Incorporating TechQuity in Virtual Care Within the Veterans Health Administration: Identifying Future Research and Operations Priorities.

BACKGROUND: The Covid-19 pandemic dramatically changed healthcare delivery, driving rapid expansion of synchronous (i.e., real-time) audio-only and video telehealth, otherwise known as virtual care. Yet evidence describes significant inequities in virtual care utilization, with certain populations more dependent on audio-only virtual care than video-based care. Research is needed to inform virtual care policies and processes to counteract current inequities in access and health outcomes. OBJECTIVE: Given the importance of incorporating equity into virtual care within the Veterans Health Administration (VHA), we convened a Think Tank to identify priorities for future research and virtual care operations focused on achieving equitable implementation of virtual care within the VHA. METHODS: We used participatory activities to engage clinicians, researchers, and operational partners from across the VHA to develop priorities for equitable implementation of virtual care. We refined priorities through group discussion and force-ranked prioritization and outlined next steps for selected priorities. KEY RESULTS: Think Tank participants included 43 individuals from the VHA who represented diverse geographical regions, offices, and backgrounds. Attendees self-identified their associations primarily as operations (n = 9), research (n = 28), or both (n = 6). We identified an initial list of 63 potential priorities for future research and virtual care operations. Following discussion, we narrowed the list to four priority areas: (1) measure inequities in virtual care, (2) address emerging inequities in virtual care, (3) deploy virtual care equitably to accommodate differently abled veterans, and (4) measure and address potential adverse consequences of expanded virtual care. We discuss related information, data, key partners, and outline potential next steps. CONCLUSIONS: This Think Tank of research and operational partners from across the VHA identified promising opportunities to incorporate equity into the design and implementation of virtual care. Although much work remains, the priorities identified represent important steps toward achieving this vital goal.

Patient and Provider Experience of Electronic Patient Portals and Secure Messaging in Mental Health Treatment.

Objective: Electronic health record patient portals were promoted to enhance patient engagement. However, organizations often deny patient access to records of treatment for mental health disorders. This study explores patient and provider experience of patient electronic access to the mental health treatment record and the use of secure messaging. Materials and Methods: Online surveys of a sample of mental health patients (N = 168) and providers (N = 80) addressed their experience using patient portals and secure messaging. Results: Only 29 of the 80 providers (36%) worked at organizations which provided patients electronic access to mental health records. Of these 29 providers, 72% endorsed that patients requested a change in the provider note, 69% endorsed patients asked more questions, 55% endorsed patients reported they experienced significant distress after accessing portal, and 21% reported patients engaged in negative and/or self-destructive behavior toward themselves or others. Of patients with access to mental health notes (N = 37), 86% endorsed that they gained a better understanding of what was discussed in the appointment, 84% trusted their health care provider more, 76% felt comforted or relieved after reading their health information, and 57% reported they were better able to take medications as prescribed. Both patients and providers enjoyed the efficiency of secure messaging. Open-text responses are also presented. Conclusions: The implementation of electronic access to mental health notes requires a transition from viewing the medical record as the exclusive tool of providers to that of a collaborative tool for patients and providers to achieve treatment goals.

Accelerating Implementation of Virtual Care in an Integrated Health Care System: Future Research and Operations Priorities.

BACKGROUND: Virtual care is critical to Veterans Health Administration (VHA) efforts to expand veterans' access to care. Health care policies such as the Veterans Access, Choice, and Accountability (CHOICE) Act and the Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act impact how the VHA provides care. Research on ways to refine virtual care delivery models to meet the needs of veterans, clinicians, and VHA stakeholders is needed. OBJECTIVE: Given the importance of virtual approaches for increasing access to high-quality VHA care, in December 2019, we convened a Think Tank, Accelerating Implementation of Virtual Care in VHA Practice, to consider challenges to virtual care research and practice across the VHA, discuss novel approaches to using and evaluating virtual care, assess perspectives on virtual care, and develop priorities to enhance virtual care in the VHA. METHODS: We used a participatory approach to develop potential priorities for virtual care research and activities at the VHA. We refined these priorities through force-ranked prioritization and group discussion, and developed solutions for selected priorities. RESULTS: Think Tank attendees (n = 18) consisted of VHA stakeholders, including operations partners (e.g., Office of Rural Health, Office of Nursing Services, Health Services Research and Development), clinicians (e.g., physicians, nurses, psychologists, physician assistants), and health services researchers. We identified an initial list of fifteen potential priorities and narrowed these down to four. The four priorities were (1) scaling evidence-based practices, (2) centralizing virtual care, (3) creating high-value care within the VHA with virtual care, and (4) identifying appropriate patients for virtual care. CONCLUSION: Our Think Tank took an important step in setting a partnered research agenda to optimize the use of virtual care within the VHA. We brought together research and operations stakeholders and identified possibilities, partnerships, and potential solutions for virtual care.

