Implementing Automated Text Messaging for Patient Self-management in the Veterans Health Administration: Qualitative Study Applying the Nonadoption, Abandonment, Scale-up, Spread, and Sustainability Framework.

BACKGROUND: The Veterans Health Administration (VHA) is deploying an automated texting system (aTS) to support patient self-management. OBJECTIVE: We conducted a qualitative evaluation to examine factors influencing national rollout of the aTS, guided by the Nonadoption, Abandonment, Scale-up, Spread, and Sustainability (NASSS) framework, which is intended to support the evaluation of novel technologies. METHODS: Semistructured interviews were conducted with 33 staff and 38 patients who were early adopters of the aTS. Data were analyzed following deductive and inductive approaches using a priori codes and emergent coding based on the NASSS. RESULTS: We identified themes across NASSS domains: (1) Condition: The aTS was considered relevant for a range of patient needs; however, perceptions of patient suitability were guided by texting experience and clinical complexity rather than potential benefits. (2) Technology: Onboarding of the aTS presented difficulty and the staff had different opinions on incorporating patient-generated data into care planning. (3) Value: Supply-side value relied on the flexibility of the aTS and its impact on staff workload whereas demand-side value was driven by patient perceptions of the psychological and behavioral impacts of the aTS. (4) Adopters: Limited clarity on staff roles and responsibilities presented challenges in incorporating the aTS into clinical processes. (5) Organization: Staff were willing to try the aTS; however, perceptions of leadership support and clinic readiness hindered usage. (6) Wider system: Staff focused on enhancing aTS interoperability with the electronic medical record. (7) Embedding and adaptation over time: The interplay of aTS versatility, patient and staff demands, and broader societal changes in preferences for communicating health information facilitated aTS implementation. CONCLUSIONS: VHA's new aTS has the potential to further engage patients and expand the reach of VHA care; however, patients and staff require additional support to adopt, implement, and sustain the aTS. The NASSS highlighted how the aTS can be better embedded into current practices, which patients might benefit most from its functionality, and which aspects of aTS messages are most relevant to self-management. TRIAL REGISTRATION: ClinicalTrials.gov NCT03898349; https://clinicaltrials.gov/ct2/show/NCT03898349.

Health-Related Goal Setting and Achievement Among Veterans with High Technology Adoption.

BACKGROUND: There is increasing recognition of the importance of supporting patients in their health-related goals. Patient-provider discussions and health-related mobile applications (apps) can support patients to pursue health goals; however, their impact on patient goal setting and achievement is not well understood. OBJECTIVE: To examine the relationships between the following: (1) patient demographics, patient-provider discussions, and health-related goal setting and achievement, and (2) patient mobile health app use and goal achievement. DESIGN: Cross-sectional survey. PARTICIPANTS: Veterans who receive Veterans Health Administration (VA) healthcare and are users of VA patient-facing technology. MAIN MEASURES: Veteran demographics, goal-related behaviors, and goal achievement. METHODS: Veterans were invited to participate in a telephone survey. VA administrative data were linked to survey data for additional health and demographic information. Logistic regression models were run to identify factors that predict health-related goal setting and achievement. KEY RESULTS: Among respondents (n=2552), 75% of patients indicated having set health goals in the preceding 6 months and approximately 42% reported achieving their goal. Men (vs. women) had lower odds of setting goals (OR: 0.71; CI95: 0.53-0.97), as did individuals with worse (vs. better) health (OR: 0.18; CI95: 0.04-0.88). Individuals with advanced education-some college/college degrees, and post-college degrees (vs. no college education)-demonstrated higher odds of setting goals (OR: 1.35; CI95: 1.01-1.79; OR: 1.71; CI95: 1.28-2.28, respectively). Those who reported having discussed their goals with their providers were more likely to set goals (OR: 3.60; CI95: 2.97-4.35). Patient mobile health app use was not statistically associated with goal achievement. CONCLUSIONS: Efforts to further promote patient-led goal setting should leverage the influence of patient-provider conversations. Use of patient-facing technologies, specifically mobile health apps, may facilitate goal-oriented care, but further work is needed to examine the potential benefits of apps to support patient goals, particularly if providers discuss and endorse use of those apps with patients.

Supporting the Implementation of Connected Care Technologies in the Veterans Health Administration: Cross-Sectional Survey Findings from the Veterans Engagement with Technology Collaborative (VET-C) Cohort.

BACKGROUND: Widespread adoption, use, and integration of patient-facing technologies into the workflow of health care systems has been slow, thus limiting the realization of their potential. A growing body of work has focused on how best to promote adoption and use of these technologies and measure their impacts on processes of care and outcomes. This body of work currently suffers from limitations (eg, cross-sectional analyses, limited patient-generated data linked with clinical records) and would benefit from institutional infrastructure to enhance available data and integrate the voice of the patient into implementation and evaluation efforts. OBJECTIVE: The Veterans Health Administration (VHA) has launched an initiative called the Veterans Engagement with Technology Collaborative cohort to directly address these challenges. This paper reports the process by which the cohort was developed and describes the baseline data being collected from cohort members. The overarching goal of the Veterans Engagement with Technology Collaborative cohort is to directly engage veterans in the evaluation of new VHA patient-facing technologies and in so doing, to create new infrastructure to support related quality improvement and evaluation activities. METHODS: Inclusion criteria for veterans to be eligible for membership in the cohort included being an active user of VHA health care services, having a mobile phone, and being an established user of existing VHA patient-facing technologies as represented by use of the secure messaging feature of VHA's patient portal. Between 2017 and 2018, we recruited veterans who met these criteria and administered a survey to them over the telephone. RESULTS: The majority of participants (N=2727) were male (2268/2727, 83.2%), White (2226/2727, 81.6%), living in their own apartment or house (2519/2696, 93.4%), and had completed some college (1176/2701, 43.5%) or an advanced degree (1178/2701, 43.6%). Cohort members were 59.9 years old, on average. The majority self-reported their health status as being good (1055/2725, 38.7%) or very good (524/2725, 19.2%). Most cohort members owned a personal computer (2609/2725, 95.7%), tablet computer (1616/2716, 59.5%), and/or smartphone (2438/2722, 89.6%). CONCLUSIONS: The Veterans Engagement with Technology Collaborative cohort is an example of a VHA learning health care system initiative designed to support the data-driven implementation of patient-facing technologies into practice and measurement of their impacts. With this initiative, VHA is building capacity for future, rapid, rigorous evaluation and quality improvement efforts to enhance understanding of the adoption, use, and impact of patient-facing technologies.

