1
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Bhattacharyya O, Rawl SM, Dickinson SL, Haggstrom DA. Comparison of health information exchange data with self-report in measuring cancer screening. BMC Med Res Methodol 2023; 23:172. [PMID: 37491208 PMCID: PMC10367403 DOI: 10.1186/s12874-023-01907-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 03/30/2023] [Indexed: 07/27/2023] Open
Abstract
BACKGROUND Efficient measurement of the receipt of cancer screening has been attempted with electronic health records (EHRs), but EHRs are commonly implemented within a single health care setting. However, health information exchange (HIE) includes EHR data from multiple health care systems and settings, thereby providing a more population-based measurement approach. In this study, we set out to understand the value of statewide HIE data in comparison to survey self-report (SR) to measure population-based cancer screening. METHODS A statewide survey was conducted among residents in Indiana who had been seen at an ambulatory or inpatient clinical setting in the past year. Measured cancer screening tests included colonoscopy and fecal immunochemical test (FIT) for colorectal cancer, human papilloma virus (HPV) and Pap tests for cervical cancer, and mammogram for breast cancer. For each screening test, the self-reported response for receipt of the screening (yes/no) and 'time since last screening' were compared with the corresponding information from patient HIE to evaluate the concordance between the two measures. RESULTS Gwet's AC for HIE and self-report of screening receipt ranged from 0.24-0.73, indicating a fair to substantial concordance. For the time since receipt of last screening test, the Gwet's AC ranged from 0.21-0.90, indicating fair to almost perfect concordance. In comparison with SR data, HIE data provided relatively more additional information about laboratory-based tests: FIT (19% HIE alone vs. 4% SR alone) and HPV tests (27% HIE alone vs. 12% SR alone) and less additional information about procedures: colonoscopy (8% HIE alone vs. 23% SR alone), Pap test (13% HIE alone vs. 19% SR alone), or mammography (9% HIE alone vs. 10% SR alone). CONCLUSION Studies that use a single data source should consider the type of cancer screening test to choose the optimal data collection method. HIE and self-report both provided unique information in measuring cancer screening, and the most robust measurement approach involves collecting screening information from both HIE and patient self-report.
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Affiliation(s)
- Oindrila Bhattacharyya
- Department of Economics, Indiana University Purdue University, Indianapolis, IN, USA
- James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
- The William Tierney Center for Health Services Research, Regenstrief Institute Inc, Indianapolis, IN, USA
| | - Susan M Rawl
- Indiana University School of Nursing, Indiana University Melvin and Bren Simon Cancer Comprehensive Center, Indianapolis, IN, USA
| | - Stephanie L Dickinson
- Department of Epidemiology and Biostatistics, Indiana University School of Public Health-Bloomington, Bloomington, IN, USA
| | - David A Haggstrom
- VA HSR&D Center for Health Information and Communication, Roudebush VA, Indianapolis, IN, USA.
- Division of General Internal Medicine and Geriatrics, Indiana University School of Medicine, Indianapolis, IN, USA.
- Center for Health Services Research, Regenstrief Institute, Indianapolis, IN, USA.
- Indiana University Cancer Center, Indianapolis, IN, USA.
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2
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Koufacos NS, May J, Judon KM, Franzosa E, Dixon BE, Schubert CC, Schwartzkopf AL, Guerrero VM, Traylor M, Boockvar KS. Improving Patient Activation among Older Veterans: Results from a Social Worker-Led Care Transitions Intervention. JOURNAL OF GERONTOLOGICAL SOCIAL WORK 2022; 65:63-77. [PMID: 34053407 PMCID: PMC8982469 DOI: 10.1080/01634372.2021.1932003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 05/14/2021] [Accepted: 05/16/2021] [Indexed: 06/12/2023]
Abstract
Older veterans enrolled in the Veterans Health Administration (VHA) often use both VHA and non-VHA providers for their care. This dual use, especially around an inpatient visit, can lead to fragmented care during the time of transition post-discharge. Interventions that target patient activation may be valuable ways to help veterans manage complex medication regimens and care plans from multiple providers. The Care Transitions Intervention (CTI) is an evidence-based model that helps older adults gain confidence and skills to achieve their health goals post-discharge. Our study examined the impact of CTI upon patient activation for veterans discharged from non-VHA hospitals. In total, 158 interventions were conducted for 87 veterans. From baseline to follow-up there was a significant 1.7-point increase in patient activation scores, from 5.4 to 7.1. This association was only found among those who completed the intervention. The most common barriers to completion were difficulty reaching the veteran by phone, patient declining the intervention, and rehospitalization during the 30 days post-discharge. Care transitions guided by social workers may be a promising way to improve patient activation. However, future research and practice should address barriers to completion and examine the impact of increased patient activation on health outcomes.
