**Transcript of Cyberseminar**

**Patient Aligned Care Teams (PACT) Demonstration Labs Series**

**Dual use of VA and non-VA Services by Veterans in PACT**

**Presenters: Gary Rosenthal, MD; Mary Charlton, PhD; Carolyn Turvey, PhD**

**May 15, 2013**

**Dual use of VA and non-VA Services by Veterans in PACT**

**May 15, 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: gary-rosenthal@uiowa.edu or carolyn-turvey@uiowa.edu or mary.charlton@va.gov*

Gary Rosenthal:I wanted to just welcome everybody to our presentation today. Thank you for your time. The general area that we are going to touch on, I think, we recognize is so increasingly important and that is the dual use of VA and non-VA services by dually eligible Veterans and we think that moving forward, this area has particular salience as the Affordable Care Act has implemented. In today’s seminar, we have sort of organized our presentations into three different segments. I am going to start and will take hopefully about 10 or 12 minutes and just define for you the extent of dual use of non-VA services among VA primary care patients based on analysis that we have done of merged VA-Medicare data and then discuss some of the implications of dual use for the PACT model and for effective care coordination. We will then shift focus and Mary Charlton will talk about work that she has done looking at the perceptions of VA and non-VA physicians regarding care coordination across different systems and then she will also talk about the development of a comanagement toolkit that she has done through the Rural Health Resource Center. And then Carolyn Turvey will talk about her work on using my HealtheVet to facilitate the transfer of information from VA to non-VA providers. And I think as we will emphasize that I can it is going to be increasingly important for us to think about how we can transfer information across systems to ensure care coordination. 

Mary Turvey:Thank you.

Gary Rosenthal:So I guess, Molly, you want to go over the first poll question?

Moderator: Sure, I would be happy to. Thank you. So right now, ladies and gentleman, I am going to go ahead and launch a poll question. You are going to see it pop up on your screen. So please click the circle next to the answer that best describes your primary role in VA. The answer options are student trainee or fellow clinician, researcher, manager or policy maker, or other. And we do appreciate your responses. It does help the presenters gear their talk a little more selectively. We have already had 70 percent of our audience vote, but the answers are still streaming in. So I am going to give people just a few more seconds to get their responses.

While you are filling this out, I just want to remind people that if you have a question, please type it into the question faction, do not use the hand raising icon as I cannot unmute you.

And I am going to go ahead and close the poll now and share the results. It looks like we have 21 percent reporting student trainee or fellow clinician, 21 percent researchers, 23 percent manager or policy makers, and 34 percent other. So I would like to thank our respondents and I will turn it back to you, Gary.

Gary Rosenthal:Okay, great. Thanks. So I am going to put in – next several slides I am going to present to you, results of analyses that we have done looking at patterns of dual use among VA primary care patients. This just – this slide just briefly goes over some of the key issues regarding the methods. So this – these analyses were based on merged VA-Medicare data during 2010 for 15 of the 22 VISNs that were encompassed by our data use agreement with Virex [PH]. These analyses are limited to patients who are 65 years and older who had Medicare eligibility and who had one or more VA primary care patients. So this in – so these were targeting people that are users of primary care within the VA and not just VA enrollee and this concluded roughly 1.1 million patients of whom 53 percent were assigned to a VA Medical Center, main medical center for primary care and 47 percent were assigned to a CBOC. 

The results that I am going to show look at the proportions of patients that used VA and Medicare services for different types of care. So we are going to start with – so this first set of results looks at the use of primary care, specialty care, and emergency room care. And the proportion of patients that used VA services for these different areas are shown in the blue bars and the proportions that use – Medicare funded services are shown in the maroon bars. I will also note that the VA results include patients who received care at VA facilities as well as patients who received care outside the VA, but whose care was paid for on a fee basis. So by definition, 100 percent of the population used VA primary care and you can see that more – a little more than one-third of these patients also used Medicare services for some type of primary care. 

When we go outside of primary care and looking out outpatient visits for physician specialty care, we find that roughly equivalent percents of patients use the VA and use Medicare services for specialty care and then we move to use of the emergency room, we can see that three times as many Veterans used a – had an emergency room visit that was paid for by Medicare than used the VA for emergency room care. When we look at other types of services, as might be expected, 20 percent of Veterans used the VA for mental health services. Only a very small percentage of patients used Medicare services for mental health services. In looking at diagnostic radiology, patients were somewhat more likely to use Medicare for diagnostic radiology services than the VA. And then we look at sort of a range of rehabilitation services, we find that the VA was more likely to provide that type of care to Veterans.

The next results look at hospitalizations and this, to us, this is one of the more interesting findings that we think has a lot of implications for care coordination impact and we find that 18 percent of patients in our sample were hospitalized in a non-VA hospital paid by Medicare and only 7 percent of patients had hospitalizations in a VA hospital. So when Veterans – this cohort of Veterans is hospitalized, they are more than two times as likely to be hospitalized outside of the VA and we find somewhat similar relations when we broke hospitalization down just to looking at hospitalizations that were medical in nature and hospitalizations that involved surgery.

The next set of slides show how these use of services varies according to the site of primary care for Veterans whether they receive primary care in a main medical center through CBOC, as we said. So all of these patients received primary care through the VA by definition of the cohort, but we can see that the patients in CBOCs were slightly more likely to utilize primary care services through Medicare. But again, more than one-third of patients receiving primary care in the VA are also receiving primary care services from Medicare. 

In looking at other types of services, this is looking at outpatient specialty care and we see that patients in VA medical centers were somewhat more likely to receive their specialty care within the VA. However, when we look at CBOC patients, we see that the opposite is true that when CBOC patients receive outpatient specialty care, they are more likely to get it outside of the VA. This shows the same data for emergency room care and again, you can see that the general trend that when patients go to the emergency room, they are more likely to use Medicare services than VA services and these differences are much larger for patients receiving primary care and CBOC. And then this looks at the use of inpatient care and we see the same kind of relationship that again that all patients were more likely to utilize Medicare for inpatient care than the VA. But these differences are much greater for patients receiving primary care in CBOCs. 

