IHRISS Contributors

Carolyn TurveyJeff SolomonStephanie ShimadaBeth Ann PetrakisMichael OhlKim NaziThomas HoustonAllen Gifford Allen GiffordBarbara BokhourSteve Asch Keith McInneSteve Asch
Internet and My HealtheVet us

Chronic Disease Disease Self‐Managem

Managem

I i ntervention for H lh ea t ‐Rl d e ate Internet S 

Skills (IHRISS)

RRP 09‐192, QUERI HIV ‐ HCV

Keith McInnes, ScD, MS

D b ecem er 7th, 2010

Keith.McInnes@va.gov
Overview

• Background: Background: Internet, Internet, EMRs, My HealtheVet

• Study Objectives• Methods: sites, participants participants, training training interven

interven

• Preliminary results from hepatitis C group• Conclusions and next steps
Audience: Your familiarity with M

Heal ht eVet

• Know very little about MHV• Know medium amount about MHV• Know a lot about MHV

• My job is in some way connected with M
Audience: How would you desc

your work?

• Research, primarily• Clinical / patient care, primarily• O ht er (e.g. operations, management)

primarily

61% of American Adults Look Online for 

If i n ormation

Of these “e‐patients patients ,” 60% say they (or someone someone they know) help

medical advice/information found on the internet.

– 60% Æ information found affected a decision about how to trea

or condition.

– 56% Æ changed their overall approach to maintaining their heal

health of someone they care for.

– 53% Æ led them to ask Dr new questions, or to get a 2nd opinio

– 49% Æ changed their thinking on diet, exercise, or stress.

– 38% Æ affected a decision about whether to see a doctor.

– 38% Æ changed their coping with a chronic condition or pain.

Pew Internet & American Life Project (June 2009)
Electronic Medical Records Records (EM

Less than 20% of ambulatory ambulatory care physici

physici

have an electronic medical record (DesR

2008 NEJM)

Less than 20% of US h il osp tals have an el 

e

medical record system. (Jha 2009 NEJM
EMRs enable Personal Health Re

( ) PHRs

• Kaiser Permanente• Group Health Cooperative• VA’s My Heal ht eVet ( ) MHV
What is My HealtheVet (MHV

• Keep health journals• View VA medication list• O dr er refills of VA medi i cat ons

• Receive reminders (e.g. screening)

• Secure messaging (at selected VAs)

• VA appointments (early 2011)

• “Blue Button”
Factual/Clarification Questions on MH
Intervention for Health‐Related Internet 

Skills (IHRISS)

Specific Aims

1. Group training training on MHV and Internet Internet for health, wi

Veterans with HIV or hepatitis C (HCV).

2. Increase Veteran self‐management in health throu

in MHV & Internet.

3. Develop more efficient and flexible means of deliv

training.
Methods

• VA medical centers: 1 urban, 1 suburban, and 1 rura

– Recruitment over 6 week period; Incentives provided

– 4 sessions in computer training room

– Groups of 6‐8 Veterans with either HIV or hep C
Methods

• Evaluation

– Questionnaires pre & post– Focus group– semi‐structured interview

– Ethnographic observation

• Measures

• Frequency of Internet & MHV use.• Knowledge Knowledge of HCV / HIV• Self‐efficacy for information seeking and Internet use (NCI/HI

• Engagement in care (patient activation measure, PAM)

• Information Information, Motivation Motivation, Behavioral Behavioral Skills (IMB model)
Methods

Content:

1. Search2. Evaluate3. Transact4. C i ommun cate

Training methods

– Si l ng e and in pairs

– Team building

– Role plays

– HomeworkC il urr culum modld e e after K li h a c man et al. 2006 J Cons Clin P hl syc o o
Training Training Content Content – ‘P‐I‐L‐O‐T

Purpose (What is the website for?):________________________________________________________Information (Good information? Do you trust it?):________________________________________________________Links (Does it have good links? Any you want to go to or remember for lat

________________________________________________________

Originator (Who made this site? Name of company, organization or perso

________________________________________________________

Timeliness (Has it been updated in last 1‐2 years? Do you think it is missin

information?)

