VA Center for Innovation

Challenge Area

New Models of Dialysis and Renal Disease Treatment

Pilot Location

VA Puget Sound Health Care System (Seattle, Washington)

Company

AWAK Technologies

The Challenge

More than 10,000 Veterans undergo dialysis treatment for end stage renal disease (ESRD), and approximately 3,000 additional Veterans reach ESRD every year. Dialysis is a costly treatment, in terms of dollars and time spent for the patient treatment. For Veterans who live in rural areas, treatment several times a week at a VA or VA contracted medical center can pose serious issues in terms of transportation and extended wait times at these facilities. Despite these challenges and disruptions to a patient’s life, the medical necessity of dialysis for ESRD Veterans is constant – it is life saving treatment that a patient cannot go without.

The Solution

The Automated Wearable Artificial Kidney (AWAK) allows Veterans to receive continuous peritoneal dialysis via a small (approximately 3 lbs.) wearable device. This mechanism more accurately mimics kidney function than traditional dialysis, resulting in enhanced care and better health. While AWAK improves the numbers in patients’ charts, it also enriches quality of life, providing a dialysis treatment that is as mobile and independent as the Veterans themselves.

Instead of the traditional, periodic dialysis treatment, the AWAK continuously removes toxins and water from the blood. This round-the-clock dialysis steadies metabolic and fluid states, eliminating the peaks between and plummets after episodic dialysis appointments. This equilibrium makes patients feel better, as AWAK “applies a more consistent bandage to your system and improves your prospects of life,” says program manager Clint Latimer.

With need for only two 30-minute interruptions to change cartridges and remove ultrafiltrate, Veterans have more freedom to go about their daily lives. AWAK reduces the need for appointments, medications, and dietary and travel restrictions. Consequently, VA medical centers can decrease the cost of staffing and equipment maintenance. This is particularly important for regional facilities that have been designated for dialysis. Ultimately, VA Centers will have more room – both in space and schedule – for other patients. But most importantly, it can improve the quality of life significantly for a patient.

AWAK is easy to use and the portability, usability, and betterment of care that it provides foreshadows self-dialysis as a staple within the ESRD home – not just with the Veteran community, but with the more than half a million people in the U.S. with ESRD. As Margaret Hannon, Acting Director of Operations in VA’s Office of Research & Development, recounts, “So many Veterans have called to inquire [about AWAK]; I think it will certainly be a life-changer for thousands.”

Next Steps

Since receiving funding from VA, the artificial kidney has undergone various stages of development. Chemicals have been tested both inside and outside the apparatus, and the mechanism itself has already been refined into a smaller, lighter version. The testing at VA Medical Centers began in 2012 and will continue through 2013 to validate safety and efficacy and the device will eventually need to undergo the FDA approval process.

Challenge Area

Spinal Cord Injury (SCI)

Pilot Location

Memphis, TN

Company

VHA Employee Innovation

The Challenge

More than 42,000 Veterans suffer and live with spinal cord injuries (SCI) in the United States. In fact, roughly 16 percent of all Americans living with SCI are Veterans, and many of these Veterans receive rehabilitation at one of VA’s 24 SCI centers. Although the severity of these injuries may vary, often these Veterans become quadriplegics or paraplegics and face the challenges associated with transitioning to civilian life with physical limitations. Easing these challenges provides a better quality of life for those suffering with SCI.

The Solution

Environmental control beds for patients in an SCI unit grant Veterans greater control in their lives. These simple bedside technologies enable Veterans to adjust bed positions, flip on the lights, change the TV channel, or dial a phone. Patients can now perform these actions independently, without the assistance of a nurse, transforming the impossible task into an everyday motion.

Each bed is equipped with an environmental control unit that has “arms,” which hold a microphone, sip and puff straw, TV, and tablet interface. By using voice activation, breath and suction, eye pupil movement, and toggle switches, these devices act as an extension to the body. As a result, patients in the SCI units can control their environments, and nurses can dedicate more time to patient care activities. Because these devices are fairly straightforward, both Veterans and nurses find them easy to learn and use.

While environmental controls empower disabled Veterans with increased self-sufficiency, it also improves their quality of life. For the first time, these technologies pair clinical needs with personal entertainment. Now disabled Veterans can surf the Internet, read eBooks, and update their Facebook pages. “One of the Veterans’ favorite elements is the Skype function,” reports Chief Biomedical Engineer Sheena House, whose dedicated pursuit to create these technologies was made possible largely by VACI funding. “Many of these Veterans are far away from home, and now they can communicate and see their families at the same time. Patients keep asking me if they can be the next one to test the bed.”