So I just wanted to quickly summarize some of the key findings from this work and then we will just highlight, briefly, what we feel some of the important implications are. So essentially we found that 37 percent of Medicare eligible patients receiving primary care through the VA also received non-VA primary care services. And Medicare eligible VA patients were more likely to receive mental health and rehab services from the VA; however, there were as likely to receive outpatient specialty care from non-VA providers as from a VA provider. And they were much more likely to receive emergency room care and inpatient care from non-VA providers. And then the use of non-VA care was higher in patients receiving care in CBOCs which is probably something that we had anticipated seeing before we did the analyses.

So in terms of the implications of this large amount of dual use, I think from a Veteran’s perspective, the ability to – we have to recognize the ability to use VA and non-VA care gives them more choices and greater access. And I think it is also important to recognize that outside of the VA, many patients receive medical care from different healthcare systems. But it is – I think it is also important to recognize that the high use of non-VA care by older Veterans poses significant challenge to how we coordinate care and how we do population management through the PACT model. And these challenges may be particularly significant for sicker patients who are more likely to be hospitalized or utilize the emergency room as well as patients receiving primary care in COBCs. And I think it is – we look ahead, the ability to effectively manage patients across VA and non-VA settings will require greater inter activity between VA and non-VA providers, an active flow of information about diagnostic tests, clinic visits, hospitalizations, emergency room visits and medications they may be receiving from different providers. I think it is also, from a system and policy level, it is important to recognize that this high level of dual use really poses challenges to understanding sort of the long term effects on utilization and Veteran outcomes of the PACT model.

So I am sure there will be questions about some of these areas that we can come back to in the Q&A period. But at this point, I will turn things over to Mary Charlton.

Mary Charlton:Thank you, Gary. Okay. So as Gary just discussed and Dr. Atkins recently mentioned in the most recent issue of the HSR&D Forum, it may not be ideal for Veterans to use multiple healthcare systems, but it is their choice to do so. And as Gary just showed, we know that many are choosing to use multiple healthcare systems. And also, many Veterans are in the unique situation of having two primary care providers. This does not happen in other situations, I think, outside the VA and so therefore it is not necessarily addressed in the majority of the patients under medical home literature. And therefore, no formal organizational infrastructure exists to guide that information exchange or facilitate care coordination on behalf of Veterans.

So we at the VA Rural Health Resource Center in the Central Region and I have a CD set about to gather information about the current state of comanagement and find out if there are any best practices from key stakeholders that we could use to develop resources and tools to facilitate comanagement. And I am mostly going to focus on primary care and I hope that a lot of the people who responded in the other category to the first poll questions are clinicians because I would like to hear if people have any feedback about what they think of our findings and if that sounds like that matches their experience.

So we went ahead and spoke with three groups of key stakeholders, rural Veterans, and I do think that a lot of these results are applicable to all Veterans, but because we are in the Rural Health Resource Center and, as Gary eluded to up on his presentation, it does seem to be – rural Veterans do seem to have a relatively higher rate of dual use compared to their urban counterparts, but I think the issues are the same across rural and urban Veterans. We also spoke with VA providers and non-VA providers and based on their feedback, we created a toolkit to help improve communications between VA and non-VA providers which I will talk about in a few minutes. But first, Molly is going to ask a quick polling question to find out where our audience members stand on the issue of who is responsible for facilitating communications between VA and non-VA providers and then we can compare that with what we found from our stakeholder groups that we talked with.

Moderator: Great, thank you so much. It looks like the answers are already coming in. The answer choices are Veteran, non-VA, local provider or practice, VA provider or VA healthcare system, both VA and non-VA providers are equally responsible, or another entity, for example, Regional Health Information Exchange. And it looks like half of our audient has voted already. Again, I see some people trying raise their hand through the icon. In order to answer the question, please just click the circle next to the answer option as I cannot unmute you. Okay and the answers have stopped streaming in. We had about a 62 percent response rate and I am going to go ahead and close the poll and share the results at this time. So you will see that 33 percent report Veteran, 1 percent non-VA provider practice, 1 percent VA provider or VA healthcare system, 64 percent both VA and non-VA providers are equally responsible, and 1 percent call on another entity. So I thank you very much for those responses. And at this time, I am going to turn it back over.

Mary Charlton:Great, thank you. And that is very interesting and I will incorporate those results in when I talk about the different stakeholder perspective. So – oops, there we go – maybe. All right, I do not know if I have control. Okay, here we go. So I am going to focus mostly on the non-VA provider perspective, but I wanted to quickly touch on some highlights of what Veterans and VA providers had to say specifically about the question you were just asked. Dr. Bryant Howren from our center asked Veterans, it was predominantly rural Veterans, but he asked who is responsible for communications between providers. And as you will see from the slide, almost half said it was their responsibility followed by local providers. Only about 11 percent said it was the responsibility of VA providers and surprisingly to me, even fewer thought it was both the VA and non-VA providers’ responsibility. And in our – in this question, his responses were 13 percent referred to this other entity and the people who wrote an answer said an administrator or something like that or said that they just thought someone should do it but they did not know who.

So while this can be interpreted as a good thing, Veterans see themselves as playing an active role in their healthcare. It could also be a reflection of VA providers telling Veterans that if they choose to see outside providers then it is their responsibility to pass communications back and forth among the providers or the Veterans perceiving that communication between VA and non-VA providers does not happen unless they are the conduit and make it happen. So as I will talk about later, not all of the stakeholders found this to be ideal. And also 91 percent reported being inconvenienced because of poor communication between providers. So again, these are primarily rural Veterans and they were in Iowa City catchment area. 

