My HealtheVet and Secure Messaging Patient-Centered Medical Home Las Vegas, NV April 2010 Session Overview • My HealtheVet and The Medical Home • Patient Engagement and Online Tools • Secure Messaging Experience • Implementing Secure Messaging My HealtheVet: A Tool to Deliver PCMH Engaging Patients Using Secure Messaging Paul Nichol, MD Susan Woods, MD, MPH New Models of Care Personal Health Records (PHR) and Secure Messaging: Integral to PCMH American College of Physicians Homebuilder Survey Uses e-mail to provide appropriate care Uses website that enables patients to initiate appt. Allows the PHR linked to the practice record Allows patient to import record to PHR National Committee for Quality Assurance (NCQA) Advanced Electronic Communications Availability of interactive website Electronic Care Management support Patient Centered Primary Care Teamlet Administrative Provider Veteran RN Care Manager Clinical Support Support (Physician, NP, PA) Customer Service Direct Patient Care Direct Patient Care Direct Patient Care •Initial point of contact •Scheduled Clinic Visits Schedule appointments •Scheduled Clinic Visits •Assist with triage •Patient Advocate •Walk in or Urgent Visits As needed or requested by •Walk in or Urgent Visits •Address customer service primary care team •Assist providers with •Group Visits •Group Visits exams/procedures concerns & coordinating solutions. •Telephone Visits •Telephone Visits •Incoming telephone demand Appointment check in •Incoming telephone demand •Perform treatments (EKGs, V/S, •Hand-off communication (including correct ID) blood sugar, etc) •Pertinent Clinical Reminders •Triage/place orders by protocol Assists providers •Utilizes kiosk to check in •Pertinent Clinical Reminders •Administer meds, wound care •Prepare paperwork requested when available (performs •Pertinent Clinical Reminders Secure Messaging In-Person Authentication) by the Veteran and/or PCP •Triaged messages from patients Secure Messaging •Specialty consult completion •Updates insurance & •Triaged messages from patients •E-mail with consultants demographic info Secure Messaging tracking •E-mail with consultants •Coordinate information •Triage messages from patients exchange for the co-managed Care Management Face to Face Visits patient •Virtual review of patients •Arrive on time Care Management •Manage telephone demand including inpatients •Virtual/F2F in-depth and ongoing •Bring medications Care Management (receiving and documenting) •Identify high risk for •Required Paperwork review of patients including •Manage appointment hospitalization. inpatients •Track/administer required scheduling including EWL & •Health risk assessment •Identify high risk for immunizations •Appropriate for CCHT, OEF/OIF, completion (with RN) recall. HBPC hospitalization. •Triage phone calls for •Pre-visit patient reminder calls •Lab work completion •Initiate appropriate consultations •Preventive care needs appointments Face to Face Visits •Non VA records Prepare for Primary Care for CCHT, CM, OEF/OIF, HBPC, •Coordinate group visits •Appointment check in •View alerts Visit hospice/palliative care •Identify additional services •Assists w/My HealtheVet •Diagnostic result •Discuss care with specialty needed by Veteran/Family •Discuss concerns and registration •Discuss care with/refer to plan of care consultants •Performs In-Person specialty consultants •Preventive/chronic disease care Authentication •Traveling veterans •Utilize My HealtheVet needs •Assists with updating and •Medication Reconciliation •Contact PC “teamlet” •Triage to other team members as verifying demographics and with any insurance information •Refer to other team members as appropriate appropriate problems/concerns that •Non VA records Team Work arise during/after face to •View alerts •Daily huddle Team Work face encounter. •Daily huddle Team Work •Follow-up calls •Team meetings •Team Meeting •Daily huddle •Team Meeting Participate Team Work •Attend committees, Education Clinic support •Midlevel Collaboration •Daily huddle •Identify & prepare required patient advisory groups, •New patient orientation •Team Meeting forms, documents/records prior and task forces •Assist with patient education to clinic session Education •Faxing, copying, mail mgt •New patient orientation Education •Provider CME , Grand Rounds •New patient orientation Clinic Support •Manage clinic grids •Manage office supplies & •Teaching trainees •Mentor/precept nurse trainees •Daily equipment/supply checks setup •Patient health •Keep exam rooms stocked education/coaching What is the experience of health systems using patient portals and personal health records? Experience at Group Health Secure Email is core function of MyGroupHealth Dispelling Myths Patients respectful of clinician time Patient connect to clinicians as trusted source of information Opportunity to manage challenging patients Workflow efficiencies Triage – filter, asynchronous communication Time motion study suggests Secure Message/e-visit takes half the time of a phone visit Improved documentation of care Dr. Matt Handley, presentation to VA Secure Messaging Workgroup, December 2009 Shifting Demand: If e-mail were not available, would you... MyGroupHealth Satisfaction Survey, 2004 N=630 (2004), N=646 (2006) 2006 How would you rate the value of secure e-mail in enhancing in person visits? “This is the best health care I have ever had! I love the online services the friendly employees and GHC's overall desire to help me be healthy. I'm from California and GHC beats any health care they had to offer.” MyGroupHealth Satisfaction Survey, N=645 (2004), N=666(2006) Kaiser – Patient Portal Usage 49.2 Million results 6,000,000 viewed (since launch) 5,000,000 Registered members 4,000,000 3.4 Million users Lab test results viewed online 3,000,000 E-mails sent to 19.3 Million Emails providers Visits to past visit 2,000,000 information Online prescription refills 1,000,000 0 From Jan Oldenburg, Kaiser Internet Services Group “The laying on of hands will increasingly include the pressing of keys. This emerging model will improve the practice of medicine but will also bring new challenges.” - JH Stone Communication between physicians and patients in the era of e- medicine. New England Journal of Medicine, 2007 Complementary Tools: EHR & PHR VA Electronic My HealtheVet Health Personal Record Health (EHR) Record (PHR) Comprehensive record Secure web-based portal At all care sites Patient & family centered Decision support Information and services Clinical reminders Multiple levels of access Patient safety Increasing offerings over time Internet Use in the U.S., 2008 • 74% of adults in U.S. • 87% ages 18-29; 72% ages 50-64 • 41% age 65 and older • 64% living in rural areas • 77% white, 64% black, 58% Hispanic • 57% if < $30,000 per year Pew Internet & American Life Project www.pewinternet.org Our Veterans and their families are increasingly online and engaged in their own health and care. My HealtheVet Use (February 2010) 956,500 Registered 179,427 Authenticated Requires in-person process Required to use Secure Messaging Over 14 million Rx Refills Processed Averaging 111,000 refills weekly in 2010 Authenticated Users Can: • Refill Prescriptions • View Medications • Research Health Information • Get Wellness Reminders • Track & Graph Their Metrics • Use Health Journals • Use Self-Assessment • See Wellness Calendar • Access eBenefits Manage Medications 23 Track Health Data Vitals & Readings Labs & Tests Health History Family Health History Military History Allergies Immunizations Journals Personal Health Summary 1. Hypertension 2. Influenza Vaccine 3. Pneumococcal Vaccine 4. Colorectal Cancer Screening 5. Lipid Measurement 6. LDL Target 7. Body Mass Index (BMI)>25.0 8. Diabetes Foot Exam 9. Diabetes Hemoglobin A1C 10. Diabetes Retinal Exam 