My HealtheVet MHV

1
My HealtheVet (MHV) 127 Improve Healthcare
and Cost Outcomes

• David M. Douglas MD
• Belinda Dalton

2
Agenda

• Introduction and Literature review
• Review MHV and MHV Pilot
• Study design
• Outcomes
• Implications
• QA

3
Consumer Health Informatics

• Consumer Health Informatics is the branch of
  medical informatics that
• analyses consumers' needs for information
• studies and implements methods of making
  information accessible to consumers and
• models and integrates consumers' preferences into
  medical information systems.
• Medical Informatics initially focused on
  providers and institutions then applied same
  principles to consumers
• Expert systems would provide the greatest
  benefit to those with the least previous
  knowledge.

Eysenbach BMJ 2000
4
What is a Personal Health Record?

• The Personal Health Record (PHR) is an
  Internet-based set of tools that allows people to
  access and coordinate their lifelong health
  information.
• People can use their PHR as a communications hub
  to send email to doctors, transfer information to
  specialists, receive test results and access
  online self-help tools.
• PHR connects each of us to the incredible
  potential of modern health care and gives us
  control over our own information.

• Markle Foundation

5
Why deliver health care interventions over the
Internet?

• Reducing cost and increasing convenience for
  users
• Reduction of health service costs
• Reduction of isolation of users
• The need for timely information
• Reduction of stigma
• Increased user and supplier control of the
  intervention

• Griffiths, et al (J Med Internet Res
  20068(2)e10)

6
Why deliver health care interventions over the
Internet?

• Possible drawbacks
• Potential for reinforcing the problems the
  intervention was designed to help
• May overcome isolation of time, mobility, and
  geography, but may be no substitute for
  face-to-face contact
• Future evaluation
• Incorporate the cost not just to the health
  service, but also to users and their social
  networks
• Be alert to unintended effects of Internet
  delivery of health interventions, and include a
  comparison with more traditional modes of delivery

• Griffiths, et al (J Med Internet Res
  20068(2)e10)

7
Existing literature on PHR evaluation is scant

• Cintron, et al - J Palliat Med. 2006 Dec9(6)
  1320-8. The effect of a web-based,
  patient-directed intervention on knowledge,
  discussion, and completion of a health care
  proxy. Intervention did not increase patient
  completion of HCP but improved knowledge.
• Wang, et al - IEEE Trans Inf Technol Biomed. 2004
  Sep8(3) 287-97. Personal health information
  management system and its application in referral
  management. Patients and providers reported
  enhanced communication via PHR.

8
Existing literature on PHR evaluation is scant

• Ross et al - J Med Internet Res. 2004 May
  146(2) e12. Providing a web-based online
  medical record with electronic communication
  capabilities to patients with congestive heart
  failure randomized trial. Access to online
  medical record for CHF patients was feasible and
  improved adherence.
• Kim et al - Conf Proc IEEE Eng Med Biol Soc.
  20045 3159-62. Application and evaluation of
  personal health information management system.
  Providers satisfied with the content of patients
  personal health information and used it for
  triage of referrals.

9
VA is in midst of large scale deployment and
evaluation of PHR

• My HealtheVet
• MHV Pilot

10
My HealtheVet
11
My HealtheVet
12
My HealtheVet National Program
More than 437,330 Registered Users

• Online Prescription Refills
• Health Education Information
• Self-assessment Tools
• Health Journals and eLogs
• Veteran Specific Conditions
• Seasonal Health Reminders
• Wellness Calendar
• One stop Benefits/Services
• And More

Incremental releases of new features VistA EHR ?
Secure Messaging ? Delegation
13
Registered Patients My HealtheVet - National

• 437,330 registered
• 11,210,482 visits by June 31, 2007
• 3,328,153 Rx refilled online since August 31, 2005

14
My HealtheVet UsageTotal Registrants
Over 11,200,000 visits to the My HealtheVet
website (12/2005 6/2007)
15
My HealtheVet UsagePrescription Refills
16
My HealtheVet Registrant Age Distribution National
Site
17
My HealtheVet Statistics