Now we will move on to briefly some highlights from the VA provider perspective and this was another project team led by Dr. Heather Reisinger, a medical anthropologist, from our center who conducted interviews with provider and clinic staff throughout VISN 23. Now this was just before the PACT model was implemented in VA. And about one-third of the VA personnel they spoke with were providers, one-third were nurses, and one-third were administrative staff and they talked with people in hospital clinics, community-based out region clinics, and contract clinics. I am sorry. I am having trouble advancing my – all right, there they go. So I am just going to cover quickly the top five scenes that emerged from those interviews. 

First, coordination of care with local providers is challenging. And I am going to share, quickly, a quote relates to this theme. VA providers said we have a lot of medication mix ups because the local doctors put the patients on something that I was already treating. I have had patients that are taking two different strengths of Synthroid, for instance, because they did not know they were supposed to stop one and start the other. 

Number two, duplication of diagnostic services may occur due to inadequate communication or sometimes possibly due to local VA policy. And one example of this was providers saying they have had a sleep study done outside the VA and decide they need to have a CPAP machine. They have to go through the whole thing again through the VA in order to qualify for the CPAP machine. So that is two sleep studies. And again, I am not sure if that is due to VA policy or communication, but that provider saw that as sort of a wasteful duplicate of process.

Relationships with local providers may be underdeveloped and one provider said when we find out a patient has a non-VA provider, I do a lot of calling doctors for records and some of the offices are excellent about getting us what we need as far records go. But there are a few offices that I call, when I identify myself as calling from the VA, I get attitude right away. I have had that happen a couple of times, but most of them are pretty good. So in most of the quotes we got related to this issue, it definitely does not sound like VA personnel are necessarily proactively reaching out to community providers in their areas to develop relationships. It is more that they are interacting on a case by case basis when these issues arrive.

Medical record exchange is a source of inefficiency and may delay or hinder care. And I will just share one more quote with you here. One provider said we have a chronic communication problem with outside providers and the patients themselves to make sure that we get progress notes, especially progress notes that reflect medication changes. They come in here with this prescription. Once their medications change, we really need the progress note from the outside provider saying what the rational for that med change is. It is the patient’s responsibility to do that. Our case managers and I, we do get involved and make calls to the doctors themselves, but it does not really fit into our time very well. So this, again, kind of illustrates where many people do perceive that it is the Veteran’s responsibility to provide that information and facilitate communication. 

And again, this keeps coming up; misunderstandings with local providers over medication prescribing are often frustrating. 

So then we will move on to the Local Provider Perspective. So we conducted some surveys and interviews with Iowa primary care providers who are part of the IRENE Research Network which is the Iowa Research Network. It is a practice-based research network administered by the University of Iowa, Department of Family Medicine. It has been around since 2001. At the time we did our surveys and interviews, they had 270 members from across the State of Iowa. We mailed them surveys and asked if we could contact them for a telephone interview. Sixty seven completed written surveys so that is about a 25 percent response rate which we realize is not approaching 50 percent by any means, but I do think it is important to keep in mind that many community physicians probably do not see a critical mass of VA users and may not have seen this as something that impacts them. So if you think about the number of VA users and the number of people in our country, it really kind of equates to less than three percent of our populations, our VA users. So you are going to get, I think, a lot of providers who do not see a lot of VA users or they do not know that they have VA users because they are not systematically asking people that and then 21 agreed to do an interview with us. I will open my slide here. Thank you.

So when we asked the local providers how would you describe your clinic’s communication with VA clinics, the non-VA providers, 73 percent said poor or non-existent. Only three percent said excellent, 19 percent saying adequate.  So it does look like there might be some room for improvement. 

Non-VA providers felt that they were interacting with the VA as a system rather than communicating with VA providers as individuals. The difficulties in communication were often attributed to the inability to access or identify the VA provider. One interview, we described the provider interaction as suboptimal and he said that I do not mean to blame the VA physician for that problem. I see it more as a system problem on the part of the VA because of the difficulty communicating with the VA. For example, it is very, very difficult to call the VA and actually contact the physician that has cared for the patient and get in touch with them on the telephone on a semi-urgent or urgent basis. And one provider described the VA phone system as impenetrable. 

Then we asked the local providers how information how information is exchanged with VA providers. Most report – almost all reported that the patient is the main vehicle of communication. However, most felt that this was not ideal and could place a burden on patients for management of their own care. And one provider said, I do not think we can rely on patients to be totally knowledgeable about what they have or have not had done for evaluation and testing.

We asked them if they felt poor communication has led to poor outcome. We did not really define that in any way. We just sort of left it broad and 42 percent agreed that poor communication of the VA provider has led to poor patient outcome. 

Local providers expressed concerns mostly about changing medication, about VA providers changing medications without their knowledge and indicating that could be quite dangerous to patient outcome. Some non-VA providers were more familiar with the VA formulary than others. Those that were unfamiliar with the formulary expressed interest in learning how to access it. Almost none of them knew that it was available on an internet website. 

Interviews also revealed that other concerns about poor patient outcomes besides medications centered on lack of continuity of care, delays of emergent transfers to a VA inpatient facility, duplicate testing, and ignorance of test results. 

So to summarize our findings from a study of non-VA providers, it appeared to us that these providers lacked the basic information necessary to navigate communications with VA providers and that they did see this as an issue. And we know that there have been great models out there such as the Transitional Care Clinic at the VA Nebraska, Iowa Healthcare System. This actually has a physical presence in that medical center involves LPNs and the pharmacist can be a point of contact. There’s been some other variations of that program that are really ideal to have people there, but since that is not possible necessarily in all VAs and clinics, we sort of set about to attack the side that there is some basic information that is provided to non-VA providers might really help facilitate communication. We do know that Electronic Health Exchange is a more ideal way and we hope that is the way of the future and Carolyn has some very interesting information to present about that. But in the meantime, we decided to create standardized tools that can be used nationally. The idea being that the VA could use these tools to send out consistent, easy to understand messages about how to manage patients using both health systems.

