The U.S. Department of Veterans Affairs provides medical services for more than eight million veterans each year through the Veterans Health Administration, the largest integrated healthcare system in the country with over 1,700 sites of care. However, much of VHA's infrastructure was designed and built decades ago under an older concept of healthcare delivery that focused on hospital-centered, inpatient care.
To better address the medical needs of today's veterans, the VHA has launched a number of mobile healthcare initiatives. Neil Evans, M.D., and Kathleen Frisbee, MPH, Ph.D.c, who co-direct the VHA's Connected Health Office, spoke with FierceMobileHealthcare about the agency's mHealth pilot programs.
FMH: What is your vision for mobile healthcare and why is the VHA investing in mHealth?
Frisbee (right): I can almost answer that in one sentence--mobile healthcare is inherently mobile and we believe that's the future, both for providers because it improves their efficiency and for patients because it allows them to increase their interaction with the healthcare system through their mobile technology. That's why we're investing in it.
FMH: How would you describe where the VHA is at in terms of implementation of mHealth? When did you first start testing or piloting these technologies?
Evans: We really started to explore this in late 2010 when we began our first pilot. When we talk about developing a platform with a suite of mobile apps to empower both patients to manage their healthcare and providers to better deliver healthcare on-the-go, that effort started in earnest in early 2011.
Frisbee: The first thing we did was a pilot in 2011 to look at the security issues and risks and then to test mobile apps with providers. From there, we began to build out our infrastructure to support the mobile applications and we built a mobile framework, which is a secure way of delivering these apps. At the end of 2012, we let a contract for a mobile applications environment, where we do all the development of our apps. And, we just had a proposal approved that's going to allow DOD and VA to do joint development of mobile apps in that mobile applications environment. We have a contract for mobile device management software with AirWatch which is to secure all of the devices for our staff.
We just released our Family Caregiver suite of apps, which is 10 apps that are designed for family caregivers and the seriously injured veterans that they care for. We also just released the Veteran Appointment Request app which allows veterans to request appointments over the mobile device. And, probably towards the latter part of May we'll be releasing our next app, which is called the My Story app that collects information from veterans to share with their providers.
In terms of where we are, we've invested heavily in the security and the infrastructure early on to make sure that we have our foundation right. During that time we were doing the development of the apps and now, finally, we're beginning to release the apps. We have a whole bunch of other apps that are in the queue right now that we're working on as well.
FMH: It sounds like you have a very robust cycle of mobile health apps that you are releasing. How many mHealth apps do you have currently and what is the goal of application development?
Evans (left): We've spent a lot of time trying to think through a strategy for how we determine which mobile apps we should invest in developing. In my mind, the mobile applications that it makes sense for us as an organization to fund and develop are applications that have connections to our back-end clinical systems and allow clinicians or patients to make better health decisions because of access to their personal data. Of course, it is done in a secure way that complies with HIPAA and FIPS 140-2. That's the real value--applications that help them manage their healthcare.
We have been focusing on developing applications that meet the specific needs of our veteran patients and help them better engage and communicate with their healthcare teams. We've also been focusing on applications that will allow our healthcare teams to deliver better care. We've spent time running focus groups with veterans and providers during our initial pilots to identify what they view as their most acute needs on mobile devices. And, we've used that to help prioritize our development queue.
When we develop applications, we, of course, always pilot them before we launch them nationally. We want to make sure that the apps work and there are no patient safety issues before we release them to the field. The VA apps will be on the relevant app stores for patients and for providers we will have an internal app library and we can deliver the applications directly to providers' devices through the mobile device management software as well.
FMH: You mentioned some of the apps you recently released. What are some of the other examples of apps?
Frisbee: We have a number of apps that basically complement the functionality of our electronic health record and display the information from the EHR to the provider and will also allow the provider to write to the electronic health record.
FMH: When is this Mobile Blue Button app slated for completion?
Frisbee: That's due to be completed in July.
FMH: What other apps are in the works?
Frisbee: Another concept that we're doing is looking at how to design apps around specific, discrete workflows. So, for example, there's an immunization app which is designed to improve the efficiency of immunizations by taking all the tasks associated with it and bundling it into a single app. We also will be releasing at some point our first game app that uses gaming technology to improve cholesterol and blood pressure in our veterans.
Those are some examples. We have approximately 10 apps that are in pilot testing and over 20 apps in the development queue right now. We've also released a request for information for a mobile imaging app as well. We want to have mobile apps for diagnostic quality radiology images. So, that's something we're planning in the future.
FMH: When you develop these apps, are they developed in-house or are you leveraging what's available commercially?
Frisbee: We do both. We have in-house development as well as contracts for development.
FMH: Is VHA device agnostic or is all your app development iOS based?
Evans: Some of our initial applications that are in pilot right now are iOS native applications. The applications currently in the queue for development, and the Appointment Request app and My Story app, are HTML5 applications so they can run in any browser. We have no need of apps for Android right now.
At the moment, the only devices that have been approved for use in the VA are iOS devices and BlackBerry. We are hoping to test the Windows platform as well. And, we're working on that right now setting up a test of a Windows-based tablet. Certainly, Android will be on the horizon as well given its benefits.
We don't have a Bring Your Own Device policy or program in the VA. So, at the moment, mobile devices that are on the VA's network must be government-furnished equipment.
FMH: What can you tell me about the iPads given to family caregivers of Iraq and Afghanistan veterans?
Evans: As part of the pilot for the patient-facing applications, which is called the VA Mobile Family Caregiver pilot, we are distributing 1,120 iPads to caregivers of veterans who were seriously injured in the post-9/11 conflicts. We developed a suite of applications to help support them as they care for their loved ones. Those include an application that we call a Summary of Care app that provides veterans access to their own health data from the electronic health record. It doesn't persist on the device. It's only there when they're using the application.
There's also a prescription refill application, an app to manage PTSD symptoms, and a pain management app – all of these communicate back to our health record system. An application also lets veterans to designate their loved one as a surrogate which allows their caregiver to act on their behalf and view their data. A notification application enables them to set up reminders to take their medication. A journal application also records self-entered data such as blood pressure measurement, meals, and exercise.
As part of that pilot testing, we're providing them with a device for a year with data services. They get two gigabytes per month of data services and, of course, if they have WiFi availability they can connect to that on their own. We're then using data from that pilot to measure the effectiveness of providing mobile applications to folks to manage their healthcare. The pilot itself is really just starting and we're distributing devices right now this month.
Frisbee: This pilot is really our first experience using mobile device management software from AirWatch. And, so there's been a learning curve getting the devices provisioned.
Editor's note: This interview has been edited for length and clarity.