nurse and patient (Gorodenkoff/


Protecting at-risk veterans during a time of transition

The Department of Veteran’s Affairs faces a historic health care delivery challenge. As it transitions to a new electronic health record (EHR) system, VA is also tasked with providing more holistic care to servicemen and women identified as high-risk. Disrupting patient engagement and care is not an option.

To meet this challenge, the VA is instituting care coordinators in its facilities. Often called care “quarterbacks,” these coordinators are tasked with overseeing the entire picture of a patient’s care, which is especially important for veterans with chronic conditions such as diabetes. However, it’s common practice for Veterans Health Administration sites to use multiple clinical decision support (CDS) systems to support a variety of patient populations. These can include HealthShare Referral Management, Joint Legacy Viewer and multiple SharePoint spreadsheets.

This approach leads to disjointed patient information, data siloed in multiple systems and databases and crushing workloads for coordinators who are typically responsible from overseeing anywhere from 200 to 1,200 patients. This disjointed care model is not just immensely tedious, it is error-prone and puts high-risk patients at even greater risk of readmission.

To better serve at-risk veterans, care coordinators need CDS technology that creates a holistic care dashboard to present all patient data in real-time. Here is an example of how powerful such integrated technology can be.

Meet Emma, a proud United States veteran.

Emma is hospitalized with elevated blood sugar levels and diagnosed with Type 2 diabetes. If everything goes according to her care plan, she will be treated and quickly discharged with everything she needs to manage her diabetes and get back to a healthy life. Sounds simple and straightforward.

But what if Emma lives alone? What if she doesn’t have reliable transportation? What if members of Emma’s care team only have a siloed view of their own interactions with her, unaware of other care she is or is not receiving? In this scenario, Emma could easily miss a follow-up appointment, accidently overmedicate and end up rushed back to the hospital.

Now let’s play this scenario out when all the “dots” connect with integrated CDS technology, including the linkage of outpatient care with in-patient data. For the first time, this total picture can also include socio-economic data, such as transportation issues that could affect accessibility to care. After Emma receives her diagnosis of diabetes mellitus, her entire care team is given a clear view of her patient profile. Everything from her diagnosis, consults, labs and medications are readily available for fast collaboration and action.

Because Emma’s care team knows ahead of time that she lives alone and without reliable transportation, they take appropriate action before scheduling her follow-up appointment to ensure she has a ride. Emma arrives for her follow-up appointment as scheduled. She receives the additional support she needs to fully understand her diagnosis and how to medicate correctly moving forward. This kind of care honors our commitment to veterans and returns them to their healthy lives.

An integrated, real-time CDS care dashboard has these features:

Flexible and EHR agnostic

New CDS technology can be EHR agnostic, working with any existing health care workflows. It can also serve as a system of patient engagement that is separate from, but integrated with, the facility’s EHR system of record. In theory, an EHR platform could be both, and for years that is what some have promised. But historically EHRs cannot serve as systems of engagement because they were not designed with the unique work processes of healthcare in mind.

The VA is in the middle of a decade-long transition to a new EHR system, Cerner Millennium. A CDS care dashboard would allow the VA to not only protect but improve care to at-risk veterans while this massive and complicated changeover progresses.

Liberating for care coordinators

The VA has demonstrated its commitment to better care through the promotion of the care coordinator role. However, throwing people at the problem can go only so far if those care quarterbacks aren’t empowered by technology to help them handle their enormous workloads. 

Going from manual coordination to a reliable, software-powered process allows coordinators to handle far more patient files and fulfill the promise of their role. They could use the dashboard to quickly search all readmissions for those that showed a hemoglobin A1C of 9 or above, indicating diabetes -- without having to access all the individual patient files.

Best practices “baked in”

Moving to a software-powered process takes advantage of regular updates and the network effect. CDS software can be regularly updated and pushed out via the cloud, giving every VA facility the benefit of the latest best practices. And the more VA facilities that adopt such solutions, the faster and more powerful the improvements become.

Coordinator caseloads typically include a high percentage of high-risk patients. A human might be able to manually review every patient chart once a week, at best. How much better is it to have right software that can look at desired at-risk indicator, every second? With new CDS technology, the VA shows how architecting today for an integrated future will better support the EHR transition and the ultimate mission.

About the Author

Paula Sanchez is a manager and clinical systems analyst at DSS, Inc.


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