Oh, I am sorry. I am going to go back to and just mention that the toolkit that I am going to talk about, here is the website to get there. Right now it is listed on Rural Health website and it is posted in a sort of customizable form so while the information I am going to talk about here is related to our toolkit that we use in Iowa. It can be modified for the different healthcare systems.

So it includes a brochure which contains just an overview of key information that kept coming up through our interviews, release of information, medications, contacting VA providers, My Healthevet, and emergency care. And I will go into each of those a little bit in the next few slides. And also a draft of an introduction letter which is meant to provide a basic over again and would ideally come from a VA PACT team perhaps to send out information to the providers in their community. It has got good customizable information and it contains information on those key points of pain that came up through the interviews. It could also be customized to be about a specific patient saying hey, we know we are both managing Tom Smith and we would like you to know these things about how medications work in the VA and things like that.

There is a medication FAQ sheet which talks about filling outside prescriptions at the VA. It explains that they must be rewritten by a VA provider. In some cases it is the VA provider’s prerogative to say that they wish to see the patient themselves before they will make any changes. It includes information that would be necessary to include if the VA provider were to rewrite this prescription. It also contains information on the formulary and how to access that website. It also contains a little information sheet about non-formulary information so it explains that if the non-VA provider feels very strongly that the Veteran needs to be on a non-formulary request, here is the information that the VA provider would have to include to even have any hope of getting that through.

Release of information, that was another big thing that came up so we included a FAQ sheet on that. It describes different ways to submit release of information. It has got the form and it also talks about the continuity of care clause and just even working that out in our own medical center we had to talk to about 17 different people and got 17 different answers but we feel like we finally came up with a resolution of what the rules actually are and they are included in that. 

And then information sheets about local facility location services and contact information. We realize a lot of this is available on the internet, but a lot of providers are not familiar with how to find it. So it is in just a more condensed format. 

It also contains some information about My HealtheVet. It discusses how a Veteran can register and go through the in person automation process and information on services currently available at My HealtheVet. 

And finally, it contains an emergency care sheet which is some basic information for Veterans and what to do in emergency situation would be helpful perhaps to non-VA providers as well and some wallet cards that could be completed by a VA PACT team and be service quick references to Veterans that they could give to their non-VA provider with the contact information of their VA provider to help facilitate communication.

So we did mail these back out. At the time, there was 297 providers in that IRENE network and as you can see, the majority, about three-quarters indicated it could help improve care coordination, improve safety in patient outcome, and that they would use the toolkit information in their practice. So we will continue to pilot it, hopefully refine it. We are working with some people in the Eastern Region Center and then we want to get this out there and get more feedback. So I hope you find it useful. And I want to make sure Carolyn has time to do her information. I will turn it over.

Carolyn Turvey:Okay. So consistent with Mary’s work, I am trying to find a solution to improve the care coordination between VA and non-VA providers and much of the work that I am going to be presenting here is part of my work with CADRE but also the eHealth query in working with My HealtheVet which is the VA’s Veterans Personal Health Records where the Veteran has access to their CPR medical information, but they can also enter in some of their own information into My HealtheVet.

So My HealtheVet is the VA’s electronic personal health record. It allows viewing of the medical record, online prescription refills, secure messaging, appointment viewing. Veterans are now able to see their labs there. As of January of this year, they are able to see visit notes from their doctors. There is information about problem lists and hospitalization. So it is a very complete electronic access to the Veteran’s VA healthcare information and the Veteran can also go in and self-enter information. For example, they can self-enter over the counter medications or medications they receive from non-VA pharmacies. As of March 31, 2013, there were more than two million registered users.

Today, what I am going to talk to you about is the Blue Button Feature. This is a feature that is shared by the VA electronic personal health record but also the Department of Defense and Medicare. It is a federal government wide initiative to provide easy access to what is kind of an executive summary that has the key information for healthcare. So it has the medication list, most recent labs, allergies. These can be tailored, customized, so Veterans can choose to what – the information they include, but the basic blue button would have a quick executive summary of key medical information for Veterans and it can be downloaded as a PDF or as an electronic text file and then shared with others to improve care coordination. As of March 31, 2013, there were about three-quarter of a million, 750,000, unique users of the Blue Button Feature.

The study I am going to present is the results from Rapid Response Protocol that it was just funded by the eHealth query and this was a two part evaluation study of the Blue Button Feature in My HealtheVet. The first part of the study was a survey of Veterans using My HealtheVet to find out if and how they were using the Blue Button Feature. In particular, I asked many questions kind of similar to the ones that Mary had reviewed, but similar questions about care coordination. Then I did qualitative interviews of key stakeholders. So I interviewed Veterans, VA providers, and non-VA providers specifically about their experiences with care coordination between the VA and non-VA providers and what their perceptions were of the Blue Button Feature of My HealtheVet. These were all conducted starting about May 2012 and finished up January of this year.

So I am going to start with the online survey. The online survey is a pop up that occurs for Veterans when they are in My HealtheVet. After they have clicked on at least four pages, they will get kind of a little icon that says would you like to complete an online survey. I gather many of you have seen these types of surveys. They are kind of the standard industry – industry standard in evaluating websites and for Veterans and My HealtheVet, they are very responsive to completing these surveys so the sampling percentage low but the response rate was 17 percent. The time period for this survey, we did a specific custom questions related to the Blue Button was March of 2012 through May of 2012 and there are 22,000 – 23,000 completed surveys.