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Affiliation(s)
- Nicholas S Koufacos
- Geriatric Research Education and Clinical Center, James J. Peters VA, Bronx, New York, USA
| | - Justine May
- Center for Health Information and Communication, Health Services Research & Development Service, Richard L. Roudebush VA, Indianapolis, Indiana, USA
| | - Kimberly M Judon
- Geriatric Research Education and Clinical Center, James J. Peters VA, Bronx, New York, USA
| | - Emily Franzosa
- Geriatric Research Education and Clinical Center, James J. Peters VA, Bronx, New York, USA
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Brian E Dixon
- Center for Health Information and Communication, Health Services Research & Development Service, Richard L. Roudebush VA, Indianapolis, Indiana, USA
- Department of Epidemiology, Indiana University, Fairbanks School of Public Health, Indianapolis, Indiana, USA
- Center for Biomedical Informatics, Regenstrief Institute, Center for Biomedical Informatics, Indianapolis, Indiana, USA
| | - Cathy C Schubert
- Center for Health Information and Communication, Health Services Research & Development Service, Richard L. Roudebush VA, Indianapolis, Indiana, USA
- Department of Medicine, Indiana University, School of Medicine, Indianapolis, Indiana, USA
| | - Ashley L Schwartzkopf
- Center for Health Information and Communication, Health Services Research & Development Service, Richard L. Roudebush VA, Indianapolis, Indiana, USA
| | - Vivian M Guerrero
- Geriatric Research Education and Clinical Center, James J. Peters VA, Bronx, New York, USA
| | - Morgan Traylor
- Center for Health Information and Communication, Health Services Research & Development Service, Richard L. Roudebush VA, Indianapolis, Indiana, USA
| | - Kenneth S Boockvar
- Geriatric Research Education and Clinical Center, James J. Peters VA, Bronx, New York, USA
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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3
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Dixon BE, Judon KM, Schwartzkopf AL, Guerrero VM, Koufacos NS, May J, Schubert CC, Boockvar KS. Impact of event notification services on timely follow-up and rehospitalization among primary care patients at two Veterans Affairs Medical Centers. J Am Med Inform Assoc 2021; 28:2593-2600. [PMID: 34597411 DOI: 10.1093/jamia/ocab189] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 08/17/2021] [Accepted: 08/20/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE To examine the effectiveness of event notification service (ENS) alerts on health care delivery processes and outcomes for older adults. MATERIALS AND METHODS We deployed ENS alerts in 2 Veterans Affairs (VA) medical centers using regional health information exchange (HIE) networks from March 2016 to December 2019. Alerts targeted VA-based primary care teams when older patients (aged 65+ years) were hospitalized or attended emergency departments (ED) outside the VA system. We employed a concurrent cohort study to compare postdischarge outcomes between patients whose providers received ENS alerts and those that did not (usual care). Outcome measures included: timely follow-up postdischarge (actual phone call within 7 days or an in-person primary care visit within 30 days) and all-cause inpatient or ED readmission within 30 days. Generalized linear mixed models, accounting for clustering by primary care team, were used to compare outcomes between groups. RESULTS Compared to usual care, veterans whose primary care team received notification of non-VA acute care encounters were 4 times more likely to have phone contact within 7 days (AOR = 4.10, P < .001) and 2 times more likely to have an in-person visit within 30 days (AOR = 1.98, P = .007). There were no significant differences between groups in hospital or ED utilization within 30 days of index discharge (P = .057). DISCUSSION ENS was associated with increased timely follow-up following non-VA acute care events, but there was no associated change in 30-day readmission rates. Optimization of ENS processes may be required to scale use and impact across health systems. CONCLUSION Given the importance of ENS to the VA and other health systems, this study provides guidance for future research on ENS for improving care coordination and population outcomes. TRIAL REGISTRATION ClinicalTrials.gov NCT02689076. "Regional Data Exchange to Improve Care for Veterans After Non-VA Hospitalization." Registered February 23, 2016.
