User login
Implementing Smoking Cessation Telehealth Technologies Within the VHA: Lessons Learned
Health care systems need practical, scalable methods to reach patients and connect them to available, evidence-based resources. Ideally, these systems need to be resource nonintensive to deploy, maintain, and use. They should also be low cost, have a relative advantage to the organization, be sensitive to patient needs, use available resources, and have rigorous evidence regarding their effect on patient-centered outcomes.1,2 Phone service is one way to reach people that remains viable. More than 97% of Americans own a cellphone of some kind, and 40% still have a landline.3,4 One intervention that has been increasingly used in routine care settings is an interactive voice response (IVR) system that uses phones for connecting to patients.
IVR systems are a type of telehealth that provides information or adjunct health services through use of a telecommunication platform and information technologies.5 These systems are automated telephone systems that use prerecorded or text-to-speech–generated messages that allow respondents to provide and access information without a live agent.6 Text messaging (SMS) is another modality that can be used to asynchronously engage with participants. IVR systems have been used successfully for many health conditions and services, such as improving veterans’ adherence to continuous positive airway pressure, colorectal cancer screening, and cognitive behavioral therapy.7-10 By building on existing technology and infrastructure, IVR systems can be a cost-effective option for health care system services.
A 2016 Cochrane review of IVR systems for smoking cessation identified 7 studies.11 Although none used opt-out mechanisms (where individuals are automatically enrolled in programs until they decide not to participate) to engage people without an expressed motivation to quit, these interventions seemed safe and were promisingly effective. Among patients enrolled in primary care, a trial of an IVR system led to a higher quit rate: 18% vs 8%.12
In one study, patients in the emergency department, particularly older ones, preferred phone-based interventions over SMS.13 IVR-based proactive tobacco cessation systems are cost-effective and have been successfully used in the US Department of Veterans Affairs (VA).14,15 IVR systems using opt-out approaches are being studied, though their effectiveness in this setting has not been proven. The pros and cons of different interventions need to be explored since there is likely a tradeoff between feasibility and effectiveness. For example, intensive smoking cessation interventions are more effective but often require more resources to implement and sustain.16 Basing interventions that are not resource intensive within a reputable organizational system may amplify the effectiveness.17
This endeavor to establish an IVR system was initiated as part of our research study, a randomized trial of the Teachable Moment to Opt-Out of Tobacco (TeaM OUT) intervention at the VA Portland Health Care System in Oregon. We measured the reach and effectiveness of a novel, proactive, resource nonintensive, and pragmatic intervention to engage veterans with a recently diagnosed lung nodule who smoke cigarettes.18 Our research team extracted the contact information for patients currently smoking and found to a have a pulmonary nodule from the VA Corporate Data Warehouse.19 We then manually uploaded those data to an IVR website where the system contacted patients to connect them to smoking cessation resources on an opt-out basis. In the research study, we measured the acceptability and effectiveness of the TeaM OUT intervention using quantitative and qualitative methods.
We developed and implemented an IVR system for use at 4 facilities: VA Portland Health Care System, Minneapolis VA Health Care System, Ralph H. Johnson VA Medical Center (Charleston, NC), and the Baltimore VA Medical Center. Setting up any type of wide-scale technology within the VA can be challenging. Due to our experience in developing and implementing the IVR system in the VA, we share what we have learned about the process of finding, contracting, developing, and implementing an IVR system. We share our experiences with developing and implementing this system to provide guidance for those who may want to establish an IVR system (or similar technologies) within the VA.
Lessons Learned
During our development and implementation process, we learned several lessons about setting up an IVR system in the VA. It is important to note that VA facilities may have differing processes, and policies frequently change; thus coordination with departments (eg, contracting, finance, Office of Information and Technology [OIT], etc) to verify the following strategies is essential (Figure).
Vendor Selection
Check with the local OIT and contracting offices to see if the facility has previously used any vendors for these services and for advice on selection. We compiled a list of questions that may be helpful based on our discussions with 4 vendors, prior to selection of a vendor already VA-approved (Appendix). There are also questions to think about in parallel with choosing a vendor. Contact your OIT, contracting, and privacy (if necessary) offices before choosing a vendor.
Online Security
After selecting a vendor, if you want an online portal to view, upload, or downloaddata, then you will need to initiate the single sign-on internal (SSOI) process (www.data.va.gov/dataset/Single-Sign-On-Internal-SSOi-/cber-kxf9). Other benefits of a website are to identify call patterns (eg, no one picks up after the 10th call) and track respondents’ selections. The SSOI process can take up to 1 year. Notably, the website login at minimum needs to be created by the IVR vendor to start the process. After the SSOI is approved you can add more to the website beyond just the login capability. Note that the script needs to be finalized prior to SSOI initiation. You will need to initiate with the SSOI team, then the vendor will need to complete the process.
Contracting
Concurrent with the above steps, contact the contracting office to get a sense of the paperwork and timeline. Make sure you are comfortable with the vendor’s responses to the questions in the Appendix, and view their written proposal or scope of work (SOW) to ensure they can do what the project protocol demands.
