Program Profile

Suicide prevention is the leading clinical priority for the US Department of Veterans Affairs (VA).¹ An average of 18 veterans died by suicide each day in 2021.² Numerous risk factors for veteran suicide have been identified, including mental health disorders, comorbidities, access to firearms, and potentially lethal medications.^3-5 To better understand groups of patients at risk of suicide in medical settings, the authors have previously compared demographic and clinical risk factors between patients who died by suicide by using firearms or other means with matched patients who did not die by suicide (control group) to examine the impact of lack of social support, financial stress,⁶ legal problems,⁷ homelessness,⁸ and discrimination.⁹ The number of cooccurring risk factors a veteran experiences is associated with a greater likelihood of suicide attempts over time.¹⁰ In addition, some risk factors are social and environmental risk factors known as social determinants of health (SDoH), including financial stability and access to health care, food, housing, and education. ¹¹ SDoH may influence health outcomes more broadly and are associated with greater risk of suicide.^12,13

The VA offers programming to address suicide risk factors. However, not all veterans are eligible for VA care. Further, some veterans prefer to obtain non-VA services in their communities. Providing veterans with community resources that address risk factors, particularly SDoH, may be a worthwhile strategy for reducing suicide. Such resources have demonstrated success; for example, greater use of housing services was associated with a reduced risk for suicide-related mortality among unhoused veterans.¹²

The challenges that veterans experience can go beyond the scope of services the VA provides. For example, while the VA provides some services related to homelessness, justice involvement, and assistance with home loans, these services are often limited. Other services for veterans to address SDoH may require access to community resources, including food banks, employment assistance, respite and childcare services, and transportation assistance. Some veterans also may have experienced institutional betrayal, which could be a barrier to VA care and may motivate veterans to address their needs in the community.¹⁴ Veterans therefore may need a range of services beyond those within the VA. Leveraging community resources for veterans at risk for suicide is critical, as these resources may help to mitigate suicide risk.

An emerging emphasis of the VA is improving coordination with community partners to prevent veteran suicide. In 2019, the VA launched an improved Veterans Community Care Program, which implemented portions of the VA MISSION Act of 2018 to create additional connection to community care for VA-enrolled veterans. This includes assisting veterans in gaining access to specialty services not offered at a local VA medical center (VAMC), getting access to services sooner, and receiving care if they do not live near a VAMC.¹⁵ In addition, the COMPACT Act allows veterans in acute suicidal crisis to receive emergency health care through either VA or non-VA facilities at no cost.¹⁶ The VA National Strategy for Preventing Veteran Suicide 2018-2028 is a 10-year plan to reduce veteran suicide rates that includes initiatives to increase connections between VA and community agencies.¹⁷ A suicide prevention community toolkit is available online for health care professionals (HCPs) (and others, including employers) outside of the VA who may be unfamiliar with best practices for working with veterans at risk for suicide.¹⁸

The challenge, however, is that there is often a lack of “connectedness” between VA suicide prevention coordinators and community resources to address suicide risk factors and related social determinants of health. These services include, but are not limited to suicide prevention, mental health counseling (particularly no/low-cost services), unemployment resources, financial assistance and counseling, housing assistance, and identity-related supportive spaces. A major stumbling block in connecting resources with veterans (regardless of discharge status) who need them is there is no single, national organization with a comprehensive, community-based network that can serve in this intermediary role.

Community asset mapping (CAM), also known as asset mapping or environmental scanning, is a way to bridge the gap.¹⁹ CAM provides a method for identifying and aligning community resources relative to a specific need.²⁰ CAM may be used to build community relationships in service of veteran suicide prevention. This process can help individuals learn about and make use of organizations and services within their communities. CAM also helps connect HCPs so they can network, exchange ideas, and collaborate with an eye toward increasing the availability of services and enhancing care coordination. CAM also allows community members (eg, leaders, organizations, individuals) to identify possible gaps in services that address suicide risk factors and solve these problems.

This article details CAM for suicide prevention, which can be utilized by the VA and community organizations alike. Within the VA, CAM can be used by HCPs and administrators, such as VA community engagement and partnership coordinators, to identify potential partnering organizations. For those who serve veterans outside of the VA, CAM can be used to connect at-risk individuals to resources that can enhance their care. This process can help increase the overall knowledge of, and access to, community resources.

COMMUNITY ASSET MAPPING

The University of California, Los Angeles Center for Health Policy Research provides 6 steps for the CAM process.²¹ These steps include: (1) defining the boundaries of people and places that comprise the community; (2) identifying people and organizations who share similar interests and goals; (3) determining the assets to include; (4) creating an inventory of all organizations’ assets; (5) creating an inventory of individuals’ assets; and (6) organizing the assets on a map. To address the needs of the veteran population, we’ve taken these 6 steps and adapted them to create a CAM for veterans at risk for suicide (Figure). The discussion that follows details how these steps can be implemented to identify community resources that address social determinants of health that may contribute to suicide risk. The goal is to prevent veteran suicide.

Step 1: Define Community Reach. The first step is to identify the geographical boundaries of the community. This may include all veterans within a catchment area (eg, veterans within 60 miles of a VAMC). Defining the geographical parameters of the community will provide structure to the effort so that the resource list is as comprehensive as possible.

Steps 2 and 3: Identify Community Members with Shared Goals; Identify Assets. It is important to identify community members who share similar interests and goals, including people with specific knowledge and skills, organizations with particular goals, and community partners with a broad reach. To begin building a list of referrals, reach out to colleagues within the VA system who are familiar with community resources for those with suicide risk factors. The local VA Transition and Care Management (TCM) office is a resource that connects those transitioning from military to civilian sectors with needed resources, and thus may be a helpful resource while building a CAM. Additionally, each office has a transition patient advocate, who is trained to resolve care-related concerns and may be familiar with community resources.

VA HCPs that can assist include Community Engagement and Partnership Coordinators, Suicide Prevention Coordinators, Local Recovery Coordinators, and substance abuse counselors. In addition, VA patient services, patient safety, and public affairs office staff—as well as VA Homeless Programs—may be good resources. Every VA health care system has care coordinators focused on military sexual trauma, intimate partner violence, and lesbian, gay, bisexual, transgender, queer+ care. These care coordinators may be able to provide information on community resources that address social determinants of health (eg, discrimination, violence).

Reaching out to key community resources and asking for recommendations of other groups that provide assistance to veterans can also be productive. You can start by connecting with veterans service organizations (VSOs), Vet Centers, Veterans Experience Offices (VEO), and Community Veterans Engagement Boards (CVEBs). The VEO is an office designed around VA and community engagement efforts. This office utilizes the CVEBs to foster a 2-way communication feedback loop between veterans and local VA facilities regarding community engagement efforts and outreach.²² CVEBs are particularly valuable sources of information because veterans directly contribute to the conversation about community engagement by describing the difficulties and successes they’ve experienced. Veteran feedback about how a particular resource met their needs can inform which community services are prioritized for inclusion in the resource list. In addition, CVEBs may have a listing of local government, military, and/or community resources that provide services for veterans. Consider, too, organizations that are unrelated to an individual’s veteran status, but speak to their race/ethnicity, sexual orientation, gender identity, spirituality, socioeconomic status, or disability.

Step 4: Continue to Build Inventory. Use online searches to identify additional resources in the community that are known to have local relationships. These include state suicide prevention coordinators, mental health organizations, and other resources that address social determinants of health (eg, public health and human service organizations, faith-based organizations, collegial organizations). A list of links and search tips are available in the Table.

Steps 5 and 6: Create Document; Organize and Disseminate Information. A spreadsheet can be used to document organization information (Appendix). It is critical to record: (1) the name of the organization or individual; (2) the local address and a point of contact with contact information; (3) services offered to veterans; (4) services specific to suicide prevention, or that address risk factors for suicide; and (5) whether the referral organization is partnered with the VA Community Care Network, which is comprised of contracted HCPs who contract with the VA to provide care to veterans.²³

Once a document is created, it can be disseminated through VA offices and among community partners who work with veterans at risk for suicide. It should also be stored in a centralized location such as a shared folder so that it can be continuously updated.

Regularly updating the list is vital so the resource list can continue to be helpful in addressing veterans’ needs and reducing suicide risk factors. Continued collaboration with those in the community can help ensure the resource list is up to date with all available services and pertinent contact information. It can also go far in strengthening collaborative bonds.

IMPLEMENTATION

To illustrate the use of CAM for veteran suicide prevention, we offer a case example of CAM conducted by the VA Patient Safety Center of Inquiry — Suicide Prevention Collaborative (VA PSCI-SPC) team, consisting of 4 team members. A veteran was included as a team member and assisted with the CAM process.

The VA PSCI-SPC sought to identify community services for veterans in Colorado who were not enrolled in VA health care and had risk factors for suicide. Next, the team reached out to colleagues and asked about community organizations that work with individuals at risk for suicide. VA PSCI-SPC outreach resulted in a list of assets that included resources to address mental health, legal concerns, employment, homelessness/housing, finances, religion, peer support, food insecurity, exercise, intimate partner violence, sexual and gender identity needs, and peer support. VSOs and CVEBs were also added to the list.

Next, the team continued to build on the inventory and identified state suicide prevention coordinators; health care systems; regional suicide prevention commissions; Colorado Department of Health and Human Services; program coordinators for Governor’s and Mayor’s Challenges to Prevent Suicide Among Service Members, Veterans, and their Families; veterans councils; universities (eg, counseling clinics, legal clinics); and foundations devoted to general and veteran-specific suicide prevention within the region.

All the identified resources were inventoried. Details were gathered about each of the organizations, including addresses, points of contact and phone numbers, descriptions of services offered for veterans, descriptions of suicide prevention services offered, whether or not organizations were not-for-profit, the mission of the organizations, and whether or not the organizations were under contract for VA Community Care. Finally, the resource spreadsheet was created and disseminated among stakeholders to be used to enhance veteran suicide care. Stakeholders included social workers, psychologists, and nurse practitioners working with veterans. The list was circulated to VA and community partners as needed.

The VA PSCI-SPC resource document was only 1 benefit of CAM. The asset mapping also resulted in the creation of a learning collaborative comprised of VA and community partners, designed to share knowledge of best practices in suicide prevention and create an established referral network for veterans at risk for suicide.²⁴ Ultimately, the goal of the CAM and the creation of the learning collaborative was to better connect veterans to care in order to decrease suicide risk. A secondary benefit of this community connectedness is that the list of resources produced by CAM became a living document that was, and continues to be, updated as the network became aware of new resources and resources that were no longer available. The VA PSCI-SPC learning collaborative met quarterly to discuss implementation of suicide prevention best practices within their organization.

Data from the VA PSCI-SPC learning collaborative via CAM revealed that organizations felt more efficacious in implementing suicide prevention best practices, noticed increased connections and collaborations with community organizations with the goal of providing services to veterans, and resulted in staff training that improved services provided to veterans.²⁴ This is supported by other findings of a literature review of suicide prevention interventions, which indicated that programs with an established community support network were more effective at reducing suicide rates.²⁵ CAM therefore may be a process through which greater community connection and increased knowledge of resources may help prevent suicide among veterans.

It seems reasonable that the CAM processes used by the VA PSCI-SPC can be implemented within the regional Veterans Integrated Service Networks to identify assets in a specific geographical area to address challenges with social determinants of health and potentially decrease veteran suicide risk.

CONCLUSIONS

CAM can be used to identify and build relationships with community resources that address the stressors that place veterans at risk for suicide. Six proposed steps to CAM for veterans at risk for suicide include: defining community reach (the map); identifying community members and organizations with shared goals; identifying assets within the community; continuing to build inventory; creating a document; and organizing and disseminating the information (while continuing to update the resources).²¹

CAM can be used to connect veterans with resources to address needs related to adverse social determinants of health that may heighten their risk for suicide. For example, veterans facing legal challenges can connect with a legal clinic; those having difficulties paying bills can obtain financial assistance; those who need help completing their VA claims can connect with the Veterans Benefits Administration or VSOs to assist them with their claims; and those experiencing discrimination can connect with organizations where they may experience acceptance, safety, and support. Broad community support surrounding suicide risk factors can be critical for effective suicide prevention.²⁵

CAM may also be helpful for HCPs and others involved in veteran health care. For example, community mapping can be utilized by newly hired community engagement and partnership coordinators as a tool for outlining resources available for veterans in their community and as a framework to continually update their resource network. CAM develops community awareness, integrates resources, and enhances service utilization, which may assist in veteran suicide prevention by increasing care coordination.¹⁷ Finally, mapping community resources can create awareness of the many resources available to help veterans, even before suicide becomes a consideration.

Suicide prevention is the leading clinical priority for the US Department of Veterans Affairs (VA).¹ An average of 18 veterans died by suicide each day in 2021.² Numerous risk factors for veteran suicide have been identified, including mental health disorders, comorbidities, access to firearms, and potentially lethal medications.^3-5 To better understand groups of patients at risk of suicide in medical settings, the authors have previously compared demographic and clinical risk factors between patients who died by suicide by using firearms or other means with matched patients who did not die by suicide (control group) to examine the impact of lack of social support, financial stress,⁶ legal problems,⁷ homelessness,⁸ and discrimination.⁹ The number of cooccurring risk factors a veteran experiences is associated with a greater likelihood of suicide attempts over time.¹⁰ In addition, some risk factors are social and environmental risk factors known as social determinants of health (SDoH), including financial stability and access to health care, food, housing, and education. ¹¹ SDoH may influence health outcomes more broadly and are associated with greater risk of suicide.^12,13

The VA offers programming to address suicide risk factors. However, not all veterans are eligible for VA care. Further, some veterans prefer to obtain non-VA services in their communities. Providing veterans with community resources that address risk factors, particularly SDoH, may be a worthwhile strategy for reducing suicide. Such resources have demonstrated success; for example, greater use of housing services was associated with a reduced risk for suicide-related mortality among unhoused veterans.¹²

The challenges that veterans experience can go beyond the scope of services the VA provides. For example, while the VA provides some services related to homelessness, justice involvement, and assistance with home loans, these services are often limited. Other services for veterans to address SDoH may require access to community resources, including food banks, employment assistance, respite and childcare services, and transportation assistance. Some veterans also may have experienced institutional betrayal, which could be a barrier to VA care and may motivate veterans to address their needs in the community.¹⁴ Veterans therefore may need a range of services beyond those within the VA. Leveraging community resources for veterans at risk for suicide is critical, as these resources may help to mitigate suicide risk.

An emerging emphasis of the VA is improving coordination with community partners to prevent veteran suicide. In 2019, the VA launched an improved Veterans Community Care Program, which implemented portions of the VA MISSION Act of 2018 to create additional connection to community care for VA-enrolled veterans. This includes assisting veterans in gaining access to specialty services not offered at a local VA medical center (VAMC), getting access to services sooner, and receiving care if they do not live near a VAMC.¹⁵ In addition, the COMPACT Act allows veterans in acute suicidal crisis to receive emergency health care through either VA or non-VA facilities at no cost.¹⁶ The VA National Strategy for Preventing Veteran Suicide 2018-2028 is a 10-year plan to reduce veteran suicide rates that includes initiatives to increase connections between VA and community agencies.¹⁷ A suicide prevention community toolkit is available online for health care professionals (HCPs) (and others, including employers) outside of the VA who may be unfamiliar with best practices for working with veterans at risk for suicide.¹⁸

The challenge, however, is that there is often a lack of “connectedness” between VA suicide prevention coordinators and community resources to address suicide risk factors and related social determinants of health. These services include, but are not limited to suicide prevention, mental health counseling (particularly no/low-cost services), unemployment resources, financial assistance and counseling, housing assistance, and identity-related supportive spaces. A major stumbling block in connecting resources with veterans (regardless of discharge status) who need them is there is no single, national organization with a comprehensive, community-based network that can serve in this intermediary role.

Community asset mapping (CAM), also known as asset mapping or environmental scanning, is a way to bridge the gap.¹⁹ CAM provides a method for identifying and aligning community resources relative to a specific need.²⁰ CAM may be used to build community relationships in service of veteran suicide prevention. This process can help individuals learn about and make use of organizations and services within their communities. CAM also helps connect HCPs so they can network, exchange ideas, and collaborate with an eye toward increasing the availability of services and enhancing care coordination. CAM also allows community members (eg, leaders, organizations, individuals) to identify possible gaps in services that address suicide risk factors and solve these problems.

This article details CAM for suicide prevention, which can be utilized by the VA and community organizations alike. Within the VA, CAM can be used by HCPs and administrators, such as VA community engagement and partnership coordinators, to identify potential partnering organizations. For those who serve veterans outside of the VA, CAM can be used to connect at-risk individuals to resources that can enhance their care. This process can help increase the overall knowledge of, and access to, community resources.

COMMUNITY ASSET MAPPING

The University of California, Los Angeles Center for Health Policy Research provides 6 steps for the CAM process.²¹ These steps include: (1) defining the boundaries of people and places that comprise the community; (2) identifying people and organizations who share similar interests and goals; (3) determining the assets to include; (4) creating an inventory of all organizations’ assets; (5) creating an inventory of individuals’ assets; and (6) organizing the assets on a map. To address the needs of the veteran population, we’ve taken these 6 steps and adapted them to create a CAM for veterans at risk for suicide (Figure). The discussion that follows details how these steps can be implemented to identify community resources that address social determinants of health that may contribute to suicide risk. The goal is to prevent veteran suicide.

Step 1: Define Community Reach. The first step is to identify the geographical boundaries of the community. This may include all veterans within a catchment area (eg, veterans within 60 miles of a VAMC). Defining the geographical parameters of the community will provide structure to the effort so that the resource list is as comprehensive as possible.

Steps 2 and 3: Identify Community Members with Shared Goals; Identify Assets. It is important to identify community members who share similar interests and goals, including people with specific knowledge and skills, organizations with particular goals, and community partners with a broad reach. To begin building a list of referrals, reach out to colleagues within the VA system who are familiar with community resources for those with suicide risk factors. The local VA Transition and Care Management (TCM) office is a resource that connects those transitioning from military to civilian sectors with needed resources, and thus may be a helpful resource while building a CAM. Additionally, each office has a transition patient advocate, who is trained to resolve care-related concerns and may be familiar with community resources.

VA HCPs that can assist include Community Engagement and Partnership Coordinators, Suicide Prevention Coordinators, Local Recovery Coordinators, and substance abuse counselors. In addition, VA patient services, patient safety, and public affairs office staff—as well as VA Homeless Programs—may be good resources. Every VA health care system has care coordinators focused on military sexual trauma, intimate partner violence, and lesbian, gay, bisexual, transgender, queer+ care. These care coordinators may be able to provide information on community resources that address social determinants of health (eg, discrimination, violence).

Reaching out to key community resources and asking for recommendations of other groups that provide assistance to veterans can also be productive. You can start by connecting with veterans service organizations (VSOs), Vet Centers, Veterans Experience Offices (VEO), and Community Veterans Engagement Boards (CVEBs). The VEO is an office designed around VA and community engagement efforts. This office utilizes the CVEBs to foster a 2-way communication feedback loop between veterans and local VA facilities regarding community engagement efforts and outreach.²² CVEBs are particularly valuable sources of information because veterans directly contribute to the conversation about community engagement by describing the difficulties and successes they’ve experienced. Veteran feedback about how a particular resource met their needs can inform which community services are prioritized for inclusion in the resource list. In addition, CVEBs may have a listing of local government, military, and/or community resources that provide services for veterans. Consider, too, organizations that are unrelated to an individual’s veteran status, but speak to their race/ethnicity, sexual orientation, gender identity, spirituality, socioeconomic status, or disability.

Step 4: Continue to Build Inventory. Use online searches to identify additional resources in the community that are known to have local relationships. These include state suicide prevention coordinators, mental health organizations, and other resources that address social determinants of health (eg, public health and human service organizations, faith-based organizations, collegial organizations). A list of links and search tips are available in the Table.

Steps 5 and 6: Create Document; Organize and Disseminate Information. A spreadsheet can be used to document organization information (Appendix). It is critical to record: (1) the name of the organization or individual; (2) the local address and a point of contact with contact information; (3) services offered to veterans; (4) services specific to suicide prevention, or that address risk factors for suicide; and (5) whether the referral organization is partnered with the VA Community Care Network, which is comprised of contracted HCPs who contract with the VA to provide care to veterans.²³

Once a document is created, it can be disseminated through VA offices and among community partners who work with veterans at risk for suicide. It should also be stored in a centralized location such as a shared folder so that it can be continuously updated.

Regularly updating the list is vital so the resource list can continue to be helpful in addressing veterans’ needs and reducing suicide risk factors. Continued collaboration with those in the community can help ensure the resource list is up to date with all available services and pertinent contact information. It can also go far in strengthening collaborative bonds.

IMPLEMENTATION

To illustrate the use of CAM for veteran suicide prevention, we offer a case example of CAM conducted by the VA Patient Safety Center of Inquiry — Suicide Prevention Collaborative (VA PSCI-SPC) team, consisting of 4 team members. A veteran was included as a team member and assisted with the CAM process.

The VA PSCI-SPC sought to identify community services for veterans in Colorado who were not enrolled in VA health care and had risk factors for suicide. Next, the team reached out to colleagues and asked about community organizations that work with individuals at risk for suicide. VA PSCI-SPC outreach resulted in a list of assets that included resources to address mental health, legal concerns, employment, homelessness/housing, finances, religion, peer support, food insecurity, exercise, intimate partner violence, sexual and gender identity needs, and peer support. VSOs and CVEBs were also added to the list.

Next, the team continued to build on the inventory and identified state suicide prevention coordinators; health care systems; regional suicide prevention commissions; Colorado Department of Health and Human Services; program coordinators for Governor’s and Mayor’s Challenges to Prevent Suicide Among Service Members, Veterans, and their Families; veterans councils; universities (eg, counseling clinics, legal clinics); and foundations devoted to general and veteran-specific suicide prevention within the region.

All the identified resources were inventoried. Details were gathered about each of the organizations, including addresses, points of contact and phone numbers, descriptions of services offered for veterans, descriptions of suicide prevention services offered, whether or not organizations were not-for-profit, the mission of the organizations, and whether or not the organizations were under contract for VA Community Care. Finally, the resource spreadsheet was created and disseminated among stakeholders to be used to enhance veteran suicide care. Stakeholders included social workers, psychologists, and nurse practitioners working with veterans. The list was circulated to VA and community partners as needed.

