A Re-conceptualization of Access for 

21st Century Healthcare

John Fortney, PhD

Investigator

HSR&D Center for Mental Healthcare and Outcomes Research

Central Arkansas Veterans Healthcare System

Director

Division of Health Services Research

Department of Psychiatry, University of Arkansas for Medical Sciences

Associated Director of Research

South Central Mental Illness Research Education Clinical Center

Central Arkansas Veterans Healthcare System
Acknowledgements

• CeMHOR/MIRECC Investigators

• Brenda Booth, PhD

• Greer Sullivan, MD

• Ellen Fischer, PhD

• Access SOTA Planning Committee

• David Atkins, MD

• Karen Bossi, MA

• Hayden Bosworth, PhD

• Leonard Egede, MD

• Seith Eisen, MD

• Gregory Eslinger

• Maurillo Garcia-Maldonado, MD

• Nancy Greer, PhD

• Kara Hawthorne, LCSW

• Barbara Holt, PhD

• Peter Kaboli, MD

• Joseph Kvedar, MD

• Ryan Lilly

• Linda Lipson, MA

• Geraldine McGlynn, MEd

• Janet Murphy, MBA

• Thomas Nesbitt, MD

• Rebecca Slifkin PhD

• Bonnie Wakefield, PhD

• Frances Weaver, PhD
Why Re-conceptualize Access?

• Healthcare Reform

– Shift from acute-care paradigm to episode-of-care 

paradigm

• Growth in Health Information Technology

– Shift in emphasis from face-to-face, patient-toprovider encounters towards continuous digital 

communication among patients, peers, and 

providers

• Conceptualization of access must evolve as 

the paradigm for healthcare delivery shifts 
Why Focus on VA Healthcare System

• Access represents the “fit” between the clinical needs 

of the individual and the ability of the healthcare 

system to meet those needs

• For a conceptual framework for access to facilitate 

improvements in care, it must be applied to a 

healthcare system that is capable of learning

• VA is national leader in the implementation of health 

information technology:

– electronic health records (CPRS)

– personal health records (MyHealtheVet)

– interactive video (Polycom)

– remote monitoring (HealthBuddy)
Outline of Presentation

1. Digital Encounterless Utilization 

2. Weaknesses of Traditional Conceptual 

Frameworks of Access 

3. Presentation of a Re-Conceptualization of 

Access

4. Measuring Access in the New Framework 

5. Future Directions for Research
Traditional Conceptualization of 

Utilization and Access 

• Face-to-face encounter with a provider

• Typical measures of access

– Providers per population in county

– Distance to closest provider

– Usual source of care

– Insurance coverage

– Visit copayment rate
Digital Patient-to-Provider Utilization

• Synchronous digital patient-to-provider 

encounters (e-health visits)

– Interactive Video

– Web-based Video

– Telephone (voice)

– Cell Phone (voice)

– Smartphone (voice and video)
Digital Encounterless Utilization

• Asynchronous digital patient-to-provider communication

– Interactive Voice Response

– Text messaging

– Email

– Chat Rooms

– Remote Monitoring

• Smartphones

• Kiosks

• Web-based portals 

• Personal electronic monitoring devices

– Wearable monitoring devices

– Portable monitoring devices

– Sensors integrated into homes and automobiles
Digital Encounterless Utilization (cont.)

• Digital provider-to-provider communications

– Telephone, cell phone, smartphone

– Email 

– Text messaging 

– Shared dashboard

– Electronic medical records

– Personal health records
Digital Encounterless Utilization (cont.)

• Digital peer-to-peer communications

– Social networking

– On-line forums 

– Telephones, cell phones, smartphones

– Text messaging 

– Email
Digital Encounterless Utilization (cont.)

• Synchronous digital encounters between 

patients and computer applications

– PC-based applications

– Web-based applications

– Smartphone-based applications 
Weakness of Traditional Conceptual 

Frameworks of Access

• Traditional measures of Access do not 

consider digital encounterless utilization of 

services

• Traditional conceptualizations of Access are 

too broadly defined

– Utilization

– Quality

– Outcomes
Re-conceptualization of Access

• Access to Care

– represents the opportunity and potential ease of having 

face-to-face and virtual interactions among a care team 

(including a patient, and their formal providers, informal 

caregivers, peers, and computer applications).

