Large-scale assessment of missed opportunity risks in a complex hospital setting.

In this research, we apply a large-scale logistic regression analysis to assess the patient missed opportunity risks at a complex VA (US Department of Veterans Affairs) hospital in three categories, namely, no-show alone, no-show combined with late patient cancellation and no-show combined with late patient and clinic cancellations. The analysis includes unique explanatory variables related to VA patients for predicting missed opportunity risks. Furthermore, we develop two aggregated weather indices by combining many weather measures and include them as explanatory variables. The results indicate that most of the explanatory variables considered are significant factors for predicting the missed opportunity risks. Patients with afternoon appointment, higher percentage service connected, and insurance, married patients, shorter lead time and appointments with longer appointment length are consistently related to lower risks of missed opportunity. Furthermore, the VA patient-related factors and the two proposed weather indices are useful predictors for the risks of no-show and patient cancellation. More importantly, this research presents an effective procedure for VA hospitals and clinics to analyze the missed opportunity risks within the complex VA information technology system, and help them to develop proper interventions to mitigate the adverse effects caused by the missed opportunities.

Communication enhancement and best practices for co-managing dual care rural Veteran patients by VA and non-VA providers: a survey study.

Many rural Veteran patients receive healthcare services from both Veterans Affairs (VA) and non-VA providers. Effective management of dual care Veteran patients to ensure the best clinical outcomes is a VA mission. The previous VA studies indicate that coordination between VA and non-VA providers has been lacking for dual care management of Veteran patients. In this study, we propose that VA proactively shares information with non-VA providers to enhance the communication process and identify the best practices to be carried out by both VA and non-VA providers for better coordination. Structured questionnaires are designed and distributed to VA and non-VA providers to obtain their evaluations on the proposed VA proactive information sharing approaches and the best practice items for dual care management. The non-VA provider respondents largely support the proposed proactive sharing items by VA, with the lowest average score being 3.96 out of a 5.0 scale on one item. In terms of the best practice items on co-managing dual care patients, three out of five items are overall rated higher than 4.0 from both sides. A pair-wise comparison between VA and non-VA perspectives further shows that the difference in average ratings of a proposed item could be significant. For such best practice items, the implementations from both sides may not be most effective.

Transitions in dual care for veterans: non-federal physician perspectives.

Many veterans receive care from both the Veterans Health Administration (VHA) and the non-VHA health system, or dual care. Non-federal physicians practicing in Nebraska were surveyed to examine their perspectives on the organization and delivery of dual care provided to veterans. A paper-based survey was mailed to all 1,287 non-federal primary care physicians (PCPs) and a purposive sample of 765 specialist physicians practising in Nebraska. Rural physicians are more likely to incorporate care coordination practices in their clinical practice, compared to urban physicians. More rural physicians report difficulties in patient transfers, and referrals to the VHA, in prescribing for veteran patients, and in contacting a VHA provider in an emergent situation regarding their veteran patient. More PCPs also report difficulties in referrals to the VHA. However, more rural and primary care physicians follow up with their veteran patients post referral to the VHA. There was agreement among the physicians that the current dual care system needed improvements to provide timely, efficient, coordinated and high quality care to veterans. The specific areas identified for improvement were coordination of care, information sharing, medication management, streamlining of patient transfers, reimbursement for care provided outside the VA, and better delineation and clarity of the boundaries of each system and roles and responsibilities of VA and non-VA providers in the care of veterans.

Rural veterans' perspectives of dual care.

The purpose of this study was to develop an in-depth understanding of the barriers and enablers of effective dual care (care obtained from the Veterans Health Administration [VHA] and the private health system) for rural veterans. Telephone interviews of a random sample of 1,006 veterans residing in rural Nebraska were completed in 2010. A high proportion of the rural veterans interviewed reported receiving dual care. The common reasons cited for seeking care outside the VHA (or VA [Veterans Administration]) included having an established relationship with a non-VA provider and distance to the nearest VA medical center. Almost half of the veterans who reported having a personal doctor or nurse reported that this was a non-VA provider. Veterans reported high levels of satisfaction with the quality of care they receive. Ordinal logistic regression models found that veterans who were Medicare beneficiaries, and who rated their health status higher had higher satisfaction with dual care. The reasons cited by the veterans for seeking care at the VHA (quality of VHA care, lower costs of VHA care, entitlement) and veterans perceptions about dual care (confused about where to seek care for different ailments, perceived lack of coordination between VA and non VA providers) were significant predictors of veterans' satisfaction with dual care. This study will guide policymakers in the VA to design a shared care system that can provide seamless, timely, high quality and veteran centered care.

