Strengthening Patient-Provider Connections:
Military Medical/CBRN Technology – February, 2010 – As an indication of how broadly the Department of Veterans Affairs seeks to share information, the Phoenix Veterans Affairs (VA) Health Care System recently had a homeless veteran on “national call” so he could share with others how he uses My HealtheVet. The myhealth.va.gov Website is available to active-duty military personnel and veterans, their families and caregivers as a repository of health information and an electronic personal health record that allows veterans an active role in their health care.
According to Victoria Reyes, a library technician and point of contact for My HealtheVet, while this individual was without a home and struggling, My HealtheVet served as something stable in his life. It was a place where the system maintained his records and kept track of prescriptions and other information, while also informing the veteran where he needed to be regarding health care options, challenges and even treatments, despite his homeless situation.
Officially launched on Veterans Day 2003, the system serves as an educational tool for a variety of conditions as well as a live, 24-hour link to health care providers and specialists. It’s also just one entry point into the vast repository of medical records that exist within the VA medical system. A variety of devices, particularly containing electronic personal medical records, are tracking patients’ experiences in the hospital, in transition between medical providers and possibly from Department of Defense coverage to that of the VA.
Crucial to all of these is a progression toward seamless integration of a variety of medical information and near real-time coverage of a variety of patient statistics, ailments and needs, while bringing the patient himself into the loop about his own personal health situation, which often can appear as a sea of jargon and frustration.
LEVELS OF ACCESS
My HealtheVet, for example, is just one tool with literally millions of components. The system is broken into three tiers.
The first tier allows anyone to get basic health information online. Utilizing two medical libraries on the system, visitors to My HealtheVet can obtain information on healthy living and how to stay healthy. The system also provides components to help visitors stay alert to possible changes in veteran medical status as well as any other health-related information.
In the second tier, veterans can officially register with My HealtheVet and can do additional tasks, such as refill prescriptions online. In the third tier, a veteran is able to read prescriptions, view medical history back several years and get “wellness reminders” tailored to individual needs, such as reminders for annual lab work or flu shots.
Theresa Hancock, national director of My HealtheVet, said the entire process was designed to “prove that using self-service and giving patients access to their medical records and key things that they needed to share with outside providers actually had a benefit and worked.”
Hancock noted that VA is now partnering with the Defense Department’s Tricare online Web portal to consolidate information from a variety of multiple providers. As a result, patients don’t have to carry around paper records, and it encourages patients to become more involved in their health.
According to Hancock, since My HealtheVet began the system has handled 13 million prescription refills and seen 34 million site visits. In addition, about 120,000 veterans have participated in the “in-person authentication process” which gets them to “tier three” of the My Healthe- Vet system.
INFORMED PATIENTS
As a repository for medical record information, My HealtheVet might be growing, but other innovations have come on the market in recent years that also provide an abundance of information to patients and caregivers from a slightly different angle.
TeleHealth Services, for example, utilizes technology that educates patients with its telephone-initiated guided response system. It is an on-demand education system that puts the patient education and recovery process in the hands of clinical staff as well as patients and families. A patient basically can dial into a patient video education directory at the bedside.
Matthew Barker, director of marketing for TeleHealth Services, said the VA is a special circumstance in that the government mandates patient education. What TeleHealth can do, he added, is be the delivery system for the content, but it allows the VA to give a standard patient education curriculum across several facilities. He said his company’s system is currently used by more than two dozen VA facilities around the country.
“You have a set curriculum that is either prescribed to you via your clinical staff, or if you’re just actually wanting to browse some other interest points … you’re able to dial into the system and then watch all of that educational content on demand,” he said.
That education is not only an informational benefit, however. It’s a matter of comfort, and oftentimes can be the attitude adjustment a patient might need to improve his health. It’s definitely something that Michael O’Neil, founder and CEO of GetWellNetwork realized about 10 years ago. While a graduate student at Georgetown University in Washington, D.C., he was diagnosed with cancer. As a patient, he said he felt like he was “on the outside looking in on a process.” Enduring this physically and psychologically traumatic experience, he said, was a defining moment.
“Every morning at about nine o’clock in the morning, you wanted it to be like clockwork that your physician would come in and tell you all of the things that were going on with you that day,” he said, but such visits by the doctor weren’t that predictable. “What you could predict is this young kid would come in my room every morning, and he was the TV guy, and he would ask me for six bucks to turn on my 15 year-old crappy television in the corner of the room that had about nine static-y channels on it.”
Perceiving that the television, or some equivalent device, could serve as a conduit to accurate, official information available at any time, GetWellNetwork developed a workflow engine called Patient Pathways that allows integration of a variety of systems—clinical, financial and others—in a hospital.
“Based on those inputs going into those other systems, we ask the question all the time: ‘What could the patient directly benefit from?’” O’Neil said. “For example, if a physician enters an order for a medication … in our world, that’s simply a trigger to interrupt Oprah or interrupt the local news to say to a patient in real-time … ’You’ve just been prescribed prednisone; it’s an important medication for the following reasons; click here to learn about what you feel as a side effect while you’re actually being ministered this medication.’”
