**Transcript of Cyberseminar**

**VIReC Clinical Informatics Series**

**The My HealtheVet Personal Health Record Portal in 2013: New Features, Study Findings, and Opportunities**

**Presenters:  Kim Nazi, PhD, FACHE ; Fran Weaver, PhD**

**May 21, 2013**

**The My HealtheVet Personal Health Record Portal in 2013: New Features, Study Findings, and Opportunities**

**May 21, 2013**

*This is an unedited transcript of this session. As such, it may contain omissions or errors due to sound quality or misinterpretation. For clarification or verification of any points in the transcript, please refer to the audio version posted at www.hsrd.research.va.gov/cyberseminars/catalog-archive.cfm or contact: virec@va.gov*

Moderator:Good afternoon, everyone and welcome. This session is part of the VA Information Resource Center’s ongoing clinical informatics cyberseminar series. The series aims are to provide information about research and quality improvement applications and clinical informatics and also information about approaches for evaluating clinical informatics applications. Thank you to cider for providing technical and promotional support for this series. Questions will be monitored during the talk. In the Q&A portion of go-to webinar and VIReC will present them to the speakers at the end of this session. A brief evaluation questionnaire will appear when you close GoToWebinar. Please take a few moments to complete it. Let us know if there is a specific topic area or suggested speaker that you would like us to consider for future sessions. 

At this time I would like to introduce our speakers for today Dr. Kim Nazi and Dr. Fran Weaver. Dr. Nazi is a management analyst in the Veterans and Consumer Health Informatics Office and the VHA Office of Informatics and Analytics. Dr. Weaver is director of the HSR&D Centers of Excellence at Hines VA Hospital, research director for the spinal cord injury query program, and a VA HSR&D career sciences awardee. She is also professor in the department of medicine and director of the program in health services research at Loyola University Chicago. Without further ado may I present Dr. Nazi and Dr. Weaver. 

Kim Nazi:Well, thank you very much. This is Kim Nazi and we are so pleased to have a chance to provide you with some information today. We have got a lot of great information to cover so we will be moving right along. And notice that the last time we had an opportunity to come and present the My Healthe Vet program it was in April of 2008 and of course a lot of things have changed since then. We would like to start by having a poll question, sort of get a sense of who is in our cyber audience today. So if you could take a few minutes and just respond to the poll that we are showing on the screen. And the question is which best describes your work at VA? So please take a moment and respond to that poll. Thank you. It looks like the majority of our attendees today are all in the research area followed by administrative and clinical. Thanks so much for participating in the poll. 

So let us have our objectives for today’s session. We have three significant objectives. We would like to provide you with a brief overview of the new and enhanced features including the expansion of the VA Blue Button. Then I would like to share some study findings from a study I conducted about My Health*e*Vet with some important findings related to adoption of PHR and secure messaging. And then Fran will present some strategies and opportunities for research collaboration. 

So what’s My Healthe Vet? of course the goal of My Health*e*Vet is to provide Veterans with an easy to use personal health record including trusted health education resources and a variety of tools. It is also very important that we provide VA patients with easier access to their personal health information. And in many cases that information resides in the VA electronic health record. We also want to provide them with tools to understand and manage their information and then of course support the important need to be able to communicate easily and securely with the healthcare community. Slide five shows just an overview of My Health*e*Vet features. This has been updated since we shared this a few years ago. We still continue to have a basic personal health record that patients can self-enter information in. 

We also continue to offer our online transactions such as VA prescription refill and prescription refill today still remains the most popular of our service. And we offer a number of trusted health education resources, access to information from the VA electronic health record for those VA patients who are authenticating. We also offer secure messaging with the VA healthcare team and the VA Blue Button and the Concierge Button. And I will be describing a little bit more about those as we go through. 

Just to give you an update on the statistics, we have really seen a lot of tremendous growth in the use of My Health*e*Vet. We remain having three types of accounts. And our language has changed a bit in talking about these. We still have a basic account, though, any user can self-register for an account on the site and utilize their self-entered personal health record features. For those who are Veterans or VA patients we now have an advanced account through which their basic identity can be matched and then correlated with the VA electronic health record and that would be an advanced account. And then what we used to call IPA or in person authenticated – once a Veteran or VA patient has been authenticated they now have a premium account. And it is very important for our VA patients to get those premium accounts because then they have access to all the really robust features that My Health*e*Vet offers. 

One new feature that we added this year was an icon that appears in the member lockout box so that it is easy for Veterans to identify the type of account that they have. We have seen a lot of growth in use of My Health*e*Vet. We now have logged more than ninety million visits. Currently as of April we have more than two point two million registered users and more than one point one million of those registrants now have a premium or authenticated account. Online prescription refill continues to be the most popular feature of the site. And just to give you an example of the scope we actually process, more than one million requests in January 2013 alone. 

