MHV 404: Secure Messaging for the Quadrad

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MHV 404 Secure Messagingfor the Quadrad

• David M. Douglas MD
• July 16, 2008

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Learning Objectives

• Experience the Secure Messaging Application from
  the viewpoint of the various users
• Veteran
• Provider (Physician, NP, PA)
• Clinical Team Member (RN, Rx, Medical Assistant)
• Triage Staff
• Administrator
• Understand how message templates and triage
  groups are set up to increase efficiency and
  limit information overload to the Primary Care
  Provider
• Follow a message through its life cycle including
  capture to CPRS

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Agenda

• Introduction to MHV and Secure Messaging
• Secure Messaging Pilot Project
• SM from various User Perspectives
• Secure Messaging Templates
• Triage Groups and Business Models
• How the Quadrad can help
• QA

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Portland VA Medical Center

• 303 bed tertiary care facility
• 2 Divisions
• 4 CBOCs and 2 more planned for FY 2009
• 59,000 Uniques/yr
• 608,000 Clinic Visits/yr
• 8600 Admits/yr
• MHV Pilot Site
• MHV IPA Leader
• MHV SM Test Site

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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 electronic messages to doctors, transfer
  information to specialists, receive test results
  and access online self-help tools.

• Markle Foundation

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MHV is VAs Award Winning PHR
http//www.reuters.com/article/pressRelease/idUS16
853727-Dec-2007PRN20071227
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My HealtheVet Vision
IMAGINE gtgtgt gtgtgt
Knowledgeable patients are better able to make
informed health care choices, stay healthy,
and seek services when they need them.

• Electronic records
• Comprehensive accessible record for all sites of
  care
• Patient safety
• Decision support
• Care coordination
• Partnerships

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Pilot Informs National Release
My HealtheVet Pilot

• Medical Record Extracts
• Self-entered Metrics
• Patient Health Education Libraries
• Delegation

• Demographics, Admissions, Appointments,
  Prescriptions
• Vitals Allergies
• Progress Notes, Discharge Summaries
• Basic Problem List information
• Lab Reports Chemistry, Microbiology, Microscopy,
  Cytology, Pathology
• ECG Radiology reports
• Wellness Reminders
• Co-payment Balances

www.health-evet.va.gov
N 7,500 pilot participants at nine VAMCs
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My HealtheVet National Program

• Online Prescription Refills
• Health Education Information
• Condition Centers
• Self-assessment Tools
• Health Journals e-Logs
• Veteran Specific Conditions
• Seasonal Health Reminders
• Wellness Calendar
• Complete Medications View
• and more

www.myhealth.va.gov
Incremental releases of new features (VistA EHR,
Secure Messaging, Delegation)
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Robust Patient Health Education
Common Conditions Age-Related Macular
Degeneration Bipolar Disorder Cataracts Colds
Colorectal Cancer Depression Diabetes
Diabetic Retinopathy Glaucoma Coronary Heart
Disease Heart Failure High Blood Cholesterol
Hypertension Influenza Post Traumatic Stress
Disorder Schizophrenia Stroke
Healthy Living Centers Healthy Eating Physical
Activity Center Smoking Tobacco Use
Cessation Mental Health Screening Tools Alcohol
Use Screening (AUDIT-C) Depression Screening
(PHQ-9) PTSD Screening (PCL) Substance Abuse
Screening (ASSIST) Medical Libraries MedlinePlus
HealthWise Service Related Conditions
(VHI) Spinal Cord Injury Post Traumatic Stress
Disorder Traumatic Brain Injury Hearing Impairment
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3-Tier Access Model

• 3 Tier
• Access
• Model
• Visitors
• Registrants
• In Person Authentication (IPA)

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Personal Information

Personal Information In Case of
Emergency Printable Wallet Card My
Profile Account Management
www.myhealth.va.gov
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Pharmacy

Pharmacy Refill Prescriptions Prescriptions
History Medications, OTC, Herbals,
Supplements Complete Medication List
www.myhealth.va.gov
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Research Centers for Health