The VA PSCI-SPC resource document was only 1 benefit of CAM. The asset mapping also resulted in the creation of a learning collaborative comprised of VA and community partners, designed to share knowledge of best practices in suicide prevention and create an established referral network for veterans at risk for suicide.²⁴ Ultimately, the goal of the CAM and the creation of the learning collaborative was to better connect veterans to care in order to decrease suicide risk. A secondary benefit of this community connectedness is that the list of resources produced by CAM became a living document that was, and continues to be, updated as the network became aware of new resources and resources that were no longer available. The VA PSCI-SPC learning collaborative met quarterly to discuss implementation of suicide prevention best practices within their organization.

Data from the VA PSCI-SPC learning collaborative via CAM revealed that organizations felt more efficacious in implementing suicide prevention best practices, noticed increased connections and collaborations with community organizations with the goal of providing services to veterans, and resulted in staff training that improved services provided to veterans.²⁴ This is supported by other findings of a literature review of suicide prevention interventions, which indicated that programs with an established community support network were more effective at reducing suicide rates.²⁵ CAM therefore may be a process through which greater community connection and increased knowledge of resources may help prevent suicide among veterans.

It seems reasonable that the CAM processes used by the VA PSCI-SPC can be implemented within the regional Veterans Integrated Service Networks to identify assets in a specific geographical area to address challenges with social determinants of health and potentially decrease veteran suicide risk.

CONCLUSIONS

CAM can be used to identify and build relationships with community resources that address the stressors that place veterans at risk for suicide. Six proposed steps to CAM for veterans at risk for suicide include: defining community reach (the map); identifying community members and organizations with shared goals; identifying assets within the community; continuing to build inventory; creating a document; and organizing and disseminating the information (while continuing to update the resources).²¹

CAM can be used to connect veterans with resources to address needs related to adverse social determinants of health that may heighten their risk for suicide. For example, veterans facing legal challenges can connect with a legal clinic; those having difficulties paying bills can obtain financial assistance; those who need help completing their VA claims can connect with the Veterans Benefits Administration or VSOs to assist them with their claims; and those experiencing discrimination can connect with organizations where they may experience acceptance, safety, and support. Broad community support surrounding suicide risk factors can be critical for effective suicide prevention.²⁵

CAM may also be helpful for HCPs and others involved in veteran health care. For example, community mapping can be utilized by newly hired community engagement and partnership coordinators as a tool for outlining resources available for veterans in their community and as a framework to continually update their resource network. CAM develops community awareness, integrates resources, and enhances service utilization, which may assist in veteran suicide prevention by increasing care coordination.¹⁷ Finally, mapping community resources can create awareness of the many resources available to help veterans, even before suicide becomes a consideration.

Suicide prevention is the leading clinical priority for the US Department of Veterans Affairs (VA).¹ An average of 18 veterans died by suicide each day in 2021.² Numerous risk factors for veteran suicide have been identified, including mental health disorders, comorbidities, access to firearms, and potentially lethal medications.^3-5 To better understand groups of patients at risk of suicide in medical settings, the authors have previously compared demographic and clinical risk factors between patients who died by suicide by using firearms or other means with matched patients who did not die by suicide (control group) to examine the impact of lack of social support, financial stress,⁶ legal problems,⁷ homelessness,⁸ and discrimination.⁹ The number of cooccurring risk factors a veteran experiences is associated with a greater likelihood of suicide attempts over time.¹⁰ In addition, some risk factors are social and environmental risk factors known as social determinants of health (SDoH), including financial stability and access to health care, food, housing, and education. ¹¹ SDoH may influence health outcomes more broadly and are associated with greater risk of suicide.^12,13

The VA offers programming to address suicide risk factors. However, not all veterans are eligible for VA care. Further, some veterans prefer to obtain non-VA services in their communities. Providing veterans with community resources that address risk factors, particularly SDoH, may be a worthwhile strategy for reducing suicide. Such resources have demonstrated success; for example, greater use of housing services was associated with a reduced risk for suicide-related mortality among unhoused veterans.¹²

The challenges that veterans experience can go beyond the scope of services the VA provides. For example, while the VA provides some services related to homelessness, justice involvement, and assistance with home loans, these services are often limited. Other services for veterans to address SDoH may require access to community resources, including food banks, employment assistance, respite and childcare services, and transportation assistance. Some veterans also may have experienced institutional betrayal, which could be a barrier to VA care and may motivate veterans to address their needs in the community.¹⁴ Veterans therefore may need a range of services beyond those within the VA. Leveraging community resources for veterans at risk for suicide is critical, as these resources may help to mitigate suicide risk.

An emerging emphasis of the VA is improving coordination with community partners to prevent veteran suicide. In 2019, the VA launched an improved Veterans Community Care Program, which implemented portions of the VA MISSION Act of 2018 to create additional connection to community care for VA-enrolled veterans. This includes assisting veterans in gaining access to specialty services not offered at a local VA medical center (VAMC), getting access to services sooner, and receiving care if they do not live near a VAMC.¹⁵ In addition, the COMPACT Act allows veterans in acute suicidal crisis to receive emergency health care through either VA or non-VA facilities at no cost.¹⁶ The VA National Strategy for Preventing Veteran Suicide 2018-2028 is a 10-year plan to reduce veteran suicide rates that includes initiatives to increase connections between VA and community agencies.¹⁷ A suicide prevention community toolkit is available online for health care professionals (HCPs) (and others, including employers) outside of the VA who may be unfamiliar with best practices for working with veterans at risk for suicide.¹⁸

The challenge, however, is that there is often a lack of “connectedness” between VA suicide prevention coordinators and community resources to address suicide risk factors and related social determinants of health. These services include, but are not limited to suicide prevention, mental health counseling (particularly no/low-cost services), unemployment resources, financial assistance and counseling, housing assistance, and identity-related supportive spaces. A major stumbling block in connecting resources with veterans (regardless of discharge status) who need them is there is no single, national organization with a comprehensive, community-based network that can serve in this intermediary role.

Community asset mapping (CAM), also known as asset mapping or environmental scanning, is a way to bridge the gap.¹⁹ CAM provides a method for identifying and aligning community resources relative to a specific need.²⁰ CAM may be used to build community relationships in service of veteran suicide prevention. This process can help individuals learn about and make use of organizations and services within their communities. CAM also helps connect HCPs so they can network, exchange ideas, and collaborate with an eye toward increasing the availability of services and enhancing care coordination. CAM also allows community members (eg, leaders, organizations, individuals) to identify possible gaps in services that address suicide risk factors and solve these problems.

This article details CAM for suicide prevention, which can be utilized by the VA and community organizations alike. Within the VA, CAM can be used by HCPs and administrators, such as VA community engagement and partnership coordinators, to identify potential partnering organizations. For those who serve veterans outside of the VA, CAM can be used to connect at-risk individuals to resources that can enhance their care. This process can help increase the overall knowledge of, and access to, community resources.

COMMUNITY ASSET MAPPING

The University of California, Los Angeles Center for Health Policy Research provides 6 steps for the CAM process.²¹ These steps include: (1) defining the boundaries of people and places that comprise the community; (2) identifying people and organizations who share similar interests and goals; (3) determining the assets to include; (4) creating an inventory of all organizations’ assets; (5) creating an inventory of individuals’ assets; and (6) organizing the assets on a map. To address the needs of the veteran population, we’ve taken these 6 steps and adapted them to create a CAM for veterans at risk for suicide (Figure). The discussion that follows details how these steps can be implemented to identify community resources that address social determinants of health that may contribute to suicide risk. The goal is to prevent veteran suicide.

Step 1: Define Community Reach. The first step is to identify the geographical boundaries of the community. This may include all veterans within a catchment area (eg, veterans within 60 miles of a VAMC). Defining the geographical parameters of the community will provide structure to the effort so that the resource list is as comprehensive as possible.

Steps 2 and 3: Identify Community Members with Shared Goals; Identify Assets. It is important to identify community members who share similar interests and goals, including people with specific knowledge and skills, organizations with particular goals, and community partners with a broad reach. To begin building a list of referrals, reach out to colleagues within the VA system who are familiar with community resources for those with suicide risk factors. The local VA Transition and Care Management (TCM) office is a resource that connects those transitioning from military to civilian sectors with needed resources, and thus may be a helpful resource while building a CAM. Additionally, each office has a transition patient advocate, who is trained to resolve care-related concerns and may be familiar with community resources.

VA HCPs that can assist include Community Engagement and Partnership Coordinators, Suicide Prevention Coordinators, Local Recovery Coordinators, and substance abuse counselors. In addition, VA patient services, patient safety, and public affairs office staff—as well as VA Homeless Programs—may be good resources. Every VA health care system has care coordinators focused on military sexual trauma, intimate partner violence, and lesbian, gay, bisexual, transgender, queer+ care. These care coordinators may be able to provide information on community resources that address social determinants of health (eg, discrimination, violence).

Reaching out to key community resources and asking for recommendations of other groups that provide assistance to veterans can also be productive. You can start by connecting with veterans service organizations (VSOs), Vet Centers, Veterans Experience Offices (VEO), and Community Veterans Engagement Boards (CVEBs). The VEO is an office designed around VA and community engagement efforts. This office utilizes the CVEBs to foster a 2-way communication feedback loop between veterans and local VA facilities regarding community engagement efforts and outreach.²² CVEBs are particularly valuable sources of information because veterans directly contribute to the conversation about community engagement by describing the difficulties and successes they’ve experienced. Veteran feedback about how a particular resource met their needs can inform which community services are prioritized for inclusion in the resource list. In addition, CVEBs may have a listing of local government, military, and/or community resources that provide services for veterans. Consider, too, organizations that are unrelated to an individual’s veteran status, but speak to their race/ethnicity, sexual orientation, gender identity, spirituality, socioeconomic status, or disability.

Step 4: Continue to Build Inventory. Use online searches to identify additional resources in the community that are known to have local relationships. These include state suicide prevention coordinators, mental health organizations, and other resources that address social determinants of health (eg, public health and human service organizations, faith-based organizations, collegial organizations). A list of links and search tips are available in the Table.

Steps 5 and 6: Create Document; Organize and Disseminate Information. A spreadsheet can be used to document organization information (Appendix). It is critical to record: (1) the name of the organization or individual; (2) the local address and a point of contact with contact information; (3) services offered to veterans; (4) services specific to suicide prevention, or that address risk factors for suicide; and (5) whether the referral organization is partnered with the VA Community Care Network, which is comprised of contracted HCPs who contract with the VA to provide care to veterans.²³

Once a document is created, it can be disseminated through VA offices and among community partners who work with veterans at risk for suicide. It should also be stored in a centralized location such as a shared folder so that it can be continuously updated.

Regularly updating the list is vital so the resource list can continue to be helpful in addressing veterans’ needs and reducing suicide risk factors. Continued collaboration with those in the community can help ensure the resource list is up to date with all available services and pertinent contact information. It can also go far in strengthening collaborative bonds.

IMPLEMENTATION

To illustrate the use of CAM for veteran suicide prevention, we offer a case example of CAM conducted by the VA Patient Safety Center of Inquiry — Suicide Prevention Collaborative (VA PSCI-SPC) team, consisting of 4 team members. A veteran was included as a team member and assisted with the CAM process.

The VA PSCI-SPC sought to identify community services for veterans in Colorado who were not enrolled in VA health care and had risk factors for suicide. Next, the team reached out to colleagues and asked about community organizations that work with individuals at risk for suicide. VA PSCI-SPC outreach resulted in a list of assets that included resources to address mental health, legal concerns, employment, homelessness/housing, finances, religion, peer support, food insecurity, exercise, intimate partner violence, sexual and gender identity needs, and peer support. VSOs and CVEBs were also added to the list.

Next, the team continued to build on the inventory and identified state suicide prevention coordinators; health care systems; regional suicide prevention commissions; Colorado Department of Health and Human Services; program coordinators for Governor’s and Mayor’s Challenges to Prevent Suicide Among Service Members, Veterans, and their Families; veterans councils; universities (eg, counseling clinics, legal clinics); and foundations devoted to general and veteran-specific suicide prevention within the region.

All the identified resources were inventoried. Details were gathered about each of the organizations, including addresses, points of contact and phone numbers, descriptions of services offered for veterans, descriptions of suicide prevention services offered, whether or not organizations were not-for-profit, the mission of the organizations, and whether or not the organizations were under contract for VA Community Care. Finally, the resource spreadsheet was created and disseminated among stakeholders to be used to enhance veteran suicide care. Stakeholders included social workers, psychologists, and nurse practitioners working with veterans. The list was circulated to VA and community partners as needed.

The VA PSCI-SPC resource document was only 1 benefit of CAM. The asset mapping also resulted in the creation of a learning collaborative comprised of VA and community partners, designed to share knowledge of best practices in suicide prevention and create an established referral network for veterans at risk for suicide.²⁴ Ultimately, the goal of the CAM and the creation of the learning collaborative was to better connect veterans to care in order to decrease suicide risk. A secondary benefit of this community connectedness is that the list of resources produced by CAM became a living document that was, and continues to be, updated as the network became aware of new resources and resources that were no longer available. The VA PSCI-SPC learning collaborative met quarterly to discuss implementation of suicide prevention best practices within their organization.

Data from the VA PSCI-SPC learning collaborative via CAM revealed that organizations felt more efficacious in implementing suicide prevention best practices, noticed increased connections and collaborations with community organizations with the goal of providing services to veterans, and resulted in staff training that improved services provided to veterans.²⁴ This is supported by other findings of a literature review of suicide prevention interventions, which indicated that programs with an established community support network were more effective at reducing suicide rates.²⁵ CAM therefore may be a process through which greater community connection and increased knowledge of resources may help prevent suicide among veterans.

It seems reasonable that the CAM processes used by the VA PSCI-SPC can be implemented within the regional Veterans Integrated Service Networks to identify assets in a specific geographical area to address challenges with social determinants of health and potentially decrease veteran suicide risk.

CONCLUSIONS

CAM can be used to identify and build relationships with community resources that address the stressors that place veterans at risk for suicide. Six proposed steps to CAM for veterans at risk for suicide include: defining community reach (the map); identifying community members and organizations with shared goals; identifying assets within the community; continuing to build inventory; creating a document; and organizing and disseminating the information (while continuing to update the resources).²¹

CAM can be used to connect veterans with resources to address needs related to adverse social determinants of health that may heighten their risk for suicide. For example, veterans facing legal challenges can connect with a legal clinic; those having difficulties paying bills can obtain financial assistance; those who need help completing their VA claims can connect with the Veterans Benefits Administration or VSOs to assist them with their claims; and those experiencing discrimination can connect with organizations where they may experience acceptance, safety, and support. Broad community support surrounding suicide risk factors can be critical for effective suicide prevention.²⁵

CAM may also be helpful for HCPs and others involved in veteran health care. For example, community mapping can be utilized by newly hired community engagement and partnership coordinators as a tool for outlining resources available for veterans in their community and as a framework to continually update their resource network. CAM develops community awareness, integrates resources, and enhances service utilization, which may assist in veteran suicide prevention by increasing care coordination.¹⁷ Finally, mapping community resources can create awareness of the many resources available to help veterans, even before suicide becomes a consideration.

Evidence-based psychotherapy (EBP) for posttraumatic stress disorder (PTSD), such as prolonged exposure (PE), is supported by multiple clinical practice guidelines and is expected to be available to veterans served by the Veterans Health Administration (VHA).^1-5 However, traditional models of EBP delivery with 1 or 2 sessions weekly have high dropout rates.^6,7 Few veterans who could benefit from such EBPs receive them, and those who do have low completion rates.^8,9 Over a 15-year period, VHA records review of > 265,500 veterans with PTSD showed only 9.1% completed EBP treatment that included but was not limited to PE.¹⁰

One empirically supported solution that has yet to be widely implemented is delivering EBPs for PTSD in a massed or accelerated format of ≥ 3 sessions weekly.¹¹ While these massed models of EBP delivery for PTSD are promising, their implementation is limited in federal health care settings, such as the VHA.¹² PE therapy is a first-line treatment for PTSD that has been evaluated in numerous clinical trials since the early 1990s and in a wide range of trauma populations.^13,14 Massed PE is effective and PE has been found to be effective both in-person and via telehealth.^11,15,16

Another approach to accelerated PE is the inclusion of a massed PE course within a broader treatment context that includes augmentation of the massed PE with additional services, this is referred to as an intensive outpatient model (IOP).¹⁷ PE-IOP has also been shown to be feasible, acceptable, and effective with increased completion rates in comparison to the traditional (1 or 2 sessions weekly) model of PE.^12,16,18,19 Ragsdale et al describe a 2-week IOP with multiple treatment tracks, including a PTSD track. The PTSD treatment track includes massed PE and additional standard services including case management, wellness services, family services, and a single session effective behaviors group. Additional augmentation services are available when clinically indicated (eg, repetitive transcranial magnetic stimulation, transcranial direct current stimulation treatment, psychoeducation, motivational interviewing, and/or relapse prevention).¹⁷

Rauch et al studied the first 80 patients completing an IOP program that consisted of PE (5 sessions weekly) and complementary interventions (eg, mindfulness and yoga) and reported a 96% retention rate, significant reductions of self-reported PTSD symptoms, significant reduction in self-reported co-occurring depression symptoms, and significant increase in self-reported satisfaction with social functioning. ¹⁸ In another study, Sherril et al explored patient reactions to participation in massed PE (5 sessions weekly) and found that patients reported significantly more positive than negative reactions. Sherrill et al noted that according to patients, the benefits of massed PE included a structured format that limits avoidance and distraction. The resulting fast pace of progress enhanced motivation; however, drawbacks included short-term discomfort and time demands.¹⁹ Yamokoski et al explored the feasibility of massed PE in a larger study of PTSD treatment in an intensive outpatient track (IOT) in a VHA PTSD clinic with minimal staffing. The 48 patients who completed IOT PTSD treatment in 2 or 4 weeks (including 35 patients who received massed PE) had high retention rates (85%), reported high satisfaction, and had significantly reduced PTSD and depression symptoms.¹²

The massed IOT PE model implemented by Yamokoski et al included the primary EBP intervention of massed PE with adjunctive groups. The addition of these groups increased both retention and patient-reported satisfaction. The PE-IOP model implemented by Rauch et al and Sherrill et al also included wellness and educational groups, as well as access to complementary interventions such as mindfulness and yoga.^18,19 The addition of wellness education along with a primary EBP aligned with the VHA focus on whole health well-being and wellness. The whole health approach includes understanding the factors that motivate a patient toward health and well-being, provision of health education, and providing access to complementary interventions such as mindfulness.²⁰ Dryden et al describe the whole health transformation within VHA as a proactive approach to addressing employee and patient wellness and health. Their research found that the whole health model promoted well-being in patients and staff and was sustained even during the COVID-19 pandemic.²¹ Dryden et al also noted that use of virtual technologies facilitated and promoted continued whole health implementation. The literature illustrates that: (1) massed PE can be provided with complementary education and wellness offerings, and that such offerings may increase both retention and satisfaction by enriching the massed PE treatment (eg, delivering PE-IOP); (2) whole health including wellness education and complementary interventions (eg, mindfulness, motivational enhancement) promotes well-being in both patients and mental health professionals; and (3) whole health education and complementary interventions can be delivered virtually.

Health Care Need

Prior to the implementation of a massed EBP for PTSD program at US Department of Veterans Affairs (VA) Pacific Islands Health Care System (VAPIHCS), our setting included a traditional outpatient program for treatment of PTSD and a 12- bed residential program for treatment of PTSD for male-identified (self-identified and identified as male in the electronic medical record) veterans via a cohort model with an 8- or 9-week length of stay. Both programs were located on Oahu. Thus, veterans who received care at VAPIHCS had access to PE in both outpatient and residential settings and via in-person and telehealth modalities. However, their access to PE was limited to the traditional models of PE delivery (eg, 1 or 2 session per week) and very few veterans outside of the island of Oahu had accessed PE treatment for PTSD. Moreover, when looking at PE reach within VAPIHCS, in the fiscal year prior to the implementation of the massed EBP program, only 32 of the > 5000 eligible veterans with a PTSD diagnosis had received PE. VAPIHCS serves veterans in a catchment area across the Pacific Basin which includes 3 time zones: Hawaii Standard Time (HST), Chamorro Standard Time (ChST), and Samoa Standard Time (SST). ChST is 20 hours ahead of HST, making service delivery that is inclusive for patients in Guam and Saipan especially challenging when providing care from Hawaii or other US states or territories. Given all of this, implementation of a new program offering accelerated PE virtually to any veterans with PTSD within the VAPIHCS would increase access to and reduce barriers to receiving PE.

PROGRAM DESCRIPTION

The Intensive Virtual EBP Team (iVET) for PTSD consists of an accelerated course of PE therapy and whole health education provided via VA Video Connect (VVC). iVET is a 3-week program and includes 3 parts: (1) massed individual PE therapy for PTSD; (2) group whole health and wellness classes; and (3) individual health coaching to address personal wellness goals. Programming is offered over 10-hour days to increase access across multiple time zones, especially to allow for participation in Guam and Saipan.

When a patient is referred to the iVET, their first contact is a video (or telephone) appointment with a registered nurse (RN) for a screening session. The screening session is designed to educate the patient about the program, including interventions, time commitment, and resources required for participation. In addition, following the educational discussion, the RN completes screening for safety with the patient including suicidal ideation and risk, as well as intimate partner violence risk. If urgent safety concerns are present, a licensed social worker or psychologist will join the screening to complete further assessment of risk and to address any safety concerns. Following screening, patients are scheduled for a VVC intake with a licensed therapist (social worker or psychologist) to complete the Clinician-Administered PTSD Scale (CAPS-5) for the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition), a clinical interview for PTSD assessment. Patients are also sent a secure link to complete a measurement-based care (MBC) battery of self-report measures including measures assessing demographics, PTSD symptoms, anxiety symptoms, depression symptoms, substance use, quality of life (QOL), and satisfaction with mental health care. The results of the CAPS-5 and self-report measures are discussed with the patient during the intake session when planning next steps and engaging in shared decision-making. This initial VVC intake not only allows for diagnostic goodness of fit but also provides the opportunity to troubleshoot any technical difficulties the patients might have with the virtual platforms.

There are minimal exclusion criteria for participation in iVET, which include active unmanaged psychosis or manic symptoms, recent suicidal crises (attempt within 8 weeks), active nonsuicidal self-injurious behaviors (within 8 weeks), and moderate-to-severe cognitive impairment. Following intake, patients are scheduled to begin their course of care with iVET. Upon completion of intake, patients are sent program materials for their individual and group classes, asked to obtain or request a recording device, and told they will receive email links for all VVC appointments. Patients are admitted to the iVET in a rolling admission fashion, thereby increasing access when compared to closed group and/or cohort models of care.

