FORUM translating research 

into quality health care 

for veterans

A publication of the VA Office of Research 

& Development, Health Services Research 

& Development Service, Center for 

Information Dissemination and Education 

Resources, in conjunction with AcademyHealth

November 2006

Contents 

Director’s Letter 2 

Response to Commentary 3 

Research Highlights 4 

HSR&D National 

Meeting 6

VA Health Services Research & Development Service 

The Changing Face and Pace of VA Ambulatory Care 

Recently Forum interviewed Alan S. Perry, 

M.H.A., FACHE, Director, VA Central 

California Health Care System 

■ Every day, 900 patients access the VA Central 

California Health Care System’s (CCHCS) 

ambulatory services. What systems does the 

CCHCS have in place to optimize patient 

encounters? 

A number of changes from the ambulatory 

system of 5 to 10 years ago have enabled the 

CCHCS to improve access to services we offer 

through our ambulatory care system. First, we 

offer advanced clinic access in primary and 

specialty care so that our patients can get an 

appointment usually within a week and in 

some cases the same day. Second, we’ve put 

into place service agreements between Primary 

Care and Specialty Care that extend to cardiology, 

ENT, ophthalmology, orthopedics, gastroenterology, audiology, mental health, and even 

imaging. These agreements help us reduce 

wait times and ensure that every effort is made 

to secure an appointment within 30 days. 

To help orient our newest patients, the CCHCS 

offers weekly group meetings that give newcomers the information they need to maneuver 

through our system with things such as telephone care and pharmacy reordering. We also 

offer group educational counseling—run by an 

interdisciplinary health care team—for congestive heart failure patients, diabetics, and those 

patients seeking smoking cessation counseling. 

We have a process in place to help reduce medication errors by reviewing all of the patient’s 

medications at admission, discharge, or at any 

change in level of care. In addition, we place a 

high priority on customer service training for 

all employees to empower them to solve problems and ensure patient satisfaction. 

We face a number of challenges in offering ou

patients an optimal ambulatory care encounte

First among these is determining when a 

group versus an individual encounter is the 

best approach to improving health care outcomes and what level of provider is best for 

group encounters. Research in this area would 

be helpful, especially as we continue to grappl

with increasing numbers of patients suffering 

from chronic conditions such as diabetes. 

Another challenge is overcoming language an

cultural barriers so that we communicate effec

tively and ensure patient adherence to treatmen

guidelines. One third of our patients are 

Hispanic, and while veterans typically speak 

English well, many of their family members— 

who are often also their caregivers and who ar

critical to patient compliance—do not. 

Treatment decision making in the ambulatory 

setting is another challenge. For example, wha

are the best screening methods or other tools 

for efficiently assessing patient needs? 

■ VA is lauded as the leader in the country in 

implementation of the electronic medical record. 

How does this technology affect patient encounter

at CCHCS? 

The electronic medical record (EMR) has greatl

enhanced our ambulatory care services in 

terms of diagnosis, treatment, and efficiency. 

Prior to a patient visit, our providers use EMR 

for data recovery and chart review. Clinical 

continued on page 
2 ■ Forum/November 2006 

Director’s Letter 

Much of what we do in HSR&D is aimed 

at improving the effectiveness and outcomes of health care for veterans. Fittingly, 

optimizing systems of care is the focus of 

this issue of FORUM, which begins with 

a thoughtful discussion of facility-level 

systems and challenges. Next, we highlight several research projects that illustrate ways in which HSR&D is working to 

advance knowledge and evidence for systems improvements. 

At our most recent State of the Art 

Conference (SOTA), the agenda focused 

on “Managing Complexity in Chronic 

Care.” Held in September, the SOTA 

brought together a multi-disciplinary 

group of 90 experts to discuss complex 

care from both the patient and systems 

perspectives. As background for discussions, HSR&D commissioned seven papers 

on topics ranging from the prevalence of 

complex chronic conditions to the patient’s 

experience, and from the business case 

for and information systems needed to 

support improved care. Work group and 

panel discussions were lively and informative and resulted in several interesting 

recommendations that are expected to 

inform future research solicitations. The 

Journal of General Internal Medicine will 

publish final papers in a supplement next 

year. We are also working on other dissemination strategies for the SOTA deliberations and recommendations. 