Puente para cuidar (bridge to caring): A palliative care patient navigator and counseling intervention to improve distress in Latino/as with advanced cancer.

OBJECTIVE: Interventions are needed to improve mental health (ie, depression, anxiety) and palliative care (ie, symptoms, goals of care, and advance care planning) outcomes in Latino/as with advanced cancer. METHODS: An interprofessional study team used the ecological validity model and a participatory approach to adapt an evidence-based counseling intervention for Latino/as and integrate the counseling intervention with an evidence-based patient navigator intervention. Next, a small pilot study was conducted to understand and improve the feasibility of the integrated puente para cuidar intervention. RESULTS: Adaptations were made to language, literacy, and content of the counseling intervention, and video vignettes of the counseling case studies were produced on the recommendation of Latino/a stakeholders. Bicultural, bilingual patient navigators were used as "cultural brokers" between Latino/a patients and the counselor. The pilot study of puente para cuidar demonstrated feasibility based on participant perception of helpfulness and acceptability and nearing goal visit completion rates. CONCLUSIONS: A culturally adapted intervention to address mental health and palliative care needs in Latino/as with advanced cancer was developed from prior evidenced-based interventions using a cultural adaptation model and a participatory approach. The intervention is ready for effectiveness testing.

Impact of Patient Portal Use on Duplicate Laboratory Tests in Diabetes Management.

Background: Patients seek care across multiple health care settings. One coordination issue is the unnecessary duplication of laboratory across different health care settings. This analysis examined the association between patient portal use and duplication of laboratory testing among Veterans who are dual users of Veterans Affairs (VA) and non-VA providers. Materials and Methods: A national sample of Veterans who were newly authenticated users of the portal during fiscal year (FY) 2013 who used Blue Button at least once were compared with a random sample of Veterans who were not registered to use the portal. From these two groups, Veterans who were also Medicare-eligible users in FY2014 were identified. Duplicate testing was defined as receipt of more than five HbA1c (hemoglobin A1c) in 1 year. Results: Use of the Blue Button decreased the odds of duplicate HbA1c testing in VA and Medicare-covered facilities across three comparisons: (1) overall between users and nonusers: portal users were less likely to have duplicate testing; (2) pre-post comparison: there was a trend toward lower duplicate testing in both groups across time; and (3) pre-post comparisons accounting for use of the portal: the trend toward lower duplicate testing was greater in Blue Button users. Conclusion: Duplicate HbA1c testing was significantly lower in dual users of VA and Medicare services who used the Blue Button feature of their VA patient portal. Non-VA providers encounter barriers to access of complete information about Veterans who also use VA health care. Provider endorsement of consumer-mediated health information exchange could help further this model of sharing information.

Identifying critical psychotherapy targets in serious cardiac conditions: The importance of addressing coping with symptoms, healthcare navigation, and social support.

OBJECTIVE: In seriously ill cardiac patients, several psychotherapy efficacy studies demonstrate little to no reduction in depression or improvement in quality of life, and little is known about how to improve psychotherapies to best address the range of patient needs. An interpersonal and behavioral activation psychotherapy was a key component of the Collaborative Care to Alleviate Symptoms and Adjust to Illness (CASA) multisite randomized clinical trial. Although depressive symptoms did improve in the CASA trial, questions remain about how best to tailor psychotherapies to the needs of seriously ill patient populations. The study objective was to describe psychosocial needs emerging during a clinical trial of a palliative care and interpersonal and behavioral activation psychotherapy intervention that were not specifically addressed by the psychotherapy. METHOD: During the CASA trial, patient needs were prospectively tracked by the psychotherapist in each visit note using an a priori code list. Preplanned analysis of study data using directed content analysis was conducted analyzing the a priori code list, which were collapsed by team consensus into larger themes. The frequency of each code and theme were calculated into a percentage of visits. RESULT: A total of 150 patients received one or more visits from the therapist and were included in the analysis. Participants screened positive for depressive disorder (47%), had poor heart failure-specific health status (mean Kansas City Cardiomyopathy Questionnaire score = 48.6; SD = 17.4), and multiple comorbidities (median 4.3). Common needs that emerged during the therapy included difficulty coping with fatigue (48%), pain (28%), and satisfaction issues with medical care (43%). The following broader themes emerged: social support (77% of sessions), unmet symptom needs (67%), healthcare navigation (48%), housing, legal, safety, and transportation (32%), and end of life (12%). SIGNIFICANCE OF RESULTS: Coping with chronic symptoms and case management needs commonly emerged during psychotherapy visits. Future psychotherapy interventions in seriously ill populations should consider the importance of coping with chronic symptoms and case management.

