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Veteran Engagement with Electronic Health Technologies
MARCH 12, 2014
Neil C. Evans, MDCo-Director, Connected Health Office of Informatics and Analytics, Veterans Health Administration
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VETERANS HEALTH ADMINISTRATION
About VA
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VETERANS HEALTH ADMINISTRATION
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***
VETERANS HEALTH ADMINISTRATION
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
VETERANS HEALTH ADMINISTRATION
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.
VETERANS HEALTH ADMINISTRATION
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
VETERANS HEALTH ADMINISTRATION
VHA’s Current Priorities
• Patient Aligned Care Teams (PACT)
• Connected Health Care
• Access
• Homelessness
• Mental Health Care
• Standardization
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VETERANS HEALTH ADMINISTRATION
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.
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VETERANS HEALTH ADMINISTRATION
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
VETERANS HEALTH ADMINISTRATION
VA Connected Health (Virtual Care)
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VETERANS HEALTH ADMINISTRATION
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
VETERANS HEALTH ADMINISTRATION
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.
VETERANS HEALTH ADMINISTRATION
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)
VETERANS HEALTH ADMINISTRATION
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
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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)
VETERANS HEALTH ADMINISTRATION
• 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
VETERANS HEALTH ADMINISTRATION
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
SC
AN
-EC
HO
Use of videoconferencing technology to seek expertise from specialists located 100-500 miles away
VETERANS HEALTH ADMINISTRATION 2
VA Connected Health (Virtual Care)Where is VA Going?
VETERANS HEALTH ADMINISTRATION
VA Mobile / mHealth
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mHEALTH
VETERANS HEALTH ADMINISTRATION
Is there interest in mHealth?
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6.8 BILLION MOBILE-CELLULAR SUBSCRIPTIONS
VETERANS HEALTH ADMINISTRATION
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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VETERANS HEALTH ADMINISTRATION 37
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
VETERANS HEALTH ADMINISTRATION
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
VETERANS HEALTH ADMINISTRATION
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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VETERANS HEALTH ADMINISTRATION
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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VETERANS HEALTH ADMINISTRATION
VA Mobile Framework
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VETERANS HEALTH ADMINISTRATION
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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VETERANS HEALTH ADMINISTRATION
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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VETERANS HEALTH ADMINISTRATION
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
VETERANS HEALTH ADMINISTRATION
VA Mobile Health Staff Apps
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Healthcare Team-Facing
Apps
VETERANS HEALTH ADMINISTRATION
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
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VETERANS HEALTH ADMINISTRATION
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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VETERANS HEALTH ADMINISTRATION
VA Mobile Health Provider Program
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Photographs from Washington, DC VAMC Distribution
VETERANS HEALTH ADMINISTRATION
VA Mobile Health Veteran Apps
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Veteran-Facing Apps
VETERANS HEALTH ADMINISTRATION
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
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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
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Expert Care and Self Care
Information Sharing
Transactions
Communications
VETERANS HEALTH ADMINISTRATION
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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VETERANS HEALTH ADMINISTRATION
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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VETERANS HEALTH ADMINISTRATION
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
VETERANS HEALTH ADMINISTRATION
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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VETERANS HEALTH ADMINISTRATION
VA Mobile Launchpad (iOS Version)
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VETERANS HEALTH ADMINISTRATION
• Medications
• Labs
• Problem List
• Radiology Reports
• Progress Notes
• Demographics
• Vitals
Summary of Care App Displays EHR Data
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VETERANS HEALTH ADMINISTRATION
• Vitals
• Exercise
• Diet
• Mood
• Communications
Journal App
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VETERANS HEALTH ADMINISTRATION
RxRefill App
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• Allows Veterans to request prescription refills
VETERANS HEALTH ADMINISTRATION
How Caregivers are Supported
• Training – Quick Start Guide– Videos
• Help Desk • Newsletter
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VETERANS HEALTH ADMINISTRATION
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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VETERANS HEALTH ADMINISTRATION
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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VETERANS HEALTH ADMINISTRATION
VA Family Caregiver Pilot – Baseline Caregiver Strain
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Average: 5.54 STD: 3.68 Median: 5
VETERANS HEALTH ADMINISTRATION
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.
VETERANS HEALTH ADMINISTRATION
Family Caregiver Pilot App Utilization
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Jun Jul Aug Sep0
100200300400500600700
Number of Unique Users per Month
VETERANS HEALTH ADMINISTRATION
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
VETERANS HEALTH ADMINISTRATION
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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VETERANS HEALTH ADMINISTRATION
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
VETERANS HEALTH ADMINISTRATION
Mobile Blue Button
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VETERANS HEALTH ADMINISTRATION
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
VETERANS HEALTH ADMINISTRATION
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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VETERANS HEALTH ADMINISTRATION
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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VETERANS HEALTH ADMINISTRATION
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
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