Motivation and Barriers to Using the Veterans Health Information Exchange: A Survey of Veterans Affairs ‘Superusers’

Introduction

The Department of Veterans Affairs (VA) Veterans Health Information Exchange (VHIE), formerly known as the Virtual Lifetime Electronic Record (VLER) Health Program, is a Veteran-focused portfolio of programs that gives VA and authorized Community Care Partners secure access to certain parts of a Veteran’s electronic health record for the purpose of care coordination across the health care continuum. VHIE established a technological platform to securely exchange health information between VA and the community, both at an organizational level (VA Exchange) and at the personal provider level (VA Direct Messaging). VHIE connects the Department of Veteran Affairs with care organizations through national networks (e.g., eHealth Exchange). Today, VA is connected to more than 314 eHealth Exchange members and will expand community provider access to Veterans health information by joining the CommonWell Health Alliance and Carequality national networks.

Each day, thousands of documents are sent and received by VA and community providers to coordinate the care of patients. However, VA provider adoption and utilization of the VHIE, specifically the Joint Legacy Viewer (JLV), remains low and far from the critical mass necessary to achieve desired impacts on Veterans care and on health care costs. As of March 2019, JLV usage reports showed only 17.3% of 311,920 VA staff with access to JLV were Active Users logging in to the system.

Provider adoption is one of the four pillars of the VHIE Program⁽¹⁾ and increasing VA provider utilization is key to program success for several reasons:

1. Veterans Health Administration (VHA) Directive 6371, released April 30, 2019, established that VA medical facilities “must implement the Veterans Health Information Exchange (VHIE) Program…which provides the capability of electronic health information exchange (eHIE)…to advance the delivery of Veteran-centered clinical care⁽²⁾.” The directive requires implementing VHIE (JLV) technology and educating and training VHA staff on the use of the VA Exchange.

2. The VA MISSION Act of 2018 specifically addresses health data exchange between VA and the private sector⁽³⁾ and opened the door for a shift to opt-out consent (no signed consent required) for Veteran participation in VHIE. This policy change will drastically increase the amount of Veterans health information available for electronic exchange and will create internal and external expectations that (all) VA providers use the VA Exchange to manage Veterans care.

3. Most enrolled Veterans (80%) have other health insurance (e.g., Medicare, Medicaid, Tricare, private insurance) and are likely to receive care outside of VA⁽⁴⁾. This rate could be higher for rural Veterans as community care may be more accessible than VA care.

4. “Repetition of medical services by providers is one of the major sources of healthcare costs⁽⁵⁾,” and use of HIEs to coordinate patient care can reduce redundant and unnecessary medical tests and lead to significant cost savings⁶-⁸.

In 2016, the VA Office of Rural Health (ORH) and VHIE program office began collaborating on a social marketing (communications) project to increase VA provider adoption and utilization of the VHIE. The VHIE Superuser Survey, conducted in 2018, was designed to help gain a deeper understanding of VA employees demonstrating the “model” behavior – accessing and using the VA Exchange at a high rate. The survey investigated VHIE utilization patterns and user perceptions about the VHIE and its use, as well as data of interest to the VHIE program regarding the user experience, including system access, use case(s), data quality, training, and barriers and facilitators to using the VHIE.

The survey also sought to discover psychographic information about “superusers” to better understand them as a consumer of HIE technology.

Survey findings will inform the development of a strategic communications campaign to increase VHIE adoption and utilization by VA providers and staff. In addition, knowledge gained from the VHIE Superusers survey will be used to help prioritize enhancements to the program, reduce and remove barriers to VHIE adoption and utilization, and improve the user experience.

HIE adoption is also an issue facing community health care organizations and barriers are similar to those experienced by VA(^9-13). This work serves to add to existing knowledge about the motivators, facilitators, and barriers to HIE adoption; and the use of social marketing in interventions to influence provider behavior change.