Lifelong Learning for Clinical Practice: How to Leverage Technology for Telebehavioral Health Care and Digital Continuing Medical Education.

PURPOSE OF REVIEW: Psychiatric practice continues to evolve and play an important role in patients' lives, the field of medicine, and health care delivery. Clinicians must learn a variety of clinical care systems and lifelong learning (LLL) is crucial to apply knowledge, develop skills, and adjust attitudes. Technology is rapidly becoming a key player-in delivery, lifelong learning, and education/training. RECENT FINDINGS: The evidence base for telepsychiatry/telemental health via videoconferencing has been growing for three decades, but a greater array of technologies have emerged in the last decade (e.g., social media/networking, text, apps). Clinicians are combining telepsychiatry and these technologies frequently and they need to reflect on, learn more about, and develop skills for these technologies. The digital age has solidified the role of technology in continuing medical education and day-to-day practice. Other fields of medicine are also adapting to the digital age, as are graduate and undergraduate medical education and many allied mental health organizations. In the future, there will be more online training, simulation, and/or interactive electronic examinations, perhaps on a monthly cycle rather than a quasi-annual or 10-year cycle of recertification.

A Decade of Veteran Voices: Examining Patient Portal Enhancements Through the Lens of User-Centered Design.

BACKGROUND: Health care systems have entered a new era focused on patient engagement. Patient portals linked to electronic health records are recognized as a promising multifaceted tool to help achieve patient engagement goals. Achieving significant growth in adoption and use requires agile evaluation methods to complement periodic formal research efforts. OBJECTIVE: This paper describes one of the implementation strategies that the Department of Veterans Affairs (VA) has used to foster the adoption and sustained use of its patient portal, My HealtheVet, over the last decade: an ongoing focus on user-centered design (UCD). This strategy entails understanding the users and their tasks and goals and optimizing portal design and functionality accordingly. Using a case study approach, we present a comparison of early user demographics and preferences with more recent data and several examples to illustrate how a UCD can serve as an effective implementation strategy for a patient portal within a large integrated health care system. METHODS: VA has employed a customer experience analytics (CXA) survey on its patient portal since 2007 to enable ongoing direct user feedback. In a continuous cycle, a random sample of site visitors is invited to participate in the Web-based survey. CXA model questions are used to track and trend satisfaction, while custom questions collect data about users' characteristics, needs, and preferences. In this case study, we performed analyses of descriptive statistics comparing user characteristics and preferences from FY2008 (wherein "FY" means "fiscal year") to FY2017 and user trends regarding satisfaction with and utilization of specific portal functions over the last decade, as well as qualitative content analysis of user's open-ended survey comments. RESULTS: User feedback has guided the development of enhancements to core components of the My HealtheVet portal including available features, content, interface design, prospective functional design, and related policies. Ten-year data regarding user characteristics and portal utilization demonstrate trends toward greater patient engagement and satisfaction. Administration of a continuous voluntary Web-based survey is an efficient and effective way to capture veterans' voices about who they are, how they use the patient portal, needed system improvements, and desired additional services. CONCLUSIONS: Leveraging "voice-of-the-customer" techniques as part of patient portal implementation can ensure that such systems meet users' needs in ways that are agile and most effective. Through this strategy, VA has fostered significant adoption and use of My HealtheVet to engage patients in managing their health.

Best Practices in Videoconferencing-Based Telemental Health April 2018.

