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My HealtheVet (MHV) #127:
Improve Healthcare and Cost
Outcomes
David M. Douglas MD
Belinda Dalton
1
Agenda
I. Introduction and Literature review
II. Review MHV and MHV Pilot
III. Study design
IV. Outcomes
V. Implications
VI. Q&A
2
Consumer Health Informatics
• Consumer Health Informatics is the branch of medical
informatics that
– analyses consumers' needs for information
– studies and implements methods of making information
accessible to consumers; and
– models and integrates consumers' preferences into medical
information systems.
• Medical Informatics initially focused on providers and
institutions then applied same principles to consumers
• “Expert systems would provide the greatest benefit to
those with the least previous knowledge.”*
Eysenbach BMJ 2000
3
What is a Personal Health Record?
The Personal Health Record (PHR) is an Internet-
based set of tools that allows people to access
and coordinate their lifelong health information.
People can use their PHR as a communications
hub: to send email to doctors, transfer information
to specialists, receive test results and access
online self-help tools.
PHR connects each of us to the incredible potential
of modern health care and gives us control over
our own information.
Markle Foundation
4
Why deliver health care interventions
over the Internet?
• Reducing cost and increasing
convenience for users
• Reduction of health service costs
• Reduction of isolation of users
• The need for timely information
• Reduction of stigma
• Increased user and supplier control of
the intervention
Griffiths, et al (J Med Internet Res 2006;8(2):e10)
5
Why deliver health care interventions
over the Internet?
• Possible drawbacks
– Potential for reinforcing the problems the intervention
was designed to help
– May overcome isolation of time, mobility, and
geography, but may be no substitute for face-to-face
contact
• Future evaluation
– Incorporate the cost not just to the health service, but
also to users and their social networks
– Be alert to unintended effects of Internet delivery of
health interventions, and include a comparison with
more traditional modes of delivery
Griffiths, et al (J Med Internet Res 2006;8(2):e10)
6
Existing literature on PHR evaluation is
scant
Cintron, et al - J Palliat Med. 2006 Dec;9(6):
1320-8. The effect of a web-based, patient-
directed intervention on knowledge,
discussion, and completion of a health care
proxy. Intervention did not increase patient
completion of HCP but improved knowledge.
Wang, et al - IEEE Trans Inf Technol Biomed.
2004 Sep;8(3): 287-97. Personal health
information management system and its
application in referral management. Patients
and providers reported enhanced
communication via PHR.
7
Existing literature on PHR evaluation is
scant
Ross et al - J Med Internet Res. 2004 May 14;6(2):
e12. Providing a web-based online medical
record with electronic communication
capabilities to patients with congestive heart
failure: randomized trial. Access to online
medical record for CHF patients was feasible
and improved adherence.
Kim et al - Conf Proc IEEE Eng Med Biol Soc.
2004;5: 3159-62. Application and evaluation
of personal health information management
system. Providers satisfied with the content of
patients personal health information and used it
for triage of referrals.
8
VA is in midst of large scale deployment
and evaluation of PHR
My HealtheVet
MHV Pilot
9
My HealtheVet
10
My HealtheVet
11
My HealtheVet National Program
More than 437,330 Registered Users
•Online Prescription Refills
•Health Education Information
•Self-assessment Tools
•Health Journals and eLogs
•Veteran Specific Conditions
•Seasonal Health Reminders
•Wellness Calendar
•One stop Benefits/Services
•And More…
Incremental releases of new features
VistA EHR Secure Messaging Delegation
12
Registered Patients
My HealtheVet - National
• 437,330 registered
• 11,210,482 visits by June 31, 2007
• 3,328,153 Rx refilled online since August
31, 2005
13
My HealtheVet Usage
Total Registrants
450,000
400,000
Number of Registrants
350,000
300,000
250,000
200,000
150,000
100,000
50,000
0
Jul-06
May-06
Sep-06
Oct-06
Mar-07
May-07
Mar-06
Dec-05
Apr-06
Dec-06
Jun-06
Apr-07
Feb-06
Nov-06
Feb-07
Jun-07
Jan-06
Aug-06
Jan-07
Months
Over 11,200,000 visits to the My HealtheVet website
(12/2005 – 6/2007)
14
My HealtheVet Usage
Prescription Refills
250,000
Over 3,300,000 Prescriptions Refilled since Rollout
(August 31, 2005)
200,000
Number of Rx Refills
150,000
100,000
50,000
0
Apr-07
Jul-06
Dec-06
Mar-06
Oct-05
May-06
Oct-06
Mar-07
May-07
Dec-05
Apr-06
Jun-06
Sep-05
Sep-06
Nov-05
Jan-06
Feb-06
Aug-06
Nov-06
Jan-07
Feb-07
Jun-07
Months
15
My HealtheVet Registrant Age Distribution
National Site
80,000
June 2007
70,000
No. Veterans Enrolled
60,000
50,000
40,000
30,000
20,000
10,000
0
<20 20- 25- 30- 35- 40- 45- 50- 55- 60- 65- 70- 75- 80- 85- >90
24 29 34 39 44 49 54 59 64 69 74 79 84 89
Age Grouping
16
My HealtheVet Statistics
Over 3.3 million Refills Processed
Daily Average Rx refills for 2006 is approximately 4,500
92% Veterans
60% Patients
5% VA Employees
3% Care Providers
3% Advocate/Family
17
My HealtheVet Pilot Program
Over 7,365 Pilot participants at 9 VA Medical Centers
· Demographics, admissions, and
appointments
· Vitals and allergies
· Prescriptions
· Progress notes
· Discharge summaries
· Basic problem list information
· Lab reports: chemistry,
microbiology, microscopy,
cytology and pathology
· ECG and radiology reports
Medical Record extracts
Self-entered metrics
Patient Health Education Libraries
Patient controlled secure information sharing
18
MHV Personal Health Record
VA Electronic Medical Record •The VistA Computerized
Patient Record System
• CPRS (CPRS) is the authoritative VA
• VistA medical record.
