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Virtual care teams are groups of clinicians
and patients working across time,
space, and organizational boundaries
using digital modes of communication
(e.g., telehealth, ehealth, mhealth,
and electronic exchange of health
information). The goal of the Virtual
Specialty Care (VSC) QUERI is to support
operational partners (Office of Rural
Health, Office of Connected Care, and
Mental Health Services) in the national
rollout of promising clinical practices that
incorporate virtual care technologies in
order to improve access to high-quality
specialty care for rural Veterans.
Due to the remote locations of rural
Veterans and the rapidly evolving
technologies used in interventions
designed to better reach them, it is
challenging to conduct traditional
randomized controlled trials (RCTs) with
this population. While the technology
could theoretically be "frozen in time"
and the effectiveness of the technology facilitated
clinical intervention evaluated
using traditional clinical trial methods, the
technology would be obsolete by the end
of the trial and results would not inform
practice, policy or science.1
As a result, there are relatively few RCTs
that have established a strong evidence
base for technology-facilitated clinical
interventions designed to improve access
and outcomes for rural Veterans. Thus, the
challenge for VSC QUERI investigators is
to not only develop, evaluate, and refine
implementation strategies for promising
practices targeting rural Veterans, but
also to evaluate the clinical effectiveness
of promising practices that incorporate
rapidly evolving virtual care technologies.
Using hybrid effectiveness-implementation
trial designs, VSC QUERI projects simultaneously
collect data about the impact
of the technology-facilitated intervention
on clinical outcomes and data about the
impact of the implementation strategy on
provider adoption and reach into the rural
Veteran population.
The traditional research-to-practice paradigm
is founded on the assumption that
clinical interventions are optimized and
perfected prior to implementation during
efficacy and effectiveness RCTs. Clinical
interventions are typically standardized
with protocols, and implementation efforts
focus on maximizing fidelity and minimizing
deviations from the intervention protocol
during deployment. Alterations to the
intervention protocol during deployment
are assumed to negatively impact outcomes
and are considered "voltage drop."
In stark contrast to the traditional
research-to-practice pathway, the
VSC QUERI program embraces the
philosophy that clinical interventions
incorporating virtual care technologies
will be constantly evolving and improving
over time. The VSC QUERI program
is conceptually based on the Dynamic
Sustainability Framework, which
argues that an intervention can only be
optimized through ongoing development,
evaluation, and refinement across a
variety of technological platforms and
clinical contexts. The VSC QUERI
emphasizes protocol flexibility over
fidelity to maximize fit between the
clinical intervention and the preferences,
needs and resources of the practice
setting in which it is being deployed.
The Dynamic Sustainability Framework
also acknowledges that practice settings
and policies will change over time and
that the clinical intervention will need
to adapt over time in order to maintain
sustainability.2
There are currently no implementation
science paradigms for deploying clinical
interventions that rely on virtual care
technologies. The introduction of a new
disruptive technology directly impacts
patient and provider task behaviors; individuals
must change their behavior to
accommodate the new technology. Implementation
is even more difficult when the
introduction of the technology challenges
existing workflows and routines of care
teams. Successful implementation of the
technology may be determined less by
features of the technology and more by the
complex interaction between the technology
and team dynamics. Because clinical
workflow often varies across care teams,
technologies that might be successfully adopted
in one clinical context may not work
in another. It is critical to approach the
implementation of technology-facilitated
clinical interventions as a site-specific
team learning process.
VSC QUERI implementation strategies
combine elements of Rapid Ethnographic
Assessment (REA) techniques
and Systems Redesign methods. REA is
an anthropologic technique that relies
upon first-person observations of practices
on site and open-ended interviewing
to develop a real-time understanding of
how an intervention fits into the existing
clinical workflow. A critical element of
Systems Redesign is mapping the existing
clinical workflow, sometimes called
flow-mapping.3 Once the clinical workflow
map is completed, the facilitation team can
help frontline providers determine how to
modify the existing clinical workflow to
incorporate the new technology-facilitated
clinical intervention. In addition, the facilitation
team can help frontline providers determine whether and how the clinical
intervention itself needs to be customized
to fit into the existing clinical workflow.
VSC QUERI projects will help determine
whether these implementation strategies
are more effective than standard
approaches when deploying promising
clinical practices that incorporate virtual
care technologies in VA.
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Mohr DC, et al. "Continuous Evaluation of
Evolving Behavioral Intervention Technologies,"
American Journal of Preventive Medicine 2013;
45(4):517-23.
-
Chambers DA, RE Glasgow, and KC Stange "The
Dynamic Sustainability Framework: Addressing
the Paradox of Sustainment Amid Ongoing
Change," Implementation Science 2013; 8:117.
-
Davies, M. 2009. "Systems Redesign Framework
for Improvement (TAMMCS)." VHA Office of
Systems Redesign.
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