Logistical Lessons Learned in Designing and Executing a Photo-Elicitation Study in the Veterans Health Administration

Participatory photography research methods have been used to successfully engage and collect in-depth information from individuals whose voices have been traditionally marginalized in clinical or research arenas. However, participatory photography methods can introduce unique challenges and considerations regarding study design, human subject protections, and other regulatory barriers, particularly with vulnerable patient populations and in highly regulated institutions. Practical guidance on navigating these complex, interrelated methodological, logistical, and ethical issues is limited. Using a case exemplar, we describe our experiences with the planning, refinement, and initiation of a research study that used photo-elicitation interviews to assess the healthcare experiences of homeless and marginally housed United States Veterans. We discuss practical issues and recommendations related to study design, logistical “pitfalls” during study execution, and ensuring human subjects protections in the context of a study with a highly vulnerable patient population taking place in a highly risk-averse research environment

Improving the patient experience through patient portals: Insights from experienced portal users

Background: Patient portals have become part of the ecosystem of care as both patients and providers use them for a range of activities both individually and collaboratively. As patients and providers gain greater experience using portals, their use and needs related to portals may evolve. Objective: This study aimed to learn from experienced patient portal users to improve our understanding of their perspectives on portal use for collaboration and engagement as well as explore how using a portal influenced their experiences with primary care providers. Methods: Qualitative study involving 29 semi-structured interviews with family medicine patients from a large Academic Medical Center (AMC). Interviewees were patients with chronic conditions who had been identified by their providers as experienced portal users. Interview transcripts were analyzed using rigorous qualitative methods. Results: Common themes emerged around both logistical and psychological benefits of portal use. Logistical benefits included increased efficiency, improved ability to track their health information, and better documentation of communications and information during and between office visits. Psychological benefits were a greater sense of collaboration in care, increased trust in providers, and enhanced engagement in health care activities. Conclusion: Experienced portal users discussed ways in which patient portals improved both their ability to manage their care and their relationships with providers. Frequent users described a sense of collaboration with their providers and greater trust in the relationship. These findings suggest that portal use may be a mechanism through which patients can increase patient engagement and improve the patient experience

An interventional informatics approach to development and evaluation of population-based health and web technologies

Field of study: Informatics.Dr. Suzanne A. Boren, Dissertation Supervisor.Includes vita."December 2017."Interventional informatics is the use of health information technology (HIT) that drives evidence-based and evidence-generating practices to inform an improved health delivery system. Current HIT lacks movement towards data-driven infrastructures designed to promote information gathering, sharing, and new knowledge discovery in several areas. This thesis undertakes three specific areas where gaps exist. First, in undertaking quality improvement initiatives aligned with fidelity to program models, a web-based practice exchange was designed, built, tested and launched. Second, a systematic review of eHealth technology instruments for outcomes and evaluation components geared towards patient outcomes was conducted, uncovering gaps in the availability of psychometrically sound measures to evaluate eHealth technologies. Third, a study was conducted to establish a baseline of satisfaction and usability among medical care providers with the current advance care planning process (ACP) and documentation within the electronic medical record (EMR). This study discovered barriers to use of the EMR to retrieve ACP documents and prioritization areas for improvements to begin.Includes bibliographical references (pages 155-170)

Patient Health Record Systems Scope and Functionalities: Literature Review and Future Directions

Background: A new generation of user-centric information systems is emerging in health care as patient health record (PHR) systems. These systems create a platform supporting the new vision of health services that empowers patients and enables patient-provider communication, with the goal of improving health outcomes and reducing costs. This evolution has generated new sets of data and capabilities, providing opportunities and challenges at the user, system, and industry levels. Objective: The objective of our study was to assess PHR data types and functionalities through a review of the literature to inform the health care informatics community, and to provide recommendations for PHR design, research, and practice. Methods: We conducted a review of the literature to assess PHR data types and functionalities. We searched PubMed, Embase, and MEDLINE databases from 1966 to 2015 for studies of PHRs, resulting in 1822 articles, from which we selected a total of 106 articles for a detailed review of PHR data content. Results: We present several key findings related to the scope and functionalities in PHR systems. We also present a functional taxonomy and chronological analysis of PHR data types and functionalities, to improve understanding and provide insights for future directions. Functional taxonomy analysis of the extracted data revealed the presence of new PHR data sources such as tracking devices and data types such as time-series data. Chronological data analysis showed an evolution of PHR system functionalities over time, from simple data access to data modification and, more recently, automated assessment, prediction, and recommendation. Conclusions: Efforts are needed to improve (1) PHR data quality through patient-centered user interface design and standardized patient-generated data guidelines, (2) data integrity through consolidation of various types and sources, (3) PHR functionality through application of new data analytics methods, and (4) metrics to evaluate clinical outcomes associated with automated PHR system use, and costs associated with PHR data storage and analytics