VA Blue Button was a new addition to the site back in August of 2010 and we have had more than seven hundred and seventy thousand unique Blue Button users since that time. And those users have downloaded more than three point six million VA Blue Button files. Of course secure messaging is a very powerful tool for our patients to communicate with their healthcare team and others. And we have now had more than six hundred and forty thousand VA patients who have opted in to use secure messaging. For amount of growth, a lot of exponential growth especially in the last year. 

I would just like to briefly cover a few highlights of some of the new features of My Health*e*Vet. We added the food journal and the activity journal to the Blue Button for all registered users. These were data that could be self-entered into the portal previously and now are also available if that is selected in their VA Blue Button. In January 2013 we had probably one of the most significant releases in recent history. We are following on the heels of the My Health*e*Vet pilot. We now made available a lot of the rich data that is available in the VA electronic health record, available for our premium account holders to include in their VA Blue Button including VA notes. We also added a new information product, the VA continuity of care document. 

This is the summary of clinical information from VA’s electronic health records in an XML file format. And that file format is important because it contains standards for interoperability and it can also be exchanged between providers. This was a giant leap forward in terms of offering a structured data set and one that really positions us well for meaningful use. We also thought initially in XML file format. In March we added a style sheet so that users could download the style sheet and view the XML file and the data that it contains. And we also added a very user friendly PDF file format. And of course like the other access to the EHR data this also requires a premium My Health*e*Vet account. 

My Goals is part of the My Recovers plan suite of tools. And this new functionality helps Veterans to set individual relevant recovery goals and then to track progress towards achieving their goals. In the June release we will also make this self-entered data available as part of the VA Blue Button. And you can learn much more about these features and many of the other additions to My Health*e*Vet at our product website and I have included the link there. 

So let us think a little bit about the VA Blue Button. This is a very important part of My Health*e*Vet. This January release we have an option to include a much more robust dataset. So usually we add this to the GUI portion of My Health*e*Vet. We specifically chose to make more data available in patient’s hands through the VA Blue Button. The VA Blue Button enables Veterans to view and print and download an electronic file that contains all of their available personal health information. So for those VA patients with a premium account that actually includes not only their self-entered data but also the data from the VA’s electronic health records. 

There are three file formats, the text version and the Blue Button text output as well as a CVS file. Veterans can also easily customize their VA Blue Button by picking the types of information that they wish to include and also the date range. So using these two customization features it is very easy for Veterans to create Blue Button outputs that contain just the information that they need for a particular need. So for example, if a patient is preparing for a six month clinic visit and they wanted to just include their self-entered medications and supplements as well as their VA prescription history with a couple of clicks they could customize their output and prepare a file that really meets their needs. 

We are temporarily having a suspension of the PDF file format for both the Blue Button and also the VA CCV. And the reason for that is we have some concerns about Veterans who may be using tablet computers and the temporary files that may be created on those computers. So we have briefly suspended that and we are in the process of developing some additional content instruction for users and some additional options to be able to download the PDF view without incurring a temp file creation. So let us see those go on to be developed and deployed and then we will be able to again offer the PDF function. 

Let us take a look at some of the data classes that are included in the VA Blue Button. Here is a look at the self-reported data classes and of course I mentioned that we recently added the food journal and the activity journal. In terms of the data from the VA electronic health records, very important data to place in Veteran’s hands, you can see that we previously offered several types of information. We recently added a whole new set of information from the VA electronic health record and that includes the addition of microbiology lab test results, VA demographics, treating facilities in the last few years, the VA problem list which contains all active problems, VA admissions and discharges including discharge summaries, VA notes which is all progress notes, vitals and readings, pathology reports include surgical pathology, cytology, electron microscopy, VA radiology reports, and also a list of EKG studies that have been performed. 

We also offer one data element from the Department of Defense and that is the military service information. This can be very valuable to Veterans because it enables them to have data about their military service history and for example, for Veterans who are seeking employment to really translate that experience into knowledge, skills, and ability to seek employment. 

I mentioned the VA continuity of care document and what a really important addition that is as a new information product in the VA Blue Button. It is an XML file format although as I mentioned we now also offer a style sheet as well as the PDF file format. For those other healthcare systems that can consume this type of information if the patient can provide this XML file it would be very easy, then, for another non-VA healthcare provider to incorporate that into their medical record. There are also a number of skills that can consume this type of file. So for example, if a Veteran chose to use a personal health record system like Microsoft Healthflow they would actually be able to import this continuity of care document and combine their VA data with data from other systems. 