Automated Text Messaging With Patients in Department of Veterans Affairs Specialty Clinics: Cluster Randomized Trial.

BACKGROUND: Acceptability of mobile phone text messaging as a means of asynchronous communication between health care systems and patients is growing. The US Department of Veterans Affairs (VA) has adopted an automated texting system (aTS) for national rollout. The aTS allows providers to develop clinical texting protocols to promote patient self-management and allows clinical teams to monitor patient progress between in-person visits. Texting-supported hepatitis C virus (HCV) treatment has not been previously tested. OBJECTIVE: Guided by the Practical, Robust Implementation and Sustainability Model (PRISM), we developed an aTS HCV protocol and conducted a mixed methods, hybrid type 2 effectiveness implementation study comparing two programs supporting implementation of the aTS HCV protocol for medication adherence in patients with HCV. METHODS: Seven VA HCV specialty clinics were randomized to usual aTS implementation versus an augmented implementation facilitation program. Implementation process measures included facilitation metrics, usability, and usefulness. Implementation outcomes included provider and patient use of the aTS HCV protocol, and effectiveness outcomes included medication adherence, health perceptions and behaviors, and sustained virologic response (SVR). RESULTS: Across the seven randomized clinics, there were 293 facilitation events using a core set of nine implementation strategies (157 events in augmented implementation facilitation, 136 events in usual implementation). Providers found the aTS appropriate with high potential for scale-up but not without difficulties in startup, patient selection and recruitment, and clinic workflow integration. Patients largely found the aTS easy to use and helpful; however, low perceived need for self-management support contributed to high declination. Reach and use was modest with 197 patients approached, 71 (36%) enrolled, 50 (25%) authenticated, and 32 (16%) using the aTS. In augmented implementation facilitation clinics, more patients actively used the aTS HCV protocol compared with usual clinic patients (20% vs 12%). Patients who texted reported lower distress about failing HCV treatment (13/15, 87%, vs 8/15, 53%; P=.05) and better adherence to HCV medication (11/15, 73%, reporting excellent adherence vs 6/15, 40%; P=.06), although SVR did not differ by group. CONCLUSIONS: The aTS is a promising intervention for improving patient self-management; however, augmented approaches to implementation may be needed to support clinician buy-in and patient engagement. Considering the behavioral, social, organizational, and technical scale-up challenges that we documented, successful and sustained implementation of the aTS may require implementation strategies that operate at the clinic, provider, and patient levels. TRIAL REGISTRATION: Retrospectively registered at ClinicalTrials.gov NCT03898349; https://clinicaltrials.gov/ct2/show/NCT03898349.

Patient prioritization of comorbid chronic conditions in the Veteran population: Implications for patient-centered care.

OBJECTIVE: Patients with comorbid chronic conditions may prioritize some conditions over others; however, our understanding of factors influencing those prioritizations is limited. In this study, we sought to identify and elaborate a range of factors that influence how and why patients with comorbid chronic conditions prioritize their conditions. METHODS: We conducted semi-structured, one-on-one interviews with 33 patients with comorbidities recruited from a single Veterans Health Administration Medical Center. FINDINGS: The diverse factors influencing condition prioritization reflected three overarching themes: (1) the perceived role of a condition in the body, (2) self-management tasks, and (3) pain. In addition to these themes, participants described the rankings that they believed their healthcare providers would assign to their conditions as an influencing factor, although few reported having shared their priorities or explicitly talking with providers about the importance of their conditions. CONCLUSION: Studies that advance understanding of how and why patients prioritize their various conditions are essential to providing care that is patient-centered, reflecting what matters most to the individual while improving their health. This analysis informs guideline development efforts for the care of patients with comorbid chronic conditions as well as the creation of tools to promote patient-provider communication regarding the importance placed on different conditions.

Older Veteran Digital Disparities: Examining the Potential for Solutions Within Social Networks.

BACKGROUND: Older adults typically have less access to the Internet than other age groups, and older Veterans may use the Internet even less due to economic and geographic reasons. OBJECTIVE: To explore solutions to this problem, our study examined older Veterans' reported ability to access technology through their close social ties. METHODS: Data were collected via mail survey from a sample of Veterans aged 65 years and older (N=266). RESULTS: Nearly half (44.0%, 117/266) of the sample reported having no Internet access. Yet, among those without current access, older Veterans reported having a median of 5 (IQR 7) close social ties with home Internet access. These older Veterans also reported that they would feel comfortable asking a median of 2 (IQR 4) social ties for help to access the Internet, and that a median of 2 (IQR 4) social ties would directly access the Internet for the older Veteran to help with health management. CONCLUSIONS: Findings suggest that even older Veterans without current Internet access have at least two social ties with home Internet who could be called upon for technology support. Thus, older Veterans may be willing to call upon these "surrogate seekers" for technology assistance and support in health management. This has implications for the digital divide, technology design, and health care policy.