Well the first thing we asked them was whether or not they have ever used the Blue Button. Thirty five percent of the respondents were currently using the Blue Button Feature of My HealtheVet, 916 or 4 percent had used the Blue Button in the past but do not use it any longer. But the majority, 61 percent had never used the Blue Button Feature of My HealtheVet.

I did go on to ask the Blue Button users what they were using the Blue Button for. For starters of the Blue Button users, 44 percent had providers who were not affiliated with the VA and I think it is interesting that this percentage is really comparable to some of the ranges that Dr. Rosenthal was presenting in the earlier part of the presentation. So there is a very large number of these Blue Button users who have non-VA providers.

We asked them, first off, questions about how their providers communicate the VA and the non-VA providers. By far, the greatest endorse that they share the information themselves. This was choose all that apply so that is why it does not – we did not force them to choose one, but 52 percent said that they share the information, 15 percent said that they do not know. I think it is interesting that if you ask providers they often think of mail or faxing the information. Only 13 percent endorse that their VA and non-VA providers communicate through mail or fax.

We then asked them how satisfied they are with communication between their VA and non-VA providers. I guess the good news is that 35 percent said that they were very satisfied, 16 percent said they were completely satisfied, but there was a fair percentage, 27, 10, and 12 percent satisfied that were a bit more moderate in their endorsement with 12 percent saying that they were not at all satisfied.

Remember that these are the Veterans that are answering these questions. These are Veterans who are using the Blue Button.

Of the Veterans of the Blue Button users who had a non-VA provider, we asked them how many of you shared your Blue Button printout which is the PDF that contains the key medical information from CPRS plus any of their self-entered information with their non-VA provider. It was actually a minority, only 21 percent were using it in that regard which I consider unfortunate because I do think that this is a key opportunity to really improve care coordination. Granted, it does involve Veteran participation which had its pluses and minuses but I think that that is part of our overall goal of activating patients to be managing their healthcare. So it would be nice to start to look at ways to increase the number of Blue Button users who use their Blue Button printout or the Blue Button Feature to help inform their non-VA providers about VA care.

Those who did share the Blue Button with their non-VA providers, 68 percent said that they felt it was very helpful, 19 percent said it was somewhat helpful, a very small minority, 0.5 percent said it was not at all helpful, and 12.5 percent said that they did not know meaning they shared it with the provider but they could not tell either way if it really registered in the provider if it was helpful in any of the healthcare decisions.

We wanted to look at who were using the Blue Button for care coordination. I did this analysis in part to get kind of a user case scenario to understand what, at least on the Veteran side, what groups were perceiving this as a really important function and that might give me a sense of how they were using it. A lot of Veteran characteristics were the strongest predictors of whether or not they use the Blue Button for care coordination. One was internet ability. So the Blue Button is really specifically designed to be very useable, but there were a number of results from this evaluation that indicated that usability is still an issue, that it is still not exactly clear to Veterans how to go in and get this summary of their healthcare information, and those who rated themselves as more advanced or even at least intermediate in internet ability were more likely to endorse using the Blue Button printout and care coordination. 

Then there were two questions about – that had to do with just health information management. Veterans who said they value – they have it – they value having their own copy of their medical record highly, this was on a liker scale of one to five. Those who endorsed more highly valuing having their own copy of their medical records were more likely to be people who use the Blue Button in care coordination. Those who endorsed having a specific system to organize their health information were more likely to use the Blue Button and then diabetics and those with lung disease. I think with the diabetics, it kind of leaps out at you that they would want to share things like recent labs or hemoglobin a1c with their non-VA providers just for information but also to reduce duplication laboratories possibly. With lung disease, it is a little less evident, but I gather it is to share information about the status of their health and possibly also labs. 

So the rest of the slides I am going to review some of the information we got from quan – I am sorry, qualitative interviews. That is the type of qualitative interviews with non-VA providers and there is going to be some duplication of themes. They reported that communication with VA providers was unsystematic and highly variable and relies primarily in the patient. So it is a fairly negative slide. With the VA we get nothing. If we need something, we have to call the VA or have the patient acquire it. Nothing is ever sent automatically from the VA and most of the time I do not even know that they see the VA. I do not even know that they are a VA patient. And that was the theme that came up a number of times when talking with non-VA providers that just by happenstance they find out that the patient is also being seen at the VA. So it is not even a matter that they know they are an identified VA patient and they are having trouble getting the information. Often, they do not even know that the Veteran has other healthcare providers that are at the VA.

What we did do is show the non-VA providers samples of the Blue Button printout with the test patient’s information in the printout and asked them what they thought about the format and whether or not they thought it would be helpful. I think one of their comments and suggestions was that they thought it was too long. It is a very comprehensive list and in order to make it kind of easy to scan for information, there is a lot of white space on the pages. That was purposeful, but I think the providers felt like a little overwhelmed by how long the printout would be. Even some of the more abbreviated printouts would be maybe 10 to 15 pages long. We asked them how they would like to receive this information, if they would like the patient to bring a paper copy in. Most of them endorsed really wanting to receive the information electronically before the clinic visit and they would most like to have it received electronically in their own electronic medical record. So they are starting to talk about health information exchange.

My study and my work has been primarily to engage Veterans in the process. But I have to say, providers tended to think that they would like to have the information electronically and then they can talk about that with the Veteran, but they were not necessarily enthused about relying on the Veteran to bring the paper in to the visit.

We asked them what were the content features that they felt would be most valuable in the Blue Button printout, medication list, medication history, lab results, problem lists, allergies, and immunizations. They were interested in only the most recent clinic notes. They did not really feel like they would have time to review all of the clinic notes, but they kind of wanted to know what was the last chapter in the patient’s narrative and so they wanted to at least look at the most recent clinic note. And they wanted laboratory and vital information. They thought it would be most helpful it was presented in a trending format.