• Over 3.3 million Refills Processed
  
• Daily Average Rx refills for 2006 is
  approximately 4,500

18
My HealtheVet Pilot Program
Over 7,365 Pilot participants at 9 VA Medical
Centers

• Demographics, admissions, and appointments
• Vitals and allergies
• Prescriptions
• Progress notes
• Discharge summaries
• Basic problem list information
• Lab reports chemistry, microbiology, microscopy,
  cytology and pathology
• ECG and radiology reports

Medical Record extracts Self-entered
metrics Patient Health Education
Libraries Patient controlled secure information
sharing
19
MHV Personal Health Record
VA Electronic Medical Record

• The VistA Computerized Patient Record System
  (CPRS) is the authoritative VA medical record.
• The veteran "owns" his/her My HealtheVet
  Personal Health Record.
• The veteran can request that a copy of key
  portions of his/her VistA record be
  electronically extracted and sent to the My
  HealtheVet system.
• The veteran controls access (delegation).

• CPRS
• VistA
• BCMA
• VistA Imaging

20
My HealtheVet Pilot Project

• MHV Pilot Project allows veterans to access
  personal health records over the Internet.
• For 2 years, Portland VAMC has been one of 9
  sites to participate in the MHV Pilot Project.
• gt5000 veterans at PVAMC access their own medical
  records using MHV.
• Initially many staff opposed the pilot because of
  the fears of unintended adverse consequences if
  patients have online access to medical records.

21
PVAMC Medical Staff Council September 15, 2004

• Motion before the Council
• Portland VAMC will participate in a pilot project
  to allow veterans electronic access to their
  medical records
• Resistance to the pilot was fierce
• Discussion
• Increase in provider workload
• Telephone Care will be deluged
• Patient dissatisfaction, overreaction, and
  hysteria
• Negative impact on paper based ROI
• Congressional and Patient Advocate Complaints
• Medical record will now be censored
• This will ruin the practice of medicine

22
PVAMC Medical Staff Council September 15, 2004

• Compromise MHV Pilot will be allowed but
• CPRS Consult allows PCP to serve as a gatekeeper
• Maximum of 30 patients/month
• Patients must have classroom training
• 3-4 week turnaround for veteran access
• Careful monitoring of provider workload,
  complaints, chart amendment requests, and
  potential ROI backlog.
• Strategy Engineer (cumbersome) MHV process to
  limit enrollment until impact can be measured

23
Initial Impact

• Provider workload/dissatisfaction goes up because
  of the gatekeeper role
• Mental Health providers report that limiting
  their patients access adds no value
• Patient complaints go up because of
• 2-4 week wait for access
• Quotas limiting enrollment to 30/month
• Provider opts out
• 3 complaints about content of the medical record
• 1 CPRS Chart Amendment request

24
PVAMC Medical Staff CouncilMarch 15, 2005

• Resistance had evaporated.
• Providers do not want to be a gatekeeper
• Hold For Review requirement waived for (most)
  Mental Health Clinics
• Patients highly satisfied
• Enrollment process must be streamlined
• Eliminate classroom requirement
• Engineer 1 Hour Photoshop Model of MHV Pilot
  enrollment

25
Kiosk (15 min. process)
Veteran walks up and fills out application
26
15 Minute Photoshop Model

• Veteran fills out application at Kiosk
• Clerk opens My HealtheVet user menu
• Reprint 'Welcome' Letter For Registered Veteran
• DSS/ROI Records Check
• Create e-vault
• Assemble User packet
• In-Person Authentication
• Veteran signs 5345-a
• Update Databases
• Veteran receives username, password, and
  information packet

27
(No Transcript)
28
But which veterans signed up ?

• Inverse Care Law Availability of health care is
  inversely proportional to need.
• OR
• Those in the worst health are least likely to
  receive services.
• AS APPLIED TO MHV
• The sickest veterans are least likely to have
  access to or know how to use a computer.
• (J Tudor Hart, 1971, The inverse care law,
  Lancet 1 405-12)

29
Markle Foundation Presentation

• Connecting Americans with their Health
  CareDecember 7-8, 2006
• VA presentation on MHV well received but followed
  by numerous questions on evaluation.
• PVAMC urged to further evaluate its experience
  with the MHV Pilot.