In August, the Scientific Merit Review 

Board reviewed 131 proposals and we hope 

to fund 28 of these in fiscal year 2007. In 

addition, we continue to receive strong 

applications for Career Development 

Awards under the new ORD-wide program 

designed for both clinicians and nonclinicians. We expect to fund 9 of the 36 

applications reviewed in September. 

Planning continues for the HSR&D 

National Meeting, scheduled for February 

21-23, 2007. Visit www.hsrd.research.va.gov/ 

meetings/2007/ for the latest details. 

Shirley Meehan, M.B.A., Ph.D. 

Acting Director, HSR&D 

reminders appear on the computer screen 

alerting providers about immunizations 

and screenings. Providers can easily access 

a patient’s history, or can order medications 

with a couple of key strokes. EMR also 

allows the provider and patient to review 

the medical record together and discuss 

trends over time. 

For all its benefits, the EMR offers some 

challenges when it comes to the patient 

encounter. Our appointments have 

stretched from 20 to 30 minutes to allow 

providers sufficient time for data review 

and input. What do we know about how 

best to manage the time and resources of 

the patient, provider, and the computer in 

the exam room? What are best practices in 

terms of the physical layout of the exam 

room and communications to enhance 

sharing of electronic information between 

providers and patients? 

■ How have advances in technology such as 

the Internet and wireless devices affected the 

way that CCHCS meets the health care needs 

of its patient population? 

The availability of text messaging and wireless computer access has definitely changed 

the pace of care. Providers can quickly 

communicate with one another from various 

locations; they can access images that were 

taken at another facility; and with telemedicine consultations they can care for patients 

in remote locations. We also have patients 

with home monitoring devices that track 

vital information on their conditions. 

MyHealtheVet will eventually allow patients 

access from home through the Internet to 

information about their appointments, 

medications, and their medical records. 

These reduce patient travel and clinic time 

and help to increase our efficiency. 

A challenge we face is determining how best 

to maximize the convenience and benefits of 

these technologies for our patients. As we 

hand over more control of care to patients, 

what is the right balance between them tak­

“As we hand over more control of 

care to patients, what is the right 

balance between them taking 

charge of their own care and those 

of us who are clinically responsible 

for monitoring that care?” 

ing charge of their own care and those of us 

who are clinically responsible for monitoring 

that care? 

■ How is your facility meeting the needs of 

the new veterans from conflicts in Iraq and 

Afghanistan? 

Like the majority of VA facilities, we have a 

case management program to help us track 

and assist the 950 veterans from these con

flicts registered as patients at CCHCS. 

Some of them were referred to us from the 

Department of Defense or from the VA 

Polytrauma Center in Palo Alto, and others 

simply arrived as walk-ins. We also conduc

outreach to new veterans. We try to get our 

arms around them as quickly as possible and 

get their cases managed. In caring for these 

new veterans, we are seeing very young men 

and women with injuries to the extremities, 

mental health needs, and dental needs. 

One challenge for us is how to effectively 

screen for and treat post traumatic stress 

disorder (PTSD). Another is how best to 

reach out to the veterans who might not 

seek care for themselves. In addition, how 

do we help very young men and women 

acknowledge that their injuries are long 

term or permanent and provide them with 

the appropriate services to help them optimize what they can do? 

At CCHCS we continuously strive to provide optimal evidence-based care for all of 

our patients. ■ 
Forum/November 2006 ■ 

Response to Commentary
 

HSR&D Working to Meet New Challenges in 

VA Ambulatory Care 

By Richard M. Frankel, Ph.D., VA HSR&D Center on Implementing Evidence-Based 

Practice, Indianapolis VAMC 

In this issue’s lead commentary, Alan Perry, 

Director of the VA Central California Health 

System (CCHCS), states that every day 

900 patients access CCHCS’ ambulatory 

services. That’s approximately 234,000 

opportunities per year to engage veterans 

in health-enhancing processes and outcomes of care—nothing to be sneezed at! 