11. Mammography Screening 12. Cervical Cancer Screening My HealtheVet Website Survey • 96% login from home • 1 out of 2 login monthly • 1 out of 4 login weekly or more • 3 out of 4 login for Rx refill • 64% would like to securely email their provider American Customer Satisfaction Survey (ASCI) October 2007 – October 2009 What is Secure Messaging? Secure, encrypted within My HealtheVet Electronic, bi-directional communication Asynchronous (not at same time) For enrolled participants only For non-urgent issues Can triage messages across a team Can save messages saved to CPRS VA Secure Messaging Pilot Sites BEDFORD ERIE HC Team 11 PUGET SOUND HC Team 29 Patients 116 HC Team 37 Patients 62 Patients 330 BOSTON HC Team 60 PORTLAND Patients 479 HC Team 56 Patients 380 WASHINGTON DC HC Team 65 Patients 767 MARTINEZ HC Team 25 Patients 357 ALASKA HC Team 18 Patients 85 Effective Messaging Respond within 3 business days Triage to appropriate person Simple, conversational language Higher level of care if appropriate Use surrogates as needed Dr. Woods – Hello. I just received a new bottle of You told me at the clinic yesterday the blood pressure medicine. It’s that I should get the shot for the same name but the pill doesn’t My back is really hurting bad. I run shingles. But I didn’t getIthe shot. look the same. Should take it? out of pain meds in about 3 days. Should I wait or do I need to come back in? VA Secure Messaging Experience Is patient centered o Patients find it convenient and personal Takes a healthcare team o Triage model = specific team roles Offers efficiencies of care o With positive patient feedback Is used as intended Meeting My HealtheVet Goals • Improving Access to Services • Enhancing Health Literacy • Improving Communication • Increasing Satisfaction “This is a great thing for us. I love being able to refill prescriptions.” Veteran-Provider Interaction with My HealtheVet Secure Messaging U.S. Army Veteran Devin Nuszbaum David M. Douglas, MD The dreaded phone tree??? 2: Directory 0: Operator XXXXX AudioCare 3: Enrollment/ Application Pharmacy CSS 1: Direct Transfer Eligibility X 50810 DID x 55069 (pm: Dayton 51850) 0 (pm: voicemail) 1 2 AudioInquiry Order Refills 3 Start 4 Appt Reminders Main Greeting 5 4. AudioCare 1 for 45 days 53651 9 6 Automated 2 Check on the 7 Services Status of Refills 1 DID x 55201 2 all others AudioCare star 4 Request a Primary Care 1 Pharmacy options Renewal Pt’s directed to call team Incorrect entry 2 8 extension via DID line YYYYY 0 9 5. Scheduling Agents Portland 1 DID & x 53494 1 DID x 51495 (after 8-4:30: VM MPC Portland 2 (pm: Dayton 51850 Voicemail Access 3 message) x 50960 4 (pm: Dayton 51850) Portland 2 Vancouver 1 DID x 51497 PDX VA Phone Tree – v1.0 rev 2.1.08 1 1 x 31665 (pm: Dayton 51850) (pm: Dayton 51850) 2 MPC Vancouver 2 Themes 6: Primary Care 3 x 50970 4 (pm: Dayton Vancouver 2 Portland 3 x 50980 5 · Patient and caller self management 6 51850) x 31901 DID x 51496 (pm: Dayton 51850) (pm: Dayton 51850) · Simple, clear menus · Pleasant, calm, consistent voice PC Salem DID x 51499 · Fail safe loops for incorrect actions – no dead Portland 4 (pm: Dayton 51850) ends for caller DID x 51498 7: Specialty Clinics (pm: Dayton 51850) x 50820 (pm: Dayton 51850) PC Bend 2008 QWEST phone book DID x 51494 numbers grossly incorrect (pm: Dayton 51850) East Portland 1 Eligibility and Information DID x 51007 503-273-5289 (pm: Dayton 51850) PC North Coast x 52593 Currently AudioCare appt (pm: Dayton 51850) East Portland 2 pressing 9 goes to 50950 DID x 51008 chg to 53494. At times this (pm: Dayton 51850) 1 also cycles back to 2 PC East Portland Audiocare 55201! 