Research Health Healthy Living Centers Diseases
and Condition Centers Service Related
Conditions Common Conditions Mental
Health Medical Library MedlinePlus HealthWise
www.myhealth.va.gov
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Accessing Care

Get Care Caregivers Providers and
Physicians Treatment Facilities Treatment
Locations My Coverage Health Insurance Health
Calendar
www.myhealth.va.gov
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Tracking Health

Track Health Vitals Readings Labs
Tests Health History Family Health
History Military History Allergies Immunizations J
ournals Personal Health Summary
www.myhealth.va.gov
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Enhancements planned for My HealtheVet

• FY08 MHV Releases
• View Appointments
• Chemistry/Lab Extracts
• Patient/Clinician Secure Messaging
• Wellness Reminders (patient friendly view of
  Clinical Reminders)
• FY09 MHV Releases PHR Extracts
• Content Management System
• Metrics and Clinical Reporting Infrastructure
• My Recovery Plan
• CPRS view of Veteran Self-Entered Data
• Disaster Recovery Site

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Secure Messaging (SM)
Veteran Portal Send to Team Read Respond Health
Care Team Portal Read a Message Send a
Message Forward a Message Admin. Functions
Secure Messaging
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Advantages of Electronic Messaging

• Asynchronous communication
• More efficient than phone or FAX
• Creates a searchable record
• Can be Latered
• Message can be crafted on your time and your
  schedule.
• Enables performance improvement through
  management reports

• Shipley/Schwalbe

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Comparison of Secure Messaging and E-Mail
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An Example of Message Breakdown (3000 msgs/11
months)
SourceUniversity of Michigan - Steve Katz,
MDJAMIA, Nov.2004
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Other Experience with Secure Messaging

• Patient Access to an Electronic Health Record
  With Secure Messaging Impact on Primary Care
  Utilization
• A study performed by Kaiser Permanente on a large
  population that showed a 7 to 10 drop in
  outpatient visits and a 14 drop in telephone
  contacts as a result of secure messaging.
• Experiences of Patients Who Were Early Adopters
  of Electronic Communication With Their Physician
  Satisfaction, Benefits, and Concerns
• A study in the American Journal of Managed Care
  that showed 95 of respondents felt e-mail was a
  more efficient means of communication with their
  physicians than the telephone. 77 said they
  were able to communicate without a face-to-face
  appointment.

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SM Pilot Project Charge Letter

• SM intended to be a VA standard of care
• Pilot Project limited to Primary care and
  intended to
• Demonstrate technical integrity and usability
• Design and test business models
• Develop approaches for In-Person Authentication
  (IPA)
• Formulate recommendations for national
  implementation

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SM Pilot Project Charge Letter

• Goals for National Release
• Wide adoption of SMS by patients
• High provider satisfaction with the system
• Ongoing measurement of volume, response times and
  escalation rates, demonstrating safe and
  effective practices within VHA

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SM Implementation Co-Chairs David Douglas MD
and Brian Laufer MD

• SM Pilot Sites
• Boston Portland
• Puget Sound Washington DC
• Local Implementation Teams
• PCP, RN, Rx, IT, CAC, Telephone Care, Clerical
  and Admin Support, MHV POC
• Weekly Teleconferences and Sharepoint
• National Support
• MHV Office, Patient Safety, Patient Education,
  Usability, Public Affairs,
• Vendor Support
• Patriot Technologies

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Local SM Project Charter

• Project Team Development
• Identify Management Team, meeting schedule
• Identify Implementation Team, meeting schedule
• Establish communication mechanism
• Practice/Provider Recruitment
• Provide briefing to Primary Care
• Identify Primary Care providers and Staff who
  will participate
• Identify associated Customer Service Specialists,
  Nurse Care Managers, Schedulers, and any other
  staff who may be involved.