Recent innovations that have greatly facilitated care at CCHCS include a sophisticated 

electronic medical record system, advance 

clinic access, and service agreements 

between primary and specialty care services. 

Despite, or perhaps because of these innovations, a number of challenges remain. 

For example, we do not know when a 

group appointment is better than an individual visit, when and how language and 

cultural barriers affect patient adherence, 

and which screening and treatment decisions are feasible and effective in the 

ambulatory setting. 

The Promise of Group Appointments 

Group medical appointments (GMAs) are 

a relatively new form of practice. They typically involve a physician or health care 

team, e.g. physician, behaviorist, nutritionist, etc., interacting for 60 to 90 minutes 

with either a drop-in group medical 

appointment (DIGMA) or an identified 

cohort of patients who meet on an ongoing 

basis. At Kaiser Permanente, for example, 

DIGMAs have been used for the past several years to work with distressed high utilizers of medical care. The initial results 

have been encouraging. Utilization has 

gone down in this group and satisfaction 

with care has increased. Patients point to 

the value of social support that comes from 

being able to speak with others who have 

the same condition and to benefit from 

their wisdom and experience as well as the 

physician’s. 

Despite its promise, the use of GMAs in the 

VA system will require additional study to 

determine its effectiveness in chronic disease management. At this point, we do not 

know which chronic diseases are best treated using GMAs as compared with individual visits. Likewise, age may be an important factor in determining who benefits 

most from a GMA approach. There is evidence in the literature that older, frail 

patients do well in this setting but studies 

have not yet compared groups of older and 

younger patients.1 In addition, we need to 

address questions of confidentiality, waiting 

time, and patient flow, as well as drop-out 

rates, before full implementation of GMAs 

can occur. 

VA has become a national leader in promoting early detection and screening and is 

currently funding research on best practices 

for patient self management. Another area 

for continued research is barriers that occur 

when differences in language and culture 

exist between physician and patient, and 

the effect of these barriers on patient adherence. In addition to cultural differences in 

language and literacy levels, communication about adherence itself may be sub optimal. One study found that primary care 

physicians and surgeons checked for 

patient comprehension—a key to ensuring 

adherence—only 1.5 percent of the time.2 

More research into the conditions under 

which language and culture in the medical 

visit create barriers to adherence will help 

address this problem. 

The Science of Implementation 

In making study findings practical, 

researchers distinguish between what work

under controlled conditions (efficacy) and 

what works in the real world (effectiveness)

This distinction is the central challenge of 

the science of implementation. Knowing 

that a flu shot for every veteran is a worthy 

goal does not ensure that every veteran will 

take advantage of the opportunity to receive 

one. Naturalistic observation and qualitative 

research methods that get at the patient’s 

experience of care can be powerful tools in 

bridging the gap between the ideal and the 

actual. A classic study by Inui and Carter 

demonstrated that successive rounds of indepth interviews with veterans to identify 

and weigh barriers to obtaining flu shots 

resulted in an increase in utilization from 3

percent to nearly 80 percent. More research 

of this kind will be necessary to bridge the 

gap between knowledge of what’s feasible 

and what works in day-to-day practice. 

It is heartening to see the progress VA 

ambulatory care is making at CCHCS and 

other facilities. We have many research 

challenges ahead of us but we have made 

substantial progress in research and development toward identifying and implementing the best evidence and practices that 

provide the most benefit to our patients. 

Our veterans deserve no less than our very 

best efforts to bring knowledge from the 

bench to the bedside and from clinical trial

to the clinical encounter. ■ 

References 

1 Noffsinger EB, Sawyer DR, Scott JC. 

Group Medical Visits: the Future? Patient 

Care 2003; 37:18-27. 

