"For the first time I am seriously fighting burnout": clinician experiences with a challenging electronic health record transition.

Objectives: The Department of Veterans Affairs (VA) is transitioning from its legacy electronic health record (EHR) to a new commercial EHR in a nationwide, rolling-wave transition. We evaluated clinician and staff experiences to identify strategies to improve future EHR rollouts. Materials and Methods: We completed a convergent mixed-methods formative evaluation collecting survey and interview data to measure and describe clinician and staff experiences. Survey responses were analyzed using descriptive statistics; interview transcripts were coded using a combination of a priori and emergent codes followed by qualitative content analysis. Qualitative and quantitative findings were compared to provide a more comprehensive understanding of participant experience. Employees of specialty and primary care teams at the first nationwide EHR transition site agreed to participate in our study. We distributed surveys at 1-month pre-transition, 2 months post-transition, and 10 months post-transition to each of the 68 identified team members and completed longitudinal interviews with 30 of these individuals totaling 122 semi-structured interviews. Results: Interview participants reported profoundly disruptive experiences during the EHR transition that persisted at 1-year post implementation. Survey responses indicated training difficulties throughout the transition, and sharp declines (P ≤ .05) between pre- and post-go-live measures of EHR usability and increase in EHR burden that were perceived to be due in part to system inefficiencies, discordant positive messaging that initially ignored user challenges, and inadequate support for and attention to ongoing EHR issues. Participants described persistent high levels of stress associated with these disruptions. Discussion: Our findings highlight strategies to improve employee experiences during EHR transitions: (1) working with Oracle Cerner to resolve known issues and improve usability; (2) role-based training with opportunities for self-directed learning; (3) peer-led support systems and timely feedback on issues; (4) messaging that responds to challenges and successes; and (5) continuous efforts to support staff with issues and address clinician and staff stress and burnout. Conclusion: Our findings provide relevant strategies to navigate future EHR transitions while supporting clinical teams.

Clinician and staff experiences with frustrated patients during an electronic health record transition: a qualitative case study.

BACKGROUND: Electronic health record (EHR) transitions are known to be highly disruptive, can drastically impact clinician and staff experiences, and may influence patients' experiences using the electronic patient portal. Clinicians and staff can gain insights into patient experiences and be influenced by what they see and hear from patients. Through the lens of an emergency preparedness framework, we examined clinician and staff reactions to and perceptions of their patients' experiences with the portal during an EHR transition at the Department of Veterans Affairs (VA). METHODS: This qualitative case study was situated within a larger multi-methods evaluation of the EHR transition. We conducted a total of 122 interviews with 30 clinicians and staff across disciplines at the initial VA EHR transition site before, immediately after, and up to 12 months after go-live (September 2020-November 2021). Interview transcripts were coded using a priori and emergent codes. The coded text segments relevant to patient experience and clinician interactions with patients were extracted and analyzed to identify themes. For each theme, recommendations were defined based on each stage of an emergency preparedness framework (mitigate, prepare, respond, recover). RESULTS: In post-go-live interviews participants expressed concerns about the reliability of communicating with their patients via secure messaging within the new EHR portal. Participants felt ill-equipped to field patients' questions and frustrations navigating the new portal. Participants learned that patients experienced difficulties learning to use and accessing the portal; when unsuccessful, some had difficulties obtaining medication refills via the portal and used the call center as an alternative. However, long telephone wait times provoked patients to walk into the clinic for care, often frustrated and without an appointment. Patients needing increased in-person attention heightened participants' daily workload and their concern for patients' well-being. Recommendations for each theme fit within a stage of the emergency preparedness framework. CONCLUSIONS: Application of an emergency preparedness framework to EHR transitions could help address the concerns raised by the participants, (1) mitigating disruptions by identifying at-risk patients before the transition, (2) preparing end-users by disseminating patient-centered informational resources, (3) responding by building capacity for disrupted services, and (4) recovering by monitoring integrity of the new portal function.

Patients' Perspectives on Medication-Related Suicide Prevention Interventions Delivered in Emergency Settings.