30
Questions asked at the Markle presentation

• Analysis of effect of MHV Pilot
• Inverse Care Law Are MHV Pilot enrollees
  healthier, younger, and more affluent?
• Patient dissatisfaction, overreaction, and
  hysteria Did MHV Pilot enrollees
  disproportionately utilize Telephone Care,
  Emergency Department, or voice complaints related
  to MHV?
• Mental Health Notes Did lack of Hold for
  Review requirement for Mental Health clinics
  lead to dissatisfaction?
• Draft Evaluation Metrics Does access to
  appointments and treatment plan affect
  utilization measures such as clinic cancellations
  or no-shows?
• Expert systems would provide the greatest
  benefit to those with the least previous
  knowledge. Did access to information
  (particularly wellness reminders) improve patient
  outcomes?

31
Limited evaluation of MHV Pilot has already been
done

• IRB approved Masters level Research Project
• ROI Office Utilization
• Chart Amendment Requests

32
Veteran Satisfaction with MHV Pilot

• IRB approved Research Project
• Evaluation of MHV Implementation at Portland VAMC
• Methods Survey 2 groups
• classroom training n62
• Hard Copy Manual n59

• Lee, Michelle Evaluation of MyHealtheVet
  Implementation at the
• Portland Veterans Affairs Medical Center Masters
  Thesis Feb 23, 2006

33
Veteran Satisfaction with MHV Pilot

• No significant difference in how useful the
  veterans rated classroom vs. paper based training
• No significant difference in ease of remembering
  information learned in classroom vs. paper based
  training
• No significant difference in veterans perception
  that MHV was easy to use
• No significant difference in high degree of
  satisfaction with access to PHR

34
Empowerment Statements

• I am better prepared for my office visits.
• 62 agree or strongly agree
• I can better understand the instructions from my
  doctor
• 67 agree or strongly agree
• I have more control and power to manage my health
  care
• 74 agree or strongly agree

35
Veteran to Veteran

• I would recommend MHV to my friends.
• 84 agree or strongly agree
• I believe all veterans should use MHV.
• 81 agree or strongly agree

36
MHV enrollment reduces use of paper
37
MHV Enrollment reduces visits to the Bricks and
Mortar Release of Information Office
38
Does access to a PHR increase requests for Chart
Amendment?

• 36 Chart Amendment requests in FY 05-06 out of 4
  million clinical documents
• 23 not enrolled in MHV
• 13 enrolled in MHV
• 3 requests predated MHV enrollment
• 10 requests followed MHV enrollment
• 14 of PVAMC Patients are enrolled in MHV
• 28 of Chart Amendments are from patients
  enrolled in MHV
• Chart Amendment requests appear to increase with
  MHV enrollment although this is a relatively rare
  event.

39
IRB Approved Research Project

• Title of Project IMPACT OF MHV PILOT ON
  UTILIZATION
• Principal Investigator David M. Douglas MD
• Co-Investigators Blake Lesselroth MD, Rose
  Campbell, Pat Tidmarsh, Belinda Dalton

40
IRB Approved Research Project

• ABSTRACT
• 3 key MeSH terms Patient Access to Records,
  Internet and Medical Records Systems,
  Computerized
• Objectives The objective of this study is to
  conduct an electronic chart review to better
  understand the demographics of the MHV pilot
  population and then to see what effect enrollment
  in the pilot had on utilization and outcomes.
• Plan Write a MUMPS routine to gather
  demographic, utilization, and outcomes data on
  veterans enrolled in the MHV pilot.

