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ORIGINAL RESEARCH
Promoting Access Through Complementary eHealth
Technologies: Recommendations for VA’s Home Telehealth
and Personal Health Record Programs
Timothy P. Hogan, PhD1,2,3, Bonnie Wakefield, PhD, RN2,4, Kim M. Nazi, MA5,
Thomas K. Houston, MD, MPH2,6,7, and Frances M. Weaver, PhD1,2,3
1
Center for Management of Complex Chronic Care & Spinal Cord Injury Quality Enhancement Research Initiative, Edward Hines, Jr. VA
Hospital, Hines, IL, USA; 2eHealth Quality Enhancement Research Initiative, National eHealth QUERI Coordinating Center, Edith Nourse Rogers
Memorial Veterans Hospital, Bedford, MA, USA; 3Program in Health Services Research, Stritch School of Medicine, Loyola University Health
System, Loyola University Chicago, Maywood, IL, USA; 4VA Health Services Research and Development Center for Comprehensive Access &
Delivery Research and Evaluation (CADRE), Iowa City VA Medical Center, Iowa City, IA, USA; 5Veterans and Consumers Health Informatics
Office, Office of Health Information, Veterans Health Administration, US Department of Veterans Affairs, Washington, DC, USA; 6Center for
Health Quality, Outcomes & Economic Research (CHQOER), Bedford VAMC, Bedford, MA, USA; 7Division of Health Informatics and
Implementation Science, University of Massachusetts Medical School, Worcester, MA, USA.
BACKGROUND: Many healthcare organizations have
embraced eHealth technologies in their efforts to promote patient-centered care, increase access to services,
and improve outcomes.
OBJECTIVE: Using the Department of Veterans Affairs
(VA) as a case study, this paper presents two specific
eHealth technologies, the Care Coordination Home
Telehealth (CCHT) Program and the My HealtheVet
(MHV) personal health record (PHR) portal with integrated secure messaging, and articulates a vision of
how they might be implemented as part of a patientcentric healthcare model and used in a complementary
manner to enhance access to care and to support
patient-centered care.
METHODS: Based on our experience and ongoing work
with both programs, we offer a series of recommendations for pursuing and ultimately achieving this vision.
CONCLUSION: VA’s CCHT and MHV programs are
examples of an expanding repertoire of eHealth applications available to patients and healthcare teams. VA’s
new patient-centric healthcare model represents a
significant shift in the way that services are delivered
and a profound opportunity to incorporate eHealth
technologies like the CCHT and MHV programs into
clinical practice to increase access to care, and to
ensure the responsiveness of such technologies to the
preferences and circumstances of patients.
KEY WORDS: eHealth; patient-centered medical home; telehealth;
personal health records; veteran.
J Gen Intern Med 26(Suppl 2):628–35
DOI: 10.1007/s11606-011-1765-y
© Society of General Internal Medicine 2011
INTRODUCTION
eHealth has been described as an emerging, multidisciplinary
field focused on the delivery or enhancement of health
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information and health services through information and
communication technologies (ICTs)1. Advances in eHealth have
simplified the tasks of finding and using health information,
led to the creation of tools to help consumers engage and
collaborate more fully in the healthcare process2,3, and have
supported efforts to connect with consumers, disseminate
information, offer new services, improve clinical encounters,
and support disease management independent of geographic
locations4–9. eHealth also has the potential to enhance access
to healthcare services by offering novel channels for communication and information flow that complement existing systems. The capability for patients and providers to exchange
secure messages and the automated transmission of patient
data from in-home devices exemplify “continuous access” to
care as articulated by the Institute of Medicine10 and help
redefine access to care more broadly as “the opportunity and
potential ease of having face-to-face and virtual interactions
among a care team,” including patients, healthcare providers,
informal caregivers, peers, and computer applications11,12. At
present, healthcare organizations both within and beyond the
United States (U.S.) are moving to design a wide range of
eHealth technologies that offer different features and functionalities. Although the meaningful use of these technologies has
the potential to improve healthcare processes and outcomes13,
there are challenges associated with their implementation14.
