Original Research

Effects of Computer-Based Documentation Procedures on Health Care Workload Assessment and Resource Allocation: An Example From VA Sleep Medicine Programs

Fed Pract. 2020 August;37(8):368-374 | 10.12788/fp.0023

References

1. World Health Organization. Workload indicators of staffing need (WISN). https://www.who.int/hrh/resources/WISN_Eng_UsersManual.pdf?ua=1. Published December 2015. Accessed June 24, 2020.

2. American Association for Respiratory Care. Position statement: best practices in respiratory care productivity and staffing. https://www.aarc.org/wp-content/uploads/2017/03/statement-of-best-practices_productivity-and-staffing.pdf. Revised July 2015. Accessed June 24, 2020.

3. Wu DTY, Smart N, Ciemins EL, Lanham HJ, Lindberg C, Zheng K. Using EHR audit trail logs to analyze clinical workflow: a case study from community-based ambulatory clinics. AMIA Annu Symp Proc. 2018;2017:1820-1827. Published 2018 Apr 16.

4. US Department of Veterans Affairs, Veterans Health Administration. https://www.va.gov/health.

5. Cohen T. VA crisis: solutions exist, but haven’t happened, panel hears. https://www.cnn.com/2014/06/12/politics/va-reforms/index.html. Published June 12, 2014. Accessed June 24, 2020.

6. Richardson B. IG probes uncover more problems at VA hospitals. https://thehill.com/policy/defense/258652-ig-probes-uncover-more-problems-at-va-hospitals. Published October 30, 2015. Accessed June 24, 2020.

7. Slack D. Inaccurate VA wait times prelude thousands of vets from getting outside care, probe finds. USA Today. March 3, 2017. https://www.usatoday.com/story/news/politics/2017/03/03/veterans-affairs-inspector-general-widespread-inaccuracies-wait-times/98693856. Accessed June 24, 2020.

8. US Department of Veterans Affairs, Office of the Inspector General. Veterans Health Administration: audit of physician staffing levels for specialty care services. https://www.va.gov/oig/pubs/VAOIG-11-01827-36.pdf. Published December 27, 2012. Accessed June 24, 2020.

9. Government Accountability Office. VA health care: improvements needed in data and monitoring of clinical productivity and efficiency. https://www.gao.gov/assets/690/684869.pdf. Published May 2017. Accessed June 24, 2020.

10. US Department of Veterans Affairs, Veterans Health Administration. VHA Directive 1082. Patient care data capture. https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=3091. Published March 24, 2015. Accessed June 24, 2020.

11. US Department of Veterans Affairs, Veterans Health Administration. VHA Handbook 1006.02. VHA site classifications and definitions. https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=2970. Published December 30, 2013. Accessed June 24, 2020.

12. Alexander M, Ray MA, Hébert JR, et al. The National Veteran Sleep Disorder Study: Descriptive Epidemiology and Secular Trends, 2000-2010. Sleep. 2016;39(7):1399-1410. Published 2016 Jul 1. doi:10.5665/sleep.5972.

13. A Caldwell J, Knapik JJ, Lieberman HR. Trends and factors associated with insomnia and sleep apnea in all United States military service members from 2005 to 2014. J Sleep Res. 2017;26(5):665-670. doi:10.1111/jsr.12543

14. Klingaman EA, Brownlow JA, Boland EM, Mosti C, Gehrman PR. Prevalence, predictors and correlates of insomnia in US army soldiers. J Sleep Res. 2018;27(3):e12612. doi:10.1111/jsr.12612

15. Sharafkhaneh A, Richardson P, Hirshkowitz M. Sleep apnea in a high risk population: a study of Veterans Health Administration beneficiaries. Sleep Med. 2004;5(4):345-350. doi:10.1016/j.sleep.2004.01.019.

16. Sarmiento KF, Folmer RL, Stepnowsky CJ, et al. National Expansion of Sleep Telemedicine for Veterans: The TeleSleep Program. J Clin Sleep Med. 2019;15(9):1355-1364. doi:10.5664/jcsm.7934

17. Van Dongen HP, Maislin G, Mullington JM, Dinges DF. The cumulative cost of additional wakefulness: dose-response effects on neurobehavioral functions and sleep physiology from chronic sleep restriction and total sleep deprivation [published correction appears in Sleep. 2004 Jun 15;27(4):600]. Sleep. 2003;26(2):117-126. doi:10.1093/sleep/26.2.117

18. Johnson EO, Roth T, Breslau N. The association of insomnia with anxiety disorders and depression: exploration of the direction of risk. J Psychiatr Res. 2006;40(8):700-708. doi:10.1016/j.jpsychires.2006.07.008