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Affiliation(s)
- Brian E Dixon
- Department of Veterans Affairs, Health Services Research & Development Service, Center for Health Information and Communication, Indianapolis, Indiana, USA.,Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana, USA.,Center for Biomedical Informatics, Regenstrief Institute, Indianapolis, Indiana, USA
| | - Kimberly M Judon
- Department of Veterans Affairs, James J. Peters VA Medical Center, Bronx, New York, USA
| | - Ashley L Schwartzkopf
- Department of Veterans Affairs, Health Services Research & Development Service, Center for Health Information and Communication, Indianapolis, Indiana, USA
| | - Vivian M Guerrero
- Department of Veterans Affairs, James J. Peters VA Medical Center, Bronx, New York, USA
| | - Nicholas S Koufacos
- Department of Veterans Affairs, James J. Peters VA Medical Center, Bronx, New York, USA
| | - Justine May
- Department of Veterans Affairs, Health Services Research & Development Service, Center for Health Information and Communication, Indianapolis, Indiana, USA
| | - Cathy C Schubert
- Department of Veterans Affairs, Health Services Research & Development Service, Center for Health Information and Communication, Indianapolis, Indiana, USA.,Division of Geriatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Kenneth S Boockvar
- Department of Veterans Affairs, James J. Peters VA Medical Center, Bronx, New York, USA.,Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Franzosa E, Traylor M, Judon KM, Guerrero Aquino V, Schwartzkopf AL, Boockvar KS, Dixon BE. Perceptions of event notification following discharge to improve geriatric care: qualitative interviews of care team members from a 2-site cluster randomized trial. J Am Med Inform Assoc 2021; 28:1728-1735. [PMID: 33997903 DOI: 10.1093/jamia/ocab074] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 04/02/2021] [Accepted: 04/09/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To assess primary care teams' perceptions of a health information exchange (HIE) event notification intervention for geriatric patients in 2 Veterans Health Administration (VHA) medical centers. MATERIALS AND METHODS We conducted a qualitative evaluation of an event notification alerting primary care teams to non-VHA hospital admissions and emergency department visits. Data were collected through semistructured interviews (n = 23) of primary care team physicians, nurses and medical assistants. Study design and analysis were guided by the Consolidated Framework for Implementation Research (CFIR). RESULTS Team members found the alerts necessary, helpful for filling information gaps, and effective in supporting timely follow-up care, although some expressed concern over scheduling capacity and distinguishing alerts from other VHA notices. Participants also suggested improvements including additional data on patients' diagnosis and discharge instructions, timing alerts to patients' discharge (including clear next steps), including additional team members to ensure alerts were acted upon, and implementing a single sign-on. DISCUSSION Primary care team members perceived timely event notification of non-VHA emergency department visits and hospital admissions as potentially improving post-discharge follow-up and patient outcomes. However, they were sometimes unsure of next steps and suggested the alerts and platform could be streamlined for easier use. CONCLUSIONS Event notifications may be a valuable tool in coordinating care for high-risk older patients. Future intervention research should explore the optimal amount and types of information and delivery method across sites and test the integration of alerts into broader care coordination efforts.
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Affiliation(s)
- Emily Franzosa
- Geriatric Research, Education, and Clinical Center, James J. Peters VA Medical Center, Bronx, New York, USA.,Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Morgan Traylor
- Department of Veterans Affairs, Health Services Research & Development Service, Center for Health Information and Communication, Indianapolis, Indiana, USA
| | - Kimberly M Judon
- Geriatric Research, Education, and Clinical Center, James J. Peters VA Medical Center, Bronx, New York, USA
| | - Vivian Guerrero Aquino
- Geriatric Research, Education, and Clinical Center, James J. Peters VA Medical Center, Bronx, New York, USA
| | - Ashley L Schwartzkopf
- Department of Veterans Affairs, Health Services Research & Development Service, Center for Health Information and Communication, Indianapolis, Indiana, USA
| | - Kenneth S Boockvar
- Geriatric Research, Education, and Clinical Center, James J. Peters VA Medical Center, Bronx, New York, USA.,Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Brian E Dixon
- Department of Veterans Affairs, Health Services Research & Development Service, Center for Health Information and Communication, Indianapolis, Indiana, USA.,Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana, USA.,Center for Biomedical Informatics, Regenstrief Institute, Indianapolis, Indiana, USA
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5
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Reasons Older Veterans Use the Veterans Health Administration and Non-VHA Care in an Urban Environment. J Am Board Fam Med 2021; 34:291-300. [PMID: 33832997 PMCID: PMC9036939 DOI: 10.3122/jabfm.2021.02.200332] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 11/03/2020] [Accepted: 11/03/2020] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Older veterans in urban settings rely less on the Veterans Health Administration (VHA) health care, suggesting deficits of access and services for aging veterans. We aimed to identify reasons for VHA and non-VHA use across the health status of older, urban-dwelling veterans. METHODS We examined open-ended responses from 177 veterans who were enrolled in primary care at the Bronx VA Medical Center, used non-VHA care in prior 2 years, and completed baseline interviews in a care coordination trial from March 2016 to August 2017. Using content analysis, we coded and categorized key terms and concepts into an established access framework. This framework included 5 categories: acceptability (relationship, second opinion), accessibility (distance, travel); affordability; availability (supply, specialty care); and accommodation (organization, wait-time). Self-reported health status was stratified by excellent/very good, good, and fair/poor. RESULTS We were able to categorize the responses of 166 veterans, who were older (≥75 years, 61%), minority race and ethnicity (77%), and low income (<$25,000/y, 51%). Veterans mentioned acceptability (42%) and accessibility (37%) the most, followed by affordability (33%), availability (25%), and accommodation (11%). With worse self-reported health status, accessibility intensified (excellent/very good, 24%; fair/poor, 46%; P = .031) particularly among minority veterans, while acceptability remained prominent (excellent/very good, 49%; fair/poor, 37%; P = .25). Other categories were mentioned less with no significant difference across health status. CONCLUSIONS Even in an urban environment, proximity was a leading issue with worse health. Addressing urban accessibility and coordination for older, sicker veterans may enhance care for a growing vulnerable VHA population.