If the vendor has previously worked with the VA, contact your local contract office (usually part of the Finance Office) for updated forms. We needed the 6500.6 Checklist, Document Checklist for Service Requests, Single Source Justification, Research & Development Order (if research-related), and Vendor File Request forms. The vendor can help complete these forms. Review the proposal/SOW and budget first, knowing that budgets have a wide range and depend on the length and complexity of the script, number of calls, number of respondents, etc. For example, our quote was $110,000 over 4 years, including development, training, hosting on a secure server, and maintenance. Our IVR system will call about 5000 patients across 4 sites. Each patient will receive up to 15 calls over 2 weeks if they do not answer. We created 2 IVR lines (1 inbound and 1 outbound). Next, contact the lead of the local OIT and contracting departments by email to justify sharing veteran information with a contracted entity via approved methods. Finally, contact the privacy officer and information security officer. Discuss where software would be installed, whether cloud storage would be used, and what information can be shared/stored. Remember that the rules may differ for research vs nonresearch projects. Also, determine whether a data-use agreement between the VA and the vendor is needed and how the institutional review board (if research) gets integrated.
If using an outside vendor who has never worked with the VA, submit form 6550.6. Note that contracting requires several months. First, contact OIT and contracting departments. Again, you will need to justify sharing veteran information with a contracted entity. Next, complete the Project Special Forces Software and Privacy Threshold Analysis process to purchase the system. Set up a meeting with OIT to determine other forms and next steps. Business need/case use form and data security categorization may be needed. If the software needs to be installed on a VA computer, you will need to submit a Technical Reference Model request if it does not have an entry.
Vendors can answer technical questions from the contracting office, especially about the SOW, but the VA team needs to write the contract and manage all documentation and communication. You will also need sole source documentation (receive from contracting office) with justification for why you want to use a specific vendor. If you do not have that justification, in cooperation with the contracts office, you must solicit bids from other companies. Importantly, understand the staff support needed for contracting and build into your timeline and budget. Not surprisingly, we found that in-person or phone meetings were invaluable compared with email correspondence. Meet with all parties involved early and often. Once the contract is clear, this begins the build process where the vendor can program and record the script. This process usually takes 1 to 2 months.
Patient Engagement, Tracking, and Long-term Support
The new Patient Engagement, Tracking, and Long-term Support (PETALS) initiative is an excellent place to start with any VA IVR-related questions. PETALS is used for research.20 We hoped to use this system for our study, but its implementation was delayed until 2022. The PETALS system is designed for VA investigators who conduct research studies and need a secure platform that is compliant with VA policies for deploying SMS and IVR systems for research.20 At this time, PETALS is for use only with veterans, so if research will occur outside the VA, you must use an outside vendor. Users who want to set up a new IVR system can ask their local contracting office whether any contracts have already been established for IVR development and support.
From our perspective as researchers who are not telehealth savvy, we encountered several delays from failing to ask the appropriate questions or inability to navigate complicated systems. For instance, there were several tasks that needed to be completed and were not included in the original timeline developed by the vendor and researcher. Therefore, it is important to have clear communication on both sides about who is doing what, when, and how. We tried to detail these unexpected steps to help researchers, administrators, or other VA employees in the future.
Conclusions
IVR systems, once they are developed and implemented, can be efficient, low-cost, resource-nonintensive solutions in a health care setting that can effectively connect patients with needed health care services. Our experience developing an IVR system within the VA was challenging and was a huge learning curve for our research team. We hope that our experience and lessons will help VA personnel in the future.
Acknowledgments
Thank you to everyone involved in this project and who answered questions about the process, especially Nicolle Marinec, MPH; Toan Tran, and Molly Delorit, BA. This study and Christopher Slatore, MD, are supported by an award from the US Department of Veterans Affairs (HSR&D IIR 19-425). It was also supported by resources from the Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon (VAPORHCS).