41
IRB Approved Research Project

• Although many PHRs have been deployed in the US
  and around the world, the MHV Pilot is unusual in
  that it allows internet-based access to
  electronic progress notes from the EHR.
• Kaiser Permanente by comparison has several
  hundred thousand patients enrolled in a PHR but
  does not provide access to electronic progress
  notes.
• There has been intense interest in the following
  question
• What impact has the MHV Pilot (and in particular
  ability to view content from the EHR) had on
  utilization and patient outcomes?
• Statistical Methods Since this is a
  retrospective chart review, the intent is to
  report descriptive statistics only which would
  help to set the stage for a subsequent controlled
  study.

42
Methodology

• Identify those veterans with
• 2 or more downloads
• Enrolled prior to April 7, 2006
• Write MUMPS routine to extract data on
• Demographics
• Utilization
• Clinical Reminders

43
Why do downloads matter?
44
Downloads
45
Downloads
46
Wide range of download frequency

• PATIENT A
• DOWNLOAD DATE MAY 7,2006 1746
• SUBCOUNT 1
• --------------------------------------------------
  ------------------------------
• PATIENT B
• DOWNLOAD DATE JUL 21,2005 1747
• DOWNLOAD DATE JUL 28,2005 0945
• DOWNLOAD DATE JUL 29,2005 1345
• DOWNLOAD DATE JUL 31,2005 1745
• DOWNLOAD DATE AUG 1,2005 2146
• DOWNLOAD DATE AUG 2,2005 1746
• DOWNLOAD DATE AUG 3,2005 2150
• DOWNLOAD DATE AUG 8,2005 0947
• DOWNLOAD DATE AUG 10,2005 1352
• DOWNLOAD DATE AUG 13,2005 2150
• DOWNLOAD DATE AUG 16,2005 1346
• DOWNLOAD DATE AUG 19,2005 0945
• DOWNLOAD DATE AUG 23,2005 1025
• DOWNLOAD DATE AUG 27,2005 1745

• Patient B (continued)
• DOWNLOAD DATE JAN 11,2006 2145
• DOWNLOAD DATE JAN 29,2006 1747
• DOWNLOAD DATE FEB 9,2006 0949
• DOWNLOAD DATE FEB 14,2006 1346
• DOWNLOAD DATE FEB 17,2006 1357
• DOWNLOAD DATE FEB 24,2006 0945
• DOWNLOAD DATE MAR 3,2006 1746
• DOWNLOAD DATE MAR 10,2006 0950
• DOWNLOAD DATE MAR 20,2006 1345
• DOWNLOAD DATE DEC 20,2005 1747
• DOWNLOAD DATE DEC 30,2005 2151
• DOWNLOAD DATE APR 14,2006 0947
• DOWNLOAD DATE APR 24,2006 0945
• DOWNLOAD DATE MAY 6,2006 2013
• DOWNLOAD DATE MAY 11,2006 0947
• DOWNLOAD DATE MAY 13,2006 0945
• DOWNLOAD DATE MAY 23,2006 0946
• DOWNLOAD DATE MAY 29,2006 0145

47
PARAMETERS

• Criteria used to determine if a MHV participant
  should be included in data gathering
• Active entry in the national file HEALTH EVET
  REGISTER
• Veterans enrollment date was prior to April 6,
  2006
• c. At least two downloads recorded in the
  national file HEALTH EVET DOWNLOAD SUMMARY
• Note No test patients were included.

48

• One primary routine is used to gather the
  veterans that meet all three criteria. Specific
  report routines are called from within the
  primary routine.
• All reports are called from within the primary
  routine to ensure the same veterans are used in
  every report.
• The count of veterans that are active and
  enrolled prior to April 6, 2006 was verified by a
  Fileman report that searched for active entries
  that had enrolled prior to
• April 7, 2006.
• First enrollment date in our Health Evet
  Register file is November 25, 2002.