OBJECTIVE: Encouraging patients at risk for suicide to reduce access to potentially lethal medications and drugs is a key component of evidence-based suicide prevention. However, little research has been done to inform interventions for reducing intentional self-harm. METHODS: Semistructured interviews were conducted with 28 U.S. veterans who sought emergency care from the Veterans Health Administration between 2021 and 2023 to explore veterans' perspectives on medication-related interventions, including opinions on intervention components (e.g., medication return envelopes). Matrix analysis was used to aggregate data into categories, which were predefined by using constructs from the health belief model (e.g., perceived benefits). RESULTS: The participating veterans generally endorsed interventions as acceptable and were particularly supportive of distributing medication return envelopes. However, they often conceptualized these efforts as steps to prevent unintentional overdose or theft-not necessarily to prevent suicide-and rarely indicated that such interventions were appropriate for themselves. Across the interviews, participants identified important facilitators to care, such as ensuring that interventions were convenient and accounted for the perceived cost of disposing medications. Perspectives on engaging family or friends in interventions were mixed. The importance of the interventions was more readily acknowledged among participants with previous opioid use exposure-perspectives that appeared to stem from lived experiences. CONCLUSIONS: This study contributes important foundational knowledge that can be used to inform research and clinical initiatives aimed at preventing medication- and drug-related suicides.

Improving the Usability of Written Exposure Therapy for Therapists in the Department of Veterans Affairs Telemental Health: Formative Study Using Qualitative and User-Centered Design Methods.

BACKGROUND: User modifications are common in evidence-based psychosocial interventions (EBPIs) for mental health disorders. Often, EBPIs fit poorly into clinical workflows, require extensive resources, or pose considerable burden to patients and therapists. Implementation science is increasingly researching ways to improve the usability of EBPIs before implementation. A user-centered design can be used to support implementation methods to prioritize user needs and solutions to improve EBPI usability. OBJECTIVE: Trauma-focused EBPIs are a first-line treatment for patients with posttraumatic stress disorder (PTSD) in the Department of Veterans Affairs. Written exposure therapy (WET) is a brief, trauma-focused EBPI wherein patients handwrite about trauma associated with their PTSD. Initially developed for in-person delivery, WET is increasingly being delivered remotely, and outcomes appear to be equivalent to in-person delivery. However, there are logistical issues in delivering WET via video. In this evaluation, we explored usability issues related to WET telehealth delivery via videoconferencing software and designed a solution for therapist-facing challenges to systematize WET telehealth delivery. METHODS: The Discover, Design and Build, and Test framework guided this formative evaluation and served to inform a larger Virtual Care Quality Enhancement Research Initiative. We used qualitative descriptive methods in the Discover phase to understand the experiences and needs of 2 groups of users providing care within the Department of Veterans Affairs: in-person therapists delivering WET via video because of the COVID-19 pandemic and telehealth therapists who regularly deliver PTSD therapies. We then used user-centered design methods in the Design and Build phase to brainstorm, develop, and iteratively refine potential workflows to address identified usability issues. All procedures were conducted remotely. RESULTS: In the Discover phase, both groups had challenges delivering WET and other PTSD therapies via telehealth because of technology issues with videoconferencing software, environmental distractions, and workflow disruptions. Narrative transfer (ie, patients sending handwritten trauma accounts to therapists) was the first target for design solution development as it was deemed most critical to WET delivery. In the Design and Build phase, we identified design constraints and brainstormed solution ideas. This led to the development of 3 solution workflows that were presented to a subgroup of therapist users through cognitive walkthroughs. Meetings with this subgroup allowed workflow refinement to improve narrative transfers. Finally, to facilitate using these workflows, we developed PDF manuals that are being refined in subsequent phases of the implementation project (not mentioned in this paper). CONCLUSIONS: The Discover, Design and Build, and Test framework can be a useful tool for understanding user needs in complex EBPI interventions and designing solutions to user-identified usability issues. Building on this work, an iterative evaluation of the 3 solution workflows and accompanying manuals with therapists and patients is underway as part of a nationwide WET implementation in telehealth settings.

Protocol for a pragmatic trial testing a self-directed lifestyle program targeting weight loss among patients with obstructive sleep apnea (POWER Trial).

