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RRP 11-241 – HSR&D Study

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RRP 11-241
A Clinic-Based Intervention to Promote Veteran Enrollment in My HealtheVet
Steven R Simon MD MPH BS
VA Boston Healthcare System Jamaica Plain Campus, Jamaica Plain, MA
Boston, MA
Funding Period: October 2011 - September 2012

BACKGROUND/RATIONALE:
Accelerating adoption of My HealtheVet (MHV), VA's web- based patient portal, is a central component of VA's vision of improving the quality of care and access to care for all Veterans. To date, low rates of MHV registration and in-person authentication (IPA) have prevented Veterans and the VA from fully realizing MHV's potential contribution to transformation.

OBJECTIVE(S):
The objectives of this study were to: (a) evaluate the primary care environment's receptivity to MHV and design a clinic-based implementation program to accelerate My HealtheVet registration and IPA; (b) pilot the clinic-based implementation program to increase MHV IPA, developed and refined through the formative evaluation; and (c) develop an operations manual to disseminate the pilot implementation program.

METHODS:
To achieve our objectives, we carried out in-depth semi-structured interviews with primary care clinic staff and key informants in VISN-1 and the Veterans/Consumer Health Informatics Office, and focus-group discussions with Veterans to identify the optimal approach to integrating MHV registration and authentication into the standard operating procedure of the primary care clinic. Using structured engineering techniques, observations of clinic staff were conducted in their usual care activities, enabling us to develop strategies for incorporating MHV enrollment and authentication more successfully into the workflow.
A multipronged intervention was deployed, encompassing education, marketing and registration support over an 8-week period at VA Boston -West Roxbury Primary Care:
1.Education: Veterans, registered but not authenticated in My HealtheVet, with scheduled Primary Care appointments were targeted in our intervention. These Veterans, as a component of their standing pre-appointment call, were informed of their status, the benefits of authenticating and asked to visit the MHV registration desk either before or after their scheduled appointment. Additionally, Veterans were reminded of the points made during the pre-appointment call at Primary Care check-in on the day of their appointment.
2.Marketing: Our initial analyses noted the need for MHV promotion among Veterans, but also medical center staff. Primary Care PACT teams were made aware of our intervention, the benefits of MHV for Veterans and Staff through by means of group presentations, in-depth interviews and provision of MHV promotional materials were implemented as components of our marketing plan.
3.Registration Support: Our formative analysis noted insufficient and inconsistent MHV support within Primary Care as well as the VA Boston as a whole. To mitigate this, our intervention provided registration support by MHV staff, Telehealth and study staff at the West Roxbury VA MHV support desk. For the length of our intervention, staff support was available for MHV registration for Veterans targeted in our intervention.

FINDINGS/RESULTS:
I. PRIMARY CARE CLINIC OBSERVATIONS: 3 researchers observed (10 hours) high variability in clinic processes surrounding MHV enrollment:
-Presence and involvement of clinical champions
-Non-standardization of MHV Documentation & descriptions of MHV

II. VETERAN FOCUS GROUPS
Authenticated , previously enrolled in MHV; 2 focus groups (N=11)
-Motivation to enroll in MHV:
o Information seeking
o Simplified process for accessing medical records
-Suggestions to improve MHV:
o Increased content
o System needs to work
-Suggestions to improve MHV enrollment
o Dedicated MHV support person

Non-Authenticated, not enrolled in MHV; 2 focus groups (N=12)
Similar to authenticated group, but had encountered obstacles enrolling
4/7 had unsuccessfully tried to authenticate
-Problems enrolling in MHV:
o Complicated enrollment procedures
o Closed office
o User-interface (account creation errors, difficulty navigating website)
-Suggested ways to promote MHV
o Play MHV video in primary care waiting area
o Dedicated MHV support person
o Do not promote in primary care, they are already busy with

III. INTERVIEWS
Key Informant Interviews (N=10)
Strategies identified for increasing MHV enrollment included:
-Education
-Marketing
-MHV Registration Support

Provider Interviews (N=4)
Factors that influence providers discussing MHV during primary care appointments
Impedes:
-Felt registering patients or MHV in general?? was a "nuisance"
- Not relevant to many of their patients
- Worried about time constraints
- Thought someone else should be helping Veterans enroll in MHV
Promotes
-MHV enhanced their practice
-Facilitated conversations with patients outside of complicated phone system

IIII. Home Based Primary Care (HBPC) Interviews
Veteran Interview (N = 15)
-Majority of home bound vets are interested in access to MHV, but haven't been exposed to information about its benefits or how to enroll
-Need for caregiver involvement in MHV on behalf of the vet
Provider Interview (N = 3)
-Social worker can assess patient's ability to use MHV and enroll patients during an initial overall assessment
-Willing to learn how to complete the IPA process
o Obviates need for Veteran to visit Medical Center for IPA
-Will need training program on MHV functionality and the enrollment process
-Provider-identified concerns about MHV:
o Patient confusion over test results
o Patient frustration with navigating MHV


IMPACT:
The barriers to and facilitators of MHV adoption have already been shared with MHV coordinators nationally and are contributing to improvements in the rate of Veteran enrollment and authentication. Upon completing final analyses of the pilot intervention, we will share those findings with the MHV coordinators and MHV program office and anticipate elements of the intervention program being disseminated widely.

PUBLICATIONS:

Conference Presentations

  1. Grochow R, Stewart M, Fix GM, McInnes DK, Boardman J, Simon SR. VA Electronic Portal: Increasing access for Veterans Receiving Home-Based Primary Care. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2012 Jun 9; Orlando, FL.


DRA: Health Systems
DRE: Technology Development and Assessment
Keywords: QUERI Implementation
MeSH Terms: none