2 Braddock CH, Edwards KA, Hasenberg 

NM, et al. Informed Decision Making in 

Outpatient Practice: Time to Get Back to 

Basics. The Journal of the American Medical 

Association 1999; 282:2313-20. 
4 ■ Forum/November 2006 

Research Highlights
 

Teledermatology Improves Access to Care by 

Improving Time to Intervention 

By John D. Whited, M.D., M.H.S., Durham HSR&D Center of Excellence 

Timely delivery of specialty care and the 

ever-increasing demand for those services 

are challenges facing the VA. As the primary 

care population base increases, so to does 

the demand for specialty services such as 

dermatology. In addition, the decentralization of VA health care through the expansion of community-based outpatient clinics 

will require innovative means of delivering 

dermatologic care to these remote sites of 

primary care. Teledermatology is one means 

of addressing these needs. Visually-oriented 

specialties such as dermatology seem well 

suited to telemedicine technology. Teledermatology has the potential to improve consult processes and provide care in both 

remote sites of primary care, such as 

community-based outpatient clinics, and in 

centralized sites of dermatologic care at VA 

Medical Centers. 

Improving Time to Intervention 

Through a VA HSR&D funded study 

“Health Services Implications of a 

Teledermatology Consult System,” we 

began to address the question of how teledermatology could impact access to care. 

Study subjects were randomized to either a 

“store and forward” teledermatology consult 

or the conventional consult process. “Store 

and forward” teledermatology consults generate “still” digital images coupled with a 

standardized history collection for review 

by a dermatologist consultant. Usual care 

implies that the conventional text-based 

consult system is reviewed and typically 

results in a visit to the dermatology clinic. 

The dermatologist consultants would then 

decide whether a clinic visit was required 

and, if so, the timing of that visit. 

We hypothesized that the additional information contained in the teledermatology 

consult, particularly the visual data, would 

improve time to intervention and that this 

may occur in one of two ways. First, dermatologists could identify those patients that 

do not require a clinic visit. For example, 

dermatologists could determine that a subject with a benign skin lesion (e.g., seborrheic 

keratosis) requires no further intervention. 

The dermatologist could relay that information back to the referring clinician and avert 

a dermatology clinic visit. Second, triage 

decisions can be affected. Dermatologists 

could triage a skin lesion with high malignant potential directly to a procedural clinic 

visit for biopsy and avoid both the need for 

a diagnostic clinic visit and the associated 

wait period for such a visit. 

Based on our actual visit analysis, we found 

that teledermatology significantly decreased 

the time to intervention. Subjects in the 

teledermatology study arm reached a point 

of intervention by a median of 50 days, 

compared to a median of 137.5 days in usual 

care (p = 0.0027). All 140 usual care subjects were scheduled for a dermatology clinic visit. Twenty-five of the 135 subjects that 

randomized to teledermatology were not 

scheduled for a clinic visit. Only one of 

those 25 subjects subsequently presented 

for a clinic visit during the follow-up period. 

The use of telemedicine in general, and 

teledermatology specifically, has several 

potential implications for VA health care. 

High demand for services coupled with limited dermatology resources result in long 

wait times for routine dermatologic care— 

a situation that is not unique to the VA. 

Given VA’s fixed dermatology resources, 

teledermatology may be one strategy to 

manage the high demand for services. 

Satisfaction with Teledermatology 

Avoiding the need to schedule a portion of 

teledermatology referrals for a dermatology 

clinic visit opens up clinic time for those 

patients that are identified as requiring a 

dermatology clinic-based intervention. 

Some patients can be managed based on 

advice provided by the dermatologist consultant and implemented by the referring 

clinician. More effective triage of referrals 

may result in better timing of clinic visits. 

Rather than relying only on textual informa

tion to assess acuity, teledermatology consults provide the dermatologist consultant 

with visual information with which to mak

that decision. 

Intuitively, more timely care might reasonably be expected to result in improved satis

faction among both clinicians and patients

In fact, that is what was found in another 

product of this study. Overall, dermatologists, referring clinicians, and patients wer

all satisfied with the teledermatology 

process. This project provides evidence tha

teledermatology may play an important rol

in managing VA health care resources and 

improving health care delivery. ■ 

References 

Whited JD, Hall RP, Foy ME, et al. 

Teledermatology’s Impact on Time to 

Intervention Among Referrals to a 

Dermatology Consult Service. Telemedicine 

Journal and e-Health 2002; 8:313-21. 