As an important feature enhancement in alignment with the meaningful use of criteria for not just being able to view and download information but also supporting the patient need to be able to transmit information securely we are also beginning to work on a future enhancement which is enabling a share button that will enable a premium account holder to not only view or download their continuity of care document but also to be able to authorize the system to share that via a direct protocol, let us say, to a non-VA provider who is also treating the patient. 

I would like to touch upon the inclusion of VA progress notes, VA notes, within the VA Blue Button. That happened in January. And it is very important to keep in mind that like all of the data in our health records patients have a legal right to access all this information and often patients do that, today we have the release of information office. Adding this information to the VA Blue Button simply makes this more easily accessible. And we would envision this being a much more efficient way for patients to obtain copies of their information rather than having to drive to a VA facility and request paper or electronic copy of their information. 

We also have quite a bit of experience with this, keep in mind that we offered the My Health*e*Vet pilot program I was actually in VISN 2 at the time and our medical centers were pilot sites. We ran that pilot program from 2000 thru 2010, learned quite a bit from that program and really demonstrated the value of providing patients with easy access to the information contained in the health records. And pretty compelling research evidence from the pilot program. In order to prepare the organization for this change a multi-disciplinary workgroup co-chaired by Dr. Susan Woods and myself began meeting back in November to identify communication and education needs. 

We actually were fortunate to have representation from all the major clinical program offices and clinical specialties. That group was really instrumental in helping us to surface any concerns and develop some strategies to address those concerns. And we actually in the program office conducted more than fifty briefings from October thru this last March in order to be sure that we have broad awareness of the fact the patient can now access this information more easily. And really to understand the positive benefit and to incorporate that into our healthcare system. 

So focusing on the VA notes we are calling this initiative VA OpenNotes. We are proud to report that we are actively partnering with the Robert Wood Johnson Foundation and the OpenNotes initiative. So in this initiative VA Notes now includes author and progress notes. We opted to start conservatively and begin with a perspective approach that was deployed in January. We began with notes that were written on or after January first of this year. VA Notes like many of the EHR data classes are currently having a 7 day hold meaning that they become available for the patient to include in their blue button 7 calendar days after the note has been completed. Of course we are – have been giving some consideration to making more timely access to information and quite honestly when we look at our tools to collect direct feedback from Veterans while they find access to this data to be very beneficial they really do want that access to be more timely. 

And oftentimes it is actionable information that would be very important for the patient to have access to it in a timely manner. And in fact just late last week our program office convened with clinical and senior leadership and received guidance to reduce those hold periods. And what that means for us is that June we will see more timely access to information. Those hold periods that apply to several of the VA data classes will be reduced from seven days to three days. And there is one exception to that: for VA pathology reports that will remain at a fourteen day hold. So these are important changes that will be upcoming in our June release. Again you can learn much more about that by speaking with your My Health*e*Vet coordinator and also we have a number of resources available to you on the product website. 

Just touching upon the My Health*e*Vet pilot I just wanted to share with you one of the studies that was conducted and in the study we surveyed all of the pilot participants, had a pretty good response rating, really discovered from the perspective of the patient having access to their personal health information it really improved communication. It helped them to stick to their treatment and plan. They felt that it improved their healthcare and that information and services would be useful. So lots of great data coming out of the pilot program the first – that experience was very helpful in developing the same functionality in the national program. 

So now I would like to take a moment and ask you to participate in another poll. And this poll will ask you to comment on which statement most closely describes your opinion about patients having access to VA notes. And there are three options. So please take a moment and respond to that post so that we can take a temperature check with our audience today. While you are responding to that I would just we had a lot of positive feedback from Veterans about having access to their progress now. For example, Veterans health was gonna say that. A lot happens in the fifteen minute clinical visit and that it is really valuable to be able to have access to information from that visit after the visit because it contains important information to remember what was said in the visit and also be able to follow instructions or guidance that was provided by the healthcare team. 

And I can see from the results that seventy-one percent of you think that the benefits outweigh the risks. It has been our experience with the pilot program and with VA OpenNotes to date. And of course we will continue to evolve that. And thanks for participating in the poll. It is very helpful to us. So there was our first objective. Now I would like to turn attention to briefly present some study findings from a qualitative study that was done last year in order to understand the healthcare change perspective about personal health records and use of secure messaging. Here is a reference, the study findings were recently published in the Journal of Medical Internet Research. 

