137-MHV, My HealtheVet Personal Health Record Use the

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					      My HealtheVet
Personal Health Record Use:
     the Who, What & Why
Based on Direct Veteran Feedback

               Kim M. Nazi
         Veterans and Consumers
         Health Informatics Office
              Today’s Session                     2




What do veterans think about My HealtheVet?
What additional online services do they want?
What can we learn from direct veteran feedback?

• Overview of Performance Evaluation Program
• Results of American Customer Satisfaction
Index (ACSI) Survey (>60,000 random samples)
• Additional evaluation techniques and new
opportunities for research collaboration.
RE-AIM (Extended)                                           3




       *an extension of the RE-AIM Framework at www.re-aim.org
    Performance Evaluation Strategies                       4




• Web analytic tools to monitor usage patterns
• Customized indicators for relevant dimensions of RE-AIM
• Satisfaction surveys to measure/track satisfaction and
enable direct feedback (ACSI, Pilot Surveys, SHEP)
• Research collaborations to address research agenda
questions in scientifically rigorous studies
• Dissemination of results
• Program optimization based on evaluation results
               Statistics Summary                        5




• Nearly 24 million veterans and 259,000 VA Staff are
  eligible to use My HealtheVet; almost 8 million
  veterans enrolled in VA
• More than 598,000 registered users
  (72% are VA patients)
• More than 70,000 Veterans have been In Person
  Authenticated (IPA)
• More than 6.1 Million prescription refills have been
  processed since August 31, 2005
• More than 18 million visits to My HealtheVet since
  launched in November 2003
Who? What? Where? How? Why?                6




    Who are our users?
    What are their
    characteristics, needs, and
    preferences?
    Where do they access My HealtheVet?
    How often?
    Why?
    What is working well and what can be
    improved?
                My HealtheVet ACSI Survey                              7


American Customer Satisfaction Survey


                                        Data Collection Period:
                                        October 2007 – May 2008
                                        61,186 respondents
                                        (random sample)

                                        Sampling Parameters:
                                        Sampling percentage: 4%
                                        Loyalty factor: 4 pages

                                        Response Rates:
                                        My HealtheVet average: 17.0%
                                        ForeSee average: 6.5%
How the ACSI Model Works                          8




                  Site visitors’ impressions of
                  key web site elements drive
                  customer satisfaction, which,
                  in turn, drives their future
                  behaviors.
            My HealtheVet ACSI Results                             9




1. Which of the following best describes you?
 93 %   Veteran                        MHV Registration Data

  4%    Family member of veteran       86 % Veteran
  1%    Other role                      4 % VA Employee
                                        3 % Health Care Provider
 <1 %   VA employee                     2 % Veteran Advocate
 <1 %   Federal government employee     1 % Other

 <1 %   Veteran Service Organization   *72 % VA Patient
 <1 %   General public

  N=61186
            My HealtheVet ACSI Results                      10




2. What is your age range?
  1%    19 to 30 years            MHV Registration Data

  4%    31 to 40 years            12 % Under 40
 11 %   41 to 50 years            66 % 40 to 69 years old
                                  22 % 70 or older
 34 %   51 to 60 years   79 %
 34 %   61 to 70 years            Median age is 60

 16 %   71 or older

  N=59981
            My HealtheVet ACSI Results                             11




3. In which state do you currently reside?
  9%  Florida                              MHV Registration Data
  9%  Texas
  8%  California                           Top 10 States
                                           1. Florida
  5%  Pennsylvania                         2. California
  4%  New York                             3. Texas
                                           4. Pennsylvania
  4%  Georgia                              5. Washington
  3%  Ohio, Arizona, Michigan, Indiana,    6. Oregon
                                           7. New York
       Oregon, Illinois, North Carolina,   8. Ohio
       Washington, Wisconsin               9. North Carolina
                                           10. Georgia
  1 % All other states represented
  1 % Lives “elsewhere”
  N=22037
           My HealtheVet ACSI Results             12