Patients receiving care in iVET attend 2 or 3 telehealth appointments daily with practice exercises daily between telehealth sessions. The primary EBP intervention in the iVET for PTSD program is a massed or accelerated course of PE, which includes 4 primary components: psychoeducation, in-vivo exposure, imaginal exposure, and breathing retraining. Specifically, PE is delivered in 4 90-minute individual sessions weekly allowing completion of the full PE protocol, to fidelity, in 3 weeks. In addition to receiving this primary intervention, patients also participate in four 50-minute group sessions per week of a whole health and wellness education class and have access to one 30- to 60-minute session weekly of individual health coaching should they wish to set wellness goals and receive coaching in support of attaining wellness goals. During iVET, patients are invited to complete MBC batteries of selfreport measures including measures assessing PTSD symptoms, anxiety symptoms, depression symptoms, substance use, QOL, and satisfaction with mental health care at sessions 1, 5, 9, and the final session of PE. Following discharge from the iVET, patients are offered 1-month, 3-month, and 6-month individual postdischarge check-up sessions with a therapist where they are invited to complete MBC measures and review relapse prevention and maintenance of treatment gains. Likewise, they are offered 1-month, 3-month, and 6-month postdischarge check-up sessions with an RN focused on maintaining wellness gains.

The iVET for PTSD staff includes 3 therapists (psychologists or social workers) and an RN. Additionally, the iVET for PTSD is supported by a program manager and a program support assistant. The primary cost of the program is salary for staff. Additional iVET for PTSD resources included computer equipment for staff and minimal supplies. Due to the virtual environment of care, iVET staff telework and do not require physical space within VAPIHCS.

OUTCOMES

All veterans receiving care in iVET for PTSD are invited to complete a MBC at multiple timepoints including pretreatment, during PE treatment, and posttreatment. The MBC measures included self-reported demographics, a 2-item measure of satisfaction with mental health services, the Brief Addiction Monitor-Intensive Outpatient Program questionnaire,²² the Generalized Anxiety Disorder-7 scale,^23, the Patient Health Questionnaire (PHQ-9),²⁴ the QOL Enjoyment and Satisfaction Questionnaire- Short Form,²⁵ and the PTSD Checklist for DSM-5 (PCL-5), both weekly and monthly versions. ^26,27

The retention rate has averaged 81% since the iVET for PTSD opened in 2022. To date, 132 veterans have completed the iVET for PTSD program, including a full course of massed PE (Table 1). Veterans experienced reduced PTSD (P < .005), depression (P < .005), anxiety (P < .005), and substance use risk (P < .005). Veterans experienced improved QOL (P < .005) and reported high satisfaction with mental health care in iVET for PTSD (Table 2). Veterans also experienced reduced thoughts of death or suicidal ideation (SI) based on PHQ-9 item 9 responses. When looking categorically at presence or absence of SI on PHQ-9 item 9, a significant relationship was found between the absence of suicidal ideation and completion of a course of massed PE: X² (1, N = 132) = 13.75, P < .001. In addition, veterans who completed the program showed a significant decrease in severity of SI as measured continuously (range, 0-3) on PHQ-9 item 9 (P < .005).

Another important aspect to consider when implementing massed models of EBP is the impact on employee well-being and job satisfaction. The impact of EBP on staff was assessed following the initial EBP project. To explore this further, all staff members in the iVET for PTSD were invited to engage in a small program evaluation. iVET staff were guided through a visualization meditation intended to recall a typical workday 1 month prior to starting their new position with iVET. After the visualization meditation, staff completed the Professional Quality of Life (ProQOL) scale, a 30-item, self-reported questionnaire for health care workers that evaluates compassion satisfaction, perceived support, burnout, secondary traumatic stress, and moral distress.²⁸ One week later, staff were asked to complete the ProQOL again to capture their state after the first 6 months into their tenure as iVET staff. iVET employees experienced significantly increased perceived support (P < .05), reduced burnout (P < .05), reduced secondary traumatic stress (P < .05), and reduced moral distress (P < .05). Team members also remarked on the rewarding nature of the work and care model.

Future Directions

Future research should aim to sustain these outcomes as the iVET program continues to serve more veterans. Another important line of inquiry is longer-term follow-up, as exploring if outcomes are maintained over time is an important question that has not been answered in this article. In addition, we hope to see the accelerated model of care applied to treatment of other presenting concerns in mental health treatment (eg, anxiety, depression, insomnia). Expansion of accelerated mental health treatment into other federal and non-federal health care settings is another worthy direction. Finally, while short term (6 months) assessment of staff satisfaction in iVET was promising, ongoing assessment staff satisfaction over a longer timeframe (1-5 years) is also important.

CONCLUSIONS

PE for PTSD has been demonstrated to be effective and improve functioning and is supported by multiple clinical practice guidelines.1-5 However, as federal practitioners, we must consider the reality that many of the individuals who could benefit are not engaging in PE and there is a high dropout rate for those that do. It is vital that we envision a future state where access to PE for PTSD is equitable and inclusive, retention rates are dramatically improved, and clinicians providing PE do not experience high rates of burnout.

We must continue exploring how we can better care for our patients and colleagues. We posit that the development of programs, or tracks within existing programs, that provide massed or accelerated PE for PTSD with virtual delivery options is an imperative step toward improved care. Federal health care settings treating trauma-exposed patients with PTSD, such as those within the US Department of Defense, Indian Health Services, Federal Bureau of Prisons, and VA, are well positioned to implement programs like iVET. We believe this model of care has great merit and foresee a future where all patients seeking PTSD treatment have the option to complete an accelerated or massed course of PE should they so desire. The experiences outlined in this article illustrate the feasibility, acceptability, and sustainability of such programs without requiring substantial staffing and financial resources.

Evidence-based psychotherapy (EBP) for posttraumatic stress disorder (PTSD), such as prolonged exposure (PE), is supported by multiple clinical practice guidelines and is expected to be available to veterans served by the Veterans Health Administration (VHA).^1-5 However, traditional models of EBP delivery with 1 or 2 sessions weekly have high dropout rates.^6,7 Few veterans who could benefit from such EBPs receive them, and those who do have low completion rates.^8,9 Over a 15-year period, VHA records review of > 265,500 veterans with PTSD showed only 9.1% completed EBP treatment that included but was not limited to PE.¹⁰

One empirically supported solution that has yet to be widely implemented is delivering EBPs for PTSD in a massed or accelerated format of ≥ 3 sessions weekly.¹¹ While these massed models of EBP delivery for PTSD are promising, their implementation is limited in federal health care settings, such as the VHA.¹² PE therapy is a first-line treatment for PTSD that has been evaluated in numerous clinical trials since the early 1990s and in a wide range of trauma populations.^13,14 Massed PE is effective and PE has been found to be effective both in-person and via telehealth.^11,15,16

Another approach to accelerated PE is the inclusion of a massed PE course within a broader treatment context that includes augmentation of the massed PE with additional services, this is referred to as an intensive outpatient model (IOP).¹⁷ PE-IOP has also been shown to be feasible, acceptable, and effective with increased completion rates in comparison to the traditional (1 or 2 sessions weekly) model of PE.^12,16,18,19 Ragsdale et al describe a 2-week IOP with multiple treatment tracks, including a PTSD track. The PTSD treatment track includes massed PE and additional standard services including case management, wellness services, family services, and a single session effective behaviors group. Additional augmentation services are available when clinically indicated (eg, repetitive transcranial magnetic stimulation, transcranial direct current stimulation treatment, psychoeducation, motivational interviewing, and/or relapse prevention).¹⁷

Rauch et al studied the first 80 patients completing an IOP program that consisted of PE (5 sessions weekly) and complementary interventions (eg, mindfulness and yoga) and reported a 96% retention rate, significant reductions of self-reported PTSD symptoms, significant reduction in self-reported co-occurring depression symptoms, and significant increase in self-reported satisfaction with social functioning. ¹⁸ In another study, Sherril et al explored patient reactions to participation in massed PE (5 sessions weekly) and found that patients reported significantly more positive than negative reactions. Sherrill et al noted that according to patients, the benefits of massed PE included a structured format that limits avoidance and distraction. The resulting fast pace of progress enhanced motivation; however, drawbacks included short-term discomfort and time demands.¹⁹ Yamokoski et al explored the feasibility of massed PE in a larger study of PTSD treatment in an intensive outpatient track (IOT) in a VHA PTSD clinic with minimal staffing. The 48 patients who completed IOT PTSD treatment in 2 or 4 weeks (including 35 patients who received massed PE) had high retention rates (85%), reported high satisfaction, and had significantly reduced PTSD and depression symptoms.¹²

The massed IOT PE model implemented by Yamokoski et al included the primary EBP intervention of massed PE with adjunctive groups. The addition of these groups increased both retention and patient-reported satisfaction. The PE-IOP model implemented by Rauch et al and Sherrill et al also included wellness and educational groups, as well as access to complementary interventions such as mindfulness and yoga.^18,19 The addition of wellness education along with a primary EBP aligned with the VHA focus on whole health well-being and wellness. The whole health approach includes understanding the factors that motivate a patient toward health and well-being, provision of health education, and providing access to complementary interventions such as mindfulness.²⁰ Dryden et al describe the whole health transformation within VHA as a proactive approach to addressing employee and patient wellness and health. Their research found that the whole health model promoted well-being in patients and staff and was sustained even during the COVID-19 pandemic.²¹ Dryden et al also noted that use of virtual technologies facilitated and promoted continued whole health implementation. The literature illustrates that: (1) massed PE can be provided with complementary education and wellness offerings, and that such offerings may increase both retention and satisfaction by enriching the massed PE treatment (eg, delivering PE-IOP); (2) whole health including wellness education and complementary interventions (eg, mindfulness, motivational enhancement) promotes well-being in both patients and mental health professionals; and (3) whole health education and complementary interventions can be delivered virtually.

Health Care Need

Prior to the implementation of a massed EBP for PTSD program at US Department of Veterans Affairs (VA) Pacific Islands Health Care System (VAPIHCS), our setting included a traditional outpatient program for treatment of PTSD and a 12- bed residential program for treatment of PTSD for male-identified (self-identified and identified as male in the electronic medical record) veterans via a cohort model with an 8- or 9-week length of stay. Both programs were located on Oahu. Thus, veterans who received care at VAPIHCS had access to PE in both outpatient and residential settings and via in-person and telehealth modalities. However, their access to PE was limited to the traditional models of PE delivery (eg, 1 or 2 session per week) and very few veterans outside of the island of Oahu had accessed PE treatment for PTSD. Moreover, when looking at PE reach within VAPIHCS, in the fiscal year prior to the implementation of the massed EBP program, only 32 of the > 5000 eligible veterans with a PTSD diagnosis had received PE. VAPIHCS serves veterans in a catchment area across the Pacific Basin which includes 3 time zones: Hawaii Standard Time (HST), Chamorro Standard Time (ChST), and Samoa Standard Time (SST). ChST is 20 hours ahead of HST, making service delivery that is inclusive for patients in Guam and Saipan especially challenging when providing care from Hawaii or other US states or territories. Given all of this, implementation of a new program offering accelerated PE virtually to any veterans with PTSD within the VAPIHCS would increase access to and reduce barriers to receiving PE.

PROGRAM DESCRIPTION

The Intensive Virtual EBP Team (iVET) for PTSD consists of an accelerated course of PE therapy and whole health education provided via VA Video Connect (VVC). iVET is a 3-week program and includes 3 parts: (1) massed individual PE therapy for PTSD; (2) group whole health and wellness classes; and (3) individual health coaching to address personal wellness goals. Programming is offered over 10-hour days to increase access across multiple time zones, especially to allow for participation in Guam and Saipan.

When a patient is referred to the iVET, their first contact is a video (or telephone) appointment with a registered nurse (RN) for a screening session. The screening session is designed to educate the patient about the program, including interventions, time commitment, and resources required for participation. In addition, following the educational discussion, the RN completes screening for safety with the patient including suicidal ideation and risk, as well as intimate partner violence risk. If urgent safety concerns are present, a licensed social worker or psychologist will join the screening to complete further assessment of risk and to address any safety concerns. Following screening, patients are scheduled for a VVC intake with a licensed therapist (social worker or psychologist) to complete the Clinician-Administered PTSD Scale (CAPS-5) for the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition), a clinical interview for PTSD assessment. Patients are also sent a secure link to complete a measurement-based care (MBC) battery of self-report measures including measures assessing demographics, PTSD symptoms, anxiety symptoms, depression symptoms, substance use, quality of life (QOL), and satisfaction with mental health care. The results of the CAPS-5 and self-report measures are discussed with the patient during the intake session when planning next steps and engaging in shared decision-making. This initial VVC intake not only allows for diagnostic goodness of fit but also provides the opportunity to troubleshoot any technical difficulties the patients might have with the virtual platforms.

There are minimal exclusion criteria for participation in iVET, which include active unmanaged psychosis or manic symptoms, recent suicidal crises (attempt within 8 weeks), active nonsuicidal self-injurious behaviors (within 8 weeks), and moderate-to-severe cognitive impairment. Following intake, patients are scheduled to begin their course of care with iVET. Upon completion of intake, patients are sent program materials for their individual and group classes, asked to obtain or request a recording device, and told they will receive email links for all VVC appointments. Patients are admitted to the iVET in a rolling admission fashion, thereby increasing access when compared to closed group and/or cohort models of care.

Patients receiving care in iVET attend 2 or 3 telehealth appointments daily with practice exercises daily between telehealth sessions. The primary EBP intervention in the iVET for PTSD program is a massed or accelerated course of PE, which includes 4 primary components: psychoeducation, in-vivo exposure, imaginal exposure, and breathing retraining. Specifically, PE is delivered in 4 90-minute individual sessions weekly allowing completion of the full PE protocol, to fidelity, in 3 weeks. In addition to receiving this primary intervention, patients also participate in four 50-minute group sessions per week of a whole health and wellness education class and have access to one 30- to 60-minute session weekly of individual health coaching should they wish to set wellness goals and receive coaching in support of attaining wellness goals. During iVET, patients are invited to complete MBC batteries of selfreport measures including measures assessing PTSD symptoms, anxiety symptoms, depression symptoms, substance use, QOL, and satisfaction with mental health care at sessions 1, 5, 9, and the final session of PE. Following discharge from the iVET, patients are offered 1-month, 3-month, and 6-month individual postdischarge check-up sessions with a therapist where they are invited to complete MBC measures and review relapse prevention and maintenance of treatment gains. Likewise, they are offered 1-month, 3-month, and 6-month postdischarge check-up sessions with an RN focused on maintaining wellness gains.

The iVET for PTSD staff includes 3 therapists (psychologists or social workers) and an RN. Additionally, the iVET for PTSD is supported by a program manager and a program support assistant. The primary cost of the program is salary for staff. Additional iVET for PTSD resources included computer equipment for staff and minimal supplies. Due to the virtual environment of care, iVET staff telework and do not require physical space within VAPIHCS.

OUTCOMES

All veterans receiving care in iVET for PTSD are invited to complete a MBC at multiple timepoints including pretreatment, during PE treatment, and posttreatment. The MBC measures included self-reported demographics, a 2-item measure of satisfaction with mental health services, the Brief Addiction Monitor-Intensive Outpatient Program questionnaire,²² the Generalized Anxiety Disorder-7 scale,^23, the Patient Health Questionnaire (PHQ-9),²⁴ the QOL Enjoyment and Satisfaction Questionnaire- Short Form,²⁵ and the PTSD Checklist for DSM-5 (PCL-5), both weekly and monthly versions. ^26,27

The retention rate has averaged 81% since the iVET for PTSD opened in 2022. To date, 132 veterans have completed the iVET for PTSD program, including a full course of massed PE (Table 1). Veterans experienced reduced PTSD (P < .005), depression (P < .005), anxiety (P < .005), and substance use risk (P < .005). Veterans experienced improved QOL (P < .005) and reported high satisfaction with mental health care in iVET for PTSD (Table 2). Veterans also experienced reduced thoughts of death or suicidal ideation (SI) based on PHQ-9 item 9 responses. When looking categorically at presence or absence of SI on PHQ-9 item 9, a significant relationship was found between the absence of suicidal ideation and completion of a course of massed PE: X² (1, N = 132) = 13.75, P < .001. In addition, veterans who completed the program showed a significant decrease in severity of SI as measured continuously (range, 0-3) on PHQ-9 item 9 (P < .005).

Another important aspect to consider when implementing massed models of EBP is the impact on employee well-being and job satisfaction. The impact of EBP on staff was assessed following the initial EBP project. To explore this further, all staff members in the iVET for PTSD were invited to engage in a small program evaluation. iVET staff were guided through a visualization meditation intended to recall a typical workday 1 month prior to starting their new position with iVET. After the visualization meditation, staff completed the Professional Quality of Life (ProQOL) scale, a 30-item, self-reported questionnaire for health care workers that evaluates compassion satisfaction, perceived support, burnout, secondary traumatic stress, and moral distress.²⁸ One week later, staff were asked to complete the ProQOL again to capture their state after the first 6 months into their tenure as iVET staff. iVET employees experienced significantly increased perceived support (P < .05), reduced burnout (P < .05), reduced secondary traumatic stress (P < .05), and reduced moral distress (P < .05). Team members also remarked on the rewarding nature of the work and care model.

Future Directions

Future research should aim to sustain these outcomes as the iVET program continues to serve more veterans. Another important line of inquiry is longer-term follow-up, as exploring if outcomes are maintained over time is an important question that has not been answered in this article. In addition, we hope to see the accelerated model of care applied to treatment of other presenting concerns in mental health treatment (eg, anxiety, depression, insomnia). Expansion of accelerated mental health treatment into other federal and non-federal health care settings is another worthy direction. Finally, while short term (6 months) assessment of staff satisfaction in iVET was promising, ongoing assessment staff satisfaction over a longer timeframe (1-5 years) is also important.

CONCLUSIONS

PE for PTSD has been demonstrated to be effective and improve functioning and is supported by multiple clinical practice guidelines.1-5 However, as federal practitioners, we must consider the reality that many of the individuals who could benefit are not engaging in PE and there is a high dropout rate for those that do. It is vital that we envision a future state where access to PE for PTSD is equitable and inclusive, retention rates are dramatically improved, and clinicians providing PE do not experience high rates of burnout.

We must continue exploring how we can better care for our patients and colleagues. We posit that the development of programs, or tracks within existing programs, that provide massed or accelerated PE for PTSD with virtual delivery options is an imperative step toward improved care. Federal health care settings treating trauma-exposed patients with PTSD, such as those within the US Department of Defense, Indian Health Services, Federal Bureau of Prisons, and VA, are well positioned to implement programs like iVET. We believe this model of care has great merit and foresee a future where all patients seeking PTSD treatment have the option to complete an accelerated or massed course of PE should they so desire. The experiences outlined in this article illustrate the feasibility, acceptability, and sustainability of such programs without requiring substantial staffing and financial resources.

Evidence-based psychotherapy (EBP) for posttraumatic stress disorder (PTSD), such as prolonged exposure (PE), is supported by multiple clinical practice guidelines and is expected to be available to veterans served by the Veterans Health Administration (VHA).^1-5 However, traditional models of EBP delivery with 1 or 2 sessions weekly have high dropout rates.^6,7 Few veterans who could benefit from such EBPs receive them, and those who do have low completion rates.^8,9 Over a 15-year period, VHA records review of > 265,500 veterans with PTSD showed only 9.1% completed EBP treatment that included but was not limited to PE.¹⁰

One empirically supported solution that has yet to be widely implemented is delivering EBPs for PTSD in a massed or accelerated format of ≥ 3 sessions weekly.¹¹ While these massed models of EBP delivery for PTSD are promising, their implementation is limited in federal health care settings, such as the VHA.¹² PE therapy is a first-line treatment for PTSD that has been evaluated in numerous clinical trials since the early 1990s and in a wide range of trauma populations.^13,14 Massed PE is effective and PE has been found to be effective both in-person and via telehealth.^11,15,16

Another approach to accelerated PE is the inclusion of a massed PE course within a broader treatment context that includes augmentation of the massed PE with additional services, this is referred to as an intensive outpatient model (IOP).¹⁷ PE-IOP has also been shown to be feasible, acceptable, and effective with increased completion rates in comparison to the traditional (1 or 2 sessions weekly) model of PE.^12,16,18,19 Ragsdale et al describe a 2-week IOP with multiple treatment tracks, including a PTSD track. The PTSD treatment track includes massed PE and additional standard services including case management, wellness services, family services, and a single session effective behaviors group. Additional augmentation services are available when clinically indicated (eg, repetitive transcranial magnetic stimulation, transcranial direct current stimulation treatment, psychoeducation, motivational interviewing, and/or relapse prevention).¹⁷

Rauch et al studied the first 80 patients completing an IOP program that consisted of PE (5 sessions weekly) and complementary interventions (eg, mindfulness and yoga) and reported a 96% retention rate, significant reductions of self-reported PTSD symptoms, significant reduction in self-reported co-occurring depression symptoms, and significant increase in self-reported satisfaction with social functioning. ¹⁸ In another study, Sherril et al explored patient reactions to participation in massed PE (5 sessions weekly) and found that patients reported significantly more positive than negative reactions. Sherrill et al noted that according to patients, the benefits of massed PE included a structured format that limits avoidance and distraction. The resulting fast pace of progress enhanced motivation; however, drawbacks included short-term discomfort and time demands.¹⁹ Yamokoski et al explored the feasibility of massed PE in a larger study of PTSD treatment in an intensive outpatient track (IOT) in a VHA PTSD clinic with minimal staffing. The 48 patients who completed IOT PTSD treatment in 2 or 4 weeks (including 35 patients who received massed PE) had high retention rates (85%), reported high satisfaction, and had significantly reduced PTSD and depression symptoms.¹²

The massed IOT PE model implemented by Yamokoski et al included the primary EBP intervention of massed PE with adjunctive groups. The addition of these groups increased both retention and patient-reported satisfaction. The PE-IOP model implemented by Rauch et al and Sherrill et al also included wellness and educational groups, as well as access to complementary interventions such as mindfulness and yoga.^18,19 The addition of wellness education along with a primary EBP aligned with the VHA focus on whole health well-being and wellness. The whole health approach includes understanding the factors that motivate a patient toward health and well-being, provision of health education, and providing access to complementary interventions such as mindfulness.²⁰ Dryden et al describe the whole health transformation within VHA as a proactive approach to addressing employee and patient wellness and health. Their research found that the whole health model promoted well-being in patients and staff and was sustained even during the COVID-19 pandemic.²¹ Dryden et al also noted that use of virtual technologies facilitated and promoted continued whole health implementation. The literature illustrates that: (1) massed PE can be provided with complementary education and wellness offerings, and that such offerings may increase both retention and satisfaction by enriching the massed PE treatment (eg, delivering PE-IOP); (2) whole health including wellness education and complementary interventions (eg, mindfulness, motivational enhancement) promotes well-being in both patients and mental health professionals; and (3) whole health education and complementary interventions can be delivered virtually.