49

• All reports, except demographic, gather data for
  year previous to enrollment and data for year
  after enrollment.
• Report generated is based on what menu option is
  selected by the user. For example, when person
  selects the demographic report option, a variable
  is set to indicate demographic.
• VistA menu option created for user to generate
  reports
• Select Options To Generate MHV Research Data (2
  dwnlds) Option ?
• A Display MHV Research Project Pt Appt
  Summary (2)
• D Display MHV Research Project Pt Demo
  Counters (2)
• I Display MHV Research Project Pt
  Income Summary (2)
• N Display MHV Research Project Pt Names
  (2)
• P Display MHV Research Pro Pt Advocate
  Summary (2)
• T Disp MHV Res. Proj Pt TIU Notes (Prior
  Yr) (2)

50
DEMOGRAPHIC DATA

• All data is gathered from the national PATIENT
  file unless otherwise indicated.
• Number found for each component had to match the
  number of veterans that were found in the primary
  routine as meeting the required criteria.

51
DEMOGRAPHIC COMPONENT SUMMARY

• 1. Average Age
• 2. Count of Vets with Date Of Death entry
• 4. Covered By Insurance (Yes, No, Unknown, N/A)
• 5. Primary Eligibility - (Field looks at
  Eligibility Code file) Sample SC Less 50
• 6. Enrollment Priority (Use portion of national
  programming to gather each veterans
  Group/Sub-group)
• Sample Group 1, Group 7c, Group 8g
• 7. Type of Patient (Field looks at Type Of
  Patient file) Sample SC Veteran

52
DEMOGRAPHIC COMPONENT SUMMARY

• 8. Combat Indicator (Yes, No, N/A)
• 9. Unemployable (Yes, No, N/A)
• 10. Period of Service (Field looks at Period of
  Service file)
• 11. Vesting Status (To gather each veterans
  status, used
• the portion of Reno Vesting software that
  displays veterans vesting status on Patient
  Inquiry screen)
• 12. Race (Field looks at Race file.) Vet can
  answer multiple times and all answers
  included
• 13. Ethnicity (Field looks at Ethnicity file) Vet
  can answer multiple times and all answers
  included
• 14. OEF/OIF (OIF, OEF, Unknown OEF/OIF) Multiple
  answers and all included

53
APPOINTMENT DATA

• Viewed each veterans appointment history data
  which is contained in their PATIENT file entry.
• There are two reports created under this one
  routine.
• Report One Displays count of appointments by
  status i.e., Checked Out, Cancelled by Patient,
  Cancelled by Patient w/Rebook
• Report Two Displays count of appointments that
  were unscheduled and count of appointments that
  were scheduled

54
APPOINTMENT DATASample 1

• Sample of Report One Count by Status
• TOTAL Checked Out
• Year Prior 26482
• Year After 28923
• TOTAL Clinic Cancelled
• Year Prior 4494
• Year After 5504

55
APPOINTMENT DATASample 2

• Sample of Report Two Unsch vs Sched Count
• YEAR PRIOR TOTAL SCHEDULED APPTS 35494
• YEAR PRIOR TOTAL 'UNSCHEDULED' APPTS 1545
• MH5I ECU PSYCH 19
• ECU NEURO-AREA A 9
• ?other clinics and counts
• YEAR AFTER TOTAL SCHEDULED APPTS 40675
• YEAR AFTER TOTAL 'UNSCHEDULED' APPTS 1360
• MH5I ECU PSYCH 14
• ECU NEURO-AREA A 6
• ?other clinics and counts

56
APPOINTMENT DATA VERIFICATION

• All verification steps were followed for both the
  data gathered for year prior and for data
  gathered for year after.
• One - every veteran was reviewed.
• Two - selected two veterans at random and
  generated appointment data using the national
  Appointment Management option. Compared that
  data to the appointment report generated by the
  appointment-by-status routine for this project.

57
APPOINTMENT DATA VERIFICATION

• Three
• a. The total number of appointments in the year
  prior had to be the same in both report 1 and
  report 2.
• b. The total number of appointments in the year
  after had to be the same in both report 1 and
  report 2.
• c. In the unscheduled vs scheduled report, the
  number of appointments listed for clinic
  sub-totals had to equal the total unscheduled
  number.

