Preconception Care in the Veterans Health Administration.

Preconception care (PCC), defined as a set of interventions to help women optimize their health and well-being prior to pregnancy, can improve pregnancy outcomes and is recommended by national organizations including the Centers for Disease Control and Prevention and the American College of Obstetricians and Gynecologists. Women Veterans who use the Department of Veterans Affairs (VA) health care system may face elevated risks of adverse pregnancy and birth outcomes due to a high prevalence of chronic medical and mental health conditions as well as psychosocial stressors including sexual trauma history and intimate partner violence. Many women Veterans of childbearing age experience poverty and homelessness, which are key social determinants of poor reproductive health outcomes. Furthermore, racial/ethnic disparities in maternal and neonatal outcomes are well documented, and nearly half of women Veterans of reproductive age are minority race/ethnicity. High-quality, equitable, patient-centered PCC services to address modifiable risks in this population are therefore a priority for VA. In this article, we provide a brief background of PCC, discuss the health risks of Veterans associated with adverse pregnancy outcomes, and highlight VA initiatives related to PCC. Lastly, we discuss implications and future directions for PCC research and policy within VA and across other health systems.

The future state of clinical data capture and documentation: a report from AMIA's 2011 Policy Meeting.

Much of what is currently documented in the electronic health record is in response toincreasingly complex and prescriptive medicolegal, reimbursement, and regulatory requirements. These requirements often result in redundant data capture and cumbersome documentation processes. AMIA's 2011 Health Policy Meeting examined key issues in this arena and envisioned changes to help move toward an ideal future state of clinical data capture and documentation. The consensus of the meeting was that, in the move to a technology-enabled healthcare environment, the main purpose of documentation should be to support patient care and improved outcomes for individuals and populations and that documentation for other purposes should be generated as a byproduct of care delivery. This paper summarizes meeting deliberations, and highlights policy recommendations and research priorities. The authors recommend development of a national strategy to review and amend public policies to better support technology-enabled data capture and documentation practices.

The value proposition in the widespread use of telehealth.

Telehealth has great potential to improve access to care but its adoption in routine health care has been slow. The lack of clarity about the value of telehealth implementations has been one reason cited for this slow adoption. The Center for Information Technology Leadership has examined the value of telehealth encounters in which there is a provider both with the patient and at a distance from the patient. We considered three models of telehealth: store-and-forward, real-time video and hybrid systems. Evidence from the literature was extrapolated using a simulation, which found that the hybrid model was the most cost-effective of the three. The simulation predicted savings of $4.3 billion per year if hybrid telehealth systems were to be implemented in emergency rooms, prisons, nursing home facilities and physician offices across the US. We also conducted a sensitivity analysis to determine which factors most affected costs and savings. For all three telehealth models, the highest sensitivities were to the cost of a face-to-face visit, the cost of a telehealth visit and the success rate of a telehealth visit, i.e. the proportion of telehealth visits that avoided the need for a face-to-face visit. Payers, providers and policy-makers should work together to remove the barriers to the adoption of telehealth in order to make it widely available to all.

Formative evaluation: a critical component in EHR implementation.

This Viewpoint paper has grown out of a presentation at the American College of Medical Informatics 2007 Winter Symposium, the resulting discussion, and several activities that have coalesced around an issue that most informaticians accept as true but is not commonly considered during the implementation of Electronic Health Records (EHR) outside of academia or research institutions. Successful EHR implementation is facilitated and sometimes determined by formative evaluation, usually focusing on process rather than outcomes. With greater federal funding for the implementation of electronic health record systems in health care organizations unfamiliar with research protocols, the need for formative evaluation assistance is growing. Such assistance, in the form of tools and protocols necessary to do formative evaluation and resulting in successful EHR implementations, should be provided by practicing medical informaticians.

Benefits of information technology-enabled diabetes management.

OBJECTIVE: To determine the financial and clinical benefits of implementing information technology (IT)-enabled disease management systems. RESEARCH DESIGN AND METHODS: A computer model was created to project the impact of IT-enabled disease management on care processes, clinical outcomes, and medical costs for patients with type 2 diabetes aged >25 years in the U.S. Several ITs were modeled (e.g., diabetes registries, computerized decision support, remote monitoring, patient self-management systems, and payer-based systems). Estimates of care process improvements were derived from published literature. Simulations projected outcomes for both payer and provider organizations, scaled to the national level. The primary outcome was medical cost savings, in 2004 U.S. dollars discounted at 5%. Secondary measures include reduction of cardiovascular, cerebrovascular, neuropathy, nephropathy, and retinopathy clinical outcomes. RESULTS: All forms of IT-enabled disease management improved the health of patients with diabetes and reduced health care expenditures. Over 10 years, diabetes registries saved $14.5 billion, computerized decision support saved $10.7 billion, payer-centered technologies saved $7.10 billion, remote monitoring saved $326 million, self-management saved $285 million, and integrated provider-patient systems saved $16.9 billion. CONCLUSIONS: IT-enabled diabetes management has the potential to improve care processes, delay diabetes complications, and save health care dollars. Of existing systems, provider-centered technologies such as diabetes registries currently show the most potential for benefit. Fully integrated provider-patient systems would have even greater potential for benefit. These benefits must be weighed against the implementation costs.

Cost of interconnecting health information exchanges to form a national network.

Despite the demonstrated need for a national health information network (NHIN), there has been little progress in turning this need into reality beyond limited local demonstrations. One barrier is the lack of information evaluating the potential costs of connecting these local networks to form a national network. The Center for Information Technology Leadership (CITL), in conjunction with national experts, developed assumptions around the components needed to develop the NHIN. These assumptions were largely based on the architectural approach suggested by the Connecting for Health Common Framework for such a network. Using these assumptions, CITL collected cost data from three different markets engaging in healthcare information exchange (HIE). These costs were then extrapolated to the nation based on population density data from the U.S. Census Bureau. The CITL model projected an initial deployment cost of $97 million and an annual maintenance cost of $41 million for HIE across the NHIN.