1. Lewis CC, Mettert K, Lyon AR. Determining the influence of intervention characteristics on implementation success requires reliable and valid measures: results from a systematic review. Implement Res Pract. 2021;2:2633489521994197. doi:10.1177/2633489521994197
2. Damschroder LJ, Lowery JC. Evaluation of a large-scale weight management program using the consolidated framework for implementation research (CFIR). Implement Sci. 2013;8:51. Published 2013 May 10. doi:10.1186/1748-5908-8-51
3. Pew Research Center. Mobile Fact Sheet. April 7, 2021. Accessed June 6, 2023. https://www.pewresearch.org/internet/fact-sheet/mobile/
4. Lieser EK. Study: Only 40 Percent of U.S. Households Have a Landline. The National Interest. March 20, 2020. Accessed June 6, 2023. https://nationalinterest.org/blog/buzz/study-only-40-percent-us-households-have-landline-135212
5. Lee H, Friedman ME, Cukor P, David Ahern. Interactive voice response system (IVRS) in health care services. Nurs Outlook. 2003;51(6):277-283. doi:10.1016/S0029-6554(03)00161-1
6. IBM Cloud Education. What is interactive voice response (IVR)? IBM. March 15, 2021. Accessed June 6, 2023. https://www.ibm.com/cloud/learn/interactive-voice-response
7. Sparrow D, Aloia M, Demolles DA, Gottlieb DJ. A telemedicine intervention to improve adherence to continuous positive airway pressure: a randomised controlled trial. Thorax. 2010;65(12):1061-1066. doi:10.1136/thx.2009.133215
8. Cohen-Cline H, Wernli KJ, Bradford SC, Boles-Hall M, Grossman DC. Use of interactive voice response to improve colorectal cancer screening. Med Care. 2014;52(6):496-499. doi:10.1097/MLR.0000000000000116
9. Graham J, Tomcavage J, Salek D, Sciandra J, Davis DE, Stewart WF. Postdischarge Monitoring Using Interactive Voice Response System Reduces 30-Day Readmission Rates in a Case-managed Medicare Population. Med Care. 2012;50(1):50-57. doi:10.1097/MLR.0b013e318229433e
10. Piette JD, Newman S, Krein SL, et al. Patient-centered pain care using artificial intelligence and mobile health tools: a randomized comparative effectiveness trial. JAMA Intern Med. 2022;182(9):975-83. doi:10.1001/jamainternmed.2022.3178
11. Posadzki P, Mastellos N, Ryan R, et al. Automated telephone communication systems for preventive healthcare and management of long-term conditions. Cochrane Database Syst Rev. 2016;12(12):CD009921. Published 2016 Dec 14. doi:10.1002/14651858.CD009921.pub2
12. Haas JS, Linder JA, Park ER, et al. Proactive tobacco cessation outreach to smokers of low socioeconomic status: A randomized clinical trial. JAMA Intern Med. 2015;175(2):218-226. doi:10.1001/jamainternmed.2014.6674
13. Fingrut W, Stewart L, Cheung KW. Choice of smoking cessation counselling via phone, text, or email in emergency department patients. Prev Med Rep. 2016;4:597-600. doi:10.1016/j.pmedr.2016.10.010
14. Levy DE, Klinger EV, Linder JA, et al. Cost-effectiveness of a health system-based smoking cessation program. Nicotine Tob Res. 2017;19(12):1508-1515. doi:10.1093/ntr/ntw243
15. Heapy AA, Higgins DM, LaChappelle KM, et al. Cooperative pain education and self-management (COPES): Study design and protocol of a randomized non-inferiority trial of an interactive voice response-based self-management intervention for chronic low back pain. BMC Musculoskelet Disord. 2016;17:85. doi:10.1186/s12891-016-0924-z
16. Chen D, Wu LT. Smoking cessation interventions for adults aged 50 or older: a systematic review and meta-analysis. Drug Alcohol Depend. 2015;154:14-24. doi:10.1016/j.drugalcdep.2015.06.004
17. Bennett-Levy J, Richards D, Farrand P, et al. Oxford Guide to Low Intensity CBT Interventions. 1st ed. Oxford University Press; 2010.
18. Unger S, Golden SE, Melzer AC, et al. Study design for a proactive teachable moment tobacco treatment intervention among patients with pulmonary nodules. Contemp Clin Trials. 2022;121:106908. doi:10.1016/j.cct.2022.106908
19. US Department of Veterans Affairs. VA Information Resource Center [Internet]. VIReC Research User Guides. 2016. https://www.virec.research.va.gov/Resources/RUGs.asp
20. PETALS. US Department of Veteran Affairs. Updated June 14, 2021. Accessed June 6, 2023. https://www.annarbor.hsrd.research.va.gov/ANNARBORHSRDRESEARCH/PETALS.asp
Health care systems need practical, scalable methods to reach patients and connect them to available, evidence-based resources. Ideally, these systems need to be resource nonintensive to deploy, maintain, and use. They should also be low cost, have a relative advantage to the organization, be sensitive to patient needs, use available resources, and have rigorous evidence regarding their effect on patient-centered outcomes.1,2 Phone service is one way to reach people that remains viable. More than 97% of Americans own a cellphone of some kind, and 40% still have a landline.3,4 One intervention that has been increasingly used in routine care settings is an interactive voice response (IVR) system that uses phones for connecting to patients.
IVR systems are a type of telehealth that provides information or adjunct health services through use of a telecommunication platform and information technologies.5 These systems are automated telephone systems that use prerecorded or text-to-speech–generated messages that allow respondents to provide and access information without a live agent.6 Text messaging (SMS) is another modality that can be used to asynchronously engage with participants. IVR systems have been used successfully for many health conditions and services, such as improving veterans’ adherence to continuous positive airway pressure, colorectal cancer screening, and cognitive behavioral therapy.7-10 By building on existing technology and infrastructure, IVR systems can be a cost-effective option for health care system services.
