Veterans’ Perceptions of Full Access 

Health Records Throu

g y h the M

y Hea

Pilot Program

Susan Woods, MD, MPH

Erin Schwartz PhD Erin Schwartz, PhD

June 20, 2012
40 Years Ago....

......there was a ‘Proposa
“with record in hand, the patient would...

....get more complete information, a source of sa.... have higher compliance by less reliance on m....might even result in fewer mistakes”

Shenkin B, Warner D. New England Journal 
Delbanco T et. al. 
Background

• In 1996, HIPAA established the rig

patients to review their medical recrequest amendments

• Yet few do due to lack of awarene

Yet few do, due to lack of awarene

because of an arduous process

• When surveyed, most adults indica

they want full access to their recordthey want full access to their record
Background

Clinician concerns for sharing clinica• Potential for patient harm Potential for patient harm• Patient unable to understand informa• Burden on clinical workflow• Patients critiquing provider performan
Shared NHS Electronic Reco

• P ti t S N 231 (3 ti 

P

atien

t

Survey 

N = 231 (3 practices

• Access - Kiosk or Internet (HealthSpa• R l esu ts

– 86% accessed records– P h lth f t Poorer 

health more 

frequen

t access

– Age, ethnicity not associated with freque

– 38% found errors (48% did not take acti

38% found errors (48% did not take acti

– 76% more involved in care– 9% more worried about health 9% more worried about health– 75% felt more confident in GP (3% less 

Bhavnani et al. Family Practice 2010
Open Notes Study

• RWJF Pioneer Portfolio• Beth Israel Deaconess, Harborview, 

Geisin

g

e

r

• 100 providers and 20,000 patients• Access provider notes through patien

Access provider notes through patien

• Email notification with new note uplo• 2010 to 2011 (access continues)• Baseline and follow Baseline and follow

-up surveys up surveys

Walker J et. al. Ann Int
My HealtheVet Pilot (MHV

• Initial PHR prototype offered Veteran patien

‘virtual window’ into their electronic health r

• The MHV Pilot afforded a unique opportuni

examine pp g atient experience reviewing clinic

• Available from 2000 - July 2010• 9 sites: Oregon, Florida, New York, Washin• Total 7 464 enrolled Portland OR with 5 36

Total 7,464 enrolled, Portland, OR with 5,36

MyHealtheVet Pilot

• Access from 2000 until July 2010• Nine pilot sites: Oregon, Florida, New 

Washington, D.C. enrolled 7,464 Vete

• Portland, OR had highest recruitment 

5,361 ( %) 71.8 Veterans enrolled
Purpose

To describe the patients’ experience viewing full medical records includinviewing full medical records includin

progress notes, through the use of a 

personal h lth d (PHR) l health record (PHR)
Qualitative Study Design

• Purposeful sampling of only those pa

who accessed their records

• Five focus groups conducted betwee

November 2009 and January 2011 November 2009 and January 2011

• One group comprised of participants 

accessed record 1 to 3 times accessed record

1 to

3 times

• The other 4 focus groups were comp

participants who accessed record 10 times 
Methods

• Semi-structured interviews to elicit feed

– Expectations about MHV Pilot and record a– How participants used their health record in– Perceptions of access to records, and how 

impacted their health and their healthcare

• Themes of interest emerged inductively 

analysis after all data are collected

• Two researchers independently coded; 

Two researchers independently coded; 

met regularly to reach consensus
Participants

• Total of 30 Veterans and 6 family m• Veterans aged 49 to 82 years old Veterans aged 49 to 82 years old• Four Veterans (11%) were women Four Veterans (11%) were women• Five of 6 family members were wo
Results - Three themes characte

patient experience

1. Electronic access to all records had an eff

communication during and between visits communication during and between visits

2. Patients reported access improved knowle

ab t th i h lth d l d t t 

bou

t th

eir own 

health, an

d le

d

to grea

ter 

& participation in decision-making

3. Electronic access was perceived by patien

improving the quality of their care
Theme 1: Enhanced communic

between patients and provide

• Reminder tool: remembering appointments & sc• Communication tool: valuable supplement to vis• Health information exchange: coordinating care 

