Electronic health information exchange (HIE) holds promise to improve quality of care for patients receiving care in multiple sites, and to improve outcomes associated with care handoffs and transfers. Among older veterans who also have Medicare coverage, 42.6% have been reported to use both VA and Medicare services, representing approximately 1 million veterans. Cross-site and cross-system service utilization results in test duplication, medication prescribing errors, and adverse events that lead to worse health outcomes and excess hospital utilization. In response to these observations, the VA initiated the Virtual Lifetime Electronic Record (VLER) program to implement HIE between VA and non-VA providers, and currently 29 non-VA partner sites exchange care summaries between non-VA and VA systems. HIE also has the potential to impact care through encounter notifications that enable VA providers to respond in a timely fashion to events they might otherwise be unaware of. Specifically, notification of a non-VA hospital admission or emergency department (ED) visit could provide a VA provider or team an opportunity schedule VA follow-up, perform medication reconciliation, and address post-acute health issues that might prevent future VA or non-VA hospital utilization. While the VLER program has not yet implemented or tested this alerting capability, such notifications are developing outside the VA in support of Accountable Care Organizations (ACOs) .
The overall objective of this study is to examine the impact of VA provider notification when older veterans utilize non-VA inpatient or ED services, and to compare approaches to responding to this notification. Developments that support the feasibility of this study at the proposed sites, Bronx and Indianapolis, are: 1) each VA medical center's relationship with a well-functioning regional health information-exchange organization (RHIO) that can provide real-time notification of non-VA encounters, and 2) each VA's experience with short-term, geriatric care transitions programs that provide services that have been shown to be effective in preventing adverse events and hospital readmission after hospital discharge.
The overall objective of this project is to examine the effectiveness, cost, and implementation acceptance of VA provider notification of non-VA hospitalization or emergency department (ED) visit using electronic health information exchange (HIE), with or without provision of evidence-based post-hospital transitional care services. Specific Aim 1 is to examine the impact of these approaches on preventing hospital admission or readmission as the primary outcome, and, as secondary outcomes, increasing provider follow-up, improving patient's condition self-knowledge, and preventing medication errors after discharge. Specific Aim 2 is to examine the effect of these approaches on VA and non-VA costs. Specific Aim 3 is to examine the acceptance of these approaches among VA and non-VA stakeholders.
This is a mixed methods study. For Aim 1 we will conduct a trial in which notifications of non-VA hospital admissions and ED visits for older veteran participants will be communicated to their VA PACT providers in the Bronx and Indianapolis from the local Regional Health Information Organizations (RHIOs). In addition for Aim 1, enrolled veterans will be cluster-randomized by PACT to receive a geriatric post-hospital care transitions intervention n=233 or notification-alone n=233. We will compare effects on hospital admission and readmission 90 days after discharge, VA provider follow-up, patient's condition self-knowledge, and medication discrepancies after discharge, using data obtained from record review, interview, and warehouse sources. For Aim 2 we will compare effects on VA and non-VA costs using VA administrative data and RHIO service use data. For Aim 3 we will conduct interviews with stakeholders, including veteran participants, and examine implementation barriers and facilitators to the notification and coordination interventions at the two sites.
As of January 3, 2018, we have recruited 425 participants (198 in Bronx and 227 in Indianapolis) of a projected number (as of this date) of 444. We expect recruitment to be completed in Q3-Q4 of project year 4. A challenge/delay we have experienced is fewer non-VA encounters than projected but that number has accelerated over the past 6 months.
We performed an interim analysis of responses to the baseline veteran questionnaire. This questionnaire asked the veterans: "What are your reasons for using both VA and non-VA doctors/hospitals?" Responses were coded independently by two reviewers into themes, which were then categorized into an established conceptual framework of access. This framework included five components: availability (supply, specialty care); accessibility (distance, emergency services); accommodation (organization, wait-time); affordability; and acceptability (relationship, second opinion). Among veterans completing the baseline questionnaire (N=164), acceptability (44.5%) and accessibility (37.8%) were the most frequently mentioned components. With worse self-report health status, accessibility became the most frequently mentioned component and demonstrated the greatest variation (Fair/Poor, 47.2% vs. Excellent/very good, 25%). Within accessibility, veterans with fair/poor health status mentioned emergency care (55.9%) and distance (47.9%) most commonly, favoring non-VA care (64.0%). Some illustrative quotes were: "Traveling is the main reason. I can't handle it anymore" and "Emergency, [it's] more convenient. Doctors/hospitals are about 1 block away. I can walk." The implication of these results is that, while greater choice and closer alternatives may provide more convenient care, the VA should consider the barriers of distance in urban settings for aging veterans with declining health status. The integration of transportation services, telemedicine technologies, or improving communication with closer non-VA care may provide better continuity and coordination for aging and sicker urban-dwelling veterans.
This study will produce information on the effectiveness, cost, safety, and implementation of VA provider notification of non-VA hospital admission or ED visit followed by a post-hospital geriatrics coordination intervention, as compared to notification alone. Findings from this research will inform VA's approach to improving service delivery for older veterans and inform its approach to implementing HIE alerts to VA providers as its HIE capabilities expand.
- Dixon BE, Schwartzkopf AL, Guerrero VM, May J, Koufacos NS, Bean AM, Penrod JD, Schubert CC, Boockvar KS. Regional data exchange to improve care for veterans after non-VA hospitalization: a randomized controlled trial. BMC medical informatics and decision making. 2019 Jul 4; 19(1):125.
- Dixon BE, Boockvar KS. Event Notification in Support of Population Health: The Promise and Challenges from a Randomized Controlled Trial. Studies in health technology and informatics. 2017 Jan 1; 245:1357.
HSR&D or QUERI Articles
- Boockvar KS, Peters JJ, Dixon BE. Health Information Exchange Holds Potential to Benefit Veterans. HSR&D FORUM: Translating Research into Quality Healthcare for Veterans. 2018 Dec 1; 2018(Winter): 7-8.