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Research Highlight

Recent legislation such as the Veterans Access, Accountability and Choice Act of 2014, signals that VA will increasingly act as a purchaser of healthcare. Even before enactment of the Choice Act, dual use—when Veterans seek care from both VA and community providers—was prevalent, with estimates ranging from 30 to 75 percent. Historically, the majority of dual use of healthcare services in the community occurred among Veterans who were also eligible for Medicare. Looking ahead, dual use is expected to grow as more Vietnam War era Veterans become eligible for Medicare, and as federal legislation continues to expand Veterans' options for receiving care in the community. As VA increases its investment in providing Veterans with greater access to care in the community, more exploration of the complex determinates, processes, and outcomes of dual use is needed.

Since 2012, our team has been studying communication between VA and community providers. Initially, we conducted qualitative interviews with Veterans, community providers who treat Veterans, and VA providers. Of these groups, community providers expressed by far the most frustration with communication during care transitions. One community provider stated, "With VA, we get nothing...[when] we need something we have to call the VA or have the patient acquire it...nothing is ever sent automatically from the VA...and most of the time I don't even know that they see the VA...I don't know they're a VA patient."

This quote illustrates several common themes that emerged from our interviews: 1) poor communication; 2) no systematic identification of patients who receive both VA and in-the-community care; and 3) reliance on patients to communicate with community providers about healthcare received at VA and vice versa.

My HealtheVet, VA's patient portal, allows Veterans to download a summary of their VA health information using the Blue Button feature. The VA Health Summary, also known as a Continuity of Care Document (CCD) includes their recent medication list, problem list, laboratory results, and allergies, as well as other health information extracted from their VA electronic health record.

An online survey of 14,000 My HealtheVet users confirmed a high level of dual use among Blue Button users (44 percent) and validated qualitative interview findings that Veterans are primarily responsible for exchanging health information between VA and community providers. A pilot study tested the impact of training Veterans to use the Blue Button feature to generate and share a copy of their VA Health Summary. Of these trainees, 90 percent shared their summary with their community provider. When these Veterans shared their VA Health Summary with their community providers, 90 percent of the providers said it improved their ability to manage the Veterans' medications, and 32 percent of the providers determined that they did not need to order some laboratory tests because they had access to the needed information in the VA Health Summary. A larger nationwide quality improvement pilot of 600+ Veteran trainees, funded by the VA Office of Rural Health, found similar positive results in terms of Veteran and community provider satisfaction.

We are now building on this focused intervention to address broader issues in communication between VA and community providers. In this study, we are training Veterans: 1) to use both their VA and non-VA patient portals to engage in a bi-directional exchange of health information between VA and community providers; and 2) to enroll in the Veterans Health Information Exchange, or Virtual Lifetime Electronic Record (VLER) program if they choose. We are also educating community providers about VA health information exchange and care coordination using a "co-management toolkit." Finally, we are asking Veterans to develop a list of all their VA and community providers and to indicate what roles they believe each provider plays on their health team. Primary outcomes are Veteran and provider satisfaction as well as care quality indicators, such as medication list concordance and reduction in duplicate laboratories.

VA needs a more integrated process where operational leadership, clinicians, and health informaticists work closely together to develop a unified care coordination system. Such an effort may require focusing on one or two information technologies and consolidating VA care coordination programs. However, over time this would promote greater VA provider engagement, improve information sharing processes, and ultimately provide dual use Veterans with highly-coordinated quality care.

1. Turvey C, et al. "Blue Button Use by Patients to Access and Share Health Record Information Using the Department of Veterans Affairs' Online Patient Portal," Journal American Medical Informatics Association 2014; 21(4): 657-63.

2. Klein DM, et al. "Use of the Blue Button Online Tool for Sharing Health Information: Qualitative Interviews with Patients and Providers," Journal of Medical Internet Research 2015; 17(8): e199.

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