization

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Jun Jul Aug Sep0

100200300400500600700

Number of Unique Users per Month


Percentage of Reported Reasons for Non-Use of Family Caregiver Apps

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DS Login IssuesApp IssuesUsabilityMisinformationPersonalLanguage BarrierNo iPad/Not a caregiver

219 Non-Users


VA Family Caregiver Pilot – Preliminary analysis

Significant Predictors of Mobile Health App use include the following• Veteran Age – Mobile Health App use decreases with

increases in the age of the Veteran.• Caregiver-Veteran relationship – Odds of use increase if

caregiver is a spouse of the Veteran.• Urban/Rural – Odds of use increase if the Veteran lives in a

rural location.• Mental Health Diagnosis – Odds of use increase of if the

Veteran has a mental health diagnosis.

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Veteran Appointment Request App • Allows Veterans to request

appointments for primary care and mental health care using a Mobile App– Includes Mobile App-

specific to both the Veterans and Appointment Clerk’s needs

– Mobile Web App can be used on multiple mobile devices or from desktop

– Pilot includes more than 600 Veterans at Washington, DC and Palo Alto VAMCs

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MyStory App (Personal Health Inventory)

• Allows Veterans to identify what is most important to them in terms of life and wellness goals to achieve those goals– Provides ability for Veterans to

share information with their support teams (e.g., VA health care team, family and friends, life coach, support group, personal trainer, etc.)

– Three-month pilot includes 30 Veterans at North Chicago, East Orange, Fayetteville (NC), Denver, West Los Angeles, Salisbury and Columbia VAMCs


Mobile Blue Button

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New Veteran-Facing Mobile Apps in Development

• Text Messaging Program (Annie)• Patient Personal Health Plan• Women’s Health• Mission Health (Gaming App)• Wellness Check (Bio-surveillance Reporting)• Pre-visit Agenda and Post-Visit Plan• Cardiac Rehabilitation• Chronic Kidney Disease• VA Benefits App

73For more information, visit http://mobilehealth.va.gov


What we have Learned

• Barriers to Use– Low computer literacy– Access problems with credentials

• Facilitators to Use – Availability of support– Easy to use interface– Knowledge that Healthcare Team is involved– Trusted Invitation to Participate

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Critical Factors for Success

• Senior leadership commitment to “care at a distance”• Intelligent design and implementation

– User-centered development and design– Ease of use!!!– Integration with core IT systems and data– Accounts for provider and patient workflows– Informed by pilots, with rapid-cycle corrections– Adequately resourced implementation

• Effective Communication to patients about the value of these technologies– Extension of the relationship– Personal invitation to participate

• Accessible user support and low barrier to entry

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Contact Information

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Neil C. Evans, MDCo-Director, Connected Health (Clinical Director)Department of Veterans AffairsWashington, D.C., [email protected]

VA Mobile Health Websitehttp://mobilehealth.va.gov

mailto:[email protected]

http://mobilehealth.va.gov/