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Dixon BE, Luckhurst C, Haggstrom DA. Leadership Perspectives on Implementing Health Information Exchange: Qualitative Study in a Tertiary Veterans Affairs Medical Center. JMIR Med Inform 2021; 9:e19249. [PMID: 33616542 PMCID: PMC7939932 DOI: 10.2196/19249] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 08/15/2020] [Accepted: 12/04/2020] [Indexed: 11/21/2022] Open
Abstract
Background The US Department of Veterans Affairs (VA) seeks to achieve interoperability with other organizations, including non-VA community and regional health information exchanges (HIEs). Objective This study aims to understand the perspectives of leaders involved in implementing information exchange between VA and non-VA providers via a community HIE. Methods We interviewed operational, clinical, and information technology leaders at one VA facility and its community HIE partner. Respondents discussed their experiences with VA-HIE, including barriers and facilitators to implementation, and the associated impact on health care providers. Transcribed interviews were coded and analyzed using immersion-crystallization methods. Results VA and community HIE leaders found training to be a key factor when implementing VA-HIE and worked cooperatively to provide several styles and locations of training. During recruitment, a high-touch approach was successfully used to enroll patients and overcome their resistance to opting in. Discussion with leaders revealed the high levels of complexity navigated by VA providers and staff to send and retrieve information. Part of the complexity stemmed from the interconnected web of information systems and human teams necessary to implement VA-HIE information sharing. These interrelationships must be effectively managed to guide organizational decision making. Conclusions Organizational leaders perceived information sharing to be of essential value in delivering high-quality, coordinated health care. The VA continues to increase access to outside care through the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act. Along with this increase in non-VA medical care, there is a need for greater information sharing between VA and non-VA health care organizations. Insights by leaders into barriers and facilitators to VA-HIE can be applied by other national and regional networks that seek to achieve interoperability across health care delivery systems.
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Affiliation(s)
- Brian E Dixon
- VA HSR&D Center for Health Information and Communication, Richard L Roudebush Veterans Affairs Medical Center, Indianapolis, IN, United States.,Department of Epidemiology, Indiana University Richard M Fairbanks School of Public Health, Indianapolis, IN, United States.,Center for Biomedical Informatics, Regenstrief Institute, Indianapolis, IN, United States
| | - Cherie Luckhurst
- VA HSR&D Center for Health Information and Communication, Richard L Roudebush Veterans Affairs Medical Center, Indianapolis, IN, United States.,Orthopaedic Surgery Research, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN, United States
| | - David A Haggstrom
- VA HSR&D Center for Health Information and Communication, Richard L Roudebush Veterans Affairs Medical Center, Indianapolis, IN, United States.,Division of General Internal Medicine and Geriatrics, Indiana University School of Medicine, Indianapolis, IN, United States.,Center for Health Services Research, Regenstrief Institute, Indianapolis, IN, United States
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7
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Lira LL, Chandrasekar J. The State of Research in Veterans Studies: A Systematic Literature Review. JOURNAL OF VETERANS STUDIES 2020. [DOI: 10.21061/jvs.v6i2.191] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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8
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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 Med Inform Decis Mak 2019; 19:125. [PMID: 31272427 PMCID: PMC6611045 DOI: 10.1186/s12911-019-0849-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 06/24/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Coordination of care, especially after a patient experiences an acute care event, is a challenge for many health systems. Event notification is a form of health information exchange (HIE) which has the potential to support care coordination by alerting primary care providers when a patient experiences an acute care event. While promising, there exists little evidence on the impact of event notification in support of reengagement into primary care. The objectives of this study are to 1) examine the effectiveness of event notification on health outcomes for older adults who experience acute care events, and 2) compare approaches to how providers respond to event notifications. METHODS In a cluster randomized trial conducted across two medical centers within the U.S. Veterans Health Administration (VHA) system, we plan to enroll older patients (≥ 65 years of age) who utilize both VHA and non-VHA providers. Patients will be enrolled into one of three arms: 1) usual care; 2) event notifications only; or 3) event notifications plus a care transitions intervention. In the event notification arms, following a non-VHA acute care encounter, an HIE-based intervention will send an event notification to VHA providers. Patients in the event notification plus care transitions arm will also receive 30 days of care transition support from a social worker. The primary outcome measure is 90-day readmission rate. Secondary outcomes will be high risk medication discrepancies as well as care transitions processes within the VHA health system. Qualitative assessments of the intervention will inform VHA system-wide implementation. DISCUSSION While HIE has been evaluated in other contexts, little evidence exists on HIE-enabled event notification interventions. Furthermore, this trial offers the opportunity to examine the use of event notifications that trigger a care transitions intervention to further support coordination of care. TRIAL REGISTRATION ClinicalTrials.gov NCT02689076. "Regional Data Exchange to Improve Care for Veterans After Non-VA Hospitalization." Registered 23 February 2016.
