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Response to Commentary

Connected Health

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.

Ongoing HSR&D and QUERI Research

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.

Framework to Guide Future Research

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.

References

1. Friedman, C.P. "A 'Fundamental Theorem' of Biomedical Informatics," Journal of the American Medical Informatics Association 2009; 16(2):169-70.
2. 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.
3. 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.