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Local SM Project Charter

• Current Telecommunication Processes
• Examine current telecommunication processes
• Map out VA Telephone Care Information flow for
  use opportunity of overlay of SMS
• Identify all communication processes of
  participating providers and staff that fall
  outside of Telephone Care (pharmacy, laboratory)
• Patient Recruitment Options
• Determine the number of patients previously
  through the IPA process or waiting for the IPA
  process, who are in panels of participating
  Primary Care providers.
• Identify options for recruiting patients,
  including those IPAd and new prospects. Examine
  opportunities for more intensive recruitment
  efforts, and who must be involved.
• Secure Messaging Models
• Explore models used in other organizations
  Group Health, Kaiser, Greenfield, etc.

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Testing and Implementation Phases

• March 2008 Pre-Alpha Testing focused on
  Technical Integrity and Usability
• June 2008 SM Functionality Testing
• August 2008 SM Administrative Functionality
• September 2008 National Release
• Tentative

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SM Metrics

• Secure Messaging Performance Evaluation
  encompasses
• system reports (including the development of a
  dashboard for common metrics)
• satisfaction surveys for patient, provider, and
  staff participants
• a prioritized research agenda
• related data comparisons external to the SM
  system for benchmarking (e.g. telephone workload,
  visits workload)

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Workload Credit

• A SECONDARY stop code, 719, will be implemented
  10/1/08
• Primary stop code remains the same as is
  currently used (e.g. primary care stop code that
  is currently used for outpatient clinic)
• Messages that meet the criteria for an on-line
  evaluation can be saved as a TIU progress note
• An on-line medical evaluation is defined as a
  non-face to face evaluation and management (EM)
  code
• Codes are broken out into services provided by
• Physician-99444
• Qualified nonphysician health care professional

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Workload Credit

• An evaluation and management service MUST occur
  in order to use this code
• A problem must be present
• Review of patient history must be done
• A recommendation or medical decision making must
  be documented
• Code is used only ONCE for the SAME episode of
  care in a 7 day period
• Patient must be an established patient
• Communication can be with PATIENT, GUARDIAN OR
  HEALTH CARE PROFESSIONAL
• EXAMPLE 1 An established patient sends secure
  message to her physician outlining an onset of
  new symptoms. The physician reviews the patients
  history and determines that a medication
  adjustment is in order. The physician advices
  the patient to adjust her medications. The
  patient is to contact the physician in 2 weeks if
  the symptoms do not improve.

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Secure Messaging User Types
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The Tour of SMS

• We are going to take a tour of SMS from various
  perspectives
• Veteran
• Provider (Physician, NP, PA)
• Clinical Team Member (RN, Rx, Medical Assistant)
• Triage Staff
• Administrator
• We are going to see some of the major
  functionality for each of our users

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Veteran Accesses SM
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Veteran Inbox
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Veteran replying to messages
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Veteran sends a message
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SM launched from CPRS Tools
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Provider, Clinical Team Member, Triage Staff
Access SM
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PCP Inbox
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PCP Views Message
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Replying to a message
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Clinician Search for a Recipient
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Clinician Create a Personal Distribution Group
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Clinician and Patient New Message Notification

• This allows patients and clinicians to be
  notified at an e-mail address that they have new
  messages.
• Only the fact that messages have arrived is sent
  in the e-mail. No message content is ever sent.
• Users can set the threshold for notifications to
  be sent so they do not have to be notified every
  time a single message arrives.

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Patient clicks on Preferences
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New Message Notification Patient
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New Message Notification Provider
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Clinician Triage Perform Clinician Triage
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Clinician Triage Perform Clinician Triage
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Administrator Create a Clinician Triage Group
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Administrator Run Reports
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System Reports

• Messages by Provider
• Messages by Triage Group
• Messages by Category
• Discovery Audit Report
• System Health Monitor
• Active Participant Report
• Response Turnaround Time Report

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On Demand Reports

• Providers Opted In
• Clinical Team Members Opted In
• Triage Staff Opted In
• Patients Opted In
• Messages Escalated
• Provider Messages
• Clinical Team Member Messages

