Web-based Patient Portal to 

Directly Elicit a ComprehensDirectly Elicit

a Comprehens

Medical History

Ann Walia, MD,

Chief of Anesthesiology & Perioperative Care,

Tennessee Valley Healthcare System,

Professor of Anesthesiology Professor of Anesthesiology

Vanderbilt University Medical Center

Nashville TN.

VIReC Clinical Informatics Seminar

July 23, 2012
Contact Information:

Tennessee Valley Healthcare system1310, 24th Avenue SouthN h ill TN 37212 Nas

h

ville, TN 37212

ann.walia@ vanderbilt.eduann.walia@va.govOff: 615 Off: 615

- 873

-7003

615-343-9419
POLL
Today’s discussion

•Frame the opportunity Frame the opportunity•Describe the innovation and resu

Describe the innovation and resu

•Share lessons learned Share lessons learned
The unmet need

•Remote triage of patients to the appropr

Remote triage of patients to the appropr

setting improves quality, increases patiesatisfaction, and reduces cost

•An accurate and timely medical history i

essenti l f bli t ti t t i ti

al for enabling remo

te patien

t

t

ria

•Current methods for collecting medical h

Current methods for collecting medical h

often deliver inaccurate and delayed res

–Generic paper Generic paper

-based forms based forms

–Clinicians serving as expensive scribes–Partial and/or perishable EMR data

Partial and/or perishable EMR data
The opportunity

•Leverage the internet to facilitate patie

self-servi i idi ti l d ice in providing a timely an

d

accurate medical history, specific to th

context of care context of care

•Provide this 

patient-directed medical h

in real-time to clinicians to facilitate oppatient triage and management
VA preoperative triage oppo

•Patients and families 

unnecessaril

y inconvenienced 

with in-person visitsP ti li i dl l Ne

•

Preoperative cli

nics needlessly 

overwhelmed with patient 

volume

Ne

ef

volume t

•VA incurrin

g subs

t

anti

al e

xcess

t

cu g subs a a e cess

cost
TVHS preop situation—a mic

VA Tennessee Valley Healthcare System (TVHS)—Nashville campus

•4500 surgeries annually•All pre-surgical patients are evaluated 

clinic except inpatients ( ~ 6000 patien

•Significant burden on elderly; time off w

the younger Vets the younger Vets

•In

-person visits, associated mileage person visits, associated mileage

reimbursement, and expensive diagnotests may be unnecessary for many pa
VHA Innovation Program gra

C l Offi h i i l i

Background

•

Central Office soug

ht innovative solutio

the preoperative issues highlighted at 

but prevalent across the VA but prevalent across the VA

•After a rigorous marketplace scan, After

a rigorous marketplace scan,

MedSleuth, Inc. and their BREEZETM preoperative software was identified as 

good fit

•We applied for and received a VHA We applied for and received

a VHA

Innovation Program grant after a peer 

evaluation of 178 submitted letters of ievaluation of 178 submitted letters of i
VHA Innovation grant object

Provide a novel uSoftware

-as

-

a

-Ser

Ser

test environment 

d t t f demons

tra

te a 

fun

prototype that eff

screens and i tr ag

surgical patients 

anesthetic risk
BREEZE telemedicine triage

Fast track

Healthy 

Fast track

ASA 1/2

• 15-minute web-based 

patient questionnaire

Preop clinic

patient questionnaire

• Triage based on 

patient medications Unhealthy

ASA 3/4

and machine learning

• Summary output for 

patients andpatients and

clinicians
Medication-driven approach

BREEZE 4000+ drug database 
Associated disease states

BREEZE complete drug-disease association data
BREEZE comprehensive out
Project deliverables

• Customize web

-based preoperative softwa

√

Central Office requirements

Customize web based preoperative softwa

(BREEZETM, MedSleuth, Inc.) to VA requir

√

•Evaluate and optimize BREEZE for ease o

accurac

y b

y the VA 

p

o

pulation

√

y y pp

–30 randomly selected VA employees com

survey and traditional preanesthetic ques

–Results evaluated by 2 objective VA 

anesthesiologists

– Validated in larger patient cohort (n=75)

• Develop bi-directional HL7 interface with n

√

production version of CPRS 
VA Summary Evaluation of B

Total patients evaluated = 31; Dec. 2009

Scores Evaluator "A" Evaluator 3 (80

-85%) 0/3 (0%) 1

1/3 ( 0 03%

1 

(

0.03%

4 ( 85-90%) 13/31 ( 41.9%) 9/31 ( 29%)5 ( 90-100%) 18/31 ( 58%) 21/31 ( 67.7

Aggregate evaluation scores > 4 (i.e., greater than 85% accuracy)= 96.8

%
BREEZE evaluation results

VA employees and patient cohort (n=106)