BACKGROUND: Obesity comprises the single greatest reversible risk factor for obstructive sleep apnea (OSA). Despite the potential of lifestyle-based weight loss services to improve OSA severity and symptoms, these programs have limited reach. POWER is a pragmatic trial of a remote self-directed weight loss care among patients with OSA. METHODS: POWER randomizes 696 patients with obesity (BMI 30-45 kg/m2) and recent diagnosis or re-confirmation of OSA 1:1 to either a self-directed weight loss intervention or usual care. POWER tests whether such an intervention improves co-primary outcomes of weight and sleep-related quality of life at 12 months. Secondary outcomes include sleep symptoms, global ratings of change, and cardiovascular risk scores. Finally, consistent with a hybrid type 1 approach, the trial embeds an implementation process evaluation. We will use quantitative and qualitative methods including budget impact analyses and qualitative interviews to assess barriers to implementation. CONCLUSIONS: The results of POWER will inform population health approaches to the delivery of weight loss care. A remote self-directed program has the potential to be disseminated widely with limited health system resources and likely low-cost.

Impacts of an Electronic Health Record Transition on Veterans Health Administration Health Professions Trainee Experience.

BACKGROUND: Adoption of electronic health care records (EHRs) has proliferated since 2000. While EHR transitions are widely understood to be disruptive, little attention has been paid to their effect on health professions trainees' (HPTs) ability to learn and conduct work. Veterans Health Administration's (VA) massive transition from its homegrown EHR (CPRS/Vista) to the commercial Oracle Cerner presents an unparalleled-in-scope opportunity to gain insight on trainee work functions and their ability to obtain requisite experience during transitions. OBJECTIVE: To identify how an organizational EHR transition affected HPT work and learning at the third VA go-live site. DESIGN: A formative mixed-method evaluation of HPT experiences with VHA's EHR transition including interviews with HPTs and supervisors at Chalmers P. Wylie VA Outpatient Clinic in Columbus, OH, before (~60 min), during (15-30 min), and after (~60 min) go-live (December 2021-July 2022). We also conducted pre- (March 2022-April 2022) and post-go live (May 2022-June 2022) HPT and employee surveys. PARTICIPANTS: We conducted 24 interviews with HPTs (n=4), site leaders (n=2), and academic affiliates (n=2) using snowball sampling. We recruited HPTs in pre- (n=13) and post-go-live (n=10) surveys and employees in pre- (n=408) and post-go-live (n=458) surveys. APPROACH: We conducted interviews using a semi-structured guide and grounded prompts. We coded interviews and survey free text data using a priori and emergent codes, subsequently conducting thematic analysis. We conducted descriptive statistical analysis of survey responses and merged interview and survey data streams. KEY RESULTS: Our preliminary findings indicate that the EHR transition comprehensively affected HPT experiences, disrupting processes from onboarding and training to clinical care contributions and training-to-career retention. CONCLUSIONS: Understanding HPTs' challenges during EHR transitions is critical to effective training. Mitigating the identified barriers to HPT training and providing patient care may lessen their dissatisfaction and ensure quality patient care during EHR transitions.

"Everything's so Role-Specific": VA Employee Perspectives' on Electronic Health Record (EHR) Transition Implications for Roles and Responsibilities.

BACKGROUND: Electronic health record (EHR) transitions are increasingly widespread and often highly disruptive. It is imperative we learn from past experiences to anticipate and mitigate such disruptions. Veterans Affairs (VA) is undergoing a large-scale transition from its homegrown EHR (CPRS/Vista) to a commercial EHR (Cerner), creating a unique opportunity of shedding light on large-scale EHR-to-EHR transition challenges. OBJECTIVE: To explore one facet of the organizational impact of VA's EHR transition: its implications for employees' roles and responsibilities at the first VA site to implement Cerner Millennium EHR. DESIGN: As part of a formative evaluation of frontline staff experiences with VA's EHR transition, we conducted brief (~ 15 min) and full-length interviews (~ 60 min) with clinicians and staff at Mann-Grandstaff VA Medical Center in Spokane, WA, before, during, and after transition (July 2020-November 2021). PARTICIPANTS: We conducted 111 interviews with 26 Spokane clinicians and staff, recruited via snowball sampling. APPROACH: We conducted audio interviews using a semi-structured guide with grounded prompts. We coded interview transcripts using a priori and emergent codes, followed by qualitative content analysis. KEY RESULTS: Unlike VA's previous EHR, Cerner imposes additional restrictions on access to its EHR functionality based upon "roles" assigned to users. Participants described a mismatch between established institutional duties and their EHR permissions, unanticipated changes in scope of duties brought upon by the transition, as well as impediments to communication and collaboration due to different role-based views. CONCLUSIONS: Health systems should anticipate substantive impacts on professional workflows when EHR role settings do not reflect prior workflows. Such changes may increase user error, dissatisfaction, and patient care disruptions. To mitigate employee dissatisfaction and safety risks, health systems should proactively plan for and communicate about expected modifications and monitor for unintended role-related consequences of EHR transitions, while vendors should ensure accurate role configuration and assignment.