In 2010, the U.S. Department of Veterans Affairs (VA)
undertook a series of transformational initiatives to “design a
veteran-centric healthcare model and infrastructure to help
veterans navigate the healthcare delivery system and receive
coordinated care”15. As part of this effort, VA supports the use
of technology in conjunction with virtual medicine and is
implementing a patient-centered medical home (PCMH) model
at all VA primary care locations which is referred to as Patient
Aligned Care Teams (PACT)16–18. PACT is managed by primary
care providers in collaboration with other clinical and nonclinical VA staff and has tremendous potential to reshape the
healthcare experiences of the approximately 8 million veterans
currently enrolled in the VA healthcare system; many of whom
are described as having a “complex” health status. Complexity
may encompass eligibility for care across multiple systems19,
Hogan et al.: Complementary eHealth Technologies
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numerous chronic health conditions20, and residence in rural
or highly rural areas21 with limited insurance coverage and
limited access to healthcare facilities22.
Using VA as a case study, we present two specific eHealth
technologies, the Care Coordination Home Telehealth (CCHT)
Program and the My HealtheVet (MHV) personal health record
(PHR) portal, as vehicles to enhance consumer access to health
care and explore how their respective features and functionalities might be used together to provide seamless, patientcentered care. For the full potential of these two technologies to
be realized, they must work together synergistically. To that
end, we offer a series of recommendations as to how this might
be accomplished. Although VA may be somewhat unique from
an organizational and policy perspective, the experiences of VA
stakeholders with eHealth technologies provides valuable
lessons to those in other healthcare systems.
BACKGROUND
VA’s Care Coordination Home Telehealth (CCHT)
Program
Telehealth involves the use of ICTs to deliver health services in
situations where the care recipient is separated by distance
from the care provider23. Supported by the VA Office of
Telehealth Services, formerly known as the Office of Care
Coordination, the CCHT program provides chronic care management to facilitate veteran access to care in the least
restrictive environment possible—the home. As presented in
Table 1, videophones and messaging devices, which rely on
standard telephone lines, link veterans with care coordinators.
Messaging devices in the veteran’s home are programmed with
a set of questions (called disease management protocols), to
which the veteran responds by pressing buttons. The
responses prompt the care coordinator to deliver potential
interventions and/or education, consult with members of the
care team, or telephone the veteran for further assessment or
to provide advice. Peripheral devices, such as blood pressure
cuffs or blood glucose meters, can also connect to the
messaging device for easy data downloading and transmission.
Table 1. Aspects of the Care Coordination Home Telehealth
Program
Target Populations
- Patients with one or more chronic care needs
Equipment
- Telephones, personal computers, interactive voice response
- In-home messaging/monitoring devices
- Biometric devices (e.g., blood pressure cuff, glucose meter)
- Videophones, telemonitors
- Digital cameras
Care Management Strategies
- Disease Management Protocols (DMP)—a set of questions that
proactively identify symptoms, behaviors and health factors that
affect disease management. They also deliver education regarding
the disease and its management.
- Routine monitoring of vital status (e.g., weight, blood pressure, blood
sugar)
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The CCHT program allows for the monitoring of key parameters in large groups of veterans, thus facilitating easier and
quicker intervention when needed. Previous studies of veterans with chronic conditions who used CCHT have shown lower
mortality24 and healthcare utilization25–27, as well as improved
quality of life26 and more timely receipt of care28. Other work
has found increased time to readmission among veterans with
heart failure29, including a dose-response relationship30,31.
Veterans engaged with the program report that it “reassures”
them and lets them know that they are “doing the right
thing”32.
VA’s My HealtheVet (MHV) Personal Health Record
(PHR) Portal
Contemporary personal health records (PHRs) have been
described as electronic applications “through which individuals can access, manage and share their health information,
and that of others for whom they are authorized, in a private,
secure, and confidential environment”33. Designed to address
consumer health information needs, PHRs consist of information supplied, organized, and owned by consumers, and may
also include content provided by healthcare organizations. My
HealtheVet (MHV) (http://www.myhealth.va.gov), VA’s integrated, Web-based PHR portal brings together information
self-entered by veterans, data extracts from VA’s electronic
health record (EHR), self-management tools, health education
materials, and additional services such as Secure Messaging
in an effort to engage veterans in their own healthcare and to
promote collaboration among healthcare stakeholders34–36.
