Department of Veterans Affairs 1 VHA Innovation Program Remote Veteran Apnea Management Portal...

Department of Veterans Affairs 1

VHA Innovation Program

Remote Veteran Apnea Management Portal (#687)

Project Director: Samuel T. Kuna, MDPhiladelphia VAMC, Station 642, VISN 04

Collaborator: Carl Stepnowsky, PhDVA San Diego Healthcare System, Station 664,

VISN 22

Department of Veterans Affairs

Project Background

Problem Statement• Obstructive Sleep Apnea (OSA) is a sleep-related

breathing disorder that is now recognized as a major public health problem

• Patients with OSA are at increased risk of serious medical consequences including motor vehicle accidents, hypertension, heart attacks, strokes and death

• High prevalence of OSA in veterans; 17% of middle aged adult males in US are estimated to have moderate to severe OSA

• The wide disparity of sleep resources across VHA are unable to meet this patient need Lack of standardized care – up to 20% of testing is

outsourced Long patient wait times – up to 6 month wait times Limited access to diagnosis and treatment – up to

80% of patients with OSA are undiagnosed and therefore not treated

2


Top 10 Chronic Conditions in VHA Veterans

3

Yoon et al, 2008

Hyper

tens

ion

Diabe

tes

OSA

Heart

Conditio

ns

Depre

ssion

Arthrit

is

PTSD

COPD

Cance

r

Subs

tanc

t Abu

se0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%


Disparity in VHA Sleep Services

VA Sleep Service Inventory (FY12); 110/150 (73%) sites reported

40 VA Medical Centers not reporting likely have limited programsAll sites could benefit from REVAMP 4

Management and testing48%

Management but no testing 14%

No management No testing 11%


The Remote Veteran Apnea Management Portal (REVAMP) Solution

A web-based clinical management pathway for veterans with OSA

Validated questionnaires completed online • eliminates paper forms, increases symptom reporting, accesses outcomes Online videos instructing Veterans how to perform their home

sleep test• replaces in-person instruction Treatment with auto-adjusting positive airway pressure

(autoPAP)• eliminates need of additional sleep testing Wireless transmission of home autoPAP data to REVAMP website • enables patients and providers to monitor treatment results• allows remote pressure changes on home unit Clinical management by phone calls and video teleconferencing• increases clinical efficiencies; reduces patient travel and lost work hours Auto-generation of progress notes and integration with CPRS • increases clinical work-flow efficiencies

5


Existing Models versus

Inpatient Diagnostic Home Diagnostic

Little Data for Providers / Difficult Data Collection

Lots of Data for Patients and Providersa meaningful use of technology

Anecdotal Promotion of Compliance Transparent, Meaningful Engagement

+ +

Wireless Data TransmissionAutoPAP adherence Data

Patient QuestionairesAutomated CPRS progress

notes

So.. how’s it going

with the CPAP?

I see you’re doing great

with the CPAP!

$1,680 $990


Execution Status

September 2012 Intellica, Corp. selected as vendorOct – Feb 2013 REVAMP website developed with both

provider- and patient-facing portals• Integration with electronic medical

record (CPRS)• Integration with ResMed and Philips

PAP devicesMarch – May 2013 Troubleshooting and refinement of websiteJune 2013 – present Pilot testing

• 21 enrollees at Philadelphia VAMC and 18 at VA San Diego Healthcare System

• Positive patient and provider feedbackSeptember 2013 Approval of no-cost extension for continued pilot testing through February 2014

7


VA Center for Innovations ISB Selection Criteria

Summary Value = 1 * (23+37) = 60

Business Value = 10 + (-7) + 10 + 10 = 23

Clinical Value = 10 + 10 + 10 + 3 + 4 = 37

8

Criteria See…Self-Assigned

Score

Compliance Slide 9 1

Five-Year Net Operational Cost Change Slide 10 10

Implementation Cost Slide 11 -7

Clinical Impact (Broadness) Slide 12 10

Clinical Impact (Degree) Slide 13 10

Business Impact (Broadness) Slide 14 10

Business Impact (Degree) Slide 14 10

Patient Safety Slide 15 4

Patient Value Slide 16 10

Healthcare Disparity Slide 17 3


Business Case: Compliance

REVAMP is compliant with published guidelines and practice parameter reports from the VHA, the American Academy of Sleep Medicine and the Centers for Medicare and Medicaid Services.Many VA Medical Centers are unable to achieve these guidelines because of insufficient resources, including staff and equipment

Self-assigned score = 1 9


Business Case: Five-Year Net Operational Cost Change

(all figures in millions)

Self-assigned score = +10 10

Year 1 Year 2 Year 3 Year 4 Year 5

($100,000,000)