"Like One Long Battle:" Employee Perspectives of the Simultaneous Impact of COVID-19 and an Electronic Health Record Transition.

BACKGROUND: Healthcare organizations regularly manage external stressors that threaten patient care, but experiences handling concurrent stressors are not well characterized. OBJECTIVE: To evaluate the experience of Veterans Affairs (VA) clinicians and staff navigating simultaneous organizational stressors-an electronic health record (EHR) transition and the COVID-19 pandemic-and identify potential strategies to optimize management of co-occurring stressors. DESIGN: Qualitative case study describing employee experiences at VA's initial EHR transition site. PARTICIPANTS: Clinicians, nurses, allied health professionals, and local leaders at VA's initial EHR transition site. APPROACH: We collected longitudinal qualitative interview data between July 2020 and November 2021 once before and 2-4 times after the date on which the health system transitioned; this timing corresponded with local surges of COVID-19 cases. Interviewers conducted coding and analysis of interview transcripts. For this study, we focused on quotes related to COVID-19 and performed content analysis to describe recurring themes describing the simultaneous impact of COVID-19 and an EHR transition. KEY RESULTS: We identified five themes related to participants' experiences: (1) efforts to mitigate COVID-19 transmission led to insufficient access to EHR training and support, (2) clinical practice changes in response to the pandemic impacted EHR workflows in unexpected ways, (3) lack of clear communication and inconsistent enforcement of COVID-19 policies intensified pre-existing frustrations with the EHR, (4) managing concurrent organizational stressors increased work dissatisfaction and feelings of burnout, and (5) participants had limited bandwidth to manage competing demands that arose from concurrent organizational stressors. CONCLUSION: The expected challenges of an EHR transition were compounded by co-occurrence of the COVID-19 pandemic, which had negative impacts on clinician experience and patient care. During simultaneous organizational stressors, health care facilities should be prepared to address the complex interplay of two stressors on employee experience.

Assessing Electronic Health Record (EHR) Use during a Major EHR Transition: An Innovative Mixed Methods Approach.

BACKGROUND: Electronic health record (EHR) transitions are inherently disruptive to healthcare workers who must rapidly learn a new EHR and adapt to altered clinical workflows. Healthcare workers' perceptions of EHR usability and their EHR use patterns following transitions are poorly understood. The Department of Veterans Affairs (VA) is currently replacing its homegrown EHR with a commercial Cerner EHR, presenting a unique opportunity to examine EHR use trends and usability perceptions. OBJECTIVE: To assess EHR usability and uptake up to 1-year post-transition at the first VA EHR transition site using a novel longitudinal, mixed methods approach. DESIGN: A concurrent mixed methods strategy using EHR use metrics and qualitative interview data. PARTICIPANTS: 141 clinicians with data from select EHR use metrics in Cerner Lights On Network®. Interviews with 25 healthcare workers in various clinical and administrative roles. APPROACH: We assessed changes in total EHR time, documentation time, and order time per patient post-transition. Interview transcripts (n = 90) were coded and analyzed for content specific to EHR usability. KEY RESULTS: Total EHR time, documentation time, and order time all decreased precipitously within the first four months after go-live and demonstrated gradual improvements over 12 months. Interview participants expressed ongoing concerns with the EHR's usability and functionality up to a year after go-live such as tasks taking longer than the old system and inefficiencies related to inadequate training and inherent features of the new system. These sentiments did not seem to reflect the observed improvements in EHR use metrics. CONCLUSIONS: The integration of quantitative and qualitative data yielded a complex picture of EHR usability. Participants described persistent challenges with EHR usability 1 year after go-live contrasting with observed improvements in EHR use metrics. Combining findings across methods can provide a clearer, contextualized understanding of EHR adoption and use patterns during EHR transitions.

Clinician Perspectives on Delivering Medication Treatment for Opioid Use Disorder during the COVID-19 Pandemic: A Qualitative Evaluation.