A 2016 Cochrane review of IVR systems for smoking cessation identified 7 studies.11 Although none used opt-out mechanisms (where individuals are automatically enrolled in programs until they decide not to participate) to engage people without an expressed motivation to quit, these interventions seemed safe and were promisingly effective. Among patients enrolled in primary care, a trial of an IVR system led to a higher quit rate: 18% vs 8%.12
In one study, patients in the emergency department, particularly older ones, preferred phone-based interventions over SMS.13 IVR-based proactive tobacco cessation systems are cost-effective and have been successfully used in the US Department of Veterans Affairs (VA).14,15 IVR systems using opt-out approaches are being studied, though their effectiveness in this setting has not been proven. The pros and cons of different interventions need to be explored since there is likely a tradeoff between feasibility and effectiveness. For example, intensive smoking cessation interventions are more effective but often require more resources to implement and sustain.16 Basing interventions that are not resource intensive within a reputable organizational system may amplify the effectiveness.17
This endeavor to establish an IVR system was initiated as part of our research study, a randomized trial of the Teachable Moment to Opt-Out of Tobacco (TeaM OUT) intervention at the VA Portland Health Care System in Oregon. We measured the reach and effectiveness of a novel, proactive, resource nonintensive, and pragmatic intervention to engage veterans with a recently diagnosed lung nodule who smoke cigarettes.18 Our research team extracted the contact information for patients currently smoking and found to a have a pulmonary nodule from the VA Corporate Data Warehouse.19 We then manually uploaded those data to an IVR website where the system contacted patients to connect them to smoking cessation resources on an opt-out basis. In the research study, we measured the acceptability and effectiveness of the TeaM OUT intervention using quantitative and qualitative methods.
We developed and implemented an IVR system for use at 4 facilities: VA Portland Health Care System, Minneapolis VA Health Care System, Ralph H. Johnson VA Medical Center (Charleston, NC), and the Baltimore VA Medical Center. Setting up any type of wide-scale technology within the VA can be challenging. Due to our experience in developing and implementing the IVR system in the VA, we share what we have learned about the process of finding, contracting, developing, and implementing an IVR system. We share our experiences with developing and implementing this system to provide guidance for those who may want to establish an IVR system (or similar technologies) within the VA.
Lessons Learned
During our development and implementation process, we learned several lessons about setting up an IVR system in the VA. It is important to note that VA facilities may have differing processes, and policies frequently change; thus coordination with departments (eg, contracting, finance, Office of Information and Technology [OIT], etc) to verify the following strategies is essential (Figure).
Vendor Selection
Check with the local OIT and contracting offices to see if the facility has previously used any vendors for these services and for advice on selection. We compiled a list of questions that may be helpful based on our discussions with 4 vendors, prior to selection of a vendor already VA-approved (Appendix). There are also questions to think about in parallel with choosing a vendor. Contact your OIT, contracting, and privacy (if necessary) offices before choosing a vendor.
Online Security
After selecting a vendor, if you want an online portal to view, upload, or downloaddata, then you will need to initiate the single sign-on internal (SSOI) process (www.data.va.gov/dataset/Single-Sign-On-Internal-SSOi-/cber-kxf9). Other benefits of a website are to identify call patterns (eg, no one picks up after the 10th call) and track respondents’ selections. The SSOI process can take up to 1 year. Notably, the website login at minimum needs to be created by the IVR vendor to start the process. After the SSOI is approved you can add more to the website beyond just the login capability. Note that the script needs to be finalized prior to SSOI initiation. You will need to initiate with the SSOI team, then the vendor will need to complete the process.
Contracting
Concurrent with the above steps, contact the contracting office to get a sense of the paperwork and timeline. Make sure you are comfortable with the vendor’s responses to the questions in the Appendix, and view their written proposal or scope of work (SOW) to ensure they can do what the project protocol demands.
If the vendor has previously worked with the VA, contact your local contract office (usually part of the Finance Office) for updated forms. We needed the 6500.6 Checklist, Document Checklist for Service Requests, Single Source Justification, Research & Development Order (if research-related), and Vendor File Request forms. The vendor can help complete these forms. Review the proposal/SOW and budget first, knowing that budgets have a wide range and depend on the length and complexity of the script, number of calls, number of respondents, etc. For example, our quote was $110,000 over 4 years, including development, training, hosting on a secure server, and maintenance. Our IVR system will call about 5000 patients across 4 sites. Each patient will receive up to 15 calls over 2 weeks if they do not answer. We created 2 IVR lines (1 inbound and 1 outbound). Next, contact the lead of the local OIT and contracting departments by email to justify sharing veteran information with a contracted entity via approved methods. Finally, contact the privacy officer and information security officer. Discuss where software would be installed, whether cloud storage would be used, and what information can be shared/stored. Remember that the rules may differ for research vs nonresearch projects. Also, determine whether a data-use agreement between the VA and the vendor is needed and how the institutional review board (if research) gets integrated.
If using an outside vendor who has never worked with the VA, submit form 6550.6. Note that contracting requires several months. First, contact OIT and contracting departments. Again, you will need to justify sharing veteran information with a contracted entity. Next, complete the Project Special Forces Software and Privacy Threshold Analysis process to purchase the system. Set up a meeting with OIT to determine other forms and next steps. Business need/case use form and data security categorization may be needed. If the software needs to be installed on a VA computer, you will need to submit a Technical Reference Model request if it does not have an entry.