4. Please indicate your period of military service:
  60 %   Vietnam War
  19 %   Peacetime service
  13 %   Desert Shield / Desert Storm
  10 %   Korean War
   5%    Global War on Terror (OEF/OIF)
   5%    World War II
   4%    Other
   2%    Not applicable

    N=72139
             My HealtheVet ACSI Results                     13




5. Are you a registered
user on the web site?
  95 % Yes
   2 % No
   3 % Not sure
                                MHV Registration Data

   N=61186                       2.5 % of all Veterans
                                 7.3 % of all Enrollees
                                12.5 % of all VA Patients
            My HealtheVet ACSI Results   14




6. Have you visited your
VA facility in person to
show your ID and be
“in-person authenticated”
(IPA)?
  60 %   Yes
  23 %   No
  16 %   Not sure
   1%    Not applicable

  N=61186
             My HealtheVet ACSI Results                                             15




7. If not, why have you not been “in-person
authenticated” (IPA)? [Open-Ended Question]
 190   Other (e.g. didn’t know)
  23   Appointments
                             Did not know that I should do that.
  21   Authenticate
                             Didn't know it was necessary or even available.
  20   Forgot
                             I don't know what that means. I go to the VA every 6
  18   Register              months or so and show my Veterans Universal
  15   Not sure              Access Identification card but I don't know if that
                             means I am In-person authenticated.
  14   Needed
  12   Form
                            Many visitors who are not “In-Person
  10   Clinic               Authenticated” are confused about what it
   9   Paper                means or how they go through the process.
 388   Total responses
             My HealtheVet ACSI Results   16




8. Did you take part in a
pilot project for the
My HealtheVet website?

  75 % No
   6 % Yes
  19 % Not sure

   N=38565
             My HealtheVet ACSI Results    17




9. From which locations do you access My
HealtheVet?
  96 %   Home
  11 %   Workplace
   3%    My VA Medical Center
   3%    Friend’s or relative’s home
   2%    A place in my community
   1%    School
   1%    Other
   N=20645
           My HealtheVet ACSI Results                                18




10. Where do you most frequently access My
HealtheVet?
  93 %   Home
   5%    Workplace
   1%    Friend’s or relative’s home
   1%    My VA Medical Center
   1%    Other
   1%    A place in my community       Visitors most frequently
                                       access the site from their
   1%    School                        home (93%), followed by
                                       their workplace (5%). It
   N=17643                             appears that the more
                                       convenient the access, the
                                       more satisfied the visitor.
             My HealtheVet ACSI Results          19




11. Most often, what type of connection do you
use to access the Internet?
  91 % High-speed access
       (cable modem, DSL, T1, wireless)
   7 % Dial-up access
       (through a modem and telephone line)
   1 % Not sure about the type
       of Internet connection

   N=17640
                My HealtheVet ACSI Results                              20




12. How frequently do you access the My
HealtheVet web site?
    49 % About once a month
    25 % About once a week
    12 % First time
     5 % About every six months
     4 % Daily
     3 % Less than every six months
     2 % More than once a day
      N=61186
First-time and infrequent visitors score satisfaction lower than more
frequent visitor groups. This is not unusual because these groups
are typically less familiar with the site.
            My HealtheVet ACSI Results                      21




13. Please rate your ability in using the Internet:
 69 % Advanced (frequently use Internet and search for
      information)
 28 % Intermediate (use the Internet for a few things)
  3 % Beginner or novice (just starting / don’t use much)
  N=18594
            My HealtheVet ACSI Results            22




14. In general, how would you rate your overall
health?
  4%    Excellent
 17 %   Very good
 39 %   Good
 30 %   Fair
 10 %   Poor
  N=18594
           My HealtheVet ACSI Results        23




15. How much time would it take for you to
travel to the nearest VA facility?
  11 %   Less than 15 minutes
  21 %   15 minutes to less than ½ hour
  31 %   ½ hour to less than 1 hour
  20 %   1 hour to less than 1 ½ hours
   9%    1 ½ hours to less than 2 hours
   8%    2 hours or more

