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Background: Electronic health record (EHR) implementations, whether replacing paper or electronic systems, are major social and organizational transformations. Yet studies of EHR-to-EHR transitions have largely neglected to elucidate accompanying social and organizational changes. One such underexplored change is the standardization of clinical practice in the context of EHR transitions. The Department of Veterans Affairs (VA) has begun a decade-long process of replacing the approximately 130 separate versions of its homegrown EHR with a single commercial EHR system. This provides an opportunity to explore the standardization of clinical practice amidst an EHR transition., Objective: To identify, in the context of a large-scale EHR transition, (1) the scope and content of clinical standardization and (2) the anticipated implications of such standardization., Design: Qualitative study., Participants: Twenty-nine members of VA councils established for the EHR transition., Approach: We conducted semi-structured interviews, which were professionally transcribed, and analyzed first using rapid analysis methods, followed by coding and content analysis., Key Results: Clinical standardization across facilities was a central goal of the EHR transition, encompassing computerized recommendations, order sets, professional roles/permissions, and clinical documentation. The anticipated implications of this standardization include (i) potential efficiency gains, with less duplicated effort across facilities; (ii) expanded bureaucracy; and (iii) increased uniformity, reducing both wanted and unwanted variation in care., Conclusions: EHR systems shape a wide range of clinical processes, particularly in a large organization like VA with a long history of EHR use. This makes standardization of EHR content a powerful mechanism for standardizing clinical practice itself, which can bring dramatic collateral consequences. Organizations undergoing EHR transitions need to recognize the important role that clinical standardization plays by treating EHR transitions as major organizational transformations in the governance of clinical practice., (© 2023. The Author(s).)

Introduction: Telehealth has the potential to improve access and timeliness of care, enabling primary care teams to deliver hybrid (virtual/in-person) services that will likely extend beyond the COVID-19 pandemic. To optimize its use and sustainability, it is imperative to understand how primary care teams perceive the suitability of telehealth services, including appropriate choice of mode (telephone or video). However, there is limited research on providers' decision-making processes surrounding telehealth use in primary care, including whether to use telephone or video, which this VA-focused study addresses. We examined how primary care (PC) team members determine whether to use telehealth and the mode of delivery, in the care of patients., Methods: Qualitative case study that included 15 semi-structured interviews with employees who provided or supported telehealth care at primary care clinics at the Veterans Health Administration. We used a team-based rapid analysis approach to identify experiences using telehealth soon after COVID-19's emergence, consisting of the creation of structured summaries of each transcribed interview. The lead author then identified and compiled themes and sub-themes related to the suitability of telehealth in primary care, as well as associated quotes from transcripts. Resulting themes and quotes were reviewed and validated by 2 members of the project team., Results: Primary care team members considered several factors when assessing both the suitability of telehealth for appointments, and mode of use. They were largely guided by patient-related factors including patient preferences, specific health issues, and access to technology. Additional considerations centered on team members' personal preferences and factors that supported the wellbeing of the team, such as the flexibility to work from home (work-life balance) and protection from infection. Generally, participants viewed the option of both telephone and video telehealth modalities as useful tools in the care of patients although a few respondents emphasized its inferiority to in-person care., Conclusions: Determining the suitability of telehealth services, including appropriate choice of mode is complex. Its suitability is tied to a variety of factors related to multilevel resources, preferences, and timing. When appropriate, telehealth should be considered a useful tool in the care of patients and for employee well-being.

Background: Serious mental illnesses (SMI) are common, disabling, and challenging to treat, requiring years of monitoring and treatment adjustments. Stress or reduced medication adherence can lead to rapid worsening of symptoms and behaviors. Illness exacerbations and relapses generally occur with little or no clinician awareness in real time, leaving limited opportunity to modify treatments. Previous research suggests that passive mobile sensing may be beneficial for individuals with SMI by helping them monitor mental health status and behaviors, and quickly detect worsening mental health for prompt assessment and intervention. However, there is too little research on its feasibility and acceptability and the extent to which passive data can predict changes in behaviors or symptoms., Objective: The aim of this research is to study the feasibility, acceptability, and safety of passive mobile sensing for tracking behaviors and symptoms of patients in treatment for SMI, as well as developing analytics that use passive data to predict changes in behaviors and symptoms., Methods: A mobile app monitors and transmits passive mobile sensor and phone utilization data, which is used to track activity, sociability, and sleep in patients with SMI. The study consists of a user-centered design phase and a mobile sensing phase. In the design phase, focus groups, interviews, and usability testing inform further app development. In the mobile sensing phase, passive mobile sensing occurs with participants engaging in weekly assessments for 9 months. Three- and nine-month interviews study the perceptions of passive mobile sensing and ease of app use. Clinician interviews before and after the mobile sensing phase study the usefulness and feasibility of app utilization in clinical care. Predictive analytic models are built, trained, and selected, and make use of machine learning methods. Models use sensor and phone utilization data to predict behavioral changes and symptoms., Results: The study started in October 2020. It has received institutional review board approval. The user-centered design phase, consisting of focus groups, usability testing, and preintervention clinician interviews, was completed in June 2021. Recruitment and enrollment for the mobile sensing phase began in October 2021., Conclusions: Findings may inform the development of passive sensing apps and self-tracking in patients with SMI, and integration into care to improve assessment, treatment, and patient outcomes., Trial Registration: ClinicalTrials.gov NCT05023252; https://clinicaltrials.gov/ct2/show/NCT05023252., International Registered Report Identifier (irrid): DERR1-10.2196/39010., (©Alexander S Young, Abigail Choi, Shay Cannedy, Lauren Hoffmann, Lionel Levine, Li-Jung Liang, Melissa Medich, Rebecca Oberman, Tanya T Olmos-Ochoa. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 05.08.2022.)

When COVID-19 emerged, the U.S. Veterans Health Administration (VA) was in the process of implementing a national contingency staffing program called Clinical Resource Hubs (CRHs). CRHs were intended to provide regional contingency staffing for primary and mental health clinics experiencing staffing shortages primarily through telehealth. Long-term plans (year 2) included emergency management support. Early in the implementation, we conducted semi-structured interviews with CRH directors and national program leaders (n = 26) and used a rapid analysis approach to identify actions taken by CRHs to support the resiliency of the VA healthcare system during the pandemic. We found that the CRH program was flexible and nimble enough to allow VA to leverage providers at hubs to better respond to the demands of COVID-19. Actions taken at hubs to sustain patient access and staff resiliency during the pandemic included supporting call centers and training VA providers on virtual care delivery. Factors that facilitated CRH's emergency response included hub staff expertise in telehealth and the increased acceptability of virtual care among key stakeholders. We conclude that hub providers serving as contingency staff, as well as specialization in delivering virtual outpatient and inpatient care, enabled VA health system resiliency and recovery during the COVID-19 pandemic.