Adam Darkins

Care Coordination/Home Telehealth: the systematic implementation of health informatics, home telehealth, and disease management to support the care of veteran patients with chronic conditions.

Between July 2003 and December 2007, the Veterans Health Administration (VHA) introduced a national home telehealth program, Care Coordination/Home Telehealth (CCHT). Its purpose was to coordinate the care of veteran patients with chronic conditions and avoid their unnecessary admission to long-term institutional care. Demographic changes in the veteran population necessitate VHA increase its noninstitutional care (NIC) services 100% above its 2007 level to provide care for 110,000 NIC patients by 2011. By 2011, CCHT will meet 50% of VHAs anticipated NIC provision. CCHT involves the systematic implementation of health informatics, home telehealth, and disease management technologies. It helps patients live independently at home. Between 2003 and 2007, the census figure (point prevalence) for VHA CCHT patients increased from 2,000 to 31,570 (1,500% growth). CCHT is now a routine NIC service provided by VHA to support veteran patients with chronic conditions as they age. CCHT patients are predominantly male (95%) and aged 65 years or older. Strict criteria determine patient eligibility for enrollment into the program and VHA internally assesses how well its CCHT programs meet standardized clinical, technology, and managerial requirements. VHA has trained 5,000 staff to provide CCHT. Routine analysis of data obtained for quality and performance purposes from a cohort of 17,025 CCHT patients shows the benefits of a 25% reduction in numbers of bed days of care, 19% reduction in numbers of hospital admissions, and mean satisfaction score rating of 86% after enrolment into the program. The cost of CCHT is

Outcomes of 98,609 U.S. Department of Veterans Affairs Patients Enrolled in Telemental Health Services, 2006–2010

1,600 per patient per annum, substantially less than other NIC programs and nursing home care. VHAs experience is that an enterprise-wide home telehealth implementation is an appropriate and cost-effective way of managing chronic care patients in both urban and rural settings.

Healthcare utilization among veterans undergoing chemotherapy: the impact of a cancer care coordination/home-telehealth program.

OBJECTIVEnThe study assessed clinical outcomes of 98,609 mental health patients before and after enrollment in telemental health services of the U.S. Department of Veterans Affairs between 2006 and 2010.nnnMETHODSnThe study compared number of inpatient psychiatric admissions and days of psychiatric hospitalization among patients who participated in remote clinical videoconferencing during an average period of six months before and after their enrollment in the telemental health services.nnnRESULTSnBetween 2006 and 2010, psychiatric admissions of telemental health patients decreased by an average of 24.2% (annual range 16.3%-38.7%), and the patients days of hospitalization decreased by an average of 26.6% (annual range 16.5%-43.5%). The number of admissions and the days of hospitalization decreased for both men and women and in 83.3% of the age groups.nnnCONCLUSIONSnThis four-year study, the first large-scale assessment of telemental health services, found that after initiation of such services, patients hospitalization utilization decreased by an average of approximately 25%.

Framework for a National Teleretinal Imaging Program to Screen for Diabetic Retinopathy in Veterans Health Administration Patients

The 2001 Institute of Medicine report indicted that the US healthcare system fails to provide high-quality care, and offered 6 aims of improvement that would redesign the delivery of care for the 21st century. This study compared the use of Department of Veterans Affairs (VA) inpatient and outpatient services of cancer patients enrolled in a Cancer Care Coordination/Home-Telehealth (CCHT) program that involved remote management of symptoms (eg, emotional distress, pain) via home-telehealth technologies to a control group of cancer patients receiving standard VA care. Using a matched case-control design, 2 control patients per case were selected, matched by tumor type and cancer stage. There were 43 Cancer CCHT patients and 82 control group patients. Based on a medical record review of each patient, the total number of cancer-related services (defined as visits that were expected given the patients cancer diagnosis and treatment protocol) and preventable services (defined as visits needed outside of those expected given the cancer diagno-sis and planned treatment) were calculated over a 6-month period. Poisson multivariate regression models were used to estimate the adjusted relative risks (RRs) for the effects of the Cancer CCHT program on the service use outcomes. Cancer CCHT patients had significantly fewer preventable services (clinic visits: RR = 0.03, 95% confidence interval [CI] = 0.00–0.24; bed days of care (BDOC) for hospitalization [all-cause]: RR = 0.50, 95% CI = 0.37–0.67; hospitalizations [chemotherapy related]: RR = 0.43, 95% CI = 0.21–0.91; and BDOC for hospitalizations [chemotherapy related]: RR = 0.49, 95% CI = 0.34–0.71) than the control group. This study offered some preliminary evidence that patients enrolled in a Cancer CCHT program can successfully manage multiple complex symptoms without utilizing inpatient and outpatient services.

Remote patient–provider communication and quality of life: empirical test of a dialogic model of cancer care

Digital retinal imaging with remote image interpretation (teleretinal imaging) is an emerging healthcare technology for screening patients for diabetic retinopathy (DR). The Veterans Health Administration (VHA) convened an expert panel in 2001 to determine and resolve the requisite clinical, quality and training, information technology, and healthcare infrastructure issues associated with deploying a teleretinal imaging system. The panel formulated consensus recommendations based on available literature and identified areas of uncertainty that merited further clarification or research. Subsequent VHA experience with teleretinal imaging and accumulated scientific evidence support nationwide regionalized deployment of teleretinal imaging to screen for DR. The goal is to screen approximately 75,000 patients in the first year of the program, which commenced in 2006. This program will increase patients access to screening for DR, provide outcomes data, and offer a unique platform for systematically evaluating the role of this technology in the care of diabetic eye disease and routine eye-care practice.