Methods

Social marketing uses commercial marketing concepts and techniques to promote voluntary behavior change, and has been employed by international and national public health intervertions for decades(14, 15). The social marketing process includes nine process elements completed across three phases: I) Research and Planning, II) Strategy Design, and III) Implementation and Evaluation⁽¹⁶⁾. It is “an invaluable referent from which to design, implement, evaluate, and manage large-scale, broad-based behavior-change focused programs⁽¹⁷⁾.” Though patients (consumers) are generally the intended target, social marketing may also be used to influence behavior change in health care providers(^18-20).

The VHIE Superuser Survey was developed as the research vehicle to collect the quantitative and qualitative data necessary to complete the consumer analysis, market analysis, and channel analysis elements of Phase I. Survey questions were designed to elicit information regarding the VHIE user experience as well as to answer six strategic questions posed by the consumer-based health communications (CHC) process. Answers to these questions (below) provide insight into the consumer’s reality and “lead to communications that are relevant, meaningful, and compelling to the audience⁽²¹⁾.”

1. Who will the target consumer be and what are they like?

2. What action should the target take as a result of communication?

3. What reward should the message promise the consumer?

4. How can the promise be made credible?

5. What communications openings and vehicles should be used?

6. What image should distinguish the action?⁽²¹⁾

To confirm the selection of the VHIE Superuser as an appropriate model of the desired behavior, questions based on Theory of Planned Behavior constructs were included to assess target audience members’ intention to perform the desired behavior (VHIE utilization in the workflow), their attitude toward the desired behavior, subjective norm, and perceived behavioral control.

VA Research Electronic Data Capture (REDCap), a web-based application for building and managing online surveys, was used to create open-ended, single-select, multi-select, and Likert Scale questions. VHIE and ORH staff, and VHIE Rural Health Community Coordinators tested the survey and provided feedback regarding question clarity and survey completion time. The final VHIE Superuser survey consisted of 32 questions and addressed four domains: Access, Utilization, Data Quality, and User Experience.

VHIE analytics were used to identify VA medical centers/healthcare systems retrieving documents from external sources at high (>14,000 patient record views/facility) and low (<2,000 patient record views/facility) rates. Nine sites were selected for participation in the VHIE Superuser survey; four designated as rural and five as urban.⁽²²⁾ [Comparison of rural and urban is of interest to the ORH as rural Veterans may be more likely to obtain care in the community due to distance/travel time to a VA facility, and ORH supports VHIE Community Coordinators at 56 rural VA Medical Centers.]

As this reseach was focused on the VHIE “consumer” and identifying current behavior and a model of the desired behavior, a purposive sample was established consisting of 162 VHIE users with the highest number of patient record views at their site in the previous six months. Email addresses for the target Superusers were confirmed in the VA Outlook Global Address List; five were “undeliverable” reducing the total survey population to 157.

The initial survey email was sent July 17, 2018 and survey reminder emails were sent July 24^th, July 31^st, and August 7^th. To increase the survey completion rate (only 15.3% as of 7/31/18), content and formatting changes were made to the final two email reminders. Emails were personalized with information specific to the recipient, such as their position title and home facility; and persuasive language and visually-appealing graphic elements were added.

Results

The final survey response rate of 52.2% was calculated using a sample size of 82. The sample was comprised of 36 participants from four rural sites (44%) and 46 participants from five urban sites (56%). Among all survey respondents there was wide variation in years worked at VA, with the shortest duration six months and the longest tenure slightly more than 38 years. The mean time employed with VA was 10.6 years. Nurses responded to the survey invitation at the highest rate (39.0%), followed by physicians (26.8%) and pharmacists (13.4%). Respondents who selected the “Other” category (23) included Psychologists (6), Social Workers (4), and Vocational Rehabilitation Counselors/Specialists (4).