•100% of participants able to complete ( l ith h l f f il ) ( alone or with

h

elp o

f

famil

y

)

•Average time to complete Average time to complete

≤ 20 minutes 20 minutes

•75% very satisfied or satisfied•Over 97% survey accuracy and 

compl t e

teness
Similar preop results elsewh

n = 670 patients 

95% patient satisfaction Median time to comple

Dissatisfied 2:00 Time to complete (minutes) 

5%

1:301:45

45% 50%

Satisfied Very 

S ti fi d

0:451:001:15

S

ati

sfi

e

d

0:150:30

0 20 40 

Age (years)
...including improved produ

Patients per nurse practitioner (NP) per day

45%

NP productivity 

improvement

10.5

7 2.

January, 2010(w/o BREEZE)

January, 2011(w/ BREEZE)

(w/o BREEZE) (w/ BREEZE)
...and reduced travel burden

n = 160 patients by round trip miles traveled

Remote tria

ge eli

gible Not eli

gible 

54

24

27

14

g g

g 

Avg 

7

11

3

2

158 m

69%

66

1

2

69%

Remote 

triage 

6

0

2

2

1

eligible

2

00

1

00
Medical Histories beyond pr

n = 1000 living kidney donor 

evaluations

98% patient satisfaction

Text Tra

stu

• 98% patient satisfaction• 96% patient ease of use• 97% l ti t 97% completion ra

t

e

• 9 minutes median time to complete

• 24% remote triage of ineligible donors• 41% increase in received donor medical histo

same time period in 2010* same time period in 2010*

• 30% projected increase in living donor kidney 

transplantation **

• 30% improved Transplant Nurse coordinator p

• Immediate availability of donor information to 

Immediate availability of donor information to 

several week delay using paper-based medic

* Raw data,

3 month time period , ** projected on

6 months raw data 2012 when 
BREEZE IT architecture
BREEZE connectivity to CPR

•Bi-directional HL7 data connection establi

and confirmed between BREEZE and CPwithin Innovation “sandbox” environment

•Sample HL7 message exchanged:

Header HL7 Message Tra

Vertical

tab

The HL7 message is wrapped using a header and trailer (immediately followed by a carriage return):

Fiesep

tab character(0x0B)

followed by

a carriage return):

MSH|^~\&||.|||199908180016||ADT^A04|ADT.1.1698593|P|2.5PID|1||000395122||TEST^PATIENT^C^^^||19880517180606|M|

sep

cha(0x

•Opportunity for easy integration with exist

systems (e g Innovian Centricity)systems

(

e.g., Innovian, Centricity)
Preoperative benefits of rem

•Identify and stratify perioperative risk ear

Identify and stratify perioperative risk ear

–Implement clinical care pathways–Reduce post-op complications and LOS–Mitigate day-of OR delays and cancella

–Optimize ordering of expensive lab and 

di ti t t diagnostic 

tes

t

s

•

“Fast

-track

” 20

-30% of patients in a 1a fa

30% of patients in

a 1a fa

eliminating unnecessary travel & testing 

•Improve patient and clinician satisfaction

D ti li i d d 

•

Decompress preoperative cli

nic an

d re

du
Potential benefits beyond pr

•Potential to utilize BREEZE platform for a

Potential to utilize BREEZE platform for a

medical history needs within the VA, e.g.

–Initial medical history for new patients in

Initial medical history for new patients in

C&P

–Efficient tool to 

pp p o

pulate CPRS 

patient 

–Scheduling triage for all outpatient appo–Medication reconciliation

•Opportunity to create a truly patient-frien

interface within the VA system unleashininterface within the VA system, unleashin

benefits of telemedicine for patients and 

caregivers (My HealtheVet)caregivers (My HealtheVet)
Lessons learned

• Patients can provide their medical histories on th

own, via a web-based 

platform

• The medical histories collected are at least as 

accurate if not more accurate than those collectaccurate, if not more accurate, than those collect

through current modalities

• With an accurate and timely medical history the 

With an accurate and timely medical history, the 

benefits of remote triage can be realized for patieand their caregivers

• Preop process recognized as a problem area by 

leadershi

p.

• Breeze to be incorporated as THE primary porta

history in SQWM initiativehistory in SQWM initiative.