• Actual Access to Care

– represents those directly-observable and objectively 

measurable dimensions of access that predict perceived 

access to care. 

• Perceived Access to Care

– represents those self-reported and subjective dimensions 

of access that predict utilizing healthcare services. 
Utilization

Face-to-face 

Patient-to-provider encounters

Provider-to-provider consults

Peer-to-peer support

Digital 

Patient-to-provider

Provider-to-provider consults

Peer-to-Peer support

Use of computer applications 

Quality

Technical

Interpersonal

Outcomes

Symptoms

Side-effects

Functioning

Quality of life

Cost

Satisfaction

Utilization matches preferences

Quality of care

Outcomes of care

Perceived Need for Care

Symptom burden

Susceptibility

Stoicism

Treatment efficacy

Self efficacy

Perceived Access to Care

Geographical

Travel burden

Temporal

Time burden

Digital

Connectivity gap

Usability problems

Information silos

Financial

Eligibility complexity

Payment burden

Cultural

Lack of understanding

Skepticism

Self Stigma

Actual Accessto Care

Geographical

Travel distance/time

Temporal

Time constraints

Waiting time

Digital

Connectivity

Information sharing

Financial

Eligibility

Out of pocket costs

Cultural

Language match

Provider stigma

VA Healthcare System Structure

VA Provider Characteristics

Community Attributes

Veteran Characteristics

Veteran Perceptions of Care
Utilization

Face-to-face 

Patient-to-provider encounters

Provider-to-provider consults

Peer-to-peer support

Digital 

Patient-to-provider

Provider-to-provider consults

Peer-to-Peer support

Use of computer applications 

Quality

Technical

Interpersonal

Outcomes

Symptoms

Side-effects

Functioning

Quality of life

Cost

Satisfaction

Utilization matches preferences

Quality of care

Outcomes of care

Perceived Need for Care

Symptom burden

Susceptibility

Stoicism

Treatment efficacy

Self efficacy

Perceived Access to Care

Geographical

Travel burden

Temporal

Time burden

Digital

Connectivity gap

Usability problems

Information silos

Financial

Eligibility complexity

Payment burden

Cultural

Lack of understanding

Skepticism

Self Stigma

Actual Accessto Care

Geographical

Travel distance/time

Temporal

Time constraints

Waiting time

Digital

Connectivity

Information sharing

Financial

Eligibility

Out of pocket costs

Cultural

Language match

Provider stigma

VA Healthcare System Structure

VA Provider Characteristics

Community Attributes

Veteran Characteristics

Veteran Perceptions of Care
Utilization

Face-to-face 

Patient-to-provider encounters

Provider-to-provider consults

Peer-to-peer support

Digital 

Patient-to-provider

Provider-to-provider consults

Peer-to-Peer support

Use of computer applications 

Quality

Technical

Interpersonal

Outcomes

Symptoms

Side-effects

Functioning

Quality of life

Cost

Satisfaction

Utilization matches preferences

Quality of care

Outcomes of care

Perceived Need for Care

Symptom burden

Susceptibility

Stoicism

Treatment efficacy

Self efficacy

Perceived Access to Care

Geographical

Travel burden

Temporal

Time burden

Digital

Connectivity gap

Usability problems

Information silos

Financial

Eligibility complexity

Payment burden

Cultural

Lack of understanding

Skepticism

Self Stigma

Actual Accessto Care

Geographical

Travel distance/time

Temporal

Time constraints

Waiting time

Digital

Connectivity

Information sharing

Financial

Eligibility

Out of pocket costs

Cultural

Language match

Provider stigma

VA Healthcare System Structure

VA Provider Characteristics

Community Attributes

Veteran Characteristics

Veteran Perceptions of Care
Utilization

Face-to-face 

Patient-to-provider encounters

Provider-to-provider consults

Peer-to-peer support

Digital 

Patient-to-provider

Provider-to-provider consults

Peer-to-Peer support

Use of computer applications 

Quality

Technical

Interpersonal

Outcomes

Symptoms

Side-effects

Functioning

