Program Profile

Prior to the COVID-19 pandemic, health care systems had been increasingly focused on expanding care delivery through clinical video telehealth (CVT) services.^1-3 These modalities offer clinicians and patients opportunities to interact without needing face-to-face visits. CVT services offer significant advantages to patients who encounter challenges accessing traditional face-to-face services, including those living in rural or underserved areas, individuals with mobility limitations, and those with difficulty attending appointments due to work or caregiving commitments.⁴ The COVID-19 pandemic accelerated the expansion of CVT services to mitigate the spread of the virus.¹

Despite its evident advantages, widespread adoption of CVT has encountered resistance.² Physicians have frequently expressed concerns about the reliability and functionality of CVT platforms for scheduled encounters and frustration with inadequate training.^4-6 Additionally, there is a lack trust in the technology, as physicians are unfamiliar with reimbursement or workload capture associated with CVT. Physicians have concerns that telecommunication may diminish the intangible aspects of the “art of medicine.”⁴ As a result, the implementation of telehealth services has been inconsistent, with successful adoption limited to specific medical and surgical specialties.⁴ Only recently have entire departments within major health care systems expressed interest in providing comprehensive CVT services in response to the challenges posed by the COVID-19 pandemic.⁴

The Veterans Health Administration (VHA) of the US Department of Veterans Affairs (VA) provides an appropriate setting for assessing clinician perceptions of telehealth services. Since 2003, the VHA has significantly expanded CVT services to eligible veterans and has used the VA Video Connect (VVC) platform since 2018.^7-10 Through VVC, VA staff and clinicians may schedule video visits with patients, meet with patients through virtual face-to-face interaction, and share relevant laboratory results and imaging through screen sharing. Prior research has shown increased accessibility to care through VVC. For example, a single-site study demonstrated that VVC implementation for delivering psychotherapies significantly increased CVT encounters from 15% to 85% among veterans with anxiety and/or depression.¹¹

The VA New Mexico Healthcare System (VANMHCS) serves a high volume of veterans living in remote and rural regions and significantly increased its use of CVT during the COVID-19 pandemic to reduce in-person visits. Expectedly, this was met with a variety of challenges. Herein, we sought to assess physician perspectives, concerns, and attitudes toward VVC via semistructured interviews. Our hypothesis was that VA physicians may feel uncomfortable with video encounters but recognize the growing importance of such practices providing specialty care to veterans in rural areas.

METHODS

A semistructured interview protocol was created following discussions with physicians from the VANMHCS Medicine Service. Questions were constructed to assess the following domains: overarching views of video telehealth, perceptions of various applications for conducting VVC encounters, and barriers to the broad implementation of video telehealth. A qualitative investigation specialist aided with question development. Two pilot interviews were conducted prior to performing the interviews with the recruited participants to evaluate the quality and delivery of questions.

All VANMHCS physicians who provided outpatient care within the Department of Medicine and had completed ≥ 1 VVC encounter were eligible to participate. Invitations were disseminated via email, and follow-up emails to encourage participation were sent periodically for 2 months following the initial request. Union approval was obtained to interview employees for a research study. In total, 64 physicians were invited and 13 (20%) chose to participate. As the study did not involve assessing medical interventions among patients, a waiver of informed consent was granted by the VANMHCS Institutional Review Board. Physicians who participated in this study were informed that their responses would be used for reporting purposes and could be rescinded at any time.

Data Analysis

Semistructured interviews were conducted by a single interviewer and recorded using Microsoft Teams. The interviews took place between February 2021 and December 2021 and lasted 5 to 15 minutes, with a mean duration of 9 minutes. Verbal informed consent was obtained from all participants before the interviews. Interviewees were encouraged to expand on their responses to structured questions by recounting past experiences with VVC. Recorded audio was additionally transcribed via Microsoft Teams, and the research team reviewed the transcriptions to ensure accuracy.

The tracking and coding of responses to interview questions were conducted using Microsoft Excel. Initially, 5 transcripts were reviewed and responses were assessed by 2 study team members through open coding. All team members examined the 5 coded transcripts to identify differences and reach a consensus for any discrepancies. Based on recommendations from all team members regarding nuanced excerpts of transcripts, 1 study team member coded the remaining interviews. Thematic analysis was subsequently conducted according to the method described by Braun and Clarke.¹² Themes were developed both deductively and inductively by reviewing the direct responses to interview questions and identifying emerging patterns of data, respectively. Indicative quotes representing each theme were carefully chosen for reporting.

RESULTS

Thirteen interviews were conducted and 9 participants (69%) were female. Participating physicians included 3 internal medicine/primary care physicians (23%), 2 nephrologists (15%), and 1 (8%) from cardiology, endocrinology, hematology, infectious diseases, palliative care, critical care, pulmonology, and sleep medicine. Years of post training experience among physicians ranged from 1 to 9 years (n = 5, 38%), 10 to 19 years (n = 3, 23%), and . 20 years (n = 5, 38%). Seven participants (54%) had conducted ≥ 5 VVC visits, with 1 physician completing > 50 video visits (Table).

Using open coding and a deductive approach to thematic analysis, 5 themes were identified: (1) VVC software and internet connection issues affected implementation; (2) patient technological literacy affected veteran and physician comfort with VVC; (3) integration of supportive measures was desired; (4) CVT services may increasingly be used to enhance access to care; and (5) in-person encounters afforded unique advantages over CVT. Illustrative quotes from physicians that reflect these themes can be found in the Appendix.

Theme 1: VVC software and internet connection issues affected its implementation. Most participants expressed concern about the technical challenges with VVC. Interviewees cited inconsistencies for both patients and physicians receiving emails with links to join VVC visits, which should be generated when appointments are scheduled. Some physicians were unaware of scheduled VVC visits until the day of the appointment and only received the link via email. Such issues appeared to occur regardless whether the physicians or support staff scheduled the encounter. Poor video and audio quality was also cited as significant barriers to successful VVC visits and were often not resolvable through troubleshooting efforts by physicians, patients, or support personnel. Given the limited time allotted to each patient encounter, such issues could significantly impact the physician’s ability to remain on schedule. Moreover, connectivity problems led to significant lapses, delays in audio and video transmission, and complete disconnections from the VVC encounter. This was a significant concern for participants, given the rural nature of New Mexico and the large geographical gaps in internet service throughout the state.

Theme 2: Patient technological literacy affected veteran and physician comfort with VVC. Successful VVC appointments require high-speed Internet and compatible hardware. Physicians indicated that some patients reported difficulties with critical steps in the process, such as logging into the VVC platform or ensuring their microphones and cameras were active. Physicians also expressed concern about older veterans’ ability to utilize electronic devices, noting they may generally be less technology savvy. Additionally, physicians reported that despite offering the option of a virtual visit, many veterans preferred in-person visits, regardless of the drive time required. This appeared related to a fear of using the technology, which led veterans to believe that virtual visits do not provide the same quality of care as in-person visits.

Theme 3: Integration of supportive measures is desired. Interviewees felt that integrated VVC technical assistance and technology literacy education were imperative. First, training the patient or the patient’s caregiver on how to complete a VVC encounter using the preferred device and the VVC platform would be beneficial. Second, education to inform physicians about common troubleshooting issues could help streamline VVC encounters. Third, managing a VVC encounter similarly to standard in-person visits could allow for better patient and physician experience. For example, physicians suggested that a medical assistant or a nurse triage the patient, take vital signs, and set them up in a room, potentially at a regional VA community based outpatient clinic. Such efforts would also allow patients to receive specialty care in remote areas where only primary care is generally offered. Support staff could assist with technological issues, such as setting up the VVC encounter and addressing potential problems before the physician joins the encounter, thereby preventing delays in patient care. Finally, physicians felt that designating a day solely for CVT visits would help prevent disruption in care with in-person visits.

Theme 4: CVT services may increasingly be used to enhance access to care. Physicians felt that VVC would help patients encountering obstacles in accessing conventional in person services, including patients in rural and underserved areas, with disabilities, or with scheduling challenges.4 Patients with chronic conditions might drive the use of virtual visits, as many of these patients are already accustomed to remote medical monitoring. Data from devices such as scales and continuous glucose monitors can be easily reviewed during VVC visits. Second, video encounters facilitate closer monitoring that some patients might otherwise skip due to significant travel barriers, especially in a rural state like New Mexico. Lastly, VVC may be more efficient than in person visits as they eliminate the need for lengthy parking, checking in, and checking out processes. Thus, if technological issues are resolved, a typical physician’s day in the clinic may be more efficient with virtual visits.

Theme 5: In-person encounters afforded unique advantages over CVT. Some physicians felt in-person visits still offer unique advantages. They opined that the selection of appropriate candidates for CVT is critical. Patients requiring a physical examination should be scheduled for in person visits. For example, patients with advanced chronic kidney disease who require accurate volume status assessment or patients who have recently undergone surgery and need detailed wound inspection should be seen in the clinic. In-person visits may also be preferable for patients with recurrent admissions, or those whose condition is difficult to assess; accurate assessments of such patients may help prevent readmissions. Finally, many patients are more comfortable and satisfied with in-person visits, which are perceived as a more standard or traditional process. Respondents noted that some patients felt physicians may not focus as much attention during a VVC visit as they do during in-person visits. There were also concerns that some patients feel more motivation to come to in-person visits, as they see the VA as a place to interact with other veterans and staff with whom they are familiar and comfortable.

DISCUSSION

VANMHCS physicians, which serves veterans across an expansive territory ranging from Southern Colorado to West Texas. About 4.6 million veterans reside in rural regions, constituting roughly 25% of the total veteran population, a pattern mirrored in New Mexico.¹³ Medicine Service physicians agreed on a number of themes: VVC user-interface issues may affect its use and effectiveness, technological literacy was important for both patients and health care staff, technical support staff roles before and during VVC visits should be standardized, CVT is likely to increase health care delivery, and in-person encounters are preferred for many patients.

This is the first study to qualitatively evaluate a diverse group of physicians at a VA medical center incorporating CVT services across specialties. A few related qualitative studies have been conducted external to VHA, generally evaluating clinicians within a single specialty. Kalicki and colleagues surveyed 16 physicians working at a large home-based primary care program in New York City between April and June 2020 to identify and explore barriers to telehealth among homebound older adults. Similarly to our study, physicians noted that many patients required assistance (family members or caregivers) with the visit, either due to technological literacy issues or medical conditions like dementia.¹⁴

Heyer and colleagues surveyed 29 oncologists at an urban academic center prior to the COVID-19 pandemic. Similar to our observations, the oncologists said telemedicine helped eliminate travel as a barrier to health care. Heyer and colleagues noted difficulty for oncologists in performing virtual physical examinations, despite training. This group did note the benefits when being selective as to which clinical issues they would handle virtually vs in person.¹⁵

Budhwani and colleagues reported that mental health professionals in an academic setting cited difficulty establishing therapeutic relationships via telehealth and felt that this affected quality of care.¹⁶ While this was not a topic during our interviews, it is reasonable to question how potentially missed nonverbal cues may impact patient assessments.

Notably, technological issues were common among all reviewed studies. These ranged from internet connectivity issues to necessary electronic devices. As mentioned, these barriers are more prevalent in rural states like New Mexico.

Limitations

All participants in this study were Medicine Service physicians of a single VA health care system, which may limit generalizability. Many of our respondents were female (69%), compared with 39.2% of active internal medicine physicians and therefore may not be representative.¹⁷ Nearly one-half of our participants only completed 1 to 4 VVC encounters, which may have contributed to the emergence of a common theme regarding technological issues. Physicians with more experience with CVT services may be more skilled at troubleshooting technological issues that arise during visits.

CONCLUSIONS

Our study, conducted with VANMHCS physicians, illuminated 5 key themes influencing the use and implementation of video encounters: technological issues, technological literacy, a desire for integrated support measures, perceived future growth of video telehealth, and the unique advantages of in-person visits. Addressing technological barriers and providing more extensive training may streamline CVT use. However, it is vital to recognize the unique benefits of in-person visits and consider the benefits of each modality along with patient preferences when selecting the best care venue. As health care evolves, better understanding and acting upon these themes will optimize telehealth services, particularly in rural areas. Future research should involve patients and other health care team members to further explore strategies for effective CVT service integration.