Vendors can answer technical questions from the contracting office, especially about the SOW, but the VA team needs to write the contract and manage all documentation and communication. You will also need sole source documentation (receive from contracting office) with justification for why you want to use a specific vendor. If you do not have that justification, in cooperation with the contracts office, you must solicit bids from other companies. Importantly, understand the staff support needed for contracting and build into your timeline and budget. Not surprisingly, we found that in-person or phone meetings were invaluable compared with email correspondence. Meet with all parties involved early and often. Once the contract is clear, this begins the build process where the vendor can program and record the script. This process usually takes 1 to 2 months.
Patient Engagement, Tracking, and Long-term Support
The new Patient Engagement, Tracking, and Long-term Support (PETALS) initiative is an excellent place to start with any VA IVR-related questions. PETALS is used for research.20 We hoped to use this system for our study, but its implementation was delayed until 2022. The PETALS system is designed for VA investigators who conduct research studies and need a secure platform that is compliant with VA policies for deploying SMS and IVR systems for research.20 At this time, PETALS is for use only with veterans, so if research will occur outside the VA, you must use an outside vendor. Users who want to set up a new IVR system can ask their local contracting office whether any contracts have already been established for IVR development and support.
From our perspective as researchers who are not telehealth savvy, we encountered several delays from failing to ask the appropriate questions or inability to navigate complicated systems. For instance, there were several tasks that needed to be completed and were not included in the original timeline developed by the vendor and researcher. Therefore, it is important to have clear communication on both sides about who is doing what, when, and how. We tried to detail these unexpected steps to help researchers, administrators, or other VA employees in the future.
Conclusions
IVR systems, once they are developed and implemented, can be efficient, low-cost, resource-nonintensive solutions in a health care setting that can effectively connect patients with needed health care services. Our experience developing an IVR system within the VA was challenging and was a huge learning curve for our research team. We hope that our experience and lessons will help VA personnel in the future.
Acknowledgments
Thank you to everyone involved in this project and who answered questions about the process, especially Nicolle Marinec, MPH; Toan Tran, and Molly Delorit, BA. This study and Christopher Slatore, MD, are supported by an award from the US Department of Veterans Affairs (HSR&D IIR 19-425). It was also supported by resources from the Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon (VAPORHCS).
Health care systems need practical, scalable methods to reach patients and connect them to available, evidence-based resources. Ideally, these systems need to be resource nonintensive to deploy, maintain, and use. They should also be low cost, have a relative advantage to the organization, be sensitive to patient needs, use available resources, and have rigorous evidence regarding their effect on patient-centered outcomes.1,2 Phone service is one way to reach people that remains viable. More than 97% of Americans own a cellphone of some kind, and 40% still have a landline.3,4 One intervention that has been increasingly used in routine care settings is an interactive voice response (IVR) system that uses phones for connecting to patients.
IVR systems are a type of telehealth that provides information or adjunct health services through use of a telecommunication platform and information technologies.5 These systems are automated telephone systems that use prerecorded or text-to-speech–generated messages that allow respondents to provide and access information without a live agent.6 Text messaging (SMS) is another modality that can be used to asynchronously engage with participants. IVR systems have been used successfully for many health conditions and services, such as improving veterans’ adherence to continuous positive airway pressure, colorectal cancer screening, and cognitive behavioral therapy.7-10 By building on existing technology and infrastructure, IVR systems can be a cost-effective option for health care system services.
A 2016 Cochrane review of IVR systems for smoking cessation identified 7 studies.11 Although none used opt-out mechanisms (where individuals are automatically enrolled in programs until they decide not to participate) to engage people without an expressed motivation to quit, these interventions seemed safe and were promisingly effective. Among patients enrolled in primary care, a trial of an IVR system led to a higher quit rate: 18% vs 8%.12
In one study, patients in the emergency department, particularly older ones, preferred phone-based interventions over SMS.13 IVR-based proactive tobacco cessation systems are cost-effective and have been successfully used in the US Department of Veterans Affairs (VA).14,15 IVR systems using opt-out approaches are being studied, though their effectiveness in this setting has not been proven. The pros and cons of different interventions need to be explored since there is likely a tradeoff between feasibility and effectiveness. For example, intensive smoking cessation interventions are more effective but often require more resources to implement and sustain.16 Basing interventions that are not resource intensive within a reputable organizational system may amplify the effectiveness.17
This endeavor to establish an IVR system was initiated as part of our research study, a randomized trial of the Teachable Moment to Opt-Out of Tobacco (TeaM OUT) intervention at the VA Portland Health Care System in Oregon. We measured the reach and effectiveness of a novel, proactive, resource nonintensive, and pragmatic intervention to engage veterans with a recently diagnosed lung nodule who smoke cigarettes.18 Our research team extracted the contact information for patients currently smoking and found to a have a pulmonary nodule from the VA Corporate Data Warehouse.19 We then manually uploaded those data to an IVR website where the system contacted patients to connect them to smoking cessation resources on an opt-out basis. In the research study, we measured the acceptability and effectiveness of the TeaM OUT intervention using quantitative and qualitative methods.
