Kathleen Painter, RN, MSN

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My HealtheVet Secure Messaging Electronic
Patient/Nurse Communication

• Presented by
• Kathleen Painter, RN, MSN
• My HealtheVet Chief Health Informatics Office
• Patti Morrison, RN, BSN
• PVAMC Primary Care Operations Manager

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Class Objectives

• Provide an overview of the VA Personal Health
  Record My HealtheVet
• Characterize the electronic patient-doctor
  relationship
• Describe use of "secure messaging in clinical
  practice
• Show the required steps for using secure
  messaging for patient care
• Understand the characteristics of clinical
  adoption

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Ground Rules

• Please write any questions on the 3X5 cards
  provided
• Room assistants will collect the cards and we
  will attempt to respond as time permits to all
  questions
• If we run out of time, your questions and answers
  will be posted on the VeHU website

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My HealtheVet - National Program

• My HealtheVet Personal Health Record,
• a web-based health management tool,
• provides veterans a single point of
• access to personalized medical information,
  health education information, and self-management
  tools.
• My HealtheVet (MHV) Services and Products
• Online Prescription Refills Complete
  Medications View
• Condition Centers Health Education
  Information
• Self-assessment Tools Health Journals
  e-Logs
• Seasonal Health Reminders Secure Messaging

More than 500,000 Registered Users
www.myhealth.va.gov
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My HealtheVet Services today

• Online Prescription Refills
• Complete Medications View
• Condition Centers
• Health Education Information
• Self-assessment Tools
• Health Journals e-Logs

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Dimensions of Engagement

• What do patients want?
• What does the health care team want?
• Understanding current attitudes
• What do we want our patients to do
• Access and use their personal health information
• Manage their own health using IT based tools

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What do patients say they want?
The survey of 2,264 adults was conducted Sept.5
through Sept. 7, 2006 (Wall Street Journal,
9/12/06)
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What do patients say they want?
The survey of 2,264 adults was conducted Sept.5
through Sept. 7, 2006 (Wall Street Journal,
9/12/06)
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Patient Health care Team Relationships
Communication

• Face-to-face
• Written
• Telephone
• Internet
• Secure Messaging

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My HealtheVet - Secure Messaging
MHV Secure Messaging

• MHV Secure Messaging is a complementary online
  clinical service provided through the MHV website
  that facilitates the delivery of healthcare
  services and may improve healthcare outcomes by
  
• Improving accessibility
• Improving patient-healthcare team collaboration
• Promoting patient self-management

Patients are asking for Secure Messaging!
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Electronic Communication
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My HealtheVet - Secure Messaging
MHV Secure Messaging

• Electronic bi-directional, asynchronous
  communication for non-urgent health care
  questions issues
• Provides efficient and secure communication
  mechanisms based on proven and widely accepted IT
  protocols
• Secure messaging is not e-mail

Response time is 3 business days
offering another communications channel for
patients and healthcare team members.
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My HealtheVet - Secure Messaging
How is Secure Messaging Different from e-mail?
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My HealtheVet - Secure Messaging
Common Features

• Bi-directional communications
• Messages can be sent and received from the
  patient and healthcare team members
• Messages routed through a triage team
• The facility or clinic practice pattern
  determines the composition of the triage team
• New message notification
• Designate surrogate
• Escalation notification
• Save Secure Messages as Progress Notes
• Performance reports

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Self-Management and Secure Messaging
Functionality

• Renew meds
• Request appointments
• Contact health care team for non-urgent issues
• Message their provider with non-urgent issues

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Secure Messaging
Frequent Types of Secure Messages

• Updates to Physicians 41
• Prescription Renewals 24
• Health Questions 13
• Test Results 11
• Needing Referral 9
• Thank Yous / Apologies 9
• Appointments 5
• Non-Health Questions 5
• Billing 3
• Sensitive Content 5
• Urgent Need 0

• Addressed a Single Issue 83
• Require Physician Response 43

most messages are direct and related to one
issue Dr. Byrne, PCP Loma Linda SM Pilot Site
Source University of Michigan - Steve Katz,
MD JAMIA, Nov.2004
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My HealtheVet - Secure Messaging
Who will utilize Secure Messaging?

• My HealtheVet registered VA patients who have
  completed In-Person Authentication
• Providers who are enrolled into Secure Messaging
• Clinical and non-clinical staff trained to assist
  with message triage

All Participants Must Be MHV Registrants and
Completed the In-Person Authentication Process
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My HealtheVet - Secure Messaging
What can you do?