________________________________________________________
Factual/Clarification Questions abo

I i? ntervention

?
Preliminary Results
Participant Characteristic

• 8 veterans with HCV

• All White

• 7 male, 1 f l ema e

• Ages 48‐65

• 5 high school; 3 with some college

• Low household income (most <$12,000)

• 5 unstably housed

• Wide range of computer skills(similar demographics demographics for HIV+ group)
IPA Results

• 7 out of 8 IPA d’ in group one (HCV)• 5 of 6 IPA’d in group two (HIV)
Self‐Efficacy Efficacy Results Results (n 8

=

Information Seeking and Internet Use (7‐items)• How confident are you that you can...

– Find information about HCV treatments– Discuss treatments with your doctor– Use internet to find health information

• Increase from 6 3. to 8 5. , on a 0 to 10 scale (S

(S

p=.02)

[adapted from NCI – HINTS study]
Patient Patient Activation Activation ( engageme

(“engageme

13 PAM items. Examples:• I am confident I can help prevent or reduce problems

associated with my health.

• I know what each of my prescribed medications does

• I am confident that I can tell a doctor concerns I have 

when he or she does not ask.

No change from baseline to post‐training measure (bot

mean 3= 6. , St Dev = 0 3) .

(PAM from Hibbard et al. 2004 HSR)
Interview Results

• Viewing & Refilling medications easy and popular• Impressed with variety of websites devoted to HCV research

• Felt more informed about their health

• Felt more informed as patients

Bringing information from MHV/internet to the doctor’s appoin

“...helped ...helped the doctor view me as an informed informed patient . patient”.Another felt:“...a sense of k i now ng something i d nstea of b i e ng totally bl k” an .
Interview Results: Information Foun

the Web

“ I went to the website of one of the colleges in I went to the website of one of the colleges in

California. I think it was Berkeley, and, they a wealth of information for Hep C which was 

reason why I took this class to begin with, yobecause of the diagnosis and ... it's just a weai f ti Th h t th It information. There was so much out there. It 

just absolutely amazing.”
Observation Results ‐ Challenge

• Getting group together same place & sa

time

• Password & IPA challenges• Pitching the training to different skill lev

• Surfing versus learning
Observation Results ‐ Streng

• Group dynamic was positive positive• Comfortable being in group where HCV 

status was known

• Networking: VA, resources, health, hou• Helping each other: peer internet “expe
Conclusions

1) A group training program helped Veterans...

• Gain Internet and MHV skills

• Feel more confident confident about interacting interacting with the VA clinicians clinicians, 

• Take care of health care needs online (e.g. medication refills)

2) Resource Resource intensive intensive intervention; intervention; Significant Significant time commitment commitment f

participants

3) This approach to i i ncreasing self‐management, via MHV and Inte

be especially useful for Veterans who face actual or perceived VA health care and to health‐related information.

– Stigmatized conditions– Rural veterans

4) Need to find right mix of in‐person meetings for those with fewer skills 

confidence; confidence; and remote learning learning techniques techniques for others. others.
Next Steps

• Completion of rural group; Analysis Analysis• Try on larger scale, with less intensive

intervention

• Expand the emphasis on self‐managem

tools
Acknowledgements

• Carla Azersky• James Magiera

• Linda McCoy
Audience: Impact of MHV

Which of the following following aspects aspects of MHV do 

think will have the largest positive impa

Veterans Veterans’ health care experience experience in the 

– Appointment views– Viewing Viewing and refilling refilling VA medications medications– Secure messaging with VA providers– Vie ing Viewing VA laborator laboratory res lts results– None of these will have much impact
Questions?

Keith.McInnes@va.gov