VA Provider-Facing mHealth

Neil C. Evans, MD

Associate Chief of Staff, Informatics & Co-Chief, Primary Care

Deyne Bentt, MD

Assistant Chief, Informatics & Assistant Chief, Anesthesiology

Washington DC Veterans Affairs Medical Center
Who is here?

a. VA healthcare provider

b. Non-VA healthcare provider

c. Research Professional

d. Administrator

e. IT Professional

f. Other

Poll Question #1
Do you own a

smartphone?

a. Yes

b. No

Poll Question #2
Do you own a tablet (iPad, Kindle Fire, Android 

tablet, etc)?

a. Yes

b. No

Poll Question #3
Manhattan Research “Taking the Pulse” Survey

(2041 US physicians surveyed)

• May 2011

– 30% of US physicians owned an iPad

– 28% of US physicians planned to purchase one in 

the next six months

– 81% of US physicians owned a smartphone

– 75% of US physicians owned at least one Apple 

product

Mobile Devices and US Healthcare Providers
Manhattan Research “Taking the Pulse” Survey

(3015 US physicians surveyed)

• May 2012

– Tablet use up to 62% of physicians (increased 

from 30-35% last year)

– 50% of tablet-owning physicians have used them 

at the point-of-care

– Smartphone use remains very high

Mobile Devices and US Healthcare Providers
• 21st Century VA Guiding Principles

people-centric, results-driven, forward-looking

• “VA’s transformation will leverage the power of 21st century 

technology and know-how.” Secretary Eric Shinseki (Strategic 

Plan FY 10-14)

• The VA Innovation Initiative was created to tap into the 

creativity, talent, and expertise of VA employees, private sector 

companies, and academic partners – encouraging the 

contribution and development of innovations that improve the 

delivery of high-quality, accessible, highly-satisfying, and costefficient care. 

VA Innovation Initiative (VAi2)
• Partnership with 

• January 2011 through December 2011

• Goals

– Work through security issues to allow use of 

iOS devices within the VA environment.

– Develop an iOS app to allow display of selected 

patient data from Vista on mobile devices.

– Develop a prototype VA App Library (Store)

– Pilot iOS devices and the patient viewer app at 

the DC VAMC 

VAi2 Innovation Project – iHealth Adapter
Mobility Vision

• Embrace Innovation / mHealth.

• Provide Decision Support and VA Clinical Data efficiently at the 

point of care.

• Improving Caregiver/Veteran Interaction, Access to Information, 

and Benefits.

• Assure Information Security
Improved Workplace Productivity

with Mobile Smart Devices
Device provisioning & 

configuration 

Configuration & profile 

testing 

Asset management 

Policy enforcement 

Threat modeling 

Pilot & security validation 
1

All traffic is single, 

double, or triply 

encrypted

2

Sensitive data does 

not persist on devices 

or uses FIPS 

encryption at rest

3

Read only (to start)

Good

Active Sync 

Email

Good Tech

Email

iHealth 

Clinical App

MDM 

Agent

Wi-Fi (WPA2 

Encryption Tunnel)

SSL

SSL

SSL

SSL

Triple Encryption:

1.TLS encryption through –

2.WPA2 encrypted tunnel, through –

3.FIPS certified VPN encrypted tunnel

Double Encryption:

1.TLS encryption through –

2.WPA2 encrypted tunnel

T L S

T L S EXCHANGE 

SERVER

IHEALTH 

ADAPTE

R

T L S

VISTA

I N S I D E V A 

F A C I L I T Y A N D 

I A B O U N D A R Y

Double Encryption:

1.TLS encryption through –

2.WPA2 encrypted tunnel

Single Encryption:

1. TLS encryption through 

Double Encryption:

1.TLS encryption through –

2.WPA2 encrypted tunnel

INTERNAT ACCESS to Non-VA 

Sites (from Home, Store, Car)

FIPS Certified Encryption Tunnel

WPA2 Encryption Tunnel

VA Certificate and SSL Encryption

FIPS TLS Encryption VPN Client (Encrypted Tunnel)

FIPS

FIPS

ATT 3G (No 

Encryption Tunnel)

I N T E R N E T A C C E S S t o N o n - V A S i t e s 

( f r o m H o m e , S t o r e , C a r )

T L S

No Data 

Persists

No VA

Data

256-bit

AES

256-bit

AES

FIPS

Wi-Fi (WPA2 

Encryption Tunnel)

ATT 3G (No Encryption 

Tunnel)

T L S

Data does not Persist or 

FIPS Encryption at Rest

256-bit AES Hardware Encryption

Architecture / Security
Architecture / Security 
14

VA Enterprise Application Store
Decision Support / Patient Education Apps
Decision Support / Patient Education Apps
Improved Workplace Productivity

with Mobile Smart Devices
Jones

•••••••

Q W

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return

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Z X C V B N M

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,

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.

S D F G H J K L

Application Development: VAi2 
Application Development: VAi2 

smith

Q W

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return

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Z X C V B N M

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.