58
APPOINTMENT DATACompare Unscheduled vs Scheduled

• Clinics that allow unscheduled appointments
  either have ECU in the name, Emergency in the
  name, or Unscheduled in the name.
• File man report run on Hosp Loc file for clinic
  names that contain ECU, Emergency, or
  Unscheduled. Reviewed for those that should not
  be included. Two clinics were found they had a
  word that included ecu. Program automatically
  counted those as scheduled if found.
• As an appointment is found and counted for the
  status report, the clinic name is reviewed to
  determine if it contains one of the three names
  described above.
• If the clinic name contains one of the three, it
  is counted as unscheduled. If it does not, it is
  counted as scheduled.

59
PATIENT ADVOCATE DATA

• Used the national file Consumer Contact which
  is part of the national Patient Representative
  software.
• All data gathered for both year prior and year
  after.
• Two summaries generated (a) Number of vets with
  at least one entry and number with no entries,
  (b) Data was sorted/counted by the field Contact
  Made By.

60
PATIENT ADVOCATE DATA SAMPLE

• NUMBER OF VETERANS WITH AT LEAST ONE ENTRY
• AND
• NUMBER OF VETERANS WITHOUT ENTRY
• --------------------------------------------------
  -------------------
• YEAR PRIOR
• At least one entry 168
• None 1260
• YEAR AFTER
• At least one entry 150
• None 1278
• SUMMARY BY 'CONTACT MADE BY' DESGINATION
• --------------------------------------------
• PATIENT (PA)
• Year Prior 292
• Year After 247

61
PATIENT ADVOCATE DATAVERIFICATION

• Number of veterans that had at least one entry in
  the file was gathered and the number of veterans
  with no entry in the file was gathered. The
  total had to equal the number of veterans that
  met initial project criteria.
• As an entry was found, no matter the Contact
  Made By setting, it was added to a total (one
  total for year prior and one total for year
  after). If there was no contact made data, it
  was counted as N/A.
• At the end of summary report, the sub-totals
  generated for each Contact Made By had to equal
  its appropriate total i.e., year prior or year
  after.

62
TIU NOTES DATA

• Fileman used to create a report of all TIU titles
  that contain phrase tele. All titles included
  in the programming except Telehealth.
• Program uses the TIU Document file. As veteran
  found that meets the original criteria, the
  program looks through that patients progress
  note entries in the file for a title that
  contains one of the tele phrases.
• Two reports generated (each one has data for year
  prior and data for year after)
• Report 1 Count of notes found for each of the
  tele phrases
• Report 2 Summary of number of titles per
  veteran
• As an entry is found, appropriate Rpt 1 sub-total
  counter is adjusted. Once all completed data
  gathering for that veteran, Rpt 2 appropriate
  sub-counter is adjusted.

63
TIU NOTES DATA - Report 1

• Sample From our TEST account
• Notes contain TELEPHONE
• Year Prior 2617
• Year After 821
• Notes contain TELE-
• Year Prior 1286
• Year After 376
• Notes contain TELECARE
• Year Prior 742
• Year After 230
• Notes contain TELEMEDICINE
• Year Prior 2
• Year After 0

64
TIU NOTES DATA - Report 2

• Sample From our TEST account
• NUMBER OF TITLES PER VETERAN - SUMMARY
• (YEAR PRIOR TO ENROLLMENT AND YEAR AFTER
  ENROLLMENT)
• //////////////////////////////////////////////////
  ////////////////////
• ZERO Titles
• Year Prior 806
• Year After 876
• ONE Title
• Year Prior 268
• Year After 247
• TWO Titles
• Year Prior 122
• Year After 98
• THREE Titles
• Year Prior 75

65
TIU NOTES DATA - Report 2

• Sample From our TEST account
• FIVE Titles
• Year Prior 17
• Year After 23
• SIX - TEN Titles
• Year Prior 54
• Year After 47
• ELEVEN - FIFTEEN Titles
• Year Prior 11
• Year After 7
• SIXTEEN - TWENTY Titles
• Year Prior 4
• Year After 4
• TWENTY ONE OR GREATER Titles

66
TIU NOTES VERIFICATION

• Fileman report created to generate data for
  random veterans. Verified that both reports
  found exactly the same data as the Fileman
  report.
• Report 1 lf Fileman indicated the sample
  veteran should have five titles with phrase
  Telecare, then Report 1 should have count of
  five for Telecare.
• Report 2 The sub-totals of all categories
  should equal the total of veterans that met
  original criteria.

