Over the past several years, accelerated by the Covid-19 pandemic, immersive technologies — including virtual reality and augmented or mixed reality, also known collectively as extended reality — have shown mounting promise in their ability to enhance clinical care delivery and support clinical staff. These immersive systems can be used alongside standard of care in several areas and, at minimum, be used as additional ways to augment evidence-based therapies. These noninvasive and easy-to-use tools have demonstrated the ability to effectively channel patient experience into therapeutic activities, facilitate home-based care, provide valuable longitudinal patient data, and enhance treatment adherence. Given this promise, immersive health care applications have spread across the U.S. Veterans Health Administration (VA), building additional evidence for efficacy and laying implementation groundwork. To date, VA has documented more than 40 indications for immersive technology utilization within the organization, with more in the pipeline. Early exploration of immersive technology in VA began with 5 sites and 10 staff engaged in a Community of Practice and has now grown to 172 sites and more than 2,400 engaged VA staff. The most uptake and impact have been seen in pain management, physical rehabilitation, and mental health care, including anxiety, depression, and posttraumatic stress disorder. Crucial to further scaling the use of immersive technology, VA has developed standardized resources, such as knowledge networks, implementation guides, electronic health record templates, and standard operating procedures. VA continues to offer opportunities for more heads in headsets, because this is an effective way to demonstrate to veterans and staff how immersive technology can enhance care. Key to future success in VA will entail increasing equitable access, growing the scope of content, standardizing training for staff and patients, and improving processes for synthesizing and analyzing relevant data to optimize these tools. Through these activities and continued planning, VA is poised to define the landscape of immersive technology in health care and inform adoption beyond VA.

BACKGROUND:The Joint Commission recently named reduction of health care disparities and improvement of health care equity as quality and safety priorities (Leadership [LD] Standard LD.04.03.08 and National Patient Safety Goal [NPSG] Standard NPSG.16.01.01). As the largest integrated health system, the Veterans Health Administration (VHA) sought to leverage these new accreditation standards to further integrate and expand existing tools and initiatives to reduce health care disparities and address health-related social needs (HRSNs).INITIATIVES AND TOOLS:A combination of existing data tools (for example, Primary Care Equity Dashboard), resource tools (for example, Assessing Circumstances and Offering Resources for Needs tool), and a care delivery approach (for example, Whole Health) are discussed as quality improvement opportunities to further integrate and expand how VHA addresses health care disparities and HRSNs. The authors detail the development timeline, building, limitations, and future plans for these tools and initiatives.COORDINATION OF INITIATIVES:Responding to new health care equity Joint Commission standards led to new implementation strategies and deeper partnerships across VHA that facilitated expanded dissemination, technical assistance activities, and additional resources for VHA facilities to meet new standards and improve health care equity for veterans. Health care systems may learn from VHA's experiences, which include building actionable data platforms, employing user-centered design for initiative development and iteration, designing wide-reaching dissemination strategies for tools, and recognizing the importance of providing technical assistance for stakeholders.FUTURE DIRECTIONS:VHA continues to expand implementation of a diverse set of tools and resources to reduce health care disparities and identify and address unmet individual veteran HRSNs more widely and effectively.

Background: Within a year of the start of the COVID-19 pandemic, the US Department of Veterans Affairs (VA) was managing about 300 COVID-19-related research projects across roughly 100 facilities, which has since grown to more than 900 projects.This robust set of activities arose from an existing enterprise strategy and aimed at identifying needs for supporting the clinical care mission, more rapidly leveraging resources, and coordinating research across the VA.The VA's efforts to implement an enterprise strategy before March 2020 positioned its research community to dynamically partner with other federal agencies, academic institutions, and industry in addressing a national public health emergency.Observations: The VA research enterprise involves a broad range of functions, scientific and clinical leaders, and organizational resources to enhance the health and care of veterans and the nation.The scope of research activities enables it to support its priorities while also partnering with others who share in mutual commitments to veteran health.Moving toward being the nation's learning health care system, the VA's leadership support, staff, patient volunteers, and partners were key contributors to a national response to COVID-19.Swift action and consistent communication helped address the complexities of the pandemic and strengthened the VA's ability to prepare and mobilize for emergencies and other potential disease outbreaks.Documenting strategies and practices can enhance future opportunities aimed at addressing the most challenging health care needs while also focusing on the primary mission to serve veterans.Conclusions: The COVID-19 pandemic contributed to critical knowledge and lessons that enabled the VA to advance enterprise goals, particularly in the context of its health care system.Sharing these unique processes and experiences will inform current and future partnerships among research, clinical, and public health communities oriented to serve veterans and the nation through scientific innovation.

This panel paper is the second installment in a six-part Nursing Outlook special edition based on the 2022 Emory Business Case for Nursing Summit. The 2022 summit convened national nursing, health care, and business leaders to explore possible solutions to nursing workforce crises, including the nursing shortage. Each of the summit’s four panels authored a paper in the special edition on their respective topic(s), and this panel paper focuses on the topic of nursing workforce growth. It discusses priority areas for academia to help ameliorate nursing shortages, including through changes to nursing curricula and/or programming, greater attention to nursing financial needs (including nursing student loans), and regulatory reforms.