OBJECTIVE: The coronavirus disease 2019 (COVID-19) pandemic necessitated changes in opioid use disorder care. Little is known about COVID-19's impact on general healthcare clinicians' experiences providing medication treatment for opioid use disorder (MOUD). This qualitative evaluation assessed clinicians' beliefs about and experiences delivering MOUD in general healthcare clinics during COVID-19. METHODS: Individual semistructured interviews were conducted May through December 2020 with clinicians participating in a Department of Veterans Affairs initiative to implement MOUD in general healthcare clinics. Participants included 30 clinicians from 21 clinics (9 primary care, 10 pain, and 2 mental health). Interviews were analyzed using thematic analysis. RESULTS: The following 4 themes were identified: overall impact of the pandemic on MOUD care and patient well-being, features of MOUD care impacted, MOUD care delivery, and continuance of telehealth for MOUD care. Clinicians reported a rapid shift to telehealth care, resulting in few changes to patient assessments, MOUD initiations, and access to and quality of care. Although technological challenges were noted, clinicians highlighted positive experiences, including treatment destigmatization, more timely visits, and insight into patients' environments. Such changes resulted in more relaxed clinical interactions and improved clinic efficiency. Clinicians reported a preference for in-person and telehealth hybrid care models. CONCLUSIONS: After the quick shift to telehealth-based MOUD delivery, general healthcare clinicians reported few impacts on quality of care and highlighted several benefits that may address common barriers to MOUD care. Evaluations of in-person and telehealth hybrid care models, clinical outcomes, equity, and patient perspectives are needed to inform MOUD services moving forward.

Design and methods of a randomized trial testing "Advancing care for COPD in people living with HIV by implementing evidence-based management through proactive E-consults (ACHIEVE)".

Chronic obstructive pulmonary disease (COPD) is one of the most common comorbid diseases among aging people with HIV (PWH) and is often mismanaged. To address this gap, we are conducting the study, "Advancing care for COPD in people living with HIV by Implementing Evidence-based management through proactive E-consults (ACHIEVE)." This intervention optimizes COPD management by promoting effective, evidence-based care and de-implementing inappropriate therapies for COPD in PWH receiving care at Veteran Affairs (VA) medical centers. Study pulmonologists are proactively supporting ID providers managing a population of PWH who have COPD, offering real-time evidence-based recommendations tailored to each patient. We are leveraging VA clinical and informatics infrastructures to communicate recommendations between the study team and clinical providers through the electronic health record (EHR) as an E-consult. If effective, ACHIEVE could serve as a model of effective, efficient COPD management among PWH receiving care in VA. This paper outlines the rationale and methodology of the ACHIEVE trial, one of a series of studies funded by the National Heart, Lung, and Blood Institute (NHLBI) within the ImPlementation REsearCh to DEvelop Interventions for People Living with HIV (PRECluDE) consortium to study chronic disease comorbidities in HIV populations.

A mixed-methods evaluation of why an implementation trial failed to engage veterans with posttraumatic stress disorder in trauma-focused psychotherapy.

An effectiveness trial found that telemedicine collaborative care for posttraumatic stress disorder (PTSD) significantly increased engagement in trauma-focused psychotherapy (TFP) and improved PTSD symptoms. However, in a subsequent implementation trial, very few veterans enrolled in collaborative care initiated TFP. We conducted a mixed-methods evaluation to determine why veterans did not initiate TFP in the implementation trial. After conducting chart reviews of 1,071 veterans with PTSD enrolled in collaborative care, patients were categorized into four mutually exclusive TFP groups: TFP not discussed; TFP discussed, declined; TFP discussed, did not decline; and TFP initiated. We conducted semistructured interviews with 43 unique patients and 58 unique providers (i.e., care managers and mental health specialists). Almost half (48.6%) of the veterans had no documentation of discussing TFP with their care manager; another 28.9% discussed it but declined. Most veterans (77.1%) had an encounter with a mental health specialist, 36.8% of whom never discussed TFP, and 35.7% of whom discussed it but declined. Providers reported that many veterans were not able, willing, or ready to engage in TFP and that non-trauma-focused therapies were better aligned with their treatment goals. Veterans gave numerous reasons for not initiating TFP, including having bad prior experiences with TFP and wanting to avoid thinking about past traumatic experiences. Commonly cited reasons for noninitiation were providers never discussing TFP with veterans and veterans declining TFP after discussing it with their provider. Interventions, such as shared decision-making tools, may be needed to engage providers and patients in informed discussions about TFP.