We developed and implemented an IVR system for use at 4 facilities: VA Portland Health Care System, Minneapolis VA Health Care System, Ralph H. Johnson VA Medical Center (Charleston, NC), and the Baltimore VA Medical Center. Setting up any type of wide-scale technology within the VA can be challenging. Due to our experience in developing and implementing the IVR system in the VA, we share what we have learned about the process of finding, contracting, developing, and implementing an IVR system. We share our experiences with developing and implementing this system to provide guidance for those who may want to establish an IVR system (or similar technologies) within the VA.
Lessons Learned
During our development and implementation process, we learned several lessons about setting up an IVR system in the VA. It is important to note that VA facilities may have differing processes, and policies frequently change; thus coordination with departments (eg, contracting, finance, Office of Information and Technology [OIT], etc) to verify the following strategies is essential (Figure).
Vendor Selection
Check with the local OIT and contracting offices to see if the facility has previously used any vendors for these services and for advice on selection. We compiled a list of questions that may be helpful based on our discussions with 4 vendors, prior to selection of a vendor already VA-approved (Appendix). There are also questions to think about in parallel with choosing a vendor. Contact your OIT, contracting, and privacy (if necessary) offices before choosing a vendor.
Online Security
After selecting a vendor, if you want an online portal to view, upload, or downloaddata, then you will need to initiate the single sign-on internal (SSOI) process (www.data.va.gov/dataset/Single-Sign-On-Internal-SSOi-/cber-kxf9). Other benefits of a website are to identify call patterns (eg, no one picks up after the 10th call) and track respondents’ selections. The SSOI process can take up to 1 year. Notably, the website login at minimum needs to be created by the IVR vendor to start the process. After the SSOI is approved you can add more to the website beyond just the login capability. Note that the script needs to be finalized prior to SSOI initiation. You will need to initiate with the SSOI team, then the vendor will need to complete the process.
Contracting
Concurrent with the above steps, contact the contracting office to get a sense of the paperwork and timeline. Make sure you are comfortable with the vendor’s responses to the questions in the Appendix, and view their written proposal or scope of work (SOW) to ensure they can do what the project protocol demands.
If the vendor has previously worked with the VA, contact your local contract office (usually part of the Finance Office) for updated forms. We needed the 6500.6 Checklist, Document Checklist for Service Requests, Single Source Justification, Research & Development Order (if research-related), and Vendor File Request forms. The vendor can help complete these forms. Review the proposal/SOW and budget first, knowing that budgets have a wide range and depend on the length and complexity of the script, number of calls, number of respondents, etc. For example, our quote was $110,000 over 4 years, including development, training, hosting on a secure server, and maintenance. Our IVR system will call about 5000 patients across 4 sites. Each patient will receive up to 15 calls over 2 weeks if they do not answer. We created 2 IVR lines (1 inbound and 1 outbound). Next, contact the lead of the local OIT and contracting departments by email to justify sharing veteran information with a contracted entity via approved methods. Finally, contact the privacy officer and information security officer. Discuss where software would be installed, whether cloud storage would be used, and what information can be shared/stored. Remember that the rules may differ for research vs nonresearch projects. Also, determine whether a data-use agreement between the VA and the vendor is needed and how the institutional review board (if research) gets integrated.
If using an outside vendor who has never worked with the VA, submit form 6550.6. Note that contracting requires several months. First, contact OIT and contracting departments. Again, you will need to justify sharing veteran information with a contracted entity. Next, complete the Project Special Forces Software and Privacy Threshold Analysis process to purchase the system. Set up a meeting with OIT to determine other forms and next steps. Business need/case use form and data security categorization may be needed. If the software needs to be installed on a VA computer, you will need to submit a Technical Reference Model request if it does not have an entry.
Vendors can answer technical questions from the contracting office, especially about the SOW, but the VA team needs to write the contract and manage all documentation and communication. You will also need sole source documentation (receive from contracting office) with justification for why you want to use a specific vendor. If you do not have that justification, in cooperation with the contracts office, you must solicit bids from other companies. Importantly, understand the staff support needed for contracting and build into your timeline and budget. Not surprisingly, we found that in-person or phone meetings were invaluable compared with email correspondence. Meet with all parties involved early and often. Once the contract is clear, this begins the build process where the vendor can program and record the script. This process usually takes 1 to 2 months.
Patient Engagement, Tracking, and Long-term Support
The new Patient Engagement, Tracking, and Long-term Support (PETALS) initiative is an excellent place to start with any VA IVR-related questions. PETALS is used for research.20 We hoped to use this system for our study, but its implementation was delayed until 2022. The PETALS system is designed for VA investigators who conduct research studies and need a secure platform that is compliant with VA policies for deploying SMS and IVR systems for research.20 At this time, PETALS is for use only with veterans, so if research will occur outside the VA, you must use an outside vendor. Users who want to set up a new IVR system can ask their local contracting office whether any contracts have already been established for IVR development and support.
From our perspective as researchers who are not telehealth savvy, we encountered several delays from failing to ask the appropriate questions or inability to navigate complicated systems. For instance, there were several tasks that needed to be completed and were not included in the original timeline developed by the vendor and researcher. Therefore, it is important to have clear communication on both sides about who is doing what, when, and how. We tried to detail these unexpected steps to help researchers, administrators, or other VA employees in the future.