Health EquityVol. 7, No. 1 Special Collection: Improving Care for Veterans Through Health Equity Research (#1/14)Open AccessCreative Commons licenseImproving Care for Veterans Through Health Equity ResearchRachel Ramoni and Carolyn ClancyRachel RamoniOffice of Research and Development, Department of Veterans Affairs, Washington, District of Columbia, USA.Search for more papers by this author and Carolyn Clancy*Address correspondence to: Carolyn Clancy, MD, Discovery, Education and Affiliate Networks, Department of Veterans Affairs, Washington, DC 20420, USA. E-mail Address: carolyn.clancy@va.govDiscovery, Education and Affiliate Networks, Department of Veterans Affairs, Washington, District of Columbia, USA.Search for more papers by this authorPublished Online:30 May 2023https://doi.org/10.1089/heq.2023.0017AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail Veterans are a diverse population of individuals united by their service to our country. In addition to providing health care to Veterans, Veterans Affairs (VA) also has a mission to conduct research to improve Veterans' and indeed our nation's well-being. To succeed in that mission, we recognize that we must actively promote diversity, equity, and inclusion (DEI) across the full range of domains, including the research workforce, representation in research, and funding DEI research.VA is committed to serving all Veterans, and we are honored to write the introductory column for this special edition of VA Health Equity Research. It represents the efforts of a team of people who are passionate about improving Veterans' well-being through actions to enhance DEI. We lost one of those team members, the late Mitchell Mirkin, far too soon. Mitch was the acting director of VA Research Communications, and he was instrumental to the conception of this special collection. This issue is dedicated to his memory.Research across the translational continuum requires diversity in skill sets, experiences, and perspectives. There are many benefits that flow from a diverse health-equity-focused VA research enterprise: fostering scientific innovation, contributing to VA's robust learning environments, improving the equity and quality of research, and increasing the likelihood that underrepresented Veteran populations participate in and benefit from health research.For these reasons, and many more, we are excited for the opportunity to highlight examples of health equity research conducted by VA investigators, as well as DEI efforts by the VA community.In this issue, Dr. Suma Muralidhar, director of the VA Million Veteran Program (MVP), and colleagues describe efforts to support diversity and representation in VA research. With >912,000 enrollees, MVP is committed to expanding the participation of women Veterans. In 2022, MVP's first digital women's campaign resulted in a 54% increase in the number of women Veterans enrolled in the program. MVP resources have sparked many significant research projects. For example, Dr. Shiuh-Wen Luoh and colleagues from the VA Portland Health Care System describe their use of MVP data to develop breast cancer risk scores for women Veterans of African American ancestry.We also highlight key DEI initiatives carried out by VA research. Our colleagues in the Veterans Health Administration Office of Health Equity, led by Dr. Ernest Moy, illustrate VA's efforts to combat the COVID-19 pandemic by addressing structural disparities. Dr. Charles Michael Hart describes the Atlanta VA Health Care System–Morehouse School of Medicine Partnered Core Recruiting Site. And two articles highlight the VA Office of Research and Development's (ORD) efforts to diversify the VA Research workforce through mentored supplement awards: a first-person perspective of ORD's Research Supplements to Promote Diversity program, and a discussion on racial differences in vascular assessments by DEI research supplement awardee Dr. Olamide Alabi and her mentors. These programs are vital to attracting the best and brightest early-career researchers to the VA research enterprise.Finally, we would like to introduce a series of articles that cover the wide-ranging effects of health care disparities. An article written by Dr. Bharati Prasad, and colleagues, presents clinical research on racial and socioeconomic drivers of disparities in sleep health. Dr. John Blosnich explores important issues surrounding disclosure of health data in research for sexual- and gender-minority Veterans. And Dr. Leslie Hausmann and coauthors highlight just how important it is to include equity into quality improvement efforts in an integrated health care system.We hope that you enjoy exploring this special issue as much as we did.Authors' ContributionsWriting—original draft preparation by R.R. Writing—reviewing and editing by C.C.DisclaimerThe opinions expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States Government.Author Disclosure StatementNo competing financial interests exist.Funding InformationNo funding was received for this article.Cite this article as: Ramoni R, Clancy C (2023) Improving care for veterans through health equity research, Health Equity 7:1, 290–291, DOI: 10.1089/heq.2023.0017.Abbreviations UsedDEIdiversity, equity, and inclusionMVPMillion Veteran ProgramORDOffice of Research and DevelopmentVHAVeterans Health AdministrationFiguresReferencesRelatedDetails Volume 7Issue 1Jun 2023 Information© Rachel Ramoni and Carolyn Clancy 2023; Published by Mary Ann Liebert, Inc.To cite this article:Rachel Ramoni and Carolyn Clancy.Improving Care for Veterans Through Health Equity Research.Health Equity.Jun 2023.290-291.http://doi.org/10.1089/heq.2023.0017creative commons licensePublished in Volume: 7 Issue 1: May 30, 2023Open accessThis Open Access article is distributed under the terms of the Creative Commons License [CC-BY] ( http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.PDF download

