Connected Health at the Department of Veterans Affairs Kathleen L. Frisbee, PhDc, MPH Co-Director, Connected Health Office Office 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. 151 Medical Centers 985 Outpatient Clinics 820 Community-Based 151 Hospital-Based 8 Mobile 6 Independent 300 Vet Centers ID:07 Created for VHA Overview Version 1.6/13/2011 Updated 1/9/2013 to reflect FY 2013 4th Quarter pocket card: http://vaww.va.gov/VHAOPP/vast3.asp (rounded to nearest tenths place) 70 Mobile Vet Centers 103 Domiciliary Residential Rehabilitation Programs 135 Community Living Centers Source: FY 2012-2013 End-of-Year Pocket Card

Estimated Collections: Advanced Appropriations: VHA Budget Summary $55.1 B $57.5 B $53.1 B $50.7 B Estimated Collections: $2.93B Advanced Appropriations: $54.6B ID:08 Created for VHA Overview Version 10/07/2011 Updated 12/19/13 with info from 10A3 NOTE: Table includes funding transferred to Joint VA/DoD Medical Care Special Programs in 2011 and 2012.

FY 2013 End-of-Year Totals Enrollees………………………………………………………………......8.9 Million Unique Patients Treated…………………………………............6.5 Million Outpatient Visits………………………………………................86.4 Million Outpatient Surgeries…………………………………………………..….292,600 Inpatient Admissions…………………………………………….……….694,700 Lab Tests (Inpatient & Outpatient)………………………….…266 Million Prescriptions Dispensed (30-Day Equivalent)……......268.6 Million Prosthetics Services Performed……………………..………..15.9 Million ID:09 Created for VHA Overview Version 1.7/18/2011 Updated 1/9/2013 to reflect FY 2013 4th Quarter pocket card: http://vaww.va.gov/VHAOPP/vast3.asp (rounded to nearest tenths place) Source: FY 2012-2013 End-of-Year Pocket Card

VHA’s Mission and Vision Honor America’s Veterans by providing exceptional health care that improves their health and well-being. 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. ID:24 Created 11/4/13

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: Provide Veterans personalized, proactive, patient-driven health care Achieve measureable improvements in health outcomes Align resources to deliver sustained value to Veterans ID:26 Created by LGaegler on 9/30/13

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 ID:12 Created for VHA Overview Version 1.6/13/2011 Updated 11/05/13 with FY13 data from HTM.

VHA’s Current Priorities Patient Aligned Care Teams (PACT) Connected Health Care Access Homelessness Mental Health Care Standardization ID:27 Created by LGaegler on 9/30/13 8

VA Connected Health Aligning virtual care technologies to create a seamless, unified experience for Veterans 9

Importance of Connected Health Technologies Remote Monitoring Mobile Health 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 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%

Estimated Veterans Served in 2013 VA Connected Health 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 2,487,000 Blue Button 881,000 Secure Messaging 2008 795,000 Veteran Mobile Apps 2013 Field testing Staff Mobile Apps Veteran Point of Service Kiosks >4M transactions

VA Telehealth Services Provided care to 608,900 patients… …amounting to 1,793,496 telehealth episodes of care Home Telehealth (HT) Care and case management of chronic conditions and provision of non-institutional care support to patients. Uses in-home and mobile technologies to manage diabetes, chronic heart failure, hypertension, obesity , head injury, depression, etc. Store and Forward Telehealth (SFT) TeleRetinal Imaging, TeleDermatology, TeleWound Care, TeleSpirometry, Tele-Sleep Studies TeleCardiology. Clinical Video Telehealth (CVT) Real-time video consultation that covers 44 clinical specialties including: Tele-Intensive Care, TeleMental Health, TeleCardiology, TeleNeurology, TeleSurgery, Women’s Telehealth, Tele-Primary Care, TeleSCI care, TeleAmputation Care, TeleAudiology, Remote Nursing Home Consultation, TelePathology, etc. Forty-five percent of these patients lived in rural areas, and may otherwise have had limited access to VA health care; the number of Veterans receiving care via VA’s telehealth services is growing approximately 22% annually. In FY2013, 144,520 Veterans enrolled for VA home telehealth services, 41,430 of those patients were supported by Home Telehealth to live independently in their own homes, patients who otherwise would have needed long-term institutional care. Recognized as an international leader in telehealth development/implementation Provided care from 151 VA Medical Centers (VAMCs) and over 705 Community Based Outpatient Clinics (CBOCs) to 608,900 patients…amounting to 1,793,496 telehealth episodes of care Reductions in Utilization FY 2012 Home Telehealth - reduces bed days of care – 58% Home Telehealth – reduces hospital admissions – 38% Clinical Video Telehealth – reduces bed days of care 56% for mental health care Patient Satisfaction Home Telehealth - 85% mean score Store-and-Forward Telehealth –96% mean score Clinical Video Telehealth - 93% mean score Travel Reduction Savings Clinical Video Telehealth – $34.45 per consultation Store and Forward Telehealth - $38.81 per consultation Home Telehealth Savings $1,999 per annum per patient Reductions and Satisfaction data from FY12 Telehealth Services’ Report Card In FY12, for 1,439 TMH patients, There was a 30% reduction in admissions in home telemental health in their first six months of care when reviewed to a comparative period of time before enrollment.  This resulted in a 56% reduction (-3,026 days) bed days of care (BDOC). Source routine VA HT outcome data.  Travel reductions savings and HT savings calculated by ARC

