Emerging Technologies for Clinicians and Practices: Insights from the VA

1. Emerging Technologies for Clinicians and Practices: Insights from the VA Moderator: Robert Kaiser, MD MHScFACP AGSF

2. Faculty Disclosures • Hamilton – no relevant disclosures • Kaiser – no relevant disclosures • Matthews – no relevant disclosures • Ong – no relevant disclosures • Schafer – no relevant disclosures • Tubbesing – no relevant disclosures • Tyler – no relevant disclosures • Zimmerman – no relevant disclosures

3. Objectives • List the four types of technology presented. • Describe the differences in these technologies and when they would be utilized. • Critique the technologies for application in their own practice.

4. Mobile Electronic Documentation: Report on the VA Innovations Project Ivy Matthews, RN MSN – HBPC Program Director Lebanon VAMC Charles Tyler, III, RN BSN – Clinical Applications Coordinator Lebanon VAMC

5. VA Innovation: A Plea From Our Frontlines • “No reliable or consistent internet connection!” • “Where’s my work? I lost all my progress notes!” • “I can’t get back into my patient medical records.” • “I waste too much time printing everything I need for my home visit.”

6. VA Innovation: We Built An Application Solution! • Secure electronic access to patient health information. • Documentation at the point of care without dependence on wireless connectivity.

7. VA Innovation: Our Innovative Legacy • Originally developed for the Home Based Primary Care Program by OIT Developer Shawn Elliott Alexandria, Louisiana. • The MED Project was established in 2009 with alfa testing in five VHA HBPC programs. • MED implemented in “real time” clinical care from May-September of 2011. • Software application released and is available at all VA sites.

8. VA Innovation: The MED Legacy Continues • VA “homegrown” solution; VA staff developed and VA approved • Free, not a commercial product • Customizable to meet discipline specific information and documentation needs

9. VA Innovation:M.E.D.Under the hood • Simple to use, nothing fancy, easy to fix, and gets the job done • Like my 1978 Chevette • The clinical job is complicated enough. • Shouldn’t have to worry about the tech

10. VA Innovation: Why Invent Something New? • Same documentation templates • Secure current summary of clinical care • Upload to EHR on return to office

11. VA Innovation: We Built An Application Solution! • VA site had an idea and talented local IT resources • No special funding • Unique in VA software • Database on device which communicates with Vista when on the network to update templates and purge patient data. • Very little maintenance once installed. Local Informatics and IT

12. VA Innovation: Latest Innovation • VA HBPC Innovations Pilot Project-at 10 VA Sites • Addresses staff need for lighter more portable devices. Already a lot to carry. • Dell Venue Pro 11 tablets provide latest (at time of project start) Windows software, Windows 8, touch screen capability to allow Veterans to sign consents and other documents. • VA Mobile Help Desk support • Improve user experience with option of wireless connection or M.E.D.

13. VA Innovation: Catch the Wave! Innovative doesn’t have to mean new. It can simply be rethinking your current situation and resources, and finding creative ideas and tools to fill any new niches you identify. And with the time and money you save… Turn “up tight” into “hang loose”!

14. Utility of the BL Health Tablet for Home Visits Stephen Zimmerman, RN MS ATC CCM COHN

15. Tablet Statistics • 10.4" touch screen LCD display • Lightweight-Weighs 4.1 lbs • Built-in 3G/4G LTE wireless • Built-in Webcam for video conferencing • Wireless medical device connectivity • Additional serial and USB connections • Ethernet and telephone connection ports

16. Secure Connection Within VA Network • HIPPA Compliant • Secure data transfer • No storage of data during encounter

17. Processing For Initiating Patient Call The CVT Patient Tablet must be accessed from within the VA network to ensure patient confidentiality. Jabber software can be used – but is not the best connection for this device.

18. Initiating a Patient Call cont. Dial: SIP:050005AE.bltablet.evn.va.gov • Session can only be initiated by a provider. Patient cannot initiate a CVT encounter. • Overall sound and video quality are best with the EX codecs

19. CVT Tablet • Peripherals connect to the tablet via USB ports or Bluetooth

20. Peripheral Devices • Peak Flow Meter • Stethoscope • PT/INR meter • Glucometer

21. Peripheral Devices Cont. • High Definition Exam Camera with Manual focus and close up imaging. • Scale • BP Meter

22. Stethoscope Provides live streaming audio of lung and heart sounds • Provider can listen via head-phones or ear buds.

23. Technology Limitations • The CVT Patient Tablet accesses the VA Network using a 4G (or 3G) cellular signal. • So – for patients with poor cellular signals, the tablet might not be the right device. • Use the Verizon Network accessibility map for probable connection advice – but recognize that there are pockets of poor cellular service across the nation.