Electronic health information in use: Characteristics that support employee workflow and patient care.

The aim of this investigation was to assess helpful and challenging aspects of electronic health information with respect to clinical workflow and identify a set of characteristics that support patient care processes. We conducted 20 semi-structured interviews at a Veterans Affairs Medical Center, with a fully implemented electronic health record (EHR), and elicited positive and negative examples of how information technology (IT) affects the work of healthcare employees. Responses naturally shed light on information characteristics that aid work processes. We performed a secondary analysis on interview data and inductively identified characteristics of electronic information that support healthcare workflow. Participants provided 199 examples of how electronic information affects workflow. Seventeen characteristics emerged along with four primary domains: trustworthy and reliable; ubiquitous; effectively displayed; and adaptable to work demands. Each characteristic may be used to help evaluate health information technology pre- and post-implementation. Results provide several strategies to improve EHR design and implementation to better support healthcare workflow.

Exploring the persistence of paper with the electronic health record.

OBJECTIVE: Healthcare organizations are increasingly implementing electronic health records (EHRs) and other related health information technology (IT). Even in institutions which have long adopted these computerized systems, employees continue to rely on paper to complete their work. The objective of this study was to explore and understand human-technology integration factors that may be causing employees to rely on paper alternatives to the EHR. METHODS: We conducted semi-structured interviews with 20 key-informants in a large Veterans Affairs Medical Center (VAMC), with a fully implemented EHR, to understand the use of paper-based alternatives. Participants included clinicians, administrators, and IT specialists across several service areas in the medical center. RESULTS: We found 11 distinct categories of paper-based workarounds to the use of the EHR. Paper use related to the following: (1) efficiency; (2) knowledge/skill/ease of use; (3) memory; (4) sensorimotor preferences; (5) awareness; (6) task specificity; (7) task complexity; (8) data organization; (9) longitudinal data processes; (10) trust; and (11) security. We define each of these and provide examples that demonstrate how these categories promoted paper use in spite of a fully implemented EHR. CONCLUSIONS: In several cases, paper served as an important tool and assisted healthcare employees in their work. In other cases, paper use circumvented the intended EHR design, introduced potential gaps in documentation, and generated possible paths to medical error. We discuss implications of these findings for EHR design and implementation.

Quality improvement toward decreasing high-risk medications for older veteran outpatients.

OBJECTIVES: To examine the effectiveness of a quality improvement program to decrease prescribing of high-risk medications. DESIGN: Single cohort, pre- and postintervention. SETTING: Regional network of Department of Veterans Affairs medical facilities. PARTICIPANTS: Outpatient veterans aged 65 and older who received one or more high-risk medications and the prescribing clinicians. INTERVENTION: A two-stage intervention was implemented. First, a real-time warning message to prescribers appeared whenever one of the high-risk drugs was ordered; second, a personally addressed letter from the Chief Medical Officer asking prescribers to consider discontinuing the high-risk medication along with a copy of the Beers criteria article, a list of suggested alternatives to high-risk medications, and a list of older patients receiving the high-risk medications who had upcoming appointments with these prescribers. MEASUREMENTS: The primary outcome was the absence of prescribed high-risk medications for all patients in the cohort during the postintervention period. For a subgroup of the cohort whose prescribers received the second-stage intervention, an additional outcome was the absence of prescribed high-risk medications within the subgroup. RESULTS: Two thousand seven hundred fifty-three unique patients were identified in the cohort; 1,396 (50.7%) had high-risk medications discontinued, resulting in a significant decrease in the number of patients prescribed high-risk medications from the preintervention period to the postintervention period (P<.001). Of the 801 patients in the subgroup, 72.0% (n=577) had high-risk medications discontinued (P<.001). CONCLUSION: This multimethod intervention significantly decreased prescribing of high-risk medications to older patients. Further studies are needed to confirm the findings.

The use of telehealth for diabetes management: a qualitative study of telehealth provider perceptions.