And so I would like to kind of set the stage for this before we kind of take a look at the key findings. For decades we have been thinking about the anticipated benefits of personal health records, actually since the landmark institute of medicine report Crossing the Quality Chasm. Of course a number of benefits that we anticipate – if our patients were to use personal health records that we would incur. And yet I am calling this a paradox, I think it is pretty striking that over the last decade and a half or so we continue to see reports that consumer interest in personal health records is high while  adoption of personal health records is relatively low. And I would caveat this that I think we have seen quite a bit of growth in the last year. We also saw historically the growth and demise of various personal health record models. If you remember, back in the day there was the untethered, standalones, and then the tethered and personal health record systems. We saw both Microsoft and Google enter the space and then Google Health suspend their offering because they were unable to generate enough adoption. We also saw great evolution in patient portal systems, not just within VA but of course in many of our partner organizations. Kaiser Permanente, I think, being a notable example. 

And of course we have also seen this trajectory of meaningful use. So not only to implement technology beginning with electronic health records but also to demonstrate that when you use that technology in meaningful ways. We also know that focusing on the paradox that customers value transactional services, they are here to accomplish tasks, and they want tools that provide convenience. They expect easy access to their personal health information, and also that it is very important who is sponsoring that access and they do value trusted relationships with healthcare providers and organizations. And I would suggest that there is a new paradigm, that for decades we talked about this growth of consumer empowerment. And while the idea is rich and as important as it was since the phrase was coined, I really think we have learned that we have to kind of peel away the onion, if you will. So consumer empowerment was just part of the equation. And the healthcare professional endorsement and engagement with patient PHR use is crucial and indeed may be transformational. 

We have seen a number of studies in the literature that point to that. And healthcare professionals and assistants really need to just not offer portals but also to really integrate that into the fabric of care and meaningful use. So for example, for the empowered consumer who may show up other VA clinic visits with self –generated information. And what is the response of the provider to that? I think that will have a pretty important implication in terms of what happens next. We also have learned that healthcare professionals do value tools that engage and activate patients, certainly they recognize that the patient generated data is a really rich source of data but that we must invoke it in ways that make it accessible to the healthcare team and also manageable. 

And also that even as we offer solutions to patients they much integrate with clinical workload. And of course I am sure that all of you aware of the sense of ownership and also efficiency in terms of relative advantage over existing or other solutions. So the essential research problem that I have been to follow needs to really just say this growth of consumer empowerment, we have this PHR paradox. We really need to also explore the social organizational concepts that healthcare delivery. Most of the healthcare in this country is delivered in this way. And to also just focus to the relationship that patients have with their healthcare team as well information focusing on work tasks and work preferences. 

And indeed much of the focus has been on patients. Actually little is known about the perspective of healthcare professionals and also to really understand PHR use not just as a separate tool but as a component of healthcare workers influenced by organizational factors and of course your work preferences. I drew a quick conceptual framework for the study. I am sure many of you are familiar with Technologies-in-practice framework which places focus not just on the technology but also on the human agency and the resulting practices that emerge from use of that technology, also the Diffusion of Innovations theory and the information ecology model which represents the dynamic between the technology people in practices in those systems. 

I chose a qualitative method. I conducted in-depth interviews with thirty healthcare professionals, ten providers, ten nurses, and ten pharmacists. I used a purposeful and theoretical sampling and had an initial background questionnaire to understand the depth of experience with four different features of interest. Of course that followed contemporary qualitative methods. Early on I also discovered that most of the experience of healthcare professionals was actually with secure messaging. And interestingly the study occurred at a time when we were moving down the trajectory of implementing patient aligned care teams. So I also added to the study a study of the trajectory of secure messaging implementation since that had such an important impact on the outcome.

And just to give you a glance at that I really traced it from the early days of March 2004 all the way up to the offering of incentivizing performance measures and moving kind of from this organizing voluntary program to where we have had some performance measures that call for implementation of secure messaging across the nation. 

And then briefly just some key things that emerged from the study. I found that there was a general awareness of My Health*e*Vet in healthcare professional communities but also little familiarity with its features prior to the implementation of secure messaging. Secure messaging seems to be kind of a point at which the ecosystem changed. Not only was it kind of putting My Health*e*Vet further on the radar for healthcare professionals but it was also implemented in a different way that included education and training and a lot of focus on integration within the clinical workflow. Using secure messaging healthcare professionals reported some very interesting _____ [0:28:55]. 

For example, it actually lowered the threshold at which patients initiated communication. So healthcare professionals would have frequent communication in between traditional visits. And also that patients felt more maybe if they had a question or  concern that did not necessarily warrant requesting an appointment or even a phone call but they had a great comfort level in sending a secure message to the team. In terms of efficiency like other studies this study revealed that use of secure messaging was both convenient and efficient. Avoiding phone tag, and at times eliminating the need for an actual physical visit. The patient self-reported medications via secure messaging is different in that it was more timely, actionable, and bidirectional. 