Appendix

Prior to the COVID-19 pandemic, health care systems had been increasingly focused on expanding care delivery through clinical video telehealth (CVT) services.^1-3 These modalities offer clinicians and patients opportunities to interact without needing face-to-face visits. CVT services offer significant advantages to patients who encounter challenges accessing traditional face-to-face services, including those living in rural or underserved areas, individuals with mobility limitations, and those with difficulty attending appointments due to work or caregiving commitments.⁴ The COVID-19 pandemic accelerated the expansion of CVT services to mitigate the spread of the virus.¹

Despite its evident advantages, widespread adoption of CVT has encountered resistance.² Physicians have frequently expressed concerns about the reliability and functionality of CVT platforms for scheduled encounters and frustration with inadequate training.^4-6 Additionally, there is a lack trust in the technology, as physicians are unfamiliar with reimbursement or workload capture associated with CVT. Physicians have concerns that telecommunication may diminish the intangible aspects of the “art of medicine.”⁴ As a result, the implementation of telehealth services has been inconsistent, with successful adoption limited to specific medical and surgical specialties.⁴ Only recently have entire departments within major health care systems expressed interest in providing comprehensive CVT services in response to the challenges posed by the COVID-19 pandemic.⁴

The Veterans Health Administration (VHA) of the US Department of Veterans Affairs (VA) provides an appropriate setting for assessing clinician perceptions of telehealth services. Since 2003, the VHA has significantly expanded CVT services to eligible veterans and has used the VA Video Connect (VVC) platform since 2018.^7-10 Through VVC, VA staff and clinicians may schedule video visits with patients, meet with patients through virtual face-to-face interaction, and share relevant laboratory results and imaging through screen sharing. Prior research has shown increased accessibility to care through VVC. For example, a single-site study demonstrated that VVC implementation for delivering psychotherapies significantly increased CVT encounters from 15% to 85% among veterans with anxiety and/or depression.¹¹

The VA New Mexico Healthcare System (VANMHCS) serves a high volume of veterans living in remote and rural regions and significantly increased its use of CVT during the COVID-19 pandemic to reduce in-person visits. Expectedly, this was met with a variety of challenges. Herein, we sought to assess physician perspectives, concerns, and attitudes toward VVC via semistructured interviews. Our hypothesis was that VA physicians may feel uncomfortable with video encounters but recognize the growing importance of such practices providing specialty care to veterans in rural areas.

METHODS

A semistructured interview protocol was created following discussions with physicians from the VANMHCS Medicine Service. Questions were constructed to assess the following domains: overarching views of video telehealth, perceptions of various applications for conducting VVC encounters, and barriers to the broad implementation of video telehealth. A qualitative investigation specialist aided with question development. Two pilot interviews were conducted prior to performing the interviews with the recruited participants to evaluate the quality and delivery of questions.

All VANMHCS physicians who provided outpatient care within the Department of Medicine and had completed ≥ 1 VVC encounter were eligible to participate. Invitations were disseminated via email, and follow-up emails to encourage participation were sent periodically for 2 months following the initial request. Union approval was obtained to interview employees for a research study. In total, 64 physicians were invited and 13 (20%) chose to participate. As the study did not involve assessing medical interventions among patients, a waiver of informed consent was granted by the VANMHCS Institutional Review Board. Physicians who participated in this study were informed that their responses would be used for reporting purposes and could be rescinded at any time.

Data Analysis

Semistructured interviews were conducted by a single interviewer and recorded using Microsoft Teams. The interviews took place between February 2021 and December 2021 and lasted 5 to 15 minutes, with a mean duration of 9 minutes. Verbal informed consent was obtained from all participants before the interviews. Interviewees were encouraged to expand on their responses to structured questions by recounting past experiences with VVC. Recorded audio was additionally transcribed via Microsoft Teams, and the research team reviewed the transcriptions to ensure accuracy.

The tracking and coding of responses to interview questions were conducted using Microsoft Excel. Initially, 5 transcripts were reviewed and responses were assessed by 2 study team members through open coding. All team members examined the 5 coded transcripts to identify differences and reach a consensus for any discrepancies. Based on recommendations from all team members regarding nuanced excerpts of transcripts, 1 study team member coded the remaining interviews. Thematic analysis was subsequently conducted according to the method described by Braun and Clarke.¹² Themes were developed both deductively and inductively by reviewing the direct responses to interview questions and identifying emerging patterns of data, respectively. Indicative quotes representing each theme were carefully chosen for reporting.

RESULTS

Thirteen interviews were conducted and 9 participants (69%) were female. Participating physicians included 3 internal medicine/primary care physicians (23%), 2 nephrologists (15%), and 1 (8%) from cardiology, endocrinology, hematology, infectious diseases, palliative care, critical care, pulmonology, and sleep medicine. Years of post training experience among physicians ranged from 1 to 9 years (n = 5, 38%), 10 to 19 years (n = 3, 23%), and . 20 years (n = 5, 38%). Seven participants (54%) had conducted ≥ 5 VVC visits, with 1 physician completing > 50 video visits (Table).

Using open coding and a deductive approach to thematic analysis, 5 themes were identified: (1) VVC software and internet connection issues affected implementation; (2) patient technological literacy affected veteran and physician comfort with VVC; (3) integration of supportive measures was desired; (4) CVT services may increasingly be used to enhance access to care; and (5) in-person encounters afforded unique advantages over CVT. Illustrative quotes from physicians that reflect these themes can be found in the Appendix.

Theme 1: VVC software and internet connection issues affected its implementation. Most participants expressed concern about the technical challenges with VVC. Interviewees cited inconsistencies for both patients and physicians receiving emails with links to join VVC visits, which should be generated when appointments are scheduled. Some physicians were unaware of scheduled VVC visits until the day of the appointment and only received the link via email. Such issues appeared to occur regardless whether the physicians or support staff scheduled the encounter. Poor video and audio quality was also cited as significant barriers to successful VVC visits and were often not resolvable through troubleshooting efforts by physicians, patients, or support personnel. Given the limited time allotted to each patient encounter, such issues could significantly impact the physician’s ability to remain on schedule. Moreover, connectivity problems led to significant lapses, delays in audio and video transmission, and complete disconnections from the VVC encounter. This was a significant concern for participants, given the rural nature of New Mexico and the large geographical gaps in internet service throughout the state.

Theme 2: Patient technological literacy affected veteran and physician comfort with VVC. Successful VVC appointments require high-speed Internet and compatible hardware. Physicians indicated that some patients reported difficulties with critical steps in the process, such as logging into the VVC platform or ensuring their microphones and cameras were active. Physicians also expressed concern about older veterans’ ability to utilize electronic devices, noting they may generally be less technology savvy. Additionally, physicians reported that despite offering the option of a virtual visit, many veterans preferred in-person visits, regardless of the drive time required. This appeared related to a fear of using the technology, which led veterans to believe that virtual visits do not provide the same quality of care as in-person visits.

Theme 3: Integration of supportive measures is desired. Interviewees felt that integrated VVC technical assistance and technology literacy education were imperative. First, training the patient or the patient’s caregiver on how to complete a VVC encounter using the preferred device and the VVC platform would be beneficial. Second, education to inform physicians about common troubleshooting issues could help streamline VVC encounters. Third, managing a VVC encounter similarly to standard in-person visits could allow for better patient and physician experience. For example, physicians suggested that a medical assistant or a nurse triage the patient, take vital signs, and set them up in a room, potentially at a regional VA community based outpatient clinic. Such efforts would also allow patients to receive specialty care in remote areas where only primary care is generally offered. Support staff could assist with technological issues, such as setting up the VVC encounter and addressing potential problems before the physician joins the encounter, thereby preventing delays in patient care. Finally, physicians felt that designating a day solely for CVT visits would help prevent disruption in care with in-person visits.

Theme 4: CVT services may increasingly be used to enhance access to care. Physicians felt that VVC would help patients encountering obstacles in accessing conventional in person services, including patients in rural and underserved areas, with disabilities, or with scheduling challenges.4 Patients with chronic conditions might drive the use of virtual visits, as many of these patients are already accustomed to remote medical monitoring. Data from devices such as scales and continuous glucose monitors can be easily reviewed during VVC visits. Second, video encounters facilitate closer monitoring that some patients might otherwise skip due to significant travel barriers, especially in a rural state like New Mexico. Lastly, VVC may be more efficient than in person visits as they eliminate the need for lengthy parking, checking in, and checking out processes. Thus, if technological issues are resolved, a typical physician’s day in the clinic may be more efficient with virtual visits.

Theme 5: In-person encounters afforded unique advantages over CVT. Some physicians felt in-person visits still offer unique advantages. They opined that the selection of appropriate candidates for CVT is critical. Patients requiring a physical examination should be scheduled for in person visits. For example, patients with advanced chronic kidney disease who require accurate volume status assessment or patients who have recently undergone surgery and need detailed wound inspection should be seen in the clinic. In-person visits may also be preferable for patients with recurrent admissions, or those whose condition is difficult to assess; accurate assessments of such patients may help prevent readmissions. Finally, many patients are more comfortable and satisfied with in-person visits, which are perceived as a more standard or traditional process. Respondents noted that some patients felt physicians may not focus as much attention during a VVC visit as they do during in-person visits. There were also concerns that some patients feel more motivation to come to in-person visits, as they see the VA as a place to interact with other veterans and staff with whom they are familiar and comfortable.

DISCUSSION

VANMHCS physicians, which serves veterans across an expansive territory ranging from Southern Colorado to West Texas. About 4.6 million veterans reside in rural regions, constituting roughly 25% of the total veteran population, a pattern mirrored in New Mexico.¹³ Medicine Service physicians agreed on a number of themes: VVC user-interface issues may affect its use and effectiveness, technological literacy was important for both patients and health care staff, technical support staff roles before and during VVC visits should be standardized, CVT is likely to increase health care delivery, and in-person encounters are preferred for many patients.

This is the first study to qualitatively evaluate a diverse group of physicians at a VA medical center incorporating CVT services across specialties. A few related qualitative studies have been conducted external to VHA, generally evaluating clinicians within a single specialty. Kalicki and colleagues surveyed 16 physicians working at a large home-based primary care program in New York City between April and June 2020 to identify and explore barriers to telehealth among homebound older adults. Similarly to our study, physicians noted that many patients required assistance (family members or caregivers) with the visit, either due to technological literacy issues or medical conditions like dementia.¹⁴

Heyer and colleagues surveyed 29 oncologists at an urban academic center prior to the COVID-19 pandemic. Similar to our observations, the oncologists said telemedicine helped eliminate travel as a barrier to health care. Heyer and colleagues noted difficulty for oncologists in performing virtual physical examinations, despite training. This group did note the benefits when being selective as to which clinical issues they would handle virtually vs in person.¹⁵

Budhwani and colleagues reported that mental health professionals in an academic setting cited difficulty establishing therapeutic relationships via telehealth and felt that this affected quality of care.¹⁶ While this was not a topic during our interviews, it is reasonable to question how potentially missed nonverbal cues may impact patient assessments.

Notably, technological issues were common among all reviewed studies. These ranged from internet connectivity issues to necessary electronic devices. As mentioned, these barriers are more prevalent in rural states like New Mexico.

Limitations

All participants in this study were Medicine Service physicians of a single VA health care system, which may limit generalizability. Many of our respondents were female (69%), compared with 39.2% of active internal medicine physicians and therefore may not be representative.¹⁷ Nearly one-half of our participants only completed 1 to 4 VVC encounters, which may have contributed to the emergence of a common theme regarding technological issues. Physicians with more experience with CVT services may be more skilled at troubleshooting technological issues that arise during visits.