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Affiliation(s)
- Brian E. Dixon
- Department of Veterans Affairs, Health Services Research & Development Service, Center for Health Information and Communication, 1481 W. 10th St, 11H, Indianapolis, IN 46202 USA
- Indiana University, Fairbanks School of Public Health, 1050 Wishard Blvd, Indianapolis, IN 46202 USA
- Regenstrief Institute, Center for Biomedical Informatics, 1101 W 10th St, Indianapolis, IN 46202 USA
| | - Ashley L. Schwartzkopf
- Department of Veterans Affairs, Health Services Research & Development Service, Center for Health Information and Communication, 1481 W. 10th St, 11H, Indianapolis, IN 46202 USA
| | - Vivian M. Guerrero
- Department of Veterans Affairs, James J. Peters VA Medical Center, 130 W Kingsbridge Rd, Bronx, NY 10468 USA
| | - Justine May
- Department of Veterans Affairs, Health Services Research & Development Service, Center for Health Information and Communication, 1481 W. 10th St, 11H, Indianapolis, IN 46202 USA
| | - Nicholas S. Koufacos
- Department of Veterans Affairs, James J. Peters VA Medical Center, 130 W Kingsbridge Rd, Bronx, NY 10468 USA
| | - Andrew M. Bean
- Department of Veterans Affairs, James J. Peters VA Medical Center, 130 W Kingsbridge Rd, Bronx, NY 10468 USA
| | - Joan D. Penrod
- Department of Veterans Affairs, James J. Peters VA Medical Center, 130 W Kingsbridge Rd, Bronx, NY 10468 USA
- Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl, New York, NY 10029 USA
| | - Cathy C. Schubert
- Department of Veterans Affairs, Health Services Research & Development Service, Center for Health Information and Communication, 1481 W. 10th St, 11H, Indianapolis, IN 46202 USA
- Indiana University, School of Medicine, 1101 W. 10th St, Indianapolis, IN 46202 USA
| | - Kenneth S. Boockvar
- Department of Veterans Affairs, James J. Peters VA Medical Center, 130 W Kingsbridge Rd, Bronx, NY 10468 USA
- Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl, New York, NY 10029 USA
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Mattocks KM, Cunningham K, Elwy AR, Finley EP, Greenstone C, Mengeling MA, Pizer SD, Vanneman ME, Weiner M, Bastian LA. Recommendations for the Evaluation of Cross-System Care Coordination from the VA State-of-the-art Working Group on VA/Non-VA Care. J Gen Intern Med 2019; 34:18-23. [PMID: 31098968 PMCID: PMC6542862 DOI: 10.1007/s11606-019-04972-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
In response to widespread concerns regarding Veterans' access to VA care, Congress enacted the Veterans Access, Choice and Accountability Act of 2014, which required VA to establish the Veterans Choice Program (VCP). Since the inception of VCP, more than two million Veterans have received care from community providers, representing approximately 25% of Veterans enrolled in VA care. However, expanded access to non-VA care has created challenges in care coordination between VA and community health systems. In March 2018, the VA Health Services Research & Development Service hosted a VA State of the Art conference (SOTA) focused on care coordination. The SOTA convened VA researchers, program directors, clinicians, and policy makers to identify knowledge gaps regarding care coordination within the VA and between VA and community systems of care. This article provides a summary and synthesis of relevant literature and provides recommendations generated from the SOTA about how to evaluate cross-system care coordination. Care coordination is typically evaluated using health outcomes including hospital readmissions and death; however, in cross-system evaluations of care coordination, measures such as access, cost, Veteran/patient and provider satisfaction (including with cross-system communication), comparable quality metrics, context (urban vs. rural), and patient complexity (medical and mental health conditions) need to be included to fully evaluate care coordination effectiveness. Future research should examine the role of multiple individuals coordinating VA and non-VA care, and how these coordinators work together to optimize coordination.