    N=17771
              My HealtheVet ACSI Results                      24




16. What were you trying to accomplish today
in My HealtheVet?
 76 % Request a prescription refill
 24 % Access prescription history from my VA medical record
 18 % Look up information about a medication
 14 % Enter/keep track of personal information
     (e.g. my caregivers)
 13 % Enter/keep track of personal health care information
     (e.g. blood pressure)
  9 % Other
  6 % Research a health condition
  6 % Find information about VA benefits
  2 % Find a VA health care facility
   N=102101
            My HealtheVet ACSI Results       25




17. How were you trying to locate this
information?
 41 %   Browsing (following links in page)
 31 %   Quick links
 21 %   Top navigation bar
 16 %   Search feature
 10 %   Site map
  6%    Other

  N=75312
           My HealtheVet ACSI Results                           26




18. Did you accomplish what you wanted to?
 70 %   Yes
 19 %   Partially
 12 %   No
    %   Not finished [added May 2008]
 N=61186

                                 A review of the open ended
                                 comments, reveals most visitors
                                 who wanted to accomplish “other”
                                 things mentioned:
                                 • make and/or view appointments
                                 • view medical records
                                 • view prescription information
          My HealtheVet ACSI Results                                                27




19. If you did not accomplish what you wanted to
in My HealtheVet please specify what you wanted
to do: [Open-Ended Question]
  69 Appointments
  45 Other Topics          Lab results and other info in my VA medical record.
  35 Medical Records       Wanted to check upcoming appointments.
  18 Refill                I wanted to refill a prescription. The website kept
                           asking me to log in when I clicked on the refill link.
  18 Prescription
  14 Lab
                       Those unable to accomplish their goals wanted to:
  13 Pay                      • Refill prescriptions
   9 Meds                     • View appointments
   8 Register                 • View medical records
   7 Password
 246 Total Responses
            My HealtheVet ACSI Results              28




20. If you did not accomplish what you wanted to
what will you do next?
 29 %   Continue looking on My HealtheVet
 23 %   Come back to My HealtheVet later
 21 %   Call the Veterans Health Administration
 13 %   Other
  7%    Give up
  4%    E-mail the Veterans Health Administration
  3%    Look elsewhere online

  N=10723
             My HealtheVet ACSI Results                                   29




21. If you have used any of the following
features, which, if any, did you find particularly
useful? Which, if any, have you had difficulty
using?
• Health Education Libraries & Condition Centers (Research Health)
• Personal Health Care Information (Caregivers, Treatment Facilities, etc.)
• Online Prescription Refill Requests (Pharmacy)
• My Medications & Supplements (Self-entered Pharmacy)
• My Complete Medications List (Combined view of both VA and self-entered)
• HealtheLogs (Vitals, Tests, Allergies)
• Health Calendar (Get Care)
• Health History (Personal, Family, or Military)
• Personal Health Summary (Track Health)
            My HealtheVet ACSI Results               30




22. What additional services would you like to
see on My HealtheVet?
88 %   View my upcoming appointments
76 %   Change or schedule my appointments
75 %   Look at information in my VA medical record
67 %   Online secure communication with my doctor

N=319282
            My HealtheVet ACSI Results                            31




22. What additional services would you like to
see on My HealtheVet? (continued)
49 % Checking that different medications I take are safe when
      used together
36 % Notification of new content/features on the site
36 % Advance check-in for my VA clinic visits
33 % Reminders of preventive care I need (e.g. shots)
27 % Monthly email newsletter
24 % Share information with other people (e.g. family, doctor)
21 % Educational programs
17 % Advanced directive (e.g. living will, power of attorney, etc.)
 9 % Other
 8 % Information about the quality of VA health care
N=319282
             My HealtheVet ACSI Results                       32