• Triage Staff Messages
• Patient Messages
• Total Messages
• Messages Saved as TIU Notes
• Messages Read
• Messages Unread

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Secure Messaging Templates

• Insert pre-defined content into body of message
• Allows messages to be categorized by type
• Template categories given to SM workgroup were
• Rx, Appointment, Lab or Test Result, Change of
  Address, Health Information, and Administrative
• Analysis of 50 Telephone Care Messages
• 1) PCP Appt  12/50 24
• 2) Rx Refill/Renewal 17/50 34
• 3) Health Information 17/50 34
• 4) Specialty Referral 2/50 1
• 5) Laboratory/Test Info 6/50 12
• 6) Administrative Issue 5/50 10

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SM Templates
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Secure Messaging Templates

• SM Template functionality is SIMPLE (Think
  Google)
• Sender sees a pull down list of templates
• Selecting a template inserts boilerplate text
• Further development of the message is limited to
• Inserting Xs between left and right square
  brackets X to indicate a choice or to indicate
  that the text that follows applies.
• Filling in blanks _______ left in template
  sentences to provide the necessary information.
• Deleting text that does not apply to this
  message.
• Adding text by keystroke.

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Request Appointment
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Appointment Scheduled
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Change of Address Template
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Lab or Test Result Template
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Health Information Template
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Administrative Issue Template
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Request Rx Renewal
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Rx Message in the Inbox
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Rx has been renewed
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Save to CPRS?
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Rx Renewal Thread saved to CPRS
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Patient requests another renewal
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PCP replies
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PCP saves to CPRS
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Thread saved as an Addendum
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Patient reads the reply
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Preferences include Distribution Groups
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Create a Personal Distribution Group
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Potential Business Models
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Potential Business Models
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Potential Business Models
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Potential Business Models
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12 step program for successful implementation

• Identify Facility and Clinical Champions
• Establish Clinical Adoption Timeline
• Identify Executive Sponsors
• Identify Implementation Team
• Plan SM Communications and Outreach

• Healthcare Team and Staff Recruitment
• Communications Workflow Mapping
• Patient Recruitment
• Table Top Exercise
• Education and Training
• Go Live Event
• Success Measurement

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Identify Facility and Clinical Champions

• Recommended Timeframe
• Identification of the SM Facility and Clinical
  Champions should be completed at least three
  months prior to the scheduled Go Live Date.
• Success Activities
• The SM Facility Champion and SM Clinical Champion
  are selected.
• Champions review the National Clinical Adoption
  Implementation Guide, SM Clinical Adoption
  Toolkit and SM Implementation Checklist to
  understand scope of work.
• SM Implementation Checklist
• Depending on the size of the facility and
  workloads of the SM Facility Champion and SM
  Clinical Champion, SM Coordinators can be
  identified to handle functions as assigned.

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Establish Clinical Adoption Timeline

• The SM Facility and Clinical Champions together
  create a draft Time Table that identifies when
  Key Steps must occur for a successful
  implementation.
• Recommended Timeframe
• This step should be completed at least three
  months prior to the Go Live Date and prior to the
  first meeting of the Executive Sponsors.
• Success Activities
• Review SM Clinical Adoption Time Line, your local
  schedules, events and dependencies which will
  affect your Time Table.

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Identify Executive Sponsors

• Identify Executive Sponsors such as Facility
  Director, Chief Informatics Officer, Chief of
  Staff, Nurse Executives and others. Encourage
  their participation by highlighting the
  facilitys role as an innovator in MHV Personal
  Health Record (PHR) e-health services adoption.
• Develop SM Charter for Executive Sponsor
  Sign-Off.
• Contact sponsors and call first meeting.
• Discuss requirements and assignment of human and
  financial resources required to successfully
  implement SM.
• Secure necessary resources.
• Establish executive briefing schedule to keep
  Executive Sponsors apprised of the implementation
  status. These briefings may be included as part
  of other regularly-scheduled meetings at which
  all Executive Sponsors attend.
• Facilitate Executive Sponsor briefings to VISN
  executives and other relevant committees.