• BCMA • The veteran "owns" his/her
• VistA Imaging My HealtheVet Personal
Health Record.
• The veteran can request that
a copy of key portions of
his/her VistA record be
electronically extracted and
sent to the My HealtheVet
system.
• The veteran controls access
(delegation). 19
My HealtheVet Pilot Project
• MHV Pilot Project allows veterans to access
personal health records over the Internet.
• For 2 years, Portland VAMC has been one of 9
sites to participate in the MHV Pilot Project.
• >5000 veterans at PVAMC access their own
medical records using MHV.
• Initially many staff opposed the pilot because of
the fears of unintended adverse consequences if
patients have online access to medical records.
20
PVAMC Medical Staff Council
September 15, 2004
• Motion before the Council
– Portland VAMC will participate in a pilot project to allow veterans
electronic access to their medical records
• Resistance to the pilot was fierce
• Discussion
– Increase in provider workload
– Telephone Care will be deluged
– Patient dissatisfaction, overreaction, and hysteria
– Negative impact on paper based ROI
– Congressional and Patient Advocate Complaints
– Medical record will now be censored
– “This will ruin the practice of medicine”
21
PVAMC Medical Staff Council
September 15, 2004
• Compromise: MHV Pilot will be allowed but
– CPRS Consult allows PCP to serve as a gatekeeper
– Maximum of 30 patients/month
– Patients must have classroom training
– 3-4 week turnaround for veteran access
– Careful monitoring of provider workload, complaints,
chart amendment requests, and potential ROI
backlog.
• Strategy: Engineer (cumbersome) MHV process
to limit enrollment until impact can be measured
22
Initial Impact
• Provider workload/dissatisfaction goes up
because of the gatekeeper role
• Mental Health providers report that limiting their
patients access adds no value
• Patient complaints go up because of
– 2-4 week wait for access
– Quotas limiting enrollment to 30/month
– Provider opts out
• 3 complaints about content of the medical record
• 1 CPRS Chart Amendment request
23
PVAMC Medical Staff Council
March 15, 2005
• Resistance had evaporated.
• Providers do not want to be a gatekeeper
• Hold For Review requirement waived for
(most) Mental Health Clinics
• Patients highly satisfied
• Enrollment process must be streamlined
• Eliminate classroom requirement
• Engineer “1 Hour Photoshop Model” of
MHV Pilot enrollment
24
Kiosk (15 min. process)
Veteran walks up and fills out application
25
15 Minute Photoshop Model
Veteran fills out application at Kiosk
Clerk opens My HealtheVet user menu
Reprint 'Welcome' Letter For Registered Veteran
DSS/ROI Records Check
Create e-vault
Assemble User packet
In-Person Authentication
Veteran signs 5345-a
Update Databases
Veteran receives username, password, and
information packet
26
27
But which veterans signed up ?
• Inverse Care Law: Availability of health
care is inversely proportional to need.
OR
• Those in the worst health are least likely to
receive services.
AS APPLIED TO MHV
• The sickest veterans are least likely to
have access to or know how to use a
computer.
(J Tudor Hart, 1971, The inverse care law, Lancet 1 405-12)
28
Markle Foundation Presentation
Connecting Americans with their Health Care
December 7-8, 2006
VA presentation on MHV well received but
followed by numerous questions on
evaluation.
PVAMC urged to further evaluate its
experience with the MHV Pilot.
29
Questions asked at the Markle
presentation
• Analysis of effect of MHV Pilot
– Inverse Care Law: Are MHV Pilot enrollees healthier, younger,
and more affluent?
