Connected Health at the Department of Veterans

AffairsKathleen L. Frisbee, PhDc, MPHCo-Director, Connected Health

OfficeOffice of Informatics and Analytics

Veterans Health Administration

Hospital System to Health System

In 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.

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

• 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

• 70 Mobile Vet Centers

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$0.0

$20.0

$40.0

$60.0

$80.0

2011 2012 2013 2014

Appropriations Collections

VHA Budget Summary

$50.7 B $53.1 B $55.1 B

NOTE: Table includes funding transferred to Joint VA/DoD Medical Care Special Programs in 2011 and 2012.

$57.5 B

Advanced Appropriations:

$54.6B

Estimated Collections:

$2.93B

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FY 2013 End-of-Year Totals

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

Enrollees………………………………………………………………......8.9 MillionUnique Patients Treated…………………………………............6.5 Million

Outpatient Visits………………………………………................86.4 MillionOutpatient Surgeries…………………………………………………..….292,600Inpatient Admissions…………………………………………….……….694,700

Lab Tests (Inpatient & Outpatient)………………………….…266 MillionPrescriptions Dispensed (30-Day Equivalent)……......268.6 MillionProsthetics Services Performed……………………..………..15.9 Million

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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

Mission: Honor America’s Veterans by providing exceptional health

care that improves their health and well-being.

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Next Step in VHA’s Transformation

By 2017, VHA aims to be nationally recognized as a leader for population health, improvement strategies, personalized care,

and maximizing health outcomes in a cost-effective and sustainable manner.

VHA Strategic Goals:1. Provide Veterans personalized, proactive, patient-driven health care2. Achieve measureable improvements in health outcomes3. Align resources to deliver sustained value to Veterans

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VA’s Health Care Expertise

VA is one of the largest civilian employers in the federal government and one of the largest health care employers in the world.

288,000+ Total VHA Employees

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VHA’s Current Priorities

Patient Aligned Care Teams (PACT)

Connected Health Care

Access

Homelessness

Mental Health Care

Standardization

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VA Connected Health

Aligning virtual care

technologies to create a seamless,

unified experience for

Veterans

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Importance of Connected Health Technologies

Video Visits

Global market for Video Visits is expected to increase tenfold by 2018, expanding into a $13.7 billion market

50% reduction in readmissions with Video visits/monitoring, a study found

Mobile HealthRemote Monitoring

Forecasted savings from remote patient monitoring 36 billion over the next five years

22 million households are expected to use virtual care solutions in 2018, up from one million in 2013

By 2018 mHealth is forecasted to increase by 61% to be a $26 billion market

Text appointment reminders reduced no-shows by 20-90%

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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

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VA Telehealth Services

Provided care to 608,900 patients…

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

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My HealtheVet (www.myhealth.va.gov)

107 million+ visits

2.5 million+ registered users

843,000 opted-in to use

Secure Messaging

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VA Blue Button

Enhances Access to Personal Health

Information

Fosters Patient Engagement

Supports Patient-Centered Care

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Secure Messaging

Patients and providers are able to communicate securely online through VA’s Secure Messaging

accessible through My HealtheVet.15

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 16

Veterans Point of Service Kiosks

Kiosks have been shown to save hospitals up to $7 per check-in

Utilization of kiosks has been shown to

increase patient satisfaction by

reducing waits and offering greater

convenience 1717

SCAN-ECHO

Use of videoconferencing

technology to seek expertise

from specialists located 100-500

miles away

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My HealtheVet – VA’s Personal Health Record

Secure Email with Providers

Download Health Data (Blue Button)

Health Education LibraryRefill PrescriptionsView AppointmentsEnter Patient Generated

Data (PGD)

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Secure Messaging (16.4%)Registered Users (38.9%)

Premium Users (26.8%)

Growth in My HealtheVet Adoption by VA Patients

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My HealtheVet Benefits

Kaiser Permanente has a 63% adoption of secure messaging, if VA is able to achieve a comparable adoption the following benefits are possible:– 2 – 6.2% increase in HEDIS measures for glycemic, cholesterol

and blood pressure– 6.9 – 11.1% increase in HEDIS measures for patients with

hypertension, diabetes or both– 20 person decrease in urgent care visits per 1,000 patients per

monthKaiser Permanente patients are 2.6 times more likely

to remain customers if they use Kaiser Permanente’s PHR 21

Efforts to Align and Increase My HealtheVet

Use New Architecture and cloud hostingRedesign of interface based on Veteran feedbackRefocus on doing high demand functions well Consolidate PGD with PGD data from other applications

(e.g., mobile) and allow providers to viewCreate the same experience across My HealtheVet and

Mobile AppsExpand to use other established credentialing systemsAllow online proofing Sign up Veterans for My HealtheVet when they enrollEstablish delegation capability

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VA Mobile Health (mHealth)

mHEALTH

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Foundation Building

Mobile Apps Development/Production Environment

Mobile ArchitectureMobile Device Management SoftwareMobile GovernanceMobile Certification ProcessMobile Branding Veteran App Library Patient Generated Data Architecture and

PoliciesMobile Device Support Contract 24

Mobile Application Environment

• Standardizing Apps and their development; Reducing Costs

• Common Dev Tools

• Common Services and Software Library

• Environments:• Development• Integration• Pre-Prod• Production

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VA Mobile Architecture

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Patient Generated Data (PGD)

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How to Summarize PGD Data

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Mobile Development Lifecycle

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VA-DoD Stand Alone Apps

VA Mental Health Apps

Available on iTunes

Apps are native and do not connect to the VA network.