CONCLUSIONS

Our study, conducted with VANMHCS physicians, illuminated 5 key themes influencing the use and implementation of video encounters: technological issues, technological literacy, a desire for integrated support measures, perceived future growth of video telehealth, and the unique advantages of in-person visits. Addressing technological barriers and providing more extensive training may streamline CVT use. However, it is vital to recognize the unique benefits of in-person visits and consider the benefits of each modality along with patient preferences when selecting the best care venue. As health care evolves, better understanding and acting upon these themes will optimize telehealth services, particularly in rural areas. Future research should involve patients and other health care team members to further explore strategies for effective CVT service integration.

Appendix

Prior to the COVID-19 pandemic, health care systems had been increasingly focused on expanding care delivery through clinical video telehealth (CVT) services.^1-3 These modalities offer clinicians and patients opportunities to interact without needing face-to-face visits. CVT services offer significant advantages to patients who encounter challenges accessing traditional face-to-face services, including those living in rural or underserved areas, individuals with mobility limitations, and those with difficulty attending appointments due to work or caregiving commitments.⁴ The COVID-19 pandemic accelerated the expansion of CVT services to mitigate the spread of the virus.¹

Despite its evident advantages, widespread adoption of CVT has encountered resistance.² Physicians have frequently expressed concerns about the reliability and functionality of CVT platforms for scheduled encounters and frustration with inadequate training.^4-6 Additionally, there is a lack trust in the technology, as physicians are unfamiliar with reimbursement or workload capture associated with CVT. Physicians have concerns that telecommunication may diminish the intangible aspects of the “art of medicine.”⁴ As a result, the implementation of telehealth services has been inconsistent, with successful adoption limited to specific medical and surgical specialties.⁴ Only recently have entire departments within major health care systems expressed interest in providing comprehensive CVT services in response to the challenges posed by the COVID-19 pandemic.⁴

The Veterans Health Administration (VHA) of the US Department of Veterans Affairs (VA) provides an appropriate setting for assessing clinician perceptions of telehealth services. Since 2003, the VHA has significantly expanded CVT services to eligible veterans and has used the VA Video Connect (VVC) platform since 2018.^7-10 Through VVC, VA staff and clinicians may schedule video visits with patients, meet with patients through virtual face-to-face interaction, and share relevant laboratory results and imaging through screen sharing. Prior research has shown increased accessibility to care through VVC. For example, a single-site study demonstrated that VVC implementation for delivering psychotherapies significantly increased CVT encounters from 15% to 85% among veterans with anxiety and/or depression.¹¹

The VA New Mexico Healthcare System (VANMHCS) serves a high volume of veterans living in remote and rural regions and significantly increased its use of CVT during the COVID-19 pandemic to reduce in-person visits. Expectedly, this was met with a variety of challenges. Herein, we sought to assess physician perspectives, concerns, and attitudes toward VVC via semistructured interviews. Our hypothesis was that VA physicians may feel uncomfortable with video encounters but recognize the growing importance of such practices providing specialty care to veterans in rural areas.

METHODS

A semistructured interview protocol was created following discussions with physicians from the VANMHCS Medicine Service. Questions were constructed to assess the following domains: overarching views of video telehealth, perceptions of various applications for conducting VVC encounters, and barriers to the broad implementation of video telehealth. A qualitative investigation specialist aided with question development. Two pilot interviews were conducted prior to performing the interviews with the recruited participants to evaluate the quality and delivery of questions.

All VANMHCS physicians who provided outpatient care within the Department of Medicine and had completed ≥ 1 VVC encounter were eligible to participate. Invitations were disseminated via email, and follow-up emails to encourage participation were sent periodically for 2 months following the initial request. Union approval was obtained to interview employees for a research study. In total, 64 physicians were invited and 13 (20%) chose to participate. As the study did not involve assessing medical interventions among patients, a waiver of informed consent was granted by the VANMHCS Institutional Review Board. Physicians who participated in this study were informed that their responses would be used for reporting purposes and could be rescinded at any time.

Data Analysis

Semistructured interviews were conducted by a single interviewer and recorded using Microsoft Teams. The interviews took place between February 2021 and December 2021 and lasted 5 to 15 minutes, with a mean duration of 9 minutes. Verbal informed consent was obtained from all participants before the interviews. Interviewees were encouraged to expand on their responses to structured questions by recounting past experiences with VVC. Recorded audio was additionally transcribed via Microsoft Teams, and the research team reviewed the transcriptions to ensure accuracy.

The tracking and coding of responses to interview questions were conducted using Microsoft Excel. Initially, 5 transcripts were reviewed and responses were assessed by 2 study team members through open coding. All team members examined the 5 coded transcripts to identify differences and reach a consensus for any discrepancies. Based on recommendations from all team members regarding nuanced excerpts of transcripts, 1 study team member coded the remaining interviews. Thematic analysis was subsequently conducted according to the method described by Braun and Clarke.¹² Themes were developed both deductively and inductively by reviewing the direct responses to interview questions and identifying emerging patterns of data, respectively. Indicative quotes representing each theme were carefully chosen for reporting.

RESULTS

Thirteen interviews were conducted and 9 participants (69%) were female. Participating physicians included 3 internal medicine/primary care physicians (23%), 2 nephrologists (15%), and 1 (8%) from cardiology, endocrinology, hematology, infectious diseases, palliative care, critical care, pulmonology, and sleep medicine. Years of post training experience among physicians ranged from 1 to 9 years (n = 5, 38%), 10 to 19 years (n = 3, 23%), and . 20 years (n = 5, 38%). Seven participants (54%) had conducted ≥ 5 VVC visits, with 1 physician completing > 50 video visits (Table).

Using open coding and a deductive approach to thematic analysis, 5 themes were identified: (1) VVC software and internet connection issues affected implementation; (2) patient technological literacy affected veteran and physician comfort with VVC; (3) integration of supportive measures was desired; (4) CVT services may increasingly be used to enhance access to care; and (5) in-person encounters afforded unique advantages over CVT. Illustrative quotes from physicians that reflect these themes can be found in the Appendix.

Theme 1: VVC software and internet connection issues affected its implementation. Most participants expressed concern about the technical challenges with VVC. Interviewees cited inconsistencies for both patients and physicians receiving emails with links to join VVC visits, which should be generated when appointments are scheduled. Some physicians were unaware of scheduled VVC visits until the day of the appointment and only received the link via email. Such issues appeared to occur regardless whether the physicians or support staff scheduled the encounter. Poor video and audio quality was also cited as significant barriers to successful VVC visits and were often not resolvable through troubleshooting efforts by physicians, patients, or support personnel. Given the limited time allotted to each patient encounter, such issues could significantly impact the physician’s ability to remain on schedule. Moreover, connectivity problems led to significant lapses, delays in audio and video transmission, and complete disconnections from the VVC encounter. This was a significant concern for participants, given the rural nature of New Mexico and the large geographical gaps in internet service throughout the state.

Theme 2: Patient technological literacy affected veteran and physician comfort with VVC. Successful VVC appointments require high-speed Internet and compatible hardware. Physicians indicated that some patients reported difficulties with critical steps in the process, such as logging into the VVC platform or ensuring their microphones and cameras were active. Physicians also expressed concern about older veterans’ ability to utilize electronic devices, noting they may generally be less technology savvy. Additionally, physicians reported that despite offering the option of a virtual visit, many veterans preferred in-person visits, regardless of the drive time required. This appeared related to a fear of using the technology, which led veterans to believe that virtual visits do not provide the same quality of care as in-person visits.

Theme 3: Integration of supportive measures is desired. Interviewees felt that integrated VVC technical assistance and technology literacy education were imperative. First, training the patient or the patient’s caregiver on how to complete a VVC encounter using the preferred device and the VVC platform would be beneficial. Second, education to inform physicians about common troubleshooting issues could help streamline VVC encounters. Third, managing a VVC encounter similarly to standard in-person visits could allow for better patient and physician experience. For example, physicians suggested that a medical assistant or a nurse triage the patient, take vital signs, and set them up in a room, potentially at a regional VA community based outpatient clinic. Such efforts would also allow patients to receive specialty care in remote areas where only primary care is generally offered. Support staff could assist with technological issues, such as setting up the VVC encounter and addressing potential problems before the physician joins the encounter, thereby preventing delays in patient care. Finally, physicians felt that designating a day solely for CVT visits would help prevent disruption in care with in-person visits.

Theme 4: CVT services may increasingly be used to enhance access to care. Physicians felt that VVC would help patients encountering obstacles in accessing conventional in person services, including patients in rural and underserved areas, with disabilities, or with scheduling challenges.4 Patients with chronic conditions might drive the use of virtual visits, as many of these patients are already accustomed to remote medical monitoring. Data from devices such as scales and continuous glucose monitors can be easily reviewed during VVC visits. Second, video encounters facilitate closer monitoring that some patients might otherwise skip due to significant travel barriers, especially in a rural state like New Mexico. Lastly, VVC may be more efficient than in person visits as they eliminate the need for lengthy parking, checking in, and checking out processes. Thus, if technological issues are resolved, a typical physician’s day in the clinic may be more efficient with virtual visits.

Theme 5: In-person encounters afforded unique advantages over CVT. Some physicians felt in-person visits still offer unique advantages. They opined that the selection of appropriate candidates for CVT is critical. Patients requiring a physical examination should be scheduled for in person visits. For example, patients with advanced chronic kidney disease who require accurate volume status assessment or patients who have recently undergone surgery and need detailed wound inspection should be seen in the clinic. In-person visits may also be preferable for patients with recurrent admissions, or those whose condition is difficult to assess; accurate assessments of such patients may help prevent readmissions. Finally, many patients are more comfortable and satisfied with in-person visits, which are perceived as a more standard or traditional process. Respondents noted that some patients felt physicians may not focus as much attention during a VVC visit as they do during in-person visits. There were also concerns that some patients feel more motivation to come to in-person visits, as they see the VA as a place to interact with other veterans and staff with whom they are familiar and comfortable.

DISCUSSION

VANMHCS physicians, which serves veterans across an expansive territory ranging from Southern Colorado to West Texas. About 4.6 million veterans reside in rural regions, constituting roughly 25% of the total veteran population, a pattern mirrored in New Mexico.¹³ Medicine Service physicians agreed on a number of themes: VVC user-interface issues may affect its use and effectiveness, technological literacy was important for both patients and health care staff, technical support staff roles before and during VVC visits should be standardized, CVT is likely to increase health care delivery, and in-person encounters are preferred for many patients.

This is the first study to qualitatively evaluate a diverse group of physicians at a VA medical center incorporating CVT services across specialties. A few related qualitative studies have been conducted external to VHA, generally evaluating clinicians within a single specialty. Kalicki and colleagues surveyed 16 physicians working at a large home-based primary care program in New York City between April and June 2020 to identify and explore barriers to telehealth among homebound older adults. Similarly to our study, physicians noted that many patients required assistance (family members or caregivers) with the visit, either due to technological literacy issues or medical conditions like dementia.¹⁴

Heyer and colleagues surveyed 29 oncologists at an urban academic center prior to the COVID-19 pandemic. Similar to our observations, the oncologists said telemedicine helped eliminate travel as a barrier to health care. Heyer and colleagues noted difficulty for oncologists in performing virtual physical examinations, despite training. This group did note the benefits when being selective as to which clinical issues they would handle virtually vs in person.¹⁵

Budhwani and colleagues reported that mental health professionals in an academic setting cited difficulty establishing therapeutic relationships via telehealth and felt that this affected quality of care.¹⁶ While this was not a topic during our interviews, it is reasonable to question how potentially missed nonverbal cues may impact patient assessments.

Notably, technological issues were common among all reviewed studies. These ranged from internet connectivity issues to necessary electronic devices. As mentioned, these barriers are more prevalent in rural states like New Mexico.