The number of Americans over age 65 is projected to soar to 94.7 million by 2060, and the population of those 85 years and older is expected to double in the same time frame.1 In addition to meeting the demands of an ever-growing older adult population, many health systems are unprepared to meet the complex care needs of older adults, often emphasizing cure over care. Older adults routinely receive unwanted treatment that does not align with their priorities, miss necessary evidence-based care, undergo functional decline when mobility is not encouraged, experience avoidable delirium and cognitive decline, and are harmed by high-risk medications.2 To address these challenges, The John A. Hartford Foundation and the Institute for Healthcare Improvement (IHI) launched the Age-Friendly Health Systems (AFHS) initiative in 2017.3 AFHS aims to introduce a framework of evidence-based practices, known as the “4Ms” (what matters, medication, mentation, and mobility), across clinical care settings to improve care and reduce harm for older adults. Additionally, AFHS aims to provide person-centered care aligned with what matters to older adults and their family members or caregivers, and builds the foundation for healthier aging for all.3 The AFHS movement benefits older adults by customizing care based on each person's unique health goals and care preferences, improving quality-of-care, and delivering care in a more cost-effective manner with the potential to reduce the risk of preventable complications, hospital readmissions, and emergency department (ED) visits.4-10 IHI offers two levels of recognition for clinical care settings: Level 1, Participant recognition is achieved when teams create a plan to implement the 4Ms, and Level 2, Committed to Care Excellence is awarded to teams that have successfully implemented these practices and submitted 3 months of counts on the number of older adults impacted by 4Ms care. As of October 2022, IHI has recognized more than 2900 participants in the AFHS movement.3 Both levels of recognition are important milestones for teams; however, health systems are challenged to build on the initial success of individual care settings to scale and spread the 4Ms system-wide. To accomplish this, health systems may leverage action communities, 7-month virtual learning communities, to accelerate the adoption of the 4Ms through monthly webinars and peer-to-peer learning.3, 11 Alternatively, health systems may develop an enterprise-wide plan for sharing knowledge about 4Ms care for older adults and supporting 4Ms implementation across the system. While IHI does not offer a system-level recognition, IHI encourages leaders and sponsors in the movement to set an aim to guide the entire health system on their age-friendly journey. As the number of older Americans surges, health systems nationwide are challenged to meet their needs. Nearly half of Veterans enrolled in VA health care are over age 65 compared to 21% of civilians.12 The number of Veterans aged 85 and older is anticipated to increase by 38% between 2019 and 2039 thus necessitating the involvement of the Veterans Health Administration (VHA) in initiatives such as AFHS to better meet the needs of our oldest Veterans.13 The VHA set the aim to become the largest age-friendly health system in the U.S. As of November 1, 2022, 152 care settings across 78 VA Medical Centers (VAMCs) have been recognized by IHI with more than a third of those teams earning Level 2 recognition. VHA is reaching older Veterans across the system with 4Ms care in diverse settings, including inpatient units, outpatient primary care, surgical and specialty care clinics, Home Based Primary Care (HBPC), hospital at home,14, 15 spinal cord injury units, emergency departments (ED), the Caring for Older Adults and Caregivers at Home (COACH) dementia support program, Geriatric Resources for Assessment and Care of Elders (GRACE) care management,16 and Community Living Centers (CLCs, analogous to nursing homes). This commentary highlights how VHA is working toward system-wide spread and offers key insights in this special journal issue. VHA is the largest integrated health care system in the U.S., providing services to over 9 million enrolled Veterans at 1298 health care facilities.17 VHA accepted the AFHS call to action to enhance the care of older Veterans, considering their health care preferences, aims, and priorities to improve care quality and safety. Joining the AFHS movement has offered VHA a unique opportunity to introduce the 4Ms across many types of care settings and integrate these practices with existing initiatives. For example, AFHS supports VHA's journey to become an enterprise-wide high reliability organization (HRO) with a goal of achieving “zero harm.”18 AFHS is also consistent with the cultural transformation embodied by Whole Health, an enterprise-wide approach in which Veterans are empowered to discover their mission, aspiration, or purpose (what matters) and take charge of their health and well-being through clinical care and complementary and integrative health.19 Although AFHS is aligned with VHA's efforts for HRO and Whole Health, this initiative is nationally led by the VHA Office of Geriatrics and Extended Care (GEC). GEC has a designated national lead for AFHS to coordinate efforts at the system level and with individual teams. This helps to align AFHS with the strategic goals of the system and with existing programs and services that facilitate providing 4Ms care to all older adults. Since March 2020, VA teams have joined the AFHS movement through the self-paced Do-It-Yourself (DIY) pathway to recognition or through voluntary enrollment in an action community led by IHI, the American Hospital Association (AHA), or the VHA. GEC has leveraged the experience and expertise of early adopters through monthly office hours, following IHI's “all teach, all learn” model,20, 21 creating a learning environment in which all contributions are valued. During office hours, new recognitions are celebrated, and teams are invited to share recent challenges and successes. Positive peer pressure from enthusiastic champions has helped recruit sites that may be hesitant to join. Between monthly office hours, the national lead provides 1:1 coaching to teams as requested, walking sites through the recognition process with IHI. By simplifying the steps to putting the 4Ms into practice, teams are encouraged to seek IHI recognition to celebrate the high-quality care they are already providing while addressing any gaps to reliably assess and act on all 4Ms. At the system level, GEC has promoted the AFHS movement by highlighting the success of early adopters and empowering VA teams to choose their own implementation strategy for 4Ms care. Many VA teams choose to get started in clinical care settings that already have an interdisciplinary team with geriatrics training in place, such as the CLC, HBPC, or a geriatric primary care clinic. These teams can rapidly build on their current workflows where one or more of the 4Ms is often already assessed and acted on. The 4Ms framework allows teams to customize their plan and timeline for implementation, gaining buy-in from frontline staff and Veterans to make improvements to their workflows. This approach has increased the likelihood that staff are invested in their team's success in securing recognition from IHI. Each year, GEC creates a communications plan and sets annual goals for AFHS. These annual goals are informed by a national steering committee comprised of champions across the VHA. To achieve these annual goals, the steering committee creates any needed workgroups. For example, the electronic health record (EHR) workgroup was formed in August 2021 with the goal of creating a national 4Ms note template for all care settings and disciplines providing 4Ms care across VHA. With the new national 4Ms note template in place, VHA can track the number of care settings documenting 4Ms care, removing the need for manual chart audits for Level 2 recognition, and gaining an understanding of the number of Veterans impacted by 4Ms care annually. Another area of focus for GEC has been planning the first VA Action Community, now underway from October 2022 through April 2023. To accomplish this, additional