The system drives communication to the TV and then right to the patient. It can test comprehension of information and also report on how much pain a patient is in. At the same time, the information is routed back to two places at once in real-time: the patient’s electronic health record and actual medical personnel on-hand who can react to changes in condition, pain levels or any other development as a result of the information transfer to and from patients.
The “workflow engine,” he said, is the crux of the application and allows Patient Pathways to include a variety of information in virtually any area that could possibly help support the patient and caregivers.
“We can literally take a trigger that says, ’There’s an Arabic-speaking woman in the bed and she happens to be 56 years old; let’s leverage that information to ask her when her last mammography screening was and invite her to actually register for one while she’s here,’” he said.
O’Neil said that the utilization of this is four- to five-times that of a system that would pull you away from the TV experience itself. It’s essentially a bedside health care system with personal computer capabilities such as browsing the Internet and sending email, he said.
For hospitals and health systems to adopt this technology, O’Neil said software integration at a facility takes just about 90 days from “contract signing to, as we would say, first patient touching the system.” For the VA, he added that GetWellNetwork has been talking to around 15 to 20 VA hospitals and hopes to launch the system within the VA in the near future.
BEDSIDE DATA
While not all of such technology begins with the military, a lot of innovations do flow from the military and then end up on commercial shelves. One such company that first began with the military market is CliniComp, which about 26 years ago was looking to come up with technology that could provide a 99.9 percent “up time” in an intensive care unit (ICU), so any clinician could access any patient record without interruption, according to the company’s president, Alan Portela.
Originally, CliniComp established connectivity with ancillary systems and developed data acquisition devices that allowed the company to “cut through” data for bedside instruments. With this early technology, health care providers could enter times and figure out what data a patient had at a given time.
The first large installation of this technology for CliniComp was in 1987 at Naval Medical Center San Diego, for not just the ICU but also other areas of the hospital. A few years later in 1993, they received a contract to automate Madigan Army Medical Center in Tacoma, Wash. The cornerstone of the company’s products is “high acuity clinical information systems” Portela said.
“[The] interesting thing, on the military side, what we call high acuity—we had a number of installs throughout the last 20 years that started at San Diego,” he said. “Basically this led to … a selection process less than a year ago looking for an inpatient documentation system, and we were selected, and we received the contract in April of 2009 to automate all the military treatment facilities.”
When CliniComp received the contract, the Defense Department already had 40 percent automation with the company’s Essentris product in “high acuity” areas. The Essentris Product Suite basically replaces medical charts and allows medical personnel to collect and access a variety of data in an electronic medical record. According to CliniComp’s Essentris specifications, the system “integrates, organizes, calculates and presents critical data to reduce errors, save time and enhance quality” for patients.
“You have to realize that you cannot accomplish meaningful use if you cannot collect meaningful data,” Portela said. “In the past we reacted to what happened to patients, but the more you collect the data, the more you can do algorithms to start figuring out what are the patterns, [such as]: ‘How am I going to notice if this patient is going to have a heart attack in an hour?’”
The information then goes into a “global data repository” where every piece of data collected throughout a patient visit is stored so decision-makers can view it when necessary. In the next few months, Portela said CliniComp should automate about nine or 10 VA facilities.
“With the contract and the deployments that are happening as we speak, the [military health system] will be on 100 percent automation in high acuity areas over the next 18 months,” Portela said.
DISTANCE LEARNING
Record keeping, easily tracked patient histories and patient records are only part of the larger picture, however. Sometimes the record, image or diagnosis must be immediate, when life hinges on communication between a patient in one remote location and a practitioner in another.
GlobalMedia Group, as an example of one company working in this area, says it works to aid such situations through telehealth products centered on camera and imaging technology.
“We use our communications software, and we can have … just a tech[nician] in Afghanistan put a slide under a microscope, and someone from Harvard or any of the medical schools or facilities [can] give a diagnosis live as they are pushing that slide,” said Joel Barthelemy, managing director of GlobalMedia.
It started while the company was working with the Department of Homeland Security and Tulane University, where doctors asked GlobalMedia if it could develop software that would allow remote pathology capability. As a result, GlobalMedia developed CapSure, a system with a camera on top of a microscope that can broadcast megapixel images in a live stream directly from that microscope to another location.
Among the many locations the system is in place, Barthelemy noted use of the system at Atlanta’s Emory University Hospital Midtown—formerly Emory Crawford Long Hospital—where seven neuropathologists are in residence. The system allows pathologists to give a diagnosis while a patient is on the operating table in another location. All they need is a computer hookup.
Such ability has led to a camera redesign, Barthelemy said, creating a camera about the size of a “dry-erase marker” called the TotalExam camera, that now even allows a clinician to examine things such as eyes and the throat, and connects to CapSure software so a doctor can view images remotely.
With the VA’s large and continuing deployment of telemedicine, Barthelemy said such technology provides quicker diagnoses from professionals that might be in residence at larger major hospitals.
It’s a crucial step that, along with VA’s technology growth, MyHealtheVet and all the technology in between, provides the information, peace of mind and sometimes critical care to military personnel from the Middle East to the Midwest and beyond, by bringing patients into the loop and providing near real-time coverage for them and their health care providers within the system.