Perceived shared decision-making among patients undergoing lower-limb amputation and their care teams: A qualitative study.

BACKGROUND: Shared decision-making (SDM) is increasingly advocated in the care of vascular surgery patients. The goal of this investigation was to gain a greater understanding of the patient and provider experience of SDM during clinical decision-making around the need for lower-extremity amputation and amputation level related to chronic limb-threatening ischemia (CLTI) in the Veterans Health Administration. METHODS: Semistructured interviews in male Veterans with CLTI, vascular surgeons, physical medicine and rehabilitation physicians, and podiatric surgeons. Interviews were analyzed using team-based content analysis to identify themes related to amputation-level decisions. RESULTS: We interviewed 22 patients and 21 surgeons and physicians and identified 4 themes related to SDM: (1) providers recognize the importance of incorporating patient preferences into amputation-level decisions and strive to do so; (2) patients do not perceive that they are included as equal partners in decisions around amputation or amputation level; (3) providers perceive several obstacles to including patients in amputation level decisions; and (4) patients describe facilitators to their involvement in SDM. CONCLUSIONS: Despite the recognized importance SDM in amputation decision-making, patients often perceived that their opinion was not solicited. This may result from provider perception of significant challenges to SDM posed by the clinical context of amputation. Patients identified key features that might enhance SDM including presentation of clear, concise information, and the importance of communicating concern during the discussion. These findings point to gaps in the provision of patient-centric care through SDM discussions at the time of amputation.

Mortality Conversations Between Male Veterans and Their Providers Prior to Dysvascular Lower Extremity Amputation.

BACKGROUND: Among patients facing lower extremity amputation due to dysvascular disease, the mortality risk is very high. Given this, as well as the importance of a patient-centered approach to medical care, informing patients about their possible risk of dying may be important during preoperative shared decision-making. The goal of this investigation was to gain an understanding of patient and provider experiences discussing mortality within the context of amputation within the Veterans Health Administration. METHODS: Semistructured interviews were performed with Veterans with peripheral arterial disease and/or diabetes, vascular and podiatric surgeons, and physical medicine and rehabilitation physicians. Interviews were analyzed using team-based content analysis to identify themes related to amputation-level decisions. RESULTS: We interviewed 22 patients and 21 surgeons and physicians and identified 3 themes related to conversations around mortality: (1) both patients and providers report that mortality conversations are not common prior to amputation; (2) while most providers find value in mortality conversations, some express concerns around engaging in these discussions with patients; and (3) some patients perceive mortality conversations as unnecessary, but many are open to engaging in the conversation. CONCLUSIONS: Providers may benefit from introducing the topic with patients, including providing the context for why mortality conversations may be valuable, with the understanding that patients can always decline to participate should they not be interested or comfortable discussing this issue.

VA Outreach Is an Essential Area for Improving Veterans' Health Care Accessibility.

INTRODUCTION: The Veterans Health Administration (VHA) is tasked with providing access to health care to veterans of military service. However, many eligible veterans have either not yet enrolled or underutilized VHA services. Further study of barriers to access before veterans enroll in VHA care is necessary to understand how to address this issue. The ChooseVA (née MyVA Access) initiative aims to achieve this mission to improve veterans' health care access. Although veteran outreach was not specifically addressed by the initiative, it is a critical component of improving veterans' access to health care. Findings from this multisite evaluation of ChooseVA implementation describe sites' efforts to improve VHA outreach and veterans' experiences with access. MATERIALS AND METHODS: This quality improvement evaluation employed a multi-method qualitative methodology, including 127 semi-structured interviews and 81 focus groups with VHA providers and staff ("VHA staff") completed during 21 VHA medical center facility site visits between July and November 2017 and 48 telephone interviews with veterans completed between May and October 2018. Interviews and focus groups were transcribed and analyzed using deductive and inductive analysis to capture challenges and strategies to improve VHA health care access (VHA staff data), experiences with access to care (veteran data), barriers and facilitators to care (staff and veteran data), contextual factors, and emerging categories and themes. We developed focused themes describing perceived challenges, descriptions of VHA staff efforts to improve veteran outreach, and veterans' experiences with accessing VHA health care. RESULTS: VHA staff and veteran respondents reported a lack of veteran awareness of eligibility for VHA services. Veterans reported limited understanding of the range of services offered. This awareness gap served as a barrier to veterans' ability to successfully access VHA health care services. Veterans described this awareness gap as contributing to delayed VHA enrollment and delayed or underutilized health care benefits and services. Staff focused on community outreach and engaging veterans for VHA enrollment as part of their efforts to implement the ChooseVA access initiative. Staff and veteran respondents agreed that outreach efforts were helpful for engaging veterans and facilitating access. CONCLUSIONS: Although efforts across VHA programs informed veterans about VHA services, our results suggest that both VHA staff and veterans agreed that missed opportunities exist. Gaps include veterans' lack of awareness or understanding of VHA benefits for which they qualify for. This can result in delayed access to care which may negatively impact veterans, including those separating from the military and vulnerable populations such as veterans who experience pregnancy or homelessness.