An Autoethnographic Account of Innovation at the US Department of Veterans Affairs

The history of the U.S. Department of Veterans Affairs (VA) health information technology (HIT) has been characterized by both enormous successes and catastrophic failures. While the VA was once hailed as the way to the future of twenty-first-century health care, many programs have been mismanaged, delayed, or flawed, resulting in the waste of hundreds of millions of taxpayer dollars. Since 2015 the U.S. Government Accountability Office (GAO) has designated HIT at the VA as being susceptible to waste, fraud, and mismanagement. The timely central research question I ask in this study is, can healthcare IT at the VA be healed? To address this question, I investigate a HIT case study at the VA Center of Innovation (VACI), originally designed to be the flagship initiative of the open government transformation at the VA. The Open Source Electronic Health Record Alliance (OSEHRA) was designed to promote the open innovation ecosystem public-private-academic partnership. Based on my fifteen years of experience at the VA, I use an autoethnographic methodology to make a significant value-added contribution to understanding and modeling the VA’s approach to innovation. I use several theoretical information system framework models including People, Process, and Technology (PPT), Technology, Organization and Environment (TOE), and Technology Adaptive Model (TAM) and propose a new adaptive theory to understand the inability of VA HIT to innovate. From the perspective of people and culture, I study retaliation against whistleblowers, organization behavioral integrity, and lack of transparency in communications. I examine the VA processes, including the different software development methodologies used, the development and operations process (DevOps) of an open-source application developed at VACI, the Radiology Protocol Tool Recorder (RAPTOR), a Veterans Health Information Systems and Technology Architecture (VistA) radiology workflow module. I find that the VA has chosen to migrate away from inhouse application software and buy commercial software. The impact of these People, Process, and Technology findings are representative of larger systemic failings and are appropriate examples to illustrate systemic issues associated with IT innovation at the VA. This autoethnographic account builds on first-hand project experience and literature-based insights

Facilitating implementation of research evidence (FIRE): A randomised controlled trial and process evaluation of two models of facilitation informed by the promoting action on research implementation in health services (PARIHS) framework

Background: The PARIHS framework proposes that successful implementation of research evidence results from the complex interplay between the evidence to be implemented, the context of implementation and the facilitation processes employed. Facilitation is defined as a role (the facilitator) and a process (facilitation strategies/methods). Empirical evidence comparing different facilitation approaches is limited; this paper reports a trial of two different types of facilitation represented in the PARIHS framework. Methods: A pragmatic cluster randomised controlled trial with embedded process evaluation was undertaken in 24 long-term nursing care settings in four European countries. In each country, sites were randomly allocated to standard dissemination of urinary incontinence guideline recommendations and one of two types of external-internal facilitation, labelled Type A and B. Type A facilitation was a less resource intensive approach, underpinned by improvement methodology; Type B was a more intensive, emancipatory model of facilitation, informed by critical social science. The primary outcome was percentage documented compliance with guideline recommendations. Process evaluation was framed by realist methodology and involved quantitative and qualitative data collection from multiple sources. Findings: Quantitative data were obtained from reviews of 2313 records. Qualitative data included over 332 hours of observations of care; 39 hours observation of facilitation activity; 471 staff interviews; 174 resident interviews; 120 next of kin/carer interviews; and 125 stakeholder interviews. There were no significant differences in the primary outcome between study arms and all study arms improved over time. Process data revealed three core mechanisms that influenced the trajectory of the facilitation intervention: alignment of the facilitation approach to the needs and expectations of the internal facilitator and colleagues; engagement of internal facilitators and staff in attitude and action; and learning over time. Data from external facilitators demonstrated that the facilitation interventions did not work as planned, issues were cumulative and maintenance of fidelity was problematic. Implications for D&I Research: Evaluating an intervention - in this case facilitation - that is fluid and dynamic within the methodology of a randomised controlled trial is complex and challenging. For future studies, we suggest a theoretical approach to fidelity, with a focus on mechanisms, as opposed to dose and intensity of the intervention