Next Steps

After initial usability testing of two beds, 58 new beds are being installed in the Memphis SCI Center. Each bed can be personalized for the patient’s abilities, and confidential data can be removed from the devices once the patient is discharged. Due to the ease of use and amalgamation of tools, these technologies can be easily implemented into SCI centers and eventually the home. Environmental controls units are improving the lives of Veterans who have been impacted most, restoring activity and self-sufficiency.

Special Project

OSEHRA Innovation Profile

The Challenge

VA manages the largest integrated health network in the country, providing care to more than 6 million Veterans, and operating more than 150 hospitals, 800 clinics and 135 skilled nursing facilities. VA’s Electronic Health Record (EHR), called VistA (Veterans Health Information Systems and Technology Architecture), is the electronic information service that is central to the quality of care that VA delivers on this large scale.

As VA’s clinicians and researchers advance and improve models of care at an increasing rate and across a spectrum that includes evolving treatment for traumatic brain injury, post traumatic stress and mental health; outreach to rural Veterans; the introduction of mobile devices for clinicians, patients, and caregivers, the rate of innovation in VistA to support these clinical advances is increasingly difficult to maintain.

While versions of VistA are used in non-VA government health care, by the Departments of Defense and Health and Human Services, and in multiple private sector settings, there is no mechanism for sharing improvements between versions or for collaboration among VistA users and developers.

This unnecessary isolation has a damping effect on the rate of EHR innovation and prevents the full potential of VistA from being reached.

The Solution

Open source models have demonstrated success in multiple applications and markets by enabling a broad range of participants with different skill sets and representing different organizations and motivations to collaborate effectively. VA recognized that the creation of a robust open source community required the establishment of a custodial agent, or central governing body, to organize the community and catalyze its growth. VACI provided the leadership, direction, and funding required to establish this in OSEHRA, the Open Source Electronic Health Record Agent, in late 2011.

OSEHRA provides the foundation and the environment for an open and collaborative group of developers, researchers, and users engaged in advancing electronic health records and related technology, supporting the clinical advances promoted by VA and by health care providers and networks globally.

In operation for less than a year, OSHERA now has more than 1000 members representing more than 120 organizations from both the public and private sectors and academia. Technical operations, including a code repository, certification tests, development tools, and collaboration aids have been established. Work groups have been launched, allowing full community participation in a number of important projects and activities:

• VistA refactoring, which reorganizes the code to make it easier to maintain and easier to develop new applications
• Code convergence, to establish a common core codebase and make sharing of innovations easier to achieve
• Web services development, which provides modern programming interfaces for the rapid creation of new applications
• The update of VA’s My HealtheVet platform, moving it to an open source technology stack that supports greater exchange of patient health information

“The open source model provides much more innovation by allowing a wide variety of people and organizations to apply their particular expertise for the common good,” said Mike O’Neill, senior advisor to the VACI Director and OSEHRA board member. “And at the end of the day, these innovations directly impact the care we are able to deliver to Veterans.”

Next Steps

OSEHRA is deeply engaged in working with VA and other community members to modernize VistA, establishing a common core codebase throughout VA and across industry while improving the programming interfaces that developers will use to rapidly build new VistA-based applications.

As VA and DoD continue the design and development of a joint and integrated electronic health record, OSEHRA provides the means for implementing an open standards and open source software approach to the creation of a next-generation EHR.

And OSEHRA will continue its support for the longer-term objective to enable a commercial market based on open source EHR software, allowing national and international health care to benefit from the outcome-improving impact of VistA and increasing the innovation pool that can provide benefit back to VA.

Challenge Area

Polytrauma

Pilot Location

McGuire VA Medical Center, Richmond VA

Company

MedRed

The Challenge

Many Servicemembers who served combat tours in Iraq and Afghanistan suffer from polytrauma, complex injuries to multiple body parts and organs occurring simultaneously. One of the most common afflictions of polytrauma is traumatic brain injury (TBI). As a result of severe impact to the head, Veterans with TBI commonly experience behavioral changes, memory loss and difficulty accomplishing day-to-day tasks. Each symptom of TBI can require specific, separate treatment – and the severity of TBI may necessitate that a family member manage rehabilitation logistics. Because of this compound recovery plan and greater reliance on caregivers, information and treatment requirements for Veterans with TBI need to be tightly coordinated, easily accessible and manageable for all members of the care team.

The Solution

MedRed’s “TBI Toolbox” integrates local, state and federal levels of health care records in a way that easily and accurately merges health histories and treatment. This system allows for clinician recordkeeping and analysis of treatment, and improves connections between patients and their care teams. It is especially helpful when coordinating multiple components of TBI rehabilitation.

