Table 6 VHR use within the healthcare continuum

Veteran Activities

• Schedule medical visit

(2, 14, 16)

• List problems to be discussed at appointment

(3, 4, 14, 16)

• Complete Healthy Living Assessment (6)

• Identify symptoms and current treatments

(3, 14, 16, 22)

• Review and update personal information

(16, 20)

• Review and update insurance information

(16, 20)

• Check-in (20)

• Check-out (20)

• Schedule follow-up visit

(2, 14, 15, 16)

• Measure health indices

(9, 15, 22)

• Learn about condition (4, 10, 11, 14, 15, 16, 17, 19)

• Seeking information about condition and treatment plan

(3, 6, 8, 10, 11, 14, 15,16, 17, 19)

• Follow-up with providers

(2, 14, 15, 16)

• Self-management activities

(1, 6, 8, 10, 11,12, 22, 23)

• Monitoring health indices (1, 6, 8, 15, 16, 22)

• Managing personal health information

(3, 8)

• Identifying need for additional medical visits (2, 8, 14, 22, 23)

• Communicating with health care team

(1, 3, 14, 15, 16)

• Labs and test (9)

Primary Care Team Member Activities

• Schedule medical visit

(14, 15, 16)

• Prepare Veteran for appointment (e.g., fast for labs, list concerns to be discussed)

(14, 15, 16)

• Stratify hospitalization risk (4)

• Coordinate with staff in preparation for appointment

(5, 13, 16, 18, 21, 23)

• Schedule follow-up visit

(14, 15, 16)

• Measure and document health indices

(5, 9, 14, 15, 16, 22)

• Obtain medical history

(3, 5, 7, 14, 15, 16, 21, 22)

• Physical examination

(15, 16)

• Documentation of assessment and plan

(5, 21)

• Coordinate care with other providers and services

(3, 5, 13, 18, 21)

• Educate patient on plan and conditions

(4, 10, 11, 14, 15, 16, 17, 19, 23)

• Prescribe medication (5)

• Send Veteran to Travel for reimbursement on appointment travel

(13, 16)

• Staff create registered nurse follow-up messages

(1, 13, 14, 18)

• Home health assessment for personal care needs and follow-up on resources

(5, 14, 15, 16)

• Communicating with health care team

(5, 13, 14, 15, 16, 21)

• Labs and test (5, 9)

• Medication reconciliation

(5, 12, 14, 15, 16, 17)

• Patient data reporting (4, 5, 21, 22)

• Educate patient

(10, 11, 14, 15, 16, 17, 19, 23)

Collaborative Activities

• Discuss Advanced Directives

(5, 16)

• Prioritize discussion points

(14, 15, 16)

• Assist with review and update personal information

(16, 20)

• Assist with review and update insurance information

(16, 20)

• Assist with Check-in (20)

• Assist with Check-out (20)

• Measure health indices

(5, 9, 14, 15, 16, 22)

• Discuss concerns/symptoms/current treatment

(6, 8, 14, 15, 16)

• Labs and tests

(5, 9)

• Complete required forms

(5, 21)

• Consenting for procedures (5, 21)

• Collect data from journaling, Fitbit, etc.

(1, 3, 6, 8, 10, 11, 14, 15, 16, 22)

• Implement treatment plan

(1, 5, 8, 10, 11, 19, 22, 23)

• Revise treatment plan

(1, 5, 8, 10, 11, 22, 23)