Health information exchange: coordinating care 

VA & non-VA providers

• Preparing for encounters: improved understand

Preparing for encounters: improved understand

questions to ask during a in-person visit
Quotes: Communication

• “Often I’d get er stressed at a doctor’s app

“Often I’d get very stressed at

a doctor’s app

don’t remember half of what’s going on and on to eVet and get my information and go, ‘o

not i i h hi h h l d d 

in sync wit

h this...t

hat 

h

elpe

d a great 

dea

•

“I can go in and ask more intelligent question

I can go in and ask more intelligent question

don’t have to spend as much time with them explaining everything to me. And then, with m

l l t th d t ’ ffi I d ’t h h level up a

t the 

doc

tor’s office, I don’t

hear 

h

a

then we may have to do it again and again ahel

ps us to have better communication”.
Theme 2: Enhanced knowledge, se

and participation in care

• Insight into health conditions & provider reaso

improved understanding of conditions, treatme

& id ti & provider perspectives

• Self-directed research: participants in all group

using Internet to look up health-related informa

• Personal motivation & behavior change: lifesty

Personal motivation

& behavior change: lifesty

changes were made as a result of reviewing re

• Participatory decision Participatory decision

-making: patients used k

making: patients used k

gained by reading records to make decisions a
Quotes: Self-Care & Participa

“Well, you could just pop over to Google or go 

library in there, a dictionary in there, you cou

over to that and check it out and see what it over to that and check it out and see what it 

’ 

instead of sitting there sweating it out trying 

out what it is out what it is. ”

“Made me feel more responsible for myself too 

Made me feel more responsible for myself too

there’s no excuses. You know, it’s right there

know. You can know. You can t’ use ‘the doctor didn the doctor didn t’ tell you tell you 
Theme 3: Patient contribution to 

• Monitoring care: longitudinal views allow pat

on decision-makin

g on care and services

• Advocating for quality care: reminding provid

follow

-up or care needed up or care needed

• Pointing out and discussing discrepancies• Observations on electronic records: preferen

thorough notes; comments on thorough notes; comments on ‘templates templates’
Quotes: Quality – Patient as The

Clinical Reminder

“I had an ultrasound on my liver and they gave th

saw it online It said saw it online. It said, ‘Re

-do in six months do in six months’. We

We

months came around and nothing happened. Sknow, y, , I called the doctor and I say, ‘Well, it sai

months, re-do’ and he said, ‘Well, let me look arecords’. He says, ‘Oh yeah, they did say that’hadn’t reminded him, I probably wouldn’t have 
Quotes: Quality 

– Patient Dec

“I don’t think I had to go as often [to the doctobecause...yeah, because I could see my resusee what was going on and I didn’t, I didn’t geout waiting to hear back from somebody who never call A d I did ’t k h 

ll me. 

A

n

d so I did

n’t, you 

know, 

have 
Quotes: Quality – Patient as Adv

“And sometimes, you want to change doc

result of what the doctor said. Not beca

describing it wrong, but he’s describing incompetently because you know yoursthan he does in many cases.”
Lack of Significant Harm

No explicit declaration of harm• Woman (wife of Veteran with cancer) on O

Woman (wife of Veteran with cancer) on O

Note: “I would rather not have known. Thelot of little thin

g y

s that were wrote, 

you know

step what had happened in his operation.”

• “Well, we don’t want to tell the person this 

that ma

y p y, y make them u

pset or it may,

you k

I say that’s a lot of bull. I want to know.”
Conclusion

• Evidence shows that activated pati

achieve higher levels of self-care a

satisfaction.