– Patient dissatisfaction, overreaction, and hysteria: Did MHV Pilot
enrollees disproportionately utilize Telephone Care,
Emergency Department, or voice complaints related to MHV?
– Mental Health Notes: Did lack of “Hold for Review”
requirement for Mental Health clinics lead to dissatisfaction?
– Draft Evaluation Metrics Does access to appointments and
treatment plan affect utilization measures such as clinic
cancellations or no-shows?
– “Expert systems would provide the greatest benefit to those with
the least previous knowledge.”* Did access to information
(particularly wellness reminders) improve patient outcomes?
30
Limited evaluation of MHV Pilot has
already been done
• IRB approved Masters level Research
Project
• ROI Office Utilization
• Chart Amendment Requests
31
Veteran Satisfaction with MHV Pilot
• IRB approved Research Project:
– Evaluation of MHV Implementation at Portland VAMC
• Methods: Survey 2 groups
– classroom training n=62
– Hard Copy Manual n=59
Lee, Michelle; Evaluation of MyHealtheVet Implementation at the
Portland Veterans Affairs Medical Center; Masters Thesis Feb 23, 2006
32
Veteran Satisfaction with MHV Pilot
• No significant difference in how useful the
veterans rated classroom vs. paper based training
• No significant difference in ease of remembering
information learned in classroom vs. paper based
training
• No significant difference in veterans perception
that MHV was easy to use
• No significant difference in high degree of
satisfaction with access to PHR
33
Empowerment Statements
• I am better prepared for my office visits.
– 62% agree or strongly agree
• I can better understand the instructions from
my doctor
– 67% agree or strongly agree
• I have more control and power to manage my
health care
– 74% agree or strongly agree
34
Veteran to Veteran
• I would recommend MHV to my friends.
– 84% agree or strongly agree
• I believe all veterans should use MHV.
– 81% agree or strongly agree
35
MHV enrollment reduces use of paper
36
MHV Enrollment reduces visits to the “Bricks
and Mortar” Release of Information Office
37
Does access to a PHR increase
requests for Chart Amendment?
• 36 Chart Amendment requests in FY 05-06 out of 4 million
clinical documents
– 23 not enrolled in MHV
– 13 enrolled in MHV
• 3 requests predated MHV enrollment
• 10 requests followed MHV enrollment
• 14% of PVAMC Patients are enrolled in MHV
• 28% of Chart Amendments are from patients enrolled in
MHV
Chart Amendment requests appear to increase with MHV
enrollment although this is a relatively rare event.
38
IRB Approved Research Project
Title of Project: IMPACT OF MHV PILOT
ON UTILIZATION
Principal Investigator: David M. Douglas
MD
Co-Investigators: Blake Lesselroth MD,
Rose Campbell, Pat Tidmarsh, Belinda
Dalton
39
IRB Approved Research Project
ABSTRACT:
3 key MeSH terms: Patient Access to Records, Internet
and Medical Records Systems, Computerized
Objectives: The objective of this study is to conduct an
electronic chart review to better understand the
demographics of the MHV pilot population and then to
see what effect enrollment in the pilot had on utilization
and outcomes.
Plan: Write a MUMPS routine to gather demographic,
utilization, and outcomes data on veterans enrolled in
the MHV pilot.
40
IRB Approved Research Project
Although many PHRs have been deployed in the US and around the
world, the MHV Pilot is unusual in that it allows internet-based
access to electronic progress notes from the EHR.
Kaiser Permanente by comparison has several hundred thousand
patients enrolled in a PHR but does not provide access to electronic
progress notes.
There has been intense interest in the following question:
What impact has the MHV Pilot (and in particular ability to view
content from the EHR) had on utilization and patient outcomes?
Statistical Methods: Since this is a retrospective chart review, the
intent is to report descriptive statistics only which would help to set
the stage for a subsequent controlled study.
41
Methodology
• Identify those veterans with
– 2 or more downloads
– Enrolled prior to April 7, 2006
• Write MUMPS routine to extract data on
– Demographics
– Utilization
– Clinical Reminders
42
Why do downloads matter?