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Identify Implementation Team

• SM Clinical Champion
• Nurses
• Primary Care Physician
• Lab
• Pharmacist
• Clinical Application Coordinators

• Administrative Assistants
• IT Representative
• MHV POC
• SM Clinical Coordinator
• Public Affairs Office

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Communications and Outreach

• Identify target internal and external audiences
• Develop a plan to determine when and how
  audiences will receive communications
• Select and initiate production of approved
  communications products
• Identify significant facility events during which
  SM may be promoted.
• Create a plan to deliver products and promotion
  activities to audiences within a stated schedule.
• Identify delivery dates for communications
  products and place delivery dates and
  Communications and Outreach events into SM
  Implementation Time Table.
• Produce communications products needed locally to
  deliver messages to local audience groups.

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Healthcare Team and Staff Recruitment

• Introduce SM to appropriate healthcare providers
  and staff.
• Identify Primary Care Providers, healthcare teams
  and staff who will participate in the initial
  roll out. Work with the participating Primary
  Care Providers to identify triage team members.
  Provide triage team members contact information
  to SM Administrator to set up access.
• Depending on the scope of your facility rollout,
  SM Coordinators can be identified to handle
  functions as assigned at the clinic or healthcare
  team level.

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Communications Workflow Mapping

• Using Sample Workflows and SM workflows developed
  at Alpha Test Sites as templates, map current
  patient communication workflow processes. Include
  communications routed to other departments such
  as pharmacy and emergency.
• Map VA Telephone Care Information and other local
  patient communications flows for an opportunity
  to adapt as SM model.
• Based on the workflows you document for your
  facility, develop and record a proposed SM
  Patient Communications Workflow
• Validate workflows with SM Facility Champion.

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Patient Recruitment

• Identify options for recruiting patients.
  Consider patients who are in
• Specific chronic disease or high-risk diagnosis
  management populations
• Telehealth/e-communications programs
• Determine the Primary Care Physicians patients
  who are interested in participating and meet the
  required criteriaMHV registrants and have
  completed the IPA process.
• Secure patients acknowledgement of participating
  status through IPA process.
• Present SM as a roll out e-health service when
  discussing participation with patients. Explain
  that not every patient or provider will have
  access to SM when the service goes live at your
  facility. Healthcare teams and IPAed patients
  will be added as quickly as the facility can
  manage.

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Table Top Exercise

• Plan the SM communications triage/routing
  processes.
• This exercise is an efficient and thorough method
  of testing your triage model assumptions and
  identifying communication gaps.
• For the Table Top Exercise, prepare sample
  messages that reflect typical patient-healthcare
  team interchanges at your facility that test all
  aspects of your proposed SM communications
  process.
• Document your workflow decisions and communicate
  this process to the SM Facility Champion and all
  participating healthcare teams.

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Education and Training

• A good working knowledge of how SM works and how
  it contributes to a patient-centric,
  consumer-driven, provider friendly healthcare
  system goes a long way toward speeding adoption
  by patients and healthcare teams.
• Success Activities
• Establish an education and training plan using
  approved VHA training resources.
• Education Links (Hyperlinked to VHA sites)
• Patient Links (Hyperlinked to VHA sites)
• Healthcare Team Links (Hyperlinked to VHA
  sites)
• Obtain training materials and identify
  presenters.
• Schedule training starting at least one month
  prior and completing no later than two weeks
  prior to the Go Live Date.