• Sharing all clinical notes with patie

serve as an important component omeaningful use of electronic health meaningful use of electronic health

records and health information exc
Limitations

• Participants from a single medical cente

included those using MHV Pilot in time 

• Responders may represent those more 

satisfied than MHV Pilot users in generasatisfied than MHV Pilot users in genera

• Many enrolled in Portland had not viewe

records18 months before the study – co

done so previously and had different ex
Discussion

• Overwhelmingly, patients reported reviewing re

was a posii i d f l itive experience and not stressful

• Patients showed greater participation in their h

their healthcare, reviewing data in unpressured 

• Cumulative effect of access to all health record

suggests improved care efficiency and effectivewhile also enhancing the patient experience

• Reports demonstrate change to patient-provide

relationship, in a variety of ways

• Clinical workflow impact unclear but suggests i
Implications

As VA moves toward shared access to recAs VA moves toward shared access to rec• Traditional roles of patients, providers are ch• New skills are needed to enhance communic

leverag pp g p p 

e opportunities for greater patient pa

that will occur with shared records

• Patient access to health records including c

Patient access to health records, including c

notes, may translate into care that is more emore satisfyg p p ing for patients and health profe
Study Investigators

Susan Woods, MD, MPHErin Schwartz, PhDAnais Tuepker, PhDNancy Press, RN, PhDKim Nazi, PhDCarolyn Turvey, PhDPaul Nichol, MD
Questions?

Susan.woods@va.gov

Erin.schwartz@va.gov

http://www.sharedhealthdata.com
VISN 22 VISN 22

Veterans Assessment & Improvement Lab (VAIL

PI: Lisa Rubenstein, MD, MSPH PI: Lisa Rubenstein, MD, MSPH

Point of Care Enrollment in MyHealt

IntegratedEducation, Authentication and Reg

POC - MHV iEAR

Maher Roman, MD, MBA, FACP

Chief, Primary Care Teaching Team & Women’s Health Center

Redlands Blvd Outpatient Clinic – VA Loma Linda HCS

HSR&D CyberSeminars Webinar:

"PACT - MyHealtheVet: Early Lessons on Enrollment and 

June 20, 2012 12:00 PM - 1:00 PM ES
PHR Prior Evidence: Users v

Non

-Users

• Non-VA Studies: Users more likely t

– Female– High morbidity– Age < 65– Primary care provider who uses secure 

messaging with other patients

• MHV Stud

y: Pharmac

y pp , a ointmen

important to veterans (>85%)

– 64% want to communicate with their 

p 

h
Aim

• Enhance teamlet enrollment of patien

enrollment of patien

–Discuss patient concerns–Increase provider awareness

• Assess how often lack of computer acce

prevents enrollment prevents enrollment
Is an Upgrad

Department of Veteran’s Affairs FY12-14 Metrics

f

Yes, if you wa

• 40% of care non 

face-to-face.

• View VA All

Reactions

• Receive We

• 25% of patients 

authenticated, and 

15% opted in

• Receive Wel• View VA Ap

15% opted-in • P ti i t 

Participate 

Messaging

• Be ready to 

Be ready to 

HealtheVet enhance yo

H lth R Health Rec

Ask the 

Coord

MyHealtheVet Volunteer Susan shows Veteran Jerry how to use 

MyHealtheVet -VA Loma Linda Healthcare System 

(Photo: Courtesy of Elizabeth Tran, MPh – Health System Specialist Intern)

Coord

facili
QI Diagnosis: 

Mapping the Enrollment Process Mapping the Enrollment Process

• In person authentication (IPA) In person authentication (IPA)

–A release of information–Often done by MHV coordinator o

somewhere else

• Opting In—at home, on MHV website

–Name on authentication form often 

Name on authentication form often 

• Sending a test message

–No instant reply No instant reply
Local Issues Identified

• Drop in voltage from IPA to Secure M• Providers ( Providers

(TEAMLETs!) are the best ) are the best

“marketers” for patients, yet are 

disconnected from enrollment disconnected from enrollment

–Little follow-through from brochure 

action
Approach

• Loma Linda VA Redlands Boulevard Q

Council project to promote Council project to promote Point of 

Point of 

Enrollment 

• Rationale:

–Teamlets can best overcome patien–PACT LVN’ h th i ht kill t 

PACT LVN’s have the right skills to 

–POC enrollment will simplify and ex

process 
MHV-POC Toolkit 

3 Physical Elements (RIB): 

1. Reminder2. IPA form3. B h roc

hure

3 Functional Elements ( 3 Functional Elements

(EAR):

1. Education2. Authentication3. Registration
Results of Plan-Do-Study-Act Cy

S d Ch ll ! Success and Ch

allenges

!
Rate of Enrollment and Barrie

From Reminder Data From Reminder Data

• 1695 patients patients

“who were never who were never-e

e

the past” seen from March to Se

2011:

–742 (44%) 742 (44%) were auth ti t d t

thentica

t

e

d on t

via teamlets

–492 (29%) had no computer/interne–221 

( ) 13%

) were not interested

–231 (14%) other 
VA Loma Linda Healthcare System 

Percentage of Veterans IPA'd for My HealtheVet 

30%

by Module as of January 27, 2012 

20%25%

GOAL 25%

13.1%

15%

20%

eterans IPA'd

11.1%

12.2%

10.0%

10%

% of Ve

5%

Source: VSSC Secure Messaging Adoption PCMM Report

0%

Module 1 Module 2 Module 3 Module 4 
MHV-POC Spread Progres

• PDSA cycle #2 (fall 2011) spre

–G t L A l (GLA) t S l d 

Grea

ter 

Los 

Angeles (GLA) a

t

Sepulve

d

Rubenstein’s Teamlet (Green Team)

• PDSA cycle #3 (2012) reminde

– All Loma Linda (Jan. 2012)

– All GLA sites VA (Jan. 2012)

– San Diego VA Oceanside CBOC (June –

L

o g eac ( equested ay 0 n

g Beach VA 

(

requested May 2

012 

implementation pending) 
30%

MHV In-person Authentication – Loma Linda

25%

Mdl 1 4

15%20%

ent IPA'ed 

Redlands Blvd 

Outpatient Clinic 

(RBOC) 

Implements

Modules 1 - 4

Implement

10%

Perce

0%5%

Y10 Y10

10

Y10 Y10 Y10 Y10 Y10 Y10 Y10 Y10 Y10 Y11 Y11 Y11 Y11 Y11 Y11 Y11 Y11 Y11 Y11 Y11 Y11 Y12 Y12 Y12 

OCT FY

NOV FY

DEC FY 

JAN F

Y

FEB FY

MAR FY

APR FY

MAY FY

JUN FY

JUL FY

AUG FY

SEP FY

OCT FY

NOV FY

DEC FY

JAN FY

FEB FY

MAR FY

APR FY

MAY FY

JUN FY

JUL FY

AUG FY

SEP FY

OCT FY

NOV FY

DEC FY
16%

MHV Opted-In Loma Linda

12%14%

Modules 1 - 4 

Il t

8%

10%12%

Opted-In 

Redlands Blvd Outpatient Clinic

Implement

in January 201

4%6%8%

Percent O

Outpatient Clinic

(RBOC) 

Implements

in March 2011

0%2%4% 0%

OCT FY10

NOV FY10

DEC FY 10

JAN FY10

FEB FY10

MAR FY10

APR FY10

MAY FY10

JUN FY10

JUL FY10

AUG FY10

SEP FY10

OCT FY11

NOV FY11

DEC FY11

JAN FY11

FEB FY11

MAR FY11

APR FY11

MAY FY11

JUN FY11

JUL FY11

AUG FY11

SEP FY11

OCT FY12

NOV FY12

DEC FY12
14.0%

MHV In-person Authentication Greater LA

12.0%

GLA reminder

turned on Sepulveda Green

Team implementsMHV reminder

8.0%

10.0%

IPA'ed 

4 0%6.0%

Percent I

2.0%4.0%0.0%
MHV-POC Spread Progress Evolution/A

What really works?! What really works?!