Health Care Need

Prior to the implementation of a massed EBP for PTSD program at US Department of Veterans Affairs (VA) Pacific Islands Health Care System (VAPIHCS), our setting included a traditional outpatient program for treatment of PTSD and a 12- bed residential program for treatment of PTSD for male-identified (self-identified and identified as male in the electronic medical record) veterans via a cohort model with an 8- or 9-week length of stay. Both programs were located on Oahu. Thus, veterans who received care at VAPIHCS had access to PE in both outpatient and residential settings and via in-person and telehealth modalities. However, their access to PE was limited to the traditional models of PE delivery (eg, 1 or 2 session per week) and very few veterans outside of the island of Oahu had accessed PE treatment for PTSD. Moreover, when looking at PE reach within VAPIHCS, in the fiscal year prior to the implementation of the massed EBP program, only 32 of the > 5000 eligible veterans with a PTSD diagnosis had received PE. VAPIHCS serves veterans in a catchment area across the Pacific Basin which includes 3 time zones: Hawaii Standard Time (HST), Chamorro Standard Time (ChST), and Samoa Standard Time (SST). ChST is 20 hours ahead of HST, making service delivery that is inclusive for patients in Guam and Saipan especially challenging when providing care from Hawaii or other US states or territories. Given all of this, implementation of a new program offering accelerated PE virtually to any veterans with PTSD within the VAPIHCS would increase access to and reduce barriers to receiving PE.

PROGRAM DESCRIPTION

The Intensive Virtual EBP Team (iVET) for PTSD consists of an accelerated course of PE therapy and whole health education provided via VA Video Connect (VVC). iVET is a 3-week program and includes 3 parts: (1) massed individual PE therapy for PTSD; (2) group whole health and wellness classes; and (3) individual health coaching to address personal wellness goals. Programming is offered over 10-hour days to increase access across multiple time zones, especially to allow for participation in Guam and Saipan.

When a patient is referred to the iVET, their first contact is a video (or telephone) appointment with a registered nurse (RN) for a screening session. The screening session is designed to educate the patient about the program, including interventions, time commitment, and resources required for participation. In addition, following the educational discussion, the RN completes screening for safety with the patient including suicidal ideation and risk, as well as intimate partner violence risk. If urgent safety concerns are present, a licensed social worker or psychologist will join the screening to complete further assessment of risk and to address any safety concerns. Following screening, patients are scheduled for a VVC intake with a licensed therapist (social worker or psychologist) to complete the Clinician-Administered PTSD Scale (CAPS-5) for the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition), a clinical interview for PTSD assessment. Patients are also sent a secure link to complete a measurement-based care (MBC) battery of self-report measures including measures assessing demographics, PTSD symptoms, anxiety symptoms, depression symptoms, substance use, quality of life (QOL), and satisfaction with mental health care. The results of the CAPS-5 and self-report measures are discussed with the patient during the intake session when planning next steps and engaging in shared decision-making. This initial VVC intake not only allows for diagnostic goodness of fit but also provides the opportunity to troubleshoot any technical difficulties the patients might have with the virtual platforms.

There are minimal exclusion criteria for participation in iVET, which include active unmanaged psychosis or manic symptoms, recent suicidal crises (attempt within 8 weeks), active nonsuicidal self-injurious behaviors (within 8 weeks), and moderate-to-severe cognitive impairment. Following intake, patients are scheduled to begin their course of care with iVET. Upon completion of intake, patients are sent program materials for their individual and group classes, asked to obtain or request a recording device, and told they will receive email links for all VVC appointments. Patients are admitted to the iVET in a rolling admission fashion, thereby increasing access when compared to closed group and/or cohort models of care.

Patients receiving care in iVET attend 2 or 3 telehealth appointments daily with practice exercises daily between telehealth sessions. The primary EBP intervention in the iVET for PTSD program is a massed or accelerated course of PE, which includes 4 primary components: psychoeducation, in-vivo exposure, imaginal exposure, and breathing retraining. Specifically, PE is delivered in 4 90-minute individual sessions weekly allowing completion of the full PE protocol, to fidelity, in 3 weeks. In addition to receiving this primary intervention, patients also participate in four 50-minute group sessions per week of a whole health and wellness education class and have access to one 30- to 60-minute session weekly of individual health coaching should they wish to set wellness goals and receive coaching in support of attaining wellness goals. During iVET, patients are invited to complete MBC batteries of selfreport measures including measures assessing PTSD symptoms, anxiety symptoms, depression symptoms, substance use, QOL, and satisfaction with mental health care at sessions 1, 5, 9, and the final session of PE. Following discharge from the iVET, patients are offered 1-month, 3-month, and 6-month individual postdischarge check-up sessions with a therapist where they are invited to complete MBC measures and review relapse prevention and maintenance of treatment gains. Likewise, they are offered 1-month, 3-month, and 6-month postdischarge check-up sessions with an RN focused on maintaining wellness gains.

The iVET for PTSD staff includes 3 therapists (psychologists or social workers) and an RN. Additionally, the iVET for PTSD is supported by a program manager and a program support assistant. The primary cost of the program is salary for staff. Additional iVET for PTSD resources included computer equipment for staff and minimal supplies. Due to the virtual environment of care, iVET staff telework and do not require physical space within VAPIHCS.

OUTCOMES

All veterans receiving care in iVET for PTSD are invited to complete a MBC at multiple timepoints including pretreatment, during PE treatment, and posttreatment. The MBC measures included self-reported demographics, a 2-item measure of satisfaction with mental health services, the Brief Addiction Monitor-Intensive Outpatient Program questionnaire,²² the Generalized Anxiety Disorder-7 scale,^23, the Patient Health Questionnaire (PHQ-9),²⁴ the QOL Enjoyment and Satisfaction Questionnaire- Short Form,²⁵ and the PTSD Checklist for DSM-5 (PCL-5), both weekly and monthly versions. ^26,27

The retention rate has averaged 81% since the iVET for PTSD opened in 2022. To date, 132 veterans have completed the iVET for PTSD program, including a full course of massed PE (Table 1). Veterans experienced reduced PTSD (P < .005), depression (P < .005), anxiety (P < .005), and substance use risk (P < .005). Veterans experienced improved QOL (P < .005) and reported high satisfaction with mental health care in iVET for PTSD (Table 2). Veterans also experienced reduced thoughts of death or suicidal ideation (SI) based on PHQ-9 item 9 responses. When looking categorically at presence or absence of SI on PHQ-9 item 9, a significant relationship was found between the absence of suicidal ideation and completion of a course of massed PE: X² (1, N = 132) = 13.75, P < .001. In addition, veterans who completed the program showed a significant decrease in severity of SI as measured continuously (range, 0-3) on PHQ-9 item 9 (P < .005).

Another important aspect to consider when implementing massed models of EBP is the impact on employee well-being and job satisfaction. The impact of EBP on staff was assessed following the initial EBP project. To explore this further, all staff members in the iVET for PTSD were invited to engage in a small program evaluation. iVET staff were guided through a visualization meditation intended to recall a typical workday 1 month prior to starting their new position with iVET. After the visualization meditation, staff completed the Professional Quality of Life (ProQOL) scale, a 30-item, self-reported questionnaire for health care workers that evaluates compassion satisfaction, perceived support, burnout, secondary traumatic stress, and moral distress.²⁸ One week later, staff were asked to complete the ProQOL again to capture their state after the first 6 months into their tenure as iVET staff. iVET employees experienced significantly increased perceived support (P < .05), reduced burnout (P < .05), reduced secondary traumatic stress (P < .05), and reduced moral distress (P < .05). Team members also remarked on the rewarding nature of the work and care model.

Future Directions

Future research should aim to sustain these outcomes as the iVET program continues to serve more veterans. Another important line of inquiry is longer-term follow-up, as exploring if outcomes are maintained over time is an important question that has not been answered in this article. In addition, we hope to see the accelerated model of care applied to treatment of other presenting concerns in mental health treatment (eg, anxiety, depression, insomnia). Expansion of accelerated mental health treatment into other federal and non-federal health care settings is another worthy direction. Finally, while short term (6 months) assessment of staff satisfaction in iVET was promising, ongoing assessment staff satisfaction over a longer timeframe (1-5 years) is also important.

CONCLUSIONS

PE for PTSD has been demonstrated to be effective and improve functioning and is supported by multiple clinical practice guidelines.1-5 However, as federal practitioners, we must consider the reality that many of the individuals who could benefit are not engaging in PE and there is a high dropout rate for those that do. It is vital that we envision a future state where access to PE for PTSD is equitable and inclusive, retention rates are dramatically improved, and clinicians providing PE do not experience high rates of burnout.

We must continue exploring how we can better care for our patients and colleagues. We posit that the development of programs, or tracks within existing programs, that provide massed or accelerated PE for PTSD with virtual delivery options is an imperative step toward improved care. Federal health care settings treating trauma-exposed patients with PTSD, such as those within the US Department of Defense, Indian Health Services, Federal Bureau of Prisons, and VA, are well positioned to implement programs like iVET. We believe this model of care has great merit and foresee a future where all patients seeking PTSD treatment have the option to complete an accelerated or massed course of PE should they so desire. The experiences outlined in this article illustrate the feasibility, acceptability, and sustainability of such programs without requiring substantial staffing and financial resources.

Electronic health records (EHRs) are an integral part of modern health care. The 2009, Health Information Technology for Economic and Clinical Health Act established financial incentives for US hospitals to adopt EHRs. In 2009 only 12% of nonfederal acute care hospitals had adopted a certified EHR system, which increased to 96% by 2021.¹

EHRs have transformed the way patient data are stored and accessed, streamlining the process of providing quality patient care with improvements in efficiency, effectiveness, patient satisfaction, and safety.² Despite their widespread adoption and benefits, EHRs have generally been met with mixed physician satisfaction.³ Interactions with EHRs are linked to disproportionate time at the computer and physician burnout.^4-6

The US Department of Veterans Affairs (VA) was at the forefront of EHR development, establishing the Veterans Health Information Systems and Technology Architecture (VistA) in the 1970s. The VA released the Computerized Patient Record System (CPRS) in 1997, the first clinical user interface for VistA. In May 2018, the VA signed a $10 billion contract with Cerner (now Oracle Health) to modernize its EHR.⁷ This was later revised to $16.1 billion, and the Institute for Defense Analyses estimates it will cost $49.8 billion.⁸ The transition to Oracle Health has been faced with significant challenges, including patient safety risks and workflow inefficiencies, leading to a pause in rollout.⁹

Due to the known challenges with EHRs and the aging CPRS system (without a scheduled replacement date), innovations that facilitate the synthesis and display of clinical information are needed. To address this gap, the VA Ann Arbor Healthcare System (VAAAHS) developed the Inpatient Dashboard, an online EHR companion tool. The Inpatient Dashboard was designed to draw data from VistA to reduce time spent at the computer by streamlining clinical information presentation, standardizing inpatient notes, improving safety measures, and enhancing overall clinician satisfaction. This study evaluated the adoption and user experience with the Inpatient Dashboard.

INPATIENT DASHBOARD

The Inpatient Dashboard consists of several modules created by a contractor for the VAAAHS that is housed on VA servers with access restricted to individuals with patient health data privileges. As the Inpatient Dashboard draws data from VistA, it can display laboratory information, studies, and notes from all VA sites.

The main dashboard is a snapshot summary of patient information, including patient location, code status, last vital sign readings, vital sign ranges over the previous 24 hours, intake/output, deep vein thrombosis (DVT) prophylaxis, the presence of telemetry orders, or use of Foley or central catheters (Figure). It also includes a customizable to-do list and contact information for the patient’s clinician and nurse. Significant events, such as abnormal vital signs or speciation/sensitivities for blood cultures, are automatically populated on the to-do list. From this main dashboard overview, clinicians can customize which patients are displayed, create and print a rounding list, print a sign-out sheet, or select individual patients to open a progress note module.

Notes can be written in the patient history and physical module, progress note module, and discharge summary module. The patient history and physical module has text blocks allocated to the traditional components of a history and physical note (ie, chief complaint, history of present illness, review of systems, past medical history, family history, social history, allergies, medications, physical examination, assessment, and plan) (eAppendix 1). Some elements, such as past medical history, family history, and social history are prepopulated if the patient was previously admitted. Vital signs, laboratory results, studies, microbiology/ pathology reports, and other CPRS notes are displayed in this module.

The progress note module contains text blocks allocated to the traditional components of a progress note, such as subjective/interval events, physical examination, assessment, and plan (eAppendix 2). Vital signs, laboratory results, studies, microbiology/ pathology reports, other CPRS notes, and the patient’s medication administration record are also displayed in this module. Lastly, the discharge summary module includes patient follow-up, patient instructions, hospitalization summary, medication reconciliation, laboratory results, and studies/procedures, ensuring a comprehensive discharge summary for patients and clinicians (eAppendix 3).

A medication reconciliation tool was embedded within the history and physical and discharge summary modules. This tool has been shown to reduce medication errors in patients admitted from the emergency department to the hospital (eAppendix 4).¹⁰ The handoff/sign-out tool (eAppendix 5) accessible through the main dashboard page is modeled on the I-PASS handoff framework.^11,12 This includes the patient identifier, interval events, inpatient medications, specific sign-out guidance, sign-out tasks/to-dos, and any other pertinent information.

The Inpatient Dashboard is a team-based construct shared by the attending physicians, residents, and medical students. Each team (eg, general medicine, general surgery) is its own entity; only team members can change the content or add to the documentation. Each facility can have multiple teams caring for the same patient (eg, primary and consulting teams). Additional care members can also be incorporated (eg, pharmacists assist with medication reconciliation for admission and discharge at VAAAHS). The Inpatient Dashboard can export information directly to CPRS for clinicians to review and sign. It can also generate a note that can be pasted into CPRS.

Clinician Feedback and Satisfaction

A survey was developed to evaluate clinician experiences with using the Inpatient Dashboard as an adjunct to the CPRS. The Inpatient Dashboard was made available to general medicine teams in November 2018. The survey was conducted from December 2018 to September 2019. The study was conducted at the VAAAHS and included 4 general medicine teams. Each team included an attending physician, a senior resident, 2 to 3 interns, and 3 to 4 medical students. Eligibility was extended to any team member who used both the CPRS and Inpatient Dashboard. Participation in the survey was voluntary. All respondents were informed of the study’s purpose and encouraged to provide candid feedback to ensure the reliability and validity of the findings.

Data were collected through a semistructured survey administered via the Qualtrics platform. The questionnaire was designed to capture multidimensional insights into clinician experience, with particular focus on satisfaction, efficiency, and perceived safety when using the tool as an adjunct to CPRS compared to using CPRS alone. The questionnaire primarily used a Likert scale for responses. Surveys were emailed at the completion of a team’s 1-month inpatient block. An answer was not required for every question, resulting in slightly different response numbers for some questions.

A question regarding the tool’s impact on workload stress was added halfway through the study period, which resulted in fewer responses. Adoption was assessed by counting the Inpatient Dashboard unique users. Descriptive statistics were used within individual survey responses to report the distribution of responses. Differences in response between levels of training were assessed using a X² test of independence.

Survey Results

From September 2023 through November 2023, there were 1549 rounding printouts across 144 unique users (5 nurses, 40 medical students, 87 residents, and 12 attending physicians) and 1468 handoff printouts across 148 unique users (5 nurses, 10 medical students, 111 residents, and 22 attending physicians). The clinician survey received 68 responses from users at various levels of medical training: 23 medical students, 31 interns, 12 senior residents, and 2 attending physicians. All 68 participants confirmed they had used the Inpatient Dashboard.

User satisfaction and preference for the Inpatient Dashboard vs CPRS were assessed. Sixty-one respondents (90%) expressed overall satisfaction with the Inpatient Dashboard; 22 (32%) were extremely satisfied, and 39 (57%) were somewhat satisfied (Table 1). Three respondents (4%) were neutral, 2 (3%) were somewhat dissatisfied, and 2 (3%) were extremely dissatisfied with the Inpatient Dashboard. Responses differed by level of training (P = .03), with medical students trending towards higher satisfaction.

Respondents preferred the Inpatient Dashboard over CPRS for gathering information and writing progress notes; 42 (64%) respondents mostly favored the Inpatient Dashboard, 15 (23%) slightly favored the Inpatient Dashboard over CPRS, and 8 (12%) were neutral. One respondent (2%) slightly favored CPRS to the Inpatient Dashboard (Table 2).

Sixty-five respondents (100%) found the Inpatient Dashboard’s ability to summarize patient information in a central place helpful (Table 3). Among them, 53 (82%) respondents reported it was very or extremely helpful, 10 (15%) respondents reported it was moderately helpful, and 2 (3%) respondents reported it was slightly helpful. This feature positively impacted users’ awareness of patients with DVT prophylaxis or a Foley catheter. Ten (15%) respondents reported being much more aware, and 29 (45%) respondents reporting they were slightly more aware. The remaining 26 (40%) respondents reported no change in awareness.

The Inpatient Dashboard was reported to save time preparing for physician rounds by 52 (80%) respondents, contributing to much greater efficiency for 29 (45%) respondents and slightly more efficiency for 23 (35%) respondents. However, 10 (15%) respondents reported no change in efficiency, and 3 (5%) respondents reduced efficiency, with 1 (2%) respondent reporting it slightly less efficient and 2 (3%) respondents reporting it much less efficient. Responses differed by level of training (P = .01), with medical students trending towards higher efficiency. Of the 23 respondents who reported on the Inpatient Dashboard’s impact on daily workload stress level, 22 (96%) indicated the tool had a stress-reducing effect, with 9 (39%) experiencing a major reduction in stress level, and 13 (57%) experiencing somewhat reduced stress level. Only 1 participant (4%) reported no change in stress. No participants reported an increase in stress.

DISCUSSION

The adoption of EHRs has transformed operational modalities in contemporary health care systems, heralding advancements in patient satisfaction, safety, and overall quality and efficiency of care.^1,2 However, EHRs still present challenges, predominantly around clinician satisfaction, marked by instances of burnout and increased time spent on computers.^2-6 In this context, the Inpatient Dashboard, an online companion to the CPRS, exemplifies how user-centered innovations in EHRs can address and mitigate associated challenges.

The Inpatient Dashboard has been well received with most respondents of the survey conducted in this study indicating they were both satisfied with the instrument and preferring it to CPRS. This high approval aligns with existing literature on the potential advantages of user-centered design in health care technology.¹³ The tool has gained widespread acceptance at the VAAAHS even in the absence of obligatory usage or institutional incentives. The appeal of the Inpatient Dashboard may stem from its increased efficiency, with most users affirming its timesaving nature. While CPRS can only display local notes, laboratory results, and studies, the Inpatient Dashboard can display data from across all VA sites. The VA Joint Longitudinal Viewer can similarly display data from across all sites, but the display is not streamlined as it is in the Inpatient Dashboard. The Inpatient Dashboard incorporates this clinical information into a single page to facilitate day-to-day workflow and dynamic documentation (ie, reviewing laboratory results, medications, writing notes, and signing out patients). This increased efficiency allows clinicians to counter 2 common barriers to EHR implementation: productivity loss and insufficient time.¹⁴

The association between EHRs and improved quality and safety in health care is well-documented.³ The Inpatient Dashboard fortifies this association by enhancing awareness around patient status, evidenced by a majority of respondents, and by integrating a medication reconciliation tool to decrease medication errors on transition from the emergency department to inpatient hospitalization.¹⁰

The Inpatient Dashboard’s impact on alleviating daily workload stress is noteworthy, with almost all respondents experiencing reduced stress levels and physician burnout, which has been linked to deteriorating well-being, compromised patient safety, and escalated health care costs.^15,16 The heightened susceptibility of physicians to burnout compared to other professionals underscores the imperative for incorporating stress-mitigating interventions in the EHR.^17,18

While responses to most questions did not significantly differ by training levels, overall satisfaction with the Inpatient Dashboard and its ability to save time preparing for rounds were rated higher by medical students. This may be attributable to a greater derived benefit from collating and presenting data to learners with less familiarity with the native EHR. It is also notable that the Inpatient Dashboard allows medical students to directly contribute to a patient’s note, which could be another driver in satisfaction. While most interns still felt the Inpatient Dashboard enabled them to save time preparing for rounds, there were a considerable number of ‘no change’ responses, which suggests some interns may not have modified their existing prerounding strategies. These associations are limited by the relatively small number of respondents by learner category, with senior medical residents and attending physicians being underrepresented.

While there are a multitude of dashboards available at the VA, most are made to track certain quality metrics and are used more by administrative and leadership staff. The Inpatient Dashboard was created specifically for frontline clinicians to facilitate their day-to-day workflow and dynamic documentation. This tool can additionally help with quality metrics, though its main purpose was and is to make clinician workflow easier and more efficient.

These results are especially timely because the VA is modernizing its EHR by transitioning to Oracle Health.⁷ Due to the numerous reports both from veterans and VA clinicians that the Oracle Health EHR is not meeting expectations, deployment at further sites has been halted while improving the experience of the 5 institutions using Oracle Health is prioritized.⁹ The Inpatient Dashboard, instead of being merely an enhancement to CPRS, could emerge as a potential bridge to Oracle Health if adapted to display data from Oracle Health as it does VistA. This would facilitate a smoother, more integrated transition for those health care institutions employing the Inpatient Dashboard.

Limitations

The reliance on self-reported data inherently carries the risk of bias, and the absence of objective measures, like time-tracking studies, limits the quantifiable assessment of the Inpatient Dashboard efficacy. The single-center nature of the study also may restrict the generalizability of the results.

