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RRP 11-408 – HSR Study

RRP 11-408
Working with Veterans Organizations to Encourage Use of My HealtheVet
Jeffrey C Whittle, MD MPH
Clement J. Zablocki VA Medical Center, Milwaukee, WI
Milwaukee, WI
Funding Period: May 2012 - October 2013
Despite the promise of electronic health resources, there is evidence from a variety of sources, including VHA, that they have not led to the improved self management that many envisioned. Although VHA has worked to ensure the functionality and ease of use of My HealtheVet, the VA patient portal, a key barrier is patient acceptance and familiarity. Peer support, particularly in group settings, can improve health-related behaviors. Such approaches may increase and improve MHV use. We have worked extensively with veterans' service organizations, such as the American Legion, to help them mobilize their substantial positive peer relationships to support improved health behaviors.

Our goal in the present project was to develop and test a peer-based mechanism to increase My HealtheVet (MHV) use by members of veterans' service organizations (VSO). Since this was an implementation research project, we also intended that this pilot would establish an infrastructure with the American Legion that would allow for generalizing the lessons learned in the present project to other VSO settings across the state of Wisconsin. We addressed 3 specific aims:

1)To demonstrate that trained members of VSO can provide basic MHV education and support within their VSO unit using mobile computers.
2)To demonstrate that this intervention increases MHV registration, in-person authentication (IPA), and reported use of MHV among veteran post members.
3)To create clear, concise, and portable resources that will make it possible to replicate this process in other VSO units or other community settings.

This implementation study was a cluster-randomized intervention with delayed controls. Working with the leadership of the American Legion, we identified 12 posts that expressed willingness to participate in the project. The leaders of these posts (typically the commander and/or adjutant) agreed to encourage post members to participate in all aspects of the research study. We trained 1 to 6 peer mentors (super-users or SU) from each these posts using adaptations of the peer training approach we used for a previous project. Our original goal had been to require 2 SU per post, but two of the twelve posts ended up with a single SU due to changes in availability of the planned second SU. We trained the SU to use laptops with wireless broadband Internet access and a supplemental 30 inch monitor for teaching sessions at their posts. We loaded the computers with software that documents unique sessions (i.e., separate input of a username and password), websites visited, and amount of time at each website. We trained the SU to provide lessons regarding MHV use to his/her fellow post members at 4 monthly post meetings.

To identify the impact of the training, we first grouped the posts into 3 geographically defined clusters of four posts. We then randomly selected one cluster as the first intervention group, providing them with the computers and training during the first 4 months of the intervention. After 5 months (allowing for the fact that some meetings were either cancelled or had competing agenda items such that the training could not take place), we moved the computers to the next 4 posts and repeated the intervention. Finally, we moved the computers to the last 4 posts. For these posts, we provided less intensive support, with an initial face to face exchange of computers then remote support of lesson plans. We have collected computer tracking data, surveys, direct observation of presentations at posts, focus groups with post members, and interviews with SUs to assess the impact of the program. We will test changes in registration, IPA, and MHV use through before and after surveys. Our analysis will adjust for clustering within posts. We have transcribed our focus groups and interviews verbatim and analyzed them using qualitative methods.

We successfully recruited SU at all 12 participating posts. All SU reported that they were able to present the 4 lesson series at post meetings. All noted that many veterans who used VHA for healthcare were not MHV users. They also noted that the majority of Legionnaires did not use VHA for healthcare. The SU were able to administer the survey at the planned intervals at all 12 participating posts. The number of respondents was 183, 160 and 197 during rounds 1, 2, and 3, respectively, for a total of 540 useable surveys. This reflects an overall response rate of 63.68% (540/848 veterans in attendance); the rate was 58.65%, 61.30%, and 71.64% in rounds 1, 2, and 3, respectively. The overall response rate varied substantially by post, from 34% to 100%. These survey showed that the proportion of responding post members who had heard of MHV, who had used MHV and who had authenticated all increased significantly over time, between 2 and 3 fold.

In our qualitative analyses we have identified some important lessons for future iterations of such interventions. Most importantly, the advanced age of many of the veterans is a significant barrier to participation/interest in MHV. They lack both interest in the technology and skills to make using MHV feasible. Other barriers to using MHV included factors associated with MHV itself. For example, the registration/authentication process was reported to be cumbersome and frustrating and the website itself was considered to be too complicated for the computer savvy of most users. Two aspects of the program counteracted these barrier, but only to a small extent: 1) having the SUs easily accessible to provide personal support and assistance in the process of registering, logging in and navigating the website; and 2) having a family member interested in MHV. Specifically, we noted that when the wives of veterans were present for MHV demonstrations, they often seemed interested, but it is not clear whether or not they actually encouraged its use or used it themselves for accessing information. This should be further explored in future programming.

Other important themes were as follows: 1) the interest of non-VA users in MHV was limited; 2) the veterans who did use the MHV mainly used it for prescriptions and appointments; 3) having the computers with wi-fi at the posts was helpful to the program, although mainly for one-on-one demonstrations after the meeting.

Our review of computer usage revealed several important insights. First, the time spent in face to face contact with the SU correlated with the intensity with which they used the computers. Just one post among the third group of four posts was a regular user of the computer at each meeting where our MHV training should have been presented. It appears that simply providing the materials and computer to the post did not lead to an educational session. Second, the computers were primarily used during post meetings to make presentations and to help individual members sign up for MHV. Despite presentations about the relative value of various internet health sites, only MHV was used more than once. It was rare that the computer was used for recreational purposes - e.g., to search for information regarding non-health related topics. Finally, SU would use personal or post computers if their post had internet access, since that was usually faster than our cellular modem.

This project has solidified our relationship with the American Legion statewide office. It has demonstrated that we can deliver educational interventions through an existing network of veteran meeting places, and that these efforts were associated with a substantial increase in familiarity, use and registration for premium use of MHV. The Legionnaires who served as SU expressed a willingness to continue in their role as a local resource for veterans who wanted to use MHV. We believe that this approach has the potential to increase MHV use, but is expensive, in part because of the need for personal contacts with the super users by the study team.

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DRE: Technology Development and Assessment
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