23. Please describe your experience with
navigation on this website:
 80 % I had no difficulty navigating on this site
  9 % I was able to find general information, but could not
       find the specific content that I needed
  5 % Too many buttons or links to other places
  5 % Links did not take me where I expected
  4 % Other navigational issue
  4 % I experienced links that went nowhere, error
       messages, or other technical difficulties

   N=24211
            My HealtheVet ACSI Results                               33




24. Did you use the web site’s search feature
today?
  76 % No          Less than one-fourth (24%) of visitors used
                   the site’s search feature.
  24 % Yes
                   The most notable differences between these
  N=19413          groups are that search users are significantly
                   less likely to return and to recommend the site
                   compared to non-search users.
            My HealtheVet ACSI Results                            34




25. Please describe your experience with the
site’s search feature:
 71 % I had no difficulty using the search feature on this site
  9%  Results were not related to what I was looking for
  8%  Other search issue
  7%  Could not tell what information the search results
       would take me to
  6 % Returned no results/received error message
  3 % Too few results
  3 % Too many results
  N=19413
                               My HealtheVet ACSI Results                                                                                              35




…experience with the site’s search feature:

                                                                                    Could not tell what
                            I had no difficulty   Results were not                   information the      Returned no
                             using the search     related to what I   Other search search results would results/received   Too many   Too few
                                 feature          was looking for        issue          take me to       error message      results   results   Overall
               Responses:         2,375                 281               265              254                 206            99        99      3,579
                                   71%                   8%               8%                8%                 6%             3%        3%
Content                             86                   69                73               73                  65            69        65        82
Functionality                       85                   62                68               70                  59            64        63        81
Look and Feel                       85                   68                75               68                  65            63        68        81
Navigation                          83                   56                64               56                  47            53        56        77
Search                              85                   51                65               55                  45            49        53        78
Site Performance                    85                   69                74               69                  63            72        67        81
Satisfaction                        83                   46                58               51                  40            47        46        75
Organization Satisfaction           88                   56                63               58                  47            53        56        81
Recommend                           90                   59                70               63                  50            58        59        84
Return                              93                   70                79               76                  62            70        70        90




 N=19413
               My HealtheVet ACSI Results                                          36




26. Where you aware that there is a virtual tour
available on the My HealtheVet web site?
   59 % Yes
   35 % No
    6 % Not sure

     N=21627



Visitors aware of the virtual tour are:
• More likely to be registered users (97%, compared to 93% unaware)
• More likely to be IPA’d (66%, compared to 50% unaware)
• More likely to strongly agree or agree that the site improved their ability to
    manage their health (61%, compared to 53% unaware)
                My HealtheVet ACSI Results                                             37




27. If you played the virtual tour did you find it
useful?
  63 %    I didn’t play the virtual tour
  16 %    It was very useful
  12 %    It was somewhat useful
   5%     Don’t know/can’t remember
   4%     It was not very useful

    N=11199

Visitors that found the virtual tour useful are:
• More likely to have accomplished their goal (81%, compared to 29%, “not useful”)
• Less likely to have difficulty navigating the site (7%, compared to 60%, “not useful”)
• Less likely to use search (35%, compared to 49%, “not useful”)
          My HealtheVet ACSI Results   38




28. Do you use a mobile phone?

  76 % Yes
  24 % No

  N=884
            My HealtheVet ACSI Results   39




29. Which mobile phone features
do you use?

 100 %   Phone calls
  29 %   Built in camera
  25 %   Text messaging
   8%    Access the Internet
   5%    Games
   2%    Other

   N=884
            My HealtheVet ACSI Results              40




30. Have you prepared a document (e.g.
advanced directive, living will, durable power of
attorney for health care) to help your loved ones
and health care providers make medical
decisions if you ever become too sick to
communicate your wishes?
 51 % No
 49 % Yes

 N=884
            My HealtheVet ACSI Results            41




31. If yes, what type of document have your
prepared?
 63 %   Non-VA advance directive or living will
 28 %   VA Living Will
 21 %   VA Durable Power of Attorney
  4%    Don’t know
  3%    Other

