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Connected health technologies, or virtual care, constitute a new "Model of Care" for augmenting efficient, safe, high-quality, continuous, coordinated
delivery of evidence-based services to Veterans and families. In the prior sentence, "augmenting" is an important word. Connected health must not be viewed
as a replacement for current high-quality care, but follows instead from the fundamental theorem of informatics: a person or teams (including health care
providers, Veterans, and informal caregivers) working in partnership with a supportive technology or information resource is "better" than unassisted individuals working alone.1 As with health informatics, a parent discipline, connected health is more about people, workflow, and the interactions
between people than it is about the specific technology itself.
Considerable research related to connected health, funded by HSR&D and QUERI, is underway. Example projects extend from observational analyses related
to connected health implementation and efficiency, to implementation research initiatives testing the potential use of existing technologies. Like other
health care systems across the nation, VA is committed to understanding the
implications of connected health technologies for cost and value. Recognizing the need for evidence, VA investigators conducted a retrospective cohort
study of 132 VA facilities that were implementing patient-to-clinicalteam secure messaging in primary care. The study revealed that higher secure
messaging use was associated with lower urgent care utilization rates; early adopters of secure messaging achieved a greater decrease in urgent care
utilization over time than later adopters (-20 urgent care visits per 1,000 patients per month).2 Although these findings need
replication, identification of potential return on investment (i.e., reduction in unnecessary urgent care) is critical to driving future connected health implementation.
Further, in an ongoing QUERI Service-Directed Project (SDP 12-258), VA investigators are evaluating the potential of proactive, previsit secure messaging. After training patient aligned care teams in the potential of pre-visit planning to support patient engagement and effective doctor-patient communication, secure messages are being sent to Veterans
to encourage them to plan for their visit and reply to the message with "three things" they would like to talk to their health care provider about during their upcoming appointment.
The investigators are evaluating the impact of an external implementation program on adopting the practice of pre-visit secure messaging in a randomized stepped wedge implementation trial. A review of HSR&D and QUERI databases reveals a variety of other projects related to connected health, including several that advance the basic science of health informatics through efforts to mine clinical data and provide patient-centered decision support (HIR 09-005, Qing Zeng).
Importantly, connected health should not be viewed as focused solely on Veterans. As noted in the commentary by Evans and Frisbee, codirectors of the Connected Health Office, in
its ideal state, connected health is bi-directional and involves both Veterans and the teams of professionals providing VA health care. All technologies that connect with our Veterans have reciprocal repercussions for health care providers and the clinical system, some intended and positive, some unintended and negative. Research
in this area must consider the perspectives and experiences of all stakeholders: Veterans, their families, their health care providers, and broader health care systems.
Studies should also be designed to detect potential
positive effects on health care and health,
and also the unintended consequences of these
technologies. VA investigators have published
a new eight-dimensional sociotechnical model
specifically designed to address the challenges
involved in design, development, implementation,
use, and evaluation of information technology
(such as connected health) within complex
adaptive health care systems.3 Highlighting the
interdependent factors that influence connected
health, this sociotechnical model is being used
to guide a project recently funded by QUERI.
Dr. Stephanie Shimada is principal investigator
of this rapid response project titled, "Developing
a Taxonomy of Unintended Consequences of
eHealth Implementation." This ground-breaking
pre-implementation project hopes to lay a framework
to guide future research initiatives.
Technologies are currently reshaping the experience
and practice of health care as much as they
have in finance, commerce, and other sectors
of the economy. In approaching this exciting
transformation, VA scientists must balance
understanding of connected health from the
patient and from the health care system perspectives.
We must also be mindful of the duality of
positive effects and possible unintended consequences.
The commentary also addresses the
important issue of equity. As we implement connected
health strategies, we must avoid health
care disparities—and encourage approaches
that will ensure adoption of connected health
by all Veterans. Challenges, both new and those
yet to be identified, may emerge as health care
systems attempt to pursue connected health as
a model for augmenting efficient, safe, highquality,
continuous, and coordinated health care.
VA HSR&D and QUERI programs have begun
and must continue to lead the way in researching
these promising technologies.
- Friedman, C.P. "A 'Fundamental Theorem' of Biomedical
Informatics," Journal of the American Medical Informatics Association
- Shimada, S.L. et al. "Patient-provider Secure Messaging in
VA: Variations in Adoption and Association with Urgent
Care Utilization," Medical Care 2013; 51(3 Suppl 1):S21-8.
- Sittig, D.F. and H. Singh. "A New Sociotechnical Model
for Studying Health Information Technology in Complex
Adaptive Healthcare Systems," Quality & Safety in
Health Care 2010; 19 Suppl 3:i68-74.