Telemental health, in the form of interactive videoconferencing, has become a critical tool in the delivery of mental health care. It has demonstrated the ability to increase access to and quality of care, and in some settings to do so more effectively than treatment delivered in-person. This article updates and consolidates previous guidance developed by The American Telemedicine Association (ATA) and The American Psychiatric Association (APA) on the development, implementation, administration, and provision of telemental health services. The guidance included in this article is intended to assist in the development and delivery of effective and safe telemental health services founded on expert consensus, research evidence, available resources, and patient needs. It is recommended that the material reviewed be contemplated in conjunction with APA and ATA resources, as well as the pertinent literature, for additional details on the topics covered.

The Use of Telemedicine and Mobile Technology to Promote Population Health and Population Management for Psychiatric Disorders.

PURPOSE OF REVIEW: This article discusses recent applications in telemedicine to promote the goals of population health and population management for people suffering psychiatric disorders. RECENT FINDINGS: The use of telemedicine to promote collaborative care, self-monitoring and chronic disease management, and population screening has demonstrated broad applicability and effectiveness. Collaborative care using videoconferencing to facilitate mental health specialty consults has demonstrated effectiveness in the treatment of depression, PTSD, and also ADHD in pediatric populations. Mobile health is currently being harnessed to monitor patient symptom trajectories with the goal of using machine learning algorithms to predict illness relapse. Patient portals serve as a bridge between patients and providers. They provide an electronically secure shared space for providers and patients to collaborate and optimize care. To date, research has supported the effectiveness of telemedicine in promoting population health. Future endeavors should focus on developing the most effective clinical protocols for using these technologies to ensure long-term use and maximum effectiveness in reducing population burden of mental health.

Psychometric Properties of Patient-Facing eHealth Evaluation Measures: Systematic Review and Analysis.

BACKGROUND: Significant resources are being invested into eHealth technology to improve health care. Few resources have focused on evaluating the impact of use on patient outcomes A standardized set of metrics used across health systems and research will enable aggregation of data to inform improved implementation, clinical practice, and ultimately health outcomes associated with use of patient-facing eHealth technologies. OBJECTIVE: The objective of this project was to conduct a systematic review to (1) identify existing instruments for eHealth research and implementation evaluation from the patient's point of view, (2) characterize measurement components, and (3) assess psychometrics. METHODS: Concepts from existing models and published studies of technology use and adoption were identified and used to inform a search strategy. Search terms were broadly categorized as platforms (eg, email), measurement (eg, survey), function/information use (eg, self-management), health care occupations (eg, nurse), and eHealth/telemedicine (eg, mHealth). A computerized database search was conducted through June 2014. Included articles (1) described development of an instrument, or (2) used an instrument that could be traced back to its original publication, or (3) modified an instrument, and (4) with full text in English language, and (5) focused on the patient perspective on technology, including patient preferences and satisfaction, engagement with technology, usability, competency and fluency with technology, computer literacy, and trust in and acceptance of technology. The review was limited to instruments that reported at least one psychometric property. Excluded were investigator-developed measures, disease-specific assessments delivered via technology or telephone (eg, a cancer-coping measure delivered via computer survey), and measures focused primarily on clinician use (eg, the electronic health record). RESULTS: The search strategy yielded 47,320 articles. Following elimination of duplicates and non-English language publications (n=14,550) and books (n=27), another 31,647 articles were excluded through review of titles. Following a review of the abstracts of the remaining 1096 articles, 68 were retained for full-text review. Of these, 16 described an instrument and six used an instrument; one instrument was drawn from the GEM database, resulting in 23 articles for inclusion. None included a complete psychometric evaluation. The most frequently assessed property was internal consistency (21/23, 91%). Testing for aspects of validity ranged from 48% (11/23) to 78% (18/23). Approximately half (13/23, 57%) reported how to score the instrument. Only six (26%) assessed the readability of the instrument for end users, although all the measures rely on self-report. CONCLUSIONS: Although most measures identified in this review were published after the year 2000, rapidly changing technology makes instrument development challenging. Platform-agnostic measures need to be developed that focus on concepts important for use of any type of eHealth innovation. At present, there are important gaps in the availability of psychometrically sound measures to evaluate eHealth technologies.

The Characteristics of Pain in Patients Diagnosed with Depression and Heart Failure.