Coupling MedRed’s electronic data capturing system with wireless devices, TBI Toolbox facilitates data and medical information sharing between VA clinicians and partners at the U.S. Department of Defense (DOD). Populated with “smart forms,” the TBI Toolbox helps clinicians organize, standardize and automate patient data. This consolidated record source allows clinicians to access the most up-to-date, comprehensive patient information, even in emergencies or remote locations.

Funding from VA provided MedRed with the resources to add the Patient Portal, which provides Veterans with TBI greater access to their records and better management of their health care needs. Patients can complete intake and evaluation forms online and receive appointment reminders. All the data they import builds out the system, giving clinicians a better sense of the patient’s status and a method to track pathways and results. “TBI treatment can’t be measured like other conditions,” says program manager Shane McNamee. “You can’t tell outcomes after three days; you need three years. With this system in place, we’re creating a way to evaluate treatment methods. Even though time will tell how the system is working, we’re all hopeful that this is going to make big difference and improve TBI care.”

Next Steps

Currently, TBI Toolbox is in use at Walter Reed National Military Medical Center, where the system has been directed toward facilitating integrated care for traumatic brain injuries. MedRed is also working to incorporate the military’s electronic health record system, the Armed Forces Health Longitudinal Technology Application (AHLTA), into TBI Toolbox. After hosting a number of training courses at the Hunter Holmes McGuire VA Medical Center in Richmond, Va., clinicians are testing the system. Once the pilot phase is complete, VA will evaluate feedback for possible implementation enterprise wide.

Challenge Area

Telehealth

Pilot Location

Washington, DC - VA Medical Center

Company

Agilex, Inc.

The Challenge

In a typical healthcare setting, access to a patient’s electronic medical record requires a clinician to share a PC that is wheeled around the unit or floor on a cart. The doctor or nurse has to go to the PC, often in a different location than the patient, to access the patient record. This creates a break in the flow of communications with the patient, additional administration time for the provider and less than ideal circumstances for the patient-provider relationship. What if a provider had a patient’s electronic medical record with her, anywhere in the medical center?

The Solution

VA and Agilex jointly developed mobile applications (apps) for iPads so medical records can be accessed by the health care provider from anywhere in the clinical setting, at any time. The apps were designed to increase the convenience and accessibility of health care and to strengthen communications between clinicians and patients. The apps can facilitate day-to-day administrative tasks and expand communications among VA’s health care team.

The apps allow a provider to view and update the patient’s medical record in real time, view lab data, radiology reports, medication information, appointments, problems list, integrated clinical schedule and more, all from an iPad.

To accomplish this, the Agilex team worked closely with VA clinicians to design the applications that would be most useful. They also worked together with the VA IT security team to ensure that security controls were met, so that patient information is accessible only by the appropriate personnel.

The use of mobile devices – iPads in this case – has the potential to translate into more time spent with patients, and less time on administrative tasks. In the end, this could decrease waiting times for Veterans, and allows the provider to spend more time caring for patients.

Next Steps

The apps were tested at Washington D.C.’s VA Medical Center over a four-month period to answer the following questions:

• Are the devices and applications relevant to our clinical work?
• Do they add value to our health care delivery system?
• Were they easy to use?

The first pilot test received positive results, with feedback focusing on potential new applications as well as improvements to the current applications. Once these changes are implemented, a second field test will be conducted and results will be evaluated for broad deployment throughout VA’s health care system. It also opens the door for other innovators to develop apps for VA health care providers, since the foundation has already been created.

The apps are being considered for use in other areas, including an upcoming pilot for use by VA Family Caregivers in the home. These apps may include self-entered data tools for tracking regular medical conditions such as blood pressure and glucose levels for diabetics. PTSD symptoms and pain management can also be tracked. With the medical field just beginning to explore the many uses of mobile technology, the potential is wide open for future life-changing innovations.

Challenge Area

Telehealth

Pilot Location

Atlanta, Georgia VA Medical Center

Company

Kinetic Muscles, Inc.

The Challenge

When a Veteran suffers from a stroke, neuromuscular and neurological rehabilitation can be a long and arduous road, requiring hospital stays and numerous doctor and therapy visits. If the patient loses the ability to move a hand or a foot due to stroke or other brain injury, he can be left feeling frustrated, even hopeless. Many hours and many repetitions of movement therapy are necessary for the patient to regain motion and improve his quality of life.

The exercises and therapy can be repetitious and boring. Patients often resist performing the exercises and the therapy equipment is often located in a clinical setting, so the Veteran has to commute to and from therapy. For many Veterans living in rural communities, the commute and inconvenience can add another burden on the Veteran and his family.