So in future directions, we are currently starting a collaboration with Office of Rural Health, PACT, My HealtheVet, and Health and Human Services to pilot having Veterans transfer their care coordination document which is now a part of My HealtheVet in the Blue Button. It is a briefer summary of the Veterans’ healthcare information that can be sent electronically by the Veteran, hopefully. That is what we are aiming to pilot. And it is a function that is scheduled to be released in the upcoming year, send a copy of this care coordination document to their non-VA providers. 

We are looking to also study how Veterans can use the Blue Button printout to improve care coordination receiving care at critical access hospitals and to explore the impact of both of these types of methods of transferring VA health information to non-VA providers on utilization and provider and Veteran satisfaction.

So that finishes my talk and we will go on to the third poll question.

Moderator: Excellent. Thank you very much. I am going to go ahead and launch the third poll now. And for our attendees, please, once again, check the box that is best for your answer. And the question is what are viable approaches for VA to address issues related to dual use of services of Veterans? First answer option nothing, current approaches work well, improve access to VA services, broaden the types of services available through the VA, better approaches to exchanging info between VA and non-VA providers. I am sorry, that should have read develop better approaches to exchanging information between VA and non-VA providers and lastly, facilitate care coordination between VA and non-VA providers. And you can select all that apply. So feel free to give that some good thought and we have had 50 percent of our audience vote so far but answers are still streaming in. So I am going to give people a few more seconds. We do appreciate your responses, once again. And while I am waiting for all of the responses to come in, please note that we will be moving on to the Q&A section – I am sorry, Q&A session. So if you have a question you would like to submit, please type it in.  All right and 65 percent of our audience has voted. I am going to go ahead and close the poll and share the results. We have one percent that says nothing, current approaches work well, 28 say improve access to VA services, 27 report broaden the types of services available through the VA, 73 percent also feel that better approach – developing better approaches for exchanging information between VA and non-VA providers would be a good approach, and 66 percent also say facilitate care coordination between VA and non-VA providers. So thank you very much.

And at this time, I am going to close the poll and I will turn it back over one more time so that we have just a nice slide we can look at during the Q&A. And with that, we will go ahead and get started. We do have some good questions that have come in. The first question, how does patients care provided by non-VA get into the VA’s CPRS or the IEHR?

Carolyn Turvey:I do not think that – so My HealtheVet, the direction of information sharing is in one direction in that either through the Blue Button or through any other way that the Veteran would print it out, it would be the VA information going to the non-VA provider. Within My HealtheVet, the Veteran can self-enter information from their non-VA providers like non-VA medication lists or over the counter medications. Unfortunately, that self-entered information is not uploaded into CPRS and people have talked about that, but I – I guess I cannot speak for the My HealtheVet Program office, but I am not aware of that feature coming down the pike anytime soon.

Moderator: Thank you for that reply. The next question, if it is supposed to be patient centered care then the patient has the responsibility. Just a little comment there and I believe that was with regard to one of the poll questions. We have another comment. The toolkit material section is very helpful. Thank you for sharing this information with us. And another question, how have providers noted barriers with release of information paperwork, whether sending or receiving, as a problem?

Mary Charlton:Yeah, that was something that came up quite a bit. I think, you know what, I have not proven this, but I think the VA policies are slightly different from what happens outside the VA, how the communications exchange outside the VA and so there is a lot of confusion just within VA about the continuity of care and when you can release information without the Veterans’ signature. So you can imagine if there is confusion within the VA about VA policies, there is a lot more confusion outside of the VA. People did not understand where that form was, why there was a specific form like that. I do not think they generally use that same form outside the VA. People did not understand that the patient had to sign for it each time like they could not sign a release to say I want to give my non-VA provider my VA information over the next six months or the next year. 

I think VA providers were kind of surprised that that could not happen that it is only done at a one-time thing and it sort of be retrospective report for that one visit. There was confusion about that, but people did appreciate that continuity of care clause, I guess you could call it, where if it is an established patient, so it is not the first time a non-VA provider has seen the patient, an established patient and they need something, they can submit a written request to the VA and fax that over. If it is an emergency situation, they can indicate that and get a response back much more quickly. But I think just the different mechanisms were confusing to everybody both within and outside the VA. And like I said, it took us several conversations to get it ironed out and to get that release of information FAQ sheet to a place where everybody agreed that it was correct and that it was a correct interpretation. So I definitely recommend taking a look at that. Hopefully it is not different in every VA. I do not think it is, but that is always possible.

Moderator: Okay, we do have – thank you for the response. We do have some follow up information from our audience regarding the CPS – the CPRS issue. One person responded that outside records can be scanned into CPRS and the turnaround time is about two weeks for the information. So we thank you for that. And----

Mary Charlton:So another group that has access to those.

Moderator: The next question that came in: Can Vets read full text notes via My HealtheVet and if so, will that influence how candid providers will be in their notes? For example, alcohol and substance abuse history.

Carolyn Turvey:So as of January, VA notes is open and Veterans, I believe, can see the text of all of their provider notes. I think the eHealth query is going to explore whether or not that will have an impact on provider candidness. I hope it does not have an impact on provider accuracy. I think that for a long time now providers have been told to write their notes expecting that at some point patients can read them. So I am thinking – we are hoping it is not too radical a change in how providers communicate in CPRS. But I do know that the eHealth query and the number of people and including just anecdotally providers saying well now that they can read my notes I cannot say this, that, or the other thing. I know My HealtheVet has been trying to address those concerns individually, but again, there is going to be some exploration, I think, in the research world looking at whether or not and how patterns of communication change now that Veterans have easier access to their medical record. I think the distinction to make is that they have always had access to their medical record but having it now online and through My HealtheVet; it is obvious that it is much easier so it is much more likely to occur.

Gary Rosenthal:This is also, I think, just a generalizable phenomenon in healthcare that as EMRs get more broadly implemented, most EMR systems do have a personal health record and there is an increasing trend in non – among non-VA providers to give patients full access to the clinical notes.