Heart failure (HF) is a costly and growing health problem that is routinely complicated by chronic pain and depression. The purpose of this paper is to describe the characteristics of pain and pain management in depressed HF patients. In this descriptive cross-sectional study, we analyzed data from 62 participants with depression and class II-IV HF. Study variables of interest were collected from the Brief Pain Inventory, Beck Depression Inventory, and Rand-36. Almost all participants (98%) had some pain in the past month and most had pain in the last 24 hours (66%). The median pain score was 4 (0-10 scale) with the majority reporting moderate to severe pain. The median pain interference score was 4.42 (0-10 scale) with the majority reporting moderate to extreme interference. Medication to treat pain was used by all participants who reported pain, with only 5% also using nonpharmacologic treatment. The majority of participants reported moderate or severe pain while also having moderate to extreme pain interference. Nonpharmacologic pain treatments were severely underused. Women were more likely to have higher levels of pain intensity and more pain interference than men, suggesting that additional screening for the impact of pain is especially important in women. The wide variety of body areas affected, along with moderate to high intensity pain and considerable interference scores reported, indicate that pain was ineffectively treated. Nonpharmacologic treatments should be considered to decrease the impact of pain.

The Relationships Among Pain, Depression, and Physical Activity in Patients With Heart Failure.

INTRODUCTION: Increasing patients' physical activity levels holds many opportunities to facilitate health and well-being among those with heart failure (HF) by improving HF symptoms and decreasing depression and pain. Given low exercise participation rates, an essential first step to increase exercise rates is to evaluate how pain and depression may further influence engagement in exercise programs. AIMS: The aims of this study were to describe the level of physical activity and exercise that patients with HF with depression achieve and to investigate the relationships among pain, depression, total activity time, and sitting time. METHODS: In this correlational cross-sectional study, we analyzed data from 61 participants with depression and New York Heart Association class II to IV HF. RESULTS AND CONCLUSIONS: The total time spent being active was less than 1 hour per day. Depressed patients with HF have much lower physical activity levels than the general public. Decreasing sitting time and increasing light activity levels hold promise to improve pain and depression symptoms.

The Veteran-Initiated Electronic Care Coordination: A Multisite Initiative to Promote and Evaluate Consumer-Mediated Health Information Exchange.

INTRODUCTION: Information continuity is critical to person-centered care when patients receive care from multiple healthcare systems. Patients can access their electronic health record data through patient portals to facilitate information exchange. This pilot was developed to improve care continuity for rural Veterans by (1) promoting the use of the Department of Veterans Affairs (VA) patient portal to share health information with non-VA providers, and (2) evaluating the impact of health information sharing at a community appointment. MATERIALS AND METHODS: Veterans from nine VA healthcare systems were trained to access and share their VA Continuity of Care Document (CCD) with their non-VA providers. Patients and non-VA providers completed surveys on their experiences. RESULTS: Participants (n = 620) were primarily older, white, and Vietnam era Veterans. After training, 78% reported the CCD would help them be more involved in their healthcare and 86% planned to share it regularly with non-VA providers. Veterans (n = 256) then attended 277 community appointments. Provider responses from these appointments (n = 133) indicated they were confident in the accuracy of the information (97%) and wanted to continue to receive the CCD (96%). Ninety percent of providers reported the CCD improved their ability to have an accurate medication list and helped them make medication treatment decisions. Fifty percent reported they did not order a laboratory test or another procedure because of information available in the CCD. CONCLUSIONS: This pilot demonstrates feasibility and value of patient access to a CCD to facilitate information sharing between VA and non-VA providers. Outreach and targeted education are needed to promote consumer-mediated health information exchange.

An individually-tailored smoking cessation intervention for rural Veterans: a pilot randomized trial.

BACKGROUND: Tobacco use remains prevalent among Veterans of military service and those residing in rural areas. Smokers frequently experience tobacco-related issues including risky alcohol use, post-cessation weight gain, and depressive symptoms that may adversely impact their likelihood of quitting and maintaining abstinence. Telephone-based interventions that simultaneously address these issues may help to increase treatment access and improve outcomes. METHODS: This study was a two-group randomized controlled pilot trial. Participants were randomly assigned to an individually-tailored telephone tobacco intervention combining counseling for tobacco use and related issues including depressive symptoms, risky alcohol use, and weight concerns or to treatment provided through their state tobacco quitline. Selection of pharmacotherapy was based on medical history and a shared decision interview in both groups. Participants included 63 rural Veteran smokers (mean age = 56.8 years; 87 % male; mean number of cigarettes/day = 24.7). The primary outcome was self-reported 7-day point prevalence abstinence at 12 weeks and 6 months. RESULTS: Twelve-week quit rates based on an intention-to-treat analysis did not differ significantly by group (Tailored = 39 %; Quitline Referral = 25 %; odds ratio [OR]; 95 % confidence interval [CI] = 1.90; 0.56, 5.57). Six-month quit rates for the Tailored and Quitline Referral conditions were 29 and 28 %, respectively (OR; 95 % CI = 1.05; 0.35, 3.12). Satisfaction with the Tailored tobacco intervention was high. CONCLUSIONS: Telephone-based treatment that concomitantly addresses other health-related factors that may adversely affect quitting appears to be a promising strategy. Larger studies are needed to determine whether this approach improves cessation outcomes. TRIAL REGISTRATION: ClinicalTrials.gov identifier number NCT01592695 registered 11 April 2012.