• Send a message
• Reply to a message
• Triage a message
• Complete a message
• Save message as TIU note

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Patient Opt In
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Healthcare Team

• Logging into Secure Messaging
• 1. Connect to the Secure Messaging Portal
• 2. Type your NT Username in the UserName field.
• 3. Type the NT password in the Password field.
• Click on the Login Button.
• If you need assistance with your password,
  contact your local IT support staff.

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My HealtheVet - Secure Messaging
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Viewing a Message
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Reading the Message
Read message
Read message
Read message
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Sending a Message
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Triage Staff Assigns a Message
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Save Messages as a TIU Progress Note
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Possible Advantages

• Patient/provider relationships
• Reduce non urgent telephone calls and pages for
  providers
• Quality of care
• Communication

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Possible Advantages

• Provider and patient satisfaction
• Care efficiency
• Written record
• Messages
• Customized
• Guided messages

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Secure Messaging

• Implementation
• of
• Secure Messaging

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Success Factors
MHV Clinical Adoption Veterans and Consumers
Health Informatics Office (V/CHIO)? is
committed to providing you the clinical adoption
tools to assist in the adoption of Secure
Messaging in your facility.
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Secure Messaging Clinical Adoption
MHV Clinical Adoption
Clinical adoption is the planning,
implementation, education, training, and
monitoring of the modification and transformation
of organizational, tactical, and behavioral
clinical processes and work flows necessary to
adopt new on line clinical services.
..provides the health care team an opportunity to
prepare for the change instead of reacting to the
change.
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Secure Messaging Clinical Adoption

• Leadership
• Strong project management
• Clear decision-making
• Organizational expertise
• Strategy for adoption

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Securing Messaging Clinical Adoption
V/CHIO Clinical Adoption Testing Process

• Establish a multidisciplinary Implementation work
  group (national leadership, technologist, SMES,
  field representation/front line)
• Test functionality of technical and clinical
  relevance/applicability and impact.
• Develop and test clinical adoption tools and
  materials during the pre-alpha phase.
• Analyze and synthesis test data and participant
  feedback.
• Modify clinical adoption tools as appropriate
• Provide ongoing evaluation identification of
  improvement opportunities

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Securing Messaging Clinical Adoption
SM Clinical Adoption Tools

• National Clinical Adoption Guide
• Secure Messaging Toolkit
• Implementation Team education material
• Staff education material
• Patient education material
• Communication materials
• Outreach campaign materials

Field tested tools will be provided to help you
identify and implement success strategies for
your facility
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Mapping the process

• SME started meeting with Stakeholders fall of
  2007
• Project Team Development
• Identify management team, meeting schedule
• Identify implementation team, meeting schedule
• Establish communication mechanism
• Practice/Provider Recruitment
• Provide briefing to Primary Care
• Identify Primary Care providers and Staff who
  will participate
• Identify associated Customer Service Specialists,
  Nurse Care Managers, Schedules, and any other
  staff who may be involved.

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Introduction, socialization

• Identifying stakeholders
• Establishing clear goals/outcomes
• Educating
• Discussing
• Listening
• Brainstorming
• Listening
• Trying/testing
• Listening
• Evaluating
• Repeat
• Clinical adoption

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Secure Messaging Clinical Adoption
Education and Training. the cornerstone to all
successful clinical adoption endeavors

• Video
• On line tutorial
• Web pages with resources
• CD/DVD
• Face-to-face training
• Quick Reference Guides
• Web-based modules
• National training calls

Our implementation was so successful because
training was provided by the clinician. Health
Care Providers Loma Linda SMS Pilot
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Secure Messaging Clinical Adoption
Secure Messaging Toolkit

• Key Implementation Steps
• Checklist and Time Line
• Generic clinical work flow
• Table Top Exercise
• Communications planning tools
• Education and training guidelines
• Outreach campaign guidelines
• Reference to other pertinent resources and
  toolkits

The objective of the SM Toolkit is to ensure
your success by providing How-To key steps and
tools.
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Secure Messaging Clinical Adoption Update
Secure Messaging Table Top Exercise
The Secure Messaging Table Top Exercise is a
paper-based simulation of anticipated messaging
scenarios and clinical work flow.
Simulate the most common types of messages so the
Team understands how to respond to the messages.

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My HealtheVet Personal Health Record
Secure Messaging Table Top Exercise

• Purpose
  Allow
  implementation team/test team to evaluate the
  integration of secure messaging services in their
  clinical communications/processes before
  implementing the application.
• Desired outcomes
  Identify clinical process
  improvement/modification opportunities prior to
  implementing Secure Messaging.