Table 2 presents the core components of MHV and the threetiered access model on which it is based, with increased system
functionality available at each level37. The VA “Blue Button”
launched in the summer of 2010 enables registered users to
download an electronic copy of their personal health information
available in MHV. As of May 2011, more than 240,000 unique
MHV users have used the VA Blue Button. Direct feedback from
veterans, gathered through the American Customer Satisfaction
Index (ACSI), an industry standard online survey tool, is used to
prioritize the development and release of new system additions38.
Other planned functionality includes viewing additional EHR
data extracts and the delegation of account access to others.
As of April 2011, MHV had been visited over 51 million times,
over 1.2 million individuals had registered (85% are veterans),
and over 327,000 veterans were authenticated users39. The
majority of system adopters are male (91%), between 51 and
70 years old (68%), served during the Vietnam War (60%), access
MHV from home (96%), and use the system to order VA
prescription refills (75%)40. One-third of MHV users live one or
more hours away from a VA facility41. Published studies documenting the effects of MHV use on healthcare processes and
outcomes are still limited; however, researchers within VA’s
health services research and development service (HSR&D) are
establishing work in this area.
Chumbler and colleagues42 suggest that the integration
of eHealth applications may spark further innovation in
both the CCHT and MHV programs. They describe how
telehealth programs can be used to collect patient information
remotely and PHR programs can subsequently function as a kind
of interactive repository in which to manage that information. We
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concur with this vision; however, we also advocate for a more
process-oriented perspective on access to care and disease
management, focusing on potential ways that these programs
could be integrated in a complementary manner.
SYNERGIES BETWEEN THE CCHT AND MHV
PROGRAMS
Table 3 presents a series of healthcare elements—resources,
processes, and activities that are an inherent part of managing
health—and the various functionalities of the CCHT and MHV
programs that map to each element27,34,35,43. Although there is
some overlap, we suggest how the respective functions provided by
the two programs might be drawn upon in combination to enhance
different healthcare elements, including access to care. The concept
of “trajectory,” which encompasses the physiological unfolding of
disease as well as the corresponding efforts made to manage disease
course44, is particularly useful in this context as it underscores the
changing, dynamic nature of healthcare needs and management
activities, and the frequently assumed but less frequently articulated point that different CCHT and MHV functions will be more or
less appropriate (and useful) at different points in time. As a
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veteran’s circumstances change, the CCHT and MHV functions
that they are using may also change for optimal use. The scenarios
presented in Textbox 1 highlight the need for healthcare providers
to continually reassess a patient’s situation, consider the repertoire
of available eHealth tools, and to advocate for their use accordingly
in concert with patient needs and preferences.
In the remainder of this paper we discuss several recommendations that we believe, based on existing evidence, should be
considered in order to realize this vision.
RECOMMENDATIONS FOR REALIZING
THE SYNERGIES BETWEEN THE CCHT AND MHV
PROGRAMS
1. At the System Level, Re-envision and Integrate
CCHT and MHV into the New Model of Care
Across VA, the implementation of the PACT model represents a
profound and transformative shift in the way that healthcare
services are accessed by and delivered to veterans. The PACT
model provides a platform which we can use to examine how the
Textbox 1. Use Scenarios - CCHT and MHV over the Trajectories of Chronic Heart
Failure and Diabetes
John is a 62 year old Vietnam-era Veteran who has chronic heart failure and diabetes.