Whited JD, Hall RP, Foy ME, et al. Patient 

and Clinician Satisfaction with a Store and 

Forward Teledermatology Consult System. 

Telemedicine Journal and e-Health 2004; 

10:422-31. 
Forum/November 2006 ■ 

Improving Eye Care for Veterans with Diabetes 

By Steven J. Bernstein, M.D., M.P.H., and Sarah L. Krein, Ph.D., R.N., HSR&D Center for 

Practice Management and Outcomes Research, VA Ann Arbor Healthcare System 

Diabetes affects nearly 20 percent of veterans who use the VA health care system, or 

more than one million veterans. Diabetes is 

the leading cause of new cases of blindness 

in adults ages 20-74 in the United States. 

In the VA, approximately one-fourth of all 

eye procedures performed in 1998 were in 

persons with diabetes; among VA patients 

with diabetes examined by an ophthalmologist nearly 5 percent were blind. Yet, 90 

percent of visual loss due to diabetic 

retinopathy can be prevented through optimal medical and ophthalmologic care. 

Given the devastating impact of diabetes on 

veterans and known mechanisms to prevent diabetes-related visual loss, the 

Diabetes-QUERI has focused some of its 

effort on this problem. 

Pilot Promotes Close Follow-Up 

Over the past five years, the Diabetes-QUERI 

has conducted a series of studies to determine optimal screening intervals and to 

identify circumstances surrounding preventable visual loss among patients with 

diabetes. In addition, we implemented a 

pilot project to promote close follow-up of 

patients at high risk of developing diabetic 

eye disease. This work included performing 

a cost-utility study; carrying out a medical 

record review; conducting survey and semistructured interviews with VA health care 

providers who provide ophthalmologic care 

to patients with diabetes; surveying patients 

regarding their experiences receiving eye 

care provided by VA; developing means to 

capture information not readily available in 

current medical records; and lobbying to 

make screening criteria more evidence based. 

We found that while annual screening is 

cost-effective for diabetic patients with very 

poor glycemic control, it is not appreciably 

better in preventing blindness than screening every two to three years for those 

patients whose previous exam was normal. 

For patients with known eye disease, close 

monitoring or surveillance is a key factor in 

preventing diabetes related blindness. In 

fact, a medical record review of 238 VA and 

non-VA patients who had undergone retinal 

photocoagulation for diabetic retinopathy or 

macular edema identified 102 patients (43 

percent) whose visual loss was considered 

potentially preventable with earlier treatment. However, none of these cases 

involved a patient who had gone one to 

three years without a screening exam. On 

the other hand, two-thirds of cases were 

associated with inadequate follow-up of 

those with identified disease, delays in treatment scheduling, or unexpectedly rapid disease progression. 

These findings suggested that the prevailing 

performance measure, which encouraged 

an annual exam for all patients with diabetes, could potentially hurt quality. Trying 

to screen everyone annually consumes much 

of the eye care clinic’s limited resources, 

making it more difficult to aggressively 

monitor and follow-up those at highest risk. 

Preventing Visual Loss 

To address some of these issues, we undertook an eye care improvement project to 

prevent visual loss among VA patients with 

diabetes. This project involved shifting 

responsibility for the coordination of diabetes eye care to the eye clinic and using 

automated tools to facilitate less frequent 

screening of low risk patients and more 

aggressive follow-up of those at higher risk

A cornerstone of the project was the 

Progressive Reminder and Scheduling 

System (PRSS), which was designed to 

automatically track patients. The PRSS 

requires knowing the patient’s risk of devel

oping diabetic eye disease (which is 

assigned by the eye care provider following 

a clinical exam), the recommended time fo

the patient’s next visit, and the appointmen

status—which includes whether an appoin

ment is scheduled, whether a visit is made

or if the appointment is cancelled or missed

Currently, only appointment status is available in an extractable electronic format from 

the VA electronic medical record. Since the 

scheduling system is distinct from the rest 

of the electronic health record, we were 

unable to develop a fully automated proactive scheduling system, however, we did 

develop a simplified, manual version of the 

PRSS that has been used at one study site. 

