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VA pilot brings together mHealth and EHRs for better care

By Jennifer Bresnick

- Through its focus on mobile technology and patient-centric features like the Blue Button Initiative, the Department of Veterans Affairs (VA) has proven itself a leader in the difficult task of getting patients to engage with their providers on a meaningful level.  In July, the VA announced the beginning of the Family Caregiver Pilot, which paired seriously wounded veterans and their caregivers with iPads, pre-loaded with a suite of health management tools.

More than four months into the successful project, Dr. Neil Evans, Associate Chief of Staff of Informatics and Co-Chief of Primary Care at the Washington, D.C. VA Medical Center spoke to EHRintelligence about the effectiveness of mHealth tools and the starring role of technology in the VA’s healthcare ecosystem.

How is mHealth integrated into overall care for your patients?

We feel like the real value of mobile applications for patients or for their caregivers are things that either make it easier for the caregiver or their veteran to communicate with their healthcare team or with the VA in general to empower better communication.

We want to empower better self-management of health.  Reviewing their own personal data, that’s really part of self-management, to be able to see their data from the EHR.  It’s not just about seeing the data.  It’s also about generating their own patient-generated data to help inform the care team.  We don’t want to produce patient-generated data just to generate it, but also to help empower the relationship with their care team.

We also want to ease transactions.  Successfully negotiating your healthcare system is about getting prescription refills, making appointments, cancelling appointments, and dealing with transactions that can seem to get in the way of actually improving health, which is our real goal.  If we make those transactions easier, then they fade out of the forefront in the patients’ minds, and we can really allow the platform to serve as a way to help patients better self-manage their health, but also to have those open lines of communication with their healthcare teams so that we can help them manage their health together.

What sort of apps are involved in the VA’s mHealth pilot programs?

There’s an application called the Health Summary app.  This lets the patient or their caregiver actually see data from the EHR.  That includes progress notes that their healthcare team has written, lists of their medications, the problem list that we have for allergies, demographic information, laboratory data, radiology results, pathology results, et cetera.  We’re really putting the data from their EHR into the hands of the caregiver and their veteran.

There is also something that we call the journal app.  It lets veterans and their caregivers enter, view, and track vital signs and other patient-generated health information like blood glucose.  It includes an area just to document their contact with the healthcare system, so they can remember that they already spoke to Nancy to schedule their CT next week.

The particularly valuable part of that application is that that data that they’re entering is available, if they’d like it to be, for their healthcare provider as well.  So, they’re entering blood pressures to help them understand their own management of hypertension, but that blood pressure is also shared and available to the healthcare team to make decisions and to help management the healthcare of that individual.

We have several apps that are really focused particularly on common problems that veterans in this population deal with.  The VA Pain Coach app has evidence-based strategies for managing chronic pain.  There are questionnaires that patients can then take to help us better understand – and help them better understand – their pain and how they’re dealing with it.  The VA PTSD Coach is similar.  We tied it into our EHR for VA patients, so that when they take the surveys in there about how their PTSD is doing that the information actually gets shared into their record.

Another that I’m particularly proud of is the Care for Caregiver app.  I think this is something that often gets missed.  This is an app that is specifically designed to support the caregiver themselves by creating awareness of their personal strain level, giving them tools for self-management, providing advice about coping skills, psychological education, and then also connections to resources that the VA has available for them.

Has there been a lot of interest among patients and caregivers?

We’re getting a lot of great feedback about it, and we’ve learned a couple lessons.  We sent a letter to the 4,000 caregivers and asked them if they wanted to receive this iPad, and we got 1,000 back who said that they wanted to participate in the program.  We figured that if you volunteered to receive the iPad, you likely were somebody who understood potentially the value of an iPad or perhaps comfortable with technology, maybe had used an iPad before.

What’s interesting is that that has proven to definitely not be the case.  People were interested simply in having tools to help better manage their loved one’s healthcare and their needs, and they weren’t necessarily technologically advanced individuals.  Actually, some of the bigger challenges have been about helping folks learn how to use the iPad itself.

My mom and dad are not necessarily the most technologically savvy people, but they still are using their banking mobile app, and because it makes things easier for them.  It makes things more convenient.  We’re earlier in that journey than some of those other industries.  But I think if it’s done well, it will make it more convenient to access the resources you need to manage your own health and to get the expert care that you need.  I think if it’s done well, if you make it easy, people will use it, and they’ll use it independent of the generation or their familiarity with technology.

How should patient-generated data and mHealth apps fit into a clinician’s workflow?

We’re spending an awful lot of time discussing that very question.  I think that the real power of mobile health, again, is in fostering the relationship between patients and their care team.  That’s a big part of the power of it, but that also means you have to make it easy for the clinician to fit review of this data into their workflow.

And it’s not hard to imagine that some clinicians are concerned about the fact that their day is already filled with activities just managing face-to-face business.  How are they going to integrate or even understand patient-generated data, particularly if it’s a large volume of it?  We don’t have this solved.  So, I don’t want to say that here’s how we’re going to deal with this issue, because one of the reasons we’re still doing a pilot is to try to figure how to best fit this in.

The National eHealth Collaborative, working with the Office of the National Coordinator, have put together a technical expert panel trying to recommended best practices for dealing with patient-generated data.  And we have three VA individuals participating on that panel, thinking through what should be done.  We have some high level groups within the VA working actually with clinicians to figure out what would best fit into their workflow.

I’ll tell you what I think will work.  I think for large volume patient-generated data, that the data needs to be accessible for them when they need it in the EHR, tagged as patient-generated data.  I think asking a clinician to review every piece of data as it comes in is completely untenable.  Again, it’s about empowering the patient, it’s about telling the patient when they need to reach out to their healthcare team to ask for help.

So, if we build analytics into our systems, I feel like we should be able to alert patients that something seems to be out of line.  Maybe we can put a button into the mobile app to let them send a secure message to their provider saying, “I’ve been getting a lot of high blood pressures.  Can you take a look at that?”  The provider then needs to be able to quickly take a look at that in their primary workflow.

But I think the first challenge is getting the data available and visible easily within the provider’s primary workflow application.  And then, the second challenge is how we actually design these applications to really foster that communication.

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