Primary Care Provider Experience With Proactive E-Consults to Improve COPD Outcomes and Access to Specialty Care.

Background: Often patients with chronic obstructive pulmonary disease (COPD) receive poor quality care with limited access to pulmonologists. We tested a novel intervention, INtegrating Care After Exacerbation of COPD (InCasE), that improved patient outcomes after hospitalization for COPD. InCasE used population-based identification of patients for proactive e-consultation by pulmonologists, and tailored recommendations with pre-populated orders timed to follow-up with primary care providers (PCPs). Although adoption by PCPs was high, we do not know how PCPs experienced the intervention. Objective: Our objective was to assess PCPs' experience with proactive pulmonary e-consults after hospitalization for COPD. Methods: We conducted a convergent mixed methods study among study PCPs at 2 medical centers and 10 outpatient clinics. PCPs underwent semi-structured interviews and surveys. We performed descriptive analyses on quantitative data and inductive and deductive coding based on prespecified themes of acceptability, appropriateness, and feasibility for qualitative data. Key Results: We conducted 10 interviews and 37 PCPs completed surveys. PCPs perceived InCasE to be acceptable and feasible. Facilitators included the proactive consult approach to patient identification and order entry. PCPs also noted the intervention was respectful and collegial. PCPs had concerns regarding appropriateness related to an unclear role in communicating recommendations to patients. PCPs also noted a potential decrease in autonomy if overused. Conclusion: This evaluation indicates that a proactive e-consult intervention can be deployed to collaboratively manage the health of populations with COPD in a way that is acceptable, appropriate, and feasible for primary care. Lessons learned from this study suggest the intervention may be transferable to other settings and specialties.

U.S. veterans' experiences and factors associated with use of a smartphone application to self-manage unhealthy alcohol use.

Unhealthy alcohol use is common among Operations Enduring and Iraqi Freedom (OEF/OIF) veterans, yet barriers discourage treatment-seeking. Mobile applications (apps) that deliver alcohol interventions have potential to address these barriers and increase treatment receipt. Few studies have qualitatively assessed users' experiences with apps to manage alcohol use. We assessed OEF/OIF veterans' experiences with Step Away, an app to reduce alcohol-related risks, to identify factors that may influence engagement. This single-arm pilot study recruited OEF/OIF veterans with positive alcohol screens nationwide using mail/telephone. Veterans aged 18-55 who exceeded drinking guidelines and owned an iPhone were eligible. Twenty-one (16 men, 5 women) of 55 participants completed interviews. Interviews were analyzed using thematic analysis. Participants found Step Away easy to use, although setup was time consuming. Participants reported increased awareness of alcohol use, highlighting daily assessment, weekly feedback, goal setting, and high-risk notification features as helpful and associated awareness with an intent to decrease use. Participants described Step Away as informative, with over half reporting they would use it outside of the study and most recommending it. Suggestions for improvement included greater personalization and control over features. Step Away features appear to influence engagement and increase users' awareness about alcohol consumed and factors associated with drinking, as well as intent to change. Assessment, feedback, and customization features of apps may facilitate app engagement. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

A mixed-methods evaluation of the national implementation of the Hospital-Acquired Pneumonia Prevention by Engaging Nurses (HAPPEN) initiative.