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Go Live Event

• Working with the SM Facility Champion and
  Executive Sponsors, determine date, time, scope
  and format for event
• SM Overview Presentation
• SM Patient Brochures
• SM Patient Frequently Asked Questions (FAQs)
• Healthcare Team Brochures
• Healthcare Team Frequently Asked Questions (FAQs)

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Success Measurement

• System reports
• Provider Opt In
• Patient Opt In
• Message Escalation
• Others
• Satisfaction surveys for patient, provider, and
  staff participants
• Benchmark against Telephone Care Volume

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3-Tier Access Model

• 3 Tier
• Access
• Model
• Visitors
• Registrants
• In Person Authentication (IPA)

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Visitors
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Registrants
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In-Person Authentication

• In-Person Authentication (IPA) is a process used
  to verify a My HealtheVet (MHV) user's identity.
  Registered MHV users who are VA patients that
  have completed the IPA process will be able to
  view the names of their VA prescriptions.
• Before In Person Authentication can occur,
  several requirements must be met
• The user must be registered as a VA patient in
  their MHV account
• The user must view the MHV Orientation Video
• The user must download, read and sign the VA
  Form, 10-5345a-MHV (PDF)
• The user must present a form of government issued
  photo identification to a qualified VA staff
  member at their VA facility to be physically
  proofed

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Why is In-Person Authentication so important?

• Important enhancements to MHV will only be
  available to veterans who have been IPAd
• Secure Messaging
• Vista Extracts
• Co-Pay Balances

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IPA stats by VISN and Facility
128 Facilities.Top 10 are bolded.
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Some sobering statistics on IPA

• 5.5 million veteran patients in VHA
• 70 thousand have been IPAd or 1.3
• 221,000 unique veterans will be seen in VISN 20
  in FY 08
• 7310 have been IPAd or 3.3
• 59,000 unique veterans will be seen at Portland
  VAMC in FY 08
• 4807 have been IPAd or 8.1
• At this rate, it would take 100 years to IPA 5.5
  million veterans! ?

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IPA requires strong support from the Quadrad

• Hire 1-2 full time staff dedicated to IPA
• Monitor weekly IPA reports
• Set stretch goals for IPA and incorporate them
  into performance contracts
• Create an enrollment kiosk and place it in the
  part of the hospital with the highest visibility
  and heaviest traffic flow (usually main hospital
  lobby)
• Create IPA enrollment packets and take them to
  waiting rooms (Rx, Radiology, Specialty Clinics,
  Primary Care) where veterans have a lot of time
  on their hands. Ask veterans to fill out the
  forms and bring them to the kiosk later.

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IPA requires strong support from the Quadrad

• Take IPA enrollment packets to inpatients and go
  back to pick them up later.
• Visit CBOCs and train check-in clerks to IPA
  veterans
• Ask facility CIO to allow you to check out a
  laptop with a broadband card to take to off
  station events.
• Give presentations to Veteran Service
  Organizations and ask them to invite you to off
  station events which veterans will attend (VSO
  meetings, Veterans Day, Memorial Day, 4th of July
  Events, Veteran Workfairs, etc)
• Give presentation to your transition advocate and
  ask to accompany him/her to events for veterans
  transitioning from DOD to VA

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GS-4 IPA Program Support Clerk
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IPA Kiosk
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IPA Kiosk
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National Rollout of Secure Messaging

• Secure Messaging will be implemented as a phased
  release
• Round 1 is expected to include at least 1
  facility per VISN and will be restricted to
  primary care. Clinical adoption guidelines,
  toolkit materials, and related processes
  established during SM testing phases will be
  employed during Round 1. Prior to launching
  Round 1, we expect a memorandum to be sent to
  VISN management providing SM implementation-relate
  d guidance. The duration of Round 1 has not yet
  been determined.
• VISNs will play a central/critical role during
  the implementation of Secure Messaging
• VISNs will designate Round 1 sites and will work
  with National MHV Office and others to establish
  SM schedules for the remaining sites within their
  VISNs. During Round 1, each VISN is expected to
  establish implementation teams that will lead
  rollout efforts during subsequent rounds within
  their respective VISNs.
• A suspense date for completing the national
  rollout of Secure Messaging has not yet been
  determined.

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Resources

• My HealtheVet Portal www.myhealth.va.gov
• My HealtheVet Product Website ( Internet)
• http//vaww.appc1.va.gov/MyHealtheVet/
• My HealtheVet/VALU IT Training Website (Internet)
  
• http//vaww.vistau.med.va.gov/VistaU/mhv/default.h
  tmLinks

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