My HealtheVet (www.myhealth.va.gov) 107 million+ visits 2.5 million+ registered users 843,000 opted-in to use Secure Messaging Veteran’s Personal Health Record Self-Service Prescription Refill Access to Labs, Appointments and Secure Messaging Ability to download Physician Notes and other content from EHR More than 107 million visits Over 2.5 million registered users More than 1.3 million users have a Premium (authenticated) account Over 47.3 million VA prescription refills since August 2005 More than 918,000 unique VA Blue Button users since August 2010 More than 5.2 million VA Blue Button file downloads More than 843,000 VA patients opted in to use Secure Messaging

VA Blue Button Enhances Access to Personal Health Information Fosters Patient Engagement Supports Patient-Centered Care Enhances Veteran access to personal health information from the VA Electronic Health Record and other key data sources Fosters patient engagement Encourages activation Supports patient-centered care As of FY 2013, more than 880,000 users. Established in 2010.

Secure Messaging Veterans served in FY2013: 801,849 In FY 2013, VA expanded its use of Secure Messaging in: Primary Care Specialty Care Surgical Care In FY 2013, VA launched Secure Messaging in: Mental Health Dentistry Rehabilitation Prosthetic Services Patients and providers are able to communicate securely online through VA’s Secure Messaging accessible through My HealtheVet.

Patient-Centered Care VA Mobile VA Mobile aims to improve the health of Veterans by expanding care beyond traditional settings. VA mobile applications (Apps) deliver evidence-based tools and connections to health data and VA care teams while on-the-go. Patient-Centered Care: Providing Veterans with additional opportunities to become active partners in their health care. Data Mobility: Providing opportunities for VA’s health care teams to more easily engage with and empower Veterans and Caregivers in the management of their health and well-being. Pilot programs are used to evaluate how Apps increase convenient access to health care, improve patient engagement and strengthen communication among Veterans, Caregivers and VA clinicians. The Apps support a range of health care management tools, facilitate day-to-day administrative tasks and expand education and communication. Pilot programs allow VA to gather user feedback, allowing for corrections and enhancements. For more information, visit mobilehealth.va.gov. VA mobile applications (Apps) deliver evidence-based tools and connections to health data and VA care teams while on-the-go. Patient-Centered Care Data Mobility

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 Empower Veterans to have more control over their personal and medical information and gives them the capability to ensure their information is current and accurate. Allow Veterans to view upcoming appointments, update personal information, review insurance information and check their account balances. Increase convenience and improve the check-in process. In FY2013, 4 million+ transactions; established in 2010 17

SCAN-ECHO Use of videoconferencing technology to seek expertise from specialists located 100-500 miles away Scan-Echo: Specialty Care Access Networks-Extension for Community Healthcare Outcomes In many rural and remote areas, Veterans and their primary care providers do not have easy access to specialty care services and expertise. VA is using video teleconferencing to increase access to specialty care for Veterans in rural and medically underserved areas. SCAN-ECHO links several primary care providers, many of whom are in different rural communities, simultaneously enabling rural primary care clinicians to gain the knowledge needed to provide care that was not previously available in their communities. It also enables Veterans with chronic conditions requiring complex care to get the medical care they need. In FY 2013, SCAN-ECHO served more than 1,600 Veterans.