resources were obtained for staffing. With these resources, the national team has grown to include one diffusion specialist, one clinical consultant, and two project coordinators. To spread awareness about the VA Action Community, GEC provided a memorandum to VAMC leadership, announcing VHA's commitment to the AFHS movement and offering optional enrollment for interested sites. GEC also presented AFHS and the VA Action Community on several national calls to leadership at all levels. As a result, enrollment was met with an overwhelming response. Upon the close of registration, there were a total of 145 teams enrolled from 69 VAMCs, and the online Age-Friendly Community of Practice grew to over 900 members from July to November 2022. The breadth of AFHS offers an essential opportunity for VHA and other health systems to build on multiple notable but isolated pilots. This journal issue highlights the work of three VHA research teams and their evaluation of AFHS in geriatric EDs and geriatric telemedicine. To gain a better understanding of goal concordant care and missed opportunities, Cogan22 completed a cross-sectional survey of over 1 million VHA enrollees by age group to evaluate disparities in addressing what matters (e.g., health goals), mentation (e.g., depression, stress, personal problems), and medications. The team found that lower rates of assessing and acting on what matters and mentation were missed opportunities for age-friendly care.22 McQuown23 found that emergency medicine providers were addressing medication using a polypharmacy screen, mobility using a screening tool, or fall risk assessment, and mentation was assessed using delirium and cognitive impairment screening instruments. However, the team lacked a formalized way to assess and act on what matters. McQuown23 notes that due to the nature of the ED, integration of the 4Ms in this setting is challenging, particularly in addressing what matters in an efficient, yet thoughtful, and appropriate manner. The team found that combining telemedicine and home visits after a geriatric ED visit helps to identify unmet care needs, support caregivers, and address what matters. Specially trained and accredited geriatric EDs may serve as an entry point for care and provide an opportunity to identify high-risk older Veterans who would benefit from comprehensive screening guided by the 4Ms. Postdischarge monitoring is traditionally completed by telephone or a face-to-face follow-up visit in primary care. As an alternative, geriatric ED aftercare may be provided via telemedicine and/or home visits 48–72 hours after discharge to reduce hospital readmissions, their associated costs, and increase patient satisfaction.23-25 McQuown23 and Dryden26 explore the benefits of and health outcomes from AFHS through the Geriatric Research, Education, and Clinical Center (GRECC) Connect (geriatric telemedicine), and the Supporting Community Outpatient, Urgent Care, and Telehealth Services (SCOUTS) programs. These programs align with the AFHS model and are associated with the expanded geriatric “5Ms” (adding multi-complexity) as described by the American Geriatric Society's Health in Aging Foundation.27 Both programs provide opportunities to improve care and support caregivers, particularly in rural areas, and they met an unexpected surge in need during the height of the COVID-19 pandemic.23, 26 National shortages of geriatricians and mental health professionals combined with access disparities (e.g., long travel distance to health care, mobility, or visual challenges) are barriers to meeting the needs of older adults, and telemedicine is helping to bridge that gap for Veterans. GRECC Connect uses telemedicine to improve care quality and patient experience and focus on (a) what matters by planning care with patient and caregiver goals and care preferences in mind, (b) completing a thorough review of medication options and deprescribing high-risk medications when appropriate, (c) assessing and acting on mentation providing advice about activities to improve mood and cognition, (d) facilitating delivery of needed adaptive equipment, home safety evaluation, and physical therapy referral to address mobility to maintain function and safety, and (e) providing care coordination, caregiver support, and education to meet the multi-complexity needs of each older Veteran.26 Dryden reported the following AFHS outcomes related to geriatric specialty telemedicine: reduced polypharmacy (medication), improved physical and cognitive well-being (what matters, mobility, and mentation, for example, lower blood pressure, better sleep quality, improved memory, less anxiety, lower fall risk), and improved adherence to their treatment regimen.26 Challenges noted by the Dryden and McQuown research teams include setting patient and caregiver expectations upfront and acknowledging the limits of what is known about cognitive impairment and its progression, awareness of racial and socioeconomic disparities in rural settings (e.g., reliable internet access), and meeting the complex needs of patients with hearing, visual, and cognitive impairment who may have difficulty absorbing and recalling information and connecting through telemedicine.23, 26 Reliably incorporating the 4Ms into care for older adults can help address coordination across programs and initiatives, address disparities in discussing health goals, support 4Ms documentation, and measure health outcomes associated with age-friendly care. However, there is still work to be done as age-friendly care only reaches a portion of older adults who would benefit and there are challenges associated with dissemination and scale and spread across an entire system.4 The COVID-19 pandemic provided a unique opportunity to find other ways to connect with patients and caregivers, and telemedicine met that need. However, there is a need for additional research on the effectiveness of 4Ms care across clinical care settings and the impact of increased access to geriatricians and mental health providers through telemedicine. There is also a need to improve our understanding of the impact of psychological health (e.g., posttraumatic stress disorder and depression), cognitive impairment, and hearing and visual impairment on missed opportunities to provide age-friendly care. Evaluation of AFHS implementation includes measurement of the extent of implementation and whether it improved patient care and safety. Questions may include: (a) what proportion of older adults received age-friendly 4Ms care? (b) did the age-friendly interventions produce relevant health outcomes? (c) did the interventions become standard of practice? (d) was age-friendly care delivered with high fidelity? (e) is the age-friendly practice sustainable? and (f) what is the effect of age-friendly 4Ms care on caregiver burden and nursing home utilization?11, 28 Over 60% of health care organizations fail to successfully implement change.29 For health systems working to implement AFHS, leaders are encouraged to (a) set an aim for the organization that clearly presents an age-friendly vision, (b) build a coalition of champions supported by dedicated national staffing, (c) promote the value of 4Ms care, and (d) incorporate the 4Ms into the EHR to make this information accessible and measurable over time. We believe the principles of AFHS should be regularly communicated with teams and leaders at all levels of the organization, highlighting impactful stories from patients and staff. Health systems should designate a lead for the movement and add additional staff as the initiative grows to continue to support the teams involved. One consideration might be to lead an action community for the organization. Health systems should begin planning early on in their age-friendly journey on how to document 4Ms care in the EHR. It is important to make information about what matters to older adults accessible to all members of the care team. When documentation of all 4Ms is being captured consistently in the EHR, health systems may further explore the link between each M, positive health outcomes for older adults, and opportunities for improvement to ensure equitable access to age-friendly care. There is no funding to report. The authors report no conflicts of interest.

