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State of Care for Veterans with Chronic
Chapter 1 - Background and Perspective
Department of Veterans Affairs, Veterans Health Administration
The Department of Veterans Affairs (VA) Veterans Health Administration (VHA) is a federal comprehensive healthcare system serving eligible, enrolled US Veterans. Organizationally, the VHA is divided into 21 geographic regions called Veteran Integrated Service Networks or VISNs, each of which encompasses a number of local healthcare systems. These 128 local healthcare systems include over 1,100 facilities consisting of medical centers, community based outpatient clinics (CBOCs), domiciliaries, extended care facilities, hospices, and specialty centers for mental health, blind rehabilitation, spinal cord injury, polytrauma and traumatic brain injury. In federal fiscal year 2008, there were 7.8 million VHA enrollees and 5.6 million (72%) of them received care at a VHA facility. Nationwide, VHA inpatient care involved 641,000 discharges (70% of which were for acute care) totaling 4.3 million bed days of care. That year, the average daily census in nursing homes was 33,782 Veterans. Over 67 million outpatient visits were provided by the VHA in fiscal year 2008, 13.7 million of which were at CBOCs. Additional information on the general Veteran population can be found at http://www1.va.gov/vetdata/.
Overview of Program Office and Quality Initiatives
The Office of Public Health and Environmental Hazards improves Veterans' health through prevention, outreach, treatment and surveillance. It focuses on specific populations of Veterans including women Veterans, Veterans with HIV/AIDS, Veterans with hepatitis C (HCV), and Veterans exposed to hazardous materials during military service. The Office also manages VHA.s medical response to emergencies and protects the safety and health of VHA employees. Additional information on the Office of Public Health and Environmental Hazards is available at www.publichealth.va.gov.
The Public Health Strategic Health Care Group (PHSHG) is an organizational unit within the Office of Public Health and Environmental Hazards. PHSHG's mission is to improve the health of Veterans through the development of sound policies and programs related to several major public health concerns including: HCV infection, HIV infection, seasonal influenza, smoking and tobacco use, and emerging infections of public health significance including healthcare associated infections. PHSHG strives to promote the highest quality, comprehensive care for Veterans and to have that care recognized as the standard by which all healthcare in the United States is measured. PHSHG efforts include patient care activities, clinician education, patient education, prevention activities, policy development, and research directed at continuous improvement of medical and preventive services delivered to Veterans. Additional information on the PHSHG is available at www.publichealth.va.gov/about/pubhealth/index.asp.
The Clinical Public Health Program Office (CPHP), a component of PHSHG, oversees the VA National Hepatitis C Program. The Hepatitis C Program works to ensure that patients with or at risk for HCV receive the highest quality healthcare services. Led by PHSHG and carried out by providers at VA medical facilities across the country, the program takes a comprehensive approach to HCV that includes:
- Universal screening for risk of HCV infection
- Effective counseling and testing for those at risk
- Education for patients and their families
- Prevention and harm reduction
- Clinician training on the latest information regarding the management of HCV including antiviral therapy
- Promotion of excellence in clinical care
- Proactive research to improve clinical care
- Data-based quality improvement
The Hepatitis C Resource Center (HCRC) network is an integral part of VA's National Hepatitis C Program and is overseen by CPHP. Initially funded in 2002, the four HCRCs, located in Minneapolis, San Francisco, Seattle/Portland, and West Haven, work closely with CPHP and other elements of PHSHG to develop best practices in HCV prevention, clinical care, patient and provider education, and program evaluation for use within VA as well as within other medical care systems. Projects of the HCRCs include:
- Improving screening and testing methods
- Development of patient education materials
- Assessing impact of co-morbidities on chronic HCV treatment decisions (e.g. mental illness, substance abuse, or concurrent HIV infection) and piloting effective models of care to address these challenges
- Development and dissemination of models of interdisciplinary care to optimize effective management of chronic HCV
- Training of VA healthcare providers on hepatitis C diagnosis and care, including reduction of risk from co-morbidities and management of complications of chronic HCV infection
- Surveying HCV clinicians to better understand HCV care delivery in VHA
- Development and dissemination of clinical standards for managing patients with all stages of HCV
- Development of telehealth models of care to improve access to care for Veterans with chronic HCV
Over the period covered by this report, the HCRC program was instrumental in developing treatment guidelines, educational materials for Veterans and providers, and numerous products and staff educational programs with the goal of improving the quality of care for Veterans with chronic HCV. Additional information on the HCRC program including access to guidelines and educational materials for both Veterans and clinicians can be found on the internet at www.hepatitis.va.gov and within VHA at vaww.hepatitis.va.gov.