The mediation reconciliation part of this study was quite interesting and what healthcare professionals shared was that medication reconciliation is a process. And it really always comes back to the dialogue between the patients. So although patients may be keeping and providing even medications what was different about secure messaging is that it was more timely and also bidirectional. So it gave us the kind of dialogue that bidirectional communication, that collaborative work such as medication reconciliation really requires – so that is  a really good example of being able to take the technology but really think about how it fits and how it applies to enable participants to accomplish the work. 

So now i would just like to briefly cover some of the most important findings of the study. I mentioned that several of the My Health*e*Vet features were reported as underutilized by healthcare professionals while secure messaging they really felt kind of put My Health*e*Vet on their radar back for them. The tools that were underutilized what I spoke with healthcare professionals about where the patient health education resources, the tools to support medication reconciliation, and also the tools to enable patient tracking and self-reporting of data. And there were some important reasons why healthcare professionals had previously limited endorsement of these tools or some things that need to happen in order for these to be more readily made part of the clinical visit. 

Having said that, of course, there were some beautiful exceptions to this where for example, a nurse would describe how she really effectively utilized My Health*e*Vet patient education resources and the dramatic impact that had on her patients The second key finding was that there were several factors that really facilitated or inhibited the adoption, use, or endorsement of patient use by these healthcare professionals. The study revealed a number of these key factors including education and training opportunities geared towards healthcare professionals, integration with the existing technology used to accomplish the work, alignment with the workflow within the setting of these, incentives that affect the intended users. 

For example, secure messaging which arrived and was implemented in a way ultimately moving kind of an organic program to really one that the younger secretaries had some performance measures for in terms of targeting level headed options. And if you look at the growth trends and map that to the implementation milestones that occurred you can really observe the impact of such incentives. Another thing, for example, is access to information entered by patients. If you continue to aim towards having features available a delegation feature in My Health*e*Vet so patients can authorize sharing of their information with the healthcare team. Any absence of delegation that was present in the pilot, are not in the national program yet, healthcare professionals have concerns about endorsing use of a particular thing. So I – patient – this understanding I think if they enter information into the portal that the healthcare professionals are also able to access that information. 

And moving onto finding number three: studying the secure messaging was really the missing element of a complex information ecology. Thinking about the organization and all that is part of the ecology and its implementation acted as a catalyst for change. We really saw from these from these healthcare professionals, of course, that once secure messaging came about and was part of the suite of tools for My Health*e*Vet it really changed the perception of My Health*e*Vet. It made some of those other tools more useful because it enabled the communication that was so key and it also had shaping effects on workflow, work practices, and the flow of information. 

So for example, it was not just using secure messaging instead of using the telephone. It was also thinking about using secure messaging, for example, for pre-appointment planning, to actually improve the workflow and really then focus the clinical visit not on the exchange of information but on the clinical needs and discussion with the patient. Number four: secure messaging has had dramatic consequences for communication and there is some beautiful data – beautifully rich data as part of this. As healthcare professionals really describes the impact that secure messaging has had in enhancing communication, enhancing access, helping them to know their patients better, and ultimately improving the relationship that they have with those patients that they are secure messaging with. 

Just a couple of data to share with you because it is really powerful data from this qualitative study. One healthcare provider, primary care doctor, that really gives you a conversation that you might not otherwise have had. And to really think about how the patients and MDs are able to have a better understanding, better perspective, and therefore emerging challenges. Another example from a healthcare provider who said that it is really a different kind of information gathering journey and one that really strengthens the relationship. And this provider was a primary care doc talking about secure messaging. And just one last example: this was another healthcare provider who said using secure messaging with her patients that face to face visits just really seemed to have a better flow. 

And I just love this quote so I am going to share it with you. Really enabling the patient to set the agenda and then say what they would like to accomplish and then we launch from there in the direction that the patient really wants to travel. This provider also said that with secure messaging this is the best healthcare in all of her years of practice that she has ever been able to deliver. So some pretty compelling data from there. I just would like to wrap up this section but sharing with you a couple more things and I will go through these rather quickly so that you can also accomplish our next objective. 

These considerations for asynchronous electronic communications which is really secure messaging. Recognizing that it is best done within existing relationship, noting that healthcare professionals can pretty easily move between methods of communication, so for example, healthcare providers and nurses, feel very comfortable using secure messaging because they felt very confident in being able to move to a different forum if that was warranted. So, for example, if they felt this particular patient whom they knew really warranted a phone call they would feel very comfortable hopping over and switching methods. 

There are also unanticipated consequences like every other use of technology, right. Some of these are positive and some of these are negative. Just one interesting example would be the use of pharmacists reporting that patients now using secure messaging for prescription refill requests rather than using the online tool and of course that creates a whole another set of workflows. 