43
Downloads
44
Downloads
45
Wide range of download frequency
PATIENT: A Patient: B (continued)
DOWNLOAD DATE: JAN 11,2006 21:45
DOWNLOAD DATE: MAY 7,2006 17:46 DOWNLOAD DATE: JAN 29,2006 17:47
DOWNLOAD DATE: FEB 9,2006 09:49
SUBCOUNT 1 DOWNLOAD DATE: FEB 14,2006 13:46
DOWNLOAD DATE: FEB 17,2006 13:57
-------------------------------------------------------------------------------- DOWNLOAD DATE: FEB 24,2006 09:45
DOWNLOAD DATE: MAR 3,2006 17:46
PATIENT: B DOWNLOAD DATE: MAR 10,2006 09:50
DOWNLOAD DATE: MAR 20,2006 13:45
DOWNLOAD DATE: DEC 20,2005 17:47
DOWNLOAD DATE: DEC 30,2005 21:51
DOWNLOAD DATE: JUL 21,2005 17:47 DOWNLOAD DATE: APR 14,2006 09:47
DOWNLOAD DATE: APR 24,2006 09:45
DOWNLOAD DATE: JUL 28,2005 09:45 DOWNLOAD DATE: MAY 6,2006 20:13
DOWNLOAD DATE: MAY 11,2006 09:47
DOWNLOAD DATE: JUL 29,2005 13:45 DOWNLOAD DATE: MAY 13,2006 09:45
DOWNLOAD DATE: MAY 23,2006 09:46
DOWNLOAD DATE: JUL 31,2005 17:45 DOWNLOAD DATE: MAY 29,2006 01:45
DOWNLOAD DATE: JUN 1,2006 21:47
DOWNLOAD DATE: AUG 1,2005 21:46 DOWNLOAD DATE: JUN 8,2006 21:53
DOWNLOAD DATE: JUN 30,2006 21:52
DOWNLOAD DATE: AUG 2,2005 17:46 DOWNLOAD DATE: JUL 21,2006 17:49
DOWNLOAD DATE: AUG 10,2006 21:48
DOWNLOAD DATE: AUG 3,2005 21:50 DOWNLOAD DATE: AUG 16,2006 21:49
DOWNLOAD DATE: AUG 24,2006 01:45
DOWNLOAD DATE: AUG 8,2005 09:47 DOWNLOAD DATE: SEP 8,2006 21:46
DOWNLOAD DATE: OCT 6,2006 21:45
DOWNLOAD DATE: AUG 10,2005 13:52 DOWNLOAD DATE: NOV 1,2006 09:45
DOWNLOAD DATE: DEC 21,2006 11:20
DOWNLOAD DATE: AUG 13,2005 21:50 DOWNLOAD DATE: DEC 21,2006 13:45
DOWNLOAD DATE: DEC 27,2006 17:47
DOWNLOAD DATE: AUG 16,2005 13:46 DOWNLOAD DATE: JAN 4,2007 13:47
DOWNLOAD DATE: JAN 12,2007 17:51
DOWNLOAD DATE: AUG 19,2005 09:45 DOWNLOAD DATE: JAN 30,2007 21:45
DOWNLOAD DATE: JAN 31,2007 13:46
DOWNLOAD DATE: AUG 23,2005 10:25 DOWNLOAD DATE: FEB 1,2007 16:53
DOWNLOAD DATE: FEB 3,2007 00:50
DOWNLOAD DATE: AUG 27,2005 17:45 DOWNLOAD DATE: FEB 5,2007 16:56
DOWNLOAD DATE: FEB 7,2007 13:06
DOWNLOAD DATE: AUG 31,2005 13:49 DOWNLOAD DATE: FEB 9,2007 16:53
DOWNLOAD DATE: FEB 10,2007 12:53
DOWNLOAD DATE: SEP 1,2005 21:45 DOWNLOAD DATE: FEB 12,2007 12:52
DOWNLOAD DATE: FEB 12,2007 21:02
DOWNLOAD DATE: SEP 6,2005 21:47 DOWNLOAD DATE: FEB 15,2007 16:58
DOWNLOAD DATE: FEB 21,2007 08:52
DOWNLOAD DATE: SEP 8,2005 09:45 DOWNLOAD DATE: FEB 26,2007 12:55
DOWNLOAD DATE: FEB 26,2007 20:51
DOWNLOAD DATE: SEP 10,2005 21:47 DOWNLOAD DATE: FEB 27,2007 08:51
DOWNLOAD DATE: FEB 28,2007 08:50
DOWNLOAD DATE: OCT 1,2005 21:45 DOWNLOAD DATE: MAR 1,2007 16:55
DOWNLOAD DATE: MAR 2,2007 16:51
DOWNLOAD DATE: OCT 6,2005 09:45 DOWNLOAD DATE: MAR 4,2007 16:52
DOWNLOAD DATE: MAR 5,2007 16:54
DOWNLOAD DATE: OCT 9,2005 17:47 DOWNLOAD DATE: MAR 8,2007 09:17
DOWNLOAD DATE: MAR 9,2007 16:50
DOWNLOAD DATE: OCT 14,2005 21:46 DOWNLOAD DATE: MAR 12,2007 13:01
DOWNLOAD DATE: MAR 13,2007 12:56
DOWNLOAD DATE: OCT 19,2005 09:47 DOWNLOAD DATE: MAR 14,2007 20:50
DOWNLOAD DATE: MAR 16,2007 12:56
DOWNLOAD DATE: OCT 29,2005 21:46 DOWNLOAD DATE: MAR 19,2007 20:52
DOWNLOAD DATE: MAR 21,2007 20:52
DOWNLOAD DATE: NOV 6,2005 09:46 DOWNLOAD DATE: MAR 28,2007 08:52
DOWNLOAD DATE: MAR 28,2007 16:51
DOWNLOAD DATE: NOV 12,2005 13:46 DOWNLOAD DATE: MAR 29,2007 16:52
DOWNLOAD DATE: APR 4,2007 08:51
DOWNLOAD DATE: NOV 30,2005 17:49 DOWNLOAD DATE: APR 4,2007 09:48
DOWNLOAD DATE: APR 4,2007 16:54
DOWNLOAD DATE: DEC 1,2005 13:45 DOWNLOAD DATE: APR 5,2007 20:51
DOWNLOAD DATE: APR 12,2007 09:09
DOWNLOAD DATE: DEC 5,2005 21:47 DOWNLOAD DATE: APR 16,2007 20:52