N ever before has the need for a modernized electronic record supporting Veterans' health been clearer.A common, interoperable platform that seamlessly connects records from military service to VA is essential to our mission of caring for those who have served in our nation's military and for their families, caregivers, and survivors.Such a platform is critical to VA becoming a high-reliability organization that ensures enterprise-wide consistency in clinical practice.It is also fundamental to our role as a learning health system that informs US health care overall.As seen in the private sector, electronic health record (EHR) deployment, even under the best of circumstances, is rarely seamless.The fact that VA began its transition to a new system 7 months into a global pandemic added an unprecedented layer of complexity.Additionally, unlike deployments in the private sector, this transition occurred under the public microscope and with a high level of transparency.Together, these two recurring components of quality improvementaccountability and transparency-have been foundational to VA's history as a learning health care system. 1 Another chapter in that history, as noted by several papers, has been the evolution of the VA research program to promote actionable inquiry on ongoing changes in VA healthcare.This type of inquiry can help assure that successive EHR deployments are enhanced through shared learning and subsequent improvements.The nation's emergence from the pandemic, as well as new priorities such as the PACT Act, 1 makes our commitment to being a learning health care system even more important.As further context for these, as well as other articles, this commentary provides a synopsis of VA's longstanding EHR work, lessons learned from initial deployment, and research questions that VA is poised to address.