What is interesting, though, in kind of digging in that, too, a little deeper is thinking about it from a communication perspective in which patients really value kind of that human dialogue, right. So the pharmacist would refill the prescription and then respond and say hey, Mr. Jones, I have refilled your prescription. Thanks for writing today. You ought to get that in a week. And contrasting that would be the experience of the patient simply check boxing an application. So that gets some thoughts that in part human need that we have for communication. And of course there are lots of opportunities for clinical process design. So if none of these tools are available I think the next part of the journey for My Health*e*Vet is really to embed use of this technology in meaningful ways within the clinical delivery system. 

And then a couple of additional considerations: for those of you in the [inaud.] sciences who are not quite familiar, I was thinking about, for example, the importance of fit with your existing system, the important role of performance measures as incentives and really thinking about the journey to implement personal health records and really focusing on our activities and processes, the work that these features are intended to support. So that we not only build the technology but we built it in way that supports the work and the tasks and also if that is collaborative work to be sure that we also built that into the clinical information system in a way that supports clinical workflow. 

More areas for future research, and of course these are the spectrum, everything from adoption to implementation, to education, information flow communication. So it is a new world. We live in a ubiquitous time of electronic communication. I think there is across all these things lots of opportunities for additional research to be done that will really help us to understand and improve patient use of technology. And then the implications, kind of going back to the idea of the paradox in which we have consumers who express the desire to use personal health records but limited adoption given all things to really think about the important influence of healthcare professionals as they endorse and utilize these tools in concert with patient needs. 

To do that of course we need to be sure that all of our healthcare professionals also understand the features, have ample opportunities for training and education. We give thought to how this fits with healthcare processes such as medication reconciliation. And then also careful attention to not just workflow but also the implications for work [inaud.]. And here is just I am sharing with you kind of the view of the world just to think about how these personal health record tools might fit in the various activities that are involved in a typical patient trajectory. 

So that is a lot of ground to cover. I hope that you are now a bit more familiar with some of the new and enhanced features for My Health*e*Vet secure messaging and the VA Blue Button. Thanks for the opportunity to share with you some of the findings from our recent qualitative study and some important implications from those findings. The next segment of this call will focus on strategies and opportunities for research collaboration. And before I pass the baton to Dr. Weaver we are going to ask you to participate in one more poll. And this poll asks you to tell us, all of you in our cyber audience today, are you currently conducting or planning to conduct a research study that involves My Health*e*Vet. So please take a moment to respond to that poll. And then Dr. Weaver will present next. 

And it looks like at least a third of you are either currently or planning to conduct a research study that may involve My Health*e*Vet. Another twenty percent are not sure. And there are a number of people who are not planning to and perhaps you will be intrigued by some of the information that we presented today and consider joining us in our research collaboration efforts. And that said I would like to now introduce a wonderful colleague, Dr. Fran Weaver. Dr. Weaver is the chair of our My Health*e*Vet clinical advisory board research infrastructure workgroup. And she is really, really helped us to try to accomplish lots of progress and trying to build a strong infrastructure to support collaboration with VA researchers. Fran?

Fran Weaver:Thank you Kim, and hello everyone. I just have a few slides talking about research opportunities following Kim’s very interesting presentation. So when I think about My Health*e*Vet I think about My Health*e*Vet as an intervention and also as a source of data. In the eHealth QUERI which was established almost three years ago now, was established to work with technology, MVA, or healthcare delivery particularly with My Health*e*Vet. And their primary objectives for the first three years have focused on patient adoption of the My Health*e*Vet platform and how best can we utilize these technologies in a meaningful way to promote patient healthcare. 

As Kim mentioned I am the chair of the research infrastructure workgroup for My Health*e*Vet. And our purpose is to identify strategies and procedures to help you as researchers conduct the search that involves My Health*e*Vet. One of the most frequent requests that we get are requests and letters and support from My Health*e*Vet as part of applications for grants or career development or through other funding type mechanisms. And those letters may also involve working with the eHealth QUERI and eHealth QUERI and research infrastructure workgroup work in conjunction to make sure that we have the appropriate letters that are sent out to the investigators to include in the packages. 

So for projects that would align with the eHealth QUERI letter of support I would direct you to the eHealth QUERI group. Their website to learn more about how they – you can work with them and obtain letters of support. For those of you who are working with My Health*e*Vet, whether or not you are aligned with the eHealth QUERI you may want a letter of endorsement from My Health*e*Vet for research that you are doing. We have put together a request checklist that helps us to better evaluate what your needs are and whether what you are proposing to do is feasible through My Health*e*Vet. So in that request checklist which if you are interested in worrying about that, please email me, we ask whether the project requires any resources from My Health*e*Vet? Is there something that you need from My Health*e*Vet in terms of data, access, information? Second do you specifically require access to any My Health*e*Vet data such as the administrative data, patient self-entered data, or other sources of data such as the American – consumer satisfaction index questionnaire that is part of the My Health*e*Vet site. 