3 x 50960 4 East Portland 3 (pm: Dayton 51850) DID x 51009 (pm: Dayton 51850) East Portland 4 DID x 51010 (pm: Dayton 51850) I’m out of refills. Now what? Hmm, maybe Secure Messaging? “Doc I am out of refills” Meanwhile back at the clinic… De-identified notification Same username and password The Secure Message The Doctor replies The Veteran’s de-identified notification No problem; Your Rx is on its way Secure Messaging Best Practices Tracey Martin, RN Nurse Manager VA Boston Healthcare System 46 Marketing SM Perks to the Team Telephone Secure Messaging • Tag, you’re it! • No phone tag. • Leave a message? Not • Message goes to the sure who will hear it person it was intended for • The waiting is the hardest • Resolve message in real part time or when you have time • “While I have you on the • Less rambling/ focused phone….” discussion • Release of information • MHV release resolves the issues ROI issues VA World: Postal distress (packaging, addressing, transporting) Map the Triage Process Look at how your TEAM manages “demand” care Plan and appoint members of the care TEAM to receive the initial Secure Messages. *No one team member works in isolation! Primary Roles in SM triage • Medical Support Assistant, Program Support Assistant, Clerical staff • Clinical Associates: Health Technician, Nursing Assistant, Pharmacy Technician • Nurses: LPN, RN • Can these staff members be the triage team? Tertiary Roles in SM Management • Clinical Pharmacy • Dietitian • Social Worker • Mental Health Provider • Primary Care Provider • Other members of the multi-disciplinary team Example of a SM Team The triage team receives the message, troubleshoots the concern and forwards or assigns to another team member only if needed Veteran Provider_PrimaryCare_Site 1. IPA’d 2. Enrolled into Secure Messaging Triage Team Provider Health Technician LPN RN Social Worker Mental Health Provider MSA Pharmacist Dietitian Traditional Secure Messaging Requests driven by PATIENT • Administrative Question • Appointment Request • Change of Address Request • Health Information Question • Lab or Test Results Question • Medication Prescription Question Best Practices • Secure Messaging is currently being utilized in various VA clinical settings across the nation. • Some examples: Audiology Mental Health HBPC Tele-health *******Primary Care******* Primary Care Pre-planning • Arrive early • Bring updated medication list • Communicate concerns • Do labs • Ensure updated shared care info is received • Fax number • Give administrative staff updated demographics/insurance/community provider list. Utility: Using Secure Messaging for Anticoagulation Clinic SM SENT TO PT W/ HEALTH QUESTIONS PT RESPONDS BACK TO PROVIDER W/I 24 HOURS OF ANTICOAGULATION APPOINTMENT IF RESPONSES ARE BENIGN, PT COMES TO CLINIC FOR BLOODWORK ONLY & THEN GOES HOME! INR RESULTS ARE REVIEWED BY CLINIC PROVIDER SM SENT BACK TO PT WITH RESULTS, DOSING INSTRUCTIONS & EXPECTED RETURN DATE PT RESPONDS BY SM THAT RESULTS AND INSTRUCTIONS WERE RECEIVED MOVE! Clinics • Utilize for patients who are unable to attend face-to-face appointments • Goal setting/sharing • Problem solving • MOVE! Along….. Virtual MOVE! Other PCMH Uses • Announce special clinics i.e. seasonal flu, H1N1, special educational programs… • Post-visit follow-up: – labs/discussion, exam results, procedure education – interim communication • CaSe or CaRe management • Caregiver communication/support. Roll Out of Secure Messaging The VISN 5 Experience Kate Andrews, MD Quality Management Officer Primary Care Lead Physician 58 VISN 5 59 VISN 5 Enrollment Based Market Share Active Patients Enrollees (Enrollees to Veteran Population) 193,174 25% 107,305 Enrollees Patients Urban Rural % Rural Urban Rural % Rural 146,054 48,042 25% 77,482 29,773 28% Roll Out of Secure Messaging • Partner with the National MyHealtheVet and Secure Messaging Teams – Weekly Conference Calls – SharePoint – Implementation Check List – Make Connections 61 Roll Out of Secure Messaging • Solicit Leadership Support – Sell SM by presenting to Leadership at key committee meetings and through personal contact – Make SM a component of your operational plan – VISN 5 roll