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Affiliation(s)
- Kristin M Mattocks
- VA Central Western Massachusetts Healthcare System, Leeds, MA, USA. .,Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA.
| | | | - A Rani Elwy
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA, USA.,Department of Psychiatry and Human Behavior, Alpert Medical School, Brown University, Providence, RI, USA
| | - Erin P Finley
- South Texas Veterans Health Care System, San Antonio, TX, USA.,University of Texas Health Science Center, San Antonio, TX, USA
| | - Clinton Greenstone
- VHA Office of Community Care, Washington, DC, USA.,University of Michigan Medical School, Ann Arbor, MI, USA
| | - Michelle A Mengeling
- The Center for Comprehensive Access & Delivery Research and Evaluation (CADRE) and VA Office of Rural Health (ORH), Veterans Rural Health Resource Center-Iowa City (VRHRC-IC), Iowa City VA Health Care System, Iowa City, IA, USA.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Steven D Pizer
- VA Boston Healthcare System, Boston, MA, USA.,Boston University School of Public Health, Boston, MA, USA
| | - Megan E Vanneman
- Informatics, Decision-Enhancement and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA.,Department of Internal Medicine/Division of Epidemiology & Department of Population Health Sciences/Division of Health System Innovation and Research, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Michael Weiner
- VA Health Services Research and Development Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA.,Regenstrief Institute, Inc., Indianapolis, IN, USA.,Center for Health Services and Outcomes Research, Indiana University, Indianapolis, IN, USA
| | - Lori A Bastian
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA.,Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT, USA
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10
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Dixon BE, Embi PJ, Haggstrom DA. Information technologies that facilitate care coordination: provider and patient perspectives. Transl Behav Med 2018; 8:522-525. [PMID: 29800411 DOI: 10.1093/tbm/ibx086] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Health information technology is a core infrastructure for the chronic care model, integrated care, and other organized care delivery models. From the provider perspective, health information exchange (HIE) helps aggregate and share information about a patient or population from several sources. HIE technologies include direct messages, transfer of care, and event notification services. From the patient perspective, personal health records, secure messaging, text messages, and other mHealth applications may coordinate patients and providers. Patient-reported outcomes and social media technologies enable patients to share health information with many stakeholders, including providers, caregivers, and other patients. An information architecture that integrates personal health record and mHealth applications, with HIEs that combine the electronic health records of multiple healthcare systems will create a rich, dynamic ecosystem for patient collaboration.
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Affiliation(s)
- Brian E Dixon
- Department of Epidemiology, Indiana University, Richard M. Fairbanks School of Public Health, Indianapolis, IN, USA.,Regenstrief Institute, Inc., Indianapolis, IN, USA.,Center for Health Information and Communication, Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service, IN, USA
| | - Peter J Embi
- Regenstrief Institute, Inc., Indianapolis, IN, USA
| | - David A Haggstrom
- Regenstrief Institute, Inc., Indianapolis, IN, USA.,Center for Health Information and Communication, Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service, IN, USA.,Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
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11
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Pope CA, Davis BH, Wine L, Nemeth LS, Haddock KS, Hartney T, Axon RN. Perceptions of U.S. Veterans Affairs and community healthcare providers regarding cross-system care for heart failure. Chronic Illn 2018; 14:283-296. [PMID: 28906129 DOI: 10.1177/1742395317729887] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES This study explores perceptions of US Veterans Affairs (VA) and non-VA healthcare providers caring for Veterans with heart failure (HF) regarding Veteran knowledge and motivations for dual use, provider roles in recommending and coordinating dual use, systems barriers and facilitators, and suggestions for improving cross-system care. METHODS Twenty VA and 11 non-VA providers participated in semi-structured interviews, which were analyzed using parallel qualitative content and discourse analysis. RESULTS VA and non-VA providers described variable HF knowledge and self-management among Veterans, and both groups described the need for improved education addressing medication adherence, self-care, and management of acute symptoms. Both groups described highly limited roles for providers in shaping choices surrounding dual use. VA and non-VA providers had significantly different perceptions regarding the availability, quality, and effectiveness of VA HF services. Multiple non-VA providers expressed frustration with and difficulty in contacting VA providers, accessing records, and making referrals into the VA system. Suggestions for improved care focused on patient education and care coordination. DISCUSSION Dual healthcare system use for Veterans is increasingly common. Similarities and contrasts in perceptions of VA and non-VA providers are instructive and should be incorporated into future policy and program initiatives.