Scenario 1: John has been able to manage his conditions well with the assistance of his primary
care provider (PCP). During his last outpatient clinic visit, John was asked by his PCP to
carefully monitor his body weight as even a small increase could lead to an exacerbation of his
heart failure. Having heard about some of the self-monitoring features available through MHV,
John registered and completed the IPA process before leaving the VA facility that day. Once
home, he weighed himself, logged onto MHV, and entered his weight under the Track Health
section. He continued this practice daily for the next month and shared his data with his PCP
upon his return to the clinic. Using this information, the PCP made a slight adjustment to John’s
medication. John continues to monitor his weight and knows to contact his PCP if he experiences
more than a two pound increase from his baseline weight. John also started to refill his
prescriptions online through the Pharmacy section of MHV.
Scenario 2: John has been monitoring his weight using MHV. However, his diabetes has
worsened and he is having trouble maintaining his weight. He recently had a brief hospitalization
due to an exacerbation of his heart failure. Because his care has become more complicated, his
PCP recommended that he use the CCHT telehealth system. On a daily basis, John uses CCHT to
report his weight, blood sugar and blood pressure. The disease management protocols in place
for heart failure and diabetes also provide information and education to John regarding how best
to manage his conditions. The care coordinator reviews John’s information daily and either
contacts him directly with additional counseling and advice or contacts his providers if the data
suggest that he may need a change in treatment plan. At that point, the PCP may intervene with a
different medication dose or new prescription, or schedule John to come in for an appointment.
He and his PCP sometimes work out these details by exchanging secure messages through MHV.
John also continues to use MHV to refill his prescriptions and to review the Research Health
section of the portal which provides trusted information about diabetes and heart failure.
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Table 2. Components of MHV and Their Associated Functionality
Personal Information
- Store and maintain contact/emergency contact information R, I
- Manage account profile, preferences, and options R, I
- Print selected personal/medical information on a pre-formatted wallet
card R, I
Pharmacy
- Request refills for VA prescriptions R, I
- View history of all VA prescriptions R, I
- Record the name, start/end date, prescription number, and dosage for
medications, over-the-counter drugs, herbals and supplements R, I
- View and print a complete summary of VA and self-entered
medications R, I
Research Health
- Search collections of evidence-based health information A, R, I
- Access health screening tools, mental health resources, and related
articles A, R, I
- Take online course offerings to promote mental health A, R, I
Get Care
- Store information pertaining to caregivers and providers R, I
- Keep records of healthcare facilities visited and their locations R, I
- Organize health insurance information R, I
- Maintain a health calendar including events, appointments, reminders, and to-do lists R, I
- View VA Appointments and set reminder notifications via email I
Track Health
- Create and maintain a personal, family, and military health history R, I
- Track and graph vitals, readings, and other health measures R, I
- Record allergies by date, severity, reaction, diagnosis R, I
- Document immunization information, including date, method used,
and any reactions R, I
- Document tests by name, date, location performed, provider’s name,
and results R, I
- Track medical events including illnesses and other issues R, I
- Maintain diaries to monitor food intake and exercise routines R, I
- View VA Allergies extracted from the VA electronic health record I
- Select information to print out as a shareable Blue Button report R, I
MHV Community
- Access information about benefits and resources, VHA-related news
and events A, R, I
- Explore links to additional online resources A, R, I
Wellness Reminders
- View customized VA Wellness Reminders for preventative care and
screens I
Secure Messaging
- Exchange secure electronic messages with healthcare team members
for non-urgent needs (currently available at selected sites with further
expansion to all VA facilities in 2011) I
VA Blue Button: Download My Data
- Generate and download an electronic copy of personal health
information available in MHV R, I
A
Denotes features that are available to anyone who visits the MHV webportal-PHR
R
Denotes features that are limited to users who have registered with
MHV
I
Denotes features that are limited to users who have completed an
identity verification process known as in-person authentication
CCHT and MHV programs complement one another, and more
importantly, determine how they can be meaningfully integrated
into VA’s new model of care. Doing so will require interaction
among different stakeholder groups that have traditionally
operated in separate domains. Strengthening these relationships
is an important step towards the elimination of latent organizational silos that are characteristic of large systems. Relevant
program offices will need to identify shared strategic priorities,
common functional requirements, and opportunities for synergistic use. Creation of an eHealth advisory board representing
both CCHT and MHV may be useful in this regard and enable the
development of a unified voice with which to convey information
to policymakers.