Conclusions
IVR systems, once they are developed and implemented, can be efficient, low-cost, resource-nonintensive solutions in a health care setting that can effectively connect patients with needed health care services. Our experience developing an IVR system within the VA was challenging and was a huge learning curve for our research team. We hope that our experience and lessons will help VA personnel in the future.
Acknowledgments
Thank you to everyone involved in this project and who answered questions about the process, especially Nicolle Marinec, MPH; Toan Tran, and Molly Delorit, BA. This study and Christopher Slatore, MD, are supported by an award from the US Department of Veterans Affairs (HSR&D IIR 19-425). It was also supported by resources from the Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon (VAPORHCS).
1. Lewis CC, Mettert K, Lyon AR. Determining the influence of intervention characteristics on implementation success requires reliable and valid measures: results from a systematic review. Implement Res Pract. 2021;2:2633489521994197. doi:10.1177/2633489521994197
2. Damschroder LJ, Lowery JC. Evaluation of a large-scale weight management program using the consolidated framework for implementation research (CFIR). Implement Sci. 2013;8:51. Published 2013 May 10. doi:10.1186/1748-5908-8-51
3. Pew Research Center. Mobile Fact Sheet. April 7, 2021. Accessed June 6, 2023. https://www.pewresearch.org/internet/fact-sheet/mobile/
4. Lieser EK. Study: Only 40 Percent of U.S. Households Have a Landline. The National Interest. March 20, 2020. Accessed June 6, 2023. https://nationalinterest.org/blog/buzz/study-only-40-percent-us-households-have-landline-135212
5. Lee H, Friedman ME, Cukor P, David Ahern. Interactive voice response system (IVRS) in health care services. Nurs Outlook. 2003;51(6):277-283. doi:10.1016/S0029-6554(03)00161-1
6. IBM Cloud Education. What is interactive voice response (IVR)? IBM. March 15, 2021. Accessed June 6, 2023. https://www.ibm.com/cloud/learn/interactive-voice-response
7. Sparrow D, Aloia M, Demolles DA, Gottlieb DJ. A telemedicine intervention to improve adherence to continuous positive airway pressure: a randomised controlled trial. Thorax. 2010;65(12):1061-1066. doi:10.1136/thx.2009.133215
8. Cohen-Cline H, Wernli KJ, Bradford SC, Boles-Hall M, Grossman DC. Use of interactive voice response to improve colorectal cancer screening. Med Care. 2014;52(6):496-499. doi:10.1097/MLR.0000000000000116
9. Graham J, Tomcavage J, Salek D, Sciandra J, Davis DE, Stewart WF. Postdischarge Monitoring Using Interactive Voice Response System Reduces 30-Day Readmission Rates in a Case-managed Medicare Population. Med Care. 2012;50(1):50-57. doi:10.1097/MLR.0b013e318229433e
10. Piette JD, Newman S, Krein SL, et al. Patient-centered pain care using artificial intelligence and mobile health tools: a randomized comparative effectiveness trial. JAMA Intern Med. 2022;182(9):975-83. doi:10.1001/jamainternmed.2022.3178
11. Posadzki P, Mastellos N, Ryan R, et al. Automated telephone communication systems for preventive healthcare and management of long-term conditions. Cochrane Database Syst Rev. 2016;12(12):CD009921. Published 2016 Dec 14. doi:10.1002/14651858.CD009921.pub2
12. Haas JS, Linder JA, Park ER, et al. Proactive tobacco cessation outreach to smokers of low socioeconomic status: A randomized clinical trial. JAMA Intern Med. 2015;175(2):218-226. doi:10.1001/jamainternmed.2014.6674
13. Fingrut W, Stewart L, Cheung KW. Choice of smoking cessation counselling via phone, text, or email in emergency department patients. Prev Med Rep. 2016;4:597-600. doi:10.1016/j.pmedr.2016.10.010
14. Levy DE, Klinger EV, Linder JA, et al. Cost-effectiveness of a health system-based smoking cessation program. Nicotine Tob Res. 2017;19(12):1508-1515. doi:10.1093/ntr/ntw243
15. Heapy AA, Higgins DM, LaChappelle KM, et al. Cooperative pain education and self-management (COPES): Study design and protocol of a randomized non-inferiority trial of an interactive voice response-based self-management intervention for chronic low back pain. BMC Musculoskelet Disord. 2016;17:85. doi:10.1186/s12891-016-0924-z
16. Chen D, Wu LT. Smoking cessation interventions for adults aged 50 or older: a systematic review and meta-analysis. Drug Alcohol Depend. 2015;154:14-24. doi:10.1016/j.drugalcdep.2015.06.004
17. Bennett-Levy J, Richards D, Farrand P, et al. Oxford Guide to Low Intensity CBT Interventions. 1st ed. Oxford University Press; 2010.