CONCLUSIONS

Optimal integration of EHRs into health care delivery is critical to high-quality patient care and operational efficiency. The Inpatient Dashboard is an example of an innovative, user-centric solution that integrated and presented clinical information in a way that produced high satisfaction and adoption by users at a VA hospital.

Electronic health records (EHRs) are an integral part of modern health care. The 2009, Health Information Technology for Economic and Clinical Health Act established financial incentives for US hospitals to adopt EHRs. In 2009 only 12% of nonfederal acute care hospitals had adopted a certified EHR system, which increased to 96% by 2021.¹

EHRs have transformed the way patient data are stored and accessed, streamlining the process of providing quality patient care with improvements in efficiency, effectiveness, patient satisfaction, and safety.² Despite their widespread adoption and benefits, EHRs have generally been met with mixed physician satisfaction.³ Interactions with EHRs are linked to disproportionate time at the computer and physician burnout.^4-6

The US Department of Veterans Affairs (VA) was at the forefront of EHR development, establishing the Veterans Health Information Systems and Technology Architecture (VistA) in the 1970s. The VA released the Computerized Patient Record System (CPRS) in 1997, the first clinical user interface for VistA. In May 2018, the VA signed a $10 billion contract with Cerner (now Oracle Health) to modernize its EHR.⁷ This was later revised to $16.1 billion, and the Institute for Defense Analyses estimates it will cost $49.8 billion.⁸ The transition to Oracle Health has been faced with significant challenges, including patient safety risks and workflow inefficiencies, leading to a pause in rollout.⁹

Due to the known challenges with EHRs and the aging CPRS system (without a scheduled replacement date), innovations that facilitate the synthesis and display of clinical information are needed. To address this gap, the VA Ann Arbor Healthcare System (VAAAHS) developed the Inpatient Dashboard, an online EHR companion tool. The Inpatient Dashboard was designed to draw data from VistA to reduce time spent at the computer by streamlining clinical information presentation, standardizing inpatient notes, improving safety measures, and enhancing overall clinician satisfaction. This study evaluated the adoption and user experience with the Inpatient Dashboard.

INPATIENT DASHBOARD

The Inpatient Dashboard consists of several modules created by a contractor for the VAAAHS that is housed on VA servers with access restricted to individuals with patient health data privileges. As the Inpatient Dashboard draws data from VistA, it can display laboratory information, studies, and notes from all VA sites.

The main dashboard is a snapshot summary of patient information, including patient location, code status, last vital sign readings, vital sign ranges over the previous 24 hours, intake/output, deep vein thrombosis (DVT) prophylaxis, the presence of telemetry orders, or use of Foley or central catheters (Figure). It also includes a customizable to-do list and contact information for the patient’s clinician and nurse. Significant events, such as abnormal vital signs or speciation/sensitivities for blood cultures, are automatically populated on the to-do list. From this main dashboard overview, clinicians can customize which patients are displayed, create and print a rounding list, print a sign-out sheet, or select individual patients to open a progress note module.

Notes can be written in the patient history and physical module, progress note module, and discharge summary module. The patient history and physical module has text blocks allocated to the traditional components of a history and physical note (ie, chief complaint, history of present illness, review of systems, past medical history, family history, social history, allergies, medications, physical examination, assessment, and plan) (eAppendix 1). Some elements, such as past medical history, family history, and social history are prepopulated if the patient was previously admitted. Vital signs, laboratory results, studies, microbiology/ pathology reports, and other CPRS notes are displayed in this module.

The progress note module contains text blocks allocated to the traditional components of a progress note, such as subjective/interval events, physical examination, assessment, and plan (eAppendix 2). Vital signs, laboratory results, studies, microbiology/ pathology reports, other CPRS notes, and the patient’s medication administration record are also displayed in this module. Lastly, the discharge summary module includes patient follow-up, patient instructions, hospitalization summary, medication reconciliation, laboratory results, and studies/procedures, ensuring a comprehensive discharge summary for patients and clinicians (eAppendix 3).

A medication reconciliation tool was embedded within the history and physical and discharge summary modules. This tool has been shown to reduce medication errors in patients admitted from the emergency department to the hospital (eAppendix 4).¹⁰ The handoff/sign-out tool (eAppendix 5) accessible through the main dashboard page is modeled on the I-PASS handoff framework.^11,12 This includes the patient identifier, interval events, inpatient medications, specific sign-out guidance, sign-out tasks/to-dos, and any other pertinent information.

The Inpatient Dashboard is a team-based construct shared by the attending physicians, residents, and medical students. Each team (eg, general medicine, general surgery) is its own entity; only team members can change the content or add to the documentation. Each facility can have multiple teams caring for the same patient (eg, primary and consulting teams). Additional care members can also be incorporated (eg, pharmacists assist with medication reconciliation for admission and discharge at VAAAHS). The Inpatient Dashboard can export information directly to CPRS for clinicians to review and sign. It can also generate a note that can be pasted into CPRS.

Clinician Feedback and Satisfaction

A survey was developed to evaluate clinician experiences with using the Inpatient Dashboard as an adjunct to the CPRS. The Inpatient Dashboard was made available to general medicine teams in November 2018. The survey was conducted from December 2018 to September 2019. The study was conducted at the VAAAHS and included 4 general medicine teams. Each team included an attending physician, a senior resident, 2 to 3 interns, and 3 to 4 medical students. Eligibility was extended to any team member who used both the CPRS and Inpatient Dashboard. Participation in the survey was voluntary. All respondents were informed of the study’s purpose and encouraged to provide candid feedback to ensure the reliability and validity of the findings.

Data were collected through a semistructured survey administered via the Qualtrics platform. The questionnaire was designed to capture multidimensional insights into clinician experience, with particular focus on satisfaction, efficiency, and perceived safety when using the tool as an adjunct to CPRS compared to using CPRS alone. The questionnaire primarily used a Likert scale for responses. Surveys were emailed at the completion of a team’s 1-month inpatient block. An answer was not required for every question, resulting in slightly different response numbers for some questions.

A question regarding the tool’s impact on workload stress was added halfway through the study period, which resulted in fewer responses. Adoption was assessed by counting the Inpatient Dashboard unique users. Descriptive statistics were used within individual survey responses to report the distribution of responses. Differences in response between levels of training were assessed using a X² test of independence.

Survey Results

From September 2023 through November 2023, there were 1549 rounding printouts across 144 unique users (5 nurses, 40 medical students, 87 residents, and 12 attending physicians) and 1468 handoff printouts across 148 unique users (5 nurses, 10 medical students, 111 residents, and 22 attending physicians). The clinician survey received 68 responses from users at various levels of medical training: 23 medical students, 31 interns, 12 senior residents, and 2 attending physicians. All 68 participants confirmed they had used the Inpatient Dashboard.

User satisfaction and preference for the Inpatient Dashboard vs CPRS were assessed. Sixty-one respondents (90%) expressed overall satisfaction with the Inpatient Dashboard; 22 (32%) were extremely satisfied, and 39 (57%) were somewhat satisfied (Table 1). Three respondents (4%) were neutral, 2 (3%) were somewhat dissatisfied, and 2 (3%) were extremely dissatisfied with the Inpatient Dashboard. Responses differed by level of training (P = .03), with medical students trending towards higher satisfaction.

Respondents preferred the Inpatient Dashboard over CPRS for gathering information and writing progress notes; 42 (64%) respondents mostly favored the Inpatient Dashboard, 15 (23%) slightly favored the Inpatient Dashboard over CPRS, and 8 (12%) were neutral. One respondent (2%) slightly favored CPRS to the Inpatient Dashboard (Table 2).

Sixty-five respondents (100%) found the Inpatient Dashboard’s ability to summarize patient information in a central place helpful (Table 3). Among them, 53 (82%) respondents reported it was very or extremely helpful, 10 (15%) respondents reported it was moderately helpful, and 2 (3%) respondents reported it was slightly helpful. This feature positively impacted users’ awareness of patients with DVT prophylaxis or a Foley catheter. Ten (15%) respondents reported being much more aware, and 29 (45%) respondents reporting they were slightly more aware. The remaining 26 (40%) respondents reported no change in awareness.

The Inpatient Dashboard was reported to save time preparing for physician rounds by 52 (80%) respondents, contributing to much greater efficiency for 29 (45%) respondents and slightly more efficiency for 23 (35%) respondents. However, 10 (15%) respondents reported no change in efficiency, and 3 (5%) respondents reduced efficiency, with 1 (2%) respondent reporting it slightly less efficient and 2 (3%) respondents reporting it much less efficient. Responses differed by level of training (P = .01), with medical students trending towards higher efficiency. Of the 23 respondents who reported on the Inpatient Dashboard’s impact on daily workload stress level, 22 (96%) indicated the tool had a stress-reducing effect, with 9 (39%) experiencing a major reduction in stress level, and 13 (57%) experiencing somewhat reduced stress level. Only 1 participant (4%) reported no change in stress. No participants reported an increase in stress.

DISCUSSION

The adoption of EHRs has transformed operational modalities in contemporary health care systems, heralding advancements in patient satisfaction, safety, and overall quality and efficiency of care.^1,2 However, EHRs still present challenges, predominantly around clinician satisfaction, marked by instances of burnout and increased time spent on computers.^2-6 In this context, the Inpatient Dashboard, an online companion to the CPRS, exemplifies how user-centered innovations in EHRs can address and mitigate associated challenges.

The Inpatient Dashboard has been well received with most respondents of the survey conducted in this study indicating they were both satisfied with the instrument and preferring it to CPRS. This high approval aligns with existing literature on the potential advantages of user-centered design in health care technology.¹³ The tool has gained widespread acceptance at the VAAAHS even in the absence of obligatory usage or institutional incentives. The appeal of the Inpatient Dashboard may stem from its increased efficiency, with most users affirming its timesaving nature. While CPRS can only display local notes, laboratory results, and studies, the Inpatient Dashboard can display data from across all VA sites. The VA Joint Longitudinal Viewer can similarly display data from across all sites, but the display is not streamlined as it is in the Inpatient Dashboard. The Inpatient Dashboard incorporates this clinical information into a single page to facilitate day-to-day workflow and dynamic documentation (ie, reviewing laboratory results, medications, writing notes, and signing out patients). This increased efficiency allows clinicians to counter 2 common barriers to EHR implementation: productivity loss and insufficient time.¹⁴

The association between EHRs and improved quality and safety in health care is well-documented.³ The Inpatient Dashboard fortifies this association by enhancing awareness around patient status, evidenced by a majority of respondents, and by integrating a medication reconciliation tool to decrease medication errors on transition from the emergency department to inpatient hospitalization.¹⁰

The Inpatient Dashboard’s impact on alleviating daily workload stress is noteworthy, with almost all respondents experiencing reduced stress levels and physician burnout, which has been linked to deteriorating well-being, compromised patient safety, and escalated health care costs.^15,16 The heightened susceptibility of physicians to burnout compared to other professionals underscores the imperative for incorporating stress-mitigating interventions in the EHR.^17,18

While responses to most questions did not significantly differ by training levels, overall satisfaction with the Inpatient Dashboard and its ability to save time preparing for rounds were rated higher by medical students. This may be attributable to a greater derived benefit from collating and presenting data to learners with less familiarity with the native EHR. It is also notable that the Inpatient Dashboard allows medical students to directly contribute to a patient’s note, which could be another driver in satisfaction. While most interns still felt the Inpatient Dashboard enabled them to save time preparing for rounds, there were a considerable number of ‘no change’ responses, which suggests some interns may not have modified their existing prerounding strategies. These associations are limited by the relatively small number of respondents by learner category, with senior medical residents and attending physicians being underrepresented.

While there are a multitude of dashboards available at the VA, most are made to track certain quality metrics and are used more by administrative and leadership staff. The Inpatient Dashboard was created specifically for frontline clinicians to facilitate their day-to-day workflow and dynamic documentation. This tool can additionally help with quality metrics, though its main purpose was and is to make clinician workflow easier and more efficient.

These results are especially timely because the VA is modernizing its EHR by transitioning to Oracle Health.⁷ Due to the numerous reports both from veterans and VA clinicians that the Oracle Health EHR is not meeting expectations, deployment at further sites has been halted while improving the experience of the 5 institutions using Oracle Health is prioritized.⁹ The Inpatient Dashboard, instead of being merely an enhancement to CPRS, could emerge as a potential bridge to Oracle Health if adapted to display data from Oracle Health as it does VistA. This would facilitate a smoother, more integrated transition for those health care institutions employing the Inpatient Dashboard.

Limitations

The reliance on self-reported data inherently carries the risk of bias, and the absence of objective measures, like time-tracking studies, limits the quantifiable assessment of the Inpatient Dashboard efficacy. The single-center nature of the study also may restrict the generalizability of the results.

CONCLUSIONS

Optimal integration of EHRs into health care delivery is critical to high-quality patient care and operational efficiency. The Inpatient Dashboard is an example of an innovative, user-centric solution that integrated and presented clinical information in a way that produced high satisfaction and adoption by users at a VA hospital.

Electronic health records (EHRs) are an integral part of modern health care. The 2009, Health Information Technology for Economic and Clinical Health Act established financial incentives for US hospitals to adopt EHRs. In 2009 only 12% of nonfederal acute care hospitals had adopted a certified EHR system, which increased to 96% by 2021.¹

EHRs have transformed the way patient data are stored and accessed, streamlining the process of providing quality patient care with improvements in efficiency, effectiveness, patient satisfaction, and safety.² Despite their widespread adoption and benefits, EHRs have generally been met with mixed physician satisfaction.³ Interactions with EHRs are linked to disproportionate time at the computer and physician burnout.^4-6

The US Department of Veterans Affairs (VA) was at the forefront of EHR development, establishing the Veterans Health Information Systems and Technology Architecture (VistA) in the 1970s. The VA released the Computerized Patient Record System (CPRS) in 1997, the first clinical user interface for VistA. In May 2018, the VA signed a $10 billion contract with Cerner (now Oracle Health) to modernize its EHR.⁷ This was later revised to $16.1 billion, and the Institute for Defense Analyses estimates it will cost $49.8 billion.⁸ The transition to Oracle Health has been faced with significant challenges, including patient safety risks and workflow inefficiencies, leading to a pause in rollout.⁹

Due to the known challenges with EHRs and the aging CPRS system (without a scheduled replacement date), innovations that facilitate the synthesis and display of clinical information are needed. To address this gap, the VA Ann Arbor Healthcare System (VAAAHS) developed the Inpatient Dashboard, an online EHR companion tool. The Inpatient Dashboard was designed to draw data from VistA to reduce time spent at the computer by streamlining clinical information presentation, standardizing inpatient notes, improving safety measures, and enhancing overall clinician satisfaction. This study evaluated the adoption and user experience with the Inpatient Dashboard.

INPATIENT DASHBOARD

The Inpatient Dashboard consists of several modules created by a contractor for the VAAAHS that is housed on VA servers with access restricted to individuals with patient health data privileges. As the Inpatient Dashboard draws data from VistA, it can display laboratory information, studies, and notes from all VA sites.

The main dashboard is a snapshot summary of patient information, including patient location, code status, last vital sign readings, vital sign ranges over the previous 24 hours, intake/output, deep vein thrombosis (DVT) prophylaxis, the presence of telemetry orders, or use of Foley or central catheters (Figure). It also includes a customizable to-do list and contact information for the patient’s clinician and nurse. Significant events, such as abnormal vital signs or speciation/sensitivities for blood cultures, are automatically populated on the to-do list. From this main dashboard overview, clinicians can customize which patients are displayed, create and print a rounding list, print a sign-out sheet, or select individual patients to open a progress note module.

Notes can be written in the patient history and physical module, progress note module, and discharge summary module. The patient history and physical module has text blocks allocated to the traditional components of a history and physical note (ie, chief complaint, history of present illness, review of systems, past medical history, family history, social history, allergies, medications, physical examination, assessment, and plan) (eAppendix 1). Some elements, such as past medical history, family history, and social history are prepopulated if the patient was previously admitted. Vital signs, laboratory results, studies, microbiology/ pathology reports, and other CPRS notes are displayed in this module.

The progress note module contains text blocks allocated to the traditional components of a progress note, such as subjective/interval events, physical examination, assessment, and plan (eAppendix 2). Vital signs, laboratory results, studies, microbiology/ pathology reports, other CPRS notes, and the patient’s medication administration record are also displayed in this module. Lastly, the discharge summary module includes patient follow-up, patient instructions, hospitalization summary, medication reconciliation, laboratory results, and studies/procedures, ensuring a comprehensive discharge summary for patients and clinicians (eAppendix 3).

A medication reconciliation tool was embedded within the history and physical and discharge summary modules. This tool has been shown to reduce medication errors in patients admitted from the emergency department to the hospital (eAppendix 4).¹⁰ The handoff/sign-out tool (eAppendix 5) accessible through the main dashboard page is modeled on the I-PASS handoff framework.^11,12 This includes the patient identifier, interval events, inpatient medications, specific sign-out guidance, sign-out tasks/to-dos, and any other pertinent information.

The Inpatient Dashboard is a team-based construct shared by the attending physicians, residents, and medical students. Each team (eg, general medicine, general surgery) is its own entity; only team members can change the content or add to the documentation. Each facility can have multiple teams caring for the same patient (eg, primary and consulting teams). Additional care members can also be incorporated (eg, pharmacists assist with medication reconciliation for admission and discharge at VAAAHS). The Inpatient Dashboard can export information directly to CPRS for clinicians to review and sign. It can also generate a note that can be pasted into CPRS.

Clinician Feedback and Satisfaction

A survey was developed to evaluate clinician experiences with using the Inpatient Dashboard as an adjunct to the CPRS. The Inpatient Dashboard was made available to general medicine teams in November 2018. The survey was conducted from December 2018 to September 2019. The study was conducted at the VAAAHS and included 4 general medicine teams. Each team included an attending physician, a senior resident, 2 to 3 interns, and 3 to 4 medical students. Eligibility was extended to any team member who used both the CPRS and Inpatient Dashboard. Participation in the survey was voluntary. All respondents were informed of the study’s purpose and encouraged to provide candid feedback to ensure the reliability and validity of the findings.

Data were collected through a semistructured survey administered via the Qualtrics platform. The questionnaire was designed to capture multidimensional insights into clinician experience, with particular focus on satisfaction, efficiency, and perceived safety when using the tool as an adjunct to CPRS compared to using CPRS alone. The questionnaire primarily used a Likert scale for responses. Surveys were emailed at the completion of a team’s 1-month inpatient block. An answer was not required for every question, resulting in slightly different response numbers for some questions.

A question regarding the tool’s impact on workload stress was added halfway through the study period, which resulted in fewer responses. Adoption was assessed by counting the Inpatient Dashboard unique users. Descriptive statistics were used within individual survey responses to report the distribution of responses. Differences in response between levels of training were assessed using a X² test of independence.

Survey Results

From September 2023 through November 2023, there were 1549 rounding printouts across 144 unique users (5 nurses, 40 medical students, 87 residents, and 12 attending physicians) and 1468 handoff printouts across 148 unique users (5 nurses, 10 medical students, 111 residents, and 22 attending physicians). The clinician survey received 68 responses from users at various levels of medical training: 23 medical students, 31 interns, 12 senior residents, and 2 attending physicians. All 68 participants confirmed they had used the Inpatient Dashboard.

User satisfaction and preference for the Inpatient Dashboard vs CPRS were assessed. Sixty-one respondents (90%) expressed overall satisfaction with the Inpatient Dashboard; 22 (32%) were extremely satisfied, and 39 (57%) were somewhat satisfied (Table 1). Three respondents (4%) were neutral, 2 (3%) were somewhat dissatisfied, and 2 (3%) were extremely dissatisfied with the Inpatient Dashboard. Responses differed by level of training (P = .03), with medical students trending towards higher satisfaction.

Respondents preferred the Inpatient Dashboard over CPRS for gathering information and writing progress notes; 42 (64%) respondents mostly favored the Inpatient Dashboard, 15 (23%) slightly favored the Inpatient Dashboard over CPRS, and 8 (12%) were neutral. One respondent (2%) slightly favored CPRS to the Inpatient Dashboard (Table 2).

Sixty-five respondents (100%) found the Inpatient Dashboard’s ability to summarize patient information in a central place helpful (Table 3). Among them, 53 (82%) respondents reported it was very or extremely helpful, 10 (15%) respondents reported it was moderately helpful, and 2 (3%) respondents reported it was slightly helpful. This feature positively impacted users’ awareness of patients with DVT prophylaxis or a Foley catheter. Ten (15%) respondents reported being much more aware, and 29 (45%) respondents reporting they were slightly more aware. The remaining 26 (40%) respondents reported no change in awareness.

The Inpatient Dashboard was reported to save time preparing for physician rounds by 52 (80%) respondents, contributing to much greater efficiency for 29 (45%) respondents and slightly more efficiency for 23 (35%) respondents. However, 10 (15%) respondents reported no change in efficiency, and 3 (5%) respondents reduced efficiency, with 1 (2%) respondent reporting it slightly less efficient and 2 (3%) respondents reporting it much less efficient. Responses differed by level of training (P = .01), with medical students trending towards higher efficiency. Of the 23 respondents who reported on the Inpatient Dashboard’s impact on daily workload stress level, 22 (96%) indicated the tool had a stress-reducing effect, with 9 (39%) experiencing a major reduction in stress level, and 13 (57%) experiencing somewhat reduced stress level. Only 1 participant (4%) reported no change in stress. No participants reported an increase in stress.

DISCUSSION

The adoption of EHRs has transformed operational modalities in contemporary health care systems, heralding advancements in patient satisfaction, safety, and overall quality and efficiency of care.^1,2 However, EHRs still present challenges, predominantly around clinician satisfaction, marked by instances of burnout and increased time spent on computers.^2-6 In this context, the Inpatient Dashboard, an online companion to the CPRS, exemplifies how user-centered innovations in EHRs can address and mitigate associated challenges.

