1. 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

2. 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 Community-Based Hospital-Based Mobile Independent
300 Vet Centers
ID:07
Created for VHA Overview Version 1.6/13/2011
Updated 1/9/2013 to reflect FY th Quarter pocket card:
(rounded to nearest tenths place)
70 Mobile Vet Centers
103 Domiciliary Residential Rehabilitation Programs
135 Community Living Centers
Source: FY End-of-Year Pocket Card

3. 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.

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

5. 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

6. 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

7. 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.

8. 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

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

10. 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%

11. 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

12. 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 % 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

13. 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

14. 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.

15. 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.

16. 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

17. 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

18. SCAN-ECHO
Use of videoconferencing technology to seek expertise from specialists located 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.

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

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

21. 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

22. 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

23. VA Mobile Health (mHealth)23

24. 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

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

26. VA Mobile Architecture

27. Patient Generated Data (PGD)

28. How to Summarize PGD Data

29. Mobile Development Lifecycle

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

31. VA Mobile Health Veteran Apps
Veteran-Facing Apps

32. 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

33. 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

34. 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

35. VA Launchpad

36. 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

37. 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

38. 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.

39. 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.”

40. High Level Process for Messaging in Annie
Clinical Staff: Creates a Protocol and sends document via 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

41. 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

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

43. 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

44. 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

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

46. Phase 1 – Commercial Apps

47. Phase 2 VA-Developed Apps47

48. Phase 1 Provider Feedback

49. Phase 1 Provider Feedback

50. Phase 1 Provider Feedback

51. Phase 1 Provider Feedback

52. Phase 1 Provider Feedback

53. Phase 1 Provider Feedback

54. 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

55. 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
Neil C. Evans, MD Co-Director (Clinical Lead) Connected Health Office, Office of Informatics and Analytics
VA Mobile Health Website