Provides the health care team an opportunity to
prepare for the change instead of reacting to
the change.
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My HealtheVet Personal Health Record
Participants Role and Responsibilities during
Table Top Exercise
Implementation Team Talk through the
processing of each type of secure
message identified in the
communication work flow.
Identify and document work flow
improvement opportunities,
modifications, and challenges
Select Facilitator Maintain ground rules
Identify when the implementation team appears
confused and encourage forward progression
CANNOT PARTICIPATE IN DECISION MANAGEMENT
Record Keeper Capture
modifications to work flow and meeting minutes

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My HealtheVet Personal Health Record
Table Top Exercise Process
NOTE Document current communications work flow
prior to the Table Top Exercise. 1. Facilitator
forwards message to initial reviewer. 2.
Initial reviewer explains his/her action(s). 3.
Initial reviewer forwards message to the next
receiver in the work flow. 4. Continue
forwarding the message until the message is
completed. 5. Document any improvement/modificati
on work flow opportunities or technical
challenges.
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MHV Personal Health Record Clinical Adoption
Secure Messaging Clinical Work flow

• Secure Messaging Clinical Telecommunication Work
  flow
• Model current clinical business processes
• Incorporate processes/systems that have worked
  well for your site or other sites
• Evaluate integration of Secure Messaging into
  current clinical business processes
• Portland modeled the work flow after the
  telehealth program
• Identify significant contact points
• Modify clinical business processes
• Test modified clinical business processes

Provides the health care team an opportunity to
prepare for the change instead of reacting to
the change.
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Past implementation

• 1. The Portland VA
• implemented the use/application of
  various technology, work flow processes, models
  of care, types of visits...etc.
• 2. Look back through all of the iterations
• not start early
• stakeholders not represented
• no champion's)
• infrastructure not in place
• Did not benchmark or too late in process.

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Nurses role

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Potential Business Models

• Modelled current work flow Processes
• Telecommunication and walk-in processes
• Map out VA Telephone Care information flow
• Identify all communication processes of
  participating providers and staff that fall
  outside Telephone Care (Pharmacy, laboratory)
• Nurses role (Nurse Care Manager)
• How will RN role be same
• How will RN role be different
• Already taking care of these patients in less
  efficient manner
• Chronic care model
• Advice nurse
• Delegation

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Potential Business Models
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Potential Business Models
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Secure Messaging Clinical Adoption Update
Integrated Clinical Adoption Testing

• SM Application Functionality Testing
• Six sites
• Testing period spring-summer 2008
• Test functionality of application
• Exchange of actual information
• Participants PCPs and associated health care
  team members, 4 patients/PCP
• Second round of clinical adoption testing

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Development for pre-alpha and alpha phase

• Solidify team members
• Address questions concerns
• Enroll veterans for Alpha Phase
• Incorporate what was learned from table top
  exercise.
• Solidify business rules.

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Secure Messaging Clinical Adoption Update
Integrated Clinical Adoption Testing

• SM Administrative Functionality Testing
• Additional sites
• Start date Summer 2008
• Increased participants
• Exchange of actual information
• Additional SM features
• Facility establish triage teams
• Run performance reports

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Secure Messaging Clinical Adoption
Communication Strategies

• Approved product messaging and language
• Communication brochures
• Frequently Asked Questions
• Approved press releases

Communicating information about the new
productinternally and externallyis vital to the
success of your implementation.
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Secure Messaging Clinical Adoption
Continuous performance evaluation is key to the
long term success of MHV.

• Performance Metrics
• Workload Effortnumber of messages responded to
  by specific classification (providers,
  clinicians, triage team)
• Clinical processes--number of escalated messages
  (messages not completed within 3 business day)

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Struggles/concerns

• Finding time to meet with all team members
• Delays in implementation
• Why does SM notification have to come through
  outlook
• How are we going to take on this additional work
  load?
• It is all going to fall on the RN.

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Successes identified by team

• Delicate communication with patient more
  comfortable
• Confidentiality/HIPPA
• Concise and abbreviated
• Improve prioritization and organization
• Manage the work load rather than the work load
  managing us
• Optimizes space needs
• Proactive communication

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Lessons Learned

• Need to enculturate the belief with patients that
  communicating with the health care team is the
  same as communicating with the provider
• Partner in health care.
• Perceived benefits savings (time and money),
  decreased frustrations by staff and patients
  maximize resources (meets ACA principles)?

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My HealtheVet
VA's personal health record, anywhere, anytime
internet access to health care! Celebrating 5
years www.myhealth.va.gov