Limitations

All participants in this study were Medicine Service physicians of a single VA health care system, which may limit generalizability. Many of our respondents were female (69%), compared with 39.2% of active internal medicine physicians and therefore may not be representative.¹⁷ Nearly one-half of our participants only completed 1 to 4 VVC encounters, which may have contributed to the emergence of a common theme regarding technological issues. Physicians with more experience with CVT services may be more skilled at troubleshooting technological issues that arise during visits.

CONCLUSIONS

Our study, conducted with VANMHCS physicians, illuminated 5 key themes influencing the use and implementation of video encounters: technological issues, technological literacy, a desire for integrated support measures, perceived future growth of video telehealth, and the unique advantages of in-person visits. Addressing technological barriers and providing more extensive training may streamline CVT use. However, it is vital to recognize the unique benefits of in-person visits and consider the benefits of each modality along with patient preferences when selecting the best care venue. As health care evolves, better understanding and acting upon these themes will optimize telehealth services, particularly in rural areas. Future research should involve patients and other health care team members to further explore strategies for effective CVT service integration.

Appendix

Supporting meaningful research that has a positive impact on the health and quality of life of veterans is a priority of the US Department of Veterans Affairs Office of Research and Development.¹ For nearly a century, VA researchers have been conducting high quality studies. To continue this trajectory, it is imperative to attract, train, and retain exceptional investigators while nurturing their development throughout their careers.²

Mentorship is defined as guidance provided by an experienced and trusted party to another (usually junior) individual with the intent of helping the person succeed. It benefits the mentee, mentor, and their institutions.³ Mentorship is crucial for personal and professional development as well as productivity, which may help reduce clinician burnout.^4-7 Conversely, a lack of mentorship could have negative effects on work satisfaction and stagnate career progression.⁸

Mentorship is vital for developing and advancing a VA investigator’s research agenda. Funding, grant writing, and research design were among the most discussed topics in a large comprehensive mentorship program for academic faculty.⁹ However, there are several known barriers to effective research mentorship; among them include a lack of resources, time constraints, and competing clinical priorities.^10,11

Finding time for effective one-on-one research mentoring is difficult within the time constraints of clinical duties; a group mentorship model may help overcome this barrier. Group mentorship can aid in personal and professional development because no single mentor can effectively meet every mentoring need of an individual.¹² Group mentorship also allows for the exchange of ideas among individuals with different backgrounds and the ability to utilize the strengths of each member of the group. For example, a member may have methodological expertise, while another may be skilled in grantsmanship. A team of mentors may be more beneficial for both the mentors (eg, establish a more manageable workload) and the mentee (eg, gains a broader perspective of expertise) when compared to having a single mentor.³

Peer mentorship within the group setting may also yield additional benefits. For example, having a supportive peer group may help reduce stress levels and burnout, while also improving overall well-being.^3,13 Formal mentorship programs do not frequently discuss concerns such as work-life balance, so including peers as mentors may help fill this void.⁹ Peer mentorship has also been found to be beneficial in providing mentees with pooled resources and shared learning.^12,13 This article describes the components, benefits, impacts, and challenges of a group research mentorship program for VA clinicians interested in conducting VA-relevant research.

Program Description

The VA Clinical Research Mentorship Program was initiated at the VA Ann Arbor Healthcare System (VAAAHS) in October 2015 by the Chief of Medicine to assist VA clinician investigators with developing and submitting VA clinical science and health services research grant applications. The program offers group and one-on-one consultation services through the expertise of 2 experienced investigators/faculty mentors who also serve as program directors, each of whom devote about 3 to 5 hours per month to activities associated with the mentorship program (eg, attending the meeting, reviewing materials sent by mentees, and one-on-one discussions with mentees).

The program also fostered peer-led mentorship. This encourages all attendees to provide feedback during group sessions and communication by mentees outside the group sessions. An experienced project manager serves as program coordinator and contributes about 4 hours per month for activities such as attending, scheduling, and sending reminders for each meeting, distributing handouts, reviewing materials, and answering mentee’s questions via email. A statistician and additional research staff (ie, an epidemiologist and research assistant) do not attend the recurring meetings, but are available for offline consultation as needed. The program runs on a 12-month cycle with regular meetings occurring twice monthly during the 9-month academic period. Resources to support the program, primarily program director(s) and project coordinator effort, are provided by the Chief of Medicine and through the VAAAHS affiliated VA Health Systems Research (formerly Health Services Research & Development) Center of Innovation.

Invitations for new mentees are sent annually. Mentees expressing interest in the program outside of its annual recruitment period are evaluated for inclusion on a rolling basis. Recruitment begins with the program coordinator sending email notifications to all VAAAHS Medicine Service faculty, section chiefs, and division chiefs at the VAAAHS academic affiliate. Recipients are encouraged to distribute the announcement to eligible applicants and refer them to the application materials for entry consideration into the program. The application consists of the applicant’s curriculum vitae and a 1-page summary that includes a description of their research area of interest, how it is relevant to the VA, in addition to an idea for a research study, its potential significance, and proposed methodology. Applicant materials are reviewed by the program coordinator and program directors. The applicants are evaluated using a simple scoring approach that focuses on the applicant’s research area and agenda, past research training, past research productivity, potential for obtaining VA funding, and whether they have sufficient research time.

Program eligibility initially required being a physician with ≥ 1/8 VA appointment from the Medicine Service. However, clinicians with clinical appointments from other VA services are also accepted for participation as needed. Applicants must have previous research experience and have a career goal to obtain external funding for conducting and publishing original research. Those who have previously served as a principal investigator on a funded VA grant proposal are not eligible as new applicants but can remain in the program as peer mentors. The number of annual applicants varies and ranges from 1 to 11; on average, about 90% of applicants receive invitations to join the program.

Sessions

The program holds recurring meetings twice monthly for 1 hour during the 9-month academic year. However, program directors are available year-round, and mentees are encouraged to communicate questions or concerns via email during nonacademic months. Prior to the COVID-19 pandemic, all meetings were held in-person. However, the group pivoted to virtual meetings and continues to utilize this format. The dedicated program coordinator is responsible for coordinating meetings and distributing meeting materials.

Each session is informal, flexible, and supportive. Attendance is not enforced, and mentees are allowed to join meetings as their schedules permit; however, program directors and program coordinator attend each meeting. In advance of each session, the program coordinator sends out a call for agenda items to all active members invited to discuss any research related items. Each mentee presents their ideas to lead the discussion for their portion of the meeting with no defined format required.

A variety of topics are covered including, but not limited to: (1) grant-specific concerns (eg, questions related to specific aim pages, grantsmanship, postsubmission comments from reviewers, or postaward logistics); (2) research procedures (eg, questions related to methodological practices or institutional review board concerns); (3) manuscript or presentation preparation; and (4) careerrelated issues. The program coordinator distributes handouts prior to meetings and mentees may record their presentations. These handouts may include, but are not limited to, specific aims pages, analytical plans, grant solicitations, and PowerPoint presentations. If a resource that can benefit the entire group is mentioned during the meeting, the program coordinator is responsible for distribution.

The program follows a group facilitated discussion format. Program directors facilitate each meeting, but input is encouraged from all attendees. This model allows for mentees to learn from the faculty mentors as well as peer mentees in a simultaneous and efficient fashion. Group discussions foster collective problem solving, peer support, and resource sharing that would not be possible through individualized mentorship. Participants have access to varied expertise during each session which reduces the need to seek specialized help elsewhere. Participants are also encouraged to contact the program directors or research staff for consultation as needed. Some one-on-one consultations have transitioned to a more sustained and ongoing mentorship relationship between a program director and mentee, but most are often brief email exchanges or a single meeting.

Participants

Since its inception in 2015, 35 clinicians have enrolled in the program. The mentees are equally distributed by sex and practice in a variety of disciplines including gastroenterology, hematology/oncology, cardiology, and general medicine (Table 1). Mentees have submitted 33 grant proposals addressing a variety of health care issues to a diverse group of federal and nonfederal funding agencies (Table 2). As of May 15, 2024, 19 (58%) of the submitted applications have been funded.

Many factors contribute to a successfully funded grant application, and several mentees report that participating in the mentorship program was helpful. For example, a mentee became the first lead investigator for a VA Cooperative Studies Program funded at VAAAHS. The VA Cooperative Studies Program, a division of the Office of Research and Development, plans and conducts large multicenter clinical trials and epidemiological studies within the VA via a vast network of clinician investigators, statisticians, and other key research experts.¹⁴

Several program mentees have also received VA Clinical Science Research and Development Career Development Awards. The VA Career Development program supports investigators during their early research careers with a goal of retaining talented researchers committed to improving the health and care of veterans.¹⁵

Survey Responses

Mentee productivity and updates are tracked through direct mentee input, as requested by the program coordinator. Since 2022, participants could complete an end-of-year survey based on an assessment tool used in a VAAAHS nonresearch mentorship program.¹⁶ The survey, distributed to mentees and program directors, requests feedback on logistics (eg, if the meeting was a good use of time and barriers to attendance); perceptions of effectiveness (eg, ability to discuss agenda items, helpfulness with setting and reaching research goals, and quality of mentors’ feedback); and the impact of the mentoring program on work satisfaction and clinician burnout. Respondents are also encouraged to leave open-ended qualitative feedback.

To date the survey has elicited 19 responses. Seventeen (89%) indicated that they agree or strongly agree the meetings were an effective use of their time and 11 (58%) indicated that they were able to discuss all or most of the items they wanted to during the meeting. Sixteen respondents (84%) agreed the program helped them set and achieve their research goals and 14 respondents (74%) agreed the feedback they received during the meeting was specific, actionable, and focused on how to improve their research agenda. Seventeen respondents (89%) agreed the program increased their work satisfaction, while 13 respondents (68%) felt the program reduced levels of clinician burnout.

As attendance was not mandatory, the survey asked participants how often they attended meetings during the past year. Responses were mixed: 4 (21%) respondents attended regularly (12 to 16 times per year) and 8 (42%) attended most sessions (8 to 11 times per year). Noted barriers to attendance included conflicts with patient care activities and conflicts with other high priority meetings.

Mentees also provided qualitive feedback regarding the program. They highlighted the supportive environment, valuable expertise of the mentors, and usefulness of obtaining tailored feedback from the group. “This group is an amazing resource to anyone developing a research career,” a mentee noted, adding that the program directors “fostered an incredibly supportive group where research ideas and methodology can be explored in a nonthreatening and creative environment.”

Conclusions

This mentorship program aims to help aspiring VA clinician investigators develop and submit competitive research grant applications. The addition of the program to the existing robust research environments at VAAAHS and its academic affiliate appears to have contributed to this success, with 58% of applications submitted by program mentees receiving funding.

In addition to funding success, we also found that most participants have a favorable impression of the program. Of the participants who responded to the program evaluation survey, nearly all indicated the program was an effective use of their time. The program also appeared to increase work satisfaction and reduce levels of clinician burnout. Barriers to attendance were also noted, with the most frequent being scheduling conflicts.

This program’s format includes facilitated group discussion as well as peer mentorship. This collaborative structure allows for an efficient and rich learning experience. Feedback from multiple perspectives encourages natural networking and relationship building. Incorporating the collective wisdom of the faculty mentors and peer mentees is beneficial; it not only empowers the mentees but also enriches the experience for the mentors. This program can serve as a model for other VA facilities—or non-VA academic medical centers—to enhance their research programs.