The management of clinical risk in telemedicine applications

We examined the feasibility of a Cancer Care Dialogues Model, with daily telehealth interactions between patients at home and their care coordinator, who acted as an adjunct to the oncologist. The patient and the care coordinator used a home messaging device, connected via the ordinary telephone network. Thirty-four patients with a new diagnosis of cancer and whose treatment plan included chemotherapy taken at a single clinic were enrolled and followed for six months. The home messaging device collected information daily on common symptoms associated with chemotherapy. On average, the patients had the home messaging device for 120 days (range 30–180). The mean cooperation rate was 84% (range 4–100). No variables were significantly associated with patient cooperation in the dialogues over time. The health-related quality of life (HRQL) mean score at baseline was 73.9 (SD 15.4), and the mean score at six months was 78.4 (SD 14.5). After adjusting for demographic and clinical factors, there was a 6.5-point increase in HRQL score between the baseline and end of treatment, which represented an important clinical difference. Management of nervousness/worry over time through cancer care dialogues is important in maintaining HRQL and can be assisted by remote home messaging.

Enhancing Access of Combat-Wounded Veterans to Specialist Rehabilitation Services: The VA Polytrauma Telehealth Network

Any telemedicine application should be viewed in terms of its health-care context, the clinical process it is enabling, and whether it is appropriate to apply telemedicine to that process. Telemedicine should be used as a tool to enable the transfer of clinical information which, by being transferred, will reduce clinical risks. Because managing clinical services involves knowing where clinical decisions are being made, it is important to ensure that telemedicine activity is recorded as part of the routine clinical and investigative data sets that will be kept for clinical audit and health-service costing purposes. There may be areas of health-care delivery where the telemedicine solution becomes the treatment of choice. In this event, not to provide telemedicine may be unethical and may expose a service to high clinical risk. If a service is based on the use of telemedicine, it is important to ensure that the technical specifications are adequate, that the system is sufficiently reliable, and that there are adequate back-up provisions in the case of system failure.

Changing the Location of Care: Management of Patients with Chronic Conditions in Veterans Health Administration Using Care Coordination/home Telehealth

Operations Iraqi Freedom and Enduring Freedom have resulted in U.S. military personnel sustaining combat wounds of unprecedented severity and complexity that necessitate long-term rehabilitation. To meet what are often conflicting requirements in providing severely wounded veterans with timely and convenient access to specialist rehabilitation care, and to enable them to return to their local communities, the Veterans Health Administration has developed a state-of-the-art Polytrauma Telehealth Network that enhances access to such services by linking Veterans Administration rehabilitation facilities. This article describes the clinical, technical, and business process issues involved in the development of this network.

Defining Core Issues in Utilizing Information Technology to Improve Access: Evaluation and Research Agenda

The way that societal changes influence how health services are delivered to people with chronic diseases and conditions exemplifies how policy responses must now acknowledge patient and caregiver preferences for care. New healthcare-associated information technologies are allowing patients to choose their location for care and realize their preferences [1]. Previous long-term care policy projections had anticipated that todays healthcare system would be challenged to meet the growing need for long-term institutional care and to care for an aging population whose chronic disease incidence and prevalence would rise dramatically [2-3]. During the intervening 25 years, many factors [4-6], including reduced disability levels in the elderly, increased disposable income, changes in chronic disease patterns, and initiatives to increase caregiver and community support, have moved the long-term care equation toward noninstitutional settings. When appropriate and given the choice, many people prefer to remain living independently in their homes and/or communities and to avoid or delay placement in long-term institutional care facilities [7]. Healthcare systems must respond to a complex and continually evolving long-term care agenda that expects these systems to restructure how they provide care and, in doing so, develop noninstitutional care services that reach directly into patients homes. Among the noninstitutional care services routinely delivered by the Veterans Health Administration (VHA) is care coordination. Care coordination has been explicitly designed to meet the changing healthcare needs of a veteran population that is aging and coping with the limitations imposed on their lives and longevity by chronic diseases and conditions, e.g., diabetes, chronic heart failure (CHF), spinal cord injury (SCI), posttraumatic stress disorder (PTSD), depression, chronic obstructive pulmonary disease (COPD), stroke, multiple sclerosis (MS), and hypertension. VHA defines care coordination as-- the use of health informatics, telehealth, and disease management to enhance and extend care and case management activities to facilitate access to care and improve the health of designated individuals and populations with the specific intent of providing the right care in the right place at the right time (http://www.va.gov/occ/). VHA uses a range of telehealth technologies to support three classes of care coordination programs in its 154 Department of Veterans Affairs medical centers. Care coordination/home telehealth (CCHT) programs use telehealth technologies, including digital cameras, videophones, messaging/ monitoring devices, and telemonitors, to coordinate care directly from a patients home. Care coordination/general telehealth (CCGT) programs use videoconferencing technologies to provide clinical services, e.g., telemental health between hospitals and community-based outpatient clinics (CBOCs). Care coordination/ store-and-forwards (CCSF) allow VHA to provide teleretinal imaging, dermatology, wound care, and pathology services to rural and remote locations. CCHT, CCGT, and CCSF enable VHA to make specialist care, e.g., rehabilitation, more widely available and accessible to veteran patients, especially those who find access to care challenging because they live in remote or rural areas. Care coordination enhances care by changing its location to a more accessible site or supporting the ongoing provision of care at a current site in which, for example, recruitment of specialist staff such as eye care professionals is problematic, e.g., in a remote or rural location. Fundamental to VHAs ability to change the location of care by reconfiguring face-to-face care and introducing services that extend into patients homes, community settings, and CBOCs has been the full implementation of a comprehensive computerized health record (CHR). Currently, the patients with chronic diseases to whom changing location of care applies most are those at risk of long-term institutional care placement. …

E-patient Connectivity and the Near Term Future

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.