The Solution

To address the convenience and cost of therapies, VA partnered with Kinetic Muscles to develop robotic devices that deliver stroke therapy at home, using technology taken from video games, to engage the Veteran.

By merging digital and robotic technologies with neuroscience, they have created small, easy to use devices that help the patient work on hand and foot motion, performing the repetitive activities that are instrumental for improvement after a stroke.

The Hand Mentor and Foot Mentor provide assistance for patients to achieve full extension while at home. Feedback and incremental goals, that a clinician can set, encourage the patient to increase range of motion. Importantly, the devices record the patient’s activity for analysis by the clinician, sent via a modem provided by Kinetic Muscles, so clinicians can stay informed of progress and results.

The repetitive practice not only strengthens the muscle, but it has also been shown to help the brain to rewire itself and find ways to operate around areas damaged by the stroke or injury.

The patient does not have to leave home to perform this important therapy, so his or her life is not as impacted or disrupted. And because the devices are designed to replicate aspects of video games, the patient can stay engaged in the exercise, even enjoying it, potentially increasing the compliance by the patient to stay with the exercises.

Next Steps

VA is in the pilot phase of testing these devices at the VA Medical Center in Atlanta. Once the pilot is completed, VA will evaluate results to decide whether to proceed with additional testing or launch across the VA network.

Challenge Area

Innovative Housing Solutions to Address Veteran Homelessness

Pilot Location

Northampton, Massachusetts

Company

Soldier On

The Challenge

On any given night in the U.S., more than 275,000 Veterans can be found huddled on the streets. One in five homeless Americans is a Veteran, and many struggle with mental health issues, substance abuse problems and other health concerns that require treatment. Because shelters and health care services have limited resources, they often can only provide short-term solutions. Homeless Veterans frequently end up back on the streets or bounce from emergency rooms, mental health wards, justice courts and shelters. Finding support can be especially challenging as Veterans transition back to civilian life. Lenny Costa, a formerly homeless Veteran who lived in one of Soldier On’s communities, explains: “It seemed like you couldn’t find your place anywhere. That was my biggest struggle. I couldn’t find where I belonged in society. You have this camaraderie in military, and you have great areas of responsibility, and then all of a sudden when you’re discharged, you’re back into the real world and where you’re pretty much on your own.”

In 2009, President Obama and U.S. Department of Veterans Affairs Secretary Eric K. Shinseki announced the Federal government’s goal to end Veteran homelessness by 2015. Together with partners and supporters nationwide, VA is determined to meet that challenge.

The Solution

Soldier On develops permanent supportive housing to help homeless Veterans live self-sufficiently and securely. The cost-effective units within these villages are constructed rapidly using replicable, modular, LEED-certifiable building techniques. VACI is funding a build of 44 units in Leeds, Mass., based on Soldier On’s Veterans community in Pittsfield, Mass., as a pilot to determine whether this approach proves an effective tool in the ambitious goal of eliminating Veteran chronic homelessness by 2015. This model shows early signs of promise: Only four Veterans have moved out in two years.

Each community’s main street is lined with housing units as individual as the Veterans who call them home. Inside, Veterans personalize their own space, taking ownership of their new house – and their new life. The community does not “judge you by your past; they judge you by your desire to make a change in your life. If you really want to make a change in your life, we provide you with all the tools here,” says Veteran Willie, a resident and council member in the Pittsfield village. Like any homeowners’ association, a council helps to sustain the community, and SoliderOn appoints Veterans who have previously been homeless to this board. These peer councilmembers oversee that the logistical needs of the housing community are met, but they also act as act as mentors, providing guidance, inspiration, and counsel to fellow residents. They help to foster a culture of trust, relationships, accountability, and the expectation of responsibility required of every homeowner. With this empowering environment and in knowing that behind every door on the street lives a Veteran, here these former Servicemembers find that camaraderie again.

The same fellowship expands beyond the village itself, as Veterans become integrated into the surrounding communities. They volunteer building cabins at Boy Scout camps, running 12-step meetings or giving speeches at the local high school. Each of Soldier On’s villages includes a greenhouse, and the Veteran-nurtured blossoms are used to decorate downtown streets and bring brightness to burial ceremonies. Says Zeno, who coaches basketball, football, and soccer as “just something to get the kids off the streets […] that’s one thing I’m proud of, being an asset to the community now. I’m not just taking; I’m giving back.”

Next Steps

In Leeds, Mass., land leases are almost finalized, and the groundbreaking for the next community, funded in part by VACI, is scheduled for early 2013. Soldier On continues to pursue additional funding to increase the total number of units to 70 on the VAMC campus in Leeds, aiming to provide more transitional housing units for homeless women Veterans.