Dr. Laura Petersen directs the Houston Center for Quality of Care and Utilization Studies and is leader on a new research project called Improving Quality and Safety through Better Communication in Patient Aligned Care Teams (PACTs). (Photo: Baylor College of Medicine" )
One of the areas addressed by VA's new CREATE research initiative is primary care. Here, Barbara Murphy checks the blood pressure of VA patient Hyslof Jones at the Philadelphia VA Medical Center. (Photo by Tommy Leonardi)
The phrase "health researcher" may conjure images of white-coated scientists tinkering with test tubes, or doctors testing a new drug on patients in a
But there's also a class of researchers who examine health care itself. They put health care systems under the microscope. They look at everything from the
computer technology used in health care, to the small talk between doctor and patient that goes on during an office visit.
VA has a nationwide cadre of health services researchers who are leaders in the field. They examine how VA care is delivered to Veterans and propose ways
to make it better. Much of their work has been put into practice. Their studies in the 1990s helped transform VA care, and their studies today continue to
have wide impacts.
The implementation gap
At the same time, though, many study results never make it beyond the pages of the New England Journal of Medicine, the Annals of Internal Medicine, or other medical journals. The findings are not translated into improvements in care. The research fails to touch
"There's been some excellent health services research that has not been implemented by VA," notes David Atkins, MD, MPH, VA's acting director of Health
Services Research and Development.
If people like Atkins have their way, that scenario will be a thing of the past. He is one of the driving forces behind a new model of health services
research in VA that leverages partnerships with clinical leaders and policymakers. The idea is to get input and buy-in from managers and decision-makers
from the outset, even on the very topics being studied. Every phase of the research is carried out in this collaborative mode. So even as study results are
being analyzed and published, operations people are already working with researchers on how to apply them in real-world care—in VA hospitals and clinics
A new model to bridge the gap
The model is called "Collaborative Research to Enhance Transformation and Excellence"—or CREATE. Atkins helped devise the approach along with his
predecessor, Seth Eisen, MD, MSc, who retired last year after a decades-long, fruitful career as a VA health services researcher and director. Many VA
researchers—and health system leaders—had input into the model, as well.
To get a better sense of how CREATE works, consider a VA research team headed by Laura Petersen, MD, MPH, one of six initial groups funded under the
For years, Petersen has led the Houston Center for Quality of Care and Utilization Studies. Among other areas, the group is well-known for its research on
VA's electronic medical record system and how to make it work better for providers and patients. And it has partnered with VA facilities around the country
to measure the quality of chronic disease care.
Praise from partners
With CREATE funding, several investigators in the group are now turning their attention to a related theme: how to improve communication in patient-aligned
care teams, or PACTs. These medical teams provide primary care to Veterans, with an emphasis on patient-centered, preventive care.
Among other issues, the CREATE team will look at how to make sure abnormal test results are acted on quickly by PACT providers. This could speed cancer
diagnosis, for example, thus getting patients into treatment sooner and potentially saving lives.
Multiple studies, diverse perspectives
The CREATE framework means several things in this case. First, there is a broad mosaic of collaborators. The investigators themselves are based at two
sites—Houston and Salt Lake City. Two Veterans Integrated Service Networks (VISNs) are involved—the Great Lakes VA Healthcare System, and the South Central
VA Health Care System. Also among the partners: the VA Primary Care Program Office, in Washington, DC. The eyes of clinical leaders and senior managers are
on the research from day one. The questions being studied are the very ones these health-system leaders have identified as crucial for Veteran care.
Says Petersen, "The goal for such a rich set of local and national perspectives is to ease implementation of our work not only in the VISNs that are
directly involved, but also at local facilities throughout the entire VHA [Veterans Health Administration]."
Second, the CREATE involves a "suite" of related studies—three in this case—that are designed to complement each other. One focuses on cancer diagnosis,
another on heart failure treatment, and a third on care coordination.
Navy Petty Officer 2nd Class Kimberley Ryan guides Afghan children to a class in Helmand province in January 2012. (Photo by Cpl. Ed Galo, USMC)
"Studies that are single and disconnected produce much slower progress," notes Atkins.
What other CREATEs are under way?
In addition to the CREATE discussed above—Improving Quality and Safety through Better Communication in PACTs—five other CREATE projects were recently funded by VA Health Services Research and Development:
- Evidence-Based Therapies for PTSD
- Long-Term Care
- Pain Management and Patient Aligned Care
- Promoting Value and Access in VA's Substance Use Disorder Services
- Women Veterans' Healthcare
For details on each, visit www.hsrd.research.va.gov/create.
Third, CREATE studies are designed from the ground up to be implementable.
For example, the leader of the cancer project, Hardeep Singh, MD, MPH, is an expert on electronic medical records and patient safety. He wants to learn the
best ways to get information about patients—including reminders about test results—into the hands of providers so it doesn't get lost or backlogged in a
sea of emails and computer alerts.
Innovations that mesh with clinical work flow
"A major part of this CREATE," says Singh, "is to work with primary care teams to determine what the best means are for communicating information about
patient needs at the 'point of care'—defined as any setting in which a provider evaluates clinical information and makes a health care decision." In other
words, that could be while the patient is sitting in the exam room, or when he is at home and the care team is reviewing his chart.
"For example, PACT members would suggest the best strategies and means for delivering information related to abnormal test results that require follow-up,"
says Singh. "We want to build communication pathways that are consistent with their work flow."
Singh says his research uses a "socio-technical" approach that appreciates that technology doesn't exist in a vacuum; it has to mesh with how people do
their work and interact with others in their workplace.
Petersen, Singh, and the others on the CREATE are no strangers to working hand in hand with clinical and program-office partners. Petersen has briefed
senior VHA leadership about her work 42 times. Singh has worked closely with VA's National Center for Patient Safety for five years.
But Petersen says CREATE brings the collaborative approach to yet a new level. Part of that, she says, is because of the "deliberate design efforts and the
financial commitments" on the part of all the partners.
She says she hopes to see the mindset and the model spread further. "CREATE sends an important message—that science and practice should work together
toward a long and fruitful marriage."