$0

$100,000,000

$200,000,000

$300,000,000

$400,000,000

$500,000,000

Annual Cost Annual Benefit Annual Net Benefit

Annual Performance (millions) Year 1 Year 2 Year 3 Year 4 Year 5 Total Annual Cost $3.4 $5.9 $16.4 $10.2 $10.2 $46.0

Annual Benefit $1.4 $3.9 $80.0 $228.0 $452.3 $766.0 Annual Net Benefit ($2.1) ($2.0) $64.1 $217.9 $442.0 $720.0


Business Case: Implementation Cost

11

Cost ProfileYear 1

VISNYear 2

Region Year 3 Year 4 Year 55-Year Total

REVAMP Product (Software) Development $1,200,000 $1,750,000 $2,500,000 $1,250,000 $1,250,000 $7,950,000 CPAP Shipping Services $750,000 $1,500,000 $6,000,000 $5,000,000 $5,000,000 $18,250,000 Purchase of Monitors (For OSA Diagnosis) $250,000 $500,000 $2,000,000 $500,000 $500,000 $3,750,000 Space Leases for Regional Hubs $100,000 $500,000 $2,000,000 $2,000,000 $2,000,000 $6,600,000 Telecom Equipment for Phone Consults $100,000 $300,000 $1,200,000 $300,000 $300,000 $2,200,000 Staff Training $136,400 $457,000 $1,119,400 $275,000 $275,000 $2,262,800 Other Costs (C&A, Staff Time) $877,000 $900,000 $1,550,000 $850,000 $850,000 $5,027,000

Annual Total: $3,413,400 $5,907,000 $16,369,400 $10,175,000 $10,175,000 $46,039,800

Cummulative Costs: $9,320,400 $25,689,800 $35,864,800 $46,039,800 ---

Years 1 and 2 are Implementation Phase I• Year 1: VISN-wide implementation• Year 2: Regional ImplementationYears 3+ are National Implementation5-year Total Cost Projection: $46.0 million

Self-assigned score = -7

Self-assigned score = 1


Business Case – Clinical Impact (Broadness)

OSA performance measures published by the American Academy of Sleep Medicine/Nat’l Committee for Quality Assurance include: • Documentation of subjective daytime sleepiness• Documentation of diagnostic apnea-hypopnea index

(AHI)• Positive airway pressure (PAP) prescription• Utilization of objective PAP adherence and efficacy dataREVAMP meets and exceeds all of these measures: • Uses self-administered, online questionnaires with

automatic scoring for the comprehensive assessment of symptoms

• Reports the diagnostic AHI as well as daily AHI from PAP device

• Provides patients and practitioners daily access to the PAP data

• REVAMP is designed to assess two other important metrics: patient centered outcomes and patient satisfaction

Self-assigned Broadness Factor Score = 10

12


Business Case – Clinical Impact (Degree)

Published research by both Dr. Kuna and Dr. Stepnowsky has shown:• Home sleep testing is a reliable and valid way to

increase diagnostic capacity in veterans with OSA without reducing quality

• Patient adherence to PAP treatment is increased by at least 33% when patients and practitioners have access to the PAP data and can use that data to inform clinical management

• It is expected that REVAMP will positively impact each OSA performance measure.

Self-assigned Degree Factor Score = 10

13


Business Case – Business Impact

REVAMP improves quality of work being performed:• OSA clinical decision-making is better informed• Best practices are standardized to reduce service

variability• Clinical data are of higher quality and easier to access

and use• Better OSA management reduces organizational riskREVAMP improves VA staff efficiency and workflow:• Practitioner time for clinical encounters reduced by 50%• Direct costs reduced by 22% compared to current

modelsREVAMP improves Veteran/Beneficiary’s experience:• Reduces patient wait time, burden of travel, and lost

work hours• Provides self-help educational materials• Promotes patient self-managementSelf-assigned score = 10 & 10

14


Business Case - Patient Safety

By improving access to diagnosis and treatment, REVAMP offers the potential to reduce mortality and morbidity in veterans with OSA. Treatment of OSA has been shown to:• Reduce the risk of cardiovascular disease• Reduce blood pressure in patients with OSA and

hypertension• Improve daytime alertness (i.e., reduce the risk of motor

vehicle & workplace accidents)• Improve depression and mood (and reduces irritability)• Improve quality of life - bed partners sleep betterA 2010 studied conducted by McKinsey and Harvard Medical School estimated an annual per patient cost of $3,000 for each case of unmanaged OSA

Self-assigned score = 415


Business Case – Patient Value

REVAMP will benefit veterans with OSA in a number of ways:• Increases patient access to diagnostic testing and

treatment• Reduces patient wait times • Reduces veteran travel time and lost work hours• Promotes patient self-management