S D F G H J K L
Application Development: VAi2 

smith
Application Development: VAi2 

smith
Application Development: VAi2 

smith
Application Development: VAi2 

smith
• Three month pilot Washington DC VA Medical 

Center (September – December 2011)

• Thirty providers – Clinical Apps, 15 iPads, 15 

iPhones

• Metrics:

– Performance

– Usage

– Four surveys – pre-pilot, 1,2,3 months

 Satisfaction, usability, clinical impact

Pilot Metrics and Monitoring
Performance

3

1

2 2

2

2

2

2

3 Seconds

1

Initial 

implementation 

data retrieval 

issue

2

Version update 

downloads

3

Ram failure on 

server
Data and Cellular Usage

• iPad Data - 0.23 GB

• iPhone Data – 0.41 GB

• iPhone Minutes – 330 min

Service Provider Monthly Data/Minutes Usage (Average) 

Average Monthly Kbs (iPad)

Kbs

Sep-11 Oct-11 Nov-11

Average Monthly Kbs (iPhone)

450k

400k

350k

300k

250k

200k

150k

100k

50k

0

Sep-11 Oct-11 Nov-11

300

300

250

200

150

100

50

0

Minutes

Average Monthly Minutes (iPhone)

Sep-11 Oct-11 Nov-11

450k

400k

350k

300k

250k

200k

150k

100k

50k

0
• Pre-survey

– 26% never used an iOS device

– 30% average user

– 44% facile iOS device user

Provider Usage

38%

23% 8%

31%

Usage Per Day

Greater than 5 times per 

day

Not every week

Not every day, but at 

least weekly

Daily, but 5 times or less 

per day
Device and Network Satisfaction

Connect to the VA 

network by VPN 

while on 3G only

Connect to the VA 

network by VPN 

while on WiFi

The touch screen 

as an input device

Ability to quickly 

become familiar 

with the device 

(iPhone/iPad)

0% 10% 20% 30% 40% 50% 60%

PERCENT OF RESPONSES

Very Satisfied

Somewhat Satisfied

Neither Satisfied nor Dissatisfied

Somewhat Dissatisfied

Very Dissatisfied
Application Performance Satisfaction

Email Access from 

the iPhone/iPad

Clinic Schedule and 

Calendar Integration

Ability to Display 

Clinical Information 

Accurately (safety)

Ability to Support 

Effective Work Flow

Screen Loading Time 

Using Pharmacy 

Application

Screen Loading Time 

Using Lab Application

Screen Loading Time 

Using Patient Summary

0% 10% 20% 30% 40% 50% 60% 70% 80%

PERCENT OF RESPONSES

Very Satisfied

Somewhat Satisfied

Neither Satisfied nor Dissatisfied

Somewhat Dissatisfied

Very Dissatisfied
Impact on Healthcare Delivery

Large Positive Impact

Moderate Impact

Neutral Impact (Neither 

Positive or Negative)

Your 

Productivity

Ability to Share 

Information with the 

Patient

Ability to 

Communicate with

the Patient

Ability to Review 

Important Patient 

Information

Ability to 

Communicate with 

Other Providers in a...

Ability to Deliver 

Healthcare

0% 10% 20% 30% 40% 50% 60% 70%

Very Dissatisfied

Somewhat Dissatisfied
• Effective enterprise clinical apps should interact seamlessly with 

the electronic health record.

• Touch-enabled devices deserve touch-optimized apps. Otherwise, 

frustration ensues.

• Give providers access to some data and they will immediately 

want it all.

• Great ideas for niche/focused apps to optimize workflow and care 

are abundant. It’s important to create the structure to allow 

rapid iterative development of these focused apps, once the data 

source has been made available to the mobile platform.

• Involve end users in development/feedback at all steps along the 

way. Pursue an agile development strategy.

Further Key Findings of Pilot
So, What’s Next?
Chronic Disease Trends Are Shaping 

Health Care Redesign 

Chronic disease spending comprises 

80% of $2 trillion spent on health care

Changes in behavior could reduce chronic disease 

morbidity by 80% (WHO estimate)

30-50% of patients with chronic diseases do not adhere 

to prescribed medication(s) (WHO estimate) 

By 2015, 41% of American adults 

are projected to be obese

Diabetes

14M in 1995  35M in 2015  47M in 2025
The mobile phone has become the biggest 

platform in the history of mankind.

More than 

five billion 

total 

subscribers.

More than 

one billion 

3G 

subscribers 

today.

Expected to be 

2.8 billion by 

2014.

Cell phones 

are the 

number one 

global 

computing 

device
Institutionalized care

Telehealth

Home Based Care

Outpatient Care

Mobile Health - An Engagement Model of Healthcare Delivery, not a 

Treatment Model

20+ Million 

8 Million 

5 Million 

< 1 Million

Veterans Impacted

VA Mobile Health: 

Expanding Care for Veterans

Personalized

Convenient

Coordinated

Accessible
VA Caregiver Mobile Health Pilot

1,000 Family Caregivers

Pre-loaded iPads with VA Mobile 

Health Apps

Pilot evaluation (research study) to 

inform next steps
Summary of Care App
Journal App
Journal App 

Vitals Sign Entry/Tracking
Mobile Prescription Refill App
Notification and Reminders App
Enterprise availability of apps

Cloud hosting

• VA staff access regardless of 

location

• Veteran access to all their 

VA information

Cross-Platform Development

• HTML5 development
• Print, copy, share

• Expand data domain access and viewing

• Mobile secure messaging

• Clinic directories

• Clerk appointing of Veteran requests (web)

Provider applications in development
• Expand secure messaging

• Context management

• Resume functionality

• Voice dictation integration

• Data reconciliation

• Patient reports

• Wound care app

• Intensive care unit (ICU) app

• Orders management app

Further plans...

• Mobile imaging

• Remote patient monitoring

• Facility and bed locator

• Antibiotic drug resistance

• Vital signs

• Progress note

• Surgical pathology/cytology app

• VA/DoD mobile provider

• Schedule integration

Patient-provider expansion
• Biosurveillance app

• My goals app

• Care plan app

• Caring for women Veterans 

app

• Customize views/search

• Immunization 

campaign app

• Coumadin clinic app

Further plans...

• Preconception and prenatal 

care app

• Maternity tracking and care 

coordination app

• Patient consent app

• Health competition app

• Enter progress notes

• Consults management app

Patient-provider expansion
Questions?