DOWNLOAD DATE: APR 20,2007 08:51
DOWNLOAD DATE: DEC 9,2005 21:46 DOWNLOAD DATE: MAY 14,2007 08:50
DOWNLOAD DATE: MAY 19,2007 12:50
DOWNLOAD DATE: MAY 25,2007 13:33
DOWNLOAD DATE: MAY 30,2007 16:55
DOWNLOAD DATE: JUN 5,2007 08:50
DOWNLOAD DATE: JUN 12,2007 16:52
DOWNLOAD DATE: JUN 19,2007 16:50
DOWNLOAD DATE: JUN 22,2007 13:01
DOWNLOAD DATE: JUN 29,2007 08:58
DOWNLOAD DATE: JUL 10,2007 00:52
46
PARAMETERS
Criteria used to determine if a MHV participant
should be included in data gathering:
a. Active entry in the national file “HEALTH EVET
REGISTER”
b. Veteran‟s enrollment date was prior to April 6,
2006
c. At least two downloads recorded in the
national file “HEALTH EVET DOWNLOAD
SUMMARY”
Note: No test patients were included.
47
• One primary routine is used to gather the veterans that
meet all three criteria. Specific report routines are
„called‟ from within the primary routine.
• All reports are „called‟ from within the primary routine to
ensure the same veterans are used in every report.
• The count of veterans that are active and enrolled prior
to April 6, 2006 was verified by a Fileman report that
searched for active entries that had enrolled prior to
April 7, 2006.
• First enrollment date in our “Health Evet Register” file is
November 25, 2002.
48
• All reports, except demographic, gather data for year previous to enrollment
and data for year after enrollment.
• Report generated is based on what menu option is selected by the user.
For example, when person selects the demographic report option, a
variable is set to indicate „demographic‟.
• VistA menu option created for user to generate reports:
Select Options To Generate MHV Research Data (2 dwnlds) Option: ?
A Display MHV Research Project Pt Appt Summary (2)
D Display MHV Research Project Pt Demo Counters (2)
I Display MHV Research Project Pt Income Summary (2)
N Display MHV Research Project Pt Names (2)
P Display MHV Research Pro Pt Advocate Summary (2)
T Disp MHV Res. Proj Pt TIU Notes (Prior Yr) (2)
49
DEMOGRAPHIC DATA
• All data is gathered from the national
PATIENT file unless otherwise indicated.
• Number found for each component had to
match the number of veterans that were
found in the primary routine as meeting
the required criteria.
50
DEMOGRAPHIC COMPONENT
SUMMARY
1. Average Age
2. Count of Vets with Date Of Death entry
4. Covered By Insurance (Yes, No, Unknown, N/A)
5. Primary Eligibility - (Field looks at Eligibility Code file)
Sample: SC Less 50%
6. Enrollment Priority (Use portion of national programming
to gather each veteran‟s Group/Sub-group)
Sample: Group 1, Group 7c, Group 8g
7. Type of Patient (Field looks at Type Of Patient file)
Sample: SC Veteran
51
DEMOGRAPHIC COMPONENT
SUMMARY
8. Combat Indicator (Yes, No, N/A)
9. Unemployable (Yes, No, N/A)
10. Period of Service (Field looks at Period of Service file)
11. Vesting Status (To gather each veteran‟s status, used
the portion of Reno Vesting software that displays
veteran‟s vesting status on Patient Inquiry screen)
12. Race (Field looks at Race file.) Vet can answer
multiple times and all answers included
13. Ethnicity (Field looks at Ethnicity file) Vet can answer
multiple times and all answers included
14. OEF/OIF (OIF, OEF, Unknown OEF/OIF) Multiple
answers and all included
52
APPOINTMENT DATA
• Viewed each veteran‟s appointment history data
which is contained in their PATIENT file entry.
• There are two reports created under this one
routine.