Quality of life

Cost

Satisfaction

Utilization matches preferences

Quality of care

Outcomes of care

Perceived Need for Care

Symptom burden

Susceptibility

Stoicism

Treatment efficacy

Self efficacy

Perceived Access to Care

Geographical

Travel burden

Temporal

Time burden

Digital

Connectivity gap

Usability problems

Information silos

Financial

Eligibility complexity

Payment burden

Cultural

Lack of understanding

Skepticism

Self Stigma

Actual Accessto Care

Geographical

Travel distance/time

Temporal

Time constraints

Waiting time

Digital

Connectivity

Information sharing

Financial

Eligibility

Out of pocket costs

Cultural

Language match

Provider stigma

VA Healthcare System Structure

VA Provider Characteristics

Community Attributes

Veteran Characteristics

Veteran Perceptions of Care
Veteran Perceptions of Care Utilization

Face-to-face 

Patient-to-provider encounters

Provider-to-provider consults

Peer-to-peer support

Digital 

Patient-to-provider

Provider-to-provider consults

Peer-to-Peer support

Use of computer applications 

Quality

Technical

Interpersonal

Outcomes

Symptoms

Side-effects

Functioning

Quality of life

Cost

Satisfaction

Utilization matches preferences

Quality of care

Outcomes of care

Perceived Need for Care

Symptom burden

Susceptibility

Stoicism

Treatment efficacy

Self efficacy

Perceived Access to Care

Geographical

Travel burden

Temporal

Time burden

Digital

Connectivity gap

Usability problems

Information silos

Financial

Eligibility complexity

Payment burden

Cultural

Lack of understanding

Skepticism

Self Stigma

Actual Accessto Care

Geographical

Travel distance/time

Temporal

Time constraints

Waiting time

Digital

Connectivity

Information sharing

Financial

Eligibility

Out of pocket costs

Cultural

Language match

Provider stigma

VA Healthcare System Structure

VA Provider Characteristics

Community Attributes

Veteran Characteristics
Utilization

Face-to-face 

Patient-to-provider encounters

Provider-to-provider consults

Peer-to-peer support

Digital 

Patient-to-provider

Provider-to-provider consults

Peer-to-Peer support

Use of computer applications 

Quality

Technical

Interpersonal

Outcomes

Symptoms

Side-effects

Functioning

Quality of life

Cost

Satisfaction

Utilization matches preferences

Quality of care

Outcomes of care

Perceived Need for Care

Symptom burden

Susceptibility

Stoicism

Treatment efficacy

Self efficacy

Perceived Access to Care

Geographical

Travel burden

Temporal

Time burden

Digital

Connectivity gap

Usability problems

Information silos

Financial

Eligibility complexity

Payment burden

Cultural

Lack of understanding

Skepticism

Self Stigma

Actual Accessto Care

Geographical

Travel distance/time

Temporal

Time constraints

Waiting time

Digital

Connectivity

Information sharing

Financial

Eligibility

Out of pocket costs

Cultural

Language match

Provider stigma

VA Healthcare System Structure

VA Provider Characteristics

Community Attributes

Veteran Characteristics

Veteran Perceptions of Care
Utilization

Face-to-face 

Patient-to-provider encounters

Provider-to-provider consults

Peer-to-peer support

Digital 

Patient-to-provider

Provider-to-provider consults

Peer-to-Peer support

Use of computer applications 

Quality

Technical

Interpersonal

Outcomes

Symptoms

Side-effects

Functioning

Quality of life

Cost

Satisfaction

Utilization matches preferences

Quality of care

Outcomes of care

Perceived Need for Care

Symptom burden

Susceptibility

Stoicism

Treatment efficacy

Self efficacy

Perceived Access to Care

Geographical

Travel burden

Temporal

Time burden

Digital

Connectivity gap

Usability problems

Information silos

Financial

Eligibility complexity

Payment burden

Cultural

Lack of understanding

Skepticism

Self Stigma

Actual Accessto Care

Geographical

Travel distance/time

Temporal

Time constraints

Waiting time

Digital

Connectivity

Information sharing

Financial

Eligibility