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It will also be important to continue to foster collaborations
among CCHT, MHV, and the VA research community. VA’s Quality
Enhancement Research Initiative (QUERI) implementation research program is intended to improve the quality of healthcare
for veterans through the implementation of evidence-based clinical
practices as well as the translation of research findings and
recommendations into routine clinical work. In April 2011, VA
established a new QUERI center dedicated to eHealth with a focus
on “consumer-directed” ICT innovations intended for use by
veterans and their families. The eHealth QUERI has two major
goals, 1) to augment access to VA healthcare services through
implementation and use of eHealth; and 2) to enhance veteran selfmanagement and participation in collaborative care through the
design, evaluation, and implementation of appropriate eHealth
tools45. In the first two quarters of 2011, eHealth QUERI investigators submitted 11 grant applications intended to support these
goals. eHealth QUERI has also begun to facilitate dialogue between
the VA research community and relevant program offices to align
researchers with the goals of the CCHT and MHV programs and the
system-wide pursuit of the PACT model. In the long-term, we
believe that such research will be a driver of innovation, and
see the eHealth QUERI as an organizational entity which will
play an important role in exploring issues of interoperability
and integration between the evolving CCHT and MHV
programs, and new emergent eHealth technologies.
2. At the Organizational Level, Support Healthcare
Teams to Incorporate CCHT and MHV into Clinical
Practice
Across organizational contexts, there is a growing realization
that healthcare providers play a key role in shaping the
adoption of eHealth technologies46,47. The integration of the
CCHT and MHV programs into the PACT model raises questions regarding how this can be practically accomplished in the
course of daily clinical work. PACT members must not only be
educated about such tools, but inspired to use them in
combination, leveraging their respective strengths to optimize
access to care, the delivery of services, and ultimately veteran
health outcomes. The MHV secure messaging function currently being deployed nationally is a case in point. Secure
messaging is being integrated within PACT as a communication platform to supplement existing communication channels
and represents an effective linkage between CCHT and MHV.
For veterans who are already using CCHT in their homes, the
ability to exchange secure messages with PACT members
represents a promising means to further support interaction
and communication, as well as self-management.
Incorporating CCHT and MHV into the clinical practices of PACT
members will not be without challenges. Available evidence from
other healthcare systems suggests that in some cases, healthcare
providers may have only limited awareness of eHealth technologies
and a limited view of their functionalities and benefits48–50, while
others may have questions about the validity of patient-entered
data and apprehension about potential liability. Furthermore, in
the case of CCHT and MHV, more responsibilities may be added to
already overburdened clinical staff in terms of monitoring, management, communication, and the handling of potentially large
volumes of data originating from patients51,52. These points further
underscore the need to deploy and integrate available technologies
in the most efficient manner possible.
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Table 3. Comparison of Healthcare Elements and Functionality of
CCHT and MHV
Healthcare
Elements
CCHT Functionality
MHV Functionality
Target population
Veterans with one
or multiple chronic
conditions
In-home:
messaging/
monitoring devices,
biometric devices
such as blood
pressure cuffs and
glucose meters,
videophones,
telemonitors,
interactive voice
response, digital
cameras
Frequent input of
key vital signs and
information,
available for
viewing at any
time by the care
coordinator,
including viewing
during patient
clinic visits
All veterans
Equipment/
technologies
Access to Care
Coordination
of care
Communication
(between providers
and patients)
Disease Prevention
& Health Promotion
Frequent
information
regarding vital
signs and other
clinical information
sent from patient
to care coordinator;
coordinator
intervenes if data
indicate patient is
at risk
Frequent
transmission of
patient data to
coordinator
Coordinator
contacts patient if
there is a need;
may also interact
with provider
Regular
monitoring of
health-related data
Can provide
education and
information on
health lifestyle,
and customized
messages on select
devices
Table 3. (Continued)
Healthcare
Elements
CCHT Functionality
MHV Functionality
Self management
(patient takes
responsibility
for care)
Reduce/avoid
hospitalizations
and ER visits by