Recent developments in the use of online resources and mobile technologies to support mental health care.

This review describes recent developments in online and mobile mental health applications, including a discussion of patient portals to support mental health care. These technologies are rapidly evolving, often before there is systematic investigation of their effectiveness. Though there are some reviews of the effectiveness of mental health mobile apps, perhaps the more significant development is innovation in technology evaluation as well as new models of interprofessional collaboration in developing behavioural health technologies. Online mental health programs have a strong evidence base. Their role in population health strategies needs further exploration, including the most effective use of limited clinical staff resources. Patient portals and personal health records serve to enhance mental health treatment also, though concerns specific to mental health must be addressed to support broader adoption of portals. Provider concerns about sharing psychiatric notes with patients hinder support for portals. Health information exchange for mental health information requires thoughtful consent management strategies so mental health patients can benefit. Finally, the broad array of health information technologies may overwhelm patients. User-friendly, well-designed, patient-centred health information technology homes may integrate these functions to promote a holistic approach to care plans and overall wellness. Such technology homes have special security needs and require providers and patients to be well informed about how best to use these technologies to support behavioural health interventions.

Depression and disability in migraine: the role of pain acceptance and values-based action.

BACKGROUND: Migraine is a complex neurological disorder that substantially impairs a person's functioning and is often comorbid with depression. Currently, little is known about psychological coping strategies that may underlie disability and depression in patients with migraine. PURPOSE: This study examines concurrent relations between depression and disability on the one hand and pain acceptance and values-based action on the other hand in patients with migraine. METHOD: Ninety-three patients with migraine and depressive symptoms-being evaluated for a larger project examining the impact of a behavioral intervention on depression in patients with migraine-completed measures of depression, disability, pain acceptance, and values-based action. Using multiple regression analyses, the contributions of pain acceptance and values-based action to depression and disability were assessed. RESULTS: Low pain acceptance was strongly associated with depression and disability (r s(2) = .15-.37) in these patients. Low pain acceptance also explained unique variance in disability, beyond that of depression. Values-based action related modestly to depression and disability (r s(2) = .02-.07). CONCLUSION: Pain acceptance can contribute to our understanding of psychological health and functioning. An important next step would be to examine whether targeting acceptance in treatment of patients with migraine would lead to improvements in their mental health and functioning.

Use of the Blue Button Online Tool for Sharing Health Information: Qualitative Interviews With Patients and Providers.

BACKGROUND: Information sharing between providers is critical for care coordination, especially in health systems such as the United States Department of Veterans Affairs (VA), where many patients also receive care from other health care organizations. Patients can facilitate this sharing by using the Blue Button, an online tool that promotes patients' ability to view, print, and download their health records. OBJECTIVE: The aim of this study was to characterize (1) patients' use of Blue Button, an online information-sharing tool in VA's patient portal, My HealtheVet, (2) information-sharing practices between VA and non-VA providers, and (3) how providers and patients use a printed Blue Button report during a clinical visit. METHODS: Semistructured qualitative interviews were conducted with 34 VA patients, 10 VA providers, and 9 non-VA providers. Interviews focused on patients' use of Blue Button, information-sharing practices between VA and non-VA providers, and how patients and providers use a printed Blue Button report during a clinical visit. Qualitative themes were identified through iterative rounds of coding starting with an a priori schema based on technology adoption theory. RESULTS: Information sharing between VA and non-VA providers relied primarily on the patient. Patients most commonly used Blue Button to access and share VA laboratory results. Providers recognized the need for improved information sharing, valued the Blue Button printout, and expressed interest in a way to share information electronically across settings. CONCLUSIONS: Consumer-oriented technologies such as Blue Button can facilitate patients sharing health information with providers in other health care systems; however, more education is needed to inform patients of this use to facilitate care coordination. Additional research is needed to explore how personal health record documents, such as Blue Button reports, can be easily shared and incorporated into the clinical workflow of providers.