We also will ask you for a copy of your proposal, a draft is fine so we have a sense of what it is that you are proposing to do. When is the grant to be submitted and we ask for two and three week’s notice in order to develop that letter so that the infrastructure group can review it, make sure that what you are requesting is indeed feasible and aligned with the VA My Health*e*Vet mission. And then once that letter has been drafted it is routed through My Health*e*Vet for signature and then back to the investigator. And it has been a relatively smooth process in most cases. Especially if we have advanced warning. 

In terms of My Health*e*Vet data and sources, when we presented back in 2008, and I cannot remember – cannot believe it was that long ago, we had put together a table of the different types of data and courses of data that are related to My Health*e*Vet. And when we looked at it, Kim and I looked at it recently, we realized that it needs a lot of updating because so many things have happened as Kim showed in her earlier slides. There have been so many new functions and features that have been rolled out in the last less than a year that we really are not up to speed on all the data and sources that are available. But this just gives you a bit of a flavor of what you might work with as a researcher. So there is administrative data that is collected when an individual registers on My Health*e*Vet. There is some demographics information. We also know the level of My Health*e*Vet access, the basic advanced and premium levels, the date and type of transactions that occurred. So if you wanted to know when an individual was refilling a medication through My Health*e*Vet that type of information is available through administrative – the administrative data sources. 

Web analytics helps you track where individual go when they are on My Health*e*Vet website. So if you are interested in looking at whether they are visiting certain pages and what order they are visiting them in. And now we have the Blue Button downloads that we know how frequently and in what format individuals are downloading their information. Patient self-entered information, things like tracking their health, their health history, their medications, their goals, those are patient owned data. Those are entered by the patient and are only available for research if you have the patient’s permission and they – the patient provides that information to you. 

The American Consumer Satisfaction Index is the survey that individuals will be asked to complete when they visit at least four pages on My Health*e*Vet. It is a pop-up. It is managed by Foresee. And it collects a lot of information about patient demographics, reason for the visit to My Health*e*Vet, what kind of views they are interested in, how satisfied they are with the site. There are a set of custom questions that are rotated through the satisfaction survey at various intervals. They are typically related to new information or features that are rolled out. They plan to have a set of questions related to secure messaging in the near future. Anyone who is interested in working with the consumer satisfaction index data would have to complete a data use agreement that would have to be vetted through the My Health*e*Vet office. If anybody is interested in that I can provide a copy of the DUA that you would need to complete. 

Other data and sources that I think you may be familiar with if you are interested in at what level an individual is accessing My Health*e*Vet there is a flag data that is available both at the national and local level. The shep data can be used to look at some issues related to My Health*e*Vet. We work closely with My Health*e*Vet coordinators. Every facility has one. They are a wealth of information regarding My Health*e*Vet. And then the PACT Compass measures which are available through the VSSC provide you information about using My Health*e*Vet transactions such as secure messaging. 

Lastly we wanted to talk a little bit about some of the frequently asked questions that Kim, myself, and some others have been receiving in the last several months as secure messaging has become more available and familiar to folks. And this is something that we hope to disseminate through a number of mechanisms, through the eHealth QUERI, through the My Health*e*Vet website, two other mechanisms as well. And this is something that we have reviewed this policy workgroup and infrastructure workgroup and the privacy ops  in the VA. So individuals often ask whether My Health*e*Vet administrative data can be used for research. Before that could happen there were some major changes that had to be made in terms of the system of records for My Health*e*Vet and the My Health*e*Vet terms and conditions that come up when an individual registers on My Health*e*Vet. 

Those had to be modified to specify research as a purpose of use for administrative data – for projects that are authorized and IRB approved. That took a significant amount of time but we have made it through both of those kinks now and research is now a specified use for My Health*e*Vet administrative data. My Health*e*Vet is working with the VSSC now to populate the My Health*e*Vet data march within the corporate data warehouse. This is not yet available but we hope that will be available in the near future. Requests would then be managed through the DART system similar to other program office data that you are familiar with. 

A second question is whether My Health*e*Vet administrative data such as email can be used for research related communication. The answer to that is no. the terms and conditions that were modified for My Health*e*Vet do not specify that account email, the individual’s answer when they set up their registration can be used for research related communication. So at this point, no, we cannot use patient emails to communicate. 