Supporting meaningful research that has a positive impact on the health and quality of life of veterans is a priority of the US Department of Veterans Affairs Office of Research and Development.¹ For nearly a century, VA researchers have been conducting high quality studies. To continue this trajectory, it is imperative to attract, train, and retain exceptional investigators while nurturing their development throughout their careers.²

Mentorship is defined as guidance provided by an experienced and trusted party to another (usually junior) individual with the intent of helping the person succeed. It benefits the mentee, mentor, and their institutions.³ Mentorship is crucial for personal and professional development as well as productivity, which may help reduce clinician burnout.^4-7 Conversely, a lack of mentorship could have negative effects on work satisfaction and stagnate career progression.⁸

Mentorship is vital for developing and advancing a VA investigator’s research agenda. Funding, grant writing, and research design were among the most discussed topics in a large comprehensive mentorship program for academic faculty.⁹ However, there are several known barriers to effective research mentorship; among them include a lack of resources, time constraints, and competing clinical priorities.^10,11

Finding time for effective one-on-one research mentoring is difficult within the time constraints of clinical duties; a group mentorship model may help overcome this barrier. Group mentorship can aid in personal and professional development because no single mentor can effectively meet every mentoring need of an individual.¹² Group mentorship also allows for the exchange of ideas among individuals with different backgrounds and the ability to utilize the strengths of each member of the group. For example, a member may have methodological expertise, while another may be skilled in grantsmanship. A team of mentors may be more beneficial for both the mentors (eg, establish a more manageable workload) and the mentee (eg, gains a broader perspective of expertise) when compared to having a single mentor.³

Peer mentorship within the group setting may also yield additional benefits. For example, having a supportive peer group may help reduce stress levels and burnout, while also improving overall well-being.^3,13 Formal mentorship programs do not frequently discuss concerns such as work-life balance, so including peers as mentors may help fill this void.⁹ Peer mentorship has also been found to be beneficial in providing mentees with pooled resources and shared learning.^12,13 This article describes the components, benefits, impacts, and challenges of a group research mentorship program for VA clinicians interested in conducting VA-relevant research.

Program Description

The VA Clinical Research Mentorship Program was initiated at the VA Ann Arbor Healthcare System (VAAAHS) in October 2015 by the Chief of Medicine to assist VA clinician investigators with developing and submitting VA clinical science and health services research grant applications. The program offers group and one-on-one consultation services through the expertise of 2 experienced investigators/faculty mentors who also serve as program directors, each of whom devote about 3 to 5 hours per month to activities associated with the mentorship program (eg, attending the meeting, reviewing materials sent by mentees, and one-on-one discussions with mentees).

The program also fostered peer-led mentorship. This encourages all attendees to provide feedback during group sessions and communication by mentees outside the group sessions. An experienced project manager serves as program coordinator and contributes about 4 hours per month for activities such as attending, scheduling, and sending reminders for each meeting, distributing handouts, reviewing materials, and answering mentee’s questions via email. A statistician and additional research staff (ie, an epidemiologist and research assistant) do not attend the recurring meetings, but are available for offline consultation as needed. The program runs on a 12-month cycle with regular meetings occurring twice monthly during the 9-month academic period. Resources to support the program, primarily program director(s) and project coordinator effort, are provided by the Chief of Medicine and through the VAAAHS affiliated VA Health Systems Research (formerly Health Services Research & Development) Center of Innovation.

Invitations for new mentees are sent annually. Mentees expressing interest in the program outside of its annual recruitment period are evaluated for inclusion on a rolling basis. Recruitment begins with the program coordinator sending email notifications to all VAAAHS Medicine Service faculty, section chiefs, and division chiefs at the VAAAHS academic affiliate. Recipients are encouraged to distribute the announcement to eligible applicants and refer them to the application materials for entry consideration into the program. The application consists of the applicant’s curriculum vitae and a 1-page summary that includes a description of their research area of interest, how it is relevant to the VA, in addition to an idea for a research study, its potential significance, and proposed methodology. Applicant materials are reviewed by the program coordinator and program directors. The applicants are evaluated using a simple scoring approach that focuses on the applicant’s research area and agenda, past research training, past research productivity, potential for obtaining VA funding, and whether they have sufficient research time.

Program eligibility initially required being a physician with ≥ 1/8 VA appointment from the Medicine Service. However, clinicians with clinical appointments from other VA services are also accepted for participation as needed. Applicants must have previous research experience and have a career goal to obtain external funding for conducting and publishing original research. Those who have previously served as a principal investigator on a funded VA grant proposal are not eligible as new applicants but can remain in the program as peer mentors. The number of annual applicants varies and ranges from 1 to 11; on average, about 90% of applicants receive invitations to join the program.

Sessions

The program holds recurring meetings twice monthly for 1 hour during the 9-month academic year. However, program directors are available year-round, and mentees are encouraged to communicate questions or concerns via email during nonacademic months. Prior to the COVID-19 pandemic, all meetings were held in-person. However, the group pivoted to virtual meetings and continues to utilize this format. The dedicated program coordinator is responsible for coordinating meetings and distributing meeting materials.

Each session is informal, flexible, and supportive. Attendance is not enforced, and mentees are allowed to join meetings as their schedules permit; however, program directors and program coordinator attend each meeting. In advance of each session, the program coordinator sends out a call for agenda items to all active members invited to discuss any research related items. Each mentee presents their ideas to lead the discussion for their portion of the meeting with no defined format required.

A variety of topics are covered including, but not limited to: (1) grant-specific concerns (eg, questions related to specific aim pages, grantsmanship, postsubmission comments from reviewers, or postaward logistics); (2) research procedures (eg, questions related to methodological practices or institutional review board concerns); (3) manuscript or presentation preparation; and (4) careerrelated issues. The program coordinator distributes handouts prior to meetings and mentees may record their presentations. These handouts may include, but are not limited to, specific aims pages, analytical plans, grant solicitations, and PowerPoint presentations. If a resource that can benefit the entire group is mentioned during the meeting, the program coordinator is responsible for distribution.

The program follows a group facilitated discussion format. Program directors facilitate each meeting, but input is encouraged from all attendees. This model allows for mentees to learn from the faculty mentors as well as peer mentees in a simultaneous and efficient fashion. Group discussions foster collective problem solving, peer support, and resource sharing that would not be possible through individualized mentorship. Participants have access to varied expertise during each session which reduces the need to seek specialized help elsewhere. Participants are also encouraged to contact the program directors or research staff for consultation as needed. Some one-on-one consultations have transitioned to a more sustained and ongoing mentorship relationship between a program director and mentee, but most are often brief email exchanges or a single meeting.

Participants

Since its inception in 2015, 35 clinicians have enrolled in the program. The mentees are equally distributed by sex and practice in a variety of disciplines including gastroenterology, hematology/oncology, cardiology, and general medicine (Table 1). Mentees have submitted 33 grant proposals addressing a variety of health care issues to a diverse group of federal and nonfederal funding agencies (Table 2). As of May 15, 2024, 19 (58%) of the submitted applications have been funded.

Many factors contribute to a successfully funded grant application, and several mentees report that participating in the mentorship program was helpful. For example, a mentee became the first lead investigator for a VA Cooperative Studies Program funded at VAAAHS. The VA Cooperative Studies Program, a division of the Office of Research and Development, plans and conducts large multicenter clinical trials and epidemiological studies within the VA via a vast network of clinician investigators, statisticians, and other key research experts.¹⁴

Several program mentees have also received VA Clinical Science Research and Development Career Development Awards. The VA Career Development program supports investigators during their early research careers with a goal of retaining talented researchers committed to improving the health and care of veterans.¹⁵

Survey Responses

Mentee productivity and updates are tracked through direct mentee input, as requested by the program coordinator. Since 2022, participants could complete an end-of-year survey based on an assessment tool used in a VAAAHS nonresearch mentorship program.¹⁶ The survey, distributed to mentees and program directors, requests feedback on logistics (eg, if the meeting was a good use of time and barriers to attendance); perceptions of effectiveness (eg, ability to discuss agenda items, helpfulness with setting and reaching research goals, and quality of mentors’ feedback); and the impact of the mentoring program on work satisfaction and clinician burnout. Respondents are also encouraged to leave open-ended qualitative feedback.

To date the survey has elicited 19 responses. Seventeen (89%) indicated that they agree or strongly agree the meetings were an effective use of their time and 11 (58%) indicated that they were able to discuss all or most of the items they wanted to during the meeting. Sixteen respondents (84%) agreed the program helped them set and achieve their research goals and 14 respondents (74%) agreed the feedback they received during the meeting was specific, actionable, and focused on how to improve their research agenda. Seventeen respondents (89%) agreed the program increased their work satisfaction, while 13 respondents (68%) felt the program reduced levels of clinician burnout.

As attendance was not mandatory, the survey asked participants how often they attended meetings during the past year. Responses were mixed: 4 (21%) respondents attended regularly (12 to 16 times per year) and 8 (42%) attended most sessions (8 to 11 times per year). Noted barriers to attendance included conflicts with patient care activities and conflicts with other high priority meetings.

Mentees also provided qualitive feedback regarding the program. They highlighted the supportive environment, valuable expertise of the mentors, and usefulness of obtaining tailored feedback from the group. “This group is an amazing resource to anyone developing a research career,” a mentee noted, adding that the program directors “fostered an incredibly supportive group where research ideas and methodology can be explored in a nonthreatening and creative environment.”

Conclusions

This mentorship program aims to help aspiring VA clinician investigators develop and submit competitive research grant applications. The addition of the program to the existing robust research environments at VAAAHS and its academic affiliate appears to have contributed to this success, with 58% of applications submitted by program mentees receiving funding.

In addition to funding success, we also found that most participants have a favorable impression of the program. Of the participants who responded to the program evaluation survey, nearly all indicated the program was an effective use of their time. The program also appeared to increase work satisfaction and reduce levels of clinician burnout. Barriers to attendance were also noted, with the most frequent being scheduling conflicts.

This program’s format includes facilitated group discussion as well as peer mentorship. This collaborative structure allows for an efficient and rich learning experience. Feedback from multiple perspectives encourages natural networking and relationship building. Incorporating the collective wisdom of the faculty mentors and peer mentees is beneficial; it not only empowers the mentees but also enriches the experience for the mentors. This program can serve as a model for other VA facilities—or non-VA academic medical centers—to enhance their research programs.

Supporting meaningful research that has a positive impact on the health and quality of life of veterans is a priority of the US Department of Veterans Affairs Office of Research and Development.¹ For nearly a century, VA researchers have been conducting high quality studies. To continue this trajectory, it is imperative to attract, train, and retain exceptional investigators while nurturing their development throughout their careers.²

Mentorship is defined as guidance provided by an experienced and trusted party to another (usually junior) individual with the intent of helping the person succeed. It benefits the mentee, mentor, and their institutions.³ Mentorship is crucial for personal and professional development as well as productivity, which may help reduce clinician burnout.^4-7 Conversely, a lack of mentorship could have negative effects on work satisfaction and stagnate career progression.⁸

Mentorship is vital for developing and advancing a VA investigator’s research agenda. Funding, grant writing, and research design were among the most discussed topics in a large comprehensive mentorship program for academic faculty.⁹ However, there are several known barriers to effective research mentorship; among them include a lack of resources, time constraints, and competing clinical priorities.^10,11

Finding time for effective one-on-one research mentoring is difficult within the time constraints of clinical duties; a group mentorship model may help overcome this barrier. Group mentorship can aid in personal and professional development because no single mentor can effectively meet every mentoring need of an individual.¹² Group mentorship also allows for the exchange of ideas among individuals with different backgrounds and the ability to utilize the strengths of each member of the group. For example, a member may have methodological expertise, while another may be skilled in grantsmanship. A team of mentors may be more beneficial for both the mentors (eg, establish a more manageable workload) and the mentee (eg, gains a broader perspective of expertise) when compared to having a single mentor.³

Peer mentorship within the group setting may also yield additional benefits. For example, having a supportive peer group may help reduce stress levels and burnout, while also improving overall well-being.^3,13 Formal mentorship programs do not frequently discuss concerns such as work-life balance, so including peers as mentors may help fill this void.⁹ Peer mentorship has also been found to be beneficial in providing mentees with pooled resources and shared learning.^12,13 This article describes the components, benefits, impacts, and challenges of a group research mentorship program for VA clinicians interested in conducting VA-relevant research.

Program Description

The VA Clinical Research Mentorship Program was initiated at the VA Ann Arbor Healthcare System (VAAAHS) in October 2015 by the Chief of Medicine to assist VA clinician investigators with developing and submitting VA clinical science and health services research grant applications. The program offers group and one-on-one consultation services through the expertise of 2 experienced investigators/faculty mentors who also serve as program directors, each of whom devote about 3 to 5 hours per month to activities associated with the mentorship program (eg, attending the meeting, reviewing materials sent by mentees, and one-on-one discussions with mentees).