Business Case – REVAMP Addresses the Following Healthcare Disparities

Geographical disparities• Veterans in remote and rural areas will have access to

diagnostic testing and treatment through REVAMP\Sleep resource disparities across VHA medical facilities• Veterans at VAMCs without sleep resources will be able

to obtain testing and treatment through REVAMP Healthcare disparities in disabled veterans• Disabled veterans with OSA who are unable to travel to

a VA medical facility will have access to care through REVAMP

Racial healthcare disparities• Veterans can access REVAMP using their iPhones,

Android phones, and iPads and thereby will reach a majority of veterans



Contributors to REVAMP

VA Philadelphia: Samuel Kuna, MD, Barry Fields, MD, Aileen Love, MD, Sue McCloskey, NP, Keith Davies, Diane Richardson, PhD, Carson Clark, Jennifer True, PhDVA San Diego: Kathleen Sarmiento, MD, Carl Stepnowsky, PhD, Sue Hacklander, Kathleen DiVerno, Todd Smith, Carolina Smales.VA Central Office: Marta Render, MD.Intellica Corp: Vince Fonseca, MD, Jeff Fischer, Jose Lago, Rafa Morales, Marisol Smith, David Santana, Craig Rebo.CPAP Manufacturers:• Philips Respironics: Mark D’Angelo, Bill Hardy, Peter

Ridgway• ResMed, Inc: Cary Shames, DO, Adam Benjafield, Amy

CookVA Center for Innovations: Blake Henderson 18


Extra slides

19


A personalized, interactive web-site for veterans with OSA that promotes self-management by providing feedback on test results, PAP treatment, and response to treatment

Remote Veteran Apnea Management Portal

• Intake and FU questionnaires to evaluate patients and track clinical outcomes

• Graphical displays of PAP and questionnaire data• Videos and educational materials• FAQ for self-management• Secure messaging• Questionnaire responses autofill progress notes• Interface with VA electronic medical record


Remote Veteran Apnea Management Portal Clinical Pathway

Electronic intake sleep

questionnaire

Home Sleep Testing

Treatment with positive airway pressure device

Initial evaluation with sleep provider

Follow-up questionnaires and

evaluations

REVAMP website

Phone call

Sleep test scored/interpreted

APAP device ordered

Reviews responses

Initial evaluation

with patientSleep study

ordered

DME company delivers device

1- and 3-month follow-up evaluations

REVAMP website/ Phone

calls

Sleep Center ProviderVeteran at Home

Reviews wireless APAP data

Linking Interface

Equipment mailed

REVAMP Website


CPRS

Wireless PAP Data

Standardized history and sleep study collection

Patient centered outcomes

REVAMP provides standardized, patient outcome based management of

OSA


REVAMP Login Page


Tom John


J Jones


Robert Jones


Tom John


REVAMP Success Metrics

Use objective measures and validated questionnaires to evaluate the success of the remote ambulatory pathway:

Assess improvement in functional outcomes (i.e., quality of life).

• Daytime function will significantly improve. Monitor failure rate of home sleep testing.

• Failure rate on home sleep testing will be less than 10%. Objectively measure patient adherence to autoPAP

treatment.• Adherence to treatment will be adequate.

Assess patient satisfaction with the care.• Veterans will be satisfied with their care.

Assess Veterans’ rating of their remote interaction with the sleep provider.

• Veterans will express satisfaction with their interaction with the provider.


REVAMP Challenges & Risks

Not all Veterans will be able to participate in home sleep testing. A patient with two failed studies will be scheduled for in-lab testing. Not all patients will be candidates for treatment with an autoPAP device. Strong patient safety measures are built into the pathway to identify these patients so they can be scheduled for in-lab testing.Veterans may not return the portable monitors and modems. We have developed a successful process to retrieve the equipment.Not all Veterans will have internet access. However, REVAMP is compatible with I-phones, Androids, and I-pads. These devices are bridging the digital divide allowing veterans over a wide range of socioeconomic strata access to REVAMP.


Support for REVAMP and Next Steps

VA Sleep Network Meeting (VASN):• REVAMP was presented at the national VASN meeting in

Baltimore in June, 2013 and was very well-received:• Well over 25 sites inquired about its availability and time

to roll-outVACO Support:• Marta Render, MDNext Steps:• Conduct VISN-wide implementation leading to regional

implementation• Expand pilot testing to identify areas for refinement and

issues associated with implementation

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FY09 FY10 FY11 FY120

20,000

40,000

60,000

80,000

100,000

120,000

140,000

TotalCPAP/APAPBiPAPBiPAP S/T and ASV

Number of PAP units distributed - FY09-FY12


VA OSA Diagnostic Demand

2012 2013 2014 2015 2016 2017 20180

200,000

400,000

600,000

800,000

1,000,000

1,200,000

1,400,000

1,600,000

1,800,000

# OSA DxYear


REVAMP Model of Care

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Health Care Costs of Unmanaged OSAMcKinsey Study with Harvard, 2010

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Department of Veterans Affairs 1 VHA Innovation Program Remote Veteran Apnea Management Portal...

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