Can My Health*e*Vet secure messaging content be used for research? Well, the first thing that you should know is that the content of secure messages is not stored in corporate data warehouse, nor will it be. Activity related to secure messaging will be stored supporting the PACT Compass. And it will be available through VSSC. So we will know whether patients sent secure messages, how many messages they sent, that kind of activity, but not the content. To access content of secure messaging would be similar to patient self-entered information. It would require IRB approval and patient informed consent and the patient would have to actually provide that information to you through something like a Blue Button download. 

Can secure messaging be used for research communication? We identified three scenarios in which this might occur. The first is for research related communication. So for example, say you have a group of patients that in a study where you periodically need them to do something such as respond to a web-based survey. You could think about secure messaging as a way to contact those individuals and say hey, it is the three month follow up and we need you to go to the website and complete your survey. Currently at this point in time that option is not available but we think that this could be a very important mechanism for use of the secure messaging. But we want to work out the kinks. And we are recommending a pilot be done to explore the use of this mechanism for communication and then identify any issues and resolve those before this is made available on a larger framework. 

Using secure messaging to deliver interventions, My Health*e*Vet is very supportive of this view within the IRB framework. So if you are proposing to study an intervention, for example, three visit planning, for example, where you want to look at whether communicating with patients in advance of a visit to understand what their concerns are and then addressing those in the visit. You could do that through messaging and we are supportive of that within the IRB framework. 

And lastly use of secure messaging for study recruitment. We do not recommend this. And the reason we do not recommend this is this could be perceived as burdensome or inappropriate by patients and it could dilute the patient provider channel of communication. So at this point in time we do not see the ability to use the secure messaging for recruitment of Veterans into studies. Just very quickly, I know we are almost out of time, we have gotten over fifty requests for letters to sort in the last (several years] for all kinds of different projects. And here is a list of the different types of topics of which people have approached us about so you can see it really does cover a wide scope of issues. So I am going to stop and we do have a few minutes for questions. 

Moderator:First question: on slide five I did not see secure messaging for call center staff to submit an electronic message on behalf of a Veteran to their care team. I heard this was a new feature. Can you talk about this feature and if and when it will be available? 

Kim:This is Kim. Could you repeat the very first part of that again? 

Moderator:Yes. On slide five I did not see secure messaging for call center staff to submit and electronic message on behalf of a Veteran to their care team. I heard this was a new feature, can you talk about this feature and if and when it will be available. 

Kim:I will take an action item to answer that question but I can say today is that we implemented secure messaging, we then really focused on having teams to be sure that PACT teams at every facility across the country were utilizing secure messaging with their patients. We then kind of expanded to focus on surgical and specialty teams. And we are also doing some piloting administrative areas. This question kind of points to something where I think there is perhaps a local innovative group. And so I will take the action item to spend a little bit more about that, discuss it with our kind of leads and provide a response to that. If there is an effective use that fits within the current triage structure or what the administrative portal enables and so have begun to use that. And I think it is a great way to communicate with the patients. 

Moderator:Great, thank you for that. Did the hold periods recently change? 

Kim:That is a great question. This is Kim again. I probably covered that quite quickly given all the information we wanted to share with you. The hold periods have gone in place since the January release. What I shared today is that we have been giving some consideration to changing those and those will be changing in the June release. For those data classes that have a seven day hold period those will change to a three day hold. And the only exception to that is the VA pathology reports which is currently a fourteen day hold and will remain as fourteen day hold. We have just worked with senior and clinical leadership our – Theresa Hancock and so shared that with our My Health*e*Vet coordinators and champions but it is fresh news. 

They will be working to provide additional tools and resources. We have got a number of venues to do that not only on our product website but we also have through the forums with the My Health*e*Vet coordinators, so we will be comparing – we can be sure that all of our VA staff across the country are made aware of the changes since Kent supports – certainly it is a wonderful change in terms of responding to patients who really do want more timely answers to their information. 

Moderator:Great, thank you for that. We are at the top of the hour. The remaining questions can be answered offline. I would like to thank doctors Nazi and Weaver for taking the time to develop this presentation. Please forward any remaining questions to VIReC’s help desk at Virec@va.gov. Our next session is scheduled for Tuesday, June 18th and is entitled *Care Assessment Need Score*: *A tool for Care Management and the Patient Care Assessment System.*The speakers are Tamara Box and Dr. Stevenson. We hope you can join us. Heidi, back to you. 

Heidi:Great, thank you. And I do want to thank Kim and Fran for taking the time to put everything together and present today. We really appreciate the time you put into it. And for our audience just a reminder as you leave the session today you will be prompted with a feedback survey. We would really appreciate if you took a few moments to fill that out. We really do read through all of your feedback. If that feedback survey does not pop up for you we will be sending you the link in the archive notice when that is sent out. Once again thank you to everyone for joining us for today’s Viric clinical informatics cyberseminar and we hope to see you at a future session. Thank you. 

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