It is important to note survey participants responded to questions based on their experience with either one or both VHIE user interfaces: VistAWeb or the Joint Legacy Viewer (JLV). VistAWeb, an intranet web application providing read-only access to individual patient electronic health records (EHR) was implemented in 2010 and served as VA’s first health information exchange (HIE). To modernize the system and meet Federal mandates for interoperability, JLV was deployed to all VA Medical Centers in 2014. JLV, co-developed by VA and the Department of Defense (DoD), connects VA to the private sector through national networks and enables users to view comprehensive electronic health records from all VA, DoD, and community health information exchange partner facilities where a Veteran receives care. An important difference between JLV and VistAWeb is that VistAWeb allows for aggregated data views that combine internal and external data in single data displays (e.g., allergies together, medications together, problems, etc.). VistAWeb, which was scheduled to be decommissioned in September 2017, was still available and in use during the survey period.

Survey Domain #1: VHIE Access

To better understand the “how” and “how often” aspects of VHIE access, and to identify any access issues, questions in this domain concerned the interface used to view Veterans non-VA (community) health information, frequency of access, and perceptions of ease in accessing the VHIE. Respondents were also asked to share open comments about VHIE navigation in general.

Survey participants were asked to select all methods used to access Veterans non-VA health information. More than half of respondents (52.6%) reported using JLV, and slightly more than a third (35.3%) used VistAWeb; 61.4% selected both JLV and VistAWeb. This may indicate that VHIE Superusers were early adopters of VistAWeb and that many have been successfully transitioned to JLV.

Almost three-quarters of Superusers (73.4%) access the VHIE daily, and overall ease of accessing data in the VA Exchange was rated “Neutral” (3.03) on a 5-point Likert Scale. Regarding access, 82% of survey respondents (n=67) provided comments about VHIE navigation and the user interface. Qualitative analysis of text responses revealed three predominate themes: connectivity, functionality, and a preference for VistAWeb over JLV. For both connectivity and functionality, the speed (slowness) of the system was an overarching theme. Almost one quarter of respondents (22.4%) used the word “slow” in regard to connecting and logging into the VA Exchange as well as loading documents (patient records), and “time-consuming” was referenced five times. Inaccessibility to the VHIE because the “system was down” was cited by 11 respondents, and 10 specifically referred to issues with the log in process (two-factor authentication). Almost one-fifth of survey respondents (19.4%) mentioned the transition from VistAWeb to JLV, compared the functionality and user friendliness of the two interfaces, or declared a preference for the system they had already been trained to use and are accustomed to using in their workflow.

VHIE Access Themes – Sample of Supporting Superuser Quotes

Theme #1: Connectivity issues prevent access to the VHIE.

“Becomes problematic when sites are not available or when the JLV goes down as there is no other alternative to get the info I need.”

“JLV is not quickly accessible to log in and sometimes goes down.”

Theme #2: Functionality and navigation inhibit utilization of the VHIE (JLV).

“Too limited – can’t search, often have to open multiple single entries to try to find what you’re looking for. Often need information like a test result that is not retrievable (not the most recent or several years ago).”

“I find JLV somewhat difficult to navigate to [location] information I am seeking.”

Theme #3: Superusers were comfortable using VistAWeb and prefer it over JLV.

“When Vista Web was available, the information I was able to access was more useful and decreased the time to find pertinent data that would help the clinical team make treatment decisions…”

“I prefer to use VistAWeb over JLV - some of that may be that I have more experience with VW, but it also allows us to access information not available in JLV.”

Survey Domain #2: VHIE Utilization

The second survey domain assessed utilization of the VHIE as influenced by Veteran patient characteristics, community health data types searched for in the VA Exchange, and how community data was used in the work setting. Participants were asked to check all responses that applied to the statement, “I access VLER/VHIE when working with a Veteran who…” Selection of [Veteran] “has self-reported care in the community” prompted a follow-up question regarding the type of community care reported by the Veteran.

Sixty-eight percent of respondents reported using VHIE to look up patient records when working with a new enrollee or patient transferred from the DoD, and 61.8% accessed the VHIE when a Veteran self-reported community care. Interestingly, 36.8% reported a Veteran-initiated request to look up their health record. Almost half of the respondents (48.7%) selected “Other Patient Type” and provided varied text responses. Most commented on clinically-specific situations, but use of the VHIE when a Veteran referenced medication(s) prescribed by a provider outside VA emerged as a theme.