identifying and
intervening on
adverse events,
knowledge deficits
and negative health
related behaviors
Self monitoring
(patient records
vital status over
time)
Patient information
sent to care
coordinator over
telehealth system
(patient typically
does not see or
have access to data)
Condition-specific
and Healthy
Living Centers
Medical databases
Mental health
resources
Online courses and
learning center
My Health Goals
(in development)
Personal health
history
Military health
history
Family health
history
Personal health
summary
Allergies,
immunizations
Food and activity
journals
Medications, over
the counter dugs,
herbals, and
supplements records,
my complete
medications
Veteran delegation
of MHV access to
family members,
healthcare providers,
or others of their
choosing (future
development)
Health eLogs (blood
pressure, blood sugar,
cholesterol, body
temperature, weight,
heart rate, pain,
pulse oximetry)
(only accessible to
patients unless hard
copy printed and
shared with provider)
Medical events log
VA prescription history
Internet web portal
Online prescription
refills
Appointment
requests (through
secure messaging)
Laboratory results
(in field testing)
View VA
appointments and
notifications (in
field testing)
Secure messaging
(non-urgent
requests)
Advanced clinic
check-in (future
development)
Store and maintain
information
regarding providers,
treatment facilities
and locations, and
insurance coverage
Documenting test
results Health
calendar
VA Blue Button
My Complete
Medications (both
VA and self-entered
medication history)
Secure messaging
between patient
and health
care providers
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3. At the Veteran-Patient Level, Tailor use of CCHT
and MHV to Reflect Personal Preferences
and Circumstances
Wellness reminders
Health risk
assessments (in
development)
Screening tools
Health education
resources
(continued on next page)
As PACT is integrated into clinical practice, we should anticipate that the experiences of veterans accessing care through
VA will also shift. In the course of their interactions with the
system and their teams of providers, it will be essential to
understand their unique circumstances, their awareness of
and orientations toward eHealth technologies, and to prioritize
use of programs like CCHT and MHV accordingly. Moreover,
the appropriateness of such tools should be continually
assessed and their use adapted so that they align with changes
in a veteran’s health management trajectory. This raises a set
of social, cognitive, technical, and health issues that must be
addressed.
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To begin, the usability of eHealth technologies can be
problematic. Devices and websites are sometimes poorly
designed and not intuitive to use53,54 leading to lower overall
satisfaction. This point can be further compounded among
individuals who have mild to moderate cognitive impairment
and struggle to understand and use ICTs independently55.
Further, despite some evidence that individuals with high
numbers of chronic conditions are more likely to use eHealth
technologies56, veterans who could benefit the most from
CCHT and MHV may be less amenable to using them. Similar
to the larger population33,47, some may worry about the
privacy and security of their health information, either selfentered into MHV, extracted from the medical record, or
transferred to VA healthcare providers. In addition, the
presence of telehealth devices in the home and even the use
of particular Web-based health resources may make it more
apparent that a person has a chronic disease, something that
some individuals prefer not to disclose57.
Finally, for many, managing personal health information
is often a collaborative process involving an individual and
members of their social network58,59. Data from the Pew
Internet and American Life project60 suggest that 48% of
those who report using the Internet for health are looking for
information for someone other than themselves. Veterans,
their spouses, children, friends, and other informal caregivers all may play an important role in access to care and
patient self-management. One could consider use of CCHT
and MHV as a set of family system interventions. Moving
forward, VA should proactively include veteran-delegated
informal caregiver support and data sharing in the policies,
technical functions, and implementation programs for CCHT
and MHV.
4. Examine How Disparities May Encumber use
of CCHT and MHV and Intervene Accordingly
Following the incorporation of PACT into clinical practice and
the accounting of veteran preferences and circumstances, we
must consider how disparities can hinder access to and use of
programs like CCHT and MHV and identify strategies to
address those disparities. Factors leading to disparities may
exist within or outside of the VA system, and some will be more
amenable to immediate intervention than others.