19. Léger D, Bayon V, Ohayon MM, et al. Insomnia and accidents: cross-sectional study (EQUINOX) on sleep-related home, work and car accidents in 5293 subjects with insomnia from 10 countries. J Sleep Res. 2014;23(2):143-152. doi:10.1111/jsr.12104

20. Franklin KA, Lindberg E. Obstructive sleep apnea is a common disorder in the population-a review on the epidemiology of sleep apnea. J Thorac Dis. 2015;7(8):1311-1322. doi:10.3978/j.issn.2072-1439.2015.06.11

21. Javaheri S, Redline S. Insomnia and Risk of Cardiovascular Disease. Chest. 2017;152(2):435-444. doi:10.1016/j.chest.2017.01.026

22. Linz D, McEvoy RD, Cowie MR, et al. Associations of obstructivesSleepaApnea with atrial fibrillation and continuous positive airway pressure treatment: a review. JAMA Cardiol. 2018;3(6):532-540. doi:10.1001/jamacardio.2018.0095

23. Ogilvie RP, Lakshminarayan K, Iber C, Patel SR, Lutsey PL. Joint effects of OSA and self-reported sleepiness on incident CHD and stroke. Sleep Med. 2018;44:32-37. doi:10.1016/j.sleep.2018.01.004

Discussion

Inaccuracies in CBD procedures can adversely affect health care workload assessment and allocation, contributing to ongoing challenges faced by sleep medicine clinics and other VHA programs that have limited staff yet strive to provide timely and high-quality care to veterans. “Not only does inaccurate coding contribute to miscalculations in staffing and resource allocation, it can also contribute to inaccuracies in overall measures of VA healthcare efficiency,” the GAO reported to Congress.⁹ The GAO went on to recommend that the VA should ensure the accuracy of underlying staffing and workload data. VHA sleep medicine programs have made efforts to educate HCPs and administrators on the importance of accurate CBD as a tool for accurate data capture that is necessary to facilitate improvements in health care availability and delivery.

In 2018, the VA Sleep Program Office released an updated set of Stop Code changes, including expansion of telehealth codes and improved designation of laboratory and home sleep testing services. These changes are anticipated to result in accurate documentation of VA sleep clinic workload and services, especially as the VA TeleSleep EWI to reach rural veterans expands.¹⁶ In light of the improved accuracy of reporting of delivered sleep services due to changes in Stop Codes over the past 4 years, VHA sleep medicine providers continue to advocate for allocation of resources commensurate with their clinical workload. An appropriate administrative response to the significant clinical workload performed by disproportionately few providers should include the authorization of increased resources and personnel for sleep medicine as well as providing the tools needed to further streamline workflow efficiency (eg, artificial intelligence, machine learning, and population health management).

Conclusions

Despite the barriers faced by many large integrated health care systems, VHA sleep medicine leadership continues to implement changes in CBD protocols that improve the accuracy of clinical workload tracking and reporting. Ultimately, these changes will support proposals for increased resources necessary to improve the quality and availability of sleep care for veterans. This example from VA illustrates the importance of accurate workload capture and its role in informing administrators of health care systems as they strive to meet the needs of patients. Although some VA sleep medicine programs continue to face challenges imposed by systemwide limitations, the ORH TeleSleep Program is a major initiative that improves veterans’ access to care by disseminating and implementing effective telehealth technologies and strategies.¹⁶

Acknowledgments

This work was supported by a VA Office of Rural Health Enterprise-Wide Initiative.

References

1. World Health Organization. Workload indicators of staffing need (WISN). https://www.who.int/hrh/resources/WISN_Eng_UsersManual.pdf?ua=1. Published December 2015. Accessed June 24, 2020.

2. American Association for Respiratory Care. Position statement: best practices in respiratory care productivity and staffing. https://www.aarc.org/wp-content/uploads/2017/03/statement-of-best-practices_productivity-and-staffing.pdf. Revised July 2015. Accessed June 24, 2020.

3. Wu DTY, Smart N, Ciemins EL, Lanham HJ, Lindberg C, Zheng K. Using EHR audit trail logs to analyze clinical workflow: a case study from community-based ambulatory clinics. AMIA Annu Symp Proc. 2018;2017:1820-1827. Published 2018 Apr 16.

4. US Department of Veterans Affairs, Veterans Health Administration. https://www.va.gov/health.

5. Cohen T. VA crisis: solutions exist, but haven’t happened, panel hears. https://www.cnn.com/2014/06/12/politics/va-reforms/index.html. Published June 12, 2014. Accessed June 24, 2020.

6. Richardson B. IG probes uncover more problems at VA hospitals. https://thehill.com/policy/defense/258652-ig-probes-uncover-more-problems-at-va-hospitals. Published October 30, 2015. Accessed June 24, 2020.