The Inpatient Dashboard has been well received with most respondents of the survey conducted in this study indicating they were both satisfied with the instrument and preferring it to CPRS. This high approval aligns with existing literature on the potential advantages of user-centered design in health care technology.¹³ The tool has gained widespread acceptance at the VAAAHS even in the absence of obligatory usage or institutional incentives. The appeal of the Inpatient Dashboard may stem from its increased efficiency, with most users affirming its timesaving nature. While CPRS can only display local notes, laboratory results, and studies, the Inpatient Dashboard can display data from across all VA sites. The VA Joint Longitudinal Viewer can similarly display data from across all sites, but the display is not streamlined as it is in the Inpatient Dashboard. The Inpatient Dashboard incorporates this clinical information into a single page to facilitate day-to-day workflow and dynamic documentation (ie, reviewing laboratory results, medications, writing notes, and signing out patients). This increased efficiency allows clinicians to counter 2 common barriers to EHR implementation: productivity loss and insufficient time.¹⁴

The association between EHRs and improved quality and safety in health care is well-documented.³ The Inpatient Dashboard fortifies this association by enhancing awareness around patient status, evidenced by a majority of respondents, and by integrating a medication reconciliation tool to decrease medication errors on transition from the emergency department to inpatient hospitalization.¹⁰

The Inpatient Dashboard’s impact on alleviating daily workload stress is noteworthy, with almost all respondents experiencing reduced stress levels and physician burnout, which has been linked to deteriorating well-being, compromised patient safety, and escalated health care costs.^15,16 The heightened susceptibility of physicians to burnout compared to other professionals underscores the imperative for incorporating stress-mitigating interventions in the EHR.^17,18

While responses to most questions did not significantly differ by training levels, overall satisfaction with the Inpatient Dashboard and its ability to save time preparing for rounds were rated higher by medical students. This may be attributable to a greater derived benefit from collating and presenting data to learners with less familiarity with the native EHR. It is also notable that the Inpatient Dashboard allows medical students to directly contribute to a patient’s note, which could be another driver in satisfaction. While most interns still felt the Inpatient Dashboard enabled them to save time preparing for rounds, there were a considerable number of ‘no change’ responses, which suggests some interns may not have modified their existing prerounding strategies. These associations are limited by the relatively small number of respondents by learner category, with senior medical residents and attending physicians being underrepresented.

While there are a multitude of dashboards available at the VA, most are made to track certain quality metrics and are used more by administrative and leadership staff. The Inpatient Dashboard was created specifically for frontline clinicians to facilitate their day-to-day workflow and dynamic documentation. This tool can additionally help with quality metrics, though its main purpose was and is to make clinician workflow easier and more efficient.

These results are especially timely because the VA is modernizing its EHR by transitioning to Oracle Health.⁷ Due to the numerous reports both from veterans and VA clinicians that the Oracle Health EHR is not meeting expectations, deployment at further sites has been halted while improving the experience of the 5 institutions using Oracle Health is prioritized.⁹ The Inpatient Dashboard, instead of being merely an enhancement to CPRS, could emerge as a potential bridge to Oracle Health if adapted to display data from Oracle Health as it does VistA. This would facilitate a smoother, more integrated transition for those health care institutions employing the Inpatient Dashboard.

Limitations

The reliance on self-reported data inherently carries the risk of bias, and the absence of objective measures, like time-tracking studies, limits the quantifiable assessment of the Inpatient Dashboard efficacy. The single-center nature of the study also may restrict the generalizability of the results.

CONCLUSIONS

Optimal integration of EHRs into health care delivery is critical to high-quality patient care and operational efficiency. The Inpatient Dashboard is an example of an innovative, user-centric solution that integrated and presented clinical information in a way that produced high satisfaction and adoption by users at a VA hospital.

Neurologic disorders are major causes of death and disability. Globally, the burden of neurologic disorders continues to increase. The prevalence of disabling neurologic disorders significantly increases with age. As people live longer, health care systems will face increasing demands for treatment, rehabilitation, and support services for neurologic disorders. The scarcity of established modifiable risks for most of the neurologic burden demonstrates how new knowledge is required to develop effective prevention and treatment strategies.¹

A single-center study for chronic headache at a rural institution found that, when combined with public education, clinician education not only can increase access to care but also reduce specialist overuse, hospitalizations, polypharmacy, and emergency department visits.² A predicted shortage of neurologists has sparked increased interest in the field and individual neurology educators are helping fuel its popularity.^3-5

TELE-EDUCATION

Educating the next generation of health professionals is 1 of 4 statutory missions of the US Department of Veterans Affairs (VA).⁶ Tele-education (also known as telelearning and distance learning) deviates from traditional in-person classroom settings, in which the lecture has been a core pedagogic method.⁷ Audio, video, and online technologies provide health education and can overcome geographic barriers for rural and remote clinicians.⁸ Recent technological improvements have allowed for inexpensive and efficient dissemination of educational materials, including video lectures, podcasts, online modules, assessment materials, and even entire curricula.⁹

There has been an increase in the awareness of the parallel curriculum involving self-directed and asynchronous learning opportunities. ¹⁰ Several studies report knowledge gained via tele-education is comparable to conventional classroom learning.^11-13 A systematic review of e-learning perceptions among health care students suggested benefits (eg, learning flexibility, pedagogical design, online interactions, basic computer skills, and access to technology) and drawbacks (eg, limited acquisition of clinical skills, internet connection problems, and issues with using educational platforms).¹

The COVID-19 pandemic forced an abrupt cessation of traditional in-person education, forcing educational institutions and medical organizations to transition to telelearning. Solutions in the education field appeared during the pandemic, such as videoconferencing, social media, and telemedicine, that effectively addressed the sudden cessation of in-person medical education.¹⁵

Graduate medical education in neurology residency programs served as an experimental set up for tele-education during the pandemic. Residents from neurology training programs outlined the benefits of a volunteer lecturer-based online didactic program that was established to meet this need, which included exposure to subspeciality topics, access to subspecialist experts not available within the department, exposure to different pedagogic methods, interaction with members of other educational institutions and training programs, career development opportunities, and the potential for forming a community of learning.¹⁶

Not all recent educational developments are technology-based. For example, instruction focused on specific patient experiences, and learning processes that emphasize problem solving and personal responsibility over specific knowledge have been successful in neurology.^17,18 Departments and institutions must be creative in finding ways to fund continuing education, especially when budgets are limited.¹⁹

ANNUAL NEUROLOGY SEMINAR

An annual Veterans Health Administration (VHA) neurology seminar began in 2019 as a 1-day in-person event. Neurologists at the Michael E. DeBakey VA Medical Center in Houston presented in 50-minute sessions. Nonspecialist clinical personnel and neurology clinicians attended the event. Attendees requested making the presentations widely available and regularly repeating the seminar.

The second neurology seminar took place during the COVID-19 pandemic. It was conducted online and advertised across the Veterans Integrated Services Network (VISN) 16. The 1-day program had 204 participants who were primarily nurses (59%) and physicians (21%); 94% agreed with the program objectives (Table 1). Participants could earn CME credits for the 7 presentations primarily by VHA experts.

Based on feedback and a needs assessment, the program expanded in 2021 and 2022. With support from the national VHA neurology office and VHA Employee Education System (EES), the Institute for Learning, Education, and Development (ILEAD), the feedback identified topics that resonate with VHA clinicians. Neurological disorders in the fields of stroke, dementia, and headache were included since veterans with these disorders regularly visit primary care, geriatrics, mental health, and other clinical offices. Updates provided in the diagnosis and treatment of common neurological disorders were well received. Almost all speakers were VHA clinicians, which allowed them to focus on topics relevant to clinical practice at the VHA.

Attendance has increased annually. In 2021, 550 clinicians registered (52% nurses) and 433 completed the postseminar survey (Table 2). In 2022, 635 participants registered and 342 completed evaluations, including attendees from other federal agencies who were invited to participate via EES TRAIN (Training Finder Real-time Affiliate Integrated Network). Forty-seven participants from other federal agencies, including the US Department of Defense, National Institute of Health, and Centers for Disease Control and Prevention, completed the feedback evaluation via TRAIN (Table 3). Participants report high levels of satisfaction each year (mean of 4.5 on a 5-point scale). Respondents preferred conventional lecture presentation and case-based discussions for the teaching format and dementia was the most requested topic for future seminars (Table 4).

The content of each seminar was designed to include . 1 topic relevant to current clinical practice. The 2020 seminar covered topics of cerebrovascular complications of COVID- 19 and living well with neurodegenerative disease in the COVID-19 era. In 2021, the seminar included COVID-19 and neurologic manifestations. In 2022, topics included trends in stroke rehabilitation. In addition, ≥ 1 session addressed neurologic issues within the VHA. In 2020, the VA Deputy National Director of Neurology presented on the VHA stroke systems of care. In 2021, there was a presentation on traumatic brain injury (TBI) in the military. In 2022, sessions covered long term neurologic consequences of TBI and use of telemedicine for neurologic disorders. Feedback on the sessions were positive (eAppendix, available at doi:10.12788/fp.0545).

At the request of the participants, individual presentations were shared via email by the course director and speakers. In collaboration with the EES, each session was recorded and the 2022 seminar was made available to registrants in TMS and EES TRAIN and via the VHA Neurology SharePoint.

DISCUSSION

The annual VHA neurology seminar is a 1-day neurology conference that provides education to general neurologists and other clinicians caring for patients with neurologic disorders. It is the first of its kind neurology education program in the VHA covering most subspecialties in neurology and aims at improving neurologic patient care and access through education. Sessions have covered stroke, epilepsy, sleep, amyotrophic lateral sclerosis, neuropathy, dementia, movement disorders and Parkinson disease, headaches, multiple sclerosis, neurorehabilitation, and telehealth.

The seminar has transitioned from an inperson meeting to a virtual format, making neurology education more convenient and accessible. The virtual format provides the means to increase educational collaborations and share lecture platforms with other federal agencies. The program offers CME credits at no cost to government employees. Recorded lectures can also be asynchronously viewed from the Neurology SharePoint without the ability to earn CME credits. These recordings may be used to educate trainees as well.

The seminar aims to educate all health care professionals caring for patients with neurologic disorders. It aims to eliminate neurophobia, the fear of neural sciences and clinical neurology, and help general practitioners, especially in rural areas, take care of patients with neurologic disorders. The seminars introduce general practitioners to VHA neurology experts; the epilepsy, headache multiple sclerosis, and Parkinson disease centers of excellence; and the national programs for telestroke and teleneurology.

Education Support in the VHA

The EES/ILEAD provides a wide variety of learning opportunities to VHA employees on a broad range of topics, making it one of the largest medical education programs in the country. Pharmacists, social workers, psychologists, therapists, nurses, physician assistants, and physicians have access to certified training opportunities to gain knowledge and skills needed to provide high-quality, veteran-centered care.

A review of geriatrics learning activities through the EES found > 15,000 lectures from 1999 to 2009 for > 300,000 attendees.²⁰ To our knowledge, a review of neurology-related learning activities offered by the EES/ILEAD has not been completed, but the study on geriatrics shows that a similar review would be feasible, given the integrated education system, and helpful in identifying what topics are covered, formats are used, and participants are engaged in neurology education at the VHA. This is a future project planned by the neurology education workgroup.

The EES/ILEAD arranged CME credit for the VHA Neurology Seminar and assisted in organizing an online event with > 500 attendees. Technology support and tools provided by EES during the virtual seminar, such as polling and chat features, kept the audience engaged. Other specialties may similarly value a virtual, all-day seminar format that is efficient and can encourage increased participation from practitioners, nurses, and clinicians.

Future Growth

We plan to increase future participation in the annual neurology seminar with primary care, geriatrics, neurology, and other specialties by instituting an improved and earlier marketing strategy. This includes working with the VHA neurology office to inform neurology practitioners as well as other program offices in the VHA. We intend to host the seminar the same day every year to make it easy for attendees to plan accordingly. In the future we may consider hybrid in-person and virtual modalities if feasible. We plan to focus on reaching out to other government agencies through platforms like TRAIN and the American Academy of Neurology government sections. Securing funding, administrative staff, and protected time in the future may help expand the program further.

Limitations

While a virtual format offers several advantages, using it removes the feel of an in-person meeting, which could be viewed by some attendees as a limitation. The other challenges and drawbacks of transitioning to the virtual platform for a national meeting are similar to those reported in the literature: time zone differences, internet issues, and participants having difficulty using certain online platforms. Attendance could also be limited by scheduling conflicts.¹⁶ Despite a large audience attending the seminar, many clinicians do not get protected time from their institutions. Institutional and leadership support at national and local levels will likely improve participation and help participants earn CME credits. While we are still doing a preliminary needs assessment, a formal needs assessment across federal governmental organizations will be helpful.

CONCLUSIONS

The annual VHA neurology seminar promotes interprofessional education, introduces neurology subspecialty centers of excellence, improves access to renowned neurology experts, and provides neurology-related updates through a VHA lens. The program not only provides educational updates to neurology clinicians, but also increases the confidence of non-neurology clinicians called to care for veterans with neurological disorders in their respective clinics.

Neurologic disorders are major causes of death and disability. Globally, the burden of neurologic disorders continues to increase. The prevalence of disabling neurologic disorders significantly increases with age. As people live longer, health care systems will face increasing demands for treatment, rehabilitation, and support services for neurologic disorders. The scarcity of established modifiable risks for most of the neurologic burden demonstrates how new knowledge is required to develop effective prevention and treatment strategies.¹

A single-center study for chronic headache at a rural institution found that, when combined with public education, clinician education not only can increase access to care but also reduce specialist overuse, hospitalizations, polypharmacy, and emergency department visits.² A predicted shortage of neurologists has sparked increased interest in the field and individual neurology educators are helping fuel its popularity.^3-5

TELE-EDUCATION

Educating the next generation of health professionals is 1 of 4 statutory missions of the US Department of Veterans Affairs (VA).⁶ Tele-education (also known as telelearning and distance learning) deviates from traditional in-person classroom settings, in which the lecture has been a core pedagogic method.⁷ Audio, video, and online technologies provide health education and can overcome geographic barriers for rural and remote clinicians.⁸ Recent technological improvements have allowed for inexpensive and efficient dissemination of educational materials, including video lectures, podcasts, online modules, assessment materials, and even entire curricula.⁹

There has been an increase in the awareness of the parallel curriculum involving self-directed and asynchronous learning opportunities. ¹⁰ Several studies report knowledge gained via tele-education is comparable to conventional classroom learning.^11-13 A systematic review of e-learning perceptions among health care students suggested benefits (eg, learning flexibility, pedagogical design, online interactions, basic computer skills, and access to technology) and drawbacks (eg, limited acquisition of clinical skills, internet connection problems, and issues with using educational platforms).¹

The COVID-19 pandemic forced an abrupt cessation of traditional in-person education, forcing educational institutions and medical organizations to transition to telelearning. Solutions in the education field appeared during the pandemic, such as videoconferencing, social media, and telemedicine, that effectively addressed the sudden cessation of in-person medical education.¹⁵

Graduate medical education in neurology residency programs served as an experimental set up for tele-education during the pandemic. Residents from neurology training programs outlined the benefits of a volunteer lecturer-based online didactic program that was established to meet this need, which included exposure to subspeciality topics, access to subspecialist experts not available within the department, exposure to different pedagogic methods, interaction with members of other educational institutions and training programs, career development opportunities, and the potential for forming a community of learning.¹⁶

Not all recent educational developments are technology-based. For example, instruction focused on specific patient experiences, and learning processes that emphasize problem solving and personal responsibility over specific knowledge have been successful in neurology.^17,18 Departments and institutions must be creative in finding ways to fund continuing education, especially when budgets are limited.¹⁹

ANNUAL NEUROLOGY SEMINAR

An annual Veterans Health Administration (VHA) neurology seminar began in 2019 as a 1-day in-person event. Neurologists at the Michael E. DeBakey VA Medical Center in Houston presented in 50-minute sessions. Nonspecialist clinical personnel and neurology clinicians attended the event. Attendees requested making the presentations widely available and regularly repeating the seminar.

The second neurology seminar took place during the COVID-19 pandemic. It was conducted online and advertised across the Veterans Integrated Services Network (VISN) 16. The 1-day program had 204 participants who were primarily nurses (59%) and physicians (21%); 94% agreed with the program objectives (Table 1). Participants could earn CME credits for the 7 presentations primarily by VHA experts.

Based on feedback and a needs assessment, the program expanded in 2021 and 2022. With support from the national VHA neurology office and VHA Employee Education System (EES), the Institute for Learning, Education, and Development (ILEAD), the feedback identified topics that resonate with VHA clinicians. Neurological disorders in the fields of stroke, dementia, and headache were included since veterans with these disorders regularly visit primary care, geriatrics, mental health, and other clinical offices. Updates provided in the diagnosis and treatment of common neurological disorders were well received. Almost all speakers were VHA clinicians, which allowed them to focus on topics relevant to clinical practice at the VHA.

Attendance has increased annually. In 2021, 550 clinicians registered (52% nurses) and 433 completed the postseminar survey (Table 2). In 2022, 635 participants registered and 342 completed evaluations, including attendees from other federal agencies who were invited to participate via EES TRAIN (Training Finder Real-time Affiliate Integrated Network). Forty-seven participants from other federal agencies, including the US Department of Defense, National Institute of Health, and Centers for Disease Control and Prevention, completed the feedback evaluation via TRAIN (Table 3). Participants report high levels of satisfaction each year (mean of 4.5 on a 5-point scale). Respondents preferred conventional lecture presentation and case-based discussions for the teaching format and dementia was the most requested topic for future seminars (Table 4).

The content of each seminar was designed to include . 1 topic relevant to current clinical practice. The 2020 seminar covered topics of cerebrovascular complications of COVID- 19 and living well with neurodegenerative disease in the COVID-19 era. In 2021, the seminar included COVID-19 and neurologic manifestations. In 2022, topics included trends in stroke rehabilitation. In addition, ≥ 1 session addressed neurologic issues within the VHA. In 2020, the VA Deputy National Director of Neurology presented on the VHA stroke systems of care. In 2021, there was a presentation on traumatic brain injury (TBI) in the military. In 2022, sessions covered long term neurologic consequences of TBI and use of telemedicine for neurologic disorders. Feedback on the sessions were positive (eAppendix, available at doi:10.12788/fp.0545).

At the request of the participants, individual presentations were shared via email by the course director and speakers. In collaboration with the EES, each session was recorded and the 2022 seminar was made available to registrants in TMS and EES TRAIN and via the VHA Neurology SharePoint.

DISCUSSION

The annual VHA neurology seminar is a 1-day neurology conference that provides education to general neurologists and other clinicians caring for patients with neurologic disorders. It is the first of its kind neurology education program in the VHA covering most subspecialties in neurology and aims at improving neurologic patient care and access through education. Sessions have covered stroke, epilepsy, sleep, amyotrophic lateral sclerosis, neuropathy, dementia, movement disorders and Parkinson disease, headaches, multiple sclerosis, neurorehabilitation, and telehealth.

The seminar has transitioned from an inperson meeting to a virtual format, making neurology education more convenient and accessible. The virtual format provides the means to increase educational collaborations and share lecture platforms with other federal agencies. The program offers CME credits at no cost to government employees. Recorded lectures can also be asynchronously viewed from the Neurology SharePoint without the ability to earn CME credits. These recordings may be used to educate trainees as well.

The seminar aims to educate all health care professionals caring for patients with neurologic disorders. It aims to eliminate neurophobia, the fear of neural sciences and clinical neurology, and help general practitioners, especially in rural areas, take care of patients with neurologic disorders. The seminars introduce general practitioners to VHA neurology experts; the epilepsy, headache multiple sclerosis, and Parkinson disease centers of excellence; and the national programs for telestroke and teleneurology.

Education Support in the VHA

The EES/ILEAD provides a wide variety of learning opportunities to VHA employees on a broad range of topics, making it one of the largest medical education programs in the country. Pharmacists, social workers, psychologists, therapists, nurses, physician assistants, and physicians have access to certified training opportunities to gain knowledge and skills needed to provide high-quality, veteran-centered care.

A review of geriatrics learning activities through the EES found > 15,000 lectures from 1999 to 2009 for > 300,000 attendees.²⁰ To our knowledge, a review of neurology-related learning activities offered by the EES/ILEAD has not been completed, but the study on geriatrics shows that a similar review would be feasible, given the integrated education system, and helpful in identifying what topics are covered, formats are used, and participants are engaged in neurology education at the VHA. This is a future project planned by the neurology education workgroup.

The EES/ILEAD arranged CME credit for the VHA Neurology Seminar and assisted in organizing an online event with > 500 attendees. Technology support and tools provided by EES during the virtual seminar, such as polling and chat features, kept the audience engaged. Other specialties may similarly value a virtual, all-day seminar format that is efficient and can encourage increased participation from practitioners, nurses, and clinicians.

Future Growth

We plan to increase future participation in the annual neurology seminar with primary care, geriatrics, neurology, and other specialties by instituting an improved and earlier marketing strategy. This includes working with the VHA neurology office to inform neurology practitioners as well as other program offices in the VHA. We intend to host the seminar the same day every year to make it easy for attendees to plan accordingly. In the future we may consider hybrid in-person and virtual modalities if feasible. We plan to focus on reaching out to other government agencies through platforms like TRAIN and the American Academy of Neurology government sections. Securing funding, administrative staff, and protected time in the future may help expand the program further.

Limitations

While a virtual format offers several advantages, using it removes the feel of an in-person meeting, which could be viewed by some attendees as a limitation. The other challenges and drawbacks of transitioning to the virtual platform for a national meeting are similar to those reported in the literature: time zone differences, internet issues, and participants having difficulty using certain online platforms. Attendance could also be limited by scheduling conflicts.¹⁶ Despite a large audience attending the seminar, many clinicians do not get protected time from their institutions. Institutional and leadership support at national and local levels will likely improve participation and help participants earn CME credits. While we are still doing a preliminary needs assessment, a formal needs assessment across federal governmental organizations will be helpful.

CONCLUSIONS

The annual VHA neurology seminar promotes interprofessional education, introduces neurology subspecialty centers of excellence, improves access to renowned neurology experts, and provides neurology-related updates through a VHA lens. The program not only provides educational updates to neurology clinicians, but also increases the confidence of non-neurology clinicians called to care for veterans with neurological disorders in their respective clinics.

