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2019 HSR&D/QUERI National Conference Abstract

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4124 — Improving discrepancies between VA national databases and local understandings of service provision: Implications for research of new VA initiatives

Lead/Presenter: Rendelle Bolton,  COIN - Bedford/Boston
All Authors: Bolton RE ((Center for Evaluating Patient-Centered Care in VA, Center for Healthcare Organization and Implementation Research; Brandeis University Heller School)), Hyde, J (Center for Evaluating Patient-Centered Care in VA; Center for Healthcare Organization and Implementation Research; Boston University School of Public Health), Dryden, E (Center for Evaluating Patient-Centered Care in VA; Center for Healthcare Organization and Implementation Research) Dvorin, K (Center for Evaluating Patient-Centered Care in VA; Center for Healthcare Organization and Implementation Research) Wu, J (Center for Evaluating Patient-Centered Care in VA; Center for Healthcare Organization and Implementation Research) Zeliadt, S (Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care; University of Washington School of Public Health) Bokhour, BG (Center for Evaluating Patient-Centered Care in VA; Center for Healthcare Organization and Implementation Research; Boston University School of Public Health)

Objectives:
Health services researchers routinely rely on national databases constructed from electronic health and billing records to study healthcare cost, utilization, and outcomes. As new initiatives like Whole Health (WH) are adopted in VA, high quality data captured in national databases is critical for understanding implementation and effectiveness. As part of a large mixed-methods evaluation of WH implementation, we examined how 18 WH Flagship sites documented WH services, guided by national protocols.

Methods:
We used audit-feedback methodology in concert with a larger implementation evaluation to inform improvements in data capture and coding. This methodology was selected based on observed gaps in consistent data capture identified during quarterly semi-structured interviews and site surveys of implementation progress. Each site provided a comprehensive list of coding practices for all WH services using a structured template. We used a content analysis to examine this data within and between sites. Lists were also compared to WH encounters documented in national databases. Follow-up interviews clarified discrepancies and explored coding/documentation barriers. Constant comparison facilitated identification of variation and challenges in data capture across sites and common barriers experienced. Results were shared with sites and VA operational partners responsible for issuing national guidance.

Results:
We identified discrepancies between sites' understanding of local WH service provision and data captured nationally; national databases did not reflect the amount of WH provided. We found substantial variation in WH service coding/documentation within and between sites: (1) similar activities were coded differently; (2) different activities were coded similarly; and (3) variation depended on service location/provider. Common barriers to consistent coding included varied conceptualizations of "what counts" as WH; discrepancies in national rules for data capture; legacy coding; limited coordination; and concerns with workload credit.

Implications:
Despite national guidance, sites faced numerous local challenges that impacted consistent coding of WH services. Findings suggest that establishment of guidance needs to be paired with monitoring and local problem solving to improve consistency.

Impacts:
Implementation of new services requires consistency in coding and documentation in order to maximize the ability to capture how, when and to whom services are provided. Implementation studies can help identify discrepancies and inconsistencies that affect research outcomes.