7. Slack D. Inaccurate VA wait times prelude thousands of vets from getting outside care, probe finds. USA Today. March 3, 2017. https://www.usatoday.com/story/news/politics/2017/03/03/veterans-affairs-inspector-general-widespread-inaccuracies-wait-times/98693856. Accessed June 24, 2020.

8. US Department of Veterans Affairs, Office of the Inspector General. Veterans Health Administration: audit of physician staffing levels for specialty care services. https://www.va.gov/oig/pubs/VAOIG-11-01827-36.pdf. Published December 27, 2012. Accessed June 24, 2020.

9. Government Accountability Office. VA health care: improvements needed in data and monitoring of clinical productivity and efficiency. https://www.gao.gov/assets/690/684869.pdf. Published May 2017. Accessed June 24, 2020.

10. US Department of Veterans Affairs, Veterans Health Administration. VHA Directive 1082. Patient care data capture. https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=3091. Published March 24, 2015. Accessed June 24, 2020.

11. US Department of Veterans Affairs, Veterans Health Administration. VHA Handbook 1006.02. VHA site classifications and definitions. https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=2970. Published December 30, 2013. Accessed June 24, 2020.

12. Alexander M, Ray MA, Hébert JR, et al. The National Veteran Sleep Disorder Study: Descriptive Epidemiology and Secular Trends, 2000-2010. Sleep. 2016;39(7):1399-1410. Published 2016 Jul 1. doi:10.5665/sleep.5972.

13. A Caldwell J, Knapik JJ, Lieberman HR. Trends and factors associated with insomnia and sleep apnea in all United States military service members from 2005 to 2014. J Sleep Res. 2017;26(5):665-670. doi:10.1111/jsr.12543

14. Klingaman EA, Brownlow JA, Boland EM, Mosti C, Gehrman PR. Prevalence, predictors and correlates of insomnia in US army soldiers. J Sleep Res. 2018;27(3):e12612. doi:10.1111/jsr.12612

15. Sharafkhaneh A, Richardson P, Hirshkowitz M. Sleep apnea in a high risk population: a study of Veterans Health Administration beneficiaries. Sleep Med. 2004;5(4):345-350. doi:10.1016/j.sleep.2004.01.019.

16. Sarmiento KF, Folmer RL, Stepnowsky CJ, et al. National Expansion of Sleep Telemedicine for Veterans: The TeleSleep Program. J Clin Sleep Med. 2019;15(9):1355-1364. doi:10.5664/jcsm.7934

17. Van Dongen HP, Maislin G, Mullington JM, Dinges DF. The cumulative cost of additional wakefulness: dose-response effects on neurobehavioral functions and sleep physiology from chronic sleep restriction and total sleep deprivation [published correction appears in Sleep. 2004 Jun 15;27(4):600]. Sleep. 2003;26(2):117-126. doi:10.1093/sleep/26.2.117

18. Johnson EO, Roth T, Breslau N. The association of insomnia with anxiety disorders and depression: exploration of the direction of risk. J Psychiatr Res. 2006;40(8):700-708. doi:10.1016/j.jpsychires.2006.07.008

19. Léger D, Bayon V, Ohayon MM, et al. Insomnia and accidents: cross-sectional study (EQUINOX) on sleep-related home, work and car accidents in 5293 subjects with insomnia from 10 countries. J Sleep Res. 2014;23(2):143-152. doi:10.1111/jsr.12104

20. Franklin KA, Lindberg E. Obstructive sleep apnea is a common disorder in the population-a review on the epidemiology of sleep apnea. J Thorac Dis. 2015;7(8):1311-1322. doi:10.3978/j.issn.2072-1439.2015.06.11

21. Javaheri S, Redline S. Insomnia and Risk of Cardiovascular Disease. Chest. 2017;152(2):435-444. doi:10.1016/j.chest.2017.01.026

22. Linz D, McEvoy RD, Cowie MR, et al. Associations of obstructivesSleepaApnea with atrial fibrillation and continuous positive airway pressure treatment: a review. JAMA Cardiol. 2018;3(6):532-540. doi:10.1001/jamacardio.2018.0095

23. Ogilvie RP, Lakshminarayan K, Iber C, Patel SR, Lutsey PL. Joint effects of OSA and self-reported sleepiness on incident CHD and stroke. Sleep Med. 2018;44:32-37. doi:10.1016/j.sleep.2018.01.004

Effects of Computer-Based Documentation Procedures on Health Care Workload Assessment and Resource Allocation: An Example From VA Sleep Medicine Programs

References

Discussion

Conclusions

Pages

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