As shown in Figure 1, more than half of respondents (52.6%) reported Veterans referencing receiving diagnostic imaging in the community. Specialty care treatment and visiting community Emergency Rooms (ERs) were both reported by 47.4% of respondents, followed by labs in the community (43.4%) and community care for a chronic condition (40.8%). Less than one-third mentioned Veterans acknowledging health care from a community provider through the Veterans Choice Program.

Figure 1.

Types of community care reported by Veterans to VHIE Superusers (n=76).

In terms of interest in specific data categories, nine of the 13 listed data types were reported by more than half of survey respondents (=>51.3%) (Figure 2). More than three-quarters of respondents searched for problems/medical history (78.9%) and lab results (77.6%). While viewing all data types has the potential to impact and improve care coordination, more than two-thirds of respondents reported searching for lab results (#2), imaging results (#3), medications (#4), and procedures (#5); which may contribute to cost reduction through eliminating duplication.

Figure 2.

Data types searched for in VHIE (n=76).

Responses to the question regarding utilization of Veteran health information obtained through the VA Exchange are shown in Figure 3. The top five uses, (1) reviewing treatment course for chronic illness, (2) reviewing community hospitalizations/ED notes, (3) preparing for scheduled appointments, (4) coordinating care, and (5) managing medications were reported by more than half of respondents.

Figure 3.

VHIE Superuser data use cases (n=76).

Survey Domain #3: VHIE Data Quality

The third survey domain assessed Superusers perceptions of the quality of the health information (i.e., data accuracy and completeness) received from the VA Exchange. The overall mean score for data quality was 3.85 on a 5-point Likert Scale where “1 = Very Poor” and “5 = Very Good.” Close to two-thirds of respondents (63.9%) rated VHIE data quality as either “Very Good” or “Somewhat Good.”

The top three responses selected for the question regarding data quality issues experienced when using VHIE were (1) incomplete data (59.3%), (2) duplicate data in multiple locations (37.3%), and (3) “other” data quality issue” (33.9%). Five survey participants who selected “Other data quality issue” reported that there were “no problems” with data quality, and one respondent added, “other than not every facility can/has signed up to play with us.”

When asked about specific data not currently available that would be helpful in their work, several respondents referred to progress notes - either more or better (from the community). Other responses included a list of patients’ current providers, surgical history, and psychological evaluations. Two items suggested by multiple respondents were current and past appointments (VA and community) and prescriptions written by community providers. It should be noted that this was not a required question, yet 10 respondents voluntarily responded with “not applicable” or “none,” indicating they were able to access the information to perform their work.

Survey Domain #4: VHIE User Experience

The final domain of the VHIE Superuser survey collected information regarding the VHIE user experience and perceptions of benefits and drawbacks. In addition, motivation for VHIE use, facilitators and barriers affecting utilization, and VHIE training received were addressed in this domain.

Sixty-six survey participants shared their perception of the benefit(s) of using the VHIE in their work. Qualitative analysis of the text responses revealed three predominate themes: coordination and continuity of care, access to outside information, and better patient care. Expediting health record sharing (i.e., the process to obtain Veterans health information from other VA and non-VA providers) and eliminating duplication (e.g., tests, treatment) were also strong themes.

VHIE Benefits Themes – Sample of Supporting Superuser Quotes

Theme #1: VHIE use helps provide coordination and continuity of care.

“Accessing digital information in real time is invaluable in providing coordinated, comprehensive care.”

“Helpful tool to increase continuity, efficiency, and thoroughness for patient care.”

Theme #2: VHIE use provides access to helpful health information from other VA and non-VA providers.

“Being able to gather a complete medical picture of the Veteran from both VA and non-VA care to provide the best possible care possible.”

“It allows me to follow the Veterans who receive their primary care outside the VA - to follow labs, follow medication dosing, and see the education that has been provided by non-VA providers.”

Theme #3: VHIE use leads to better patient care.