The program also fostered peer-led mentorship. This encourages all attendees to provide feedback during group sessions and communication by mentees outside the group sessions. An experienced project manager serves as program coordinator and contributes about 4 hours per month for activities such as attending, scheduling, and sending reminders for each meeting, distributing handouts, reviewing materials, and answering mentee’s questions via email. A statistician and additional research staff (ie, an epidemiologist and research assistant) do not attend the recurring meetings, but are available for offline consultation as needed. The program runs on a 12-month cycle with regular meetings occurring twice monthly during the 9-month academic period. Resources to support the program, primarily program director(s) and project coordinator effort, are provided by the Chief of Medicine and through the VAAAHS affiliated VA Health Systems Research (formerly Health Services Research & Development) Center of Innovation.

Invitations for new mentees are sent annually. Mentees expressing interest in the program outside of its annual recruitment period are evaluated for inclusion on a rolling basis. Recruitment begins with the program coordinator sending email notifications to all VAAAHS Medicine Service faculty, section chiefs, and division chiefs at the VAAAHS academic affiliate. Recipients are encouraged to distribute the announcement to eligible applicants and refer them to the application materials for entry consideration into the program. The application consists of the applicant’s curriculum vitae and a 1-page summary that includes a description of their research area of interest, how it is relevant to the VA, in addition to an idea for a research study, its potential significance, and proposed methodology. Applicant materials are reviewed by the program coordinator and program directors. The applicants are evaluated using a simple scoring approach that focuses on the applicant’s research area and agenda, past research training, past research productivity, potential for obtaining VA funding, and whether they have sufficient research time.

Program eligibility initially required being a physician with ≥ 1/8 VA appointment from the Medicine Service. However, clinicians with clinical appointments from other VA services are also accepted for participation as needed. Applicants must have previous research experience and have a career goal to obtain external funding for conducting and publishing original research. Those who have previously served as a principal investigator on a funded VA grant proposal are not eligible as new applicants but can remain in the program as peer mentors. The number of annual applicants varies and ranges from 1 to 11; on average, about 90% of applicants receive invitations to join the program.

Sessions

The program holds recurring meetings twice monthly for 1 hour during the 9-month academic year. However, program directors are available year-round, and mentees are encouraged to communicate questions or concerns via email during nonacademic months. Prior to the COVID-19 pandemic, all meetings were held in-person. However, the group pivoted to virtual meetings and continues to utilize this format. The dedicated program coordinator is responsible for coordinating meetings and distributing meeting materials.

Each session is informal, flexible, and supportive. Attendance is not enforced, and mentees are allowed to join meetings as their schedules permit; however, program directors and program coordinator attend each meeting. In advance of each session, the program coordinator sends out a call for agenda items to all active members invited to discuss any research related items. Each mentee presents their ideas to lead the discussion for their portion of the meeting with no defined format required.

A variety of topics are covered including, but not limited to: (1) grant-specific concerns (eg, questions related to specific aim pages, grantsmanship, postsubmission comments from reviewers, or postaward logistics); (2) research procedures (eg, questions related to methodological practices or institutional review board concerns); (3) manuscript or presentation preparation; and (4) careerrelated issues. The program coordinator distributes handouts prior to meetings and mentees may record their presentations. These handouts may include, but are not limited to, specific aims pages, analytical plans, grant solicitations, and PowerPoint presentations. If a resource that can benefit the entire group is mentioned during the meeting, the program coordinator is responsible for distribution.

The program follows a group facilitated discussion format. Program directors facilitate each meeting, but input is encouraged from all attendees. This model allows for mentees to learn from the faculty mentors as well as peer mentees in a simultaneous and efficient fashion. Group discussions foster collective problem solving, peer support, and resource sharing that would not be possible through individualized mentorship. Participants have access to varied expertise during each session which reduces the need to seek specialized help elsewhere. Participants are also encouraged to contact the program directors or research staff for consultation as needed. Some one-on-one consultations have transitioned to a more sustained and ongoing mentorship relationship between a program director and mentee, but most are often brief email exchanges or a single meeting.

Participants

Since its inception in 2015, 35 clinicians have enrolled in the program. The mentees are equally distributed by sex and practice in a variety of disciplines including gastroenterology, hematology/oncology, cardiology, and general medicine (Table 1). Mentees have submitted 33 grant proposals addressing a variety of health care issues to a diverse group of federal and nonfederal funding agencies (Table 2). As of May 15, 2024, 19 (58%) of the submitted applications have been funded.

Many factors contribute to a successfully funded grant application, and several mentees report that participating in the mentorship program was helpful. For example, a mentee became the first lead investigator for a VA Cooperative Studies Program funded at VAAAHS. The VA Cooperative Studies Program, a division of the Office of Research and Development, plans and conducts large multicenter clinical trials and epidemiological studies within the VA via a vast network of clinician investigators, statisticians, and other key research experts.¹⁴

Several program mentees have also received VA Clinical Science Research and Development Career Development Awards. The VA Career Development program supports investigators during their early research careers with a goal of retaining talented researchers committed to improving the health and care of veterans.¹⁵

Survey Responses

Mentee productivity and updates are tracked through direct mentee input, as requested by the program coordinator. Since 2022, participants could complete an end-of-year survey based on an assessment tool used in a VAAAHS nonresearch mentorship program.¹⁶ The survey, distributed to mentees and program directors, requests feedback on logistics (eg, if the meeting was a good use of time and barriers to attendance); perceptions of effectiveness (eg, ability to discuss agenda items, helpfulness with setting and reaching research goals, and quality of mentors’ feedback); and the impact of the mentoring program on work satisfaction and clinician burnout. Respondents are also encouraged to leave open-ended qualitative feedback.

To date the survey has elicited 19 responses. Seventeen (89%) indicated that they agree or strongly agree the meetings were an effective use of their time and 11 (58%) indicated that they were able to discuss all or most of the items they wanted to during the meeting. Sixteen respondents (84%) agreed the program helped them set and achieve their research goals and 14 respondents (74%) agreed the feedback they received during the meeting was specific, actionable, and focused on how to improve their research agenda. Seventeen respondents (89%) agreed the program increased their work satisfaction, while 13 respondents (68%) felt the program reduced levels of clinician burnout.

As attendance was not mandatory, the survey asked participants how often they attended meetings during the past year. Responses were mixed: 4 (21%) respondents attended regularly (12 to 16 times per year) and 8 (42%) attended most sessions (8 to 11 times per year). Noted barriers to attendance included conflicts with patient care activities and conflicts with other high priority meetings.

Mentees also provided qualitive feedback regarding the program. They highlighted the supportive environment, valuable expertise of the mentors, and usefulness of obtaining tailored feedback from the group. “This group is an amazing resource to anyone developing a research career,” a mentee noted, adding that the program directors “fostered an incredibly supportive group where research ideas and methodology can be explored in a nonthreatening and creative environment.”

Conclusions

This mentorship program aims to help aspiring VA clinician investigators develop and submit competitive research grant applications. The addition of the program to the existing robust research environments at VAAAHS and its academic affiliate appears to have contributed to this success, with 58% of applications submitted by program mentees receiving funding.

In addition to funding success, we also found that most participants have a favorable impression of the program. Of the participants who responded to the program evaluation survey, nearly all indicated the program was an effective use of their time. The program also appeared to increase work satisfaction and reduce levels of clinician burnout. Barriers to attendance were also noted, with the most frequent being scheduling conflicts.

This program’s format includes facilitated group discussion as well as peer mentorship. This collaborative structure allows for an efficient and rich learning experience. Feedback from multiple perspectives encourages natural networking and relationship building. Incorporating the collective wisdom of the faculty mentors and peer mentees is beneficial; it not only empowers the mentees but also enriches the experience for the mentors. This program can serve as a model for other VA facilities—or non-VA academic medical centers—to enhance their research programs.

Background

Many Veterans with cancer experience substantial side effects related to their chemotherapy treatments resulting in impaired quality of life. Prompt management of such symptoms can improve adherence to therapy and potentially clinical outcomes. Previous studies in cancer patients have shown that mobile apps can improve symptom management and quality of life, though there are limited studies using oncology-focused apps in the VA population. The VA Annie App is an optimal platform for Veterans since it relies primarily on SMS-based texting and not on internet capabilities. This would address several well-known barriers to Veterans’ care access (limited internet connectivity, transportation) and enhance symptom reporting between infrequent provider visits. Providers can securely collect app responses within the VA system and there is already considerable VA developer experience with designing complex protocols. The OCTAGON project (Optimizing Cancer Care with Telehealth Assessment for Goal-Oriented Needs) will have the following goals: 1) To develop Annie App protocols to assist in management of cancer and/or chemotherapy-related symptoms (OCTAGON intervention), 2) To examine initial acceptability, feasibility, and Veteran-reported outcomes, 3) To explore short term effects on the utilization of VA encounters.

Methods

All patients who are primarily being managed at the VA Ann Arbor for their cancer therapy and are receiving one of the following therapies are considered eligible: EGFR inhibitors (lung cancer), antiandrogen therapies (prostate cancer), BTK inhibitors (lymphoma).

Discussion

Drug-specific protocols will be developed in conjunction with clinical pharmacists with experience in outpatient oral chemotherapy toxicity monitoring. Questions will have either a Yes/No, or numerical response. Interventions will be administered weekly for the first 3 months after enrollment, then decrease to monthly for a total of 6 months on protocol. Patients will be directed to contact their providers with any significant changes in tolerability. Planned data collected will include intervention question responses, adverse events, demographics, diagnosis, disease response, hospitalizations, treatment dose reductions or interruptions, provider and staff utilization. Survey responses to assess treatment acceptability (Treatment Acceptability/Adherence Scale), usability (System Usability Scale), general health (PROMIS-GH), and patient satisfaction will also be collected. Funding: VA Telehealth Research and Innovation for Veterans with Cancer (THRIVE).

Background

Many Veterans with cancer experience substantial side effects related to their chemotherapy treatments resulting in impaired quality of life. Prompt management of such symptoms can improve adherence to therapy and potentially clinical outcomes. Previous studies in cancer patients have shown that mobile apps can improve symptom management and quality of life, though there are limited studies using oncology-focused apps in the VA population. The VA Annie App is an optimal platform for Veterans since it relies primarily on SMS-based texting and not on internet capabilities. This would address several well-known barriers to Veterans’ care access (limited internet connectivity, transportation) and enhance symptom reporting between infrequent provider visits. Providers can securely collect app responses within the VA system and there is already considerable VA developer experience with designing complex protocols. The OCTAGON project (Optimizing Cancer Care with Telehealth Assessment for Goal-Oriented Needs) will have the following goals: 1) To develop Annie App protocols to assist in management of cancer and/or chemotherapy-related symptoms (OCTAGON intervention), 2) To examine initial acceptability, feasibility, and Veteran-reported outcomes, 3) To explore short term effects on the utilization of VA encounters.

Methods

All patients who are primarily being managed at the VA Ann Arbor for their cancer therapy and are receiving one of the following therapies are considered eligible: EGFR inhibitors (lung cancer), antiandrogen therapies (prostate cancer), BTK inhibitors (lymphoma).

Discussion

Drug-specific protocols will be developed in conjunction with clinical pharmacists with experience in outpatient oral chemotherapy toxicity monitoring. Questions will have either a Yes/No, or numerical response. Interventions will be administered weekly for the first 3 months after enrollment, then decrease to monthly for a total of 6 months on protocol. Patients will be directed to contact their providers with any significant changes in tolerability. Planned data collected will include intervention question responses, adverse events, demographics, diagnosis, disease response, hospitalizations, treatment dose reductions or interruptions, provider and staff utilization. Survey responses to assess treatment acceptability (Treatment Acceptability/Adherence Scale), usability (System Usability Scale), general health (PROMIS-GH), and patient satisfaction will also be collected. Funding: VA Telehealth Research and Innovation for Veterans with Cancer (THRIVE).