OBJECTIVE: To describe healthcare provider, veteran, and organizational barriers to, challenges to, and facilitators of implementation of the oral care Hospital-Acquired Pneumonia Prevention by Engaging Nurses (HAPPEN) initiative to prevent non-ventilator-associated hospital-acquired pneumonia (NV-HAP). DESIGN: Concurrent mixed methods. Qualitative interviews of staff and patients were conducted in addition to a larger survey of VA employees regarding implementation. SETTING: Medical surgical or extended care units in 6 high-complexity (01a-c) VA hospitals. PARTICIPANTS: Between January 2020 and February 2021, we interviewed 7 staff and 7 veterans, and we received survey responses from 91 staff. INTERVENTION: Provide education, support, and oral care supplies to prevent NV-HAP. RESULTS: Barriers to HAPPEN implementation and tracking at the pilot sites included maintaining oral care supplies and completion of oral care documentation. Facilitators for HAPPEN implementation included development of supportive formal and informal nurse leaders, staff engagement, and shared beliefs in the importance of care quality and infection prevention. Nurses worked together as a team to provide consistent oral care. Oral care was viewed as an essential infection control practice (not just "a task") and was considered part of the "culture" and "mission" in caring for veterans. CONCLUSIONS: Nurse leaders and direct-care staff were engaged throughout HAPPEN implementation, and most reported feeling supported and well prepared as they walked through the steps. Veterans reported positive experiences and increased knowledge about prevention of pneumonia. Lessons learned included building a community of practice and sharing expertise, which led to the successful replication of the HAPPEN initiative nationwide, improving patient safety and care quality and influencing health policy.

Primary Care Physician Perspectives on the Influence of Patient Values, Health Priorities, and Preferences on Clinical Decision-Making for Complex Patients with Multimorbidity: A Qualitative Study.

Introduction: The prevalence of patients with multimorbidity (ie, multiple chronic conditions) is increasing. Clinical decision-making guided by patients' values, health priorities and goals, and treatment preferences is particularly important in the context of interacting diseases and psychosocial needs. Physicians face challenges incorporating patient perspectives into care plans. We examined primary care physician (PCP) views on the influence of patients' values, health priorities and goals, and preferences on clinical decisions for patients with multimorbidity and increased psychosocial complexity. Methods: We conducted semi-structured telephone interviews with 23 PCPs within patient-centered medical home teams in a nationally integrated health system in the United States between May and July 2020. Data were analyzed via thematic analysis with deductive and inductive coding. Results: Three major themes emerged: 1. Patient personal values were rarely explicitly discussed in routine clinical encounters but informed more commonly discussed concepts of patient priorities, goals, and preferences; 2. Patient values, health priorities and goals, and preferences were sources of divergent views about care plans between healthcare teams, patients, and families; 3. Physicians used explicit strategies to communicate and negotiate about patient values, health priorities and goals, and preferences when developing care plans, including trust-building; devoting extra effort to individualizing care; connecting patient values to healthcare recommendations; deliberate elicitation and acknowledgement of patient concerns; providing "space" for patient perspectives; incorporating family into care planning; pairing physician to patient priorities; and collaborative teamwork. Conclusion: Primary care physicians perceive patient values, health priorities and goals, and preferences as influential during clinical decision-making for complex patients with multimorbidity. Participants used concrete strategies to negotiate alignment of these aspects when physician-patient divergence occurred. While rarely discussed directly in clinical encounters, personal values affected patient health priorities, goals, and preferences during care planning, suggesting a clinical role for more deliberate elicitation and discussion of patient values for this population.

"I was Unsure at First": A Qualitative Evaluation of Patient Perceptions of VA Clinical Video Telehealth Visits in the V-IMPACT Program.

Virtual Integrated Multi-Site Patient Aligned Care Team (V-IMPACT) was a Veterans Health Administration (VHA) initiative created to increase access to primary care for Veterans through Clinical Video Telehealth (CVT) appointments. Between January and August 2019, we conducted 48 semi-structured qualitative interviews with Veterans who had a V-IMPACT appointment. Many participants shared feelings of skepticism before their first appointments but for some, their opinions changed. Veterans talked about how their opinion of video care changed for the better when it made care more convenient or timelier or met their health care needs. For some Veterans, their opinion about video care stayed the same or worsened because they had a poor relationship or rapport with their provider, did not feel like they received needed care, or did not feel like video care was useful. These findings offer an opportunity for telecare providers to better understand and support patients and to deliver effective care in the context of rapidly growing telehealth modalities.