67
Selection Criteria

• Total of MHV Pilot enrollees 5360
• Enrolled prior to 4/7/06 to allow for a year
  before/year after comparison 4202
• Limit present study to MHV Pilot enrollees with 2
  or more downloads
• Active per national field
• n 1423

68
Back to the Inverse Care Law

• Are MHV Pilot enrollees healthier, younger, and
  more affluent?

69
Demographics

• 1423 veterans with 2 or more downloads
• Average age 60
• COVERED BY INSURANCE?
• Yes 786
• No 617
• Unknown 15
• N/A 5

70
Most MHV Pilot enrollees rated SC disabled

• PRIMARY ELIGIBILITY
• SERVICE CONNECTED gt50 597 (42)
• SC LESS THAN 50 278 (20)
• NSC, VA PENSION 54
  (4)
• NSC 476
  (33)
• HUMANITARIAN EMERGENCY 3 (0.2)
• AID ATTENDANCE 10
  (0.7
• HOUSEBOUND 2 (0.01)
  
• PURPLE HEART RECIPIENT 1 (0.01)

71
PERIOD OF SERVICE
MHV PVAMC WORLD WAR II 6
12 PRE-KOREAN 0 0.4 KOREAN
7 11 POST-KOREAN
8 7 VIETNAM ERA 56 45 POST-VIETN
AM 12 10 OTHER OR NONE
0 2 OTHER NON-VETERANS 0 0 PERSIAN
GULF WAR 11 12
72
Priority Groups as a measure of income

• ENROLLMENT PRIORITY (No data on file 29)
• GROUP 1        598 42 (50 SC or more
  unemployable)
• GROUP 2        118 8 (30-40 SC)
• GROUP 3        121 8 (ex-POWs Purple Heart
  10-20 SC)
• GROUP 4        19 1 (Aid Attendance
  Housebound )
• GROUP 5        317 22 (NSC, non-compens. 0SC
  and income lt VA Means Test)
• GROUP 6        14 1 (compensable 0SC)
• GROUP 7c       38 3 (gtVA Means Test but
  ltGeographic Threshold)
• GROUP 8a       7 0.5 (Noncompensable 0
  service-connected veterans enrolled as of
  1/16/03)
• GROUP 8c       161 11 (NSC vets enrolled as
  of 1/16/03)
• GROUP 8g        3 0.01 (NSC vets applying
  for enrollment after 1/16/03)

73
MHV Pilot enrollees less likely to be PG 8
compared to VA

• ENROLLMENT PRIORITY
• MHV VA PVAMC
• GROUP 1        598 42 15 22
• GROUP 2        118 9 7 8
• GROUP 3        121 9 12 11
• GROUP 4        19 1 3 4
• GROUP 5        317 23 31 33
• GROUP 6        14 1 3 2
• GROUP 7c       38 3 0.2 0.1
• GROUP 8a       7 0.5 2
  1
• GROUP 8c       161 11 21 15
• GROUP 8g        3 0.01 4 0.5

74
Utilization

• Did MHV Pilot enrollees disproportionately
  utilize Telephone Care or Unscheduled Walk-In
  Clinics?

75
Telephone and Unscheduled Visits declined after
MHV Pilot enrollment

• FY prior to enrollment
• Telephone 2228
• Care
• Primary 2327
• Care
• Unscheduled 1540

• FY after enrollment
• Telephone 2050
• Care
• Primary 2501
• Care
• Unscheduled 1358

76
Utilization

• Were MHV Pilot enrollees more likely to keep
  appointments and less likely to No-Show?