Predicting clinical risk is an important part of healthcare and can inform decisions about treatments, preventive interventions, and provision of extra services. The field of predictive models has been revolutionized over the past two decades by electronic health record data; the ability to link such data with other demographic, socioeconomic, and geographic information; the availability of high-capacity computing; and new machine learning and artificial intelligence methods for extracting insights from complex datasets. These advances have produced a new generation of computerized predictive models, but debate continues about their development, reporting, validation, evaluation, and implementation. In this review we reflect on more than 10 years of experience at the Veterans Health Administration, the largest integrated healthcare system in the United States, in developing, testing, and implementing such models at scale. We report lessons from the implementation of national risk prediction models and suggest an agenda for research.

As many health systems have been working to become high-reliability organizations (HROs), health equity has been largely absent from discussions and applications of HRO principles. This is a serious oversight. Disparities in health and health care represent systematic failures to achieve reliable outcomes for certain groups. Acceptance of disparities is antithetical to the essential HRO goal of "zero harm." We propose adding Equity to HROs in the most literal sense by designating it as a key component and achieving High Equity Reliability Organizations. We describe how equity should be a crucial element of all 5 HRO core concepts: sensitivity to operations, preoccupation with failure, deference to expertise, resilience, and reluctance to simplify.

EditorialsJanuary 2021Virtual Care and the Pandemic: Are We Reaching All Patients?FREECarolyn M. Clancy, MD and Susan Kirsh, MD, MPHCarolyn M. Clancy, MDDiscovery, Education and Affiliate Networks, Veterans Health Administration, Washington, DC (C.M.C.)Search for more papers by this author and Susan Kirsh, MD, MPHVeterans Health Administration, Washington, DC (S.K.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M20-5593 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Faced with the rapid spread of a new, highly contagious virus, the Veterans Health Administration (VHA) was well positioned to provide virtual care at scale. The VHA's legacy in telehealth combined with newly enacted legislation easing the provision of services across state lines enabled the nation's largest integrated health care system to pivot quickly.In their article, Baum and colleagues (1) document the VHA's experience by comparing the number of face-to-face appointments provided in 2016 to 2019 with the number provided during the initial 10 weeks of the coronavirus disease 2019 (COVID-19) pandemic. Their findings confirm a swift expansion of virtual care, including telephone and video visits, and a parallel decrease of in-person visits. Their research also adds to the body of literature on expansion of virtual care in the U.S. Department of Veterans Affairs (VA) and other organizations during the COVID-19 pandemic (2–4). On balance, the study found a decrease of 30% in 2020 appointments compared with 2016 to 2019. The authors note that these findings prompt important questions about the potential effect of delayed access to in-person care on patient-level outcomes.Driven by the need to keep veterans (who are among the highest-risk groups for COVID-19) safe, minimize risk for those with nonacute medical needs, and conserve personal protective equipment, telehealth applications and virtual care proliferated, seemingly overnight. In addition to using standardized tools to identify those with complex needs and at highest risk (and proactively reach out to them), care teams at local VA facilities were aided by March 2020 guidance from national primary care and mental health leadership to prioritize these efforts. As the data show, virtual visits address, and will continue to address, the critically important need of providing essential health care while minimizing patient risk. However, lessons to be learned from virtual care transcend its use as a substitute for in-person visits.For example, clinicians and all health professional trainees should come to regard virtual visits as an opportunity to further engage with patients and their families. Family members can participate in virtual visits from thousands of miles away, adding new dimensions (and information about the patient) to the appointment. Going forward, there is much to learn about using technology to enhance the dynamics of provider–patient communications instead of attempting to simply replicate in-person dynamics. How providers best communicate and engage with patients is different from face-to-face visits, and further information is needed to optimize the patient–provider relationship and experience (5).Virtual visits also provide the opportunity to monitor chronic conditions; support wellness; and conduct virtual examinations, such as with an interactive virtual stethoscope. The VA is exploring these options across primary care, mental health, specialty care, and other health professions. Moreover, to further support primary care teams, remote monitoring of patients with diabetes who are at increased risk for amputations and asynchronous advice via text messages to patients concerned about COVID-19 are also increasing. The VHA's strongest track record using telehealth relates to mental health care, for which there is a strong evidence base of effectiveness.With 19.3% of Americans and 30% of veterans enrolled in the VHA living in rural areas (6, 7), the pandemic has heightened awareness of the need for state licensure waivers and technology upgrades for virtual care. Temporary waivers for state-specific licensure, such as those adopted by the Centers for Medicare & Medicaid Services and some states, should be granted permission to enable rapid augmentation of clinical capacity in highly affected areas. However, as seen from the current public health crisis, limitations associated with these waivers differ, resulting in an inconsistent landscape of laws (8). With regard to technology, the digital divide is narrowing, but the gap in connectivity in rural America and internet affordability remain challenges for many. Strategies to boost cellular signal and roll out 5G in the short term, coupled with cellular and broadband expansion efforts, are needed to provide every American the choice to receive care from home (9).Overall, further investigation is needed to determine the optimal combination of virtual and in-person care for different clinical conditions and patient populations, especially for those with complex medical, social, and behavioral needs. In a recent quality improvement effort, a survey asked veterans about the modality of care they preferred, and 27% responded that they preferred video visits if clinically appropriate. As a learning health care system, the VHA is using such information to further evaluate and research potential strategies. In addition, the organization is collecting best practices to disseminate and scale throughout the system.The rapid switch from in-person to virtual appointments across the VHA and most of U.S. health care is unprecedented, impressive, and here to stay. The COVID-19 pandemic has inextricably changed the way we think of care delivery, with rapid evolution of virtual care. We now have a unique opportunity to redefine postpandemic care with continued use of virtual care in the VA and other health systems. We must understand how best to integrate emerging virtual care tools (for example, vital sign monitoring from watches, products to augment the virtual visit physical examination, and home laboratory testing). To fully realize the potential of all these and emerging technologies, evidence is needed as to whom they benefit most. In addition, policymakers have signaled that virtual care is here to stay. Baum and colleagues have provided a critical starting point for understanding how to optimize the virtual visit experience.References1. Baum A, Kaboli PJ, Schwartz MD. Reduced in-person and increased telehealth outpatient visits during the COVID-19 pandemic. Ann Intern Med. 2021;174:129-31. doi:10.7326/M20-3026 LinkGoogle Scholar2. Heyworth L, Kirsh S, Zulman D, et al. Expanding access through virtual care: the VA's early experience with Covid-19. NEJM Catal Innov Care Deliv. 1 July 2020. doi:10.1056/CAT.20.0327 CrossrefGoogle Scholar3. Wosik J, Fudim M, Cameron B, et al. Telehealth transformation: COVID-19 and the rise of virtual care. J Am Med Inform Assoc. 2020;27:957-962. [PMID: 32311034] doi:10.1093/jamia/ocaa067 CrossrefMedlineGoogle Scholar4. Mehrotra A, Ray K, Brockmeyer DM, et al. Rapidly converting to “virtual practices”: outpatient care in the era of COVID-19. NEJM Catal Innov Care Deliv. 1 April 2020. doi:10.1056/CAT.20.0091 CrossrefGoogle Scholar5. Lee TH. Creating the new normal: the clinician response to COVID-19. NEJM Catal Innov Care Deliv. 17 March 2020. doi:10.1056/CAT.20.0076 CrossrefGoogle Scholar6. U.S. Census Bureau. New census data show differences between urban and rural populations [news release]. 8 December 2016. Accessed at www.census.gov/newsroom/press-releases/2016/cb16-210.html on 6 August 2020. Google Scholar7. Spoont M, Greer N, Su J, et al. Rural vs. urban ambulatory health care. Department of Veterans Affairs (US); 2011. Accessed at www.ncbi.nlm.nih.gov/books/NBK56144 on 6 August 2020. Google Scholar8. Federation of State Medical Boards. U.S. states and territories modifying requirements for telehealth in response to COVID-19. Accessed at www.fsmb.org/siteassets/advocacy/pdf/states-waiving-licensure-requirements-for-telehealth-in-response-to-covid-19.pdf on 6 August 2020. Google Scholar9. Federal Communications Commission. Inquiry concerning deployment of advanced telecommunications capability to all Americans in a reasonable and timely fashion (FCC-19-44). Accessed at www.fcc.gov/document/broadband-deployment-report-digital-divide-narrowing-substantially-0 on 3 August 2020. Google Scholar Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: Discovery, Education and Affiliate Networks, Veterans Health Administration, Washington, DC (C.M.C.)Veterans Health Administration, Washington, DC (S.K.)Acknowledgment: The authors thank the following members of the VHA Office of Connected Care for their contributions to this manuscript: Neil Evans, MD, chief officer; Kathleen L. Frisbee, MPH, PhD, executive director, Connected Health; and Kevin Galpin, MD, executive director, Telehealth Services.Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M20-5593.Corresponding Author: Carolyn M. Clancy, MD, Discovery, Education and Affiliate Networks, Veterans Health Administration, 810 Vermont Avenue Northwest, Washington, DC 20420; e-mail, Carolyn.[email protected]gov.Current Author Addresses: Dr. Clancy: Discovery, Education and Affiliate Networks, Veterans Health Administration, 810 Vermont Avenue Northwest, Washington, DC 20420.Dr. Kirsh: Veterans Health Administration, 810 Vermont Avenue Northwest, Washington, DC 20420.This article was published at Annals.org on 10 August 2020. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoReduced In-Person and Increased Telehealth Outpatient Visits During the COVID-19 Pandemic Aaron Baum , Peter J. Kaboli , and Mark D. Schwartz Metrics Cited byThe Impact of the COVID-19 Pandemic on Tobacco Treatment Program Implementation at National Cancer Institute-Designated Cancer CentersLessons Learned: Building a Comprehensive Telehealth Quality ProgramExamining organization and provider challenges with the adoption of virtual domestic violence and sexual assault interventions in Alberta, Canada, during the COVID-19 pandemicThe Digital Divide: Do Older Adults with Serious Illness Access Telemedicine?Treatment of Tobacco SmokingWhere Are We Headed? Diagnosing Abnormal Head Shapes Through Virtual Care VisitsTelehealth Delivery of Tobacco Cessation Treatment in Cancer Care: An Ongoing Innovation Accelerated by the COVID-19 Pandemic January 2021Volume 174, Issue 1Page: 116-117KeywordsCOVID-19Health careHealth information technologyPsychiatry and mental healthQuality improvementResearch laboratoriesRural areasTelemedicineVeteran careVital signs ePublished: 10 August 2020 Issue Published: January 2021 PDF downloadLoading ...

