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Implementing Automated Text Messaging for Patient Self-management in the Veterans Health Administration: Qualitative Study Applying the Nonadoption, Abandonment,
Scale-up, Spread, and Sustainability Framework
Hogan TP. Implementing Automated Text Messaging for Patient Self-management in the Veterans Health Administration: Qualitative Study Applying the Nonadoption, Abandonment,
Scale-up, Spread, and Sustainability Framework. Journal of medical Internet research. 2021 Sep 1; 9(11):12.
Background: The Veterans Health Administration (VHA) is deploying an automated texting system (aTS) to support patient
Objective: We conducted a qualitative evaluation to examine factors influencing national rollout of the aTS, guided by the
Nonadoption, Abandonment, Scale-up, Spread, and Sustainability (NASSS) framework, which is intended to support the evaluation
of novel technologies.
Methods: Semistructured interviews were conducted with 33 staff and 38 patients who were early adopters of the aTS. Data
were analyzed following deductive and inductive approaches using a priori codes and emergent coding based on the NASSS.
Results: We identified themes across NASSS domains: (1) Condition: The aTS was considered relevant for a range of patient
needs; however, perceptions of patient suitability were guided by texting experience and clinical complexity rather than potential
benefits. (2) Technology: Onboarding of the aTS presented difficulty and the staff had different opinions on incorporating
patient-generated data into care planning. (3) Value: Supply-side value relied on the flexibility of the aTS and its impact on staff
workload whereas demand-side value was driven by patient perceptions of the psychological and behavioral impacts of the aTS.
(4) Adopters: Limited clarity on staff roles and responsibilities presented challenges in incorporating the aTS into clinical processes.
(5) Organization: Staff were willing to try the aTS; however, perceptions of leadership support and clinic readiness hindered
usage. (6) Wider system: Staff focused on enhancing aTS interoperability with the electronic medical record. (7) Embedding and
adaptation over time: The interplay of aTS versatility, patient and staff demands, and broader societal changes in preferences for
communicating health information facilitated aTS implementation.
Conclusions: VHA's new aTS has the potential to further engage patients and expand the reach of VHA care; however, patients
and staff require additional support to adopt, implement, and sustain the aTS. The NASSS highlighted how the aTS can be better embedded into current practices, which patients might benefit most from its functionality, and which aspects of aTS messages
are most relevant to self-management.