77
Utilization as measured by Clinic Cancellation or
No-Shows
78
Increase in Patient Cancellation but also in
No-Shows

• TOTAL Checked Out
• Year Prior 26383
• Year After 28860
• TOTAL Patient Cancelled
• Year Prior 3637
• Year After 4558
• TOTAL Patient No Show
• Year Prior 1632
• Year After 1995

79
Did MHV Pilot enrollees react negatively to what
they read?
Were MHV Pilot enrollees more likely to contact
the Patient Advocate?
80
Inappropriate Documentation

• "Patient suffers from paranoia""Vexatious
  complainant""Reads too many textbooks""Keeps a
  filthy house""Alcoholic""Drug abuser""Suffers
  from memory lapses""Over anxious""In need of
  psychiatric help""Imaginary symptoms"

"Symptoms over exaggerated""Dysfunctional
family""Munchausen type syndrome""All in the
mind""Work shy""I dont believe she is mentally
ill in the ordinary sense of the word""Not
easily managed""Laxative abuser"

• Sufferers of Iatrogenic Neglect

81
Patient Advocate Utilization

• NUMBER OF VETERANS WITH AT LEAST ONE ENTRY 
  ANDNUMBER OF VETERANS WITHOUT ENTRY    
• YEAR PRIOR       At least one entry
  168       None 1257
•  
•      YEAR AFTER       At least one entry
  150       None 1275

•   TOTAL        Year Prior  322       Year
  After  277

82
Chart Review of Patient Advocate Entries

• 1 entry found somatization? in a Primary Care
  Note offensive
• 1 entry reported MHV documented Prostate Cancer
  but when staff sat down to go over MHV with him,
  the report read Prostate Normal
• 1 entry indicated veteran had used MHV Feedback
  option to try to get a sooner appt
• 1 entry indicated veterans ex-wife was reading
  his medical records via MHV but this veteran had
  never enrolled in MHV
• None of the Patient Advocate notes referenced the
  content of mental health notes

83
Will expert systems provide the most benefit to
those with the least knowledge?
84
Quality Outcomes as measured by Reminders Due
Report

•  3/15/2005             Due
• DIABA1Cgt9                30               
• REPORT HTN gt160/100                98
• IHD LDLCgt120             3
• Influenza Immunization         326

• 7/20/2007              Due
• DIABA1Cgt9            27
• REPORT HTN gt160/100              66
• IHD LDL-Cgt120        23
• Influenza Immunization         417

85
Quality Outcomes as measured by Reminders Due
Report

• 3/15/2005     Due
• PAP Smear 33
• Colorectal 301
• Breast Cancer 26

• 7/20/2007      Due
• PAP Smear 17            
• Colorectal 245
• Breast Cancer 18

86
Conclusions

• Only 1/3 of enrollees had 2 or more downloads
• MHV Pilot enrollees disproportionately SC with
  fewer PG 8s compared to all veterans
• MHV Pilot enrollees less likely to be WWII
  veterans and more likely to be Vietnam era
  veterans

87
Conclusions

• The unintended consequences feared as a result of
  internet-based access to electronic medical
  records did not materialize
• No evidence of increased utilization of Telephone
  Care, Unscheduled Clinic Visits, or Patient
  Advocate Contacts
• No evidence that veterans objected to content of
  Mental Health notes
• MHV Pilot status associated with decrease in
  Reminders Due but this was not a controlled study

88
Questions asked at the Markle presentation

• Analysis of effect of MHV Pilot
• Inverse Care Law Are MHV Pilot enrollees
  healthier, younger, and more affluent?
• Patient dissatisfaction, overreaction, and
  hysteria Did MHV Pilot enrollees
  disproportionately utilize Telephone Care,
  Emergency Department, or voice complaints related
  to MHV?
• Draft Evaluation Metrics Does access to
  appointments and treatment plan affect
  utilization measures such as clinic cancellations
  or no-shows?
• Expert systems would provide the greatest
  benefit to those with the least previous
  knowledge. Did access to information
  (particularly wellness reminders) improve patient
  outcomes?

89
Implications

• Initial fears about MHV Pilot not supported by
  data
• Veteran utilization of PHR highly variable
• Controlled studies now needed to compare
  effectiveness of MHV with more traditional modes
  of care delivery
• Next step is to engage specific provider clinics
  to serve as intervention and control groups

90
Q A