24. Plug and play technology. • Convenience of in home visit with • medical provider. • Peripherals which expand the utility of • the tablet. • Increased efficiency and productivity with a reduction in non-productive time spent driving to patient’s home. Benefits of BL Tablet

25. Benefits of BL Tablet cont. • Education can be presented via the tablet r/t the patient’s specific diagnosis. Can be watched at a time determined by the patient. • The patient education can be voluntary or required. • Can be part of CVT session or at intervals determined by the plan of care.

26. Challenges Related To Using BL Tablet • Staff acceptance of the technology • Tablet reliability/connectivity • For VA employees –significant training before use of the tablet.

27. Challenges Continued • Patient acceptance of the CVT encounter as equivalent to face to face visit. • Tablet availability. • Private Sector billing process r/t incentivizing CVT visits.

28. Providing Access to Mental Health through HBPC Video Visits Marie Schafer, MSN RN – Nurse Manager, Telehealth Vene Hamilton, JD MS – Nurse Manager, HBPC

29. CVT Into the Home • CVT into the Home focuses on the delivery of commonly occurring and high frequency patient encounters between a clinical care site and the patient’s home. • Provides a ‘face-to-face’ visit between patient and clinician via Telehealth modality.

30. Mission Critical • Telehealth services are mission-critical to the future direction of VA care to Veterans • Telehealth is one of VA’s major transformational initiatives aimed at ensuring care is convenient, accessible and veteran-centered.

31. Needs Assessment • Access to patients who are homebound • CVT Into Home Deployment Checklist • Telehealth Service Agreements • Clinic Creation for workload capture • Provider/HBPC RN equipment issuance & training

32. Stakeholders

33. Challenges • During the infancy stage, challenges were as follows: • Provider & Patient buy in of this modality • Provider/patient/clinician being comfortable utilizing the technology • Technology glitches related to pixilation, sound and connectivity

34. CVT into Home Clinic Utilization • Fiscal Year 2013- 0 (infancy stages/discussion) • Fiscal Year 2014- 57 • Fiscal Year 2015- 78 • Fiscal Year 2016- 34 (as of March, 2016)

35. Travel Cost Savings(Time and Money) • Fiscal Year 2013- $0.00 • Fiscal Year 2014- $81,225.00 • Fiscal Year 2015- $111,150.00 • Fiscal Year 2016 - $48,450.00

36. Patient/Provider Satisfaction • Surveys were disseminated among the patients, caregivers and provider utilizing Telehealth modality • Patients/Caregivers reported 100% satisfaction-convenience getting care without the taxing effort of leaving home • Provider reported 100% satisfaction

37. Expansion Possibilities • Currently, have 1 Psychiatrist providing mental health services to HBPC patients. • Future goal- add at least 2 other Psychiatrist over the next 12 months

38. Outcomes • Telehealth in the Home increases access to specialty care • Telehealth can reduce the influx of patients at the VA while providing high quality care to the patient • Reduction in office care for aging Veterans and Veterans living in rural areas, who need continual care • Convenient for rural patients & those with diagnoses that affect mobility

39. Acknowledgments • Dr. Susana Prieto • HBPC Nursing Staff • Chief of Staff Leadership • Nursing Leadership • OIT Services

40. Using Geographic Information System (GIS) Software to Optimize HBPC Practice Sarah Tubbesing, MD MSc Michael Ong, MD PhD VA Greater Los Angeles Healthcare System

41. Background • This project has been implementing tools and processes for Home Based Primary Care (HBPC) staff to learn and use Geographic Information Systems (GIS) geo-mapping software for practice management. • Improved efficiency helps increase the reach of HBPC’s clinically-effective, patient-centered extended care program.

42. How Sites Typically Map • HBPC Programs need secure, shareable maps to efficiently manage clinicians’ travel to patients’ homes.

43. What is GIS? • Geographic Information Systems (GIS) approaches allow for the integration of multiple data sources, visual representations of complex geographic data, and the application of various spatial analytic techniques to answer a variety of questions • GIS approaches have long been used in many fields (e.g. delivery services to establish efficient travel route for couriers) • now quickly gaining recognition as effective means to answer complex, ecological questions in health promotion, public health, community medicine, and epidemiology.

44. Initial Pilot Experiences • VA Greater Los Angeles HBPC piloted the use of GIS mapping in 2012-2013 to improve its practice efficiency • decreased potential travel distance between patients for NPs from 3.7 miles to 1.4 miles (p<0.5)

45. National Mentored Program • The pilot program expanded to 8 HBPC sites in 2014, and to and additional 8 sites in 2015, making a total of 17 sites including Greater Los Angeles. • VHA holds an enterprise license for the ArcGIS for Server software that is housed on its servers and supported by existing VHA technical staff.

47. How sites are using GIS maps • Facilitating patient assignments to clinical care teams • Improving organization and efficiency of staff territories • Planning day-to-day travel • Managing remote parking of government vehicles • Identifying geographical areas for potential HBPC program expansion • Developing emergency preparedness plans • Demonstrating HBPC program issues tofacility administration

48. Practice Management

49. Emergency Preparedness

50. Strategic Planning