The Center for Quality Management in Public Health (CQMPH), also a component of the PHSHG, is based at the VA Palo Alto Health Care System. CQMPH oversees the Clinical Case Registry (CCR) for HCV. CQMPH's mission is to catalyze continual innovation and improvement in VHA clinical care via the use of quality management techniques and the strategic use of clinical information systems. This work is possible because of the unique VHA electronic medical record (EMR). Taking advantage of clinical data from the VHA's EMR, CQMPH develops centralized patient registries, and enhances local registry functions to provide clinicians useful information about their populations of Veterans with HCV. CQMPH staff members provide support to VHA clinicians and administrative staff to enhance their ability to use the CCR. CQMPH also provides other electronic tools such as optional Clinical Reminders. All these efforts are designed to enhance the quality of care delivered to Veterans.
Electronic Medical Records, the Clinical Case Registry (CCR), and CCR Reports
VHA has a state of the art electronic medical record (EMR) covering all aspects of healthcare delivery and documentation. Electronic tools use healthcare data to provide clinicians with patient-centric reminders and guidance related to care delivery including safety functions such as drug-drug interaction and allergy checks, reminders to provide vaccinations, laboratory tests and screenings, and alerts regarding abnormal results or procedures. The VHA EMR also includes population management tools, such as the Clinical Case Registry (CCR). The CCR software, deployed throughout VHA, provides a registry at every VHA facility to support local care delivery and populates a national clinical database. Staff members at VHA facilities serve as local registry coordinators, reviewing the medical records of Veterans with laboratory results and/or diagnosis codes reflecting potential infection with HCV and in cases of chronic infection, confirming their addition to the local CCR. Addition of a Veteran to a local registry triggers his or her addition to the national CCR, which is created through extraction of specific clinical data from the local EMR. Data elements extracted to the national CCR include information on allergies, demographics, diagnoses, inpatient stays, laboratory tests, outpatient visits, prescriptions, procedures, and radiology.
Using data from all VHA facilities, periodic summary reports are created on the population of Veterans with chronic HCV receiving care in the VHA. These reports use the latest available data and provide information at the national, VISN, and local healthcare system levels to VHA clinicians, administrators, and researchers. Each report is based on an extract of CCR data on a specific date. In each extract, CCR historical data is updated with current data for Veterans already in the CCR and with historical and current data for Veterans recently added to the CCR. Because CCR data collection is dynamic, reports covering the same period using extracts created on different dates are not necessarily identical. Nonetheless, comparison of information from reports created in different periods is useful for monitoring trends. The ultimate goal of these reports is to provide information to guide clinical, quality improvement, and administrative activities directed to assuring safe, effective and efficient care for Veterans with chronic HCV.
In addition, local healthcare system staff have access to population management reporting tools in their local CCR software. While such local reports are based only on data from the local healthcare system (as opposed to the national CCR) they permit the user to examine a variety of process and outcome related questions.
Examples of valuable ways the local and national CCR supports clinical practice include:
- Measurement of patient volume and disease severity to inform decisions about how care is delivered, allocation of staff and other resources
- Assessment of adherence to national guideline recommendations or medication criteria for use
- Identification of trends over time, such as screening practices, hepatocellular carcinoma (HCC) diagnosis, vaccination, or monitoring of treatment
- Describing patient demographic characteristics and co-morbidities to assess types of services likely to be required, such as treatment for age-related issues or chronic conditions.
- Measurement of treatment outcomes and effectiveness of current practices, protocols or guidelines including production of reports from the national CCR by PHSHG
- Performing ongoing comparison across VISNs or healthcare systems of like size to identify variation that may indicate quality issues or opportunities for improvement
Feedback reporting is a fundamental strategy that PHSHG employs to achieve its mission to assure the highest quality, comprehensive care to Veterans. This State of Care Report joins PHSHG's efforts in clinical surveillance, patient care activities, clinician education, patient education, prevention activities, and research directed at continuous improvement of medical and preventive services delivered to Veterans with chronic HCV.