Background

Many Veterans with cancer experience substantial side effects related to their chemotherapy treatments resulting in impaired quality of life. Prompt management of such symptoms can improve adherence to therapy and potentially clinical outcomes. Previous studies in cancer patients have shown that mobile apps can improve symptom management and quality of life, though there are limited studies using oncology-focused apps in the VA population. The VA Annie App is an optimal platform for Veterans since it relies primarily on SMS-based texting and not on internet capabilities. This would address several well-known barriers to Veterans’ care access (limited internet connectivity, transportation) and enhance symptom reporting between infrequent provider visits. Providers can securely collect app responses within the VA system and there is already considerable VA developer experience with designing complex protocols. The OCTAGON project (Optimizing Cancer Care with Telehealth Assessment for Goal-Oriented Needs) will have the following goals: 1) To develop Annie App protocols to assist in management of cancer and/or chemotherapy-related symptoms (OCTAGON intervention), 2) To examine initial acceptability, feasibility, and Veteran-reported outcomes, 3) To explore short term effects on the utilization of VA encounters.

Methods

All patients who are primarily being managed at the VA Ann Arbor for their cancer therapy and are receiving one of the following therapies are considered eligible: EGFR inhibitors (lung cancer), antiandrogen therapies (prostate cancer), BTK inhibitors (lymphoma).

Discussion

Drug-specific protocols will be developed in conjunction with clinical pharmacists with experience in outpatient oral chemotherapy toxicity monitoring. Questions will have either a Yes/No, or numerical response. Interventions will be administered weekly for the first 3 months after enrollment, then decrease to monthly for a total of 6 months on protocol. Patients will be directed to contact their providers with any significant changes in tolerability. Planned data collected will include intervention question responses, adverse events, demographics, diagnosis, disease response, hospitalizations, treatment dose reductions or interruptions, provider and staff utilization. Survey responses to assess treatment acceptability (Treatment Acceptability/Adherence Scale), usability (System Usability Scale), general health (PROMIS-GH), and patient satisfaction will also be collected. Funding: VA Telehealth Research and Innovation for Veterans with Cancer (THRIVE).

Background

From 2000-2022 there were over 200 new drug and over 500 indication approvals specific to oncology. The rate of approvals has increased exponentially, making it difficult to maintain an up-to-date, standardized practice. Nationally, Veterans Affairs (VA) formulary decisions can take time given a lengthy approval process. Locally, the need was identified to incorporate new drugs and data into practice more rapidly. When bringing requests to the facility Pharmacy and Therapeutics (P&T) Committee, it was recognized that the membership consisting of non-oncology practitioners did not allow for meaningful discussion of utilization. In 2017, a dedicated oncology drug review committee (DRC) comprised of oncology practitioners and a facility formulary representative was created as a P&T workgroup. Purpose: Evaluate and describe the utility of forming a local oncology DRC to incorporate new drugs and data into practice.

Methods

DRC minutes from December 2017 to May 2023 were reviewed. Discussion items were categorized into type of review. Date of local review was compared to national formulary criteria for use publication dates, and date of FDA approval for new drugs or publication date for new data, where applicable. Items were excluded if crucial information was missing from minutes. Descriptive statistics were used.

Results

Over 65 months, 38 meetings were held. Thirty total members include: pharmacists, physicians, fellows, and advanced practice providers. Items reviewed included: 36 new drugs (ND), 36 new indications/data (NI), 14 institutional preferences, 10 new dosage form/biosimilars, 4 drug shortages and 2 others. The median time from ND approval to discussion was 3 months (n= 36, IQR 3-6) and NI from publication was 3 months (n=30, IQR 1-8). Nearly all (34/36, 94%) ND were reviewed prior to national review. Local review was a median of 7 months before national, with 11 drugs currently having no published national criteria for use (n=25, IQR 2-12).

Conclusions

DRC formation has enabled faster incorporation of new drugs/indications into practice. It has also created an appropriate forum for in-depth utilization discussions, pharmacoeconomic stewardship, and sharing of formulary and medication related information. VA Health Systems could consider implementing similar committees to review and implement up-to-date oncology practices.

Background

From 2000-2022 there were over 200 new drug and over 500 indication approvals specific to oncology. The rate of approvals has increased exponentially, making it difficult to maintain an up-to-date, standardized practice. Nationally, Veterans Affairs (VA) formulary decisions can take time given a lengthy approval process. Locally, the need was identified to incorporate new drugs and data into practice more rapidly. When bringing requests to the facility Pharmacy and Therapeutics (P&T) Committee, it was recognized that the membership consisting of non-oncology practitioners did not allow for meaningful discussion of utilization. In 2017, a dedicated oncology drug review committee (DRC) comprised of oncology practitioners and a facility formulary representative was created as a P&T workgroup. Purpose: Evaluate and describe the utility of forming a local oncology DRC to incorporate new drugs and data into practice.

Methods

DRC minutes from December 2017 to May 2023 were reviewed. Discussion items were categorized into type of review. Date of local review was compared to national formulary criteria for use publication dates, and date of FDA approval for new drugs or publication date for new data, where applicable. Items were excluded if crucial information was missing from minutes. Descriptive statistics were used.

Results

Over 65 months, 38 meetings were held. Thirty total members include: pharmacists, physicians, fellows, and advanced practice providers. Items reviewed included: 36 new drugs (ND), 36 new indications/data (NI), 14 institutional preferences, 10 new dosage form/biosimilars, 4 drug shortages and 2 others. The median time from ND approval to discussion was 3 months (n= 36, IQR 3-6) and NI from publication was 3 months (n=30, IQR 1-8). Nearly all (34/36, 94%) ND were reviewed prior to national review. Local review was a median of 7 months before national, with 11 drugs currently having no published national criteria for use (n=25, IQR 2-12).

Conclusions

DRC formation has enabled faster incorporation of new drugs/indications into practice. It has also created an appropriate forum for in-depth utilization discussions, pharmacoeconomic stewardship, and sharing of formulary and medication related information. VA Health Systems could consider implementing similar committees to review and implement up-to-date oncology practices.

Background

From 2000-2022 there were over 200 new drug and over 500 indication approvals specific to oncology. The rate of approvals has increased exponentially, making it difficult to maintain an up-to-date, standardized practice. Nationally, Veterans Affairs (VA) formulary decisions can take time given a lengthy approval process. Locally, the need was identified to incorporate new drugs and data into practice more rapidly. When bringing requests to the facility Pharmacy and Therapeutics (P&T) Committee, it was recognized that the membership consisting of non-oncology practitioners did not allow for meaningful discussion of utilization. In 2017, a dedicated oncology drug review committee (DRC) comprised of oncology practitioners and a facility formulary representative was created as a P&T workgroup. Purpose: Evaluate and describe the utility of forming a local oncology DRC to incorporate new drugs and data into practice.

Methods

DRC minutes from December 2017 to May 2023 were reviewed. Discussion items were categorized into type of review. Date of local review was compared to national formulary criteria for use publication dates, and date of FDA approval for new drugs or publication date for new data, where applicable. Items were excluded if crucial information was missing from minutes. Descriptive statistics were used.

Results

Over 65 months, 38 meetings were held. Thirty total members include: pharmacists, physicians, fellows, and advanced practice providers. Items reviewed included: 36 new drugs (ND), 36 new indications/data (NI), 14 institutional preferences, 10 new dosage form/biosimilars, 4 drug shortages and 2 others. The median time from ND approval to discussion was 3 months (n= 36, IQR 3-6) and NI from publication was 3 months (n=30, IQR 1-8). Nearly all (34/36, 94%) ND were reviewed prior to national review. Local review was a median of 7 months before national, with 11 drugs currently having no published national criteria for use (n=25, IQR 2-12).

Conclusions

DRC formation has enabled faster incorporation of new drugs/indications into practice. It has also created an appropriate forum for in-depth utilization discussions, pharmacoeconomic stewardship, and sharing of formulary and medication related information. VA Health Systems could consider implementing similar committees to review and implement up-to-date oncology practices.

Background

In December of 2023, the Survivorship Coordinator at VA Connecticut spearheaded a multidisciplinary collaboration to offer PHASER testing to all patients newly diagnosed with a GI malignancy and/ or patients with a known GI malignancy and a new recurrence that might necessitate chemotherapy. The PHASER panel includes two genes that are involved in the metabolism of two commonly used chemotherapy drugs in this patient population.

Methods

By identifying patients who may have impaired metabolism prior to starting treatment, the doses of the appropriate drugs, 5FU and irinotecan, can be adjusted if appropriate, leading to less toxicity for patients while on treatment and fewer lingering side-effects from treatment. We are tracking all of the patients who are being tested and will report quarterly to the Cancer Committee on any findings with a specific focus on whether any dose-adjustments were made to Veteran’s chemotherapy regimens as the result of this testing.

Discussion

We have developed a systematic process centered around GI tumor boards to ensure that testing is done at least two weeks prior to planned chemotherapy start-date to ensure adequate time for testing results to be received. We have developed a systematic process whereby primary care providers and pharmacists are alerted to the PHASER results and patients’ non-oncology medications are reviewed for any recommended adjustments. We will have 9 months of data to report on at AVAHO as well as lessons learned from this new quality improvement process. Despite access to pharmacogenomic testing at VA, there can be variations between VA sites in terms of uptake of this new testing. VA Connecticut’s PHASER testing initiative for patients with GI malignancies is a model that can be replicated throughout the VA. This initiative is part of a broader focus at VA Connecticut on “pre-habilitation” and pre-treatment testing that is designed to reduce toxicity of treatment and improve quality of life for cancer survivors.

Background

In December of 2023, the Survivorship Coordinator at VA Connecticut spearheaded a multidisciplinary collaboration to offer PHASER testing to all patients newly diagnosed with a GI malignancy and/ or patients with a known GI malignancy and a new recurrence that might necessitate chemotherapy. The PHASER panel includes two genes that are involved in the metabolism of two commonly used chemotherapy drugs in this patient population.

Methods

By identifying patients who may have impaired metabolism prior to starting treatment, the doses of the appropriate drugs, 5FU and irinotecan, can be adjusted if appropriate, leading to less toxicity for patients while on treatment and fewer lingering side-effects from treatment. We are tracking all of the patients who are being tested and will report quarterly to the Cancer Committee on any findings with a specific focus on whether any dose-adjustments were made to Veteran’s chemotherapy regimens as the result of this testing.

Discussion

We have developed a systematic process centered around GI tumor boards to ensure that testing is done at least two weeks prior to planned chemotherapy start-date to ensure adequate time for testing results to be received. We have developed a systematic process whereby primary care providers and pharmacists are alerted to the PHASER results and patients’ non-oncology medications are reviewed for any recommended adjustments. We will have 9 months of data to report on at AVAHO as well as lessons learned from this new quality improvement process. Despite access to pharmacogenomic testing at VA, there can be variations between VA sites in terms of uptake of this new testing. VA Connecticut’s PHASER testing initiative for patients with GI malignancies is a model that can be replicated throughout the VA. This initiative is part of a broader focus at VA Connecticut on “pre-habilitation” and pre-treatment testing that is designed to reduce toxicity of treatment and improve quality of life for cancer survivors.

Background

In December of 2023, the Survivorship Coordinator at VA Connecticut spearheaded a multidisciplinary collaboration to offer PHASER testing to all patients newly diagnosed with a GI malignancy and/ or patients with a known GI malignancy and a new recurrence that might necessitate chemotherapy. The PHASER panel includes two genes that are involved in the metabolism of two commonly used chemotherapy drugs in this patient population.

Methods

By identifying patients who may have impaired metabolism prior to starting treatment, the doses of the appropriate drugs, 5FU and irinotecan, can be adjusted if appropriate, leading to less toxicity for patients while on treatment and fewer lingering side-effects from treatment. We are tracking all of the patients who are being tested and will report quarterly to the Cancer Committee on any findings with a specific focus on whether any dose-adjustments were made to Veteran’s chemotherapy regimens as the result of this testing.