• Report One – Displays count of appointments by
status; i.e., Checked Out, Cancelled by Patient,
Cancelled by Patient w/Rebook
• Report Two – Displays count of appointments
that were „unscheduled‟ and count of
appointments that were „scheduled‟
53
APPOINTMENT DATA
Sample 1
Sample of Report One = Count by Status
TOTAL Checked Out:
Year Prior: 26482
Year After: 28923
TOTAL Clinic Cancelled:
Year Prior: 4494
Year After: 5504
54
APPOINTMENT DATA
Sample 2
Sample of Report Two = Unsch vs Sched Count
YEAR PRIOR TOTAL SCHEDULED APPTS: 35494
YEAR PRIOR TOTAL 'UNSCHEDULED' APPTS: 1545
MH5I ECU PSYCH +: 19
ECU NEURO-AREA A: 9
other clinics and counts
YEAR AFTER TOTAL SCHEDULED APPTS: 40675
YEAR AFTER TOTAL 'UNSCHEDULED' APPTS: 1360
MH5I ECU PSYCH +: 14
ECU NEURO-AREA A: 6
other clinics and counts
55
APPOINTMENT DATA
VERIFICATION
All verification steps were followed for both the
data gathered for year prior and for data
gathered for year after.
* One - every veteran was reviewed.
* Two - selected two veterans at random and
generated appointment data using the national
Appointment Management option. Compared
that data to the appointment report generated by
the appointment-by-status routine for this
project.
56
APPOINTMENT DATA
VERIFICATION
* Three –
a. The total number of appointments in the year prior had to
be the same in both report 1 and report 2.
b. The total number of appointments in the year after had to
be the same in both report 1 and report 2.
c. In the unscheduled vs scheduled report, the number of
appointments listed for clinic sub-totals had to equal the total
unscheduled number.
57
APPOINTMENT DATA
Compare Unscheduled vs Scheduled
• Clinics that allow unscheduled appointments either have
“ECU” in the name, “Emergency” in the name, or
“Unscheduled” in the name.
File man report run on Hosp Loc file for clinic names that
contain „ECU‟, Emergency, or Unscheduled. Reviewed
for those that should not be included. Two clinics were
found – they had a word that included „ecu.‟ Program
automatically counted those as scheduled if found.
• As an appointment is found and counted for the status
report, the clinic name is reviewed to determine if it
contains one of the three names described above.
• If the clinic name contains one of the three, it is counted
as unscheduled. If it does not, it is counted as
scheduled.
58
PATIENT ADVOCATE DATA
• Used the national file “Consumer Contact” which
is part of the national “Patient Representative”
software.
• All data gathered for both year prior and year
after.
• Two summaries generated: (a) Number of vets
with at least one entry and number with no
entries, (b) Data was sorted/counted by the field
„Contact Made By.”
59
PATIENT ADVOCATE DATA SAMPLE
• NUMBER OF VETERANS WITH AT LEAST ONE ENTRY
• AND
• NUMBER OF VETERANS WITHOUT ENTRY
• ---------------------------------------------------------------------
• YEAR PRIOR:
• At least one entry: 168
• None: 1260
• YEAR AFTER:
• At least one entry: 150
• None: 1278
• SUMMARY BY 'CONTACT MADE BY' DESGINATION
• --------------------------------------------
• PATIENT (PA):
• Year Prior: 292
• Year After: 247
• RELATIVE (RE):
• Year Prior: 23
• Year After: 20
• ----------------- data removed for slide
• TOTAL
• Year Prior: 322
• Year After: 277
60
PATIENT ADVOCATE DATA
VERIFICATION
• Number of veterans that had at least one entry in the file
was gathered and the number of veterans with no entry
in the file was gathered. The total had to equal the
number of veterans that met initial project criteria.
• As an entry was found, no matter the „Contact Made By‟
setting, it was added to a total (one total for year prior
and one total for year after). If there was no „contact
made‟ data, it was counted as N/A.
• At the end of summary report, the sub-totals generated
for each „Contact Made By‟ had to equal its appropriate
total; i.e., year prior or year after.
61
TIU NOTES DATA
• Fileman used to create a report of all TIU titles that
contain phrase „tele‟. All titles included in the
programming except „Telehealth‟.
• Program uses the TIU Document file. As veteran found
that meets the original criteria, the program looks
through that patient‟s progress note entries in the file for
a title that contains one of the „tele‟ phrases.
• Two reports generated (each one has data for year prior
and data for year after)
Report 1 – Count of notes found for each of the „tele‟
phrases
Report 2 – Summary of number of titles per veteran
• As an entry is found, appropriate Rpt 1 sub-total counter
is adjusted. Once all completed data gathering for that
veteran, Rpt 2 appropriate sub-counter is adjusted.