Academy of Medicine's Emerging Stronger After COVID-19: Priorities for Health System Transformation initiative, which commissioned papers from experts on how 9 key sectors of the health, health care, and biomedical science fi elds

Nadim Mahmud, MD, MS, MPH, MSCE; David A. Asch, MD, MBA; Jessica Sung, BA; Catherine Reitz, MPH; Mary S. Coniglio, MBA; Caitlin McDonald, MPH; Donna Bernard, MSN; Shivan J. Mehta, MD, MBA, MSHP

This Viewpoint describes US health system performance during the COVID-19 pandemic using the National Academy of Medicine's 2001 Quality Chasm framework, focusing on system cohesion, organizational capabilities, and environment of care.

As this supplement goes to press, the Veteran Health Administration’s (VHA) electronic health record system is undergoing a critical transition; from a largely home-grown system to a widely used co...

Ideas and Opinions15 January 2019Testing Novel Payment and Delivery Approaches Through the Veterans Health Administration's New Center for InnovationSteven D. Pizer, PhD, Austin B. Frakt, PhD, Kyle Sheetz, MD, MS, and Carolyn Clancy, MDSteven D. Pizer, PhDBoston University School of Public Health, Boston, Massachusetts (S.D.P.)Search for more papers by this author, Austin B. Frakt, PhDVA Boston Healthcare System, Boston University School of Public Health, and Harvard T.H. Chan School of Public Health, Boston, Massachusetts (A.B.F.)Search for more papers by this author, Kyle Sheetz, MD, MSUniversity of Michigan, Ann Arbor, Michigan (K.S.)Search for more papers by this author, and Carolyn Clancy, MDVeterans Health Administration, Washington, DC (C.C.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M18-2225 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail In May 2018, Congress passed the VA [Veterans Affairs] Maintaining Systems and Strengthening Integrated Outside Networks (MISSION) Act to consolidate programs that provide veterans access to non-VA care and to formally establish a coordinated, high-performing network of VA and private-sector providers (1). The MISSION Act also established a VA Center for Innovation for Care and Payment (“Center”) to be staffed by VA employees and contractors with expertise in demonstrations and evaluations. Through the Center, the VA will have the ability to test novel payment and service delivery models. Although the VA is already recognized as a national leader in quality ...References1. Ogrysko N. Trump signs VA MISSION Act into law, though funding questions remain. Federal News Network. 6 June 2018. Accessed at https://federalnewsradio.com/veterans-affairs/2018/06/trump-signs-va-mission-act-into-law-though-funding-questions-remain on 23 September 2018. Google Scholar2. Perla RJ, Pham H, Gilfillan R, Berwick DM, Baron RJ, Lee P, et al. Government as innovation catalyst: lessons from the early Center for Medicare and Medicaid Innovation models. Health Aff (Millwood). 2018;37:213-21. [PMID: 29401006] doi:10.1377/hlthaff.2017.1109 CrossrefMedlineGoogle Scholar3. Minegishi T, Frakt AB, Garrido MM, Gellad WF, Hausmann LRM, Lewis ET, et al. Randomized program evaluation of the VHA Stratification Tool for Opioid Risk Mitigation (STORM): a research and clinical operations partnership to examine effectiveness. Subst Abus. 2018 [Forthcoming]. Google Scholar4. Haffajee RL, Bohnert ASB, Lagisetty PA. Policy pathways to address provider workforce barriers to buprenorphine treatment. Am J Prev Med. 2018;54:S230-42. [PMID: 29779547] doi:10.1016/j.amepre.2017.12.022 CrossrefMedlineGoogle Scholar5. Kessler RC, Hwang I, Hoffmire CA, McCarthy JF, Petukhova MV, Rosellini AJ, et al. Developing a practical suicide risk prediction model for targeting high-risk patients in the Veterans Health Administration. Int J Methods Psychiatr Res. 2017;26. [PMID: 28675617] doi:10.1002/mpr.1575 CrossrefMedlineGoogle Scholar6. Prentice JC, Frakt AB, Pizer SD. Metrics that matter. J Gen Intern Med. 2016;31 Suppl 1:70-3. [PMID: 26951272] doi:10.1007/s11606-015-3559-0 CrossrefMedlineGoogle Scholar7. Frakt AB, Pizer SD. The promise and perils of big data in healthcare. Am J Manag Care. 2016;22:98-9. [PMID: 26885669] MedlineGoogle Scholar8. Frakt AB, Prentice JC, Pizer SD, Elwy AR, Garrido MM, Kilbourne AM, et al. Overcoming challenges to evidence-based policy development in a large, integrated delivery system. Health Serv Res. 2018. [PMID: 29862494] doi:10.1111/1475-6773.12986 CrossrefMedlineGoogle Scholar9. Ogrysko N. VA signs long-awaited contract with Cerner for new electronic health record. Federal News Network. 17 May 2018. Accessed at https://federalnewsradio.com/veterans-affairs/2018/05/va-signs-long-awaited-contract-with-cerner-for-new-electronic-health-record on 23 July 2018. Google Scholar Author, Article, and Disclosure InformationAffiliations: Boston University School of Public Health, Boston, Massachusetts (S.D.P.)VA Boston Healthcare System, Boston University School of Public Health, and Harvard T.H. Chan School of Public Health, Boston, Massachusetts (A.B.F.)University of Michigan, Ann Arbor, Michigan (K.S.)Veterans Health Administration, Washington, DC (C.C.)Disclaimer: The content of this article reflects the opinions of the authors and not the official position of the U.S. Department of Veterans Affairs, Boston University, or Harvard University.Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M18-2225.Corresponding Author: Austin B. Frakt, PhD, Partnered Evidence-based Policy Resource Center, VA Boston Health Care System, 150 South Huntington Avenue, Mail Stop 152H, Boston, MA 02130; e-mail, [email protected]edu.Current Author Addresses: Drs. Pizer and Frakt: Partnered Evidence-based Policy Resource Center, VA Boston Health Care System, 150 South Huntington Avenue, Mail Stop 152H, Boston, MA 02130.Dr. Sheetz: Department of Surgery, University of Michigan Medical School, 2101 Taubman Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109.Dr. Clancy: Deputy Undersecretary for Discovery, Education, and Affiliated Networks, Veterans Health Administration, 810 Vermont Avenue NW, Washington, DC 20420.Author Contributions: Conception and design: S.D. Pizer, A.B. Frakt, C. Clancy.Analysis and interpretation of the data: A.B. Frakt.Drafting of the article: S.D. Pizer, K. Sheetz, C. Clancy.Critical revision of the article for important intellectual content: S.D. Pizer, A.B. Frakt.Final approval of the article: S.D. Pizer, A.B. Frakt, K. Sheetz, C. Clancy.Administrative, technical, or logistic support: A.B. Frakt.This article was published at Annals.org on 25 December 2018. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics Cited byInnovation Centers in Health Care Delivery Systems: Structures for Success 15 January 2019Volume 170, Issue 2Page: 112-113KeywordsElectronic medical recordsHealth careHealth care policyInformation storage and retrievalMotivationPsychiatry and mental healthQuality improvementSuicideSurgeryVeteran care ePublished: 25 December 2018 Issue Published: 15 January 2019 PDF downloadLoading ...