Perhaps the most practical issue we are currently confronted with is differential access to Web-based tools among
veterans. A recent study found that 55% of veterans had
Internet access, but that access was more common in younger
veterans and in those who were white, had greater than a high
school education, and an annual income greater than
$12,000/year61. McInnes and colleagues62 reported that approximately 29% of veterans used the Internet to search for
health information and that higher education, urban residence, and poorer self-reported health status were positively
associated with health-related Internet use. Many existing
telehealth technologies still require a telephone land line for
data transmission, but even when land lines are available,
telecommunications infrastructure, particularly in rural areas,
can be unreliable29. Reliance on cellular and smart phones to
the exclusion of land lines by some veterans may yield further
disparities in CCHT use. VA is currently contracting for
interactive voice response (IVR) technology that can be
accessed from any phone and adapters that can interface with
CCHT messaging devices to support communication through a
veteran’s cellular service. If a telehealth application requires
use of a personal computer with a broadband Internet
connection, both cost and lack of broadband access can
impede use.
Although MHV strives to accommodate the simplest means of
connectivity (e.g., dial up), the aforementioned limitations are still
applicable. Point of care kiosks designed to allow veterans to
manage their personal information, check-in for and schedule
appointments, complete business transactions, and complete
surveys, may also offer a means to increase access to MHV inclinic as could Internet-connected computers available in public
community settings (e.g., libraries). Finally, with rapidly increasing cell phone use, mobile smart phone platforms are quickly
becoming a viable alternative to PC-directed web applications.
Provision of mobile phone applications could not only provide
equitable access, but enable momentary interventions,
unchained from the desktop PC. However, the additional costs
of such interventions should be considered. Further research,
including budget impact analyses and simulation experiments
are needed to understand the potential for these solutions to
reduce differential access.
CONCLUSION
As Fortney11,12 has argued, access is a multidimensional
concept of which digital access, the connectivity that enables
communication and information sharing among healthcare
stakeholders, is a key domain. In the years ahead, the number,
type and sophistication of eHealth technologies that support
communication and information sharing will continue to grow.
Home telehealth and PHRs are just two examples of technologies that can improve health care access and further enhance
the patient’s role as an important stakeholder in care management and decision making. As eHealth initiatives continue
to evolve, different barriers may become more or less important
over time. Similarly, new, and as yet, unidentified challenges
may emerge as healthcare systems attempt to pursue more
patient-centric models of care. The proliferation of eHealth
technologies themselves may become a barrier, particularly if
they do not communicate with the electronic medical record
and patients must deal with multiple, non-integrated user
interfaces. Despite these barriers, home telehealth and PHRs
provide a set of complementary tools that can be employed to
enhance access and meet individual patient needs in the
context of their specific condition(s), living situation, and care
management preferences. Taken together, these eHealth applications can support transitions and ongoing care along the
health management trajectory.
VA is a leader in the use of eHealth applications to improve
healthcare access and ultimately, health outcomes. The patient-centric healthcare model that VA has recently adopted,
with its focus on information technology and coordination,
team-based practice, routine patient feedback, and improved
access to care (e.g.,63), underscores the importance of embracing the kind of complementary vision of the CCHT and MHV
programs that we have articulated here. To do so will require a
paradigm shift to go beyond the organizational construction
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and management of eHealth tools into “programs” and reconsider eHealth features as a repertoire of tools available to
patients and their healthcare teams. As such, the dramatic
transformation of VA healthcare currently underway may
represent an opportune time to do so. Certainly from a veteran
perspective, this kind of synergy is both optimal and a
reasonable expectation. Ultimately, the direct application of
these tools in optimal ways across care settings will be a litmus
test of progress in this area.
Acknowledgements: We would like to thank the organizers of the
"Improving Access to VA Care" State of the Art (SOTA) conference
held in Arlington, VA, September 21–22, 2010, for the original
opportunity to develop this manuscript.
Conflicts of Interest: None disclosed
Corresponding Author: Timothy P. Hogan, PhD; Center for
Management of Complex Chronic Care, Edward Hines, Jr. VA
Hospital, 5000 S. 5th Avenue, Hines, IL 60141, USA
(e-mail: timothy.hogan@va.gov).
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