BACKGROUND: Monitoring and Messaging Devices (MMDs) are telehealth systems used by patients in their homes, and are designed to promote patient self-management, patient education, and clinical monitoring and follow-up activities. Although these systems have been widely promoted by health care systems, including the Veterans Health Administration, very little information is available on factors that facilitate use of the MMD system, or on barriers to use. METHODS: We conducted in-depth qualitative interviews with clinicians using MMD-based telehealth programs at two Veterans Affairs Medical Centers in the Midwestern United States. RESULTS: Findings suggest that MMD program enrollment is limited by both clinical and non-clinical factors, and that patients have varying levels of program participation and system use. Telehealth providers see MMDs as a useful tool for monitoring patients who are interested in working on management of their disease, but are concerned with technical challenges and the time commitment required to use MMDs. CONCLUSION: Telehealth includes a rapidly evolving and potentially promising range of technologies for meeting the growing number of patients and clinicians who face the challenges of diabetes care, and future research should explore the most effective means of ensuring successful program implementation.

Outcomes associated with a home care telehealth intervention.

To determine whether adding telehealth technology to traditional home care services increases health-related quality of life (HRQOL) and home care satisfaction, and decreases resource utilization among home care patients. This trial included 37 home care patients receiving services in a Veterans Affairs medical center, randomized into intervention and control groups. Outcome measures included patient satisfaction and HRQOL at baseline and 6-month follow- up, and the use of inpatient and outpatient services before and during the 6-month study period. Intervention group patients reported greater improvement in the mental health component of HRQOL, (t = 2.27; df = 15; p = 0.04). Satisfaction with the telehealth equipment was high (means exceeded 4.0 on six measures ranging from 1-5). However, no statistically significant differences were observed between intervention and control groups in terms of changes in physical health, inpatient admissions, bed days of care, emergency department visits, or general satisfaction with home care services. Intervention group members did show a trend (p = 0.10) toward fewer overall outpatient visits (mean = 29.1; standard deviation [SD] +/- 30.1) compared to those receiving traditional home care services (mean = 38.9; SD +/- 28.9) The use of telehealth services as an adjunct to traditional home care is associated with greater improvements in mental health status and a trend toward lower use of inpatient and outpatient healthcare services. Further work, utilizing larger sample sizes, is needed to investigate the relationship between telehealth services, the use of healthcare resources, and other outcomes.

Perspectives from the Veterans Health Administration about opportunities and barriers in telemedicine.

We used qualitative interviews to examine the perceptions of direct providers of telemedicine services, primary care providers (PCPs) and hospital administrators about opportunities and barriers to the implementation of telemedicine services in a network of Veterans Health Administration hospitals. A total of 37 interviews were conducted (response rate of 28%) with 17 direct telemedicine providers, nine PCPs and 11 administrators. The overall inter-coder reliability across all themes was high (Scott's pi = 0.94). Direct telemedicine providers generally agreed that telemedicine improved rapport with patients, and respondents in all three groups generally agreed that telemedicine improves access, productivity, and the quality and coordination of care. Respondents mentioned several benefits to home telemedicine, including the ability to better manage chronic diseases, provide frequent clinician contact, facilitate quick responses to patient needs and provide care in patient's homes. Most respondents anticipated future growth in telemedicine services. Barriers to telemedicine implementation included technical challenges, the need for more education and training for patients and staff, preferences for in-person care, the need for programme improvement and the need for additional staff time to provide telemedicine services.

Research in home-care telemedicine: challenges in patient recruitment.

This study reports challenges in recruiting patients for a randomized controlled trial of homecare telemedicine. Descriptive statistics on patient eligibility for home-care telemedicine services and patient refusals for participation are provided. Frequency counts of reasons for study exclusion and participant refusal and Chi-square tests to compare race and age-related differences are given. Of 302 home-care patients reviewed, 197 (65.2%) did not meet inclusion criteria. The most common reasons for study exclusion were patients either needing <2 visits per month (n = 59, 30%) or >3 skilled nurse visits per week (n = 46, 23.4%). Of the eligible patients (n = 105), 79 persons (75.2%) refused participation. The most common reasons for refusals were lack of perceived addition benefit of telemedicine (n = 27, 34.2%), and that routine health care was sufficient (n = 23, 29.1%). Higher than expected proportions of patients did not meet chosen eligibility criteria or refused to participate. These results should be helpful in designing home-care telemedicine programs and clinical trials.