IMPORTANCE Concerns have been raised about the adequacy of health care access among patients cared for within the United States Department of Veterans Affairs (VA) health care system. OBJECTIVES To determine wait times for new patients receiving care at VA medical centers and compare wait times in the VA medical centers with wait times in the private sector (PS). DESIGN, SETTING, AND PARTICIPANTS A retrospective, repeated cross-sectional study was conducted of new appointment wait times for primary care, dermatology, cardiology, or orthopedics at VA medical centers in 15 major metropolitan areas in 2014 and 2017. Comparison data from the PS came from a published survey that used a secret shopper survey approach. Secondary analyses evaluated the change in overall and unique patients seen in the entire VA system and patient satisfaction survey measures of care access between 2014 and 2017. MAIN OUTCOMES AND MEASURES The outcome of interest was patient wait time. Wait times in the VA were determined directly from patient scheduling. Wait times in the PS were as reported in Merritt Hawkins surveys using the secret shopper method. RESULTS Compared with the PS, overall mean VA wait times for new appointments in 2014 were similar (mean [SD] wait time, 18.7 [7.9] days PS vs 22.5 [7.3] days VA; P =.20). Department of Veterans Affairs wait times in 2014 were similar to those in the PS across specialties and regions. In 2017, overall wait times for new appointments in the VA were shorter than in the PS (mean [SD], 17.7 [5.9] vs 29.8 [16.6] days; P <.001). This was true in primary care (mean [SD], 20.0 [10.4] vs 40.7 [35.0] days; P =.005), dermatology (mean [SD], 15.6 [12.2] vs 32.6 [16.5] days; P <.001), and cardiology (mean [SD], 15.3 [12.6] vs 22.8 [10.1] days; P =.04). Wait times for orthopedics remained longer in the VA than the PS (mean [SD], 20.9 [13.3] vs 12.4 [5.5] days; P =.01), although wait time improved significantly between 2014 and 2017 in the VA for orthopedics while wait times in the PS did not change (change in mean wait times, increased 1.5 days vs decreased 5.4 days; P =.02). Secondary analysis demonstrated an increase in the number of unique patients seen and appointment encounters in the VA between 2014 and 2017 (4 996 564 to 5 118 446, and 16 476 461 to 17 331 538, respectively), and patient satisfaction measures of access also improved (satisfaction scores increased by 1.4%, 3.0%, and 4.0% for specialty care, routine primary care, and urgent primary care, P <.05). CONCLUSIONS AND RELEVANCE Although wait times in the VA and PS appeared to be similar in 2014, there have been interval improvements in VA wait times since then, while wait times in the PS appear to be static. These findings suggest that access to care within the VA has improved over time.