Out of pocket costs

Cultural

Language match

Provider stigma

VA Healthcare System Structure

VA Provider Characteristics

Community Attributes

Veteran Characteristics

Veteran Perceptions of Care
Utilization

Face-to-face 

Patient-to-provider encounters

Provider-to-provider consults

Peer-to-peer support

Digital 

Patient-to-provider

Provider-to-provider consults

Peer-to-Peer support

Use of computer applications 

Quality

Technical

Interpersonal

Outcomes

Symptoms

Side-effects

Functioning

Quality of life

Cost

Satisfaction

Utilization matches preferences

Quality of care

Outcomes of care

Perceived Need for Care

Symptom burden

Susceptibility

Stoicism

Treatment efficacy

Self efficacy

Perceived Access to Care

Geographical

Travel burden

Temporal

Time burden

Digital

Connectivity gap

Usability problems

Information silos

Financial

Eligibility complexity

Payment burden

Cultural

Lack of understanding

Skepticism

Self Stigma

Actual Accessto Care

Geographical

Travel distance/time

Temporal

Time constraints

Waiting time

Digital

Connectivity

Information sharing

Financial

Eligibility

Out of pocket costs

Cultural

Language match

Provider stigma

VA Healthcare System Structure

VA Provider Characteristics

Community Attributes

Veteran Characteristics

Veteran Perceptions of Care
Utilization

Face-to-face 

Patient-to-provider encounters

Provider-to-provider consults

Peer-to-peer support

Digital 

Patient-to-provider

Provider-to-provider consults

Peer-to-Peer support

Use of computer applications 

Quality

Technical

Interpersonal

Outcomes

Symptoms

Side-effects

Functioning

Quality of life

Cost

Satisfaction

Utilization matches preferences

Quality of care

Outcomes of care

Perceived Need for Care

Symptom burden

Susceptibility

Stoicism

Treatment efficacy

Self efficacy

Perceived Access to Care

Geographical

Travel burden

Temporal

Time burden

Digital

Connectivity gap

Usability problems

Information silos

Financial

Eligibility complexity

Payment burden

Cultural

Lack of understanding

Skepticism

Self Stigma

Actual Accessto Care

Geographical

Travel distance/time

Temporal

Time constraints

Waiting time

Digital

Connectivity

Information sharing

Financial

Eligibility

Out of pocket costs

Cultural

Language match

Provider stigma

VA Healthcare System Structure

VA Provider Characteristics

Community Attributes

Veteran Characteristics

Veteran Perceptions of Care
Measurement Issues

• Actual Access

– Directly observable

– Objectively measurable

– Reliable

– Sensitive to change

– Predictive validity (of perceived acccess to care)

• Perceived Access to Care

– Self-report

– Reliable

– Sensitive to change

– Predictive validity (of utilization)
Access To What?

• Quality of Services

– First measure the quality and then measure access to 

services of different levels of quality (e.g., access to an 

evidence-based treatment).

• Population in Need

– Access should only be measured to the type of 

services that are needed.

• Patient Preferences

– Access should be measured to the type of services 

that are preferred by an individual.
Future Directions for Research

• Validate measures of Access for research

• Develop Performance Indicators for Access

– Office of Quality Performance

– Survey of Healthcare Experiences of Patients

• Identify at-risk populations

– Rural

– Minorities

– Elderly

– Low computer literacy

• Develop and test “Access Interventions”
Summary

• Paradigm shift in healthcare delivery requires a 

paradigm shift in conceptualization of access

• Incorporate the opportunity/ease of digital 

communications among patients, peers and 

providers into measures of access

• As a leader in health information technology and 

as a learning organization, VA must measure 

access and adapt itself to better fit the needs of 

at-risk populations

• Design and test e-health interventions that 

improve access
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