Workflow, Workarounds and Overwork in the Department of Veterans Affairs Problems and Solutions Stephan Fihn MD MPH Neil Evans MD Clinton Greenstone MD Austin Frakt PhD November 2017
Veterans Health Administration 2017 9.1m Enrollees 6.3m Patients Treated 84m Outpt visits 312k Outpt Surgeries 562k Inpt Admissions 1240 Sites of Care 179 Inpatient sites 170 Medical Centers 8 Residential Care 1 Extended Care 1061 Outpatient sites 24 Health Care Centers 199 Multi-Specialty 544 Primary Care 294 Other Other 58 Mobile clinics 300 Vet Centers Other Outpt Sites 2
Early Experience with Performance Measurement Integration into EHR Multidimensional cubes Dashboards Alerts and reminders Plateaued effects Proliferation Alert fatigue & information overload Clinical errors Prevention Index Flu & pneumo vaccine Breast, cervical, CRC screening Tobacco & alcohol screening/intervention Lipid screening PSA counseling Facility-level strategies undertaken to implement national PM systems may result in inappropriate clinical care, can distract providers from patient concerns Powell, et al. J Gen Intern Med 2011
How much do the following limit your ability to provide optimal, patientcentered care? (n=6,467) Proportion of respondents who say limits a great deal Clinical reminder volume 43% Recruiting and retaining providers 42% Lack of control over schedule 39% CPRS view alerts volume (e.g., provider-to-provider communication) 34% Difficulty accessing specialty care 34% Recruiting and retaining non-provider clinicians 34% Poor communication with specialists within VA 33% Inadequate time allotted to provide counseling or education 32% Time & effort to input notes 32% Inadequate time allotted to provide follow-up care 32% Poor communication with specialists outside the VA 31% Recruiting and retaining non-clinicians 31% Adoption of EHR 90 min of additional work per 8 hrs of patient care
Prevalence of Burnout in VA and Factors Influencing Burnout in Primary Care (odds ratios) VA 2017 All Employee Survey (1-5 scale) Workload 3.8 Staffing level 3.0 Burnout 2.1 (lower is better) Tenure with VA <6 mos. referent 6 12 mos. 1.2 2-15 yrs 2.2 >15 yrs 2.7 PCP overcapacity 1.0 Patient intensity (DCG Average) 0.9 Staffed to 3.0 ratio of team members to PCP 0.8 >75% of time doing work someone w/less training could do 1.3 Participatory decision-making on team 0.7 Chaotic/stressful environment 4.3 Helfrich et al, J Gen Intern Med 2014 5
Improving Workflows and More Staffing/Teamwork Standardized Workflows: Cerner/DoD/Intermountain Integrated decision support Reduction in performance measures Local solutions Enhanced patient engagement Better care integration 6
Higher Burnout On Primary Care Teams in Relation to Staffing Turnover, Panel Size Helfrich et al., 2017, J Gem Intern Med
Connected Care Technologies in the VA and their Impact on Workflow, Workarounds, and Workload Connected Care Access and the Veteran Experience will be enhanced through information and communication technologies that are effectively integrated into the daily lives of Veterans and VA Staff. 8
Patient-Driven Workarounds / Workflow Enhancements Society s digital transformation is changing consumer expectations and is allowing for new workarounds many of which can actually prove be workflow enhancements, if they are implemented/integrated well. Examples Simplified Transactions (e.g. - Online Prescription Refills, Reminders) Secure Messaging (Direct e-mail exchanges between patients and their health care teams, cutting out inefficient call centers and phone trees) Access to Clinical Data (e.g. Blue Button) Access to Clinical Notes (e.g. Open Notes) Telephone Visits Video Visits Patient Generated Data Remote Home Monitoring 9
Telehealth as a Strategy to Enhance Accessibility, Capacity, and Quality Across an Integrated Health Care System Where VA Telehealth Occurs Home Home Telehealth Remote Monitoring VA Video Connect Secure Messaging Telephone Visits Apps, Annie How VA Implements Telehealth Facility Telehealth encounters delivered to facility CBOCs and into the home Clinic Video Telehealth Store and Forward Telehealth Referrals and Veteran training for homebased services SCAN-ECHO Regional Telehealth Resource Hubs TeleDermatology TeleMental Health TelePrimary Care TeleRehabiitation TeleSleep Hospital TeleICU TeleStroke National Expert TeleConsultation National TeleMental Health Center TeleRadiology TeleGenonics
Ongoing Workflow Challenges Anticipated from Increasingly Intersecting Care Modalities Connected Care (Virtual Care) In-Person VA Care Community Care 11
Activities of the Local CC Department The local VA Community Care department is the clinic that coordinates all services for Veterans outside the VA Healthcare System. Activities of the local VA Community Care department 12
Goal for Community Care and Veteran Journey Our goal is to deliver a program that is easy to understand, simple to administer, and meets the needs of Veterans and their families, community providers, and VA staff. 13
Operating Model Foundational Elements Five foundational elements enable a consistent operational design and set of activities nationwide for the local VA CC department. 14
Tools & Technology to Support Transformation Tool Community Viewer Consult Tool Box CPP FBCS (mod) HealthShare Referral Manager (HSRM) One Consult template CPP PPMS REFDOC Virtru Pro Benefit Program that sends referrals to community providers securely giving them access to Veteran records; a new platform similar to the joint legacy viewer New program for use by VA providers and Community Care staff that documents standardized and trackable statements on to a consult in order to screen / triage and track the veteran throughout the community care experience The community care portal allows communication and exchange of health information among community providers, VA providers, Community Care staff and potential scheduling and care coordination contractors Modified referral and authorization system such that a 10-0386 will no longer be required New, industry-tested referral and authorization system Provides VA providers, VA clinic staff and Community Care staff with a new community care consult template that standardizes and streamlines the internal and external consult process Enables staff to view patient and consult information, create, assign, and track care coordination tasks, and set reminders and alerts for each episode of care Provider Profile Management System is a searchable database of community provider information New program that compiles medical information quickly to form a complete referral package for Community Care staff to send to community providers Secure email system for VA providers and Community Care staff to communicate with community providers 15