My HealtheVet – VA’s Personal Health Record Secure Email with Providers Download Health Data (Blue Button) Health Education Library Refill Prescriptions View Appointments Enter Patient Generated Data (PGD)

Growth in My HealtheVet Adoption by VA Patients Registered Users (38.9%) Premium Users (26.8%) Secure Messaging (16.4%)

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 month Kaiser 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 hosting Redesign of interface based on Veteran feedback Refocus on doing high demand functions well Consolidate PGD with PGD data from other applications (e.g., mobile) and allow providers to view Create the same experience across My HealtheVet and Mobile Apps Expand to use other established credentialing systems Allow online proofing Sign up Veterans for My HealtheVet when they enroll Establish delegation capability 22

VA Mobile Health (mHealth) 23

Foundation Building Mobile Apps Development/Production Environment Mobile Architecture Mobile Device Management Software Mobile Governance Mobile Certification Process Mobile Branding Veteran App Library Patient Generated Data Architecture and Policies Mobile Device Support Contract

Mobile Application Environment Standardizing Apps and their development; Reducing Costs Common Dev Tools Common Services and Software Library Environments: Development Integration Pre-Prod Production

VA Mobile Architecture

Patient Generated Data (PGD)

How to Summarize PGD Data

Mobile Development Lifecycle

VA-DoD Stand Alone Apps VA Mental Health Apps Available on iTunes Apps are native and do not connect to the VA network.

VA Mobile Health Veteran Apps Veteran-Facing Apps

Veteran-Facing VA Mobile Apps In Field Testing Family Caregiver Suite of Apps Veteran Appointment Request My Story Soon-to-be Released Summary of Care Mobile Blue Button VA Launchpad

VA Family Caregiver Mobile Health Pilot Timeline 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 Mailing to 4,000+ Caregivers August 2012 1,200 Caregivers Responded “Yes” September 2012 Mailing to Notify of Selection, Request Loaner Agreement, Invite into Study November 2012 May 2013 Distribute 800+ iPads

Family Caregiver Suite of Apps Pain Coach – Supports pain management Care4Caregiver – Supports Caregiver stress Journal – Allows for the recording of vitals, exercise, meals, contacts RxRefill – Assists with refilling VA prescriptions Summary of Care – Displays data from electronic health record (EHR) PTSD Coach – Supports PTSD management Health Advocate – Allows Veteran to designate a health advocate Health Assessment – Provides Veteran with a convenient way to take various health self-assessments Notifications and Reminders – Sets medication reminders and receive notifications from VA care team

VA Launchpad

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

Veteran-Facing Mobile Apps in Development Text Messaging Program (Annie) Patient Personal Health Plan Women’s Health Mission Health (Gaming App) Wellness Check (Bio-surveillance Reporting) Pre-Visit Agenda and Post-Visit Plan Cardiac Rehabilitation Chronic Kidney Disease VA Benefits App 37

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.

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.”

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

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

VA Mobile Health Staff Apps Health Care Team-Facing Apps 42

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 43

VA Mobile Health Provider Pilot Sites Initial Pilot Sites: Nashville Orlando Washington, DC Pilot Sites: Pittsburgh Denver Seattle St. Cloud Las Vegas Miami Martinsburg White River Junction Columbus, Ohio Potential five additional sites: Palo Alto Albuquerque Durham Tomah Cheyenne

VA Mobile Health Provider Program March 2014 distribution at Washington, DC VAMC

Phase 1 – Commercial Apps

Phase 2 VA-Developed Apps 47

Phase 1 Provider Feedback

Phase 1 Provider Feedback

Phase 1 Provider Feedback

Phase 1 Provider Feedback

Phase 1 Provider Feedback

Phase 1 Provider Feedback

VA Health Care Team-Facing Apps in Development Patient Viewer (Data Review, Note Entry, Order Entry) Immunization Warfarin Monitoring VA Mobile Imaging Caring for Women Vets Pre-Conception Care Pregnancy Chronic Kidney Disease Safe Women Prescribing Maternity Care Coordinator Scheduling Calendar View Secure Messaging Joint VA-DOD Patient Viewer Launchpad Mobile ECG Viewer

Contact Information Kathleen L. Frisbee, PhDc, MPH Co-Director (Program Lead) Connected Health Office, Office of Informatics and Analytics Department of Veterans Affairs Washington, D.C., USA Kathleen.Frisbee@va.gov Neil C. Evans, MD Co-Director (Clinical Lead) Connected Health Office, Office of Informatics and Analytics Neil.Evans@va.gov VA Mobile Health Website http://mobilehealth.va.gov