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FORUM - Translating research into quality health care for Veterans

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Research Highlight

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.

  1. Mohr DC, et al. "Continuous Evaluation of Evolving Behavioral Intervention Technologies," American Journal of Preventive Medicine 2013; 45(4):517-23.
  2. Chambers DA, RE Glasgow, and KC Stange "The Dynamic Sustainability Framework: Addressing the Paradox of Sustainment Amid Ongoing Change," Implementation Science 2013; 8:117.
  3. Davies, M. 2009. "Systems Redesign Framework for Improvement (TAMMCS)." VHA Office of Systems Redesign.

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