62
TIU NOTES DATA - Report 1
Sample: From our TEST account:
Notes contain TELEPHONE:
Year Prior: 2617
Year After: 821
Notes contain TELE-:
Year Prior: 1286
Year After: 376
Notes contain TELECARE:
Year Prior: 742
Year After: 230
Notes contain TELEMEDICINE:
Year Prior: 2
Year After: 0
63
TIU NOTES DATA - Report 2
Sample: From our TEST account:
NUMBER OF TITLES PER VETERAN - SUMMARY
(YEAR PRIOR TO ENROLLMENT AND YEAR AFTER ENROLLMENT)
//////////////////////////////////////////////////////////////////////
ZERO Titles:
Year Prior: 806
Year After: 876
ONE Title:
Year Prior: 268
Year After: 247
TWO Titles:
Year Prior: 122
Year After: 98
THREE Titles:
Year Prior: 75
Year After: 66
FOUR Titles:
Year Prior: 48
Year After: 36
64
TIU NOTES DATA - Report 2
Sample: From our TEST account:
FIVE Titles:
Year Prior: 17
Year After: 23
SIX - TEN Titles:
Year Prior: 54
Year After: 47
ELEVEN - FIFTEEN Titles:
Year Prior: 11
Year After: 7
SIXTEEN - TWENTY Titles:
Year Prior: 4
Year After: 4
TWENTY ONE OR GREATER Titles:
Year Prior: 0
Year After: 1
TOTAL FOR YEAR PRIOR (SHOULD = # VETS) 1405
TOTAL FOR YEAR AFTER (SHOULD = # VETS) 1405
65
TIU NOTES
VERIFICATION
• Fileman report created to generate data for
random veterans. Verified that both reports
found exactly the same data as the Fileman
report.
• Report 1 – lf Fileman indicated the sample
veteran should have five titles with phrase
„Telecare,‟ then Report 1 should have count of
five for „Telecare‟.
• Report 2 – The sub-totals of all categories
should equal the total of veterans that met
original criteria.
66
Selection Criteria
• Total # of MHV Pilot enrollees = 5360
• Enrolled prior to 4/7/06 to allow for a year
before/year after comparison = 4202
• Limit present study to MHV Pilot enrollees
with 2 or more downloads
• Active per national field
• n = 1423
67
Back to the Inverse Care Law…
Are MHV Pilot enrollees healthier, younger,
and more affluent?
68
Demographics
• 1423 veterans with 2 or more downloads
• Average age 60
• COVERED BY INSURANCE?
– Yes: 786
– No: 617
– Unknown: 15
– N/A: 5
69
Most MHV Pilot enrollees
rated SC disabled
PRIMARY ELIGIBILITY:
SERVICE CONNECTED >50%: 597 (42%)
SC LESS THAN 50% 278 (20%)
NSC, VA PENSION: 54 (4%)
NSC: 476 (33%)
HUMANITARIAN EMERGENCY: 3 (0.2%)
AID & ATTENDANCE: 10 (0.7%
HOUSEBOUND: 2 (0.01%)
PURPLE HEART RECIPIENT: 1 (0.01%)
70
PERIOD OF SERVICE
MHV PVAMC
WORLD WAR II: 6% 12%
PRE-KOREAN: ~0% 0.4%
KOREAN: 7% 11%
POST-KOREAN: 8% 7%
VIETNAM ERA: 56% 45%
POST-VIETNAM: 12% 10%
OTHER OR NONE: ~0% 2%
OTHER NON-VETERANS: ~0% ~0%
PERSIAN GULF WAR: 11% 12%
71
Priority Groups as a measure of income
ENROLLMENT PRIORITY: (No data on file 29)
GROUP 1: 598 42% (50% SC or more; unemployable)
GROUP 2: 118 8% (30%-40% SC)
GROUP 3: 121 8% (ex-POWs; Purple Heart; 10-20% SC)
GROUP 4: 19 1% (Aid & Attendance; Housebound )
GROUP 5: 317 22% (NSC, non-compens. 0%SC and income <
VA Means Test)
GROUP 6: 14 1% (compensable 0%SC)
GROUP 7c: 38 3% (>VA Means Test but <Geographic
Threshold)
GROUP 8a: 7 0.5% (Noncompensable 0% service-connected
veterans enrolled as of 1/16/03)
GROUP 8c: 161 11% (NSC vets enrolled as of 1/16/03)
GROUP 8g: 3 0.01% (NSC vets applying for enrollment after
1/16/03)
72
MHV Pilot enrollees less likely to be PG
8 compared to VA
ENROLLMENT PRIORITY:
MHV VA PVAMC
GROUP 1: 598 42% 15% 22%
GROUP 2: 118 9% 7% 8%
GROUP 3: 121 9% 12% 11%
GROUP 4: 19 1% 3% 4%
GROUP 5: 317 23% 31% 33%
GROUP 6: 14 1% 3% 2%
GROUP 7c: 38 3% 0.2% 0.1%
GROUP 8a: 7 0.5% 2% 1%
GROUP 8c: 161 11% 21% 15%
GROUP 8g: 3 0.01% 4% 0.5%
73
Utilization
Did MHV Pilot enrollees
disproportionately utilize Telephone
Care or Unscheduled Walk-In Clinics?
