» Back to Table of Contents
Recent legislation such as the Veterans
Access, Accountability and Choice Act
of 2014, signals that VA will increasingly
act as a purchaser of healthcare. Even
before enactment of the Choice Act, dual
use—when Veterans seek care from both
VA and community providers—was
prevalent, with estimates ranging from 30
to 75 percent. Historically, the majority
of dual use of healthcare services in the
community occurred among Veterans
who were also eligible for Medicare.
Looking ahead, dual use is expected to
grow as more Vietnam War era Veterans
become eligible for Medicare, and as
federal legislation continues to expand
Veterans' options for receiving care in
the community. As VA increases its
investment in providing Veterans with
greater access to care in the community,
more exploration of the complex
determinates, processes, and outcomes of
dual use is needed.
Since 2012, our team has been studying
communication between VA and community
providers. Initially, we conducted
qualitative interviews with Veterans, community
providers who treat Veterans, and
VA providers. Of these groups, community
providers expressed by far the most
frustration with communication during
care transitions. One community provider
stated, "With VA, we get nothing...[when]
we need something we have to call the VA
or have the patient acquire it...nothing is
ever sent automatically from the VA...and
most of the time I don't even know that
they see the VA...I don't know they're a
VA patient."
This quote illustrates several common
themes that emerged from our interviews:
1) poor communication; 2) no systematic
identification of patients who receive both
VA and in-the-community care; and 3)
reliance on patients to communicate with
community providers about healthcare
received at VA and vice versa.
My HealtheVet, VA's patient portal, allows
Veterans to download a summary of their
VA health information using the Blue Button
feature. The VA Health Summary, also
known as a Continuity of Care Document
(CCD) includes their recent medication
list, problem list, laboratory results, and allergies,
as well as other health information
extracted from their VA electronic health
record.
An online survey of 14,000 My HealtheVet
users confirmed a high level of dual use
among Blue Button users (44 percent) and
validated qualitative interview findings that
Veterans are primarily responsible for exchanging
health information between VA
and community providers. A pilot study
tested the impact of training Veterans to
use the Blue Button feature to generate and
share a copy of their VA Health Summary.
Of these trainees, 90 percent shared their
summary with their community provider.
When these Veterans shared their VA
Health Summary with their community
providers, 90 percent of the providers said
it improved their ability to manage the
Veterans' medications, and 32 percent of
the providers determined that they did not
need to order some laboratory tests because
they had access to the needed information
in the VA Health Summary. A larger nationwide
quality improvement pilot of 600+
Veteran trainees, funded by the VA Office
of Rural Health, found similar positive results
in terms of Veteran and community
provider satisfaction.
We are now building on this focused intervention
to address broader issues in
communication between VA and community
providers. In this study, we are
training Veterans: 1) to use both their VA
and non-VA patient portals to engage in a
bi-directional exchange of health information
between VA and community providers;
and 2) to enroll in the Veterans Health
Information Exchange, or Virtual Lifetime
Electronic Record (VLER) program if they
choose. We are also educating community
providers about VA health information
exchange and care coordination using a
"co-management toolkit." Finally, we are
asking Veterans to develop a list of all
their VA and community providers and to
indicate what roles they believe each provider
plays on their health team. Primary
outcomes are Veteran and provider satisfaction
as well as care quality indicators,
such as medication list concordance and
reduction in duplicate laboratories.
VA needs a more integrated process where
operational leadership, clinicians, and
health informaticists work closely together
to develop a unified care coordination system.
Such an effort may require focusing
on one or two information technologies
and consolidating VA care coordination
programs. However, over time this would
promote greater VA provider engagement,
improve information sharing processes,
and ultimately provide dual use Veterans
with highly-coordinated quality care.
1. Turvey C, et al. "Blue Button Use by Patients to Access
and Share Health Record Information Using
the Department of Veterans Affairs' Online Patient
Portal," Journal American Medical Informatics Association
2014; 21(4): 657-63.
2. Klein DM, et al. "Use of the Blue Button Online Tool
for Sharing Health Information: Qualitative Interviews
with Patients and Providers," Journal of Medical
Internet Research 2015; 17(8): e199.
|