VISTA / CPRS For Patient Care: Rural VA Telehealth Technologies EMR / CPRS Order Entry VA Telehealth Technologies: Rural Continuity of care for patients across the continuum Focus = Patient & their optimal care Examine: episodic vs.. continuous care = typical vs. atypical Allows re-evaluation of how patients connect with the health care delivery system Acquire, Store & Coordinate patient information Care Coordination Telehealth Manage patient data, image, sound, video in ways that enhance care: forwarded or retrieved as needed 1 2 Care Coordination: History Care Coordination: Concept Piloted at VA Bay Pines, FL VA July 2003: VHA Office of Care Coordination (OCC) Webpage: http://www.carecoordination.va.gov/ Anticipated & Proactive delivery of healthcare using: Trained Personnel to implement:»telehealth & Health informatics»disease vs. symptom management Areas of focus CCHT: Care Coordination Home Telehealth CCGT: Care Coordination General Telehealth CCSF: Care Coordination Store and Forward Increase access to care Facilitate Providing the right care in the right place at the right time 3 4 Care Coordination: Targets Chronic conditions High utilization: Clinic, ER, Hospital Difficult access: rural Daily assessment Education & Coordination from a patient perspective Presently serving thousand of veterans Care Coordination: Implementation Match patient with technology & personnel Patient characteristics»sensory deficits, clinical needs, phone lines Technology»Various specific types used»simple may be the best Personnel»infrastructure critical 5 6 1
Care Coordination Home Telehealth Three areas of focus Home Telehealth General (real time) Telehealth Store & Forward Telehealth Care Coordination Home Telehealth Management from a patients perspective Disease specific: may be limiting Symptom based: broad approach: example Facilitate coordination of care between» Patient & others» Clinicians» Service entities: clinics & hospitals Maintain independence 7 8 Perspective: Symptom Management Select patients based on high-utilization rather than clinical parameters Known characteristics of high-utilization: Multiple chronic conditions Fragmented care Care seeking behavior Poly-pharmacy Rural under-utilization issue Structure of the intervention Daily question set transmitted by modem Patient inputs responses Auto triggers + Nurse care-manager response 9 10 Content of the intervention Custom built question library focused on: Review of physical and mental health symptoms Medication regimens and adherence Standardized outcome scales such as patient satisfaction Educational content / games for preventive health and disease states Goals of the intervention Adjunct to primary care Option for geriatric care management Early detection of symptoms Encourages adherence to care plan Provides access to rural / isolated veterans 11 12 2
Impact There is high satisfaction with Telehealth in: Rural populations Older patients Patients report improved communication with the primary care provider No increase in clinical contact Devices Used: Home Telehealth Health Buddy Decision support tool Risk stratification Compliance tracking Trending reports KMEA Video Phone Used alone or in adjunct with Health Buddy Patient who require more face-to-face contact Others 13 14 General (real time) Telehealth General (real time) Telehealth: example Need to reach veterans close to where they live: rural / isolated 30-40% veterans live in rural areas Patient isolation: travel conditions, weather, medical conditions etc Over 700 community based clinics» Primary care focused & Often no specialty care access Outreach clinics» Smaller communities & may not have MD access Method of delivering care Bring patient to care: transportation Bring care to patient: community / home via technology Tele primary care Tele mental health Tele polytrauma Tele rehabilitation Tele surgery Tele dermatology Tele wound management Tele pathology Tele ICU 15 16 General (real time) Telehealth: Rural example Elko Clinic Timeline = Process + Collaboration Elko Tele health Clinic 250 miles from SLC VA Different time zone Adverse winter weather High mountain passes Estimated veteran population: 4,000 very scattered 250 enrolled at SLC 4/05-10/05 Stakeholders meetings 1/06 Preparation of contract for space 7/06 Contract finalized 8/06 806 TEACH grant awarded 11/06 Clinic open house 12/06 First patients seen Present Over 400 unique patients Only 350 initially identified 17 18 3
Clinic Staff Opening Day Amber Donnelli, RN Holly Martin, NP Nancy Dailey, RN Community members, local healthcare providers, the media and 67 veterans and their families attended. 19 20 Reception and Waiting Area Pt. education materials Educational videos Enrollment forms VA benefit booklets Elko Clinic 2 Exam rooms 21 22 Typical Clinic Visit Non urgent care Lab draws & results sent electronically to SLC VA Elko RN prepares patient: VS & Clinical Reminders Elko RN Initiates tele health visit with SLC PCP Elko RN does Follow up & education Minimize face to face visits at SLC VA Lessons Learned Form long-term collaboration and partnerships Assure bandwidth selection matches equipment Plan for growth: define milestones Set up for administering immunizations, tb skin tests, simple lab tests 23 24 4
Store & Forward Telehealth: Portable & CBOCs Tele dermatology Tele retinal Imaging Tele radiology Thousands of veterans served Conclusion: VA Technology: Telehealth Enhances the relationship between: Veterans & healthcare & communities Allows implementation of : current evidence based care parameters Veterans enjoy better health outcomes across the care continuum with improved satisfaction 25 26 Technology and Patient Safety: EMR / CPRS Cause & Effect Patient Controlled Analgesia MD decides on PCA modality Paper or Verbal Orders Free Text Manually entered into VISTA Patient Controlled Analgesic Multiple methods for ordering PCA (CPRS-new orders, manual delay, and consults/procedures, paper orders faxed to pharmacy, and verbal orders entered as Nursing text orders) resulting in delay of treatment. CPRS ORDERS Free Text agent/dose interval/bolus Consult Package Automatically downloads into VISTA CPRS requires the PCA orders (agent, dose, and frequency) be entered by free text resulting in either wrong agent, dose, and frequency administered or delay in treatment due to time needed to clarify orders. Incorrectly programmed PCA pump resulting in wrong dosages being administered to the patient. 27 28 Interventions BEFORE Forced Order Entry: EMR / CPRS Limit free text opportunities Define modes of administration & definitions loading PCA basal Eliminate paper or verbal orders Piloted in General Surgery 29 30 5
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Outcomes Duplicate Drug Class over rides reduced by 13% Pre-implementation 45.9% Post-implementation 32.8% Laxative use: increased Dosing errors: eliminated 37 38 PCA Patient Incidents VA Technology: Telehealth & EMR / CPRS 14 12 10 8 6 4 2 0 Oct- 00 Nov- 00 RCA team Implementation Dec- 1-Jan 1-Feb 1-1-Apr 1-1-Jun 1-Jul 1-1-Sep 1-Oct 1-00 Mar May Aug Nov 1-2-Jan 2-Feb 2- Dec Mar Allows innovative & safe healthcare delivery to Veterans Example: Care Coordination» Home Telehealth» General (real time) Telehealth» Store & Forward Telehealth Example: Forced Order Entry Demonstrated Improvements in: High Quality Healthcare Outcome Measures Improved Cost allocations Improved Patient Satisfaction 39 40 7