Our research has produced important infor

mation to help us further understand 

patients’ risk status and potential gaps in 

follow-up at VA eye care clinics. Our research 

also offers general lessons for implementation science, especially as it relates to proac

tive, risk-stratified scheduling and follow-up

Also, in conjunction with these projects, 

both the Health Plan Employer Data and 

Information Set (HEDIS) and VA revised 

and adopted diabetes performance measures 

allowing every other year eye exams for 

patients at low risk (with continued annual 

exams for high risk patients). 

Work by the Diabetes-QUERI to promote 

changes in the delivery of eye care services 

for veterans with diabetes demonstrates the 

promise of the QUERI model in facilitating 

the more rapid implementation of evidence 

into practice. ■ 
6 ■ Forum/November 2006 

Research Highlights
 

Implementing Information Systems and 

Technologies to Improve Health Care Delivery 

By Bradley N. Doebbeling, M.D., M.Sc., Steven M. Hare, M.S., Mindy Flanagan, Ph.D., 

VA HSR&D Center on Implementing Evidence-Based Practice, Indianapolis VAMC 

The VA pioneered the use of information 

and communications technology (IT) to 

deliver improved health care services. High 

patient satisfaction rates, readily available 

real-time information, improved delivery 

processes, reduced administrative and clinical redundancy, and improved quality and 

safety have resulted from effective implementation of IT in VA. 

Barriers and Opportunities to 

Integrating IT 

Unfortunately, barriers to changing health 

care delivery systems loom large, slowing 

the acceptance and use of IT within patient, 

provider, organization, and health care system 

domains. These deterrents include the following: costs associated with development, 

testing, implementation, and training for 

IT initiatives; lack of financial and return on 

investment models; concerns regarding 

privacy and security of personal health 

records; lack of senior administration and 

leadership support and priority; and scarcity 

of clinical time and resources to adapt existing processes and practices to incorporate 

the use of new technologies. 

Significant opportunities exist to better integrate IT into acute care. In a nationally representative study of 448 U.S. hospitals, 

including all VA acute hospitals, we examined the impact of hospital practices to prevent and control antimicrobial resistance 

(AMR). Implementation of recommended 

practices for antimicrobial use and optimization of the duration of empirical antibiotic prophylaxis were associated with a 

lower prevalence of AMR. Use of automated 

antimicrobial order entry and use of computerized decision support were not associated with lower rates of AMR, although relatively few hospitals had implemented computerized order entry for health care providers. 

In fact, many of the facilities that reported 

use of computer support tools in implementing AMR guidelines were VA facilities. 

Use of Computerized Tools 

For example, our Indiana Accelerating 

Change and Transformation in Organizations 

and Networks (ACTION) Collaborative is 

implementing evidence-based practices 

using a lean six sigma approach to engage 

front-line staff to markedly reduce methicillinresistant bacteria (MRSA) infection and 

creating an informatics tool for electronic 

sharing of laboratory data across hospitals. 

Participating hospitals determine if a presenting patient has been cultured for MRSA 

at other hospitals, leading to a cost reduction in unnecessary cultures and quick 

determination of isolation. We expect this 

implementation initiative to reduce the 

spread of MRSA infections around the 

Indianapolis community. Our efforts build 

upon the VA initiative underway in a number of VA facilities, led by Dr. Robert Mude

at the Pittsburgh VAMC and funded by 

VA’s Office of Quality and Performance. 

As a second example, the Indianapolis 

VAMC developed and implemented a standardized handoff tool, as recommended by 

the 2006 JCAHO National Patient Safety 

Goals. Many communication errors occur 

during “handoffs,” when a patient’s care is 

transferred from one care provider to 

another. We are currently conducting a formative evaluation, funded by HSR&D, of 

the existing computerized patient handoff 

tool developed at the Indianapolis VAMC. 

continued on page 

HSR&D National Meeting in February 2007 

HSR&D’s 25th National Meeting will be held on February 21-23, 2007 at the Hyatt Regency 

Crystal City, in Arlington, Virginia. This scientific meeting helps to facilitate integration of ideas 

and information between VA’s research community and the clinical, management, and policymaking communities. The meeting will help ensure that VA policy is informed by evidencebased research and research is responsive to the needs of managers and the organization. 