Neurologic disorders are major causes of death and disability. Globally, the burden of neurologic disorders continues to increase. The prevalence of disabling neurologic disorders significantly increases with age. As people live longer, health care systems will face increasing demands for treatment, rehabilitation, and support services for neurologic disorders. The scarcity of established modifiable risks for most of the neurologic burden demonstrates how new knowledge is required to develop effective prevention and treatment strategies.¹

A single-center study for chronic headache at a rural institution found that, when combined with public education, clinician education not only can increase access to care but also reduce specialist overuse, hospitalizations, polypharmacy, and emergency department visits.² A predicted shortage of neurologists has sparked increased interest in the field and individual neurology educators are helping fuel its popularity.^3-5

TELE-EDUCATION

Educating the next generation of health professionals is 1 of 4 statutory missions of the US Department of Veterans Affairs (VA).⁶ Tele-education (also known as telelearning and distance learning) deviates from traditional in-person classroom settings, in which the lecture has been a core pedagogic method.⁷ Audio, video, and online technologies provide health education and can overcome geographic barriers for rural and remote clinicians.⁸ Recent technological improvements have allowed for inexpensive and efficient dissemination of educational materials, including video lectures, podcasts, online modules, assessment materials, and even entire curricula.⁹

There has been an increase in the awareness of the parallel curriculum involving self-directed and asynchronous learning opportunities. ¹⁰ Several studies report knowledge gained via tele-education is comparable to conventional classroom learning.^11-13 A systematic review of e-learning perceptions among health care students suggested benefits (eg, learning flexibility, pedagogical design, online interactions, basic computer skills, and access to technology) and drawbacks (eg, limited acquisition of clinical skills, internet connection problems, and issues with using educational platforms).¹

The COVID-19 pandemic forced an abrupt cessation of traditional in-person education, forcing educational institutions and medical organizations to transition to telelearning. Solutions in the education field appeared during the pandemic, such as videoconferencing, social media, and telemedicine, that effectively addressed the sudden cessation of in-person medical education.¹⁵

Graduate medical education in neurology residency programs served as an experimental set up for tele-education during the pandemic. Residents from neurology training programs outlined the benefits of a volunteer lecturer-based online didactic program that was established to meet this need, which included exposure to subspeciality topics, access to subspecialist experts not available within the department, exposure to different pedagogic methods, interaction with members of other educational institutions and training programs, career development opportunities, and the potential for forming a community of learning.¹⁶

Not all recent educational developments are technology-based. For example, instruction focused on specific patient experiences, and learning processes that emphasize problem solving and personal responsibility over specific knowledge have been successful in neurology.^17,18 Departments and institutions must be creative in finding ways to fund continuing education, especially when budgets are limited.¹⁹

ANNUAL NEUROLOGY SEMINAR

An annual Veterans Health Administration (VHA) neurology seminar began in 2019 as a 1-day in-person event. Neurologists at the Michael E. DeBakey VA Medical Center in Houston presented in 50-minute sessions. Nonspecialist clinical personnel and neurology clinicians attended the event. Attendees requested making the presentations widely available and regularly repeating the seminar.

The second neurology seminar took place during the COVID-19 pandemic. It was conducted online and advertised across the Veterans Integrated Services Network (VISN) 16. The 1-day program had 204 participants who were primarily nurses (59%) and physicians (21%); 94% agreed with the program objectives (Table 1). Participants could earn CME credits for the 7 presentations primarily by VHA experts.

Based on feedback and a needs assessment, the program expanded in 2021 and 2022. With support from the national VHA neurology office and VHA Employee Education System (EES), the Institute for Learning, Education, and Development (ILEAD), the feedback identified topics that resonate with VHA clinicians. Neurological disorders in the fields of stroke, dementia, and headache were included since veterans with these disorders regularly visit primary care, geriatrics, mental health, and other clinical offices. Updates provided in the diagnosis and treatment of common neurological disorders were well received. Almost all speakers were VHA clinicians, which allowed them to focus on topics relevant to clinical practice at the VHA.

Attendance has increased annually. In 2021, 550 clinicians registered (52% nurses) and 433 completed the postseminar survey (Table 2). In 2022, 635 participants registered and 342 completed evaluations, including attendees from other federal agencies who were invited to participate via EES TRAIN (Training Finder Real-time Affiliate Integrated Network). Forty-seven participants from other federal agencies, including the US Department of Defense, National Institute of Health, and Centers for Disease Control and Prevention, completed the feedback evaluation via TRAIN (Table 3). Participants report high levels of satisfaction each year (mean of 4.5 on a 5-point scale). Respondents preferred conventional lecture presentation and case-based discussions for the teaching format and dementia was the most requested topic for future seminars (Table 4).

The content of each seminar was designed to include . 1 topic relevant to current clinical practice. The 2020 seminar covered topics of cerebrovascular complications of COVID- 19 and living well with neurodegenerative disease in the COVID-19 era. In 2021, the seminar included COVID-19 and neurologic manifestations. In 2022, topics included trends in stroke rehabilitation. In addition, ≥ 1 session addressed neurologic issues within the VHA. In 2020, the VA Deputy National Director of Neurology presented on the VHA stroke systems of care. In 2021, there was a presentation on traumatic brain injury (TBI) in the military. In 2022, sessions covered long term neurologic consequences of TBI and use of telemedicine for neurologic disorders. Feedback on the sessions were positive (eAppendix, available at doi:10.12788/fp.0545).

At the request of the participants, individual presentations were shared via email by the course director and speakers. In collaboration with the EES, each session was recorded and the 2022 seminar was made available to registrants in TMS and EES TRAIN and via the VHA Neurology SharePoint.

DISCUSSION

The annual VHA neurology seminar is a 1-day neurology conference that provides education to general neurologists and other clinicians caring for patients with neurologic disorders. It is the first of its kind neurology education program in the VHA covering most subspecialties in neurology and aims at improving neurologic patient care and access through education. Sessions have covered stroke, epilepsy, sleep, amyotrophic lateral sclerosis, neuropathy, dementia, movement disorders and Parkinson disease, headaches, multiple sclerosis, neurorehabilitation, and telehealth.

The seminar has transitioned from an inperson meeting to a virtual format, making neurology education more convenient and accessible. The virtual format provides the means to increase educational collaborations and share lecture platforms with other federal agencies. The program offers CME credits at no cost to government employees. Recorded lectures can also be asynchronously viewed from the Neurology SharePoint without the ability to earn CME credits. These recordings may be used to educate trainees as well.

The seminar aims to educate all health care professionals caring for patients with neurologic disorders. It aims to eliminate neurophobia, the fear of neural sciences and clinical neurology, and help general practitioners, especially in rural areas, take care of patients with neurologic disorders. The seminars introduce general practitioners to VHA neurology experts; the epilepsy, headache multiple sclerosis, and Parkinson disease centers of excellence; and the national programs for telestroke and teleneurology.

Education Support in the VHA

The EES/ILEAD provides a wide variety of learning opportunities to VHA employees on a broad range of topics, making it one of the largest medical education programs in the country. Pharmacists, social workers, psychologists, therapists, nurses, physician assistants, and physicians have access to certified training opportunities to gain knowledge and skills needed to provide high-quality, veteran-centered care.

A review of geriatrics learning activities through the EES found > 15,000 lectures from 1999 to 2009 for > 300,000 attendees.²⁰ To our knowledge, a review of neurology-related learning activities offered by the EES/ILEAD has not been completed, but the study on geriatrics shows that a similar review would be feasible, given the integrated education system, and helpful in identifying what topics are covered, formats are used, and participants are engaged in neurology education at the VHA. This is a future project planned by the neurology education workgroup.

The EES/ILEAD arranged CME credit for the VHA Neurology Seminar and assisted in organizing an online event with > 500 attendees. Technology support and tools provided by EES during the virtual seminar, such as polling and chat features, kept the audience engaged. Other specialties may similarly value a virtual, all-day seminar format that is efficient and can encourage increased participation from practitioners, nurses, and clinicians.

Future Growth

We plan to increase future participation in the annual neurology seminar with primary care, geriatrics, neurology, and other specialties by instituting an improved and earlier marketing strategy. This includes working with the VHA neurology office to inform neurology practitioners as well as other program offices in the VHA. We intend to host the seminar the same day every year to make it easy for attendees to plan accordingly. In the future we may consider hybrid in-person and virtual modalities if feasible. We plan to focus on reaching out to other government agencies through platforms like TRAIN and the American Academy of Neurology government sections. Securing funding, administrative staff, and protected time in the future may help expand the program further.

Limitations

While a virtual format offers several advantages, using it removes the feel of an in-person meeting, which could be viewed by some attendees as a limitation. The other challenges and drawbacks of transitioning to the virtual platform for a national meeting are similar to those reported in the literature: time zone differences, internet issues, and participants having difficulty using certain online platforms. Attendance could also be limited by scheduling conflicts.¹⁶ Despite a large audience attending the seminar, many clinicians do not get protected time from their institutions. Institutional and leadership support at national and local levels will likely improve participation and help participants earn CME credits. While we are still doing a preliminary needs assessment, a formal needs assessment across federal governmental organizations will be helpful.

CONCLUSIONS

The annual VHA neurology seminar promotes interprofessional education, introduces neurology subspecialty centers of excellence, improves access to renowned neurology experts, and provides neurology-related updates through a VHA lens. The program not only provides educational updates to neurology clinicians, but also increases the confidence of non-neurology clinicians called to care for veterans with neurological disorders in their respective clinics.

Prior to the COVID-19 pandemic, health care systems had been increasingly focused on expanding care delivery through clinical video telehealth (CVT) services.^1-3 These modalities offer clinicians and patients opportunities to interact without needing face-to-face visits. CVT services offer significant advantages to patients who encounter challenges accessing traditional face-to-face services, including those living in rural or underserved areas, individuals with mobility limitations, and those with difficulty attending appointments due to work or caregiving commitments.⁴ The COVID-19 pandemic accelerated the expansion of CVT services to mitigate the spread of the virus.¹

Despite its evident advantages, widespread adoption of CVT has encountered resistance.² Physicians have frequently expressed concerns about the reliability and functionality of CVT platforms for scheduled encounters and frustration with inadequate training.^4-6 Additionally, there is a lack trust in the technology, as physicians are unfamiliar with reimbursement or workload capture associated with CVT. Physicians have concerns that telecommunication may diminish the intangible aspects of the “art of medicine.”⁴ As a result, the implementation of telehealth services has been inconsistent, with successful adoption limited to specific medical and surgical specialties.⁴ Only recently have entire departments within major health care systems expressed interest in providing comprehensive CVT services in response to the challenges posed by the COVID-19 pandemic.⁴

The Veterans Health Administration (VHA) of the US Department of Veterans Affairs (VA) provides an appropriate setting for assessing clinician perceptions of telehealth services. Since 2003, the VHA has significantly expanded CVT services to eligible veterans and has used the VA Video Connect (VVC) platform since 2018.^7-10 Through VVC, VA staff and clinicians may schedule video visits with patients, meet with patients through virtual face-to-face interaction, and share relevant laboratory results and imaging through screen sharing. Prior research has shown increased accessibility to care through VVC. For example, a single-site study demonstrated that VVC implementation for delivering psychotherapies significantly increased CVT encounters from 15% to 85% among veterans with anxiety and/or depression.¹¹

The VA New Mexico Healthcare System (VANMHCS) serves a high volume of veterans living in remote and rural regions and significantly increased its use of CVT during the COVID-19 pandemic to reduce in-person visits. Expectedly, this was met with a variety of challenges. Herein, we sought to assess physician perspectives, concerns, and attitudes toward VVC via semistructured interviews. Our hypothesis was that VA physicians may feel uncomfortable with video encounters but recognize the growing importance of such practices providing specialty care to veterans in rural areas.

METHODS

A semistructured interview protocol was created following discussions with physicians from the VANMHCS Medicine Service. Questions were constructed to assess the following domains: overarching views of video telehealth, perceptions of various applications for conducting VVC encounters, and barriers to the broad implementation of video telehealth. A qualitative investigation specialist aided with question development. Two pilot interviews were conducted prior to performing the interviews with the recruited participants to evaluate the quality and delivery of questions.

All VANMHCS physicians who provided outpatient care within the Department of Medicine and had completed ≥ 1 VVC encounter were eligible to participate. Invitations were disseminated via email, and follow-up emails to encourage participation were sent periodically for 2 months following the initial request. Union approval was obtained to interview employees for a research study. In total, 64 physicians were invited and 13 (20%) chose to participate. As the study did not involve assessing medical interventions among patients, a waiver of informed consent was granted by the VANMHCS Institutional Review Board. Physicians who participated in this study were informed that their responses would be used for reporting purposes and could be rescinded at any time.

Data Analysis

Semistructured interviews were conducted by a single interviewer and recorded using Microsoft Teams. The interviews took place between February 2021 and December 2021 and lasted 5 to 15 minutes, with a mean duration of 9 minutes. Verbal informed consent was obtained from all participants before the interviews. Interviewees were encouraged to expand on their responses to structured questions by recounting past experiences with VVC. Recorded audio was additionally transcribed via Microsoft Teams, and the research team reviewed the transcriptions to ensure accuracy.

The tracking and coding of responses to interview questions were conducted using Microsoft Excel. Initially, 5 transcripts were reviewed and responses were assessed by 2 study team members through open coding. All team members examined the 5 coded transcripts to identify differences and reach a consensus for any discrepancies. Based on recommendations from all team members regarding nuanced excerpts of transcripts, 1 study team member coded the remaining interviews. Thematic analysis was subsequently conducted according to the method described by Braun and Clarke.¹² Themes were developed both deductively and inductively by reviewing the direct responses to interview questions and identifying emerging patterns of data, respectively. Indicative quotes representing each theme were carefully chosen for reporting.

RESULTS

Thirteen interviews were conducted and 9 participants (69%) were female. Participating physicians included 3 internal medicine/primary care physicians (23%), 2 nephrologists (15%), and 1 (8%) from cardiology, endocrinology, hematology, infectious diseases, palliative care, critical care, pulmonology, and sleep medicine. Years of post training experience among physicians ranged from 1 to 9 years (n = 5, 38%), 10 to 19 years (n = 3, 23%), and . 20 years (n = 5, 38%). Seven participants (54%) had conducted ≥ 5 VVC visits, with 1 physician completing > 50 video visits (Table).

Using open coding and a deductive approach to thematic analysis, 5 themes were identified: (1) VVC software and internet connection issues affected implementation; (2) patient technological literacy affected veteran and physician comfort with VVC; (3) integration of supportive measures was desired; (4) CVT services may increasingly be used to enhance access to care; and (5) in-person encounters afforded unique advantages over CVT. Illustrative quotes from physicians that reflect these themes can be found in the Appendix.

Theme 1: VVC software and internet connection issues affected its implementation. Most participants expressed concern about the technical challenges with VVC. Interviewees cited inconsistencies for both patients and physicians receiving emails with links to join VVC visits, which should be generated when appointments are scheduled. Some physicians were unaware of scheduled VVC visits until the day of the appointment and only received the link via email. Such issues appeared to occur regardless whether the physicians or support staff scheduled the encounter. Poor video and audio quality was also cited as significant barriers to successful VVC visits and were often not resolvable through troubleshooting efforts by physicians, patients, or support personnel. Given the limited time allotted to each patient encounter, such issues could significantly impact the physician’s ability to remain on schedule. Moreover, connectivity problems led to significant lapses, delays in audio and video transmission, and complete disconnections from the VVC encounter. This was a significant concern for participants, given the rural nature of New Mexico and the large geographical gaps in internet service throughout the state.

Theme 2: Patient technological literacy affected veteran and physician comfort with VVC. Successful VVC appointments require high-speed Internet and compatible hardware. Physicians indicated that some patients reported difficulties with critical steps in the process, such as logging into the VVC platform or ensuring their microphones and cameras were active. Physicians also expressed concern about older veterans’ ability to utilize electronic devices, noting they may generally be less technology savvy. Additionally, physicians reported that despite offering the option of a virtual visit, many veterans preferred in-person visits, regardless of the drive time required. This appeared related to a fear of using the technology, which led veterans to believe that virtual visits do not provide the same quality of care as in-person visits.

Theme 3: Integration of supportive measures is desired. Interviewees felt that integrated VVC technical assistance and technology literacy education were imperative. First, training the patient or the patient’s caregiver on how to complete a VVC encounter using the preferred device and the VVC platform would be beneficial. Second, education to inform physicians about common troubleshooting issues could help streamline VVC encounters. Third, managing a VVC encounter similarly to standard in-person visits could allow for better patient and physician experience. For example, physicians suggested that a medical assistant or a nurse triage the patient, take vital signs, and set them up in a room, potentially at a regional VA community based outpatient clinic. Such efforts would also allow patients to receive specialty care in remote areas where only primary care is generally offered. Support staff could assist with technological issues, such as setting up the VVC encounter and addressing potential problems before the physician joins the encounter, thereby preventing delays in patient care. Finally, physicians felt that designating a day solely for CVT visits would help prevent disruption in care with in-person visits.

Theme 4: CVT services may increasingly be used to enhance access to care. Physicians felt that VVC would help patients encountering obstacles in accessing conventional in person services, including patients in rural and underserved areas, with disabilities, or with scheduling challenges.4 Patients with chronic conditions might drive the use of virtual visits, as many of these patients are already accustomed to remote medical monitoring. Data from devices such as scales and continuous glucose monitors can be easily reviewed during VVC visits. Second, video encounters facilitate closer monitoring that some patients might otherwise skip due to significant travel barriers, especially in a rural state like New Mexico. Lastly, VVC may be more efficient than in person visits as they eliminate the need for lengthy parking, checking in, and checking out processes. Thus, if technological issues are resolved, a typical physician’s day in the clinic may be more efficient with virtual visits.

Theme 5: In-person encounters afforded unique advantages over CVT. Some physicians felt in-person visits still offer unique advantages. They opined that the selection of appropriate candidates for CVT is critical. Patients requiring a physical examination should be scheduled for in person visits. For example, patients with advanced chronic kidney disease who require accurate volume status assessment or patients who have recently undergone surgery and need detailed wound inspection should be seen in the clinic. In-person visits may also be preferable for patients with recurrent admissions, or those whose condition is difficult to assess; accurate assessments of such patients may help prevent readmissions. Finally, many patients are more comfortable and satisfied with in-person visits, which are perceived as a more standard or traditional process. Respondents noted that some patients felt physicians may not focus as much attention during a VVC visit as they do during in-person visits. There were also concerns that some patients feel more motivation to come to in-person visits, as they see the VA as a place to interact with other veterans and staff with whom they are familiar and comfortable.

DISCUSSION

VANMHCS physicians, which serves veterans across an expansive territory ranging from Southern Colorado to West Texas. About 4.6 million veterans reside in rural regions, constituting roughly 25% of the total veteran population, a pattern mirrored in New Mexico.¹³ Medicine Service physicians agreed on a number of themes: VVC user-interface issues may affect its use and effectiveness, technological literacy was important for both patients and health care staff, technical support staff roles before and during VVC visits should be standardized, CVT is likely to increase health care delivery, and in-person encounters are preferred for many patients.

This is the first study to qualitatively evaluate a diverse group of physicians at a VA medical center incorporating CVT services across specialties. A few related qualitative studies have been conducted external to VHA, generally evaluating clinicians within a single specialty. Kalicki and colleagues surveyed 16 physicians working at a large home-based primary care program in New York City between April and June 2020 to identify and explore barriers to telehealth among homebound older adults. Similarly to our study, physicians noted that many patients required assistance (family members or caregivers) with the visit, either due to technological literacy issues or medical conditions like dementia.¹⁴

Heyer and colleagues surveyed 29 oncologists at an urban academic center prior to the COVID-19 pandemic. Similar to our observations, the oncologists said telemedicine helped eliminate travel as a barrier to health care. Heyer and colleagues noted difficulty for oncologists in performing virtual physical examinations, despite training. This group did note the benefits when being selective as to which clinical issues they would handle virtually vs in person.¹⁵

Budhwani and colleagues reported that mental health professionals in an academic setting cited difficulty establishing therapeutic relationships via telehealth and felt that this affected quality of care.¹⁶ While this was not a topic during our interviews, it is reasonable to question how potentially missed nonverbal cues may impact patient assessments.

Notably, technological issues were common among all reviewed studies. These ranged from internet connectivity issues to necessary electronic devices. As mentioned, these barriers are more prevalent in rural states like New Mexico.

Limitations

All participants in this study were Medicine Service physicians of a single VA health care system, which may limit generalizability. Many of our respondents were female (69%), compared with 39.2% of active internal medicine physicians and therefore may not be representative.¹⁷ Nearly one-half of our participants only completed 1 to 4 VVC encounters, which may have contributed to the emergence of a common theme regarding technological issues. Physicians with more experience with CVT services may be more skilled at troubleshooting technological issues that arise during visits.

CONCLUSIONS

Our study, conducted with VANMHCS physicians, illuminated 5 key themes influencing the use and implementation of video encounters: technological issues, technological literacy, a desire for integrated support measures, perceived future growth of video telehealth, and the unique advantages of in-person visits. Addressing technological barriers and providing more extensive training may streamline CVT use. However, it is vital to recognize the unique benefits of in-person visits and consider the benefits of each modality along with patient preferences when selecting the best care venue. As health care evolves, better understanding and acting upon these themes will optimize telehealth services, particularly in rural areas. Future research should involve patients and other health care team members to further explore strategies for effective CVT service integration.

Appendix

Prior to the COVID-19 pandemic, health care systems had been increasingly focused on expanding care delivery through clinical video telehealth (CVT) services.^1-3 These modalities offer clinicians and patients opportunities to interact without needing face-to-face visits. CVT services offer significant advantages to patients who encounter challenges accessing traditional face-to-face services, including those living in rural or underserved areas, individuals with mobility limitations, and those with difficulty attending appointments due to work or caregiving commitments.⁴ The COVID-19 pandemic accelerated the expansion of CVT services to mitigate the spread of the virus.¹

Despite its evident advantages, widespread adoption of CVT has encountered resistance.² Physicians have frequently expressed concerns about the reliability and functionality of CVT platforms for scheduled encounters and frustration with inadequate training.^4-6 Additionally, there is a lack trust in the technology, as physicians are unfamiliar with reimbursement or workload capture associated with CVT. Physicians have concerns that telecommunication may diminish the intangible aspects of the “art of medicine.”⁴ As a result, the implementation of telehealth services has been inconsistent, with successful adoption limited to specific medical and surgical specialties.⁴ Only recently have entire departments within major health care systems expressed interest in providing comprehensive CVT services in response to the challenges posed by the COVID-19 pandemic.⁴

The Veterans Health Administration (VHA) of the US Department of Veterans Affairs (VA) provides an appropriate setting for assessing clinician perceptions of telehealth services. Since 2003, the VHA has significantly expanded CVT services to eligible veterans and has used the VA Video Connect (VVC) platform since 2018.^7-10 Through VVC, VA staff and clinicians may schedule video visits with patients, meet with patients through virtual face-to-face interaction, and share relevant laboratory results and imaging through screen sharing. Prior research has shown increased accessibility to care through VVC. For example, a single-site study demonstrated that VVC implementation for delivering psychotherapies significantly increased CVT encounters from 15% to 85% among veterans with anxiety and/or depression.¹¹

The VA New Mexico Healthcare System (VANMHCS) serves a high volume of veterans living in remote and rural regions and significantly increased its use of CVT during the COVID-19 pandemic to reduce in-person visits. Expectedly, this was met with a variety of challenges. Herein, we sought to assess physician perspectives, concerns, and attitudes toward VVC via semistructured interviews. Our hypothesis was that VA physicians may feel uncomfortable with video encounters but recognize the growing importance of such practices providing specialty care to veterans in rural areas.