Design Strategy for Integrated Personal Health Records: Improving the User Experience of Digital Healthcare and Wellbeing

This dissertation addresses the timely problem of designing Integrated Personal Health Records (PHR). The goal is to provide citizens with digital user experiences, sustainable and flexible enough, for gaining control over their personal health information in a seamless way. Most importantly, so that people are able to reflect and act upon their selfknowledge, towards the accomplishment of their good health and wellbeing. Towards this end, the Integrated PHR as an emerging model in the field of Health IT, was the framework that set this research forward on exploring how communication and collaboration between patients and providers can be improved, which naturally impacts the field of HCI. Acknowledging that today patients are the ones who own all that is recorded about their health data, this new model was object of a design strategy that shaped the results presented in this dissertation. These have showed how patients can have more control of their health over time, through a patient-centered, organic system, which has the ability of combining multiple sources of data both from patient and provider side. As this new type of PHR fosters the creation of integrated networks, this milestone was achieved in this research by interacting with cross-channel user experiences that took part of nationwide healthcare ecosystems. The work presented herein, has demonstrated through the analysis and development of two use cases in cooperation with organizations connected to the Portuguese Ministry of Health, how an Integrated PHR can be a powerful personal tool, to be used by the citizen with undeniable value to the demands of an aging society. The use cases structured the thesis into two parts. The first part in collaboration with the Portuguese National Patient Portal, combines an Integrated PHR and incorporates the Portuguese Data Sharing Platform (PDS), which can be used by any Portuguese citizen. This use case study led to a proposal of the portal by also creating a foundational model for designing Integrated PHRs. The second part in collaboration with the Portuguese National Senior Telehealth Program (Saúde 24 Sénior), led to another proposal for an Integrated PHR, applying the outcomes from Part 1 and the requirements that derived from the findings explored in this second use case study. The proposed solution, has the potential to be used by the Portuguese senior community in the scope of home assistive care. Both proposals applied a user experience design methodology and included the development of two prototypes. The engagement of the stakeholders during the two case studies was accomplished with participatory design methods and followed a multidisciplinary approach to create solutions that would meet the human, politics and behavior interdependencies that were inherent to the process of working with large healthcare organizations. The provided contributions from this thesis intent to be part of a transition process that is changing the behavior of the healthcare sector, which is increasingly moving towards the improvement of the patient-provider relationship, patient engagement, collaborative care and positive computing, where digital technologies play a key role

Assessment of Veteran Satisfaction With Telehealth Services During the COVID-19 Pandemic

Abstract With the advent of the COVID-19 public health emergency in the United States, many U.S. veterans were unable to maintain their usual office visits due to safe access concerns. Patients were strongly encouraged to maintain their healthcare needs at home by utilizing online technology resources like telehealth services with their healthcare providers. Providing excellent healthcare services for veterans during COVID-19 became a challenge for primary care providers at many veteran healthcare organizations. Since little was known about the satisfaction of veteran clients with healthcare management using virtual care during the pandemic, this formative program evaluation was designed to survey and assess veteran clients’ satisfaction using a veteran telehealth survey tool. This study found that approximately 88% of participating veterans agreed that telehealth made positive changes in their life, 89% agreed telehealth led to positive health changes, and 90% would recommend telehealth to others. Of these participants, nearly 70% were 60 years and older, with 40% of all participants being 70–79-year-olds, primarily representing an older veteran population. Some 99% of veteran participants perceived improved health management as validating the importance of providing continued telehealth care services. This formative evaluation on telehealth care will serve to provide healthcare leaders with information on improving healthcare using telehealth services, reinforce data of the positively perceived healthcare outcomes, and support a trend of the evolving need for continued healthcare access to the veteran during challenging conditions. Keywords: veteran, telehealth, COVID-19, primary care provider

AN ASSESSMENT OF THE PROCESSING OF VETERANS BENEFITS ADMINISTRATION DISABILITY CLAIMS IN MONTANA: A CASE STUDY

The purpose of the study is to examine the effectiveness of the veteran disability claim process. The research seeks to provide clear and definitive information regarding the essential information needed to produce and submit a successful claim for veteran disability benefits. The concepts measured included: what specific information is necessary; what information is available, and how often the necessary information is received. Additionally, this research offers ideas for improvement of the VA disability claims process from the perspective of veterans and their representatives as well as tools for veterans and representatives to use as a guide for gathering the essential information necessary for a successful VA disability claim