One-day behavioral intervention in depressed migraine patients: effects on headache.

OBJECTIVE: To determine whether a 1-day behavioral intervention, aimed at enhancing psychological flexibility, improves headache outcomes of migraine patients with comorbid depression. BACKGROUND: Migraine is often comorbid with depression, with each disorder increasing the risk for onset and exacerbation of the other. Managing psychological triggers, such as stress and depression, may result in greater success of headache management. METHOD: Sixty patients with comorbid migraine and depression were assigned to a 1-day Acceptance and Commitment Training plus Migraine Education workshop (ACT-ED; N = 38) or to treatment as usual (TAU; N = 22). Patients completed a daily headache diary prior to, and for 3 months following, the intervention. Clinical variables examined included headache frequency/severity, medication use, disability, and visit to a health care professional. Comparisons were made between baseline findings and findings at the 3-month follow up. RESULTS: Participants assigned to the ACT-ED condition exhibited significant improvements in headache frequency, headache severity, medication use, and headache-related disability. In contrast, the TAU group did not exhibit improvements. The difference in headache outcomes between ACT-ED and TAU was not statistically significant over time (ie, the treatment by time interaction was nonsignificant). These results complement those of a previous report showing effects of ACT-ED vs TAU on depression and disability. CONCLUSION: A 1-day ACT-ED workshop targeting psychological flexibility may convey benefit for patients with comorbid migraine and depression.These pilot study findings merit further investigation using a more rigorously designed large-scale trial.

Effect of vitamin E and memantine on functional decline in Alzheimer disease: the TEAM-AD VA cooperative randomized trial.

IMPORTANCE: Although vitamin E and memantine have been shown to have beneficial effects in moderately severe Alzheimer disease (AD), evidence is limited in mild to moderate AD. OBJECTIVE: To determine if vitamin E (alpha tocopherol), memantine, or both slow progression of mild to moderate AD in patients taking an acetylcholinesterase inhibitor. DESIGN, SETTING, AND PARTICIPANTS: Double-blind, placebo-controlled, parallel-group, randomized clinical trial involving 613 patients with mild to moderate AD initiated in August 2007 and concluded in September 2012 at 14 Veterans Affairs medical centers. INTERVENTIONS: Participants received either 2000 IU/d of alpha tocopherol (n = 152), 20 mg/d of memantine (n = 155), the combination (n = 154), or placebo (n = 152). MAIN OUTCOMES AND MEASURES: Alzheimer's Disease Cooperative Study/Activities of Daily Living (ADCS-ADL) Inventory score (range, 0-78). Secondary outcomes included cognitive, neuropsychiatric, functional, and caregiver measures. RESULTS: Data from 561 participants were analyzed (alpha tocopherol = 140, memantine = 142, combination = 139, placebo = 140), with 52 excluded because of a lack of any follow-up data. Over the mean (SD) follow-up of 2.27 (1.22) years, ADCS-ADL Inventory scores declined by 3.15 units (95% CI, 0.92 to 5.39; adjusted P = .03) less in the alpha tocopherol group compared with the placebo group. In the memantine group, these scores declined 1.98 units less (95% CI, -0.24 to 4.20; adjusted P = .40) than the placebo group's decline. This change in the alpha tocopherol group translates into a delay in clinical progression of 19% per year compared with placebo or a delay of approximately 6.2 months over the follow-up period. Caregiver time increased least in the alpha tocopherol group. All-cause mortality and safety analyses showed a difference only on the serious adverse event of "infections or infestations," with greater frequencies in the memantine (31 events in 23 participants) and combination groups (44 events in 31 participants) compared with placebo (13 events in 11 participants). CONCLUSIONS AND RELEVANCE: Among patients with mild to moderate AD, 2000 IU/d of alpha tocopherol compared with placebo resulted in slower functional decline. There were no significant differences in the groups receiving memantine alone or memantine plus alpha tocopherol. These findings suggest benefit of alpha tocopherol in mild to moderate AD by slowing functional decline and decreasing caregiver burden. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00235716.