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The Department of Veterans Affairs (VA) has been at the vanguard of information technology (IT) and use of comprehensive electronic health records. Despite the widespread use of health IT in the VA, there are still a variety of key questions that need to be answered in order to maximize the utility of IT to improve patient access to quality services. This paper summarizes the potential of IT to enhance healthcare access, key gaps in current evidence linking IT and access, and methodologic challenges for related research. We also highlight four key issues to be addressed when implementing and evaluating the impact of IT interventions on improving access to quality care: 1) Understanding broader needs/perceptions of the Veteran population and their caregivers regarding use of IT to access healthcare services and related information. 2) Understanding individual provider/clinician needs/perceptions regarding use of IT for patient access to healthcare. 3) System/Organizational issues within the VA and other organizations related to the use of IT to improve access. 4) IT integration and information flow with non-VA entities. While the VA is used as an example, the issues are salient for healthcare systems that are beginning to take advantage of IT solutions.
Information technology (IT), especially a comprehensive electronic health record (EHR), has been central to encouraging access to high quality care within the Department of Veterans Affairs (VA) healthcare system.1–4 While the EHR is a vital IT solution in healthcare, the VA has also increased its focus on patient-oriented IT solutions such as personal health records,5,6 home patient monitoring,5,7 tele-consultation,8 and non-face-to-face disease management.9 This mirrors efforts in other large integrated healthcare systems.10
This paper summarizes areas where IT can potentially be used to increase access and key issues that should be addressed through evaluation and research. The issues discussed here are salient for healthcare systems that are working to take advantage of IT solutions.
While adoption of comprehensive EHRs in the United States was not widespread in the 2000s,11,12 the VA has had a system-wide EHR since 1997. The Computerized Patient Record System (CPRS) includes primary features defined under meaningful use criteria for EHRs13 including: clinical documentation, test results, provider order entry, and clinical decision support.1
In 2003, the VA launched both the My HealtheVet (MHV) personal health record system and the Care Coordination/Home Telehealth (CCHT) program. MHV (www.myhealth.va.gov) is a website personal health record portal that provides Veterans with the opportunity to organize their personal health information (e.g. lists of providers) and summarize that information for their healthcare team. The site also includes online VA prescription refill requests and access to trusted health education resources. For VA patients who have upgraded their account, services also include access to VA wellness reminders, VA medication history, and secure messaging with the healthcare team.6 The VA Blue Button enables registered users to download an electronic copy of their MHV personal health information.
CCHT links patients with chronic care needs to VA care teams that assist with disease management using home monitoring equipment that transmits information bi-directionally between hospital and patients’ homes via telephone and broadband connectivity.7 Furthermore, many care teams have the opportunity to utilize various tele-consultation programs.14
The VA is currently enhancing healthcare services by moving toward having care delivered by patient-aligned care teams (PACTs) developed using the patient-centered medical home (PCMH) model. A central tenet of the PACT/PCMH model is that patients should have access to in-person and virtual services to meet the variety of needs the individual may encounter.15 With appropriate planning, IT has the potential to enhance multiple aspects of access as suggested by the PACT/PCMH model,16,17 including:
The remainder of this perspective outlines key current gaps in evidence and methodologic challenges related to evaluating specific aspects of health IT that may enhance access.
VA patients are predominantly men and tend to be of lower socioeconomic status than the general United States population.25 However, the VA is currently experiencing an increase in younger veterans from the wars in Afghanistan and Iraq as well as an increase in the number of women who are entering the system.26 Because of the breadth of the system, urban and rural patients have differing needs and patterns of utilization.27,28
There is a need to better understand the needs, desires, and available resources for patients and their families about using IT solutions.29–31 This includes, 1) what services are desired; 2) what current technologies are used and/or available (e.g. Internet); 3) what skills are needed (e.g. ability to use devices); 4) are there technology design issues that may impact use (e.g. issues for patients with disabilities); and 5) do patient needs differ by patient subgroups (e.g. urban vs. rural).
Disparities have been noted in the use of patient oriented activities (e.g. glucose self-monitoring) that are often targets for IT interventions.32,33 An important aspect of evaluating the impact of IT technology on the use of services includes the reach of these services to different patient subgroups.34 Further, the effect of IT on the perception of access should be examined.
IT tools are designed to enhance traditional care, not replace it. Use of IT solutions such as EHRs and secure messaging is likely to have a significant impact on the workflow and team interaction among clinicians.35–37 For example, how will expanded use of secure messaging impact work flow in the clinic? Who will read and respond to patient messages? How will such systems change expectations of both clinicians and patients? Are there unanticipated consequences of the new tools?
Because uptake of IT interventions will require the active involvement of clinicians, it is necessary to evaluate 1) needs and desire of clinicians related to IT; 2) perceived readiness for the implementation of interventions; and 3) concerns about the impact on the practice of healthcare. Proactive measurement of readiness for organizational change may be useful in identifying potential barriers to implementation.38,39
Closely related to issues involving individual clinicians, are broader questions about how the organization will integrate IT to improve access. For example, organizations need to evaluate how IT impacts communication among specialties. Within the EHR, specialized consult templates are an example of how to ensure that multiple specialty care teams have information needed to provide care. Further, there are opportunities to utilize technology such as high resolution cameras, web portals, and remote monitoring equipment to ensure that critical information is available. A question is whether there are differences in clinical outcomes among patients when specific interventions are utilized. Additionally, organizational impacts such as costs and patient utilization may be considered. Finally, it is important to continuously enhance and evaluate policies on data security and privacy to ensure the protection of patient information.
The VA has a significant number of patients who also access other healthcare systems.40 Like all organizations seeking to meet the federal meaningful use criteria for implementation of EHRs,13 the VA is actively working on solutions to integrate healthcare information across provider organizations. A goal of the Virtual Lifetime Electronic Record (VLER) program is to develop a record of all active duty and veteran healthcare provider under the auspices of DOD, VA, and TriCare, as well as the private sector. This initiative has great potential for helping to ensure that patients receive appropriate care when they need it. IT integration has potential to enhance receipt of quality, efficient, and safe care. However, there are important technical, information flow, and privacy issues that need to be evaluated as part of these efforts.
The study of the impact of health IT on access faces important methodological challenges. These include:
Improving access to high quality health services for the Nation’s heroes is at the heart of the VA mission. Numerous IT solutions introduced during the last two decades have great potential for helping to meet this objective. Designing both the technology and content of IT interventions with explicit recognition of potential impact on access will aid in successful adoption. At the same time, the needs of different stakeholders, value of the content, and features of the technology will all need to be understood so that effective programs are implemented and utilized.
This paper summarizes deliberations of the Adoption and Implementation of IT Workgroup at the VA Health Services Research & Development (HSR&D) State of the Art Conference on Improving Access to VA Care held September 21–22 2010 in Arlington, VA. In addition to the authors, the following individuals were part of the workgroup: Leigh Anderson, MD; David Atkins, MD, MPH; Nancy Maher, Ph.D.; Kevin Vigilante, MD, MPH; and Kenneth R. Wingart, Ph.D. The last author was supported by a VA HSR&D Career Scientist Award (08–027).
Conflict of Interest With the exception of Drs. Alverson, Poropatich, and Ralston, all authors are employees of the Department of Veterans Affairs. No author received compensation for preparation of this manuscript apart from his or her employment.
Disclaimer The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.