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PPO 13-178 – HSR&D Study

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PPO 13-178
Pilot of My HealtheVet Training to Improve Co-Managed Care for Veterans
Carolyn L Turvey PhD MS
Iowa City VA Health Care System, Iowa City, IA
Iowa City, IA
Funding Period: November 2013 - October 2014

BACKGROUND/RATIONALE:
Recent studies reveal that a large portion of Veterans receiving care from the Department of Veterans Affairs (VA) also seek services outside the VA, with estimates ranging from 28-75%. Dual use will increase due to expanded non-VA care options resulting from the Patient Protection and Affordable Care Act and the more recent Veterans Access, Choice, and Accountability Act. Dual use is a concern because splitting care between two or more health systems and multiple providers may result in poor coordination of services and a loss of continuity - ultimately putting the patient at increased risk of adverse outcomes. Moreover, dual use can often lead to therapeutic or diagnostic duplication.

OBJECTIVE(S):
This study examined the effectiveness of training Veterans to use My HealtheVet (MHV) to generate a summary of their VA health care taken directly from CPRS and sharing this summary with their non-VA providers.

METHODS:
This was a pilot two-arm controlled trial where participants were randomized to receive either 1) Health Summary Training (HST) where veterans receive written and electronic training on generating and sharing their health summary OR (2) Attention Control Training (AC) on how to evaluate the validity of health information on the internet.

Veterans in both conditions were asked the date of their next medical appointment with a non-VA provider. One week before this visit, patients received provider evaluation forms that included questions about the medical visit. After the visit, patients completed a questionnaire via phone about what occurred during the visit and perceived continuity of care assessed with a modified version of Haggerty et al.'s (2012) measure. The provider forms included questions about whether or not the patient provided a VA health summary during the visit and, if so, the impact of having that information on medication management and ordering of laboratories.

VA and non-VA medical records were also obtained for the period surrounding the visit to determine the quality of medication reconciliation between providers and whether or not there was unnecessary duplication of laboratory testing. Medication reconciliation quality and unnecessary laboratory duplication were adjudicated by a Ph.D. level clinical pharmacist and a pathologist respectively.

FINDINGS/RESULTS:
Sixty-two Veterans enrolled in the study. Ten subjects withdrew prior to their non-VA medical visit and one subject was excluded from analysis. The final sample included 26 in the HST arm and 25 in the AC condition. As this is a pilot study, we initially proposed to recruit 50 veterans total, with 25 in each condition. Therefore, we reached our recruitment target.

Sample Characteristics:
The participants were 88% male, 81% married and had a mean age of 68.5 years (sd=6.1). One-third of the sample rated their health as "Fair" or "Poor". The two randomized groups did not differ on any of these variables. Of the total sample, 23 (45%) indicated they were "Not at All" or "A Little" satisfied with how their VA and non-VA providers communicated.


Effectiveness of the Training Materials:
All of the veterans in the training condition were able to generate a Health Summary of their VA care with 70% being able to do so using only the paper and online materials. Approximately half (48%) indicated that they would NOT have been able to create a Health Summary without training.

Impact of the Health Summary on the Medical Visit:
Non-VA providers for patients in the HST condition were more likely to return the evaluation form with 21 (81%) responding as compared with 12 (48%) in the AC condition. Ninety-percent of the HST patients shared their Health Summary with their provider as compared with 16% in the AC condition. Effectiveness of the training was the main study hypothesis and the group differences were highly significant (p<0.0001). Eighty percent of the providers in the HST condition indicated they would like the patient to bring this print-out to future appointments and 50% endorsed that it was new information for them. Ninety-five percent of these providers stated they had confidence in the accuracy of the information provided.

Of the providers in the HST group, 89% endorsed "Information from this health summary improved my ability to have an accurate medication list and make treatment decisions about medications". Thirty-two percent endorsed that they did not order some laboratory tests because of information available on the health summary document. When asked which information was most useful to them, providers endorsed the Medication list (47%), Laboratory Results (36%) and the Problems/Conditions (39%).

Patients in the comparison condition reported slightly lower Perceived Continuity of Care between VA and non-VA providers (Mean 2.65 (1.6) vs. 3.0 (2.2)). When asked "Did your provider seem to know what was happening with your VA care?", 24% in the AC condition endorsed "No" as compared with 11.5% in the HST condition.

Comparison of Medical Records:
A medication discrepancy metric was calculated by determining total number of medication discrepancies and dividing that by the sum of unique medications found in the combined VA and Non-VA medication lists. This produced a metric ranging from 0 (no discrepancies) to 1 (complete discordance between medical records). Estimate of discrepancy for the HST Veterans was 0.53 (sd=0.26) while that of the AC Veterans was 0.45 (sd=0.23). There were no cases of duplicate laboratories in the HST condition while there were 6 in the AC condition. Four of these 6 were deemed "Medically Justifiable" while 2 were deemed "Possibly Medically Justifiable". Unexpectedly, 10 Veterans completed laboratories one week before their non-VA medical visit per their non-VA doctors' recommendations, thereby precluding review of the Health Summary Labs before drawing. Of these, 7 were duplicate laboratories and only 2 were "Clearly Medically Justified".

IMPACT:
Veterans in the HST group were far more likely that those in the AC condition to share their VA Health Summary with their non-VA providers. Both patients and providers reported a positive impact of sharing this summary. Providers reported the information in the summary helped them to manage veteran medications better and prevented unnecessary duplication. Review of the medical record suggests modest impact on laboratory duplication but did not reveal an impact on medication discrepancies. Training Veterans to use My HealtheVet to share their health information with non-VA providers improves the coordination of care between VA and non-VA providers.

PUBLICATIONS:

Journal Articles

  1. Witry M, Klein D, Alexander B, Franciscus C, Turvey C. Medication List Discrepancies and Therapeutic Duplications Among Dual Use Veterans. Federal practitioner : for the health care professionals of the VA, DoD, and PHS. 2016 Sep 1; 33(9):14-20.
  2. Turvey CL, Klein DM, Witry M, Klutts JS, Hill EL, Alexander B, Nazi KM. Patient Education for Consumer-Mediated HIE. A Pilot Randomized Controlled Trial of the Department of Veterans Affairs Blue Button. Applied clinical informatics. 2016 Aug 3; 7(3):765-76.
Conference Presentations

  1. Witry M, Klein DM, Suiter N, Pham K, Turvey CL. Medication list discrepancies and therapeutic duplications among Veterans using both VA and non-VA clinics. Poster session presented at: American Pharmacists Association Annual Meeting; 2015 Mar 27; San Diego, CA.


DRA: Health Systems
DRE: Technology Development and Assessment, Diagnosis
Keywords: Care Coordination, Care Management Tools, Decision Support, Ethnicity/Race, Information Management, Personal Health Record
MeSH Terms: none

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