Discussion

We have developed a systematic process centered around GI tumor boards to ensure that testing is done at least two weeks prior to planned chemotherapy start-date to ensure adequate time for testing results to be received. We have developed a systematic process whereby primary care providers and pharmacists are alerted to the PHASER results and patients’ non-oncology medications are reviewed for any recommended adjustments. We will have 9 months of data to report on at AVAHO as well as lessons learned from this new quality improvement process. Despite access to pharmacogenomic testing at VA, there can be variations between VA sites in terms of uptake of this new testing. VA Connecticut’s PHASER testing initiative for patients with GI malignancies is a model that can be replicated throughout the VA. This initiative is part of a broader focus at VA Connecticut on “pre-habilitation” and pre-treatment testing that is designed to reduce toxicity of treatment and improve quality of life for cancer survivors.

Background

Lung cancer is the leading cause of cancer related deaths in the United States. The impact of treatment delay proves difficult to quantify, but increased time to treatment and subsequent progression can limit a patient’s chance for curative intent therapy. Reducing time to treatment aims to improve patient outcome and experience. This study aims to identify the median timeframes that occur in the diagnosis and treatment of lung cancer patients within a single Veteran Affair (VA) Medical Center.

Methods

A retrospective chart review was conducted on 123 new primary lung cancer cases detected by imaging between January 1, 2019 and December 31, 2022 within a single VA medical center. Exclusions were preexisting lung cancer or other malignancy. The following data was collected: time to PET scan, referrals, and treatment initiation. KruskalWallis test and Mann-Whitney U test was employed to assess differences in treatment times based on treatment modality and disease stage, respectively

Results

The median time from first abnormal image to PET scan was 26 days. The median time from initial abnormal scan to treatment was 91 days. Treatment initiation was significantly shorter in late-state disease (IV, extensive stage) at 57 days compared to early-stage disease (I-III, limited stage) at 98.5 days (p= 0.00008). There was a difference in the median time from abnormal scan to treatment initiation based on treatment modality: chemotherapy, radiation therapy, and surgical intervention occurred at 60 days, 86 days, and 98 days, respectively (p= 0.005).

Conclusions

At our institution, patients with latestage lung cancer initiate therapy significantly faster than those diagnosed with early-stage cancer. We feel this is largely due to complex, multidisciplinary coordination of early-stage disease, in contrast to those diagnosed at later stage disease who are treated in a palliative, systemic fashion. This study was instrumental at identifying key areas along the process that can be improved upon. Based on this data, changes will be implemented and studied in effort to shorten time to treatment.

Background

Lung cancer is the leading cause of cancer related deaths in the United States. The impact of treatment delay proves difficult to quantify, but increased time to treatment and subsequent progression can limit a patient’s chance for curative intent therapy. Reducing time to treatment aims to improve patient outcome and experience. This study aims to identify the median timeframes that occur in the diagnosis and treatment of lung cancer patients within a single Veteran Affair (VA) Medical Center.

Methods

A retrospective chart review was conducted on 123 new primary lung cancer cases detected by imaging between January 1, 2019 and December 31, 2022 within a single VA medical center. Exclusions were preexisting lung cancer or other malignancy. The following data was collected: time to PET scan, referrals, and treatment initiation. KruskalWallis test and Mann-Whitney U test was employed to assess differences in treatment times based on treatment modality and disease stage, respectively

Results

The median time from first abnormal image to PET scan was 26 days. The median time from initial abnormal scan to treatment was 91 days. Treatment initiation was significantly shorter in late-state disease (IV, extensive stage) at 57 days compared to early-stage disease (I-III, limited stage) at 98.5 days (p= 0.00008). There was a difference in the median time from abnormal scan to treatment initiation based on treatment modality: chemotherapy, radiation therapy, and surgical intervention occurred at 60 days, 86 days, and 98 days, respectively (p= 0.005).

Conclusions

At our institution, patients with latestage lung cancer initiate therapy significantly faster than those diagnosed with early-stage cancer. We feel this is largely due to complex, multidisciplinary coordination of early-stage disease, in contrast to those diagnosed at later stage disease who are treated in a palliative, systemic fashion. This study was instrumental at identifying key areas along the process that can be improved upon. Based on this data, changes will be implemented and studied in effort to shorten time to treatment.

Background

Lung cancer is the leading cause of cancer related deaths in the United States. The impact of treatment delay proves difficult to quantify, but increased time to treatment and subsequent progression can limit a patient’s chance for curative intent therapy. Reducing time to treatment aims to improve patient outcome and experience. This study aims to identify the median timeframes that occur in the diagnosis and treatment of lung cancer patients within a single Veteran Affair (VA) Medical Center.

Methods

A retrospective chart review was conducted on 123 new primary lung cancer cases detected by imaging between January 1, 2019 and December 31, 2022 within a single VA medical center. Exclusions were preexisting lung cancer or other malignancy. The following data was collected: time to PET scan, referrals, and treatment initiation. KruskalWallis test and Mann-Whitney U test was employed to assess differences in treatment times based on treatment modality and disease stage, respectively

Results

The median time from first abnormal image to PET scan was 26 days. The median time from initial abnormal scan to treatment was 91 days. Treatment initiation was significantly shorter in late-state disease (IV, extensive stage) at 57 days compared to early-stage disease (I-III, limited stage) at 98.5 days (p= 0.00008). There was a difference in the median time from abnormal scan to treatment initiation based on treatment modality: chemotherapy, radiation therapy, and surgical intervention occurred at 60 days, 86 days, and 98 days, respectively (p= 0.005).

Conclusions

At our institution, patients with latestage lung cancer initiate therapy significantly faster than those diagnosed with early-stage cancer. We feel this is largely due to complex, multidisciplinary coordination of early-stage disease, in contrast to those diagnosed at later stage disease who are treated in a palliative, systemic fashion. This study was instrumental at identifying key areas along the process that can be improved upon. Based on this data, changes will be implemented and studied in effort to shorten time to treatment.

Background

Despite the benefit of cancer clinical trials (CTs) in increasing medical knowledge and broadening treatment options, VA oncologists face challenges referring or enrolling Veterans in CTs including identifying appropriate CTs and navigating the referral process especially for non-VA CTs. To address these challenges, the VA National Oncology Program (NOP) provided guidance regarding community care referral for CT participation and established the Cancer Clinical Trial Nurse Navigation (CTN) service.

Methods

Referrals to CTN occur via Precision Oncology consult or email to CancerClinicalTrialsNavigation@va.gov. The CT nurse navigator educates Veterans about CTs, identifies CTs for Veterans based on disease and geographic area, provides written summaries to Veterans and VA oncologists, and facilitates communication between clinical and research teams. Descriptive statistics were used to summarize characteristics of Veterans referred to CTN and results of the CTN searches. A semi-structured survey was used to assess satisfaction from 50 VA oncologists who had used the CTN service.

Results

Between June 2023 and May 2024, 72 Veterans were referred to CTN. Patient characteristics include male (94%), non-rural (65%), median age 66.5 (range 27-80), self-reported race as White (74%) and Black (22%), cancer type as solid tumor (73%) and blood cancer (27%). The median number of CTs found for each Veteran was two (range 0 - 12). No referred Veterans enrolled in CTs, with the most common causes being CT ineligibility and desire to receive standard therapy in the VA. Twenty oncologists were educated about NOP CT guidance. The response rate to the feedback survey was modest (34%) but 94% of survey respondents rated their overall satisfaction as highly satisfied or satisfied.

Conclusions

The CTN assists Veterans and VA oncologists in connecting with CTs. The high satisfaction rate and ability to reach a racially and geographically diverse Veteran population are measures of early program success. By lowering the barriers for VA oncologists to consider CTs for their patients, the CTN expects increased and earlier referrals of Veterans, which may improve CT eligibility and participation. Future efforts to provide disease-directed education about CTs to Veterans and VA oncologists is intended to encourage early consideration of CTs.

Background

Despite the benefit of cancer clinical trials (CTs) in increasing medical knowledge and broadening treatment options, VA oncologists face challenges referring or enrolling Veterans in CTs including identifying appropriate CTs and navigating the referral process especially for non-VA CTs. To address these challenges, the VA National Oncology Program (NOP) provided guidance regarding community care referral for CT participation and established the Cancer Clinical Trial Nurse Navigation (CTN) service.

Methods

Referrals to CTN occur via Precision Oncology consult or email to CancerClinicalTrialsNavigation@va.gov. The CT nurse navigator educates Veterans about CTs, identifies CTs for Veterans based on disease and geographic area, provides written summaries to Veterans and VA oncologists, and facilitates communication between clinical and research teams. Descriptive statistics were used to summarize characteristics of Veterans referred to CTN and results of the CTN searches. A semi-structured survey was used to assess satisfaction from 50 VA oncologists who had used the CTN service.

Results

Between June 2023 and May 2024, 72 Veterans were referred to CTN. Patient characteristics include male (94%), non-rural (65%), median age 66.5 (range 27-80), self-reported race as White (74%) and Black (22%), cancer type as solid tumor (73%) and blood cancer (27%). The median number of CTs found for each Veteran was two (range 0 - 12). No referred Veterans enrolled in CTs, with the most common causes being CT ineligibility and desire to receive standard therapy in the VA. Twenty oncologists were educated about NOP CT guidance. The response rate to the feedback survey was modest (34%) but 94% of survey respondents rated their overall satisfaction as highly satisfied or satisfied.

Conclusions

The CTN assists Veterans and VA oncologists in connecting with CTs. The high satisfaction rate and ability to reach a racially and geographically diverse Veteran population are measures of early program success. By lowering the barriers for VA oncologists to consider CTs for their patients, the CTN expects increased and earlier referrals of Veterans, which may improve CT eligibility and participation. Future efforts to provide disease-directed education about CTs to Veterans and VA oncologists is intended to encourage early consideration of CTs.

Background

Despite the benefit of cancer clinical trials (CTs) in increasing medical knowledge and broadening treatment options, VA oncologists face challenges referring or enrolling Veterans in CTs including identifying appropriate CTs and navigating the referral process especially for non-VA CTs. To address these challenges, the VA National Oncology Program (NOP) provided guidance regarding community care referral for CT participation and established the Cancer Clinical Trial Nurse Navigation (CTN) service.

Methods

Referrals to CTN occur via Precision Oncology consult or email to CancerClinicalTrialsNavigation@va.gov. The CT nurse navigator educates Veterans about CTs, identifies CTs for Veterans based on disease and geographic area, provides written summaries to Veterans and VA oncologists, and facilitates communication between clinical and research teams. Descriptive statistics were used to summarize characteristics of Veterans referred to CTN and results of the CTN searches. A semi-structured survey was used to assess satisfaction from 50 VA oncologists who had used the CTN service.

Results

Between June 2023 and May 2024, 72 Veterans were referred to CTN. Patient characteristics include male (94%), non-rural (65%), median age 66.5 (range 27-80), self-reported race as White (74%) and Black (22%), cancer type as solid tumor (73%) and blood cancer (27%). The median number of CTs found for each Veteran was two (range 0 - 12). No referred Veterans enrolled in CTs, with the most common causes being CT ineligibility and desire to receive standard therapy in the VA. Twenty oncologists were educated about NOP CT guidance. The response rate to the feedback survey was modest (34%) but 94% of survey respondents rated their overall satisfaction as highly satisfied or satisfied.

Conclusions

The CTN assists Veterans and VA oncologists in connecting with CTs. The high satisfaction rate and ability to reach a racially and geographically diverse Veteran population are measures of early program success. By lowering the barriers for VA oncologists to consider CTs for their patients, the CTN expects increased and earlier referrals of Veterans, which may improve CT eligibility and participation. Future efforts to provide disease-directed education about CTs to Veterans and VA oncologists is intended to encourage early consideration of CTs.