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Affiliation(s)
- Charlene A Pope
- 1 Health Equity & Rural Outreach Innovation Center (HEROIC), Ralph H. Johnson Veterans Affairs (VA) Medical Center, Charleston, SC, USA.,2 Division General Pediatrics, Department of Pediatrics, College of Medicine, Medical University of South Carolina (MUSC), Charleston, USA
| | - Boyd H Davis
- 1 Health Equity & Rural Outreach Innovation Center (HEROIC), Ralph H. Johnson Veterans Affairs (VA) Medical Center, Charleston, SC, USA.,3 University of North Carolina-Charlotte, Charlotte, NC, USA
| | - Leticia Wine
- 1 Health Equity & Rural Outreach Innovation Center (HEROIC), Ralph H. Johnson Veterans Affairs (VA) Medical Center, Charleston, SC, USA
| | - Lynne S Nemeth
- 4 College of Nursing, Medical University of South Carolina, Charleston, SC, USA
| | - K Sue Haddock
- 5 William J.B. Dorn VA Medical Center, Columbia, SC, USA
| | - Tom Hartney
- 6 Charlie Norwood VA Medical Center, Augusta, GA, USA
| | - R Neal Axon
- 1 Health Equity & Rural Outreach Innovation Center (HEROIC), Ralph H. Johnson Veterans Affairs (VA) Medical Center, Charleston, SC, USA.,7 Department of Internal Medicine, College of Medicine, Medical University of South Carolina (MUSC), Charleston, SC, USA
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12
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Zullig LL, Goldstein KM, Bosworth HB. Changes in the Delivery of Veterans Affairs Cancer Care: Ensuring Delivery of Coordinated, Quality Cancer Care in a Time of Uncertainty. J Oncol Pract 2017; 13:709-711. [PMID: 28892409 DOI: 10.1200/jop.2017.021527] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Affiliation(s)
- Leah L Zullig
- Duke University; and Durham Veterans Affairs Health Care System, Durham, NC
| | - Karen M Goldstein
- Duke University; and Durham Veterans Affairs Health Care System, Durham, NC
| | - Hayden B Bosworth
- Duke University; and Durham Veterans Affairs Health Care System, Durham, NC
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13
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Pharmacy Use in the First Year of the Veterans Choice Program: A Mixed-methods Evaluation. Med Care 2017; 55 Suppl 7 Suppl 1:S26-S32. [PMID: 28221274 DOI: 10.1097/mlr.0000000000000661] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The Veterans Choice Program (VCP) was created to ensure timely access to health care in the Department of Veterans Affairs (VA). Under this program, medications may be ordered by select non-VA clinicians to be dispensed by VA pharmacies, creating new challenges in ensuring medication safety. OBJECTIVES To examine pharmaceutical use during the first year of the VCP and to understand barriers and facilitators for VA pharmacists to dispensing medications under the VCP. STUDY DESIGN Mixed-methods evaluation. METHODS We captured all prescriptions dispensed through the VCP and described the demographics of VCP users and their medications. We also conducted semistructured interviews of VA pharmacists, focusing on VA formulary management and experiences dispensing opioid and hepatitis C (HCV) medications. Codebook development and coding followed iterative qualitative methods. RESULTS Overall, 17,346 Veterans received 56,426 VCP prescriptions from November 7, 2014 through November 7, 2015. The total medication cost was $27 million, 90% of which was for only 2772 HCV prescriptions. Topical eye drops and opioids represented the most commonly dispensed prescriptions (15.6% and 9.2% of all prescriptions, respectively). Pharmacists reported numerous challenges to dispensing VCP medications, including time required to contact non-VA clinicians about formulary issues, requiring controlled substance prescriptions to be hand delivered to VA pharmacies, and lack of access to laboratory data required to safely dispense medications. CONCLUSIONS HCV-related medication costs predominated the first year of VCP, but this is likely to change going forward. The safe use of opioids, efficient management of nonformulary medications, and unintended new barriers to access created by the VCP must be addressed.
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14
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Dixon BE, Ofner S, Perkins SM, Myers LJ, Rosenman MB, Zillich AJ, French DD, Weiner M, Haggstrom DA. Which veterans enroll in a VA health information exchange program? J Am Med Inform Assoc 2016; 24:96-105. [PMID: 27274014 DOI: 10.1093/jamia/ocw058] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Revised: 03/06/2016] [Accepted: 03/24/2016] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To characterize patients who voluntarily enrolled in an electronic health information exchange (HIE) program designed to share data between Veterans Health Administration (VHA) and non-VHA institutions. MATERIALS AND METHODS Patients who agreed to participate in the HIE program were compared to those who did not. Patient characteristics associated with HIE enrollment were examined using a multivariable logistic regression model. Variables selected for inclusion were guided by a health care utilization model adapted to explain HIE enrollment. Data about patients' sociodemographics (age, gender), comorbidity (Charlson index score), utilization (primary and specialty care visits), and access (distance to VHA medical center, insurance, VHA benefits) were obtained from VHA and HIE electronic health records. RESULTS Among 57 072 patients, 6627 (12%) enrolled in the HIE program during its first year. The likelihood of HIE enrollment increased among patients ages 50-64, of female gender, with higher comorbidity, and with increasing utilization. Living in a rural area and being unmarried were associated with decreased likelihood of enrollment. DISCUSSION AND CONCLUSION Enrollment in HIE is complex, with several factors involved in a patient's decision to enroll. To broaden HIE participation, populations less likely to enroll should be targeted with tailored recruitment and educational strategies. Moreover, inclusion of special populations, such as patients with higher comorbidity or high utilizers, may help refine the definition of success with respect to HIE implementation.