out of SM is a 2010 VISN-wide performance measure • 60% of Primary Care Providers will be participating as part of a three- level triage team by end of Q4 62 Roll Out of Secure Messaging • Determine the Method of Roll Out – VISN 5 SM Collaborative – Teams • Each MC developed an Implementation Team • Each Implementation team is part of the VISN-wide Collaborative – Meetings • Each MC Team meets every two weeks • The VISN-wide Collaborative meets by conference call every two weeks to discuss progress, successes, barriers and national issues • Every Quarter meet face-to-face 63 Secure Messaging SUPERSTARS! DC MT VAMCHS 2nd and 4th Tues @ 1pm, 1D141 (Center for 1st and 3rd Weds at 1st and 3rd Tues @ Performance Conf 3:30pm, 54261# and 9:30am, 60222# and MC Meeting Details Room) 3C-134 Conf room Site Managers: Fname Lname Secure Messaging Facility Champion Fname Lname Fname Lname Secure Messaging Clinical Champion Fname Lname Fname Lname Fname Lname System Redesign Representative Fname Lname Fname Lname Fname Lname Nursing Representative Fname Lname Fname Lname Fname Lname Primary Care Physician or Nurse Practitioner Fname Lname Fname Lname Fname Lname Lab Representative N/A Fname Lname Fname Lname Pharmacy Representative Fname Lname Fname Lname Fname Lname Clinical Application Coordinator Fname Lname Fname Lname Fname Lname Administrative Assistant TBD Fname Lname Fname Lname IT Representative Fname Lname Fname Lname Fname Lname MAS/Business Representative Fname Lname Fname Lname Fname Lname Education or Academic Affiliations Representative N/A Fname Lname Fname Lname My HealtheVet Point of Contact Fname Lname Fname Lname Fname Lname Fname Lname Secure Messaging Clinical Coordinator TBD pending clarification of role (Social Work) Public Affairs Office Fname Lname Fname Lname Fname Lname Planetree POC or Facilitator Fname Lname Fname Lname Fname Lname Other - DC - RN, Chief, Patient Service Center Fname Lname xxxxx xxxxx Other - DC - PharmD, Chief, Pharmacy Service Fname Lname xxxxx xxxxx Other - DC - Supervisory Patient Advocate Fname Lname xxxxx xxxxx Other - MT - Managed Care CNE xxxxx John Goldizen xxxxx Other - VAMHCS - Dep Dir Managed Care xxxxx xxxxx Fname Lname Other - VAMHCS - BT Lead MD xxxxx xxxxx Fname Lname Other - VAMHCS - RN Nurse Manager xxxxx xxxxx Fname Lname Other - VAMHCS - RN Nurse Manager xxxxx xxxxx Fname Lname Other - VAMHCS - MAS xxxxx xxxxx 64 Fname Lname Using a Collaborative Model – LS1 AP1 LS2 AP2 LS3 AP3 LS4 AP4 – Nov 2009 LS1 – Nov - Dec 2009 AP1 • Develop additional AIM statements • Develop and submit action plan for implementation of SM – Jan 2010 LS2 • Didactic Session – presentations on flow mapping to look for barriers, look and feel of SM, how to create teams using the Admin Portal • Break Out Groups to identify each MC’s 1) SM Administrator(s), 2) monthly % goals for PCC providers as part of a three level triage team and 3) next three steps when they got “home” 65 Using a Collaborative Model – Jan – April 2010 AP2 • Implementation of Action Plans and development of Teamlets • Enhancing IPA capabilities – April 2010 LS3 • National Training of Teamlets and Administrators – May – July 2010 AP3 • Expansion of Teamlet training • Patient education and staggered notification – July 2010 LS4 • Identify best practices, provide MC updates – Aug – Sept 2010 AP4 • Expansion beyond PCC 66 VAMC and VISN MHV Program • Resources allocated to each Network – VISN MHV Coordinator – VAMC MHV Coordinator • VAMC MHV Program Coordinator – Planning, Organizing, Directing, Evaluating and Reporting on local MHV-related actions/activities • AND…VAMC MHV facility coordinator is responsible for – Leading and coordinating secure messaging implementation and administration – Coordinating related PCMH activities for MHV implementation – Training – Communications, Outreach and Support 67 Questions?
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