18. Unger S, Golden SE, Melzer AC, et al. Study design for a proactive teachable moment tobacco treatment intervention among patients with pulmonary nodules. Contemp Clin Trials. 2022;121:106908. doi:10.1016/j.cct.2022.106908
19. US Department of Veterans Affairs. VA Information Resource Center [Internet]. VIReC Research User Guides. 2016. https://www.virec.research.va.gov/Resources/RUGs.asp
20. PETALS. US Department of Veteran Affairs. Updated June 14, 2021. Accessed June 6, 2023. https://www.annarbor.hsrd.research.va.gov/ANNARBORHSRDRESEARCH/PETALS.asp
1. Lewis CC, Mettert K, Lyon AR. Determining the influence of intervention characteristics on implementation success requires reliable and valid measures: results from a systematic review. Implement Res Pract. 2021;2:2633489521994197. doi:10.1177/2633489521994197
2. Damschroder LJ, Lowery JC. Evaluation of a large-scale weight management program using the consolidated framework for implementation research (CFIR). Implement Sci. 2013;8:51. Published 2013 May 10. doi:10.1186/1748-5908-8-51
3. Pew Research Center. Mobile Fact Sheet. April 7, 2021. Accessed June 6, 2023. https://www.pewresearch.org/internet/fact-sheet/mobile/
4. Lieser EK. Study: Only 40 Percent of U.S. Households Have a Landline. The National Interest. March 20, 2020. Accessed June 6, 2023. https://nationalinterest.org/blog/buzz/study-only-40-percent-us-households-have-landline-135212
5. Lee H, Friedman ME, Cukor P, David Ahern. Interactive voice response system (IVRS) in health care services. Nurs Outlook. 2003;51(6):277-283. doi:10.1016/S0029-6554(03)00161-1
6. IBM Cloud Education. What is interactive voice response (IVR)? IBM. March 15, 2021. Accessed June 6, 2023. https://www.ibm.com/cloud/learn/interactive-voice-response
7. Sparrow D, Aloia M, Demolles DA, Gottlieb DJ. A telemedicine intervention to improve adherence to continuous positive airway pressure: a randomised controlled trial. Thorax. 2010;65(12):1061-1066. doi:10.1136/thx.2009.133215
8. Cohen-Cline H, Wernli KJ, Bradford SC, Boles-Hall M, Grossman DC. Use of interactive voice response to improve colorectal cancer screening. Med Care. 2014;52(6):496-499. doi:10.1097/MLR.0000000000000116
9. Graham J, Tomcavage J, Salek D, Sciandra J, Davis DE, Stewart WF. Postdischarge Monitoring Using Interactive Voice Response System Reduces 30-Day Readmission Rates in a Case-managed Medicare Population. Med Care. 2012;50(1):50-57. doi:10.1097/MLR.0b013e318229433e
10. Piette JD, Newman S, Krein SL, et al. Patient-centered pain care using artificial intelligence and mobile health tools: a randomized comparative effectiveness trial. JAMA Intern Med. 2022;182(9):975-83. doi:10.1001/jamainternmed.2022.3178
11. Posadzki P, Mastellos N, Ryan R, et al. Automated telephone communication systems for preventive healthcare and management of long-term conditions. Cochrane Database Syst Rev. 2016;12(12):CD009921. Published 2016 Dec 14. doi:10.1002/14651858.CD009921.pub2
12. Haas JS, Linder JA, Park ER, et al. Proactive tobacco cessation outreach to smokers of low socioeconomic status: A randomized clinical trial. JAMA Intern Med. 2015;175(2):218-226. doi:10.1001/jamainternmed.2014.6674
13. Fingrut W, Stewart L, Cheung KW. Choice of smoking cessation counselling via phone, text, or email in emergency department patients. Prev Med Rep. 2016;4:597-600. doi:10.1016/j.pmedr.2016.10.010
14. Levy DE, Klinger EV, Linder JA, et al. Cost-effectiveness of a health system-based smoking cessation program. Nicotine Tob Res. 2017;19(12):1508-1515. doi:10.1093/ntr/ntw243
15. Heapy AA, Higgins DM, LaChappelle KM, et al. Cooperative pain education and self-management (COPES): Study design and protocol of a randomized non-inferiority trial of an interactive voice response-based self-management intervention for chronic low back pain. BMC Musculoskelet Disord. 2016;17:85. doi:10.1186/s12891-016-0924-z
16. Chen D, Wu LT. Smoking cessation interventions for adults aged 50 or older: a systematic review and meta-analysis. Drug Alcohol Depend. 2015;154:14-24. doi:10.1016/j.drugalcdep.2015.06.004
17. Bennett-Levy J, Richards D, Farrand P, et al. Oxford Guide to Low Intensity CBT Interventions. 1st ed. Oxford University Press; 2010.
18. Unger S, Golden SE, Melzer AC, et al. Study design for a proactive teachable moment tobacco treatment intervention among patients with pulmonary nodules. Contemp Clin Trials. 2022;121:106908. doi:10.1016/j.cct.2022.106908
19. US Department of Veterans Affairs. VA Information Resource Center [Internet]. VIReC Research User Guides. 2016. https://www.virec.research.va.gov/Resources/RUGs.asp
20. PETALS. US Department of Veteran Affairs. Updated June 14, 2021. Accessed June 6, 2023. https://www.annarbor.hsrd.research.va.gov/ANNARBORHSRDRESEARCH/PETALS.asp