“Allows me to better evaluate the Veteran’s needs, previous/current care, medical stability…”

“Outside records greatly benefit Veteran care.”

Sixty-five survey participants shared text comments about their perception of the drawbacks of using the VHIE. More than half of respondents (55.4%) cited technical issues as a drawback. Within this theme, slowness of the system was the greatest drawback (30.8%), followed by inaccessibility due to the system (JLV) being down (9.25%), log in/authentication issues (7.7%) and navigation (7.7%). The second major theme concerned the lack of data available from community partners (18.5%). The third theme, “no drawbacks to VHIE use,” was mentioned by 13.8% of respondents to this question.

VHIE Drawbacks Themes – Sample of Supporting Superuser Quotes

Theme #1: Technical issues are a drawback of VHIE utilization.

“The process is so slow at times that it is not always possible to utilize in the context of a standard clinic appointment time. Just the process of logging into JLV can be cumbersome…”

“System is frequently down or access is slow, also amount and type of information is limited.”

Theme #2: Lack of information available from community providers is a drawback of VHIE utilization.

“Unfortunately, not all community providers are accessible in VHIE.”

“Limited facilities who participate and notes at outside facilities are often sparse.”

Theme #3: There are no drawbacks to using VHIE in my work.

“There is no drawback that I can think of.”

“None.”

When Superusers were asked what motivated them to use the VHIE, the overwhelming choice selected by survey participants (84.5%) was “desire to improve care coordination” A formal directive from leadership motivated less than a quarter of respondents. Fifteen respondents chose to report an “other” motivation, which included participation in a JLV test, efficiency, and for claims processing.

User Experience domain questions also intended to discover the perceptions of facilitators and barriers to utilizing the VA Exchange. Survey participants were asked to select all applicable items. Of sixty-seven respondents, more than three-quarters (77.6%) reported that ease of accessing the VHIE in the work setting facilitated its use. Other top facilitators included facility support for VHIE use, and the ability of support staff to access the VHIE.

Through their responses to questions in the VHIE Access domain, Superusers established clear themes regarding barriers and echoed them in the User Experience domain: connectivity, functionality, and a preference for VistAWeb over JLV. Ninety percent of respondents reported “slow connection or system not available” as a barrier, almost two- thirds (63.4%) perceived the “time consuming” aspect of VHIE use as a barrier, and one-third felt VHIE use interfered with the workflow. Text responses for “Other” barriers were similar to already established technology-related themes concerning the log in process, navigation, and functionality.

Eighty-three percent of survey participants indicated they had been “self-trained.” The VHA Office of Health Informatics (OHI) launched a comprehensive communications campaign to alert all VA Computerized Patient Record System (CPRS) users about the transition from VistAWeb to JLV. Although technological limitations prevent definitive attribution, the number above would suggest many users were self-trained using the JLV videos promoted in OHI communications. Other training methods, such as group training or one-on-one training were reported at significantly lower rates: 16.9% and 2.8% respectively. Those respondents who selected “Other VLER/VHIE training” (9.9%) referenced the JLV test email, word-of-mouth, and learning by trial-and-error.

It should be noted rural Superusers (69.4%) reported far more facilitators of VHIE use than their urban counterparts (30.6%). Facility support for VHIE use (83.3%), ability of support staff to access VHIE (82.4%), and effective training (75%) were the top three facilitators. VHIE Community Coordinators at rural sites were considered a facilitator by 71.4% by respondents. Rural Superusers (41.7%) also reported less barriers to VHIE utilization than urban (58.3%).

To further understand why Superusers are utilizing the VHIE at such a high rate, survey participants were asked to respond to a series of statements assessing Theory of Planned Behavior constructs. This theory, often employed by patient-level health behavior change interventions, is used to predict the likelihood of an individual performing a behavior based on attitude, subjective norm, and perceived behavioral control. On a 5-point Likert Scale where “1 = Strongly Disagree” and “5 = Strongly Agree,” respondents expressed a positive attitude about the VA Exchange and its use, support from their peers for using VHIE, and confidence to successfully use the VHIE. Each statement scored 4 or higher except for the statement regarding peer use of the VHIE (3.47). These results indicate the Superusers are a good “model” of the desired behavior (VHIE adoption and utilization).