Moderator: Thank you both for those replies. We – the next question: Has the quality of the problem list been evaluated. My impression, and I am new to the VA, is that there is little incentive to update as opposed to linking to billable code outside VA. Is there a way to improve this summary for VA and non-VA use by the Veteran?

Carolyn Turvey:I think developing an accurate problem list is up there with developing perfect medication reconciliation. It is a recognized problem that people are working on. I think PACT and care teams that is part of their central goal. So I think it is certainly a problem that people have recognized and are working on. I think electronic medical records and actually personal health records work in favor of more accuracy. One of the common things that occurs when someone gets access to their medical record is they call up and they make corrections.  Now sometimes it is a disagreement with the provider and the correction is not made, but as often as not, it is a genuine mistake in the medical record. Patients have what I call a panel of one. Doctors have a panel of 600, a panel of 800. It is tough to make sure all of their medical records are accurate, but patients just have their own medical record and it would be great if everything were 100 percent accurate, but I think now having patients being able to view their medical record, they can really partner with us in making sure that it is more accurate.

Moderator: Thank you for that reply. The next question we have is the Blue Button care coordination document used by VA providers at different VA facilities. Some of the challenges with communication and care coordination between VA and non-VA providers also exists between specialty providers in one VA facility with a primary care provider in another VA facility.

Carolyn Turvey:I think that is a great idea. It had not occurred to me. Again, the care coordination document is something that is initiated by the patient through My HealtheVet, but the patient could get that care coordination document and send it to VA provider who, for whatever reason, does not have access to the Veteran’s information at another VA facility.

Gary Rosenthal:The reason why it is better, the provider could active the----

Carolyn Turvey:No, that is – the Blue Button was just through the – I mean I am not as aware since what I do is patient facing technologies. I do the My HealtheVet. I am not as aware of what the VA is doing as far as improving provider to provider care coordination documents. I heard that there is some work going on in this area, but I am not as aware of it myself. So there might be somebody else who is better to ask that question.

Moderator: Thank you. Next question, my understanding that outside of several expectations that HIPAA allows for coordination of care without written consent exceptions being HIV, Sickle Cell, substance abuse treatment, how can we educate providers and Veterans to not self-impose additional barriers of written release?

Mary Charlton:Yeah, I think that is a good point and we of course like to think our toolkit is very useful, but if it is not getting out to the people who need to use it then it is not. So and that is one of the things that I think we need to work on and that we are focusing on is dissemination, how to get the message out there so that the person said, we are not making it worse for ourselves than it already is. The people in the Eastern Region Rural Health Resource Center in VISN 1, they have a project where they have developed specific PowerPoint presentations.  There is a longer one for staff outside of the VA and in non-VA hospitals and clinics and then there is a much shorter lunch hour kind of one for non-VA providers. And they go out and give those formal presentations to the people in their areas. They leave our toolkit with those providers. It has got that type of information. And we are working on making kind of a similar toolkit for Veterans and so boil down this information and help them understand a little bit better. But that is a good point in that people may be thinking it is actually worse than it is, making it harder than it needs to be because that continuity of care clause really does allow for people to exchange information much more easily than having the Veteran sign that form each time.

Moderator: Thank you. That is helpful. The next question, is there Congressional Legislation governing communications between VA and Civilian providers? Where would that be located?

Gary Rosenthal:I mean I am not aware of any specific legislation that would mandate or restrict communication beyond just existing regulations like HIPAA.

Mary Charlton:I think there was a VA Directive that said that it should be done. I do not think it dictates how it should be done, but just that there should be communication with VA and non-VA providers and I know out on the PACT website there is certainly the white papers and things out there that say that the PACT model should facilitate that communication and true comanagement, not just dual use where they are just using multiple healthcare systems, but comanagement where providers are working together to manage the patient, I think, that it always comes back to. That is somebody’s time to do that whether it is the Veteran’s time, whether it is the VA provider’s time, or the non-VA provider’s time. Somebody has got to do it and it just not an easy solution, I do not think, as to how that can happen in a way that makes it easier for people and makes them want to change the current culture.

Moderator: Thank you for that reply. We do have a comment that came in. Veteran responsibility is great, but we need to be aware that there is a VA population that is not able to take the responsibility nor have a family member that will.

Carolyn Turvey:I have to say this idea about is if the providers or the Veterans seems to me like a false argument. I mean I think we would like to try to get as many able people involved in the care coordination. So I think it would be great for us to work hard on getting providers to coordinate better with each other without necessarily having to have the patient do some of the work. But I certainly think we should also be working at trying to help patients get involved in that process too and I am not feeling the need that we have to specify right at the outset. It is either providers or patients. I think the reason why I asked that in my survey was simply to get a sense of how it is currently being done and how the key stakeholders are thinking it is getting done. But it was not any sort of statement that there should be one right answer to how to have the best care coordination.

Mary Charlton:Right. I think engagement by all the stakeholders is important. I do think though the reason that we wanted to include that as a polling question from my standpoint is just to see if there is any sort of a shift in the VA culture because I do think in years past, I have not been with the VA that long, but I do think it was an overt statement made to patients, it is your responsibility. If you choose to accept care outside of the VA, it is your responsibility to carry those documents back and forth.  I do think that there has been a little bit of a shift recently and particularly related to the PACT team where people are saying yes, that is great that the Veteran can be involved to the extent that they can, but it may not be ideal just to rely on them to be able to do it. Because as the person said, not all Veterans can do, especially if they do not have a family member to help. So as Carolyn said, I think it is everybody’s responsibility, but was interested in the fact that I think there has been a little shift and a little recognition just by how prevalent dual use is and how benefits of true comanagement and communication can really improve patient safety and satisfaction.

Moderator: Thank you both for those replies. Is there a target date for national rollout of VLER?