This year’s meeting theme, “Managing Recovery and Health Through the Continuum of Care,” 

is particularly well timed given current challenges to the health care system to address the shortand long-term needs of veterans returning from conflicts in Iraq and Afghanistan. Almost 500 

abstracts were submitted for competitive review and selection for presentation at the meeting, 

which will feature paper, workshop, and poster sessions addressing issues of access, clinical and 

systems improvements, quality, satisfaction, cost-effectiveness, and methods. In addition, there 

will be special talks by VA leadership, award presentations, and opportunities to explore productive collaborations between VA facility, network, and research communities to enhance the 

development and dissemination of innovative approaches to patient care and health care service 

delivery. 

For more details about the meeting agenda, to view abstracts, and for registration information, 

please visit the HSR&D Web site at http://www.hsrd.research.va.gov/meetings/2007/. 
Forum/November 2006 ■ 

Group Medical Visits: Improving Chronic 

Disease Management 

By Mary K. Goldstein, M.D., and Catharine Fenn, Ph.D., both from Geriatrics Research 

Education and Clinical Center, VA Palo Alto Health Care System, and Brian B. Hoffman, 

M.D., Medical Service, VA Boston Healthcare System 

Hypertension, a highly prevalent risk factor 

for cardiovascular disease, is in principle 

eminently treatable. Nonetheless, evidencebased target blood pressures in patients 

with hypertension are often not achieved. 

Strategies that are directed toward primary 

care clinicians with the goal of improving 

the quality of hypertension care may 

improve guideline-concordant prescribing. 

However, it is ultimately the patient who 

decides whether or not to adhere to the 

medication regimen and other, non-pharmacological measures. Therefore, patient 

self-management is key to care of chronic 

diseases such as hypertension. Lorig et.al. 

have developed a model for improving selfmanagement of chronic disease by enhancing the patients’ sense of self-efficacy for 

self-care. They showed that group participation in a chronic disease self-management 

program can improve symptom control and 

reduce limitation of activity. 

Testing a VA Group Model Design 

Group visits, used sporadically for more 

than a century in the United States, have 

become increasingly popular in recent 

years. In an HSR&D QUERI-funded project 

on translating research findings about 

hypertension into practice, we developed 

a model of group medical visits for the 

general medical clinic at VA Palo Alto, 

incorporating an approach designed to 

enhance patients’ self-efficacy for managing 

their hypertension. In our model, patients 

receive medical care in a group setting 

while interacting with each other and 

with their primary care provider. The project aim is to develop, implement, and evaluate a model of medical group visits for 

use in the VA. The design is a clusterrandomized trial. The population includes 

VA patients who have a diagnosis of hypertension and who are assigned to the panels 

of primary care physicians enrolled in 

the study. 

Our project used a staircase study design in 

which we initially enrolled three providers 

in step one to implement an initial model of 

group medical visits adapted from non-VA 

study sites. This step was followed by a formative evaluation and redesign with enrollment of three more providers in step two 

and another formative evaluation and 

redesign, culminating in enrollment of 

additional providers in step three for summative evaluation of the final model. At 

enrollment, primary care providers were 

randomized in a 2:1 ratio to conduct group 

visits or to serve as treatment-as-usual controls. We then recruited patients of these 

providers. Patients of group visits providers 

were randomized in a 2:1 ratio to participate 

in group visits (GV-patients) or to serve as 

control patients of group visits providers 

(GV-controls). Patients of control group 

providers served as treatment-as-usual controls (TAU-controls). Our study plan also 

called for tracking organizational issues that 

arose as either barriers to, or facilitators for 

the group visits program. Our primary outcome measure is blood pressure control. 

Secondary measures include medication 

adherence, patient and clinician satisfaction 

with care, self-efficacy and stages of change 

measures, and qualitative results of the 

organizational study. 

Patients see their own primary care provider 

in the group clinic sessions in a medical 

appointment shared with other patients. 