Discussion

Whether working in a rural or urban facility, those who currently use the VA Exchange most, the Superusers, share commonalities. They have a positive attitude toward VHIE, despite technical barriers impeding or preventing use. Their shared desire to deliver high quality, coordinated care to Veterans and their ability to access the VHIE throughout the work setting motivate and facilitate VHIE utilization. The Superusers believe there are benefits of incorporating use of the VA Exchange in their workflow and have identified use cases for better and more efficient care delivery. They feel that while data quality is good, gaps still exist and HIE participation by more community providers would help provide salient missing information. As 70% of the survey respondents have been with VA five years or more, they are experienced with and more comfortable using VistAWeb, but through self-directed training can develop the necessary knowledge and skills to successfully transition to JLV.

As key consumers of Veterans health information, Superusers have expressed a clear intent to look outside VA for information to coordinate Veterans care. They routinely view community medical histories, lab and imaging results, medications, and procedures and notes. They have found the value of VHIE use to co-manage care of Veterans with chronic conditions and community hospitalization or emergency department admissions. They gather information to prepare for appointments and often review discharge summaries, immunizations, and allergies.

The VHIE Superuser Survey effectively captured data and psychographic information to create a vivid picture of the model VHIE user and their reality. Survey findings and answers to the six CHC strategic questions and are currently being used to develop a communications campaign promoting the benefits of VHIE use, facility/peer support for VHIE use, and the availability of self-directed training videos to quickly gain the skills necessary to begin accessing and using the VHIE in the clinical setting (social marketing Phase II). The campaign is scheduled to launch at 56 rural VA Medical Centers in late summer 2019. Throughout the campaign JLV training video completion will be monitored; and Active JLV Users, Patient Record Views, and Unique Patients Viewed will be measured. Program evaluation (Phase III) will measure the communications intervention ability to influence behavior change and what, if any, role the self-directed JLV training played in technology adoption and utilization.

Conclusions

While the MISSION ACT of 2018 will expand access to community care for Veterans, and an opt-out policy change will dramatically increase the amount of Veterans health information to be exchanged between VA and community providers, meeting the full intent of the law and VHA Directive 6371, and maintaining Veterans trust in VA, requires a greater number of VA providers actively using the VHIE. As the opt-out consent policy for VHIE goes into effect in October 2019, Veterans will be asking their VA providers if they are viewing electronic community health records as part of standard care.

Results of the VHIE Superusers Survey are consistent with previous study findings indicating those who use the VA Exchange are motivated to do so by a desire to provide high quality, coordinated care for patients, and that technical barriers may prevent users from incorporating VHIE into their workflow and encouraging others to do the same⁽²³⁾. Video training, available for viewing at the user’s convenience, provides an attractive and effective alternative to group training or one-on-one training; especially for individuals who perceive time for skills-building as limited.

Employing the social marketing process to address low HIE utilization may be an effective approach to influencing and changing provider behavior, but requires planning and research to collect the quantitative and qualitative data necessary to understand the target audience and their reality. As the VA transition to a new EHR looms on the horizon (as it does for many community providers), an effective evidence-based communications program facilitating new health IT adoption has application inside and outside VA.

Acknowledgements

The authors would like to thank the VHIE Superusers, VHIE Community Coordinators, and VHIE program office team for their time and assistance with this study. This work was funded by the Department of Veterans Affairs Office of Rural Health and conducted in collaboration with the VA Office of Health Informatics, VHIE Program Office. It received Quality Improvement determination from the VA Maine Research and Development Committee and met compliance with VA National Center for Organizational Development, Organizational Assessment Sub- Committee and VA Office of Research and Development guidelines for surveying VA employees for VA operational and research purposes.

Figures & Table

Figure 4.

Theory of Planned Behavior Constructs and VHIE Superuser Behavioral Intent (n=72).