METHODS

A semistructured interview protocol was created following discussions with physicians from the VANMHCS Medicine Service. Questions were constructed to assess the following domains: overarching views of video telehealth, perceptions of various applications for conducting VVC encounters, and barriers to the broad implementation of video telehealth. A qualitative investigation specialist aided with question development. Two pilot interviews were conducted prior to performing the interviews with the recruited participants to evaluate the quality and delivery of questions.

All VANMHCS physicians who provided outpatient care within the Department of Medicine and had completed ≥ 1 VVC encounter were eligible to participate. Invitations were disseminated via email, and follow-up emails to encourage participation were sent periodically for 2 months following the initial request. Union approval was obtained to interview employees for a research study. In total, 64 physicians were invited and 13 (20%) chose to participate. As the study did not involve assessing medical interventions among patients, a waiver of informed consent was granted by the VANMHCS Institutional Review Board. Physicians who participated in this study were informed that their responses would be used for reporting purposes and could be rescinded at any time.

Data Analysis

Semistructured interviews were conducted by a single interviewer and recorded using Microsoft Teams. The interviews took place between February 2021 and December 2021 and lasted 5 to 15 minutes, with a mean duration of 9 minutes. Verbal informed consent was obtained from all participants before the interviews. Interviewees were encouraged to expand on their responses to structured questions by recounting past experiences with VVC. Recorded audio was additionally transcribed via Microsoft Teams, and the research team reviewed the transcriptions to ensure accuracy.

The tracking and coding of responses to interview questions were conducted using Microsoft Excel. Initially, 5 transcripts were reviewed and responses were assessed by 2 study team members through open coding. All team members examined the 5 coded transcripts to identify differences and reach a consensus for any discrepancies. Based on recommendations from all team members regarding nuanced excerpts of transcripts, 1 study team member coded the remaining interviews. Thematic analysis was subsequently conducted according to the method described by Braun and Clarke.¹² Themes were developed both deductively and inductively by reviewing the direct responses to interview questions and identifying emerging patterns of data, respectively. Indicative quotes representing each theme were carefully chosen for reporting.

RESULTS

Thirteen interviews were conducted and 9 participants (69%) were female. Participating physicians included 3 internal medicine/primary care physicians (23%), 2 nephrologists (15%), and 1 (8%) from cardiology, endocrinology, hematology, infectious diseases, palliative care, critical care, pulmonology, and sleep medicine. Years of post training experience among physicians ranged from 1 to 9 years (n = 5, 38%), 10 to 19 years (n = 3, 23%), and . 20 years (n = 5, 38%). Seven participants (54%) had conducted ≥ 5 VVC visits, with 1 physician completing > 50 video visits (Table).

Using open coding and a deductive approach to thematic analysis, 5 themes were identified: (1) VVC software and internet connection issues affected implementation; (2) patient technological literacy affected veteran and physician comfort with VVC; (3) integration of supportive measures was desired; (4) CVT services may increasingly be used to enhance access to care; and (5) in-person encounters afforded unique advantages over CVT. Illustrative quotes from physicians that reflect these themes can be found in the Appendix.

Theme 1: VVC software and internet connection issues affected its implementation. Most participants expressed concern about the technical challenges with VVC. Interviewees cited inconsistencies for both patients and physicians receiving emails with links to join VVC visits, which should be generated when appointments are scheduled. Some physicians were unaware of scheduled VVC visits until the day of the appointment and only received the link via email. Such issues appeared to occur regardless whether the physicians or support staff scheduled the encounter. Poor video and audio quality was also cited as significant barriers to successful VVC visits and were often not resolvable through troubleshooting efforts by physicians, patients, or support personnel. Given the limited time allotted to each patient encounter, such issues could significantly impact the physician’s ability to remain on schedule. Moreover, connectivity problems led to significant lapses, delays in audio and video transmission, and complete disconnections from the VVC encounter. This was a significant concern for participants, given the rural nature of New Mexico and the large geographical gaps in internet service throughout the state.

Theme 2: Patient technological literacy affected veteran and physician comfort with VVC. Successful VVC appointments require high-speed Internet and compatible hardware. Physicians indicated that some patients reported difficulties with critical steps in the process, such as logging into the VVC platform or ensuring their microphones and cameras were active. Physicians also expressed concern about older veterans’ ability to utilize electronic devices, noting they may generally be less technology savvy. Additionally, physicians reported that despite offering the option of a virtual visit, many veterans preferred in-person visits, regardless of the drive time required. This appeared related to a fear of using the technology, which led veterans to believe that virtual visits do not provide the same quality of care as in-person visits.

Theme 3: Integration of supportive measures is desired. Interviewees felt that integrated VVC technical assistance and technology literacy education were imperative. First, training the patient or the patient’s caregiver on how to complete a VVC encounter using the preferred device and the VVC platform would be beneficial. Second, education to inform physicians about common troubleshooting issues could help streamline VVC encounters. Third, managing a VVC encounter similarly to standard in-person visits could allow for better patient and physician experience. For example, physicians suggested that a medical assistant or a nurse triage the patient, take vital signs, and set them up in a room, potentially at a regional VA community based outpatient clinic. Such efforts would also allow patients to receive specialty care in remote areas where only primary care is generally offered. Support staff could assist with technological issues, such as setting up the VVC encounter and addressing potential problems before the physician joins the encounter, thereby preventing delays in patient care. Finally, physicians felt that designating a day solely for CVT visits would help prevent disruption in care with in-person visits.

Theme 4: CVT services may increasingly be used to enhance access to care. Physicians felt that VVC would help patients encountering obstacles in accessing conventional in person services, including patients in rural and underserved areas, with disabilities, or with scheduling challenges.4 Patients with chronic conditions might drive the use of virtual visits, as many of these patients are already accustomed to remote medical monitoring. Data from devices such as scales and continuous glucose monitors can be easily reviewed during VVC visits. Second, video encounters facilitate closer monitoring that some patients might otherwise skip due to significant travel barriers, especially in a rural state like New Mexico. Lastly, VVC may be more efficient than in person visits as they eliminate the need for lengthy parking, checking in, and checking out processes. Thus, if technological issues are resolved, a typical physician’s day in the clinic may be more efficient with virtual visits.

Theme 5: In-person encounters afforded unique advantages over CVT. Some physicians felt in-person visits still offer unique advantages. They opined that the selection of appropriate candidates for CVT is critical. Patients requiring a physical examination should be scheduled for in person visits. For example, patients with advanced chronic kidney disease who require accurate volume status assessment or patients who have recently undergone surgery and need detailed wound inspection should be seen in the clinic. In-person visits may also be preferable for patients with recurrent admissions, or those whose condition is difficult to assess; accurate assessments of such patients may help prevent readmissions. Finally, many patients are more comfortable and satisfied with in-person visits, which are perceived as a more standard or traditional process. Respondents noted that some patients felt physicians may not focus as much attention during a VVC visit as they do during in-person visits. There were also concerns that some patients feel more motivation to come to in-person visits, as they see the VA as a place to interact with other veterans and staff with whom they are familiar and comfortable.

DISCUSSION

VANMHCS physicians, which serves veterans across an expansive territory ranging from Southern Colorado to West Texas. About 4.6 million veterans reside in rural regions, constituting roughly 25% of the total veteran population, a pattern mirrored in New Mexico.¹³ Medicine Service physicians agreed on a number of themes: VVC user-interface issues may affect its use and effectiveness, technological literacy was important for both patients and health care staff, technical support staff roles before and during VVC visits should be standardized, CVT is likely to increase health care delivery, and in-person encounters are preferred for many patients.

This is the first study to qualitatively evaluate a diverse group of physicians at a VA medical center incorporating CVT services across specialties. A few related qualitative studies have been conducted external to VHA, generally evaluating clinicians within a single specialty. Kalicki and colleagues surveyed 16 physicians working at a large home-based primary care program in New York City between April and June 2020 to identify and explore barriers to telehealth among homebound older adults. Similarly to our study, physicians noted that many patients required assistance (family members or caregivers) with the visit, either due to technological literacy issues or medical conditions like dementia.¹⁴

Heyer and colleagues surveyed 29 oncologists at an urban academic center prior to the COVID-19 pandemic. Similar to our observations, the oncologists said telemedicine helped eliminate travel as a barrier to health care. Heyer and colleagues noted difficulty for oncologists in performing virtual physical examinations, despite training. This group did note the benefits when being selective as to which clinical issues they would handle virtually vs in person.¹⁵

Budhwani and colleagues reported that mental health professionals in an academic setting cited difficulty establishing therapeutic relationships via telehealth and felt that this affected quality of care.¹⁶ While this was not a topic during our interviews, it is reasonable to question how potentially missed nonverbal cues may impact patient assessments.

Notably, technological issues were common among all reviewed studies. These ranged from internet connectivity issues to necessary electronic devices. As mentioned, these barriers are more prevalent in rural states like New Mexico.

Limitations

All participants in this study were Medicine Service physicians of a single VA health care system, which may limit generalizability. Many of our respondents were female (69%), compared with 39.2% of active internal medicine physicians and therefore may not be representative.¹⁷ Nearly one-half of our participants only completed 1 to 4 VVC encounters, which may have contributed to the emergence of a common theme regarding technological issues. Physicians with more experience with CVT services may be more skilled at troubleshooting technological issues that arise during visits.

CONCLUSIONS

Our study, conducted with VANMHCS physicians, illuminated 5 key themes influencing the use and implementation of video encounters: technological issues, technological literacy, a desire for integrated support measures, perceived future growth of video telehealth, and the unique advantages of in-person visits. Addressing technological barriers and providing more extensive training may streamline CVT use. However, it is vital to recognize the unique benefits of in-person visits and consider the benefits of each modality along with patient preferences when selecting the best care venue. As health care evolves, better understanding and acting upon these themes will optimize telehealth services, particularly in rural areas. Future research should involve patients and other health care team members to further explore strategies for effective CVT service integration.

Appendix

Prior to the COVID-19 pandemic, health care systems had been increasingly focused on expanding care delivery through clinical video telehealth (CVT) services.^1-3 These modalities offer clinicians and patients opportunities to interact without needing face-to-face visits. CVT services offer significant advantages to patients who encounter challenges accessing traditional face-to-face services, including those living in rural or underserved areas, individuals with mobility limitations, and those with difficulty attending appointments due to work or caregiving commitments.⁴ The COVID-19 pandemic accelerated the expansion of CVT services to mitigate the spread of the virus.¹

Despite its evident advantages, widespread adoption of CVT has encountered resistance.² Physicians have frequently expressed concerns about the reliability and functionality of CVT platforms for scheduled encounters and frustration with inadequate training.^4-6 Additionally, there is a lack trust in the technology, as physicians are unfamiliar with reimbursement or workload capture associated with CVT. Physicians have concerns that telecommunication may diminish the intangible aspects of the “art of medicine.”⁴ As a result, the implementation of telehealth services has been inconsistent, with successful adoption limited to specific medical and surgical specialties.⁴ Only recently have entire departments within major health care systems expressed interest in providing comprehensive CVT services in response to the challenges posed by the COVID-19 pandemic.⁴

The Veterans Health Administration (VHA) of the US Department of Veterans Affairs (VA) provides an appropriate setting for assessing clinician perceptions of telehealth services. Since 2003, the VHA has significantly expanded CVT services to eligible veterans and has used the VA Video Connect (VVC) platform since 2018.^7-10 Through VVC, VA staff and clinicians may schedule video visits with patients, meet with patients through virtual face-to-face interaction, and share relevant laboratory results and imaging through screen sharing. Prior research has shown increased accessibility to care through VVC. For example, a single-site study demonstrated that VVC implementation for delivering psychotherapies significantly increased CVT encounters from 15% to 85% among veterans with anxiety and/or depression.¹¹

The VA New Mexico Healthcare System (VANMHCS) serves a high volume of veterans living in remote and rural regions and significantly increased its use of CVT during the COVID-19 pandemic to reduce in-person visits. Expectedly, this was met with a variety of challenges. Herein, we sought to assess physician perspectives, concerns, and attitudes toward VVC via semistructured interviews. Our hypothesis was that VA physicians may feel uncomfortable with video encounters but recognize the growing importance of such practices providing specialty care to veterans in rural areas.

METHODS

A semistructured interview protocol was created following discussions with physicians from the VANMHCS Medicine Service. Questions were constructed to assess the following domains: overarching views of video telehealth, perceptions of various applications for conducting VVC encounters, and barriers to the broad implementation of video telehealth. A qualitative investigation specialist aided with question development. Two pilot interviews were conducted prior to performing the interviews with the recruited participants to evaluate the quality and delivery of questions.

All VANMHCS physicians who provided outpatient care within the Department of Medicine and had completed ≥ 1 VVC encounter were eligible to participate. Invitations were disseminated via email, and follow-up emails to encourage participation were sent periodically for 2 months following the initial request. Union approval was obtained to interview employees for a research study. In total, 64 physicians were invited and 13 (20%) chose to participate. As the study did not involve assessing medical interventions among patients, a waiver of informed consent was granted by the VANMHCS Institutional Review Board. Physicians who participated in this study were informed that their responses would be used for reporting purposes and could be rescinded at any time.

Data Analysis

Semistructured interviews were conducted by a single interviewer and recorded using Microsoft Teams. The interviews took place between February 2021 and December 2021 and lasted 5 to 15 minutes, with a mean duration of 9 minutes. Verbal informed consent was obtained from all participants before the interviews. Interviewees were encouraged to expand on their responses to structured questions by recounting past experiences with VVC. Recorded audio was additionally transcribed via Microsoft Teams, and the research team reviewed the transcriptions to ensure accuracy.

The tracking and coding of responses to interview questions were conducted using Microsoft Excel. Initially, 5 transcripts were reviewed and responses were assessed by 2 study team members through open coding. All team members examined the 5 coded transcripts to identify differences and reach a consensus for any discrepancies. Based on recommendations from all team members regarding nuanced excerpts of transcripts, 1 study team member coded the remaining interviews. Thematic analysis was subsequently conducted according to the method described by Braun and Clarke.¹² Themes were developed both deductively and inductively by reviewing the direct responses to interview questions and identifying emerging patterns of data, respectively. Indicative quotes representing each theme were carefully chosen for reporting.

RESULTS

Thirteen interviews were conducted and 9 participants (69%) were female. Participating physicians included 3 internal medicine/primary care physicians (23%), 2 nephrologists (15%), and 1 (8%) from cardiology, endocrinology, hematology, infectious diseases, palliative care, critical care, pulmonology, and sleep medicine. Years of post training experience among physicians ranged from 1 to 9 years (n = 5, 38%), 10 to 19 years (n = 3, 23%), and . 20 years (n = 5, 38%). Seven participants (54%) had conducted ≥ 5 VVC visits, with 1 physician completing > 50 video visits (Table).

Using open coding and a deductive approach to thematic analysis, 5 themes were identified: (1) VVC software and internet connection issues affected implementation; (2) patient technological literacy affected veteran and physician comfort with VVC; (3) integration of supportive measures was desired; (4) CVT services may increasingly be used to enhance access to care; and (5) in-person encounters afforded unique advantages over CVT. Illustrative quotes from physicians that reflect these themes can be found in the Appendix.

Theme 1: VVC software and internet connection issues affected its implementation. Most participants expressed concern about the technical challenges with VVC. Interviewees cited inconsistencies for both patients and physicians receiving emails with links to join VVC visits, which should be generated when appointments are scheduled. Some physicians were unaware of scheduled VVC visits until the day of the appointment and only received the link via email. Such issues appeared to occur regardless whether the physicians or support staff scheduled the encounter. Poor video and audio quality was also cited as significant barriers to successful VVC visits and were often not resolvable through troubleshooting efforts by physicians, patients, or support personnel. Given the limited time allotted to each patient encounter, such issues could significantly impact the physician’s ability to remain on schedule. Moreover, connectivity problems led to significant lapses, delays in audio and video transmission, and complete disconnections from the VVC encounter. This was a significant concern for participants, given the rural nature of New Mexico and the large geographical gaps in internet service throughout the state.

Theme 2: Patient technological literacy affected veteran and physician comfort with VVC. Successful VVC appointments require high-speed Internet and compatible hardware. Physicians indicated that some patients reported difficulties with critical steps in the process, such as logging into the VVC platform or ensuring their microphones and cameras were active. Physicians also expressed concern about older veterans’ ability to utilize electronic devices, noting they may generally be less technology savvy. Additionally, physicians reported that despite offering the option of a virtual visit, many veterans preferred in-person visits, regardless of the drive time required. This appeared related to a fear of using the technology, which led veterans to believe that virtual visits do not provide the same quality of care as in-person visits.

Theme 3: Integration of supportive measures is desired. Interviewees felt that integrated VVC technical assistance and technology literacy education were imperative. First, training the patient or the patient’s caregiver on how to complete a VVC encounter using the preferred device and the VVC platform would be beneficial. Second, education to inform physicians about common troubleshooting issues could help streamline VVC encounters. Third, managing a VVC encounter similarly to standard in-person visits could allow for better patient and physician experience. For example, physicians suggested that a medical assistant or a nurse triage the patient, take vital signs, and set them up in a room, potentially at a regional VA community based outpatient clinic. Such efforts would also allow patients to receive specialty care in remote areas where only primary care is generally offered. Support staff could assist with technological issues, such as setting up the VVC encounter and addressing potential problems before the physician joins the encounter, thereby preventing delays in patient care. Finally, physicians felt that designating a day solely for CVT visits would help prevent disruption in care with in-person visits.

Theme 4: CVT services may increasingly be used to enhance access to care. Physicians felt that VVC would help patients encountering obstacles in accessing conventional in person services, including patients in rural and underserved areas, with disabilities, or with scheduling challenges.4 Patients with chronic conditions might drive the use of virtual visits, as many of these patients are already accustomed to remote medical monitoring. Data from devices such as scales and continuous glucose monitors can be easily reviewed during VVC visits. Second, video encounters facilitate closer monitoring that some patients might otherwise skip due to significant travel barriers, especially in a rural state like New Mexico. Lastly, VVC may be more efficient than in person visits as they eliminate the need for lengthy parking, checking in, and checking out processes. Thus, if technological issues are resolved, a typical physician’s day in the clinic may be more efficient with virtual visits.

Theme 5: In-person encounters afforded unique advantages over CVT. Some physicians felt in-person visits still offer unique advantages. They opined that the selection of appropriate candidates for CVT is critical. Patients requiring a physical examination should be scheduled for in person visits. For example, patients with advanced chronic kidney disease who require accurate volume status assessment or patients who have recently undergone surgery and need detailed wound inspection should be seen in the clinic. In-person visits may also be preferable for patients with recurrent admissions, or those whose condition is difficult to assess; accurate assessments of such patients may help prevent readmissions. Finally, many patients are more comfortable and satisfied with in-person visits, which are perceived as a more standard or traditional process. Respondents noted that some patients felt physicians may not focus as much attention during a VVC visit as they do during in-person visits. There were also concerns that some patients feel more motivation to come to in-person visits, as they see the VA as a place to interact with other veterans and staff with whom they are familiar and comfortable.

DISCUSSION

VANMHCS physicians, which serves veterans across an expansive territory ranging from Southern Colorado to West Texas. About 4.6 million veterans reside in rural regions, constituting roughly 25% of the total veteran population, a pattern mirrored in New Mexico.¹³ Medicine Service physicians agreed on a number of themes: VVC user-interface issues may affect its use and effectiveness, technological literacy was important for both patients and health care staff, technical support staff roles before and during VVC visits should be standardized, CVT is likely to increase health care delivery, and in-person encounters are preferred for many patients.

This is the first study to qualitatively evaluate a diverse group of physicians at a VA medical center incorporating CVT services across specialties. A few related qualitative studies have been conducted external to VHA, generally evaluating clinicians within a single specialty. Kalicki and colleagues surveyed 16 physicians working at a large home-based primary care program in New York City between April and June 2020 to identify and explore barriers to telehealth among homebound older adults. Similarly to our study, physicians noted that many patients required assistance (family members or caregivers) with the visit, either due to technological literacy issues or medical conditions like dementia.¹⁴

Heyer and colleagues surveyed 29 oncologists at an urban academic center prior to the COVID-19 pandemic. Similar to our observations, the oncologists said telemedicine helped eliminate travel as a barrier to health care. Heyer and colleagues noted difficulty for oncologists in performing virtual physical examinations, despite training. This group did note the benefits when being selective as to which clinical issues they would handle virtually vs in person.¹⁵

Budhwani and colleagues reported that mental health professionals in an academic setting cited difficulty establishing therapeutic relationships via telehealth and felt that this affected quality of care.¹⁶ While this was not a topic during our interviews, it is reasonable to question how potentially missed nonverbal cues may impact patient assessments.

Notably, technological issues were common among all reviewed studies. These ranged from internet connectivity issues to necessary electronic devices. As mentioned, these barriers are more prevalent in rural states like New Mexico.

Limitations

All participants in this study were Medicine Service physicians of a single VA health care system, which may limit generalizability. Many of our respondents were female (69%), compared with 39.2% of active internal medicine physicians and therefore may not be representative.¹⁷ Nearly one-half of our participants only completed 1 to 4 VVC encounters, which may have contributed to the emergence of a common theme regarding technological issues. Physicians with more experience with CVT services may be more skilled at troubleshooting technological issues that arise during visits.

CONCLUSIONS

Our study, conducted with VANMHCS physicians, illuminated 5 key themes influencing the use and implementation of video encounters: technological issues, technological literacy, a desire for integrated support measures, perceived future growth of video telehealth, and the unique advantages of in-person visits. Addressing technological barriers and providing more extensive training may streamline CVT use. However, it is vital to recognize the unique benefits of in-person visits and consider the benefits of each modality along with patient preferences when selecting the best care venue. As health care evolves, better understanding and acting upon these themes will optimize telehealth services, particularly in rural areas. Future research should involve patients and other health care team members to further explore strategies for effective CVT service integration.

Appendix