Visits are held in a conference room close t

the general medical clinic in order to facilitate short, private examinations in a regular 

exam room when necessary. The conference 

rooms also have computer access to the com

puterized patient record system. Initially, the 

sessions included a 30 minute educational 

topic presented by someone other than the 

primary care provider. 

Satisfaction with Group Visits 

As clinicians gained experience with conducting the visits, they incorporated more o

the educational content into the clinical 

review of each patient, turning the discussion to the entire group. We found that for 

both providers and patients, discussion 

topics changed over time, with initial visits 

focused exclusively on hypertension but 

later visits covering a broader range of clini

cal problems. We are now analyzing the dat

and expect to report quantitative results 

soon. Preliminary review of qualitative data

including clinician interviews and patient 

comments at the end of the study, suggest 

high rates of satisfaction with the program, 

and the general medical clinic hopes to offe

group visits as part of their regular care pro

gram in the future. ■ 

References 

Walsh JME, McDonald K, Shojania KG, et 

al. Quality Improvement Strategies for 

Hypertension Management: A Systematic 

Review. Medical Care 2006; 44(7):646-57. 

Bodenheimer T, Lorig K, Holman H, 

Grumbach K. Patient Self-Management of 

Chronic Disease in Primary Care. Journal of 

the American Medical Association 2002; 

288(19):2469-75. 
g fpg

We are collaborating with the VA National 

Center for Patient Safety (NCPS) to foster 

implementation of the handoff tool at multiple other VAMCs. 

As a final example, we are exploring applications of rapid process improvement techniques—such as lean six sigma, health care 

simulation, and systems modeling—in our 

facility to improve safety, quality and efficiency. Expected outcomes might include 

improving exam room utilization to mitigate 

both short-term and long-term demand for 

additional space, reducing appointment tardiness to achieve full compliance with 

national appointment timeliness performance 

measures, better mental health systems 

planning, and disseminating evidence-based 

clinic workflow best practices. 

For more than a decade, the VHA and the 

VAMCs across the nation have led a national 

movement to incorporate information and 

communications technologies as well as 

process and systems reengineering in 

improving care delivery. By working to break 

down known barriers to change, using technologies to provide greater information 

availability and integrity, and creating new 

collaboration models, rapid improvements 

within VA’s health care delivery systems will 

continue to lead the nation. ■ 

References 

Doebbeling BN, Chou AF, Tierney WM. 

Priorities and Strategies for Implementation of an Integrated Informatics and 

Communications Technology System for 

Evidence-based Practices. Journal General 

Internal Medicine 2006; 21:S98-105. 

Zillich AJ, Sutherland JM, Wilson SJ, et al. 

Antimicrobial Use Control Measures to 

Prevent and Control Antimicrobial Resistance in US Hospitals. Infection Control and 

Hospital Epidemiology 2006; 27:1088-95. 

Doebbeling BN, Vaughn TE, McCoy KD, 

Glassman P. Informatics Implementation 

in the Veterans Health Administration 

Healthcare System to Improve Quality of 

Care. Journal of American Medical 

Informatics Association 2006. (In press). 

FORUM 

Geraldine McGlynn, Editor-in-Chief 

Margaret Trinity, Editor 

Editorial Board 

Martin P. Charns, D.B.A., Director, VA HSR&D 

Center of Excellence, Boston, MA 

Phil Crewson, Ph.D., Assistant Director, 

VA HSR&D, Central Office 

Joseph Francis, M.D., M.P.H., Acting Deputy 

Chief Research and Development Officer, 

Associate Director, HSR&D QUERI, Central 

Office 

Rodney A. Hayward, M.D., Director, VA HSR&D 

Center of Excellence, Ann Arbor, MI 

Shirley Meehan, M.B.A., Ph.D., Acting Director, 

VA HSR&D, Central Office 

Michael J. Miller, M.D., Ph.D., Chief Medical 

Officer, VA Network #1, Bedford, MA 

Eugene Z. Oddone, M.D., M.H.Sc., Director, 

VA HSR&D Center of Excellence, Durham, NC 

Alan S. Perry, M.H.A., FACHE, Director, 

VA Central California Health Care System