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VA Mobile Health Veteran Apps

Veteran-Facing Apps

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Veteran-Facing VA Mobile Apps

In Field TestingFamily Caregiver Suite of Apps Veteran Appointment RequestMy StorySoon-to-be ReleasedSummary of CareMobile Blue ButtonVA Launchpad

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VA 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 Suite of Apps

1) Pain Coach – Supports pain management

2) Care4Caregiver – Supports Caregiver stress

3) Journal – Allows for the recording of vitals, exercise, meals, contacts

4) RxRefill – Assists with refilling VA prescriptions

5) Summary of Care – Displays data from electronic health record (EHR)

6) PTSD Coach – Supports PTSD management

7) Health Advocate – Allows Veteran to designate a health advocate

8) Health Assessment – Provides Veteran with a convenient way to take various health self-assessments

9) Notifications and Reminders – Sets medication reminders and receive notifications from VA care team

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VA Launchpad

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What We Learned from Family Caregiver Mobile

Health Pilot Access: Individuals living in rural areas are more likely to use than

urban areas Age: Likelihood of using the Apps declines by 2% for every one year

increase in age and this appears to be related to ability to obtain DS Logon credentials

Mental Health: Caregivers caring for Veterans suffering from mental health-related issues, other than PTSD, are higher users

Polytrauma: Caregivers caring for Veterans receiving polytrauma care are less likely to use the Apps and this appears related to Caregiver’s lack of time

Caregiver Preparedness: The less prepared the Caregiver feels to provide care, the more likely he/she is to use Mobile Apps

Caregiver Computer Skills: The higher the self-reported computer skills, the greater the use of the Apps

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Veteran-Facing Mobile Apps

in DevelopmentText Messaging Program (Annie)Patient Personal Health PlanWomen’s HealthMission Health (Gaming App)Wellness Check (Bio-surveillance Reporting)Pre-Visit Agenda and Post-Visit PlanCardiac RehabilitationChronic Kidney DiseaseVA Benefits App

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Annie – VA’s Disease Management Text Messaging

Program Modeled After Successful NHS

England Program – Flo named after Florence Nightingale

VA Program – Annie – named after Annie G. Fox (August 4, 1893 – January 20, 1987) was the first woman to receive the Purple Heart for combat. She served as the chief nurse in the Army Nurse Corps at Hickman Field during the Japanese attack on Pearl Harbor, on December 7, 1941.

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Annie System Capabilities

Protocol Messaging (Bidirectional): – Rules based conversations between providers and patients via the

system (e.g., “It is 10am and we have not received your blood pressure reading yet”).

– Partnered with NHS England physicians regarding clinical protocols (they have several years experience with a similar program – Flo)

Provider Messaging (Bidirectional): – Staff to staff secure quick messages

Tailored/Broadcast Messaging (Unidirectional): – Tailored to individuals or groups (e.g., age groups, diseases, facility,

time of year, etc.)– Messages such as, “flu shots are available.”

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High Level Process for Messaging in Annie

Clinical Staff: Creates a Protocol and sends

document via email to Clinical Administrator Group

Clinical Administrator: Creates a Messaging

Template for the Protocol

Clinical Staff: Assigns Messaging Template for the

Protocol to a Patient

Step 1 Step 2 Step 3

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Benefits for Text Messaging

Study found test messaging resulted in 66% increase in medication adherence

Numerous studies have shown large decreases in appointment no-shows

Increase healthy behaviors and health management

‒ Smoking cessation‒ Blood Glucose Control‒ Weight Loss‒ Asthma control

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VA Mobile Health Staff Apps

Health Care Team-Facing

Apps42

VA Mobile Health Provider Program

Distributing up to 11,000 mobile devices (tablets) at 18 VA Medical Centers for use in clinical care– 85% are iPad Minis– Phase 1: Commercial Apps – Require DISA Reviews before adding to VA

App Store– Phase 2: VA Developed Apps

Accompanied by a mobile device service contract for help desk, break/fix, provisioning

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VA Mobile Health Provider Pilot Sites

Initial Pilot Sites: – Nashville– Orlando– Washington,

DC

Potential five additional sites: – Palo Alto– Albuquerque– Durham– Tomah– Cheyenne

Pilot Sites: – Pittsburgh– Denver– Seattle– St. Cloud– Las Vegas– Miami– Martinsburg– White River

Junction– Columbus,

Ohio

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VA Mobile Health Provider Program

March 2014 distribution at Washington, DC VAMC

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Phase 1 – Commercial Apps

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Phase 2 VA-Developed Apps

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Phase 1 Provider Feedback

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Phase 1 Provider Feedback

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Phase 1 Provider Feedback

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Phase 1 Provider Feedback

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Phase 1 Provider Feedback

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Phase 1 Provider Feedback

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VA Health Care Team-Facing Apps in Development

Patient Viewer(Data Review, Note Entry, Order Entry)

Immunization Warfarin MonitoringVA Mobile ImagingCaring for Women VetsPre-Conception CarePregnancy

Chronic Kidney Disease Safe Women PrescribingMaternity Care CoordinatorScheduling Calendar ViewSecure Messaging Joint VA-DOD Patient

Viewer LaunchpadMobile ECG Viewer

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Contact Information

Kathleen L. Frisbee, PhDc, MPHCo-Director (Program Lead)Connected Health Office, Office of Informatics and AnalyticsDepartment of Veterans AffairsWashington, D.C., USAKathleen.Frisbee@va.gov

Neil C. Evans, MDCo-Director (Clinical Lead)Connected Health Office, Office of Informatics and AnalyticsDepartment of Veterans AffairsWashington, D.C., USANeil.Evans@va.gov

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

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