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Affiliation(s)
- Brian E Dixon
- Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Indianapolis, IN .,Richard M. Fairbanks School of Public Health, Indiana University.,Center for Biomedical Informatics, Regenstrief Institute, Indianapolis, IN
| | - Susan Ofner
- Department of Biostatistics, School of Medicine, Indiana University
| | - Susan M Perkins
- Richard M. Fairbanks School of Public Health, Indiana University.,Department of Biostatistics, School of Medicine, Indiana University
| | - Laura J Myers
- Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Indianapolis, IN.,Department of General Internal Medicine and Geriatrics, School of Medicine, Indiana University
| | - Marc B Rosenman
- Department of Pediatrics, Children's Health Services Research, Indiana University.,Center for Health Services Research, Regenstrief Institute, Indianapolis, IN
| | - Alan J Zillich
- Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Indianapolis, IN.,Department of Pharmacy Practice, College of Pharmacy, Purdue University, West Lafayette, IN
| | - Dustin D French
- Department of Ophthalmology and Center for Healthcare Studies, Feinberg School of Medicine, Northwestern University, Chicago, IL.,Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Indianapolis, IN
| | - Michael Weiner
- Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Indianapolis, IN.,Department of General Internal Medicine and Geriatrics, School of Medicine, Indiana University.,Center for Health Services Research, Regenstrief Institute, Indianapolis, IN
| | - David A Haggstrom
- Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Indianapolis, IN.,Department of General Internal Medicine and Geriatrics, School of Medicine, Indiana University.,Center for Health Services Research, Regenstrief Institute, Indianapolis, IN
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15
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French DD, Dixon BE, Perkins SM, Myers LJ, Weiner M, Zillich AJ, Haggstrom DA. Short-Term Medical Costs of a VHA Health Information Exchange: A CHEERS-Compliant Article. Medicine (Baltimore) 2016; 95:e2481. [PMID: 26765453 PMCID: PMC4718279 DOI: 10.1097/md.0000000000002481] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The Virtual Lifetime Electronic Record (VLER) Health program provides the Veterans Health Administration (VHA) a framework whereby VHA providers can access the veterans' electronic health record information to coordinate healthcare across multiple sites of care. As an early adopter of VLER, the Indianapolis VHA and Regenstrief Institute implemented a regional demonstration program involving bi-directional health information exchange (HIE) between VHA and non-VHA providers.The aim of the study is to determine whether implementation of VLER HIE reduces 1 year VHA medical costs.A cohort evaluation with a concurrent control group compared VHA healthcare costs using propensity score adjustment. A CHEERs compliant checklist was used to conduct the cost evaluation.Patients were enrolled in the VLER program onsite at the Indianapolis VHA in outpatient clinics or through the release-of-information office.VHA cost data (in 2014 dollars) were obtained for both enrolled and nonenrolled (control) patients for 1 year prior to, and 1 year after, the index date of patient enrollment.There were 6104 patients enrolled in VLER and 45,700 patients in the control group. The annual adjusted total cost difference per patient was associated with a higher cost for VLER enrollees $1152 (95% CI: $807-1433) (P < 0.01) (in 2014 dollars) than VLER nonenrollees.Short-term evaluation of this demonstration project did not show immediate reductions in healthcare cost as might be expected if HIE decreased redundant medical tests and treatments. Cost reductions from shared health information may be realized with longer time horizons.
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Affiliation(s)
- Dustin D French
- From the Department of Ophthalmology and the Center for Healthcare Studies, Feinberg School of Medicine, Northwestern University, and the Veterans Affairs Health Services Research and Development Service, in Chicago, IL (DDF); Department of BioHealth Informatics, Indiana University School of Informatics and Computing, VHA Health Services Research and Development Center for Health Information and Communication, and Regenstrief Institute, Inc., (BED); Department of Biostatistics, Indiana University School of Medicine, (SMP); Center for Health Information and Communication, Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service; Division of General Internal Medicine, Department of Medicine, Indiana University School of Medicine, and Regenstrief Institute, Inc. (LJM, MW, DAH); and Center for Health Information and Communication, Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service,; Regenstrief Institute, Inc.; Indiana University Center for Health Services and Outcomes Research, Indianapolis, IN; College of Pharmacy, Purdue University, West Lafayette, IN (AJZ)
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