74
Telephone and Unscheduled Visits
declined after MHV Pilot enrollment
FY prior to enrollment FY after enrollment
Telephone 2228 Telephone 2050
Care Care
Primary 2327 Primary 2501
Care Care
Unscheduled 1540 Unscheduled 1358
75
Utilization
Were MHV Pilot enrollees more likely to
keep appointments and less likely to
No-Show?
76
Utilization as measured by Clinic
Cancellation or No-Shows
77
Increase in Patient Cancellation but
also in No-Shows
TOTAL Checked Out:
Year Prior: 26383
Year After: 28860
TOTAL Patient Cancelled:
Year Prior: 3637
Year After: 4558
TOTAL Patient No Show:
Year Prior: 1632
Year After: 1995
78
Did MHV Pilot enrollees react
negatively to what they read?
Were MHV Pilot enrollees more likely to
contact the Patient Advocate?
79
Inappropriate Documentation
"Patient suffers from paranoia" "Symptoms over
"Vexatious complainant" exaggerated"
"Reads too many textbooks" "Dysfunctional family"
"Keeps a filthy house" "Munchausen type
"Alcoholic" syndrome"
"Drug abuser" "All in the mind"
"Suffers from memory lapses" "Work shy"
"Over anxious" "I don‟t believe she is
"In need of psychiatric help" mentally ill in the ordinary
"Imaginary symptoms" sense of the word"
"Not easily managed"
"Laxative abuser"
Sufferers of Iatrogenic Neglect
80
Patient Advocate Utilization
NUMBER OF VETERANS WITH AT LEAST ONE ENTRY AND
NUMBER OF VETERANS WITHOUT ENTRY
YEAR PRIOR:
At least one entry: 168
None: 1257
YEAR AFTER:
At least one entry: 150
None: 1275
TOTAL
Year Prior: 322
Year After: 277
81
Chart Review of Patient Advocate Entries
• 1 entry found “somatization?” in a Primary Care Note
offensive
• 1 entry reported MHV documented Prostate Cancer
but when staff sat down to go over MHV with him, the
report read Prostate Normal
• 1 entry indicated veteran had used MHV Feedback
option to try to get a sooner appt
• 1 entry indicated veterans ex-wife was reading his
medical records via MHV but this veteran had never
enrolled in MHV
• None of the Patient Advocate notes referenced the
content of mental health notes
82
Will expert systems provide the most
benefit to those with the least knowledge?
83
Quality Outcomes as measured by
Reminders Due Report
3/15/2005 Due 7/20/2007 Due
DIABA1C>9 30 DIABA1C>9 27
REPORT HTN REPORT HTN
>160/100 98 >160/100 66
IHD LDLC>120 3 IHD LDL-C>120 23
Influenza Influenza
Immunization 326 Immunization 417
84
Quality Outcomes as measured by
Reminders Due Report
3/15/2005 Due 7/20/2007 Due
PAP Smear 33 PAP Smear 17
Colorectal 301 Colorectal 245
Breast Cancer 26 Breast Cancer 18
85
Conclusions
• Only 1/3 of enrollees had 2 or more
downloads
• MHV Pilot enrollees disproportionately SC
with fewer PG 8s compared to all veterans
• MHV Pilot enrollees less likely to be WWII
veterans and more likely to be Vietnam
era veterans
86
Conclusions
• The unintended consequences feared as a
result of internet-based access to electronic
medical records did not materialize:
– No evidence of increased utilization of Telephone
Care, Unscheduled Clinic Visits, or Patient Advocate
Contacts
– No evidence that veterans objected to content of
Mental Health notes
• MHV Pilot status associated with decrease in
Reminders Due but this was not a controlled
study
87
Questions asked at the Markle
presentation
• Analysis of effect of MHV Pilot:
– Inverse Care Law: Are MHV Pilot enrollees healthier, younger,
and more affluent?
– Patient dissatisfaction, overreaction, and hysteria: Did MHV Pilot
enrollees disproportionately utilize Telephone Care,
Emergency Department, or voice complaints related to MHV?
– Draft Evaluation Metrics: Does access to appointments and
treatment plan affect utilization measures such as clinic
cancellations or no-shows?
– “Expert systems would provide the greatest benefit to those with
the least previous knowledge.”* Did access to information
(particularly wellness reminders) improve patient outcomes?
88
Implications
• Initial fears about MHV Pilot not supported by
data
• Veteran utilization of PHR highly variable
• Controlled studies now needed to compare
effectiveness of MHV with more traditional
modes of care delivery
• Next step is to engage specific provider clinics
to serve as intervention and control groups
89
Q&A
90
