Connected Health at the Department of Veterans Affairs

1. Connected Health at the Department of Veterans Affairs Kathleen L. Frisbee, PhDc, MPHCo-Director, Connected Health OfficeOffice of Informatics and AnalyticsVeterans 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. • 151Medical Centers • 985 Outpatient Clinics 820 Community-Based 151 Hospital-Based8 Mobile6 Independent • 300Vet Centers • 70 Mobile Vet Centers • 103 Domiciliary Residential Rehabilitation Programs • 135Community Living Centers Source: FY 2012-2013 End-of-Year Pocket Card

3. VHA Budget Summary $57.5 B $55.1 B $53.1 B $50.7 B Estimated Collections: $2.93B Advanced Appropriations: $54.6B NOTE: Table includes funding transferred to Joint VA/DoDMedical Care Special Programs in 2011 and 2012.

4. FY 2013 End-of-Year Totals Source: FY 2012-2013 End-of-Year Pocket Card 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

5. VHA’s Mission and Vision • Mission: • 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.

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

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

8. VHA’s Current Priorities Patient Aligned Care Teams (PACT) Connected Health Care Access Homelessness Mental Health Care Standardization 8

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

10. Importance of Connected Health Technologies Mobile Health Remote Monitoring 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 By 2018 mHealth is forecasted to increase by 61% to be a $26 billion market Text appointment reminders reduced no-shows by 20-90% 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

11. VA Connected Health

12. VA Telehealth Services Provided care to 608,900 patients… …amounting to 1,793,496 telehealth episodes of care

13. My HealtheVet (www.myhealth.va.gov) 107 million+ visits 2.5 million+ registered users 843,000opted-in to use Secure Messaging

14. VA Blue Button EnhancesAccess to Personal Health Information FostersPatient Engagement Supports Patient-Centered Care

15. Secure Messaging Patients and providers are able to communicate securely online through VA’s Secure Messaging accessible through My HealtheVet.

16. Patient-Centered Care VA Mobile Data Mobility VA mobile applications (Apps) deliver evidence-based tools and connections to health data and VA care teams while on-the-go.

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 17

18. SCAN-ECHO Use of videoconferencing technology to seek expertise from specialists located 100-500 miles away

19. 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)

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 HealtheVetwhen they enroll Establish delegation capability 22

23. VA Mobile Health (mHealth) 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 May2013 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 Step 3 Step 1 Step 2

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

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

46. Phase 1 – Commercial Apps

47. Phase 2 VA-Developed Apps 47

48. Phase 1 Provider Feedback

49. Phase 1 Provider Feedback

50. Phase 1 Provider Feedback