• Is it the point of care aspect? In addition to other enrollment lo• Is it the teamlet? The LVN role is beyond enrollment – “Secure 

Navigator” “SMN” is an attractive functionality that seems to w

• Is it that the reminder and what it triggers: Education 

Æ Authentic

Registration? Is the reminder just a catalyst?!

• Is it the brochure? • Is it MHV itself – what the veteran and us can do with it or throu• Or all of the above? – we’re trying to identify what works – stay • Each of the spread sites seems to adapt / evolve the process – 

from them – VAIL is after all a “LAB” 
What is in it (MHV) for me ( theTea

What is in it (MHV) for me

( theTea

Teamlet = Patient, Nurse, Physician (PN

• Asynchronous communication and • Im

proved VIRTUAL Access

• Improved Coordination• Reduction in Walk Reduction in Walk

-ins

• Reduction in phone calls• To be tested – improved clinical out• Well MHV (and secure messaging) is in lin

Well MHV (and secure messaging) is in lin

pillars: Access, Coordination, Practice Redesign
Where to go from here

Where to go from here

• Are we there yet!• Well – what is “there!”•It is just the beginning

It is just the beginning
Thank You

Loma Linda VAIL Leading Implementation 

and Functionality Evaluation 

(VAIL-LIFE) Team:

VAIL Electronic Measure(Especially Susan Vivell, PhDVAIL PCC Staff Quality C

(VAIL LIFE) Team:Essence Carmichael, MBA, Loma LindaGeorge Isaac, MD, Loma LindaAdewale Ajumobi, MD, MBA, Loma Linda

VAIL-PCC Staff, Quality C

Steering CommitteeVAIL Loma Linda Quality 

Susan Stockdale, PhD, Director, VAIL-PCCMaher Roman, MD, MBA, Loma Linda (Lead)MY HEALTHEVET COORDINATORS

John Byrne, DO, Loma L(Programmed Loma Linda Versio

MY HEALTHEVET COORDINATORSSharon Hartman, Loma Linda(Developed Veteran-Friendly MHV Brochure)Kevin Ligon, Sepulveda

Caroline Goldzweig, MD, 

(Programmed the Sepulveda VerLau-Herzberg, Amy E. VA

VA LOMA LINDA NURSING SERVICEEspecially: Denise Hallbert, LVN, Loma Linda

(Coordinated Toolkit developmen

Pamela McCarty, LVN, Loma Linda

6/19/2012 VAIL-PACT VISN22 
Contact

Maher Roman, MD, MBA, FACPMaher.Roman@va.gov909-226-1815T tP ex ager: Mh R @ h i l t Maher.Roman@archwireless.netEssence Carmichael, MBAEssence.Carmichael@va.gov909-825-7084 ext. 6167
6/20/2012 MyHealtheVet: Early Lessons on Enrollment 

and Engagement

Patient Aligned Care Teams (PACT) 

Demonstration Labs 

Roman, Maher

Schwartz, Erin

Woods, Susan

Lisa Rubenstein

If patients are able to see everything in the records, how does that affect court issues? Are providers 

and healthcare team members are to monitor what is being written in the records?

SW: Patients have a legal right to see their medical record, it is a national law. All individuals who 

document in the record should understand that is an option for Veterans. Now, this is only available on 

paper and requires the patient to go to the Release of Information Office and submit a written request. 

The MyHealtheVet Pilot offered the records electronically. This project is over; however, VA is moving 

ahead to offer this broadly, at some point in time in the future. 

