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2023 HSR&D/QUERI National Conference Abstract

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4084 — Implementation of Direct-to-Patient Mobile Teledermatology in VA

Lead/Presenter: Sara Peracca,  VA, San Francisco
All Authors: Peracca SB (VA San Francisco), Lamkin, RP (Center for Healthcare Organization and Implementation Research (CHOIR), Boston) Jackson, GL (Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham, Duke University) Mohr, DC (Center for Healthcare Organization and Implementation Research (CHOIR), Boston; Boston University School of Public Health) King, HA (Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham, Duke University) Whited, JD (Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham, Duke University) Lachica, O (VA San Francisco) Morris, I (Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham) Fonseca, A (VA Providence) Li, D Center for Healthcare Organization and Implementation Research (CHOIR), Boston Gifford, AL (Center for Healthcare Organization and Implementation Research (CHOIR), Boston, Boston University School of Medicine) Weinstock, MA (VA Providence, Brown University, Office of Connected Care) Oh, DH (VA San Francisco, UCSF Department of Dermatology, Office of Connected Care)

Objectives:
Innovative technological interventions can enhance patient access to health care but must be successfully implemented to be effective. Veterans Affairs (VA), introduced My VA Images, a direct-to-patient asynchronous teledermatology mobile application enabling established dermatology patients to receive follow-up care remotely instead of in-person. As part of a larger study to understand the impact of My VA Images on access to dermatologists, we monitored implementation of the app at 31 VA facilities.

Methods:
Inclusion criteria for implementation of the direct-to-patient app at a facility included significant prior experience with consultative asynchronous teledermatology, defined as ? 9 percent of all dermatology encounters at a particular facility in fiscal year 2018. We excluded facilities without an in-person dermatology clinic on site. Following initial pilot testing at 3 facilities, 4 groups of 7 facilities each were serially introduced to the app every 3 months starting in July 2019. We evaluated implementation over 17 months using the following types of data: Encounter data from VA’s corporate data warehouse; mobile app usage from VA’s Mobile Health database; bi-monthly implementation reports from representatives at participating facilities; phone interviews with providers at participating facilities; and documented communications between the research team, operational partner, and facility staff.

Results:
Implementation of My VA Images varied greatly, with 4 (12.9 percent) facilities making no effort to implement the app, 19 (61.3 percent) completing pre-implementation tasks such as creating required encounter locations and note titles, and testing the process, and 22.6 percent using the app with > 2 patients through the end of the study period. Eleven facilities used the app at least once with patients; 6 facilities used it 2-22 times. Two teaching facilities with dermatology residents completed the most requests, with 32.7 percent and 51.7 percent of all completed remote encounters. Nurse practitioners and physician assistants were more likely to use the app multiple times than dermatologists. While key stakeholders, including dermatology chiefs and other facility leaders, broadly expressed interest and support, facilities that began implementation prior to the COVID-19 pandemic used the new app more than those facilities that were initially exposed to the app during the pandemic (43.8 percent versus 21.4 percent), as facilities and staff focused on other priorities. Specific barriers identified consisted of concerns related to a new workflow to be learned and insufficient support staff.

Implications:
A phased implementation of My VA Images resulted in heterogeneous adoption. Support and interest in the app was not always sufficient to ensure full implementation and sustainment. While some barriers arose due to internal factors associated with using new technology and clinical workflows, others occurred due to external factors such as the COVID-19 pandemic.

Impacts:
The results illustrate that considerable heterogeneity exists in implementing mobile teledermatology, despite VA’s common mission, integrated health care system, and stakeholders’ broad interest and recognition of its importance. Identifying opportunities to target favorable sites and user groups (such as teaching facilities and physician extenders, respectively) while addressing implementation barriers such as workflow design and inadequate support may help VA optimize the initial impact of its direct-to-patient telehealth operations.