An Emergent Research and Policy Framework for Telehealth.

CONTEXT: Telehealth is a fast-growing sector in health care, using a variety of technologies to exchange information across locations and to improve access, quality, and outcomes across the continuum of care. Thousands of studies and hundreds of systematic reviews have been done, but their variability leaves many questions about telehealth's effectiveness, implementation priorities, and return on investment. OBJECTIVES: There is an urgent need for a systematic, policy-relevant framework to integrate regulatory, operational, and clinical factors and to guide future investments in telehealth research and practice. METHODS: An invited multidisciplinary group of 21 experts from AcademyHealth, the American Telemedicine Association (ATA), Kaiser Permanente Institute for Health Policy (KP), and the Physician Insurers Association of America (PIAA) met to review and discuss the components of a draft framework for policy-relevant telehealth research. The framework was revised and presented in a challenge workshop at Concordium 2016, and some additional refinements were made. The current framework encompasses the regulatory and payment policy context for telehealth, delivery system factors, and outcomes of telehealth interventions. FINDINGS: Based on the feedback at Concordium 2016, the framework seems to have potential to help educate policymakers, payers, and health systems about the value of telehealth and to frame discussions about implementation barriers, including risk management concerns, technology costs, and organizational culture. However, questions remain about how to disseminate and use the framework to help coordinate policy, research, and implementation efforts in the delivery system.

Improved Veteran Access to Care through the Veteran Health Information Exchange (VHIE) Retail Immunization Coordination Project.

The U.S. Department of Veterans Affairs (VA) Veteran Health Information Exchange (VHIE, formerly Virtual Lifetime Electronic Record, or VLER) Retail Immunization Coordination Project established a partnership between VA and Walgreens to empower Veterans to elect to receive their immunizations at a local Walgreens, which might be located closer to their home than their nearest VA facility. Analysis of Veterans immunized at Walgreens between September 2014 and January 2015 showed that 64% of study Veterans now traveled <5 miles to receive their immunization, 12% of study Veterans traveled between 5 to 10 miles, and 24% of study Veterans traveled more than 10 miles. In addition, we note that 93% of Veterans traveled less than 54 miles, the average distance rural Veterans traveled to the nearest VA facility. We conclude that the VHIE Retail Immunization Coordination Project improved Veteran access to healthcare and discuss future directions of this effort.

Assessments of the Veteran Medication Allergy Knowledge Gap and Potential Safety Improvements with the Veteran Health Information Exchange (VHIE).

The U.S. Department of Veterans Affairs (VA) Veteran Health Information Exchange (VHIE, formerly Virtual Lifetime Electronic Record, or VLER) had been deployed at all VA sites and used to exchange clinical information with private sector healthcare partners nationally. This paper examined VHIE's effect on allergy documentation. Review of all inbound VHIE transactions in FY14 showed that VHIE use was associated with a nearly eight-fold increase in allergy documentation rate. Preliminary manual document review further showed that VA and partners had shared knowledge of only 38% ofpatient allergies, while VA had exclusive knowledge of another 58% ofpatient allergies, and partners had exclusive knowledge of the last 5% of patient allergies. To our knowledge, this is the first study that examined the effect of HIE on allergy documentation.

The Department of Veterans Affairs' (VA) implementation of the Virtual Lifetime Electronic Record (VLER): findings and lessons learned from Health Information Exchange at 12 sites.

PURPOSE: We describe the Department of Veterans Affairs' (VA) Virtual Lifetime Health Electronic Record (VLER) pilot phase in 12 communities to exchange health information with private sector health care organizations and the Department of Defense (DoD), key findings, lessons, and implications for advancing Health Information Exchanges (HIE), nationally. METHODS: A mixed methods approach was used to monitor and evaluate the status of VLER Health Exchange pilot phase implementation from December 2009 through October 2012. Selected accomplishments, contributions, challenges, and early lessons that are relevant to the growth of nationwide HIE are discussed. RESULTS: Veteran patient and provider acceptance, trust, and perceived value of VLER Health Exchange are found to be high, and usage by providers is steadily growing. Challenges and opportunities to improve provider use are identified, such as better data quality and integration with workflow. Key findings and lessons for advancing HIE are identified. CONCLUSIONS: VLER Health Exchange has made great strides in advancing HIE nationally by addressing important technical and policy issues that have impeded scalability, and by increasing trust and confidence in the value and accuracy of HIE among users. VLER Health Exchange has advanced HIE interoperability standards and patient consent policies nationally. Policy, programmatic, technology, and health Information Technology (IT) standards implications to advance HIE for improved delivery and coordination of health care are discussed. The pilot phase success led to VA-wide deployment of this data sharing capability in 2013.

Data Quality and Interoperability Challenges for eHealth Exchange Participants: Observations from the Department of Veterans Affairs' Virtual Lifetime Electronic Record Health Pilot Phase.

Authors studied the United States (U.S.) Department of Veterans Affairs' (VA) Virtual Lifetime Electronic Record (VLER) Health pilot phase relative to two attributes of data quality - the adoption of eHealth Exchange data standards, and clinical content exchanged. The VLER Health pilot was an early effort in testing implementation of eHealth Exchange standards and technology. Testing included evaluation of exchange data from the VLER Health pilot sites partners: VA, U.S. Department of Defense (DoD), and private sector health care organizations. Domains assessed data quality and interoperability as it relates to: 1) conformance with data standards related to the underlying structure of C32 Summary Documents (C32) produced by eHealth Exchange partners; and 2) the types of C32 clinical content exchanged. This analysis identified several standards non-conformance issues in sample C32 files and informed further discourse on the methods needed to effectively monitor Health Information Exchange (HIE) data content and standards conformance.

Physicians' perceptions of reimbursement as a barrier to comprehensive diabetes care.

BACKGROUND: As the incidence of diabetes increases, there is growing concern about the adequacy of reimbursement levels for delivering comprehensive diabetes care. OBJECTIVE: To investigate physicians' perceptions of the adequacy of reimbursement, as well as resources (eg, staff, facilities, materials), for their treatment of diabetic patients. METHODS: A qualitative exploration using a Web-based survey of 300 physicians (200 primary care providers and 100 endocrinologists) and an online discussion group of 12 physicians, focusing on 10 services recommended by the American Diabetes Association that may be prone to underreimbursement. The 10 services were matched with 4 general diabetes care categories to assess the adequacy of care delivery. RESULTS: The majority of physician study participants perceived that most of the 10 identified services are inadequately reimbursed-83% to 95% of physicians said Medicaid reimbursement was inadequate, 75% to 89% for Medicare reimbursement, and 67% to 86% for private insurance reimbursement-leading them to spend less time with each patient. This reduction in time was a limiting factor to providing comprehensive diabetes care. The survey also revealed differences between endocrinologists and primary care physicians; for example, medical nutrition therapy was offered by 50% of endocrinology practices compared with only 29.5% of primary care practices. CONCLUSION: This study confirms previous findings that physicians perceive current reimbursement for diabetes care as too low, which limits their ability to perform all the tasks necessary to deliver comprehensive diabetes care.