Carolyn Turvey:Lifetime electronic record?

Moderator: That could possibly be it. The person is more than welcome to write in and spell out the acronym, but perhaps Veteran lifetime electronic record.

Carolyn Turvey:Yeah, that might answer it though.

Moderator: I am not sure.

Carolyn Turvey:And I am not sure about that.

Moderator: No problem. If the Blue Button Feature is available in other systems such as DOD and Medicare, could there be – could there ever be the possibility of intregat – I apologize, let me start over. If the Blue Button Feature is available in other systems such as DOD and Medicare, could there ever be the possibility of integration of these systems? This could be particularly helpful for Veterans dually enrolled in Medicare.

Carolyn Turvey:Well I know much more about work on trying to integrate the military history and I believe there is a section of the Blue Button end of My HealtheVet that is military history for Veterans because that was something Veterans asked for frequently in our surveys. I do not know of any work being done on integrating the Blue Button for Medicare into the Blue Button or for having those systems speak to each other between Medicare and the VA. It is a very interesting question. I am just not aware of any work going on in that area. That is actively a lot of coordination and current development within the VA and the DOD to try to create a unified medical record.

Gary Rosenthal:Although, I mean I think as meaningful use criteria broaden through electronic health records, there is going to be an increasing expectation that key summaries of information from the electronic medical record have to be transferrable. And I think from a system perspective, it would be important if the VA begins discussions about how its health records can best integrate with other proprietary EMRs.

Moderator: Thank you all for that response. We do have a kind attendee who wrote in to clarify what VLER means. It is the virtual lifetime electronic record.

Carolyn Turvey:Just not aware of that.

Moderator: No problem. The next question is specialty clinics – oh, somebody did want to expand on that. The VLER health is a program that shares certain parts of your healthcare record among the Department of Veterans Affairs, the Department of Defense, and selected private healthcare providers over a secured network known as the Nationwide Health Information Network, the NWHIN. And they did include a URL so if anybody is interested in that it is va.gov/vler/vlerhealthasp. So I want to thank that person. And if you need that URL again, you can always email cyberseminar@va.gov and I will be happy to provide it to you. 

Moving back to questions, if specialty clinics are ordered and the Veteran has had initial tests outside the VA, can those be scanned – oops, we have already done this one. Can it be scanned into CPRS or used or do they have to be repeated within the VA system. And it sounds like they can be scanned into CPRS, but it may take up to two weeks.

Gary Rosenthal:Right, I mean and I think the challenge though is in the scanning is just sort of the easy retrieval of the information.

Carolyn Turvey:I mean that is how they have been doing medical records release of information between VA and non-VA providers that.

Gary Rosenthal:Yeah, yeah.

Carolyn Turvey:Is kind of what they are talking about.

Mary Charlton:I think there may be some policies at play too. I am not sure what dictates when it is acceptable to use outside provider tests versus when it is not. I think generally it is, but that may be subject to differences within different VA healthcare systems and within those different VA medical centers.

Moderator: Thank you for those answers. We are getting down to the last half dozen or so. Do you all have time to stay on for just a few more minutes?

Gary Rosenthal:My – I think we have about probably – Carolyn had to leave. We probably have about another two minutes or so, but we would be happy to answer any questions by email.

Moderator: Okay and that is what we will do is I will send you the remaining questions and I will get those written responses and I will post them with the handouts in our archive catalog. And all of our attendees will receive a follow up email with a link to that. So have no fear, your question will be answered as soon as we can.

So we will go ahead and do one more question quickly. A comment came in. The VA is developing a web based charting system. They are also developing apps where Veterans will be able to download their information and it will go directly on to their chart.

Mary Charlton:Great.

Moderator: Thank you for that comment. And for the last question, could you discuss the issue of PMDs and patients faxing PMD prescriptions to VA physicians and mid-levels with the expectation that the VA clinician is to simply rewrite the PMD prescription regardless of whether the VA clinician is actually managing the medical issue. Is this in the scope of practice or is on VA formulary?

Gary Rosenthal:So I think we are just sort of trying to understand the question. So this would be for a formulary – a medication that is on formulary for which a non-VA provider is providing a prescription and is – and wishes to have the patient receive that medication through the VA. So I guess in that context, it is always – it would be a clinical decision of the VA provider about filling that prescription.

Mary Charlton:I think that is why it is important have the information necessary for that – for there to even be a possibility of that happening, they would need to perhaps know lab results or have the most recent clinical note or things like that. But as Dr. Rosenthal said, that is going to be a clinician by clinician basis and a situation by situation basis. I know some providers out there are comfortable doing that without seeing the patient depending on what it is and some prefer to see them because in the end they are ultimately accountable for the prescriptions that they write.

Moderator: Excellent. Thank you very much. I know you are – we are quickly running out of time. I appreciate you staying after in addition to our attendees staying after. I would like to give you the opportunity to make any concluding comments now.

Gary Rosenthal:I am glad – just we want to just thank everybody for their participation. I think the questions that we have received after the presentation really highlighted the importance of developing more effective ways of exchanging information and approaching it in a more systematic basis. I think it also highlights that there is not a single easy solution on the horizon over the next year or two that is going to solve this and that we are going to have to rely on a mix of different strategies and I think while we cannot place the burden for this on the patient, if we want to do proactive care coordination and population management, nonetheless, we – the patient is an important source of information and we have to actively solicit information from them on encounters they may have had outside of the VA system when we see them in clinic or in the hospital.

Moderator: Thank you very much. We really appreciate you all lending your expertise to the field and we appreciate our attendees for joining us. Once again, we will get written responses to the rest of the remaining questions and I will be sure to get those out to you. But as we are out of time, I would like to encourage our attendees to please out the survey that is going to pop up on your screen as you exit the session and I hope that everyone enjoys the rest of their day. Thank you very much. 

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