The speaker needs to be aware that there were 552,662 unique women Veterans enrolled in the VHA in 

FY11. Your “rapid” research review IS helpful in identifying the potential benefit of MyHealtheVet 

Enrollment to OUR women Veteran Health Care Program. 

LR: Thanks for the comment; will remember to continue mentioning the role of MHV for women and the 

need to explore tailoring to this group.

Do you have any preliminary data on how the clinical reminder or utilizing LVN has worked for 

enrollment? 

LR: QI results strongly support the important role of the LVN in this process. That being said, LVN’s have 

a variety of key roles on teamlets, and spread sites (after the initial pilot site) have all added additional 

personnel to the enrollment team, including e.g., trained veteran volunteers, clerical support staff who 

roam through the waiting rooms and talk to veterans about MHV, manned kiosks in the waiting room, 

and probably others. These ideas are still being tested out, and we will see which ones turn out to be 

most productive and feasible. However, it is our strong sense so far that having the LVN educated about 

MHV and how to enroll is pivotal to success, even if other personnel help complete the enrollment 

process, because of the link to the primary care provider, the reminder, and the clinical visit itself.

Concerning the secure messaging, which medical staff are pts able to communicate with? For example if 

a patient has a nurse care manager, can they communicate with them as well or is it limited to MDs/PAC/NP?

LR: Definitely, the nurse care manager can answer and is encouraged to do so. MHV is designed such 

that all teamlet members can be identified as part of the answering team, and the responsibility for 

monitoring messages can also be designated. On my teamlet, my LVN monitors the messages that also 

come to me, and answers or designates responsibility (assigns) to someone else on the team or teamlet. 

When I complete a message, I “assign” the message to myself to complete it.

Is there any timeline on the mobile app efforts? Will it be one big app or separate apps for the different 

modules of MHV?

SW: The current mobile effort is limited to piloting of a “Clinic-in-Hand” project, offering family 

caregivers for OEF/OIF Veterans with illness or disability. The plan is to ultimately have a “VA app store”. 

The goal is for veteran users to have a consistent experience – desktop or mobile – of VA functions, 

including those currently available in MyHealtheVet. 
6/20/2012 MyHealtheVet: Early Lessons on Enrollment 

and Engagement

Patient Aligned Care Teams (PACT) 

Demonstration Labs 

Roman, Maher

Schwartz, Erin

Woods, Susan

Lisa Rubenstein

Please give specific advantages and disadvantages - rural patients 

LR: The system has enormous potential applicability to rural patients. As a clinician, for example, I have 

patients who live at a distance whom I ask to update me monthly on their status. I can tell them what to 

monitor. I can also work with my nurse care manager on this. That way, the patient can have fewer inperson encounters but still be closely monitored if need be.

Does a doctor's communication with a Veteran via MyHealtheVet count as a "visit" according to 

Medicare guidelines? (Home health agencies can't provide care under Medicare payment without a 

recent doctor visit.)

LR: There is a way to count the MHV communication as a visit, but it involves copying into an encounter 

code note so it is an extra step. Pasting the MHV communication stream into the record from MHV is 

very easy, but does not create an encounter.

Thank you Dr Rubenstein for this excellent presentation. --- How long does it take to train and get a site 

started in a similar process? -- Mo (Maurilio Garcia-Maldonado, MD) 

LR: Hi, Maurilio! Your question couldn’t have been better timed as we are just completing a tool, or 

bundle, for the purpose of helping sites. If you would agree to let us know how it works and give us 

comments on how to improve it, we’d be happy to send it to you.

For the pilot study- I know your sample was over 40; any thoughts about how younger vets might 

respond?

SW: That is a good question, but we can only theorize that many of the participants’ views and 

experience will be similar in a younger population. We know that younger Veterans are more likely to be 

using technology, and have less desire to come see us in person...so we suspect there will be positive 

value of enhancing MHV functionality for younger Veterans and their caregivers and family members.