  N=884
             My HealtheVet ACSI Results               42




32. If access to medical record information were
available through My HealtheVet, which records
would you want to see?
 90 % My VA medical records
 64 % My military service records
 33 % My medical records from other non-VA medical
       providers
  5 % Not sure
  3 % I don’t want my records to be available on My
       HealtheVet
  2 % Other
   N=39953
            My HealtheVet ACSI Results        43




33. My use of the My HealtheVet personal health
record has improved my ability to manage my
health.
 17 %   Strongly agree
 39 %   Agree
 26 %   Not sure
  4%    Disagree
  3%    Strongly disagree

  N=61186
            My HealtheVet ACSI Results                                       44




34. What is the main improvement that you would
suggest for the My HealtheVet web site?
[Open-Ended Question]
                           Provide Access to Medical records and Lab/test
222 Appointments           results.
187 Medical Records        Ability to schedule and change appointments.
138 Prescription Refill    Put NAME of medication in prescription history.
 95 Doctor
 73 Meds                  Improvement suggestions mentioned most
 46 Lab                   often include:
                              • Access to medical records
 39 Test Results              • Ability to schedule and change
 38 Page Design               appointments
 31 Care                      • Prescription names and a quick link to
                              prescription refills
 26 Vet                       • Doctor communication through email or
1131 Total Responses          other secure method
       My HealtheVet ACSI Segmentations                      45



   Vietnam War vs. Global War on Terror Veterans
Vietnam War veterans are:
Less likely to be first-time visitors (24%, compared to 11%
GWOT (OEF/OIF) veterans)
Older than GWOT (OEF/OIF) visitors (99% over age 51, 76%
GWOT (OEF/OIF) under age 51)
Less likely to consider themselves advanced internet users
(68%, compared to 73% GWOT (OEF/OIF) veterans)
Less interested in their military service medical records (67%
interested, compared to 85% of GWOT (OEF/OIF) veterans)
More likely to agree that the personal health record improved
their ability to manage their health (57% strongly agree or
agree, compared to 51% of GWOT (OEF/OIF) veterans)
         My HealtheVet ACSI Results                46




Considering all of your experiences to date, how
satisfied are you with the My HealtheVet program
overall?
Results: 8.3 out of 10

How likely are you to recommend this site to
someone else?
Results: 8.6 out of 10

How likely are you to return to this site?
Results: 9.1 out of 10
ACSI Satisfaction Benchmarks   47
ACSI Element Benchmarks   48
My HealtheVet ACSI Priority Map   49
My HealtheVet ACSI Survey                 50




            Recommendations:
            • Focus on improving
              navigation and refining
              search
            • Conduct usability studies
              which emphasize task
              completion
            • Prioritize feature
              development
            • Communication strategies
              to promote IPA
            • Add functionality
            • Deeper Analysis
         Research Collaboration Goals                   51




Effective collaboration to produce evidence-based
  knowledge to inform program optimization:

• Focus on research agenda priorities
• Create effective processes for collaboration
• Align with existing methods for
  solicitation, approval, monitoring, compliance, and
  support
• Ensure operational support for studies
• Identify and address relevant policy needs
• Define and implement technical infrastructure to
  support appropriate data access strategies
     My HealtheVet Research Questions                52




• Describe how veterans are using this information
  and how use varies by distance from local VA
  (Reach / Adoption)
• Does use of MHV patient education information
  translate into knowledge (and eventually
  outcomes)? (Efficacy)
• Understand how to keep users engaged and
  connected. (Maintenance)
• Assess impact of e-services on bricks and mortar
  operations (e.g. does secure messaging decrease
  telephone workload?) (Implementation)
      My HealtheVet
Personal Health Record Use:
     the Who, What & Why
Based on Direct Veteran Feedback

               Kim M. Nazi
         Veterans and Consumers
         Health Informatics Office